Elsevier

World Neurosurgery

Volume 89, May 2016, Pages 147-152
World Neurosurgery

Original Article
Elderly Patients with Severe Traumatic Brain Injury Could Benefit from Surgical Treatment

https://doi.org/10.1016/j.wneu.2016.01.084Get rights and content

Objective

In elderly patients with severe traumatic brain injury, the use of aggressive versus conservative management remains controversial. The aim of this study was to assess the outcome of surgical alternatives for treatment of severe traumatic intracranial hematoma in patients ≥65 years old and identify factors that may contribute to the outcome.

Methods

This retrospective study included 112 patients with traumatic intracranial hematoma. Logistic regression analysis was used to identify independent predictors of unfavorable outcome. The Glasgow Outcome Scale was used to evaluate the outcome.

Results

Surgery was performed in 70 (62.5%) patients ≥65 years old. A favorable outcome occurred in 33 (47.1%) surgical patients, and 23 (32.9%) surgical patients died. Patients who underwent surgery were less likely to have an unfavorable outcome (52.9% vs. 95.2%) and less likely to die (32.9% vs. 88.1%) at 6 months postinjury compared with patients treated conservatively. Multivariate logistic regression analysis revealed that lower Glasgow Coma Scale score (≤5) was a significant factor associated with unfavorable outcome (odds ratio [OR] = 18.7, 95% confidence interval [CI] = 5.2–95.5, P < 0.001) and mortality (OR = 10.7, 95% CI = 4.4–28.5, P < 0.001). However, neurosurgical intervention was a significant factor to negatively predict unfavorable outcome (OR = 0.03, 95% CI = 0.01–0.1, P < 0.001) and mortality (OR = 0.04, 95% CI = 0.01–0.1, P < 0.001).

Conclusions

This study showed that Glasgow Coma Scale score (≤5) was a major determinant of outcome in elderly patients with severe traumatic brain injury. However, surgical treatment reduced mortality and improved outcome in the elderly patients in this study.

Introduction

The elderly population is growing rapidly worldwide, and according to a 2010 national census in China, 118.8 million people were ≥65 years old, accounting for 8.87% of the population of the country, and this number has been rising steadily. In China, it is estimated that elderly patients with traumatic brain injury (TBI) account for approximately 8% of all patients with TBI.1 TBI, especially traumatic intracranial hematoma (TIH) in elderly patients, poses a great challenge for clinicians and can have a substantial impact on the lives of the patients.

Mortality in elderly patients with TBI has been reported to be 24%–78%.2, 3 It has been well documented that elderly patients with TBI have higher mortality and, compared with their younger counterparts, are less likely to function or live independently after TBI.4, 5, 6, 7, 8, 9 Several factors were found to contribute to the poorer outcome in elderly patients, including lower Glasgow Coma Scale (GCS) scores,4, 10 preexisting systemic diseases,11, 12 systemic complications,12 closed basal cisterns and midline shift,13 and limited intensive care.14

However, whether treatment strategies are linked to TBI outcomes so far remains unclear. Given the worse outcome and higher mortality in elderly patients with TBI, many researchers recommended a conservative approach for the treatment of severe head injury of elderly patients.4, 15 Some authors16 argued that the poor outcome did not justify conservative treatment, and, on the contrary, less aggressive alternatives might be related to poor outcome.14, 17 Moreover, a previous study8 reported that some neurosurgeons were reluctant to transfer elderly patients to neurosurgical facilities and attributed the poor outcome of the patients to the conservative management. Nonetheless, other researchers demonstrated that aggressive treatment could yield better outcomes.18, 19 The use of aggressive versus conservative treatments in elderly patients with TBI remains controversial, and the neurosurgical approaches currently used for elderly patients should be critically evaluated. This study assessed the outcome of surgical treatments for severe TIH in patients ≥65 years old and attempted to identify the factors that may contribute to the outcome.

Section snippets

Patients

We conducted a retrospective study in 328 consecutive patients with TBI ≥65 years old who were admitted to the Department of Neurosurgery of Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China, between January 2008 and December 2014. Because this study focused on the impact of surgical alternatives on the outcome of TIH in elderly patients, our inclusion criteria included the following: 1) patients with acute supratentorial TIH and lowest

Clinical Features of Patients

Acute supratentorial TIH was present in 112 patients, including 30 women and 82 men. Surgery was performed in 70 patients (10 patients underwent craniotomy for hematoma removal and 60 patients underwent decompressive craniectomy), and 42 patients were treated medically because patients' family members did not give consent for surgery. The mean age of the 2 groups was 74.5 years ± 6.2 for the conservative treatment group and 73.0 years ± 4.2 for the surgical treatment group; the difference was

Discussion

TIH is an emergency medical condition that often warrants surgical intervention; if treatment is not provided promptly, an unfavorable outcome, including death, tends to result.24 Previous studies19, 25 reported that patients with TIH would benefit from neurosurgical intervention. Nonetheless, some neurosurgeons are skeptical about the worth of surgery for the treatment of head injuries in elderly patients8 and prefer conservative treatment in these cases4, 15 out of concern over worse outcomes

Conclusions

This study showed that the prognosis of elderly patients with TBI was poor. GCS score ≤5 was a major determinant of unfavorable outcome in elderly patients with TIH; however, surgical treatment might reduce the mortality and improve the outcome. Moreover, complications were not the main cause of the unfavorable outcome. Therefore, in these patients, indiscriminately rejecting a surgical approach might not be a wise choice; treatment decisions should be made on a case-by-case basis.

Acknowledgments

This work was supported by the “Dawn” Program of Science and Technology for Young Scientists of Wuhan, China (Grant No. 201150431121), and National Clinical Key Specialty Construction Project. The authors thank Wenhua Liu (Clinical and Translational Medical Center) for statistical assistance.

References (31)

  • C.W. Hukkelhoven et al.

    Patient age and outcome following severe traumatic brain injury: an analysis of 5600 patients

    J Neurosurg

    (2003)
  • A.C. Mosenthal et al.

    Isolated traumatic brain injury: age is an independent predictor of mortality and early outcome

    J Trauma

    (2002)
  • P.T. Munro et al.

    Effect of patients' age on management of acute intracranial haematoma: prospective national study

    BMJ

    (2002)
  • T. Tokutomi et al.

    Age-associated increases in poor outcomes after traumatic brain injury: a report from the Japan Neurotrauma Data Bank

    J Neurotrauma

    (2008)
  • N. Labib et al.

    Severely injured geriatric population: morbidity, mortality, and risk factors

    J Trauma

    (2011)
  • Cited by (0)

    Conflict of interest statement: There is no conflict of interest.

    View full text