What Would You Do? The Elderly Patient With Subdural Hematoma – Part 3

In previous posts, I proposed several scenarios with elderly patients presenting with subdural hematomas and discussed the use of practice guidelines to help direct their care. The principal conundrum has been in knowing who will do well vs who will not.

Today, I’ll review a paper that examined functional outcome / salvageability in patients with subdural hematomas. It is from a Swiss group that retrospectively reviewed their experience over a six year period. Interestingly, they had specific criteria in place (fifteen years ago) that would limit craniotomy to study patients with:

  • A Karnofsky Performance Scale score of 80 or more and living independently. This scale evaluates the ability to carry out activities of daily living using a score of 0 to 100. Scores > 80 indicate that there may be some symptoms of disease, but daily activities can be carried out with some effort or less.
  • No known dementia
  • No comorbidities that had a survival time of less than 12 months.
  • Desire to proceed with surgery and consent to do so.

Patients with fixed, dilated pupils were excluded. Here are the factoids:

  • 42 patients older than 65 years presented during the study period, and 37 met inclusion criteria
  • 81% of patients had comorbidities and 43% were on some type of anticoagulant or platelet agent
  • Median GCS was 8, so these patients had significant head injury
  • One third (13) died in the perioperative period, and one quarter experienced nonlethal complications
  • Anticoagulation or antiplatelet agents did not appear to affect mortality
  • Final Glasgow Outcome Scale scores were favorable (4-5) in 40% and unfavorable to severely disabled (1-3) in 60%. However, these numbers were calculated using all 37 study patients, and did not exclude the 13 who died! I’m not sure how this works, exactly.

Bottom line: Read this one closely. The authors conclude that, although morbidity, mortality, and adverse outcomes are high, there is a good outcome in 41% of patients.

Really? This is why it is so important to read the whole paper. If you just browsed the abstract and its conclusion, you would have missed the fact that they only accepted independent patients with no dementia or critical comorbidities! The patient group was highly selected which biased them toward better outcomes. Furthermore, there were only 37 people in this retrospective study. 

Personally, I learned very little from this study. I cannot use it to guide me in answering the questions I posed with the original scenarios.  Tomorrow, I’ll review a more recent paper to see if we can find any more clues.

Reference: Age and salvageability: analysis of outcome of patients older than 65 years undergoing craniotomy for acute traumatic subdural hematoma. World Neurosurg 78(3/4):306-311, 2012.

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