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Head injury in elderly Ext.. Prevalence and magnitude Elderly : older than 65 y 15 % of elderly have head injury Elderly do much less well recover than.

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Presentation on theme: "Head injury in elderly Ext.. Prevalence and magnitude Elderly : older than 65 y 15 % of elderly have head injury Elderly do much less well recover than."— Presentation transcript:

1 Head injury in elderly Ext.

2 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

3 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 dead 1 (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

4 Severe head injury 135 pt. which >65 y – who were in coma than 6 hr Fewer than 5% achieve a good outcome or moderate disabilility 3 – If coma persist than 24 hr. Chance of survival is minimal 4 3,4 Jennett et al

5 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 injury 5 66 pt. over age 65 y who under go craniotomy – 61 % died – 9% vegetative stage – 30% survive with moderate disability or good outcome 6 5 : jenett et al 6 : jamjoom et al

6 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

7 Subdural hematoma Subdural space is potential space between inner surface of dura mater and arachaniod SDH can be classified in – acute – Subacute – Chronic

8 Subdural hematoma

9 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

10 Chronic SDH Pathogenesis – Low intracranial tension – Increase mobility of brain – Brain separate from inner surface of skull, Thus bridging vein may be stretched

11 Chronic SDH (cont.) Diffuse or focal brain atrophy – Age > 40 y – alcoholism Arachanoid cyst (account for 1/3) Following craniotomy After ventricular shunt

12 Chronic SDH (cont.) After lumbar puncture After lumbar drains Deposition of metastasis tumor

13 Chronic SDH (cont.) Risk – Disturbance of coagulation ASA Anticoagulant drug Coagulopathy – Alcoholism

14 Enlarge of hematoma Hematoma liquidfied and slowly enlarge Brain shifting ICP frequently remain low or normal The thoery

15 Clinical feature Great mimic (dementia, CVA, TIA) Slowly progressive with Insidious onset Early symptom – Headache – Lethargy – Intellectual dulling – Confusion – Unsteadiness gait

16 Clinical feature (cont.) When hematoma increase in size – Consciousness Deteriorate – Focal hemispheric deficit Hemiparesis Dysphasia Eventually – Coma – Disturb pupil and EOM

17 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

18 Diagnosis CT non-contrast MRI Angiography Isotope scaning

19 Diagnosis CT scan – First week SDH is hyperdense – 2 nd – 3 rd wk SDH become isodense – > 3 rd wk SDH become hypodense

20 Acute (Hyperdense)

21 Subacute (Isodense)

22 Chronic (Hypodense)

23 Diagnosis MRI – When diagnosis is in doubt – Esp. in subacute(CT isodense) MRI hyperintense on T1/T2

24 MRI T1 T2

25 MRI vs CT

26 Treatment Simple method of surgical treatment are satisfy for almost all SDH – Burr hole – Twist drill evacuation

27 Conservative/medical method Conservative – Small chronic SDH serial scan Resorp remain unchanged in size

28 Conservative/medical method Medical method – Mannitol Only use in selected case 8,9 Suzuki and takaku

29 Burr hole drainage Most widely used for chronic SDH

30 Twist drill drainage Superior to Burr hole drainage alone – Due to under RA Disadvantage – Provoke traumatic to brain surface without realize – Limited efficacy

31 Internal shunt From subdural space to – Pleural – Peritoneal cavity Widely use in infant

32 Craniotomy Effective same as Burr hole drainage Indicated in – Repeated reaccumulation – Presence of solid and organizing clot – Loculated or superimpose collection

33 Craniotomy

34 Endoscopic technique Replace craniotomy Flexible endoscope with micro scissor

35 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 shouldnt be left more than 48 hr. Prophylactic ATB Prophylactic anticonvulsant

36 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

37 Result Subdural empyema 2% Extracranial complication (elderly) – Thromboembolism – Chest infection

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