Chronic subdural haematoma (CSDH) is a typical disease in elderly patients and encountered frequently in neurosurgical practice. With an increasing number of elderly people in the general population, there is a need to investigate risk factors (age, falls, anticoagulant or antithrombotic therapy) which could be pertinent to the development of this disease. We reviewed 354 patients undergoing surgery for CSDH over a period of 7 years (1996-2002), the occurrence being equally distributed over these years. CSDH occurred more often in elderly (≥65 years) than in younger people (69 vs 31%), and in men than in women (64 vs 36%). Falls were reported in 77% of patients. There was a trend towards a higher risk of falls in the elderly. Antithrombotic or anticoagulant therapy was present in 41% of patients, 32% of them having had falls. Overall postoperative mortality was 0% and overall recurrence rate 13.6%. CSDH in the elderly population, especially in men, is frequently associated with falls and anticoagulation or antithrombotic therapy. The indication for these medications, especially in elderly patients at risk for falls, should be carefully evaluated and controlle

Baechli, H.

Bucher, H.

Gratzl, O.

Nordmann, A.

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Neurosurg Rev (2004) 27: 263–266DOI 10.1007/s10143-004-0337-6ORIGINAL ARTICLEH. Baechli . A. Nordmann . H. C. Bucher . O. GratzlDemographics and prevalent risk factors of chronic subduralhaematoma: results of a large single-center cohort studyReceived: 13 November 2003 / Revised: 25 March 2004 / Accepted: 26 March 2004 / Published online: 18 May 2004# Springer-Verlag 2004Abstract Chronic subdural haematoma (CSDH) is atypical disease in elderly patients and encounteredfrequently in neurosurgical practice. With an increasingnumber of elderly people in the general population, thereis a need to investigate risk factors (age, falls, anticoag-ulant or antithrombotic therapy) which could be pertinentto the development of this disease. We reviewed 354patients undergoing surgery for CSDH over a period of 7years (1996–2002), the occurrence being equally distrib-uted over these years. CSDH occurred more often inelderly (≥65 years) than in younger people (69 vs 31%),and in men than in women (64 vs 36%). Falls werereported in 77% of patients. There was a trend towards ahigher risk of falls in the elderly. Antithrombotic oranticoagulant therapy was present in 41% of patients, 32%of them having had falls. Overall postoperative mortalitywas 0% and overall recurrence rate 13.6%. CSDH in theelderly population, especially in men, is frequentlyassociated with falls and anticoagulation or antithrombotictherapy. The indication for these medications, especially inelderly patients at risk for falls, should be carefullyevaluated and controlled.Keywords Chronic subdural haematoma . Falls .Anticoagulation or antithrombotic therapy . Malepreponderance . AgeingIntroductionChronic subdural haematoma (CSDH) is a commondisease in neurosurgical practice. During the past 20years burr hole followed by drainage or irrigationcraniostomy is the commonly performed procedure [16].This surgical procedure can be carried out safely, alsounder local anaesthesia. CSDH is predominantly a diseaseof the elderly [13, 15]. In the year 2000, 21% of thepopulation in Basle was older than 65 years. For a varietyof reasons, the elderly are much more mobile and take partin many leisure activities (Swiss speciality of pickingcherries leads to many falls). As the population is ageing,we have to expect more cases of CSDH in the future. Theaim of this study was to find out if there is an increasingincidence over the years, and to evaluate potential riskfactors (age, gender, falls and anticoagulation/antithrom-botic therapy) that could play an essential role in thedevelopment of CSDH.Material and methodsWe reviewed the charts of 354 consecutive patients withCSDH operated in our neurosurgical department from1996 to 2002. Diagnosis was based on computer tomo-graphy scanning or magnetic resonance imaging. Surgicaltreatment consisted of one or two burr hole craniostomiesand closed subdural drain for 48 h. Three potential riskfactors were assessed: gender, falls (defined as occurring 2months or less before hospitalisation) and anticoagulation/antithrombotic medication (warfarin, aspirin and itsderivatives).Stata 7.0 software (Stata Corporation, TX, USA) wasused for statistical analysis. To describe frequencydistributions of age, gender, falls and number of patientson anticoagulant or antithrombotic therapy we used theone sample test of proportion. To identify risk factors forthe development of CSDH we calculated relative riskratios (RR) and corresponding 95% confidence intervals(CI).These data were presented at the 8th EMN Congress, 21–24 May2003 in Graz, AustriaH. Baechli (*) . O. GratzlDepartment of Neurosurgery, University Hospital Basle,Spitalstrasse 21,4031 Basel, Switzerlande-mail: hbaechli@uhbs.chTel.: +41-61-2657522Fax: +41-61-2657138A. Nordmann . H. C. BucherDepartment of Medicine/Basle Institute for ClinicalEpidemiology, University Hospital Basle,Basel, SwitzerlandResultsPatients’ age ranged from 2 to 94 years, with a mean of68.3 years (SD±17.0). For this study patients were dividedinto two groups: (1) younger than 65 years and (2) 65years and older. The cases of CSDH were equallydistributed over the 7 years (Fig. 1). Postoperativemortality was 0%.AgeAge ≥65 years was associated with a higher incidence ofCSDH: 69% (n=245) of the patients were ≥65years,whereas 31% (n=109) were younger (p<0.0001) (Table 1).GenderCSDH was seen more frequently in men than in woman(64 vs 36%, p<0.0001). There was a significant malepreponderance in both elderly and younger patients(Table 1). In patients younger than 65 years, 70% ofpatients were men and 30% women (p<0.0001); inpatients 65 years and older, 62% were men and 38%women (p<0.0001).FallsTwo hundred seventy-two patients (77%) reported havingfalls preceding CSDH. Men and women were equallylikely to have experienced a fall preceding the develop-ment of CSDH (78 vs 75%, p>0.1). There was a trendtowards a higher risk of falls in elderly patients, but thistrend failed to reach statistical significance (RR 1.11, 95%CI 0.96–1.27, p=0.12) (Fig. 2).Anticoagulant and antithrombotic drug therapyOne hundred forty-four patients (41%) were takinganticoagulant (20%) or antithrombotic (21%) drug therapy.Elderly patients were significantly more likely to havetaken anticoagulant or antithrombotic therapy than young-er patients (RR 1.75, 95% CI 1.24–2.49, p=0.0005). Therewere no differences between men and women in the use ofthis medication (Fig. 2). Of these 144 patients, 92 (64%)had fresh haemorrhages in the CT with an onset ofsymptoms only few days previously. One hundred andfifteen patients (32%) had both preceding falls and weretaking anticoagulant or antithrombotic medication. Therewere significantly more elderly than younger patients (85vs 15%, p<0.0001, one sample test of proportion) andsignificantly more men than women (66 vs 34%,p<0.0001) having experienced falls while being onanticoagulant or antithrombotic therapy (Fig. 2).Figure 3 shows the age and gender distribution inpatients with falls who were on anticoagulant or anti-thrombotic therapy. There is a peak in the number of casesin the age group between 75 and 79 years.Fig. 1 Annual incidence (1996–2002) of CSDH in 354 patientsoperated in the Neurosurgical Clinic, BasleFig. 2 Risk factors for CSDH in 354 patients subdivided accordingto age and gender and percentage of patients with each risk factorTable 1 Age and gender distribution in 354 patients with chronic subdural haematoma operated in the Neurosurgical Clinic, Basle 1996–2002Patients, n (%) Gender (%) Age, n (%) Gender, age, n (%)n=354 (100) range 2–94 years Male, 228 (64) <65 years, 109 (31) Male*, <65 years, 76 (21) female, <65 years, 33 (9)Female, 126 (36) ≥65 years, 245 (69) Male*, ≥65 years, 152 (43) female, ≥65 years 93 (26)*p<0.0001 vs female, Chi squared test264Bilateral CSDHTwenty-two percent of all CSDH were bilateral. Therewere significantly more elderly than younger patients (86vs 14%, p<0.0001), and more men than women withbilateral CSDH (73 vs 27%, p<0.0001) (Fig. 4).One hundred thirty-eight patients, 65 years and olderhad one burr hole and 106 patients had two burr holes. Thecorresponding numbers <65years are 72 and 38.RecurrenceWe defined recurrence as follows: in patients whosesymptoms failed to improve or got worse, a CT wasperformed. If there was a recurrence of mass effect, afurther surgical intervention was carried out. Using thesecriteria, the overall recurrence rate was 13.6% (n=48) andwas independent of the number of burr hole craniostomiesused at the time of the first neurosurgical intervention(Fig. 5). Five patients needed a third operation. In totalfour secondary craniostomies were performed. Theaverage time of the second intervention was about 4weeks.DiscussionAs confirmed in our results, CSDH is a typical disease ofelderly patients [1, 6, 15]. Brain atrophy and decreasingbrain volume allow greater movements of the brain [6] andolder people also have a predisposition to trivial trauma.These factors could also explain our finding that moreelderly patients have bilateral CSDH than younger ones(Fig. 4).We could show that there are almost twice as many menwith CSDH as women. This male preponderance hasalready been described [13]. One study reports that malepreponderance diminishes with age [14]. This tendencycan be seen also in our results (2.3 times more men thanwomen in the younger group, 1.6 times in the older one(Table 1)). One reason for male preponderance could bethat men have a greater exposure to injuries generally. Inmedical practice multimorbidity in the elderly is foundmore frequently in men than in women. Our study showsthat falls were associated with CSDH in 72% of thepatients, men and women being equally likely to reportfalls (Fig. 2).Our data demonstrate that of the patients with falls,older patients reported significantly more use of anti-thrombotic or anticoagulant medication than youngerpatients. Therefore, a critical evaluation is needed inelderly patients before antithrombotic or anticoagulanttherapy is initiated.The outcome of patients with CSDH with coagulopathyis often complicated with an increased recurrence rate,which deserves attention [5]. The excess mortalityFig. 5 Recurrence rate of CSDH and number of burr holesFig. 3 Peak incidence of falls and medication for males and femalesat 75–79 yearsFig. 4 a,b Preponderance of elderly patients in monolateral andbilateral CSDH265associated with high international ratio (INR) supports theuse of less intensive treatment and more preventive actionto avoid episodes of high INR [9]. CSDH can mimictransient ischemic attacks and should be excluded beforeinitiating anticoagulation therapy [18].The risk of this therapy for causing haemorrhage shouldnot be underestimated. Already in 1992, Reymond et al.reported that aspirin is a risk factor for haemorrhage inpatients with head injuries [12]. In contrast to othersurgical fields, aspirin could make neurosurgical proce-dures impossible. Therefore, exact evaluation of coagula-tion parameters is required before operation. In patientswith proved platelet dysfunction, surgical intervention inour clinic was postponed if possible.Before starting this study, we asked ourselves whetherthe incidence of CSDH is increasing, because of wide-spread prescribing of antithrombotic or anticoagulanttherapy. In our study the frequency of CSDH remainedstable over the years 1996–2002 (Fig. 1). However, thenumber of patients with CSDH taking antithrombotic oranticoagulant therapy may be higher than suggested by ourstudy; we had to extract information about antithromboticor anticoagulant therapy from charts where informationmight have been incomplete. A lot of patients could notremember their medication and forgot to mentionespecially antithrombotic therapy, which they often tookto reduce headache or influenza symptoms.In our study, the patients consisted of a selectedsubgroup of all patients seen in the hospital with CSDHsince all our patients underwent surgical procedures. Forexample, many patients with smaller CSDH who refusedan operation were not seen in our neurosurgical clinic.Therefore, the findings of our study cannot be generalisedto patients not undergoing surgical therapy. There is oneprospective study with 43 elderly patients, which showedthat only patients with midline shift had a poor outcomewithout surgery [4]. However, in that study the number ofpatients was too small to draw general conclusions. In ourstudy, the postoperative mortality was 0% and therecurrence rate was 13.6%, which is within the reportedrange of 7.5–31% for burr hole craniostomies [3, 10, 11].Interestingly, in the literature we cannot find an exactdefinition of recurrence. In most cases diagnosis is madeclinically or radiologically.Recurrence rate, complications and factors related tothese problems, especially in the elderly, are notcompletely understood [7, 8] and have not improvedsubstantially over the past 20 years [16]. Therefore it isimportant to reduce the risk factors in developing CSDH.Another point of view is the new theory that CSDH mightbe an angiogenic disease with specific patterns of growthfactors, which play a causative role in the pathogenesis ofCSDH [17]. This could offer new anti-angiogenetictreatment options in the future.ConclusionsThe risk for surgically treated CSDH in the elderlypopulation especially in men, appears to be higher inpatients with falls and anticoagulation/antithrombotictherapy. Therefore the indication for this medicationshould be carefully evaluated and controlled, especiallyin elderly patients with risk for falls. Further prospectivestudies are needed to quantify the real incidence of CSDHin combination with anticoagulation/antithrombotic med-ication.Acknowledgement We would like to thank Dr Helen Langemannfor assistance with manuscript preparation.References1. Asghar M, Adhiyaman V, Greenway MW, Bhowmick BK,Bates A (2002) Chronic subdural haematoma in the elderly—aNorth Wales experience. J R Soc Med 95:290–2922. Gonugunta V, Buxton N (2001) Warfarin and chronic subduralhaematomas. Br J Neurosurg 15:514–5173. 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Demographics and prevalent risk factors of chronic subdural haematoma: results of a large single-center cohort study

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Demographics and prevalent risk factors of chronic subdural haematoma: results of a large single-center cohort study

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