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Head injury complicating falls and syncope: State of the art

Head injury complicating falls and syncope: State of the art. Giles Critchley Consultant Neurosurgeon Hurstwood Park Neurological Centre Brighton and Sussex University Hospitals NHS Trust. The problem. .....the other silent epidemic – falls and injuries in the home.

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Head injury complicating falls and syncope: State of the art

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  1. Head injury complicating falls and syncope: State of the art Giles Critchley Consultant Neurosurgeon Hurstwood Park Neurological Centre Brighton and Sussex University Hospitals NHS Trust

  2. The problem .....the other silent epidemic – falls and injuries in the home. These accidents increasingly involve our aging population and result in significant disability and death.

  3. The problem

  4. Traumatic brain injury Epidemiology – Socio demographic factors Mechanism of injury – falls and syncope Efficiency of healthcare system – ‘State of the art’

  5. Incidence of traumatic brain injury in different populations (selected studies)

  6. Elderly rates age range yrs inc per 100,000 USA Kraus, Nourjah 1989 65-75 200 Cooper et al 1983 60-80 150-200 Finland Kannus et al 2007 male 80-84 465 85-89 617 90 > 976 female 80-84 397 85-89 608 90> 735

  7. Age-specific rates of head injury hospitalization in Ontario, overall 1994/95 through 1998/1999 (from the Minimal Data Set of the Ontario Trauma Registry)

  8. Socio – demographic factors Age – trimodal children 0-4 yrs young adults 15 -19 yrs elderly 75 > yrs Gender – male 3: 1

  9. Causes of head injury – all ages European Brain Injury Consortium – those admitted to neurosurgical units RTA 51% Falls 12% Assault 7% CRASH study RTA 64% Falls 13% USA, 1995–2001

  10. Causes of head injury – elderly age yrs distribution India (Sinha et al 2008) 60> falls 56.3% RTA 44.1% Singapore(Gan et al 2004) 64> falls 73.8% RTA 21.5% Ireland (Phillips report 2008) 25%>65 falls 59% RTA 22%

  11. Socio – demographic factors Falls – 60% at home Alcohol – 25% falls associated with alcohol In NSU fall patients :- Aspirin – 14% Warfarin – 8%

  12. Mechanism of injury – falls and syncope Definition of falls: FICSIT, ICD , < 1metre Classification: explained, unexplained intrinsic, extrinsic recurrent, non recurrent Syncope: a transient loss of consciousness due to cerebral iscaemia

  13. Mechanism of injury – falls and syncope 40-60% of falls lead to injuries. Low impact injuries Fewer multiple injuries BUT More severe CT findings – mass lesions, SAH, mid line shift

  14. Pattern of injury diagnosis – CT scanning (MRI) Chronic subdural haematoma Contusions Acute subdural haematoma

  15. Chronic subdural haematoma

  16. Chronic subdural haematoma mean age around 71 yrs (74 yrs 20-91) head trauma identified in < 50% ‘soft’ neurological signs

  17. Chronic subdural haematoma - treatment Burr hole drainage – local/ GA Twist drill craniostomy Mini craniotomy – GA Randomised control trial

  18. Use of drains versus no drains after burr-hole evacuation of chronic subdural haematoma: a randomised controlled trial. T. Santarius et al Lancet. 2009 Sep 26;374(9695):1067-73. 108 patients drain into subdural space 107 no drain Recurrences: no drain 24% (26 /107) with drain 9.3% (10 /108) Mortality at 6 months: no drain 18.1% (19/105) with drain 8.6% (9/105)

  19. Acute subdural haematoma

  20. Acute subdural haematoma

  21. Trauma craniotomy

  22. Acute subdural haematoma more common 30% of severe HI manifestation of parenchymal damage poor prognosis – 45% mortality in elderly 79% mortality

  23. Management Conservative – allow to become chronic

  24. Cerebral contusions Coup/contrecoup Frontal / temporal Mass effect

  25. Cerebral contusions Supportive management In one series of elderly 19.3% of geriatric head injuries Mortality 40%

  26. Outcome Elderly have a worse outcome, lower admission GCS – more likely unfavourable outcome Moderate TBI in elderly similar to severe TBI in younger Outcome of mild TBI worse

  27. Outcome Reasons: decreased functional reserve loss of elasticity of blood vessels cerebral atrophy bridging veins hypertension

  28. Outcome Apoprotein E4 (APOE 4) Patients with APOE episilon 4 allelle more than twice as likely to have a poor outcome. TBI and APO E increased risk of Alzheimer’s 10 fold.

  29. Factors leading to falls Weakness Balance deficit Mobility limitation Visual deficit Cognitive impairment Postural hypotension

  30. Prevention Ward design Tai chi Stair design Lighting Helmet use in multiple fallers

  31. The Haddon Matrix Adapted from, WHO, Geneva, 2004, Queensland Australia 2004 fall prevention.

  32. The Haddon Matrix - falls Adapted from World report on road traffic injury prevention, WHO, Geneva, 2004. a

  33. Conclusions Falls are an increasing cause of head injury ‘silent epidemic’ Age is an independent predictor in outcome This increasing public health problem requires a multidisciplinary approach for prevention, treatment and rehabilitation of elderly patients

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