Early Surgical Intervention Increases TBI-Related Mortality in Older Patients

For older patients with traumatic brain injury (TBI) and acute subdural hematoma, delaying surgery yields better treatment outcomes compared with early surgical interventions, according to study findings published in the journal Brain and Spine.

There is an increased incidence of TBI among the older population and a common injury subtype is an acute subdural hematoma (aSDH). The treatment approach for TBI among the older population is not well defined and researchers aimed to inform treatment guidelines for this patient population.

The researchers assessed TBI outcomes in patients aged 65 years and older who underwent immediate, delayed, or conservative interventions for aSDH. The Glasgow Coma Score was used to assess injury severity, with a higher score indicating a worse severity.

Patient records from 1999 through 2019 were assessed for patients who experienced aSDH. Some exclusion criteria were patients with chronic subdural hematomas, Alzheimer disease, Parkinson disease, alcohol abuse disorder, or experienced a cerebrovascular accident before TBI.

A total of 272 patients fulfilled the inclusion criteria and 123 were excluded due to antithrombotic medication use before the accident. Of the 149 patients remaining, 32 underwent early decompressive surgery, 33 underwent delayed surgery (later than 24h post-TBI), and 84 were conservatively treated.

The median age of patients ranged from 75-78 years at the time of injury. There was a significant portion of patients aged 80 years and older in each treatment category: early surgery (40.6%), delayed surgery (33.3%), and conservative treatment (40.5%).

The diabetes rate was highest among patients treated with early surgery (18.8%, P <.01).

In the study group, 26.2%-42.4% of the patients had a history of cardiovascular diseases prior to TBI, 6.3%-12.1% had a history of cancer, and 6.0%-9.4% had chronic obstructive pulmonary disease (COPD).

The primary cause of TBI across all patients was fall accidents (72.7-82.1%). GCS scores were lower among patients treated with early surgery compared to those who underwent delayed surgery (GCS, 10 vs 15).

Patients who underwent early surgery had higher median midline shifts, hematoma volume, and Marshall CT score. Patients who underwent conservative treatment had an increased risk of developing a subarachnoid hemorrhage (38.1%, P = .03).

There were no statistically significant differences among groups for brain contusions (P = .13), epidural hematomas (P = .36), intracerebral hemorrhage (P = .46), and skull fractures (P = .11).

Patients who underwent early surgery had longer hospital stays and intensive care unit (ICU) admission rates (P = .05, P <.01, respectively). These patients also had the longest ICU stays and the highest redo surgery rates (P = .01 and P <.01, respectively).

“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 [hours] to perform the neurosurgical intervention can lead to better outcomes,” the researchers noted.

They concluded, “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.”

Study limitations are the small sample size and mortality being the only outcome evaluated.