Middle Meningeal Artery Embolization with Isolated Use of Coils for Treatment of Chronic Subdural Hematomas: A Case Series

Preoperative middle meningeal artery embolization in the treatment of organized chronic subdural hematoma

Organized chronic subdural hematoma is a rare form of chronic subdural hematoma. The optimal treatment method is still controversial. Preoperative middle meningeal artery embolization and craniotomy are effective methods for chronic subdural hematoma. However, there are not many reports investigating the effectiveness of these methods in treating organized chronic subdural hematoma. We report the case of a 61-year-old male patient who had a twist-drill craniostomy to treat a left hemisphere subdural hematoma. After surgery, there was a recurrence on the same side in the form of an organized subdural hematoma. The patient received preoperative left middle meningeal artery embolization. After 3 months of follow-up, a small portion of the hematoma remained, causing pressure and slightly shifting the midline to the right by 6.5 mm, and the patient no longer had clinical symptoms.

Impact of Embolisate Penetration, Type, and Technique on Results After Standalone Middle Meningeal Artery Embolization for Chronic Subdural Hematoma

BACKGROUND AND OBJECTIVES

Middle meningeal artery embolization (MMAE) has emerged as a promising modality for chronic/subacute subdural hematoma treatment; however, consensus regarding embolization technique and embolisate has not been achieved. We thus sought to compare the efficacy of distinct MMAE techniques and embolisate.

METHODS

An institutional registry was reviewed to identify patients undergoing standalone MMAE for symptomatic chronic/subacute subdural hematoma. Surgical rescue rate and time preceding 50% hematoma resolution were evaluated across 3 technical groups: aggressive penetration (AP), nonaggressive penetration with proximal coil embolization (NP-PC), and nonaggressive penetration alone (NP). Effect sizes were adjusted for demographic, neurological and radiological features through multivariable logistic and Cox regression.

RESULTS

Among 117 procedures, 33.3% achieved AP, 36.8% had NP-PC, and 29.9% had NP. The rate of surgical rescue was 2.6% after AP, 9.3% for NP-PC, and 11.4% for NP. In patients not undergoing rescue surgery, 82.4% achieved hematoma resolution ≥50% at a median imaging follow-up of 56 days; AP or NP-PC were each statistically significantly associated with enhanced hematoma resolution as compared with NP (P = .02). Similarly, sensitivity analysis within medium-size hematoma and antiplatelet/anticoagulation-at-admission subgroups revealed a superiority of resolution after AP or NP-PC. A unique, comparative secondary analysis of liquid embolisate (Onyx vs n-butyl cyanoacrylate) revealed no impact on rate of surgical rescue or hematoma resolution.

CONCLUSION

AP was associated with the lowest rate of surgical rescue, while both AP and NP-PC were associated with improved rates of hematoma resolution.

ARISE I Consensus Statement on the Management of Chronic Subdural Hematoma

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.

Immediate procedural safety of adjunctive proximal coil occlusion in middle meningeal artery embolization for chronic subdural hematomas: Experience in 137 cases

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.

Featured minimally invasive therapeutic approach for chronic subdural hematoma: Embolization of middle meningeal artery - A narrative review

Chronic subdural hematoma (c-SDH) is a frequent and serious neurological disease. It develops due to hemorrhage to the subdural space, mainly caused by head trauma. The middle meningeal artery (MMA) plays a critical role in the supply of blood to c-SDH. The decision on the type of treatment for c-SDH depends mainly on clinical and imaging evaluation. In cases in which patients are critically ill, the hematoma must be evacuated immediately. For this purpose, surgery is generally accepted as the mainstay of treatment. Among surgical techniques, twist-drill craniotomy, burr-hole craniotomy, and craniotomy are the three most used. The recurrence rate of c-SDH after surgery is an important problem with a rate of up to 30%. The technical success classification embolization of MMA (EMMA) has emerged as an effective and safe option for the treatment of c-SDH, especially those that recur. EMMA is commonly used as an adjunct to surgery or less frequently alone. The technical success of EMMA has been a promising minimal invasive strategy as an alternative or adjunctive therapy to surgical methods. Polyvinyl alcohol is the most widely used among various embolizing agents, including n-butyl cyanoacrylate, coil, and gelatin sponge. EMMA has been shown to prevent the formation or recurrence of c-SDH by eliminating blood flow to the subdural space. Complication rates are low. The large-scale comparative prospective will ensure efficacy and safety. This article aims to highlight the current information about EMMA in patients with c-SDH.

Middle meningeal artery embolization for chronic subdural hematoma: a systematic review

Background

Chronic subdural hematoma (cSDH) is one of the most common diseases in neurosurgery. Middle meningeal artery embolization (MMAE) is reportedly an option to prevent recurrence or avoid surgery in patients with cSDH. This study was performed to review the evidence on MMAE for cSDH and evaluate its safety, efficacy, indications, and feasibility.

Methods

We systematically reviewed the literature according to the PRISMA guidelines using an electronic database. The search yielded 43 articles involving 2,783 patients who underwent MMAE.

Results

The hematoma resolution, recurrence, and retreatment rates in the MMAE-alone treatment group (n = 815) were 86.7%, 6.3%, and 9.6%, respectively, whereas those in the prophylactic MMAE with combined surgery group (n = 370) were 95.6%, 4.4%, and 3.4%, respectively. The overall MMAE-related complication rate was 2.3%.

Conclusion

This study shows that MMAE alone is, although not immediate, as effective as evacuation surgery alone in reducing hematoma. The study also shows that combined treatment has a lower recurrence rate than evacuation surgery alone. Because MMAE is a safe procedure, it should be considered for patients with cSDH, especially those with a high risk of recurrence.

Drainage versus no drainage after burr-hole evacuation of chronic subdural hematoma: a systematic review and meta-analysis of 1961 patients

Chronic subdural hematoma (cSDH) is a common neurosurgical condition that can cause severe morbidity and mortality. cSDH recurs after surgical evacuation in 5-30% of patients, but drains may help reduce this risk. We aimed to investigate the effect of drainage versus no drainage on the rates of recurrence and mortality, as well as the clinical outcomes of cSDH. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched four electronic databases (PubMed, Cochrane Library, Scopus, and Web of Science) to identify eligible studies reported up to June 2022. Using Review Manager software, we reported four primary outcomes as odds ratios (ORs) and confidence intervals (CIs). The meta-analysis included a total of 10 studies with 1961 patients. The use of drainage was found to be significantly more effective than non-drainage in reducing the "mortality rate" (OR = 0.65, 95% CI 0.43 to 0.97; P = 0.04), the "recurrence rate" (OR = 0.39, 95% CI 0.28 to 0.55; P < 0.00001), and occurrence of "gross focal neurological deficit" (OR = 0.58, 95% CI 0.37 to 0.89; P = 0.01). No significant difference was found in the occurrence of a Glasgow Coma Scale score of 15 (OR = 1.21, 95% CI 0.84 to 1.76; P = 0.30). The use of drains after burr-hole irrigation reduces the recurrence, mortality, and gross focal neurological deficit rates of chronic subdural hematomas.

Extensive Roles and Technical Advances of Middle Meningeal Artery Embolization for Chronic Subdural Hematoma

Chronic subdural hematoma (CSDH) is a common pathology that typically affects the elderly in Japan, an aging society. Burr-hole irrigation is the standard treatment, but middle meningeal artery (MMA) embolization is a minimally invasive alternative. MMA embolization for CSDH has frequently been reported in recent years, and many technical innovations to improve clinical outcomes have been described. Embolic materials reaching more distally are found to avoid recurrences after MMA embolization. As a result, various studies have described the superiority of embolizing the anterior and posterior branches of the MMA, the advantages of embolic materials reaching beyond the midline, and a high degree of distal penetration using a "sugar rush technique" in which 5% soluble glucose is injected through an intermediate catheter during MMA embolization. Radiographically, reports have described the importance of a "bright falx" sign obtained by infiltrating embolic material beyond the midline and post-embolization enhancement of the dura, capsular membrane, septations, and subdural hematoma fluid as indicators of the spread of embolic materials. This review provides an overview of the current status and future challenges in MMA embolization for CSDH, focusing on technical aspects to improve clinical outcomes.

Middle meningeal artery embolization for treatment of chronic subdural hematomas: does selection of embolized branches affect outcomes?

OBJECTIVE

Middle meningeal artery (MMA) embolization (MMAE) is a new therapeutic modality for chronic subdural hematoma (cSDH). There is limited evidence comparing various MMAE procedural techniques, resulting in significant variations in technique and procedural planning. The objective of this study was to compare outcomes of MMAE by the number and location of MMA branches that were embolized.

METHODS

A single-center retrospective study of patients with cSDH treated by MMAE was conducted. Clinical outcomes, need for re-intervention, and changes in hematoma size were compared between different MMAE techniques.

RESULTS

Ninety-four cSDHs in 78 patients were included. Embolization of the proximal trunk only, distal branches only, or proximal trunk plus distal branches resulted in similar rates of need for rescue surgery (7.4%, 13.0%, and 6.8%, respectively; p = 0.66) and rates of reducing the volume of the hematoma by at least 50% (74.1%, 80.0%, and 77.5%, respectively; p = 0.88). Embolization of only one branch had similar outcomes to embolization of more than one branch, as rescue surgery rates were 9.3% and 7.8% (p = 0.80), and rates ≥ 50% volume reduction were 75.6% and 78.3% (p = 0.76), respectively. Selective embolization of the dominant MMA branch was not associated with significantly different outcomes.

CONCLUSIONS

Outcomes of distal, proximal, or combined proximal and distal MMAE in cSDH are not significantly different. Embolization of more than one branch is not associated with improved treatment efficacy. Arguably, targeting any location in the MMA provides sufficient flow restriction to enable spontaneous hematoma resolution. Accordingly, a technical planning algorithm for cSDH MMAE is suggested.

Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: Predictors of Clinical and Radiographic Failure from 636 Embolizations

Background Knowledge regarding predictors of clinical and radiographic failures of middle meningeal artery (MMA) embolization (MMAE) treatment for chronic subdural hematoma (CSDH) is limited. Purpose To identify predictors of MMAE treatment failure for CSDH. Materials and Methods In this retrospective study, consecutive patients who underwent MMAE for CSDH from February 2018 to April 2022 at 13 U.S. centers were included. Clinical failure was defined as hematoma reaccumulation and/or neurologic deterioration requiring rescue surgery. Radiographic failure was defined as a maximal hematoma thickness reduction less than 50% at last imaging (minimum 2 weeks of head CT follow-up). Multivariable logistic regression models were constructed to identify independent failure predictors, controlling for age, sex, concurrent surgical evacuation, midline shift, hematoma thickness, and pretreatment baseline antiplatelet and anticoagulation therapy. Results Overall, 530 patients (mean age, 71.9 years ± 12.8 [SD]; 386 men; 106 with bilateral lesions) underwent 636 MMAE procedures. At presentation, the median CSDH thickness was 15 mm and 31.3% (166 of 530) and 21.7% (115 of 530) of patients were receiving antiplatelet and anticoagulation medications, respectively. Clinical failure occurred in 36 of 530 patients (6.8%, over a median follow-up of 4.1 months) and radiographic failure occurred in 26.3% (137 of 522) of procedures. At multivariable analysis, independent predictors of clinical failure were pretreatment anticoagulation therapy (odds ratio [OR], 3.23; P = .007) and an MMA diameter less than 1.5 mm (OR, 2.52; P = .027), while liquid embolic agents were associated with nonfailure (OR, 0.32; P = .011). For radiographic failure, female sex (OR, 0.36; P = .001), concurrent surgical evacuation (OR, 0.43; P = .009), and a longer imaging follow-up time were associated with nonfailure. Conversely, MMA diameter less than 1.5 mm (OR, 1.7; P = .044), midline shift (OR, 1.1; P = .02), and superselective MMA catheterization (without targeting the main MMA trunk) (OR, 2; P = .029) were associated with radiographic failure. Sensitivity analyses retained these associations. Conclusion Multiple independent predictors of failure of MMAE treatment for chronic subdural hematomas were identified, with small diameter (<1.5 mm) being the only factor independently associated with both clinical and radiographic failures. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Chaudhary and Gemmete in this issue.

Middle Meningeal Artery Embolization in the Management of Chronic Subdural Hematoma: a Comprehensive Review of Current Literature

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.