Adjunctive Middle Meningeal Artery Embolization for Subdural Hematoma

Improved healthcare utilization and economic outcomes of chronic subdural hematoma treatment with middle meningeal artery embolization compared to conventional surgical drainage

BACKGROUND

Middle meningeal artery embolization (MMAE) emerges as an alternative to conventional surgical drainage (CSD) for chronic subdural hematomas (cSDH). Several studies have suggested that MMAE improves the cost efficacy of cSDH treatment. However, further comprehensive analyses of the outcomes and healthcare costs of MMAE are necessary.

METHODS

Merative MarketScan Research Database from 2017-2022 was used to compare demographics, reoperation rates, complications, healthcare utilization, and payments of patients being treated with CSD, CSD and adjunctive MMAE, or standalone MMAE for cSDH or nontraumatic subdural hemorrhage.

RESULTS

From 2017-2022, there were 2108 patients who underwent CSD (n = 2015), or CSD+MMAE (n = 23) or MMAE only (n = 70). The median age of the surgical group was 61 years (IQR 53-73 years), the surgery plus MMAE was 67 years (56-77 years) and the MMAE group was 65 years (55-77 years). Median hospital days were significantly longer for the CSD (6 (IQR 5-7) days) and CSD + MMAE (7 (IQR 6-7) days) groups compared to MMAE only (0 days(IQR 0-1)(p < 0.0001). Median index hospitalization payments were significantly higher for the CSD+MMAE group ($74,568) compared to both CSD ($39,658) (p = 0.003) and MMAE groups ($22,286) (p < 0.0001). The total median payments at six-month follow-up for the CSD group were higher compared to CSD+MMAE ($11494 vs $7300, p = 0.0017) but not compared to MMAE only ($10,680, p = 0.08).

CONCLUSIONS

The reduced complications, infection rate, hospital utilization, and costs observed in this study support MMAE as a promising treatment option in the arsenal for cSDH management.

Association between postoperative thromboembolic and hemorrhagic complications and clinical outcomes after surgery for chronic subdural hematoma in patients with anticoagulation therapy for atrial fibrillation

PURPOSE

A substantial proportion of patients undergoing surgery for chronic subdural hematoma (CSDH) use anticoagulation medication due to atrial fibrillation (AF). We assessed the risk of postoperative thromboembolic and hemorrhagic complications in CSDH surgery patients with a history of anticoagulation for AF and their association with outcome.

METHODS

This posthoc analysis of a nationwide multicenter randomized controlled trial conducted during 2020-2022 included CSDH patients undergoing surgery with a history of preoperative anticoagulation use for AF. We assessed the incidence of thromboembolic and hemorrhagic complications and their associations with functional outcomes and mortality.

RESULTS

Of 589 patients, 128 patients (median age 83 years, 24% females) were on anticoagulation medication due to AF. The incidences of postoperative thromboembolic and hemorrhagic complications were 8% and 6%, respectively. A significantly higher proportion of patients with a thromboembolic complication had unfavorable functional outcome (70% vs. 21%, p < 0.001) and higher mortality (50% vs. 14%) than those without. After adjusting for risk factors, a thromboembolic complication was independently associated with a higher risk for unfavorable outcome (OR 16.8, 95% CI 3.0-94.2) and death (OR 11.1, 95% CI 2.4-52.0). Similarly, hemorrhagic complications associated independently with unfavorable outcome, although the effect size was smaller than for thromboembolic complications.

CONCLUSION

The risk for thromboembolic complications seemed to be slightly higher than the risk for postoperative hemorrhagic complications after CSDH surgery in patients with a history of preoperative anticoagulation medication use due to AF. The occurrence of a thromboembolic complication was detrimental for patient prognosis, underscoring the importance of strategies to prevent thromboembolic events. There is an urgent need for a trial assessing the optimal timing of restarting anticoagulation medication after CSDH surgery.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT04203550.

Middle meningeal artery embolization with surgical evacuation improves outcomes in chronic subdural hematoma: a multi-institutional and multinational database study

BACKGROUND

Middle meningeal artery embolization (MMAE) is emerging as a promising adjunctive treatment in patients with chronic subdural hematomas (cSDH). This study presents real world multicenter data comparing outcomes in cSDH patients undergoing surgical treatment alone or combined with MMAE.

METHODS

This multi-institutional, multinational, retrospective, propensity-matched study utilized the TriNetX platform to compare outcomes in patients undergoing surgical evacuation and MMAE versus surgery alone for cSDH. The outcomes included inpatient readmission, need for repeat surgery, and mortality at 6 months following treatment.

RESULTS

Among 253 108 patients with cSDH, 14 568 underwent surgical evacuation and 711 underwent surgical evacuation with MMAE. Patients who underwent surgical evacuation alone had higher odds of unplanned readmission, need for repeat surgery, and mortality at 6 months, both before and after propensity score matched analysis.

CONCLUSION

Patients undergoing MMAE with surgical evacuation for cSDH had reduced mortality along with reduced rates of readmission and reoperation, suggesting MMAE as a valuable adjunct in managing cSDH.