Head Injury in the Elderly
Dr Simon John
Outline
Head Injury in the Elderly
• Two cases
• Similar GCS and ISS
• Both required intubation early
• Both treated with “curative” intent
• One excellent outcome and one mortality
• Look at the literature for outcomes in the elderly head injured / trauma patient
Outline
• Scoring tools and classifications
– GCS
– ISS
– GOS
• Head injuries
• Literature
GCS and head injury classification
• GCS
• Eyes 1 - 4
• Voice 1 - 5
• Motor 1 - 6
• Total 3 - 15
– Mild head injury 14 - 15
– Moderate head injury 9 - 13
– Severe head injury < 8
ISS - Trauma
• Injury Severity Score
– anatomical scoring system
– overall score for patients with multiple injuries
– six body regions – head, face, chest, abdomen, extremities (pelvis), external
– each injury assigned a score of 1-6
– highest score in each region used
– The 3 most severely injured body regions have their score squared and added together = ISS score
GOS
• Glasgow Outcome Scale
1: death
2: persistent vegetative state
3: severe disability
4: moderate disability
5: good outcome
GCS and ISS in our cases
• Case 1
– GCS 12 (moderate)
– ISS 17
– GOS 5
• Case 2
– GCS 13 (moderate)
– ISS 27
– GOS 1
Head Injury
• Acute
– Concussion
– Extra axial collection
• Acute Extradural Haematoma
• Acute Subdural Haematoma
• Traumatic Subarachnoid haemorrhage
– Contusion / Haematoma
– Diffuse axonal injury
• Chronic Subdural Haematoma
Extradural Haematoma
Extradural Haematoma with depressed skull fracture
Acute Subdural Haematoma
Traumatic SAH
Contusion / Haematoma
Diffuse Axonal Injury
Study of the functional outcome and mortality in elderly patients with head injuries
• J of CN, 1999; Melbourne; retrospective study (database analysis)
• 12 years, 191 patients, >65y with head injury
• Grouped by GOS:
mild (113)
moderate (29)
severe (49)
• Cross referenced by GCS: GOS 1-3 GOS 4-5
GCS <11 59/ 59 0 / 59
GCS >11 41/132 91/132
Conclusion: consider conservative treatment if GCS <11 and age >65y
Traumatic brain injury in the elderly: Increased mortality and worse functional outcome at discharge despite lower injury score
• J of T, I, I and CC, 2002; New York; retrospective study
• 1994-1995, 11,772 patients,
Mortality in severely injured elderly trauma patients - when does age become a factor
• World Journal of Surgery, 2005, Essen Germany, retrospective study
• 1993-2000, 5375 patients
Isolated traumatic brain injury: Age is an independent predictor of mortality / early outcome
• J of T, I, I and CC, 2001; New Jersey; retrospective study
• 5 years, 694 patients, 22% aged >65y
• Mortality: 30% vs 14% (p<0.001)
Poor outcome: 13% vs 5% (p<0.01)
• Head injury graded by GCS: <65y >65y
severe 30% 60%
moderate 2% 45%
mild 2% 5%
• Comorbidities: 76% of elderly, 13% of younger patients
Trauma in the very elderly: Community based study of outcomes
• J of T, I, I and CC, 2000; Cleveland; retrospective study
• 1996 trauma registry; 455 patients >80y (mean 85.9y)
• Mortality: 9.9%
• Survival grouped by ISS:
0-10: 353/362 97%
11-15: 20/25 80%
16-20: 25/30 83%
21-45: 11/31 35%
40-75: 1/ 1 0%
• Acute Care hospital vs Trauma Centre: OR 3.2 mortality (1.1-9.5); Trauma Centre significantly better outcomes with ISS 21-45.
Preinjury warfarin use among elderly patients with closed head injuries
• J of T, I, I and CC, 2004; Quebec; retrospective study
• 8 years, 384 patients >55y; 35 (9%) on warfarin
• Among warfarin users:
– Higher rate of isolated head injury (54% vs 32%) (p = 0.008)
– More severe HI (66% vs 41%) (p = 0.02)
– Higher mortality (40% vs 21%) (p = 0.01)
Effects of antiplatelet agents on outcome for elderly patients with traumatic intracranial haemorrhage
• J of T, I, I and CC, 2005; Michigan; retrospective study
• 1999-2002, 90 patients, age >50 on aspirin and / or clopidogrel
Traumatic brain injury in anticoagulated patients
• J of T, I, I and CC, 2006; Pittsburgh; retrospective study
• 1999-2002, 126 patients, adults on warfarin
• GCS < 8 91% Mortality
• GCS 13-15 81% Mortality
Management and outcome of the severely head injured patient
• ANZ J of Surgery, 2007; Sydney; retrospective study
• 96 patients >65y, GCS <8
• 1/3 palliative care
• 1/3 supportive medical care (53% mortality)
• 1/3 surgery (67% mortality)
• Mortality 71%
Mortality by age:
65-74 62%
75-84 68%
85+ 100%
• Poor outcome associated with age, comorbidities, anticoagulant use, physical reserve, reduced elasticity of organs
Elderly patients with severe head injury in coma from the outset - has anything changed?
• British Journal of Neurosurgery, 2004, Newcastle, retrospective study
• 1990-2000, 71 patients, all treated with maximum intervention
• 80% deceased
• 3% vegetative state
• 16% severely disabled
• 1% moderately disabled
Outcomes following surgical evacuation of traumatic intracranial haematomas in the elderly
• BJN, 1992; Saudi Arabia; retrospective analysis
• 10 years, 66 patients >65y (mean 72.5y)
• Allotted into outcome groups by GOS (good = 1-3, bad 4-5)
• 61% mortality
• 9% severely disabled/vegetative state
• All patients with good outcome (30%) had GCS of 5/> prior to surgery
• All patients with GCS 4/< or pupillary dilation had a poor outcome
• Outcome significantly worse in older patients
• Outcome worse if craniotomy required w/in 24h of injury
Continuation of poor surgical outcome after elderly brain injury
• Surgical Neurology, 2008, Chandigarh India, retrospective study
• 2000-2005, 45 patients, >70 years
• Mild HI 5 patients
– No mortality, 80% moderately disabled and no GOS 5
• Moderate HI 7 patients
– 5/7 (71%) died, with no GOS 5
• Severe HI 33 patients
– 25/33 (75%) died, all except one patient died or persistent vegetative state
Long-term functional status and mortality of elderly patients with severe closed head injuries
• J of T, I, I and CC, 1996; Springfield, Massachusetts; retrospective study
• 5 years, 40 patients >65y with GCS <8
• 27% alive at 3 year follow-up
• 85% that were discharged - alive but no significant improvement
• All patients with GCS 3-7 - deceased or in a vegetative state
Poor outcome – proposed mechanisms
• Poor outcome associated with inc age,
• Comorbidities,
• Anticoagulant use,
• Medications,
• dec physical reserve,
• Reduced elasticity of organs
• Cellular processes
Cellular processes implicated in poor outcome in the elderly
• Brain plasticity promoting factors
• Up regulated neurotoxic factors
– Neuronal degeneration and apoptosis
• Faster more extensive scar formation
• Decreased regenerative capacity
Conclusions
• Auckland approach – collaborative
– Mild and Moderate
– Severe
• Trauma data bases
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Ministry of Health
