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J Neurosurg 116:234–245, 2012 234 J Neurosurg / Volume 116 / January 2012 I NTRACRANIAL hemorrhage and/or hematoma due to trauma are serious conditions that often require emergent 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 interventions such as hemostatic therapy (reversal of anticoagulant therapy and coagulative induction) and pharmaceutical management of intracranial pressure 27 fail to treat intra- cranial hemorrhage efficiently or if the hematoma is too Postoperative outcomes following closed head injury and craniotomy for evacuation of hematoma in patients older 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 F ARHAN 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 1 University 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 4 College of Physicians and Surgeons, Columbia University, New York, New York; 6 Center for Surgery and Public Health, Harvard School of Public Health; and 7 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 surgical treatment for these conditions. In this study, the authors examined the relation between patient age over 80 years and postoperative 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 identified. 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. Older age was associated with longer length of hospital stay (p = 0.014), a higher rate of complications (OR 5.74, 95% CI 1.29–25.34), and a higher likelihood of requiring rehabilitation (OR 3.28, 95% CI 1.13–9.74). However, there were no statistically significant differences between the age groups in 30-day mortality or ability to recover to functional baseline status. Conclusions. The findings suggest that in comparison with younger patients, patients over 80 years of age may be 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 between older age, perioperative parameters, and postoperative outcomes following craniotomy for intracranial hemorrhage are needed. Nonetheless, the findings of this study may allow for more informed decisions with respect to the care of elderly 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 an interview with the authors.

Postoperative outcomes following closed head …neurosurgery.med.wayne.edu/pdf/lau_d_2012;_j_neurosurg.pdf · adult patients undergoing craniotomy for evacuation of ... requiring

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J Neurosurg 116:234–245, 2012

234 J Neurosurg / Volume 116 / January 2012

IntracranIal hemorrhage and/or hematoma due to trauma are serious conditions that often require emergent 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 interventions such as hemostatic therapy (reversal of anticoagulant therapy and coagulative induction) and pharmaceutical management of intracranial pressure27 fail to treat intra-cranial hemorrhage efficiently or if the hematoma is too

Postoperative outcomes following closed head injury and craniotomy for evacuation of hematoma in patients older than 80 years

Clinical articleDarryl 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 5Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan; 2Department of Public Health, Oxford University, Oxford, United Kingdom; 3Department of Epidemiology and 4College of Physicians and Surgeons, Columbia University, New York, New York; 6Center for Surgery and Public Health, Harvard School of Public Health; and 7Department 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 surgical treatment for these conditions. In this study, the authors examined the relation between patient age over 80 years and postoperative 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 identified. 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. Older age was associated with longer length of hospital stay (p = 0.014), a higher rate of complications (OR 5.74, 95% CI 1.29–25.34), and a higher likelihood of requiring rehabilitation (OR 3.28, 95% CI 1.13–9.74). However, there were no statistically significant differences between the age groups in 30-day mortality or ability to recover to functional baseline status.

Conclusions. The findings suggest that in comparison with younger patients, patients over 80 years of age may be 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 between older age, perioperative parameters, and postoperative outcomes following craniotomy for intracranial hemorrhage are needed. Nonetheless, the findings of this study may allow for more informed decisions with respect to the care of elderly 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 an interview with the authors.

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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 with intracranial hemorrhage remain high; recovery from such aggressive treatment can be prolonged, and failure to return to baseline is common. Studies from the 1980s report 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 had dropped to between 25% and 58%.8,20,35 Previous neuro-surgical studies have also demonstrated age-dependent morbidity and mortality rates, with younger patients faring better than older patients undergoing craniotomy for intracranial bleeding.13,35 However, current advances in imaging, rapid diagnostics, medical management of hemodynamic properties, and surgical techniques have improved patient outcomes,36 and a further decrease in mortality associated with treatment for intracranial bleeding has been demonstrated; in 2008, postoperative mortality associated with craniotomy for evacuation of acute subdural and epidural hematoma ranged from 22% to 41%.17,33,34

It is plausible that this overall decrease in mortality may also be reflected by improved survival among older patients. 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 higher morbidity and mortality rates than younger patients fol-lowing evacuation of intracranial hematoma and/or hem-orrhage? Because older age is a risk factor for intracranial hemorrhage after head trauma, this question is of increas-ing importance, as the geriatric population grows in size and the costs and efficacy 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 treatment of intracranial hemorrhage in patients over the age of 80 years may allow physicians to make better-informed de-cisions about treatment options for this population. As there is a paucity of research that has assessed outcomes and morbidity following neurosurgical interventions among these patients relative to younger patients, we as-sessed the relation between older age and 30-day post-operative outcomes following craniotomy for evacuation of intracranial hemorrhage and hematoma due to closed head 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 significant rise in the number of patients over the age of 80 in the US in the past several decades.38 Also, end-of-life decisions may be more relevant in this population than in patients between 65 and 80 years of age, who would be included in our exposure group if traditional geriatric cutoffs were used.

Methods and MaterialsData

Electronic medical records, including patient records and intraoperative anesthesia records, at the University of Michigan Health System were queried to identify all

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

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. Cranial nerve deficits potentially resulting from intracranial hem-orrhage were noted as well. In addition, presentation GCS scores were recorded. Computed tomography scans were analyzed to determine the type of hematoma, maximum thickness of the hematoma, and degree of midline shift of the brain. Thickness and midline shift were included in our data and reported in millimeters.

Preoperative laboratory blood values were also re-corded: including serum creatinine, hemoglobin, inter-national normalized ratio of blood coagulation, platelet count, and partial thromboplastin time. Intraoperative parameters of interest included estimated blood loss (not including the volume of blood from the hematoma), op-erative time (defined as first 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 transfer to the general floor (ICU stay immediately after surgery was counted as Day 1), total length of stay in the hospital (date of admission to date of discharge), requirement for rehabilitation, and return to baseline status (defined as re-turn of the patient’s normal physiological and mental sta-tus before the incident of intracranial bleeding). Return to baseline was measured subjectively by the associated neurosurgical care team based on patient self-report.

Complications (which include any neurological defi-cit detected after surgery compared with findings on pre-operative examination, whether transient or permanent, as well as any perioperative or postoperative events that required medical or surgical intervention up to 30 days af-ter surgery) and 30-day postoperative mortality data were collected. 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 (deficit, hydro-cephalus, pseudomeningocele, seizure, and coma), other complications (renal failure, bleeding/anemia, pulmonary embolus, 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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236 J Neurosurg / Volume 116 / January 2012

Sciences Institutional Review Board of the University of Michigan.

AnalysisFirst, univariate statistics were used to describe our

sample. Second, we employed bivariate chi-square tests to identify significant associations between covariates of interest and categorical outcomes (rehabilitation, return to baseline, complications, and mortality), along with ANOVA to assess significant associations between ex-planatory covariates of interest and continuous outcomes (ICU and total hospital stay).

Third, multivariable logistic regression models of likelihood for rehabilitation, return to baseline, 30-day mortality, and complication risk were fit and were adjust-ed for potential confounders. We adjusted for covariates found to be significantly associated with postoperative outcomes in bivariate chi-square tests. Fourth, ANCOVA models of ICU stay and hospital stay by various covari-ates were fit and were adjusted for covariates found to be significantly associated with the outcomes of interest by ANOVA.

Further analysis of the distribution of complications by type (cardiac, infection, reoperation, neurological, and other) 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 complication category. Patients with more than 1 type of complication were counted as 1 patient in each of the specific com-plication categories. Chi-square tests were used to assess the statistical significance of age-dependent differences in complication risk.

Results with probability values less than 0.050 were considered significant. This study was powered to detect a minimum odds ratio of 1.92 for patients older than 80 years relative to those 80 years or younger with 80% pow-er and a = 0.05. Posthoc power analysis was run using NCSS Power Analysis and Sample Size. All other statisti-cal analyses were run using SAS 9.2 (SAS Institute).

ResultsTable 1 shows demographic characteristics and the

results of bivariate chi-square tests between covariates and 30-day complications and mortality. Overall, 61 pa-tients had complications (a complication rate of 59.2%). There were no reported intraoperative complications (all complications were postoperative). Difference in age was significantly associated with complications (p = 0.012). Patients older than 80 years had a complication rate of 81.5%, which was higher than those aged 50–80 years and those younger than 50 years (58.3% and 45.0%, re-spectively). The overall mortality rate after craniotomy was 25.2%. Although patients older than 80 years had slightly higher absolute rates of mortality, there was no significant difference between the 3 age groups. Table 1 also describes covariates that are associated with return to baseline and need for rehabilitation. Age was not asso-ciated with significant differences in return to baseline (p = 0.816). Of 103 patients, 36.4% required rehabilitation.

Age was significantly associated with requirement for re-habilitation (p = 0.037). In the groups of patients younger than 50 years and patients between 50–79 years, 25.0% required rehabilitation; this percentage was significantly lower than in the group of patients who were older than 80 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 among patients in our sample. The mean postoperative ICU stay was 4.6 days in the total group (103 patients). Age was not associated with a significant difference in postopera-tive ICU stay (p = 0.137). The mean total hospital stay was 10.2 days in the total group. Older age was associated with longer hospital stay (p = 0.030). The mean duration of stay for patients younger than 50 years was 7.8 days, for those aged 50–80 years it was 10.0 days, and for those over 80 years old it was 12.8 days.

Table 3 shows multivariable models of postoperative outcomes risk by age, adjusted for potential confounders. Age greater than 80 years was significantly associated with increased risk of postoperative complications after adjusting 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 with significant risk for mortality. In addition, we found that patients older than 80 years were more likely to require rehabilitation compared with patients younger than 50 (OR 3.28, 95% CI 1.13–9.74). Both groups of patients 50 and older returned to baseline at a rate similar to the rate observed in patients younger than 50 years.

Table 4 shows the results of ANCOVA models of postoperative ICU stay and hospital stay, adjusted for potential confounders. Both ICU and hospital stays were significantly 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 specific postoperative complica-tions in patients over 80 years old and patients 80 years or younger. The most common complication among the older group was infection; 37.0% of the 27 patients older than 80 years had at least 1 infection (Clostridium diffi-cile causing pseudomembranous colitis, pneumonia, cel-lulitis, or sepsis).

Age-dependent differences in risk for specific com-plications are shown in Fig. 1. Infection was the only category with statistically significant 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 of age or younger was 10.5%. There were no other statisti-cally significant differences in complication rate by age: cardiac (p = 0.089), reoperation (p = 0.950), neurological (p = 0.979), and other (p = 0.829).

DiscussionIn this study about the relation between age and

postoperative outcomes following closed head injury and emergent craniotomy for evacuation of hematoma, we found that patients over 80 years of age had significantly

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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† MortalityPt 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 <50 40 (38.8) 10 (25.0) 22 (55.0) 18 (45.0) 9 (22.5) 50–79 36 (35.0) 12 (33.3) 20 (55.6) 21 (58.3) 8 (22.2) >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 <20 7 (8.0) 3 (42.9) 4 (57.1) 2 (28.6) 2 (28.6) 20–25 34 (38.6) 12 (35.3) 20 (58.8) 17 (50.0) 9 (26.5) >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 deficit 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 <0.001 0.003 0.004 3–8 23 (22.3) 10 (43.5) 7 (30.4) 17 (73.9) 10 (43.5) 9–12 32 (31.1) 14 (43.8) 10 (31.3) 24 (75.0) 11 (34.4) 13–15 48 (46.6) 12 (25.0) 38 (79.2) 20 (41.7) 5 (10.4)type of hematoma 0.333 0.023 0.268 0.472 intraparenchymal 36 (35.0) 16 (44.4) 14 (38.9) 24 (66.7) 9 (25.0) subdural 43 (41.8) 13 (30.2) 23 (53.5) 26 (60.5) 13 (30.2) epidural 24 (23.3) 7 (29.2) 18 (75.0) 11 (45.8) 4 (16.7)maximum hematoma thickness (mm) 0.408 0.192 0.284 0.216 <10 13 (14.3) 5 (38.5) 6 (46.2) 10 (76.9) 6 (46.2) 10–25 44 (48.4) 13 (29.6) 28 (63.6) 23 (52.3) 10 (22.7) >25 34 (37.4) 15 (44.1) 15 (44.1) 20 (58.8) 8 (23.5)midline shift of brain (mm) 0.783 0.021 0.334 0.017 <5 38 (40.0) 13 (34.2) 27 (71.1) 19 (50.0) 4 (10.5) 5–10 33 (34.7) 11 (33.3) 14 (42.4) 22 (66.7) 12 (36.4) >10 24 (25.3) 10 (41.7) 10 (41.7) 15 (62.5) 9 (37.5)serum creatinine (mg/dl) 0.562 0.118 0.023 0.202 <0.5 2 (2.2) 0 (0.0) 2 (100.0) 2 (100.0) 0 (0.0) 0.5–1.4 82 (89.1) 27 (32.9) 44 (53.7) 45 (54.9) 20 (24.4) >1.4 8 (8.7) 2 (25.0) 2 (25.0) 8 (100.0) 4 (50.0)

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higher rates of postoperative complications, had signifi-cantly longer hospital stays, and required rehabilitation more frequently than patients 80 years old or younger. However, the rate of mortality and return to baseline among this population was similar to what was found in younger patients. Taken together, our findings suggest that, compared with younger patients, older patients may be similarly able to return to functional baseline, but may require added postoperative medical attention in the form of rehabilitation and longer hospital stays.

Similar likelihoods of return to functional baseline and nonsignificant differences in the rate and risk of mortality were unexpected, as past studies have demon-strated worse outcomes and higher mortality rates fol-lowing neurotrauma in older patients than in younger patients.3,12,13 Our findings suggest that advancements in the management of intracranial hematomas, particularly postoperative ICU care and rehabilitation, may mitigate the increased risk of death traditionally associated with older age in past studies. There is some literature that has

supported these findings. 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 that of 354 patients, those older than 65 years of age had rates of 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 metric of frailty32 and other preoperative parameters22 have been shown 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 hemorrhages had favorable clinical outcomes, and concluded that age should not preclude treatment.4

Age above 80 years was a significant predictor of complications after emergent craniotomy for evacuation of hematoma in our study. In particular, patients older than 80 years had significantly 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† MortalityPt 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 <13.5 62 (63.3) 25 (40.32) 29 (46.8) 40 (64.5) 18 (29.0) 13.5–16.5 33 (33.7) 10 (30.3) 23 (69.7) 16 (48.5) 6 (18.2) >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 <0.8 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0.8–1.2 76 (83.5) 27 (35.3) 39 (51.3) 47 (61.8) 20 (26.3) >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 <100 36 (36.4) 8 (22.2) 15 (41.7) 27 (75.0) 15 (41.7) 100–450 61 (61.6) 27 (44.3) 38 (62.3) 31 (50.8) 9 (14.8) >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 <18 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 18–28 65 (72.2) 25 (38.5) 35 (53.9) 39 (60.0) 13 (20.0) >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 <0.001 <500 76 (73.8) 26 (34.21) 42 (55.3) 43 (56.6) 15 (19.7) 500–1000 15 (14.6) 8 (53.3) 10 (66.7) 8 (53.3) 2 (13.3) >1000 12 (11.7) 2 (16.7) 3 (25.0) 10 (83.3) 9 (75.0)transfusion 0.497 0.125 0.006 0.001 yes 33 (32.0) 10 (30.3) 14 (42.4) 26 (78.8) 15 (45.5) no 70 (68.0) 26 (37.1) 41 (58.6) 35 (50.0) 11 (15.7)operative time (hrs) 0.306 0.502 0.876 0.047 <2 53 (51.5) 21 (39.6) 30 (56.6) 31 (58.5) 9 (17.0) ≥2 50 (48.5) 15 (30.0) 25 (50.0) 30 (60.0) 17 (34.0)

* Values in parentheses are percentages. Abbreviations: INR = international normalized ratio; Pt = Patient; PTT = partial thromboplastin time. † Patients with more than 1 type of complication were counted as 1 patient in each of the specific complication categories.

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

ICU Stay Total Hospital StayPt Descriptives Mean (days) p Value Mean (days) p Value

total 4.6 ± 4.2 10.2 ± 7.6age (yrs) 0.137 0.030 <50 3.9 ± 4.5 7.8 ± 5.7 50–80 3.9 ± 3.5 10.0 ± 7.0 >80 5.9 ± 4.8 12.8 ± 10.0sex 0.964 0.596 M 4.5 ± 4.7 9.5 ± 7.7 F 4.4 ± 3.7 10.3 ± 7.7BMI 0.573 0.083 <20 6.1 ± 5.1 8.9 ± 6.6 20–25 4.2 ± 4.8 8.1 ± 7.0 >25 4.6 ± 4.2 12.1 ± 8.7diabetes mellitus <0.001 <0.001 yes 8.2 ± 7.2 17.3 ± 10.9 no 4.0 ± 3.6 8.9 ± 6.8coronary artery disease 0.017 <0.001 yes 7.5 ± 6.2 15.8 ± 11.4 no 4.1 ± 3.9 9.2 ± 7.0hypertension 0.428 0.005 yes 4.9 ± 5.6 12.6 ± 9.7 no 4.2 ± 3.3 8.2 ± 5.6anticoagulation 0.202 0.048 yes 4.0 ± 4.0 11.8 ± 9.2 no 5.2 ± 4.7 8.7 ± 6.5cranial nerve deficit 0.650 0.730 yes 5.0 ± 6.4 9.1 ± 7.2 no 4.4 ± 4.0 9.9 ± 7.8GCS score 0.719 0.489 3–8 4.6 ± 3.6 8.3 ± 5.6 9–12 4.9 ± 4.8 9.8 ± 6.8 13–15 4.1 ± 4.3 10.7 ± 9.0type of hematoma 0.734 0.630 intraparenchymal 4.6 ± 4.7 10.5 ± 7.8 subdural 4.6 ± 3.9 10.0 ± 7.4 epidural 3.8 ± 4.5 8.6 ± 8.3maximal hematoma thickness (mm) 0.356 0.752 <10 5.8 ± 5.4 10.7 ± 10.4 10–25 4.1 ± 3.8 9.5 ± 6.8 >25 4.0 ± 3.6 8.8 ± 7.3midline shift of brain (mm) 0.210 0.326 <5 5.4 ± 5.4 11.1 ± 8.7 5–10 4.2 ± 3.4 9.3 ± 6.6 >10 3.5 ± 3.5 8.1 ± 7.0serum creatinine (mg/dl) 0.242 0.793 <0.5 9.5 ± 0.7 13.5 ± 0.7 0.5–1.4 4.3 ± 4.4 9.7 ± 7.9 >1.4 5.0 ± 4.8 10.4 ± 9.9

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240 J Neurosurg / Volume 116 / January 2012

This was expected and may be attributed to a less robust immune system and consequent higher risk for infection in older patients.18,29 Moreover, the natural symbiotic flora may be less able to defend against pathogenic bacteria that colonize the intestines as the gastrointestinal tract changes 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 significantly longer hospital stays as well,19 which has been suggested in past studies.23,28 However, even in the presence of increased risk of complications, rates of mor-tality and functional recovery were similar between all age groups. An article by Ghaferi et al.11 discussed the concept of “failure to rescue” which essentially describes mortality after postoperative complications—our find-ings suggest that the management of postoperative com-plications in older patients has been effective in steering them through their postoperative course.

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

not explicitly studied, but associated with both exposures and outcomes. Second, the study included analysis of data from patients in one context and may limit the generaliz-ability of the findings. 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 rather than continuous variable, our findings do not suggest any linearity or highlight trends with regard to the relation between age and outcomes following craniotomy for in-tracranial hemorrhage.

Despite these limitations, our findings have impor-tant implications for clinical management as well as future research. As previously established, intracranial hemorrhage and hematoma can lead to neurological de-terioration, death, or both. Even with emergent medical and surgical interventions, morbidity and mortality rates are high. Our work may be of interest to clinicians and healthcare policymakers when considering the surgical management of intracranial bleeding in older patients. In complement to prompt diagnosis, which can prevent mor-bidity,14 our findings suggest that rehabilitation and longer hospital stays among older patients may yield outcomes

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

ICU Stay Total Hospital StayPt Descriptives Mean (days) p Value Mean (days) p Value

hemoglobin (g/dl) 0.006 0.029 <13.5 5.6 ± 4.8 11.7 ± 8.5 13.5–16.5 3.0 ± 2.7 7.5 ± 5.5 >16.5 1.0 ± 1.0 6.5 ± 4.9

INR 0.751 0.538 <0.8 0.8–1.2 4.5 ± 4.5 10.4 ± 8.4 >1.2 4.9 ± 4.1 9.0 ± 5.1platelets (× 103 per μl) 0.876 0.532 <100 4.6 ± 3.8 9.5 ± 7.1 100–450 4.5 ± 4.7 10.6 ± 8.2 >450 3.0 ± 2.8 5.0 ± 5.7PTT (sec) 0.446 0.268 <18 18–28 4.4 ± 4.5 10.7 ± 8.6 >28 5.2 ± 4.2 8.5 ± 5.6blood loss (ml) 0.652 0.183 <500 4.4 ± 4.5 10.2 ± 8.0 500–1000 5.1 ± 4.2 11.1 ± 5.0 >1000 3.6 ± 3.3 6.1 ± 7.9transfusion 0.810 0.576 yes 4.4 ± 4.6 9.2 ± 7.5 no 4.6 ± 3.6 10.1 ± 7.8operative time (hrs) 0.084 0.676 <2 3.7 ± 4.0 9.5 ± 8.2 ≥2 5.2 ± 4.5 10.2 ± 7.2

* Mean values are given with SDs.

J Neurosurg / Volume 116 / January 2012

Age and craniotomy following intracranial hemorrhage

241

TAB

LE 3

: Log

istic

regr

essi

on m

odel

s of

pos

tope

rativ

e ou

tcom

es ri

sks

by ri

sk fa

ctor

adj

uste

d fo

r pot

entia

l con

foun

ders

*

Reha

bilita

tion

Retur

n to B

aseli

neCo

mplic

ation

sM

orta

lityPt

Des

cript

ives

OR95

% C

Ip V

alue

OR95

% C

Ip V

alue

OR95

% C

Ip V

alue

OR95

% C

Ip V

alue

age (

yrs)

<5

0re

fre

fre

fre

fre

fre

fre

fre

fre

fre

fre

fre

f

50–8

01.4

90.

51–4

.180.4

521.0

10.

33–3

.43

0.987

2.03

0.71–

6.32

0.22

51.1

90.

52–2

1.77

0.23

8

>80

3.28

1.13–

9.74

0.033

1.12

0.29

–4.3

40.

870

5.74

1.29–

25.3

40.0

281.1

60.1

9–7.9

10.

881

sex

M

8.00

2.34

–41.3

20.0

06

Fre

fre

fre

fco

rona

ry ar

tery d

iseas

e

yes

4.31

0.32

–54.3

70.

225

no

ref

ref

ref

antic

oagu

lation

ye

s0.

820.

24–2

.910.7

55

nore

fre

fre

fcr

anial

nerv

e defi

cit

yes

0.24

0.04–

1.41

0.117

no

ref

ref

ref

GCS

scor

e

3–8

0.09

0.03–

0.38

<0.0

017.4

82.4

5–23

.11<0

.001

23.6

42.4

0–22

8.34

0.006

9–

120.1

20.0

3–0.

540.0

063.1

40.

82–1

1.44

0.092

2.85

0.3–

30.6

0.38

7

13–1

5re

fre

fre

fre

fre

fre

fre

fre

fre

ftyp

e of h

emato

ma

intra

pare

nchy

mal

0.21

0.04–

1.01

0.066

su

bdur

al0.

320.0

7–1.5

30.1

46

epidu

ral

ref

ref

ref

midli

ne sh

ift of

brain

(mm)

<5

ref

ref

ref

ref

ref

ref

5–

100.6

70.

2–2.1

40.4

941.1

40.

22–6

.25

0.87

7

>10

0.35

0.09–

1.37

0.139

3.52

1.41–

31.18

0.026

seru

m cr

eatin

ine (m

g/dl)

<0

.51.2

00.4

1–3.

660.7

56

0.5–

1.4re

fre

fre

f

>1.4

NANA

NApla

telets

(× 10

3 per

μl)

<1

000.

250.0

7–0.9

10.0

282.

830.

52–1

6.83

0.25

2

100–

450

ref

ref

ref

ref

ref

ref

>

450

NANA

NA5.

230.1

3–25

3.71

0.403

(con

tinue

d)

D. Lau et al.

242 J Neurosurg / Volume 116 / January 2012

TAB

LE 3

: Log

istic

regr

essi

on m

odel

s of

pos

tope

rativ

e ou

tcom

es ri

sks

by ri

sk fa

ctor

adj

uste

d fo

r pot

entia

l con

foun

ders

* (co

ntin

ued)

Reha

bilita

tion

Retur

n to B

aseli

neCo

mplic

ation

sM

orta

lityPt

Des

cript

ives

OR95

% C

Ip V

alue

OR95

% C

Ip V

alue

OR95

% C

Ip V

alue

OR95

% C

Ip V

alue

PTT

(sec)

<1

80.7

60.

23–2

.86

0.692

7.47

0.54

–121

.120.1

57

18–2

8re

fre

fre

fre

fre

fre

f

>28

0.27

0.08–

0.89

0.032

9.55

3.01

–95.

800.0

04blo

od lo

ss (m

l)

<500

ref

ref

ref

50

0–10

000.

20.0

1–3.7

40.

274

>1

000

9.65

1.32–

90.5

50.0

30tra

nsfu

sion

ye

s2.

350.

83–7

.30

0.140

11.9

61.4

1–99

.84

0.022

no

ref

ref

ref

ref

ref

ref

oper

ative

time (

hrs)

<

2 re

fre

fre

f

≥2

3.06

0.62–

14.74

0.164

* NA

= no

t app

licab

le; re

f = re

feren

ce.

TABLE 4: Analysis of covariance models of hospital stay by various risk factors and predictors adjusted for potential confounders

ICU Stay Total Hospital StayPt Descriptives Mean (days) p Value Mean (days) p Value

age (yrs) <50 3.9 ± 4.5 ref 7.8 ± 5.7 ref 50–79 3.9 ± 3.5 0.985 10.0 ± 7.0 0.177 >80 5.9 ± 4.8 0.039 12.8 ± 10.0 0.014diabetes mellitus yes 8.2 ± 7.2 0.007 17.3 ± 10.9 0.008 no 4.0 ± 3.6 ref 8.9 ± 6.8 refcoronary 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 refhypertension yes 12.6 ± 9.7 0.445 no 8.2 ± 5.6 refanticoagulation yes 11.8 ± 9.2 0.567 no 8.7 ± 6.5 refhemoglobin (g/dl) <13.5 5.6 ± 4.8 0.043 11.7 ± 8.5 0.210 13.5–16.5 3.0 ± 2.7 ref 7.5 ± 5.5 ref >16.5 1.0 ± 1.0 0.456 6.5 ± 4.9 0.934

Fig. 1. Comparison of postoperative complication rate by category between patients > 80 versus ≤ 80 years old with closed head injury who underwent craniotomy for evacuation of hematoma. *Infection was the only category with a statistically significant difference in rate of com-plications (p = 0.005). The difference in rate for cardiac complications was close to being significant (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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Age and craniotomy following intracranial hemorrhage

243

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

In addition, our findings 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 is particularly important37 and successful in treating elderly patients,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, taken with findings that have demonstrated that quality-of-life scores remain high for elderly survivors after undergo-ing craniotomy for intracranial hemorrhage,30 our find-ings suggest that with some added care, patients over the age of 80 may recover as successfully as younger patients and that these costs may be warranted among this popu-lation. Our findings also demonstrated that age greater than 80 years predicted the need for rehabilitation after undergoing craniotomy. A study by Cope and Hall10 has

suggested that implementing rehabilitation programs af-ter head injury is effective, and in light of our findings, rehabilitation programs that cater specifically to older patients may further improve postoperative recovery and may 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 patients undergoing 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 intracranial hemorrhage are needed.

ConclusionsCompared with younger patients, patients over 80

years of age may have a higher risk for postoperative

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

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

1 pt—UTI 1 pt—UTI (Pseudomonas)1 pt —MI 1 pt—seizure1 pt—pneumonia 1 pt—pneumothorax 1 pt—ND & cardiac arrhythmia 1 pt—wound infection1 pt—PE & DVT 1 pt—malignant hypertension & reop1 pt—atrial flutter, pneumonia, & delirium 1 pt—DVT & pneumonia1 pt—ND, reop, & pneumonia 1 pt—pneumonia & reop1 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 & reop1 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, & reop1 pt—anemia requiring transfusion, seizure, & deep wound in- fection1 pt—coma, deep infection, intubation, ventilation, & reop1 pt—ND, pneumonia, bacterial sepsis, intubation, & ventilation1 pt—ND, Stenotrophomonas pneumonia, complete heart block, seizures, hypernatremia, ARF, & mechanical ventila- tion1 pt—ARF, bleed requiring > 4 units of blood, reop, cardiac ar- rest, & cardiac arrhythmia 3 pts—ND17 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 difficile; DVT = deep vein thrombosis; MI = myocardial infarct; ND = neurological deficit; PE = pulmonary embolus; UTI = urinary tract infection.

D. Lau et al.

244 J Neurosurg / Volume 116 / January 2012

complications and significantly longer ICU and hospital stays after undergoing craniotomy for evacuation of hem-orrhage and hematoma. However, with rehabilitation, old-er patients are able to return to their functional baseline at rates similar to those of younger patients within a 30-day period and have no added 30-day mortality risk. Our findings may allow for more informed decisions when approaching the care of older patients with intracranial hemorrhage.

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 authors report no conflict of interest concerning the materials or methods used 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, Da vis. Analysis and interpretation of data: Lau. Drafting the article: Lau. Critically revising the article: all authors. Reviewed submitted version 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.,

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