University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
Clin Neurol Neurosurg. 2022 Jan;212:107069. doi: 10.1016/j.clineuro.2021.107069. Epub 2021 Nov 25.
Neurosurgical evacuation in elderly trauma patients is controversial. We analyzed impact of craniotomy for acute subdural hematoma on survival in octogenarians and nonagenarians. Methods The study population included all patients aged ≥ 80 years who presented with acute traumatic SDHs 09/01/15 - 01/01/20, with radiography indicating operative eligibility (i.e. MLS >5 mm and/or overall thickness >10 mm). Of 1054 TBIs aged ≥ 80 years, 104 (9.87%) were surgically indicated. Of these, 35 received craniotomy and 69 received supportive measures due to family/patient wishes or surgeon's professional decision. We analyzed these data using a Poisson regression adjusted for influence of covariates.
Of 35 craniotomies, 21 (60.00%) were deceased at 2 years of follow-up, compared to 48 (69.57%) deceased of 69 non-surgical patients. No significant demographic differences existed between these groups, other than age (craniotomy patients were younger; median age 84 vs 86; p < 0.001). In outcomes, the craniotomy cohort survived longer and in higher proportions (p = 0.028; Gehan-Breslow-Wilcoxon). When adjusting for covariates, this effect became more pronounced: craniotomy patients died at 41.1% the rate of non-surgical ones. Of all the covariates, only initial GCS significantly impacted the protective effect of craniotomy. In a logarithmic relationship, each point on initial GCS was associated with less benefit from surgery. We also found that patients with GCS< 3 were overall less likely to benefit from surgery. Our conclusions are limited by the impact of patient/surgeon choice on whether or not to operate. It is possible healthier subjects elected for craniotomies. We have attempted to correct for this by including comorbidities as covariates in our regression analyses.
Our results indicate a surgical benefit for this elderly cohort, consistent with prior findings of benefit in the setting of severe traumatic aSDH. Patients with worse neurologic impairment, i.e. low GCS, had the greatest survival benefit from surgical intervention.
神经外科手术清除术在老年创伤患者中存在争议。我们分析了开颅术治疗 80 岁以上急性硬膜下血肿患者的生存影响。
研究人群包括所有 2015 年 9 月 1 日至 2020 年 1 月 1 日出现急性创伤性 SDH 且影像学提示手术适应证（即 MLS >5mm 和/或总厚度>10mm）的 80 岁以上患者。1054 例年龄≥80 岁的 TBI 患者中，有 104 例（9.87%）手术指征明确。其中 35 例行开颅术，69 例因家庭/患者意愿或外科医生的专业决策而接受支持治疗。我们使用泊松回归分析调整了协变量的影响，对这些数据进行了分析。
在 35 例开颅手术中，2 年随访时有 21 例（60.00%）死亡，而 69 例非手术患者中有 48 例（69.57%）死亡。除年龄外（开颅手术患者年龄较小；中位数年龄 84 岁比 86 岁；p<0.001），这些组之间无明显的人口统计学差异。在结果方面，开颅术组存活时间更长且比例更高（p=0.028；Gehan-Breslow-Wilcoxon）。当调整协变量时，这种效果变得更加明显：开颅术患者的死亡率是未手术患者的 41.1%。在所有协变量中，只有初始 GCS 显著影响开颅术的保护作用。在对数关系中，初始 GCS 的每一点都与手术获益减少相关。我们还发现，GCS<3 的患者总体上不太可能从手术中获益。我们的结论受到患者/外科医生选择是否手术的影响。更健康的患者可能选择开颅术。我们试图通过将合并症作为回归分析中的协变量来纠正这一问题。
我们的结果表明，对于这一年龄段的患者，手术有获益，与严重创伤性急性硬膜下血肿的治疗效果一致。神经功能障碍更严重的患者，即 GCS 较低的患者，从手术干预中获得最大的生存获益。
