head injury in elderly ext.. prevalence and magnitude elderly : older than 65 y 15 % of elderly have...
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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