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Solving Brain Bleeds in the Elderly

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Wednesday, November 13, 2019 - 08:30

By Philip E. Stieg, Ph.D., M.D.
Neurosurgeon-in-Chief

When former president Jimmy Carter was hospitalized this week to treat pressure on his brain from bleeding, it brought to light a common condition that holds a special danger for the elderly. It also brings up the topic of minimally invasive surgical approaches, and why our aging population in particular can benefit from them.

The kind of trips and falls that the elderly typically suffer are not common in other individuals – young people may slip on icy pavements or trip over unseen obstacles, but for the most part they have good balance and vision and tend to stay upright. In older patients, however, a combination of poor balance and aging eyes leads to more falls. These falls can be devastating – the dangers of a broken hip are well known, but the effects of even a minor brain bleed can be insidious.

A major fall resulting in an acute bleed may be diagnosed and treated quickly, but tiny bleeds may not even be apparent when they begin. We lose brain volume as we age, so older people have space between the brain and skull that isn’t there in younger people with full, plump brains that completely fill the skull. Bridging the space forces delicate blood vessels to stretch and become vulnerable to minor injuries, so even an insignificant head bump into a cabinet door can cause a small bleed that goes unnoticed when it happens.

Over time, especially after multiple bumps, the blood forms a pool between the brain and its outer covering (the dura) called a chronic (as opposed to acute) subdural hematoma. The hematoma puts pressure on the brain, leading to symptoms that include headache, nausea, confusion, dizziness, drowsiness, even seizures. Left untreated, some chronic subdural hematomas can lead to death.

Until recently, unless a subdural hematoma was life-threatening, the surgical risk of repairing it often outweighed the potential benefit. Even the heartiest 90-year-old may not be a great candidate for open brain surgery. But thanks to new technology, advanced training, and pioneering surgeons, we can offer older patients a minimally invasive treatment that doesn’t involve major brain surgery.

Dr. Jared Knopman here at the Weill Cornell Medicine Brain and Spine Center has become the go-to neurosurgeon in New York for middle meningeal arterial (MMA) embolization for chronic subdural hematomas. That technique fixes a bleed from inside the bleeding vessel. To perform it, a specially trained neurosurgeon or interventional neuroradiologist makes a tiny incision in the upper thigh, then threads a microcatheter into the arteries feeding the subdural hematoma. Once the catheter is in position, the surgeon uses it to cut off the blood supply to the hematoma. (Read more about the procedure.)

It’s a high-tech approach that was derived from years of experience in using image-guided cerebrovascular treatments – experience that not all surgeons have – but most importantly it is much less risky than a full open surgical procedure. For an elderly patient experiencing the effects of a subdural hematoma, this minimally invasive option can quite literally be the difference between life and death.  (More about MMA embolization.)

I recently spoke with Dr. Knopman, along with one of the first patients to undergo the minimally invasive procedure, on my podcast, This Is Your Brain. Listen to the episode below to hear more about subdurals and how to repair them without open surgery.