Meeting the Rising Tide of Chronic Subdural Hematoma with Evolving Procedural Options

Chronic subdural hematoma (cSDH) is the most common neurosurgical condition affecting older adults — and its incidence continues to rise rapidly as the population ages.¹ Researchers predict that within the next decade the growth in cSDH frequency will place increasing strain on neurosurgical services and healthcare systems worldwide.

As clinicians seek safe, long-lasting solutions for an often frail patient population, emerging minimally invasive approaches such as middle meningeal artery (MMA) embolization have shown promise, and multiple large, randomized trials are currently underway.²

What Is a Subdural Hematoma?

A subdural hematoma (SDH) occurs when blood accumulates between the dura mater — the protective layers that surround your brain — and the surface of the brain. This abnormal collection of blood damages cells in the brain lining, causing inflammation and excessive cell growth.

While acute SDH is commonly caused by traumatic injury, older adults experience much higher rates of chronic subdural hematomas than the general population.^1,3 Age-related brain atrophy stretches bridging veins, making them more susceptible to rupture, even after minor or unnoticed trauma, leading to gradual symptom onset.⁴

SDH Signs and Symptoms

Symptoms may appear immediately, or develop gradually in the case of cSDH. Presentation varies depending on hematoma size and location but may include:⁴

• Confusion or coma
• Decreased memory
• Problem speaking or swallowing
• Balance or walking problems
• Drowsiness
• Headache
• Seizures
• Weakness or numbness of arms, legs or face
• Nausea/Vomiting
• Aphasia, a language disorder that impacts communication
• Visual difficulties
• Pupil size
• Ringing sound in the ears

The Growing Incidence of Chronic Subdural Hematoma

Chronic subdural hematoma is the most common neurosurgical diagnosis in seniors, with incidence increasing in parallel with life expectancy. Recurrence of the disease is common even with conventional management.² Researchers estimate that by the end of the decade, cSDH will become the most common craniosurgical disease worldwide.² In recent years, middle meningeal artery (MMA) embolization has shown promise in reducing recurrence and minimizing the need for repeat surgeries.² Procedural volumes are projected to exceed 140,000 cases annually in older adults — potentially outpacing even large vessel stroke cases — underscoring the need for scalable, minimally invasive options.¹

SDH Management Options

• MMA Embolization
  MMA embolization targets the vascular supply responsible for sustaining and recurring chronic subdural hematomas (cSDH). The MMA provides blood supply to the dura mater and feeds the membrane capillaries supplying the cSDH. This minimally invasive procedure blocks blood flow to this region, ultimately allowing the hematoma to be absorbed and decrease in size. The procedure is performed endovascularly, typically via femoral or radial artery access. Under fluoroscopic guidance, a microcatheter is navigated to the MMA, where embolic materials are deployed to close off the artery, helping in hematoma resolution.⁵

  Types of embolics include:

  • Platinum coils
  • Particulate embolics
  • Liquid embolic agents

MMA embolization is increasingly used as a primary option, adjunct to surgery, or prophylactic approach following burr hole drainage.

• Craniotomy
  This surgical procedure involves the removal of a section of the skull to access and extract the hematoma.⁵ The surgeon makes a cut through the scalp to expose the bone. A high-speed drill and saw may be used to cut a portion of the bone to access the brain, which is usually placed back in place at the end of the procedure.⁶
  
• Burr Hole Craniostomy
  Burr hole drainage is the most commonly used surgical intervention for cSDH. During this surgical procedure, one or more small holes are drilled into the skull. A tube is then inserted through the hole to help remove the blood. A subdural drainage system is often employed during the postoperative period.⁵
  

Case Study: Successful MMA Embolization for Chronic Subdural Hematoma

Dr. Allison Strickland, MD, a dual-trained neurosurgeon at University of Mississippi Medical Center in Jackson, MS, shares a case of a bilateral middle meningeal artery (MMA) embolization of a 60-year-old male patient with chronic subdural hematoma.

Case Presentation

A 60-year-old male with HIV and poor functional baseline presented to the emergency department with new onset seizures. A CT of the head demonstrated large acute on chronic right-sided subdural hematoma and small chronic left-sided subdural hematoma. Patient was not a candidate for open surgery, and was taken for bilateral middle meningeal artery embolization with SwiftPAC™.

Intervention

Access was obtained using the BENCHMARK™ 071 access catheter. The MIDWAY™ 43 delivery catheter was advanced over a 10-system microcatheter and an 0.014” guidewire into the right MMA. Bilateral MMA embolization was performed by placing one 10 cm SwiftPAC Packing Coil and one 15 cm SwiftPAC Packing Coil in the right MMA. The procedure was repeated on the left side with one 20 cm SwiftPAC Packing Coil and one 1 mm x 5 cm SwiftSET™ Coil were placed in the left MMA.