Abstract
Increasing age and lower pre-operative Glasgow coma score (GCS) are associated with worse outcome after surgery for chronic subdural haematoma (CSDH). Only few studies have quantified outcomes specific to the very elderly or comatose patients. We aim to examine surgical outcomes in these patient groups. We analysed data from a prospective multicentre cohort study, assessing the risk of recurrence, death, and unfavourable functional outcome of very elderly (≥ 90 years) patients and comatose (pre-operative GCS ≤ 8) patients following surgical treatment of CSDH. Seven hundred eighty-five patients were included in the study. Thirty-two (4.1%) patients had pre-operative GCS ≤ 8 and 70 (8.9%) patients were aged ≥ 90 years. A higher proportion of comatose patients had an unfavourable functional outcome (38.7 vs 21.7%; p = 0.03), although similar proportion of comatose (64.5%) and non-comatose patients (61.8%) functionally improved after surgery (p = 0.96). Compared to patients aged < 90 years, a higher proportion of patients aged ≥ 90 years had unfavourable functional outcome (41.2 vs 20.5%; p < 0.01), although approximately half had functional improvement following surgery. Mortality risk was higher in both comatose (6.3 vs 1.9%; p = 0.05) and very elderly (8.8 vs 1.1%; p < 0.01) groups. There was a trend towards a higher recurrence risk in the comatose group (19.4 vs 9.5%; p = 0.07). Surgery can still provide considerable benefit to very elderly and comatose patients despite their higher risk of morbidity and mortality. Further research would be needed to better identify those most likely to benefit from surgery in these groups.
Highlights
Chronic subdural haematoma (CSDH) is a common neurosurgical condition whose incidence and prevalence increase with age [1,2,3,4]
Whilst the median age of patients admitted to neurosurgical units (NSUs) for surgery is 77 [9], no consensus currently exists in the management of very elderly patients with CSDH (≥ 90 years old)
We were unable to compare the baseline characteristics of comatose patients who were transferred with those who stayed in the referring hospital, as detailed data was not collected for patients not transferred to NSU
Summary
Chronic subdural haematoma (CSDH) is a common neurosurgical condition whose incidence and prevalence increase with age [1,2,3,4]. Longitudinal studies have consistently demonstrated that age and preoperative Glasgow coma score (GCS) are associated with worse surgical outcomes [7, 8]. Whilst older patients and comatose patients are in a poorer prognostic group, the outcomes specific to these patients are not well studied. With an ageing population, determining the optimal management of CSDH in older people is of increasing importance. Whilst the median age of patients admitted to neurosurgical units (NSUs) for surgery is 77 [9], no consensus currently exists in the management of very elderly patients with CSDH (≥ 90 years old). Surgery may be delayed or refused, because of the increased risk of perioperative morbidity and mortality and the perception of an expected likelihood
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