Abstract
Introduction
Traumatic brain injury in the elderly population can have a substantial impact on patients’ quality of life. In this regard, successful treatment strategies are hard to define to date.
Research question
In order to facilitate further insight, this study assessed outcomes following acute subdural hematoma evacuation in patients aged ≥65 years in a large patient series.
Material and methods
A manual screening of the clinical records of 2999 TBI patients aged ≥65 years, admitted to the University Hospital Leuven (Belgium) between 1999 and 2019, was performed.
Results
A total of 149 patients were identified with aSDH, of whom 32 underwent early surgery, 33 underwent delayed surgery and 84 were treated conservatively. Patients who underwent early surgery had the lowest median GCS, poorest Marshall CT scores, longest hospital and ICU stay, and highest intensive care unit admission and redo surgery rates. 30-d mortality was 21.9% in patients undergoing early surgery, 3.0% in patients undergoing late surgery and 16.7% in patients who were treated conservatively.
Discussion and conclusion
In conclusion, patients in whom surgery could not be delayed had the worst presentation and poorest outcomes as opposed in patients in whom delay was possible. Surprisingly, patients treated conservatively had worse outcomes than those treated with delayed surgery. These results might indicate that if the GCS at admission is still adequate, an initial strategy of waiting and seeing might be associated with better outcomes. Future prospective studies with sufficient sample size are warranted to draw more definitive conclusions on the value of early vs. late surgery in elderly patients with aSDH.
Keywords: Traumatic brain injury, Elderly, Neurosurgery, Clinical management, Outcome, Retrospective study
Highlights
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Patients in whom surgery could not be delayed had the worst presentation and poorest outcomes.
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Patients treated conservatively had worse outcomes than patients who underwent delayed surgery.
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In cases with adequate GCS at admission, an initial strategy of wait and see might be associated with better outcomes.
1. Introduction
The incidence of Traumatic Brain Injury (TBI) in elderly people (≥65 years old) has steadily increased over the past decades (Maas et al., 2017), which is likely to increase even more with ongoing demographic shifts (Benedetto et al., 2017).
Elderly patients with TBI frequently suffer from intracranial hematomas. In particular, acute subdural hematoma (aSDH) is the most common injury type in elderly admitted to hospital after TBI, often accompanied by cerebral contusions (Harvey and Close, 2012).
It has been demonstrated that elderly patients with TBI have higher mortality rates (Benedetto et al., 2017) and are less likely to function or live independently after TBI, compared to younger patients (Gan et al., 2004; Marquez de la Plata et al., 2008; Mosenthal et al., 2002). Specifically, lower Glasgow Coma Scale (GCS) scores (Benedetto et al., 2017; Marquez de la Plata et al., 2008), pre-existing systemic diseases (Mosenthal et al., 2002; Bus et al., 2019) systemic complications (Bus et al., 2019), closed basal cisterns (Paldor et al., 2020), midline shift (Paldor et al., 2020) and limited intensive care (De Bonis et al., 2011) are risk factors that have been found to contribute to poorer outcomes in elderly patients.
Treatment strategies in this context are difficult to decide, and surgeons may be faced with a clinical dilemma, or clinical equipoise due to the lack of high-level evidence specific to the elderly population. Although neurosurgical interventions are frequently applied in elderly patients with aSDH (Bus et al., 2019; Paldor et al., 2020), many researchers recommend a more conservative approach, because of the worse outcomes and higher mortality in elderly patients (Gan et al., 2004; De Bonis et al., 2011). High practice variation has been identified in the management of elderly patients with aSDH (van Essen et al., 2022), reflecting uncertainty and potential controversy (Thompson et al., 2008; McIntyre et al., 2013). Therefore, the current study compared the clinical outcomes of TBI patients aged ≥65 years who underwent immediate, delayed or no neurosurgical intervention for aSDH, with the aim of contributing to the creation of specific clinical guidelines for these patients in the future.
2. Methods
A manual screening of the clinical records of 2999 patients aged ≥65 years, diagnosed of TBI, admitted to the University Hospital Leuven (Belgium) between 1999 and 2019, was performed.
The list of patients provided to the authors by the hospital's reporting service was based on registered diagnostic codes, following the International Statistical Classification of Diseases and Related Health Problems (ICD) 9. Only patients with an Acute Subdural Hematoma (aSDH) were included in the present analysis. The aSDH volumes were calculated on the first CT scan taken at hospital admission using the ABC/2 formula (Won et al., 2018).
Patients were excluded if they were under 65 years old, presented with a chronic subdural hematoma (cSDH), had a diagnosis of Alzheimer's disease (AD), Parkinson's disease (PD) or suffered a cerebrovascular accident prior to TBI, had alcohol abuse, were under antithrombotic treatment or presented a Do Not Resuscitate (DNR) order.
All patients’ relevant clinical data, including information on previous clinical history, accident, treatment, clinical characteristics and outcomes were manually registered in an Access 2016 database for all patients fulfilling the inclusion and exclusion criteria. This database was translated into a comma-separated values (csv) file for statistical analysis, which was performed using the Pandas, Numpy and Scikit-learn packages in Python.
Injury severity was defined using the Glasgow Coma Scale (GCS) (Teasdale and Jennett, 1974) and polytrauma was defined as an Injury Severity Score (ISS) ≥16 in multiple organ systems.
3. Results
Initially, 272 patients fulfilled our inclusion criteria, of whom 123 were excluded due to antithrombotic medication intake prior to the accident. Therefore, 149 patients were included in the study, all having sustained aSDH, and of whom 32 underwent early decompressive surgery (i.e. Craniotomy within 24h post-TBI), 33 underwent delayed surgery (later than 24h post-TBI, due to clinical deterioration or enlarging hematoma size) and 84 were conservatively treated. The patients’ median age at injury ranged from 75 to 78 years. 40.6% of the patients who were treated with early surgery, 33.3% of those treated with delayed surgery and 40.5% of those treated conservatively were ≥80 years old. No statistically significant differences were found between age groups in the different studied groups.
None of the patients included in this cohort were taking antithrombotic medication prior to TBI. 26.2–42.4% of the patients had a history of cardiovascular diseases prior to TBI, 21.2–28.1% were under polypharmacy, 6.3–12.1% had a history of cancer and 6.0–9.4% had chronic obstructive pulmonary disease (COPD).
Patients treated with early surgery had the highest rate of diabetes (18.8%, p < 0.01). Moreover, 3.0% of the patients with delayed surgery and 2.4% of the patients who received conservative treatment were dependent for activities of daily living (ADL) prior to TBI.
The demographic characteristics of each of the included groups has been described in Table 1.
Table 1.
Demographic characteristics of the patients included in the three studied groups.
| Neurosurgery |
Conservative treatment (N = 84) | ANOVA p value | ||
|---|---|---|---|---|
| Early surgery (N = 32) | Delayed surgery (N = 33) | |||
| Female/Male (N (%)) | 21 (65.6)/11 (34.4) | 12 (36.4)/21 (63.6) | 41 (48.8)/43 (51.2) | 0.06 |
| Age at injury (median; IQR) | 78; 7 | 75; 10 | 77; 14 | 0.72 |
| ≥80 years old (N (%)) | 13 (40.6) | 11 (33.3) | 34 (40.5) | 0.63 |
| Cardiovascular history (N (%)) | 13 (40.6) | 14 (42.4) | 22 (26.2) | 0.14 |
| Cancer prior to TBI (N (%)) | 2 (6.3) | 4 (12.1) | 7 (8.3) | 0.95 |
| COPD prior to TBI (N(%)) | 3 (9.4) | 2 (6.1) | 5 (6.0) | 0.89 |
| Diabetes prior to TBI (N (%)) | 6 (18.8) | 2 (6.1) | 2 (2.4) | <0.01 |
| Dependency for ADL (N (%)) | 0 (0.0) | 1 (3.0) | 2 (2.4) | 0.65 |
| Polypharmacy (N (%)) | 9 (28.1) | 7 (21.2) | 20 (23.8) | 0.80 |
NA = not applicable; COPD = chronic obstructive pulmonary disease; ADL = activities for daily living.
The main cause of TBI was fall accidents in all studied patients (72.7–82.1%). Patients who underwent early surgery had the lowest median GCS score at admission, while patients who underwent delayed surgery had the highest (GCS of 10 vs. GCS of 15). With regard to CT scan assessment, patients who underwent early surgery had the highest median midline shift, hematoma volume and Marshall CT score [Table 2], whereas patients who were treated conservatively more often had associated subarachnoid hemorrhage (38.1%, p = 0,03). There were no statistically significant differences among the studied groups for brain contusions, epidural hematomas, intracerebral hemorrhage (ICH) and skull fractures (p = 0.13, p = 0.36, p = 0.46, and p = 0.11, respectively). Early surgery was also associated with longer hospital stays, intensive care unit (ICU) admission rates, longest ICU stay and highest redo surgery rates (p = 0.05, p < 0.01, p = 0.01 and p < 0.01, respectively) [Table 3].
Table 2.
Patients’ injury characteristics.
| Neurosurgery |
Conservative treatment (N = 84) | ANOVA p value p value | ||
|---|---|---|---|---|
| Early surgery (N = 32) | Delayed surgery (N = 33) | |||
| Fall accidents (N (%)) | 26 (81.3) | 24 (72.7) | 69 (82.1) | 0.51 |
| GCS (median; IQR) | 10.0; 8 | 15.0; 1 | 14; 3 | <0.01 |
| Brain contusion (N (%)) | 6 (18.8) | 6 (18.2) | 28 (33.3) | 0.13 |
| Subarachnoid hemorrhage (N (%)) | 6 (18.8) | 6 (18.2) | 32 (38.1) | 0.03 |
| Epidural hematoma (N (%)) | 2 (6.3) | 1 (3.0) | 9 (10.7) | 0.36 |
| Intraparenchymal hemorrhage (N (%)) | 0 (0.0) | 0 (0.0) | 2 (2.4) | 0.46 |
| Skull fracture (N (%)) | 10 (31.3) | 4 (12.1) | 25 (29.8) | 0.11 |
| Midline shift (N(%)) | 21 (65.6) | 20 (60.6) | 19 (22.6) | <0.01 |
| Midline shift (median; IQR) | 5.9; 5 | 4.5; 6 | 0.0; 2 | <0.01 |
| aSDH hematoma volume (mL) (median;IQR) | 13.2; 25 | 11.4; 16 | 3.1; 7 | <0.01 |
| Marshall CT score (median; IQR) | 4; 3 | 3; 1 | 2; 1 | <0.01 |
Table 3.
Patients’ clinical management.
| Neurosurgery |
Conservative treatment (N = 84) | ANOVA p value | ||
|---|---|---|---|---|
| Early surgery (N = 32) | Delayed surgery (N = 33) | |||
| Timing of surgery post-TBI (days) (median; IQR) | 0; 1 | 18; 22 | – | <0.01 |
| Hospitalization after TBI (N (%)) | 32 (100.0) | 26 (78.8) | 75 (89.3) | 0.02 |
| Hospitalization length (median;IQR) | 26; 37 | 9; 19 | 9; 17 | 0.05 |
| ICU admission (N (%)) | 20 (62.5) | 10 (30.3) | 26 (31.0) | <0.01 |
| ICU stay length (median;IQR) | 8; 0 | 0; 4 | 0; 2 | 0.01 |
| Redo surgery (N (%)) | 5 (15.6) | 3 (9.1) | 0 (0.0) | <0.01 |
Within 30 days post-TBI, 21.9% of the patients who underwent early surgery, 3.0% of the patients who underwent delayed surgery and 16.7% of the patients who were treated conservatively died. However, the differences in mortality rates among the studied groups were not statistically significant (p = 0.08) [Table 4].
Table 4.
Patients’ mortality rates.
| Neurosurgery |
Conservative treatment (N = 84) | ANOVA p value | ||
|---|---|---|---|---|
| Early surgery (N = 32) | Delayed surgery (N = 33) | |||
| Mortality 30 days (N (%)) | 7 (21.9) | 1 (3.0) | 14 (16.7) | 0.08 |
| Mortality 6 months (N (%)) | 8 (25.0) | 5 (15.2) | 25 (29.8) | 0.27 |
4. Discussion
The results obtained in the current study indicate that conservative treatment is the most often selected treatment strategy for elderly patients with aSDH. In our cohort, 56.4% of the patients were treated conservatively, 21.5% underwent a neurosurgical intervention within the first 24 h post-TBI, and 22.14% underwent delayed neurosurgery later than 24h post-TBI. Patients who received early surgery were clearly in a poorer state than those in whom the surgeons decided that there was time to delay surgical decompression. The highest mortality rate was observed in the early surgery group (21.9%).
Treatment strategies in patient with TBI are usually chosen based on clinical findings such as GCS, computed tomography (CT) results and intracranial pressure (ICP). However, treatment decision for elderly patients with TBI are not straightforward. Patient autonomy and Quality of Life need to be considered, and the prognosis of these patients is often rather poor (Mak et al., 2012). Hence, deciding on a surgical treatment such as craniotomy or craniectomy in elderly patients easily becomes a challenging decision with little ground for evidence-based support (Feliciano and De Jesús, 2008, 2008van Essen et al., 2019).
A neurosurgical intervention is often decided because the patient is judged to be able to survive, while a conservative treatment is chosen in occasions in which the outcome is thought to remain unfavorable whatever treatment is chosen (van Essen et al., 2017). The evacuation of a hematoma through a craniotomy can be life-saving, but at the same time may lead to the survival of a patient with a poor quality of life (QoL) or even absence of independent functioning (Cooper et al., 1976; Honeybul et al., 2013). Unfortunately, no elderly-specific prognostic tools exist to reliably predict outcomes. Decisions may then also be biased by other factors, such as surgeons’ training, different hospital policies, and the intuition and personal opinions of the neurosurgeon (van Essen et al., 2017).
Currently, there is a tendency toward less aggressive treatments in the elderly (Mak et al., 2012). A recent instrumental variable analysis in aSDH in elderly showed no difference in outcomes between patients treated in an aggressive versus a more conservative center (opting for delayed surgery). In the present analysis, it cannot be discriminated whether these elderly individuals had a better outcome prognosis with initially conservative treatment versus immediate surgical treatment (Wan et al., 2016). Thus, the high mortality and morbidity among older patients with TBI can constitute a self-fulfilling prophecy and policy for early surgery (Wan et al., 2016).
Previous studies have shown controversial results regarding outcomes after neurosurgery in elderly patients with TBI. Shimoda et al. Wan et al. and Brazinova et al. reported improved functional outcomes and reduced mortality in patients who underwent neurosurgical interventions (Wan et al., 2016; Shimoda et al., 2014; Brazinova et al., 2010). However, other studies have reported better outcomes after conservative treatment (Trevisi et al., 2020).
The favorable results found in some previous studies might indicate that there is still hope for these patients and that indiscriminately rejecting a surgical approach might not always be the best solution. Nevertheless, this needs to be further investigated.
The main limitation of the study was the small sample size of the studied groups, which depended on the number of admitted patients who fulfilled our in-/exclusion criteria and was out of the authors’ control. Future randomized clinical trials with larger sample sizes will be necessary to draw more consistent conclusions.
Furthermore, the presented data were retrospectively collected. Therefore, standardized functional outcome measurements were not available for all patients and mortality was the only possible outcome available in all. Future studies should also consider different outcome measures regarding the patients’ dependency levels and Quality of Life after neurosurgical intervention and conservative treatment.
Despite these limitations, we believe that this study can positively contribute to reduce the existing research gap in the TBI research field around this matter.
The results obtained from this study seem to indicate that in those cases where the GCS score at admission is still adequate, waiting longer than 24h to perform the neurosurgical intervention can lead to better outcomes. However, these results are based on a low sample size and need to be carefully interpreted. Future prospective larger-size data collection for matched-pair analysis is necessary to draw conclusions. For the moment, individual case analyses should be performed to make clinical decisions. The development of specific prognostic tools and further investigations able to clarify which neurosurgical interventions would be useful for which patients should now be prioritized to improve outcomes and Quality of Life in elderly patients with TBI.
5. Conclusion
Patients who underwent early neurosurgical treatment had the highest 30-day mortality rates, but also presented with the most severe injuries at admission. Patients who underwent delayed surgery had a better outcome. Future prospective studies with a sufficient sample size are warranted to draw more definitive conclusions on the value of early vs. late surgery in elderly patients with aSDH.
Authorship confirmation statement
All authors contributed to the study conception and design. The data collection and analysis was performed by Rebeca Alejandra Gavrila Laic. The first draft of the manuscript was written by Rebeca Alejandra Gavrila Laic and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Author(s’) disclosure statement(s)
The authors declare that they have no competing interests.
Funding statement
This work was supported by Fund for Scientific Research –Flanders (FWO) and Helaers foundation.
Handling Editor: Dr W Peul
Appendix.
Appendix A. Variables registered in our digital database
| Variable |
|---|
| Study ID |
| Gender |
| Marital status |
| Date of birth |
| Date of death (in case of deceased patients) |
| Age at death (in case of deceased patients) |
| Current age |
| Living place before TBI |
| Was the patient living alone before TBI? |
| ADL dependency before TBI |
| Previous history of hematological conditions |
| Previous history of cardiovascular conditions |
| Previous anticoagulant intake |
| Polypharmacy |
| Previous history of depression |
| Previous musculoskeletal problems |
| Previous walking aid |
| Date of accident |
| Age at the moment of the accident |
| Cause of TBI |
| Type of TBI |
| Polytrauma |
| Place of accident |
| Safety measures used during accident |
| Accident description |
| Brain injury type |
| Brain injury location |
| GCS (eyes, motor, verbal and total) at the moment of the accident |
| ICU admission |
| Date of ICU admission |
| Date of ICU discharge |
| Total number of days in ICU |
| Mortality in ICU |
| Hospitalization |
| Number of days between TBI and hospitalization |
| Date of admission to the hospital |
| GCS (eyes, motor, verbal and total) at hospital admission |
| Pupils' size at hospital admission |
| Pupils' reactivity at hospital admission |
| Face asymmetry during hospitalization |
| Tracheotomy |
| Intubation |
| Sedation |
| Paralysis |
| ICP monitoring |
| Date of brain surgery |
| Type of brain surgery |
| Date of second brain surgery |
| Type of second brain surgery |
| Rehabilitation during hospitalization |
| Type of rehabilitation during hospitalization |
| Disorientation at hospital admission |
| Decrease of consciousness at hospital admission |
| Speech problems at hospital admission |
| Amnesia after accident |
| Pain and type of pain at hospital admission |
| Mini Mental Score Extended (MMSE) during hospitalization |
| Date of hospital discharge |
| Total days of hospitalization |
| Presence of a ''Do not attempt resuscitation'' (DNR) code |
| DNR code date |
| Mortality during hospitalization |
| Mortality within 30 days after TBI |
| Mortality within 6 months after TBI |
| Transfer to an institution after hospital discharge |
| Date of transfer to an institution |
| Reason of transfer to an institution |
| Living place after TBI |
| Does the patient live alone after TBI? |
| ADL dependency after TBI |
| Total number of hospitalizations after TBI |
| Motor disturbances after TBI |
| Walking aid use after TBI |
| Pain after TBI |
| Reason of pain after TBI |
| Depression/other psychological problems after TBI |
| Speech disturbances after TBI |
| Rehabilitation (and type of rehabilitation) after TBI |
| Stroke after TBI |
| Date of stroke after TBI |
| Number of registered accidents after TBI |
| Cause of accidents after TBI |
| Type of accidents after TBI |
| Place of accidents after TBI |
| Safety measures after TBI |
| Post-TBI accidents' description |
| Brain surgery after hospital discharge |
| Diagnose of neurodegenerative disorders after TBI |
| Date of neurodegenerative disorder diagnose |
| Number of years between TBI and neurodegenerative disease diagnose |
| MMSE score after hospital discharge |
| MMSE score date |
| MMSE score category |
| Glasgow Outcome Score Extended (GOS-E) 6 months post-TBI |
| ADL dependency post-TBI |
| Presence of epilepsy after TBI |
| Psychiatric problems after TBI |
ID = identifier; TBI = Traumatic Brain Injury; GCS = Glasgow Coma Score; ICU=Intensive Care Unit; MMSE = Mini Mental Score Extended; DNR = Do not attempt resuscitation order.
Appendix B. Registered cardiovascular conditions
| Type of cardiovascular condition |
|---|
| Arterial hypertension (AHT) |
| Hypotension |
| Tachy-brady syndrome |
| Arrhytmia |
| Pacemaker |
| Atrial fibrillation |
| Ventricle fibrillation |
| Venous thrombose |
| Peripheral vascular disease |
| Cardiomyopathy |
| Cardiomegaly |
| Aortic valve stenosis |
| Artificial heart valve implantation |
| Previous myocardial infarct |
| Angor pectoris |
| Aneurysma |
| Hypercholesterolemia |
| Thoracic pain syndrome |
| Ischemic heart disease |
| Ischemic coronary disease |
| Chronic total oclusion |
| Carotid stenosis |
| Cardiac insufficiency |
| Heart valves' insufficiency |
| Arterial insufficiency |
| Coronopathy |
| Supraventricular tachycardia |
| Decompensated heart failure (DHF) |
| Cardiac decompensation |
| Aortic valve stenosis |
| Ventricle hypertrophy |
| Alcoholic cardiomyopathy |
| Venous insufficiency |
| Inferior cava vein syndrome |
| Macroangiopathy |
| Coronary atheromatosis |
References
- Benedetto N., Gambacciani C., Montemurro N., Morganti R., Perrini P. Surgical management of acute subdural haematomas in elderly: report of a single center experience. Br. J. Neurosurg. 2017;31(2):244–248. doi: 10.1080/02688697.2016.1244249. [DOI] [PubMed] [Google Scholar]
- Brazinova A., Mauritz W., Leitgeb J., Wilbacher I., Majdan M., Janciak I., et al. Outcomes of patients with severe traumatic brain injury who have Glasgow Coma Scale scores of 3 or 4 and are over 65 years old. J. Neurotrauma. 2010;27(9):1549–1555. doi: 10.1089/neu.2010.1315. [DOI] [PubMed] [Google Scholar]
- Bus S., Verbaan D., Kerklaan B.J., Sprengers M.E.S., Vandertop W.P., Stam J., et al. Do older patients with acute or subacute subdural hematoma benefit from surgery? Br. J. Neurosurg. 2019;33(1):51–57. doi: 10.1080/02688697.2018.1522418. [DOI] [PubMed] [Google Scholar]
- Cooper P.R., Rovit R.L., Ransohoff J. Hemicraniectomy in the treatment of acute subdural hematoma: a re-appraisal. Surg. Neurol. 1976;5(1):25–28. [PubMed] [Google Scholar]
- De Bonis P., Pompucci A., Mangiola A., Paternoster G., Festa R., Nucci C.G., et al. Decompressive craniectomy for elderly patients with traumatic brain injury: it's probably not worth the while. J Neurotrauma [Internet] 2011;28(10) doi: 10.1089/neu.2011.1889. 2043–8. Available from: [DOI] [PubMed] [Google Scholar]
- Feliciano C.E., De Jesús O. Conservative management outcomes of traumatic acute subdural hematomas. Puert. Rico Health Sci. J. 2008;27(3):220–223. [PubMed] [Google Scholar]
- Gan B.K., Lim J.H.G., Ng I.H.B. Outcome of moderate and severe traumatic brain injury amongst the elderly in Singapore. Ann. Acad. Med. Singapore. 2004;33(1):63–67. [PubMed] [Google Scholar]
- Harvey L.A., Close J.C.T. Traumatic brain injury in older adults: characteristics, causes and consequences. Injury. 2012;43(11):1821–1826. doi: 10.1016/j.injury.2012.07.188. [DOI] [PubMed] [Google Scholar]
- Honeybul S., Janzen C., Kruger K., Ho K.M. Decompressive craniectomy for severe traumatic brain injury: is life worth living? J. Neurosurg. 2013;119(6):1566–1575. doi: 10.3171/2013.8.JNS13857. [DOI] [PubMed] [Google Scholar]
- Maas A.I.R., Menon D.K., Adelson P.D., Andelic N., Bell M.J., Belli A., et al. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol. 2017;16(12):987–1048. doi: 10.1016/S1474-4422(17)30371-X. [DOI] [PubMed] [Google Scholar]
- Mak C.H.K., Wong S.K.H., Wong G.K., Ng S., Wang K.K.W., Lam P.K., et al. Traumatic brain injury in the elderly: is it as bad as we think? Current translational geriatrics and experimental gerontology reports. 2012;1:171–178. doi: 10.1007/s13670-012-0017-2. United States. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Marquez de la Plata C.D., Hart T., Hammond F.M., Frol A.B., Hudak A., Harper C.R., et al. Impact of age on long-term recovery from traumatic brain injury. Arch Phys Med Rehabil [Internet] 2008;89(5):896–903. doi: 10.1016/j.apmr.2007.12.030. https://www.sciencedirect.com/science/article/pii/S0003999308000725 Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
- McIntyre A., Mehta S., Janzen S., Aubut J., Teasell R.W. A meta-analysis of functional outcome among older adults with traumatic brain injury. NeuroRehabilitation. 2013;32(2):409–414. doi: 10.3233/NRE-130862. [DOI] [PubMed] [Google Scholar]
- Mosenthal A.C., Lavery R.F., Addis M., Kaul S., Ross S., Marburger R., et al. Isolated traumatic brain injury: age is an independent predictor of mortality and early outcome. J. Trauma. 2002;52(5):907–911. doi: 10.1097/00005373-200205000-00015. [DOI] [PubMed] [Google Scholar]
- Paldor I., Peso D., Sviri G.E. Decompressive craniectomy in elderly patients with traumatic brain injury. J Clin Neurosci Off J Neurosurg Soc Australas. 2020;78:269–272. doi: 10.1016/j.jocn.2020.03.030. [DOI] [PubMed] [Google Scholar]
- Shimoda K., Maeda T., Tado M., Yoshino A., Katayama Y., Bullock M.R. Outcome and surgical management for geriatric traumatic brain injury: analysis of 888 cases registered in the Japan Neurotrauma Data Bank. World Neurosurg. 2014;82(6):1300–1306. doi: 10.1016/j.wneu.2014.08.014. [DOI] [PubMed] [Google Scholar]
- Teasdale G., Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet (London, England) 1974;2(7872):81–84. doi: 10.1016/s0140-6736(74)91639-0. [DOI] [PubMed] [Google Scholar]
- Thompson H.J., Rivara F.P., Jurkovich G.J., Wang J., Nathens A.B., MacKenzie E.J. Evaluation of the effect of intensity of care on mortality after traumatic brain injury. Crit. Care Med. 2008;36(1):282–290. doi: 10.1097/01.CCM.0000297884.86058.8A. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Trevisi G., Sturiale C.L., Scerrati A., Rustemi O., Ricciardi L., Raneri F., et al. Acute subdural hematoma in the elderly: outcome analysis in a retrospective multicentric series of 213 patients. Neurosurg. Focus. 2020;49(4):E21. doi: 10.3171/2020.7.FOCUS20437. [DOI] [PubMed] [Google Scholar]
- van Essen T.A., de Ruiter G.C.W., Kho K.H., Peul W.C. Neurosurgical treatment variation of traumatic brain injury: evaluation of acute subdural hematoma management in Belgium and The Netherlands. J. Neurotrauma. 2017;34(4):881–889. doi: 10.1089/neu.2016.4495. [DOI] [PubMed] [Google Scholar]
- van Essen T.A., den Boogert H.F., Cnossen M.C., de Ruiter G.C.W., Haitsma I., Polinder S., et al. Variation in neurosurgical management of traumatic brain injury: a survey in 68 centers participating in the CENTER-TBI study. Acta Neurochir. 2019;161(3):435–449. doi: 10.1007/s00701-018-3761-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- van Essen T.A., Lingsma H.F., Pisică D., Singh R.D., Volovici V., den Boogert H.F., et al. Surgery versus conservative treatment for traumatic acute subdural haematoma: a prospective, multicentre, observational, comparative effectiveness study. Lancet Neurol. 2022;21(7):620–631. doi: 10.1016/S1474-4422(22)00166-1. [DOI] [PubMed] [Google Scholar]
- Wan X., Liu S., Wang S., Zhang S., Yang H., Ou Y., et al. Elderly patients with severe traumatic brain injury could benefit from surgical treatment. World Neurosurg. 2016;89:147–152. doi: 10.1016/j.wneu.2016.01.084. [DOI] [PubMed] [Google Scholar]
- Won S.-Y., Zagorcic A., Dubinski D., Quick-Weller J., Herrmann E., Seifert V., et al. Excellent accuracy of ABC/2 volume formula compared to computer-assisted volumetric analysis of subdural hematomas. PLoS One. 2018;13(6) doi: 10.1371/journal.pone.0199809. [DOI] [PMC free article] [PubMed] [Google Scholar]