Acute Traumatic Epidural Hematoma in Geriatri, case report
Hematoma Epidural Traumatis Akut
pada Geriatri, laporan kasus
Aulia Agung
Sanubari1*, Dety
Nirbhita2, Geizar Arsika R3
Sebelas Maret University, Indonesia1*3
Kasih Ibu Hospital Surakarta, Indoenesia2*
Email:
[email protected]
*Correspondence: 1) Aulia Agung Sanubari
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DOI: 10.59141/comserva.v4i7.2594 |
ABSTRACT Cedera Otak Traumatis (TBI) pada populasi lansia merupakan masalah kesehatan global yang semakin signifikan, dengan jatuh menjadi penyebab utama cedera kepala pada kelompok usia ini. Hematoma epidural akut (AEDH), meskipun jarang terjadi pada orang dewasa yang lebih tua, menghadirkan tantangan unik karena adhesi dura mater yang kuat ke tengkorak,
yang umumnya mengurangi terjadinya hematoma. Namun, ketika AEDH terjadi, hal itu dapat menyebabkan
komplikasi parah yang memerlukan intervensi tepat waktu. Studi kasus ini
menyajikan seorang pria berusia 66 tahun dengan AEDH yang disebabkan oleh
kecelakaan kendaraan bermotor. Pasien, yang awalnya menunjukkan gejala
ringan, didiagnosis dengan AEDH di daerah parietotemporooccipital kanan
melalui pencitraan CT kranial. Kraniotomi dilakukan, dan hematoma
dikeringkan, yang mengarah pada pemulihan penuh. Kasus ini menggarisbawahi
pentingnya pengenalan dini dan intervensi untuk AEDH pada lansia, kelompok
yang sering berisiko tinggi karena penyakit penyerta seperti hipertensi dan
gangguan keseimbangan. Ini juga menyoroti perlunya strategi manajemen khusus
geriatri, karena patofisiologi AEDH berbeda pada orang dewasa yang lebih tua
dibandingkan dengan pasien yang lebih muda. Temuan menunjukkan bahwa
diagnosis tepat waktu dan intervensi bedah dapat secara signifikan
meningkatkan hasil klinis dalam kasus AEDH di kalangan lansia, dan menekankan
pentingnya mengatasi risiko spesifik usia dalam manajemen TBI. Kata kunci: Hematoma Epidural
Akut, Lansia, Cedera Otak Traumatis |
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ABSTRACT Traumatic Brain Injury
(TBI) in the elderly population is an increasingly significant global health
concern, with falls being the leading cause of head injuries in this age
group. Acute epidural hematomas (AEDH), though rare in older adults, present
unique challenges due to the strong adhesion of the dura mater to the skull,
which generally reduces the occurrence of hematomas. However, when AEDH does
occur, it can lead to severe complications that require timely intervention.
This case study presents a 66-year-old male with AEDH caused by a motor
vehicle accident. The patient, who initially exhibited mild symptoms, was
diagnosed with AEDH in the right parietotemporooccipital
region via cranial CT imaging. A craniotomy was performed, and the hematoma
was drained, leading to a full recovery. This case underscores the importance
of early recognition and intervention for AEDH in the elderly, a group often
at increased risk due to comorbidities such as hypertension and balance
disorders. It also highlights the need for geriatric-specific management
strategies, as the pathophysiology of AEDH differs in older adults compared
to younger patients. The findings suggest that timely diagnosis and surgical
intervention can significantly improve clinical outcomes in AEDH cases among
the elderly, and emphasize the importance of addressing age-specific risks in
TBI management. Kata
kunci: Acute Epidural Hematoma, Elderly, Traumatic Brain Injury |
INTRODUCTION
Traumatic Brain Injury (TBI) among
the elderly population is becoming an increasingly significant global health
issue as the aging population grows. According to the World Health Organization
(WHO), falls are the second leading cause of unintentional injury deaths
globally, with older adults particularly at risk due to age-related physical
and cognitive impairments (WHO, 2018). Acute epidural hematomas (AEDH), though
rare in this demographic, present unique challenges due to the strong adhesion
of the dura mater to the cranial bones in older adults, which generally reduces
the likelihood of hematoma formation. However, when AEDH occurs, it often leads
to severe complications requiring prompt intervention (Kocabı�ak
et al., 2010; Yang et al., 2021).
In Indonesia, TBI cases are on the
rise, with head injuries accounting for a significant portion of trauma-related
emergency visits. South Sulawesi records the highest prevalence of head
injuries at 12.8%, while Jambi reports the lowest at 4.5% (CDC, 2014; Niryana et al., 2020). These statistics underline the
pressing need to address geriatric head injuries as a public health priority,
considering the increased vulnerability of older adults to complications
stemming from comorbidities like hypertension and balance disorders (Pavlovic
et al., 2019).
The elderly population faces unique
risks, as falls are the primary cause of head injuries in this age group,
contrasting with traffic accidents, which are more prevalent among younger
individuals (Yang et al., 2021). The delay in recognizing AEDH in geriatric
patients can result in irreversible neurological damage. This underscores the
necessity for timely diagnosis and targeted management to mitigate adverse
outcomes (Stippler, 2016).
Despite significant advancements in
understanding TBI, research focusing on AEDH among elderly populations remains
sparse. Most available studies emphasize younger demographics, leaving a gap in
knowledge regarding injury patterns, treatment modalities, and prognostic
factors unique to older adults (Zigouris, 2022).
Addressing this gap can lead to more effective clinical protocols and better
outcomes for geriatric patients.
Previous studies highlight
age-related differences in AEDH. For example, AEDH in the elderly often occurs
in the parietotemporooccipital region, attributed to
the weakened dura mater attachment in these areas (Stippler, 2016). Research by
Pavlovic et al. (2019) and Zigouris (2022) emphasizes
the need for geriatric-specific management strategies, as timely interventions
significantly improve survival rates. The CDC also highlights the global burden
of TBI, urging healthcare systems to adapt to the specific needs of vulnerable
populations (CDC, 2014; WHO, 2018).
This research aims to investigate the injury patterns and
mechanisms of acute epidural hematomas (AEDH) in elderly populations, providing
a deeper understanding of how these injuries manifest in this age group.
Additionally, it seeks to assess the differences in AEDH presentation between
geriatric and younger patients, highlighting age-specific characteristics that
may influence diagnosis and treatment. Furthermore, the study intends to
propose tailored management protocols for AEDH in the elderly, with the goal of
improving clinical outcomes and ensuring that treatment approaches are
optimized for this vulnerable demographic.
The findings from this research are
anticipated to offer several benefits. From a clinical perspective, the study
aims to enable early recognition and timely intervention for AEDH in elderly
patients, reducing the risk of complications. In terms of policy implications,
the research supports the development of age-specific traumatic brain injury
(TBI) prevention programs that address the unique needs of older adults.
Lastly, the study is expected to enhance care protocols by informing healthcare
practitioners about geriatric-specific management strategies, thereby improving
the quality of care provided to elderly patients with AEDH. These insights
collectively contribute to better health outcomes and quality of life for this
growing segment of the population.
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CASE REPORT
A 66-year-old
male patient was admitted to the emergency room with the complaints of persistent
headache, nausea, and tendency to sleeping. He had a history motor vehicle
accident 3 days ago. He didn�t have any spesific
history besides this. At physical examination, he had a just soft tissue
swelling at right frontotemporal region. At neurological examination, he was
conscious orientated-cooperated, moderately prone to sleeping and agitated. His
pupils were anisochoric (4ml/3ml) and didn�t have
facial asimetry. He had sign of lateralisation to the
left. Glasgow Coma Score (GCS) was 15. Other system examinations didn�t show
any abnormality. Cranial Computerized Tomography (CT) showed AEDH at the right parietotemporooccipital region estimated volume 129 cc,
width 4,6 cm with midline shift 0.5 cm to the left. (Fig. 1).
Figure 1. Cranial Computerized Tomography (CT)
The patient
was operated. craniotomy was accomplished using horse shoe design incision. AEDH
was drained. Postoperatively his GCS was 15 and he was discharged with
recommendations.
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RESULTS AND DISCUSSION
Acute Epidural Hematome (AEDH) can result from injury to the middle
meningeal artery, the middle meningeal vein, the diploic veins, or the venous
sinuses. Bleeding from the middle meningeal artery has been considered the main
source for Acute epidural hematome5. TBIs are attributed to several mechanisms of injury, including falls,
motor vehicle or other types of road injuries, sports-related injuries, and
interpersonal physical violence or violence by other means (e.g., blast
injury). These injury mechanisms vary by geographical region, socioeconomic
factors, age, and sex. Indeed, stratifying by geographical region can
illuminate clear differences in injury type and overall burden of disease6. Motor vehicle
accident was the cause of AEDH in our patient. GCS, age, pupillary
abnormalities, associated intracranial lesions, time between neurological
deterioration and surgery, and intracranial pressure (ICP) have been identified
as important factors determining outcome from AEDH.
AEDH in the
elderly is rare. There are only a few studies involving AEDH in geriatric age
group. EDH is more common in young people although it does occur in all age
groups, but it is rare before the age of 2 years or after the age of 60 years
because of tenacious dural attachment to the inner table of the skull in these
age groups7.
Presentation
may range widely from normal mental status to severe intracerebral injury in
the elderly although acute deterioration may occur in previously conscious
patients8. Falls are the main cause of head traumas in the elderly
due to the accompanying diseases whereas traffic accidents are the main cause
in the other age groups6. Therefore, the factors that may explain
the good prognosis observed in the elderly are the trauma mechanism and
compensatory intracranial behaviour9.
In surgical series, EDH are more frequently located in the temporoparietal and
temporal regions as compared with other locations. In 2 to 5% of patients,
bilateral EDH are found and there seems to be a slight
predominance of right- sided EDH over left-sided lesions. In the elderly, most
AEDH cases developed in the parietal region, unlike younger patients. This site
of predilection can be attributed to the fact that, with increasing age, the
dura mater is more loosely attached to the inner table of the parietal bone
than elsewhere in the calvarium, and it is therefore more easily detached on
impact10. In our patient AEDH at right parietotemporooccipital
regions were the site of involvement
CONCLUSION
Acute Epidural Hematoma
(AEDH) in the geriatric population is a rare but potentially life-threatening
condition if not treated promptly. In elderly patients, the dura mater tends to
adhere more strongly to the inner surface of the skull, which reduces the
frequency of AEDH compared to younger individuals. However, trauma, such as
motor vehicle accidents, can still cause significant head injuries, as observed
in this case. Prompt diagnosis through imaging techniques, such as CT scans,
and immediate surgical intervention are crucial for improving clinical outcomes
in AEDH cases. In this particular case, the patient, who had AEDH in the parietotemporooccipital region, showed substantial
improvement following craniotomy and hematoma drainage. Although geriatric
patients may have better prognoses with early treatment, the difference in
injury mechanisms, like a higher incidence of falls, should be considered in
clinical decision-making.
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