head injury craniotomi hematom

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J Neurosurg 116:234–245, 2012

234 J Neurosurg / Volume 116 / January 2012

INTRACRANIAL hemorrhage and/or hematoma dueto trauma are serious conditions that often requireemergent surgical intervention; if immediate treat-

ment is not provided, morbidity and mortality are high.31 Intracranial hemorrhage can lead to acute neurological

deterioration, cardiovascular instability,25 localized me-chanical damage to brain tissue,9,15,24 perilesional edema,39 increased intracranial pressure,31 brainstem compression,herniation,2 and death.8 When conservative interventionssuch as hemostatic therapy (reversal of anticoagulanttherapy and coagulative induction) and pharmaceuticalmanagement of intracranial pressure27 fail to treat intra-cranial hemorrhage efciently or if the hematoma is too

Postoperative outcomes following closed head injuryand craniotomy for evacuation of hematoma in patientsolder than 80 years

Clinical article

DARRYL LAU, B.A., 1 ABDULRAHMAN M. EL-SAYED, B.S., 2– 4 JOHN E. ZIEWACZ, M.D., M.P.H., 5–7 PRIYA JAYACHANDRAN, B.A., 1 FARHAN S. HUQ, B.S.E., 1 GRETTEL J. ZAMORA-BERRIDI, M.H.S., 1

MATTHEW

C. DAVIS

, B.A.,

1

AND

STEPHEN

E. SULLIVAN

, M.D.

5

1University of Michigan Medical School and 5 Department of Neurosurgery, University of Michigan, Ann

Arbor, Michigan; 2 Department of Public Health, Oxford University, Oxford, United Kingdom;3 Department of

Epidemiology and 4College of Physicians and Surgeons, Columbia University, New York, New York; 6 Center

for Surgery and Public Health, Harvard School of Public Health; and7 Department of Surgery, Brigham and

Women’s Hospital, Boston, Massachusetts

Object. Advances in the management of trauma-induced intracranial hematomas and hemorrhage (epidural,subdural, and intraparenchymal hemorrhage) have improved survival in these conditions over the last several de-cades. However, there is a paucity of research investigating the relation between patient age and outcomes of surgicaltreatment for these conditions. In this study, the authors examined the relation between patient age over 80 years andpostoperative outcomes following closed head injury and craniotomy for intracranial hemorrhage.

Methods. A consecutive population of patients undergoing emergent craniotomy for evacuation of intracranial

hematoma following closed head trauma between 2006 and 2009 was identied. Using multivariable logistic regres-sion models, the authors assessed the relation between age (> 80 vs ≤ 80 years) and postoperative complications,intensive care unit stay, hospital stay, morbidity, and mortality.

Results. Of 103 patients, 27 were older than 80 years and 76 patients were 80 years of age or younger. Olderage was associated with longer length of hospital stay (p = 0.014), a higher rate of complications (OR 5.74, 95% CI1.29–25.34), and a higher likelihood of requiring rehabilitation (OR 3.28, 95% CI 1.13–9.74). However, there wereno statistically signicant differences between the age groups in 30-day mortality or ability to recover to functionalbaseline status.

Conclusions. The ndings suggest that in comparison with younger patients, patients over 80 years of age maybe similarly able to return to preinjury functional baselines but may require increased postoperative medical atten-tion in the forms of rehabilitation and longer hospital stays. Prospective studies concerned with the relation betweenolder age, perioperative parameters, and postoperative outcomes following craniotomy for intracranial hemorrhageare needed. Nonetheless, the ndings of this study may allow for more informed decisions with respect to the care ofelderly patients with intracranial hemorrhage. (DOI: 10.3171/2011.7.JNS11396)

KEY WORDS • age • craniotomy • hematoma • intracranial hemorrhage •

morbidity • trauma • traumatic brain injury

Abbreviations used in this paper: BMI = body mass index; GCS= Glasgow Coma Scale; ICU = intensive care unit.

Click here to listen to the podcast featuring aninterview with the authors.

http://jnsonline.org/2011/09/01/jns-august-2011-postoperative-outcomes-following-closed-head-injury-and-craniotomy/http://jnsonline.org/2011/09/01/jns-august-2011-postoperative-outcomes-following-closed-head-injury-and-craniotomy/


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Age and craniotomy following intracranial hemorrhage

235

large for nonsurgical treatments,16 a craniotomy for evac-uation of the hematoma or hemorrhage may be required.

However, even with a craniotomy, reported postop-erative morbidity and mortality rates for patients withintracranial hemorrhage remain high; recovery fromsuch aggressive treatment can be prolonged, and failureto return to baseline is common. Studies from the 1980sreport mortality rates ranging from 65% to 90% after cra-niotomy for evacuation of acute subdural hematomas.13 By the 1990s, mortality rates for the same procedure haddropped to between 25% and 58%.8,20,35 Previous neuro-surgical studies have also demonstrated age-dependentmorbidity and mortality rates, with younger patientsfaring better than older patients undergoing craniotomyfor intracranial bleeding.13,35 However, current advancesin imaging, rapid diagnostics, medical management ofhemodynamic properties, and surgical techniques haveimproved patient outcomes,36 and a further decreasein mortality associated with treatment for intracranialbleeding has been demonstrated; in 2008, postoperative

mortality associated with craniotomy for evacuation ofacute subdural and epidural hematoma ranged from 22%to 41%.17,33,34

It is plausible that this overall decrease in mortalitymay also be reected by improved survival among olderpatients. Given the breadth and scope of medical and sur-gical advancements, this raises an interesting and valu-able question: Do older patients continue to suffer highermorbidity and mortality rates than younger patients fol-lowing evacuation of intracranial hematoma and/or hem-orrhage? Because older age is a risk factor for intracranialhemorrhage after head trauma, this question is of increas-ing importance, as the geriatric population grows in sizeand the costs and efcacy of end-of-life care continue to

be a contentious topic of debate.7,12,26 An improved under-standing of the potential risks of craniotomy for treatmentof intracranial hemorrhage in patients over the age of 80years may allow physicians to make better-informed de-cisions about treatment options for this population. Asthere is a paucity of research that has assessed outcomesand morbidity following neurosurgical interventionsamong these patients relative to younger patients, we as-sessed the relation between older age and 30-day post-operative outcomes following craniotomy for evacuationof intracranial hemorrhage and hematoma due to closedhead trauma. The age criterion used in this study was pa-tient age over 80 years at time of surgery; this criterion

was chosen because there has been a signicant rise inthe number of patients over the age of 80 in the US in thepast several decades.38 Also, end-of-life decisions may bemore relevant in this population than in patients between65 and 80 years of age, who would be included in ourexposure group if traditional geriatric cutoffs were used.

Methods and Materials

Data

Electronic medical records, including patient recordsand intraoperative anesthesia records, at the Universityof Michigan Health System were queried to identify all

adult patients undergoing craniotomy for evacuation ofhematoma or hemorrhage between the beginning of 2006and the end of 2009. We identied all patients sufferingclosed head trauma resulting in intracranial hemorrhageand hematoma requiring evacuation. The indications forcraniotomy for evacuation of hematoma were hemorrhagewith mass effect and/or neurological decline. Of the 111consecutive patients identied, 8 patients with additionalcomorbidities and diagnosis of HIV/AIDS, multiple cra-nial hematomas, brain tumors/lesions, or skull fracturesrequiring cranioplasty were excluded from this analy-sis since these comorbidities required additional medi-cal and/or surgical intervention that might confound theanalysis. In all cases, intraparenchymal hematoma, sub-dural hematoma, or epidural hematoma was diagnosed byimaging.

Our covariate set for this study included demograph-ic and baseline clinical variables: age at surgery, sex, BMI(calculated using the standard formula of weight in kg/[height in meters]2), and prior diagnosis of diabetes mel-

litus, coronary artery disease, or hypertension. Cranialnerve decits potentially resulting from intracranial hem-orrhage were noted as well. In addition, presentation GCSscores were recorded. Computed tomography scans wereanalyzed to determine the type of hematoma, maximumthickness of the hematoma, and degree of midline shift ofthe brain. Thickness and midline shift were included inour data and reported in millimeters.

Preoperative laboratory blood values were also re-corded: including serum creatinine, hemoglobin, inter-national normalized ratio of blood coagulation, plateletcount, and partial thromboplastin time. Intraoperativeparameters of interest included estimated blood loss (notincluding the volume of blood from the hematoma), op-

erative time (dened as rst incision to last surgical dress-ing), need of blood transfusion, and complications.Postoperative outcomes with which we were con-

cerned included length of stay in the ICU until transferto the general oor (ICU stay immediately after surgerywas counted as Day 1), total length of stay in the hospital(date of admission to date of discharge), requirement forrehabilitation, and return to baseline status (dened as re-turn of the patient’s normal physiological and mental sta-tus before the incident of intracranial bleeding). Returnto baseline was measured subjectively by the associatedneurosurgical care team based on patient self-report.

Complications (which include any neurological de-cit detected after surgery compared with ndings on pre-

operative examination, whether transient or permanent,as well as any perioperative or postoperative events thatrequired medical or surgical intervention up to 30 days af-ter surgery) and 30-day postoperative mortality data werecollected. Complications included cardiac complications(arrhythmias, myocardial infarct, and cardiac arrest), in-fection (urinary tract infection, pneumonia, wound infec-tion, cellulitis, pseudomembranous colitis, and sepsis),reoperation, neurological complications (decit, hydro-cephalus, pseudomeningocele, seizure, and coma), othercomplications (renal failure, bleeding/anemia, pulmonaryembolus, deep vein thrombosis, delirium, respiratory fail-ure, ileus, and malignant hypertension), and death.

This study was reviewed and approved by the Medical


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Sciences Institutional Review Board of the University ofMichigan.

Analysis

First, univariate statistics were used to describe oursample. Second, we employed bivariate chi-square tests

to identify signicant associations between covariates ofinterest and categorical outcomes (rehabilitation, returnto baseline, complications, and mortality), along withANOVA to assess signicant associations between ex-planatory covariates of interest and continuous outcomes(ICU and total hospital stay).

Third, multivariable logistic regression models oflikelihood for rehabilitation, return to baseline, 30-daymortality, and complication risk were t and were adjust-ed for potential confounders. We adjusted for covariatesfound to be signicantly associated with postoperativeoutcomes in bivariate chi-square tests. Fourth, ANCOVAmodels of ICU stay and hospital stay by various covari-ates were t and were adjusted for covariates found to be

signicantly associated with the outcomes of interest byANOVA.

Further analysis of the distribution of complicationsby type (cardiac, infection, reoperation, neurological, andother) and by age group (> 80 vs ≤ 80 years) was also per-formed. If a patient had a particular complication type,he or she was counted as 1 patient for that complicationcategory. Patients with more than 1 type of complicationwere counted as 1 patient in each of the specic com-plication categories. Chi-square tests were used to assessthe statistical signicance of age-dependent differencesin complication risk.

Results with probability values less than 0.050 were

considered signicant. This study was powered to detecta minimum odds ratio of 1.92 for patients older than 80years relative to those 80 years or younger with 80% pow-er and a = 0.05. Posthoc power analysis was run usingNCSS Power Analysis and Sample Size. All other statisti-cal analyses were run using SAS 9.2 (SAS Institute).

Results

Table 1 shows demographic characteristics and theresults of bivariate chi-square tests between covariatesand 30-day complications and mortality. Overall, 61 pa-tients had complications (a complication rate of 59.2%).

There were no reported intraoperative complications (allcomplications were postoperative). Difference in age wassignicantly associated with complications (p = 0.012).Patients older than 80 years had a complication rate of81.5%, which was higher than those aged 50–80 yearsand those younger than 50 years (58.3% and 45.0%, re-spectively). The overall mortality rate after craniotomywas 25.2%. Although patients older than 80 years hadslightly higher absolute rates of mortality, there was nosignicant difference between the 3 age groups. Table 1also describes covariates that are associated with returnto baseline and need for rehabilitation. Age was not asso-ciated with signicant differences in return to baseline (p= 0.816). Of 103 patients, 36.4% required rehabilitation.

Age was signicantly associated with requirement for re-habilitation (p = 0.037). In the groups of patients youngerthan 50 years and patients between 50–79 years, 25.0%required rehabilitation; this percentage was signicantlylower than in the group of patients who were older than80 years (51.9%).

Table 2 shows postoperative ICU and hospital stay, as

well as the results of an ANOVA between explanatory co-variates of interest and both outcomes of interest amongpatients in our sample. The mean postoperative ICU staywas 4.6 days in the total group (103 patients). Age wasnot associated with a signicant difference in postopera-tive ICU stay (p = 0.137). The mean total hospital staywas 10.2 days in the total group. Older age was associatedwith longer hospital stay (p = 0.030). The mean durationof stay for patients younger than 50 years was 7.8 days,for those aged 50–80 years it was 10.0 days, and for thoseover 80 years old it was 12.8 days.

Table 3 shows multivariable models of postoperativeoutcomes risk by age, adjusted for potential confounders.Age greater than 80 years was signicantly associatedwith increased risk of postoperative complications afteradjusting for potential confounders. Compared with pa-tients younger than 50 years, the odds ratio of complica-tions among patients older than 80 years was 5.74 (95%CI 1.29–25.34). Age was not, however, associated withsignicant risk for mortality. In addition, we found thatpatients older than 80 years were more likely to requirerehabilitation compared with patients younger than 50(OR 3.28, 95% CI 1.13–9.74). Both groups of patients 50and older returned to baseline at a rate similar to the rateobserved in patients younger than 50 years.

Table 4 shows the results of ANCOVA models ofpostoperative ICU stay and hospital stay, adjusted for

potential confounders. Both ICU and hospital stays weresignicantly longer in patients older than 80 years (p =0.039 and p = 0.014, respectively, for comparison with pa-tients younger than 50 years).

Table 5 reports the specic postoperative complica-tions in patients over 80 years old and patients 80 yearsor younger. The most common complication among theolder group was infection; 37.0% of the 27 patients olderthan 80 years had at least 1 infection (Clostridium dif-cile causing pseudomembranous colitis, pneumonia, cel-lulitis, or sepsis).

Age-dependent differences in risk for specic com-plications are shown in Fig. 1. Infection was the onlycategory with statistically signicant age-dependent dif -

ferences in prevalence (p = 0.005). The prevalence of in-fection among the patients older than 80 years was 37.0%and the prevalence of infection among those 80 years ofage or younger was 10.5%. There were no other statisti-cally signicant differences in complication rate by age:cardiac (p = 0.089), reoperation (p = 0.950), neurological(p = 0.979), and other (p = 0.829).

Discussion

In this study about the relation between age andpostoperative outcomes following closed head injury andemergent craniotomy for evacuation of hematoma, wefound that patients over 80 years of age had signicantly


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TABLE 1: Descriptive statistics and results of bivariate chi-square tests between demographic and medical covariates and postoperative

outcomes*

Rehabilitation Return to Baseline Complications† Mortality

Pt Descriptives No. of Pts No. of Pts p Value No. of Pts p Value No. of Pts p Value No. of Pts p Value

total 103 36 (35.0) 55 (53.4) 61 (59.2) 26 (25.2)

age (yrs) 0.037 0.816 0.012 0.530 80 27 (26.2) 14 (51.9) 13 (48.2) 22 (81.5) 9 (33.3)

sex 0.213 0.106 0.159 0.026

M 60 (58.3) 18 (30.0) 28 (46.7) 39 (65.0) 20 (33.3)

F 43 (41.8) 18 (41.9) 27 (62.8) 22 (51.2) 6 (14.0)

BMI 0.930 0.779 0.104 0.687

25 47 (53.4) 17 (36.2) 24 (51.1) 31 (66.0) 9 (19.2)

diabetes mellitus 0.440 0.471 0.107 0.870

yes 11 (10.7) 5 (45.5) 7 (63.6) 9 (81.8) 3 (27.3) no 92 (89.3) 31 (33.7) 48 (52.2) 52 (56.5) 23 (25.0)

coronary artery disease 0.730 0.660 0.037 0.716

yes 10 (9.7) 3 (30.0) 6 (60.0) 9 (90.0) 3 (30.0)

no 93 (90.3) 33 (35.5) 49 (52.7) 52 (55.9) 23 (24.7)

hypertension 0.788 0.737 0.432 0.942

yes 39 (37.9) 23 (35.9) 20 (51.3) 25 (64.1) 10 (25.6)

no 64 (62.1) 13 (33.3) 35 (54.7) 36 (56.3) 16 (25.0)

anticoagulation 0.949 0.469 0.034 0.433

yes 37 (35.9) 13 (35.1) 18 (48.7) 27 (73.0) 11 (29.7)

no 66 (64.1) 23 (34.8) 37 (56.1) 34 (51.5) 15 (22.7)

cranial nerve decit 0.745 0.013 0.335 0.103

yes 11 (10.7) 4 (36.4) 2 (18.2) 8 (72.7) 5 (45.5)

no 92 (89.3) 32 (34.8) 53 (57.6) 53 (57.6) 21 (22.8)

GCS score 0.141


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higher rates of postoperative complications, had signi-cantly longer hospital stays, and required rehabilitationmore frequently than patients 80 years old or younger.However, the rate of mortality and return to baselineamong this population was similar to what was foundin younger patients. Taken together, our ndings suggest

that, compared with younger patients, older patients maybe similarly able to return to functional baseline, but mayrequire added postoperative medical attention in the formof rehabilitation and longer hospital stays.

Similar likelihoods of return to functional baselineand nonsignicant differences in the rate and risk ofmortality were unexpected, as past studies have demon-strated worse outcomes and higher mortality rates fol-lowing neurotrauma in older patients than in youngerpatients.3,12,13 Our ndings suggest that advancements inthe management of intracranial hematomas, particularlypostoperative ICU care and rehabilitation, may mitigatethe increased risk of death traditionally associated witholder age in past studies. There is some literature that has

supported these ndings. A recent study showed prom-ising outcomes in older patients after neurosurgical in-tervention for intracranial hemorrhage and hematoma.1 Also, a cohort study done by Baechli et al.5 showed thatof 354 patients, those older than 65 years of age had ratesof mortality similar to those of younger patients after

undergoing neurosurgical interventions for subdural he-matoma. Age may not be an adequate indicator for like-lihood of postsurgical recovery; rather a clinical metricof frailty32 and other preoperative parameters22 have beenshown to be effective in predicting survival rates postop-eratively. Also, regarding the value of neurosurgical treat-ment among the elderly, a recent study showed that pa-tients 70 years and older with subarachnoid hemorrhageshad favorable clinical outcomes, and concluded that ageshould not preclude treatment.4

Age above 80 years was a signicant predictor ofcomplications after emergent craniotomy for evacuationof hematoma in our study. In particular, patients olderthan 80 years had signicantly higher rates of infection.

TABLE 1: Descriptive statistics and results of bivariate chi-square tests between demographic and medical covariates and postoperative

outcomes* (continued)

Rehabilitation Return to Baseline Complications† Mortality

Pt Descriptives No. of Pts No. of Pts p Value No. of Pts p Value No. of Pts p Value No. of Pts p Value

hemoglobin (g/dl) 0.264 0.078 0.307 0.305

16.5 3 (3.1) 0 (0.0) 1 (33.3) 2 (66.7) 0 (0.0)

INR 0.742 0.886 0.893 0.978

1.2 15 (16.5) 6 (40.0) 8 (53.3) 9 (60.0) 4 (26.7)

platelets (× 103 per μl) 0.052 0.045 0.062 0.009

450 2 (2.0) 0 (0.0) 0 (0.0) 1 (50.0) 1 (50.0)

PTT (sec) 0.041 0.403 0.727 0.021

28 25 (27.8) 4 (16.0) 11 (44.0) 16 (64.0) 11 (44.0)

blood loss (ml) 0.135 0.080 0.190


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TABLE 2: Analysis of variance between demographic and medical covariates and outcomes*

ICU Stay Total Hospital Stay

Pt Descriptives Mean (days) p Value Mean (days) p Value

total 4.6 ± 4.2 10.2 ± 7.6

age (yrs) 0.137 0.030

80 5.9 ± 4.8 12.8 ± 10.0

sex 0.964 0.596

M 4.5 ± 4.7 9.5 ± 7.7

F 4.4 ± 3.7 10.3 ± 7.7

BMI 0.573 0.083

25 4.6 ± 4.2 12.1± 8.7

diabetes mellitus


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This was expected and may be attributed to a less robustimmune system and consequent higher risk for infectionin older patients.18,29 Moreover, the natural symbiotic oramay be less able to defend against pathogenic bacteriathat colonize the intestines as the gastrointestinal tractchanges with age,6 making older patients more suscep-tible to nosocomial infections. The higher rate of post-operative complications we found may also contribute

to signicantly longer hospital stays as well,19 which hasbeen suggested in past studies.23,28 However, even in thepresence of increased risk of complications, rates of mor-tality and functional recovery were similar between allage groups. An article by Ghaferi et al.11 discussed theconcept of “failure to rescue” which essentially describesmortality after postoperative complications—our nd-ings suggest that the management of postoperative com-plications in older patients has been effective in steeringthem through their postoperative course.

There are several limitations concerning the nd-ings of the presented research. First, this study was retro-spective; therefore, it is plausible that the associations wenoted may have been confounded by underlying factors

not explicitly studied, but associated with both exposuresand outcomes. Second, the study included analysis of datafrom patients in one context and may limit the generaliz-ability of the ndings. Third, although we based our de-lineation of age groups on previous research in the area,because of our treatment of age as a categorical ratherthan continuous variable, our ndings do not suggest anylinearity or highlight trends with regard to the relation

between age and outcomes following craniotomy for in-tracranial hemorrhage.

Despite these limitations, our ndings have impor-tant implications for clinical management as well asfuture research. As previously established, intracranialhemorrhage and hematoma can lead to neurological de-terioration, death, or both. Even with emergent medicaland surgical interventions, morbidity and mortality ratesare high. Our work may be of interest to clinicians andhealthcare policymakers when considering the surgicalmanagement of intracranial bleeding in older patients. Incomplement to prompt diagnosis, which can prevent mor-bidity,14 our ndings suggest that rehabilitation and longerhospital stays among older patients may yield outcomes

TABLE 2: Analysis of variance between demographic and medical covariates and outcomes* (continued)


Pt Descriptives Mean (days) p Value Mean (days) p Value

hemoglobin (g/dl) 0.006 0.029

16.5 1.0 ± 1.0 6.5 ± 4.9

INR 0.751 0.538

1.2 4.9 ± 4.1 9.0 ± 5.1

platelets (× 103 per μl) 0.876 0.532

450 3.0 ± 2.8 5.0 ± 5.7

PTT (sec) 0.446 0.268

28 5.2 ± 4.2 8.5 ± 5.6

blood loss (ml) 0.652 0.183

1000 3.6 ± 3.3 6.1 ± 7.9

transfusion 0.810 0.576

yes 4.4 ± 4.6 9.2 ± 7.5

no 4.6 ± 3.6 10.1 ± 7.8

operative time (hrs) 0.084 0.676


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T A B L E 3 : L o g i s t i c r e g r e s s i o n m o d e l s o f

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T A B L E 3 : L o g i s t i c r e g r e s s i o n m o d e l s o f

p o s t o p e r a t i v e o u t c o m e s r i s k s b y r i s k f a c

t o r a d j u s t e d f o r p o t e n t i a l c o n f o u n d e r s * ( c o n t i n u e d )

R e h a b i l i t a t i o n

R e t u r n t o B a s e l i n e

C o m

p l i c a t i o n s

M o

r t a l i t y

P t D e s c r i p t i v e s

O R

9 5 % C

I

p V a l u e

O R

9

5 % C

I

p V a l u e

O R

9 5

% C

I

p V a l u e

O R

9 5 %

C I

p V a l u e

P T T ( s e c )

< 1 8

0 . 7

6

0 . 2

3 – 2 . 8

6

0 . 6

9 2

7 . 4

7

0 . 5

4 – 1

2 1 . 1

2

0 . 1

5 7

1 8 – 2 8

r e f

r e f

r e f

r e f

r e f

r e f

> 2 8

0 . 2

7

0 . 0

8 – 0 . 8

9

0 . 0

3 2

9 . 5

5

3 . 0

1 – 9 5 . 8

0

0 . 0

0 4

b l o o d l o s s ( m l )

< 5 0 0

r e f

r e f

r e f

5 0 0 – 1 0 0 0

0 . 2

0 . 0

1 – 3 . 7

4

0 . 2

7 4

> 1 0 0 0

9 . 6

5

1 . 3

2 – 9 0 . 5

5

0 . 0

3 0

t r a n s f u s i o n

y e s

2 . 3

5

0 . 8 3

– 7 . 3

0

0 . 1

4 0

1 1 . 9

6

1 . 4

1 – 9 9 . 8

4

0 . 0

2 2

n o

r e f

r e f

r e f

r e f

r e f

r e f

o p e r a t i v e t i m e ( h r s )

< 2

r e f

r e f

r e f

≥ 2

3 . 0

6

0 . 6

2 – 1

4 . 7

4

0 . 1

6 4

* N A = n o t a p p l i c a b l e ; r e f = r e f e r e n c e .

TABLE 4: Analysis of covariance models of hospital stay

by various risk factors and predictors adjusted for

potential confounders


Pt Descr ipt ives Mean (days) p Value Mean (days) p Value

age (yrs) 80 5.9 ± 4.8 0.039 12.8 ± 10.0 0.014

diabetes mellitus

yes 8.2 ± 7.2 0.007 17.3 ± 10.9 0.008

no 4.0 ± 3.6 ref 8.9 ± 6.8 ref

coronary artery

disease

yes 7.5 ± 6.2 0.100 15.8 ± 11.4 0.102

no 4.1 ± 3.9 ref 9.2 ± 7.0 ref

hypertension

yes 12.6 ± 9.7 0.445 no 8.2 ± 5.6 ref

anticoagulation

yes 11.8 ± 9.2 0.567

no 8.7 ± 6.5 ref

hemoglobin (g/dl)

16.5 1.0 ± 1.0 0.456 6.5 ± 4.9 0.934

FIG. 1. Comparison of postoperative complication rate by categorybetween patients > 80 versus ≤ 80 years old with closed head injurywho underwent craniotomy for evacuation of hematoma. *Infection wasthe only category with a statistically signicant difference in rate of com-plications (p = 0.005). The difference in rate for cardiac complicationswas close to being signicant (p = 0.089); the rates for reoperation (p =0.950), neurological complications (p = 0.979), and other complications(p = 0.829) were not.


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243

similar to those of younger patients after craniotomy forevacuation of intracranial hemorrhage and hematoma.

In addition, our ndings may be important for end-of-life care guidelines, more broadly. Craniotomy re-mains a valid and safe technique for the management of

older patients with emergent intracranial bleeds14 and isparticularly important37 and successful in treating elderlypatients,7 but is an expensive procedure.21 It has been re-ported that the average craniotomy procedure itself costs$15,867 at high-volume centers.21 Nevertheless, takenwith ndings that have demonstrated that quality-of-lifescores remain high for elderly survivors after undergo-ing craniotomy for intracranial hemorrhage,30 our nd-ings suggest that with some added care, patients over theage of 80 may recover as successfully as younger patientsand that these costs may be warranted among this popu-lation. Our ndings also demonstrated that age greaterthan 80 years predicted the need for rehabilitation afterundergoing craniotomy. A study by Cope and Hall10 has

suggested that implementing rehabilitation programs af-ter head injury is effective, and in light of our ndings,rehabilitation programs that cater specically to olderpatients may further improve postoperative recovery andmay be warranted.

Investigators interested in postneurosurgical sequel-ae in patients over the age of 80 might consider the rela-tion between age and similar outcomes among patientsundergoing different interventions such as spinal fusions,aneurysms requiring craniotomy, and craniotomy for tu-mor resection. In addition, large prospective studies con-cerned with the relation between age and intra- and post-operative outcomes following craniotomy for intracranialhemorrhage are needed.

Conclusions

Compared with younger patients, patients over 80years of age may have a higher risk for postoperative

TABLE 5: Comparison of postoperative complications in patients stratied by age*

Age > 80 Yrs (27 pts) Age ≤ 80 Yrs (76 pts)

1 pt—UTI 1 pt—UTI (Pseudomonas)

1 pt —MI 1 pt—seizure

1 pt—pneumonia 1 pt—pneumothorax

1 pt—ND & cardiac arrhythmia 1 pt—wound infection

1 pt—PE & DVT 1 pt—malignant hypertension & reop

1 pt—atrial utter, pneumonia, & delirium 1 pt—DVT & pneumonia

1 pt—ND, reop, & pneumonia 1 pt—pneumonia & reop

1 pt—pneumonia, respiratory failure, ventilation, & deep

wound infection

1 pt—chronic recurrent hematoma & reop

1 pt—ND, bacterial pneumonia, pseudomeningocele, & car-

diac atrial arrhythmia

1 pt—malignant hypertension & reop

1 pt—ND, pneumonia, pseudomeningocele, & reop 1 pt—ventilation & reop

1 pt—left upper-extremity DVT, right lower-extremity DVT,

C. diff. infection, MI, & cardiac arrhythmia

1 pt—ND & reop

1 pt—ND & bacterial sepsis; required postop intubation &

mechanical ventilation, & reop

1 pt—coma & ventilation

1 pt—ileus, C. diff. infection, hydrocephalus, cellulitis, pneu-

monia, & reop

1 pt—ND, cardiac arrhythmia, & reop

9 pts—death 1 pt—ND, cardiac arrhythmia, & reop

1 pt—anemia requiring transfusion, seizure, & deep wound in-

fection

1 pt—coma, deep infection, intubation, ventilation, & reop

1 pt—ND, pneumonia, bacterial sepsis, intubation, & ventilation

1 pt—ND, Stenotrophomonas pneumonia, complete heart

block, seizures, hypernatremia, ARF, & mechanical ventila-

tion

1 pt—ARF, bleed requiring > 4 units of blood, reop, cardiac ar-

rest, & cardiac arrhythmia3 pts—ND

17 pts—death

* Complications occurred in 22 (81%) of the 27 patients in the > 80 age group and 39 (51%) of the 76 patients in the ≤ 80 age

group. Abbreviations: ARF = acute renal failure; C. diff. = Clostridium difcile; DVT = deep vein thrombosis; MI = myocardial infarct;

ND = neurological decit; PE = pulmonary embolus; UTI = urinary tract infection.


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D. Lau et al.


complications and signicantly longer ICU and hospitalstays after undergoing craniotomy for evacuation of hem-orrhage and hematoma. However, with rehabilitation, old-er patients are able to return to their functional baselineat rates similar to those of younger patients within a 30-day period and have no added 30-day mortality risk. Ourndings may allow for more informed decisions when

approaching the care of older patients with intracranialhemorrhage.

Disclosure

This study was funded in part by grants from the Rhodes Trust(to A.M.E.-S.) and the NIH (HSO 18537-01 to J.E.Z.). The authorsreport no conflict of interest concerning the materials or methodsused in this study or the findings specified in this paper.

Author contributions to the study and manuscript prepara-tion include the following. Conception and design: Lau, Ziewacz.Acquisition of data: Lau, Jayachandran, Huq, Zamora-Berridi,Davis. Analysis and interpretation of data: Lau. Drafting the article:Lau. Critically revising the article: all authors. Reviewed submittedversion of manuscript: all authors. Approved the final version of the

manuscript on behalf of all authors: El-Sayed. Statistical analysis:El-Sayed, Lau. Administrative/technical/material support: El-Sayed,Lau. Study supervision: Ziewacz, El-Sayed.

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Manuscript submitted March 7, 2011.Accepted July 18, 2011.Please include this information when citing this paper: pub-

lished online August 26, 2011; DOI: 10.3171/2011.7.JNS11396. Address correspondence to: Abdulrahman M. El-Sayed, B.S.,

Department of Epidemiology, Columbia University, 722 West 168thStreet, 15th Floor, New York, New York 10031. email: [email protected].

head injury craniotomi hematom

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