Dear Editor,
As India’s elderly population expands, anesthesiologists are increasingly tasked with managing neurosurgical emergencies in frail individuals with reduced physiological reserve. Chronic subdural hematoma (cSDH) in this group carries recurrence rates of up to 70%, with reoperation rates of 10%–20%.[1] While burr-hole evacuation under general anesthesia (GA) is the standard treatment, it may not always be ideal for frail patients. Frailty, marked by a diminished ability to maintain homeostasis under stress, heightens the risk of poor postoperative outcomes. Middle meningeal artery embolization (MMAE) has recently emerged as a minimally invasive alternative, often performed under local anesthesia (LA).[2]
We managed two elderly patients in whom frailty-guided anesthetic decision-making led to a shift from surgical to endovascular intervention. Their clinical details, intraoperative challenges, and outcomes are summarized in Table 1. Both experienced recurrences following initial GA-based surgical evacuation and subsequently underwent successful MMAE under LA without complications.
Table 1.
Clinical summary of two elderly patients with chronic subdural hematoma managed with frailty-informed anesthetic planning and middle meningeal artery embolization
| Patient | Age/Sex | Comorbidities | Preoperative GCS | Diagnosis and Initial Procedure | Mode of Injury | Anesthetic Course | Recurrence | mFI-5 Score | Definitive Management | Outcome |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 72/M | Hypertension, diabetes, prior coronary angioplasty (on Aspirin 75 mg HS) | E4V5M6 with right hemiparesis | Right fronto-temporo-parietal chronic SDH; minicraniotomy under GA | Fall | Intraop hypotension requiring vasopressors; ICU admission | Yes (1 month later), with GCS E3V4M5 and right-sided weakness | 2 | Bilateral MMA embolization under LA | Discharged on day 2; complete recovery at 3 months with GOSE 8 |
| 2 | 94/M | Prior stroke (not on antiplatelets), dementia, fixed flexion deformity | E3V1M5 | Left fronto-temporo-parietal chronic SDH; burr-hole evacuation under GA | Spontaneous | Difficult airway; intraop hypotension requiring vasopressors | Yes (post-op day 2); drowsiness with drop in GCS from E4V2M6 to E3V1M5 | 3 | Bilateral MMA embolization under LA | Neurologically intact at discharge with discharge GOSE 6 |
M=Male; HS: at bedtime; GCS=Glasgow coma scale score; GA=general anesthesia; ICU=intensive care unit; mfI-5=modified frailty index, MMA=middle meningeal artery, LA=local anesthesia; GOSE=Glasgow outcome scale extended
Data show that frail and prefrail patients aged >70 have a >15% chance of intraoperative hypotension during elective surgeries, with over 25% developing hypotension at induction.[3] Frailty is linked not just with incidence but also with prolonged duration of hypotension—a predictor of adverse outcomes in neurosurgical patients. Sustained mean arterial pressures <65 mmHg increase the risk of stroke, myocardial injury, acute kidney injury, and mortality.[4] Despite growing recognition of frailty as a critical risk factor, it is rarely considered in emergency anesthesia decision-making. Tools such as the modified frailty index-5 offer rapid frailty assessment even in urgent scenarios.
While prehabilitation can help mitigate risk in elective cases, such strategies are not feasible in emergencies like cSDH, where patients may be obtunded and require rapid intervention. Recent reviews on frailty in neuroanesthesia emphasize its prognostic relevance in surgical cSDH,[5] but largely overlook alternative treatment pathways. MMAE, which targets the neovasculature supplying the subdural membranes, offers a pathophysiologically rational and technically safe alternative. Importantly, it can be performed under LA, bypassing the hemodynamic and cognitive risks of GA in the frail elderly. While previously mainly reserved for recurrence, evidence is growing for its use in selected primary cases.
Though no prospective trials currently exist, recent population-level data suggest that frailty may have a lower prognostic impact on outcomes following MMAE than surgical evacuation, with the Risk Analysis Index showing lower effect sizes and poorer discrimination for worse outcomes in the MMAE-only group, implying that frail patients may fare better with this less invasive approach.[2] However, frailty-specific comparisons remain limited, and this gap in evidence persists. Until more definitive data are available, anesthesiologists should advocate for frailty screening and consider LA-based strategies like MMAE to tailor care for high-risk elderly patients.
List of abbreviations
| Abbreviation | Definition |
|---|---|
| cSDH | Chronic subdural haematoma |
| GA | General anaesthesia |
| MMAE | Middle meningeal artery embolization |
| LA | Local anaesthesia |
| mFI | Modified frailty index |
Contributions
| Role | Dr. Prachi Sharma | Dr. Ashoo Wadehra | Dr. Kavita Sandhu |
|---|---|---|---|
| Concepts | ✓ | ✓ | ✓ |
| Design | ✓ | ✓ | |
| Definition of intellectual content | ✓ | ✓ | ✓ |
| Literature search | ✓ | ✓ | |
| Clinical management | ✓ | ✓ | ✓ |
| Manuscript writing | ✓ | ||
| Manuscript editing and review | ✓ | ✓ | ✓ |
| Guarantor | ✓ |
Patient declaration of consent statement
Appropriate patient consent has been obtained.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
References
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