Implantation of a reservoir for refractory chronic subdural hematoma

Efficacy and safety of middle meningeal artery embolization in the management of refractory or chronic subdural hematomas: a systematic review and meta-analysis

INTRODUCTION

Refractory or chronic subdural hematomas (cSDH) constitute a challenging entity that neurosurgeons face frequently nowadays. Middle meningeal artery embolization (MMAE) has emerged in the recent years as a promising treatment option. However, solid evidence that can dictate management guidelines is still lacking.

METHODS

We conducted a systematic review and meta-analysis (MA) in compliance with the PRISMA guidelines to evaluate the efficacy and safety of MMAE compared with conventional treatments for refractory or cSDH. Databases were searched up to March 2019. Using a random-effects model, meta-analyses of proportions and risk difference were conducted recurrence, need for surgical rescue, and complications.

RESULTS

Eleven studies (177 patients) were included. Majority (116, 69%) were males with a weighted mean age of 71 + -19.5 years. Meta-analysis of proportions showed treatment failure to be 2.8%, need for surgical rescue 2.7%, and embolization-related complications 1.2%. Meta-analysis of risk-difference between embolized and non-embolized patients showed a 26% (p < 0.001, 95% CI 21%-31%, I² = 0) lower risk of hematoma recurrence in MMAE. Similarly, in the embolized group, the need for surgical rescue was 20% less (p < 0.001, 95% CI = 12%-27%, I² = 12.4), and complications were 3.6% less (p = 0.008, 95% CI 1%-6%, I² = 0) compared to conventional groups.

CONCLUSIONS

Although MMAE appears to be a promising treatment for refractory or cSDH, drawing definitive conclusions remains limited by paucity of data and small sample sizes. Multicenter, randomized, prospective trials are needed to compare embolization to conventional treatments like watchful waiting, medical management, or surgical evacuation. More extensive research on MMAE could begin a new era in the minimally invasive management of cSDH.

Angiogenesis in the Septum and Inner Membrane of Refractory Chronic Subdural Hematomas: Consideration of Findings after Middle Meningeal Artery Embolization with Low-concentration n-butyl-2-cyanoacrylate

The middle meningeal artery (MMA) is suggested to play an important role in the recurrence of chronic subdural hematomas (CSDHs). However, the exact mechanisms involved in the recurrence of CSDHs still remain unknown. For recurring CSDHs, MMA embolization is performed using low-concentration n-butyl-2-cyanoacrylate (NBCA) at our hospital. We report new findings and a discussion related to the mechanism of CSDH recurrence based on the imaging findings after MMA embolization, and cases that required craniotomy due to recurrence. The study included eight patients with recurrent CSDH, defined as ipsilateral hematoma re-enlargement within 3 months, and treated with MMA embolization. MMA embolization was performed successfully in all eight patients with no complications. Of the eight patients treated, one patient required craniotomy for the evacuation of CSDHs due to hematoma re-enlargement. NBCA casts were observed in the inner membrane of CSDHs in five of the eight patients by postoperative computed tomography scans. In the case that required craniotomy, the formation of neovasculatures was observed in the inner membrane of the CSDH. Our results suggested that angiogenesis also occurs in the septum and inner membrane through the MMA and the outer membrane of the CSDH. Additionally, these neovascular vessels may be involved in the recurrence of CSDH after MMA embolization. In a future larger study, it is necessary to elucidate in detail the vascular architecture of the CSDH membrane associated with the hematoma re-enlargement, and the effectiveness of MMA embolization that embolized to these peripheral neovascular vessels.

How to Treat Chronic Subdural Hematoma? Past and Now

Treatment of chronic subdural hematoma (CSDH) is relatively straightforward, however, there is still some debate regarding the best strategy for treatment. The most practical recommendations of up to date were identified by a review of literature. The author reviewed the literature on CSDH management from the past to now to identify the best methods. Till 1970s, craniotomy was the most commonly used method. Burr hole (BH) became the most preferred method from 1980s. In 1977, twist drill (TD) craniostomy was introduced. Closed system drainage after a BH or a TD became the most frequently used surgical method. Although nonsurgical treatment is often successful, trephination has more advantages, such as rapid resolution of the symptoms and short period of hospitalization. Nonsurgical treatment is possible in asymptomatic patients with a small CSDH. For the symptomatic patients with CSDH, trephination is the treatment of choice, either by BH or TD. In gray zone between surgery and medical treatment, shared decision making can be an ideal approach. For the recurrent CSDHs, repeated trephination is still effective for patients with a low risk of recurrence. If the risk of recurrence is high, additional management would be helpful. For the refractory CSDHs, it is necessary to obliterate the subdural space.

Fibrin glue injection into the hematoma cavity for refractory chronic subdural hematoma: A case report

Background:

Repeat burr hole irrigation and drainage has been effective in most cases of recurrent chronic subdural hematoma (CSDH), however, refractory cases require further procedures or other interventions.

Case Description:

An 85-year-old male presented with left CSDH, which recurred five times. The hematoma was irrigated and drained through a left frontal burr hole during the first to third surgery and through a left parietal burr hole during the fourth and fifth surgery. The hematoma had no septation and was well-evacuated during each surgery. Antiplatelet therapy for preventing ischemic heart disease was stopped after the second surgery, the hematoma cavity was irrigated with artificial cerebrospinal fluid at the third surgery, and the direction of the drainage tube was changed to reduce the postoperative subdural air collection at the fourth surgery. However, none of these interventions was effective. He was successfully treated by fibrin glue injection into the hematoma cavity after the fifth surgery.

Conclusion:

This procedure may be effective for refractory CSDH in elderly patients.

Middle Meningeal Artery Embolization in Recurrent Chronic Subdural Hematoma Combined with Arachnoid Cyst

Chronic subdural hematoma (CSDH) is a collection of old blood and its breakdown products between the surface of the brain parenchyma and the outermost layer called the dura. The most common treatment option for primary CSDH is burr-hole trephination; however, the treatment method for recurrent CSDH is still widely debated. An arachnoid cyst (AC) is a sac filled with cerebrospinal fluid located between the brain or spinal cord and the arachnoid membrane, which is one of the three meninges covering the brain or spinal cord. Although it is rare, the cyst is associated with CSDH in juveniles, and the recurrence rate of CSDH increases in such cases. Much of the literature has supported the preventive role of middle meningeal artery (MMA) embolization in recurrent CSDH. We report a 13-year-old male patient with recurrent CSDH and AC where the early intervention of MMA embolization was proven effective in preventing the further recurrence of CSDH.

Usefulness of interventional embolization of the middle meningeal artery for recurrent chronic subdural hematoma: Five cases and a review of the literature

PURPOSE

Although several strategies against recurrent chronic subdural hematoma (CSDH) have been proposed, no consensus has been established. Recently, middle meningeal artery (MMA) embolization has been proposed as radical treatment for recurrent CSDH. We wanted to estimate the usefulness of MMA embolization for recurrent CSDH.

METHODS

From February 2012 to June 2013, 110 patients with CSDH underwent single burr-hole surgery with irrigation and drainage. Among these patients, 13 showed recurrent hematoma formation and were retreated surgically. Furthermore, repeated recurrence of CSDH was observed in six patients. Five of these six patients underwent middle meningeal artery (MMA) embolization with polyvinyl alcohol particles. All five patients with interventional treatment were observed for four to 60 weeks.

RESULTS

No more recurrence of CSDH was observed in any of the patients. During the follow-up period, no patients suffered from any side effects or complications from the interventional treatment.

CONCLUSION

MMA embolization with careful attention paid to the procedure might be a treatment of choice for recurrent CSDH.

Recurrence of a Refractory Chronic Subdural Hematoma after Middle Meningeal Artery Embolization That Required Craniotomy

Middle meningeal artery (MMA) embolization has been performed to treat refractory chronic subdural hematoma (CSDH) with good reported outcomes. We have treated three cases of CSDH with MMA embolization to date, but there was a postoperative recurrence in one patient, which required a craniotomy for hematoma removal and capsulectomy. MMA embolization blocks the blood supply from the dura to the hematoma outer membrane in order to prevent recurrences of refractory CSDH. Histopathologic examination of the outer membrane of the hematoma excised during craniotomy showed foreign-body giant cells and neovascular proliferation associated with embolization. Because part of the hematoma was organized in this case, the CSDH did not resolve when the MMA was occluded, and the development of new collateral pathways in the hematoma outer membrane probably contributed to the recurrence. Therefore, in CSDH with some organized hematoma, MMA embolization may not be effective. Magnetic resonance imaging (MRI) should be performed in these patients before embolization.

Pneumocephalus after surgical evacuation of chronic subdural hematoma: Is it a serious complication?

Background:

Pneumocephalus is commonly encountered after surgical evacuation of chronic subdural hematoma (CSDH). This study was done to study the incidence, clinical presentation, and management of patients who developed pneumocephalus after surgical evacuation of CSDH.

Materials and Methods:

This prospective study was carried out on consecutive 50 patients who had received surgical treatment for CSDH. All the patients included were followed-up postoperatively with regular clinical and computed tomography (CT) examinations immediately postoperatively, before discharge, and 2 months after surgery. Pneumocephalus was classified into simple and tension, based upon the clinical and radiological criteria. The neurologic grading system of Markwalder et al was used to evaluate the surgical results.

Results:

The immediate postoperative CT scan showed pneumocephalus in 22 patients (44%). Tension pneumocephalus was found in two patients who did not require any further surgery. There was statistically significant increase in the incidence of pneumocephalus (immediate and postoperative) in the patients aged over 60 years as well as those presenting with a midline shift more than 5 mm in their CT scan. With regard to the 22 cases of pneumocephalus, good postoperative results were found in 16 patients (73%), while bad results were found in 6 patients (27%). No statistically significant difference in the outcome between patients who had pneumocephalus after surgery and those who had not.

Conclusion:

Pneumocephalus after surgical evacuation of CSDH is a common finding in the immediate CT scan as well as at time of discharge. Tension pneumocephalus may not require surgical intervention and simple aspiration of air using a syringe may be sufficient.

The surgical management of chronic subdural hematoma

Chronic subdural hematoma (cSDH) is an increasingly common neurological disease process. Despite the wide prevalence of cSDH, there remains a lack of consensus regarding numerous aspects of its clinical management. We provide an overview of the epidemiology and pathophysiology of cSDH and discuss several controversial management issues, including the timing of post-operative resumption of anticoagulant medications, the effectiveness of anti-epileptic prophylaxis, protocols for mobilization following evacuation of cSDH, as well as the comparative effectiveness of the various techniques of surgical evacuation. A PubMed search was carried out through October 19, 2010 using the following keywords: "subdural hematoma", "craniotomy", "burr-hole", "management", "anticoagulation", "seizure prophylaxis", "antiplatelet", "mobilization", and "surgical evacuation", alone and in combination. Relevant articles were identified and back-referenced to yield additional papers. A meta-analysis was then performed comparing the efficacy and complications associated with the various methods of cSDH evacuation. There is general agreement that significant coagulopathy should be reversed expeditiously in patients presenting with cSDH. Although protocols for gradual resumption of anti-coagulation for prophylaxis of venous thrombosis may be derived from guidelines for other neurosurgical procedures, further prospective study is necessary to determine the optimal time to restart full-dose anti-coagulation in the setting of recently drained cSDH. There is also conflicting evidence to support seizure prophylaxis in patients with cSDH, although the existing literature supports prophylaxis in patients who are at a higher risk for seizures. The published data regarding surgical technique for cSDH supports primary twist drill craniostomy (TDC) drainage at the bedside for patients who are high-risk surgical candidates with non-septated cSDH and craniotomy as a first-line evacuation technique for cSDH with significant membranes. Larger prospective studies addressing these aspects of cSDH management are necessary to establish definitive recommendations.

Efficacy of middle meningeal artery embolization in the treatment of refractory chronic subdural hematoma

BACKGROUND

There are no established treatment procedures for repeatedly recurring chronic subdural hematoma (CSH). In this study, we discussed the efficacy of middle meningeal artery (MMA) embolization in preventing recurrence of CSH.

METHODS

We performed superselective angiography of MMA in four patients who suffered from repeated recurrence of CSH. After angiography, we performed embolization of MMA with endovascular procedure.

RESULTS

In all cases, superselective angiography of MMA revealed diffuse abnormal vascular stains that seemed to represent the macrocapillaries in the outer membrane of CSH. In all the patients, there were no recurrences or enlargements of CSH after the embolization of the MMA.

CONCLUSION

MMA embolization can be an effective adjuvant procedure in preventing the recurrence of CSH.