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Kan P, Fiorella D, Dabus G, Samaniego EA, Lanzino G, Siddiqui AH, Chen H, Khalessi AA, Pereira VM, Fifi JT, Bain MD, Colby GP, Wakhloo AK, Arthur AS. ARISE I Consensus Statement on the Management of Chronic Subdural Hematoma. Stroke 2024; 55:1438-1448. [PMID: 38648281 DOI: 10.1161/strokeaha.123.044129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/10/2024] [Indexed: 04/25/2024]
Abstract
ARISE (Aneurysm/AVM/cSDH Roundtable Discussion With Industry and Stroke Experts) organized a one-and-a-half day meeting and workshop and brought together representatives from academia, industry, and government to discuss the most promising approaches to improve outcomes for patients with chronic subdural hematoma (cSDH). The emerging role of middle meningeal artery embolization in clinical practice and the design of current and potential future trials were the primary focuses of discussion. Existing evidence for imaging, indications, agents, and techniques was reviewed, and areas of priority for study and key questions surrounding the development of new and existing treatments for cSDH were identified. Multiple randomized, controlled trials have met their primary efficacy end points, providing high-level evidence that middle meningeal artery embolization is a potent adjunctive therapy to the standard (surgical and nonsurgical) management of neurologically stable cSDH patients in terms of reducing rates of disease recurrence. Pooled data analyses following the formal conclusion and publication of these trials will form a robust foundation upon which guidelines can be strengthened for cSDH treatment modalities and optimal patient selection, as well as delineate future lines of investigation.
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Affiliation(s)
- Peter Kan
- Department of Neurosurgery, The University of Texas Medical Branch, Galveston (P.K.)
| | - David Fiorella
- Department of Neurosurgery, Stony Brook University, NY (D.F.)
| | - Guilherme Dabus
- Interventional Neuroradiology and Neuroendovascular Surgery, Miami Neuroscience Institute and Miami Cardiac and Vascular Institute-Baptist Hospital, FL (G.D.)
| | - Edgar A Samaniego
- Department of Neurology, The University of Iowa Hospitals and Clinics (E.A.S.)
| | | | - Adnan H Siddiqui
- Department of Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, NY (A.H.S.)
| | - Huanwen Chen
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (H.C.)
| | - Alexander A Khalessi
- Department of Neurological Surgery, University of California, San Diego, La Jolla (A.A.K.)
| | - Vitor Mendes Pereira
- Division of Neuroradiology, Department of Medical Imaging and Division of Neurosurgery, Department of Surgery, University Health Network, Toronto Western Hospital, ON, Canada (V.M.P.)
| | - Johanna T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.)
| | - Mark D Bain
- Cerebrovascular Center, Departments of Neurology and Neurosurgery, Neurological Institute, Cleveland Clinic Foundation, OH (M.D.B.)
| | - Geoffrey P Colby
- Department of Neurosurgery, University of California Los Angeles David Geffen School of Medicine (G.P.C.)
| | - Ajay K Wakhloo
- Department of Interventional Neuroradiology, Lahey Hospital & Medical Center, Burlington, MA (A.K.W.)
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis (A.S.A.)
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Chen H, Colasurdo M, Malhotra A, Gandhi D, Bodanapally UK. Advances in chronic subdural hematoma and membrane imaging. Front Neurol 2024; 15:1366238. [PMID: 38725642 PMCID: PMC11079242 DOI: 10.3389/fneur.2024.1366238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/14/2024] [Indexed: 05/12/2024] Open
Abstract
Chronic subdural hematoma (cSDH) is projected to become the most common cranial neurosurgical disease by 2030. Despite medical and surgical management, recurrence rates remain high. Recently, middle meningeal artery embolization (MMAE) has emerged as a promising treatment; however, determinants of disease recurrence are not well understood, and developing novel radiographic biomarkers to assess hematomas and cSDH membranes remains an active area of research. In this narrative review, we summarize the current state-of-the-art for subdural hematoma and membrane imaging and discuss the potential role of MR and dual-energy CT imaging in predicting cSDH recurrence, surgical planning, and selecting patients for embolization treatment.
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Affiliation(s)
- Huanwen Chen
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Marco Colasurdo
- Department of Interventional Radiology, Oregon Health & Science University, Portland, OR, United States
| | - Ajay Malhotra
- Department of Radiology, Yale New Haven Hospital, New Haven, CT, United States
| | - Dheeraj Gandhi
- Department of Radiology, University of Maryland Medical Center, Baltimore, MD, United States
- Department of Neurology, University of Maryland Medical Center, Baltimore, MD, United States
- Department of Neurosurgery, University of Maryland Medical Center, Baltimore, MD, United States
| | - Uttam K. Bodanapally
- Department of Radiology, University of Maryland Medical Center, Baltimore, MD, United States
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Ellens NR, Schartz D, Kohli G, Rahmani R, Akkipeddi SMK, Mattingly TK, Bhalla T, Bender MT. Safety and efficacy comparison of embolic agents for middle meningeal artery embolization for chronic subdural hematoma. J Cerebrovasc Endovasc Neurosurg 2024; 26:11-22. [PMID: 37828746 PMCID: PMC10995466 DOI: 10.7461/jcen.2023.e2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/26/2023] [Accepted: 08/03/2023] [Indexed: 10/14/2023] Open
Abstract
OBJECTIVE To perform a systematic review and meta-analysis evaluating the efficacy of middle meningeal artery embolization in terms of both clinical and radiographic outcomes, when performed with different embolic agents. METHODS A systematic literature review and meta-analysis was performed to evaluate the impact of embolic agents on outcomes for middle meningeal artery (MMA) embolization. The use of polyvinyl alcohol (PVA) with or without (±) coils, N-butyl cyanoacrylate (n-BCA) ± coils, and Onyx alone were separately evaluated. Primary outcome measures were recurrence, the need for surgical rescue and in-hospital periprocedural complications. RESULTS Thirty-one studies were identified with a total of 1,134 patients, with 786 receiving PVA, 167 receiving n-BCA, and 181 patients receiving Onyx. There was no difference in the recurrence rate (5.5% for PVA, 4.5% for n-BCA, and 6.5% for Onyx, with P=0.71) or need for surgical rescue (5.0% for PVA, 4.0% for n-BCA, and 6.9% for Onyx, with P=0.89) based on the embolic agent. Procedural complications also did not differ between embolic agents (1.8% for PVA, 3.6% for n-BCA, and 1.6% for Onyx, with P=0.48). CONCLUSIONS Rates of recurrence, need for surgical rescue, and periprocedural complication following MMA embolization are not impacted by the type of embolic agent utilized. Ongoing clinical trials may be used to further investigate these findings.
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Affiliation(s)
- Nathaniel R. Ellens
- Department of Neurosurgery, University of Rochester Medical Center, New York, USA
| | - Derrek Schartz
- Department of Imaging Sciences, University of Rochester Medical Center, New York, USA
| | - Gurkirat Kohli
- Department of Neurosurgery, University of Rochester Medical Center, New York, USA
| | - Redi Rahmani
- Department of Neurosurgery, University of Rochester Medical Center, New York, USA
| | | | - Thomas K. Mattingly
- Department of Neurosurgery, University of Rochester Medical Center, New York, USA
| | - Tarun Bhalla
- Department of Neurosurgery, University of Rochester Medical Center, New York, USA
| | - Matthew T. Bender
- Department of Neurosurgery, University of Rochester Medical Center, New York, USA
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Palmer B, Campbell M, Maertz K, Narigon L, Herzing K, Santry H, Boyce W, Narayanan R, Patel A. Analysis of middle meningeal artery embolization for the treatment of chronic, acute on chronic, and subacute subdural hematomas. Surg Neurol Int 2024; 15:71. [PMID: 38468652 PMCID: PMC10927174 DOI: 10.25259/sni_607_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 02/07/2024] [Indexed: 03/13/2024] Open
Abstract
Background Chronic subdural hematoma (cSDH) is a common sequela of traumatic brain injury. Middle meningeal artery embolization (MMAE) has shown promising results as an emerging minimally invasive alternative treatment. The purpose of this study is to examine the safety and efficacy of MMAE performed in patients with cSDH, acute-on-chronic, and subacute SDH with a traumatic etiology. Methods This retrospective study included cases performed at a Level II Trauma Center between January 2019 and December 2020 for MMAE of cSDHs. Data collected included patient demographic characteristics and comorbidities, SDH characteristics, complications, and efficacy outcomes. The lesion measurements were collected before the procedure, 4-6 weeks and 3-6 months post-procedure. Results In our patient population, 78% (39) either had lesions improve or completely resolved. The sample included 50 patients with a mean age of 74 years old. Statistically significant reductions in lesion size were found from pre- to post-procedure in the left lesions, right lesions, and midline shifts. The left lesions decreased from 13.88 ± 5.70 mm to 3.19 ± 4.89 mm at 3-6 months with P < 0.001. The right lesions decreased from 13.74 ± 5.28 mm to 4.93 ± 7.46 mm at 3-6 months with P = 0.02. Midline shifts decreased from 3.78 ± 3.98 mm to 0.48 ± 1.31 mm at 3-6 months with P = 0.02. No complications were experienced for bleeding, hematoma, worsening SDH, pseudoaneurysm, or stroke. Conclusion Our pilot study from a single center utilizing MMAE demonstrates that MMAE is successful without increasing treatment-related complications not only for cSDH but also in acute-on-cSDH and SDH with a subacute component.
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Affiliation(s)
- Brandi Palmer
- Department of Trauma and Acute Care Surgery, Kettering Health Main Campus, Kettering, Ohio, United States
| | - Melody Campbell
- Department of Trauma and Acute Care Surgery, Kettering Health Main Campus, Kettering, Ohio, United States
| | - Kellie Maertz
- Department of Trauma and Acute Care Surgery, Kettering Health Main Campus, Kettering, Ohio, United States
| | - Laurie Narigon
- Department of Trauma and Acute Care Surgery, Kettering Health Main Campus, Kettering, Ohio, United States
| | - Karen Herzing
- Department of Trauma and Acute Care Surgery, Kettering Health Main Campus, Kettering, Ohio, United States
| | - Heena Santry
- Department of Trauma and Acute Care Surgery, Kettering Health Main Campus, Kettering, Ohio, United States
| | - William Boyce
- Department of Radiology, Kettering Health Main Campus, Kettering, Ohio, United States
| | - Ragavan Narayanan
- Department of Trauma and Acute Care Surgery, Kettering Health Main Campus, Kettering, Ohio, United States
| | - Akil Patel
- Department of Kettering Brain and Spine, Kettering Health Main Campus, Kettering, Ohio, United States
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Salem MM, Sioutas GS, Khalife J, Kuybu O, Caroll K, Nguyen Hoang A, Baig AA, Salih M, Khorasanizadeh M, Baker C, Mendez AA, Cortez G, Abecassis ZA, Rodriguez JFR, Davies JM, Narayanan S, Cawley CM, Riina HA, Moore JM, Spiotta AM, Khalessi AA, Howard BM, Hanel R, Tanweer O, Tonetti DA, Siddiqui AH, Lang MJ, Levy EI, Kan P, Jovin T, Grandhi R, Srinivasan VM, Ogilvy CS, Gross BA, Jankowitz BT, Thomas AJ, Levitt MR, Burkhardt JK. General Versus Nongeneral Anesthesia for Middle Meningeal Artery Embolization for Chronic Subdural Hematomas: Multicenter Propensity Score Matched Study. Neurosurgery 2024:00006123-990000000-01069. [PMID: 38412228 DOI: 10.1227/neu.0000000000002874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 12/01/2023] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The choice of anesthesia type (general anesthesia [GA] vs nongeneral anesthesia [non-GA]) in middle meningeal artery embolization (MMAE) procedures for chronic subdural hematomas (cSDH) differs between institutions and left to care team discretion given lack of standard guidelines. We compare the outcomes of GA vs non-GA in MMAE. METHODS Consecutive patients receiving MMAE for cSDH at 14 North American centers (2018-2023) were included. Clinical, cSDH characteristics, and technical/clinical outcomes were compared between the GA/non-GA groups. Using propensity score matching (PSM), patients were matched controlling for age, baseline modified Rankin Scale, concurrent/prior surgery, hematoma thickness/midline shift, and baseline antiplatelet/anticoagulation. The primary end points included surgical rescue and radiographic success rates (≥50% reduction in maximum hematoma thickness with minimum 2 weeks of imaging). Secondary end points included technical feasibility, procedural complications, and functional outcomes. RESULTS Seven hundred seventy-eight patients (median age 73 years, 73.2% male patients) underwent 956 MMAE procedures, 667 (70.4%) were non-GA and 280 were GA (29.6%). After running 1:3 PSM algorithm, this resulted in 153 and 296 in the GA and non-GA groups, respectively. There were no baseline/procedural differences between the groups except radial access more significantly used in the non-GA group (P = .001). There was no difference between the groups in procedural technical feasibility, complications rate, length of stay, surgical rescue rates, or favorable functional outcome at the last follow-up. Subsequent 1:1 sensitivity PSM retained the same results. Bilateral MMAE procedures were more performed under non-GA group (75.8% vs 67.2%; P = .01); no differences were noted in clinical/radiographic outcomes between bilateral vs unilateral MMAE, except for longer procedure duration in the bilateral group (median 73 minutes [IQR 48.3-100] vs 54 minutes [39-75]; P < .0001). Another PSM analysis comparing GA vs non-GA in patients undergoing stand-alone MMAE retained similar associations. CONCLUSION We found no significant differences in radiological improvement/clinical outcomes between GA and non-GA for MMAE.
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Affiliation(s)
- Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Georgios S Sioutas
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Jane Khalife
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Okkes Kuybu
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kate Caroll
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | - Alex Nguyen Hoang
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Ammad A Baig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Mira Salih
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Massachusetts, USA
| | - Mirhojjat Khorasanizadeh
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Massachusetts, USA
| | - Cordell Baker
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Aldo A Mendez
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gustavo Cortez
- Department of Cerebrovascular and Endovascular Surgery, Baptist Neurological Institute and Lyerly Neurosurgery, Jacksonville, Florida, USA
| | - Zachary A Abecassis
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | | | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Sandra Narayanan
- Departments of Neurology and Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - C Michael Cawley
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Howard A Riina
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, USA
| | - Justin M Moore
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Massachusetts, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Alexander A Khalessi
- Department of Neurosurgery, University of California-San Diego, La Jolla, California, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ricardo Hanel
- Department of Cerebrovascular and Endovascular Surgery, Baptist Neurological Institute and Lyerly Neurosurgery, Jacksonville, Florida, USA
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel A Tonetti
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Michael J Lang
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Tudor Jovin
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Massachusetts, USA
| | - Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Ajith J Thomas
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Michael R Levitt
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
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Risch F, Berlis A, Kroencke T, Schwarz F, Maurer CJ. Discrimination of Hemorrhage and Contrast Media in a Head Phantom on Photon-Counting Detector CT Data. AJNR Am J Neuroradiol 2024; 45:183-187. [PMID: 38164551 DOI: 10.3174/ajnr.a8093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/07/2023] [Indexed: 01/03/2024]
Abstract
In this anthropomorphic head phantom study, samples containing blood and contrast agent with concentrations ranging from 0 to 6 mg iodine per milliliter and another set of samples without blood for reference were scanned with a photon-counting detector CT using a standard cranial protocol. It was demonstrated that photon-counting detector CT can reliably distinguish hemorrhage and contrast media, including density determination of the latter. The technology promises to add value in several neuroimaging applications.
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Affiliation(s)
- Franka Risch
- From the Department of Diagnostic and Interventional Radiology (F.R., T.K., F.S.), University Hospital Augsburg, Augsburg, Germany
| | - Ansgar Berlis
- Department of Diagnostic and Interventional Neuroradiology (A.B., C.J.M.), University Hospital Augsburg, Augsburg, Germany
| | - Thomas Kroencke
- From the Department of Diagnostic and Interventional Radiology (F.R., T.K., F.S.), University Hospital Augsburg, Augsburg, Germany
- Centre for Advanced Analytics and Predictive Sciences (T.K.), University Augsburg, Augsburg, Germany
| | - Florian Schwarz
- From the Department of Diagnostic and Interventional Radiology (F.R., T.K., F.S.), University Hospital Augsburg, Augsburg, Germany
- Medical Faculty (F.S.), Ludwig Maximilian University Munich, Munich, Germany
| | - Christoph J Maurer
- Department of Diagnostic and Interventional Neuroradiology (A.B., C.J.M.), University Hospital Augsburg, Augsburg, Germany
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Bodanapally UK, Aarabi B, Liang Y, Khalid M, Fleiter TR, Gandhi D. Quantitative DECT of Iodine in Chronic Subdural Hematoma as Surrogate of Membrane Exudation: A Pilot Feasibility Study. J Comput Assist Tomogr 2023; 47:951-958. [PMID: 37948371 DOI: 10.1097/rct.0000000000001501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
Abstract
OBJECTIVE We explore the feasibility to estimate the exudation from chronic subdural hematoma (CSDH) membranes, by using dual-energy computed tomography (DECT) quantification of iodine leak and test if the derived quantitative variables and membrane morphology correlates with hematoma volume, internal architecture (homogeneous, laminar, separated, and trabecular types), and fractional hyperdense hematoma at presentation. METHODS In this retrospective study, consecutive CSDH patients with postcontrast DECT head images from January 2020 and June 2021 were analyzed. Predictor variables derived from DECT were correlated with outcome variables followed by mixed-effects regression analysis. RESULTS The study included 36 patients with 50 observations (mean age, 72.6 years; standard deviation, 11.6 years); 31 were men. Dual-energy CT variables that correlated with hematoma volume were external membrane volume (ρ, 0.37; P = 0.008) and iodine concentration (ρ, -0.29; P = 0.04). Variables that correlated with separated type of hematoma were total iodine leak (median [Q 1 , Q 3 ], 68.3 mg [48.5, 88.9] vs 38.8 mg [15.5, 62.9]; P = 0.001) and iodine leak per unit membrane volume (median [Q 1 , Q 3 ], 16.47 mg/mL [10.19, 20.65] vs 8.68 mg/mL [5.72, 11.41]; P = 0.002). Membrane grade was the only variable that correlated with fractional hyperdense hematoma (ρ, 0.28; P = 0.05). Regression analysis showed total iodine leak as the strongest predictor of separated type hematoma (odds ratio [95% confidence interval], 1.06 per mg [1.01, 1.1]). CONCLUSIONS Dual-energy CT demonstrates iodine leak from CSDH membranes. The variables derived from DECT correlated with hematoma volume, internal architecture, and fractional hyperdense hematoma.
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Affiliation(s)
| | | | | | - Mazhar Khalid
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | | | - Dheeraj Gandhi
- From the Department of Diagnostic Radiology and Nuclear Medicine
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Su X, Ma Y, Zhang H. Letter to the Editor Regarding "Middle Meningeal Artery Embolization for Membranous versus Nonmembranous Subdural Hematomas: A Retrospective and Multicenter Cohort Study. World Neurosurg 2023; 179:246. [PMID: 38078389 DOI: 10.1016/j.wneu.2023.07.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 07/08/2023] [Indexed: 12/18/2023]
Affiliation(s)
- Xin Su
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yongjie Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
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Omura Y, Ishiguro T. Middle meningeal artery embolization for chronic subdural hematoma: a systematic review. Front Neurol 2023; 14:1259647. [PMID: 37881312 PMCID: PMC10593964 DOI: 10.3389/fneur.2023.1259647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 09/25/2023] [Indexed: 10/27/2023] Open
Abstract
Background Chronic subdural hematoma (cSDH) is one of the most common diseases in neurosurgery. Middle meningeal artery embolization (MMAE) is reportedly an option to prevent recurrence or avoid surgery in patients with cSDH. This study was performed to review the evidence on MMAE for cSDH and evaluate its safety, efficacy, indications, and feasibility. Methods We systematically reviewed the literature according to the PRISMA guidelines using an electronic database. The search yielded 43 articles involving 2,783 patients who underwent MMAE. Results The hematoma resolution, recurrence, and retreatment rates in the MMAE-alone treatment group (n = 815) were 86.7%, 6.3%, and 9.6%, respectively, whereas those in the prophylactic MMAE with combined surgery group (n = 370) were 95.6%, 4.4%, and 3.4%, respectively. The overall MMAE-related complication rate was 2.3%. Conclusion This study shows that MMAE alone is, although not immediate, as effective as evacuation surgery alone in reducing hematoma. The study also shows that combined treatment has a lower recurrence rate than evacuation surgery alone. Because MMAE is a safe procedure, it should be considered for patients with cSDH, especially those with a high risk of recurrence.
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Affiliation(s)
| | - Taichi Ishiguro
- Department of Neurosurgery, Tokyo Women's Medical University Yachiyo Medical Center, Yachiyo, Chiba, Japan
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Mowla A, Abdollahifard S, Farrokhi A, Yousefi O, Valibeygi A, Azami P. Middle Meningeal Artery Embolization with Liquid Embolic Agents for Chronic Subdural Hematoma: A Systematic Review and Meta-analysis. J Vasc Interv Radiol 2023; 34:1493-1500.e7. [PMID: 37182671 DOI: 10.1016/j.jvir.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 04/03/2023] [Accepted: 05/04/2023] [Indexed: 05/16/2023] Open
Abstract
PURPOSE To assess the efficacy and safety of middle meningeal artery (MMA) embolization with liquid embolic agents and the outcomes of patients following this procedure. MATERIALS AND METHODS A review of the literature was conducted to identify studies investigating the efficacy and safety of MMA embolization with liquid embolic agents in patients with chronic subdural hematoma (cSDH) in PubMed, Scopus, Embase, and Web of Science. The keywords "liquid embolic agent," "middle meningeal artery," "cSDH," and "embolization" as well as their synonyms were used to build up the search strategy. The R statistical software and random-effects model were used for analysis. Heterogeneity was reported as I2, and publication bias was calculated using the Egger test. RESULTS Of 628 articles retrieved, 14 studies were eligible to be included in this study. Data of 276 patients were analyzed. n-Butyl cyanoacrylate and ethylene vinyl alcohol copolymer were the most commonly used embolic agents. This study revealed a pooled mortality rate of 0% (95% confidence interval [CI], 0.00%-100%), recurrence and failure rate of 3% (95% CI, 1%-10%), reoperation/reintervention rate of 4% (95% CI, 2%-12%), rate of size decrease of 94% (95% CI, 79%-98%), technical success rate of 100% (95% CI, 76%-100%), and adverse event rate of 1% (95% CI, 0.00%-4%). CONCLUSIONS With low mortality, recurrence, reoperation, and adverse event rates and a remarkable decrease in the size of hematomas, MMA embolization with liquid embolic agents may be considered a safe and effective treatment option in patients in whom surgical intervention has previously failed and as an alternative to conventional treatments.
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Affiliation(s)
- Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, California.
| | - Saeed Abdollahifard
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz; Research Center for Neuromodulation and Pain, Shiraz
| | - Amirmohammad Farrokhi
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz; Research Center for Neuromodulation and Pain, Shiraz
| | - Omid Yousefi
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz
| | - Adib Valibeygi
- Fasa Neuroscience Circle, Student Research Committee, Fasa University of Medical Sciences, Fasa, Iran
| | - Pouria Azami
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz
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Nakagawa I, Kotsugi M, Yokoyama S, Maeoka R, Tamura K, Takeshima Y, Matsuda R, Yamada S, Nishimura F, Park YS, Nakase H. Extensive Roles and Technical Advances of Middle Meningeal Artery Embolization for Chronic Subdural Hematoma. Neurol Med Chir (Tokyo) 2023; 63:327-333. [PMID: 37286481 PMCID: PMC10482489 DOI: 10.2176/jns-nmc.2023-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/03/2023] [Indexed: 06/09/2023] Open
Abstract
Chronic subdural hematoma (CSDH) is a common pathology that typically affects the elderly in Japan, an aging society. Burr-hole irrigation is the standard treatment, but middle meningeal artery (MMA) embolization is a minimally invasive alternative. MMA embolization for CSDH has frequently been reported in recent years, and many technical innovations to improve clinical outcomes have been described. Embolic materials reaching more distally are found to avoid recurrences after MMA embolization. As a result, various studies have described the superiority of embolizing the anterior and posterior branches of the MMA, the advantages of embolic materials reaching beyond the midline, and a high degree of distal penetration using a "sugar rush technique" in which 5% soluble glucose is injected through an intermediate catheter during MMA embolization. Radiographically, reports have described the importance of a "bright falx" sign obtained by infiltrating embolic material beyond the midline and post-embolization enhancement of the dura, capsular membrane, septations, and subdural hematoma fluid as indicators of the spread of embolic materials. This review provides an overview of the current status and future challenges in MMA embolization for CSDH, focusing on technical aspects to improve clinical outcomes.
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12
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Dzaye O, Brahmbhatt A, Abajian A, Moussa AM, Yu KKH, Moss NS, Newman WC, Lis E, Tabar V, Cornelis FH. Middle meningeal artery embolization using cone-beam computed tomography augmented guidance in patients with cancer. Diagn Interv Imaging 2023; 104:368-372. [PMID: 36973119 PMCID: PMC10625426 DOI: 10.1016/j.diii.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/14/2023] [Accepted: 03/15/2023] [Indexed: 03/29/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the safety and efficacy of middle meningeal artery embolization (MMAE) performed under cone-beam computed tomography (CBCT) augmented guidance in patients with cancer. MATERIALS AND METHODS Eleven patients with cancer (seven women, four men; median age, 75 years; age range: 42-87 years) who underwent 17 MMAEs under CBCT with a combination of particles and coils for chronic subdural hematoma (SDH) (n = 6), postoperative SDH (n = 3), or preoperative embolization of meningeal tumor (n = 2) from 2022 to 2023 were included. Technical success, fluoroscopy time (FT), reference dose (RD), kerma area product (KAP) were analyzed. Adverse events and outcomes were recorded. RESULTS The technical success rate was 100% (17/17). Median MMAE procedure duration was 82 min (interquartile range [IQR]: 70, 95; range: 63-108 min). The median FT was 24 min (IQR: 15, 48; range: 21.5-37.5 min); the median RD was 364 mGy (IQR: 37, 684; range: 131.5-444.5 mGy); and the median KAP was 46.4 Gy.cm2 (9.6, 104.5; range: 30.2-56.6 Gy.cm2). No further interventions were needed. The adverse event rate was 9% (1/11), with one pseudoaneurysm at the puncture site in a patient with thrombocytopenia, which was treated by stenting. The median follow-up was 48 days (IQR; 14, 251; range: 18.5-91 days]. SDH reduced in 11 of 15 SDHs (73%) as evidenced by follow-up imaging, with a size reduction greater than 50% in 10/15 SDHs (67%) . CONCLUSION MMAE under CBCT is a highly effective treatment option, but appropriate patient selection and careful consideration of potential risks and benefits is important for optimal patient outcomes.
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Affiliation(s)
- Omar Dzaye
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Weill Cornell Medical College, New York, NY 10065, USA
| | - Akshaar Brahmbhatt
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Weill Cornell Medical College, New York, NY 10065, USA
| | - Aaron Abajian
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Weill Cornell Medical College, New York, NY 10065, USA
| | - Amgad M Moussa
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Weill Cornell Medical College, New York, NY 10065, USA
| | - Kenny K H Yu
- Weill Cornell Medical College, New York, NY 10065, USA; Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Nelson S Moss
- Weill Cornell Medical College, New York, NY 10065, USA; Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - William C Newman
- Weill Cornell Medical College, New York, NY 10065, USA; Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Eric Lis
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Weill Cornell Medical College, New York, NY 10065, USA
| | - Viviane Tabar
- Weill Cornell Medical College, New York, NY 10065, USA; Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Francois H Cornelis
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Weill Cornell Medical College, New York, NY 10065, USA.
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13
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Sioutas GS, Vivanco-Suarez J, Shekhtman O, Matache IM, Salem MM, Burkhardt JK, Srinivasan VM, Jankowitz BT. Liquid embolic agents for middle meningeal artery embolization in chronic subdural hematoma: Institutional experience with systematic review and meta-analysis. Interv Neuroradiol 2023:15910199231183132. [PMID: 37322877 DOI: 10.1177/15910199231183132] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Abstract
INTRODUCTION Chronic subdural hematoma (CSDH) is associated with high recurrence rates. Middle meningeal artery embolization (MMAE) has emerged as a promising treatment option. In this systematic review and meta-analysis, we aimed to assess the safety and efficacy of MMAE for CSDH using liquid embolic agents and compare them with particles. METHODS We systematically reviewed all studies describing MMAE for CSDH with liquid embolic agents, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Additionally, we included a cohort of patients from our institution using liquid and particle embolic agents. Data were analyzed using random-effects proportions and comparisons meta-analysis, and statistical heterogeneity was assessed. RESULTS A total of 18 studies with 507 cases of MMAE with liquid embolic agents (including our institutional experience) were included in the analysis. The success rate was 99% (95% confidence interval [CI]: 98-100%), all complications rate was 1% (95% CI: 0-5%), major complications rate was 0% (95% CI: 0-0%), and mortality rate was 1% (95% CI: 0-6%). The rate of hematoma size reduction was 97% (95% CI: 73-100%), complete resolution 64% (95% CI: 33-87%), radiographic recurrence 3% (95% CI: 1-7%), and reoperation 3% (95% CI: 1-7%). No significant differences in outcomes were found between liquid and particle embolic agents. Sensitivity analyses revealed that liquid embolic agents were associated with lower reoperation rates in upfront MMAE (risk ratio 0.13, 95% CI: 0.02-0.95). CONCLUSION MMAE with liquid embolic agents is safe and effective for the treatment of CSDH. Outcomes are comparable to particles, but liquids were associated with a decreased risk of reoperation in upfront MMAE. However, further studies are needed to support our findings.
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Affiliation(s)
- Georgios S Sioutas
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Juan Vivanco-Suarez
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Oleg Shekhtman
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Irina-Mihaela Matache
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
- Department of Physiology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
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14
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Desir LL, Narayan V, Ellis J, Gordon D, Langer D, Ortiz R, Serulle Y. Middle Meningeal Artery Embolization in the Management of Chronic Subdural Hematoma: a Comprehensive Review of Current Literature. Curr Neurol Neurosci Rep 2023; 23:109-119. [PMID: 37037979 DOI: 10.1007/s11910-023-01262-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2023] [Indexed: 04/12/2023]
Abstract
PURPOSE OF REVIEW Chronic subdural hematoma (cSDH) is a common intracranial hemorrhagic disorder with a high incidence rate among the elderly. While small, asymptomatic cSDH may resolve spontaneously, surgical intervention has been the treatment of choice for larger, symptomatic cases. Surgical evacuation of cSDH may be associated with high rates of recurrence, and even asymptomatic cSDH cases tend to progress. Over the last few years, middle meningeal artery (MMA) embolization has proven to be a safe non-invasive treatment of choice with favorable outcomes and a low recurrence rate. The ensuing paper discusses current treatment modalities for cSDH and reviews existing literature on the anatomy of MMA and its embolization as a treatment option for cSDH. RECENT FINDINGS Recent studies show that traumatic head injury leading to subdural hemorrhage can induce neovascularization that may initiate a cycle of recurrent subdural hematoma. Distal branches of MMA supply blood to the dural layers. Several studies have revealed that embolization of the MMA can stop the neovascularization process and blood flow. In addition, patients who underwent MMA embolization had a significantly quicker brain re-expansion and lower recurrence rate. Although the management of cSDH is still very much a dilemma, recent research findings bring MMA embolization to light as a promising treatment alternative and adjunctive therapy.
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Affiliation(s)
- Likowsky L Desir
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA
- City University of New York School of Medicine, New York, NY, USA
| | - Vinayak Narayan
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA
| | - Jason Ellis
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA
| | - David Gordon
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA
| | - David Langer
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA
| | - Rafael Ortiz
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA
| | - Yafell Serulle
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA.
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
- Neuroendovascular Surgery, Phelps Hospital, Sleepy Hollow, NY, USA.
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15
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Ku JC, Dmytriw AA, Essibayi MA, Banihashemi MA, Vranic JE, Ghozy S, Altschul D, Regenhardt RW, Stapleton CJ, Yang VXD, Patel AB. Embolic Agent Choice in Middle Meningeal Artery Embolization as Primary or Adjunct Treatment for Chronic Subdural Hematoma: A Systematic Review and Meta-analysis. AJNR Am J Neuroradiol 2023; 44:297-302. [PMID: 36797028 PMCID: PMC10187811 DOI: 10.3174/ajnr.a7796] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 01/24/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Middle meningeal artery embolization is an emerging treatment option for chronic subdural hematomas. PURPOSE Our aim was to assess outcomes following middle meningeal artery embolization by different techniques, including in comparison with traditional surgical methods. DATA SOURCES We searched the literature databases from inception to March 2022. DATA SELECTION We selected studies reporting outcomes after middle meningeal artery embolization as a primary or adjunctive treatment for chronic subdural hematoma. DATA ANALYSIS We analyzed the risk of recurrence of chronic subdural hematoma, reoperation for recurrence or residual hematoma, complications, and radiologic and clinical outcomes using random effects modeling. Additional analyses were performed on the basis of whether middle meningeal artery embolization was used as the primary or adjunct treatment and by embolic agent type. DATA SYNTHESIS Twenty-two studies were included with 382 patients with middle meningeal artery embolization and 1373 surgical patients. The rate of subdural hematoma recurrence was 4.1%. Fifty (4.2%) patients underwent a reoperation for a recurrent or residual subdural hematoma. Thirty-six (2.6%) experienced postoperative complications. The rates of good radiologic and clinical outcomes were 83.1% and 73.3%, respectively. Middle meningeal artery embolization was significantly associated with decreased odds of subdural hematoma reoperation (OR = 0.48; 95% CI, 23.4-99.1; P = .047) compared with surgery. The lowest rates of subdural hematoma radiologic recurrence, reoperation, and complications were observed among patients receiving embolization with Onyx, whereas good overall clinical outcome occurred most commonly with combined polyvinyl alcohol and coils. LIMITATIONS A limitation was the retrospective design of studies included. CONCLUSIONS Middle meningeal artery embolization is safe and effective, either as a primary or adjunctive treatment. Treatment using Onyx seems to yield lower rates of recurrence, rescue operation, and complications whereas particles and coils produce good overall clinical outcomes.
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Affiliation(s)
- J C Ku
- From the Division of Neurosurgery (J.C.K.)
| | - A A Dmytriw
- Neuroendovascular Program (A.A.D., J.E.V., R.W.R., C.J.S., A.B.P.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Neurointerventional Program (A.A.D., V.X.D.Y.), Department of Clinical Neurological Sciences & Medical Imaging, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - M A Essibayi
- Departments of Radiology (M.A.E., S.G.), Mayo Clinic, Rochester, Minnesota
- Department of Neurosurgery (M.A.E., D.A.), Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
| | - M A Banihashemi
- Department of Surgery and Institute of Medical Science (M.A.B.), University of Toronto, Toronto, Ontario, Canada
| | - J E Vranic
- Neuroendovascular Program (A.A.D., J.E.V., R.W.R., C.J.S., A.B.P.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - S Ghozy
- Departments of Radiology (M.A.E., S.G.), Mayo Clinic, Rochester, Minnesota
- Nuffield Department of Primary Care Health Sciences and Department for Continuing Education (EBHC program) (S.G.), Oxford University, Oxford, UK
| | - D Altschul
- Department of Neurosurgery (M.A.E., D.A.), Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
| | - R W Regenhardt
- Neuroendovascular Program (A.A.D., J.E.V., R.W.R., C.J.S., A.B.P.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - C J Stapleton
- Neuroendovascular Program (A.A.D., J.E.V., R.W.R., C.J.S., A.B.P.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - V X D Yang
- Neurointerventional Program (A.A.D., V.X.D.Y.), Department of Clinical Neurological Sciences & Medical Imaging, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - A B Patel
- Neuroendovascular Program (A.A.D., J.E.V., R.W.R., C.J.S., A.B.P.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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16
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Msheik A, Fares Y, Mohanna M, Aoude A, Shkeir M, Chehade F, Kanj A, Mohanna A. Middle meningeal artery embolisation: The review of a new treatment for chronic subdural hematomas. Surg Neurol Int 2023; 14:66. [PMID: 36895214 PMCID: PMC9990792 DOI: 10.25259/sni_1096_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/03/2023] [Indexed: 02/26/2023] Open
Abstract
Background This is a literature review aiming to provide an update about the recent findings related to the efficacy of middle meningeal artery embolization (MMAE) in the treatment of chronic subdural hematomas (cSDHs), comparison with conventional therapy and deduction of the current recommendations and indications. Methods The literature is reviewed using a search through the PubMed index using keywords. Studies are then screened, skimmed, and thoroughly read. 32 studies fulfilled the inclusion criteria and are included in the study. Results Five indications for the application of MMA embolization (MMAE) are deducted from the literature. The usage as a preventive measure after surgical treatment of symptomatic cSDHs in patients with a high risk of recurrence and the usage as a standalone procedure has been the most common reasons for indication of this procedure. Rates of failures for the aforementioned indications have been 6.8% and 3.8%, respectively. Conclusion The safety of MMAE as a procedure is regarded as a general theme in the literature and can be considered for future applications. Usage of this procedure in clinical trials with more patient segregation and timeframe assessment relative to surgical intervention are recommendations of this literature review.
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Affiliation(s)
- Ali Msheik
- Department of Neurological Surgery, Lebanese University, Faculty of Medical Sciences
| | - Youssef Fares
- Department of Neurological Surgery, Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Lebanon
| | - Mohammad Mohanna
- Department of Oncology, Cleveland Clinic, Weston, Florida, United States
| | - Ahmad Aoude
- Department of Neurological Surgery, Al Rassoul Al-Azam Hospital
| | - Mohamad Shkeir
- Head of Radiology Department, Zahraa Hospital University Medical Center
| | - Feras Chehade
- Department of Nuclear Medicine Radiobiology Radiopathology, Faculty of Medical Sciences, Lebanese University
| | - Ali Kanj
- Radiology Department, Bahman Hospital, Faculty of Medicine, Lebanese University
| | - Assaad Mohanna
- Head of Department of Radiology, Faculty of Medicine, Lebanese University, Bahman Hospital, Centre Hospitalier Vallee de la Maurienne-France, Beirut, Lebanon
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17
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Shehabeldin M, Amllay A, Jabre R, Chen CJ, Schunemann V, Herial NA, Gooch MR, Mackenzie L, Choe H, Tjoumakaris S, Rosenwasser RH, Jabbour P, Kozak O. Onyx Versus Particles for Middle Meningeal Artery Embolization in Chronic Subdural Hematoma. Neurosurgery 2022; 92:979-985. [PMID: 36700752 DOI: 10.1227/neu.0000000000002307] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 10/14/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Middle meningeal artery (MMA) embolization has recently emerged as a treatment option for chronic subdural hematoma (cSDH). It is considered a simple and potentially safe endovascular procedure. OBJECTIVE To compare between 2 different embolic agents; onyx (ethylene vinyl alcohol) and emboparticles (polyvinyl alcohol particles-PVA) for endovascular treatment of cSDH. METHODS A retrospective analysis of all patients who underwent MMA embolization for cSDH treatment in 2 comprehensive centers between August 2018 and December 2021. Primary outcomes were failure of embolization and need for rescue surgical evacuation. RESULTS Among 97 MMA embolizations, 49 (50.5%) received onyx and 48 (49.5%) received PVA. The presence of acute or subacute on cSDH was higher in the PVA group 11/49 (22.5%) vs 30/48 (62.5%), respectively, P < .001. There were no significant differences between both groups regarding failure of embolization 6/49 (12.2%) vs 12/48 (25.0%), respectively, P = .112, and need of unplanned rescue surgical evacuation 5/49 (10.2%) vs 8/48 (16.7%), respectively, P = .354. Hematoma thickness at late follow-up was significantly smaller in the PVA group 7.8 mm vs 4.6 mm, respectively; P = .017. CONCLUSION Both onyx and PVA as embolic agents for cSDH can be used safely and have comparable clinical and surgical outcomes.
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Affiliation(s)
- Mohamed Shehabeldin
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Abdelaziz Amllay
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Roland Jabre
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, University of Texas Health Science Center, Houston, Texas, USA
| | - Victoria Schunemann
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA.,Department of Neurosurgery, Abington Memorial Hospital, Abington, Pennsylvania, USA
| | - Nabeel A Herial
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Larami Mackenzie
- Neurovascular Division, Abington Memorial Hospital, Jefferson Health, Abington, Pennsylvania, USA
| | - Hana Choe
- Neurovascular Division, Abington Memorial Hospital, Jefferson Health, Abington, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Osman Kozak
- Neurovascular Division, Abington Memorial Hospital, Jefferson Health, Abington, Pennsylvania, USA
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18
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Henry J, Amoo M, Kissner M, Deane T, Zilani G, Crockett MT, Javadpour M. Management of Chronic Subdural Hematoma: A Systematic Review and Component Network Meta-analysis of 455 Studies With 103 645 Cases. Neurosurgery 2022; 91:842-855. [PMID: 36170165 DOI: 10.1227/neu.0000000000002144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 07/14/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a common neurosurgical condition with a high risk of recurrence after treatment. OBJECTIVE To assess and compare the risk of recurrence, morbidity, and mortality across various treatments for CSDH. METHODS A systematic review and meta-analysis was performed. PubMed/MEDLINE, EMBASE, SCOPUS, and Web of Science were searched from January 01, 2000, to July 07, 2021. The primary outcome was recurrence, and secondary outcomes were morbidity and mortality. Component network meta-analyses (CNMAs) were performed for surgical and medical treatments, assessing recurrence and morbidity. Incremental risk ratios (iRRs) with 95% CIs were estimated for each component. RESULTS In total, 12 526 citations were identified, and 455 studies with 103 645 cases were included. Recurrence occurred in 11 491/93 525 (10.8%, 95% CI 10.2-11.5, 418 studies) cases after surgery. The use of a postoperative drain (iRR 0.53, 95% CI 0.44-0.63) and middle meningeal artery embolization (iRR 0.19, 95% CI 0.05-0.83) reduced recurrence in the surgical CNMA. In the pharmacological CNMA, corticosteroids (iRR 0.47, 95% CI 0.36-0.61) and surgical intervention (iRR 0.11, 95% CI 0.07-0.15) were associated with lower risk. Corticosteroids were associated with increased morbidity (iRR 1.34, 95% CI 1.05-1.70). The risk of morbidity was equivalent across surgical treatments. CONCLUSION Recurrence after evacuation occurs in approximately 10% of cSDHs, and the various surgical interventions are approximately equivalent. Corticosteroids are associated with reduced recurrence but also increased morbidity. Drains reduce the risk of recurrence, but the position of drain (subdural vs subgaleal) did not influence recurrence. Middle meningeal artery embolization is a promising treatment warranting further evaluation in randomized trials.
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Affiliation(s)
- Jack Henry
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - Michael Amoo
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.,Department of Neurosurgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Malia Kissner
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Thomas Deane
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Gulam Zilani
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Matthew T Crockett
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.,Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.,Department of Neurosurgery, Royal College of Surgeons in Ireland, Dublin, Ireland.,Department of Academic Neurology, Trinity College Dublin, Dublin, Ireland
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19
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Angiogenetic Factors in Chronic Subdural Hematoma Development. Diagnostics (Basel) 2022; 12:diagnostics12112787. [PMID: 36428849 PMCID: PMC9689028 DOI: 10.3390/diagnostics12112787] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/15/2022] [Accepted: 11/04/2022] [Indexed: 11/16/2022] Open
Abstract
The levels of angiogenic factors were analyzed in eight patients who underwent the embolization of chronic subdural hematoma (CSDH) with non-adhesive liquid embolic agents. Four of these patients had previously undergone surgical treatment for hematoma removal and had recurrences of a similar volume, and four had an increase in hematoma volume due to rebleeding. The levels of vascular endothelial growth factor (VEGF), matrix metallopeptidase 9 (MMP 9), angiopoietin-2 (Ang2), transforming growth factor beta 1 (TGF-β1) and platelet-derived growth factor BB (PDGF-BB) in the arterial and venous blood were analyzed. The most significant results were obtained from the peripheral venous blood samples. The levels of VEGF in the samples of all the patients were close to normal or slightly decreased. There was an increase in the MMP9 levels (the factor that contributes to the disintegration of the vessel wall components) in all the patients. The Ang2 and especially the PDGF TGF-β1 (the factor that plays an important role in the growth of the vessel wall from the already existing blood vessel tissue) levels were distinctly low in most of the cases and slightly elevated only in a number of patients who had previously been operated on. The results obtained show that there is an imbalance in the angiogenesis factors in patients with rebleeding CSDH. At the same time, the factors determining the formation of the vessel wall were reduced, and the levels of factors contributing to the degradation of extracellular matrix components were significantly increased. Such factors could help us to anticipate the increased risk of hemorrhages. Highlights: The levels of VEGF, MMP 9, Ang2, TGF-β1 and PDGF-BB in the arterial and venous blood were analyzed. The most significant results were obtained from the peripheral venous blood samples. The results obtained show that there is an imbalance in the angiogenesis factors in patients with rebleeding CSDH. Such a profile of factors could help us to anticipate the increased risk of hemorrhages.
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20
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DOFUKU S, SATO D, NAKAMURA R, OGAWA S, TORAZAWA S, SATO M, OTA T. Sequential Middle Meningeal Artery Embolization after Burr Hole Surgery for Recurrent Chronic Subdural Hematoma. Neurol Med Chir (Tokyo) 2022; 63:17-22. [PMID: 36223949 PMCID: PMC9894617 DOI: 10.2176/jns-nmc.2022-0164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Middle meningeal artery embolization (MMAE) for chronic subdural hematoma (CSDH) is a novel, minimally invasive treatment. The indications and treatment practices for MMAE are variable and remain controversial. This study aimed to evaluate a strategy involving sequential MMAE after burr hole surgery for treating recurrent CSDH. We performed a retrospective analysis of data from consecutive patients who had undergone MMAE using liquid embolic agents within approximately 2 weeks after burr hole surgery for recurrent CSDH from September 2020 to March 2022. We analyzed patient characteristics, procedural details, CSDH recurrence after MMAE, surgical rescue, and complications. Six of the nine patients who underwent MMAE for CSDH recurrence were male, and the median age was 85 (range, 70-94) years. Five of the nine patients were being administered antithrombotic agents. The median duration between the burr hole surgery and MMAE procedure was 10 (range, 3-25) days. Anterior and posterior convexity branches were targeted for embolization using low-concentration N-butyl cyanoacrylate (NBCA), and the abnormal vascular networks with a cotton wool appearance disappeared after embolization in all cases. The NBCA distribution was observed by high-resolution computed tomography during the procedure; in three of nine cases, the NBCA penetrated not only the MMA but also the inner membrane. No recurrence, surgical rescue, or complications were observed in any patient during the median follow-up period of 3 months. As a minimally invasive treatment for recurrent CSDH, sequential MMAE after burr hole surgery may be a safe and effective option for preventing recurrence.
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Affiliation(s)
- Shogo DOFUKU
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Daisuke SATO
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Rika NAKAMURA
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Shotaro OGAWA
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Seiei TORAZAWA
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Masayuki SATO
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Takahiro OTA
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
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21
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Khorasanizadeh M, Chang YM, Enriquez-Marulanda A, Mizuhashi S, Salem MM, Gomez-Paz S, Siddiq F, Kan P, Moore J, Ogilvy CS, Thomas AJ. Morphological changes in chronic subdural hematomas following upfront middle meningeal artery embolization: sequence, timing, and association with outcomes. J Neurosurg 2022; 137:235-248. [PMID: 34826814 DOI: 10.3171/2021.8.jns211691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 08/09/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Middle meningeal artery embolization (MMAE) is an increasingly utilized approach for the treatment of chronic subdural hematomas (CSDHs). The course of morphological progression of CSDHs following MMAE is poorly understood. Herein, the authors aimed to describe these morphological changes and assess their prognostic significance for the outcomes on follow-up. METHODS A single-institution retrospective cohort study of CSDH cases treated by upfront MMAE, without prior or adjunctive surgical evacuation, was performed. Clinical outcomes, complications, and the need for rescue surgery on follow-up were recorded. Hematomas were categorized into 6 morphological subtypes. All baseline and follow-up head CT scans were assessed for CSDH structural appearance, density, and loculation. Changes in CSDH size were quantified via 3D reconstruction for volumetric measurement. RESULTS Overall, 52 CSDHs in 45 patients treated with upfront MMAE were identified. Hematomas were followed for a mean of 92.9 days. Volume decreased by ≥ 50% in 79.6% of the CSDHs. The overall rescue surgery rate was 9.6%. A sequence of morphological changes after MMAE was identified. Hematomas that diverged from this sequence (5.4%) all progressed toward treatment failure and required rescue surgery. The CSDHs were categorized into early, intermediate, and late stages based on the baseline morphological appearance. Progression from early to intermediate and then to late stage took 12.7 and 30.0 days, respectively, on average. The volume of early/intermediate- and late-stage hematomas decreased by ≥ 50%, a mean of 78.2 and 47.6 days after MMAE, respectively. Early- and intermediate-stage hematomas showed a trend toward more favorable outcomes compared with late-stage hematomas. The density of homogeneous hypodense hematomas (HSDHs) transiently increased immediately after MMAE (p < 0.001). A marked decrease in density and volume 1 to 3 weeks after MMAE in HSDHs was detected, the lack of which indicated an eventual need for rescue surgery. In HSDHs, a baseline mean density of < 20 HU, and a lower density than baseline by 1 month post-MMAE were predictors of favorable outcomes. The baseline hematoma volume, axial thickness, midline shift, and loculation were not correlated with MMAE outcomes. Loculated, trabecular, and laminar hematomas, which are known to have unfavorable surgical outcomes, had MMAE outcomes similar to those of other "surgical" hematomas. CONCLUSIONS The current study was the first to describe the nature, sequence, and timing of morphological changes of CSDHs after MMAE treatment and has identified structural features that can predict treatment outcomes.
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Affiliation(s)
| | - Yu-Ming Chang
- 2Neuroradiology Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | - Satomi Mizuhashi
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Mohamed M Salem
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Santiago Gomez-Paz
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Farhan Siddiq
- 3Division of Neurosurgery, University of Missouri, Columbia, Missouri; and
| | - Peter Kan
- 4Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas
| | - Justin Moore
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Christopher S Ogilvy
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Ajith J Thomas
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
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22
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Di Cristofori A, Remida P, Patassini M, Piergallini L, Buonanno R, Bruno R, Carrabba G, Pavesi G, Iaccarino C, Giussani CG. Middle meningeal artery embolization for chronic subdural hematomas. A systematic review of the literature focused on indications, technical aspects, and future possible perspectives. Surg Neurol Int 2022; 13:94. [PMID: 35399896 PMCID: PMC8986643 DOI: 10.25259/sni_911_2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 02/14/2022] [Indexed: 12/20/2022] Open
Abstract
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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Affiliation(s)
- Andrea Di Cristofori
- Unit of Neurosurgery, Azienda Socio SanitariaTerritoriale - Monza, Ospedale San Gerardo,
| | - Paolo Remida
- Unit of Neuroradiology, Azienda Socio Sanitaria Territoriale - Monza, Ospedale San Gerardo, Monza,
| | - Mirko Patassini
- Unit of Neuroradiology, Azienda Socio Sanitaria Territoriale - Monza, Ospedale San Gerardo, Monza,
| | - Lorenzo Piergallini
- Unit of Neuroradiology, Azienda Socio Sanitaria Territoriale - Monza, Ospedale San Gerardo, Monza,
| | - Raffaella Buonanno
- Unit of Neurosurgery, Azienda Socio SanitariaTerritoriale - Monza, Ospedale San Gerardo,
- Unit of Neurosurgery, School of Medicine and Surgery, Department of Medicine and Surgery, Università degli Studi Milano Bicocca, Milan,
| | - Raffaele Bruno
- Unit of Neurosurgery, Azienda Socio SanitariaTerritoriale - Monza, Ospedale San Gerardo,
- Unit of Neurosurgery, School of Medicine and Surgery, Department of Medicine and Surgery, Università degli Studi Milano Bicocca, Milan,
| | - Giorgio Carrabba
- Unit of Neurosurgery, Azienda Socio SanitariaTerritoriale - Monza, Ospedale San Gerardo,
- Unit of Neurosurgery, School of Medicine and Surgery, Department of Medicine and Surgery, Università degli Studi Milano Bicocca, Milan,
| | - Giacomo Pavesi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia,
- Neurosurgery Division, University Hospital of Modena, Modena, Italy
| | - Corrado Iaccarino
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia,
- Neurosurgery Division, University Hospital of Modena, Modena, Italy
| | - Carlo Giorgio Giussani
- Unit of Neurosurgery, Azienda Socio SanitariaTerritoriale - Monza, Ospedale San Gerardo,
- Unit of Neurosurgery, School of Medicine and Surgery, Department of Medicine and Surgery, Università degli Studi Milano Bicocca, Milan,
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23
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Zhu F, Wang H, Li W, Han S, Yuan J, Zhang C, Li Z, Fan G, Liu X, Nie M, Bie L. Factors correlated with the postoperative recurrence of chronic subdural hematoma: An umbrella study of systematic reviews and meta-analyses. EClinicalMedicine 2022; 43:101234. [PMID: 34988412 PMCID: PMC8703229 DOI: 10.1016/j.eclinm.2021.101234] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/08/2021] [Accepted: 11/24/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a common neurological disease, and the surgical evacuation of subdural collection remains the primary treatment approach for symptomatic patients. Postoperative recurrence is a serious complication, and several factors are correlated with postoperative recurrence. METHODS We searched Embase, Web of Science, PubMed, and Cochrane Library from their establishment to September 2020. Reports on randomized, prospective, retrospective, and overall observational studies on the management of surgical patients with CSDH were searched, and an independent reviewer performed research quality assessment. Factors that affect the postoperative recurrence of CSDH were extracted: social demographics, drugs (as the main or auxiliary treatment), surgical management, imaging, and other risk factors. We evaluated the recurrence rate of each risk factor. A random effect model was used to perform a meta-analysis, and each risk factor affecting the postoperative recurrence of CSDH was then evaluated and graded. FINDINGS In total, 402 studies were included in this analysis and 32 potential risk factors were evaluated. Among these, 21 were significantly associated with the postoperative recurrence of CSDH. Three risk factors (male, bilateral hematoma, and no drainage) had convincing evidence. The classification of evidence can help clinicians identify significant risk factors for the postoperative recurrence of CSDH. INTERPRETATION Only few associations were supported by high-quality evidence. Factors with high-quality evidence may be important for treating and preventing CSDH recurrence. Our results can be used as a basis for improving clinical treatment strategies and designing preventive methods. FUNDING No funding was received.
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Affiliation(s)
- Fulei Zhu
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Haifeng Wang
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Wenchen Li
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Shuai Han
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Jiangyuan Yuan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Chunyun Zhang
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Zean Li
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Guangyan Fan
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Xuanhui Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Meng Nie
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Li Bie
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
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24
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Endovascular Treatment of Chronic Subdural Hematomas through Embolization: A Pilot Study with a Non-Adhesive Liquid Embolic Agent of Minimal Viscosity (Squid). J Clin Med 2021; 10:jcm10194436. [PMID: 34640453 PMCID: PMC8509410 DOI: 10.3390/jcm10194436] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/17/2021] [Accepted: 09/18/2021] [Indexed: 11/17/2022] Open
Abstract
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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25
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Ironside N, Nguyen C, Do Q, Ugiliweneza B, Chen CJ, Sieg EP, James RF, Ding D. Middle meningeal artery embolization for chronic subdural hematoma: a systematic review and meta-analysis. J Neurointerv Surg 2021; 13:951-957. [PMID: 34193592 DOI: 10.1136/neurintsurg-2021-017352] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 06/13/2021] [Indexed: 12/13/2022]
Abstract
Middle meningeal artery (MMA) embolization has been proposed as a minimally invasive treatment for chronic subdural hematoma (cSDH). The aim of this systematic review and meta-analysis is to compare outcomes after MMA embolization versus conventional management for cSDH. We performed a systematic review of PubMed, Embase, Oxford Journal, Cochrane, and Google Scholar databases from April 1987 to October 2020 in accordance with PRISMA guidelines. Studies reporting outcomes after MMA embolization for ≥3 patients with cSDH were included. A meta-analysis comparing MMA embolization with conventional management was performed. The analysis comprised 20 studies with 1416 patients, including 718 and 698 patients in the MMA embolization and conventional management cohorts, respectively. The pooled recurrence, surgical rescue, and in-hospital complication rates in the MMA embolization cohort were 4.8% (95% CI 3.2% to 6.5%), 4.4% (2.8% to 5.9%), and 1.7% (0.8% to 2.6%), respectively. The pooled recurrence, surgical rescue, and in-hospital complication rates in the conventional management cohort were 21.5% (0.6% to 42.4%), 16.4% (5.9% to 27.0%), and 4.9% (2.8% to 7.1%), respectively. Compared with conservative management, MMA embolization was associated with lower rates of cSDH recurrence (OR=0.15 (95% CI 0.03 to 0.75), p=0.02) and surgical rescue (OR=0.21 (0.07 to 0.58), p=0.003). In-hospital complication rates were comparable between the two cohorts (OR=0.78 (0.34 to 1.76), p=0.55). MMA embolization is a promising minimally invasive therapy that may reduce the need for surgical intervention in appropriately selected patients with cSDH. Additional prospective studies are warranted to determine the long-term durability of MMA embolization, refine eligibility criteria, and establish this endovascular approach as a viable definitive treatment for cSDH.
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Affiliation(s)
- Natasha Ironside
- Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Candice Nguyen
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Quan Do
- Department of Internal Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Beatrice Ugiliweneza
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Emily P Sieg
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Robert F James
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dale Ding
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
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26
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Enriquez-Marulanda A, Gomez-Paz S, Salem MM, Mallick A, Motiei-Langroudi R, Arle JE, Stippler M, Papavassiliou E, Alterman RL, Ogilvy CS, Moore JM, Thomas AJ. Middle Meningeal Artery Embolization Versus Conventional Treatment of Chronic Subdural Hematomas. Neurosurgery 2021; 89:486-495. [PMID: 34171921 DOI: 10.1093/neuros/nyab192] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 04/03/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Middle meningeal artery (MMA) embolization is an emerging minimally invasive endovascular technique for chronic subdural hematoma (cSDH). Currently, limited literature exists on its safety and efficacy compared with conventional treatment (open-surgical-evacuation-only). OBJECTIVE To compare MMA embolization to conventional treatment. METHODS Retrospective analysis of patients with cSDHs treated with MMA embolization in a single center from 2018 to 2019 was performed. Comparisons were made with a historical conventional treatment cohort from 2006 to 2016. Propensity score matching analysis was used to assemble a balanced group of subjects. RESULTS A total of 357 conventionally treated cSDH and 45 with MMA embolization were included. After balancing with propensity score matching, a total of 25 pairs of cSDH were analyzed. Comparing the embolization with the conventional treatment group yielded no significant differences in complications (4% vs 4%; P > .99), clinical improvement (82.6% vs 83.3%; P = .95), cSDH recurrence (4.3% vs 21.7%; P = .08), overall re-intervention rates (12% vs 24%; P = .26), modified Rankin scale >2 on last follow-up (17.4% vs 32%; P = .24), as well as mortality (0% vs 12%; P = .09). Radiographic improvement at last follow-up was significantly higher in the open surgery cohort (73.9% vs 95.6%; P = .04). However, there was a trend for lengthier last follow-up for the historical cohort (72 vs 104 d; P = .07). CONCLUSION There was a trend for lower recurrence and mortality rates in the embolization era cohort. There were significantly higher radiological improvement rates on last follow-up in the surgical only cohort era. There were no significant differences in complications and clinical improvement.
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Affiliation(s)
| | - Santiago Gomez-Paz
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mohamed M Salem
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Akashleena Mallick
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - J E Arle
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Martina Stippler
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Efstathios Papavassiliou
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ron L Alterman
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin M Moore
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith J Thomas
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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27
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Naveed MZ, Wang P, Lee R, Taghipour M, Brady P. Utilizing dual energy CT to distinguish blood from contrast leakage following middle meningeal artery embolization for chronic subdural hematomas. J Neurointerv Surg 2021; 13:964-967. [PMID: 33883211 DOI: 10.1136/neurintsurg-2020-016953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 02/22/2021] [Accepted: 02/24/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Recently, middle meningeal artery (MMA) embolization has emerged as a potential alternative treatment option for chronic subdural hematomas (SDH). Imaging following MMA embolization often shows high density material in the subdural space, usually representing contrast leakage through the dura or, less commonly, hemorrhage. These cannot be reliably differentiated on conventional CT. Dual energy CT (DECT) provides the ability to differentiate materials that otherwise appear similar on conventional CT such as blood and iodine. METHODS A retrospective review was conducted to evaluate patients who underwent MMA embolization for SDH between May 2019 and April 2020. Post-procedural head CT performed on an IQon Elite Spectral CT detector-based DECT scanner enabled two-material decomposition to separate iodine from blood. The dual energy reconstructions used included the virtual non-contrast and iodine no-water images. RESULTS Four representative illustrative cases were selected to highlight the ability of DECT to characterize new hyperdensity on head CT following MMA embolization as blood, contrast or a combination. CONCLUSIONS DECT allows objective differentiation of contrast leakage from blood following MMA embolization. This technology can obviate the need for additional follow-up scanning and prolonged patient observation, which in turn can result in reduced costs and radiation exposure to patients.
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Affiliation(s)
- Mujtaba Zaki Naveed
- Interventional Radiology, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA
| | - Peter Wang
- Diagnostic Radiology, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA
| | - Ryan Lee
- Diagnostic Radiology, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA
| | - Mehdi Taghipour
- Interventional Radiology, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA
| | - Paul Brady
- Interventional Radiology, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA
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28
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Shotar E, Pouliquen G, Premat K, Pouvelle A, Mouyal S, Meyblum L, Lenck S, Degos V, Abi Jaoude S, Sourour N, Mathon B, Clarençon F. CTA-Based Patient-Tailored Femoral or Radial Frontline Access Reduces the Rate of Catheterization Failure in Chronic Subdural Hematoma Embolization. AJNR Am J Neuroradiol 2021; 42:495-500. [PMID: 33541902 DOI: 10.3174/ajnr.a6951] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 10/12/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Chronic subdural hematoma embolization, an apparently simple procedure, can prove to be challenging because of the advanced age of the target population. The aim of this study was to compare 2 arterial-access strategies, femoral versus patient-tailored CTA-based frontline access selection, in chronic subdural hematoma embolization procedures. MATERIALS AND METHODS This was a monocentric retrospective study. From the March 15, 2018, to the February 14, 2019 (period 1), frontline femoral access was used. Between February 15, 2019, and March 30, 2020 (period 2), the choice of the frontline access, femoral or radial, was based on the CTA recommended as part of the preoperative work-up during both above-mentioned periods. The primary end point was the rate of catheterization failure. The secondary end points were the rate of access site conversion and fluoroscopy duration. RESULTS During the study period, 124 patients (with 143 chronic subdural hematomas) underwent an embolization procedure (mean age, 74 [SD, 13] years). Forty-eight chronic subdural hematomas (43 patients) were included during period 1 and were compared with 95 chronic subdural hematomas (81 patients) during period 2. During the first period, 5/48 (10%) chronic subdural hematoma embolizations were aborted due to failed catheterization, significantly more than during period 2 (1/95, 1%; P = .009). The rates of femoral-to-radial (P = .55) and total conversion (P = .86) did not differ between the 2 periods. No significant difference was found regarding the duration of fluoroscopy (P = .62). CONCLUSIONS A CTA-based patient-tailored choice of frontline arterial access reduces the rate of catheterization failure in chronic subdural hematoma embolization procedures.
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Affiliation(s)
- E Shotar
- From the Department of Neuroradiology (E.S., G.P., K.P., A.P., S.M., L.M., S.L., N.S., F.C.)
| | - G Pouliquen
- From the Department of Neuroradiology (E.S., G.P., K.P., A.P., S.M., L.M., S.L., N.S., F.C.)
| | - K Premat
- From the Department of Neuroradiology (E.S., G.P., K.P., A.P., S.M., L.M., S.L., N.S., F.C.).,Sorbonne Université (K.P., V.D., S.A.J., B.M., F.C.), Paris, France
| | - A Pouvelle
- From the Department of Neuroradiology (E.S., G.P., K.P., A.P., S.M., L.M., S.L., N.S., F.C.)
| | - S Mouyal
- From the Department of Neuroradiology (E.S., G.P., K.P., A.P., S.M., L.M., S.L., N.S., F.C.)
| | - L Meyblum
- From the Department of Neuroradiology (E.S., G.P., K.P., A.P., S.M., L.M., S.L., N.S., F.C.)
| | - S Lenck
- From the Department of Neuroradiology (E.S., G.P., K.P., A.P., S.M., L.M., S.L., N.S., F.C.)
| | - V Degos
- Neurosurgical Anesthesiology and Critical Care (V.D.).,Sorbonne Université (K.P., V.D., S.A.J., B.M., F.C.), Paris, France
| | - S Abi Jaoude
- Neurosurgery (S.A.J., B.M.), Pitié-Salpêtrière Hospital, Paris, France.,Sorbonne Université (K.P., V.D., S.A.J., B.M., F.C.), Paris, France
| | - N Sourour
- From the Department of Neuroradiology (E.S., G.P., K.P., A.P., S.M., L.M., S.L., N.S., F.C.)
| | - B Mathon
- Neurosurgery (S.A.J., B.M.), Pitié-Salpêtrière Hospital, Paris, France.,Sorbonne Université (K.P., V.D., S.A.J., B.M., F.C.), Paris, France
| | - F Clarençon
- From the Department of Neuroradiology (E.S., G.P., K.P., A.P., S.M., L.M., S.L., N.S., F.C.).,Sorbonne Université (K.P., V.D., S.A.J., B.M., F.C.), Paris, France
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29
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Catapano JS, Ducruet AF, Nguyen CL, Baranoski JF, Cole TS, Majmundar N, Wilkinson DA, Fredrickson VL, Cavalcanti DD, Albuquerque FC. Middle meningeal artery embolization for chronic subdural hematoma: an institutional technical analysis. J Neurointerv Surg 2020; 13:657-660. [PMID: 33077579 DOI: 10.1136/neurintsurg-2020-016552] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/29/2020] [Accepted: 10/01/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Recently, middle meningeal artery (MMA) embolization has emerged as a potentially safe and effective method of treating chronic subdural hematoma (cSDH). OBJECTIVE To report a single-center experience with MMA embolization and examines the type of embolic material used, the extent of penetration, and the number of MMA branches embolized. METHODS A retrospective analysis of all patients with MMA embolization from 2018 through 2019 was performed. A failed outcome was defined as either surgical rescue and/or greater than 10 mm of hematoma residual or reaccumulation following embolization. RESULTS Of 35 patients, surgery had failed for 9 (26%) and initial conservative treatment had failed for 6 (17%). Of 41 MMA embolizations, including those in six patients with bilateral cSDH who underwent bilateral MMA embolization, 29 (72%) were performed using ethylene vinyl alcohol copolymer (Onyx), 7 (17%) using particles, and 5 (12%) using n-butyl cyanoacrylate. Both the anterior and posterior MMA divisions were embolized in 29 cases (71%); distal penetration of these branches was achieved in 25 embolizations (61%). Twenty-six (63%) cSDHs completely resolved. Complete resolution was seen in 22 of 29 hematomas (76%) in which both anterior and posterior MMA branches were occluded versus 4 of 12 (33%) following single-branch embolization (p=0.014). Embolization of one cSDH (2%) failed. CONCLUSION MMA embolization of cSDHs appears to be both safe and efficacious. Furthermore, embolization of both the anterior and posterior MMA branches may be associated with increased odds of complete resolution.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Candice L Nguyen
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | | | | | - Vance L Fredrickson
- Department of Neurosurgery, University of Southern California, Los Angeles, California, USA
| | - Daniel D Cavalcanti
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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30
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Moshayedi P, Liebeskind DS. Middle Meningeal Artery Embolization in Chronic Subdural Hematoma: Implications of Pathophysiology in Trial Design. Front Neurol 2020; 11:923. [PMID: 32973670 PMCID: PMC7481478 DOI: 10.3389/fneur.2020.00923] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/17/2020] [Indexed: 01/24/2023] Open
Abstract
Background: Chronic subdural hematoma (cSDH) is a debilitating condition with a high rate of recurrence after surgical evacuation. Summary: This review is focused on middle meningeal artery (MMA) embolization to treat cSDH. We discuss the underlying pathophysiology of chronic subdural hematoma and how cessation of arterial flow may resolve a venous hemorrhage. We also present the current evidence for MMA embolization and the roadmap for future trials. Conclusion: Frequent multimodal imaging and cSDH sampling would enable us to understand mechanisms of MMA embolization in cSDH treatment and therefore improve our ability to offer MMA embolization to the eligible population.
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Affiliation(s)
- Pouria Moshayedi
- Department of Neurology, UCLA Comprehensive Stroke Center, University of California, Los Angeles, Los Angeles, CA, United States
| | - David S Liebeskind
- Department of Neurology, UCLA Comprehensive Stroke Center, University of California, Los Angeles, Los Angeles, CA, United States
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31
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Mureb MC, Kondziolka D, Shapiro M, Raz E, Nossek E, Haynes J, Farkas J, Riina HA, Tanweer O. DynaCT Enhancement of Subdural Membranes After Middle Meningeal Artery Embolization: Insights into Pathophysiology. World Neurosurg 2020; 139:e265-e270. [DOI: 10.1016/j.wneu.2020.03.188] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 02/02/2023]
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32
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Shotar E, Meyblum L, Premat K, Lenck S, Degos V, Grand T, Cortese J, Pouvelle A, Pouliquen G, Mouyal S, Boch AL, Carpentier A, Sourour NA, Mathon B, Clarençon F. Middle meningeal artery embolization reduces the post-operative recurrence rate of at-risk chronic subdural hematoma. J Neurointerv Surg 2020; 12:1209-1213. [PMID: 32439812 DOI: 10.1136/neurintsurg-2020-016048] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 04/22/2020] [Accepted: 04/25/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Embolization of the middle meningeal artery (MMA) has emerged as a potential treatment of chronic subdural hematomas (CSDHs). OBJECTIVE To evaluate the impact on recurrence rate of postsurgical embolization of CSDH in patients with a higher than average risk of recurrence. METHODS A monocentric retrospective study was performed on retrospectively collected data. From March 2018 to December 2019, embolization of the MMA was proposed as an adjunct postoperative treatment after burr-hole surgery in patients operated for a recurrent CSDH or a CSDH with an independent recurrence risk factor, including antiplatelet therapy, full anticoagulation therapy, coagulation disorder, hepatopathy, or chronic alcoholism. Patients who had undergone postoperative embolization were compared with a historic group of patients operated between March 2016 and March 2018, selected based on the same inclusion criteria. RESULTS During the study period, 89 patients (with 74 unilateral and 15 bilateral CSDHs) were included and underwent an embolization procedure, leading to 91 out of a total of 104 MMA being embolized (88%). These were compared with 174 patients (138 unilateral and 36 bilateral CSDH) in the historic control group. One major procedure-related adverse event was registered. Four of the 89 patients (4%) required surgery for a CSDH recurrence in the embolization group, significantly less than the 24 of 174 patients (14%) in the control group (OR=0.28, 95% CI 0.07 to 0.86, p=0.02). CONCLUSIONS Postsurgical embolization of the MMA may reduce the recurrence rate of CSDHs with a risk factor of recurrence.
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MESH Headings
- Aged
- Aged, 80 and over
- Embolization, Therapeutic/adverse effects
- Embolization, Therapeutic/methods
- Embolization, Therapeutic/trends
- Female
- Hematoma, Subdural, Chronic/diagnostic imaging
- Hematoma, Subdural, Chronic/epidemiology
- Hematoma, Subdural, Chronic/surgery
- Humans
- Male
- Meningeal Arteries/diagnostic imaging
- Meningeal Arteries/surgery
- Middle Aged
- Postoperative Complications/diagnostic imaging
- Postoperative Complications/epidemiology
- Postoperative Complications/prevention & control
- Plastic Surgery Procedures/adverse effects
- Plastic Surgery Procedures/methods
- Plastic Surgery Procedures/trends
- Recurrence
- Retrospective Studies
- Risk Factors
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Affiliation(s)
- Eimad Shotar
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Louis Meyblum
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Kevin Premat
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
- Sorbonne Université, Paris, France
| | - Stéphanie Lenck
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Vincent Degos
- Sorbonne Université, Paris, France
- Neurosurgical Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Teodor Grand
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Jonathan Cortese
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Arnaud Pouvelle
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | | | - Samuel Mouyal
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Anne-Laure Boch
- Department of Neurosurgery, Pitié-Salpêtrière Hospital, Paris, France
| | - Alexandre Carpentier
- Sorbonne Université, Paris, France
- Department of Neurosurgery, Pitié-Salpêtrière Hospital, Paris, France
| | | | - Bertrand Mathon
- Sorbonne Université, Paris, France
- Department of Neurosurgery, Pitié-Salpêtrière Hospital, Paris, France
| | - Frédéric Clarençon
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
- Sorbonne Université, Paris, France
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