Corelation between traumatic

SDH with Brain Atrophy in Elderly

United States Department of
Health and Human Service: Incidence of trauma in this
Trauma is the seventh
the elderly population (age demographic will continue to
leading cause of death in the
65 and over) reached 47.8 rise with the growth of this
elderly population
million in 2015, an increase age group
of 30% since 2005
 Introduction
• Traumatic brain injury (TBI) is a leading cause of
death among trauma patients, accounting for one
third of all trauma mortalities.
• The vast majority of these injuries are attributed
to falls, followed by motor vehicle accidents,
pedestrians struck and other causes.
• The difference in outcomes compared to younger
patients may be attributed, in part, to underlying
comorbid conditions and decreased physical
reserve in elderly patients.
• Additionally, normal physiologic changes in
the aging brain, such as atrophy of the brain
parenchyma and decreased neuronal plasticity
result in increased susceptibility to cellular
loss, intracerebral vascular injury and
diminished cerebral perfusion, all of which
may contribute to poor neurologic and overall
recovery from trauma
• Subdural hemorrhage (SDH) is more common in elderly patients
• Subdural hemorrhage is a hematoma between the dura and arachnoid
membranes that occurs due to the rupture of the bridging veins

• As age increases, brain volume decreases, and the subdural space

expands

• Elderly patients with SDH may present with various symptoms ranging
from a mild headache to unconsciousness
 Clinical Aspects of Subdural
Hemorrhage (SDH)

Acute subdural hematoma (ASDH) is an

intracranial space-occupying lesion that often
occurs because of the tearing of bridging or
cortical surface veins, secondary to a physical
head trauma. `

A. Ozpinar, B. Jankowitz
 Symptoms

Small ASDHs
• Headache and meningismus

Larger ASDHs
• Altered consciousness, pupillary asymmetry, or
hemiparesis
• A dilated pupil on the ipsilateral side of the hematoma
• Contralateral motor findings because of Kernohan
notch
 Hematoma compresses the
Hematoma is compressing
contralateral cerebral
the ipsilateral cerebral
peduncle against the
peduncle, motor weakness
tentorium, weakness is on
is typically contralateral
the ipsilateral side

Radiograph: an indentation in the contralateral

cerebral crus by the tentorium

Careful attention should be paid to the elderly

patients on anticoagulants, as even a mild
head trauma can cause severe delayed ASDHs
Mortality in patients with ASDH : 50% to 90%

Majority of deaths directly attributable to the

underlying brain injury

The morbidity associated with ASDH varies

drastically with the presenting GCS score,
anticoagulant status, and other prognostic
indicators such as alcohol use, hypoxia, or
hypotension, or difficulty managing ICP
• Poor outcomes following severe head injury
have been strongly correlated with patient
age, GCS score, and pupillary examination
• These associations often deter physicians from
more aggressive management of severe injury.
• Patients older than 70 years with GCS score <9
have a 15% chance of a good outcome.
• These studies also demonstrate that patients
older than 75 years who exhibit extensor
posturing or unilateral/bilateral fixed and
dilated pupils [Glasgow outcome scale (GOS)
3–5] have no significant recovery
CSDH occurs in the dural border cell layer, which
is a loose cellular layer located between the
dura and the arachnoid matter

Initial tear of the

subdural bridging A small hematoma
vein formed that dissects Fluid draw into the
into the dural subdural space
border cell layer to
form a subdural
hematoma
• Cerebral atrophy and increased venous
fragility are often key predisposing factors for
CSDH. As the brain ages, its volume decreases
and the space between the brain and the dura
increases.
• Consequently, the brain moves more during
minor traumas (mild, asymptomatic falls) and
the bridging veins in the subdural space are
exposed to greater stretching forces.
 Symptoms

Gait difficulties and falls (57%)

confusion (33%)

extremity weakness (35%)

Headache, drowsiness or coma, speech impairment,

seizure, incontinence, visual disturbance, and vomiting
decreased cognition (35%)
• Of all the symptoms mentioned, headache is
a surprisingly uncommon symptom in the
elderly, with an incidence of 12–16%. Only 7%
of patients presented with an initial GCS score
≤8, whereas 81% of patients presented with
an initial GCS score above 12
• Approximately one-fifth of the patients had
bilateral subdural hematomas