By Brenda L. Mooney
NEW YORK — Over the next 15 years, chronic subdural hemorrhage (SDH) will become the most common adult brain condition requiring neurosurgical intervention in the United States, but healthcare systems may not be prepared to care for those patients, according to a new study.
The report, published online recently by the Journal of Neurosurgery, warns that hospitals — especially VA facilities — could be underequipped and understaffed with neurosurgeons to manage the projected increase in patients.
According to the study led by researchers at New York Harbor VAMC and the New York University Langone Medical Center, subdural hemorrhage, also known as subdural hematoma, is becoming more common in the elderly because of increased brain atrophy, greater use of anti-coagulant medications and thinning of the delicate vessels stretching between the surface of the brain and its coverings.
The result, according to study authors, is that even minor head injuries can result in bleeding on the surface of the brain that can accumulate over time and lead to serious complications. In fact, they pointed out, the trauma causing SDH often is so minor that patients have no history or memory of a head or brain trauma incident.
Researchers sought to quantify the future incidence rates for chronic SDH in both civilians and military veterans, who, along with patients with a history of alcohol abuse, are more likely to develop the condition.
To do that, they created a mathematical model after reviewing current data from VA hospital visits where SDHs were diagnosed, as well as civilian incidence rates from Finland and Japan, where accurate incidence records are available. The model, which accounts for age, gender and alcohol consumption, is designed to predict the incidence of SDH occurring from 2012-2040 as the population ages.
Records from 875,842 unique VAMC visits from 2000-2012 indicated that 695 new SDHs were identified, with 29% of these cases requiring a surgical drainage procedure. This translated to 79.4 SDHs per 100,000 veterans, with more than 70% of SDHs occurring in patients 65 years of age and older.
By 2030, when as many as 25% of U.S. residents will be older than 65, the incidence of chronic SDH will reach approximately 121.4 cases per 100,000 people in the VA population, compared to a current 79.4, and 17.6 cases per 100,000 people in the general U.S. population.
“This study suggests that the medical community, particularly those caring for our aging veterans, may need to dedicate more healthcare resources for the prevention and management of SDH,” said co-author Uzma Samadani, MD, PhD. “In 15 years, drainage for SDH will likely be the most common type of adult brain surgery performed, surpassing the number of operations required for brain tumors. If we can identify patients at risk and prevent brain atrophy from occurring as Americans age, we may be able to slow this trend. If not, we are going to need increased neurosurgical and rehabilitation capacity to manage these patients.”
Longer Hospital Stays
The study also indicated that patients with SDHs are likely to require longer hospital stays and will need more intensive physical therapy and rehabilitation than other cranial surgery patients.
“We have a very large population of elderly, and the last of the 77 million baby boomers will have turned 65 by 2030. We can anticipate that 60,000 Americans per year will develop chronic SDHs. Knowing what is ahead of us gives us time to prepare,” Samadani pointed out.
“The incidence of chronic SDH is rising; SDH is projected to become the most common cranial neurosurgical condition among adults by the year 2030,” study authors concluded.
Not all SDHs require treatment in a surgical suite, however.
In a 2013 article published in the journal Neurological Research, Samadani and her co-authors discussed the surgical treatment of the condition over a 10-year period at the Manhattan facility. Patients who had bedside treatment with a new drainage technique generally improved and were out of the hospital more quickly than those who had traditional surgery.2
Samadani introduced the use of the Subdural Evacuating Port System for selected patients with chronic subdural hematomas in 2008. The purpose of this procedure is to drain blood that has pooled on the brain’s surface using a hermetically-sealed system so the possibility for infection is minimized. The device can be used with locally injected numbing medication or very minimal sedation rather than moderate sedation or anesthesia, which can be safer for the older patient population most likely to have chronic subdural hematoma.
“In the older and more delicate patient, less is generally better.” Samadani said, “less surgery, less anesthesia.”
1 Balser D, Farooq S, Mehmood T, Reyes M, Samadani U. Actual and projected incidence rates for chronic subdural hematomas in United States Veterans Administration and civilian populations. J Neurosurg. 2015 Mar 20:1-7. [Epub ahead of print] PubMed PMID: 25794342.
2 Balser D, Rodgers SD, Johnson B, Shi C, Tabak E, Samadani U. Evolving management of symptomatic chronic subdural hematoma: experience of a single institution and review of the literature. Neurol Res. 2013 Apr;35(3):233-42. doi:10.1179/1743132813Y.0000000166. Review. PubMed PMID: 23485050.