Subdural Haemorrhage and MMA embolisation

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
@celiabradfordCopyrights apply

6. DR CELIA BRADFORD
@celiabradford
ACUTESDH
•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. Typicallya 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
RISKSPRESENTATION
•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 oldman 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
@celiabradfordSUBDURAL 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 NeuroInterventionalSurgery
June 2021

22. DR CELIA BRADFORD
@celiabradford
Methods
•Inclusion criteria
•≥3 patients undergoing MMAefor 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
•cSDHrecurrence
•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 cSDHafter prior surgical (47.8%)
•Follow up
•Range 1.5 –26.3 months
•Embolisationmaterial
•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)
cSDHrecurrence4.8% (3.2-6.5%)21.5% (0.6 –42.4%)
In-hospital complications1.7% (0.8 –2.6%)4.9% (2.8 –7.1%)
Surgical rescue4.4% (2.8 –5.9%)16.4% (5.95 –27.0%)
Favourable mRSscore 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.