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Cohen-Cohen S, Jabal MS, Rinaldo L, Savastano LE, Lanzino G, Cloft H, Brinjikji W. Middle meningeal artery embolization for chronic subdural hematoma: A single-center experience and predictive modeling of outcomes. Neuroradiol J 2024; 37:192-198. [PMID: 38147825 DOI: 10.1177/19714009231224431] [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] [Indexed: 12/28/2023] Open
Abstract
BACKGROUND Remarkable interest is rising around middle meningeal artery embolization (MMAE) as an emerging alternative therapy for chronic subdural hematoma (cSDH). The study aims to highlight a large center experience and the variables associated with treatment failure and build experimental machine learning (ML) models for outcome prediction. MATERIAL AND METHODS A 2-year experience in MMAE for managing patients with chronic subdural hematoma was analyzed. Descriptive statistical analysis was conducted using imaging and clinical features of the patients and cSDH, which were subsequently used to build predictive models for the procedure outcome. The modeling evaluation metrics were the area under the ROC curve and F1-score. RESULTS A total of 100 cSDH of 76 patients who underwent MMAE were included with an average follow-up of 6 months. The intervention had a per procedure success rate of 92%. Thrombocytopenia had a highly significant association with treatment failure. Two patients suffered a complication related to the procedure. The best performing machine learning models in predicting MMAE failure achieved an ROC-AUC of 70%, and an F1-score of 67%, including all patients with or without surgical intervention prior to embolization, and an ROC-AUC of 82% and an F1-score of 69% when only patients who underwent upfront MMAE were included. CONCLUSION MMAE is a safe and minimally invasive procedure with great potential in transforming the management of cSDH and reducing the risk of surgical complications in selected patients. An ML approach with larger sample size might help better predict outcomes and highlight important predictors following MMAE in patients with cSDH.
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Hanaoka Y, Abe D, Koyama JI, Nakamura T, Kitamura S, Horiuchi T. A new very-small-bore Simmons guiding sheath for transradial neurointervention: Technical note and initial experience. J Neuroradiol 2024; 51:214-219. [PMID: 37625629 DOI: 10.1016/j.neurad.2023.08.004] [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: 06/08/2023] [Revised: 07/22/2023] [Accepted: 08/21/2023] [Indexed: 08/27/2023]
Abstract
Transradial access during neurointerventions has increased in popularity because of reduced complications and patient preference. Nevertheless, transradial cannulation into the left common carotid artery can be difficult technically because of the lack of catheter support in the aortic arch. Furthermore, the use of large sheaths can increase the risk of complications at the access site. Here, we developed a new very-small-bore transradial system using a 3F Simmons guiding sheath, to increase the procedural success rate and minimize access-site complications. This system can represent a valuable treatment option for neurointerventions and has the potential to expand the indications for transradial access.
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Affiliation(s)
- Yoshiki Hanaoka
- Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan; Neuroendovascular Therapy Center, Shinshu University Hospital, Matsumoto, Japan.
| | - Daishiro Abe
- Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan
| | - Jun-Ichi Koyama
- Neuroendovascular Therapy Center, Shinshu University Hospital, Matsumoto, Japan
| | - Takuya Nakamura
- Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan
| | - Satoshi Kitamura
- Neuroendovascular Therapy Center, Shinshu University Hospital, Matsumoto, Japan
| | - Tetsuyoshi Horiuchi
- Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan; Neuroendovascular Therapy Center, Shinshu University Hospital, Matsumoto, Japan
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Scoville JP, Joyce E, A. Tonetti D, Bounajem MT, Thomas A, Ogilvy CS, Moore JM, Riina HA, Tanweer O, Levy EI, Spiotta AM, Gross BA, Jankowitz BT, Cawley CM, Khalessi AA, Pandey AS, Ringer AJ, Hanel R, Ortiz RA, Langer D, Levitt MR, Binning M, Taussky P, Kan P, Grandhi R. Radiographic and clinical outcomes with particle or liquid embolic agents for middle meningeal artery embolization of nonacute subdural hematomas. Interv Neuroradiol 2023; 29:683-690. [PMID: 35673710 PMCID: PMC10680958 DOI: 10.1177/15910199221104631] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 05/15/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Middle meningeal artery (MMA) embolization is an apparently efficacious minimally invasive treatment for nonacute subdural hematomas (NASHs), but how different embolisates affect outcomes remains unclear. Our objective was to compare radiographic and clinical outcomes after particle or liquid MMA embolization. METHODS Patients who had MMA embolization for NASH were retrospectively identified from a multi-institution database. The primary radiographic and clinical outcomes-50% NASH thickness reduction and need for surgical retreatment within 90 days, respectively-were compared for liquid and particle embolizations in patients treated 1) without surgical intervention (upfront), 2) after recurrence, or 3) with concomitant surgery (prophylactic). RESULTS The upfront, recurrent, and prophylactic subgroups included 133, 59, and 16 patients, respectively. The primary radiographic outcome was observed in 61.8%, 61%, and 72.7% of particle-embolized patients and 61.3%, 55.6%, and 20% of liquid-embolized patients, respectively (p = 0.457, 0.819, 0.755). Hazard ratios comparing time to reach radiographic outcome in the particle and liquid groups or upfront, recurrent, andprophylactic timing were 1.31 (95% CI 0.78-2.18; p = 0.310), 1.09 (95% CI 0.52-2.27; p = 0.822), and 1.5 (95% CI 0.14-16.54; p = 0.74), respectively. The primary clinical outcome occurred in 8.0%, 2.4%, and 0% of patients who underwent particle embolization in the upfront, recurrent, and prophylactic groups, respectively, compared with 0%, 5.6%, and 0% who underwent liquid embolization (p = 0.197, 0.521, 1.00). CONCLUSIONS MMA embolization with particle and liquid embolisates appears to be equally effective in treatment of NASHs as determined by the percentage who reach, and the time to reach, 50% NASH thickness reduction and the incidence of surgical reintervention within 90 days.
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Affiliation(s)
- Jonathan P. Scoville
- Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, Utah, USA
| | - Evan Joyce
- Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, Utah, USA
| | | | - Michael T. Bounajem
- Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, Utah, USA
| | - Ajith Thomas
- Cooper Neuroscience Institute, Camden, New Jersey, USA
| | - Christopher S. Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin M. Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Howard A. Riina
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, USA
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Elad I. Levy
- Departments of Neurosurgery and Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Alejandro M. Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Bradley A. Gross
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | | | - Alexander A. Khalessi
- Department of Neurosurgery, University of California-San Diego, La Jolla, California, USA
| | - Aditya S. Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew J. Ringer
- Mayfield Clinic, TriHealth Neuroscience Institute, Good Samaritan Hospital, Cincinnati, Ohio, USA
| | - Ricardo Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Rafael A. Ortiz
- Department of Neurosurgery, Lenox Hill Hospital, New York, New York, USA
| | - David Langer
- Department of Neurosurgery, Lenox Hill Hospital, New York, New York, USA
| | - Michael R. Levitt
- Department of Neurological Surgery, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Mandy Binning
- Department of Neurosurgery, Global Neurosciences Institute Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Philipp Taussky
- Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, Utah, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, Utah, USA
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Verhey LH, Orozco AR, Oliver M, Lyons L, Sewell AP, Tsai JPC, Mazaris P, Khan M, Singer JA. Transradial versus transfemoral access for mechanical thrombectomy in acute ischemic stroke: A retrospective cohort study. J Stroke Cerebrovasc Dis 2023; 32:107282. [PMID: 37659190 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107282] [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: 04/08/2023] [Revised: 07/21/2023] [Accepted: 07/25/2023] [Indexed: 09/04/2023] Open
Abstract
BACKGROUND The objective of this study was to compare procedural and clinical outcomes in patients with acute ischemic stroke (AIS) treated via transradial access (TRA) mechanical thrombectomy (MT) versus conventional transfemoral access (TFA). METHODS We performed a retrospective analysis of consecutive patients with AIS treated with TRA versus TFA MT at our tertiary comprehensive stroke center. Access choice was individualized based on occlusion site, aortic and arch anatomy. Outcomes were extracted from our institutional stroke registry and included procedural time, Thrombolysis in Cerebral Infarction (TICI) reperfusion score, NIHSS, 90-day mRS and 90-day mortality. Comparisons were performed using Student t-Test and Fischer's exact test as appropriate. RESULTS 175 mechanical thrombectomies were performed during the study interval; 39 (22%) were performed via TRA and 136 (79%) TFA. Access to reperfusion time was 36.3 ± 24.5 minutes in the TRA group and 21.9 ± 17.6 in the TFA group (p<0.001). The proportion of patients with a TICI reperfusion score of 2b or 3 was similar in both groups (TRA: 34 (87%) vs. TFA: 121 (89%) p=0.559. The median 90-day mRS was similar between both groups (p=0.170), as was the 90-day mortality (p = 0.509). CONCLUSIONS While TFA is faster in our cohort, TFA and TRA are both safe and effective for MT in acute ischemic stroke. While TFA remains mainstay, TRA can be valuable in variant anatomy despite its technical limitations. Individualizing access based on advanced imaging and patient factors may improve practice; however, updates in catheter and access technology are necessary to optimize outcomes with TRA.
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Affiliation(s)
- Leonard H Verhey
- Division of Neurological Surgery, Spectrum Health, Grand Rapids, MI, USA; Department of Clinical Neurosciences, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Andres Restrepo Orozco
- Division of Neurological Surgery, Spectrum Health, Grand Rapids, MI, USA; Department of Clinical Neurosciences, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Marion Oliver
- Department of Neurology, University of Toledo, Toledo, OH, USA
| | - Leah Lyons
- Division of Neurological Surgery, Spectrum Health, Grand Rapids, MI, USA
| | - Andrea P Sewell
- Division of Neurological Surgery, Spectrum Health, Grand Rapids, MI, USA
| | - Jenny P-C Tsai
- Department of Clinical Neurosciences, Michigan State University College of Human Medicine, Grand Rapids, MI, USA; Division of Neurology, Spectrum Health, Grand Rapids, MI, USA
| | - Paul Mazaris
- Division of Neurological Surgery, Spectrum Health, Grand Rapids, MI, USA; Department of Clinical Neurosciences, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Muhib Khan
- Department of Clinical Neurosciences, Michigan State University College of Human Medicine, Grand Rapids, MI, USA; Division of Neurology, Spectrum Health, Grand Rapids, MI, USA
| | - Justin A Singer
- Division of Neurological Surgery, Spectrum Health, Grand Rapids, MI, USA; Department of Clinical Neurosciences, Michigan State University College of Human Medicine, Grand Rapids, MI, USA.
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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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7
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Dowlati E, Chesney K, Carpenter AB, Rock M, Patel N, Mai JC, Liu AH, Armonda RA, Felbaum DR. Awake transradial middle meningeal artery embolization and twist drill craniostomy for chronic subdural hematomas in the elderly: case series and technical note. J Neurosurg Sci 2023; 67:471-479. [PMID: 34114433 DOI: 10.23736/s0390-5616.21.05335-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Due to prohibitive perioperative risk factors, optimal treatment for chronic subdural hematomas (cSDH) in the elderly remains unclear. Minimally invasive techniques are a viable option and include bedside subdural evacuation port system (SEPS), as well as prevention of recurrence with middle meningeal artery (MMA) embolization. We present a case series of elderly patients undergoing combined transradial MMA embolization and bed-side craniostomy as primary treatment for cSDH. METHODS Patients 70 years and older from 2019 to 2020 that underwent single setting, awake transradial MMA embolization with concurrent SEPS placement under local anesthesia were included. Those with prior treatments, interventions performed under general anesthesia, or with less than 60-day follow-up were excluded. Descriptive analyses of baseline characteristics, radiologic parameters, comorbidities, and outcome measures were completed. RESULTS Twenty elderly patients (mean age of 81.0 years) with multiple comorbidities underwent 28 MMA embolization+SEPS procedures as primary treatment for cSDH. Mean cSDH thickness was 1.8cm±0.6 cm with 7.3±3.9 mm midline shift. All patients tolerated the procedure well. 1/20 (5.0%) patients died within 30 days of the procedure. A majority of patients were discharged to home (12/20; 60.0%). There was an average of 3.6-month follow-up and one patient (5.0%) developed recurrence in the follow-up period requiring further intervention. CONCLUSIONS In select elderly patients with high perioperative risk factors, primary treatment of cSDH using awake transradial MMA embolization+SEPS placement is a minimally invasive, feasible, and safe option. Further comparative studies are warranted to evaluate efficacy of the treatment.
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Affiliation(s)
- Ehsan Dowlati
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA -
| | - Kelsi Chesney
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | | | - Mitchell Rock
- Georgetown University School of Medicine, Washington, DC, USA
| | - Nirali Patel
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Jeffrey C Mai
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
- Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Ai-Hsi Liu
- Department of Radiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Rocco A Armonda
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
- Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Daniel R Felbaum
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
- Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, USA
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8
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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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Saal-Zapata G, Murga-Villanueva A, Walker M, Ghodke B, Rodríguez-Varela R. Safety and radiologic clearance of chronic subdural hematoma after endovascular embolization using SQUID 18 in patients older than 80 years. J Neurosci Rural Pract 2023; 14:336-341. [PMID: 37181175 PMCID: PMC10174137 DOI: 10.25259/jnrp_30_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: 10/01/2022] [Accepted: 01/15/2023] [Indexed: 02/25/2023] Open
Abstract
The aim of the study was to evaluate radiographic clearance and clinical outcomes in patients over age 80 who undergo SQUID 18 embolization of the middle meningeal artery (MMA) for the management of chronic subdural hematoma (cSDH). From April 2020 to October 2021, data were obtained from patients with cSDH who underwent MMA embolization at our institution. Clinical and radiological data including pre-operative and last follow-up CT scans were analyzed. Six embolization procedures were performed in five patients using SQUID 18, a liquid embolic agent. The median age was 83 years, and three subjects were female. Two of the six cases were recurrent hematomas. MMA embolization was achieved in 100% of cases. The median diameter of the hematoma at admission was 20 mm and at last follow-up was 5.3 mm, demonstrating statistically significant radiographic clearance (P = 0.043). There were no intra or post-operative complications. Mortality was not noted during observation period. SQUID MMA embolization safely and significantly reduced the hematoma diameter and offers an alternative treatment in patients older than 80 years with cSDH.
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Affiliation(s)
- Giancarlo Saal-Zapata
- Department of Neurosurgery, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru, United States
| | - Annel Murga-Villanueva
- Department of Neurosurgery, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru, United States
| | - Melanie Walker
- Department of Neurosurgery, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru, United States
| | - Basavaraj Ghodke
- Department of Neurological Surgery, University of Washington, Seattle, Washington, United States
| | - Rodolfo Rodríguez-Varela
- Department of Neurosurgery, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru, United States
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10
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Waqas M, Monteiro A, Baig AA, Cappuzzo JM, Dossani RH, Almayman F, Singh T, Snyder KV, Levy EI, Siddiqui AH, Davies JM. Rist Guide Catheter for Endovascular Procedures: Initial Case Series from a Single Center. Interv Neuroradiol 2023; 29:108-113. [PMID: 35043703 PMCID: PMC9893241 DOI: 10.1177/15910199221074884] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/23/2021] [Accepted: 01/04/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The transradial approach (TRA) for endovascular procedures has become a frequent practice in neurointervention. Advantages of the TRA include less access-site complications, early ambulation, and less postprocedural pain. The Rist 079 radial access guide catheter (Medtronic) is the first device designed specifically for neurointerventions performed through the TRA. In this study, we report our initial experience with the Rist catheter in a variety of neurointerventional procedures, aiming to evaluate the performance of this device and discuss its limitations. METHODS A prospectively maintained database was retrospectively searched to identify patients who underwent procedures using the Rist catheter. Information on demographics, procedural details, and complications was recorded. RESULTS Seventy-eight patients were included in the study, with a mean age of 60.3 years (range, 25-92 years); 45 (57.7%) were men. The interventional or diagnostic procedure was successfully completed in 77 patients (98.7%). The radial artery was the primary access-site choice in 71 patients (91%). The most frequent type of procedures performed were coiling or stent-assisted coiling (16.7%) and angioplasty and stenting (16.7%), followed by middle meningeal artery embolization (14.1%). Crossover to femoral artery access while maintaining use of the Rist was done in 5 cases (6.4%). Reasons for access or procedural failure included anatomical anomaly of the target vessel, unfavorable geometry of the great vessels, and proximal tortuosity of the supra-aortic vessels. CONCLUSION We demonstrated a high success rate with use of the Rist catheter system for a variety of procedures.
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Affiliation(s)
- Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical
Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida
Health, Buffalo, New York, USA
| | - Andre Monteiro
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical
Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida
Health, Buffalo, New York, USA
| | - Ammad A Baig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical
Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida
Health, Buffalo, New York, USA
| | - Justin M Cappuzzo
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical
Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida
Health, Buffalo, New York, USA
| | - Rimal H Dossani
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical
Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida
Health, Buffalo, New York, USA
| | - Faisal Almayman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical
Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida
Health, Buffalo, New York, USA
| | - Trisha Singh
- Department of Neurosurgery, Gates Vascular Institute at Kaleida
Health, Buffalo, New York, USA
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical
Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida
Health, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, University at Buffalo,
Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical
Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida
Health, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, University at Buffalo,
Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
- Department of Radiology, Jacobs School of Medicine and Biomedical
Sciences, University at Buffalo, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical
Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida
Health, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, University at Buffalo,
Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
- Department of Radiology, Jacobs School of Medicine and Biomedical
Sciences, University at Buffalo, Buffalo, New York, USA
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical
Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida
Health, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, University at Buffalo,
Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
- Department of Bioinformatics, Jacobs School of Medicine and
Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
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11
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Krothapalli N, Fayad M, Patel S, Elmashad A, Sussman E, Bruno C, Grande A, Jagadeesan B, Killory B, Alberts M, Kureshi I, Ollenschleger M, Tummala R, Mehta T. Use of reverse angle guide catheter with trans-radial approach in patients undergoing middle meningeal artery embolization. Front Neurol 2022; 13:990722. [DOI: 10.3389/fneur.2022.990722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 10/10/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundTrans-radial access (TRA) for MMA embolization has grown due to lower access site complications and greater patient satisfaction. Here, we describe the feasibility of utilizing a 6F Envoy Simmons 2 (6F-SIM2) as a guide catheter with TRA and compare outcomes with trans-femoral approach (TFA) in a single center case series.MethodsWe performed a retrospective review of patients who underwent MMA embolization for management of chronic subdural hematoma (cSDH). TRA was performed by utilizing a combination of 6F 90cm Envoy (Codman & Shurtleff, Inc., Rayham, MA) Simmons 2 guide catheter and 5F 125cm Sofia (Microvention, Aliso Viejo, CA) intermediate catheter. Outcomes measured are Modified Rankin Score (mRS) at 90 days, inpatient mortality, post-embolization recurrence, fluoroscopy time and radiation exposure.ResultsA total of 71 patients underwent 97 MMA embolization overall with 65 (67%) in trans-femoral access group, 11 (11.3%) in trans-radial access without use of Simmons 2 Guide catheter group and 21 (21.6%) in trans-radial access with use of Simmons 2 Guide catheter group. There were no direct access-related complications in either group. One patient had thromboembolic stroke in trans-femoral group. There was no difference in average procedure-related total fluro time or radiation dose among all three groups.ConclusionTrans-radial approach using 6F-SIM2 guide catheter coupled with 5F Sofia intermediate catheter is safe and effective. It provides an alternative approach to access distal branches of bilateral anterior circulation in elderly patients with difficult anatomy undergoing MMA embolization.
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12
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Abstract
In this paper, I review the historical changes in the etiological concepts and surgical treatments for chronic subdural hematoma (CSDH) across the world and in Japan. I also examine future problems associated with its surgical procedures and medical costs. CSDH was first reported by Wepfer in 1657 as "delayed apoplexy." In 1857, Virchow described the famous concept of so-called "pachymeningitis hemorrhagica interna." He considered that the etiology of CSDH involved inflammation. In 1914, Trotter described the origin of CSDH as traumatic. Currently, CSDH is considered to arise with a first leak of blood from dural border cells after mild trauma. Inflammatory cells are then drawn to the border cell layer. At this point, new membranes form from activated inflammation; then, the hematoma enlarges, promoted by angiogenic factors and new capillaries. In 1883, Hulke reported successful trepanning of a patient with CSDH. Burr holes and craniotomy for removal of the hematoma were subsequently reported, and new methods were developed over the course of several decades around the world. In Japan, after the first report by Nakada in 1938, many Japanese pioneering figures of neurological surgery have studied CSDH. After Mandai reported the middle meningeal artery embolization in 2000, this method is now considered useful as an initial or second treatment for CSDH. However, the age of patients is increasing, so more minimally invasive surgeries and useful pharmacotherapies are needed. We must also consider the costs for treating CSDH, because of the increasing numbers of surgical cases.
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Affiliation(s)
- Masaaki UNO
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
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13
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The Effect of Statins on the Recurrence of Chronic Subdural Hematomas: A Systematic Review and Meta-Analysis. World Neurosurg 2022; 166:244-250.e1. [PMID: 35917921 DOI: 10.1016/j.wneu.2022.07.079] [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: 04/22/2022] [Revised: 07/15/2022] [Accepted: 07/16/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Statins have been proposed to improve the resolution of chronic subdural hematoma (cSDH), with conflicting results likely due to underpowered analysis or confounding factors, such as the use of antithrombotic medication. We performed a systematic literature review and meta-analysis to better elucidate the effect of statin therapy on cSDH recurrence. METHODS We performed a comprehensive search of PubMed, MEDLINE, and Embase databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles were included if the number of recurrences requiring surgical evacuation or leading to neurological deterioration was reported and could be extracted separately for patients who did or did not receive statin therapy. RESULTS Seven studies were included, comprising 1359 cSDH patients (statin therapy, 449 vs. non-statin therapy, 910). Age was not different between groups (P = 0.548). The proportion of men was significantly different (statin, 80.1% vs. non-statin, 74.7%; P = 0.02). Use of antithrombotic medication was significantly higher (P = 0.005) in the statin group (11.7%) than in the non-statin group (7.3%). The statin group had a non-significant lower odds of recurrence (odds ratio 0.80, 95% confidence interval 0.35-1.81). In an exploratory data analysis of 4 studies without a difference between groups in antithrombotic medication use, the statin group had significantly lower odds of recurrence (odds ratio 0.29, 95% confidence interval 0.17-0.50). CONCLUSIONS Overall, we found that statin use did not result in lower odds of cSDH recurrence, likely due to a dilution caused by the higher rate of patients on antithrombotic medications in the statin group.
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14
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Statins versus Nonstatin Use in Patients with Chronic Subdural Hematomas Treated with Middle Meningeal Artery Embolization Alone – A Single-Center Experience. World Neurosurg 2022; 168:e376-e380. [DOI: 10.1016/j.wneu.2022.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/07/2022] [Accepted: 10/08/2022] [Indexed: 11/06/2022]
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15
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Catapano JS, Scherschinski L, Rumalla K, Srinivasan VM, Cole TS, Baranoski JF, Lawton MT, Jadhav AP, Ducruet AF, Albuquerque FC. Emergency Department Visits for Chronic Subdural Hematomas within 30 Days after Surgical Evacuation with and without Middle Meningeal Artery Embolization. AJNR Am J Neuroradiol 2022; 43:1148-1151. [PMID: 35863784 PMCID: PMC9575430 DOI: 10.3174/ajnr.a7572] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/16/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Middle meningeal artery embolization after surgical evacuation of a chronic subdural hematomas is associated with fewer treatment failures than surgical evacuation. We compared emergency department visits within 30 days for patients with chronic subdural hematomas with and without adjunctive middle meningeal artery embolization. MATERIALS AND METHODS All cases of chronic subdural hematoma treated from January 1, 2018, through December 31, 2020, were retrospectively reviewed. Treatment was classified as surgery only or surgery combined with middle meningeal artery embolization. The primary outcome was 30-day emergency department presentation and readmission. RESULTS Of 137 patients who met the study criteria, 28 (20%) underwent surgery combined with middle meningeal artery embolization. Of these 28 patients, 15 (54%) underwent planned middle meningeal artery embolization and 13 (46%) underwent embolization after surgical failure. The mean chronic subdural hematoma size at presentation in the group with surgery only (n = 109, 20.5 [SD, 6.9] mm) was comparable with that in the combined group (n = 28, 18.7 [SD, 4.5] mm; P = .16). A significantly higher percentage of the surgery-only group presented to the emergency department within 30 days compared with the combined group (32 of 109 [29%] versus 2 of 28 [7%] patients; P = .02). No significant difference was found with respect to readmission (16 [15%] versus 1 [4%] patient; P = .11). Nine patients (8%) in the surgery-only group were readmitted for significant reaccumulation or residual subdural hematoma compared with only 1 patient (4%) in the combined group (P = .40). CONCLUSIONS Surgical evacuation combined with middle meningeal artery embolization in patients with chronic subdural hematoma is associated with fewer 30-day emergency department visits compared with surgery alone.
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Affiliation(s)
- J S Catapano
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - L Scherschinski
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - K Rumalla
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - V M Srinivasan
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - T S Cole
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - J F Baranoski
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - M T Lawton
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - A P Jadhav
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - A F Ducruet
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - F C Albuquerque
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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16
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Transradial versus Transfemoral Approach for Neuroendovascular Procedures: A Survey of Patient Preferences and Perspectives. World Neurosurg 2022; 163:e623-e627. [DOI: 10.1016/j.wneu.2022.04.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/08/2022] [Accepted: 04/09/2022] [Indexed: 11/23/2022]
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17
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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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18
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Désir LL, D'Amico R, Link T, Silva D, Ellis JA, Doron O, Langer DJ, Ortiz R, Serulle Y. Middle Meningeal Artery Embolization and the Treatment of a Chronic Subdural Hematoma. Cureus 2021; 13:e18868. [PMID: 34754700 PMCID: PMC8570051 DOI: 10.7759/cureus.18868] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 11/18/2022] Open
Abstract
Chronic subdural hematoma (cSDH) is a common pathology that typically affects the elderly. It is believed to occur due to injury to the dural border cells, which creates an inflammation/proliferation reaction. Ineffective repair leads to the formation of a new external layer of cells and fragile capillaries, which damage easily and can worsen the condition. Conventionally, asymptomatic cSDH is managed by observation, and symptomatic cases are treated by surgical evacuation. Unfortunately, recurrence rates of the SDH following surgical evacuation can be high. One treatment option for SDH involves embolization of the middle meningeal artery (MMA). The MMA provides blood supply to the dura mater and feeds the membrane capillaries covering the SDH. MMA embolization blocks the blood flow to this system and can promote hematoma resolution. In this paper, we review the existing literature on MMA embolization and discuss the underlying pathophysiology of cSDH.
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Affiliation(s)
- Likowsky L Désir
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
| | - Randy D'Amico
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
| | - Thomas Link
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
| | - Danilo Silva
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
| | - Jason A Ellis
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
| | - Omer Doron
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
| | - David J Langer
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
| | - Rafael Ortiz
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
| | - Yafell Serulle
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
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19
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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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20
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Carpenter A, Rock M, Dowlati E, Miller C, Mai JC, Liu AH, Armonda RA, Felbaum DR. Middle meningeal artery embolization with subdural evacuating port system for primary management of chronic subdural hematomas. Neurosurg Rev 2021; 45:439-449. [PMID: 33893872 DOI: 10.1007/s10143-021-01553-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/14/2021] [Accepted: 04/19/2021] [Indexed: 11/30/2022]
Abstract
Optimal treatment for chronic subdural hematomas remains controversial and perioperative risks and comorbidities may affect management strategies. Minimally invasive procedures are emerging as alternatives to the standard operative treatments. We evaluate our experience with middle meningeal artery (MMA) embolization combined with Subdural Evacuating Port System (SEPS) placement as a first-line treatment for patients with cSDH. A single institution retrospective review was performed of all patients undergoing intervention. Patients were stratified by treatment with MMA embolization and SEPS placement, MMA embolization and surgery, SEPS placement only, and surgery only for cSDH from 2017 to 2020, and cohorts were compared against each other. Patients treated with MMA/SEPS were more likely to be older, be on anticoagulation, have significant comorbidities, have shorter length of stay, and less likely to have symptomatic recurrence compared to SEPS only cohort. Thus, MMA/SEPS appears to be a safe and equally effective minimally invasive treatment for cSDH patients with significant comorbidities who are poor surgical candidates.
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Affiliation(s)
- Austin Carpenter
- Georgetown University School of Medicine, 3900 Reservoir Road NW, Washington, DC, USA
| | - Mitchell Rock
- Georgetown University School of Medicine, 3900 Reservoir Road NW, Washington, DC, USA
| | - Ehsan Dowlati
- Department of Neurosurgery, MedStar Georgetown University Hospital, 3800 Reservoir Road NW, PHC7, Washington, DC, USA.
| | - Charles Miller
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Jeffrey C Mai
- Department of Neurosurgery, MedStar Georgetown University Hospital, 3800 Reservoir Road NW, PHC7, Washington, DC, USA.,Department of Neurosurgery, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC, USA
| | - Ai-Hsi Liu
- Department of Radiology, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC, USA
| | - Rocco A Armonda
- Department of Neurosurgery, MedStar Georgetown University Hospital, 3800 Reservoir Road NW, PHC7, Washington, DC, USA.,Department of Neurosurgery, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC, USA
| | - Daniel R Felbaum
- Department of Neurosurgery, MedStar Georgetown University Hospital, 3800 Reservoir Road NW, PHC7, Washington, DC, USA.,Department of Neurosurgery, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC, USA
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21
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Catapano JS, Karahalios K, Srinivasan VM, Baranoski JF, Rutledge C, Cole TS, Ducruet AF, Albuquerque FC, Jadhav AP. Chronic headaches and middle meningeal artery embolization. J Neurointerv Surg 2021; 14:301-303. [PMID: 33888570 DOI: 10.1136/neurintsurg-2021-017602] [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: 04/06/2021] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND The middle meningeal artery (MMA) has been implicated in chronic headaches, but no studies have examined the relationship between MMA embolization and headaches. METHODS Patients treated with MMA embolization for a chronic subdural hematoma (cSDH) between January 1, 2018, and December 31, 2020, were retrospectively assessed. Patients with a Glasgow Coma Scale (GCS) score of 15 at discharge received a follow-up telephone call to assess their history of chronic headache, defined as a headache ≥2 years before the cSDH and symptoms ≥2 days/month. A Headache Impact Test (HIT-6) was performed during the follow-up telephone call. The primary outcome was resolution or improvement of headaches after embolization. RESULTS Of 76 patients undergoing MMA embolization for a cSDH during the study period, 56 (74%) had a discharge GCS score of 15. Of these 56 patients, 46 (82%) responded to a follow-up telephone call and were analyzed (mean [SD] age 68 [11] years; 36 [78%] men and 10 [22%] women). Nine (20%) reported chronic headaches before embolization. With a mean (SD) follow-up of 489 (173) days, eight of the nine patients reported improvement of chronic headaches, with seven having complete resolution. For these nine patients, the mean (SD) HIT-6 score was significantly higher before embolization than after embolization (64 [7.1] vs 40 [9.1], p<0.001). CONCLUSION In patients with chronic headaches who underwent MMA embolization for a cSDH, the majority reported improvement of headaches after the procedure. Future prospective studies are warranted to assess the usefulness of MMA embolization to treat chronic headaches.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Katherine Karahalios
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Caleb Rutledge
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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22
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Dornbos D. Evolution of Radial Access in Neurointerventional Surgery. AJNR Am J Neuroradiol 2021; 42:E19-E20. [PMID: 33664108 DOI: 10.3174/ajnr.a7060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- D Dornbos
- Department of NeurosurgerySemmes-Murphey ClinicUniversity of Tennessee Health Science CenterMemphis, Tennessee
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23
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Albuquerque FC. Out with a bang. J Neurointerv Surg 2020; 13:1. [PMID: 33323468 DOI: 10.1136/neurintsurg-2020-017157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ 85013-440, USA
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Rajah GB, Waqas M, Dossani RH, Vakharia K, Gong AD, Rho K, Housley SB, Rai HH, Chin F, Tso MK, Snyder KV, Levy EI, Siddiqui AH, Davies JM. Transradial middle meningeal artery embolization for chronic subdural hematoma using Onyx: case series. J Neurointerv Surg 2020; 12:1214-1218. [DOI: 10.1136/neurintsurg-2020-016185] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/22/2020] [Accepted: 05/29/2020] [Indexed: 02/06/2023]
Abstract
BackgroundMiddle meningeal artery (MMA) embolization is an emerging therapy for the resolution of subacute or chronic subdural hematoma (CSDH). CSDH patients are often elderly and have several comorbidities. We evaluated our experience with transradial access (TRA) for MMA embolization using predominantly Onyx under conscious sedation.MethodsData for consecutive patients who underwent transradial MMA embolization for CSDH during a 2-year period (2018–2019) were analyzed from a single-center, prospectively-maintained database. Patient demographics, comorbidities, ambulatory times, subdural hematoma resorption status, and guide catheter type were recorded. Conversion to femoral access and complication rates were also recorded. Univariate and multivariate analyses were performed.ResultsForty-six patients (mean age, 71.7±14.4 years) were included in this study. Mean CSDH size was 14±5.5 mm. Most (91.3%) TRA embolizations were performed with 6-French 0.071-inch Benchmark guide catheters (Penumbra). MMA embolization was successful in 44 patients (95.7%) (including two cases of TRA conversion). Twenty-one (48%) patients had a severe Charlson Comorbidity Index (>5). Symptomatic improvement was noted in 39 of 44 patients (88.6%). Mean length of stay was 4±3 days. Patients were ambulated immediately postprocedure. At mean follow-up (8±4 weeks), 86.4% of patients had complete or partial CSDH resolution. Persistent use of antiplatelet agents after the procedure was associated with failed or minimal CSDH resorption (5 of 6, 83.3% vs 9 of 38 23.7% with complete or near-complete resolution; P=0.009).ConclusionTransradial Onyx MMA embolization under conscious sedation is safe and effective for CSDH treatment. TRA may be especially useful in elderly patients with numerous comorbidities.
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