Application of Absolute Alcohol in the Treatment of Traumatic Intracranial Hemorrhage via Interventional Embolization of Middle Meningeal Artery

Middle Meningeal Arterial Embolization Combined With Drilling in the Treatment of Acute Epidural Hematoma

OBJECTIVE

The purpose of this study was to determine the technical feasibility and safety of middle meningeal arterial (MMA) embolization combined with drilling drainage in the treatment of acute epidural hematoma (AEDH) by comparing it with traditional craniotomy in the treatment.

METHODS

One hundred seventeen patients with AEDH treated for MMA embolization combined with drilling and drainage or craniotomy hematoma removal from January 2017 to September 2020 were retrospectively analyzed and divided into a craniotomy group (n=85) and a minimally invasive group (n=32). Hematoma removal was performed in the craniotomy group, and MMA embolization combined with drilling and drainage was performed in the minimally invasive group. The general clinical data, imaging data, surgery, and follow-up of the 2 groups were compared and analyzed.

RESULTS

Compared with the craniotomy group, the residual hematoma volume in the minimally invasive group was higher than in the craniotomy group. The average postoperative drainage duration in the minimally invasive group was longer than in the craniotomy group. Compared with the craniotomy group, the minimally invasive group was associated with shorter operative time, less intraoperative bleeding, and lower rates of postoperative rebleeding. In addition, the incidence of postoperative complications and length of hospitalization in the minimally invasive group were significantly shortened.

CONCLUSION

Middle meningeal arterial embolization combined with drilling and drainage in the treatment of AEDH caused by MMA active bleeding is safe, effective, and more minimally invasive, and can be promoted and applied.

Acute Subdural Hematoma Regarding Glial Cystic Changes– A Case Report and Literature Review.. [DOI: 10.21203/rs.3.rs-3967434/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background This report attempts to examine a controversial case of trauma-associated acute subdural hematoma (ASH). In that case, surgical intervention indicates an intraoperative craniectomy with trephine evacuation or, if the patient is eligible, a Decompressive Craniectomy. Clinical Case Description A 51-year-old male was referred to our emergency room due to severe dysarthria and left hemiparesis precipitated by a traumatic event to the right frontoparietal region. demonstrated an (ASH) associated with areas of cystic-glial transformation. Confirmed by CT and follow-up. Conclusion A case that illustrates and favors surgical intervention for evacuation with priority and recovery by osteoplastic craniotomy as a treatment and approaches to subdural hematoma, hematoma, and postoperative compliance after said procedure.

Middle meningeal artery embolization for chronic subdural hematoma: a systematic review

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.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Extensive Roles and Technical Advances of Middle Meningeal Artery Embolization for Chronic Subdural Hematoma

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.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Embolic Agent Choice in Middle Meningeal Artery Embolization as Primary or Adjunct Treatment for Chronic Subdural Hematoma: A Systematic Review and Meta-analysis

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.

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

BACKGROUND

Middle meningeal artery (MMA) embolization has recently emerged as a treatment option for chronic subdural hematoma (cSDH). It is considered a simple and potentially safe endovascular procedure.

OBJECTIVE

To compare between 2 different embolic agents; onyx (ethylene vinyl alcohol) and emboparticles (polyvinyl alcohol particles-PVA) for endovascular treatment of cSDH.

METHODS

A retrospective analysis of all patients who underwent MMA embolization for cSDH treatment in 2 comprehensive centers between August 2018 and December 2021. Primary outcomes were failure of embolization and need for rescue surgical evacuation.

RESULTS

Among 97 MMA embolizations, 49 (50.5%) received onyx and 48 (49.5%) received PVA. The presence of acute or subacute on cSDH was higher in the PVA group 11/49 (22.5%) vs 30/48 (62.5%), respectively, P < .001. There were no significant differences between both groups regarding failure of embolization 6/49 (12.2%) vs 12/48 (25.0%), respectively, P = .112, and need of unplanned rescue surgical evacuation 5/49 (10.2%) vs 8/48 (16.7%), respectively, P = .354. Hematoma thickness at late follow-up was significantly smaller in the PVA group 7.8 mm vs 4.6 mm, respectively; P = .017.

CONCLUSION

Both onyx and PVA as embolic agents for cSDH can be used safely and have comparable clinical and surgical outcomes.

Recent Advances and Future Directions in Middle Meningeal Artery Embolization for Chronic Subdural Hematomas

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.

Endovascular treatment of traumatic oronasal hemorrhage complicated with progressive acute epidural hemorrhage: A case report

RATIONALE

Massive oronasal hemorrhage can induce shock and is life-threatening, and early endovascular treatment is the standard of care. Few studies have reported the use of endovascular treatment for acute epidural hemorrhage (AEDH). However, endovascular treatment of oronasal hemorrhage complicated by AEDH has not yet been demonstrated. Many patients with a low to moderate volume of oronasal hemorrhage complicated by AEDH choose conservative treatment but eventually undergo craniotomy due to increased intracranial hemorrhage.

PATIENT CONCERNS

A 32-year-old man presented to our hospital with traumatic oronasal hemorrhage complicated by AEDH after being hit by a blunt object.

DIAGNOSIS

Computerized tomography suggested progressive AEDH and multiple basilar skull fractures. Emergency cerebral angiography showed rupture of the right middle meningeal artery and a branch of the left maxillary artery causing AEDH and oronasal hemorrhage.

INTERVENTIONS

The patient underwent interventional embolization to treat the ruptured intracranial vessels.

OUTCOMES

After 23 days, cranial computerized tomography showed remarkable absorption of the right frontal epidural hematoma, with the patient having a Glasgow Coma Scale score of 15.

LESSONS

This case provides a valuable treatment for patients with AEDH complicated with oronasal hemorrhage, early interventional embolization may be an effective treatment strategy to prevent further complications and ensure a good patient outcome.

Middle Meningeal Artery Embolization for the Treatment of Bilateral Chronic Subdural Hematoma

Background: Bilateral chronic subdural hematoma (bCSDH) is a frequent condition commonly linked to the need for retreatment; however, the reason for this high retreatment rate remains unclear. The middle meningeal artery (MMA) was found to have a relationship with the occurrence and development of chronic subdural hematomas. This study examines a possible method to reduce bCSDH recurrence using bilateral MMA embolization combined with bilateral burr-hole drainage.

Materials and Methods: Ten patients with bCSDH who underwent bilateral MMA embolization combined with bilateral burr-hole drainage at our hospital between June 2018 and May 2020, were retrospectively analyzed. Patients' clinical information, prognoses, imaging results, as well as surgical results were documented and analyzed.

Results: Ten patients were diagnosed with bCSDH with no comorbid brain diseases. They underwent bilateral MMA embolization combined with bilateral burr-hole drainage. We embolized the MMA immediately before burr hole drainage successfully and employed angiography to validate these results. All the patients attained relief of symptoms without adverse events, and no re-expansion or relapse was reported in the follow-up computed tomography.

Conclusion: Bilateral MMA embolization combined with bilateral burr-hole drainage is an available treatment for patients with bCSDH and may have the potential for preventing recurrence.

Endovascular Treatment of Chronic Subdural Hematomas through Embolization: A Pilot Study with a Non-Adhesive Liquid Embolic Agent of Minimal Viscosity (Squid)

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.

Traumatic epidural hematoma treated with endovascular coil embolization

Background:

Traumatic cerebrovascular injury may result in epidural hematoma (EDH) from laceration of the middle meningeal artery (MMA), which is a potentially life-threatening emergency. Treatment ranges from surgical evacuation to conservative management based on a variety of clinical and imaging factors.

Case Description:

A 14-year-old male presented to our institution after falling from his bicycle with traumatic subarachnoid hemorrhage and a right frontotemporal EDH. The patient did not meet criteria for surgical evacuation and endovascular embolization of the right MMA was performed. Rapid resolution of the EDH was observed.

Conclusion:

This case corroborates the sparse existing literature for the potential role of endovascular embolization to treat acute EDH in carefully selected patients who do not meet or have borderline indications for surgical management.

Middle meningeal artery embolization for chronic subdural hematoma: a systematic review and meta-analysis

Middle meningeal artery (MMA) embolization has been proposed as a minimally invasive treatment for chronic subdural hematoma (cSDH). The aim of this systematic review and meta-analysis is to compare outcomes after MMA embolization versus conventional management for cSDH. We performed a systematic review of PubMed, Embase, Oxford Journal, Cochrane, and Google Scholar databases from April 1987 to October 2020 in accordance with PRISMA guidelines. Studies reporting outcomes after MMA embolization for ≥3 patients with cSDH were included. A meta-analysis comparing MMA embolization with conventional management was performed. The analysis comprised 20 studies with 1416 patients, including 718 and 698 patients in the MMA embolization and conventional management cohorts, respectively. The pooled recurrence, surgical rescue, and in-hospital complication rates in the MMA embolization cohort were 4.8% (95% CI 3.2% to 6.5%), 4.4% (2.8% to 5.9%), and 1.7% (0.8% to 2.6%), respectively. The pooled recurrence, surgical rescue, and in-hospital complication rates in the conventional management cohort were 21.5% (0.6% to 42.4%), 16.4% (5.9% to 27.0%), and 4.9% (2.8% to 7.1%), respectively. Compared with conservative management, MMA embolization was associated with lower rates of cSDH recurrence (OR=0.15 (95% CI 0.03 to 0.75), p=0.02) and surgical rescue (OR=0.21 (0.07 to 0.58), p=0.003). In-hospital complication rates were comparable between the two cohorts (OR=0.78 (0.34 to 1.76), p=0.55). MMA embolization is a promising minimally invasive therapy that may reduce the need for surgical intervention in appropriately selected patients with cSDH. Additional prospective studies are warranted to determine the long-term durability of MMA embolization, refine eligibility criteria, and establish this endovascular approach as a viable definitive treatment for cSDH.