Surgical evacuation of acute subdural hematomas in patients aged 65 years or older - a bicentric experience

Objective: The optimal treatment of elderly patients with acute subdural hematomas (aSDH) remains a subject of ongoing debate. This study aimed to analyze the clinical course of patients aged 65 years or older who underwent craniotomy for aSDH evacuation. Risk factors for poor clinical outcome have not been thoroughly reported in larger cohorts. Methods: Patients who underwent craniotomy for acute or subacute subdural hematomas between 2013 and 2022 at two tertiary neurosurgical centers were retrospectively reviewed. Primary outcome measures included in-hospital mortality and clinical outcome, with Glasgow Outcome Scale (GOS) >= 4 defined as a good outcome. Results: One-hundred-sixty patients (61.3% males) with a mean age of 75.9 +/- 6.0 years at surgery were included. In-hospital mortality was 44.4%, 26.3% were discharged with GOS >= 4. Risk factors for mortality included midline shift on pre- (p = 0.036) and postoperative computed tomography (CT) scan (p = 0.00042), preoperatively dilated pupils (p = 0.0012), preoperative GCS <= 8 (p = 0.010), and the presence of intraparenchymal hemorrhage (p = 0.025). Among patients discharged with GOS < 4, 12 of 35 (34.3%) were able to return to their homes and regained a mostly independent functional status after rehabilitation.A prognostic score comprising age >75 years, midline shift >17.5 mm, parenchymal hemorrhage and dilated pupil was established to predict mortality (AUC = 0.739, 95%CI = 0.661-0.817, p = 0.00000022) and unfavorable outcome at discharge from hospital (AUC = 0.747, 95%CI = 0.666-0.827, p = 0.000002). Conclusion: Our study demonstrated high morbidity and mortality rates following craniotomy for aSDH evacuation in elderly patients. The extent of intracranial injury emerged as the primary prognostic factor for poor clinical outcomes.