Severe head injury in very old patients: to treat or not to treat? Results of an online questionnaire for neurosurgeons

Due to the aging population, neurosurgeons are confronted with an increasing number of very old patients suffering from traumatic brain injury. Many of these patients present with an acute subdural hematoma. There is a lack of data on neurosurgical decision-making in elderly people. We investigated the importance of imaging criteria, patients’ wishes, their surrogates’ wishes, and patient demographics on treatment decisions chosen by neurosurgeons. An online questionnaire was sent to all German neurosurgical units via the German Society of Neurosurgery (DGNC). The survey was based on the reported case of an unconscious 81-year-old patient with an acute subdural hematoma and consisted of 13 questions. Of these questions, nine addressed indication and treatment plan and four evaluated the neurosurgeon’s interest in gathering additional information on the patient’s social environment and supposed patient’s wishes or advance directive. Eighty-five percent of the interviewed neurosurgeons would perform an emergency operation in the presented case. Midline shift (84%), hematoma thickness (81%), and time between traumatic injury and treatment (81%) were considered to be the most important factors for surgical treatment. Gathering information on the social environment of the patient (66%) and discussion with family members (57%) were felt to be either unimportant. Neurosurgeons in Central Europe tend to treat acute subdural hematoma in very old patients based on imaging findings and according to mechanistic views. Social circumstances and patient wishes are considered to be less important. Education of the medical profession and the general public should aim to bring these factors into focus in the decision-making process.