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Kan P, Fiorella D, Dabus G, Samaniego EA, Lanzino G, Siddiqui AH, Chen H, Khalessi AA, Pereira VM, Fifi JT, Bain MD, Colby GP, Wakhloo AK, Arthur AS. ARISE I Consensus Statement on the Management of Chronic Subdural Hematoma. Stroke 2024; 55:1438-1448. [PMID: 38648281 DOI: 10.1161/strokeaha.123.044129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/10/2024] [Indexed: 04/25/2024]
Abstract
ARISE (Aneurysm/AVM/cSDH Roundtable Discussion With Industry and Stroke Experts) organized a one-and-a-half day meeting and workshop and brought together representatives from academia, industry, and government to discuss the most promising approaches to improve outcomes for patients with chronic subdural hematoma (cSDH). The emerging role of middle meningeal artery embolization in clinical practice and the design of current and potential future trials were the primary focuses of discussion. Existing evidence for imaging, indications, agents, and techniques was reviewed, and areas of priority for study and key questions surrounding the development of new and existing treatments for cSDH were identified. Multiple randomized, controlled trials have met their primary efficacy end points, providing high-level evidence that middle meningeal artery embolization is a potent adjunctive therapy to the standard (surgical and nonsurgical) management of neurologically stable cSDH patients in terms of reducing rates of disease recurrence. Pooled data analyses following the formal conclusion and publication of these trials will form a robust foundation upon which guidelines can be strengthened for cSDH treatment modalities and optimal patient selection, as well as delineate future lines of investigation.
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Affiliation(s)
- Peter Kan
- Department of Neurosurgery, The University of Texas Medical Branch, Galveston (P.K.)
| | - David Fiorella
- Department of Neurosurgery, Stony Brook University, NY (D.F.)
| | - Guilherme Dabus
- Interventional Neuroradiology and Neuroendovascular Surgery, Miami Neuroscience Institute and Miami Cardiac and Vascular Institute-Baptist Hospital, FL (G.D.)
| | - Edgar A Samaniego
- Department of Neurology, The University of Iowa Hospitals and Clinics (E.A.S.)
| | | | - Adnan H Siddiqui
- Department of Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, NY (A.H.S.)
| | - Huanwen Chen
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (H.C.)
| | - Alexander A Khalessi
- Department of Neurological Surgery, University of California, San Diego, La Jolla (A.A.K.)
| | - Vitor Mendes Pereira
- Division of Neuroradiology, Department of Medical Imaging and Division of Neurosurgery, Department of Surgery, University Health Network, Toronto Western Hospital, ON, Canada (V.M.P.)
| | - Johanna T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.)
| | - Mark D Bain
- Cerebrovascular Center, Departments of Neurology and Neurosurgery, Neurological Institute, Cleveland Clinic Foundation, OH (M.D.B.)
| | - Geoffrey P Colby
- Department of Neurosurgery, University of California Los Angeles David Geffen School of Medicine (G.P.C.)
| | - Ajay K Wakhloo
- Department of Interventional Neuroradiology, Lahey Hospital & Medical Center, Burlington, MA (A.K.W.)
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis (A.S.A.)
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Ellens NR, Schartz D, Kohli G, Rahmani R, Akkipeddi SMK, Mattingly TK, Bhalla T, Bender MT. Safety and efficacy comparison of embolic agents for middle meningeal artery embolization for chronic subdural hematoma. J Cerebrovasc Endovasc Neurosurg 2024; 26:11-22. [PMID: 37828746 PMCID: PMC10995466 DOI: 10.7461/jcen.2023.e2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/26/2023] [Accepted: 08/03/2023] [Indexed: 10/14/2023] Open
Abstract
OBJECTIVE To perform a systematic review and meta-analysis evaluating the efficacy of middle meningeal artery embolization in terms of both clinical and radiographic outcomes, when performed with different embolic agents. METHODS A systematic literature review and meta-analysis was performed to evaluate the impact of embolic agents on outcomes for middle meningeal artery (MMA) embolization. The use of polyvinyl alcohol (PVA) with or without (±) coils, N-butyl cyanoacrylate (n-BCA) ± coils, and Onyx alone were separately evaluated. Primary outcome measures were recurrence, the need for surgical rescue and in-hospital periprocedural complications. RESULTS Thirty-one studies were identified with a total of 1,134 patients, with 786 receiving PVA, 167 receiving n-BCA, and 181 patients receiving Onyx. There was no difference in the recurrence rate (5.5% for PVA, 4.5% for n-BCA, and 6.5% for Onyx, with P=0.71) or need for surgical rescue (5.0% for PVA, 4.0% for n-BCA, and 6.9% for Onyx, with P=0.89) based on the embolic agent. Procedural complications also did not differ between embolic agents (1.8% for PVA, 3.6% for n-BCA, and 1.6% for Onyx, with P=0.48). CONCLUSIONS Rates of recurrence, need for surgical rescue, and periprocedural complication following MMA embolization are not impacted by the type of embolic agent utilized. Ongoing clinical trials may be used to further investigate these findings.
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Affiliation(s)
- Nathaniel R. Ellens
- Department of Neurosurgery, University of Rochester Medical Center, New York, USA
| | - Derrek Schartz
- Department of Imaging Sciences, University of Rochester Medical Center, New York, USA
| | - Gurkirat Kohli
- Department of Neurosurgery, University of Rochester Medical Center, New York, USA
| | - Redi Rahmani
- Department of Neurosurgery, University of Rochester Medical Center, New York, USA
| | | | - Thomas K. Mattingly
- Department of Neurosurgery, University of Rochester Medical Center, New York, USA
| | - Tarun Bhalla
- Department of Neurosurgery, University of Rochester Medical Center, New York, USA
| | - Matthew T. Bender
- Department of Neurosurgery, University of Rochester Medical Center, New York, USA
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Palmer B, Campbell M, Maertz K, Narigon L, Herzing K, Santry H, Boyce W, Narayanan R, Patel A. Analysis of middle meningeal artery embolization for the treatment of chronic, acute on chronic, and subacute subdural hematomas. Surg Neurol Int 2024; 15:71. [PMID: 38468652 PMCID: PMC10927174 DOI: 10.25259/sni_607_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 02/07/2024] [Indexed: 03/13/2024] Open
Abstract
Background Chronic subdural hematoma (cSDH) is a common sequela of traumatic brain injury. Middle meningeal artery embolization (MMAE) has shown promising results as an emerging minimally invasive alternative treatment. The purpose of this study is to examine the safety and efficacy of MMAE performed in patients with cSDH, acute-on-chronic, and subacute SDH with a traumatic etiology. Methods This retrospective study included cases performed at a Level II Trauma Center between January 2019 and December 2020 for MMAE of cSDHs. Data collected included patient demographic characteristics and comorbidities, SDH characteristics, complications, and efficacy outcomes. The lesion measurements were collected before the procedure, 4-6 weeks and 3-6 months post-procedure. Results In our patient population, 78% (39) either had lesions improve or completely resolved. The sample included 50 patients with a mean age of 74 years old. Statistically significant reductions in lesion size were found from pre- to post-procedure in the left lesions, right lesions, and midline shifts. The left lesions decreased from 13.88 ± 5.70 mm to 3.19 ± 4.89 mm at 3-6 months with P < 0.001. The right lesions decreased from 13.74 ± 5.28 mm to 4.93 ± 7.46 mm at 3-6 months with P = 0.02. Midline shifts decreased from 3.78 ± 3.98 mm to 0.48 ± 1.31 mm at 3-6 months with P = 0.02. No complications were experienced for bleeding, hematoma, worsening SDH, pseudoaneurysm, or stroke. Conclusion Our pilot study from a single center utilizing MMAE demonstrates that MMAE is successful without increasing treatment-related complications not only for cSDH but also in acute-on-cSDH and SDH with a subacute component.
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Affiliation(s)
- Brandi Palmer
- Department of Trauma and Acute Care Surgery, Kettering Health Main Campus, Kettering, Ohio, United States
| | - Melody Campbell
- Department of Trauma and Acute Care Surgery, Kettering Health Main Campus, Kettering, Ohio, United States
| | - Kellie Maertz
- Department of Trauma and Acute Care Surgery, Kettering Health Main Campus, Kettering, Ohio, United States
| | - Laurie Narigon
- Department of Trauma and Acute Care Surgery, Kettering Health Main Campus, Kettering, Ohio, United States
| | - Karen Herzing
- Department of Trauma and Acute Care Surgery, Kettering Health Main Campus, Kettering, Ohio, United States
| | - Heena Santry
- Department of Trauma and Acute Care Surgery, Kettering Health Main Campus, Kettering, Ohio, United States
| | - William Boyce
- Department of Radiology, Kettering Health Main Campus, Kettering, Ohio, United States
| | - Ragavan Narayanan
- Department of Trauma and Acute Care Surgery, Kettering Health Main Campus, Kettering, Ohio, United States
| | - Akil Patel
- Department of Kettering Brain and Spine, Kettering Health Main Campus, Kettering, Ohio, United States
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Kojima A, Hosoi M, Hayashi K, Fukumura M, Saga I. Middle Meningeal Artery Embolization for Refractory Chronic Subdural Hematoma Associated with Acute Myeloid Leukemia: A Case Report. JOURNAL OF NEUROENDOVASCULAR THERAPY 2024; 18:47-52. [PMID: 38384392 PMCID: PMC10878736 DOI: 10.5797/jnet.cr.2023-0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 12/11/2023] [Indexed: 02/23/2024]
Abstract
Objective We describe a patient with leukemia-related chronic subdural hematoma (CSDH) who was successfully treated using the combination of surgical evacuation and middle meningeal artery (MMA) embolization. Case Presentation A 73-year-old man without apparent head trauma history was admitted to our hospital because of acute myeloid leukemia (AML). Head CT on admission revealed mild CSDH on both sides. Medical treatment options, including chemotherapy, were started. Since a decrease in platelet count and disseminated intravascular coagulation were observed on day 4, recombinant thrombomodulin was administered. As the patient exhibited signs of altered consciousness due to the enlargement of the right CSDH on day 10, we performed surgical drainage. Despite subsequent platelet transfusion and administration of goreisan, the right CSDH recurred within a short period. On day 17, we performed the second surgery and MMA embolization in one stage. The postoperative clinical course was favorable without recurrence of the hematoma. The patient eventually died on day 123 from a deterioration of his general condition. Conclusion Although MMA embolization has recently been recognized as an effective treatment option for recurrent CSDH, there are no published reports addressing the efficacy of MMA embolization for refractory CSDH associated with hematological malignancies. Findings from the management of this case suggest that MMA embolization can be the effective treatment option for CSDH in patients with severe hemorrhagic diathesis due to AML.
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Affiliation(s)
- Atsuhiro Kojima
- Department of Neurosurgery, Saitama City Hospital, Saitama, Saitama, Japan
| | - Masataka Hosoi
- Department of Internal Medicine, Saitama City Hospital, Saitama, Saitama, Japan
| | - Kanako Hayashi
- Department of Internal Medicine, Saitama City Hospital, Saitama, Saitama, Japan
| | - Mariko Fukumura
- Department of Neurosurgery, Saitama City Hospital, Saitama, Saitama, Japan
| | - Isako Saga
- Department of Neurosurgery, Saitama City Hospital, Saitama, Saitama, Japan
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Campos JK, Meyer BM, Zarrin DA, Khan MW, Collard de Beaufort JC, Amin G, Avery MB, Golshani K, Beaty NB, Bender MT, Colby GP, Lin LM, Coon AL. Immediate procedural safety of adjunctive proximal coil occlusion in middle meningeal artery embolization for chronic subdural hematomas: Experience in 137 cases. Interv Neuroradiol 2024:15910199231224003. [PMID: 38166510 DOI: 10.1177/15910199231224003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024] Open
Abstract
BACKGROUND Endovascular embolization of the middle meningeal artery (MMA) has emerged as an adjunctive and stand-alone modality for the management of chronic subdural hematomas (cSDH). We report our experience utilizing proximal MMA coil embolization to augment cSDH devascularization in MMA embolization. METHODS MMA embolization cases with adjunctive proximal MMA coiling were retrospectively identified from a prospectively maintained IRB-approved database of the senior authors. RESULTS Of the 137 cases, all patients (n = 89, 100%) were symptomatic and underwent an MMA embolization procedure for cSDH. 50 of the patients underwent bilateral embolizations, with 53% (n = 72) for left-sided and 47% (n = 65) for right-sided cSDH. The anterior MMA branch was embolized in 19 (14%), posterior in 16 (12%), and both in 102 (74.5%) cases. Penetration of the liquid embolic to the contralateral MMA or into the falx was present in 38 (28%) and 31 (23%) cases, respectively, and 46 (34%) cases had ophthalmic or petrous collateral (n = 41, 30%) branches. MMA branches coiled include the primary trunk (25.5%, n = 35), primary and anterior or posterior MMA trunks (20%, n = 28), or primary with the anterior and posterior trunks (54%, n = 74). A mild ipsilateral facial nerve palsy was reported, which remained stable at discharge and follow-up. Absence of anterograde flow in the MMA occurred in 137 (100%) cases, and no cases required periprocedural rescue surgery for cSDH evacuation. The average follow-up length was 170 ± 17.9 days, cSDH was reduced by 4.24 ± 0.5(mm) and the midline shift by 1.46 ± 0.27(mm). Complete resolution was achieved in 63 (46.0%) cases. CONCLUSION Proximal MMA coil embolization is a safe technique for providing additional embolization/occlusion of the MMA in cSDH embolization procedures. Further studies are needed to evaluate the potential added efficacy of this technique.
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Affiliation(s)
- Jessica K Campos
- Department of Neurological Surgery, University of California Irvine, Orange, CA, USA
| | | | - David A Zarrin
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | | | | | - Gizal Amin
- Carondelet Neurological Institute, St Joseph's Hospital, Tucson, AZ, USA
| | - Michael B Avery
- Department of Neurosurgery, Banner University Medical Center / The University of Arizona, Tucson, AZ, USA
| | - Kiarash Golshani
- Department of Neurological Surgery, University of California Irvine, Orange, CA, USA
| | - Narlin B Beaty
- Department of Neurosurgery, Florida State University, Tallahassee Memorial Hospital, Tallahassee, FL, USA
| | - Matthew T Bender
- Department of Neurosurgery, University of Rochester, Rochester, NY, USA
| | - Geoffrey P Colby
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Li-Mei Lin
- Carondelet Neurological Institute, St Joseph's Hospital, Tucson, AZ, USA
| | - Alexander L Coon
- Carondelet Neurological Institute, St Joseph's Hospital, Tucson, AZ, USA
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Matsumoto H, Matsumoto A, Miyata S, Tomogane Y, Minami H, Masuda A, Yamaura I, Yoshida Y, Hirata Y. The Effect of Japanese Herbal Medicines (Kampo) Goreisan and Saireito on the Prevention of Recurrent Chronic Subdural Hematoma: A Prospective Randomized Study. Neurosurgery 2024; 94:80-89. [PMID: 37638721 DOI: 10.1227/neu.0000000000002649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/22/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Chronic subdural hematoma (CSDH) sometimes recurs after surgical treatment and requires reoperation. In Japan, Japanese herbal medicines (Kampo), such as Goreisan and Saireito, have been used as adjunctive therapies to prevent the recurrence of CSDH. However, no prospective randomized study has proven the efficacy of Kampo medicine in all patients. To investigate whether Goreisan and Saireito reduce the postoperative recurrence of CSDH in a prospective randomized study. METHODS Between April 2017 and July 2019, a total of 118 patients who underwent initial burr hole surgery for CSDH were randomly assigned to the following 3 groups: (1) Goreisan for 3 months (Group G), (2) Saireito for 3 months (Group S), and (3) no medication (Group N). The primary end point was symptomatic recurrence within 3 months postoperatively, and the secondary end point was complications associated with the administration of Kampo medicine. RESULTS Among 118 patients, 114 (Group N, n = 39; Group G, n = 37; and Group S, n = 38) were included in our analysis. In this study, byakujutsu (containing Atractylodes rhizome ) Goreisan and Saireito were used, unlike other prospective randomized studies in which sojutsu (containing Atractylodes lancea rhizome) Goreisan was used. The overall recurrence rate was 11.4% (13/114: 10 for Group N, 2 for Group G, and 1 for Group S). The recurrence rate of Group G was significantly lower than that of Group N (5.4% vs 25.6%; P = .043). The recurrence rate of Group S was also significantly lower than that of Group N (2.6% vs 25.6%; P = .02). No patients developed complications associated with the administration of Kampo medicine. CONCLUSION This is the first study to show that Kampo medicine reduced the recurrence rate of CSDH in an overall population. This study demonstrated that byakujutsu Goreisan and Saireito may have favorable effects, unlike other studies, because byakujutsu has stronger anti-inflammatory activity than sojutsu.
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Affiliation(s)
- Hiroaki Matsumoto
- Department of Neurosurgery, Cerebrovascular Research Institute, Eisyokai Yoshida Hospital, Kobe , Hyogo , Japan
| | - Atsushi Matsumoto
- Department of Neurosurgery, Cerebrovascular Research Institute, Eisyokai Yoshida Hospital, Kobe , Hyogo , Japan
| | - Shiro Miyata
- Department of Neurosurgery, Cerebrovascular Research Institute, Eisyokai Yoshida Hospital, Kobe , Hyogo , Japan
| | - Yusuke Tomogane
- Department of Neurosurgery, Cerebrovascular Research Institute, Eisyokai Yoshida Hospital, Kobe , Hyogo , Japan
| | - Hiroaki Minami
- Department of Neurosurgery, Cerebrovascular Research Institute, Eisyokai Yoshida Hospital, Kobe , Hyogo , Japan
| | - Atsushi Masuda
- Department of Neurosurgery, Cerebrovascular Research Institute, Eisyokai Yoshida Hospital, Kobe , Hyogo , Japan
| | - Ikuya Yamaura
- Department of Neurosurgery, Cerebrovascular Research Institute, Eisyokai Yoshida Hospital, Kobe , Hyogo , Japan
| | - Yasuhisa Yoshida
- Department of Neurosurgery, Cerebrovascular Research Institute, Eisyokai Yoshida Hospital, Kobe , Hyogo , Japan
| | - Yutaka Hirata
- Department of Neurology, Cerebrovascular Research Institute, Eisyokai Yoshida Hospital, Kobe , Hyogo , Japan
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Tong X, Xue X, Liu A, Qi P. Comparative study on clinical outcomes and cost-effectiveness of chronic subdural hematomas treated by middle meningeal artery embolization and conventional treatment: a national cross-sectional study. Int J Surg 2023; 109:3836-3847. [PMID: 37830938 PMCID: PMC10720801 DOI: 10.1097/js9.0000000000000699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/13/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND The authors compared the efficacy and cost-effectiveness of middle meningeal artery embolization (MMAE) and conventional treatment for chronic subdural hematomas (cSDH). METHODS The Nationwide Readmissions Database of 9963 patients (27.2% women) with cSDH between 2016 and 2020 was analyzed. Finally, 9532 patients were included (95.7%, treated conventionally; 4.3%, treated with MMAE). Baseline demographics, comorbidities, adverse events, treatment strategies, and outcomes were compared between patients treated with MMAE and conventional treatment. After propensity score matching, the authors compared primary outcomes, including the 90-day treatment rate, functional outcome, length of hospital stays, and cost. A Markov model estimated lifetime costs and quality-adjusted life years (QALYs) associated with different treatments. The incremental cost-effectiveness ratio (ICER) was calculated to evaluate the base-case scenario. One-way, two-way, and probabilistic sensitivity analyses were performed to evaluate the uncertainty in the results. RESULTS After propensity score matching, MMAE had a lower 90-day retreatment rate (2.6 vs. 9.0%, P =0.001), shorter length of hospital stays (4.61±6.19 vs. 5.73±5.76 days, P =0.037), similar functional outcomes compared (favorable outcomes, 80.9 vs. 74.8%, P =0.224) but higher costs ($119 757.71±90 378.70 vs. $75 745.55±100 701.28, P <0.001) with conventional treatment. MMAE was associated with an additional cost of US$19 280.0 with additional QALY of 1.3. Its ICER was US$15199.8/QALY. CONCLUSION MMAE is more effective in treating cSDH than conventional treatment. Based on real-world data, though MMAE incurs higher overall costs, the Markov model showed it to be cost-effective compared to conventional treatment under the American healthcare system. These comparative and economic analyses further support the consideration of a paradigm shift in cSDH treatment.
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Affiliation(s)
- Xin Tong
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University
| | - Xiaopeng Xue
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University
| | - Aihua Liu
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University
| | - Peng Qi
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
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Rojas-Villabona A, Mohamed S, Kennion O, Padmanabhan R, Siddiqui A, Prasad M, Mukerji N. A systematic review of middle meningeal artery embolization for minimally symptomatic chronic subdural haematomas that do not require immediate evacuation. BRAIN & SPINE 2023; 3:102672. [PMID: 38021007 PMCID: PMC10668091 DOI: 10.1016/j.bas.2023.102672] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 08/30/2023] [Accepted: 09/05/2023] [Indexed: 12/01/2023]
Abstract
Introduction Embolization of the Middle Meningeal Artery (EMMA) is an emerging treatment option for patients with Chronic Subdural Haematoma (CSDH). Questions (1) Can EMMA change the natural history of untreated minimally symptomatic CSDH which do not require immediate evacuation? (2) What is the role of EMMA in the prevention of recurrence following surgical treatment? (3) Can the procedure be performed under local anaesthetic? Material and methods Systematic literature review. No randomised clinical trials available on EMMA for meta-analysis. Results Six unique large cohorts with more than 50 embolisations were identified (evidence: 3b-4). EMMA can control the progression of surgically naïve CSDH in 91.1-100% of the patients, in which haematoma expansion is halted, or the lesion decreases and resolves. Treatment failure requiring surgery occurs in 0-4.1% of the patients having EMMA as the primary and only treatment. Treatment failure requiring surgery goes up slightly to 6.8% if post-surgical patients are included. When EMMA is used as postsurgical adjunctive the risk of recurrence is 1.4-8.9% compared to 10-20% in surgical series. EMMA has minimal morbidity and it is feasible under local anaesthesia or slight sedation in the majority of cases. Conclusion There is cumulative low-quality evidence in the literature that EMMA may be able to modify the natural course of the disease. It appears effective in controlling progression of CSDHs in patients having it as a primary standing alone treatment and it reduces the risk of recurrence and the need for surgical intervention in refractory postsurgical cases or as a postsurgical adjunctive treatment with minimal morbidity (recommendation: C).
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Affiliation(s)
| | - Saffwan Mohamed
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
| | - Oliver Kennion
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
| | - Rajeev Padmanabhan
- Department of Neuroradiology, James Cook University Hospital, Middlesbrough, UK
| | - Aslam Siddiqui
- Department of Neuroradiology, James Cook University Hospital, Middlesbrough, UK
| | - Manjunath Prasad
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
| | - Nitin Mukerji
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
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Qiu Y, Xie M, Duan A, Yin Z, Wang M, Chen X, Chen Z, Gao W, Wang Z. Comparison of different surgical techniques for chronic subdural hematoma: a network meta-analysis. Front Neurol 2023; 14:1183428. [PMID: 37564732 PMCID: PMC10411900 DOI: 10.3389/fneur.2023.1183428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 06/27/2023] [Indexed: 08/12/2023] Open
Abstract
Background Chronic subdural hematoma (CSDH) is a neurosurgical condition with high prevalence. Many surgical approaches are recommended for treating CSDH, but there needs to be a consensus on the optimal technique. This network meta-analysis (NMA) compared the efficacy and safety of different surgical treatments for CSDH. Methods Electronic databases, including PubMed, Embase, and the Cochrane Library, were searched for relevant studies up to February 2023. An NMA was performed to compare the outcomes of patients with CSDH treated by single-hole or double-hole craniotomy (SBHC and DBHC, respectively), twist-drill craniotomy (TDC), mini-craniotomy, and craniotomy. The NMA protocol was registered at INPLASY (registration no. 202320114). Results The NMA included 38 studies with 7,337 patients. For efficacy outcomes, DBHC showed the highest surface under the cumulative ranking area (SUCRA) values for recurrence (96.3%) and reoperation (87.4%) rates. DBHC differed significantly from mini-craniotomy in recurrence rate (odds ratio [OR] = 0.58, 95% confidence interval [CI]: 0.35, 0.97) and from SBHC (OR = 0.48, 95% CI: 0.25, 0.91) and TDC (OR = 0.40, 95% CI: 0.20, 0.82) in reoperation rate. For operative time, TDC was superior to SBHC (mean difference [MD] = -2.32, 95% CI: -3.78 to -0.86), DBHC (MD = -3.61, 95% CI: -5.55, -1.67), and mini-craniotomy (MD = -3.39, 95% CI: -5.70, -1.08). Patients treated by TDC had a shorter hospital stay than those treated by SBHC (MD = -0.82, 95% CI: -1.51, -0.12). For safety outcomes, there were no significant differences between groups in mortality and complication rates; however, mini-craniotomy (79.8%) and TDC (78.1%) had the highest SUCRAs. Conclusion DBHC may be the most effective surgical treatment for CSDH based on the low recurrence and reoperation rates, although all examined techniques were relatively safe. Systematic review registration https://inplasy.com/inplasy-2023-2-0114/.
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Affiliation(s)
- Youjia Qiu
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Minjia Xie
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Aojie Duan
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Ziqian Yin
- Suzhou Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Menghan Wang
- Suzhou Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Xi Chen
- Department of Epidemiology and Statistics, School of Public Health, Medical College, Zhejiang University, Hangzhou, China
- School of Health, Brooks College (Sunnyvale), Milpitas, CA, United States
| | - Zhouqing Chen
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Wei Gao
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Zhong Wang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
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10
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Swamiyappan SS, Krishnaswamy V, Visweswaran V, A S, Bathala RT, Karnati H, Gupta J, K G. Recurrent Subdural Hematoma: An Institutional Experience. Cureus 2023; 15:e42582. [PMID: 37641767 PMCID: PMC10460295 DOI: 10.7759/cureus.42582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2023] [Indexed: 08/31/2023] Open
Abstract
Background Chronic subdural hematoma (CSDH) is a common neurosurgical problem, which offers a good outcome following surgery. In many cases, burr hole irrigation and drainage under local anesthesia can provide satisfactory results. However, recurrence can be a cause for concern for both the surgeon and the patient. While recurrence is not a frequent phenomenon, studies have reported rates of up to 31.6%. Aims and objectives In this study, our objective is to examine a comprehensive range of potential risk factors and provide valuable insights into identifying patients at a higher risk of recurrence to aid in surgical decision-making. Methodology This study employed a prospective and retrospective design, conducted between 2017 and 2021, at Sri Ramachandra Institute of Higher Education and Research. The study received ethical approval from the Institutional Ethics Committee. The research aimed to assess patients who underwent surgery for CSDH, with a particular focus on those who experienced recurrence. Results The average age of patients with recurrence was 71.5 years compared to 65.2 years in the no-recurrence group, but this difference did not show a significant statistical correlation. A significant male predominance was observed, with 27 men and four women affected (out of a total of 147 men and 73 women in the study), resulting in a statistically significant p-value of 0.01. On multivariate analysis, heterogenous subtypes were a significant predictor of recurrence (OR: 8.88, 95% CI: 6.96-16.54, p = 0.01). The mean midline shift in those with recurrence was 11.4 mm compared to 7.09 mm in those without recurrence. This was a statistically significant correlation with a p-value of 0.02. Regarding those with recurrence, 24 patients underwent evacuation using two burr holes, with one placed in the frontal region and another in the parietal region. All of these patients had a subdural drain placed, which was removed on postoperative day 2. The remaining eight patients underwent a mini-craniotomy for evacuation. We had four cases of refractory CSDH, all of whom underwent the second evacuation using burr holes. Three of them underwent evacuation via craniotomy, while the family of the fourth patient did not give consent for the procedure. Conclusion Patient-related factors such as gender, bilateral presentation, and the presence of hypertension and radiological factors such as the presence of heterogenous subtype and a significant midline shift are clues toward a higher chance of recurrence.
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Affiliation(s)
| | | | - Vivek Visweswaran
- Neurological Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Sangeetha A
- Neurosurgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Rav Tej Bathala
- Neurosurgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Harsh Karnati
- Neurosurgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Jayesh Gupta
- Neurological Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Ganesh K
- Neurological Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
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11
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Rodriguez B, Morgan I, Young T, Vlastos J, Williams T, Hrabarchuk EI, Tepper J, Baker T, Kellner CP, Bederson J, Rapoport BI. Surgical techniques for evacuation of chronic subdural hematoma: a mini-review. Front Neurol 2023; 14:1086645. [PMID: 37456631 PMCID: PMC10338715 DOI: 10.3389/fneur.2023.1086645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 05/30/2023] [Indexed: 07/18/2023] Open
Abstract
Chronic subdural hematoma is one of the most common neurosurgical pathologies with over 160,000 cases in the United States and Europe each year. The current standard of care involves surgically evacuating the hematoma through a cranial opening, however, varied patient risk profiles, a significant recurrence rate, and increasing financial burden have sparked innovation in the field. This mini-review provides a brief overview of currently used evacuation techniques, including emerging adjuncts such as endoscopic assistance and middle meningeal artery embolization. This review synthesizes the body of available evidence on efficacy and risk profiles for each critical aspect of surgical technique in cSDH evacuation and provides insight into trends in the field and promising new technologies.
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Affiliation(s)
- Benjamin Rodriguez
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Isabella Morgan
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
| | - Tirone Young
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Joseph Vlastos
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Tyree Williams
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Rensselaer Polytechnic Institute, Troy, NY, United States
| | - Eugene I. Hrabarchuk
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Jaden Tepper
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
| | - Turner Baker
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
| | - Christopher P. Kellner
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Joshua Bederson
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Benjamin I. Rapoport
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
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12
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Sattari SA, Yang W, Shahbandi A, Feghali J, Lee RP, Xu R, Jackson C, Gonzalez LF, Tamargo RJ, Huang J, Caplan JM. Middle Meningeal Artery Embolization Versus Conventional Management for Patients With Chronic Subdural Hematoma: A Systematic Review and Meta-Analysis. Neurosurgery 2023; 92:1142-1154. [PMID: 36929762 DOI: 10.1227/neu.0000000000002365] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/15/2022] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND The results from studies that compare middle meningeal artery (MMA) embolization vs conventional management for patients with chronic subdural hematoma are varied. OBJECTIVE To conduct a systematic review and meta-analysis on studies that compared MMA embolization vs conventional management. METHODS Medline, PubMed, and Embase databases were searched. Primary outcomes were treatment failure and surgical rescue; secondary outcomes were complications, follow-up modified Rankin scale > 2, mortality, complete hematoma resolution, and length of hospital stay (day). The certainty of the evidence was determined using the GRADE approach. RESULTS Nine studies yielding 1523 patients were enrolled, of which 337 (22.2%) and 1186 (77.8%) patients received MMA embolization and conventional management, respectively. MMA embolization was superior to conventional management for treatment failure (relative risk [RR] = 0.34 [0.14-0.82], P = .02), surgical rescue (RR = 0.33 [0.14-0.77], P = .01), and complete hematoma resolution (RR = 2.01 [1.10-3.68], P = .02). There was no difference between the 2 groups for complications (RR = 0.93 [0.63-1.37], P = .72), follow-up modified Rankin scale >2 (RR = 0.78 [0.449-1.25], P = .31), mortality (RR = 1.05 [0.51-2.14], P = .89), and length of hospital stay (mean difference = -0.57 [-2.55, 1.41], P = .57). For MMA embolization, the number needed to treat for treatment failure, surgical rescue, and complete hematoma resolution was 7, 9, and 3, respectively. The certainty of the evidence was moderate to high for primary outcomes and low to moderate for secondary outcomes. CONCLUSION MMA embolization decreases treatment failure and the need for surgical rescue without furthering the risk of morbidity and mortality. The authors recommend considering MMA embolization in the chronic subdural hematoma management.
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Affiliation(s)
- Shahab Aldin Sattari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ataollah Shahbandi
- Tehran School of Medicine, Tehran University of Medical Science, Tehran, Iran
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ryan P Lee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - L Fernando Gonzalez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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13
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Lam A, Selvarajah D, Htike SS, Chan S, Lalloo S, Lock G, Redmond K, Leggett D, Mews P. The efficacy of postoperative middle meningeal artery embolization on chronic subdural hematoma - A multicentered randomized controlled trial. Surg Neurol Int 2023; 14:168. [PMID: 37292400 PMCID: PMC10246309 DOI: 10.25259/sni_208_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 04/25/2023] [Indexed: 06/10/2023] Open
Abstract
Background Middle meningeal artery (MMA) embolization has recently emerged as a potential treatment for chronic subdural hematoma (cSDH). Numerous retrospective studies have suggested that it can potentially reduce the risk of hematoma recurrence following surgical evacuation. We have conducted a randomized controlled trial to investigate the effectiveness of postoperative MMA embolization in reducing recurrence rate, residual hematoma thickness as well as improving functional outcome. Methods Patients aged 18 or above were recruited. Following evacuation through burr hole or craniotomy, patients were randomly allocated to undergo either MMA embolization or standard care (monitoring). The primary outcome was symptomatic recurrence requiring redo evacuation. Secondary outcomes include residual hematoma thickness and modified Rankin Scale (mRS) at 6 weeks and 3 months. Results Thirty-six patients (41 cSDHs) were recruited between April 2021 and September 2022. Seventeen patients (19 cSDHs) were allocated to the embolization group and 19 patients (22 cSDHs) were in the control group. No symptomatic recurrence was observed in the treatment group while 3 control patients (15.8%) underwent repeat surgery for symptomatic recurrence, however, it was not statistically significant (P = 0.234). Furthermore, there was no significant difference in residual hematoma thickness at 6 weeks or 3 months between the two groups. All patients in the embolization group had a good functional outcome (mRS 0-1) at 3 months, which was significantly higher than the 53% observed in the control group. No complications related to MMA embolization were reported. Conclusion Further study with larger sample size is required to evaluate the efficacy of MMA embolization.
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Affiliation(s)
- Alexander Lam
- Department of Neurosurgery, Princess Alexandra Hospital, Woolloongabba, Australia
| | | | - Soe San Htike
- Department of Neurosurgery, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Sophia Chan
- Department of Neurosurgery, Princess Alexandra Hospital, Woolloongabba, Australia
| | | | - Gregory Lock
- Department of Radiology, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Kendal Redmond
- Department of Radiology, Princess Alexandra Hospital, Woolloongabba, Australia
| | - David Leggett
- Department of Radiology, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Peter Mews
- Department of Neurosurgery, Canberra Hospital, Garran, Australia
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14
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Desir LL, Narayan V, Ellis J, Gordon D, Langer D, Ortiz R, Serulle Y. Middle Meningeal Artery Embolization in the Management of Chronic Subdural Hematoma: a Comprehensive Review of Current Literature. Curr Neurol Neurosci Rep 2023; 23:109-119. [PMID: 37037979 DOI: 10.1007/s11910-023-01262-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2023] [Indexed: 04/12/2023]
Abstract
PURPOSE OF REVIEW Chronic subdural hematoma (cSDH) is a common intracranial hemorrhagic disorder with a high incidence rate among the elderly. While small, asymptomatic cSDH may resolve spontaneously, surgical intervention has been the treatment of choice for larger, symptomatic cases. Surgical evacuation of cSDH may be associated with high rates of recurrence, and even asymptomatic cSDH cases tend to progress. Over the last few years, middle meningeal artery (MMA) embolization has proven to be a safe non-invasive treatment of choice with favorable outcomes and a low recurrence rate. The ensuing paper discusses current treatment modalities for cSDH and reviews existing literature on the anatomy of MMA and its embolization as a treatment option for cSDH. RECENT FINDINGS Recent studies show that traumatic head injury leading to subdural hemorrhage can induce neovascularization that may initiate a cycle of recurrent subdural hematoma. Distal branches of MMA supply blood to the dural layers. Several studies have revealed that embolization of the MMA can stop the neovascularization process and blood flow. In addition, patients who underwent MMA embolization had a significantly quicker brain re-expansion and lower recurrence rate. Although the management of cSDH is still very much a dilemma, recent research findings bring MMA embolization to light as a promising treatment alternative and adjunctive therapy.
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Affiliation(s)
- Likowsky L Desir
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA
- City University of New York School of Medicine, New York, NY, USA
| | - Vinayak Narayan
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA
| | - Jason Ellis
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA
| | - David Gordon
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA
| | - David Langer
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA
| | - Rafael Ortiz
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA
| | - Yafell Serulle
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA.
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
- Neuroendovascular Surgery, Phelps Hospital, Sleepy Hollow, NY, USA.
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15
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Gillespie CS, Khanna S, Vivian ME, McKoy S, Yanez Touzet A, Edlmann E, Stubbs DJ, Davies BM. Is information provided within chronic subdural haematoma education resources adequate? A scoping review. PLoS One 2023; 18:e0283958. [PMID: 37023014 PMCID: PMC10079037 DOI: 10.1371/journal.pone.0283958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 03/21/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Chronic subdural haematoma (CSDH) is becoming increasingly prevalent, due to an aging population with increasing risk factors. Due to its variable disease course and high morbidity, patient centred care and shared decision making are essential. However, its occurrence in frail populations, remote from specialist neurosurgeons who currently triage treatment decisions, challenges this. Education is an important component of enabling shared decisions. This should be targeted to avoid information overload. However, it is unknown what this should be. OBJECTIVES Our objectives were to conduct analysis of the content of existing CSDH educational materials, to inform the development of patient and relative educational resources to facilitate shared decision making. METHODS A literature search was conducted (July 2021) of MEDLINE, Embase and grey literature, for all self-specified resources on CSDH education, and narrative reviews. Resources were classified into a hierarchical framework using inductive thematic analysis into 8 core domains: Aetiology, epidemiology and pathophysiology; natural history and risk factors; symptoms; diagnosis; surgical management; nonsurgical management; complications and recurrence; and outcomes. Domain provision was summarised using descriptive statistics and Chi-squared tests. RESULTS 56 information resources were identified. 30 (54%) were resources designed for healthcare professionals (HCPs), and 26 (46%) were patient-orientated resources. 45 (80%) were specific to CSDH, 11 (20%) covered head injury, and 10 (18%) referenced both acute and chronic SDH. Of 8 core domains, the most reported were aetiology, epidemiology and pathophysiology (80%, n = 45) and surgical management (77%, n = 43). Patient orientated resources were more likely to provide information on symptoms (73% vs 13%, p<0.001); and diagnosis (62% vs 10%, p<0.001) when compared to HCP resources. Healthcare professional orientated resources were more likely to provide information on nonsurgical management (63% vs 35%, p = 0.032), and complications/recurrence (83% vs 42%, p = 0.001). CONCLUSION The content of educational resources is varied, even amongst those intended for the same audience. These discrepancies indicate an uncertain educational need, that will need to be resolved in order to better support effective shared decision making. The taxonomy created can inform future qualitative studies.
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Affiliation(s)
- Conor S. Gillespie
- Department of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Samuel Khanna
- University Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - Mark E. Vivian
- University Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - Samuel McKoy
- The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Alvaro Yanez Touzet
- School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Ellie Edlmann
- Department of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Daniel J. Stubbs
- University Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - Benjamin M. Davies
- Department of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
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16
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Shotar E, Barberis E, Chougar L, Bensoussan S, Parat D, Ghannouchi H, Premat K, Lenck S, Degos V, Lehericy S, Sourour NA, Mathon B, Clarençon F. Long-Term Middle Meningeal Artery Caliber Reduction Following Trisacryl Gelatine Microsphere Embolization for the Treatment of Chronic Subdural Hematoma. Clin Neuroradiol 2023; 33:113-120. [PMID: 35796853 DOI: 10.1007/s00062-022-01189-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 06/13/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Middle meningeal artery (MMA) particle embolization is a promising treatment of chronic subdural hematomas (CSDH). The main purpose of this study is to measure MMA proximal caliber and assess the visibility of the two main MMA branches as a surrogate for long-term distal arterial patency following MMA CSDH embolization with trisacryl gelatine microspheres (TAGM). METHODS This is a single-center retrospective study. All patients having undergone MMA TAGM only embolization for CSDH treatment between 15 March 2018 and 6 June 2020 with an interpretable follow-up magnetic resonance imaging (MRI) examination and no confounding factors were included. Patients were compared with controls matched for age, sex and MRI machine. Two independent readers analyzed the MRI images. RESULTS In this study, 30 patients having undergone embolization procedures using TAGM of 36 MMAs were included. The follow-up MRI scans were performed after a mean delay of 14.8 ± 7.1 months (range 4.9-29.4 months). The mean diameter of TAGM embolized MMAs (1 mm; 95% confidence interval, CI 0.9-1.1) was significantly smaller than the mean diameter of paired control MMAs (1.3 mm; 95% CI 1.3-1.4) (p < 0.001). The mean proximal diameter of the embolized MMAs (0.9 mm; 95% CI 0.7-1.1) was significantly smaller than the mean diameter of the contralateral MMAs in the same patients (1.4 mm; 95% CI 1.3-1.6)(p < 0.001). CONCLUSION Long-term follow-up MRI demonstrated a significant impact of TAGM embolization on MMA proximal caliber as well as on the visibility of the two main MMA branches. All comparisons indicated that there was a probable lasting impact of embolization on the patency of distal branches.
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Affiliation(s)
- Eimad Shotar
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France.
| | - Eric Barberis
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Lydia Chougar
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France.,Sorbonne Université, Paris, France
| | - Sacha Bensoussan
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Damien Parat
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Haroun Ghannouchi
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Kevin Premat
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Stephanie Lenck
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Vincent Degos
- Sorbonne Université, Paris, France.,Department of Neurosurgical Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Stéphane Lehericy
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France.,Sorbonne Université, Paris, France
| | - Nader-Antoine Sourour
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Bertrand Mathon
- Sorbonne Université, Paris, France.,Department of Neurosurgery, Pitié-Salpêtrière Hospital, Paris, France
| | - Frédéric Clarençon
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France.,Sorbonne Université, Paris, France
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17
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Zeng L, Yu J, Chen R, Yang H, Li H, Zeng L, Wang J, Xu W, Hu S, Chen K. Modified Valsalva maneuver after burr-hole drainage of chronic subdural hematomas: A single-center cohort study. Front Neurol 2023; 13:1069708. [PMID: 36793801 PMCID: PMC9924088 DOI: 10.3389/fneur.2022.1069708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 12/28/2022] [Indexed: 01/31/2023] Open
Abstract
Background Previous studies on the management of chronic subdural hematoma (cSDH) mainly focused on the risk of postoperative recurrence and measures to prevent it. In this study, we propose the use of a non-invasive postoperative treatment method, the modified Valsalva maneuver (MVM), as a means of reducing the recurrence of cSDH. This study aims to clarify the effects of MVM on functional outcomes and recurrence rates. Methods A prospective study was conducted at the Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology from November 2016 to December 2020. The study included 285 adult patients who underwent burr-hole drainage for the treatment of cSDH and received subdural drains. These patients were divided into two groups: the MVM group (n = 117) and the control group (n = 98). In the MVM group, patients received treatment with a customized MVM device for at least 10 times per hour, 12 h per day. The study's primary endpoint was the recurrence rate of SDH, while functional outcomes and morbidity 3 months after surgery were the secondary outcomes. Results In the current study, 9 out of 117 patients (7.7%) in the MVM group experienced a recurrence of SDH, while 19 out of 98 patients (19.4%, p < 0.05) in the HC group experienced a recurrence of SDH. Additionally, the infection rate of diseases such as pneumonia (1.7%) was significantly lower in the MVM group compared to the HC group (9.2%, p < 0.001, odds ratio (OR = 0.1). After 3 months of the surgery, 109 out of 117 patients (93.2%) in the MVM group achieved a favorable prognosis, compared to 80 out of 98 patients (81.6%) in the HC group (p = 0.008, with an OR of 2.9). Additionally, infection rate (with an OR of 0.2) and age (with an OR of 0.9) are independent predictors of a favorable prognosis at the follow-up stage. Conclusions The use of MVM in the postoperative management of cSDHs has been shown to be safe and effective, resulting in reduced rates of cSDH recurrence and infection following burr-hole drainage. These findings suggest that MVM treatment may lead to a more favorable prognosis at the follow-up stage.
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18
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Paro MR, Ollenschleger MD, Fayad MF, Bulsara KR, Stoltz P, Martin JE, Bookland MJ, Hersh DS. Middle Meningeal Artery Embolization for Primary Treatment of a Chronic Subdural Hematoma in a Pediatric Patient: A Systematic Review of the Literature and Case Report. Oper Neurosurg (Hagerstown) 2023; 24:3-10. [PMID: 36519875 DOI: 10.1227/ons.0000000000000446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 07/29/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Middle meningeal artery (MMA) embolization is becoming increasingly studied as a safe, effective treatment for chronic subdural hematoma (cSDH) in adults. Among pediatric patients, however, MMA embolization for cSDH has been rarely described, and the potential benefit of this approach for pediatric patients remains unknown. OBJECTIVE To systematically review the literature and identify cases of pediatric MMA embolization for cSDH. We also report our experience with pediatric MMA embolization. METHODS A systematic review of the literature was performed to identify cases of pediatric MMA embolization for cSDH. Inclusion criteria included English language availability and pediatric age defined as less than 18 years. A pediatric patient treated with MMA embolization was also identified at our institution. RESULTS Five cases of pediatric MMA embolization for cSDH were identified in the literature. Two were associated with arachnoid cysts, 2 with antiplatelet/anticoagulation therapy, and 1 with abusive head trauma. There were no adverse events, and all patients demonstrated clinical and radiological improvement on follow-up. At our institution, a previously healthy 8-year-old male was found to have a right-sided acute-on-chronic SDH during a headache evaluation. A diagnostic angiogram was performed to rule out a dural arteriovenous fistula, and right-sided MMA embolization was performed concurrently. Rapid clinical and radiological improvement was observed, with complete resolution by 6 months. CONCLUSION MMA embolization may represent a treatment option for pediatric patients with cSDH.
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Affiliation(s)
- Mitch R Paro
- UConn School of Medicine, Farmington, Connecticut, USA
| | | | - Mohamad F Fayad
- Hartford Hospital, Department of Radiology, Hartford, Connecticut, USA
| | - Ketan R Bulsara
- UConn School of Medicine, Farmington, Connecticut, USA.,Department of Surgery, UConn School of Medicine, Farmington, Connecticut, USA.,Division of Neurosurgery, UConn School of Medicine, Farmington, Connecticut, USA
| | - Petronella Stoltz
- Division of Neurosurgery, Connecticut Children's, Hartford, Connecticut, USA
| | - Jonathan E Martin
- Department of Surgery, UConn School of Medicine, Farmington, Connecticut, USA.,Division of Neurosurgery, Connecticut Children's, Hartford, Connecticut, USA
| | - Markus J Bookland
- Department of Surgery, UConn School of Medicine, Farmington, Connecticut, USA.,Division of Neurosurgery, Connecticut Children's, Hartford, Connecticut, USA
| | - David S Hersh
- Department of Surgery, UConn School of Medicine, Farmington, Connecticut, USA.,Division of Neurosurgery, Connecticut Children's, Hartford, Connecticut, USA
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19
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Shehabeldin M, Amllay A, Jabre R, Chen CJ, Schunemann V, Herial NA, Gooch MR, Mackenzie L, Choe H, Tjoumakaris S, Rosenwasser RH, Jabbour P, Kozak O. Onyx Versus Particles for Middle Meningeal Artery Embolization in Chronic Subdural Hematoma. Neurosurgery 2022; 92:979-985. [PMID: 36700752 DOI: 10.1227/neu.0000000000002307] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 10/14/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Middle meningeal artery (MMA) embolization has recently emerged as a treatment option for chronic subdural hematoma (cSDH). It is considered a simple and potentially safe endovascular procedure. OBJECTIVE To compare between 2 different embolic agents; onyx (ethylene vinyl alcohol) and emboparticles (polyvinyl alcohol particles-PVA) for endovascular treatment of cSDH. METHODS A retrospective analysis of all patients who underwent MMA embolization for cSDH treatment in 2 comprehensive centers between August 2018 and December 2021. Primary outcomes were failure of embolization and need for rescue surgical evacuation. RESULTS Among 97 MMA embolizations, 49 (50.5%) received onyx and 48 (49.5%) received PVA. The presence of acute or subacute on cSDH was higher in the PVA group 11/49 (22.5%) vs 30/48 (62.5%), respectively, P < .001. There were no significant differences between both groups regarding failure of embolization 6/49 (12.2%) vs 12/48 (25.0%), respectively, P = .112, and need of unplanned rescue surgical evacuation 5/49 (10.2%) vs 8/48 (16.7%), respectively, P = .354. Hematoma thickness at late follow-up was significantly smaller in the PVA group 7.8 mm vs 4.6 mm, respectively; P = .017. CONCLUSION Both onyx and PVA as embolic agents for cSDH can be used safely and have comparable clinical and surgical outcomes.
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Affiliation(s)
- Mohamed Shehabeldin
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Abdelaziz Amllay
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Roland Jabre
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, University of Texas Health Science Center, Houston, Texas, USA
| | - Victoria Schunemann
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA.,Department of Neurosurgery, Abington Memorial Hospital, Abington, Pennsylvania, USA
| | - Nabeel A Herial
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Larami Mackenzie
- Neurovascular Division, Abington Memorial Hospital, Jefferson Health, Abington, Pennsylvania, USA
| | - Hana Choe
- Neurovascular Division, Abington Memorial Hospital, Jefferson Health, Abington, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Osman Kozak
- Neurovascular Division, Abington Memorial Hospital, Jefferson Health, Abington, Pennsylvania, USA
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20
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Mühl-Benninghaus R. Middle meningeal artery embolization for treatment of chronic subdural hematoma. RADIOLOGIE (HEIDELBERG, GERMANY) 2022; 62:17-21. [PMID: 36194287 DOI: 10.1007/s00117-022-01074-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/30/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Chronic subdural hematoma (cSDH) is caused by rupture of bridging intracranial veins located in the subdural space. Predominantly, cSDH is a disease of older adults and other predisposing risk factors include minor head trauma, cerebral atrophy, antiplatelet and anticoagulation therapies, arterial hypertension, cerebrovascular atherosclerosis, diabetes mellitus, cerebrospinal fluid loss, and excessive alcohol consumption. The incidence of cSDH is rising worldwide due to an aging population and the increased use of anticoagulant or antiplatelet medications. Clinical manifestations are varied, with altered mental status and focal neurologic deficits among the most common. METHODOLOGICAL INNOVATIONS Treatment strategies depend on the symptomatology and extent of hematoma. In general, conservative treatment is sought for patients who are asymptomatic or have only mild symptoms, whereas symptomatic patients are often treated surgically. However, the recurrence rate of cSDH may be as high as 30%. In recent years, middle meningeal artery embolization has emerged as a complementary option to surgery aimed at decreasing the recurrence rate after excision as well as an alternative therapeutic approach to surgical therapy in certain circumstances. CONCLUSION Embolization of the middle meningeal artery appears to be a promising treatment for patients with cSDH, both before and after surgical excision.
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Affiliation(s)
- Ruben Mühl-Benninghaus
- Abteilung für diagnostische und interventionelle Radiologie, Städtisches Klinikum Lüneburg, 21339, Lüneburg, Germany.
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21
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Mohamed S, Villabona A, Kennion O, Padmananbhan R, Siddiqui A, Khan S, Prasad M, Mukerji N. Middle meningeal artery embolisation for chronic subdural haematomas: the first prospective UK study. Br J Neurosurg 2022; 36:786-791. [PMID: 35892289 DOI: 10.1080/02688697.2022.2097200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background/Objectives: MMA embolisation has emerged in recent years as a safe endovascular treatment for chronic subdural haematoma. We report the first UK series of endovascular treatment of chronic subdural haematomas.Design: Prospective case series.Subjects: All adult patients referred with midline shift ≤10 mm and GCS ≥13 were considered. Patients had to be mobile with a standard origin of Middle Meningeal and Ophthalmic arteries. Patients with GCS < 13 or profound weakness (MRC grade ≤ 3) were treated with burr hole drainage and placement of subdural drains.Methods: Patients were recruited over a 14-month period from 25 October 2020 to 25 December 21 through our electronic referral system. Patients' demographics, pre-morbid modified Rankin Score (mRS), symptoms; anticoagulation and co-morbidities were prospectively collected. Suitability for endovascular treatment was discussed with the interventional neuroradiologist and neurosurgeon. SQUID-12 embolic material was used for all MMA embolisations, which was performed under general anaesthetic. Baseline CT/MRI characteristics were collected. Further imaging was obtained at 7, 21, 90 and 180 days. Clinical assessment and mRS was completed at three months.Results: Fifteen patients underwent endovascular embolisation of MMA in the study period. Of these 13 were male, median age was 79 years. Median length of stay was four days. Follow-up CT at three months has demonstrated significant reduction in both midline shift (p = 0.002) and maximum thickness of haematoma (p = 0.001). Nine patients had reached the three months' follow-up period. All of them had complete or near-complete resolution of the CSDH. One patient required surgical rescue at two months post procedure due to progression of CSDH. We report one mortality due to COVID-19.Conclusions: For select patients, MMA embolisation is a safe alternative treatment option for chronic subdural haematoma. As we gain more experience, the procedure could be performed under local anaesthetic.
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Affiliation(s)
- Saffwan Mohamed
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
| | - Alvaro Villabona
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
| | - Oliver Kennion
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
| | - Rajeev Padmananbhan
- Department of Neuroradiology, James Cook University Hospital, Middlesbrough, UK
| | - Aslam Siddiqui
- Department of Neuroradiology, James Cook University Hospital, Middlesbrough, UK
| | - Shahid Khan
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
| | - Manjunath Prasad
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
| | - Nitin Mukerji
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
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22
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NAKAO J, MARUSHIMA A, FUJITA K, FUJIMORI H, MASHIKO R, KAMEZAKI T, SATO N, SHIBATA Y, TAKANO S, ISHIKAWA E. Conservative Treatment of Chronic Subdural Hematoma with Gorei-san. Neurol Med Chir (Tokyo) 2022; 63:31-36. [PMID: 36288975 PMCID: PMC9894621 DOI: 10.2176/jns-nmc.2022-0229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Most asymptomatic patients with chronic subdural hematoma (CSDH) are followed conservatively but can require surgical treatment if the hematoma expands. We conducted a retrospective evaluation of the effect of Gorei-san on CSDH. This study included patients treated between April 2013 and March 2015. In total, 289 patients were diagnosed with CSDH and 110 patients received conservative management. Finally, 39 patients who met the requirements were registered. We retrospectively examined the age, gender, medical history, hematoma thickness, clarity of sulci below hematomas, and midline shift of the patients. The primary outcome was the median surgery-free interval, and the secondary results were the rate of CSDH shrinkage and surgery avoidance. A comparison of patient characteristics between the Gorei-san (G) and non-Gorei-san (NG) groups found no significant differences in the percentage of men, average ages, past history, thickness of CSDH (15.0 ± 3.1 mm vs. 15.3 ± 2.6 mm, p = 0.801), or midline shift (2.0 ± 2.7 mm vs. 4.0 ± 5.0 mm, p = 0.230). The median surgery-free interval was significantly different between the G and NG groups [n. r. vs. 41 days (95% CI: 5-79), log-rank p = 0.047]. The CSDH avoidance rate was not significantly different between the two groups (70.0% vs. 34.4%, p = 0.071). Additionally, the CSDH shrinkage rate was significantly different between the two groups (60.0% vs. 10.3%, p = 0.004). This retrospective study demonstrated that CSDH treatment with Gorei-san reduces hematoma significantly more than treatment that does not include Gorei-san.
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Affiliation(s)
- Junzo NAKAO
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Aiki MARUSHIMA
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Keisi FUJITA
- Department of Neurosurgery, Ibaraki Seinan Medical Center Hospital, Sashima, Ibaraki, Japan
| | - Hiroyuki FUJIMORI
- Department of Neurosurgery, Kobari General Hospital, Noda, Chiba, Japan
| | - Ryota MASHIKO
- Department of Neurosurgery, University of Tsukuba Mito Medical Center, Mito, Ibaraki, Japan
| | - Takao KAMEZAKI
- Department of Neurosurgery, Ibaraki Seinan Medical Center Hospital, Sashima, Ibaraki, Japan
| | - Naoaki SATO
- Department of Neurosurgery, Kobari General Hospital, Noda, Chiba, Japan
| | - Yasushi SHIBATA
- Department of Neurosurgery, University of Tsukuba Mito Medical Center, Mito, Ibaraki, Japan
| | - Shingo TAKANO
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Eiichi ISHIKAWA
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
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23
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DOFUKU S, SATO D, NAKAMURA R, OGAWA S, TORAZAWA S, SATO M, OTA T. Sequential Middle Meningeal Artery Embolization after Burr Hole Surgery for Recurrent Chronic Subdural Hematoma. Neurol Med Chir (Tokyo) 2022; 63:17-22. [PMID: 36223949 PMCID: PMC9894617 DOI: 10.2176/jns-nmc.2022-0164] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Middle meningeal artery embolization (MMAE) for chronic subdural hematoma (CSDH) is a novel, minimally invasive treatment. The indications and treatment practices for MMAE are variable and remain controversial. This study aimed to evaluate a strategy involving sequential MMAE after burr hole surgery for treating recurrent CSDH. We performed a retrospective analysis of data from consecutive patients who had undergone MMAE using liquid embolic agents within approximately 2 weeks after burr hole surgery for recurrent CSDH from September 2020 to March 2022. We analyzed patient characteristics, procedural details, CSDH recurrence after MMAE, surgical rescue, and complications. Six of the nine patients who underwent MMAE for CSDH recurrence were male, and the median age was 85 (range, 70-94) years. Five of the nine patients were being administered antithrombotic agents. The median duration between the burr hole surgery and MMAE procedure was 10 (range, 3-25) days. Anterior and posterior convexity branches were targeted for embolization using low-concentration N-butyl cyanoacrylate (NBCA), and the abnormal vascular networks with a cotton wool appearance disappeared after embolization in all cases. The NBCA distribution was observed by high-resolution computed tomography during the procedure; in three of nine cases, the NBCA penetrated not only the MMA but also the inner membrane. No recurrence, surgical rescue, or complications were observed in any patient during the median follow-up period of 3 months. As a minimally invasive treatment for recurrent CSDH, sequential MMAE after burr hole surgery may be a safe and effective option for preventing recurrence.
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Affiliation(s)
- Shogo DOFUKU
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Daisuke SATO
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Rika NAKAMURA
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Shotaro OGAWA
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Seiei TORAZAWA
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Masayuki SATO
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Takahiro OTA
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
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24
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Solou M, Ydreos I, Gavra M, Papadopoulos EK, Banos S, Boviatsis EJ, Savvanis G, Stavrinou LC. Controversies in the Surgical Treatment of Chronic Subdural Hematoma: A Systematic Scoping Review. Diagnostics (Basel) 2022; 12:2060. [PMID: 36140462 PMCID: PMC9498240 DOI: 10.3390/diagnostics12092060] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/15/2022] [Accepted: 08/22/2022] [Indexed: 11/23/2022] Open
Abstract
Chronic subdural hematoma (cSDH) is one of the most common neurosurgical entities, especially in the elderly population. Diagnosis is usually established via a head computed tomography, while an increasing number of studies are investigating biomarkers to predict the natural history of cSDH, including progression and recurrence. Surgical evacuation remains the mainstay of treatment in the overwhelming majority of cases. Nevertheless, many controversies are associated with the nuances of surgical treatment. We performed a systematic review of the literature between 2010 and 2022, aiming to identify and address the issues in cSDH surgical management where consensus is lacking. The results show ambiguous data in regard to indication, the timing and type of surgery, the duration of drainage, concomitant membranectomy and the need for embolization of the middle meningeal artery. Other aspects of surgical treatment-such as the use of drainage and its location and number of burr holes-seem to have been adequately clarified: the drainage of hematoma is strongly recommended and the outcome is considered as independent of drainage location or the number of burr holes.
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Affiliation(s)
- Mary Solou
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
| | - Ioannis Ydreos
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
| | - Maria Gavra
- Department of CT and MRI Imaging, “Agia Sofia” Hospital, 11527 Athens, Greece
| | - Evangelos K. Papadopoulos
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
| | - Stamatis Banos
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
| | - Efstathios J. Boviatsis
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
| | - Georgios Savvanis
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
| | - Lampis C. Stavrinou
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
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25
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Hematoma cavity separation and neomembrane thickness are potential triggers of recurrence of chronic subdural hematoma. BMC Surg 2022; 22:236. [PMID: 35725399 PMCID: PMC9210812 DOI: 10.1186/s12893-022-01687-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 06/15/2022] [Indexed: 12/05/2022] Open
Abstract
Background Chronic subdural hematoma (CSDH) is the anomalous and encapsulated accumulation of fluid of complex origin consisting of old blood, mostly or totally liquified and cerebrospinal fluid (CSF) in the subdural space usually after a head injury in the elderly. Almost all the research on surgical techniques and endoscopic assisted evacuation of CSDH focused on the just the evacuation and not abnormal anatomical structures that causes recurrences. Objectives We investigated abnormal anatomical structures that triggers recurrence of CSDH during craniotomy as well as burr-hole craniostomy with endoscopic assistance. Materials and methods We retrospectively analyzed all patients with CSDH who underwent craniostomy and burr-hole craniotomy with endoscopic assisted evacuation of hematoma between April 2017 and November 2020 at our institution. Clinical data obtained was categorized into patient-related, radiology as well as surgery and endoscopic evaluations. Results A total of 143 patients (109 men and 34 women) aged 43–94 years (mean age, 68.35 years) with CSDH were included in this study. We observed a recurrence rate of 4.9% (7/143). Recurrences occurred between 2 and 6 months after the operation in patients with recurrences. Our data revealed that, age, hypertension, history of injury, diabetes, antiplatelet or anticoagulant use were not associated with hematoma recurrence. Nevertheless, all the patients with recurrence of hematoma were males. Interestingly, our univariate and multivariate analyses found neomembrane thickness and hematoma cavity separation as independent risk factors (OR,45.822; 95% CI,2.666-787.711; p = 0.008) for the recurrence of CSDH (p < 0.05). Also, we observed thickened membranes connecting/separating the dura and the thickened arachnoid/pia matters in all the 7 patients with hematoma recurrence. Conclusions The treatment of patients with CSDH ought to include the identification and resection of abnormal thickened membranes connecting/separating the dura and the thickened arachnoid/pia matters to avoid recurrence. Comparatively, endoscopy showed hematoma cavity separation or neomembrane thickness just as seen during craniotomy.
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26
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Nia AM, Srinivasan VM, Siddiq F, Thomas A, Burkhardt JK, Lall RR, Kan P. Trends and Outcomes of Primary, Rescue, and Adjunct Middle Meningeal Artery Embolization for Chronic Subdural Hematomas. World Neurosurg 2022; 164:e568-e573. [PMID: 35552029 DOI: 10.1016/j.wneu.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 05/02/2022] [Accepted: 05/04/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Middle meningeal artery embolization (MMAE) is an effective minimally invasive treatment for chronic subdural hematomas (cSDHs). The authors investigated outcomes of primary, adjunct, and rescue MMAE and primary surgery for the treatment of cSDH using a large-scale national database. METHODS A retrospective study of all patients who underwent MMAE and/or surgery to treat cSDH was performed using the TriNetX Analytics Network. Primary MMAE was compared with adjunct and rescue MMAE and primary surgery. Primary outcomes included headache, facial weakness, mortality, and treatment failure, within 6 months. RESULTS A total of 4274 patients with cSDH met the inclusion criteria. Of these, 209 (4.9%) were treated with primary MMAE, 4050 (94.8%) were treated with primary surgery, 15 (0.35%) were treated using MMAE as an adjunct therapy, and 18 (0.42%) were treated using MMAE as a rescue following a failed surgical intervention. There were no significant differences in headache, facial weakness, and mortality between the groups. Patients who underwent primary MMAE had a significantly higher Charlson comorbidity index (P < 0.0001) than those who underwent primary surgery. The need for surgical rescue was not significantly different between primary MMAE, adjunct MMAE, and rescue MMAE (P > 0.05). Additionally, patients with primary surgery had significantly higher treatment failure than those with primary MMAE (odds ratio = 2.11, 95% confidence interval = 1.11-4.01, P = 0.020). CONCLUSIONS This analysis suggests no significant difference in the need for surgical rescue, complication, or mortality between primary MMAE, adjunct MMAE, and rescue MMAE. Additionally, primary MMAE is associated with a significantly lower need for surgical rescue than primary surgery.
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Affiliation(s)
- Anna M Nia
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Farhan Siddiq
- Division of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | - Ajith Thomas
- Department of Neurosurgery, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rishi R Lall
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA.
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27
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Lee S, Srivatsan A, Srinivasan VM, Chen SR, Burkhardt JK, Johnson JN, Raper DMS, Weinberg JS, Kan P. Middle meningeal artery embolization for chronic subdural hematoma in cancer patients with refractory thrombocytopenia. J Neurosurg 2022; 136:1273-1277. [PMID: 34624863 DOI: 10.3171/2021.5.jns21109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 05/03/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgical evacuation of chronic subdural hematoma (SDH) in cancer patients is often contraindicated owing to refractory thrombocytopenia. Middle meningeal artery embolization (MMAE) recently emerged as a potential alternative to surgical evacuation for patients with chronic SDH. The goal of this study was to evaluate the safety and efficacy of MMAE for chronic SDH in cancer patients with refractory thrombocytopenia. METHODS A multiinstitutional registry was reviewed for clinical and radiographic outcomes of cancer patients with transfusion-refractory thrombocytopenia and baseline platelet count < 75 K/µl, who underwent MMAE for chronic SDH. RESULTS MMAE was performed on a total of 31 SDHs in 22 patients, with a mean ± SD (range) platelet count of 42.1 ± 18.3 (9-74) K/µl. At the longest follow-up, 24 SDHs (77%) had reduced in size, with 15 (48%) showing > 50% reduction. Two patients required surgical evacuation after MMAE. There was only 1 procedural complication; however, 16 patients (73%) ultimately died of cancer-related complications. Median survival was significantly longer in the 16 patients with improved SDH than the 6 patients with worsened SDH after MMAE (185 vs 24 days, p = 0.029). Length of procedure, technical success rate, SDH size reduction, and complication rate were not significantly differ between patients who underwent transfemoral and transradial approaches. CONCLUSIONS Transfemoral or transradial MMAE is a potential therapeutic option for thrombocytopenic cancer patients with SDH. However, treatment benefit may be marginal for patients with high disease burden and limited life expectancy. A prospective trial is warranted to address these questions.
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Affiliation(s)
- Sungho Lee
- 1Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Aditya Srivatsan
- 1Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | | | | | - Jan-Karl Burkhardt
- 4Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
| | | | - Daniel M S Raper
- 1Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Jeffrey S Weinberg
- 3Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Peter Kan
- 5Department of Neurosurgery, The University of Texas Medical Branch, Galveston, Texas
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28
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Al-Salihi MM, Rahman MM, Al-Jebur MS, Rahman S. Letter: Middle Meningeal Artery Embolization Versus Conventional Treatment of Chronic Subdural Hematomas. Neurosurgery 2022; 90:e106-e107. [PMID: 35086981 DOI: 10.1227/neu.0000000000001858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 11/08/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
| | - Md Moshiur Rahman
- Department of Neurosurgery, Holy Family Red Crescent Medical College, Dhaka, Bangladesh
| | | | - Sabrina Rahman
- Department of Public Health, Independent University-Bangladesh, Dhaka, Bangladesh
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29
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Deng J, Wang F, Wang H, Zhao M, Chen G, Shangguan H, Yu L, Jiang C, Fang W, Yao P, Kang D, Zheng S. Efficacy of Neuroendoscopic Treatment for Septated Chronic Subdural Hematoma. Front Neurol 2022; 12:765109. [PMID: 35087465 PMCID: PMC8788945 DOI: 10.3389/fneur.2021.765109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/02/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Neuroendoscopic treatment is an alternative therapeutic strategy for the treatment of septate chronic subdural hematoma (sCSDH). However, the safety and efficacy of this strategy remain controversial. We compared the clinical outcomes of neuroendoscopic treatment with those of standard (large bone flap) craniotomy for sCSDH reported in our center. Furthermore, the safety and efficacy of the neuroendoscopic treatment procedure for sCSDH were evaluated. Methods: We retrospectively collected the clinical data of 43 patients (37 men and six women) with sCSDH who underwent either neuroendoscopic treatment or standard (large bone flap) craniotomy, such as sex, age, smoking, drinking, medical history, use of antiplatelet drugs, postoperative complications, sCSDH recurrence, length of hospital stay, and postoperative hospital stay. We recorded the surgical procedures and the neurological function recovery prior to surgery and 6 months following the surgical treatment. Results: The enrolled patients were categorized into neuroendoscopic treatment (n = 23) and standard (large bone flap) craniotomy (n = 20) groups. There were no differences in sex, age, smoking, drinking, medical history, antiplatelet drug use, postoperative complications, and sCSDH recurrence between the two groups (p > 0.05). However, the patients in neuroendoscopic treatment group had a shorter length of total hospital stay and postoperative hospital stay as compared with the standard craniotomy group (total hospital stay: 5.26 ± 1.89 vs. 8.15 ± 1.04 days, p < 0.001; postoperative hospital stay: 4.47 ± 1.95 vs. 7.96 ± 0.97 days, p < 0.001). The imaging and Modified Rankin Scale at the 6-month follow-up were satisfactory, and no sCSDH recurrence was reported in the two groups. Conclusions: The findings of this study indicate that neuroendoscopic treatment is safe and effective for sCSDH; it is minimally invasive and could be clinically utilized.
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Affiliation(s)
- Jianhong Deng
- Department of Neurosurgery, Guangze County Hospital, Nanping, China
| | - Fangyu Wang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Haojie Wang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Mingpei Zhao
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Guorong Chen
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Huangcheng Shangguan
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Lianghong Yu
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Changzhen Jiang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Wenhua Fang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Peisen Yao
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Dezhi Kang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Precision Medicine for Cancer, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Key Laboratory of Radiation Biology of Fujian Higher Education Institutions, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Shufa Zheng
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
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30
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Khelifa A, Bennafaa T, Bennabi W, Felissi Y, Aichaoui F, Morsli A. Outcome of craniotomy and membranectomy in the management of chronic subdural haematoma recurrence: A series of 17 patients. HAMDAN MEDICAL JOURNAL 2022. [DOI: 10.4103/hmj.hmj_10_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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31
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Tariq J, Bhatti SN. Adjunctive postoperative course of dexamethasone in chronic subdural hematoma: Effect on surgical outcome. Pak J Med Sci 2021; 37:1877-1882. [PMID: 34912411 PMCID: PMC8613023 DOI: 10.12669/pjms.37.7.3374] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 02/05/2021] [Accepted: 07/15/2021] [Indexed: 11/24/2022] Open
Abstract
Objectives: To compare the effect of burrhole craniostomy with and without a postoperative course of dexamethasone on recurrence rate of chronic subdural hematoma (CSDH). Methods: The study was conducted at the Department of Neurosurgery, Pakistan Institute of Medical Sciences, Islamabad, from September 2017 till May 2018. Adult patients diagnosed with CSDH and advised burrhole craniostomy were enrolled in this prospective randomized controlled trial. Participants were randomized into Group-1 (receiving two weeks dexamethasone), and Group-2 (no dexamethasone). Clinical assessment and Brain CT were done preoperatively, second postoperative day, sixth and twelfth postoperative week, with outcome assessed at twelfth postoperative week. Complications of treatment and recurrence rate were recorded. Results: Ninety-two (n=92, 46 in each group) patients were enrolled. Improvement in neurological (95.7% vs 93.5%; P=0.646) and radiological outcome (95.7% vs 93.5%; P=0.646) was similar in both groups. Complication rate was higher in Group-1 but not significantly different (58.7% vs 43.5%; P=0.535). Most frequent complication was pneumocephalus, with mortality rate equal (n=one). Recurrence was observed in 2.2% (n=1/46) patients in Group-1 and 4.3% (n=2/46) in Group-2 (P=0.557), which was not statistically significant. Conclusions: Neurological and radiological outcome, and mortality rates were similar in both groups. The recurrence rate was lower and complications slightly higher in Group-1 but these were not statistically significant.
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Affiliation(s)
- Jibran Tariq
- Jibran Tariq, MS. Senior Registrar, Department of Surgery, Peshawar Institute of Medical Sciences, Pak International Medical College, Peshawar, Pakistan
| | - Sajid Nazir Bhatti
- Sajid Nazir Bhatti, FCPS/MS. Head of Department, Department of Neurosurgery, Pakistan Institute of Medical Sciences, Shaheed Zulfiqar Ali Bhutto Medical University, Islamabad, Pakistan
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32
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Dicpinigaitis AJ, Al-Mufti F, Cooper JB, Faraz Kazim S, Couldwell WT, Schmidt MH, Gandhi CD, Cole CD, Bowers CA. Nationwide trends in middle meningeal artery embolization for treatment of chronic subdural hematoma: A population-based analysis of utilization and short-term outcomes. J Clin Neurosci 2021; 94:70-75. [PMID: 34863465 DOI: 10.1016/j.jocn.2021.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 09/29/2021] [Accepted: 10/03/2021] [Indexed: 11/29/2022]
Abstract
Middle meningeal artery (MMA) embolization represents a promising novel treatment modality for chronic subdural hematoma (cSDH), yet utilization and efficacy data are limited. This study evaluates the utilization and short-term outcomes of MMA embolization for cSDH treatment in a large national inpatient registry. cSDH patients treated with MMA embolization and/or surgical evacuation (craniotomy/burr hole drainage) were identified using the National Inpatient Sample (NIS) during 2012-2018 period. Temporal trends, complications, and discharge disposition were evaluated, and propensity score matching was implemented for adjusted comparisons and to mitigate confounding by indication. Among 60,045 cSDH patients identified, 390 (0.6%) underwent MMA embolization. Embolized patients presented more with high acute illness severity subclasses in comparison with surgically evacuated patients (53% vs. 34%, p = 0.004) yet did not experience any procedure-related hemorrhagic or ischemic complications. Although discharge disposition did not differ from those surgically managed, embolized patients had longer mean hospital stays (13 vs. 8 days, p = 0.023) and accrued greater hospital charges (p < 0.001). Following propensity adjustment, length of stay and charges remained greater in the embolization cohort, yet rates of routine discharge increased appreciably (40% vs. 30%, p = 0.141) relative to surgically treated cSDH patients. The utilization of embolization increased exponentially after 2015, reaching an apex in 2018 (3.7% of treated cSDH). This population-based national assessment demonstrates exponential increases in utilization of MMA embolization for cSDH treatment in recent years. Embolized patients had uncomplicated clinical courses and similar discharge dispositions as surgical evacuation patients. Large-scale prospective trials are warranted to further assess the efficacy of this modality.
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Affiliation(s)
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Jared B Cooper
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Syed Faraz Kazim
- Depertment of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Meic H Schmidt
- Depertment of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Chad D Cole
- Depertment of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | - Christian A Bowers
- Depertment of Neurosurgery, University of New Mexico, Albuquerque, NM, USA.
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33
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Désir LL, D'Amico R, Link T, Silva D, Ellis JA, Doron O, Langer DJ, Ortiz R, Serulle Y. Middle Meningeal Artery Embolization and the Treatment of a Chronic Subdural Hematoma. Cureus 2021; 13:e18868. [PMID: 34754700 PMCID: PMC8570051 DOI: 10.7759/cureus.18868] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 11/18/2022] Open
Abstract
Chronic subdural hematoma (cSDH) is a common pathology that typically affects the elderly. It is believed to occur due to injury to the dural border cells, which creates an inflammation/proliferation reaction. Ineffective repair leads to the formation of a new external layer of cells and fragile capillaries, which damage easily and can worsen the condition. Conventionally, asymptomatic cSDH is managed by observation, and symptomatic cases are treated by surgical evacuation. Unfortunately, recurrence rates of the SDH following surgical evacuation can be high. One treatment option for SDH involves embolization of the middle meningeal artery (MMA). The MMA provides blood supply to the dura mater and feeds the membrane capillaries covering the SDH. MMA embolization blocks the blood flow to this system and can promote hematoma resolution. In this paper, we review the existing literature on MMA embolization and discuss the underlying pathophysiology of cSDH.
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Affiliation(s)
- Likowsky L Désir
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
| | - Randy D'Amico
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
| | - Thomas Link
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
| | - Danilo Silva
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
| | - Jason A Ellis
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
| | - Omer Doron
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
| | - David J Langer
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
| | - Rafael Ortiz
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
| | - Yafell Serulle
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
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34
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Stanishevskiy AV, Babichev KN, Vinogradov EV, Gizatullin SK, Svistov DV, Kandyba DV, Savello AV. [Middle meningeal artery embolization for chronic subdural haematoma. Case series and literature review]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2021; 85:71-79. [PMID: 34714006 DOI: 10.17116/neiro20218505171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Middle meningeal artery embolization as primary method for treatment of chronic subdural hematomas became more popular in past decade. There are few large case series (>150 patients) and literature reviews characterizing advantages and drawbacks of endovascular treatment and technical features of surgeries. In this manuscript, the authors report 11 patients with chronic subdural hematoma scheduled for middle meningeal artery embolization and review the literature data on this issue.
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Affiliation(s)
| | - K N Babichev
- Kirov Military Medical Academy, St. Petersburg, Russia.,Dzhanelidze Saint Petersburg Research Institute for Emergency Care, St. Petersburg, Russia
| | - E V Vinogradov
- Burdenko Main Military Clinical Hospital, Moscow, Russia
| | | | - D V Svistov
- Kirov Military Medical Academy, St. Petersburg, Russia
| | - D V Kandyba
- Kirov Military Medical Academy, St. Petersburg, Russia.,Dzhanelidze Saint Petersburg Research Institute for Emergency Care, St. Petersburg, Russia
| | - A V Savello
- Kirov Military Medical Academy, St. Petersburg, Russia
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35
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Tamura R, Sato M, Yoshida K, Toda M. History and current progress of chronic subdural hematoma. J Neurol Sci 2021; 429:118066. [PMID: 34488045 DOI: 10.1016/j.jns.2021.118066] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 08/25/2021] [Accepted: 08/31/2021] [Indexed: 11/18/2022]
Abstract
Chronic subdural hematoma (CSDH) is characterized by an encapsulated collection of old blood. Although CSDH has become the most frequent pathologic entity in daily neurosurgical practice, there are some unresolved research questions. In particular, the causes and recurrent risk factors of CSDH remain as an object of debate. The split of the dural border layer forms a few tiers of dural border cells over the arachnoid layer. Tissue plasminogen activator plays an important role as a key factor of defective coagulation. Historically, CSDH has often been treated via burr hole craniostomy using a closed drainage system. Several different operative strategies and peri-operative strategies such as the addition of burr holes, addition of cavity irrigation, position of drain, or postural position, have been described previously. Although the direction of the drainage tube, residual air, low intensity of T1-weighted images on MRI, and niveau formation have been reported as risk factors for recurrence, antiplatelet or anticoagulant drug use has not yet been verified as a risk factor. Recently, pharmaceutical strategies, including atorvastatin, significantly improved the neurological function in CSDH patients. Many case series, without randomization, have been reported; and given its promising result, several randomized clinical trials using pharmaceutical as well as operative and perioperative strategies were initiated to obtain sufficient data. In contrast, relatively fewer basic studies have achieved clinical applications in CSDH, although it is one of the most common clinical entities. Further scientific basic research may be essential for achieving a novel treatment strategy for CSDH.
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Affiliation(s)
- Ryota Tamura
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan; Department of Neurosurgery, Kawasaki Municipal Hospital, Shinkawadori, Kawasaki-ku, Kanagawa 210-0013, Japan
| | - Mizuto Sato
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Kazunari Yoshida
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Masahiro Toda
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
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Catapano JS, Ducruet AF, Nguyen CL, Cole TS, Baranoski JF, Majmundar N, Wilkinson DA, Fredrickson VL, Cavalcanti DD, Lawton MT, Albuquerque FC. A propensity-adjusted comparison of middle meningeal artery embolization versus conventional therapy for chronic subdural hematomas. J Neurosurg 2021; 135:1208-1213. [PMID: 33636706 DOI: 10.3171/2020.9.jns202781] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 09/01/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Middle meningeal artery (MMA) embolization is a promising treatment strategy for chronic subdural hematomas (cSDHs). However, studies comparing MMA embolization and conventional therapy (surgical intervention and conservative management) are limited. The authors aimed to compare MMA embolization versus conventional therapy for cSDHs using a propensity-adjusted analysis. METHODS A retrospective study of all patients with cSDH who presented to a large tertiary center over a 2-year period was performed. MMA embolization was compared with surgical intervention and conservative management. Neurological outcome was assessed using the modified Rankin Scale (mRS). A propensity-adjusted analysis compared MMA embolization versus surgery and conservative management for all individual cSDHs. Primary outcomes included change in hematoma diameter, treatment failure, and complete resolution at last follow-up. RESULTS A total of 231 patients with cSDH met the inclusion criteria. Of these, 35 (15%) were treated using MMA embolization, and 196 (85%) were treated with conventional treatment. On the latest follow-up, there were no statistically significant differences between groups in the percentage of patients with worsening mRS scores. Of the 323 total cSDHs found in 231 patients, 41 (13%) were treated with MMA embolization, 159 (49%) were treated conservatively, and 123 (38%) were treated with surgical evacuation. After propensity adjustment, both surgery (OR 12, 95% CI 1.5-90; p = 0.02) and conservative therapy (OR 13, 95% CI 1.7-99; p = 0.01) were predictors of treatment failure and incomplete resolution on follow-up imaging (OR 6.1, 95% CI 2.8-13; p < 0.001 and OR 5.4, 95% CI 2.5-12; p < 0.001, respectively) when compared with MMA embolization. Additionally, MMA embolization was associated with a significant decrease in cSDH diameter on follow-up relative to conservative management (mean -8.3 mm, 95% CI -10.4 to -6.3 mm, p < 0.001). CONCLUSIONS This propensity-adjusted analysis suggests that MMA embolization for cSDH is associated with a greater extent of hematoma volume reduction with fewer treatment failures than conventional therapy.
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37
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Scerrati A, Visani J, Ricciardi L, Dones F, Rustemi O, Cavallo MA, De Bonis P. To drill or not to drill, that is the question: nonsurgical treatment of chronic subdural hematoma in the elderly. A systematic review. Neurosurg Focus 2021; 49:E7. [PMID: 33002869 DOI: 10.3171/2020.7.focus20237] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 07/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Chronic subdural hematoma (CSDH) is one of the most common neurosurgical pathologies, typically affecting the elderly. Its incidence is expected to grow along with the aging population. Surgical drainage represents the treatment of choice; however, postoperative complications and the rate of recurrence are not negligible. For this reason, nonsurgical alternatives (such as middle meningeal artery embolization, steroids, or tranexamic acid administration) are gaining popularity worldwide and need to be carefully evaluated, especially in the elderly population. METHODS The authors performed a systematic review according to PRISMA criteria of the studies analyzing the nonsurgical strategies for CSDHs. They collected all papers in the English language published between 1990 and 2019 by searching different medical databases. The chosen keywords were "chronic subdural hematoma," "conservative treatment/management," "pharmacological treatment," "non-surgical," "tranexamic acid," "dexamethasone," "corticosteroid," "glucocorticoid," "middle meningeal artery," "endovascular treatment," and "embolization." RESULTS The authors ultimately collected 15 articles regarding the pharmacological management of CSDHs matching the criteria, and 14 papers included the endovascular treatment. CONCLUSIONS The results showed that surgery still represents the mainstay in cases of symptomatic patients with large CSDHs; however, adjuvant and alternative therapies can be effective and safe in a carefully selected population. Their inclusion in new guidelines is advisable.
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Affiliation(s)
- Alba Scerrati
- 1Department of Morphology, Anatomy and Experimental Medicine, University of Ferrara.,2Department of Neurosurgery, Sant'Anna University Hospital, Ferrara
| | - Jacopo Visani
- 2Department of Neurosurgery, Sant'Anna University Hospital, Ferrara
| | - Luca Ricciardi
- 3Department of Neurosurgery, Pia Fondazione di Culto e Religione Cardinal G. Panico, Tricase, Lecce; and
| | - Flavia Dones
- 2Department of Neurosurgery, Sant'Anna University Hospital, Ferrara
| | - Oriela Rustemi
- 4Department of Neurosurgery, San Bortolo Hospital, Vicenza, Italy
| | - Michele Alessandro Cavallo
- 1Department of Morphology, Anatomy and Experimental Medicine, University of Ferrara.,2Department of Neurosurgery, Sant'Anna University Hospital, Ferrara
| | - Pasquale De Bonis
- 1Department of Morphology, Anatomy and Experimental Medicine, University of Ferrara.,2Department of Neurosurgery, Sant'Anna University Hospital, Ferrara
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Endovascular Treatment of Chronic Subdural Hematomas through Embolization: A Pilot Study with a Non-Adhesive Liquid Embolic Agent of Minimal Viscosity (Squid). J Clin Med 2021; 10:jcm10194436. [PMID: 34640453 PMCID: PMC8509410 DOI: 10.3390/jcm10194436] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/17/2021] [Accepted: 09/18/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Endovascular embolization using non-adhesive agents (e.g., ethylene vinyl alcohol copolymer with suspended micronized tantalum dissolved in dimethyl sulfoxide; Squid, Balt Extrusion) is an established treatment of brain arteriovenous malformations, dural arteriovenous fistulas, and hypervascular neoplasms. Middle meningeal artery (MMA) embolization is a relatively new concept for treating chronic subdural hematomas (CSDH). This study aimed to evaluate the safety and effectiveness of the use of Squid in the endovascular treatment of CSDH. METHODS Embolization was offered to patients with CSDH with minimal or moderate neurological deficits and patients who had previously undergone open surgery to evacuate their CSDH without a significant effect. Distal catheterization of the MMA was followed by embolization of the hematoma capsule with Squid 12 or Squid 18. Safety endpoints were ischemic or hemorrhagic stroke and any other adverse event of the endovascular procedure. Efficacy endpoints were the feasibility of the intended procedure and a ≥ 50% reduction of the maximum depth of the CSDH confirmed by follow-up computed tomography (CT) after >3 months. RESULTS Between November 2019 and July 2021, 10 patients (3 female and 7 male, age range 42-89 years) were enrolled. Five patients had bilateral hematomas, and five patients had previously been operated on with no significant effect and recurrent hematoma formation. The attempted embolization was technically possible in all patients. No technical or clinical complication was encountered. During a post-procedural follow-up (median 90 days), 10 patients improved clinically. A complete resolution of the CSDH was observed in 10 patients. The clinical condition of all enrolled patients during the so-far last contact was rated mRS 0 or 1. CONCLUSION A distal catheterization of the MMA for the endovascular embolization of CSDH with Squid allowed for the devascularization of the MMA and the dependent vessels of the hematoma capsule. This procedure resulted in a partial or complete resolution of the CSDH. Procedural complications were not encountered.
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Ironside N, Nguyen C, Do Q, Ugiliweneza B, Chen CJ, Sieg EP, James RF, Ding D. Middle meningeal artery embolization for chronic subdural hematoma: a systematic review and meta-analysis. J Neurointerv Surg 2021; 13:951-957. [PMID: 34193592 DOI: 10.1136/neurintsurg-2021-017352] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 06/13/2021] [Indexed: 12/13/2022]
Abstract
Middle meningeal artery (MMA) embolization has been proposed as a minimally invasive treatment for chronic subdural hematoma (cSDH). The aim of this systematic review and meta-analysis is to compare outcomes after MMA embolization versus conventional management for cSDH. We performed a systematic review of PubMed, Embase, Oxford Journal, Cochrane, and Google Scholar databases from April 1987 to October 2020 in accordance with PRISMA guidelines. Studies reporting outcomes after MMA embolization for ≥3 patients with cSDH were included. A meta-analysis comparing MMA embolization with conventional management was performed. The analysis comprised 20 studies with 1416 patients, including 718 and 698 patients in the MMA embolization and conventional management cohorts, respectively. The pooled recurrence, surgical rescue, and in-hospital complication rates in the MMA embolization cohort were 4.8% (95% CI 3.2% to 6.5%), 4.4% (2.8% to 5.9%), and 1.7% (0.8% to 2.6%), respectively. The pooled recurrence, surgical rescue, and in-hospital complication rates in the conventional management cohort were 21.5% (0.6% to 42.4%), 16.4% (5.9% to 27.0%), and 4.9% (2.8% to 7.1%), respectively. Compared with conservative management, MMA embolization was associated with lower rates of cSDH recurrence (OR=0.15 (95% CI 0.03 to 0.75), p=0.02) and surgical rescue (OR=0.21 (0.07 to 0.58), p=0.003). In-hospital complication rates were comparable between the two cohorts (OR=0.78 (0.34 to 1.76), p=0.55). MMA embolization is a promising minimally invasive therapy that may reduce the need for surgical intervention in appropriately selected patients with cSDH. Additional prospective studies are warranted to determine the long-term durability of MMA embolization, refine eligibility criteria, and establish this endovascular approach as a viable definitive treatment for cSDH.
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Affiliation(s)
- Natasha Ironside
- Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Candice Nguyen
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Quan Do
- Department of Internal Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Beatrice Ugiliweneza
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Emily P Sieg
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Robert F James
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dale Ding
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
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Onyinzo C, Berlis A, Abel M, Kudernatsch M, Maurer CJ. Efficacy and mid-term outcome of middle meningeal artery embolization with or without burr hole evacuation for chronic subdural hematoma compared with burr hole evacuation alone. J Neurointerv Surg 2021; 14:297-300. [PMID: 34187870 DOI: 10.1136/neurintsurg-2021-017450] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 06/14/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a common neurosurgical condition with high recurrence rates. Repeated microbleedings from fragile neo-vessels supplied by peripheral branches of the middle meningeal artery (MMA) are believed to be responsible for the growth and recurrence of CSDH. Thus, MMA embolization might be a promising method to prevent re-bleedings and recurrences. This study aims to assess the efficacy, complication rates, and mid-term outcome of MMA embolization with or without burr hole irrigation compared with burr hole irrigation alone. METHODS Patients diagnosed with CSDH who underwent MMA embolization and/or surgical treatment were retrospectively recruited to this single-center study. The outcome variables were defined as treatment-related complications, clinical outcome at discharge, rate of revision surgery, and CT findings during the follow-up period. RESULTS A total of 132 patients with CSDH were included in the study. The use of antiplatelet/anticoagulant medication was significantly higher in the combined treatment and embolization group (p<0.001). A trend towards fewer revision surgeries was found in the group of patients who received MMA embolization combined with burr hole irrigation (p=0.083). Follow-up was available for 73 patients (55.3%) with a mean follow-up period of 3.4±2.2 months. Eight patients (15.1%) of the surgery group showed hematoma re-accumulation and needed surgical rescue, whereas only one patient (5.0%) of the combined treatment group needed revision surgery. In all patients treated with only MMA embolization, complete hematoma resolution was found. CONCLUSION MMA embolization is a safe and efficacious minimal invasive adjuvant and/or alternative procedure for the treatment of CSDH with a reduced recurrence rate.
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Affiliation(s)
- Christina Onyinzo
- Department of Neurosurgery, Schoen Clinic Vogtareuth, Vogtareuth, Bavaria, Germany
| | - Ansgar Berlis
- Department of Diagnostic and Interventionell Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Bavaria, Germany.,Department of Neuroradiology, Schoen Clinic Vogtareuth, Vogtareuth, Bavaria, Germany
| | - Maria Abel
- Department of Neurosurgery, Schoen Clinic Vogtareuth, Vogtareuth, Bavaria, Germany
| | - Manfred Kudernatsch
- Department of Neurosurgery, Schoen Clinic Vogtareuth, Vogtareuth, Bavaria, Germany.,Research Institute Rehabilitation, Transition, Palliation, Paracelsus Medizinische Privatuniversität, Salzburg, Austria
| | - Christoph J Maurer
- Department of Diagnostic and Interventionell Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Bavaria, Germany.,Department of Neuroradiology, Schoen Clinic Vogtareuth, Vogtareuth, Bavaria, Germany
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41
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Nia AM, Srinivasan VM, Lall RR, Kan P. Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A National Database Study of 191 Patients in the United States. World Neurosurg 2021; 153:e300-e307. [PMID: 34214657 DOI: 10.1016/j.wneu.2021.06.101] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 06/21/2021] [Accepted: 06/22/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Middle meningeal artery embolization (MMAE) has been used as an effective minimally invasive treatment for chronic subdural hematoma (cSDH). The demographics and clinical outcomes after MMAE treatment for cSDH have not yet been studied using a national database. METHODS We queried all MMAE cases up to October 7, 2020, from the TriNetX Analytics Network. We identified patients >18 years old who underwent MMAE for treatment of cSDH. Patient demographics, baseline characteristics, comorbidities, and clinical outcomes were evaluated within 180 days after MMAE. Analyses of 180-day mortality and recurrence were performed after propensity score matching to control for baseline characteristics and comorbidities. RESULTS The study included 191 patients (mean age 71.2 ± 13.5 years, 73.3% male, 69.6% White, 13.6% Black/African American, and 16.8% other race). Essential hypertension (71.3%), heart disease (62.8%), type 2 diabetes mellitus (27.2%), nicotine dependence (23.6%), chronic kidney disease (19.4%), and overweight/obesity (19.4%) were among the most prevalent comorbidities. At presentation, 20.4% and 40.3% of patients were on antiplatelet and anticoagulation therapy, respectively. Outcomes within 180-day follow-up were 6.3% (1.0%-5.8% when propensity matched) for mortality (12 patients), 7.3% for craniotomy/craniectomy after MMAE (14 patients), 0.52%-5.2% for burr hole procedures (1-10 patients), and no patients with low vision/blindness. CONCLUSIONS MMAE is a safe and effective minimally invasive procedure for treatment of cSDH. This is the first analysis of patients undergoing MMAE for cSDH using a national database.
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Affiliation(s)
- Anna M Nia
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Rishi R Lall
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA.
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Enriquez-Marulanda A, Gomez-Paz S, Salem MM, Mallick A, Motiei-Langroudi R, Arle JE, Stippler M, Papavassiliou E, Alterman RL, Ogilvy CS, Moore JM, Thomas AJ. Middle Meningeal Artery Embolization Versus Conventional Treatment of Chronic Subdural Hematomas. Neurosurgery 2021; 89:486-495. [PMID: 34171921 DOI: 10.1093/neuros/nyab192] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 04/03/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Middle meningeal artery (MMA) embolization is an emerging minimally invasive endovascular technique for chronic subdural hematoma (cSDH). Currently, limited literature exists on its safety and efficacy compared with conventional treatment (open-surgical-evacuation-only). OBJECTIVE To compare MMA embolization to conventional treatment. METHODS Retrospective analysis of patients with cSDHs treated with MMA embolization in a single center from 2018 to 2019 was performed. Comparisons were made with a historical conventional treatment cohort from 2006 to 2016. Propensity score matching analysis was used to assemble a balanced group of subjects. RESULTS A total of 357 conventionally treated cSDH and 45 with MMA embolization were included. After balancing with propensity score matching, a total of 25 pairs of cSDH were analyzed. Comparing the embolization with the conventional treatment group yielded no significant differences in complications (4% vs 4%; P > .99), clinical improvement (82.6% vs 83.3%; P = .95), cSDH recurrence (4.3% vs 21.7%; P = .08), overall re-intervention rates (12% vs 24%; P = .26), modified Rankin scale >2 on last follow-up (17.4% vs 32%; P = .24), as well as mortality (0% vs 12%; P = .09). Radiographic improvement at last follow-up was significantly higher in the open surgery cohort (73.9% vs 95.6%; P = .04). However, there was a trend for lengthier last follow-up for the historical cohort (72 vs 104 d; P = .07). CONCLUSION There was a trend for lower recurrence and mortality rates in the embolization era cohort. There were significantly higher radiological improvement rates on last follow-up in the surgical only cohort era. There were no significant differences in complications and clinical improvement.
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Affiliation(s)
| | - Santiago Gomez-Paz
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mohamed M Salem
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Akashleena Mallick
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - J E Arle
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Martina Stippler
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Efstathios Papavassiliou
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ron L Alterman
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin M Moore
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith J Thomas
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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43
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Chen JW, Xu JC, Malkasian D, Perez-Rosendahl MA, Tran DK. The Mini-Craniotomy for cSDH Revisited: New Perspectives. Front Neurol 2021; 12:660885. [PMID: 34025564 PMCID: PMC8134699 DOI: 10.3389/fneur.2021.660885] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/25/2021] [Indexed: 01/04/2023] Open
Abstract
Background: Chronic subdural hematomas (cSDH) are increasingly prevalent worldwide with the increased aging population and anticoagulant use. Different surgical, medical, and endovascular treatments have had varying success rates. Primary neurosurgical interventions include burr hole drainage of the cSDH and mini-craniotomies/craniotomies with or without fenestration of the inner membrane. A key assessment of the success or failure of cSDH treatments has been symptomatic recurrence rates which have historically ranged from 5 to 30%. Pre-operative prediction of the inner subdural membrane by CT scan was used to guide our decision to perform mini-craniotomies. Release of the inner membrane facilitates the expansion of the brain and likely improves glymphatic flow. Methods: Consecutive mini-craniotomies (N = 34) for cSDH evacuation performed by a single neurosurgeon at a quaternary academic medical center/Level I trauma center from July 2018-September 2020 were retrospectively reviewed. Patient characteristics [age, gender, presenting GCS, GOS, initial CTs noting the inner subdural membrane, midline shift (MLS), cSDH width, inner membrane fenestration, cSDH recurrence, post-operative seizures, infections, length of stay] were extracted from the EMR. Results: Twenty nine patients had mini-craniotomies as primary treatment of the cSDH. Mean age = 68.9 ± 19.7 years (range 22–102), mean pre-operative GCS = 14.5 ± 1.1, mean MLS = 6.75 ± 4.2 mm, and mean maximum thickness of cSDH = 17.7 ± 6.0 mm. Twenty four were unilateral, five bilateral, 34 total craniotomies were performed. Thirty three had inner membrane signs on pre-operative head CTs and an inner subdural membrane was fenestrated in all cases except for the one craniotomy that didn't show these characteristic CT findings. Mean operating time = 79.5 ± 26.0 min. Radiographic and clinical improvement occurred in all patients. Mean improvement in MLS = 3.85 ± 2.69. There were no symptomatic recurrences, re-operations, surgical site infections, or deaths during the 6 months of follow-up. One patient was treated for post-operative seizures with AEDs for 6 months. Conclusion: Pre-operative CT scans demonstrating inner subdural membranes may guide one to target the treatment to allow release of this tension band. Mini-craniotomy with careful fenestration of the inner membrane is very effective for this. Brain re-expansion and re-establishment of normal brain interstitial flow may be important in long term outcomes with cSDH and may be related to the recent interests in brain glymphatics and dural lymphatics.
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Affiliation(s)
- Jefferson W Chen
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, United States
| | - Jordan C Xu
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, United States
| | - Dennis Malkasian
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, United States
| | - Mari A Perez-Rosendahl
- Neuropathology Division, Department of Pathology, University of California, Irvine, Orange, CA, United States
| | - Diem Kieu Tran
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, United States
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44
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Carpenter A, Rock M, Dowlati E, Miller C, Mai JC, Liu AH, Armonda RA, Felbaum DR. Middle meningeal artery embolization with subdural evacuating port system for primary management of chronic subdural hematomas. Neurosurg Rev 2021; 45:439-449. [PMID: 33893872 DOI: 10.1007/s10143-021-01553-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/14/2021] [Accepted: 04/19/2021] [Indexed: 11/30/2022]
Abstract
Optimal treatment for chronic subdural hematomas remains controversial and perioperative risks and comorbidities may affect management strategies. Minimally invasive procedures are emerging as alternatives to the standard operative treatments. We evaluate our experience with middle meningeal artery (MMA) embolization combined with Subdural Evacuating Port System (SEPS) placement as a first-line treatment for patients with cSDH. A single institution retrospective review was performed of all patients undergoing intervention. Patients were stratified by treatment with MMA embolization and SEPS placement, MMA embolization and surgery, SEPS placement only, and surgery only for cSDH from 2017 to 2020, and cohorts were compared against each other. Patients treated with MMA/SEPS were more likely to be older, be on anticoagulation, have significant comorbidities, have shorter length of stay, and less likely to have symptomatic recurrence compared to SEPS only cohort. Thus, MMA/SEPS appears to be a safe and equally effective minimally invasive treatment for cSDH patients with significant comorbidities who are poor surgical candidates.
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Affiliation(s)
- Austin Carpenter
- Georgetown University School of Medicine, 3900 Reservoir Road NW, Washington, DC, USA
| | - Mitchell Rock
- Georgetown University School of Medicine, 3900 Reservoir Road NW, Washington, DC, USA
| | - Ehsan Dowlati
- Department of Neurosurgery, MedStar Georgetown University Hospital, 3800 Reservoir Road NW, PHC7, Washington, DC, USA.
| | - Charles Miller
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Jeffrey C Mai
- Department of Neurosurgery, MedStar Georgetown University Hospital, 3800 Reservoir Road NW, PHC7, Washington, DC, USA.,Department of Neurosurgery, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC, USA
| | - Ai-Hsi Liu
- Department of Radiology, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC, USA
| | - Rocco A Armonda
- Department of Neurosurgery, MedStar Georgetown University Hospital, 3800 Reservoir Road NW, PHC7, Washington, DC, USA.,Department of Neurosurgery, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC, USA
| | - Daniel R Felbaum
- Department of Neurosurgery, MedStar Georgetown University Hospital, 3800 Reservoir Road NW, PHC7, Washington, DC, USA.,Department of Neurosurgery, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC, USA
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45
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Takei J, Hirotsu T, Hatano K, Ishibashi T, Inomata T, Noda Y, Morooka S, Murayama Y. Modified Computed Tomography Classification for Chronic Subdural Hematoma Features Good Interrater Agreement: A Single-Center Retrospective Cohort Study. World Neurosurg 2021; 151:e407-e417. [PMID: 33892165 DOI: 10.1016/j.wneu.2021.04.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/11/2021] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The present study aimed to establish whether our modified Nakaguchi computed tomography (CT) classification improves the interrater agreement of chronic subdural hematoma (CSDH) classification and prediction of CSDH recurrence relative to 2 other CT classifications. METHODS This retrospective study considered 277 consecutive patients with CSDH and 307 hematomas treated with burr-hole surgery between January 2009 and December 2018. Two neurosurgeons blinded to patients' clinical data classified the CT scans of patients with CSDH into 4 or 5 types according to the Nomura classification (high, iso, low, mixed, and layering), Nakaguchi classification (homogenous, laminar, separated, and trabecular), and our modified Nakaguchi classification (homogenous, gradation, laminar, separated, and trabecular). The κ statistic was used to evaluate the interrater agreement of the 3 CT classifications. Univariable and multivariable logistic regression analyses were used to calculate odds ratios for CSDH recurrence. RESULTS κ values of the modified, Nakaguchi, and Nomura classification were 0.78, 0.63, and 0.70, respectively. During the 3 months follow-up, the recurrence rate for CSDH was 11.4% (35/307 hematomas). Of the types defined by the modified classification, the gradation type was associated with the highest recurrence (mean recurrence rate, 15.9% ± 0.3%). Multivariable logistic regression analyses showed that a gradation-type hematoma, as defined with the modified classification, was an independent risk factor associated with recurrence (odds ratio, 2.36; 95% confidence interval, 1.11-4.98; P = 0.025). CONCLUSIONS The modified classification was useful for preoperative CT classification of CSDH and the prediction of recurrence, with high agreement between raters.
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Affiliation(s)
- Jun Takei
- Department of Neurosurgery, Fuji City General Hospital, Fuji, Shizuoka, Japan; Department of Neurosurgery, Jikei University School of Medicine, Minato-ku, Tokyo, Japan.
| | - Tatsuya Hirotsu
- Department of Neurosurgery, Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Keisuke Hatano
- Department of Neurosurgery, Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Toshihiro Ishibashi
- Department of Neurosurgery, Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Takayuki Inomata
- Department of Radiology, Fuji City General Hospital, Fuji, Shizuoka, Japan
| | - Yasuto Noda
- Department of Neurosurgery, Fuji City General Hospital, Fuji, Shizuoka, Japan
| | - Satoru Morooka
- Department of Neurosurgery, Fuji City General Hospital, Fuji, Shizuoka, Japan
| | - Yuichi Murayama
- Department of Neurosurgery, Jikei University School of Medicine, Minato-ku, Tokyo, Japan
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46
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Kan P, Maragkos GA, Srivatsan A, Srinivasan V, Johnson J, Burkhardt JK, Robinson TM, Salem MM, Chen S, Riina HA, Tanweer O, Levy EI, Spiotta AM, Kasab SA, Lena J, Gross BA, Cherian J, Cawley CM, Howard BM, Khalessi AA, Pandey AS, Ringer AJ, Hanel R, Ortiz RA, Langer D, Kelly CM, Jankowitz BT, Ogilvy CS, Moore JM, Levitt MR, Binning M, Grandhi R, Siddiq F, Thomas AJ. Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Multi-Center Experience of 154 Consecutive Embolizations. Neurosurgery 2021; 88:268-277. [PMID: 33026434 DOI: 10.1093/neuros/nyaa379] [Citation(s) in RCA: 110] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 06/27/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Middle meningeal artery (MMA) embolization has emerged as a promising treatment for chronic subdural hematoma (cSDH). OBJECTIVE To determine the safety and efficacy of MMA embolization. METHODS Consecutive patients who underwent MMA embolization for cSDH (primary treatment or recurrence after conventional surgery) at 15 centers were included. Clinical details and follow-up were collected prospectively. Primary clinical and radiographic outcomes were the proportion of patients requiring additional surgical treatment within 90 d after index treatment and proportion with > 50% cSDH thickness reduction on follow-up computed tomography imaging within 90 d. National Institute of Health Stroke Scale and modified Rankin Scale were also clinical outcomes. RESULTS A total of 138 patients were included (mean age: 69.8, 29% female). A total of 15 patients underwent bilateral interventions for 154 total embolizations (66.7% primary treatment). At presentation, 30.4% and 23.9% of patients were on antiplatelet and anticoagulation therapy, respectively. Median admission cSDH thickness was 14 mm. A total of 46.1% of embolizations were performed under general anesthesia, and 97.4% of procedures were successfully completed. A total of 70.2% of embolizations used particles, and 25.3% used liquid embolics with no significant outcome difference between embolization materials (P > .05). On last follow-up (mean 94.9 d), median cSDH thickness was 4 mm (71% median thickness reduction). A total of 70.8% of patients had >50% improvement on imaging (31.9% improved clinically), and 9 patients (6.5%) required further cSDH treatment. There were 16 complications with 9 (6.5%) because of continued hematoma expansion. Mortality rate was 4.4%, mostly unrelated to the index procedure but because of underlying comorbidities. CONCLUSION MMA embolization may provide a safe and efficacious minimally invasive alternative to conventional surgical techniques.
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Affiliation(s)
- Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Georgios A Maragkos
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Aditya Srivatsan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Visish Srinivasan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Jeremiah Johnson
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | | | - Timothy M Robinson
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Stephen Chen
- Department of Radiology, Baylor College of Medicine, Houston, Texas
| | - Howard A Riina
- Department of Neurosurgery, NYU Langone Medical Center, New York City, New York
| | - Omar Tanweer
- Department of Neurosurgery, NYU Langone Medical Center, New York City, New York
| | - Elad I Levy
- Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical College of South Carolina, Charleston, South Carolina
| | - Sami Al Kasab
- Department of Neurosurgery, Medical College of South Carolina, Charleston, South Carolina
| | - Jonathan Lena
- Department of Neurosurgery, Medical College of South Carolina, Charleston, South Carolina
| | - Bradley A Gross
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jacob Cherian
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - C Michael Cawley
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Alexander A Khalessi
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Andrew J Ringer
- Mayfield Clinic, TriHealth Neuroscience Institute, Good Samaritan Hospital, Cincinnati, Ohio
| | - Ricardo Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida
| | - Rafael A Ortiz
- Department of Neurosurgery, Lenox Hill Hospital, New York City, New York
| | - David Langer
- Department of Neurosurgery, Lenox Hill Hospital, New York City, New York
| | - Cory M Kelly
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | | | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Mandy Binning
- Department of Neurosurgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Farhan Siddiq
- Department of Neurosurgery, University of Missouri, Columbia, Montana
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Scullen T, Mathkour M, Nerva JD, Dumont AS. Commentary: Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Multi-Center Experience of 154 Consecutive Embolizations. Neurosurgery 2021; 88:E130-E132. [PMID: 33045740 DOI: 10.1093/neuros/nyaa432] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 07/20/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Tyler Scullen
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - Mansour Mathkour
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - John D Nerva
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - Aaron S Dumont
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
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Shotar E, Pouliquen G, Premat K, Pouvelle A, Mouyal S, Meyblum L, Lenck S, Degos V, Abi Jaoude S, Sourour N, Mathon B, Clarençon F. CTA-Based Patient-Tailored Femoral or Radial Frontline Access Reduces the Rate of Catheterization Failure in Chronic Subdural Hematoma Embolization. AJNR Am J Neuroradiol 2021; 42:495-500. [PMID: 33541902 DOI: 10.3174/ajnr.a6951] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 10/12/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Chronic subdural hematoma embolization, an apparently simple procedure, can prove to be challenging because of the advanced age of the target population. The aim of this study was to compare 2 arterial-access strategies, femoral versus patient-tailored CTA-based frontline access selection, in chronic subdural hematoma embolization procedures. MATERIALS AND METHODS This was a monocentric retrospective study. From the March 15, 2018, to the February 14, 2019 (period 1), frontline femoral access was used. Between February 15, 2019, and March 30, 2020 (period 2), the choice of the frontline access, femoral or radial, was based on the CTA recommended as part of the preoperative work-up during both above-mentioned periods. The primary end point was the rate of catheterization failure. The secondary end points were the rate of access site conversion and fluoroscopy duration. RESULTS During the study period, 124 patients (with 143 chronic subdural hematomas) underwent an embolization procedure (mean age, 74 [SD, 13] years). Forty-eight chronic subdural hematomas (43 patients) were included during period 1 and were compared with 95 chronic subdural hematomas (81 patients) during period 2. During the first period, 5/48 (10%) chronic subdural hematoma embolizations were aborted due to failed catheterization, significantly more than during period 2 (1/95, 1%; P = .009). The rates of femoral-to-radial (P = .55) and total conversion (P = .86) did not differ between the 2 periods. No significant difference was found regarding the duration of fluoroscopy (P = .62). CONCLUSIONS A CTA-based patient-tailored choice of frontline arterial access reduces the rate of catheterization failure in chronic subdural hematoma embolization procedures.
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Affiliation(s)
- E Shotar
- From the Department of Neuroradiology (E.S., G.P., K.P., A.P., S.M., L.M., S.L., N.S., F.C.)
| | - G Pouliquen
- From the Department of Neuroradiology (E.S., G.P., K.P., A.P., S.M., L.M., S.L., N.S., F.C.)
| | - K Premat
- From the Department of Neuroradiology (E.S., G.P., K.P., A.P., S.M., L.M., S.L., N.S., F.C.).,Sorbonne Université (K.P., V.D., S.A.J., B.M., F.C.), Paris, France
| | - A Pouvelle
- From the Department of Neuroradiology (E.S., G.P., K.P., A.P., S.M., L.M., S.L., N.S., F.C.)
| | - S Mouyal
- From the Department of Neuroradiology (E.S., G.P., K.P., A.P., S.M., L.M., S.L., N.S., F.C.)
| | - L Meyblum
- From the Department of Neuroradiology (E.S., G.P., K.P., A.P., S.M., L.M., S.L., N.S., F.C.)
| | - S Lenck
- From the Department of Neuroradiology (E.S., G.P., K.P., A.P., S.M., L.M., S.L., N.S., F.C.)
| | - V Degos
- Neurosurgical Anesthesiology and Critical Care (V.D.).,Sorbonne Université (K.P., V.D., S.A.J., B.M., F.C.), Paris, France
| | - S Abi Jaoude
- Neurosurgery (S.A.J., B.M.), Pitié-Salpêtrière Hospital, Paris, France.,Sorbonne Université (K.P., V.D., S.A.J., B.M., F.C.), Paris, France
| | - N Sourour
- From the Department of Neuroradiology (E.S., G.P., K.P., A.P., S.M., L.M., S.L., N.S., F.C.)
| | - B Mathon
- Neurosurgery (S.A.J., B.M.), Pitié-Salpêtrière Hospital, Paris, France.,Sorbonne Université (K.P., V.D., S.A.J., B.M., F.C.), Paris, France
| | - F Clarençon
- From the Department of Neuroradiology (E.S., G.P., K.P., A.P., S.M., L.M., S.L., N.S., F.C.).,Sorbonne Université (K.P., V.D., S.A.J., B.M., F.C.), Paris, France
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49
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Chen K, Wang K, Chen D, Niu H, Yang S, Wang Y. Surgical Procedure in the Treatment of Organized Chronic Subdural Hematoma: A Single-Center Experience. J Neurol Surg A Cent Eur Neurosurg 2021; 82:241-247. [PMID: 33540451 DOI: 10.1055/s-0040-1721007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Organized chronic subdural hematoma (CSDH) is a special type of CSDH. However, the optimal surgical procedure has not been established. We present our experience here to discuss the surgical procedure in treatment of organized CSDH. METHODS Thirty-three patients with organized CSDH were admitted between January 1, 2008 and January 1, 2018. Age, gender, clinical symptoms, imaging data, type of surgical procedure, Barthel index (BI), and postoperative complications were collected and retrospectively analyzed. The BI was assessed both pre and postoperatively (1 week and 1 month after surgery). RESULTS Overall, 14 patients underwent large craniotomy and 19 patients underwent small craniotomy. No significant differences in gender, age, initial clinical symptoms, and preoperative BI were found between the groups (p > 0.05). Among the 14 patients who underwent large craniotomy, 2 patients developed epilepsy after the operation, while 1 patient had postoperative aphasia. None of the patients had recurrence in 6 months postoperatively. Among the 19 patients who underwent small craniotomy, 1 patient developed an acute subdural hematoma and 1 patient developed aphasia. No obvious complications were found in the remaining 18 patients and none of the 19 patients had recurrence in 6 months postoperatively. BI scores of the small craniotomy group were significantly better than those of the large craniotomy group at 1 week postoperatively (p < 0.05). However, there was no significant difference in the 1-month results (p > 0.05). CONCLUSION According to our single-center experience, a small craniotomy for treating organized CSDH can be considered as an alternative to a larger craniotomy.
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Affiliation(s)
- Keng Chen
- Department of Neurosurgery, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
| | - Kun Wang
- Department of Neurosurgery, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
| | - Danzhi Chen
- Department of Oncological Surgery, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
| | - Huanjiang Niu
- Department of Neurosurgery, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
| | - Shuxu Yang
- Department of Neurosurgery, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
| | - Yirong Wang
- Department of Neurosurgery, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
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Catapano JS, Nguyen CL, Wakim AA, Albuquerque FC, Ducruet AF. Middle Meningeal Artery Embolization for Chronic Subdural Hematoma. Front Neurol 2020; 11:557233. [PMID: 33192990 PMCID: PMC7606850 DOI: 10.3389/fneur.2020.557233] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 09/18/2020] [Indexed: 02/03/2023] Open
Abstract
Chronic subdural hematoma (cSDH) is a common disease process associated with significant morbidity that occurs most often in elderly patients. Asymptomatic patients are typically treated conservatively, with surgical intervention reserved for patients with symptomatic and/or large hematomas that cause brain compression. However, conservatively managed cSDH cases frequently progress, and surgical evacuation of cSDH is associated with high rates of complication and recurrence. Recently, successful treatment of cSDH via middle meningeal artery (MMA) embolization has been reported in small case series and case reports. This article reviews the existing literature on MMA embolization for cSDH and discusses the need for randomized control trials and/or large prospective studies to establish the efficacy of MMA embolization for this disease.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Candice L Nguyen
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Andre A Wakim
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, United States
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