If the patient is young, an acute subdural hematoma is normally treated through a neurosurgical operation. Even among the young patients mortality and significant morbidity are highly common.

In older patients, the success rate of the surgery are made worse by the fact that many patients are typically using oral anticoagulant medications to treat other cardiovascular diseases. It is generally accepted that elderly patients who suffer from an acute subdural hematoma should not be treated surgically.

The Neurosurgical Department in Helsinki University Hospital has been an exception in its policy to also treat elderly patients with acute subdural hematomas surgically. Researchers have now determined how the patients’ functional status before the injury and the use of oral anticoagulant medications influence the prognosis of patients 75 years or older operated on for an acute subdural hematoma.

The study showed that no patients who had been brought to hospital unconscious, who had not been independent before the trauma, or who had used anticoagulants were alive at one year after the surgery.

– What was surprising, however, was that patients who were conscious at presentation, who were not using anticoagulants or were independent before the operation, recovered quite well. The expected lifespan of these patients was comparable to their age-matched peers, says MD, PhD Rahul Raj, one of the main authors.

– One should be careful to make to strong conclusions from such a small number of patients, but it seems that in approximately half of all cases, even elderly patients may benefit from surgery and recover to an independent life.

Included patients had an isolated acute subdural hematoma with no injuries to the brain tissue itself. This means that the results cannot be applied to patients with contusions or other intracranial injuries, whose treatment and prognosis are different, Raj points out.
 

THE DECISION SHOULD NOT BE BASED ON AGE ALONE

The study throws new light on the old assumption that surgical treatment of the elderly is not a sensible course of action:

– The decision to treat through surgery should not be based on age alone, even though this is common, Raj says.

Surgery of an acute subdural hematoma followed by intensive care and rehabilitation involve major costs and can cause significant suffering to patients and relatives.

– it is important to perform surgery on only the patients who are likely to benefit from it, Raj says.

– But how do you define a bad prognosis? If only one in ten patients recovers sufficiently to live at home, is the treatment worthwhile? If half of the treated patients die within the year, is the treatment worthwhile? This is not a medical decision.