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Introduction: Welcome to UAB MedCast a continuing education podcast for medical professionals bringing knowledge to your world. Here's Melanie Cole.

Host: Subdural hematomas relatively common neurosurgical problem, most often affecting older patients. New, less invasive treatments for it are becoming more common but need to gain a little more traction in the medical community here to help us with that is my guest, Dr. Jesse Jones. He's an Assistant Professor and an Interventional Neuroradiologist at UAB. Dr. Jones, it's a pleasure to have you with us today. Tell us a little bit about subdural hematomas. This relatively common neurosurgical problem. Tell us a little bit about it.

Dr. Jones: Chronic subdurals are a major health problem. It's the most common adult neurosurgical diagnosis that we see, typically affects anywhere from 13 to 17 people per thousand patients. And it's a problem where it can be a bit insidious. You know, patients will present with sometimes nonspecific symptoms, anything from a fully progressive dementia to maybe a left or a right sided weakness, more frequent falls, problems keeping their sodium levels up, and eventually, sometimes after a much medical workup they're found to have these chronic blood collections on the surface of their brain.

Host: So what are some factors that might lead to it? Tell us a little bit about that and clinical presentation. How do we identify it?

Dr. Jones: Well, there's a couple of risk factors. The primary one would probably being falls. You know, as people get older, they're a little less sure on their feet and they fall more. Add to that, the fact that a lot of older people are taking blood thinners typically for issues with their heart or perhaps they've gotten a blood clot in their leg and they've been put on some sort of anticoagulation. Well, if you combine the more frequent falls with them being on blood thinners, it's a perfect setup for getting a subdural.

Host: So characterize them for us. Is it on a basis of their size and location, the amount of time elapsed since the inciting event, age of the patients, you already mentioned a little bit. Tell us a little bit about the presentation and how you identify it.

Dr. Jones: Well, it's typically found like how I mentioned before, people will present either after a fall, say they have a big fall where they get, you know, some blood on their face or their eye and they get a cat scan, you know, through the ED. They will initially get diagnosed with what's called an acute subdural meaning the blood has just formed. Now, depending on how severe that is, a lot, oftentimes they're just observed with the hope that the blood will go away on its own. And a lot of times it does. In the cases where the blood does not go away, it becomes what we call a chronic subdural and that kind of situation, what's happening is there's an interplay between some blood being resorbed, new blood vessels forming in that potential space there on the surface of the brain, and new ruptures occurring. And these ruptures are quite small, but they're frequent and they'll lead to a progressive cycle of bleeding and re healing and further bleeding. And that's really the base of a chronic subdural.

Host: So what's the role of imaging studies in the workup?

Dr. Jones: Well, imaging is key to the diagnosis. It's very difficult to diagnose a subdural based on symptoms alone. There are some good clues, like I alluded to earlier, but they're nonspecific and a lot of things in an older patient especially, can cause those sorts of symptoms. So a cat scan or a brain MRI. They're both good methods for diagnosing a subdural.

Host: And then if you do, what are some current issues in medical or surgical management? Assess for us what you would do once you figure out and detect what's going on.

Dr. Jones: Well, a lot of it has to do with the patient's symptoms. Some of these subdurals are quite small. If they're not causing any pressing issues, they're probably best to be left alone. It's when they start growing in size that we get concerned because as the size of the subdural grows, there's further mass effect upon the brain. And it's the mass effect that leads to the symptoms I described earlier. In addition to those patients often will have headaches, which can be a good presenting symptom or a good cue as something's going on in the head.

Host: And what would be your initial treatment? What's the first line of defense besides watchful waiting?

Dr. Jones: In a symptomatic subdural, it's time to start thinking about treatment and there's a few ways to go down. Some people experimented with drugs that will increase the clotting ability of the blood. Things like Amicar that is shown not to be very successful. And there's quite a few risks associated with that in terms of causing other disorders such as MIs or DVTs. So that's typically not a favor treatment modality at this time. And that pretty much exhausts that medical management. So now we move on to more aggressive forms of therapy and traditionally that's involved a surgical approach whereby either holes are drilled into the cranium to try to aspirate or suck out what blood is in there or a more invasive surgery where part of the bone is removed and the hematoma is evacuated in a more open fashion. The bone is placed back on again. Those are probably the two most common ways of dealing with the borough hole approach, which may or may not include adding a drain for some time on the surface of the brain to try to suck up some more of that fluid or a more open craniotomy.

Host: So what's the general prognosis if it's caught early enough and how have been your outcomes?

Dr. Jones: Well, surgery can be quite effective. The issue is that these patients are old and they have a lot of comorbidities. So surgery is a big deal and a lot of patients and the patients' families are nervous about going into that. Some other approaches that we've pursued, you know, because of the issues with major operations in older people, have been more minimally invasive approaches and that would include what's called an embolization. And an embolization is an approach where a patient can be either awake or asleep and we'd go into an artery of their leg and from that leg artery we can travel all the way up into the artery, kind of supplying or feeding the subdural, and close off those arteries specifically. And what that do over time has changed the balance between the bleeding tendency in the clotting tendency of the subdural over, I'd say about three weeks to a month get significant reduction in the size of the subdural.

Host: Do you feel Dr. Jones, as I said in my intro, that this needs to gain more traction in the medical community and why? Is this an underappreciated condition that older adults are coming up with?

Dr. Jones: Well, what I'd say is that this condition is pretty well known and it's quite common. The problem is that the treatments are, the newer treatments are not as well known. And so I think a lot of people in the community, you know, practitioners, doctors, nurses are probably aren't aware of embolization and the role it may have. I think that's something that we're trying to increase the awareness of in the community because like I say, it's a less invasive approach that could be a good option. People who may not be able to undergo a larger operation.

Host: So tell other providers what you'd like them to know about referral when you feel it's important that they refer to the experts at UAB medicine. If they're a primary care provider. And as you say, dealing with the comorbid conditions for these older patients. What would you like them to know about referral?

Dr. Jones: Well, I'd like them to know that we're there for them and we're always happy to see new patients, especially patients who pose particular difficulties outside their realm of practice. You know, we are a tertiary referral center. We see a lot of difficult cases here and we're always happy to help. I think in the particular case of the subdural in a patient who has other comorbidities which make them medically complex. That's a great indication for referral because we have a team of doctors here including surgeons and interventionists who meet in a multidisciplinary approach and can find the right treatment for a particular patient.

Host: Do you have any final thoughts you'd like to leave us with about subdural hematoma?

Dr. Jones: I'd just like people to know that embolization is an emerging option that is well fit to a specific group of patients with chronic subdurals and medical comorbidities, and I hope that more awareness can be brought to the community about this approach.

Host: Thank you so much Dr. Jones for joining us and sharing your expertise about this relatively common condition, but that does require a certain level of expertise to deal with. Thank you again. And a community physician can refer a patient to UAB medicine by calling the Mist line at 1-800-UAB-MIST. That wraps up this episode of UAB Med Cast. For more information on resources available at UAB Medicine. Please visit our website at UABmedicine.org/physician. Please also remember to subscribe, rate, and review this podcast and all the other UAB Medicine podcasts. Until next time, I'm Melanie Cole.