Chronic subdural hematoma in the elderly: not a benign disease

Clinical article

View More View Less
  • Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
Print or Print + Online

Object

Chronic subdural hematoma (CSDH) is perceived to be a “benign,” easily treated condition in the elderly, but reported follow-up periods are brief, usually limited to acute hospitalization.

Methods

The authors conducted a retrospective review of data obtained in a prospectively identified consecutive series of adult patients admitted to their institution between September 2000 and February 2008 and in whom there was a CT diagnosis of CSDH. Survival data were compared to life-table data.

Results

Of the 209 cases analyzed, 63% were men and the mean age was 80.6 years (range 65–96 years). Primary surgical interventions performed were bur holes in 21 patients, twist-drill closed-system drainage in 44, and craniotomies in 72. An additional 72 patients were simply observed. Reoperations were recorded in 5 patients—4 who had previously undergone twist-drill drainage and 1 who had previously undergone a bur hole procedure (p = 0.41, chi-square analysis). Thirty-five patients (16.7%) died in hospital, 130 were discharged to rehabilitation or a skilled care facility, and 44 returned home. The follow-up period extended to a maximum of 8.3 years (median 1.45 years). Six-month and 1-year mortality rates were 26.3% and 32%, respectively.

In the multivariate analysis (step-wise logistic regression), the sole factor that predicted in-hospital death was neurological status on admission (OR 2.1, p = 0.02, for each step). Following discharge, the median survival in the remaining cohort was 4.4 years. In the Cox proportional hazards model, only age (hazard ratio [HR] 1.06/year, p = 0.02) and discharge to home (HR 0.24, p = 0.01) were related to survival, whereas the type of intervention, whether surgery was performed, size of subdural hematoma, amount of shift, bilateral subdural hematomas, and anticoagulant agent use did not affect the long- or short-term mortality rate.

Comparison of postdischarge survival and anticipated actuarial survival demonstrated a markedly increased mortality rate in the CSDH group (median survival 4.4 vs 6 years, respectively; HR 1.94, p = 0.0002, log-rank test). This excess mortality rate was also observed at 6 months postdischarge with evidence of normalization only at 1 year.

Conclusions

In this first report of the long-term outcome of elderly patients with CSDH the authors observed persistent excess mortality up to 1 year beyond diagnosis. This belies the notion that CSDH is a benign disease and indicates it is a marker of other underlying chronic diseases similar to hip fracture.

Abbreviations used in this paper:

CSDH = chronic subdural hematoma; HR = hazard ratio.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
  • 1

    Baechli H, , Nordmann A, , Bucher HC, & Gratzl O: Demographics and prevalent risk factors of chronic subdural haematoma: results of a large single-center cohort study. Neurosurg Rev 27:263266, 2004

    • Search Google Scholar
    • Export Citation
  • 2

    Camel M, & Grubb RL Jr: Treatment of chronic subdural hematoma by twist-drill craniotomy with continuous catheter drainage. J Neurosurg 65:183187, 1986

    • Search Google Scholar
    • Export Citation
  • 3

    Ernestus RI, , Beldzinski P, , Lanfermann H, & Klug N: Chronic subdural hematoma: surgical treatment and outcome in 104 patients. Surg Neurol 48:220225, 1997

    • Search Google Scholar
    • Export Citation
  • 4

    Foelholm R, & Waltimo O: Epidemiology of chronic subdural haematoma. Acta Neurochir (Wien) 32:247250, 1975

  • 5

    Gelabert-González M, , Iglesias-Pais M, , García-Allut A, & Martínez-Rumbo R: Chronic subdural haematoma: surgical treatment and outcome in 1000 cases. Clin Neurol Neurosurg 107:223229, 2005

    • Search Google Scholar
    • Export Citation
  • 6

    Gonugunta V, & Buxton N: Warfarin and chronic subdural haematomas. Br J Neurosurg 15:514517, 2001

  • 7

    Hannan EL, , Magaziner J, , Wang JJ, , Eastwood EA, , Silberzweig SB, & Gilbert M, et al.: Mortality and locomotion 6 months after hospitalization for hip fracture: risk factors and risk-adjusted hospital outcomes. JAMA 285:27362742, 2001

    • Search Google Scholar
    • Export Citation
  • 8

    Horn EM, , Feiz-Erfan I, , Bristol RE, , Spetzler RF, & Harrington TR: Bedside twist drill craniostomy for chronic subdural hematoma: a comparative study. Surg Neurol 65:150154, 2006

    • Search Google Scholar
    • Export Citation
  • 9

    Jones S, & Kafetz K: A prospective study of chronic subdural haematomas in elderly patients. Age Ageing 28:519521, 1999

  • 10

    Kaplan IW, & Meier R: Submucous lipoma of the colon. Am J Gastroenterol 31:673683, 1959

  • 11

    Magaziner J, , Simonsick EM, , Kashner TM, , Hebel JR, & Kenzora JE: Survival experience of aged hip fracture patients. Am J Public Health 79:274278, 1989

    • Search Google Scholar
    • Export Citation
  • 12

    Markwalder TM: Chronic subdural hematomas: a review. J Neurosurg 54:637645, 1981

  • 13

    Mellergård P, & Wisten O: Operations and re-operations for chronic subdural haematomas during a 25-year period in a well defined population. Acta Neurochir (Wien) 138:708713, 1996

    • Search Google Scholar
    • Export Citation
  • 14

    Mori K, & Maeda M: Surgical treatment of chronic subdural hematoma in 500 consecutive cases: clinical characteristics, surgical outcome, complications, and recurrence rate. Neurol Med Chir (Tokyo) 41:371381, 2001

    • Search Google Scholar
    • Export Citation
  • 15

    Pitto RP: The mortality and social prognosis of hip fractures. A prospective multifactorial study. Int Orthop 18:109113, 1994

  • 16

    Ramachandran R, & Hegde T: Chronic subdural hematomas—causes of morbidity and mortality. Surg Neurol 67:367373, 2007

  • 17

    Rohde V, , Graf G, & Hassler W: Complications of burr-hole craniostomy and closed-system drainage for chronic subdural hematomas: a retrospective analysis of 376 patients. Neurosurg Rev 25:8994, 2002

    • Search Google Scholar
    • Export Citation
  • 18

    Rozzelle CJ, , Wofford JL, & Branch CL: Predictors of hospital mortality in older patients with subdural hematoma. J Am Geriatr Soc 43:240244, 1995

    • Search Google Scholar
    • Export Citation
  • 19

    Santarius T, , Kirkpatrick PJ, , Ganesan D, , Chia HL, , Jalloh I, & Smielewski P, et al.: Use of drains versus no drains after burrhole evacuation of chronic subdural haematoma: a randomised controlled trial. Lancet 374:10671073, 2009

    • Search Google Scholar
    • Export Citation
  • 20

    Torihashi K, , Sadamasa N, , Yoshida K, , Narumi O, , Chin M, & Yamagata S: Independent predictors for recurrence of chronic subdural hematoma: review of 343 consecutive surgical cases. Neurosurgery 63:11251129, 2008

    • Search Google Scholar
    • Export Citation
  • 21

    Weigel R, , Schmiedek P, & Krauss JK: Outcome of contemporary surgery for chronic subdural haematoma: evidence based review. J Neurol Neurosurg Psychiatry 74:937943, 2003

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 3139 1524 131
Full Text Views 596 112 10
PDF Downloads 737 103 14
EPUB Downloads 0 0 0