Middle Meningeal Artery Embolization and the Treatment of a Chronic Subdural Hematoma

Abstract

Chronic subdural hematoma (cSDH) is a common pathology that typically affects the elderly. It is believed to occur due to injury to the dural border cells, which creates an inflammation/proliferation reaction. Ineffective repair leads to the formation of a new external layer of cells and fragile capillaries, which damage easily and can worsen the condition. Conventionally, asymptomatic cSDH is managed by observation, and symptomatic cases are treated by surgical evacuation. Unfortunately, recurrence rates of the SDH following surgical evacuation can be high. One treatment option for SDH involves embolization of the middle meningeal artery (MMA). The MMA provides blood supply to the dura mater and feeds the membrane capillaries covering the SDH. MMA embolization blocks the blood flow to this system and can promote hematoma resolution. In this paper, we review the existing literature on MMA embolization and discuss the underlying pathophysiology of cSDH.

Endoscopically observed outer membrane of chronic subdural hematoma after endovascular embolization of middle meningeal artery

“…Although intracranial hypotension in elderly patients cannot be compensated by MMA embolization, the recurrence rate should be reduced if the inflammation resolved. [5] MMA embolization is an optimal option for this purpose [3] as is the oral intake of corticosteroids [23] and Goreisan extract. [8] Endoscopic observation would help a limited number of patients with CSDH in providing information for the treatment of choice.…”

“…[2,6,12,15,24,27] Studies investigating its effectiveness and indications have been performed. [1,4,10] e inhibition of local bleeding from the outer membrane by disturbance of the blood supply is a suspected mechanism of embolization; [3] however, ischemic changes in the lesion have not been observed directly. e influence of embolization on inflammatory processes has not yet been elucidated.…”

Controversies in the Surgical Treatment of Chronic Subdural Hematoma: A Systematic Scoping Review

“…The general consensus of 12 RCTs, two non-randomized controlled studies, two prospective single arm trials, one combined prospective and retrospective controlled study, and one prospective cohort study is that MMA embolization, when applied as a primary standalone treatment, in recurrent cSDH, or as a prophylaxis after surgery, is a safe and efficient method, with lower recurrence rates when compared to the conventional management of cSDH [ 86 ]. There is, however, significant heterogeneity in data element collection, making the formulation of type A recommendations premature [ 3 , 86 , 87 , 88 , 114 , 115 , 116 , 117 , 118 , 119 , 120 , 121 , 122 , 123 ]. In four of the most recent meta-analyses by Ironside et al (2021), Srivatsan et al (2019), Haldrup et al (2020) and Jumah et al (2020), the recurrence rates in patients with cSDH who underwent the embolization of MMA either as a primary treatment or in recurrent cSDH were 4.8%, 2.1–3.6%, 2.4–4.1% and 2.8%, respectively [ 114 , 120 , 121 , 122 ].…”

Middle Meningeal Artery Embolization for Primary Treatment of a Chronic Subdural Hematoma in a Pediatric Patient: A Systematic Review of the Literature and Case Report

“…An increasing number of studies have documented low morbidity and low rates of recurrence with MMA embolization as compared with surgical evacuation. 1,2 Therefore, it has been advocated as a minimally invasive primary treatment option for patients who are suboptimal surgical candidates. Among adults, MMA embolization has also been described as an adjunct to surgical evacuation or as an option for recurrent cSDH.…”

“…Among adults, MMA embolization has also been described as an adjunct to surgical evacuation or as an option for recurrent cSDH. 1,2…”