Jan 24, 2023

How Embolization Solved Bilateral Subdural Hematomas in an 81-Year-Old Man

When an 81-year-old man arrived at the Emergency Department complaining of a severe headache, decreased appetite, nausea and confusion, a CT scan revealed bilateral chronic subdural hematomas – an unusual finding given that he hadn’t suffered a fall or other obvious head trauma.

The traditional treatment for chronic subdural hematomas is surgical drainage. But neurosurgeon Ryder Gwinn, MD referred the patient to Asif Khan, MD, for an innovative, minimally invasive procedure called middle meningeal arteryembolization. The Eastside Neuroscience Institute, a joint venture between Evergreen and Overlake, enables collaboration across the health systems and gives more Eastside patients convenient access to subspecialty expertise and state-of-the-art procedures like this one.

“We’ve found that in some cases middle meningeal arteryembolization can be as effective as surgical drainage,” Dr. Khan says. “It significantly reduces the risk of recurrence by blocking the blood flow causing the hematoma and it can be done under local anesthesia, which means most patients recover quickly and are discharged home within 12 hours.”

Stopping Subdural Hematomas at the Source

Surgical drainage requires general anesthesia and a three- to five-day hospital stay. But the fluid reaccumulates in up to 33% of patients who undergo this drainage, necessitating repeat intervention. Middle meningeal artery embolization improves on this by addressing subdural hematomas’ underlying cause.

“A subdural hemorrhage is basically a blood collection underneath the dura, and the middle meningeal artery supplies the whole dura,” Dr. Khan says. “When the subdural hematoma forms a membrane, it derives its blood supply from that artery. Embolizing the artery stops that supply of blood and accelerates blood absorption.”

Dr. Khan was one of the first physicians in the region to start performing middle meningeal artery embolization when it was developed several years ago. He and his colleagues now complete 40 to 50 of these procedures each year.

At the Eastside Neuroscience Institute, the procedure typically takes about an hour and is guided by biplane fluoroscopy, which uses real-time x-rays to help the interventional team navigate the arteries. Dr. Khan, Dustin Hayward, MD, and their colleagues guide a catheter through a small incision in the leg and up into the external carotid artery.

“Then we step down to a microcatheter so we can get into the middle meningeal artery, which is only about a millimeter in diameter,” Dr. Khan says.

At that point, the interventional team uses imaging to confirm that the artery doesn’t supply blood to any critical structures. Then the team uses the microcatheter to release microparticles that follow the blood stream and clog the capillary beds feeding the subdural hematoma.

Patients are typically up and walking within two hours of the procedure’s end and are often discharged within 12 hours.

“Surgical drainage is still appropriate when a patient has a massive subdural hematoma and needs emergent surgery to relieve compression on the brain,” Dr. Khan says. “But it can be combined with embolization to reduce recurrence and in most cases, embolization alone is appropriate because the recurrence rate is so much lower and the recovery is so much faster.”

Rapid Resolution of Symptoms

In the recent 81-year-old patient, Dr. Khan had to take the unusual step of embolizing both sides of the brain because of the patient’s bilateral subdural hematomas. The patient’s symptoms disappeared within a week, and imaging at his two-week follow-up appointment showed that both hematomas had decreased in size and stopped compressing the brain. The hematomas continued to shrink and had completely resolved by the patient’s nine-month follow-up.

“It took a little longer than usual because he had a very large fluid collection,” Dr. Khan says, “but he had an excellent outcome and even sent an email to thank the entire team for all the care he received starting in the ED, and to tell us that he was thrilled to be feeling better and back on the golf course.”

This illustrates how the Eastside Neuroscience Institute’s collaborative care benefits patients.

“Dr. Gwinn saw the benefit of embolization for this patient and sent him to me, and I do the same when I see patients who could benefit from things that I don’t directly offer,” Dr. Khan says. “That shows how the Institute has given people in the Eastside community – and beyond – access to more subspecialized doctors and the highly specialized services that leads to the best possible outcomes.”

In January 2022, the patient had large bilateral hematomas. Acute hemorrhage on the left looks similar to brain tissue; normal brain is demarcated via arrows.

The patient’s clinical symptoms resolved within one week. ACT scan at his two-week follow-up visit showed that both subdural hematomas had decreased in size.

By May, his right subdural hematoma was gone and his left was nearly gone.

At his nine-month follow-up, both subdural hematomas had completely resolved and his CT scan appeared normal.