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Groundbreaking Procedure Speeds Recovery and Minimizes Risks in Treating Subdural Hematoma


Millions of people every year experience a head injury. Sometimes it results in just a small bump or bruise. But for others, head injuries can cause dangerous damage below the surface, because you may not realize a problem exists without a visible external injury.

That was the case for Judd Jones, an active 83-year-old business owner in Salt Lake City. One day after work, he was taking a shower when he slipped and fell.

"I fell on my derrière and really hurt myself," Judd says. "I guess my head bounced into the door, but I had no recollection of that; my bottom hurt, not my head."

More than a month later, he was working in the yard when one of his arms started to tingle. The numbness spread from his fingers into his neck and back, lasted about two or three minutes, then went away. He felt pretty normal otherwise and didn't want to worry his wife, so he didn't say anything at the time.

The following day, when he experienced the same numbness and tingling—this time in the other arm—he went into the house to tell his wife. While he was trying to explain it, his wife said he started "speaking gibberish." She worried he was having a stroke and immediately took him to the emergency room at University of Utah Hospital. Doctors ordered a CAT scan of the brain and discovered pockets of blood on both sides. They diagnosed him with a chronic subdural hematoma, most likely from that fall several weeks prior.

Subdural hematomas form when blood pools between the leathery covering of the brain (called the dura matter) and the brain itself, in an area called the subdural space. These hematomas are often the result of head trauma, such as a motor vehicle accident or a fall.

It's not uncommon for people—especially older patients—to fall without realizing they hit their head. Absent other serious injuries, they may not get checked until they experience symptoms that could include nausea, vomiting, numbness, tingling, headaches, seizures, or problems walking.

In most cases, when subdural hematoma is acute—meaning it occurs right after the initial trauma—the blood that accumulates does not require surgical intervention. If the size of the acute subdural hematoma is large, doctors perform emergency surgery to remove the blood and quickly relieve pressure on the brain. However, a significant number of patients don't experience symptoms until weeks after the traumatic brain injury. These patients often have chronic subdural hematomas.

In the case of Judd's subdural hematoma, it was chronic, so blood was slowly accumulating over time. Traditionally doctors drill hole(s) into the skull to drain the blood. Though the surgery is generally safe, there are always some risks, including infection, bleeding, and seizures. Blood can also re-accumulate after the drainage procedure, putting the patient and the physician back at square one.

Since Judd had two hematomas, a traditional approach would have required drilling holes on both sides of the skull to drain the blood. Ramesh Grandhi, MD, a neurosurgeon and the doctor who treated Judd, thought a groundbreaking new procedure called a middle meningeal arterial (MMA) embolization would be a better option than traditional brain surgery. The risk of complications from even one hole, doctors explained, was about 25 percent. By Judd's calculation, a 25 percent risk multiplied by four holes meant there was basically a 100 percent chance something could go wrong. His age also factored into the decision; while he was very healthy and active, anesthesia and surgery present additional risks for anyone over the age of 80.

When Grandhi presented him with the option to try MMA embolization, Judd agreed. The following morning, he arrived in the neurointerventional suite at the University Hospital, where neurosurgeons typically conduct procedures for patients with brain aneurysms and strokes. Over the last two years, Grandhi has also been performing minimally invasive MMA embolizations to treat subdural hematomas in the suite.

Grandhi began the image-guided procedure by inserting a thin needle into the groin artery. He brought a small tube called a catheter up to Judd's neck, and then used a tiny wire to access the artery that leads to the hematoma. After accessing the artery, Dr. Grandhi used embolic agents to block up the blood vessel, cutting off the blood supply to the hematoma. With the blood supply eliminated, the chronic subdural hematoma is essentially "starved," leaving the body to break it down over time. While the minimally invasive procedure certainly has its own risks, recent reports have shown it to be very safe and effective in experienced hands.

Grandhi performed the procedure twice on Judd, once on each side, with each session taking about one hour. Judd remembers being awake the whole time, then coming out of the suite for a short time before heading home. Besides being a little tired, he experienced no significant lasting effects. He came for regular follow-ups to make sure the hematoma was dissipating and has done well in his recovery.

Today, Judd is back to work at his construction company and enjoying maintaining his two acres of land. "I just think Dr. Grandhi did a fabulous job," he says. "To me, [the MMA embolization] was by far a better way to go."