Celia Bradford takes us through the latest on the management of subdural haemorrhage (SDH). She covers acute SDH, chronic SDH and middle meningeal artery embolisation, a novel treatment for chronic SDH management in certain circumstances.

1. DR CELIA BRADFORD
@celiabradford
SUBDURAL
HAEMORRHAGE
CODA CHANGE 2022
Neurocritical Care Workshop

2. DR CELIA BRADFORD
@celiabradford
OUTLINE
• ACUTE SDH
• CHRONIC SDH
• A NOVEL TREATMENT FOR CSDH
RADIOLOGY IMAGES:
my patients + radiopedia.org

3. DR CELIA BRADFORD
@celiabradford
ANATOMY

4. DR CELIA BRADFORD
@celiabradford

5. DR CELIA BRADFORD
@celiabradford
Copyrights apply

6. DR CELIA BRADFORD
@celiabradford
ACUTE SDH
• Acute SDH
• tearing of the veins
between the arachnoid
membranes and the dura
• Arterial rupture can also
result in SDH in
approximately 20 to 30
percent of SDH cases
• RADIOLOGY
• crescent-shaped
homogeneously
hyperdense extra-axial
collection

7. DR CELIA BRADFORD
@celiabradford
CAUSES
• Trauma: most common. Typically a blow to the side of
the head causing tearing of bridging veins. Up to 30%
will have a component of arterial bleeding
• Young people: SDH develop usually after significant
trauma
• Older people: minimal trauma can result in bleed due to
cerebral atrophy and tearing of bridging veins
• OTHER CAUSES (rare)
• Cerebral aneurysm *Intracranial hypotension
• Malignancy *AVM

8. DR CELIA BRADFORD
@celiabradford
RISKS PRESENTATION
• TRAUMA
• FALLS
• >65 YEARS
• ANTICOAGULANTS/ANTI-
PLATELETS
• Headache, confusion,
cognitive decline
• Nausea, vomiting
• Ataxia
• Weakness
• Paraesthesia
• Headache

9. DR CELIA BRADFORD
@celiabradford
Radiological progression

10. DR CELIA BRADFORD
@celiabradford
CASE
• 77 year old man presents with
unsteady gait.
• He reports being fit and well and does
a daily ‘work-out’ consisting of a
shaolin body conditioning, where he
strikes parts of his body with a
bamboo brush to improve health and
circulation.
• He strikes each side of his head
during the workout

11. DR CELIA BRADFORD
@celiabradford

12. DR CELIA BRADFORD
@celiabradford
CHRONIC SDH
• Following acute SDH,
• blood resorption begins with breakdown of erythrocytes and
other cellular components.
• collagen synthesis is induced, and fibroblasts spread over the
inner surface of the dura to form a thick outer membrane.
• Subsequently, a thinner inner membrane develops,
resulting in complete encapsulation of the clot. This
process typically occurs over a time course of
approximately two weeks

13. DR CELIA BRADFORD
@celiabradford

14. DR CELIA BRADFORD
@celiabradford
ACUTE ON CHRONIC SUBDURAL
Case courtesy of Dr Sandeep Bhuta,
Radiopaedia.org, rID: 4833

15. DR CELIA BRADFORD
@celiabradford
SUBDURAL HYGROMA
Case courtesy of Dr
Karina Dorfman,
Radiopaedia.org, rID:
77527

16. DR CELIA BRADFORD
@celiabradford
MANAGEMENT
• ACUTE SDH: trauma craniotomy for large bleed with
mass effect with clot evacuation +/- craniectomy.

17. DR CELIA BRADFORD
@celiabradford
MANAGEMENT CHRONIC SDH
• Medical
• Stop anticoagulants: give PCC if on
warfarin
• Stop antiplatelet agents:
• Role of AEDs
• Role of corticosteroids
• Neurological observation
• Surgical
• Indication
• Alternatives

18. DR CELIA BRADFORD
@celiabradford
Indications for surgery
• Clinical Features
• Dilated pupils
• Rapid deterioration in GCS >2 points
• Signs of ICH
• Imaging Features
• Clot thickness > 10mm
• MLS > 5mm
• Hydrocephalus or brainstem compression

19. DR CELIA BRADFORD
@celiabradford
TIMING OF SURGERY
• If none of the above criteria; patient can be observed
for clinical deterioration
• Non-operative management may be appropriate
• Waiting several weeks makes surgery easier

20. DR CELIA BRADFORD
@celiabradford
Alternatives to surgery
• MMA embolization

21. DR CELIA BRADFORD
@celiabradford
Journal of NeuroInterventional Surgery
June 2021

22. DR CELIA BRADFORD
@celiabradford
Methods
• Inclusion criteria
• ≥3 patients undergoing MMAe for cSDH
• Post-embolization outcomes data reported on cSDH
recurrence
• English language
• Excluded:
• Review articles, letters, editorials, comments, case reports,
technical reports
• Articles with insufficient surgical outcomes data
• Articles with overlapping published data in more recent series

23. DR CELIA BRADFORD
@celiabradford
Outcomes
• Primary outcome
• cSDH recurrence
• Secondary outcomes
• Need for surgical rescue
• In-hospital complications
• Favourable outcome

24. DR CELIA BRADFORD
@celiabradford
Results
• 20 studies, 1416 patients
• 5 double arm studies (902 pts) [Conventional vs
MMAe +/- surg]
• 15 single arm studies (514 pts)
• Most based in Japan (8), USA (7), Korea (2),
France (2), China (1)
• Indication
• Upfront (28.4%), Adjunct after surgical
evacuation (23.2%), Recurrent cSDH after prior
surgical (47.8%)
• Follow up
• Range 1.5 – 26.3 months
• Embolisation material
• Particles (403), liquid (143), coils (171), micro-
spheres (86), Onyx (80)

25. DR CELIA BRADFORD
@celiabradford
Pooled outcomes data
• :
• :
• :
• :
MMAe (n=714)
Rate (95% CI)
Conventional management
(n=698)
Rate (95% CI)
cSDH recurrence 4.8% (3.2-6.5%) 21.5% (0.6 – 42.4%)
In-hospital complications 1.7% (0.8 – 2.6%) 4.9% (2.8 – 7.1%)
Surgical rescue 4.4% (2.8 – 5.9%) 16.4% (5.95 – 27.0%)
Favourable mRS score 0-2 at last
follow up
72.8% (46.3 – 99.2%) 92.3% (10.8 – 100%)

26. DR CELIA BRADFORD
@celiabradford
Adult patient presenting with a mixed density, chronic, left subdural hematoma with associated
local mass effect (A).
David Fiorella, and Adam S Arthur J NeuroIntervent Surg 2019;11:912-915
Copyright © Society of NeuroInterventional Surgery. All rights reserved.