Acute Traumatic Subdural Hematoma Outcome in Patients Older than 65 Years

Abstract

Acute subdural hematomas (SDHs) generally are reported in one-third of patients with severe traumatic brain injury. Acute SDHs are associated with a poor outcome in most cases with mortality of 40%–60%. More recently, several trials to achieve adequate decompression in cases of intracranial hypertension and diffuse brain injury or traumatic acute SDH associated with it reported failure to achieve good long-term functional recovery (2). Most reports came from developed countries with high-level health care facilities and referral systems and abundant neurosurgeons. Advanced age may not be reached in underdeveloped countries that may be medically understaffed both in equipment and in personnel. Higher early or late mortality and morbidity may be expected in this environment. Several factors have been associated with the higher mortality and morbidity including age. Extrapolation of results from developed countries to underdeveloped countries such as most African nations is difficult; however, guidelines can be drawn for standard care. Mortality can be even higher in older patients receiving oral anticoagulation at the time of injury. In a German study (7) featuring a high standard of health care availability, in 11 patients with acute SDH and an average Glasgow Coma Scale (GCS) score of 8 undergoing craniotomy, more frequent use of anticoagulants was noted in significantly older patients (average age 72 years vs. 60 years for patients without anticoagulation). These patients received adequate replacement therapy (prothrombin complex concentrates, vitamin K, and fresh frozen plasma with or without antithrombin in cases of associated disseminated intravascular coagulopathy and low-molecular-weight heparin prophylaxis for postoperative thromboembolism). At 6 months, 55% survival was achieved with a median Glasgow Outcome Scale score of 4. Mortality was 45%. Mortality was not affected by the admission GCS score of 8 or with the use of preoperative anticoagulation if proper replacement measures to rectify the