Traumatic chronic subdural hematoma over 80 years. A preliminary prospective study.

: Six very elderly patients (mean of age: 85 years with range from 80 to 95 years) with mean GCS = 12 and mean clinical grade = 2.5 affected by traumatic chronic subdural hematoma (CT mean maximum thickness = 2.8 +/- 0.46 cm with midline shift = 1.56 +/- 0.48 cm and absence of homolateral mesencefalic cistern in all case but one) underwent parietal or frontal craniectomy under temporalis muscle and 48-h closed subdural drain. There was no mortality as consequence of the operative procedure. In all the patients but one who died postoperatively from a preoperative midbrain infarction secondary to a transtentorial herniation, there was a progressive and slow clinical improvement in spite of residual markedly persistent fluid collection (CT mean maximum thickness 1.44 +/- 0.19 cm) with mass effect (CT mean midline shift = 0.5 +/- 0.17 cm) due to a some failure of the brain to re-expand. Impairment of hemodynamic reserve should be considered as important cause of failure of the brain re-expansion. Clinical and CT control within two months after discharge from hospital demonstrated further clinical improvement (mean GOS = 4.6) and resolution of subdural residual fluid collection. Basing on these results we recommend do not reoperate persistent subdural fluid collection if there is clinical improvement. The patient can be discharged from hospital or transferred to Geriatric Department where he can be clinically and CT evaluated. Only a clinical deterioration or an increase of residual subdural fluid collection provides clear indication to reoperative surgery.