Abstract
BackgroundCurrent guidelines recommend an acute subdural hematoma (ASDH) with a thickness greater than or equal to 10 mm or a midline shift greater than or equal to 5 mm be evacuated regardless of Glasgow Coma Scale (GCS). A large craniotomy versus craniectomy is the preferred surgical treatment for ASDH. A subset of patients who are typically older if not elderly meet the above criteria but have a monitorable neurologic exam. These patients can be followed and taken in a delayed manner allowing the ASDH to become chronic. The delay in treatment allows for a smaller surgery in regards to size of incision, size of craniotomy, and duration of anesthesia. MethodsBetween February 2013 and July 2019, we retrospectively identified 19 patients who underwent delayed evacuation of an ASDH, with the primary outcome being Glasgow Outcome Score (GOS) at discharge and three-month follow-up.ResultsEight patients (42%) were female and 11 patients (58%) were male. The median age was 77 years, with a range from 49 to 93 years. Sixteen patients (84%) were 60 years of age or older. Mechanism of injury was a fall for 10 patients (53%). Median number of days from initial evaluation and surgical evacuation was 11 days with a range from 6 to 31 days. Thirteen patients (68%) had a GOS of 4-5 at three-month follow-up. Six patients (32%) had a GOS 1-3 at three-month follow-up. Two mortalities (11%) recorded in the postoperative period.ConclusionSurgically evacuated ASDH in the elderly population is known to carry a significant mortality and morbidity. With close neuromonitoring, delayed intervention in older patients with an ASDH, initially meeting surgical criteria with a good neurologic exam, is a safe practice. Delayed treatment allows for smaller surgery, decreased operative time, and decreased surgical risk which affects older patients even more than younger patients.
Highlights
Current guidelines recommend that any acute subdural hematoma (ASDH) with a thickness greater than 10 mm or a midline shift greater than 5 mm on CT scan be surgically evacuated regardless of the patient’s Glasgow Coma Scale (GCS) score [1]
In order to make any comparative statement on length of surgery and blood loss, we reviewed the surgical times and changes of Hgb of elderly patients undergoing emergent evacuation of an ASDH using larger craniotomies/craniectomies
While the current American guidelines do not make a distinction between the management of acute subdural based upon age, we have found that there exists a subpopulation of patients, typically > 60 years of age, with acute subdural hematoma who can be watched they have more than 5mm of midline shift or clot thickness greater than 10 mm
Summary
Current guidelines recommend that any acute subdural hematoma (ASDH) with a thickness greater than 10 mm or a midline shift greater than 5 mm on CT scan be surgically evacuated regardless of the patient’s Glasgow Coma Scale (GCS) score [1]. Preoperative GCS has been shown to be a significant factor for postoperative outcome in elderly patients undergoing subdural hematoma (SDH) evacuation [4]. These patients represent the subset of elderly ASDH with the highest probability of doing well postoperatively. A subset of patients who are typically older if not elderly meet the above criteria but have a monitorable neurologic exam These patients can be followed and taken in a delayed manner allowing the ASDH to become chronic. The delay in treatment allows for a smaller surgery in regards to size of incision, size of craniotomy, and duration of anesthesia
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