Transradial middle meningeal artery embolization for chronic subdural hematoma using Onyx: case series

Abstract

BackgroundMiddle meningeal artery (MMA) embolization is an emerging therapy for the resolution of subacute or chronic subdural hematoma (CSDH). CSDH patients are often elderly and have several comorbidities. We evaluated our experience with transradial access (TRA) for MMA embolization using predominantly Onyx under conscious sedation.MethodsData for consecutive patients who underwent transradial MMA embolization for CSDH during a 2-year period (2018–2019) were analyzed from a single-center, prospectively-maintained database. Patient demographics, comorbidities, ambulatory times, subdural hematoma resorption status, and guide catheter type were recorded. Conversion to femoral access and complication rates were also recorded. Univariate and multivariate analyses were performed.ResultsForty-six patients (mean age, 71.7±14.4 years) were included in this study. Mean CSDH size was 14±5.5 mm. Most (91.3%) TRA embolizations were performed with 6-French 0.071-inch Benchmark guide catheters (Penumbra). MMA embolization was successful in 44 patients (95.7%) (including two cases of TRA conversion). Twenty-one (48%) patients had a severe Charlson Comorbidity Index (>5). Symptomatic improvement was noted in 39 of 44 patients (88.6%). Mean length of stay was 4±3 days. Patients were ambulated immediately postprocedure. At mean follow-up (8±4 weeks), 86.4% of patients had complete or partial CSDH resolution. Persistent use of antiplatelet agents after the procedure was associated with failed or minimal CSDH resorption (5 of 6, 83.3% vs 9 of 38 23.7% with complete or near-complete resolution; P=0.009).ConclusionTransradial Onyx MMA embolization under conscious sedation is safe and effective for CSDH treatment. TRA may be especially useful in elderly patients with numerous comorbidities.

Middle meningeal artery embolization for chronic subdural hematomas. A systematic review of the literature focused on indications, technical aspects, and future possible perspectives

“…From the analysis of the literature, we identified four indications for MMA embolization: To prevent surgery in patients with paucisymptomatic CSDHs,[ 7 , 9 , 13 - 15 , 19 , 20 , 24 , 35 - 37 , 48 , 50 , 51 ] As prophylaxis of a recurrence after a first surgery,[ 5 , 7 , 9 , 14 , 19 , 24 , 34 - 37 , 41 , 42 , 50 ] After a first recurrence to prevent further recurrence,[ 9 , 13 , 17 - 21 , 23 , 24 , 28 , 37 , 43 , 48 , 51 , 54 ] As an adjunctive treatment in case of a second surgery. [ 10 , 17 , 25 , 26 , 28 , 33 , 47 ] …”

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

“…Medicinal antiaggregation and anticoagulation are suspected of leveraging the growth of CSDHs but may not affect the frequency of postoperative recurrence [ 12 ]. Rajah et al (2020) observed that the use of antiplatelet medication after the embolization correlated with failed absorption of the CSDH [ 35 ]. Yajima et al (2020) found an increased rate of postoperative CSDH recurrence in patients under anticoagulation [ 36 ].…”

“…The penetration of the embolic agent deep into the dependent vasculature of the MMA is considered crucial by most authors. The following embolic agents have been used and were reported together with good results: Polyvinyl alcohol particles (PVA) [ 2 , 28 , 29 , 37 , 38 ] Embospheres [ 39 , 40 ] n-butyl cyanoacrylate (nBCA) [ 25 , 36 , 39 , 41 ] PVA and nBCA [ 42 , 43 ] Absolute alcohol [ 44 ] Onyx [ 35 , 45 , 46 ] Phil: Pending Squid: Pending Coils [ 37 , 47 ]. …”

“…(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.…”

Radial first or patient first: a case series and meta-analysis of transradial versus transfemoral access for acute ischemic stroke intervention

“…1-3 5 Several articles have shown the feasibility of the radial-first approach for various indications, including flow diversion, aneurysm coiling, carotid stenting, middle meningeal artery embolization, and acute ischemic stroke. [4][5][6][7][8][9][10][11] Most studies that describe a radial-first experience are noncomparative case series with considerable selection bias. Few studies provide a direct comparison of TRA with transfemoral access (TFA).…”