Middle meningeal artery embolization treatment of nonacute subdural hematomas in the elderly: a multiinstitutional experience of 151 cases

Joyce, Evan; Bounajem, Michael T.; Scoville, Jonathan; Thomas, Ajith J.; Ogilvy, Christopher S.; Riina, Howard A.; Tanweer, Omar; Levy, Elad I.; Spiotta, Alejandro M; Gross, Bradley A.; Jankowitz, Brian T.; Cawley, C. Michael; Khalessi, Alexander A.; Pandey, Aditya S.; Ringer, Andrew J.; Hanel, Ricardó A.; Ortiz, Rafael; Langer, David; Levitt, Michael R.; Binning, Mandy J.; Taussky, Philipp; Kan, Peter; Grandhi, Ramesh

doi:10.3171/2020.7.focus20518

Cited by 76 publications

(65 citation statements)

References 35 publications

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“…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.…”

Section: Introduction General Aspects Of Dural Vascular Anatomy and Pathologymentioning

confidence: 99%

Neuroanatomy of cranial dural vessels: implications for subdural hematoma embolization

Shapiro

Walker

Carroll

et al. 2021

J NeuroIntervent Surg

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Adoption of middle meningeal artery embolization in the management of chronic subdural hematomas has led to a renewed interest in dural vascular anatomy. The readily identifiable major dural arteries and potential hazards associated with their embolization are well described. Less emphasized are several levels of intrinsic dural angioarchitecture, despite their more direct relationship to dural based diseases, such as subdural hematoma and dural fistula. Fortunately, microvascular aspects of dural anatomy, previously limited to ex vivo investigations, are becoming increasingly accessible to in vivo visualization, setting the stage for synthesis of the old and the new, and providing a rationale for the endovascular approach to subdural collections in particular. In contrast with traditional anatomical didactics, where descriptions advance from larger trunks to smaller pedicles, we present a strategic approach that proceeds from a fundamental understanding of the dural microvasculature and its relationship to larger vessels.

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Section: Introduction General Aspects Of Dural Vascular Anatomy and Pathologymentioning

confidence: 99%

Neuroanatomy of cranial dural vessels: implications for subdural hematoma embolization

Shapiro

Walker

Carroll

et al. 2021

J NeuroIntervent Surg

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“…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.…”

Section: Discussionmentioning

confidence: 99%

“…Particular attention was paid to the presence of the identification of the inner membrane on the pre-operative CT scan. This is generally defined as thin hyperdense lines that parallel the skull vault and cerebrum ( 31 ). Axial and coronal views were examined for this.…”

Section: Methodsmentioning

confidence: 99%

The Mini-Craniotomy for cSDH Revisited: New Perspectives

Chen

Malkasian

et al. 2021

Front. Neurol.

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Background: Chronic subdural hematomas (cSDH) are increasingly prevalent worldwide with the increased aging population and anticoagulant use. Different surgical, medical, and endovascular treatments have had varying success rates. Primary neurosurgical interventions include burr hole drainage of the cSDH and mini-craniotomies/craniotomies with or without fenestration of the inner membrane. A key assessment of the success or failure of cSDH treatments has been symptomatic recurrence rates which have historically ranged from 5 to 30%. Pre-operative prediction of the inner subdural membrane by CT scan was used to guide our decision to perform mini-craniotomies. Release of the inner membrane facilitates the expansion of the brain and likely improves glymphatic flow.Methods: Consecutive mini-craniotomies (N = 34) for cSDH evacuation performed by a single neurosurgeon at a quaternary academic medical center/Level I trauma center from July 2018-September 2020 were retrospectively reviewed. Patient characteristics [age, gender, presenting GCS, GOS, initial CTs noting the inner subdural membrane, midline shift (MLS), cSDH width, inner membrane fenestration, cSDH recurrence, post-operative seizures, infections, length of stay] were extracted from the EMR.Results: Twenty nine patients had mini-craniotomies as primary treatment of the cSDH. Mean age = 68.9 ± 19.7 years (range 22–102), mean pre-operative GCS = 14.5 ± 1.1, mean MLS = 6.75 ± 4.2 mm, and mean maximum thickness of cSDH = 17.7 ± 6.0 mm. Twenty four were unilateral, five bilateral, 34 total craniotomies were performed. Thirty three had inner membrane signs on pre-operative head CTs and an inner subdural membrane was fenestrated in all cases except for the one craniotomy that didn't show these characteristic CT findings. Mean operating time = 79.5 ± 26.0 min. Radiographic and clinical improvement occurred in all patients. Mean improvement in MLS = 3.85 ± 2.69. There were no symptomatic recurrences, re-operations, surgical site infections, or deaths during the 6 months of follow-up. One patient was treated for post-operative seizures with AEDs for 6 months.Conclusion: Pre-operative CT scans demonstrating inner subdural membranes may guide one to target the treatment to allow release of this tension band. Mini-craniotomy with careful fenestration of the inner membrane is very effective for this. Brain re-expansion and re-establishment of normal brain interstitial flow may be important in long term outcomes with cSDH and may be related to the recent interests in brain glymphatics and dural lymphatics.

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“…Joyce et al (2020) evaluated 121 elderly patients with CSDH and MMA embolization. Adverse events were equally rare in the age groups 65–79 years (2.3%: 1× seizure, 1× infarction) and ≥80 years (1.6%: 1× temporary aphasia) [ 53 ].…”

Section: Discussionmentioning

confidence: 99%

“…(Complete) resolution: Embolization of the MMA is associated with a greater extent of CSDH volume reduction. The rate of (near) complete resolution of CSDH after MMA embolization is in the range of 30–55% [ 2 , 25 , 35 , 37 , 40 , 48 , 53 ]. Gomez-Paz et al (2020) were able to show that upfront MMA embolization in CSDH with a midline shift is feasible.…”

Section: Discussionmentioning

confidence: 99%

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

Петров

Ivanov

Рожченко

et al. 2021

JCM

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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.

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Middle meningeal artery embolization treatment of nonacute subdural hematomas in the elderly: a multiinstitutional experience of 151 cases

Cited by 76 publications

References 35 publications

Neuroanatomy of cranial dural vessels: implications for subdural hematoma embolization

Neuroanatomy of cranial dural vessels: implications for subdural hematoma embolization

The Mini-Craniotomy for cSDH Revisited: New Perspectives

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

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