Subdural Haemorrhage and MMA embolisation
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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.
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Subdural Haemorrhage and MMA embolisation
- 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
- 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
- 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
- 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.