Abstract
Background and Study Aims Surgical treatment for acute subdural hematomas (ASDHs) in elderly patients is still
considered unsatisfactory. Series focusing on the use of conventional craniotomy or
decompressive craniectomy in such patients report discouraging results. Glasgow Coma
Scale (GCS) score at admission seems to be crucial in the decision-making process.
Deteriorating patients with a GCS score between 9 and 11 are those who would benefit
most from the surgical treatment. Unfortunately, elderly patients often present other
comorbidities that greatly increase the risk of severe complications after major neurosurgical
procedures under general anesthesia. The aim of the present study was to evaluate
the feasibility of performing a mini-craniotomy under local anesthesia to treat ASDHs
in a select group of elderly patients who were somnolent but still breathing autonomously
at admission (GCS 9–11).
Material and Methods Twenty-eight elderly patients (age > 75 years) with ASDH and a GCS score at surgery
ranging from 9 to 11 were surgically treated under local anesthesia by a single burr-hole
mini-craniotomy (transverse diameter 3–5 cm) and hematoma evacuation. At the end of
the procedure, an endoscopic inspection of the surgical cavity was performed to look
for residual clots that were not visible under direct vision.
Results The median operation time was 65 minutes. Hematoma evacuation was complete in 22
cases, complete consciousness recovery was observed in all patients but one, and reoperation
was required for two patients.
Conclusion Historically, elderly patients with ASDH treated with a traditional craniotomy performed
under general anesthesia have not had a good prognosis. Our preliminary experience
with this less invasive surgical and anesthesiological approach suggests that somnolent
but autonomously breathing elderly patients could benefit from this approach, achieving
an adequate hematoma evacuation and bypassing the complications related to intubation
and artificial respiratory assistance.
Keywords
acute subdural hematoma - brain injury - elderly - local anesthesia - minimally invasive
surgery
