Show notes
Brain Surgery Takes A Remarkable New Turn With Subdural Hematoma
Jared Knopman, MD is a board-certified neurosurgeon and interventional neuroradiologist who specializes in cerebrovascular disorders, including aneurysms, AVM’s, brain tumors, and carotid occlusive disease, as well as subdural hematomas.
This interview is another cutting-edge report from Weill-Cornell Brain and Spine, following the previous exceedingly interesting report using Ultrasound for Essential Tremor with Dr. Kaplitt here at CBJ/232.
Minimally Invasive - Without Opening The Skull
Dr. Knopman reports here on his considerable experience in the use of embolization of aneurysms and Arterial-Venous Malformations [AVM's] to prevent further bleeding and death. He is also deeply experienced in the use of carotid stenting/endarterectomy, and intra-arterial chemotherapy.
In addition, he performs spinal cord stimulation and microvascular decompression for chronic pain syndromes and trigeminal neuralgia. He is one of the few neurosurgeons in New York City with dual expertise in both open neurosurgical as well as minimally invasive interventional techniques for the treatment of neurologic disease, which affords him a unique perspective in determining the optimal treatment for each individual patient's needs using the most cutting-edge technologies.
Dr. Knopman has been named to the SuperDoctors Rising Stars list, a distinction afforded the top 2.5% of physicians in his field. His expertise is widely sought and he serves as a consultant to other neurosurgeons, traveling the country to assist them in their development of advanced stenting techniques with complex aneurysms.
Just What Is This New Vascular Procedure?
Until recently, most subdural hematomas that needed to be removed required open brain surgery, with its own risks and complications, but now there is a new minimally invasive approach to these dangerous vascular roadblocks, pioneered at Weill Cornell Medicine Brain and Spine Center. Known as an MMA1 embolization, this new procedure is performed by a surgeon with expertise in image-guided cerebrovascular treatments, who threads a microcatheter from a tiny needle into the upper thigh, up to the arteries feeding the hematoma, to cut off its blood supply.
Dr. Jared Knopman is the first and only neurosurgeon performing this procedure anywhere, and he is currently engaged in a clinical trial that is also yielding important new information about the nature of these clots.
Signs and Symptoms
Subdural hematoma symptoms typically include a headache, vomiting, drowsiness, dizziness, confusion, differing pupil size, slurred speech and eventual loss of consciousness. Symptoms may appear immediately, but in some cases, they can take weeks or even months to manifest, as was the case with Chicago White Sox pitcher Danny Farquhar, who collapsed in the dugout during a game April 20, was rushed to the hospital, diagnosed with an aneurysm and immediately operated on. (As of April 23, he was still in critical condition.)
Who Is Most Susceptible?
Elderly people are at highest risk for chronic subdural hematoma because brain shrinkage causes these tiny veins to be more stretched and more vulnerable to tearing. Seniors are also more susceptible to falling as they get older, and more likely to be on blood-thinning medications, which can contribute to hemorrhaging in case of trauma. Infants are also susceptible to falls, accidents or abuse that can cause a hematoma to form.
It can also occur spontaneously, in those with a history of alcohol use, or in individuals who have suffered multiple minor head injuries, none of which individually was serious enough to cause the hematoma.
Why This Procedure?
As Dr. Knopman explains, "Whenever we take out a subdural hematoma in the OR we notice that the membrane that surrounds it is very friable and oozy. There is an inflammatory process where the hematoma can keep bleeding and re-bleeding. You have to stop this vicious cycle."
In an open brain procedure, the surgeon removes the hematoma and cauterizes the membranes to stop the bleeding. "But we can only cauterize the membranes that we see," says Dr. Knopman. "A subdural hematoma can encompass half of the skull, and we only open up a small part to drain the blood. Also, 15 percent will recur because these membranes continue to ooze in the area that you can't shut down."
Three years ago, Dr. Knopman read a case report from physicians in Asia who endovascularly [within the vessel itself] embolized [caused a clot] the middle meningeal artery (MMA) in a patient who had a subdural hematoma that kept recurring after multiple surgeries to drain the blood. "It was a last-ditch effort to stop the bleeding and it worked," he reports.
The Evolution
Dr. Knopman built upon that concept and devised a procedure as an upfront alternative for patients who have subdural hematomas that would traditionally require surgery as a first-line treatment. He is the first physician worldwide to implement this. "This is the procedure that I offered Mr. Tanner [described in this interview]. We've performed it in dozens of patients since then. Instead of going to surgery as a first step, in a select group of patients, we embolize the MMA to see if the hematoma will disappear on its own."
In MMA embolization, a neurosurgeon with expertise in image-guided cerebrovascular treatments threads a microcatheter from a tiny needle stick in the upper thigh and into the arteries feeding the subdural hematoma, then cuts off its blood supply. The success of the approach upends one of the basic understandings of subdural hematomas, which have long been previously described as venous (meaning that they are created from and supplied by blood from veins, not arteries).
Successfully treating a subdural hematoma using MMA embolization is evidence for arterial involvement in these blood pools.
Photo from Weill-Cornell website
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Thanks
Thanks, Dr. Knopman, for joining us here at CBJ to review these remarkably progressive interventions that portend dramatically improved outcomes for subdural hematomas.
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