Outcomes of chronic subdural hematoma drainage in nonagenarians and centenarians: a multicenter study

Abstract

o drain, or not to drain, that is the question." Chronic subdural hemorrhage (SDH) or hematoma is a predominantly neurological condition usually resulting from trauma and affecting elderly individuals. 2,3,14,19 Chronic SDH is not a benign condition and is regarded as a sentinel health event because of its high morbidity and mortality rates in older people.9,18 The treatment of choice for managing chronic SDHs is surgical drainage. 12,23 Large studies have shown that older age independently contributes to increased mortality and morbidity rates after the surgical drainage of chronic SDHs. 10,22,24 As the world's elderly population increases because of adabbreviatioNs CCI = Charlson Comorbidity Index; GCS = Glasgow Coma Scale; KPS = Karnofsky Performance Scale; LOS = length of stay; SDH = subdural hemorrhage. submitted September 5, 2014. accepted December 18, 2014. iNclude wheN citiNg Published online July 10, 2015; DOI: 10.3171/2014.12.JNS142053. disclosure The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. obJective Chronic subdural hemorrhage (SDH) or hematoma is a condition that affects elderly individuals. With advances in medical care, the number of nonagenarians and centenarians will increase. However, surgical treatments in this age group are associated with high rates of morbidity and mortality. Because no data are available on the rates of survival among elderly patients with chronic SDHs who undergo surgical drainage or receive only conservative care, the goal of this study was to determine survival rates in patients 90 years of age or older with symptomatic chronic SDHs. methods The authors conducted a retrospective analysis of patient data that were collected at 3 hospitals over a 13-year period (from January 2001 to June 2013). The data from patients 90 years or older with symptomatic chronic SDHs and who were offered surgical treatment were included in the analysis. Patients who underwent surgical treatment were included in the surgical group and patients who declined an operation were included in the conservative care group. The patients' Charlson Comorbidity Index score, Karnofsky Performance Scale score, dates of death, presenting symptoms, Glasgow Coma Scale score, length of stay in the hospital, discharge location, side of the SDH, and neurological improvements at 30-day and 6-month follow-ups were recorded. Data were statistically analyzed with Fisher exact test, Kaplan-Meier curves, and logistic regression. results In total, 101 patients met the inclusion criteria of this study; 70 of these patients underwent surgical drainage, and 31 received conservative care. Patients in the surgical group had statistically significantly (p < 0.001) higher survival at both the 30-day and 6-month follow-ups, with 92.9% and 81.4% of the patients in this group surviving for at least 30 days and 6 months, respectively, versus 58.1% and 41.9%, respectively, in the conservative care group. Moreover, the mean overall length o...

Chronic Subdural Hematoma with Hypodense on CT-Scan in the Elderly: Surgical Drainage or Conservative Treatment

“…Even so, the results of our study indicate that patients with severe atrophy may also benefit from surgical drainage of a chronic SDH, with a better outcome in either neurological function or mental status, compared to patients with conservative treatment. These findings are consistent with other reports [16], and brain atrophy is not a contraindication for surgical drainage.…”

“…In our study, patients over 80 years had significant improved in neurological status on 1-month after surgery while no statistical difference in patients with conservative treatment. Recent study suggested that surgery for CSDH is safe and positively recommended even in patients over 90 years old, with a lower rate of 6-month death [16]. The findings are consistent with our results, suggesting that patients over 80 years may be similarly able to return to their baseline function compared with younger patients, but may require longer hospital stays for further postoperative rehabilitation.…”

“…However, surgical treatment can result in improvement of cognitive ability in a short-term (1-month follow-up), and improvement of neurological status in a longterm (1-year follow-up), despite some patients will remain dependent with limited mRS scores. This is in contrast to past research [25,26], but more recent studies have shown the similar results to our findings [15,16].…”

“…The term "chronic" subdural hematoma has been loosely defined, with various authors applying it to those in the different stage of CSDH. According to CT scan, hematoma density is known to decrease with time, passing from a high-stage to an iso-and finally a low density stage [15,16]. Therefore, lower hematoma densities are expected to be seen in the late stage of hematoma course.…”

“…Sun et al reported that the mortality rates of the corticosteroid monotherapy group, the combination group and the surgery groups were 4%, 3%, 15%, respectively, and therefore suggested that steroid treatment in a selected group of patients is a good option, particularly in patients with co-morbidity. However, Lee et al [16] emphasized that surgical drainage of a CSDH in patient ≥ 90 years is associated with a lower rate of inpatient death and higher 6-month survival rates than for patients who receive only conservative care. This suggests that elderly patients who have preexisting co-morbidities can also benefit from surgical drainage of a CSDH with lower risks of perioperative complications.…”