Head injury in elderly

Ext. อรั�ฐา ตั�นตัโชตัExt. ศุ ภศุษฐ� จิรัวิญญู�

Ext. พรัปวิ�ณ์� พฤกษ�ป�ตัก ลExt. ก�ญจิน� ศุรัโสภณ์า

Prevalence and magnitude

• Elderly : older than 65 y• 15 % of elderly have head injury• Elderly do much less well recover than

younger ones• Can be complicated by – ICH – Chronic SDH

• Trauma of the fifth is a leading cause of death

Mild and moderate head injury

• Outcome will be more worst in the older patient– Esp. in pt. older than 55 y• In mild head injury 5 of 42 pt. over 80 was dead1 (7

fold compare to youngster)• 19 % of pt. develop ICH (one half of these died) 2

• Elderly pt. never return to their “ pre head injury status ”

1,2 : Amacher and bybee

Severe head injury

• 135 pt. which >65 y– who were in coma than 6 hr• Fewer than 5% achieve a good outcome or moderate

disabilility3

– If coma persist than 24 hr.• Chance of survival is minimal4

3,4 Jennett et al

Traumatic intracranial hematoma

• Occur 2-3 times as great in an elderly• Prognosis is very bad if traumatic ICH

superimpose on a coma producing head injury5

• 66 pt. over age 65 y who under go craniotomy– 61 % died– 9% vegetative stage– 30% survive with moderate disability or good

outcome6

5 : jenett et al6 : jamjoom et al

Long term consequence

• Follow 70 pt. with head injury (50-75 y) 7

– 21% demented– 53% diffuse or moderate cognitive impairment– 24% normal or slighty impair function

• Remark : outcome was similar in any group of head injury

7 : Mazzucchi et al

Subdural hematoma

• Subdural space is potential space between inner surface of dura mater and arachaniod

• SDH can be classified in– acute– Subacute– Chronic

Subdural hematoma

Chronic SDH

• 1.7 per 100,000 (greatest in 80s)• Present at least 2 wk• Hematoma will be– Fluid– Sump oil consistency to brownish yellow watery

fluid– Fresh blood indicate recent bleeding occur in

original liquefied hematoma

Chronic SDH

• Pathogenesis– Low intracranial tension– Increase mobility of brain– Brain separate from inner surface of skull,

Thus bridging vein may be stretched

Chronic SDH (cont.)

• Diffuse or focal brain atrophy – Age > 40 y– alcoholism

• Arachanoid cyst (account for 1/3)• Following craniotomy• After ventricular shunt

Chronic SDH (cont.)

• After lumbar puncture• After lumbar drains• Deposition of metastasis tumor

Chronic SDH (cont.)

• Risk– Disturbance of coagulation• ASA• Anticoagulant drug• Coagulopathy

– Alcoholism

Enlarge of hematoma

• Hematoma liquidfied and slowly enlarge• Brain shifting• ICP frequently remain low or normal• The thoery

Clinical feature

• Great mimic (dementia, CVA, TIA)• Slowly progressive with Insidious onset • Early symptom– Headache– Lethargy– Intellectual dulling– Confusion– Unsteadiness gait

Clinical feature (cont.)

• When hematoma increase in size – Consciousness Deteriorate– Focal hemispheric deficit• Hemiparesis• Dysphasia

• Eventually– Coma– Disturb pupil and EOM

Clinical feature

• Chance of recovery after surgery related to consciousness level when Dx– Bender classification 4 class• 1. fully alert• 2. drowsy with or without focal sign• 3. Very drowsy/stupor with or without focal sign• 4. coma with or without sign of herniation

Diagnosis

• CT non-contrast• MRI• Angiography• Isotope scaning

Diagnosis

• CT scan– First week SDH is hyperdense– 2nd – 3rd wk SDH become isodense– > 3rd wk SDH become hypodense

Acute (Hyperdense)

Subacute (Isodense)

Chronic (Hypodense)

Diagnosis

• MRI– When diagnosis is in doubt– Esp. in subacute(CT isodense) MRI hyperintense on T1/T2

MRI

T1 T2

MRI vs CT

Treatment

• Simple method of surgical treatment are satisfy for almost all SDH– Burr hole– Twist drill evacuation

Conservative/medical method

• Conservative– Small chronic SDH serial scan• Resorp• remain unchanged in size

Conservative/medical method

• Medical method– MannitolOnly use in selected case

8,9 Suzuki and takaku

Burr hole drainage

• Most widely used for chronic SDH

Twist drill drainage

• Superior to Burr hole drainage alone– Due to under RA

• Disadvantage– Provoke traumatic to brain surface without realize– Limited efficacy

Internal shunt

• From subdural space to– Pleural– Peritoneal cavity

• Widely use in infant

Craniotomy

• Effective same as Burr hole drainage• Indicated in– Repeated reaccumulation– Presence of solid and organizing clot– Loculated or superimpose collection

Craniotomy

Endoscopic technique

• Replace craniotomy• Flexible endoscope with micro scissor

Postoperative care

• Keep pt. flat / 20 degree head down for first few days

• Maintain hydration• Temporary use of high dose steriod• No good for immobilization• Drainage shouldn’t be left more than 48 hr.• Prophylactic ATB• Prophylactic anticonvulsant

Result

• Good result,but quite not good as expect– Elderly– Level of conscious when diagnose

• Complication– Reaccumulation 25%– Pneumocephalus 5%(Mount Fuji sign)– Intracerebral hemorrhage 1~-5%– Subdural / extradural hemorrhage

Result

• Subdural empyema 2%• Extracranial complication (elderly)– Thromboembolism– Chest infection