Luigi P. Gonzales, BS
Medical Student MS4
University of California, Irvine School of Medicine
Irvine, California, United States
Ivy Ren, MD
Resident Physician
Mount Sinai Hospital
New York, New York, United States
Kaitlyn Wilkey, DO
TBI Fellow
The Mount Sinai Hospital-NYC
New york city, New York, United States
Alyssa M. Volmrich, MD
Assistant Professor
Icahn School of Medicine at Mount Sinai
New York, New York, United States
74-year-old male with normal pressure hydrocephalus and ventriculoperitoneal shunt presented after a fall and acute history of difficulty ambulating. Imaging revealed bilateral acute on chronic subdural hematomas (cSDH). He underwent subdural evacuation portal shunt (SEPS) placement and middle meningeal artery embolization (MMAE). Repeat imaging showed decrease in size of the right cSDH and left cSDH. Patient was stabilized and discharged to acute rehabilitation where he made significant improvements in function and cognition.
80-year-old male with bilateral cSDH presented after a head strike and acute history of motor decline. He underwent SEPS and MMAE without complications and was discharged to acute rehabilitation within one-week post-procedure. Initial assessment from the therapy team deemed the patient to have promising prognosis for functional and cognitive recovery.
Discussions:
We present two patients who underwent less-invasive treatments of cSDH. SEPS placement is a variant of the craniostomy that involves placing a hollow screw attached to a sealed drainage system. One study demonstrated that SEPS was noninferior to craniotomy at reducing cSDH and was associated with decreased length of stay and occurrence of postoperative seizures. MMAE is a procedure that utilizes trans-arterial catheters to occlude the arterial supply to the dura. Studies found that standalone MMAE has similar clinical and radiographic outcomes compared to MMAE combined with craniotomy for management of cSDH, suggesting its potential as a viable first-line treatment. These less-invasive treatment alternatives allow patients to have a smooth transition from the acute care setting to the rehabilitation unit without the risks involved in craniotomies. Physiatrists should be wary of worsening symptoms or recurrence in patients with cSDH and have these less-invasive treatments in mind when consulting neurosurgery.
Conclusions: Physiatrists treating post-stroke patients should be familiar with less-invasive treatment modalities for cSDH, such as SEPS and MMAE, especially when referring patients to neurosurgery.
