Upfront middle meningeal artery embolization for treatment of chronic subdural hematomas in patients with or without midline shift

Gomez-Paz, Santiago; Akamatsu, Yosuke; Salem, Mohamed M; Enríquez-Marulanda, Alejandro; Robinson, Timothy; Ogilvy, Christopher S.; Thomas, Ajith J.; Moore, Justin M.

doi:10.1177/1591019920982816

Cited by 31 publications

(22 citation statements)

References 12 publications

(29 reference statements)

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“…Also, as seen in Table 2, the mean MLS for our patients was 6.75 mm. The MMA embolization has a delayed effect with an average time to resolution of MLS to be 46 days for MLS < 5 mm and 51 days for MLS>5 mm (38). The recent findings with MMA embolization suggest that the mechanism is via devascularization of the outer membranes.…”

Section: Discussionmentioning

confidence: 92%

“…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.…”

Section: Discussionmentioning

confidence: 99%

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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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Section: Discussionmentioning

confidence: 92%

Section: Discussionmentioning

confidence: 99%

The Mini-Craniotomy for cSDH Revisited: New Perspectives

Chen

Malkasian

et al. 2021

Front. Neurol.

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“…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 ] …”

Section: Discussionmentioning

confidence: 99%

“…To prevent surgery in patients with paucisymptomatic CSDHs,[ 7 , 9 , 13 - 15 , 19 , 20 , 24 , 35 - 37 , 48 , 50 , 51 ]…”

Section: Discussionmentioning

confidence: 99%

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

Cristofori

Remida

Patassini

et al. 2022

Surgical Neurology International

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Background: Chronic subdural hematoma (CSDH) is one of the most common neurosurgical diseases that affect elderly and fragile patients and as a consequence, management can be challenging. Surgery represents the standard treatment; however, alternative options are under investigation. Middle meningeal artery (MMA) embolization is considered a minimally invasive treatment although with poor evidence. In this review, we tried to summarize the findings about MMA embolization as a treatment for a CSDH to provide a useful guidance for clinical practice and for future speculative aspects. Methods: Literature review on PubMed until March 2021 was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. We conducted a research on PubMed with a various combinations of the keywords “CSDH” and “middle meningeal artery” and “embolization,” “refractory subdural hematoma,” and then we reviewed the references of the relevant studies as additional source of eligible articles. Results: Among the 35 studies eligible for this review, 22 were case series, 11 were case reports, one was a technical note, and 1 was a randomized trial. A total of 746 patients were found in the literature. Failure rate of MMA embolization was between 3.9 and 8.9% of the cases according the indication to treat CSDH (upfront vs. after surgery). Conclusion: The global impression deriving from the data available and the literature is that MMA embolization is a safe procedure with very low complications and with a low failure rate, both when associated with surgery or in case of a standalone treatment.

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“…Gomez-Paz et al (2020) were able to show that upfront MMA embolization in CSDH with a midline shift is feasible. In their series of 23 patients, improvement was achieved within 2–4 weeks, and resolution occurred within less than 2 months [ 56 ].…”

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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Upfront middle meningeal artery embolization for treatment of chronic subdural hematomas in patients with or without midline shift

Cited by 31 publications

References 12 publications

The Mini-Craniotomy for cSDH Revisited: New Perspectives

The Mini-Craniotomy for cSDH Revisited: New Perspectives

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