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Xuan HD, Minh TP, Van HD, Thanh DL, Tuan DP, Quang LT. Preoperative middle meningeal artery embolization in the treatment of organized chronic subdural hematoma. Radiol Case Rep 2024; 19:3569-3573. [PMID: 38933657 PMCID: PMC11200168 DOI: 10.1016/j.radcr.2024.04.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/18/2024] [Accepted: 04/29/2024] [Indexed: 06/28/2024] Open
Abstract
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.
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Affiliation(s)
- Hai Dao Xuan
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
- Department of Radiology, Viet Duc University Hospital, Hanoi, Vietnam
| | - Thong Pham Minh
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
| | - He Dong Van
- Department of Neurosurgery, Viet Duc University Hospital, Hanoi, Viet Nam
| | - Dung Le Thanh
- Department of Radiology, Viet Duc University Hospital, Hanoi, Vietnam
- Department of Radiology, University of Medicine and Pharmacy (VNU-UMP), Vietnam National University, Hanoi, Vietnam
| | - Dung Pham Tuan
- Department of Neurosurgery, Viet Duc University Hospital, Hanoi, Viet Nam
| | - Loc Tran Quang
- Department of Radiology, Viet Duc University Hospital, Hanoi, Vietnam
- Department of Radiology, University of Medicine and Pharmacy (VNU-UMP), Vietnam National University, Hanoi, Vietnam
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2
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Flood R, Nunn AC, Talbott J, Cox A, Minks D, Wareham J, Crossley R, Malcolm G, Patel NK, Wigfield C, Williams A, Mortimer A. Initial experience using middle meningeal artery embolisation for patients with recurrent and high-recurrence-risk chronic subdural haematoma. J Clin Neurosci 2024; 125:126-131. [PMID: 38788605 DOI: 10.1016/j.jocn.2024.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/02/2024] [Accepted: 05/19/2024] [Indexed: 05/26/2024]
Abstract
Recurrence rates following surgical management of chronic subdural haematoma (CSDH) range from 5 to 33 %. There is growing evidence which suggests middle meningeal artery embolisation (MMAe) may reduce recurrence rates when used as surgical adjunct or standalone treatment. In this study we described our experience of this new procedure in the our UK institution. Patients with recurrent CSDH or CSDH at high risk of recurrence were selected for MMAe on a case-by-case basis following MDT discussion. A departmental database was used to identify patients treated. 26 CSDH were embolised in 20 patients; 9 CSDH were de-novo and 17 were recurrent. 10/26 CSDH were treated with MMAe only. No procedural mortality, access site or thrombo-embolic complications occurred. One patient experienced symptomatic collection growth 12 h following MMAe and required surgical drainage. 15 (75 %) of patients were living at home at follow-up (mean 14 months). On imaging follow-up 15/18 showed CSDH volume reduction or resolution, 1/18 remained stable requiring no further treatment, 2/18 patients suffered recurrent CSDH requiring treatment. In both recurrent cases incomplete embolisation was noted on procedural imaging (posterior division of MMA not embolised). Persistent posterior MMA division filling was significantly associated with collection recurrence (p = 0.002). Our results suggest MMAe as a stand-alone or adjuvant therapy can be performed safely in a UK neuroscience setting and is associated with high rates of symptomatic CSDH size reduction or resolution in problematic CSDH that have either recurred or are prone to recurrence.
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Affiliation(s)
- R Flood
- Southmead Hospital, North Bristol NHS Trust, United Kingdom.
| | - A C Nunn
- Southmead Hospital, North Bristol NHS Trust, United Kingdom
| | - J Talbott
- Blackpool Victoria Hospital, Blackpool Teaching Hospital NHS Foundation Trust, United Kingdom
| | - A Cox
- Southmead Hospital, North Bristol NHS Trust, United Kingdom
| | - D Minks
- Southmead Hospital, North Bristol NHS Trust, United Kingdom
| | - J Wareham
- Southmead Hospital, North Bristol NHS Trust, United Kingdom
| | - R Crossley
- Southmead Hospital, North Bristol NHS Trust, United Kingdom
| | - G Malcolm
- Southmead Hospital, North Bristol NHS Trust, United Kingdom
| | - N K Patel
- Southmead Hospital, North Bristol NHS Trust, United Kingdom
| | - C Wigfield
- Southmead Hospital, North Bristol NHS Trust, United Kingdom
| | - A Williams
- Southmead Hospital, North Bristol NHS Trust, United Kingdom
| | - A Mortimer
- Southmead Hospital, North Bristol NHS Trust, United Kingdom
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3
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Bhattacharjee B, Dutta A. Chronic subdural hematoma treated with homeopathic medicine Hamamelis virginica: A case report. J Ayurveda Integr Med 2024; 15:100928. [PMID: 38795579 PMCID: PMC11144716 DOI: 10.1016/j.jaim.2024.100928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 02/07/2024] [Accepted: 04/02/2024] [Indexed: 05/28/2024] Open
Abstract
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.
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Affiliation(s)
- Baidurjya Bhattacharjee
- Regional Research Institute for Homoeopathy Siliguri, Central Council for Research in Homoeopathy, India.
| | - Abhijit Dutta
- International Cooperation, Ministry of AYUSH, Government of India, India
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Debs LH, Walker SE, Rahimi SY. Newer treatment paradigm improves outcomes in the most common neurosurgical disease of the elderly: a literature review of middle meningeal artery embolization for chronic subdural hematoma. GeroScience 2024:10.1007/s11357-024-01173-5. [PMID: 38691299 DOI: 10.1007/s11357-024-01173-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 04/23/2024] [Indexed: 05/03/2024] Open
Abstract
Chronic subdural hematoma (cSDH) is one of the most prevalent neurosurgical diseases, especially in the elderly. Yet, its incidence is predicted to increase further, paralleling the growth of the geriatric population. While surgical evacuation is technically straightforward, it is associated with significant morbidity and mortality. In fact, 30% of patients are expected to have hematoma recurrence and to need repeat surgical evacuation, and 20% of patients are expected to lose independence and require long-term care. A pathophysiology more complex than originally presumed explains the disappointing results observed for decades. At its core, the formation of microcapillaries and anastomotic channels with the middle meningeal artery (MMA) perpetuates a constant cycle resulting in persistence of hematoma. The rationale behind MMA embolization is simple: to stop cSDH at its source. Over the last few years, this "newer" option has been heavily studied. It has shown tremendous potential in decreasing hematoma recurrence and improving neurological outcomes. Whether combined with surgical evacuation or performed as the only treatment, the scientific evidence to its benefits is unequivocal. Here, we aimed to review cSDH in the elderly and discuss its more recent treatment options with an emphasis on MMA embolization.
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Affiliation(s)
- Luca H Debs
- Neurosurgery Department, Medical College of Georgia, Augusta, GA, USA.
| | - Samantha E Walker
- Neurosurgery Department, Medical College of Georgia, Augusta, GA, USA
| | - Scott Y Rahimi
- Neurosurgery Department, Medical College of Georgia, Augusta, GA, USA
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Chen H, Colasurdo M, Malhotra A, Gandhi D, Bodanapally UK. Advances in chronic subdural hematoma and membrane imaging. Front Neurol 2024; 15:1366238. [PMID: 38725642 PMCID: PMC11079242 DOI: 10.3389/fneur.2024.1366238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/14/2024] [Indexed: 05/12/2024] Open
Abstract
Chronic subdural hematoma (cSDH) is projected to become the most common cranial neurosurgical disease by 2030. Despite medical and surgical management, recurrence rates remain high. Recently, middle meningeal artery embolization (MMAE) has emerged as a promising treatment; however, determinants of disease recurrence are not well understood, and developing novel radiographic biomarkers to assess hematomas and cSDH membranes remains an active area of research. In this narrative review, we summarize the current state-of-the-art for subdural hematoma and membrane imaging and discuss the potential role of MR and dual-energy CT imaging in predicting cSDH recurrence, surgical planning, and selecting patients for embolization treatment.
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Affiliation(s)
- Huanwen Chen
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Marco Colasurdo
- Department of Interventional Radiology, Oregon Health & Science University, Portland, OR, United States
| | - Ajay Malhotra
- Department of Radiology, Yale New Haven Hospital, New Haven, CT, United States
| | - Dheeraj Gandhi
- Department of Radiology, University of Maryland Medical Center, Baltimore, MD, United States
- Department of Neurology, University of Maryland Medical Center, Baltimore, MD, United States
- Department of Neurosurgery, University of Maryland Medical Center, Baltimore, MD, United States
| | - Uttam K. Bodanapally
- Department of Radiology, University of Maryland Medical Center, Baltimore, MD, United States
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Catapano JS, Koester SW, Hanalioglu S, Farhadi DS, Naik A, Hartke JN, Tunc O, Winkler EA, Chang SW, Lawton MT, Jadhav AP, Ducruet AF, Albuquerque FC. Middle meningeal artery embolization associated with reduced chronic subdural hematoma volume and midline shift in the acute postoperative period. J Neurointerv Surg 2024; 16:478-481. [PMID: 37321836 DOI: 10.1136/jnis-2022-020054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/21/2023] [Indexed: 06/17/2023]
Abstract
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.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Sahin Hanalioglu
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Dara S Farhadi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Anant Naik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joelle N Hartke
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Osman Tunc
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Steven W Chang
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Egodage T, Patel PP. Updates in traumatic brain injury management: brain oxygenation, middle meningeal artery embolization and new protocols. Trauma Surg Acute Care Open 2024; 9:e001382. [PMID: 38646037 PMCID: PMC11029482 DOI: 10.1136/tsaco-2024-001382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/05/2024] [Indexed: 04/23/2024] Open
Abstract
Traumatic brain injury (TBI) confers significant morbidity and mortality, and is a pathology often encountered by trauma surgeons. Several recent trials have evaluated management protocols of patients with severe TBI. The Brain Oxygen Optimization in Severe Traumatic Brain Injury Phase-II trial (BOOST-II) evaluated efficacy and feasibility of brain oxygen measurement in severe TBI. BOOST phase 3 trial (BOOST-3) and two ongoing trials look to measure functional outcomes in this population. Furthermore, middle meningeal artery embolization has now become standard therapy for adult patients with chronic subdural hematoma (SDH) and has increasing popularity in those with recurrent SDH as an alternative to surgical intervention. In this manuscript, we review the literature, ongoing trials, and discuss current updates in the management of TBI.
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Affiliation(s)
- Tanya Egodage
- Surgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Purvi Pravinchandra Patel
- Department of Surgery, Loyola University Chicago, Maywood, Illinois, USA
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois, USA
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Schmolling ÁH, Pérez-García C, Trejo C, López-Frías A, Jaroenngarmsamer T, Rosati S, Arrazola J, Moreu M. Middle Meningeal Artery Embolization for Management of Chronic Subdural Hematoma. Radiographics 2024; 44:e230158. [PMID: 38451847 DOI: 10.1148/rg.230158] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Chronic subdural hematoma (CSDH) is a prevalent medical condition with potentially severe consequences if left untreated. While surgical removal has traditionally been the standard approach for treatment, middle meningeal artery (MMA) embolization has emerged as a promising minimally invasive alternative to reduce recurrences. This comprehensive review provides the general radiology community with an overview of MMA embolization as a therapeutic option for managing CSDH. The authors base their insights on existing evidence and their institutional experience. This overview encompasses the pathophysiology of CSDH as well as the potential advantages and limitations, safety profile, and potential complications of MMA embolization as compared with surgical treatment. The imaging findings seen before and after MMA, as well as insights into the procedural techniques used at the authors' institution, are described. On the basis of reports in the current literature, MMA embolization appears to be a safe and effective therapeutic option for managing CSDH, especially in patients who are unsuitable for surgery or at risk for recurrence. Nonetheless, further research is needed to validate these findings. Results from ongoing clinical trials hold promise for future validation and the establishment of scientific evidence. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by Chatterjee in this issue.
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Affiliation(s)
- Ángela H Schmolling
- From the Departments of Interventional Neuroradiology (A.H.S., C.P.G., C.T., A.L.F., S.R., M.M.) and Radiology (J.A.), Hospital Clínico San Carlos, Calle del Profesor Martín Lagos s/n, 28040 Madrid, Spain; and Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (T.J.)
| | - Carlos Pérez-García
- From the Departments of Interventional Neuroradiology (A.H.S., C.P.G., C.T., A.L.F., S.R., M.M.) and Radiology (J.A.), Hospital Clínico San Carlos, Calle del Profesor Martín Lagos s/n, 28040 Madrid, Spain; and Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (T.J.)
| | - Carmen Trejo
- From the Departments of Interventional Neuroradiology (A.H.S., C.P.G., C.T., A.L.F., S.R., M.M.) and Radiology (J.A.), Hospital Clínico San Carlos, Calle del Profesor Martín Lagos s/n, 28040 Madrid, Spain; and Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (T.J.)
| | - Alfonso López-Frías
- From the Departments of Interventional Neuroradiology (A.H.S., C.P.G., C.T., A.L.F., S.R., M.M.) and Radiology (J.A.), Hospital Clínico San Carlos, Calle del Profesor Martín Lagos s/n, 28040 Madrid, Spain; and Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (T.J.)
| | - Tanaporn Jaroenngarmsamer
- From the Departments of Interventional Neuroradiology (A.H.S., C.P.G., C.T., A.L.F., S.R., M.M.) and Radiology (J.A.), Hospital Clínico San Carlos, Calle del Profesor Martín Lagos s/n, 28040 Madrid, Spain; and Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (T.J.)
| | - Santiago Rosati
- From the Departments of Interventional Neuroradiology (A.H.S., C.P.G., C.T., A.L.F., S.R., M.M.) and Radiology (J.A.), Hospital Clínico San Carlos, Calle del Profesor Martín Lagos s/n, 28040 Madrid, Spain; and Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (T.J.)
| | - Juan Arrazola
- From the Departments of Interventional Neuroradiology (A.H.S., C.P.G., C.T., A.L.F., S.R., M.M.) and Radiology (J.A.), Hospital Clínico San Carlos, Calle del Profesor Martín Lagos s/n, 28040 Madrid, Spain; and Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (T.J.)
| | - Manuel Moreu
- From the Departments of Interventional Neuroradiology (A.H.S., C.P.G., C.T., A.L.F., S.R., M.M.) and Radiology (J.A.), Hospital Clínico San Carlos, Calle del Profesor Martín Lagos s/n, 28040 Madrid, Spain; and Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (T.J.)
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Iqbal J, Courville E, Kazim SF, Kogan M, Schmidt MH, Bowers CA. Role of nanotechnology in neurosurgery: A review of recent advances and their applications. World Neurosurg X 2024; 22:100298. [PMID: 38455250 PMCID: PMC10918265 DOI: 10.1016/j.wnsx.2024.100298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 02/20/2024] [Indexed: 03/09/2024] Open
Affiliation(s)
- Javed Iqbal
- School of Medicine, King Edward Medical University, Lahore, Pakistan
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA
| | - Evan Courville
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA
| | - Michael Kogan
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA
| | - Meic H. Schmidt
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA
| | - Christian A. Bowers
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA
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Ellens NR, Schartz D, Kohli G, Rahmani R, Akkipeddi SMK, Mattingly TK, Bhalla T, Bender MT. Safety and efficacy comparison of embolic agents for middle meningeal artery embolization for chronic subdural hematoma. J Cerebrovasc Endovasc Neurosurg 2024; 26:11-22. [PMID: 37828746 PMCID: PMC10995466 DOI: 10.7461/jcen.2023.e2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/26/2023] [Accepted: 08/03/2023] [Indexed: 10/14/2023] Open
Abstract
OBJECTIVE To perform a systematic review and meta-analysis evaluating the efficacy of middle meningeal artery embolization in terms of both clinical and radiographic outcomes, when performed with different embolic agents. METHODS A systematic literature review and meta-analysis was performed to evaluate the impact of embolic agents on outcomes for middle meningeal artery (MMA) embolization. The use of polyvinyl alcohol (PVA) with or without (±) coils, N-butyl cyanoacrylate (n-BCA) ± coils, and Onyx alone were separately evaluated. Primary outcome measures were recurrence, the need for surgical rescue and in-hospital periprocedural complications. RESULTS Thirty-one studies were identified with a total of 1,134 patients, with 786 receiving PVA, 167 receiving n-BCA, and 181 patients receiving Onyx. There was no difference in the recurrence rate (5.5% for PVA, 4.5% for n-BCA, and 6.5% for Onyx, with P=0.71) or need for surgical rescue (5.0% for PVA, 4.0% for n-BCA, and 6.9% for Onyx, with P=0.89) based on the embolic agent. Procedural complications also did not differ between embolic agents (1.8% for PVA, 3.6% for n-BCA, and 1.6% for Onyx, with P=0.48). CONCLUSIONS Rates of recurrence, need for surgical rescue, and periprocedural complication following MMA embolization are not impacted by the type of embolic agent utilized. Ongoing clinical trials may be used to further investigate these findings.
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Affiliation(s)
- Nathaniel R. Ellens
- Department of Neurosurgery, University of Rochester Medical Center, New York, USA
| | - Derrek Schartz
- Department of Imaging Sciences, University of Rochester Medical Center, New York, USA
| | - Gurkirat Kohli
- Department of Neurosurgery, University of Rochester Medical Center, New York, USA
| | - Redi Rahmani
- Department of Neurosurgery, University of Rochester Medical Center, New York, USA
| | | | - Thomas K. Mattingly
- Department of Neurosurgery, University of Rochester Medical Center, New York, USA
| | - Tarun Bhalla
- Department of Neurosurgery, University of Rochester Medical Center, New York, USA
| | - Matthew T. Bender
- Department of Neurosurgery, University of Rochester Medical Center, New York, USA
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11
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Perng PS, Chuang MT, Wong CE, Chang Y, Sun YT, Wang HK, Lee JS, Wang LC, Huang CY. Simple coiling of middle meningeal artery embolization for chronic subdural hematoma: An inverse probability of treatment weighting matched cohort study. Interv Neuroradiol 2024:15910199241234407. [PMID: 38418387 DOI: 10.1177/15910199241234407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2024] Open
Abstract
BACKGROUND Middle meningeal artery embolization (MMAE) for chronic subdural hematoma (CSDH) has gained much attention in recent years. However, unintended embolization may occur when employing liquid embolic agents or particles. We present our clinical experience in simple coiling of MMAE to manage CSDH. METHODS Patients underwent either surgical evacuation or MMAE with simple coiling for CSDH were reviewed. Clinical and radiographic outcomes were assessed at admission, 1-month, and 6-month intervals. Two treatment groups were matched with inverse probability of treatment weighting. RESULTS One hundred twelve patients were included, with 27 patients in MMAE group and 87 patients in surgery group. In MMAE group, significant reductions were observed in hematoma width (admission vs. 1-month, 2.04 [1.44-2.60] cm vs. 0.62 [0.37-0.95] cm, p < 0.001). The adjusted odds ratio (aOR) of surgical rescue rate (0.77 95%CI 0.13-4.47, p = 0.77), hematoma reduction (>50%) (0.21 95%CI 0.04-1.07, p = 0.06), and midline shift improvement rate (3.22, 95%CI 0.84-12.4, p = 0.09) had no substantial disparities between two groups at 1-month follow-up. In addition, no significant difference was noted between two groups in terms of hematoma reduction (>50%) at 6-month follow-up (aOR 1.09 95%CI 0.32-3.70, p = 0.89). No procedure-related complications were found in MMA embolization group. CONCLUSION Simple coiling for MMA had comparable outcomes with surgical evacuation for CSDH. Our findings suggest that simple coiling can be an alternative choice for liquid agents or particles in MMA embolization for CSDH with acceptable safety.
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Affiliation(s)
- Pang-Shuo Perng
- Section of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ming-Tsung Chuang
- Department of Medical Imaging, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chia-En Wong
- Section of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu Chang
- Section of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yuan-Ting Sun
- Department of Medical Genomics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hao-Kuang Wang
- Department of Neurosurgery, E-Da Hospital, Kaohsiung, Taiwan
| | - Jung-Shun Lee
- Section of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Cell Biology and Anatomy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Liang-Chao Wang
- Section of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Yuan Huang
- Section of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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12
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Vargas J, Pease M, Snyder MH, Blalock J, Wu S, Nwachuku E, Mittal A, Okonkwo DO, Kellogg RT. Automated Preoperative and Postoperative Volume Estimates Risk of Retreatment in Chronic Subdural Hematoma: A Retrospective, Multicenter Study. Neurosurgery 2024; 94:317-324. [PMID: 37747231 DOI: 10.1227/neu.0000000000002667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 07/17/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Several neurosurgical pathologies, ranging from glioblastoma to hemorrhagic stroke, use volume thresholds to guide treatment decisions. For chronic subdural hematoma (cSDH), with a risk of retreatment of 10%-30%, the relationship between preoperative and postoperative cSDH volume and retreatment is not well understood. We investigated the potential link between preoperative and postoperative cSDH volumes and retreatment. METHODS We performed a retrospective chart review of patients operated for unilateral cSDH from 4 level 1 trauma centers, February 2009-August 2021. We used a 3-dimensional deep learning, automated segmentation pipeline to calculate preoperative and postoperative cSDH volumes. To identify volume thresholds, we constructed a receiver operating curve with preoperative and postoperative volumes to predict cSDH retreatment rates and selected the threshold with the highest Youden index. Then, we developed a light gradient boosting machine to predict the risk of cSDH recurrence. RESULTS We identified 538 patients with unilateral cSDH, of whom 62 (12%) underwent surgical retreatment within 6 months of the index surgery. cSDH retreatment was associated with higher preoperative (122 vs 103 mL; P < .001) and postoperative (62 vs 35 mL; P < .001) volumes. Patients with >140 mL preoperative volume had nearly triple the risk of cSDH recurrence compared with those below 140 mL, while a postoperative volume >46 mL led to an increased risk for retreatment (22% vs 6%; P < .001). On multivariate modeling, our model had an area under the receiver operating curve of 0.76 (95% CI: 0.60-0.93) for predicting retreatment. The most important features were preoperative and postoperative volume, platelet count, and age. CONCLUSION Larger preoperative and postoperative cSDH volumes increase the risk of retreatment. Volume thresholds may allow identification of patients at high risk of cSDH retreatment who would benefit from adjunct treatments. Machine learning algorithm can quickly provide accurate estimates of preoperative and postoperative volumes.
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Affiliation(s)
- Jan Vargas
- Division of Neurosurgery, PRISMA Health, Greenville , South Carolina , USA
| | - Matthew Pease
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - M Harrison Snyder
- Department of Neurosurgery, Tufts Medical Center, Boston , Massachusetts , USA
| | - Jonathan Blalock
- University of South Carolina School of Medicine Greenville, Greenville , South Carolina , USA
| | - Shandong Wu
- Department of Neurosurgery, UPMC Healthcare System, Pittsburgh , Pennsylvania , USA
| | - Enyinna Nwachuku
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland , Ohio , USA
| | - Aditya Mittal
- Department of Neurosurgery, University of Pittsburgh Medical Center Medical School, Pittsburgh , Pennsylvania , USA
| | - David O Okonkwo
- Department of Neurosurgery, UPMC Healthcare System, Pittsburgh , Pennsylvania , USA
| | - Ryan T Kellogg
- Department of Neurosurgery, University of Virginia, Charlottesville , Virginia , USA
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Abdollahifard S, Farrokhi A, Yousefi O, Valibeygi A, Azami P, Mowla A. Particle embolic agents for embolization of middle meningeal artery in the treatment of chronic subdural hematoma: A systematic review and meta-analysis. Interv Neuroradiol 2024; 30:94-104. [PMID: 36112765 PMCID: PMC10956449 DOI: 10.1177/15910199221125977] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/25/2022] [Indexed: 02/18/2024] Open
Abstract
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.
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Affiliation(s)
- Saeed Abdollahifard
- Student research committee, Shiraz University of Medical Sciences, Shiraz, Iran
- Research center for neuromodulation and pain, Shiraz, Iran
| | - Amirmohammad Farrokhi
- Student research committee, Shiraz University of Medical Sciences, Shiraz, Iran
- Research center for neuromodulation and pain, Shiraz, Iran
| | - Omid Yousefi
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Adib Valibeygi
- Fasa Neuroscience Circle (FNC), Student Research Committee, Fasa University of Medical Sciences, Fasa, Iran
| | - Pouria Azami
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
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14
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Tong X, Xue X, Liu A, Qi P. Comparative study on clinical outcomes and cost-effectiveness of chronic subdural hematomas treated by middle meningeal artery embolization and conventional treatment: a national cross-sectional study. Int J Surg 2023; 109:3836-3847. [PMID: 37830938 PMCID: PMC10720801 DOI: 10.1097/js9.0000000000000699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/13/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND The authors compared the efficacy and cost-effectiveness of middle meningeal artery embolization (MMAE) and conventional treatment for chronic subdural hematomas (cSDH). METHODS The Nationwide Readmissions Database of 9963 patients (27.2% women) with cSDH between 2016 and 2020 was analyzed. Finally, 9532 patients were included (95.7%, treated conventionally; 4.3%, treated with MMAE). Baseline demographics, comorbidities, adverse events, treatment strategies, and outcomes were compared between patients treated with MMAE and conventional treatment. After propensity score matching, the authors compared primary outcomes, including the 90-day treatment rate, functional outcome, length of hospital stays, and cost. A Markov model estimated lifetime costs and quality-adjusted life years (QALYs) associated with different treatments. The incremental cost-effectiveness ratio (ICER) was calculated to evaluate the base-case scenario. One-way, two-way, and probabilistic sensitivity analyses were performed to evaluate the uncertainty in the results. RESULTS After propensity score matching, MMAE had a lower 90-day retreatment rate (2.6 vs. 9.0%, P =0.001), shorter length of hospital stays (4.61±6.19 vs. 5.73±5.76 days, P =0.037), similar functional outcomes compared (favorable outcomes, 80.9 vs. 74.8%, P =0.224) but higher costs ($119 757.71±90 378.70 vs. $75 745.55±100 701.28, P <0.001) with conventional treatment. MMAE was associated with an additional cost of US$19 280.0 with additional QALY of 1.3. Its ICER was US$15199.8/QALY. CONCLUSION MMAE is more effective in treating cSDH than conventional treatment. Based on real-world data, though MMAE incurs higher overall costs, the Markov model showed it to be cost-effective compared to conventional treatment under the American healthcare system. These comparative and economic analyses further support the consideration of a paradigm shift in cSDH treatment.
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Affiliation(s)
- Xin Tong
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University
| | - Xiaopeng Xue
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University
| | - Aihua Liu
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University
| | - Peng Qi
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
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15
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Liu R, Li Y, Richard SA, Lan Z, Liu X. Rapid disappearance of acute subdural hematoma due to abrogated hyper-fibrinolytic activity by tranexamic acid: Case report. Medicine (Baltimore) 2023; 102:e35998. [PMID: 37960780 PMCID: PMC10637492 DOI: 10.1097/md.0000000000035998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/17/2023] [Indexed: 11/15/2023] Open
Abstract
RATIONALE Acute subdural hematoma (ASDH) occurs after tearing of bridging veins within the dura resulting in the accumulation of blood between the arachnoid and dura layers within 72 hours after traumatic head injury. Also, antigen fibrin D-dimer (DD) is the principal enzymatic degradation product of cross-linked fibrin by plasmin. We observed that early tranexamic acid (TXA) treatment resolved hyper-fibrinolysis and rapid disappearance ASDH. PATIENTS CONCERNS A 48-year-old female presented with unconsciousness for 2 hours after head trauma. Her Glasgow Coma Scale score was >8 points. DIAGNOSIS Computed tomography scan established ASDH with midline shift and brainstem compression and surgery was scheduled. Also, laboratory results indicated high DD spike of 34,820 μg/L and a reduction in plasma fibrinogen 1 hour after the injury. INTERVENTION She was treated with intravenous TXA immediately after admission. OUTCOMES Her DD spike decreased remarkably in 48 hours with associated rapid disappearance of ASDH thereby averting surgical intervention. She recovered fully with no long-term complications. LESSONS Historically, hyper-fibrinolysis is associated with poor outcome in head trauma. However, early initiation of TXA which is noninvasive treatment modality for ASDH could avert surgery and reduce cost, anesthesia, and other complications associated with surgery.
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Affiliation(s)
- Rong Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, Sichuan, China
| | - Yan Li
- Department of Intensive Care Unit, Luojiang People’s Hospital, Sichuan, China
| | - Seidu A. Richard
- Department of Neurosurgery, West China Hospital, Sichuan University, Sichuan, China
- Institute of Neuroscience, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhigang Lan
- Department of Neurosurgery, West China Hospital, Sichuan University, Sichuan, China
| | - Xuesong Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, Sichuan, China
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16
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Chen H, Salem MM, Colasurdo M, Sioutas GS, Khalife J, Kuybu O, Carroll KT, Hoang AN, Baig AA, Salih M, Khorasanizadeh M, Baker C, Mendez Ruiz A, Cortez GM, Abecassis Z, Ruiz Rodríguez JF, Davies JM, Narayanan S, Cawley CM, Riina H, Moore J, Spiotta AM, Khalessi A, Howard BM, Hanel RA, Tanweer O, Tonetti D, Siddiqui AH, Lang M, Levy EI, Jovin TG, Grandhi R, Srinivasan VM, Levitt MR, Ogilvy CS, Jankowitz B, Thomas AJ, Gross BA, Burkhardt JK, Kan P. Standalone middle meningeal artery embolization versus middle meningeal artery embolization with concurrent surgical evacuation for chronic subdural hematomas: a multicenter propensity score matched analysis of clinical and radiographic outcomes. J Neurointerv Surg 2023:jnis-2023-020907. [PMID: 37932033 DOI: 10.1136/jnis-2023-020907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 10/19/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Middle meningeal artery embolization (MMAE) has emerged as a promising therapy for chronic subdural hematomas (cSDHs). The efficacy of standalone MMAE compared with MMAE with concurrent surgery is largely unknown. METHODS cSDH patients who underwent successful MMAE from 14 high volume centers with at least 30 days of follow-up were included. Clinical and radiographic variables were recorded and used to perform propensity score matching (PSM) of patients treated with standalone MMAE or MMAE with concurrent surgery. Multivariable logistic regression models were used for additional covariate adjustments. The primary outcome was recurrence requiring surgical rescue, and the secondary outcome was radiographic failure defined as <50% reduction of cSDH thickness. RESULTS 722 MMAE procedures in 588 cSDH patients were identified. After PSM, 230 MMAE procedures remained (115 in each group). Median age was 73 years, 22.6% of patients were receiving anticoagulation medication, and 47.9% had no preoperative functional disability. Median midline shift was 4 mm and cSDH thickness was 16 mm, representing modestly sized cSDHs. Standalone MMAE and MMAE with surgery resulted in similar rates of surgical rescue (7.8% vs 13.0%, respectively, P=0.28; adjusted OR (aOR 0.73 (95% CI 0.20 to 2.40), P=0.60) and radiographic failure (15.5% vs 13.7%, respectively, P=0.84; aOR 1.08 (95% CI 0.37 to 2.19), P=0.88) with a median follow-up duration of 105 days. These results were similar across subgroup analyses and follow-up durations. CONCLUSIONS Standalone MMAE led to similar and durable clinical and radiographic outcomes as MMAE combined with surgery in select patients with moderately sized cSDHs and mild clinical disease.
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Affiliation(s)
- Huanwen Chen
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
- Neurology, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marco Colasurdo
- Interventional Radiology, Oregon Health and Science University, Portland, Oregon, USA
| | - Georgios S Sioutas
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jane Khalife
- Department of Neurosurgery, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Okkes Kuybu
- Department of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Kansas, USA
| | - Kate T Carroll
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Alex Nguyen Hoang
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Ammad A Baig
- Neurosurgery, Buffalo State, The State University of New York, Buffalo, New York, USA
| | - Mira Salih
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Cordell Baker
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Aldo Mendez Ruiz
- Department of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Kansas, USA
| | | | - Zack Abecassis
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | | | - Jason M Davies
- Neurosurgery and Biomedical Engineering, Toshiba Stroke and Vascular Research Institute, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Sandra Narayanan
- Department of Neurology, Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
| | | | | | - Justin Moore
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Alexander Khalessi
- Department of Neurological Surgery, University of California San Diego, La Jolla, California, USA
| | - Brian M Howard
- Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Omar Tanweer
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Daniel Tonetti
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Michael Lang
- Department of Neurosurgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Elad I Levy
- Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Tudor G Jovin
- Neurology, Cooper University Hospital, Camden, New Jersey, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | | | - Michael R Levitt
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | | | - Brian Jankowitz
- Neurosurgery, University of Pennsylvania, Camden, Pennsylvania, USA
| | - Ajith J Thomas
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Bradley A Gross
- Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jan Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter Kan
- Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
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17
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Liu Z, Wang Y, Tang T, Zhang Y, Sun Y, Kuang X, Wei T, Zhou L, Peng A, Cao D, Hongsheng W, Qi W, Chenyi W, Shan Q. Time and Influencing Factors to Chronic Subdural Hematoma Resolution After Middle Meningeal Artery Embolization. World Neurosurg 2023; 179:e6-e14. [PMID: 36924886 DOI: 10.1016/j.wneu.2023.03.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 03/12/2023] [Indexed: 03/17/2023]
Abstract
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.
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Affiliation(s)
- Zhensheng Liu
- Department of Interventional Radiology, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Youwei Wang
- Department of Neurosurgery, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Tieyu Tang
- Department of Neurology, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Yunfeng Zhang
- Department of Neurology, the Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - Yong Sun
- Department of Interventional Radiology, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - XiongWei Kuang
- Department of Interventional Radiology, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Tingfeng Wei
- Department of Interventional Radiology, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Longjiang Zhou
- Department of Interventional Radiology, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Aijun Peng
- Department of Neurosurgery, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Demao Cao
- Department of Neurosurgery, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Wang Hongsheng
- Department of Neurosurgery, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Wentao Qi
- Department of Neurosurgery, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Wu Chenyi
- Department of Neurosurgery, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Qing Shan
- Stroke Center, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China.
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18
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Omura Y, Ishiguro T. Middle meningeal artery embolization for chronic subdural hematoma: a systematic review. Front Neurol 2023; 14:1259647. [PMID: 37881312 PMCID: PMC10593964 DOI: 10.3389/fneur.2023.1259647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 09/25/2023] [Indexed: 10/27/2023] Open
Abstract
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.
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Affiliation(s)
| | - Taichi Ishiguro
- Department of Neurosurgery, Tokyo Women's Medical University Yachiyo Medical Center, Yachiyo, Chiba, Japan
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19
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Sioutas GS, Mouchtouris N, Saiegh FA, Naamani KE, Amllay A, Becerril-Gaitan A, Velagapudi L, Gooch MR, Herial NA, Jabbour P, Rosenwasser RH, Tjoumakaris SI. Middle Meningeal Artery Embolization for Subdural Hematoma: An Institutional Cohort and Propensity Score-Matched Comparison with Conventional Management. Clin Neurol Neurosurg 2023; 233:107895. [PMID: 37556969 DOI: 10.1016/j.clineuro.2023.107895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND The treatment of non-acute subdural hematoma (NASDH) is challenging due to its high recurrence rates and comorbidities of mostly elderly patients. Middle meningeal artery embolization (MMAE) recently emerged as an alternative to surgery in the treatment of NASDH. OBJECTIVE To describe a single center's experience of MMAE with Onyx for NASDH and compare it to a surgically treated historical cohort. METHODS We performed a retrospective analysis of patients undergoing MMAE for NASDH from 2019 to 2021. MMAE was performed with ethylene vinyl alcohol copolymer (Onyx). Comparisons were made with a historical cohort from 2010 to 2018 who underwent surgical evacuation only, before and after propensity score matching. Outcomes were assessed clinically and radiographically. RESULTS We included 44 consecutive patients (55 MMAEs) who underwent MMAE, with a median follow-up of 63.5 days. Twenty-four NASDHs underwent upfront embolization, 17 adjunctive, and 14 for recurrence after prior surgical evacuation, with no significant differences in hematoma and mRS reduction between them. Two patients died during hospitalization and 2 during follow-up, unrelated to the procedure. Mean SDH thickness decreased by 48.3% ± 38.1% (P < 0.001) on last follow-up, which did not correlate with the amount of Onyx injected. Six (13.6%) patients required surgical rescue after embolization. There were no procedure-related complications. The mean modified Rankin Scale (mRS) on admission was 2.8 ± 1.5, which decreased significantly to 1 [1,4] at the last follow-up (P = 0.033). The MMAE (41 hematomas; upfront and adjunctive embolization) and Surgical Evacuation-only (461 hematomas) cohorts were balanced with propensity score mathing. Matching was successful for 41 MMAE and 41 surgical-only hematoma pairs, and only hypertension remained significantly different between the two groups, but there was no significant difference in any outcome. CONCLUSION MMAE for NASDH seems safe and effective in appropriately selected patients, non-inferior to surgery, and may become a minimally-invasive alternative. Given our encouraging results, large-scale clinical randomized trials are warranted.
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Affiliation(s)
- Georgios S Sioutas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Fadi Al Saiegh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Abdelaziz Amllay
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Andrea Becerril-Gaitan
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, TX, USA
| | - Lohit Velagapudi
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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20
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El Rahal A, Beck J, Ahlborn P, Bernasconi C, Marbacher S, Wanderer S, Burkhardt JK, Daniel RT, Ferrari A, Hausmann O, Kamenova M, Kothbauer K, Lutz K, Mariani L, Alfieri A, Schöni D, Schucht P, Raabe A, Regli L, Kuhlen D, Seule M, Soleman J, Starnoni D, Zaldivar J, Zweifel C, Schaller K, Fung C. Incidence, therapy, and outcome in the management of chronic subdural hematoma in Switzerland: a population-based multicenter cohort study. Front Neurol 2023; 14:1206996. [PMID: 37780710 PMCID: PMC10540067 DOI: 10.3389/fneur.2023.1206996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 06/19/2023] [Indexed: 10/03/2023] Open
Abstract
Background Chronic subdural hematoma (cSDH) is a disease affecting mainly elderly individuals. The reported incidence ranges from 2.0/100,000 to 58 per 100,000 person-years when only considering patients who are over 70 years old, with an overall incidence of 8.2-14.0 per 100,000 persons. Due to an estimated doubling of the population above 65 years old between 2000 and 2030, cSDH will become an even more significant concern. To gain an overview of cSDH hospital admission rates, treatment, and outcome, we performed this multicenter national cohort study of patients requiring surgical treatment of cSDH. Methods A multicenter cohort study included patients treated in 2013 in a Swiss center accredited for residency. Demographics, medical history, symptoms, and medication were recorded. Imaging at admission was evaluated, and therapy was divided into burr hole craniostomy (BHC), twist drill craniostomy (TDC), and craniotomy. Patients' outcomes were dichotomized into good (mRS, 0-3) and poor (mRS, 4-6) outcomes. A two-sided t-test for unpaired variables was performed, while a chi-square test was performed for categorical variables, and a p-value of <0.05 was considered to be statistically significant. Results A total of 663 patients were included. The median age was 76 years, and the overall incidence rate was 8.2/100,000. With age, the incidence rate increased to 64.2/100,000 in patients aged 80-89 years. The most prevalent symptoms were gait disturbance in 362 (58.6%) of patients, headache in 286 (46.4%), and focal neurological deficits in 252 (40.7%). CSDH distribution was unilateral in 478 (72.1%) patients, while 185 presented a bilateral hematoma with no difference in the outcome. BHC was the most performed procedure for 758 (97.3%) evacuations. CSDH recurrence was noted in 104 patients (20.1%). A good outcome was seen in almost 81% of patients. Factors associated with poor outcomes were age, GCS and mRS on admission, and the occurrence of multiple deficits present at the diagnosis of the cSDH. Conclusion As the first multicenter national cohort-based study analyzing the disease burden of cSDH, our study reveals that the hospital admission rate of cSDH was 8.2/100,000, while with age, it rose to 64.2/100,000. A good outcome was seen in 81% of patients, who maintained the same quality of life as before the surgery. However, the mortality rate was 4%.
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Affiliation(s)
- Amir El Rahal
- Department of Neurosurgery, University Hospital of Geneva, Faculty of Medicine, Geneva, Switzerland
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Peter Ahlborn
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Corrado Bernasconi
- Department of Neurosurgery, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Serge Marbacher
- Department of Neurosurgery, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Stefan Wanderer
- Department of Neurosurgery, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Roy Thomas Daniel
- Department of Neurosurgery, University Hospital Center of Lausanne, Lausanne, Switzerland
| | - Andrea Ferrari
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Oliver Hausmann
- Department of Neurosurgery, Hirslanden Klinik St. Anna, Luzern, Switzerland
| | - Maria Kamenova
- Department of Neurosurgery, University Hospital Basel, Faculty of Medicine, Basel, Switzerland
| | - Karl Kothbauer
- Department of Neurosurgery, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - Katharina Lutz
- Department of Neurosurgery, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital Basel, Faculty of Medicine, Basel, Switzerland
| | - Alex Alfieri
- Department of Neurosurgery, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Daniel Schöni
- Department of Neurosurgery, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Philippe Schucht
- Department of Neurosurgery, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Dominique Kuhlen
- Department of Neurosurgery, Regional Hospital Lugano (EOC), Lugano, Switzerland
| | - Martin Seule
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital Basel, Faculty of Medicine, Basel, Switzerland
| | - Daniele Starnoni
- Department of Neurosurgery, University Hospital Center of Lausanne, Lausanne, Switzerland
| | - Julien Zaldivar
- Department of Neurosurgery, University Hospital Center of Lausanne, Lausanne, Switzerland
| | - Christian Zweifel
- Department of Neurosurgery, Cantonal Hospital Graubünden, Chur, Switzerland
| | - Karl Schaller
- Department of Neurosurgery, University Hospital of Geneva, Faculty of Medicine, Geneva, Switzerland
| | - Christian Fung
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
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21
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Orscelik A, Senol YC, Bilgin C, Kobeissi H, Arul S, Cloft H, Lanzino G, Kallmes DF, Brinjikji W. Middle meningeal artery embolization combined with surgical evacuation for chronic subdural hematoma: A single-center experience of 75 cases. Interv Neuroradiol 2023:15910199231196453. [PMID: 37635326 DOI: 10.1177/15910199231196453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND Chronic subdural hematoma (cSDH) is a challenging and common neurosurgical condition. Our goal is to demonstrate that middle meningeal artery (MMA) embolization combined with surgical evacuation can be a promising adjuvant option for treatment of cSDHs and prevent recurrence in symptomatic patients who require surgical treatment. METHOD We retrospectively collected data from patients who underwent MMA embolization using polyvinyl alcohol particles and surgical evacuation with burr hole or craniotomy in a single center for the treatment of new and recurrent cSDHs. The primary outcome was recurrence of cSDH requiring surgical rescue during follow up, and secondary outcomes were defined as >50% decrease in the maximum width of cSDHs on the longest follow-up computed tomography (CT) scan, complications following procedure, and improvement in modified Rankin scale (mRS) score. RESULTS A total of 51 patients successfully underwent 72 MMA embolization procedures (96% of the total 75 cases in the cohort) combined with surgical evacuation. Seventy cases (93.3%) achieved at least 50% reduction in the size of the cSDHs on the last CT imaging. A surgical evacuation was required in five cases (6.7%) due to cSDH recurrence during the follow-up period. There were three complications (6.0%) related to embolization procedure. Forty patients (78.4%) showed improvement in mRS score. There was one mortality (2%) regardless of the embolization and evacuation. CONCLUSIONS Our study demonstrates the safety and efficacy of adjunct MMA embolization in significantly reducing size and recurrence of cSDHs.
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Affiliation(s)
| | - Yigit Can Senol
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Santhosh Arul
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Harry Cloft
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
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22
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Nakagawa I, Kotsugi M, Yokoyama S, Maeoka R, Tamura K, Takeshima Y, Matsuda R, Yamada S, Nishimura F, Park YS, Nakase H. Extensive Roles and Technical Advances of Middle Meningeal Artery Embolization for Chronic Subdural Hematoma. Neurol Med Chir (Tokyo) 2023; 63:327-333. [PMID: 37286481 PMCID: PMC10482489 DOI: 10.2176/jns-nmc.2023-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/03/2023] [Indexed: 06/09/2023] Open
Abstract
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.
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23
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Dowlati E, Chesney K, Carpenter AB, Rock M, Patel N, Mai JC, Liu AH, Armonda RA, Felbaum DR. Awake transradial middle meningeal artery embolization and twist drill craniostomy for chronic subdural hematomas in the elderly: case series and technical note. J Neurosurg Sci 2023; 67:471-479. [PMID: 34114433 DOI: 10.23736/s0390-5616.21.05335-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Due to prohibitive perioperative risk factors, optimal treatment for chronic subdural hematomas (cSDH) in the elderly remains unclear. Minimally invasive techniques are a viable option and include bedside subdural evacuation port system (SEPS), as well as prevention of recurrence with middle meningeal artery (MMA) embolization. We present a case series of elderly patients undergoing combined transradial MMA embolization and bed-side craniostomy as primary treatment for cSDH. METHODS Patients 70 years and older from 2019 to 2020 that underwent single setting, awake transradial MMA embolization with concurrent SEPS placement under local anesthesia were included. Those with prior treatments, interventions performed under general anesthesia, or with less than 60-day follow-up were excluded. Descriptive analyses of baseline characteristics, radiologic parameters, comorbidities, and outcome measures were completed. RESULTS Twenty elderly patients (mean age of 81.0 years) with multiple comorbidities underwent 28 MMA embolization+SEPS procedures as primary treatment for cSDH. Mean cSDH thickness was 1.8cm±0.6 cm with 7.3±3.9 mm midline shift. All patients tolerated the procedure well. 1/20 (5.0%) patients died within 30 days of the procedure. A majority of patients were discharged to home (12/20; 60.0%). There was an average of 3.6-month follow-up and one patient (5.0%) developed recurrence in the follow-up period requiring further intervention. CONCLUSIONS In select elderly patients with high perioperative risk factors, primary treatment of cSDH using awake transradial MMA embolization+SEPS placement is a minimally invasive, feasible, and safe option. Further comparative studies are warranted to evaluate efficacy of the treatment.
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Affiliation(s)
- Ehsan Dowlati
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA -
| | - Kelsi Chesney
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | | | - Mitchell Rock
- Georgetown University School of Medicine, Washington, DC, USA
| | - Nirali Patel
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Jeffrey C Mai
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
- Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Ai-Hsi Liu
- Department of Radiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Rocco A Armonda
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
- Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Daniel R Felbaum
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
- Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, USA
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24
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Sattari SA, Yang W, Shahbandi A, Feghali J, Lee RP, Xu R, Jackson C, Gonzalez LF, Tamargo RJ, Huang J, Caplan JM. Middle Meningeal Artery Embolization Versus Conventional Management for Patients With Chronic Subdural Hematoma: A Systematic Review and Meta-Analysis. Neurosurgery 2023; 92:1142-1154. [PMID: 36929762 DOI: 10.1227/neu.0000000000002365] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/15/2022] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND The results from studies that compare middle meningeal artery (MMA) embolization vs conventional management for patients with chronic subdural hematoma are varied. OBJECTIVE To conduct a systematic review and meta-analysis on studies that compared MMA embolization vs conventional management. METHODS Medline, PubMed, and Embase databases were searched. Primary outcomes were treatment failure and surgical rescue; secondary outcomes were complications, follow-up modified Rankin scale > 2, mortality, complete hematoma resolution, and length of hospital stay (day). The certainty of the evidence was determined using the GRADE approach. RESULTS Nine studies yielding 1523 patients were enrolled, of which 337 (22.2%) and 1186 (77.8%) patients received MMA embolization and conventional management, respectively. MMA embolization was superior to conventional management for treatment failure (relative risk [RR] = 0.34 [0.14-0.82], P = .02), surgical rescue (RR = 0.33 [0.14-0.77], P = .01), and complete hematoma resolution (RR = 2.01 [1.10-3.68], P = .02). There was no difference between the 2 groups for complications (RR = 0.93 [0.63-1.37], P = .72), follow-up modified Rankin scale >2 (RR = 0.78 [0.449-1.25], P = .31), mortality (RR = 1.05 [0.51-2.14], P = .89), and length of hospital stay (mean difference = -0.57 [-2.55, 1.41], P = .57). For MMA embolization, the number needed to treat for treatment failure, surgical rescue, and complete hematoma resolution was 7, 9, and 3, respectively. The certainty of the evidence was moderate to high for primary outcomes and low to moderate for secondary outcomes. CONCLUSION MMA embolization decreases treatment failure and the need for surgical rescue without furthering the risk of morbidity and mortality. The authors recommend considering MMA embolization in the chronic subdural hematoma management.
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Affiliation(s)
- Shahab Aldin Sattari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ataollah Shahbandi
- Tehran School of Medicine, Tehran University of Medical Science, Tehran, Iran
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ryan P Lee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - L Fernando Gonzalez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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25
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Lam A, Selvarajah D, Htike SS, Chan S, Lalloo S, Lock G, Redmond K, Leggett D, Mews P. The efficacy of postoperative middle meningeal artery embolization on chronic subdural hematoma - A multicentered randomized controlled trial. Surg Neurol Int 2023; 14:168. [PMID: 37292400 PMCID: PMC10246309 DOI: 10.25259/sni_208_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 04/25/2023] [Indexed: 06/10/2023] Open
Abstract
Background Middle meningeal artery (MMA) embolization has recently emerged as a potential treatment for chronic subdural hematoma (cSDH). Numerous retrospective studies have suggested that it can potentially reduce the risk of hematoma recurrence following surgical evacuation. We have conducted a randomized controlled trial to investigate the effectiveness of postoperative MMA embolization in reducing recurrence rate, residual hematoma thickness as well as improving functional outcome. Methods Patients aged 18 or above were recruited. Following evacuation through burr hole or craniotomy, patients were randomly allocated to undergo either MMA embolization or standard care (monitoring). The primary outcome was symptomatic recurrence requiring redo evacuation. Secondary outcomes include residual hematoma thickness and modified Rankin Scale (mRS) at 6 weeks and 3 months. Results Thirty-six patients (41 cSDHs) were recruited between April 2021 and September 2022. Seventeen patients (19 cSDHs) were allocated to the embolization group and 19 patients (22 cSDHs) were in the control group. No symptomatic recurrence was observed in the treatment group while 3 control patients (15.8%) underwent repeat surgery for symptomatic recurrence, however, it was not statistically significant (P = 0.234). Furthermore, there was no significant difference in residual hematoma thickness at 6 weeks or 3 months between the two groups. All patients in the embolization group had a good functional outcome (mRS 0-1) at 3 months, which was significantly higher than the 53% observed in the control group. No complications related to MMA embolization were reported. Conclusion Further study with larger sample size is required to evaluate the efficacy of MMA embolization.
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Affiliation(s)
- Alexander Lam
- Department of Neurosurgery, Princess Alexandra Hospital, Woolloongabba, Australia
| | | | - Soe San Htike
- Department of Neurosurgery, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Sophia Chan
- Department of Neurosurgery, Princess Alexandra Hospital, Woolloongabba, Australia
| | | | - Gregory Lock
- Department of Radiology, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Kendal Redmond
- Department of Radiology, Princess Alexandra Hospital, Woolloongabba, Australia
| | - David Leggett
- Department of Radiology, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Peter Mews
- Department of Neurosurgery, Canberra Hospital, Garran, Australia
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26
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Wu M, Wajeeh H, McPhail MN, Seyam O, Flora J, Nguyen H. Usage of Tranexamic Acid for Treatment of Subdural Hematomas. Cureus 2023; 15:e37628. [PMID: 37200656 PMCID: PMC10185923 DOI: 10.7759/cureus.37628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 04/15/2023] [Indexed: 05/20/2023] Open
Abstract
The collection of blood in the subdural layer within the cranium is classified as a subdural hematoma. Prevalence of subdural hematomas is most common among older populations with the current standard of treatment being invasive surgical evacuation for patients presenting with acute subdural hematomas with a midline shift greater than 5 mm on computed tomography (CT).Tranexamic acid (TXA) has been identified as an alternative, non-invasive option to treat patients presenting with subdural hematoma who are not suitable for surgical intervention. The presenting case involves a 90-year-old female who arrived with a code stroke with the chief complaint of right lower extremity weakness. A stroke series CT panel revealed a left frontal multiloculated subdural hematoma, measuring 130 mL with mass effect and a midline shift of 7 mm. The patient was recommended a craniotomy for hematoma evacuation or access to hospice for comfort care. A second opinion resulted in the administration of TXA. After the full completion of a TXA course, the patient achieved baseline mobility. The final measurements revealed a final hematoma volume of 10 mL and a midline shift of less than 2 mm. Current literature, as well as the case described, has begun demonstrating the efficacy of the usage of TXA in the reabsorption of subdural hematomas and should encourage further exploration into society guidelines for the usage of TXA as a non-invasive alternative to treat subdural hematomas.
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Affiliation(s)
- Michael Wu
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Hassaan Wajeeh
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Marissa N McPhail
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Omar Seyam
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Jamie Flora
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Hoang Nguyen
- Basic Sciences, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Clearwater, USA
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27
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Rutledge C, Baranoski JF, Catapano JS, Jadhav AP, Albuquerque FC, Ducruet AF. Republished: Resolution of an enlarging subdural haematoma after contralateral middle meningeal artery embolisation. J Neurointerv Surg 2023; 15:e2. [PMID: 33986110 DOI: 10.1136/neurintsurg-2021-017530.rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 11/04/2022]
Abstract
A man in his 50s presented 1 month after an automobile accident with worsening headaches and an enlarging chronic left subdural haematoma (SDH). He underwent left middle meningeal artery (MMA) embolisation. Due to tortuosity at its origin, we were unable to catheterise the MMA distally. Only proximal coil occlusion at the origin was performed. Follow-up interval head CT showed an increase in the size of the SDH with new haemorrhage, worsening mass effect and midline shift. However, he remained neurologically intact. Contralateral embolisation of the right MMA was performed with a liquid embolic agent. His headaches improved, and a follow-up head CT 3 months later showed near-complete resolution of the SDH.
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Affiliation(s)
- Caleb Rutledge
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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28
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Shotar E, Barberis E, Chougar L, Bensoussan S, Parat D, Ghannouchi H, Premat K, Lenck S, Degos V, Lehericy S, Sourour NA, Mathon B, Clarençon F. Long-Term Middle Meningeal Artery Caliber Reduction Following Trisacryl Gelatine Microsphere Embolization for the Treatment of Chronic Subdural Hematoma. Clin Neuroradiol 2023; 33:113-120. [PMID: 35796853 DOI: 10.1007/s00062-022-01189-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 06/13/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Middle meningeal artery (MMA) particle embolization is a promising treatment of chronic subdural hematomas (CSDH). The main purpose of this study is to measure MMA proximal caliber and assess the visibility of the two main MMA branches as a surrogate for long-term distal arterial patency following MMA CSDH embolization with trisacryl gelatine microspheres (TAGM). METHODS This is a single-center retrospective study. All patients having undergone MMA TAGM only embolization for CSDH treatment between 15 March 2018 and 6 June 2020 with an interpretable follow-up magnetic resonance imaging (MRI) examination and no confounding factors were included. Patients were compared with controls matched for age, sex and MRI machine. Two independent readers analyzed the MRI images. RESULTS In this study, 30 patients having undergone embolization procedures using TAGM of 36 MMAs were included. The follow-up MRI scans were performed after a mean delay of 14.8 ± 7.1 months (range 4.9-29.4 months). The mean diameter of TAGM embolized MMAs (1 mm; 95% confidence interval, CI 0.9-1.1) was significantly smaller than the mean diameter of paired control MMAs (1.3 mm; 95% CI 1.3-1.4) (p < 0.001). The mean proximal diameter of the embolized MMAs (0.9 mm; 95% CI 0.7-1.1) was significantly smaller than the mean diameter of the contralateral MMAs in the same patients (1.4 mm; 95% CI 1.3-1.6)(p < 0.001). CONCLUSION Long-term follow-up MRI demonstrated a significant impact of TAGM embolization on MMA proximal caliber as well as on the visibility of the two main MMA branches. All comparisons indicated that there was a probable lasting impact of embolization on the patency of distal branches.
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Affiliation(s)
- Eimad Shotar
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France.
| | - Eric Barberis
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Lydia Chougar
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France.,Sorbonne Université, Paris, France
| | - Sacha Bensoussan
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Damien Parat
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Haroun Ghannouchi
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Kevin Premat
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Stephanie Lenck
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Vincent Degos
- Sorbonne Université, Paris, France.,Department of Neurosurgical Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Stéphane Lehericy
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France.,Sorbonne Université, Paris, France
| | - Nader-Antoine Sourour
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Bertrand Mathon
- Sorbonne Université, Paris, France.,Department of Neurosurgery, Pitié-Salpêtrière Hospital, Paris, France
| | - Frédéric Clarençon
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France.,Sorbonne Université, Paris, France
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Ku JC, Dmytriw AA, Essibayi MA, Banihashemi MA, Vranic JE, Ghozy S, Altschul D, Regenhardt RW, Stapleton CJ, Yang VXD, Patel AB. Embolic Agent Choice in Middle Meningeal Artery Embolization as Primary or Adjunct Treatment for Chronic Subdural Hematoma: A Systematic Review and Meta-analysis. AJNR Am J Neuroradiol 2023; 44:297-302. [PMID: 36797028 PMCID: PMC10187811 DOI: 10.3174/ajnr.a7796] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 01/24/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Middle meningeal artery embolization is an emerging treatment option for chronic subdural hematomas. PURPOSE Our aim was to assess outcomes following middle meningeal artery embolization by different techniques, including in comparison with traditional surgical methods. DATA SOURCES We searched the literature databases from inception to March 2022. DATA SELECTION We selected studies reporting outcomes after middle meningeal artery embolization as a primary or adjunctive treatment for chronic subdural hematoma. DATA ANALYSIS We analyzed the risk of recurrence of chronic subdural hematoma, reoperation for recurrence or residual hematoma, complications, and radiologic and clinical outcomes using random effects modeling. Additional analyses were performed on the basis of whether middle meningeal artery embolization was used as the primary or adjunct treatment and by embolic agent type. DATA SYNTHESIS Twenty-two studies were included with 382 patients with middle meningeal artery embolization and 1373 surgical patients. The rate of subdural hematoma recurrence was 4.1%. Fifty (4.2%) patients underwent a reoperation for a recurrent or residual subdural hematoma. Thirty-six (2.6%) experienced postoperative complications. The rates of good radiologic and clinical outcomes were 83.1% and 73.3%, respectively. Middle meningeal artery embolization was significantly associated with decreased odds of subdural hematoma reoperation (OR = 0.48; 95% CI, 23.4-99.1; P = .047) compared with surgery. The lowest rates of subdural hematoma radiologic recurrence, reoperation, and complications were observed among patients receiving embolization with Onyx, whereas good overall clinical outcome occurred most commonly with combined polyvinyl alcohol and coils. LIMITATIONS A limitation was the retrospective design of studies included. CONCLUSIONS Middle meningeal artery embolization is safe and effective, either as a primary or adjunctive treatment. Treatment using Onyx seems to yield lower rates of recurrence, rescue operation, and complications whereas particles and coils produce good overall clinical outcomes.
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Affiliation(s)
- J C Ku
- From the Division of Neurosurgery (J.C.K.)
| | - A A Dmytriw
- Neuroendovascular Program (A.A.D., J.E.V., R.W.R., C.J.S., A.B.P.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Neurointerventional Program (A.A.D., V.X.D.Y.), Department of Clinical Neurological Sciences & Medical Imaging, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - M A Essibayi
- Departments of Radiology (M.A.E., S.G.), Mayo Clinic, Rochester, Minnesota
- Department of Neurosurgery (M.A.E., D.A.), Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
| | - M A Banihashemi
- Department of Surgery and Institute of Medical Science (M.A.B.), University of Toronto, Toronto, Ontario, Canada
| | - J E Vranic
- Neuroendovascular Program (A.A.D., J.E.V., R.W.R., C.J.S., A.B.P.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - S Ghozy
- Departments of Radiology (M.A.E., S.G.), Mayo Clinic, Rochester, Minnesota
- Nuffield Department of Primary Care Health Sciences and Department for Continuing Education (EBHC program) (S.G.), Oxford University, Oxford, UK
| | - D Altschul
- Department of Neurosurgery (M.A.E., D.A.), Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
| | - R W Regenhardt
- Neuroendovascular Program (A.A.D., J.E.V., R.W.R., C.J.S., A.B.P.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - C J Stapleton
- Neuroendovascular Program (A.A.D., J.E.V., R.W.R., C.J.S., A.B.P.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - V X D Yang
- Neurointerventional Program (A.A.D., V.X.D.Y.), Department of Clinical Neurological Sciences & Medical Imaging, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - A B Patel
- Neuroendovascular Program (A.A.D., J.E.V., R.W.R., C.J.S., A.B.P.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Atefi N, Alcock S, Silvaggio JA, Shankar J. Clinical Outcome and Recurrence Risk of Chronic Subdural Hematoma After Surgical Drainage. Cureus 2023; 15:e35525. [PMID: 37007398 PMCID: PMC10054842 DOI: 10.7759/cureus.35525] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 03/03/2023] Open
Abstract
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.
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31
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Fountain HB, de Monaco BA, Jagid J, Benveniste R, Cordeiro JG. Middle Meningeal Artery Embolization for Chronic Subdural Hematoma Related to Autosomal Dominant Polycystic Kidney Disease. Cureus 2023; 15:e34970. [PMID: 36938171 PMCID: PMC10019495 DOI: 10.7759/cureus.34970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 02/16/2023] Open
Abstract
Autosomal dominant polycystic kidney disease (ADPKD) is a connective tissue disease with vascular abnormalities involving multiple organs. The prevalence of ADPKD associated with a spontaneous subdural hematoma (SDH) is very low, with less than 10 cases reported in the literature to date. Symptomatic chronic SDH is classically treated with a twist drill, burr holes, or craniotomy. Recently, middle meningeal artery (MMA) embolization has emerged as an ancillary modality. We present the first case in the literature of a bilateral SDH in a young ADPKD patient successfully managed with MMA embolization. Moreover, we discuss the role of different treatment modalities on this subset of patients.
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Affiliation(s)
- Hayes B Fountain
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, USA
| | - Bernardo A de Monaco
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, USA
- Neurosurgery, University of Sao Paulo, Sao Paulo, BRA
| | - Jonathan Jagid
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, USA
| | - Ronald Benveniste
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, USA
| | - Joacir G Cordeiro
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, USA
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Msheik A, Fares Y, Mohanna M, Aoude A, Shkeir M, Chehade F, Kanj A, Mohanna A. Middle meningeal artery embolisation: The review of a new treatment for chronic subdural hematomas. Surg Neurol Int 2023; 14:66. [PMID: 36895214 PMCID: PMC9990792 DOI: 10.25259/sni_1096_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/03/2023] [Indexed: 02/26/2023] Open
Abstract
Background This is a literature review aiming to provide an update about the recent findings related to the efficacy of middle meningeal artery embolization (MMAE) in the treatment of chronic subdural hematomas (cSDHs), comparison with conventional therapy and deduction of the current recommendations and indications. Methods The literature is reviewed using a search through the PubMed index using keywords. Studies are then screened, skimmed, and thoroughly read. 32 studies fulfilled the inclusion criteria and are included in the study. Results Five indications for the application of MMA embolization (MMAE) are deducted from the literature. The usage as a preventive measure after surgical treatment of symptomatic cSDHs in patients with a high risk of recurrence and the usage as a standalone procedure has been the most common reasons for indication of this procedure. Rates of failures for the aforementioned indications have been 6.8% and 3.8%, respectively. Conclusion The safety of MMAE as a procedure is regarded as a general theme in the literature and can be considered for future applications. Usage of this procedure in clinical trials with more patient segregation and timeframe assessment relative to surgical intervention are recommendations of this literature review.
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Affiliation(s)
- Ali Msheik
- Department of Neurological Surgery, Lebanese University, Faculty of Medical Sciences
| | - Youssef Fares
- Department of Neurological Surgery, Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Lebanon
| | - Mohammad Mohanna
- Department of Oncology, Cleveland Clinic, Weston, Florida, United States
| | - Ahmad Aoude
- Department of Neurological Surgery, Al Rassoul Al-Azam Hospital
| | - Mohamad Shkeir
- Head of Radiology Department, Zahraa Hospital University Medical Center
| | - Feras Chehade
- Department of Nuclear Medicine Radiobiology Radiopathology, Faculty of Medical Sciences, Lebanese University
| | - Ali Kanj
- Radiology Department, Bahman Hospital, Faculty of Medicine, Lebanese University
| | - Assaad Mohanna
- Head of Department of Radiology, Faculty of Medicine, Lebanese University, Bahman Hospital, Centre Hospitalier Vallee de la Maurienne-France, Beirut, Lebanon
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33
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Scherschinski L, Catapano JS, Jadhav AP, Ducruet AF, Albuquerque FC. REPLY. AJNR Am J Neuroradiol 2023; 44:E3. [PMID: 36549848 PMCID: PMC9835922 DOI: 10.3174/ajnr.a7754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- L Scherschinski
- Department of NeurosurgeryBarrow Neurological Institute, St. Joseph's Hospital and Medical CenterPhoenix, Arizona
| | - J S Catapano
- Department of NeurosurgeryBarrow Neurological Institute, St. Joseph's Hospital and Medical CenterPhoenix, Arizona
| | - A P Jadhav
- Department of NeurosurgeryBarrow Neurological Institute, St. Joseph's Hospital and Medical CenterPhoenix, Arizona
| | - A F Ducruet
- Department of NeurosurgeryBarrow Neurological Institute, St. Joseph's Hospital and Medical CenterPhoenix, Arizona
| | - F C Albuquerque
- Department of NeurosurgeryBarrow Neurological Institute, St. Joseph's Hospital and Medical CenterPhoenix, Arizona
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Shehabeldin M, Amllay A, Jabre R, Chen CJ, Schunemann V, Herial NA, Gooch MR, Mackenzie L, Choe H, Tjoumakaris S, Rosenwasser RH, Jabbour P, Kozak O. Onyx Versus Particles for Middle Meningeal Artery Embolization in Chronic Subdural Hematoma. Neurosurgery 2022; 92:979-985. [PMID: 36700752 DOI: 10.1227/neu.0000000000002307] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 10/14/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Middle meningeal artery (MMA) embolization has recently emerged as a treatment option for chronic subdural hematoma (cSDH). It is considered a simple and potentially safe endovascular procedure. OBJECTIVE To compare between 2 different embolic agents; onyx (ethylene vinyl alcohol) and emboparticles (polyvinyl alcohol particles-PVA) for endovascular treatment of cSDH. METHODS A retrospective analysis of all patients who underwent MMA embolization for cSDH treatment in 2 comprehensive centers between August 2018 and December 2021. Primary outcomes were failure of embolization and need for rescue surgical evacuation. RESULTS Among 97 MMA embolizations, 49 (50.5%) received onyx and 48 (49.5%) received PVA. The presence of acute or subacute on cSDH was higher in the PVA group 11/49 (22.5%) vs 30/48 (62.5%), respectively, P < .001. There were no significant differences between both groups regarding failure of embolization 6/49 (12.2%) vs 12/48 (25.0%), respectively, P = .112, and need of unplanned rescue surgical evacuation 5/49 (10.2%) vs 8/48 (16.7%), respectively, P = .354. Hematoma thickness at late follow-up was significantly smaller in the PVA group 7.8 mm vs 4.6 mm, respectively; P = .017. CONCLUSION Both onyx and PVA as embolic agents for cSDH can be used safely and have comparable clinical and surgical outcomes.
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Affiliation(s)
- Mohamed Shehabeldin
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Abdelaziz Amllay
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Roland Jabre
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, University of Texas Health Science Center, Houston, Texas, USA
| | - Victoria Schunemann
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA.,Department of Neurosurgery, Abington Memorial Hospital, Abington, Pennsylvania, USA
| | - Nabeel A Herial
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Larami Mackenzie
- Neurovascular Division, Abington Memorial Hospital, Jefferson Health, Abington, Pennsylvania, USA
| | - Hana Choe
- Neurovascular Division, Abington Memorial Hospital, Jefferson Health, Abington, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Osman Kozak
- Neurovascular Division, Abington Memorial Hospital, Jefferson Health, Abington, Pennsylvania, USA
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35
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Salih M, Shutran M, Young M, Vega RA, Stippler M, Papavassiliou E, Alterman RL, Thomas A, Taussky P, Moore J, Ogilvy CS. Reduced recurrence of chronic subdural hematomas treated with open surgery followed by middle meningeal artery embolization compared to open surgery alone: a propensity score-matched analysis. J Neurosurg 2022:1-7. [PMID: 36681950 DOI: 10.3171/2022.11.jns222024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/09/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Middle meningeal artery embolization (MMAE) is an emerging endovascular treatment technique with proven promising results for chronic subdural hematomas (cSDHs). MMAE as an adjunct to open surgery is being utilized with the goal of preventing the recurrence of cSDH. However, the efficacy of MMAE following surgical evacuation of cSDH has not been clearly demonstrated. The authors sought to compare the outcomes of open surgery followed by MMAE versus open surgery alone. METHODS Patients who underwent surgical evacuation alone (open surgery-alone group) or MMAE along with open surgery for cSDH (adjunctive MMAE group) were identified at the authors' institution. Two balanced groups were obtained through propensity score matching. Primary outcomes included recurrence risk and reintervention rate. Secondary outcomes included decrease in hematoma size and modified Rankin Scale (mRS) score at last follow-up. Variables in the two groups were compared by use of the Mann-Whitney U-test, paired-sample t-test, and Fisher's exact test. RESULTS A total of 345 cases of open surgery alone and 52 cases of open surgery with adjunctive MMAE were identified. After control for subjective confounders, 146 patients treated with open surgery alone and 41 with adjunctive MMAE following open surgery with drain placement were included in the analysis. Before matching, the rebleeding risk and reintervention rate for open surgery trended higher in the open surgery alone than the open surgery plus MMAE group (14.4% vs 7.3%, p = 0.18; and 11.6% vs 4.9%, p = 0.17, respectively). No significant differences were seen in duration of radiographic or clinical follow-ups or decreases in hematoma size and mRS score at last follow-up. After one-to-one nearest neighbor propensity score matching, 26 pairs of cases were compared for outcomes. Rates of recurrence (7.7% vs 30.8%, p = 0.038) and overall reintervention (3.8% vs 23.1%, p = 0.049) after open surgery were found to be significantly lower in the adjunctive MMAE group than the open surgery-alone group. With one-to-many propensity score matching, 76 versus 37 cases were compared for open surgery alone versus adjunctive MMAE following open surgery. Similarly, the adjunctive MMAE group had significantly lower rates of recurrence (5.4% vs 19.7%, p = 0.037) and overall reintervention (2.7% vs 14.5%, p = 0.049). CONCLUSIONS Adjunctive MMAE following open surgery can lower the recurrence risks and reintervention rates for cSDH.
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Affiliation(s)
- Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Max Shutran
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Michael Young
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Rafael A. Vega
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Martina Stippler
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Efstathios Papavassiliou
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Ron L. Alterman
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Ajith Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Philipp Taussky
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Justin Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Christopher S. Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
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Henry J, Amoo M, Kissner M, Deane T, Zilani G, Crockett MT, Javadpour M. Management of Chronic Subdural Hematoma: A Systematic Review and Component Network Meta-analysis of 455 Studies With 103 645 Cases. Neurosurgery 2022; 91:842-855. [PMID: 36170165 DOI: 10.1227/neu.0000000000002144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 07/14/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a common neurosurgical condition with a high risk of recurrence after treatment. OBJECTIVE To assess and compare the risk of recurrence, morbidity, and mortality across various treatments for CSDH. METHODS A systematic review and meta-analysis was performed. PubMed/MEDLINE, EMBASE, SCOPUS, and Web of Science were searched from January 01, 2000, to July 07, 2021. The primary outcome was recurrence, and secondary outcomes were morbidity and mortality. Component network meta-analyses (CNMAs) were performed for surgical and medical treatments, assessing recurrence and morbidity. Incremental risk ratios (iRRs) with 95% CIs were estimated for each component. RESULTS In total, 12 526 citations were identified, and 455 studies with 103 645 cases were included. Recurrence occurred in 11 491/93 525 (10.8%, 95% CI 10.2-11.5, 418 studies) cases after surgery. The use of a postoperative drain (iRR 0.53, 95% CI 0.44-0.63) and middle meningeal artery embolization (iRR 0.19, 95% CI 0.05-0.83) reduced recurrence in the surgical CNMA. In the pharmacological CNMA, corticosteroids (iRR 0.47, 95% CI 0.36-0.61) and surgical intervention (iRR 0.11, 95% CI 0.07-0.15) were associated with lower risk. Corticosteroids were associated with increased morbidity (iRR 1.34, 95% CI 1.05-1.70). The risk of morbidity was equivalent across surgical treatments. CONCLUSION Recurrence after evacuation occurs in approximately 10% of cSDHs, and the various surgical interventions are approximately equivalent. Corticosteroids are associated with reduced recurrence but also increased morbidity. Drains reduce the risk of recurrence, but the position of drain (subdural vs subgaleal) did not influence recurrence. Middle meningeal artery embolization is a promising treatment warranting further evaluation in randomized trials.
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Affiliation(s)
- Jack Henry
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - Michael Amoo
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.,Department of Neurosurgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Malia Kissner
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Thomas Deane
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Gulam Zilani
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Matthew T Crockett
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.,Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.,Department of Neurosurgery, Royal College of Surgeons in Ireland, Dublin, Ireland.,Department of Academic Neurology, Trinity College Dublin, Dublin, Ireland
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Abstract
In this paper, I review the historical changes in the etiological concepts and surgical treatments for chronic subdural hematoma (CSDH) across the world and in Japan. I also examine future problems associated with its surgical procedures and medical costs. CSDH was first reported by Wepfer in 1657 as "delayed apoplexy." In 1857, Virchow described the famous concept of so-called "pachymeningitis hemorrhagica interna." He considered that the etiology of CSDH involved inflammation. In 1914, Trotter described the origin of CSDH as traumatic. Currently, CSDH is considered to arise with a first leak of blood from dural border cells after mild trauma. Inflammatory cells are then drawn to the border cell layer. At this point, new membranes form from activated inflammation; then, the hematoma enlarges, promoted by angiogenic factors and new capillaries. In 1883, Hulke reported successful trepanning of a patient with CSDH. Burr holes and craniotomy for removal of the hematoma were subsequently reported, and new methods were developed over the course of several decades around the world. In Japan, after the first report by Nakada in 1938, many Japanese pioneering figures of neurological surgery have studied CSDH. After Mandai reported the middle meningeal artery embolization in 2000, this method is now considered useful as an initial or second treatment for CSDH. However, the age of patients is increasing, so more minimally invasive surgeries and useful pharmacotherapies are needed. We must also consider the costs for treating CSDH, because of the increasing numbers of surgical cases.
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Affiliation(s)
- Masaaki UNO
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
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38
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Solou M, Ydreos I, Gavra M, Papadopoulos EK, Banos S, Boviatsis EJ, Savvanis G, Stavrinou LC. Controversies in the Surgical Treatment of Chronic Subdural Hematoma: A Systematic Scoping Review. Diagnostics (Basel) 2022; 12:2060. [PMID: 36140462 PMCID: PMC9498240 DOI: 10.3390/diagnostics12092060] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/15/2022] [Accepted: 08/22/2022] [Indexed: 11/23/2022] Open
Abstract
Chronic subdural hematoma (cSDH) is one of the most common neurosurgical entities, especially in the elderly population. Diagnosis is usually established via a head computed tomography, while an increasing number of studies are investigating biomarkers to predict the natural history of cSDH, including progression and recurrence. Surgical evacuation remains the mainstay of treatment in the overwhelming majority of cases. Nevertheless, many controversies are associated with the nuances of surgical treatment. We performed a systematic review of the literature between 2010 and 2022, aiming to identify and address the issues in cSDH surgical management where consensus is lacking. The results show ambiguous data in regard to indication, the timing and type of surgery, the duration of drainage, concomitant membranectomy and the need for embolization of the middle meningeal artery. Other aspects of surgical treatment-such as the use of drainage and its location and number of burr holes-seem to have been adequately clarified: the drainage of hematoma is strongly recommended and the outcome is considered as independent of drainage location or the number of burr holes.
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Affiliation(s)
- Mary Solou
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
| | - Ioannis Ydreos
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
| | - Maria Gavra
- Department of CT and MRI Imaging, “Agia Sofia” Hospital, 11527 Athens, Greece
| | - Evangelos K. Papadopoulos
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
| | - Stamatis Banos
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
| | - Efstathios J. Boviatsis
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
| | - Georgios Savvanis
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
| | - Lampis C. Stavrinou
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
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Kocharian G, Zappi KB, Carnevale J, Schwarz J, Knopman J. Recent Advances and Future Directions in Middle Meningeal Artery Embolization for Chronic Subdural Hematomas. Curr Pain Headache Rep 2022; 26:657-665. [PMID: 35802284 DOI: 10.1007/s11916-022-01068-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to present a brief background on chronic subdural hematomas (cSDH), middle meningeal artery (MMA) embolization, and its role in decreasing recurrence of cSDH. A review of the most up-to-date literature should demonstrate the efficacy of this procedure. RECENT FINDINGS The latest data shows that MMA embolization is a safe procedure, with low complication rates and low recurrence rates. While cSDH managed with surgical evacuation can have a recurrence rate upwards of 30%, MMA embolization alone or as an adjunct to surgery decreases recurrence to less than 5% in most studies. MMA embolization can be especially useful in high-risk populations such as the elderly, patients on anti-platelet medication, and those with coagulopathies. It can also be done awake, done without general anesthesia, and is significantly less invasive than traditional surgical techniques. In reviewing the literature on MMA embolization, it is clear that there are numerous retrospective studies and systematic reviews demonstrating its safety and efficacy, and some prospective dual-arm studies that present novel information. The numerous clinical trials that are currently underway should help to further establish MMA embolization as standard of care in the management of cSDH.
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Affiliation(s)
- Gary Kocharian
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 E 68thSt., M-220, Box 99, New York, NY, 10065, USA.
| | - Kyle B Zappi
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 E 68thSt., M-220, Box 99, New York, NY, 10065, USA
| | - Joseph Carnevale
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 E 68thSt., M-220, Box 99, New York, NY, 10065, USA
| | - Justin Schwarz
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 E 68thSt., M-220, Box 99, New York, NY, 10065, USA
| | - Jared Knopman
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 E 68thSt., M-220, Box 99, New York, NY, 10065, USA
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Di Cristofori A, Remida P, Patassini M, Piergallini L, Buonanno R, Bruno R, Carrabba G, Pavesi G, Iaccarino C, Giussani CG. Middle meningeal artery embolization for chronic subdural hematomas. A systematic review of the literature focused on indications, technical aspects, and future possible perspectives. Surg Neurol Int 2022; 13:94. [PMID: 35399896 PMCID: PMC8986643 DOI: 10.25259/sni_911_2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 02/14/2022] [Indexed: 12/20/2022] Open
Abstract
Background: Chronic subdural hematoma (CSDH) is one of the most common neurosurgical diseases that affect elderly and fragile patients and as a consequence, management can be challenging. Surgery represents the standard treatment; however, alternative options are under investigation. Middle meningeal artery (MMA) embolization is considered a minimally invasive treatment although with poor evidence. In this review, we tried to summarize the findings about MMA embolization as a treatment for a CSDH to provide a useful guidance for clinical practice and for future speculative aspects. Methods: Literature review on PubMed until March 2021 was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. We conducted a research on PubMed with a various combinations of the keywords “CSDH” and “middle meningeal artery” and “embolization,” “refractory subdural hematoma,” and then we reviewed the references of the relevant studies as additional source of eligible articles. Results: Among the 35 studies eligible for this review, 22 were case series, 11 were case reports, one was a technical note, and 1 was a randomized trial. A total of 746 patients were found in the literature. Failure rate of MMA embolization was between 3.9 and 8.9% of the cases according the indication to treat CSDH (upfront vs. after surgery). Conclusion: The global impression deriving from the data available and the literature is that MMA embolization is a safe procedure with very low complications and with a low failure rate, both when associated with surgery or in case of a standalone treatment.
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Affiliation(s)
- Andrea Di Cristofori
- Unit of Neurosurgery, Azienda Socio SanitariaTerritoriale - Monza, Ospedale San Gerardo,
| | - Paolo Remida
- Unit of Neuroradiology, Azienda Socio Sanitaria Territoriale - Monza, Ospedale San Gerardo, Monza,
| | - Mirko Patassini
- Unit of Neuroradiology, Azienda Socio Sanitaria Territoriale - Monza, Ospedale San Gerardo, Monza,
| | - Lorenzo Piergallini
- Unit of Neuroradiology, Azienda Socio Sanitaria Territoriale - Monza, Ospedale San Gerardo, Monza,
| | - Raffaella Buonanno
- Unit of Neurosurgery, Azienda Socio SanitariaTerritoriale - Monza, Ospedale San Gerardo,
- Unit of Neurosurgery, School of Medicine and Surgery, Department of Medicine and Surgery, Università degli Studi Milano Bicocca, Milan,
| | - Raffaele Bruno
- Unit of Neurosurgery, Azienda Socio SanitariaTerritoriale - Monza, Ospedale San Gerardo,
- Unit of Neurosurgery, School of Medicine and Surgery, Department of Medicine and Surgery, Università degli Studi Milano Bicocca, Milan,
| | - Giorgio Carrabba
- Unit of Neurosurgery, Azienda Socio SanitariaTerritoriale - Monza, Ospedale San Gerardo,
- Unit of Neurosurgery, School of Medicine and Surgery, Department of Medicine and Surgery, Università degli Studi Milano Bicocca, Milan,
| | - Giacomo Pavesi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia,
- Neurosurgery Division, University Hospital of Modena, Modena, Italy
| | - Corrado Iaccarino
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia,
- Neurosurgery Division, University Hospital of Modena, Modena, Italy
| | - Carlo Giorgio Giussani
- Unit of Neurosurgery, Azienda Socio SanitariaTerritoriale - Monza, Ospedale San Gerardo,
- Unit of Neurosurgery, School of Medicine and Surgery, Department of Medicine and Surgery, Università degli Studi Milano Bicocca, Milan,
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Martinez-Perez R, Rayo N, Tsimpas A. Endovascular therapy for the management of chronic subdural hematomas after failure of surgical drainage. Neurologia 2022; 37:157-158. [PMID: 33849735 DOI: 10.1016/j.nrl.2021.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 03/01/2021] [Indexed: 11/21/2022] Open
Affiliation(s)
- R Martinez-Perez
- Department of Neurosurgery, Anschutz Medical Campus, University of Colorado, Aurora, CO, Estados Unidos.
| | - N Rayo
- Department of Biology, Western University, London, ON, Canadá
| | - A Tsimpas
- Department of Neurosurgery, Advocate Illinois Masonic Center, Chicago, IL, Estados Unidos
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Adusumilli G, Ghozy S, Kallmes KM, Hardy N, Tarchand R, Zinn C, Lamar D, Singeltary E, Siegel L, Kallmes DF, Arthur AS, Gellissen S, Fiehler J, Heit JJ. Common data elements reported on middle meningeal artery embolization in chronic subdural hematoma: an interactive systematic review of recent trials. J Neurointerv Surg 2022; 14:1027-1032. [PMID: 35135849 DOI: 10.1136/neurintsurg-2021-018430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/15/2022] [Indexed: 11/04/2022]
Abstract
Cross study heterogeneity has limited the evidence based evaluation of middle meningeal artery embolization (MMAE) as a treatment for chronic subdural hematoma (CSDH). Ongoing trials and prospective studies suggest that heterogeneity in upcoming publications may detract from subsequent meta-analyses and systemic reviews. This study aims to describe this data heterogeneity to promote harmonization with common data elements (CDEs) in publications. ClinicalTrials.gov and PubMed were searched for published or ongoing prospective trials of MMAE. The Nested Knowledge AutoLit living review platform was utilized to classify endpoints from randomized control trials (RCTs) and prospective cohort studies comparing MMAE with other treatments. The qualitative synthesis feature was used to determine cross study overlap of outcome related data elements. Eighteen studies were included: 12 RCTs, two non-randomized controlled studies, two prospective single arm trials, one combined prospective and retrospective controlled study, and one prospective cohort study. The most commonly reported data element was recurrence (15/18), but seven heterogenous (non-comparable) definitions were used for 'recurrence'. Mortality was reported in 10/18 studies, but no common timepoint was reported in more than four studies. Re-intervention and CSDH volume were reported in eight studies, CSDH width in seven, and no other outcome was common across more than five studies. There was significant heterogeneity in data element collection even among prospective registered trials of MMAE. Even among CDEs, variation in definition and timepoints prevented harmonization. A standardized approach based on CDEs may be necessary to facilitate future meta-analyses and evidence driven evaluation of MMAE treatment of CSDH.
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Affiliation(s)
- Gautam Adusumilli
- Department of Radiology and Neurosurgery, Stanford University, Stanford, California, USA
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | | | - Nicole Hardy
- Nested Knowledge Inc, Saint Paul, Minnesota, USA
| | | | - Caleb Zinn
- Nested Knowledge Inc, Saint Paul, Minnesota, USA
| | - Duncan Lamar
- Nested Knowledge Inc, Saint Paul, Minnesota, USA
| | | | | | | | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.,Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Susanne Gellissen
- Department of Diagnostic and Interventional Neuroradiology, Universitatsklinikum Hamburg Eppendorf Klinik und Poliklinik fur Neuroradiologische Diagnostik und Intervention, Hamburg, Germany
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Radiology, Neuroadiology and Neurointervention Division, Stanford University, Stanford, California, USA
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Martinez-Perez R, Rayo N, Tsimpas A. Endovascular therapy for the management of chronic subdural hematomas after failure of surgical drainage. NEUROLOGÍA (ENGLISH EDITION) 2022; 37:157-158. [PMID: 34969634 DOI: 10.1016/j.nrleng.2021.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 03/01/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- R Martinez-Perez
- Department of Neurosurgery, Anschutz Medical Campus, University of Colorado, Aurora, CO, United States.
| | - N Rayo
- Department of Biology, Western University, London, ON, Canada
| | - A Tsimpas
- Department of Neurosurgery, Advocate Illinois Masonic Center, Chicago, IL, United States
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Zhu F, Wang H, Li W, Han S, Yuan J, Zhang C, Li Z, Fan G, Liu X, Nie M, Bie L. Factors correlated with the postoperative recurrence of chronic subdural hematoma: An umbrella study of systematic reviews and meta-analyses. EClinicalMedicine 2022; 43:101234. [PMID: 34988412 PMCID: PMC8703229 DOI: 10.1016/j.eclinm.2021.101234] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/08/2021] [Accepted: 11/24/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a common neurological disease, and the surgical evacuation of subdural collection remains the primary treatment approach for symptomatic patients. Postoperative recurrence is a serious complication, and several factors are correlated with postoperative recurrence. METHODS We searched Embase, Web of Science, PubMed, and Cochrane Library from their establishment to September 2020. Reports on randomized, prospective, retrospective, and overall observational studies on the management of surgical patients with CSDH were searched, and an independent reviewer performed research quality assessment. Factors that affect the postoperative recurrence of CSDH were extracted: social demographics, drugs (as the main or auxiliary treatment), surgical management, imaging, and other risk factors. We evaluated the recurrence rate of each risk factor. A random effect model was used to perform a meta-analysis, and each risk factor affecting the postoperative recurrence of CSDH was then evaluated and graded. FINDINGS In total, 402 studies were included in this analysis and 32 potential risk factors were evaluated. Among these, 21 were significantly associated with the postoperative recurrence of CSDH. Three risk factors (male, bilateral hematoma, and no drainage) had convincing evidence. The classification of evidence can help clinicians identify significant risk factors for the postoperative recurrence of CSDH. INTERPRETATION Only few associations were supported by high-quality evidence. Factors with high-quality evidence may be important for treating and preventing CSDH recurrence. Our results can be used as a basis for improving clinical treatment strategies and designing preventive methods. FUNDING No funding was received.
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Affiliation(s)
- Fulei Zhu
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Haifeng Wang
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Wenchen Li
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Shuai Han
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Jiangyuan Yuan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Chunyun Zhang
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Zean Li
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Guangyan Fan
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Xuanhui Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Meng Nie
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Li Bie
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
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Barros G, Bonow RH, Levitt MR. Middle Meningeal Artery Embolization as an Adjuvant Treatment for Bilateral Chronic Subdural Hematomas From Spontaneous Intracranial Hypotension: A Case Report. Cureus 2021; 13:e20609. [PMID: 35103185 PMCID: PMC8782641 DOI: 10.7759/cureus.20609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2021] [Indexed: 12/01/2022] Open
Abstract
Middle meningeal artery embolization (MMAE) is an effective initial or adjuvant treatment for chronic subdural hematomas. However, its efficacy in the setting of spontaneous intracranial hypotension has not yet been reported. We present a case of progressive bilateral chronic subdural hematomas secondary to spontaneous intracranial hypotension that failed the initial lumbar epidural blood patch. The patient underwent surgical hematoma evacuation, with adjuvant MMAE and additional epidural blood patch, with good clinical and radiographic results. This case demonstrates the potential value of MMAE for chronic subdural hematomas secondary to spontaneous intracranial hypotension.
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46
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Zhao Y, Xiao Q, Tang W, Wang R, Luo M. Efficacy and Safety of Glucocorticoids Versus Placebo as an Adjuvant Treatment to Surgery in Chronic Subdural Hematoma: A Systematic Review and Meta-Analysis of Randomized Controlled Clinical Trials. World Neurosurg 2021; 159:198-206.e4. [PMID: 34896349 DOI: 10.1016/j.wneu.2021.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 12/03/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a common neurosurgical disease with a high recurrence rate, especially among the elderly. Glucocorticoids have been tested for the treatment of CSDH in observational studies and randomized clinical trials. METHODS We systematically searched the PubMed, Embase, and Cochrane Central Register of Controlled Trials database for randomized trials from the earliest date available to May 23, 2021 that had compared glucocorticoids and placebo as a postoperative treatment of CSDH. Trials were included if the study participants were aged ≥18 years and had had CSDH after surgery. The relative risk (RR) was used to evaluate the clinical outcomes. RESULTS We included 5 eligible randomized controlled trials with a total of 1251 patients. The findings showed that the use of adjuvant glucocorticoid therapy can effectively reduce the recurrence risk of CSDH compared with placebo (RR, 0.40; 95% confidence interval [CI], 0.28-0.58; P < 0.001). No significant differences were found between the glucocorticoid and placebo groups regarding favorable neurological outcomes (RR, 1; 95% CI, 0.93-1.08; P = 0.92). We found that the use of adjuvant glucocorticoids resulted in a significant increase in psychiatric symptoms (RR, 3.22; 95% CI, 1.83-5.64; P < 0.001). No significant differences were found for infection between the 2 groups (RR, 1.86; 95% CI, 0.56-6.14; P = 0.31). CONCLUSIONS Glucocorticoid therapy can effectively reduce the recurrence risk of CSDH after surgery without an increase in the postoperative infection rate. However, significantly increased psychiatric symptoms were reported in the glucocorticoid group.
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Affiliation(s)
- Yangyang Zhao
- The First Clinical Medical College, Gannan Medical University, Ganzhou, China
| | - Qiuxiang Xiao
- Department of Pathology, The First Affiliated Hospital, Gannan Medical University, Ganzhou, China
| | - Wenxiang Tang
- The First Clinical Medical College, Gannan Medical University, Ganzhou, China
| | - Renyong Wang
- The First Clinical Medical College, Gannan Medical University, Ganzhou, China
| | - Muyun Luo
- Department of Neurosurgery, The First Affiliated Hospital, Gannan Medical University, Ganzhou, China.
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Ironside N, Chen CJ, Raper D, Ding D. Endovascular Treatment of Chronic Subdural Hematoma with Middle Meningeal Artery Embolization. World Neurosurg 2021; 155:193-195. [PMID: 34724734 DOI: 10.1016/j.wneu.2021.08.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Natasha Ironside
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Daniel Raper
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Dale Ding
- Department of Neurosurgery, University of Louisville Health System, Louisville, Kentucky, USA
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Endovascular Treatment of Chronic Subdural Hematomas through Embolization: A Pilot Study with a Non-Adhesive Liquid Embolic Agent of Minimal Viscosity (Squid). J Clin Med 2021; 10:jcm10194436. [PMID: 34640453 PMCID: PMC8509410 DOI: 10.3390/jcm10194436] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/17/2021] [Accepted: 09/18/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Endovascular embolization using non-adhesive agents (e.g., ethylene vinyl alcohol copolymer with suspended micronized tantalum dissolved in dimethyl sulfoxide; Squid, Balt Extrusion) is an established treatment of brain arteriovenous malformations, dural arteriovenous fistulas, and hypervascular neoplasms. Middle meningeal artery (MMA) embolization is a relatively new concept for treating chronic subdural hematomas (CSDH). This study aimed to evaluate the safety and effectiveness of the use of Squid in the endovascular treatment of CSDH. METHODS Embolization was offered to patients with CSDH with minimal or moderate neurological deficits and patients who had previously undergone open surgery to evacuate their CSDH without a significant effect. Distal catheterization of the MMA was followed by embolization of the hematoma capsule with Squid 12 or Squid 18. Safety endpoints were ischemic or hemorrhagic stroke and any other adverse event of the endovascular procedure. Efficacy endpoints were the feasibility of the intended procedure and a ≥ 50% reduction of the maximum depth of the CSDH confirmed by follow-up computed tomography (CT) after >3 months. RESULTS Between November 2019 and July 2021, 10 patients (3 female and 7 male, age range 42-89 years) were enrolled. Five patients had bilateral hematomas, and five patients had previously been operated on with no significant effect and recurrent hematoma formation. The attempted embolization was technically possible in all patients. No technical or clinical complication was encountered. During a post-procedural follow-up (median 90 days), 10 patients improved clinically. A complete resolution of the CSDH was observed in 10 patients. The clinical condition of all enrolled patients during the so-far last contact was rated mRS 0 or 1. CONCLUSION A distal catheterization of the MMA for the endovascular embolization of CSDH with Squid allowed for the devascularization of the MMA and the dependent vessels of the hematoma capsule. This procedure resulted in a partial or complete resolution of the CSDH. Procedural complications were not encountered.
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Dian J, Linton J, Shankar JJS. Risk of recurrence of subdural hematoma after EMMA vs surgical drainage - Systematic review and meta-analysis. Interv Neuroradiol 2021; 27:577-583. [PMID: 33525919 PMCID: PMC8392769 DOI: 10.1177/1591019921990962] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/22/2020] [Accepted: 12/01/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Chronic subdural hematoma (CSDH) is a common and debilitating neurological condition whose treatments, including burr hole drainage and craniotomy, suffer from high rates of recurrence and complication. Embolization of the middle meningeal artery (EMMA) is a promising minimally invasive approach to manage CSDH in a broad set of patients. METHODS To evaluate the efficacy and safety of EMMA, a database search was conducted including the terms "subdural hematoma; embolization; embolized; middle meningeal" was performed and yielded a total of 260 results. Following exclusion based on predefined criteria, a total of four studies were identified and outcomes including recurrence rates and complication rates were extracted for analysis. RESULTS Four studies including intervention and control groups were included with a total of n = 888 patients. The relative risk of CSDH recurrence in the EMMA (3.5%) compared to control group (23.5%) was significantly reduced when EMMA was performed (risk ratio = 0.17; 95% confidence interval (CI) 0.05-0.67). In addition, rates of complication were not significantly different between patients with conventional therapy and those who received EMMA (OR = 0.77; 95 confidence interval (CI) 0.3-1.99). CONCLUSION Based on limited data, EMMA reduces the risk of recurrence by 20% compared to surgical treatment for CSDH.
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Affiliation(s)
- Joshua Dian
- Department of Neurosurgery, University of Manitoba, Manitoba, Canada
| | - Janice Linton
- Indigenous Health Librarian & Liaison Librarian for Community Health Sciences Neil John Maclean Health Sciences Library, University of Manitoba, Manitoba, Canada
| | - Jai JS Shankar
- Department of Radiology, University of Manitoba, Manitoba, Canada
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Amoo M, O'Cearbhaill RM, McHugh P, Henry J, O'Byrne K, Ben Husien M, Javadpour M. Derivation of a Clinical Score for Prediction of Recurrence Following Evacuation of Chronic Subdural Hematoma: A Retrospective Cohort Study at a National Referral Centre. World Neurosurg 2021; 154:e743-e753. [PMID: 34343685 DOI: 10.1016/j.wneu.2021.07.126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Chronic subdural hematoma (cSDH) is a common pathology, and recurrence is a common complication, which may be predicted by certain patient and radiologic factors. Empiric radiologic surveillance has been shown to convey no benefit. METHODS A retrospective review of a prospectively collated database was performed. Preoperative and postoperative noncontrast computed tomography scans were reviewed. Radiologic appearance, preoperative hematoma volume, patient age, presence of bilateral hematomas, maximal hematoma thickness, and therapeutic coagulopathy were assessed as predictors. Receiver operating characteristic curve analysis, logistic regression, and LASSO regression were used to select potential predictors. A multivariate model was then fitted, and a score was derived. RESULTS A total of 142 patients were included. Maximal hematoma thickness >12 mm (P = 0.02) and age >65 years (P = 0.01) were found to correlate with the likelihood of recurrence. Bilateral hematomas and a hyperdense or mixed density appearance were also identified on LASSO regression. Bilateral hematomas (P = 0.19), hyperdense or mixed density (P = 0.66), maximum thickness >12 mm (P = 0.01), and age >65 years (P = 0.02) were included in the multivariate model. A 6-point score was derived. A score of >3 had a sensitivity of 89% (95% confidence interval [CI] 78%-97%) and specificity of 26% (95% CI, 17%-34%) for predicting recurrence, with recurrence significantly more likely in patients with a score of 4-6 versus those with a score of 0-3 (P = 0.02). CONCLUSIONS Certain radiologic findings may predict the recurrence of cSDH following evacuation. The score derived may be useful in identifying patients who might benefit from routine postoperative surveillance imaging.
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Affiliation(s)
- Michael Amoo
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Roisin M O'Cearbhaill
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Paul McHugh
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Jack Henry
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland
| | - Kevin O'Byrne
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Mohammed Ben Husien
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Academic Neurology, Trinity College, Dublin, Ireland
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