Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Multi-Center Experience of 154 Consecutive Embolizations

Abstract

BACKGROUND Middle meningeal artery (MMA) embolization has emerged as a promising treatment for chronic subdural hematoma (cSDH). OBJECTIVE To determine the safety and efficacy of MMA embolization. METHODS Consecutive patients who underwent MMA embolization for cSDH (primary treatment or recurrence after conventional surgery) at 15 centers were included. Clinical details and follow-up were collected prospectively. Primary clinical and radiographic outcomes were the proportion of patients requiring additional surgical treatment within 90 d after index treatment and proportion with > 50% cSDH thickness reduction on follow-up computed tomography imaging within 90 d. National Institute of Health Stroke Scale and modified Rankin Scale were also clinical outcomes. RESULTS A total of 138 patients were included (mean age: 69.8, 29% female). A total of 15 patients underwent bilateral interventions for 154 total embolizations (66.7% primary treatment). At presentation, 30.4% and 23.9% of patients were on antiplatelet and anticoagulation therapy, respectively. Median admission cSDH thickness was 14 mm. A total of 46.1% of embolizations were performed under general anesthesia, and 97.4% of procedures were successfully completed. A total of 70.2% of embolizations used particles, and 25.3% used liquid embolics with no significant outcome difference between embolization materials (P > .05). On last follow-up (mean 94.9 d), median cSDH thickness was 4 mm (71% median thickness reduction). A total of 70.8% of patients had >50% improvement on imaging (31.9% improved clinically), and 9 patients (6.5%) required further cSDH treatment. There were 16 complications with 9 (6.5%) because of continued hematoma expansion. Mortality rate was 4.4%, mostly unrelated to the index procedure but because of underlying comorbidities. CONCLUSION MMA embolization may provide a safe and efficacious minimally invasive alternative to conventional surgical techniques.

Neuroanatomy of cranial dural vessels: implications for subdural hematoma embolization

“…6 13 The notion of subdural hematoma resulting from repetitive, indolent inner layer hemorrhage naturally suggests embolization as a management strategy, first reported by Mandai et al in 2000 17 and more recently highlighted in multiple publications and reviews. [18][19][20][21][22][23][24][25][26][27][28] We may also wonder whether a straightforward procedure such as MMA embolization, with a two decades long trickle of encouraging reports, [29][30][31] would have gained attention sooner had the prevailing idea of bridging vein rupture not been adhered to as devoutly, or had the long existing literature on true pathogenesis been better known in the endovascular community.…”

The Mini-Craniotomy for cSDH Revisited: New Perspectives

“…Most reports are cautious about using MMA up front in cases where there is significant mass effect or neurological deficits. A midline shift of >5 mm or motor strength of 4/5 contralateral to the cSDH has been used as a guideline to avoid MMA embolization (25,38). As seen in Table 1, all of our patients except for two presented with symptoms/complaints that were concerning enough that they came to our ED.…”

“…There has also been much recent interest in middle meningeal artery (MMA) embolization for the treatment of cSDH. Recent series have demonstrated its efficacy in the stabilization and decrease in size of cSDH after upfront treatment ( 23 – 25 , 31 , 38 ). The attraction of these embolization techniques is the relative minimal invasive nature which is particularly of concern in the elderly and frail.…”

“…Treatment options for cSDH include surgery (15)(16)(17), observation and medications such as dexamethasone (12,(18)(19)(20) and endovascular obliteration of the meningeal artery (21)(22)(23)(24)(25). There have been numerous studies examining the different procedures.…”

Hematoma subdural crónico. Una actualización y revisión

“…Existen complicaciones reportadas con baja frecuencia, sobre todo en pacientes de edad avanzada con muchas comorbilidades. La principal es que se filtre material de embolización dentro de la arteria oftálmica o vasos vasculares del nervio facial (0,6 %), complicación que se puede manejar evitando las colaterales durante el procedimiento (70).…”