Original Article   

Journal of Neurosurgical Sciences 2022 Apr 05

DOI: 10.23736/S0390-5616.22.05648-X

Copyright © 2022 EDIZIONI MINERVA MEDICA

language: English

The role of the craniotomy size in the surgical evacuation of acute subdural hematomas in elderly patients: a retrospective multicentric study

Gianluca TREVISI ¹, Alba SCERRATI ^{2, 3}, Oriela RUSTEMI ⁴, Luca RICCIARDI ⁵, Fabio RANERI ⁴, Alberto TOMATIS ¹, Amedeo PIAZZA ⁵, Anna Maria AURICCHIO ⁶, Vito STIFANO ^{6, 7}, Michele DUGHIERO ², Pasquale DE BONIS ^{2, 3}, Annunziato MANGIOLA ^{1, 8}, Carmelo L. STURIALE ⁷ ✉

¹ Neurosurgical Unit, Ospedale Santo Spirito, Pescara, Italy; ² Department of Neurosurgery, S. Anna University Hospital, Ferrara, Italy; ³ Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy; ⁴ UOC Neurochirurgia 1, Azienda ULSS 8 Berica Ospedale San Bortolo, Vicenza, Italy; ⁵ UOC di Neurochirurgia, Azienda Ospedaliera Sant’Andrea, Dipartimento NESMOS, Sapienza, Roma, Italy; ⁶ Institute of Neurosurgery, Catholic University of the Sacred Heart, Rome, Italy; ⁷ Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome, Italy; ⁸ Department of Neurosciences, Imaging and Clinical Sciences, G. D’Annunzio University, Chieti, Italy

BACKGROUND: Elderly patients operated for an acute subdural hematoma (ASDH) frequently have a poor outcome, with a high frequency of death, vegetative status, or severe disability (Glasgow Outcome Score, GOS, 1-3). Minicraniotomy has been proposed as a minimally invasive surgical treatment to reduce the impact of surgery in the elderly population. The present study aimed to compare the influence of the size of the craniotomy on the functional outcome in patients undergoing surgical treatment for ASDH.
METHODS: We selected patients ≥70 years old admitted to 5 Italian tertiary referral neurosurgical for the treatment of a post-traumatic ASDH between January 1st 2016 and December 31st 2019. We collected demographic data, clinical data (GCS, GOS, Charlson Comorbidity Index-CCI, antiplatelet/anticoagulant therapy, neurological deficits, seizure, pupillary size, length of stay), surgical data (craniotomy size, dividing the patients into 3 groups based on the corresponding tertile, and surgery duration), radiological data (ASDH side and thickness, midline shift, other post-traumatic lesions, extent of ASDH evacuation) and we assessed the functional outcome at hospital discharge and 6-month follow-up considering GOS=1-3 as a poor outcome. ANOVA and Chi-squared tests and logistic regression models were used to assess differences in and associations between clinicalradiological characteristics and functional outcomes.
RESULTS: We included 136 patients (76 males) with a mean age of 78±6 years. Forty-five patients underwent a small craniotomy, 47 a medium size, and 44 a large craniotomy. Among the different craniotomy size groups, there were no differences in gender, anticoagulant/antithrombotic therapy, CCI, side of ASDH, ASDH thickness, preoperative GCS, focal deficits, seizures, and presence of other posttraumatic lesions. Patients undergoing small craniotomies were older than patients undergoing medium-large craniotomies; ASDH treated with medium size craniotomy were thinner than the others; patients undergoing large craniotomies showed greater midline shift and a higher rate of anisocoria. The three groups did not differ for functional outcome and postoperative midline shift, but the length of surgery and the rate of >50% of ASDH evacuation were lower in the small craniotomy group.
CONCLUSIONS: A small craniotomy was not inferior to larger craniotomies in determining functional outcomes in the treatment of ASDH in the elderly.

KEY WORDS: Acute subdural hematoma; Antithrombotic drugs; Comorbidity; Elderly; Minicraniotomy; Surgery; Traumatic brain injury