Endovascular Embolisation For Chronic Subdural Hematomas: A Powerful New Tool

The term Chronic Subdural Hematoma (c-SDH) refers to the collection of blood on the brain’s surface, under the outer covering of the brain - the dura mater. Recent research has shown that recurrent episodes of bleeding occur from dysfunctional junctional cells in the dura, resulting in the formation of a c-SDH. C-SDH is known as ‘the great mimicker’, as it can present with myriad symptomatology such as headaches, cognitive decline, nerve palsies or can be life-threatening in case of large hematomas. This in turn can lead to life-threatening mass effects on the underlying brain.

Recently, a 72-year-old  Kishan Bedi (name changed), came with headaches. His scans revealed bilateral collections of blood on the surface of the brain, which were confirmed on MRI to be Chronic Subdural Hematomas (c-SDH). He was symptomatic, however did not merit surgery as the hematomas were not very large.

The treatment of c-SDH has traditionally been a surgical evacuation of the hematoma, however, studies have shown that this is associated with a recurrence rate varying from 25-40 per cent. An exciting new development in the field of NeuroInterventional Radiology is showing tremendous promise in reducing the recurring nature of these bleeds. The procedure, termed Middle Meningeal Artery embolisation (MMA embolisation), involves threading a microcatheter into the artery which supplies the dura and injecting an agent (called an embolic agent) which devascularizes the dura, thereby preventing it from leaking into the subdural space. The procedure is safe, technically easy and can be performed via the artery from the wrist or the groin without the need for general anaesthesia. Initial studies have shown promising results, with the recurrence rates dropping by 25-40 per cent with the use of MMA embolisation. In select cases, which do not need surgical evacuation of the clot, MMA embolisation can also be performed as a standalone procedure with excellent results.

Hence, with this background, Bedi underwent MMA embolisation. In less than three months, Bedi’s hematomas completely disappeared, and he has been completely relieved of his headaches. Even more importantly, the lurking threat of having a significantly large bleed into his brain has been addressed without the need for surgery.

Looking ahead, endovascular embolisation seems to be poised for inclusion as an important tool in the armamentarium of healthcare professionals for the treatment of c-SDHs. The idea of outpatient "daycare" operations also looms tantalisingly close, providing a look into a future with even more accessibility and convenience for patients.

The emergence of endovascular embolisation is an exciting new development in the treatment of c-SDHs.

The author is Senior Consultant-Interventional Radiology, Fortis Hospital Mulund

Dr Rajeev Sivasankar

Guest Author