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Sioutas GS, Shekhtman O, Dagli MM, Salem MM, Ajmera S, Kandregula S, Burkhardt JK, Srinivasan VM, Jankowitz BT. Middle meningeal artery patency after surgical evacuation for chronic subdural hematoma. Neurosurg Rev 2024; 47:145. [PMID: 38594307 DOI: 10.1007/s10143-024-02383-3] [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: 12/11/2023] [Revised: 03/27/2024] [Accepted: 03/30/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) often requires surgical evacuation, but recurrence rates remain high. Middle meningeal artery (MMA) embolization (MMAE) has been proposed as an alternative or adjunct treatment. There is concern that prior surgery might limit patency, access, penetration, and efficacy of MMAE, such that some recent trials excluded patients with prior craniotomy. However, the impact of prior open surgery on MMA patency has not been studied. METHODS A retrospective analysis was conducted on patients who underwent MMAE for cSDH (2019-2022), after prior surgical evacuation or not. MMA patency was assessed using a six-point grading scale. RESULTS Of the 109 MMAEs (84 patients, median age 72 years, 20.2% females), 58.7% were upfront MMAEs, while 41.3% were after prior surgery (20 craniotomies, 25 burr holes). Median hematoma thickness was 14 mm and midline shift 3 mm. Hematoma thickness reduction, surgical rescue, and functional outcome did not differ between MMAE subgroups and were not affected by MMA patency or total area of craniotomy or burr-holes. MMA patency was reduced in the craniotomy group only, specifically in the distal portion of the anterior division (p = 0.005), and correlated with craniotomy area (p < 0.001). CONCLUSION MMA remains relatively patent after burr-hole evacuation of cSDH, while craniotomy typically only affects the frontal-distal division. However, MMA patency, evacuation method, and total area do not affect outcomes. These findings support the use of MMAE regardless of prior surgery and may influence future trial inclusion/exclusion criteria. Further studies are needed to optimize the timing and techniques for MMAE in cSDH management.
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Affiliation(s)
- Georgios S Sioutas
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Oleg Shekhtman
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mert Marcel Dagli
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mohamed M Salem
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sonia Ajmera
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sandeep Kandregula
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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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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Schmolling ÁH, Pérez-García C, Trejo C, López-Frías A, Jaroenngarmsamer T, Rosati S, Arrazola J, Moreu M. Middle Meningeal Artery Embolization for Management of Chronic Subdural Hematoma. Radiographics 2024; 44:e230158. [PMID: 38451847 DOI: 10.1148/rg.230158] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Chronic subdural hematoma (CSDH) is a prevalent medical condition with potentially severe consequences if left untreated. While surgical removal has traditionally been the standard approach for treatment, middle meningeal artery (MMA) embolization has emerged as a promising minimally invasive alternative to reduce recurrences. This comprehensive review provides the general radiology community with an overview of MMA embolization as a therapeutic option for managing CSDH. The authors base their insights on existing evidence and their institutional experience. This overview encompasses the pathophysiology of CSDH as well as the potential advantages and limitations, safety profile, and potential complications of MMA embolization as compared with surgical treatment. The imaging findings seen before and after MMA, as well as insights into the procedural techniques used at the authors' institution, are described. On the basis of reports in the current literature, MMA embolization appears to be a safe and effective therapeutic option for managing CSDH, especially in patients who are unsuitable for surgery or at risk for recurrence. Nonetheless, further research is needed to validate these findings. Results from ongoing clinical trials hold promise for future validation and the establishment of scientific evidence. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by Chatterjee in this issue.
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Affiliation(s)
- Ángela H Schmolling
- From the Departments of Interventional Neuroradiology (A.H.S., C.P.G., C.T., A.L.F., S.R., M.M.) and Radiology (J.A.), Hospital Clínico San Carlos, Calle del Profesor Martín Lagos s/n, 28040 Madrid, Spain; and Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (T.J.)
| | - Carlos Pérez-García
- From the Departments of Interventional Neuroradiology (A.H.S., C.P.G., C.T., A.L.F., S.R., M.M.) and Radiology (J.A.), Hospital Clínico San Carlos, Calle del Profesor Martín Lagos s/n, 28040 Madrid, Spain; and Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (T.J.)
| | - Carmen Trejo
- From the Departments of Interventional Neuroradiology (A.H.S., C.P.G., C.T., A.L.F., S.R., M.M.) and Radiology (J.A.), Hospital Clínico San Carlos, Calle del Profesor Martín Lagos s/n, 28040 Madrid, Spain; and Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (T.J.)
| | - Alfonso López-Frías
- From the Departments of Interventional Neuroradiology (A.H.S., C.P.G., C.T., A.L.F., S.R., M.M.) and Radiology (J.A.), Hospital Clínico San Carlos, Calle del Profesor Martín Lagos s/n, 28040 Madrid, Spain; and Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (T.J.)
| | - Tanaporn Jaroenngarmsamer
- From the Departments of Interventional Neuroradiology (A.H.S., C.P.G., C.T., A.L.F., S.R., M.M.) and Radiology (J.A.), Hospital Clínico San Carlos, Calle del Profesor Martín Lagos s/n, 28040 Madrid, Spain; and Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (T.J.)
| | - Santiago Rosati
- From the Departments of Interventional Neuroradiology (A.H.S., C.P.G., C.T., A.L.F., S.R., M.M.) and Radiology (J.A.), Hospital Clínico San Carlos, Calle del Profesor Martín Lagos s/n, 28040 Madrid, Spain; and Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (T.J.)
| | - Juan Arrazola
- From the Departments of Interventional Neuroradiology (A.H.S., C.P.G., C.T., A.L.F., S.R., M.M.) and Radiology (J.A.), Hospital Clínico San Carlos, Calle del Profesor Martín Lagos s/n, 28040 Madrid, Spain; and Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (T.J.)
| | - Manuel Moreu
- From the Departments of Interventional Neuroradiology (A.H.S., C.P.G., C.T., A.L.F., S.R., M.M.) and Radiology (J.A.), Hospital Clínico San Carlos, Calle del Profesor Martín Lagos s/n, 28040 Madrid, Spain; and Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (T.J.)
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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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Perng PS, Chuang MT, Wong CE, Chang Y, Sun YT, Wang HK, Lee JS, Wang LC, Huang CY. Simple coiling of middle meningeal artery embolization for chronic subdural hematoma: An inverse probability of treatment weighting matched cohort study. Interv Neuroradiol 2024:15910199241234407. [PMID: 38418387 DOI: 10.1177/15910199241234407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2024] Open
Abstract
BACKGROUND Middle meningeal artery embolization (MMAE) for chronic subdural hematoma (CSDH) has gained much attention in recent years. However, unintended embolization may occur when employing liquid embolic agents or particles. We present our clinical experience in simple coiling of MMAE to manage CSDH. METHODS Patients underwent either surgical evacuation or MMAE with simple coiling for CSDH were reviewed. Clinical and radiographic outcomes were assessed at admission, 1-month, and 6-month intervals. Two treatment groups were matched with inverse probability of treatment weighting. RESULTS One hundred twelve patients were included, with 27 patients in MMAE group and 87 patients in surgery group. In MMAE group, significant reductions were observed in hematoma width (admission vs. 1-month, 2.04 [1.44-2.60] cm vs. 0.62 [0.37-0.95] cm, p < 0.001). The adjusted odds ratio (aOR) of surgical rescue rate (0.77 95%CI 0.13-4.47, p = 0.77), hematoma reduction (>50%) (0.21 95%CI 0.04-1.07, p = 0.06), and midline shift improvement rate (3.22, 95%CI 0.84-12.4, p = 0.09) had no substantial disparities between two groups at 1-month follow-up. In addition, no significant difference was noted between two groups in terms of hematoma reduction (>50%) at 6-month follow-up (aOR 1.09 95%CI 0.32-3.70, p = 0.89). No procedure-related complications were found in MMA embolization group. CONCLUSION Simple coiling for MMA had comparable outcomes with surgical evacuation for CSDH. Our findings suggest that simple coiling can be an alternative choice for liquid agents or particles in MMA embolization for CSDH with acceptable safety.
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Affiliation(s)
- Pang-Shuo Perng
- Section of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ming-Tsung Chuang
- Department of Medical Imaging, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chia-En Wong
- Section of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu Chang
- Section of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yuan-Ting Sun
- Department of Medical Genomics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hao-Kuang Wang
- Department of Neurosurgery, E-Da Hospital, Kaohsiung, Taiwan
| | - Jung-Shun Lee
- Section of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Cell Biology and Anatomy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Liang-Chao Wang
- Section of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Yuan Huang
- Section of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Campos JK, Meyer BM, Zarrin DA, Khan MW, Collard de Beaufort JC, Amin G, Avery MB, Golshani K, Beaty NB, Bender MT, Colby GP, Lin LM, Coon AL. Immediate procedural safety of adjunctive proximal coil occlusion in middle meningeal artery embolization for chronic subdural hematomas: Experience in 137 cases. Interv Neuroradiol 2024:15910199231224003. [PMID: 38166510 DOI: 10.1177/15910199231224003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024] Open
Abstract
BACKGROUND Endovascular embolization of the middle meningeal artery (MMA) has emerged as an adjunctive and stand-alone modality for the management of chronic subdural hematomas (cSDH). We report our experience utilizing proximal MMA coil embolization to augment cSDH devascularization in MMA embolization. METHODS MMA embolization cases with adjunctive proximal MMA coiling were retrospectively identified from a prospectively maintained IRB-approved database of the senior authors. RESULTS Of the 137 cases, all patients (n = 89, 100%) were symptomatic and underwent an MMA embolization procedure for cSDH. 50 of the patients underwent bilateral embolizations, with 53% (n = 72) for left-sided and 47% (n = 65) for right-sided cSDH. The anterior MMA branch was embolized in 19 (14%), posterior in 16 (12%), and both in 102 (74.5%) cases. Penetration of the liquid embolic to the contralateral MMA or into the falx was present in 38 (28%) and 31 (23%) cases, respectively, and 46 (34%) cases had ophthalmic or petrous collateral (n = 41, 30%) branches. MMA branches coiled include the primary trunk (25.5%, n = 35), primary and anterior or posterior MMA trunks (20%, n = 28), or primary with the anterior and posterior trunks (54%, n = 74). A mild ipsilateral facial nerve palsy was reported, which remained stable at discharge and follow-up. Absence of anterograde flow in the MMA occurred in 137 (100%) cases, and no cases required periprocedural rescue surgery for cSDH evacuation. The average follow-up length was 170 ± 17.9 days, cSDH was reduced by 4.24 ± 0.5(mm) and the midline shift by 1.46 ± 0.27(mm). Complete resolution was achieved in 63 (46.0%) cases. CONCLUSION Proximal MMA coil embolization is a safe technique for providing additional embolization/occlusion of the MMA in cSDH embolization procedures. Further studies are needed to evaluate the potential added efficacy of this technique.
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Affiliation(s)
- Jessica K Campos
- Department of Neurological Surgery, University of California Irvine, Orange, CA, USA
| | | | - David A Zarrin
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | | | | | - Gizal Amin
- Carondelet Neurological Institute, St Joseph's Hospital, Tucson, AZ, USA
| | - Michael B Avery
- Department of Neurosurgery, Banner University Medical Center / The University of Arizona, Tucson, AZ, USA
| | - Kiarash Golshani
- Department of Neurological Surgery, University of California Irvine, Orange, CA, USA
| | - Narlin B Beaty
- Department of Neurosurgery, Florida State University, Tallahassee Memorial Hospital, Tallahassee, FL, USA
| | - Matthew T Bender
- Department of Neurosurgery, University of Rochester, Rochester, NY, USA
| | - Geoffrey P Colby
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Li-Mei Lin
- Carondelet Neurological Institute, St Joseph's Hospital, Tucson, AZ, USA
| | - Alexander L Coon
- Carondelet Neurological Institute, St Joseph's Hospital, Tucson, AZ, USA
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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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John K, Syed S, Kaestner T, Dashti R, Fiorella D, Sadasivan C. Liquid embolic surface area as a predictor of chronic subdural hematoma resolution in middle meningeal artery embolization. J Neurointerv Surg 2023:jnis-2023-021118. [PMID: 38050160 DOI: 10.1136/jnis-2023-021118] [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: 10/23/2023] [Accepted: 11/17/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Liquid embolic agents (LEAs) such as ethylene vinyl alcohol (EVOH) are utilized for middle meningeal artery embolization (MMAE) for chronic subdural hematomas (cSDH). LEAs may be advantageous for MMAE as they are permanent and can penetrate the microvasculature of the subdural membranes. LEA surface area (SA) can quantify this penetration. The segmentation of LEA SA is not described in the literature and may be of interest in refining MMAE technique. METHODS We retrospectively collected computerized tomography (CT) scans from 74 patients (with 95 cSDH) who underwent first-line MMAE with EVOH. Non-contrast head CTs were acquired pre-embolization, immediately post-embolization and at 1-, 3-, and 6 month follow-up. A 3D-Slicer was used to segment hematoma volumes and the liquid embolic cast. We hypothesized that greater LEA SA would be correlated with greater improvements in cSDH volumetric resolution. RESULTS There was significant resolution in cSDH volumes over the follow-up period compared to preoperative volume (p<0.0001). The LEA SA was significantly correlated with the rate of cSDH resolution at 3 months (R2=0.08, p=0.03), and 6 months (R2=0.14, p=0.01). CONCLUSIONS The correlation of LEA surface area with hematoma resolution at 3-months and 6-months suggests greater LEA penetration may improve radiographic outcomes. This study uniquely provides a quantitative radiological perspective on the effect of LEA penetration on cSDH resolution.
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Affiliation(s)
- Kevin John
- Department of Radiology, Stony Brook Medicine, Stony Brook, New York, USA
| | - Shoaib Syed
- Department of Neurological Surgery, Stony Brook Medicine, Stony Brook, New York, USA
| | | | - Reza Dashti
- Department of Neurological Surgery, Stony Brook Medicine, Stony Brook, New York, USA
| | - David Fiorella
- Department of Neurological Surgery, Stony Brook Medicine, Stony Brook, New York, USA
| | - Chander Sadasivan
- Department of Neurological Surgery, Stony Brook Medicine, Stony Brook, New York, USA
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Liu Z, Wang Y, Tang T, Zhang Y, Sun Y, Kuang X, Wei T, Zhou L, Peng A, Cao D, Hongsheng W, Qi W, Chenyi W, Shan Q. Time and Influencing Factors to Chronic Subdural Hematoma Resolution After Middle Meningeal Artery Embolization. World Neurosurg 2023; 179:e6-e14. [PMID: 36924886 DOI: 10.1016/j.wneu.2023.03.050] [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: 03/07/2023] [Accepted: 03/12/2023] [Indexed: 03/17/2023]
Abstract
OBJECTIVE We sought to describe the resolution time of chronic subdural hematoma (CSDH) after middle meningeal artery embolization (MMAE) and potential variables that may affect hematoma resolution. METHODS A retrospective analysis was performed on CSDH patients between December 2018 and December 2021. Patient characteristics, radiologic manifestations, and data of hematoma resolution were recorded. Univariate and multivariate analyses were conducted to identify predictors of CSDH resolution time. RESULTS A total of 53 patients were enrolled including 53 hematomas. Only 1 participant relapsed and did not require surgical evacuation. Hematoma resolution was observed in 27 (50.9%) at 4 months and 48 (90.6%) cases at the last radiologic follow-up. The median MMAE-to-resolution time was 19 weeks (interquartile range: 8-24). The burr-hole irrigation + MMAE group showed faster hematoma resolution than MMAE alone during early follow-up periods, but no significant difference was found at 6 months. Increased thickness of residual hematoma, excessive postoperative midline shift, high-density hematoma, mixed-density hematoma, separated hematoma, and anticoagulant or antiplatelet agents used were predictive of nonresolution at 4 months as determined by univariate analysis, whereas anticoagulant or antiplatelet agents used and high-density hematoma were not significant on multivariate analysis. No significant association was noted between hematoma resolution and comorbidities or other hematoma radiologic features. CONCLUSIONS MMAE is an effective and minimally invasive treatment for CSDH with a lower recurrence rate. The median resolution time of CSDH following MMAE was 19 weeks (interquartile range: 8-24). Burr-hole irrigation contributed to early hematoma resolution but had no significant effect at 6 months. In addition, residual hematoma thickness, postoperative midline shift, and specific type of hematoma were associated with delayed hematoma resolution at 4 months.
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Affiliation(s)
- Zhensheng Liu
- Department of Interventional Radiology, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Youwei Wang
- Department of Neurosurgery, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Tieyu Tang
- Department of Neurology, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Yunfeng Zhang
- Department of Neurology, the Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - Yong Sun
- Department of Interventional Radiology, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - XiongWei Kuang
- Department of Interventional Radiology, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Tingfeng Wei
- Department of Interventional Radiology, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Longjiang Zhou
- Department of Interventional Radiology, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Aijun Peng
- Department of Neurosurgery, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Demao Cao
- Department of Neurosurgery, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Wang Hongsheng
- Department of Neurosurgery, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Wentao Qi
- Department of Neurosurgery, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Wu Chenyi
- Department of Neurosurgery, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - Qing Shan
- Stroke Center, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China.
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10
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Sioutas GS, Mouchtouris N, Saiegh FA, Naamani KE, Amllay A, Becerril-Gaitan A, Velagapudi L, Gooch MR, Herial NA, Jabbour P, Rosenwasser RH, Tjoumakaris SI. Middle Meningeal Artery Embolization for Subdural Hematoma: An Institutional Cohort and Propensity Score-Matched Comparison with Conventional Management. Clin Neurol Neurosurg 2023; 233:107895. [PMID: 37556969 DOI: 10.1016/j.clineuro.2023.107895] [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: 05/17/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND The treatment of non-acute subdural hematoma (NASDH) is challenging due to its high recurrence rates and comorbidities of mostly elderly patients. Middle meningeal artery embolization (MMAE) recently emerged as an alternative to surgery in the treatment of NASDH. OBJECTIVE To describe a single center's experience of MMAE with Onyx for NASDH and compare it to a surgically treated historical cohort. METHODS We performed a retrospective analysis of patients undergoing MMAE for NASDH from 2019 to 2021. MMAE was performed with ethylene vinyl alcohol copolymer (Onyx). Comparisons were made with a historical cohort from 2010 to 2018 who underwent surgical evacuation only, before and after propensity score matching. Outcomes were assessed clinically and radiographically. RESULTS We included 44 consecutive patients (55 MMAEs) who underwent MMAE, with a median follow-up of 63.5 days. Twenty-four NASDHs underwent upfront embolization, 17 adjunctive, and 14 for recurrence after prior surgical evacuation, with no significant differences in hematoma and mRS reduction between them. Two patients died during hospitalization and 2 during follow-up, unrelated to the procedure. Mean SDH thickness decreased by 48.3% ± 38.1% (P < 0.001) on last follow-up, which did not correlate with the amount of Onyx injected. Six (13.6%) patients required surgical rescue after embolization. There were no procedure-related complications. The mean modified Rankin Scale (mRS) on admission was 2.8 ± 1.5, which decreased significantly to 1 [1,4] at the last follow-up (P = 0.033). The MMAE (41 hematomas; upfront and adjunctive embolization) and Surgical Evacuation-only (461 hematomas) cohorts were balanced with propensity score mathing. Matching was successful for 41 MMAE and 41 surgical-only hematoma pairs, and only hypertension remained significantly different between the two groups, but there was no significant difference in any outcome. CONCLUSION MMAE for NASDH seems safe and effective in appropriately selected patients, non-inferior to surgery, and may become a minimally-invasive alternative. Given our encouraging results, large-scale clinical randomized trials are warranted.
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Affiliation(s)
- Georgios S Sioutas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Fadi Al Saiegh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Abdelaziz Amllay
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Andrea Becerril-Gaitan
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, TX, USA
| | - Lohit Velagapudi
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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11
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Abdollahifard S, Farrokhi A, Mowla A. Application of deep learning models for detection of subdural hematoma: a systematic review and meta-analysis. J Neurointerv Surg 2023; 15:995-1000. [PMID: 36418163 DOI: 10.1136/jnis-2022-019627] [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: 09/13/2022] [Accepted: 11/09/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND This study aimed to investigate the application of deep learning (DL) models for the detection of subdural hematoma (SDH). METHODS We conducted a comprehensive search using relevant keywords. Articles extracted were original studies in which sensitivity and/or specificity were reported. Two different approaches of frequentist and Bayesian inference were applied. For quality and risk of bias assessment we used Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). RESULTS We analyzed 22 articles that included 1,997,749 patients. In the first step, the frequentist method showed a pooled sensitivity of 88.8% (95% confidence interval (CI): 83.9% to 92.4%) and a specificity of 97.2% (95% CI 94.6% to 98.6%). In the second step, using Bayesian methods including 11 studies that reported sensitivity and specificity, a sensitivity rate of 86.8% (95% CI: 77.6% to 92.9%) at a specificity level of 86.9% (95% CI: 60.9% to 97.2%) was achieved. The risk of bias assessment was not remarkable using QUADAS-2. CONCLUSION DL models might be an appropriate tool for detecting SDHs with a reasonably high sensitivity and specificity.
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Affiliation(s)
- Saeed Abdollahifard
- Medical School, Shiraz University of Medical Sciences, Shiraz, Iran
- Center for Neuromodulation and Pain, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amirmohammad Farrokhi
- Medical School, Shiraz University of Medical Sciences, Shiraz, Iran
- Center for Neuromodulation and Pain, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ashkan Mowla
- Neurological Surgery, University of Southern California, Los Angeles, California, USA
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12
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Aljabali A, Sharkawy AM, Jaradat B, Serag I, Al-Dardery NM, Abdelhady M, Abouzid M. Drainage versus no drainage after burr-hole evacuation of chronic subdural hematoma: a systematic review and meta-analysis of 1961 patients. Neurosurg Rev 2023; 46:251. [PMID: 37726502 PMCID: PMC10509130 DOI: 10.1007/s10143-023-02153-7] [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: 06/10/2023] [Revised: 09/03/2023] [Accepted: 09/07/2023] [Indexed: 09/21/2023]
Abstract
Chronic subdural hematoma (cSDH) is a common neurosurgical condition that can cause severe morbidity and mortality. cSDH recurs after surgical evacuation in 5-30% of patients, but drains may help reduce this risk. We aimed to investigate the effect of drainage versus no drainage on the rates of recurrence and mortality, as well as the clinical outcomes of cSDH. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched four electronic databases (PubMed, Cochrane Library, Scopus, and Web of Science) to identify eligible studies reported up to June 2022. Using Review Manager software, we reported four primary outcomes as odds ratios (ORs) and confidence intervals (CIs). The meta-analysis included a total of 10 studies with 1961 patients. The use of drainage was found to be significantly more effective than non-drainage in reducing the "mortality rate" (OR = 0.65, 95% CI 0.43 to 0.97; P = 0.04), the "recurrence rate" (OR = 0.39, 95% CI 0.28 to 0.55; P < 0.00001), and occurrence of "gross focal neurological deficit" (OR = 0.58, 95% CI 0.37 to 0.89; P = 0.01). No significant difference was found in the occurrence of a Glasgow Coma Scale score of 15 (OR = 1.21, 95% CI 0.84 to 1.76; P = 0.30). The use of drains after burr-hole irrigation reduces the recurrence, mortality, and gross focal neurological deficit rates of chronic subdural hematomas.
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Affiliation(s)
- Ahmed Aljabali
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
- Medical Research Group of Egypt, Negida Academy, Arlington, MA, USA
| | - Aya Mohammed Sharkawy
- Medical Research Group of Egypt, Negida Academy, Arlington, MA, USA
- Faculty of Medicine, South Valley University, Qena, Egypt
| | - Belal Jaradat
- Medical Research Group of Egypt, Negida Academy, Arlington, MA, USA
- Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Ibrahim Serag
- Medical Research Group of Egypt, Negida Academy, Arlington, MA, USA
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Nada Mostafa Al-Dardery
- Medical Research Group of Egypt, Negida Academy, Arlington, MA, USA
- Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Mariam Abdelhady
- Medical Research Group of Egypt, Negida Academy, Arlington, MA, USA
- Faculty of Medicine, October 6 University, Giza, Egypt
| | - Mohamed Abouzid
- Department of Physical Pharmacy and Pharmacokinetics, Faculty of Pharmacy, Poznan University of Medical Sciences, Rokietnicka 3 St., 60-806, Poznan, Poland.
- Doctoral School, Poznan University of Medical Sciences, 60-812, Poznan, Poland.
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13
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Zuo Q, Ni W, Yang P, Gu Y, Yu Y, Yang H, Majoie CBLM, Goyal M, Liu J, Mao Y. Managing non-acute subdural hematoma using liquid materials: a Chinese randomized trial of middle meningeal artery treatment (MAGIC-MT)-protocol. Trials 2023; 24:586. [PMID: 37710274 PMCID: PMC10503047 DOI: 10.1186/s13063-023-07608-2] [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: 05/21/2023] [Accepted: 08/28/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND The conventional treatments for non-acute subdural hematoma (SDH) are facing the challenge of high hematoma recurrence and progression. A novel treatment of middle meningeal artery (MMA) embolization showed the potential role in decreasing the recurrence and progression rate of SDH compared to conventional treatments in multiple cohort studies. A randomized controlled trial is warranted to determine the effectiveness and safety of MMA embolization for non-acute hematoma and whether MMA embolization is superior to conventional treatments to lower the symptomatic recurrence and progression rate of non-acute SDH. METHODS This is an investigator-initiated, multi-center, prospective, open-label parallel group trial with blinded outcome assessment (PROBE design) assessing superiority of MMA embolization compared to conventional treatments. A total of 722 patients are planned to be randomized 1:1 to receive MMA embolization (intervention) or conventional treatments (control). The primary outcome is the symptomatic SDH recurrence/progression rate within 90 ± 14 days post-randomization. DISCUSSION This trial will clarify whether MMA embolization could reduce the recurrence or progression rate of symptomatic non-acute SDH compared to conventional treatment. TRIAL REGISTRATION ClinicalTrials.gov. Identifier: NCT04700345, Registered on 7 January 2021.
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Affiliation(s)
- Qiao Zuo
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Wei Ni
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Pengfei Yang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yuxiang Gu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Ying Yu
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Heng Yang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Charles B L M Majoie
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Mayank Goyal
- Departments of Clinical Neuroscience and Radiology, Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jianmin Liu
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China.
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China.
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14
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Jai S, Zul K. Grading Embolization of Middle Meningeal Artery for Chronic Subdural Hematoma. Can J Neurol Sci 2023:1-5. [PMID: 37667625 DOI: 10.1017/cjn.2023.249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
BACKGROUND AND PURPOSE Embolization of middle meningeal artery (EMMA) is a relatively new treatment for chronic subdural hematoma (CSDH). To date, an objective method that assesses or describes the extent of EMMA for the treatment of CSDH does not exist. Recently, the concept of a novel grading scale for EMMA in patients with CSDH has emerged. However, this has not been applied to a clinical case setting and inter-rater reliability has not yet been studied. The purpose of this study was to validate the grading scale in clinical practice and to assess for inter-rater reliability. MATERIALS AND METHODS We retrospectively examined consecutive patients who underwent EMMA for CSDH. Patients were included if the whole head angiogram from common carotid as well as external carotid arteries before and after EMMA were available in the arterial, capillary as well as venous phases. Two independent readers, each with more than 5 years of experience in independent practice, assessed the angiograms for the grading of EMMA and assigned a score ranging between 0 and 3. The grading score between the two readers were compared using Cohen's Kappa score to assess the inter-rater reliability. RESULTS In 19 patients, we found that EMMA had no periprocedural morbidity and mortality. The number of cases in each EMMA grading score category are as follows: 0 n =1; 1 n =3; 2 n =1; and 3 n =10. There was substantial inter-rater reliability for the assessment of grading of EMMA (Kappa = 0.74). CONCLUSIONS The novel EMMA grading scheme demonstrated substantial inter-rater reliability and appears promising.
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Affiliation(s)
- Shankar Jai
- Department of Radiology, University of Manitoba, Winnipeg, Canada
| | - Kaderali Zul
- Division of Neurosurgery, University of Manitoba, Winnipeg, Canada
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15
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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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16
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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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17
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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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18
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Fiorella D, Arthur AS. Middle meningeal artery embolization for the management of chronic subdural hematoma: what a difference a few years make. J Neurointerv Surg 2023; 15:515-516. [PMID: 37192813 DOI: 10.1136/jnis-2023-020498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2023] [Indexed: 05/18/2023]
Affiliation(s)
- David Fiorella
- Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA
- State University of NY at Stony Brook, Department of Neurosurgery, Cerebrovascular Center, New York, New York, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
- Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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19
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Khorasanizadeh M, Shutran M, Garcia A, Enriquez-Marulanda A, Moore J, Ogilvy CS, Thomas AJ. Middle meningeal artery embolization for treatment of chronic subdural hematomas: does selection of embolized branches affect outcomes? J Neurosurg 2023; 138:1494-1502. [PMID: 36681986 DOI: 10.3171/2022.9.jns221663] [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: 07/16/2022] [Accepted: 09/26/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Middle meningeal artery (MMA) embolization (MMAE) is a new therapeutic modality for chronic subdural hematoma (cSDH). There is limited evidence comparing various MMAE procedural techniques, resulting in significant variations in technique and procedural planning. The objective of this study was to compare outcomes of MMAE by the number and location of MMA branches that were embolized. METHODS A single-center retrospective study of patients with cSDH treated by MMAE was conducted. Clinical outcomes, need for re-intervention, and changes in hematoma size were compared between different MMAE techniques. RESULTS Ninety-four cSDHs in 78 patients were included. Embolization of the proximal trunk only, distal branches only, or proximal trunk plus distal branches resulted in similar rates of need for rescue surgery (7.4%, 13.0%, and 6.8%, respectively; p = 0.66) and rates of reducing the volume of the hematoma by at least 50% (74.1%, 80.0%, and 77.5%, respectively; p = 0.88). Embolization of only one branch had similar outcomes to embolization of more than one branch, as rescue surgery rates were 9.3% and 7.8% (p = 0.80), and rates ≥ 50% volume reduction were 75.6% and 78.3% (p = 0.76), respectively. Selective embolization of the dominant MMA branch was not associated with significantly different outcomes. CONCLUSIONS Outcomes of distal, proximal, or combined proximal and distal MMAE in cSDH are not significantly different. Embolization of more than one branch is not associated with improved treatment efficacy. Arguably, targeting any location in the MMA provides sufficient flow restriction to enable spontaneous hematoma resolution. Accordingly, a technical planning algorithm for cSDH MMAE is suggested.
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Affiliation(s)
- MirHojjat Khorasanizadeh
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Max Shutran
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Alfonso Garcia
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Alejandro Enriquez-Marulanda
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Justin Moore
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Christopher S Ogilvy
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Ajith J Thomas
- 2Department of Neurological Surgery, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, New Jersey
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20
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de Paula MVCT, Ribeiro BDC, Melo MM, de Freitas PVV, Pahl FH, de Oliveira MF, Rotta JM. Effect of postoperative tranexamic acid on recurrence rate and complications in chronic subdural hematomas patients: preliminary results of a randomized controlled clinical trial. Neurosurg Rev 2023; 46:90. [PMID: 37071217 PMCID: PMC10111300 DOI: 10.1007/s10143-023-01991-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/08/2023] [Accepted: 04/06/2023] [Indexed: 04/19/2023]
Abstract
Chronic subdural hematoma (CSDH) is a frequent neurosurgical disease which mainly affects elderly patients. Tranexamic acid (TXA) has been hypothesized as an oral agent to avoid CSDH progression and/or recurrence. We performed an evaluation to determine whether the postoperative use of TXA reduces recurrence rate. A prospective, randomized, and controlled trial. Patients with unilateral or bilateral chronic subdural hematoma undergoing surgical treatment by burr-hole were randomized as to whether or not to use TXA in the postoperative period. We evaluated image and clinical recurrence of CSDH at follow up of 6 months and potential clinical and/or surgical complications impact of TXA. Twenty-six patients were randomized to the control group (52%) and twenty-four patients to the TXA group (48%). Follow-up ranged from 3 to 16 months. There were no significant difference between baseline data in groups regarding to age, gender, use of antiplatelet or anticoagulants, smoking, alcoholism, systemic arterial hypertension, diabetes mellitus, hematoma laterality, hematoma thickness, and drain use. Clinical and radiological recurrence occurred in three patients (6%), being two cases in TXA group (8.3%) and 1 in control group (3.8%). Postoperative complications occurred in two patients during follow-up (4%), being both cases in TXA group (8.3%), and none in the control group. Although TXA group had a higher recurrence rate (8.3%), there was no statistically significant difference between the two groups. Moreover, TXA group had two complications while control group had no complications. Although limited by experimental nature of study and small sample, our current data suggest that TXA should not be used as a potential agent to avoid recurrences of CSDH and might increase complication odds.
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Affiliation(s)
- Marcus Vinícius Carneiro Torres de Paula
- Department of Neurosurgery, Hospital do Servidor Público Estadual de São Paulo, IAMSPE, Rua Pedro de Toledo, 1800, Vila Clementino, São Paulo, 04029-000, Brazil
| | - Bernardo Duarte Chamon Ribeiro
- Department of Neurosurgery, Hospital do Servidor Público Estadual de São Paulo, IAMSPE, Rua Pedro de Toledo, 1800, Vila Clementino, São Paulo, 04029-000, Brazil
| | - Marina Mendes Melo
- Department of Neurosurgery, Hospital do Servidor Público Estadual de São Paulo, IAMSPE, Rua Pedro de Toledo, 1800, Vila Clementino, São Paulo, 04029-000, Brazil
| | - Pedro Victor Vidal de Freitas
- Department of Neurosurgery, Hospital do Servidor Público Estadual de São Paulo, IAMSPE, Rua Pedro de Toledo, 1800, Vila Clementino, São Paulo, 04029-000, Brazil
| | - Felix Hendrik Pahl
- Department of Neurosurgery, Hospital do Servidor Público Estadual de São Paulo, IAMSPE, Rua Pedro de Toledo, 1800, Vila Clementino, São Paulo, 04029-000, Brazil
| | - Matheus Fernandes de Oliveira
- Department of Neurosurgery, Hospital do Servidor Público Estadual de São Paulo, IAMSPE, Rua Pedro de Toledo, 1800, Vila Clementino, São Paulo, 04029-000, Brazil.
| | - José Marcus Rotta
- Department of Neurosurgery, Hospital do Servidor Público Estadual de São Paulo, IAMSPE, Rua Pedro de Toledo, 1800, Vila Clementino, São Paulo, 04029-000, Brazil
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21
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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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22
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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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23
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Rutledge C, Baranoski JF, Catapano JS, Jadhav AP, Albuquerque FC, Ducruet AF. Republished: Resolution of an enlarging subdural haematoma after contralateral middle meningeal artery embolisation. J Neurointerv Surg 2023; 15:e2. [PMID: 33986110 DOI: 10.1136/neurintsurg-2021-017530.rep] [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: 03/17/2021] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 11/04/2022]
Abstract
A man in his 50s presented 1 month after an automobile accident with worsening headaches and an enlarging chronic left subdural haematoma (SDH). He underwent left middle meningeal artery (MMA) embolisation. Due to tortuosity at its origin, we were unable to catheterise the MMA distally. Only proximal coil occlusion at the origin was performed. Follow-up interval head CT showed an increase in the size of the SDH with new haemorrhage, worsening mass effect and midline shift. However, he remained neurologically intact. Contralateral embolisation of the right MMA was performed with a liquid embolic agent. His headaches improved, and a follow-up head CT 3 months later showed near-complete resolution of the SDH.
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Affiliation(s)
- Caleb Rutledge
- 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
| | - Joshua S Catapano
- 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
| | - Felipe C Albuquerque
- 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
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24
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Shotar E, Barberis E, Chougar L, Bensoussan S, Parat D, Ghannouchi H, Premat K, Lenck S, Degos V, Lehericy S, Sourour NA, Mathon B, Clarençon F. Long-Term Middle Meningeal Artery Caliber Reduction Following Trisacryl Gelatine Microsphere Embolization for the Treatment of Chronic Subdural Hematoma. Clin Neuroradiol 2023; 33:113-120. [PMID: 35796853 DOI: 10.1007/s00062-022-01189-4] [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] [Received: 01/06/2022] [Accepted: 06/13/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Middle meningeal artery (MMA) particle embolization is a promising treatment of chronic subdural hematomas (CSDH). The main purpose of this study is to measure MMA proximal caliber and assess the visibility of the two main MMA branches as a surrogate for long-term distal arterial patency following MMA CSDH embolization with trisacryl gelatine microspheres (TAGM). METHODS This is a single-center retrospective study. All patients having undergone MMA TAGM only embolization for CSDH treatment between 15 March 2018 and 6 June 2020 with an interpretable follow-up magnetic resonance imaging (MRI) examination and no confounding factors were included. Patients were compared with controls matched for age, sex and MRI machine. Two independent readers analyzed the MRI images. RESULTS In this study, 30 patients having undergone embolization procedures using TAGM of 36 MMAs were included. The follow-up MRI scans were performed after a mean delay of 14.8 ± 7.1 months (range 4.9-29.4 months). The mean diameter of TAGM embolized MMAs (1 mm; 95% confidence interval, CI 0.9-1.1) was significantly smaller than the mean diameter of paired control MMAs (1.3 mm; 95% CI 1.3-1.4) (p < 0.001). The mean proximal diameter of the embolized MMAs (0.9 mm; 95% CI 0.7-1.1) was significantly smaller than the mean diameter of the contralateral MMAs in the same patients (1.4 mm; 95% CI 1.3-1.6)(p < 0.001). CONCLUSION Long-term follow-up MRI demonstrated a significant impact of TAGM embolization on MMA proximal caliber as well as on the visibility of the two main MMA branches. All comparisons indicated that there was a probable lasting impact of embolization on the patency of distal branches.
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Affiliation(s)
- Eimad Shotar
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France.
| | - Eric Barberis
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Lydia Chougar
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France.,Sorbonne Université, Paris, France
| | - Sacha Bensoussan
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Damien Parat
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Haroun Ghannouchi
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Kevin Premat
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Stephanie Lenck
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Vincent Degos
- Sorbonne Université, Paris, France.,Department of Neurosurgical Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Stéphane Lehericy
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France.,Sorbonne Université, Paris, France
| | - Nader-Antoine Sourour
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Bertrand Mathon
- Sorbonne Université, Paris, France.,Department of Neurosurgery, Pitié-Salpêtrière Hospital, Paris, France
| | - Frédéric Clarençon
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France.,Sorbonne Université, Paris, France
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25
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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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26
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Fuentes AM, Khalid SI, Mehta AI. Predictors of Subsequent Intervention After Middle Meningeal Artery Embolization for Treatment of Subdural Hematoma: A Nationwide Analysis. Neurosurgery 2023; 92:144-149. [PMID: 36129273 DOI: 10.1227/neu.0000000000002151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 07/16/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Middle meningeal artery (MMA) embolization has recently emerged as an effective technique to treat subdural hematomas (SDHs). Studies to date have been limited, largely, to single-center studies with limited follow-up and have not assessed subsequent surgical interventions and factors associated with these interventions. OBJECTIVE To evaluate rates of retreatment for SDH after MMA embolization and patient-specific factors that may be important predictors for these interventions. METHODS Using an all-payer claims database, Mariner, patients who underwent MMA embolization between January 2010 and October 2020 after the diagnosis of SDH were identified. Rates of post-MMA embolization surgical interventions, including craniotomy and burr hole drainage, were accessed within 5 years following. Patient-specific contributors to the rates of these interventions were studied using Gaussian logistic regression models. RESULTS A total of 322 patients were included. Of this cohort, 55 (17.1%) required subsequent intervention within 5 years, with 36 (11.2%) receiving burr hole evacuation and 19 (5.9%) receiving craniotomy. Factor Xa inhibitor use was independently associated with subsequent interventions after MMA embolization procedures (odds ratio: 1.20 [95% CI: 1.02-1.40]). Of the other patient factors evaluated, including age, sex, comorbidity status, and use of vitamin K antagonists, antiplatelets, and factor Xa inhibitors, none were found to be significantly associated with future interventions. CONCLUSION Although previous literature has shown MMA embolization to be safe and successful in preventing recurrent SDH, patients undergoing this procedure still carry a risk of future interventions. Patients taking factor Xa inhibitors are at especially high risk of subsequent intervention after MMA embolization.
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Affiliation(s)
- Angelica M Fuentes
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
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27
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Grading Scale for Embolization of Middle Meningeal Artery for Chronic Subdural Hematoma. Neurol Sci 2023; 50:144-146. [PMID: 35538864 DOI: 10.1017/cjn.2021.503] [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]
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28
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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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Khorasanizadeh M, Shutran M, Garcia A, Enriquez-Marulanda A, Moore JM, Ogilvy CS, Thomas AJ. Middle Meningeal Artery Embolization with Isolated Use of Coils for Treatment of Chronic Subdural Hematomas: A Case Series. World Neurosurg 2022; 165:e581-e587. [PMID: 35768059 DOI: 10.1016/j.wneu.2022.06.099] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/19/2022] [Accepted: 06/20/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Middle meningeal artery embolization (MMAE) is a novel approach for treatment of chronic subdural hematoma (cSDH). Studies comparing different procedural techniques for MMAE are lacking. It is unclear whether isolated use of coils results in suboptimal outcomes compared to when particle embolization is also performed. The objectives of this study are to describe the outcomes of coil-only MMAE and compare them with those of combined use of coils and particles. METHODS A single-institution retrospective study of cSDH cases treated by MMAE was performed. Clinical outcomes, need for rescue surgery, and changes in hematoma's size were compared between the coil-only and coil + particle groups. RESULTS Ninety-four hematomas in 78 patients were included. Twelve cases were treated by a coil-only MMAE procedure, often due to presence of dangerous ophthalmic collaterals. No treatment-related complications were observed in the coil-only group. There was no significant difference between the coil-only and coil + particle groups in baseline hematoma axial thickness, volume, midline shift, and duration of follow-up. The rate of need for rescue surgery was similar between the 2 groups (8.3% vs. 8.5%; P = 0.98). Coiling alone resulted in a similar percentage of reduction in cSDH volume (68.3% vs. 71.8%; P = 0.8) and rate of achieving ≥50% reduction in volume (81.8% vs. 76.3%; P = 0.68) compared to coils + particles. CONCLUSIONS Isolated use of coils for endovascular treatment of cSDHs can be as effective as adjunct use of particle embolization. This method eliminates the risks of cranial nerve and visual complications associated with MMAE, can prevent procedural abortion due to presence of dangerous anastomoses, and reduces the technical complexity of the procedure.
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Affiliation(s)
- MirHojjat Khorasanizadeh
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Max Shutran
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Alfonso Garcia
- 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
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith J Thomas
- Department of Neurosurgery, Cooper University Hospital, Camden, New Jersey, USA.
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30
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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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31
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Abdelsalam A, Silva MA, Luther EM, Lu VM, Thompson JW, Burks JD, Saini V, Starke RM. Commentary: Middle Meningeal Artery Embolization for Chronic Subdural Hematoma Using N-Butyl Cyanoacrylate With D5W Push Technique. Neurosurgery 2022; 91:e63-e64. [PMID: 35834326 PMCID: PMC9514732 DOI: 10.1227/neu.0000000000002051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 04/24/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Ahmed Abdelsalam
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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32
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Kocharian G, Zappi KB, Carnevale J, Schwarz J, Knopman J. Recent Advances and Future Directions in Middle Meningeal Artery Embolization for Chronic Subdural Hematomas. Curr Pain Headache Rep 2022; 26:657-665. [PMID: 35802284 DOI: 10.1007/s11916-022-01068-0] [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: 05/09/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to present a brief background on chronic subdural hematomas (cSDH), middle meningeal artery (MMA) embolization, and its role in decreasing recurrence of cSDH. A review of the most up-to-date literature should demonstrate the efficacy of this procedure. RECENT FINDINGS The latest data shows that MMA embolization is a safe procedure, with low complication rates and low recurrence rates. While cSDH managed with surgical evacuation can have a recurrence rate upwards of 30%, MMA embolization alone or as an adjunct to surgery decreases recurrence to less than 5% in most studies. MMA embolization can be especially useful in high-risk populations such as the elderly, patients on anti-platelet medication, and those with coagulopathies. It can also be done awake, done without general anesthesia, and is significantly less invasive than traditional surgical techniques. In reviewing the literature on MMA embolization, it is clear that there are numerous retrospective studies and systematic reviews demonstrating its safety and efficacy, and some prospective dual-arm studies that present novel information. The numerous clinical trials that are currently underway should help to further establish MMA embolization as standard of care in the management of cSDH.
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Affiliation(s)
- Gary Kocharian
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 E 68thSt., M-220, Box 99, New York, NY, 10065, USA.
| | - Kyle B Zappi
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 E 68thSt., M-220, Box 99, New York, NY, 10065, USA
| | - Joseph Carnevale
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 E 68thSt., M-220, Box 99, New York, NY, 10065, USA
| | - Justin Schwarz
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 E 68thSt., M-220, Box 99, New York, NY, 10065, USA
| | - Jared Knopman
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 E 68thSt., M-220, Box 99, New York, NY, 10065, USA
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33
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Samarage HM, Kim WJ, Zarrin D, Goel K, Chin-Hsiu Wang A, Johnson J, Kaneko N, Nour M, Szeder V, Tateshima S, Jahan R, Duckwiler G, Colby GP. The "Bright Falx" Sign-Midline Embolic Penetration Is Associated With Faster Resolution of Chronic Subdural Hematoma After Middle Meningeal Artery Embolization: A Case Series. Neurosurgery 2022; 91:389-398. [PMID: 35551167 DOI: 10.1227/neu.0000000000002038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 04/03/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Chronic subdural hematomas (CSDHs) are common in the elderly population and patients taking antiplatelet/anticoagulation medications. Middle meningeal artery (MMA) embolization has become an adjunctive treatment to observation and surgery. Despite many embolization techniques, best practices for optimal CSDH resolution remain unknown. OBJECTIVE To report a retrospective case series of MMA embolization for CSDHs regarding rate of hematoma improvement and the significance of distal embolic penetration into the falx. METHODS Retrospective chart review was performed on all patients who underwent MMA embolization for CSDHs between January 2017 and June 2021. Patient demographics, clinical presentation, anticoagulant use, and radiographic features were collected. Pre-embolization and postembolization computed tomography scans were analyzed for volumetric changes and assessed for midline penetration of embolic material in the falx. RESULTS MMA embolization was performed in 37 patients and 53 hemispheres. Older patients took longer to obtain complete resolution of CSDHs (r = 0.47, P = .03). Patients with larger pre-embolization (r = 0.57, P = .007) and postembolization (r = 0.56, P = .008) CSDH volumes took longer to completely resolve. Patients who had n-butyl cyanoacrylate embolization with midline penetration, as evidenced by the "bright falx" sign, had faster improvement rates than those who did not (5.64 cm3/d vs 1.2 cm3/d, P = .02). CONCLUSION Distal penetration of embolic material, particularly n-butyl cyanoacrylate, into the falx may lead to more rapid improvement of CSDH.
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Affiliation(s)
- Hasitha Milan Samarage
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - Wi Jin Kim
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - David Zarrin
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Keshav Goel
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Anthony Chin-Hsiu Wang
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - Jeremiah Johnson
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - Naoki Kaneko
- Department of Interventional Neuroradiology, University of California Los Angeles, Los Angeles, California, USA
| | - May Nour
- Department of Interventional Neuroradiology, University of California Los Angeles, Los Angeles, California, USA
| | - Viktor Szeder
- Department of Interventional Neuroradiology, University of California Los Angeles, Los Angeles, California, USA
| | - Satoshi Tateshima
- Department of Interventional Neuroradiology, University of California Los Angeles, Los Angeles, California, USA
| | - Reza Jahan
- Department of Interventional Neuroradiology, University of California Los Angeles, Los Angeles, California, USA
| | - Gary Duckwiler
- Department of Interventional Neuroradiology, University of California Los Angeles, Los Angeles, California, USA
| | - Geoffrey Philip Colby
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA.,Department of Interventional Neuroradiology, University of California Los Angeles, Los Angeles, California, USA
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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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35
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Holl DC, Blaauw J, Ista E, Dirven CMF, Kho KH, Jellema K, van der Gaag NA, Miah IP, den Hertog HM, van der Naalt J, Jacobs B, Verbaan D, Polinder S, Lingsma HF, Dammers R. National survey on the current practice and attitudes toward the management of chronic subdural hematoma. Brain Behav 2022; 12:e2463. [PMID: 35113493 PMCID: PMC8933788 DOI: 10.1002/brb3.2463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/14/2021] [Accepted: 10/31/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a frequent pathological entity in daily clinical practice. However, evidence-based CSDH-guidelines are lacking and level I evidence from randomized clinical trials (RCTs) is limited. In order to establish and subsequently implement a guideline, insight into current clinical practice and attitudes toward CSDH-treatment is required. The aim is to explore current practice and attitudes toward CSDH-management in the Netherlands. METHODS A national online survey was distributed among Dutch neurologists and neurosurgeons, examining variation in current CSDH-management through questions on treatment options, (peri)operative management, willingness to adopt new treatments and by presenting four CSDH-cases. RESULTS One hundred nineteen full responses were received (8% of neurologists, N = 66 and 35% of neurosurgeons, N = 53). A majority of the respondents had a positive experience with burr-hole craniostomy (93%) and with a conservative policy (56%). Around a third had a positive experience with the use of dexamethasone as primary (30%) and additional (33.6%) treatment. These numbers were also reflected in the treatment preferences in the presented cases. (Peri)operative management corresponded among responding neurosurgeons. Most respondents would be willing to implement dexamethasone (98%) if equally effective as surgery and tranexamic acid (93%) if effective in CSDH-management. CONCLUSION Variation was found regarding preferential CSDH-treatment. However, this is considered not to be insurmountable when implementing evidence-based treatments. This baseline inventory on current clinical practice and current attitudes toward CSDH-treatment is a stepping-stone in the eventual development and implementation of a national guideline.
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Affiliation(s)
- Dana C Holl
- Department of Neurosurgery, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, the Netherlands.,Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jurre Blaauw
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands.,Department of Neurology, University Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Erwin Ista
- Department of Internal Medicine, Nursing Science, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Clemens M F Dirven
- Department of Neurosurgery, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, the Netherlands
| | - Kuan H Kho
- Department of Neurosurgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Center, Hague, the Netherlands
| | - Niels A van der Gaag
- Haaglanden Medical Center, Haga Teaching Hospital, University Neurosurgical Center Holland (UNCH), Leiden University Medical Center, Leiden, the Netherlands
| | - Ishita P Miah
- Department of Neurology, Amphia Hospital, Breda, the Netherlands
| | | | - Joukje van der Naalt
- Department of Neurology, University Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Bram Jacobs
- Department of Neurology, University Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, the Netherlands
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36
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Regenhardt RW, Dmytriw AA, Vranic JE, Patel AB, Stapleton CJ. Middle meningeal artery embolization: preventing subdural hematoma recurrence and saving money? J Neurointerv Surg 2022; 14:745-746. [PMID: 34987070 DOI: 10.1136/neurintsurg-2021-018441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Robert W Regenhardt
- Neurosurgery and Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Adam A Dmytriw
- Neurosurgery and Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Justin E Vranic
- Neurosurgery and Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Aman B Patel
- Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
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37
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Catapano JS, Koester SW, Srinivasan VM, Rumalla K, Baranoski JF, Rutledge C, Cole TS, Winkler EA, Lawton MT, Jadhav AP, Ducruet AF, Albuquerque FC. Total 1-year hospital cost of middle meningeal artery embolization compared to surgery for chronic subdural hematomas: a propensity-adjusted analysis. J Neurointerv Surg 2021; 14:804-806. [PMID: 34880075 DOI: 10.1136/neurintsurg-2021-018327] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 11/21/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Middle meningeal artery (MMA) embolization results in fewer treatment failures than surgical evacuation for chronic subdural hematomas (cSDHs). We compared the total 1-year hospital cost for MMA embolization versus surgical evacuation for patients with cSDH. METHODS Data for patients who presented with cSDHs from January 1, 2018, through May 31, 2020, were retrospectively reviewed. Patients were grouped by initial treatment (surgery vs MMA embolization), and total hospital cost was obtained. A propensity-adjusted analysis was performed. The primary outcome was difference in mean hospital cost between treatments. RESULTS Of 170 patients, 48 (28%) underwent embolization and 122 (72%) underwent surgery. cSDHs were larger in the surgical (20.5 (6.7) mm) than in the embolization group (16.9 (4.6) mm; P<0.001); and index hospital length of stay was longer in the surgical group (9.8 (7.0) days) than in the embolization group (5.7 (2.4) days; P<0.001). More patients required additional hematoma treatment in the surgical cohort (16%) than in the embolization cohort (4%; P=0.03), and more required readmission in the surgical cohort (28%) than in the embolization cohort (13%; P=0.04). After propensity adjustment, MMA embolization was associated with a lower total hospital cost compared to surgery (mean difference -$32 776; 95% CI -$52 766 to -$12 787; P<0.001). A propensity-adjusted linear regression analysis found that unexpected additional treatment was the only significant contributor to total hospital cost (mean difference $96 357; 95% CI $73 886 to $118 827; P<0.001). CONCLUSIONS MMA embolization is associated with decreased total hospital cost compared with surgery for cSDHs. This lower cost is directly related to the decreased need for additional treatment interventions.
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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
| | - Stefan W Koester
- School of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kavelin Rumalla
- 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
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- 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
| | - 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
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38
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Catapano JS, Ducruet AF, Srinivasan VM, Rumalla K, Nguyen CL, Rutledge C, Cole TS, Baranoski JF, Lawton MT, Jadhav AP, Albuquerque FC. Radiographic clearance of chronic subdural hematomas after middle meningeal artery embolization. J Neurointerv Surg 2021; 14:1279-1283. [PMID: 34872986 DOI: 10.1136/neurintsurg-2021-018073] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/16/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Few reports discuss variables associated with improved outcomes after middle meningeal artery (MMA) embolization for chronic subdural hematomas (cSDHs). We analyzed radiographic evidence of cSDH clearance after MMA embolization to elucidate optimal techniques, hematoma clearance rates, and suitable length of follow-up. METHODS Patients who underwent MMA embolization for cSDH from January 1, 2018 through December 31, 2020 were analyzed. Patient characteristics, demographics, and technical procedural details were examined. Outcomes for cSDHs analyzed included complete or near-complete resolution at 30, 90, and 180 days following embolization. A multivariable logistic regression analysis identified variables predictive of rapid clearance and resolution of hematomas at 90 days. RESULTS The study cohort comprised 66 patients with 84 treated cSDHs. The mean (SD) cSDH size differed significantly at 30-day (8.8 (4.3) mm), 90-day (3.4 (3.0) mm), and 180-day (1.0 (1.7) mm) follow-up (p<0.001). More cSDHs had complete or near-complete resolution at 180 days (92%, 67/73) than at 90 (63%, 45/72) and 30 days (18%, 15/84) post-embolization (p<0.001). Only distal embolysate penetration was independently associated with rapid clearance (OR 3.9, 95% CI 1.4 to 11.1; p=0.01) and resolution of cSDHs at 90 days (OR 5.0, 95% CI 1.7 to 14.6; p=0.003). CONCLUSION Although 63% of cSDHs with MMA embolization had complete or near-complete resolution by 90 days post-procedure, 92% reached this stage by 180 days. Therefore, 90-day follow-up may be insufficient to determine the effectiveness of MMA embolization for cSDHs, particularly compared with surgical evacuation alone. Also, distal MMA penetration may be associated with more rapid hematoma clearance.
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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
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Candice L Nguyen
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Caleb Rutledge
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Ashutosh P Jadhav
- 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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Wilcox JT, Bakhaidar M, Saluja R, Lasry O, Marcoux J. Letter to the Editor. The weight of statistical methods. J Neurosurg 2021; 136:1208-1209. [PMID: 34798609 DOI: 10.3171/2021.8.jns211708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Jared T Wilcox
- 1Montreal Neurologic Hospital-Institute, Montreal, QC, Canada
| | | | - Rajeet Saluja
- 1Montreal Neurologic Hospital-Institute, Montreal, QC, Canada
| | - Oliver Lasry
- 1Montreal Neurologic Hospital-Institute, Montreal, QC, Canada.,2Lady Davis Institute, Jewish General Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Judith Marcoux
- 1Montreal Neurologic Hospital-Institute, Montreal, QC, Canada
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40
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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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41
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Zhang X, Wang D, Tian Y, Wei H, Liu X, Xiang T, Fan Y, Gao C, Huang J, Sha Z, Quan W, Zhang J, Jiang R. Risk Factors for Atorvastatin as a Monotherapy for Chronic Subdural Hematoma: A Retrospective Multifactor Analysis. Front Aging Neurosci 2021; 13:726592. [PMID: 34539386 PMCID: PMC8440973 DOI: 10.3389/fnagi.2021.726592] [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: 06/17/2021] [Accepted: 08/09/2021] [Indexed: 11/23/2022] Open
Abstract
Chronic subdural hematoma (CSDH) is a common form of intracranial hemorrhage in the aging population. We aimed to investigate the predictive factors for atorvastatin efficacy as a monotherapy for moderate CSDH. We retrospectively reviewed the medical records of patients who were diagnosed with moderate CSDH and received atorvastatin monotherapy between February 5, 2014, and November 7, 2015, in multiple neurosurgical departments. Univariate, multivariate and receiver operating characteristic curve analyses were performed to identify the potential significant factors indicative of the good therapeutic efficacy or poor therapeutic efficacy of atorvastatin for mild CSDH, such as age, sex, history of injury, Markwalder grading scale–Glasgow Coma Scale (MGS-GCS), Activities of Daily Life-the Barthel Index scale (ADL-BI), American Society of Anesthesiologists Physical Status classification system (ASA-PS), blood cell counts, serum levels and computed tomography findings. A total of 89 patients (75 men and 14 women) aged 24–88 years (mean age 61.95 ± 15.30 years) were followed-up for 24 weeks. Computed tomography findings at admission showed mixed-density hematoma in 22 patients, isodense hematoma in 13 patients, high-density hematoma in 26 patients, and low-density hematoma in 28 patients. In total, 3, 80, and 6 patients had MGS-GCS grades of 0, 1, and 2, respectively. The efficacy rate at 6 months was 87.6% (78/89). Eleven patients were switched to surgery due to a worsened neurological condition, of whom 8, 1, 1, and 1 had high-density, low-density, isodense and mixed-density hematomas, respectively. These patients were switched to surgery over a range of 2–27 days, with a median interval of 12 days after the medication treatment. Univariate and multivariate analyses, confirmed by ROC curves, revealed that high-density hematoma, basal cistern compression, and hematoma volume to be independent risk factors for the efficacy of atorvastatin monotherapy in patients with moderate CSDH. Atorvastatin is an effective monotherapy for the treatment of mild CSDH. High-density hematoma, basal cistern compression, and hematoma volume are independent predictors of the efficacy of atorvastatin as a non-surgical treatment. The results suggested that ADL-BI was more sensitive than the MGS-GCS and ASA-PS for determining patient outcomes in our moderate CSDH cohort.
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Affiliation(s)
- Xinjie Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Dong Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Ye Tian
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Huijie Wei
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Xuanhui Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Tangtang Xiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Yibing Fan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Chuang Gao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Jinhao Huang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Zhuang Sha
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Wei Quan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
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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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43
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Onyinzo C, Berlis A, Abel M, Kudernatsch M, Maurer CJ. Efficacy and mid-term outcome of middle meningeal artery embolization with or without burr hole evacuation for chronic subdural hematoma compared with burr hole evacuation alone. J Neurointerv Surg 2021; 14:297-300. [PMID: 34187870 DOI: 10.1136/neurintsurg-2021-017450] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 06/14/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a common neurosurgical condition with high recurrence rates. Repeated microbleedings from fragile neo-vessels supplied by peripheral branches of the middle meningeal artery (MMA) are believed to be responsible for the growth and recurrence of CSDH. Thus, MMA embolization might be a promising method to prevent re-bleedings and recurrences. This study aims to assess the efficacy, complication rates, and mid-term outcome of MMA embolization with or without burr hole irrigation compared with burr hole irrigation alone. METHODS Patients diagnosed with CSDH who underwent MMA embolization and/or surgical treatment were retrospectively recruited to this single-center study. The outcome variables were defined as treatment-related complications, clinical outcome at discharge, rate of revision surgery, and CT findings during the follow-up period. RESULTS A total of 132 patients with CSDH were included in the study. The use of antiplatelet/anticoagulant medication was significantly higher in the combined treatment and embolization group (p<0.001). A trend towards fewer revision surgeries was found in the group of patients who received MMA embolization combined with burr hole irrigation (p=0.083). Follow-up was available for 73 patients (55.3%) with a mean follow-up period of 3.4±2.2 months. Eight patients (15.1%) of the surgery group showed hematoma re-accumulation and needed surgical rescue, whereas only one patient (5.0%) of the combined treatment group needed revision surgery. In all patients treated with only MMA embolization, complete hematoma resolution was found. CONCLUSION MMA embolization is a safe and efficacious minimal invasive adjuvant and/or alternative procedure for the treatment of CSDH with a reduced recurrence rate.
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Affiliation(s)
- Christina Onyinzo
- Department of Neurosurgery, Schoen Clinic Vogtareuth, Vogtareuth, Bavaria, Germany
| | - Ansgar Berlis
- Department of Diagnostic and Interventionell Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Bavaria, Germany.,Department of Neuroradiology, Schoen Clinic Vogtareuth, Vogtareuth, Bavaria, Germany
| | - Maria Abel
- Department of Neurosurgery, Schoen Clinic Vogtareuth, Vogtareuth, Bavaria, Germany
| | - Manfred Kudernatsch
- Department of Neurosurgery, Schoen Clinic Vogtareuth, Vogtareuth, Bavaria, Germany.,Research Institute Rehabilitation, Transition, Palliation, Paracelsus Medizinische Privatuniversität, Salzburg, Austria
| | - Christoph J Maurer
- Department of Diagnostic and Interventionell Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Bavaria, Germany.,Department of Neuroradiology, Schoen Clinic Vogtareuth, Vogtareuth, Bavaria, Germany
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Rutledge C, Baranoski JF, Catapano JS, Jadhav AP, Albuquerque FC, Ducruet AF. Resolution of an enlarging subdural haematoma after contralateral middle meningeal artery embolisation. BMJ Case Rep 2021; 14:e017530. [PMID: 33906882 PMCID: PMC8076938 DOI: 10.1136/bcr-2021-017530] [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: 03/17/2021] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 11/04/2022] Open
Abstract
A man in his 50s presented 1 month after an automobile accident with worsening headaches and an enlarging chronic left subdural haematoma (SDH). He underwent left middle meningeal artery (MMA) embolisation. Due to tortuosity at its origin, we were unable to catheterise the MMA distally. Only proximal coil occlusion at the origin was performed. Follow-up interval head CT showed an increase in the size of the SDH with new haemorrhage, worsening mass effect and midline shift. However, he remained neurologically intact. Contralateral embolisation of the right MMA was performed with a liquid embolic agent. His headaches improved, and a follow-up head CT 3 months later showed near-complete resolution of the SDH.
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Affiliation(s)
- Caleb Rutledge
- 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
| | - Joshua S Catapano
- 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
| | - Felipe C Albuquerque
- 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
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45
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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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Shapiro M, Raz E, Nossek E, Srivatanakul K, Walker M, Mir O, Nelson PK. Dural venous system: angiographic technique and correlation with ex vivo investigations. J Neurointerv Surg 2021; 14:196-201. [PMID: 33727412 DOI: 10.1136/neurintsurg-2020-017237] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/22/2021] [Accepted: 02/23/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND The dural vasculature plays a key role in several important conditions, including dural fistulas and subdural collections. While in vivo investigations of intrinsic dural arterial angioarchitecture are rare, no angiographic studies of dural venous drainage exist to our knowledge. OBJECTIVE To describe methods by which dural venous drainage might be visualized with current angiographic equipment and technique, and to correlate our results with existing ex vivo literature. METHODS Digital subtraction angiography and 3D angiography (rotational and Dyna CT) of dural neurovasculature were acquired in the context of subdural hematoma embolization and normal dura. Protocols for visualization of dural venous drainage were established, and findings correlated with ex vivo studies. RESULTS Meningeal arteries supply both the skull and dura. Normal dural enhancement is accentuated by the presence of hypervascular membranes. Intrinsic meningeal veins/sinuses parallel outer layer arteries with well-known tram-tracking appearance. Dura adjacent to main arterial trunks drains via skull base foramina into the pterygopalatine venous plexus, or via emissary veins into the temporalis venous plexus. Dura near the sinuses drains into venous pouches adjacent to the sinus, before emptying into the sinus proper-possibly the same pouches implicated in the angioarchitecture of dural fistulas. Finally, posterior temporoparietal convexity dura, situated in a watershed-like region between middle and posterior meningeal territories, frequently empties into diploic and emissary veins of the skull. Wide variation in balance is expected between these three routes. Drainage patterns appear to correlate with venous embryologic investigations of Padget and ex vivo studies in adults. CONCLUSIONS Continued attention to dural venous drainage may prove useful in the diagnosis and management of dural-based vascular diseases.
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Affiliation(s)
- Maksim Shapiro
- Department of Radiology, New York University Langone Medical Center, New York, New York, USA
| | - Eytan Raz
- Department of Radiology, New York University Langone Medical Center, New York, New York, USA
| | - Erez Nossek
- Department of Neurosurgery, NYU School of Medicine, New York, New York, USA
| | | | - Melanie Walker
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Texas, USA
| | - Osman Mir
- Department of Radiology, New York University Langone Medical Center, New York, New York, USA
| | - Peter Kim Nelson
- Department of Radiology, New York University Langone Medical Center, New York, New York, USA
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Fiorella D, Hirsch JA, Arthur AS. Embolization of the middle meningeal artery for the treatment of chronic subdural hematoma: considerations for pragmatic trial design. J Neurointerv Surg 2021; 13:295-297. [PMID: 33674392 DOI: 10.1136/neurintsurg-2021-017458] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2021] [Indexed: 01/17/2023]
Affiliation(s)
- David Fiorella
- Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA .,SUNY Stony Brook, Stony Brook, New York, USA
| | - Joshua A Hirsch
- NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.,Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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48
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Shapiro M, Walker M, Carroll KT, Levitt MR, Raz E, Nossek E, Delavari N, Mir O, Nelson PK. Neuroanatomy of cranial dural vessels: implications for subdural hematoma embolization. J Neurointerv Surg 2021; 13:471-477. [PMID: 33632880 DOI: 10.1136/neurintsurg-2020-016798] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/20/2021] [Accepted: 01/21/2021] [Indexed: 02/03/2023]
Abstract
Adoption of middle meningeal artery embolization in the management of chronic subdural hematomas has led to a renewed interest in dural vascular anatomy. The readily identifiable major dural arteries and potential hazards associated with their embolization are well described. Less emphasized are several levels of intrinsic dural angioarchitecture, despite their more direct relationship to dural based diseases, such as subdural hematoma and dural fistula. Fortunately, microvascular aspects of dural anatomy, previously limited to ex vivo investigations, are becoming increasingly accessible to in vivo visualization, setting the stage for synthesis of the old and the new, and providing a rationale for the endovascular approach to subdural collections in particular. In contrast with traditional anatomical didactics, where descriptions advance from larger trunks to smaller pedicles, we present a strategic approach that proceeds from a fundamental understanding of the dural microvasculature and its relationship to larger vessels.
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Affiliation(s)
- Maksim Shapiro
- Radiology, Neurology, New York University School of Medicine, New York, New York, USA
| | - Melanie Walker
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Kate T Carroll
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Michael R Levitt
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Eytan Raz
- Radiology, NYU School of Medicine, New York, New York, USA
| | - Erez Nossek
- Neurosurgery, NYU School of Medicine, New York, New York, USA
| | - Nader Delavari
- Neurosurgery, NYU School of Medicine, New York, New York, USA
| | - Osman Mir
- Radiology, NYU School of Medicine, New York, New York, USA
| | - Peter Kim Nelson
- Radiology, Neurosurgery, NYU School of Medicine, New York, New York, USA
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