Middle meningeal artery embolization reduces the post-operative recurrence rate of at-risk chronic subdural hematoma
Eimad ShotarLouis MeyblumKévin PrematStéphanie LenckVincent DegosTéodor GrandJonathan CorteseArnaud PouvelleGeoffroy PouliquenSamuel MouyalAnne‐Laure BochAlexandre CarpentierNader SourourBertrand MathonFrédéric Clarençon
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Abstract:
Background Embolization of the middle meningeal artery (MMA) has emerged as a potential treatment of chronic subdural hematomas (CSDHs). Objective To evaluate the impact on recurrence rate of postsurgical embolization of CSDH in patients with a higher than average risk of recurrence. Methods A monocentric retrospective study was performed on retrospectively collected data. From March 2018 to December 2019, embolization of the MMA was proposed as an adjunct postoperative treatment after burr-hole surgery in patients operated for a recurrent CSDH or a CSDH with an independent recurrence risk factor, including antiplatelet therapy, full anticoagulation therapy, coagulation disorder, hepatopathy, or chronic alcoholism. Patients who had undergone postoperative embolization were compared with a historic group of patients operated between March 2016 and March 2018, selected based on the same inclusion criteria. Results During the study period, 89 patients (with 74 unilateral and 15 bilateral CSDHs) were included and underwent an embolization procedure, leading to 91 out of a total of 104 MMA being embolized (88%). These were compared with 174 patients (138 unilateral and 36 bilateral CSDH) in the historic control group. One major procedure-related adverse event was registered. Four of the 89 patients (4%) required surgery for a CSDH recurrence in the embolization group, significantly less than the 24 of 174 patients (14%) in the control group (OR=0.28, 95% CI 0.07 to 0.86, p=0.02). Conclusions Postsurgical embolization of the MMA may reduce the recurrence rate of CSDHs with a risk factor of recurrence.Keywords:
Middle meningeal artery
Chronic Subdural Hematoma
Chronic subdural hematoma (CSDH) is a condition in which blood accumulates within the subdural space and may cause neurologic deficits. CSDH patients with neurologic deficits usually will undergo surgery, but reoccurrence is common. Middle meningeal artery (MMA) embolization has been proposed as one of the CSDH treatment options, either being used as a single treatment for the neurologically stable patients or certain conditions that may not allow patients to undergo surgery, or as a perioperative treatment. The authors reported a CSDH case with neurologic deficits who was on antiplatelet treatment that underwent both burr hole and MMA embolization for curation and prevention of rebleeding. The result showed near-complete blood resorption and no neurologic deficits.
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Middle Meningeal Artery (MMA) embolization for the treatment of refractory Chronic Subdural Hematoma (CSDH) was first described by Mandai et al. in 2000. Since then, more surgeons have begun to pay attention to such surgery to treat CSDH and explore the changes in the middle meningeal artery in the formation of hematomas. We have presented three cases of chronic subdural hematoma after head trauma and compared the diameter of the middle meningeal artery in MRA images before and after chronic subdural hematoma to discuss our new understanding of CSDH.
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To study the efficacy of MMA Embolization in treating chronic subdural hematoma.
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Objective: This study evaluated the efficacy of middle meningeal artery (MMA) embolization for organized chronic subdural hematoma (OCSDH).
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Chronic subdural hematoma (cSDH) is a common condition that typically requires surgical intervention. Middle meningeal artery embolization (MMAE) has emerged as a potential alternative treatment option, although the choice of embolization material remains a topic of debate. In this case series, we report on the outcomes of 10 patients with cSDH who underwent MMAE. Most patients experienced symptom relief and a significant reduction in cSDH size post-procedure. Despite the presence of comorbidities and risk factors, most patients had positive outcomes following MMAE treatment. Only one patient required surgical intervention after the MMAE procedure due to the progression of symptoms, while MMAE successfully prevented recurrence in most patients. Our findings suggest that MMAE can be a promising treatment option for selected patients with cSDH. However, further studies are needed to compare the efficacy and safety of different embolization materials in MMAE procedures for cSDHs.
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Larson, Anthony BS; Savastano, Luis MD, PhD; Rammos, Stylianos MD; Brinjikji, Waleed MD Author Information
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Contralateral acute complications such as acute epi/subdural hematomas can be encountered after evacuation of a chronic subdural hematoma, though they are rare. We found only one case of chronic subdural hematoma following the surgery for contralateral chronic subdural hematoma, have been published in English language literature. A 73-year-old male admitted to our hospital with a right-sided subdural hematoma. The subdural hematoma was evacuated through a burr-hole. A left-sided subdural higroma appeared after operation and turned into classical subdural hematoma in the course of time. After evacuation of contralateral chronic subdural hematoma, the patient recovered completely. All stages of the development of contralateral chronic subdural hematomas were shown by serial computed tomograms. It was suggested that traumatic chronic subdural hematomas develop from mostly subdural higromas. If contralateral subdural higroma is seen after surgical evacuation of a chronic subdural hematoma, the possibility of development of contralateral chronic subdural hematoma must be kept on mind.
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Contemporary Neurosurgery: June 30, 2020 - Volume 42 - Issue 9 - p 6 doi: 10.1097/01.CNE.0000695024.76664.c3
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The purpose of this research is to compare middle meningeal artery embolization to an open craniotomy approach for the treatment of chronic subdural hematoma. TriNetX, a global federated research database network, was used for this study. This database contains de-identified patient information on over 213 million patients in 92 large healthcare organizations. Two patient cohorts were created for this study. Both groups consisted of patients who were 18 or older and had a diagnosis of nontraumatic chronic subdural hemorrhage as identified by their International Classification of Disease (ICD-10) codes, I62.03 and I62.00. Patients were excluded if they had a previous diagnosis of arteriovenous malformation (Q28.2), malignant neoplasm of the brain or other unspecified site (C71, C76), epistaxis (R04.0), cerebral aneurysm (I67.1). One cohort consisted of patients who received middle meningeal artery embolization (61624, 61626) and the other cohort consisted of patients who received an open approach for evacuation of the subdural hematoma (00C40ZZ). Both groups were matched for age, sex, race, type 2 diabetes mellitus, essential hypertension, chronic kidney disease, nicotine dependence, obesity, and ischemic heart disease. They were then measured for the outcome of the recurrence of subdural hemorrhage, the need for burr holes, or the need for craniectomy or craniotomy between seven and 180 days after the initial procedure. A total of 464 patients, with 232 patients in each arm were included in the final analysis. Patients who initially received the open approach for treatment were found to have a 16% reduced risk of developing a rebleed or needing further intervention with burr holes or another craniotomy ([RR] 0.84, 95% CI 0.72-0.99, P=0.03). Middle meningeal artery embolization in previous studies and individual case reports showed a promising alternative to the open approach in the treatment of chronic subdural hematomas and possibly a preferred route of treatment. However, the current study does not support this idea and demonstrates that middle meningeal artery embolization alone may have an increased risk of developing recurrent bleeds needing further intervention. Further investigation is needed to determine whether middle meningeal artery embolization in conjunction with an open approach for the treatment of chronic subdural hematomas would improve results.
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