Awake transradial middle meningeal artery embolization and twist drill craniostomy for chronic subdural hematomas in the elderly: case series and technical note

Endovascular treatment of chronic subdural hematoma in a dual-trained neurosurgical unit: Results and proposal of a randomized controlled trial protocol

INTRODUCTION

Chronic subdural hematoma (cSDH) is a prevalent neurosurgical condition with an increasing incidence due to the rising life expectancy and the widespread use of anticoagulant and antiplatelet therapies. Insights into the inflammatory origins of cSDH led to the exploration of Middle Meningeal Artery (MMA) embolization as a therapeutic strategy. In recent years the endovascular treatment of MMA has gained momentum. Herein we present the initial experience of a dual trained neurovascular unit implementing this therapeutic technique.

METHODS

This single-center, prospective pilot study aimed to evaluate the feasibility, safety, and efficacy of MMA embolization in the treatment of cSDH. Following ethical approval and informed consent, demographic, clinical, and radiological data were collected. Patients requiring emergent surgical treatment were excluded. The study focused on assessing clinical outcomes, including the Modified Rankin Score (mRS) and volumetric analysis of cSDH, before and after embolization.

RESULTS

Fifteen patients underwent MMA embolization, with a predominance of males (80%) and a mean age of 72.4 years. The most common presenting symptom was headache (53.3%). The average hospital stay was 3.9 days. Various embolization techniques were employed, with DMSO-EVOH being the most frequent. All procedures were successfully conducted without complications. Although not statistically significant, trends suggested better outcomes in patients with homogeneous cSDH on the CT scan, displaying the cotton wool sign on angiography and treated with EVOH-DMSO.

CONCLUSION

MMA embolization for cSDH demonstrates promise as a safe and effective treatment, potentially reducing the need for surgical intervention and recurrence rates. This study lays the groundwork for a larger, randomized controlled trial which protocol is herein presented.

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

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

Safety and efficacy comparison of embolic agents for middle meningeal artery embolization for chronic subdural hematoma

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Treatment of chronic subdural hematoma in a patient with a left ventricular assist device: Case report and review of the literature

Patients with left ventricular assist devices (LVADs) provide a unique challenge with regard to the management of subdural hematomas (SDH), due to preexisting comorbidities and induced coagulopathy. We report on the case of a 63-year-old female with a preexisting LVAD who developed an acute on chronic SDH with 15 mm of midline shift. She was successfully treated with middle meningeal artery (MMA) embolization and placement of a bedside subdural evacuating port system without hematoma recurrence at 1-year follow-up. Both operative and nonoperative management of SDHs in patients with LVAD is associated with high risk of mortality and morbidity. Chronic SDHs in this patient population can be successfully managed with a minimally invasive approach that includes MMA embolization and bedside subdural drain placement.