New treatment to reduce risk of reoperation for subdural hematoma

After hitting the head or falling, especially older people, a dangerous situation can occur where blood and fluid can collect between the surface of the brain and the dura mater that protects the brain. When such ‘subdural hematoma’ or ‘subdural hemorrhage’ occurs, reoperation is often necessary, and a new treatment method has been developed to prevent this. This is the content reported by the health and medicine webzine ‘Health Day’ based on a paper by American researchers published in the New England Journal of Medicine (NEJM) on the 21st (local time).

Professor Jared Knofman (neurosurgery) at Weill Cornell Medical College, one of the lead authors of the paper, said, “This is important because there are many cases where the disease recurs again even after the blood is removed, requiring more surgery.” He emphasized, “This is a particularly difficult problem for elderly patients, who most commonly suffer from chronic subdural hematoma.”

The new treatment combines standard hematoma surgery with embolization (blocking) of the middle dural artery in the brain. In this procedure, a compound essentially attaches to and blocks the middle meningeal artery, eliminating the need for repeat surgery. The liquid embolic agent, called Onyx, is produced by Medtronic, which funded the new clinical trial.

Embolization is minimally invasive. A small catheter containing onyx is inserted into the middle meningeal artery through a blood vessel in the wrist or groin.

Researchers reported that in a clinical trial involving 400 patients with subdural hematoma treated at 39 medical centers in the United States, they found that a combination of surgery and embolization reduced the need for reoperation by nearly threefold. Patients, with an average age of 72 years, underwent standard hematoma surgery alone (203 patients) or a combination of standard surgery and Onyx embolization.

Among those who underwent standard hematoma surgery, 11.3% required a second surgery within 3 months. On the other hand, only 4% of people who received the combo procedure required reoperation.

Professor Knopman said that blocking the middle meningeal artery using Onyx was the key to improving results. “Not only have we demonstrated how the middle meningeal artery plays a role in the formation and recurrence of subdural hematomas, but we have discovered a completely new aspect of the brain that has been unknown and untreated for decades,” he explained.

Co-lead author Professor Jason Davis, a neurosurgeon at the University at Buffalo (UB) School of Medicine, pointed out that it is especially difficult to prevent hematoma rebleeding in elderly patients who are already taking blood thinners. He explained, “Patients with chronic subdural hematoma who are taking blood thinners are at greater risk because bleeding does not stop once it starts.”

The researchers explained that one in five hematomas become chronic and require multiple surgeries, which carries risks and costs. If left untreated, “these hematomas often grow larger over time and can be very irritating to the brain, putting more pressure on the brain and preventing it from functioning properly,” Professor Davis noted.

Professor Davis was confident that the new combo procedure would change the game. “We are changing subdural hematoma from a disease that typically requires multiple surgeries to a disease that can achieve better outcomes with a simple, minimally invasive procedure,” he said.

The paper can be found at the following link: