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Ma L, Hoz SS, Doheim MF, Fadhil A, Sultany A, Al-Bayati AR, Nogueira RG, Lang MJ, Gross BA. Impact of Embolisate Penetration, Type, and Technique on Results After Standalone Middle Meningeal Artery Embolization for Chronic Subdural Hematoma. Neurosurgery 2024:00006123-990000000-01208. [PMID: 38860780 DOI: 10.1227/neu.0000000000003023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 04/05/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Middle meningeal artery embolization (MMAE) has emerged as a promising modality for chronic/subacute subdural hematoma treatment; however, consensus regarding embolization technique and embolisate has not been achieved. We thus sought to compare the efficacy of distinct MMAE techniques and embolisate. METHODS An institutional registry was reviewed to identify patients undergoing standalone MMAE for symptomatic chronic/subacute subdural hematoma. Surgical rescue rate and time preceding 50% hematoma resolution were evaluated across 3 technical groups: aggressive penetration (AP), nonaggressive penetration with proximal coil embolization (NP-PC), and nonaggressive penetration alone (NP). Effect sizes were adjusted for demographic, neurological and radiological features through multivariable logistic and Cox regression. RESULTS Among 117 procedures, 33.3% achieved AP, 36.8% had NP-PC, and 29.9% had NP. The rate of surgical rescue was 2.6% after AP, 9.3% for NP-PC, and 11.4% for NP. In patients not undergoing rescue surgery, 82.4% achieved hematoma resolution ≥50% at a median imaging follow-up of 56 days; AP or NP-PC were each statistically significantly associated with enhanced hematoma resolution as compared with NP (P = .02). Similarly, sensitivity analysis within medium-size hematoma and antiplatelet/anticoagulation-at-admission subgroups revealed a superiority of resolution after AP or NP-PC. A unique, comparative secondary analysis of liquid embolisate (Onyx vs n-butyl cyanoacrylate) revealed no impact on rate of surgical rescue or hematoma resolution. CONCLUSION AP was associated with the lowest rate of surgical rescue, while both AP and NP-PC were associated with improved rates of hematoma resolution.
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Affiliation(s)
- Li Ma
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Samer S Hoz
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mohamed F Doheim
- Department of Neurology, University of Pittsburgh Medical Center Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ali Fadhil
- Department of Neurology, University of Pittsburgh Medical Center Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Abdullah Sultany
- Department of Neurology, University of Pittsburgh Medical Center Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alhamza R Al-Bayati
- Department of Neurology, University of Pittsburgh Medical Center Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Raul G Nogueira
- Department of Neurology, University of Pittsburgh Medical Center Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael J Lang
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Bradley A Gross
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Charehsaz A, Vayisoglu T, Uyaniker ZA, Cekic E, Ozturk E, Isikay AI, Hanalioglu S. Relative Cortical Atrophy Index as a Strong Predictor of Recurrence After Surgery for Chronic Subdural Hematoma. Neurosurgery 2024:00006123-990000000-01183. [PMID: 38819170 DOI: 10.1227/neu.0000000000003013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 04/03/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Chronic subdural hematoma (CSDH) presents significant management challenges in neurosurgical practice, with recurrence being a notable postoperative consideration. This study aimed to evaluate the Relative Cortical Atrophy (RCA) Index as a predictor of recurrence after CSDH surgery. METHODS A retrospective analysis was conducted on 98 patients who underwent surgical evacuation for unilateral CSDH. The RCA Index was calculated using pre- and postoperative cranial imaging, correlating it with patient demographics, hematoma characteristics, and recurrence. Inter-rater reliability among measurements by 4 independent physicians was assessed using the intraclass correlation coefficient (ICC). Correlation and regression analyses were performed to identify the correlation of the RCA Index with other factors and their potential predicting power of CSDH recurrence, respectively. RESULTS The study population had a mean age of 74.1 (11.9) years, with a 23.5% (23 patients) recurrence rate of CSDH. The ICC analysis showed excellent inter-rater reliability for RCA Index measurements (ICC: 0.998, 95% CI: 0.997-0.998, P < .001). A higher preoperative RCA Index was significantly associated with recurrence (0.215 [0.031] in the recurrent group vs 0.125 [0.034] in the nonrecurrent group, P < .001). The preoperative RCA Index highly correlated with the postoperative RCA Index (Pearson's correlation: 0.918, P < .001), and there was only a small (average: 0.005) but significant increase in the RCA Index of the unaffected hemisphere after surgery (P = .01).The preoperative RCA Index positively correlated with age, preoperative SDH thickness and volume, and recurrence. A RCA Index cutoff value of 0.165 predicted CSDH recurrence with high sensitivity (95.6%) and specificity (93.3%) (area under the curve = 0.97, 95% CI: 0.93-1). CONCLUSION The RCA Index is a simple yet robust predictor of CSDH recurrence. Incorporating this measure into the preoperative assessment may enhance surgical planning and postoperative management, potentially reducing recurrence rates.
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Affiliation(s)
- Amin Charehsaz
- Department of Neurosurgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Tugberk Vayisoglu
- Department of Neurosurgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Zeynep Arzum Uyaniker
- Department of Neurosurgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Efecan Cekic
- Department of Neurosurgery, Polatli Duatepe State Hospital, Ankara, Turkey
| | - Ebru Ozturk
- Department of Biostatistics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ahmet Ilkay Isikay
- Department of Neurosurgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Sahin Hanalioglu
- Department of Neurosurgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
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3
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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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4
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Geraghty JR, Testai FD. Advances in neurovascular research: Scientific highlights from the 2024 international stroke conference. J Stroke Cerebrovasc Dis 2024; 33:107671. [PMID: 38447784 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Indexed: 03/08/2024] Open
Affiliation(s)
- Joseph R Geraghty
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Fernando D Testai
- Department of Neurology & Rehabilitation, University of Illinois College of Medicine, Chicago, IL, USA
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5
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Sioutas GS, Shekhtman O, Dagli MM, Salem MM, Ajmera S, Kandregula S, Burkhardt JK, Srinivasan VM, Jankowitz BT. Middle meningeal artery patency after surgical evacuation for chronic subdural hematoma. Neurosurg Rev 2024; 47:145. [PMID: 38594307 DOI: 10.1007/s10143-024-02383-3] [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: 12/11/2023] [Revised: 03/27/2024] [Accepted: 03/30/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) often requires surgical evacuation, but recurrence rates remain high. Middle meningeal artery (MMA) embolization (MMAE) has been proposed as an alternative or adjunct treatment. There is concern that prior surgery might limit patency, access, penetration, and efficacy of MMAE, such that some recent trials excluded patients with prior craniotomy. However, the impact of prior open surgery on MMA patency has not been studied. METHODS A retrospective analysis was conducted on patients who underwent MMAE for cSDH (2019-2022), after prior surgical evacuation or not. MMA patency was assessed using a six-point grading scale. RESULTS Of the 109 MMAEs (84 patients, median age 72 years, 20.2% females), 58.7% were upfront MMAEs, while 41.3% were after prior surgery (20 craniotomies, 25 burr holes). Median hematoma thickness was 14 mm and midline shift 3 mm. Hematoma thickness reduction, surgical rescue, and functional outcome did not differ between MMAE subgroups and were not affected by MMA patency or total area of craniotomy or burr-holes. MMA patency was reduced in the craniotomy group only, specifically in the distal portion of the anterior division (p = 0.005), and correlated with craniotomy area (p < 0.001). CONCLUSION MMA remains relatively patent after burr-hole evacuation of cSDH, while craniotomy typically only affects the frontal-distal division. However, MMA patency, evacuation method, and total area do not affect outcomes. These findings support the use of MMAE regardless of prior surgery and may influence future trial inclusion/exclusion criteria. Further studies are needed to optimize the timing and techniques for MMAE in cSDH management.
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Affiliation(s)
- Georgios S Sioutas
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Oleg Shekhtman
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mert Marcel Dagli
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mohamed M Salem
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sonia Ajmera
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sandeep Kandregula
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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6
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Chaliparambil RK, Nandoliya KR, Jahromi BS, Potts MB. Charlson Comorbidity Index and Frailty as Predictors of Resolution Following Middle Meningeal Artery Embolization for Chronic Subdural Hematoma. World Neurosurg 2024; 183:e877-e885. [PMID: 38218440 DOI: 10.1016/j.wneu.2024.01.049] [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: 08/26/2023] [Revised: 01/06/2024] [Accepted: 01/08/2024] [Indexed: 01/15/2024]
Abstract
BACKGROUND Research on variables associated with chronic subdural hematoma (cSDH) resolution following middle meningeal artery embolization (MMAE) is limited. This study investigated the clinical utility of age-adjusted Charlson Comorbidity Index (ACCI) and modified 5-item Frailty Index (mFI - 5) for predicting cSDH resolution following MMAE. METHODS We identified patients who underwent MMAE at our institution between January 2018 and December 2022, with at least 20 days of follow-up and one radiographic follow-up study. Patient demographics, characteristics, and outcomes were collected. Complete resolution was defined as absence of subdural collections on CT-scan at last follow-up. Nonage adjusted CCI (CCI), ACCI, and mFI - 5 scores were calculated. Univariate and multivariable logistic regression analyzed the relationship between cSDH resolution and variables. A receiver operating characteristic (ROC) curve established the utility of ACCI and mFI - 5 in predicting hematoma resolution. RESULTS The study included 85 MMAE procedures. In univariate analysis, patients without resolution were older, had higher CCI, higher ACCI, higher mFI - 5, and were more likely to have diabetes mellitus. In multivarible analysis, CCI (OR: 0.66, 95% CI: 0.48, 0.91) was independently associated with resolution controlling for age and antithrombotic resumption. The area under the ROC (AUROC) curve was 0.75 (95% CI: 0.65-0.85) for ACCI and 0.64 (95% CI: 0.52-0.76) for mFI - 5. The optimal cutoffs for predicting resolution were ACCI ≥5 (sensitivity = 0.63, specificity = 0.77), and mFI - 5 > 0 (sensitivity = 0.84, specificity = 0.43). CONCLUSIONS ACCI and mFI - 5 moderately predict MMAE resolution and may aid in medical decision-making.
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Affiliation(s)
- Rahul K Chaliparambil
- Department of Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Khizar R Nandoliya
- Department of Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Babak S Jahromi
- Department of Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Ken and Ruth Davee Department of Neurology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matthew B Potts
- Department of Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Ken and Ruth Davee Department of Neurology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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7
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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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Cirillo L, Verna F, Princiotta C, Dall’Olio M, Rustici A, Bortolotti C, Badaloni F, Mascarella D, Cortelli P, Cevoli S. Spontaneous Intracranial Hypotension and Subdural Hematomas Treatment Management Using MMA Embolization and Target Blood Patch: A Case Report. Life (Basel) 2024; 14:250. [PMID: 38398759 PMCID: PMC10890540 DOI: 10.3390/life14020250] [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: 01/02/2024] [Revised: 02/05/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024] Open
Abstract
We report a patient suffering from spontaneous intracranial hypotension (SIH) who, following a non-selective lumbar blood patch, returned to his healthcare provider with severe symptoms of neurological deficits. It was subsequently discovered that the aforementioned deficits were due to a bilateral subdural hematoma, and an emergency surgical drainage of the hematoma has been performed. However, the hematoma reformed and potential cerebrospinal fluid leakage was consequently investigated through myelography. Following the diagnostic finding of a venous diverticulum, a selective blood patch was executed in the affected area, and in order to stabilize the hematoma, an embolization of the middle meningeal arteries was performed. The combination of such operations allowed for the resorption of the hematoma and the improvement of neurological symptoms.
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Affiliation(s)
- Luigi Cirillo
- UO Neuroradiologia, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (L.C.); (C.P.); (M.D.)
- Dipartimento di Scienze Biomediche e Neuromotorie (DIBINEM), Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy;
| | - Francesca Verna
- Dipartimento di Scienze Biomediche e Neuromotorie (DIBINEM), Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy;
| | - Ciro Princiotta
- UO Neuroradiologia, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (L.C.); (C.P.); (M.D.)
| | - Massimo Dall’Olio
- UO Neuroradiologia, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (L.C.); (C.P.); (M.D.)
| | - Arianna Rustici
- Dipartimento di Scienze Biomediche e Neuromotorie (DIBINEM), Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy;
| | - Carlo Bortolotti
- UO Neurochirurgia, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (C.B.); (F.B.)
| | - Filippo Badaloni
- UO Neurochirurgia, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (C.B.); (F.B.)
| | - Davide Mascarella
- UO Clinica Neurologica Metropolitana (NEURO-MET), IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (D.M.); (P.C.); (S.C.)
| | - Pietro Cortelli
- UO Clinica Neurologica Metropolitana (NEURO-MET), IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (D.M.); (P.C.); (S.C.)
| | - Sabina Cevoli
- UO Clinica Neurologica Metropolitana (NEURO-MET), IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (D.M.); (P.C.); (S.C.)
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9
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Albalkhi I, Alaswad M, Saleh T, Senjab A, Helal B, Khan JA. Adjuvant Tranexamic Acid for Reducing Postoperative Recurrence of Chronic Subdural Hematoma in the Elderly: A Systematic Review and Meta-Analysis. World Neurosurg 2024; 182:e829-e836. [PMID: 38101544 DOI: 10.1016/j.wneu.2023.12.054] [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: 12/03/2023] [Accepted: 12/09/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a frequently encountered neurosurgical disease among the elderly. The mainstay treatment involves surgical evacuation, but recurrence rates of approximately 13% pose complications. Adjuvant treatments, including tranexamic acid (TXA), have been explored, yet consensus on their efficacy and safety in elderly patients remains uncertain. The study aims to examine the role of TXA as adjunctive therapy in reducing CSDH recurrence and explore any potential association between TXA use and thrombotic events in this patient population. METHODS The systematic review and meta-analysis adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and Cochrane Handbook standards, searching databases up to July 2023 for randomized controlled trials and propensity-matched cohorts evaluating adjuvant TXA. The primary outcome was CSDH recurrence, and the secondary outcome was thrombosis risk, measured as relative risks. RESULTS A total of 6 studies were included, comprising 1403 patients with CSDH who underwent surgical treatment. Four studies were randomized controlled trials, while the other 2 were propensity-matched cohorts. The overall pooled relative risk for CSDH recurrence in the TXA group compared to the control group was 0.41 (95% confidence interval [0.29-0.59], P < 0.01), indicating a significant reduction in recurrence with TXA treatment. CONCLUSIONS In conclusion, our study indicates that adjuvant TXA may help reduce CSDH recurrence in elderly patients undergoing surgical treatment. However, the study has limitations and there is a need for further research to validate these findings.
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Affiliation(s)
- Ibrahem Albalkhi
- Department of Neuroscience, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia; Department of Neuroradiology, Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom.
| | - Marwan Alaswad
- Department of Neuroscience, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Tariq Saleh
- Department of Neuroscience, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Abdulrahaman Senjab
- Department of Neuroscience, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Baraa Helal
- Department of Neuroscience, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Jibran Ahmad Khan
- Department of Neuroscience, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
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10
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Rickard F, Gale J, Williams A, Shipway D. New horizons in subdural haematoma. Age Ageing 2023; 52:afad240. [PMID: 38167695 DOI: 10.1093/ageing/afad240] [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: 06/05/2023] [Indexed: 01/05/2024] Open
Abstract
Subdural haematoma (SDH) is a common injury sustained by older people living with frailty and multimorbidity, and typically following falls from a standing height. Anticoagulant and antiplatelet use are commonly indicated in older people with SDH, but few data inform decision-making surrounding these agents in the context of intracranial bleeding. Opposing risks of rebleeding and thrombosis must therefore be weighed judiciously. Decision-making can be complex and requires detailed awareness of the epidemiology to ensure the safest course of action is selected for each patient. Outcomes of surgical decompression in acute SDH are very poor in older people. However, burr hole drainage can be safe and effective in older adults with symptomatic chronic SDH (cSDH). Such patients need careful assessment to ensure symptoms arise from cSDH and not from coexisting medical pathology. Furthermore, the emerging treatment of middle meningeal artery embolisation offers a well-tolerated, minimally invasive intervention which may reduce the risks of rebleeding in older adults. Nonetheless, UK SDH management is heterogenous, and no accepted UK or European guidelines exist at present. Further randomised trial evidence is required to move away from clinical practice based on historic observational data.
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Affiliation(s)
- Frances Rickard
- Consultant Geriatrician, Geriatric Major Trauma, North Bristol NHS Trust, Bristol, UK
| | - John Gale
- Clinical Fellow in Geriatric Major Trauma, North Bristol NHS Trust, Bristol, UK
| | - Adam Williams
- Consultant Neurosurgeon, Department of Neurosurgery, North Bristol NHS Trust, Bristol, UK
| | - David Shipway
- Consultant Geriatrician, Geriatric Major Trauma, North Bristol NHS Trust, Bristol, UK
- Honorary Senior Clinical Lecturer, University of Bristol, Bristol, UK
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11
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John K, Syed S, Kaestner T, Dashti R, Fiorella D, Sadasivan C. Liquid embolic surface area as a predictor of chronic subdural hematoma resolution in middle meningeal artery embolization. J Neurointerv Surg 2023:jnis-2023-021118. [PMID: 38050160 DOI: 10.1136/jnis-2023-021118] [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: 10/23/2023] [Accepted: 11/17/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Liquid embolic agents (LEAs) such as ethylene vinyl alcohol (EVOH) are utilized for middle meningeal artery embolization (MMAE) for chronic subdural hematomas (cSDH). LEAs may be advantageous for MMAE as they are permanent and can penetrate the microvasculature of the subdural membranes. LEA surface area (SA) can quantify this penetration. The segmentation of LEA SA is not described in the literature and may be of interest in refining MMAE technique. METHODS We retrospectively collected computerized tomography (CT) scans from 74 patients (with 95 cSDH) who underwent first-line MMAE with EVOH. Non-contrast head CTs were acquired pre-embolization, immediately post-embolization and at 1-, 3-, and 6 month follow-up. A 3D-Slicer was used to segment hematoma volumes and the liquid embolic cast. We hypothesized that greater LEA SA would be correlated with greater improvements in cSDH volumetric resolution. RESULTS There was significant resolution in cSDH volumes over the follow-up period compared to preoperative volume (p<0.0001). The LEA SA was significantly correlated with the rate of cSDH resolution at 3 months (R2=0.08, p=0.03), and 6 months (R2=0.14, p=0.01). CONCLUSIONS The correlation of LEA surface area with hematoma resolution at 3-months and 6-months suggests greater LEA penetration may improve radiographic outcomes. This study uniquely provides a quantitative radiological perspective on the effect of LEA penetration on cSDH resolution.
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Affiliation(s)
- Kevin John
- Department of Radiology, Stony Brook Medicine, Stony Brook, New York, USA
| | - Shoaib Syed
- Department of Neurological Surgery, Stony Brook Medicine, Stony Brook, New York, USA
| | | | - Reza Dashti
- Department of Neurological Surgery, Stony Brook Medicine, Stony Brook, New York, USA
| | - David Fiorella
- Department of Neurological Surgery, Stony Brook Medicine, Stony Brook, New York, USA
| | - Chander Sadasivan
- Department of Neurological Surgery, Stony Brook Medicine, Stony Brook, New York, USA
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12
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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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13
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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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14
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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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15
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Diana F, Romoli M, Ricchetti F, Milonia L, Salcuni A, Cirelli C, Ruzza AD, Gaudino C, Iacobucci M, Biraschi F. Lidocaine for headache prevention during chronic subdural hematoma embolization. Interv Neuroradiol 2023:15910199231198909. [PMID: 37649347 DOI: 10.1177/15910199231198909] [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: 09/01/2023] Open
Abstract
BACKGROUND Middle meningeal artery embolization (MMAE) for the management of chronic subdural hematomas (CSDH) with ethylene vinyl alcohol (EVOH) causes an evident patient discomfort due to meningeal nociceptors stimulation. The aim of this study was to assess safety and efficacy of intra-arterial lidocaine (IAL) before MMAE of CSDH with EVOH. METHODS We analyzed all consecutive patients with bilateral CSDH undergoing MMAE with EVOH. We used a monolateral IAL injection, with casual allocation. We assessed the headache felt by patients during embolization with the visual analog scale (VAS) and compared scores obtained after embolization of both sides. We followed the STROBE guidelines for case-control studies. Paired t-test and χ2 test were used to compare the distribution of variables in IAL vs control group. RESULTS Between September 2021 and March 2023, 32 patients underwent bilateral MMAE with EVOH for a CSDH. Lidocaine treatment resulted in a substantially lower VAS score compared to the control group (median 3 vs 7, p < 0.001), with no substantial side effect. Compliance also benefited from lidocaine administration. CONCLUSIONS In patients with CSDH undergoing MMAE, IAL seems to reduce pain sensation associated with EVOH injection and to increase patients' compliance during treatment.
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Affiliation(s)
- Francesco Diana
- Interventional Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Michele Romoli
- Neurology and Stroke Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | - Francesca Ricchetti
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Italy
| | - Luca Milonia
- Department of Human Neurosciences, Interventional Neuroradiology, Policlinico Umberto I, Sapienza University of Rome, Italy
| | - Andrea Salcuni
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Italy
| | - Carlo Cirelli
- Department of Human Neurosciences, Interventional Neuroradiology, Policlinico Umberto I, Sapienza University of Rome, Italy
| | - Alberto Di Ruzza
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Italy
| | - Chiara Gaudino
- Department of Human Neurosciences, Interventional Neuroradiology, Policlinico Umberto I, Sapienza University of Rome, Italy
| | - Marta Iacobucci
- Department of Human Neurosciences, Interventional Neuroradiology, Policlinico Umberto I, Sapienza University of Rome, Italy
| | - Francesco Biraschi
- Department of Human Neurosciences, Interventional Neuroradiology, Policlinico Umberto I, Sapienza University of Rome, Italy
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16
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Sioutas GS, Vivanco-Suarez J, Shekhtman O, Matache IM, Salem MM, Burkhardt JK, Srinivasan VM, Jankowitz BT. Liquid embolic agents for middle meningeal artery embolization in chronic subdural hematoma: Institutional experience with systematic review and meta-analysis. Interv Neuroradiol 2023:15910199231183132. [PMID: 37322877 DOI: 10.1177/15910199231183132] [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] [Indexed: 06/17/2023] Open
Abstract
INTRODUCTION Chronic subdural hematoma (CSDH) is associated with high recurrence rates. Middle meningeal artery embolization (MMAE) has emerged as a promising treatment option. In this systematic review and meta-analysis, we aimed to assess the safety and efficacy of MMAE for CSDH using liquid embolic agents and compare them with particles. METHODS We systematically reviewed all studies describing MMAE for CSDH with liquid embolic agents, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Additionally, we included a cohort of patients from our institution using liquid and particle embolic agents. Data were analyzed using random-effects proportions and comparisons meta-analysis, and statistical heterogeneity was assessed. RESULTS A total of 18 studies with 507 cases of MMAE with liquid embolic agents (including our institutional experience) were included in the analysis. The success rate was 99% (95% confidence interval [CI]: 98-100%), all complications rate was 1% (95% CI: 0-5%), major complications rate was 0% (95% CI: 0-0%), and mortality rate was 1% (95% CI: 0-6%). The rate of hematoma size reduction was 97% (95% CI: 73-100%), complete resolution 64% (95% CI: 33-87%), radiographic recurrence 3% (95% CI: 1-7%), and reoperation 3% (95% CI: 1-7%). No significant differences in outcomes were found between liquid and particle embolic agents. Sensitivity analyses revealed that liquid embolic agents were associated with lower reoperation rates in upfront MMAE (risk ratio 0.13, 95% CI: 0.02-0.95). CONCLUSION MMAE with liquid embolic agents is safe and effective for the treatment of CSDH. Outcomes are comparable to particles, but liquids were associated with a decreased risk of reoperation in upfront MMAE. However, further studies are needed to support our findings.
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Affiliation(s)
- Georgios S Sioutas
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Juan Vivanco-Suarez
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Oleg Shekhtman
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Irina-Mihaela Matache
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
- Department of Physiology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
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