518
Injury (1992) 23, (8). 518-520
Prrnfe~ in Greuf Britain
Justification for evacuating acute subdural haematomas in patients above the age of 75 years A. Jamjoom Division
of Neurosurgery,
King Khalid University
Hospital, Riyadh, Saudi Arabia
The author has reviewedthe outcome of 2 7 pafients aged 7.5years and over zuho had an operation for acute traumatic subdural haematoma at Frenchay Hospifal, Bristol, over a IO-yearperiod. Therewere 15 men and 12 wonlen z&h a mean age of 79.2 years. The outcome at 6 months was determinedusing the Glasgow Outcome Score. Of the patients, 15 per cent made a good recovery, I 5 per cent a poor recovery and 70 per cent died. The influence of age, sex, mechanism of injury, preoperative Glasgow Coma Score (GCS), pupillay reactivity to light, skull and limbfracfures, clinical course, CT scan appearance and timing of operation were analysed in relafiotl to the outconze. The results shozued that a preoperative GCS of 4 or less and unilateral pupillay dilatation and non-reactivity to light zoere not compatible with good survival in fhe very elderly patient with acute subdural haematoma. Under these circumstances, operafion is not justified. The prognosis was worse in patienk who were unconsciow immediately after injuv and with a CT scan showing a subdural haematoma and a haemorrhagic contusion which required urgent early intervention. The prognostic indicators present may prove UefuI in fhe selection of putienfs for active surgical inferzJenfion.
Introduction The prognosis associated with severe head injury in the elderly has been described (Teasdale et al., 1979; Carlsson et al., 1968). The increase in the percentage of elderly people in the population is likely to be matched by an increase in the number of aged patients with traumatic acute subdural haematoma who will be referred for operation (Hernesmiemi et al., 1979; Karimi-Nejad and Tritz, 1984; Amacher and Bybee, 1987). Facing limitation of resources and fear of producing vegetative or severely disabled patients, surgeons dealing with very elderly head-injured patients are likely to become more selective in operating only on patients who are likely to benefit from surgical intervention. While the literature is rich with reports on the prognostic indicators after severe head injury at all ages (Braakman et al., 1980; Jennett and Teasdale, 1984; Klun and Fettich, 1984; Levati et al., 1986; Luerssen et al., 1988), reports on the outcome of head injury in the elderly are few (Hemesniemi, 1979; Karimi-Nejad and Tritz, 1984; Amacher and Bybee, 1987; Harward III et al., 1989), and none of them attempts to define selection criteria for operation in the very elderly patient with traumatic acute subdural haematoma. This article is a review of the outcome of patients aged 75 years and over who had an operation to evacuate a c 1992 Butterworth-Heinemann 0020-1383/92/080518-03
Ltd
traumatic acute subdural haematoma. The aim is to define the clinical circumstances in which such evacuation in the very elderly is justifiable. This may prove valuable in modifying management policies.
Patients and methods The clinical record of all patients aged 75 years and over who had operations to evacuate an acute subdural haematoma at Frenchay Hospital, Bristol, between 1980 and 1989 were analysed. The study was limited to patients who had their operation within 1 week of the injury. There were no patients with important acute subdural haematoma who did not have an operation and patients who had surgery for a chronic subdural haematoma were eliminated from the study. Follow-up information was obtained from the hospital notes and from directly contacting patients, their relatives and general practitioners. The outcome was determined at 6 months using the Glasgow Outcome Score Uennett and Teasdale, 1984). Patients who returned to normality or had a moderate disability but remained independent in their daily activities were labelled as ‘good survival’. Patients who were dependent due to severe disability or remained vegetative were labelled as ‘poor survival’. The outcome was analysed of injury, the with reference to age, sex, mechanism Glasgow Coma Score (GCS) and pupillary reaction to light immediately before operation, the presence of skull and orthopaedic fractures, the clinical course from injury to operation, the preoperative CT scan findings, whether showing acute subdural haematoma alone or with additional contusion, and the timing of operation in relation to the injury. The results were analysed using the x2 test for statistical significance.
Results There were 27 cases in the series with an age range of 75-85 years (mean 79.2 years). Nineteen patients (70 per cent) died, 4 (15 per cent) had a poor survival while another 4 (15 per cent) had a good survival and continued living independently after surgery with no obvious mental impairment. There were 15 men and 12 women (ratio 1.25:1) in the series. There were more men than women in the groups of patients who died (ratio 1.4:1) or had a poor survival (ratio 3:1). However, there were more women in the good survival
Jamjoom: Evacuating acute subdural haematomas
519
Table I. Prognostic factors in relation to outcome
Factor
No. of cases
Age group (years) 75-79 16 (59%) 80-85 11 (41%) Mechanism of injury Fall 19(70%) RTA 8 (30%) GCS r5 19 (70%) 8 (30%)
Injury (1992) 23, (8). 518-520
Prrnfe~ in Greuf Britain
Justification for evacuating acute subdural haematomas in patients above the age of 75 years A. Jamjoom Division
of Neurosurgery,
King Khalid University
Hospital, Riyadh, Saudi Arabia
The author has reviewedthe outcome of 2 7 pafients aged 7.5years and over zuho had an operation for acute traumatic subdural haematoma at Frenchay Hospifal, Bristol, over a IO-yearperiod. Therewere 15 men and 12 wonlen z&h a mean age of 79.2 years. The outcome at 6 months was determinedusing the Glasgow Outcome Score. Of the patients, 15 per cent made a good recovery, I 5 per cent a poor recovery and 70 per cent died. The influence of age, sex, mechanism of injury, preoperative Glasgow Coma Score (GCS), pupillay reactivity to light, skull and limbfracfures, clinical course, CT scan appearance and timing of operation were analysed in relafiotl to the outconze. The results shozued that a preoperative GCS of 4 or less and unilateral pupillay dilatation and non-reactivity to light zoere not compatible with good survival in fhe very elderly patient with acute subdural haematoma. Under these circumstances, operafion is not justified. The prognosis was worse in patienk who were unconsciow immediately after injuv and with a CT scan showing a subdural haematoma and a haemorrhagic contusion which required urgent early intervention. The prognostic indicators present may prove UefuI in fhe selection of putienfs for active surgical inferzJenfion.
Introduction The prognosis associated with severe head injury in the elderly has been described (Teasdale et al., 1979; Carlsson et al., 1968). The increase in the percentage of elderly people in the population is likely to be matched by an increase in the number of aged patients with traumatic acute subdural haematoma who will be referred for operation (Hernesmiemi et al., 1979; Karimi-Nejad and Tritz, 1984; Amacher and Bybee, 1987). Facing limitation of resources and fear of producing vegetative or severely disabled patients, surgeons dealing with very elderly head-injured patients are likely to become more selective in operating only on patients who are likely to benefit from surgical intervention. While the literature is rich with reports on the prognostic indicators after severe head injury at all ages (Braakman et al., 1980; Jennett and Teasdale, 1984; Klun and Fettich, 1984; Levati et al., 1986; Luerssen et al., 1988), reports on the outcome of head injury in the elderly are few (Hemesniemi, 1979; Karimi-Nejad and Tritz, 1984; Amacher and Bybee, 1987; Harward III et al., 1989), and none of them attempts to define selection criteria for operation in the very elderly patient with traumatic acute subdural haematoma. This article is a review of the outcome of patients aged 75 years and over who had an operation to evacuate a c 1992 Butterworth-Heinemann 0020-1383/92/080518-03
Ltd
traumatic acute subdural haematoma. The aim is to define the clinical circumstances in which such evacuation in the very elderly is justifiable. This may prove valuable in modifying management policies.
Patients and methods The clinical record of all patients aged 75 years and over who had operations to evacuate an acute subdural haematoma at Frenchay Hospital, Bristol, between 1980 and 1989 were analysed. The study was limited to patients who had their operation within 1 week of the injury. There were no patients with important acute subdural haematoma who did not have an operation and patients who had surgery for a chronic subdural haematoma were eliminated from the study. Follow-up information was obtained from the hospital notes and from directly contacting patients, their relatives and general practitioners. The outcome was determined at 6 months using the Glasgow Outcome Score Uennett and Teasdale, 1984). Patients who returned to normality or had a moderate disability but remained independent in their daily activities were labelled as ‘good survival’. Patients who were dependent due to severe disability or remained vegetative were labelled as ‘poor survival’. The outcome was analysed of injury, the with reference to age, sex, mechanism Glasgow Coma Score (GCS) and pupillary reaction to light immediately before operation, the presence of skull and orthopaedic fractures, the clinical course from injury to operation, the preoperative CT scan findings, whether showing acute subdural haematoma alone or with additional contusion, and the timing of operation in relation to the injury. The results were analysed using the x2 test for statistical significance.
Results There were 27 cases in the series with an age range of 75-85 years (mean 79.2 years). Nineteen patients (70 per cent) died, 4 (15 per cent) had a poor survival while another 4 (15 per cent) had a good survival and continued living independently after surgery with no obvious mental impairment. There were 15 men and 12 women (ratio 1.25:1) in the series. There were more men than women in the groups of patients who died (ratio 1.4:1) or had a poor survival (ratio 3:1). However, there were more women in the good survival
Jamjoom: Evacuating acute subdural haematomas
519
Table I. Prognostic factors in relation to outcome
Factor
No. of cases
Age group (years) 75-79 16 (59%) 80-85 11 (41%) Mechanism of injury Fall 19(70%) RTA 8 (30%) GCS r5 19 (70%) 8 (30%)
