NAPLES, Fla. – About one-third of elderly patients who underwent a cranial operation for traumatic brain injury die in the hospital, and one-half are dead within a year, according to a retrospective analysis of 164 patients.

Long-term follow-up for a mean of 42 months, however, demonstrated that two-thirds of survivors had a "favorable" outcome, as indicated by a GOSE (Glasgow Outcome Scale–Extended) score of at least 5, Dr. Mark Cipolle and his colleagues reported at the annual meeting of the Eastern Association for the Surgery of Trauma.

The study demonstrates that in-hospital mortality is not an adequate measure of outcome and reflects an increasing willingness to operate on the growing elderly patient population. The patients, who were at least 65 years old, had an average age of 79.

"One thing that’s very important to understand as clinicians is that these patients don’t get operated on and immediately do better," he said. "They often don’t do better and often have a decline after surgery.

"We were not thrilled with what we were seeing at 1 year, but we were fairly happy with what we saw with the patients who did survive long term."

The cohort represents 20% of the 823 patients aged at least 65 years with a head AIS (Abbreviated Injury Scale) score of 4 (severe) or 5 (critical) who were admitted in 2004-2008 to the Christiana Care Health Care System in Newark, Del. Falls were the most common mechanism of injury.

Roughly half (51%) of patients were men, 25% were taking warfarin, and 20% were on clopidogrel. Their average international normalized ratio was 2.7.

Craniotomy was the most common operation, performed in 146 patients, followed by a burr hole in 14 and craniectomy in 4, said Dr. Cipolle, chief of trauma surgery at Christiana. In all, 156 primary procedures were performed for subdural hematoma and 8 for intraparenchymal hemorrhage. Secondary procedures in 10 patients included seven craniotomies, one burr hole, and two craniectomies.

There were 46 in-hospital deaths, with 118 patients surviving until discharge to a skilled nursing facility (51%), rehabilitation (45%), or home (4%). Within 1 year, 33 of the 118 patients died.

The study, led by general surgery resident Dr. Kevin Geffe, classified 51 patients as having a favorable outcome. They included 29 patients who died more than 1 year after discharge and 22 patients with a GOSE score of at least 5 on a follow-up scripted telephone interview.

The 89 patients with an unfavorable outcome included the 46 in-hospital deaths, the 33 patients who died within a year of discharge, and 10 survivors who had a GOSE score of less than 5. Seven patients refused the GOSE interview, and 17 were lost to follow-up.

Of several factors examined by multivariate analysis, only functional independence at discharge and prehospital warfarin – but not clopidogrel (Plavix) – use were associated with outcome, Dr. Cipolle said. Not surprisingly, patients who were awake when they came in were nearly 2.5 times more likely to have a favorable outcome (odds ratio, 2.42).

The time to the operating room was 23.6 hours among patients with a favorable outcome and 27.8 hours among those with an unfavorable outcome.

"The long [operating room] times are obviously, I think, a reflection of the chronicity of many of these hemorrhages," he said. "One of the reasons we really are interested in this problem is that we can’t help but think there’s got to be a better way to deal with these patients than waiting for them to decline to decide to start operating on them."

An analysis of in-hospital mortality found that patients with a head AIS score of 4 were less likely to undergo surgery and did significantly worse with surgery than without surgery (29% vs. 7%). Dr. Cipolle pointed out, however, that patients with an AIS score of 5 were operated on at about the same rate, and there was no significant difference in mortality between the operated and nonoperated groups (28% vs. 33.5%).

Invited discussant Dr. Gary Marshall of the University of Pittsburgh Medical Center remarked that grouping the patients as favorable vs. unfavorable seemed arbitrary. Dr. Cipolle acknowledged that they struggled with the classification scheme and said they plan to more closely determine cause of death to take away additional assumptions made in the analysis.

When asked whether the hospital has reversal strategies for warfarin and clopidogrel, Dr. Cipolle responded that a statewide reversal policy for warfarin directs that patients on the anticoagulant who have a positive CT scan be given vitamin K and fresh frozen plasma, with small doses of activated factor VII therapy for those going directly to surgery. Patients on clopidogrel or aspirin with a small amount of bleeding are not treated, whereas those with substantial bleeding are given platelets. The researchers have submitted a proposal to the National Trauma Institute to conduct a pilot study evaluating reversal of antiplatelet therapy in patients with intracranial hemorrhage, Dr. Cipolle said.

The authors and Dr. Marshall reported no conflicts of interest.

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