Middle meningeal artery embolization for the management of chronic subdural hematoma

Cost Savings on Inpatient Hospitalization for Middle Meningeal Artery Embolization in the Setting of Increased Case Volume and Low Complications Rate

BACKGROUND

Middle meningeal artery (MMA) embolization for the treatment of chronic subdural hematomas (cSDHs) is becoming increasingly prevalent. It is essential to optimize the safety and cost effectiveness of the postprocedural management. In this study, we examined our cases over time to determine the most appropriate postprocedural destination.

METHODS

This is a retrospective study of patients who underwent MMA embolization for cSDH at our institution. The study cohort was divided into 2 groups based on the year of embolization. Baseline characteristics, postprocedural complications, and length of stay were compared. Patients with shorter intensive care unit (ICU) stay were also compared to those with longer stay. Univariate statistical analysis was performed.

RESULTS

92 MMA embolizations for cSDH have been performed at our institution, of which 36 (39.1%) were done between 2019 and 2022 and 56 (60.9%) after 2023. No patients experienced stroke, cranial nerve palsy, or intraparenchymal hemorrhage after embolization. All but 5 patients were admitted to the ICU postembolization, of which 59 (64.1%) were downgraded after one day. Factors associated with a longer ICU stay included preoperative location (P = 0.002) and need for surgery (P = 0.02). Of those who came from home or nonmonitored bed, 82% were downgraded from the ICU in less than 2 days. The average cost of one night in the ICU, intermediate care, and nonmonitored unit was $3671.75, $2605.22, and $2303.81 respectively.

CONCLUSIONS

MMA embolization for cSDH is a safe procedure with low rate of procedure-related complications. In carefully selected patients, the necessity ICU admission postoperatively should be weighed against better hospital resource utilization.

Middle meningeal artery embolization following surgical evacuation of symptomatic chronic subdural hematoma improves outcomes, interim results of a prospective randomized trial

BACKGROUND

Outcomes after surgical treatment of chronic subdural hematoma (cSDH) remain undesirable in a significant proportion of patients. We aimed to show the role of middle meningeal artery (MMA) embolization and to demonstrate its benefits.

METHODS

Thirty-five patients with symptomatic cSDH were enrolled in a prospective randomized trial following evacuation surgery. Participants were randomized to embolization or control group (expectant management following surgical evacuation without embolization). Patients were followed throughout their hospitalization and outpatient follow-ups. The main goals of this planned interim analysis were to assess neurological outcome and resource utilization.

RESULTS

The groups were comparable in terms of sex, age and follow-up retention rates. Side(s) of intervention(s) and hematoma size were similar. There was no statistical difference in neurological examination improvement at discharge, but at follow-up, we observed a decline in neurologic exam in the control group (p = 0.03). Control group participants required more re-interventions (p = 0.02) and were followed in clinic and during related readmissions for longer (p = 0.02). The number of imaging studies obtained in relation to the disease management was higher in the control group (p = 0.01).

CONCLUSIONS

Our results suggest a beneficial role for the addition of MMA embolization to surgical intervention in the treatment of symptomatic chronic subdural hematoma. Neurological outcomes were significantly better in the embolization group. This contributed to less need for follow-up, re-interventions, and imaging studies.

Middle Meningeal Artery Embolization Reduces the Recurrence Rate of Chronic Subdural Hematoma: A Propensity Score Matching Analysis

To evaluate the effect of middle meningeal artery embolization (MMAE) on chronic subdural hematoma (CSDH). The authors enrolled consecutive patients with CSDH who underwent burr hole craniostomy (BHC) between January 2020 and February 2023. The primary outcome was recurrence rate, defined as an increase of hematoma width on imaging compared with the immediate postoperative imaging at a 3-month follow-up. Secondary outcomes included the rate of complications and adverse prognosis. Cohorts were balanced using 1:2 propensity score matching (PSM). A total of 271 patients were eligible for this study and divided into the MMAE group (n=23) and the BHC group (n=205). Compared with the BHC group, there was more use of anticoagulant or antiplatelet medication (47.8% vs 22.4%, P=0.008), bilateral hematoma (19.5% vs 19.5%, P=0.043), and hematoma with septations (47.8% vs 21.5%, P=0.005) in the MMAE group. After PSM, 64 cases were finally successfully matched. The logistic analysis result showed that MMAE was associated with the decreased recurrence rate of CSDH in the cohort after PSM (OR 0.072, 95% CI: 0.322~0.746, P=0.028) but not with the improved clinical prognosis (OR 0.065, 95% CI: 0.533~4.786, P=0.562). MAAE has a positive therapeutic effect on reducing the recurrence rate of CSDHs as an adjunct postoperative treatment after burr hole surgery.

Efficacy of Tailored Treatment Strategies for Chronic Subdural Hematoma Based on Hematoma Characteristics and Volume: A Retrospective Observational Study

OBJECTIVE

We assessed the effectiveness of a treatment strategy based on hematoma characteristics and volume.

METHODS

From September 2022 to December 2023 (the Study period), a 2-center retrospective observational study of initial chronic subdural hematoma was performed. The baseline period was from January 2018 to December 2019. Patients were classified into the high and low retreatment rate groups (Groups H and L, respectively). During the Study period, Group H was treated with drainage and middle meningeal artery embolization, while Group L was treated with drainage or middle meningeal artery embolization alone. During the Baseline period, all the patients were treated with drainage alone. The primary and secondary endpoints were group retreatment rates and severe procedure-related complications requiring surgical intervention and permanent sequelae, respectively.

RESULTS

Fifty-two patients were included during the Study period (31 in Group H and 21 in Group L) and 53 during the Baseline period (32 in Group H and 21 in Group L). Three (5.8%) and 9 (17.0%) patients required retreatment in the Study and Baseline periods, respectively (P = 0.12). One (3.2%) and 9 (28.1%) patients in Group H required retreatment during the Study and Baseline periods, respectively (P = 0.01). Similarly, 2 patients (9.5%) and no patient in Group L required retreatment during the Study and Baseline periods, respectively (P = 0.49). No severe complications were reported throughout.

CONCLUSIONS

Chronic subdural hematoma treatment strategies that consider to hematoma volume and characteristics have the potential to identify and reduce treatment rates in cases with high retreatment rates.

Facial nerve palsy after middle meningeal artery embolization for chronic subdural hematoma: a case report

Middle meningeal artery embolization (MMAE) has emerged as a safe and efficacious alternative to surgery for the treatment of new or recurrent chronic subdural hematoma (CSDH). Several complications such as facial palsy may suddenly occur even in the absence of evident dangerous anastomoses in the angiogram. We herein present a case-report of left facial nerve palsy after MMAE.

Endovascular Embolization and Atorvastatin Therapy for Recurrent Chronic Subdural Hematoma

Recurrent chronic subdural hematoma poses a significant clinical challenge. While craniotomy effectively removes the hematoma membrane, it is an invasive procedure associated with significant trauma. Recently, endovascular embolization of the middle meningeal artery has emerged as a promising minimally invasive alternative, demonstrating efficacy and a low recurrence rate in treating chronic subdural hematoma. Furthermore, postoperative administration of oral atorvastatin calcium may enhance hematoma absorption, thereby improving patient outcomes during the early recovery phase.

Advances in pathogenic mechanisms, diagnostic methods, surgical and non-surgical treatment, and potential recurrence factors of Chronic Subdural Hematoma: A review

Chronic Subdural Hematoma (CSDH) is a common hemorrhagic disease in neurosurgery, and with the intensification of global aging, its incidence is gradually increasing. With the advancement of scientific technology, the etiological concepts and surgical treatments for CSDH have continually evolved over time. Currently, neuroscientists' understanding of CSDH is no longer confined to bridging vein rupture; exploration of various mechanisms such as angiogenesis, maturation of blood vessels, and inflammation is also underway. In-depth exploration and discovery of pathogenic mechanisms guide the updating of clinical treatment strategies and methods. For different types of CSDH, there is now a clear guidance for the targeted selection of treatment methods. However, the current treatment of CSDH cannot completely solve all problems, and the updating of treatment methods as well as the development and validation of new effective drugs remain challenges for the future. In addition, the recurrence of CSDH is a significant issue that needs to be addressed. Although we have reviewed potential recurrent factors that may be associated, the strength of this evidence is insufficient. Future research should gradually focus on validating these recurrent factors and exploring new ones, in order to optimize the existing understanding and treatment of CSDH.

Chronic subdural hematoma treated with homeopathic medicine Hamamelis virginica: A case report

Chronic Subdural Hematoma is a prevalent neurosurgical disorder associated with old age, often resulting from trauma. The condition has limited scope for conservative management, and invasive techniques are frequently used as preferred treatment. Complications often arise due to comorbidities associated with old age. This case details the treatment of the condition in a 71-year-old patient who presented with seizures, hemiparesis, tremor, and disorientation. The patient had a history of a fall a few weeks prior. Initially, the condition was managed through surgery, but recurrence occurred, accompanied by concurrent neurological signs. The patient was subsequently treated with Hamamelis virginica 200CH through homeopathic approach. Following this treatment, the patient returned to his previous state within seven days. No recurrence was observed during the three-month follow-up. This case underscores a positive role of homeopathic medicines in managing neurosurgical conditions such as subdural hematoma. The positive outcomes of this study provide preliminary evidence that may eventually contribute to the design of appropriate clinical trials.

Grading Embolization of Middle Meningeal Artery for Chronic Subdural Hematoma

BACKGROUND AND PURPOSE

Embolization of middle meningeal artery (EMMA) is a relatively new treatment for chronic subdural hematoma (CSDH). To date, an objective method that assesses or describes the extent of EMMA for the treatment of CSDH does not exist. Recently, the concept of a novel grading scale for EMMA in patients with CSDH has emerged. However, this has not been applied to a clinical case setting and inter-rater reliability has not yet been studied. The purpose of this study was to validate the grading scale in clinical practice and to assess for inter-rater reliability.

MATERIALS AND METHODS

We retrospectively examined consecutive patients who underwent EMMA for CSDH. Patients were included if the whole head angiogram from common carotid as well as external carotid arteries before and after EMMA were available in the arterial, capillary as well as venous phases. Two independent readers, each with more than 5 years of experience in independent practice, assessed the angiograms for the grading of EMMA and assigned a score ranging between 0 and 3. The grading score between the two readers were compared using Cohen's Kappa score to assess the inter-rater reliability.

RESULTS

In 19 patients, we found that EMMA had no periprocedural morbidity and mortality. The number of cases in each EMMA grading score category are as follows: 0 n =1; 1 n =3; 2 n =1; and 3 n =10. There was substantial inter-rater reliability for the assessment of grading of EMMA (Kappa = 0.74).

CONCLUSIONS

The novel EMMA grading scheme demonstrated substantial inter-rater reliability and appears promising.

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.

Middle meningeal artery embolization associated with reduced chronic subdural hematoma volume and midline shift in the acute postoperative period

BACKGROUND

Middle meningeal artery (MMA) embolization for endovascular treatment of chronic subdural hematoma (cSDH) is growing in popularity. cSDH volume and midline shift were analyzed in the immediate postoperative window after MMA embolization.

METHODS

A retrospective analysis of cSDHs managed via MMA embolization from January 1, 2018 to March 30, 2021 was performed at a large quaternary center. Pre- and postoperative cSDH volume and midline shift were quantified with CT. Postoperative CT was obtained 12 to 36 hours after embolization. Paired t-tests were used to determine significant reduction. Multivariate analysis was performed using logistic and linear regression for percent improvement from baseline volume.

RESULTS

In total, 80 patients underwent MMA embolization for 98 cSDHs during the study period. The mean (SD) initial cSDH volume was 66.54 (34.67) mL, and the mean midline shift was 3.79 (2.85) mm. There were significant reductions in mean cSDH volume (12.1 mL, 95% CI 9.32 to 14.27 mL, P<0.001) and midline shift (0.80 mm, 95% CI 0.24 to 1.36 mm, P<0.001). In the immediate postoperative period, 22% (14/65) of patients had a>30% reduction in cSDH volume. A multivariate analysis of 36 patients found that preoperative antiplatelet and anticoagulation use was significantly associated with an expansion in volume (OR 0.028, 95% CI 0.000 to 0.405, P=0.03).

CONCLUSION

MMA embolization is safe and effective for the management of cSDH and is associated with significant reductions in hematoma volume and midline shift in the immediate postoperative period.

Middle meningeal artery embolization for chronic subdural hematoma: A single-center experience and predictive modeling of outcomes

BACKGROUND

Remarkable interest is rising around middle meningeal artery embolization (MMAE) as an emerging alternative therapy for chronic subdural hematoma (cSDH). The study aims to highlight a large center experience and the variables associated with treatment failure and build experimental machine learning (ML) models for outcome prediction.

MATERIAL AND METHODS

A 2-year experience in MMAE for managing patients with chronic subdural hematoma was analyzed. Descriptive statistical analysis was conducted using imaging and clinical features of the patients and cSDH, which were subsequently used to build predictive models for the procedure outcome. The modeling evaluation metrics were the area under the ROC curve and F1-score.

RESULTS

A total of 100 cSDH of 76 patients who underwent MMAE were included with an average follow-up of 6 months. The intervention had a per procedure success rate of 92%. Thrombocytopenia had a highly significant association with treatment failure. Two patients suffered a complication related to the procedure. The best performing machine learning models in predicting MMAE failure achieved an ROC-AUC of 70%, and an F1-score of 67%, including all patients with or without surgical intervention prior to embolization, and an ROC-AUC of 82% and an F1-score of 69% when only patients who underwent upfront MMAE were included.

CONCLUSION

MMAE is a safe and minimally invasive procedure with great potential in transforming the management of cSDH and reducing the risk of surgical complications in selected patients. An ML approach with larger sample size might help better predict outcomes and highlight important predictors following MMAE in patients with cSDH.

Novel superficial temporal artery access route for middle meningeal artery embolization and treatment of chronic subdural hematoma

We describe the use of direct superficial temporal artery puncture to access the left middle meningeal artery for embolization of a recurrent chronic subdural hematoma in a patient with a type A aortic dissection, involving the origin of the left common carotid artery which precluded conventional access from a radial or femoral approach.

Neovascularization in Outer Membrane of Chronic Subdural Hematoma : A Rationale for Middle Meningeal Artery Embolization

OBJECTIVE

Chronic subdural hematomas (cSDHs) are generally known to result from traumatic tears of bridging veins. However, the causes of repeat spontaneous cSDHs are still unclear. We investigated the changes in vasculature in the human dura mater and outer membrane (OM) of cSDHs to elucidate the cause of their spontaneous repetition.

METHODS

The dura mater was obtained from a normal control participant and a patient with repeat spontaneous cSDHs. The pathological samples from the patient included the dura mater and OM tightly adhered to the inner dura. The samples were analyzed with a particular focus on blood and lymphatic vessels by immunohistochemistry, 3-dimensional imaging using a transparent tissue clearing technique, and electron microscopy.

RESULTS

The dural border cell (DBC) layer of the dura mater and OM were histologically indistinguishable. There were 5.9 times more blood vessels per unit volume of tissue in the DBC layer and OM in the patient than in the normal control. The DBC layer and OM contained pathological sinusoidal capillaries not observed in the normal tissue; these capillaries were connected to the middle meningeal arteries via penetrating arteries. In addition, marked lymphangiogenesis in the periosteal and meningeal layers was observed in the patient with cSDHs.

CONCLUSION

Neovascularization in the OM seemed to originate from the DBC layer; this is a potential cause of repeat spontaneous cSDHs. Embolization of the meningeal arteries to interrupt the blood supply to pathological capillaries via penetrating arteries may be an effective treatment option.

Analysis of middle meningeal artery embolization for the treatment of chronic, acute on chronic, and subacute subdural hematomas

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.

A novel swine model of selective middle meningeal artery catheterization and embolization

BACKGROUND

Middle meningeal artery (MMA) embolization is a promising intervention as a stand-alone or adjunct treatment to surgery in patients with chronic subdural hematomas. There are currently no large animal models for selective access and embolization of the MMA for preclinical evaluation of this endovascular modality. Our objective was to introduce a novel in vivo model of selective MMA embolization in swine.

METHODS

Diagnostic cerebral angiography with selective microcatheter catheterization into the MMA was performed under general anesthesia in five swine. Anatomical variants in arterial meningeal supply were examined. In two animals, subsequent embolization of the MMA with a liquid embolic agent (Onyx-18) was performed, followed by brain tissue harvest and histological analysis.

RESULTS

The MMA was consistently localized as a branch of the internal maxillary artery just distal to the origin of the ascending pharyngeal artery. Additional meningeal supply was observed from the external ophthalmic artery, although not present consistently. MMA embolization with Onyx was technically successful and feasible. Histological analysis showed Onyx material within the MMA lumen.

CONCLUSIONS

Microcatheter access into the MMA in swine with liquid embolic agent delivery represents a reproducible model of MMA embolization. Anatomical variations in the distribution of arterial supply to the meninges exist. This model has a potential application for comparing therapeutic effects of various embolic agents in a preclinical setting that closely resembles the MMA embolization procedure in humans.

In vitro comparison of middle meningeal artery embolization with Squid liquid embolic agent and Contour polyvinyl alcohol particles

BACKGROUND

Liquid embolic agents and polyvinyl alcohol (PVA) particles have been used for the embolization of the middle meningeal artery (MMA) for the treatment of chronic subdural hematomas. However, the vascular penetration and distribution of these embolic agents have not yet been compared. The current study compares distribution of a liquid embolic agent (Squid) to PVA particles (Contour) in an in vitro model of the MMA.

METHODS

MMA models were embolized with Contour PVA particles 45-150 µm, Contour PVA particles 150-250 µm, and Squid-18 liquid embolic agent (n=5 each). The models were scanned and every vascular segment with embolic agent was manually marked on the images. Embolized vascular length as a percentage of control, average embolized vascular diameter, and embolization time were compared between the groups.

RESULTS

The 150-250 µm Contour particles primarily accumulated close to the microcatheter tip, yielding proximal branch occlusions. The 45-150 µm Contour particles achieved a more distal distribution, but in a patchy segmental pattern. However, the models embolized with Squid-18 had a consistently distal, near-complete and homogenous distribution. Embolized vascular length was significantly higher (76±13% vs 5±3%, P=0.0007) and average embolized vessel diameter was significantly smaller (405±25 µm vs 775±225 µm, P=0.0006) with Squid than with Contour. Embolization time with Squid was also lower (2.8±2.4 min vs 6.4±2.7 min, P=0.09).

CONCLUSIONS

Squid-18 liquid results in a considerably more consistent, distal and homogeneous pattern of embolysate distribution than Contour PVA particles in an anatomical model of the MMA tree.

Particle embolic agents for embolization of middle meningeal artery in the treatment of chronic subdural hematoma: A systematic review and meta-analysis

OBJECTIVE

In this systematic review and meta-analysis, we investigated the efficacy and safety of middle meningeal artery embolization (MMAE) using particle embolic agents to treat cSDH.

METHODS

To retrieve articles investigating outcomes of patients following MMAE with particle agents and to compare their outcome with conventional treatment, Scopus, PubMed, Embase, and Web of Science were searched using relevant keywords. Original articles with more than 10 cases were included. The meta-analysis was carried out using the R studio and the random-effects model. Publication bias was assessed using Peter's test and quality assessment using NIH tools.

RESULTS

Eleven studies with 359 patients were included. The analysis revealed a pooled recurrence rate of 5% (CI: 3-8%), a need for reoperation rate of 5% (3-9%), and a peri-procedural complication rate of 4% (CI:2-9%) following MMAE with particle embolic agents. The pooled rates of decrease in size or resolution of the hematoma were 85% (CI:66-94%) and 66% (39-86%), respectively. Comparing MMAE using particulate embolysate with conventional treatments, risk ratio (RR) of 0.10 (CI:0.04-0.27) was achieved for recurrence, 0.25(CI:0.13-0.49) for reoperation, and 0.34 (CI:0.16-0.27) for peri-procedural complications. 91% of cSDH cases responded to MMAE with particles in the way they showed either down-sizing or complete resolution of the hematoma on follow-up imaging. In comparison, this rate was found to be 63% following conventional treatment.

CONCLUSION

Middle meningeal artery embolization using particle embolysates is a safe and effective technique for the treatment of cSDH, whether as a standalone intervention or in combination with conventional treatments.

A Linear Regression Equation for Predicting the Residual Volume of Chronic Subdural Hematoma 1 Week After Surgery

Objective

The outcome of chronic subdural hematoma (CSDH) is influenced not only by the choice of treatment but also by various baseline characteristics. The main objective of this study is to identify the risk factors that can affect the prognosis of CSDH and develop a regression equation based on these risk factors.

Methods

A total of 212 patients with CSDH were included in the study. We collected clinical data including age, gender, and so on, and radiological data including preoperative hematoma volume (V1), effusion volume 1 day after surgery (V2), gas volume 1 day after surgery (V3), and so on. These were considered independent variables, while residual volume 1 week after surgery (V4) was the dependent variable. Univariate linear regression analysis was performed to identify factors that were significantly related. Subsequently, multivariate linear regression analysis was conducted to determine the relationship between each independent variable and the dependent variable. Multiple linear regression analysis was used to obtain a regression equation predicting V4.

Results

We have found that age (t = 3.109, P = 0.002), aspirin (t = 2.762, P = 0.006), hemostatic agents (haemocoagulase, t = 3.731, P < 0.001; vitamin K, t = 2.824, P = 0.005 < 0.05), V2 (t = 8.73, P < 0.001), and V3 (t = 5.968, P < 0.001) are significantly associated with V4. Furthermore, we have developed a regression equation that can predict this volume with CSDH. The fit of the model is robust with an R-squared value of 65.2% > 50%.

Conclusion

Age, aspirin, hemostatic agent, V2, and V3 are significantly associated with V4. We developed a regression equation to predict this volume with CSDH.

Tonetti D, Bounajem MT, Thomas A, Ogilvy CS, Moore JM, Riina HA, Tanweer O, Levy EI, Spiotta AM, Gross BA, Jankowitz BT, Cawley CM, Khalessi AA, Pandey AS, Ringer AJ, Hanel R, Ortiz RA, Langer D, Levitt MR, Binning M, Taussky P, Kan P, Grandhi R. Radiographic and clinical outcomes with particle or liquid embolic agents for middle meningeal artery embolization of nonacute subdural hematomas

BACKGROUND

Middle meningeal artery (MMA) embolization is an apparently efficacious minimally invasive treatment for nonacute subdural hematomas (NASHs), but how different embolisates affect outcomes remains unclear. Our objective was to compare radiographic and clinical outcomes after particle or liquid MMA embolization.

METHODS

Patients who had MMA embolization for NASH were retrospectively identified from a multi-institution database. The primary radiographic and clinical outcomes-50% NASH thickness reduction and need for surgical retreatment within 90 days, respectively-were compared for liquid and particle embolizations in patients treated 1) without surgical intervention (upfront), 2) after recurrence, or 3) with concomitant surgery (prophylactic).

RESULTS

The upfront, recurrent, and prophylactic subgroups included 133, 59, and 16 patients, respectively. The primary radiographic outcome was observed in 61.8%, 61%, and 72.7% of particle-embolized patients and 61.3%, 55.6%, and 20% of liquid-embolized patients, respectively (p = 0.457, 0.819, 0.755). Hazard ratios comparing time to reach radiographic outcome in the particle and liquid groups or upfront, recurrent, andprophylactic timing were 1.31 (95% CI 0.78-2.18; p = 0.310), 1.09 (95% CI 0.52-2.27; p = 0.822), and 1.5 (95% CI 0.14-16.54; p = 0.74), respectively. The primary clinical outcome occurred in 8.0%, 2.4%, and 0% of patients who underwent particle embolization in the upfront, recurrent, and prophylactic groups, respectively, compared with 0%, 5.6%, and 0% who underwent liquid embolization (p = 0.197, 0.521, 1.00).

CONCLUSIONS

MMA embolization with particle and liquid embolisates appears to be equally effective in treatment of NASHs as determined by the percentage who reach, and the time to reach, 50% NASH thickness reduction and the incidence of surgical reintervention within 90 days.

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

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.

Time and Influencing Factors to Chronic Subdural Hematoma Resolution After Middle Meningeal Artery Embolization

OBJECTIVE

We sought to describe the resolution time of chronic subdural hematoma (CSDH) after middle meningeal artery embolization (MMAE) and potential variables that may affect hematoma resolution.

METHODS

A retrospective analysis was performed on CSDH patients between December 2018 and December 2021. Patient characteristics, radiologic manifestations, and data of hematoma resolution were recorded. Univariate and multivariate analyses were conducted to identify predictors of CSDH resolution time.

RESULTS

A total of 53 patients were enrolled including 53 hematomas. Only 1 participant relapsed and did not require surgical evacuation. Hematoma resolution was observed in 27 (50.9%) at 4 months and 48 (90.6%) cases at the last radiologic follow-up. The median MMAE-to-resolution time was 19 weeks (interquartile range: 8-24). The burr-hole irrigation + MMAE group showed faster hematoma resolution than MMAE alone during early follow-up periods, but no significant difference was found at 6 months. Increased thickness of residual hematoma, excessive postoperative midline shift, high-density hematoma, mixed-density hematoma, separated hematoma, and anticoagulant or antiplatelet agents used were predictive of nonresolution at 4 months as determined by univariate analysis, whereas anticoagulant or antiplatelet agents used and high-density hematoma were not significant on multivariate analysis. No significant association was noted between hematoma resolution and comorbidities or other hematoma radiologic features.

CONCLUSIONS

MMAE is an effective and minimally invasive treatment for CSDH with a lower recurrence rate. The median resolution time of CSDH following MMAE was 19 weeks (interquartile range: 8-24). Burr-hole irrigation contributed to early hematoma resolution but had no significant effect at 6 months. In addition, residual hematoma thickness, postoperative midline shift, and specific type of hematoma were associated with delayed hematoma resolution at 4 months.

Middle Meningeal Artery Embolization Combined With Endoscopic Treatment for Chronic Subdural Hematoma

OBJECTIVE

To explore the clinical feasibility of middle meningeal artery (MMA) embolization combined with endoscopic treatment for new or recurrent chronic subdural hematoma (CSDH).

METHODS

Twenty patients with CSDH treated in the Binzhou Medical University Hospital from June 2020 to October 2022 were analyzed retrospectively. The clinical information, prognosis, imaging results, and surgical results of the patients were collected and analyzed. The authors first performed MMA embolization, and then endoscopic treatment of CSDH was performed after successful embolization of MMA. Results: All 20 patients with CSDH were successfully treated with MMA embolization combined with endoscope-assisted evacuation. The symptoms of all patients were relieved, no surgical complications occurred, and no rebleeding and recurrence were found in follow-up computed tomography.

CONCLUSION

Middle meningeal artery embolization combined with endoscopic treatment of CSDH has a good clinical effect, and it may prevent postoperative recurrence.

Predicting the progression of chronic subdural hematoma based on skull density

Objective

The objective of this study was to investigate potential correlations between skull density and the progression of chronic subdural hematoma (CSDH).

Methods

Patients with unilateral CSDH were retrospectively enrolled between January 2018 and December 2022. Demographic and clinical characteristics, as well as hematoma and skull density (Hounsfield unit, Hu), were collected and analyzed.

Results

The study enrolled 830 patients with unilateral CSDH until the resolution of the CDSH or progressed with surgical treatment. Of the total, 488 patients (58.80%) necessitated surgical treatment. The study identified a significant correlation between the progression of CSDH and three variables: minimum skull density (MiSD), maximum skull density (MaSD), and skull density difference (SDD) (p < 0.001). Additionally, in the multivariable regression analysis, MiSD, MaSD, and SDD were independent predictors of CSDH progression. The MiSD + SDD model exhibited an accuracy of 0.88, as determined by the area under the receiver operating characteristic curve, with a sensitivity of 0.77 and specificity of 0.88. The model's accuracy was validated through additional analysis.

Conclusion

The findings suggest a significant correlation between skull density and the CSDH progression.

Middle Meningeal Artery Embolization for the Management of Chronic Subdural Hematoma

Introduction Chronic subdural hematoma (cSDH) results from neovascularization of the subdural capsular membrane and embolization of the Middle Meningeal Artery (MMA) helps inhibit the same and prevent recurrence. Materials and methods We retrospectively reviewed the endovascular management for chronic SDH in 29 patients between 2018 to 2022. The parameters analyzed were clinical history, radiologic imaging findings, procedure details, and angiographic and clinical outcomes. Results Twenty-nine MMA embolization procedures were done. Follow-up MRI or CT done in 28 subjects, showed complete resolution in 25 patients and a significant reduction in bilateral SDH in three patients. One patient died due to renal failure and aspiration pneumonia-related complications. Ninety days mRS (modified Rankin scale) was 0 in 25 patients (86%), one in two patients, and two in one patient. Conclusions  MMA embolization for chronic SDH is a feasible, safe, and effective technique in patients with chronic and recurrent SDH.

Middle meningeal artery embolization and pediatric chronic subdural hematoma: a systematic review of the literature

Chronic subdural hematoma (CSDH) is a disease commonly found in the elderly and not a typical finding in pediatric population. History of shunt surgery, child abuse, and blood disorder are some of the common causes of pediatric CSDH (pCSDH). There is growing evidence about the role of middle meningeal artery embolization (MMAE) to manage CSDH in the elderly population with a high risk of rebleeding. However, the evidence in the pediatric population is still sparse. A systematic literature search was conducted on PubMed, Scopus, and Web of Science database from January, 2023, to March, 2023. Search strings were generated based on the combination of modified search terms, such as CSDH, MMA embolization, and child. Risk of bias was assessed using the Cochrane Risk of Bias in Nonrandomized Study for Intervention. Nine articles were included in this review. The success rate of MMA embolization in pediatric CSDH was 88.8%. Histories of ventriculoperitoneal shunt, blood coagulation disorder, and trauma were the causes of CSDH. Time to achieve success was varied from 2 to 9 months. No study with low risk of bias was found. This systematic review found no high-quality evidence regarding the role of MMA embolization in the management of pCSDH. However, due to its high success rate, MMAE could be a promising approach to treat pCSDH.

Middle Meningeal Artery Embolization with Liquid Embolic Agents for Chronic Subdural Hematoma: A Systematic Review and Meta-analysis

PURPOSE

To assess the efficacy and safety of middle meningeal artery (MMA) embolization with liquid embolic agents and the outcomes of patients following this procedure.

MATERIALS AND METHODS

A review of the literature was conducted to identify studies investigating the efficacy and safety of MMA embolization with liquid embolic agents in patients with chronic subdural hematoma (cSDH) in PubMed, Scopus, Embase, and Web of Science. The keywords "liquid embolic agent," "middle meningeal artery," "cSDH," and "embolization" as well as their synonyms were used to build up the search strategy. The R statistical software and random-effects model were used for analysis. Heterogeneity was reported as I2, and publication bias was calculated using the Egger test.

RESULTS

Of 628 articles retrieved, 14 studies were eligible to be included in this study. Data of 276 patients were analyzed. n-Butyl cyanoacrylate and ethylene vinyl alcohol copolymer were the most commonly used embolic agents. This study revealed a pooled mortality rate of 0% (95% confidence interval [CI], 0.00%-100%), recurrence and failure rate of 3% (95% CI, 1%-10%), reoperation/reintervention rate of 4% (95% CI, 2%-12%), rate of size decrease of 94% (95% CI, 79%-98%), technical success rate of 100% (95% CI, 76%-100%), and adverse event rate of 1% (95% CI, 0.00%-4%).

CONCLUSIONS

With low mortality, recurrence, reoperation, and adverse event rates and a remarkable decrease in the size of hematomas, MMA embolization with liquid embolic agents may be considered a safe and effective treatment option in patients in whom surgical intervention has previously failed and as an alternative to conventional treatments.

Lidocaine for headache prevention during chronic subdural hematoma embolization

BACKGROUND

Middle meningeal artery embolization (MMAE) for the management of chronic subdural hematomas (CSDH) with ethylene vinyl alcohol (EVOH) causes an evident patient discomfort due to meningeal nociceptors stimulation. The aim of this study was to assess safety and efficacy of intra-arterial lidocaine (IAL) before MMAE of CSDH with EVOH.

METHODS

We analyzed all consecutive patients with bilateral CSDH undergoing MMAE with EVOH. We used a monolateral IAL injection, with casual allocation. We assessed the headache felt by patients during embolization with the visual analog scale (VAS) and compared scores obtained after embolization of both sides. We followed the STROBE guidelines for case-control studies. Paired t-test and χ2 test were used to compare the distribution of variables in IAL vs control group.

RESULTS

Between September 2021 and March 2023, 32 patients underwent bilateral MMAE with EVOH for a CSDH. Lidocaine treatment resulted in a substantially lower VAS score compared to the control group (median 3 vs 7, p < 0.001), with no substantial side effect. Compliance also benefited from lidocaine administration.

CONCLUSIONS

In patients with CSDH undergoing MMAE, IAL seems to reduce pain sensation associated with EVOH injection and to increase patients' compliance during treatment.

Middle meningeal artery embolization for symptomatic chronic subdural hematoma in the setting of severe transfusion-refractory thrombocytopenia: A case study and review of literature

Background

Surgical decompression for the treatment of chronic subdural hematomas (cSDHs) is irrefutably effective; however, its utility in managing cSDH in patients with comorbid coagulopathy remains controversial. The optimal threshold for platelet transfusion in cSDH management is <100,000/mm³, according to guidelines from the American Association of Blood Banks GRADE framework. This threshold may be unachievable in refractory thrombocytopenia, though surgical intervention may still be warranted. We present a patient with symptomatic cSDH and transfusion-refractory thrombocytopenia successfully treated with middle meningeal artery embolization (eMMA). We also review the literature to identify management approaches for cSDH with severe thrombocytopenia.

Case Description

A 74-year-old male with acute myeloid leukemia presented to the emergency department with persistent headache and emesis following fall without head trauma. Computed tomography (CT) revealed a 12 mm right-sided, mixed density SDH. Platelets were <2000/mm³ initially, which stabilized to 20,000 following platelet transfusions. He then underwent right eMMA without surgical evacuation. He received intermittent platelet transfusions with platelet goal >20,000 and was discharged on hospital day 24 with resolving SDH on CT.

Conclusion

High-risk surgical patients with refractory thrombocytopenia and symptomatic cSDH may be successfully treated with eMMA without surgical evacuation. A platelet goal of 20,000/mm³ before and following surgical intervention proved beneficial for our patient. Similarly, a literature review of seven cases of cSDH with comorbid thrombocytopenia revealed five patients undergoing surgical evacuation following initial medical management. Three cases reported a platelet goal of 20,000. All seven cases resulted in stable or resolving SDH with platelets >20,000 at discharge.

Surgical techniques for evacuation of chronic subdural hematoma: a mini-review

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.

Liquid embolic agents for middle meningeal artery embolization in chronic subdural hematoma: Institutional experience with systematic review and meta-analysis

INTRODUCTION

Chronic subdural hematoma (CSDH) is associated with high recurrence rates. Middle meningeal artery embolization (MMAE) has emerged as a promising treatment option. In this systematic review and meta-analysis, we aimed to assess the safety and efficacy of MMAE for CSDH using liquid embolic agents and compare them with particles.

METHODS

We systematically reviewed all studies describing MMAE for CSDH with liquid embolic agents, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Additionally, we included a cohort of patients from our institution using liquid and particle embolic agents. Data were analyzed using random-effects proportions and comparisons meta-analysis, and statistical heterogeneity was assessed.

RESULTS

A total of 18 studies with 507 cases of MMAE with liquid embolic agents (including our institutional experience) were included in the analysis. The success rate was 99% (95% confidence interval [CI]: 98-⁠100%), all complications rate was 1% (95% CI: 0-⁠5%), major complications rate was 0% (95% CI: 0-⁠0%), and mortality rate was 1% (95% CI: 0-⁠6%). The rate of hematoma size reduction was 97% (95% CI: 73-⁠100%), complete resolution 64% (95% CI: 33-⁠87%), radiographic recurrence 3% (95% CI: 1-⁠7%), and reoperation 3% (95% CI: 1-⁠7%). No significant differences in outcomes were found between liquid and particle embolic agents. Sensitivity analyses revealed that liquid embolic agents were associated with lower reoperation rates in upfront MMAE (risk ratio 0.13, 95% CI: 0.02-⁠0.95).

CONCLUSION

MMAE with liquid embolic agents is safe and effective for the treatment of CSDH. Outcomes are comparable to particles, but liquids were associated with a decreased risk of reoperation in upfront MMAE. However, further studies are needed to support our findings.

Middle Meningeal Artery Embolization Versus Conventional Management for Patients With Chronic Subdural Hematoma: A Systematic Review and Meta-Analysis

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.

Embolization of the middle meningeal artery vs. second surgery-treatment response and volume course of recurrent chronic subdural hematomas

BACKGROUND

Despite multiple studies on the embolization of the middle meningeal artery, there is limited data on the treatment response of recurrent chronic subdural hematomas (CSDH) to embolization and on the volume change.

METHODS

We retrospectively compared the treatment response and volume change of recurrent CSDHs in a conventional group (second surgery) with an embolization group (embolization as stand-alone treatment) during the time-period from August 2019 until June 2022. Different clinical and radiological factors were assessed. Treatment failure was defined as necessity of treatment for second recurrence. Hematoma volumes were determined in the initial CT scan before first surgery, after the first surgery, before retreatment as well as in an early (1 day-2 weeks) and in a late follow-up CT scan (2-8 weeks).

RESULTS

Fifty recurrent hematomas after initial surgery were treated either by second surgery (n = 27) or by embolization (n = 23). 8/27 (26,6%) surgically treated and 3/23 (13%) of the hematomas treated by embolization needed to be treated again. This leads to an efficacy in recurrent hematomas of 73,4% in surgically treated and of 87% in embolized hematomas (p = 0.189). In the conventional group, mean volume decreased significantly already in the first follow-up CT scan from 101.7 ml (SD 53.7) to 60.7 ml (SD 40.3) (p = 0.001) and dropped further in the later follow-up scan to 46.6 ml (SD 37.1) (p = 0.001). In the embolization group, the mean volume did decrease insignificantly from 75.1 ml (SD 27.3) to 68 ml (SD 31.4) in the first scan (p = 0.062). However, in the late scan significant volume reduction to 30.8 ml (SD 17.1) could be observed (p = 0.002).

CONCLUSIONS

Embolization of the middle meningeal artery is an effective treatment option for recurrent CSDH. Patients with mild symptoms who can tolerate slow volume reduction are suitable for embolization, whereas patients with severe symptoms should be reserved for surgery.

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.

Outcomes of Particle versus Liquid Embolic Materials Used in Middle Meningeal Artery Embolization for the Treatment of Chronic Subdural Hematoma

BACKGROUND

Early evidence suggests that middle meningeal artery (MMA) embolization is an efficacious minimally invasive neuroendovascular technique for the management of chronic subdural hematoma (cSDH). Particle and liquid embolic materials are commonly used to embolize the MMA; however, studies comparing the safety and outcomes between these 2 materials are limited.

METHODS

Patients ≥18 years old who had MMA embolization for cSDH between July 15, 2020 and May 1, 2022 were retrospectively identified from a single-center database. The primary safety, radiation dosage, fluoroscopy time, and radiographic and clinical outcomes were compared between particle and liquid embolization.

RESULTS

In a cohort of 116, 48 (41.38%) were treated with liquid embolic material and 68 (58.62%) were treated with particle. The median age of the cohort was 73 years in the particle group and 73.5 years in the liquid embolic group. There was no significant difference in radiation dose or duration among both groups. There was no reported mortality associated with the procedure. One patient experienced nondisabling ischemic stroke in the particle group. Based on imaging follow-up, 3 patients in the particle group and 1 in the liquid embolic group had asymptomatic recurrence. One patient in each group had symptomatic recurrence requiring hematoma evacuation. The index median size of hematoma was 12 mm in the particle group and 11 mm in the liquid embolic group. At approximately 1 month follow-up, the median size of hematoma reduced to 6 mm in both groups.

CONCLUSIONS

Our series shows that liquid embolic and particle embolization are equally safe and effective among patients undergoing MMA embolization for management of cSDH.

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.

A Novel Case of Deep Temporal Artery (DTA) Embolization for Recurrent Subacute-Chronic Subdural Hematoma

Subdural hemorrhage (SDH) is a common neurological disease. In past, SDHs were managed either conservatively (non-surgically) or with surgical evacuation (burr hole versus craniotomy) depending on the severity. Surgical evacuation has major challenges including high recurrence rate, stoppage and reversal of antiplatelet or anticoagulation agents, risk of general anesthesia and surgery in elderly patients with multiple comorbidities. Given the above challenges, embolization of the distal branches of the middle meningeal artery (MMA) has recently emerged as an excellent alternate to surgical evacuation or conservative management. To the best of our knowledge, there is no literature on the embolization of the deep temporal artery (DTA) for subacute-chronic SDH. We report the first case of recurrent subdural hematoma post MMA embolization that was successfully treated with embolization of DTA.

Validating the Efficacy of Two Burr-Hole Craniostomy over Mini-Craniotomy for Chronic Subdural Hematoma Drainage

Background There is an increasing incidence of chronic subdural hematoma due to extended life expectancy and associated trauma and fall risk. This retrospective study evaluates the efficacy of two burr-hole craniotomy over mini-craniotomy.

Methods Sixty-five patients were recruited over 2 years, of which 56 were male and 9 were females. A patient with a chronic subdural hematoma either underwent burr-hole craniostomy or mini-craniotomy for hematoma evacuation. Glasgow coma scale (GCS) and modified Rankin score were used to assess the neurological status and interventional outcome at discharge and follow-up, respectively. A head CT scan was performed at 3 week and 3 month follow-up.

Statistical Analysis Categorical data are presented as frequency and percentage, while non-categorical data are represented as mean ± SD. Statistical significance for difference in outcome between the two groups was analyzed using the chi-square test and p-value less than 0.05 was considered statistically significant.

Results The mean age of patients was 55.6 years. Headache (35 cases), hemiparesis, and altered sensorium were seen in 20 patients, each with the main presenting symptoms. Trauma history was noted in 69.2% of patients. One (3.7%) hematoma recurrence in the burr-hole group and four (8.3%) in the mini-craniotomy group was recorded. The mean operative time was longer in the minicraniotomy group (124.2 min vs. 75.4 min; p < 0.001). A higher incidence of recurrence was noted in the craniotomy group (8.3%) than the burr-hole group (3.7%). No statistical difference in the recurrence rate, duration of hospital stay, GCS at discharge, modified Rankin score between the two study groups at discharge was noted.

Conclusion Two burr-hole craniostomy is a safe and effective surgical option to treat chronic subdural hematoma. It is also validated in patients on anticoagulants and antiplatelet medications with adequate pre-surgical correction of coagulation parameters.

Surgical treatment for chronic subdural hematoma in the elderly: A retrospective analysis

Background

Chronic subdural hematoma (CSDH) is primarily a disease of the elderly. Less invasive interventions are often offered for elderly (> 80 years) patients due to concerns for elevated surgical risk, although data suggesting a clear outcome benefit is lacking.

Methods

All patients aged 65 years or older who underwent surgical treatment for CSDH at a single institution over a 4-year period were evaluated in this retrospective analysis. Surgical options included twist drill craniostomy (TDC), burr hole craniotomy (BHC), or standard craniotomy (SC). Outcomes, demographics, and clinical data were collected. Practice patterns and outcomes for patients older than 80 years old were compared to the age 65-80 cohort.

Results

110 patients received TDC, 35 received BHC, and 54 received SC. There was no significant difference in post-operative complications, outcomes, or late recurrence (30-90 days). Recurrence at 30 days was significantly higher for TDC (37.3% vs. 2.9% vs 16.7%, p 80 group, SC had higher risk of stroke and increased length of stay.

Conclusion

Twist drill craniostomy, burr hole craniostomy, and standard craniotomy have similar neurologic outcomes in elderly patients. Presence of thick membranes is a relative contra-indication for TDC due to high 30-day recurrence. Patients > 80 have higher risk of stroke and increased length of stay with SC.

Long-Term Middle Meningeal Artery Caliber Reduction Following Trisacryl Gelatine Microsphere Embolization for the Treatment of Chronic Subdural Hematoma

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.

The Short-Term Outcome of Middle Meningeal Artery Embolization for Chronic Subdural Hematoma with Mild Symptom: Case Series

OBJECTIVE

A few reports have demonstrated the efficacy of middle meningeal artery embolization (MMAE) alone for mildly symptomatic chronic subdural hematoma (CSDH); however, the clinical course in the early posttreatment period remains unclear. The purpose of this study was to analyze the short-term outcomes of this technique at our center.

METHODS

This study was based on a retrospective analysis of a single-center consecutive case series. Patients with mildly symptomatic CSDH treated with MMAE alone between July 2020 and June 2022 were examined. Neurological examinations and head computed tomography scans were performed before treatment and 1, 7, 14, and 28 days after treatment. The clinical course of the patients was analyzed. In particular, symptom improvement within 1 week from treatment or rescue evacuation and the factors associated were evaluated.

RESULTS

Fifteen patients were included in this study. No procedure-related complications occurred. Partial or complete recovery within the first week from treatment was observed in 10 cases (66.7%), and the symptoms resolved completely in a median of 26 (6.5-33.5) days. Rescue evacuation was needed in 3 cases (20.0%). The hematoma volume and midline shift gradually decreased from baseline, with a significant improvement within the first week (P = 0.030 and 0.0032, respectively).

CONCLUSIONS

MMAE alone provides relatively early improvement in cases of mildly symptomatic CSDH and may be a potential alternative to surgical evacuation or medical therapy.

Clinical Outcome and Recurrence Risk of Chronic Subdural Hematoma After Surgical Drainage

Introduction Chronic subdural hematoma (CSDH) is one of the most encountered neurosurgical cases. CSDH is defined as the accumulation of liquified blood products in the space between the dura and the arachnoid. A reported incidence of 17.6/100,000/year has more than doubled in the past 25 years in parallel with an aging population. Surgical drainage remains the mainstay of treatment, yet it is challenged by variable recurrence risks. Less invasive embolization methods of the middle meningeal artery (EMMA) could reduce the recurrence risks. Before adopting a newer treatment (EMMA), it is prudent to establish the outcomes from surgical drainage. The purpose of this study is to assess the clinical outcome and recurrence risk in surgically treated CSDH patients in our center. Methods A retrospective search of our surgical database was done to identify CSDH patients undergoing surgical drainage in the year 2019-2020. Demographic and clinical details were collected, and quantitative statistical analysis was performed. Peri-procedural radiographic information and follow-ups were also included as per the standard of care. Results A total of 102 patients (mean age: 69 years; range: 21-100 years; male: 79) with CSDH underwent surgical drainage with repeat surgery in 13.7% of the patients (n=14). Peri-procedural mortality and morbidity were 11.8%(n=12) and 19.6% (n=20), respectively. Overall, among our patient population, recurrence was seen in 22.55% (n=23). The mean total hospital stay was 10.6 days. Conclusions Our retrospective cohort study showed an institutional CSDH recurrence risk of 22.55%, in keeping with what is reported in the literature. This baseline information is important for a Canadian setting and provides a basis for comparison for future Canadian trials.

Modified Valsalva maneuver after burr-hole drainage of chronic subdural hematomas: A single-center cohort study

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.

Subdural evacuating port system with subdural thrombolysis for the treatment of chronic subdural hematoma in patients older than 80 years

Objective

The subdural evacuating port system (SEPS) is a minimally invasive approach that can be performed under local anesthesia for the treatment of chronic subdural hematoma (CSDH). Subdural thrombolysis has been described as an exhaustive drainage strategy and found to be safe and effective for improving drainage. We aim to analyze the effectiveness of SEPS with subdural thrombolysis in patients older than 80 years.

Method

Consecutive patients aged ≥80 years old who presented with symptomatic CSDH and underwent SEPS followed by subdural thrombolysis between January 2014 and February 2021 were retrospectively studied. Outcome measures included complications, mortality, recurrence, and modified Rankin Scale (mRS) scores at discharge and 3 months.

Results

In total, 52 patients with CSDH in 57 hemispheres were operated on, with a mean age of 83.9 ± 3.3 years, and 40 (76.9%) patients were men. The preexisting medical comorbidities were observed in 39 patients (75.0%). Postoperative complications occurred in nine patients (17.3%), with two having significant complications (3.8%). The complications observed included pneumonia (11.5%), acute epidural hematoma (3.8%), and ischemic stroke (3.8%). One patient experienced contralateral malignant middle cerebral artery infarction and died of subsequent severe herniation, contributing to a perioperative mortality rate of 1.9%. Discharge and 3 months of favorable outcomes (mRS score 0-3) were achieved in 86.5% and 92.3% of patients, respectively. CSDH recurrence was observed in five patients (9.6%), and repeat SEPS was performed.

Conclusion

As an exhaustive drainage strategy, SEPS followed by thrombolysis is safe and effective with excellent outcomes among elderly patients. It is a technically easy and less invasive procedure with similar complications, mortality, and recurrence rates compared with burr-hole drainage in the literature.

Middle Meningeal Artery Embolization for the Management of Chronic Subdural Hematomas: A New-Old Treatment

Chronic subdural hematoma (cSDH) is defined as a subdural collection of blood on CT imaging that tends to persist and gradually increase in volume over time, with components that are hypodense or isodense compared to the brain. There are no proven guidelines for the management of patients with cSDH. Surgical approaches included burr hole, twist drill hole, and craniotomy-based evacuations. Outcomes after surgical removal is generally favorable, but cSDH tends to recur after the initial evacuation.Middle meningeal artery (MMA) embolization has been gaining increasing popularity among the treatments of cSDH. This is largely due to a growing population of patients with cSDH who are refractory to other treatments or in patients who present with multiple comorbidities or who are taking antiplatelet and anticoagulant medications. The goal of middle meningeal artery (MMA) embolization is to devascularize subdural membranes associated with SDH so that the balance between continued leakage and reabsorption is shifted toward reabsorption.We discuss our clinical and technical approach to cSDH treated with perioperative embolization of the MMA.

Onyx Versus Particles for Middle Meningeal Artery Embolization in Chronic Subdural Hematoma

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.