Middle Meningeal Artery Embolization for Management of Chronic Subdural Hematoma

Adjunct middle meningeal artery embolization versus surgery alone for chronic subdural hematoma: A meta-analysis and trial sequential analysis of randomized controlled trials

INTRODUCTION

Middle meningeal artery embolization (MMAE) has been studied as an adjunct to surgical evacuation for chronic subdural hematoma (cSDH). Previous meta-analyses comparing MMAE with conventional treatment for cSDH included both observational and randomized studies. To provide a more robust assessment, we performed a meta-analysis of randomized controlled trials to evaluate the outcomes of adjunct MMAE compared to surgical treatment alone.

METHODS

We searched PubMed, EMBASE, and Cochrane CENTRAL databases for studies comparing adjunct middle meningeal artery embolization to surgical treatment alone until December 2024. The outcomes assessed were treatment failure, reoperation, complications, mortality, functional outcome, and length of hospital stay. Statistical analysis was performed via R software (version 4.3.2). Heterogeneity was assessed with I2 statistics. The risk of bias was assessed using the Cochrane Risk of Bias Tool for Randomized Trials.

RESULTS

We included 6 studies with 1,422 patients, of whom 700 (49.2 %) received adjunct middle meningeal artery embolization. The mean age ranged from 64.2 to 77.4 years in the embolization group and from 70 to 74.4 years in the surgery-only group. Among the patients, 435 (54.5 %) had previous known head trauma, and 315 (22.1 %) were on antiplatelets or anticoagulants. The follow-up ranged from 90 to 180 days. Adjunct middle meningeal artery embolization reduced the occurrence of treatment failure compared to surgical treatment alone (RR 0.482; 95 % CI 0.328 to 0.708; p < 0.001; I2 = 0 %) and reoperation (RR 0.333; 95 % CI 0.212 to 0.521; p < 0.001; I2 = 0 %), however, didńt reduce the occurrence of any cause mortality (RR 0.970; 95 % CI 0.400 to 2.353; p = 0.946; I2 = 39.6 %), functional dependence at the last follow-up (RR 1.000; 95 % CI 0.726 to 1.377; p = 0.705; I2 = 0 %), or the length of stay (MD 0.576; 95 % CI -0.085 to 1.238; p = 0.088; I2 = 0 %). Furthermore, no differences were found regarding complications secondary to the surgical procedure (RR 0.902; 95 % CI 0.688 to 1.182; p = 0.455; I2 = 0 %), and the occurrence of embolization-related complication was low (RR 0.013; 95 % CI 0.006 to 0.027; I2 = 0 %). Trial sequential analysis judged the sample size sufficient for treatment failure and reoperation but suggested that further trials are needed to prove differences in surgical-related complications.

CONCLUSION

Our results confirm that middle meningeal artery embolization significantly reduces recurrence and reoperation rates compared to surgery alone, with low adverse event rates. However, the impact on functional outcomes and mortality remains uncertain, warranting further studies to clarify its long-term benefits.

Visualization of the middle meningeal artery on photon-counting detector CT: Comparison with energy-integrating detector CT

PURPOSE

The middle meningeal artery (MMA) is the target arteries for the treatment of intracranial diseases. The purpose of this study was to investigate the ability of photon-counting detector CT (PCD-CT) to improve the visualization of the MMA compared to energy-integrated detector CT (EID-CT).

METHODS

We retrospectively analyzed head CT angiography images from patients who underwent PCD-CT with ultra-high-resolution (UHR) mode between April 2023 and July 2024. We compared the images reconstructed with a slice thickness 0.2 mm and the matrix sizes 1024 × 1024 ('PCD-1024') and 512 × 512 ('PCD-512') with the same-patient images previously obtained by EID-CT with 0.75- or 1.0- mm slice thickness and the matrix size 512 × 512 ('EID-512'). Quantitatively, a region of interest (ROI) was placed on the maxillary artery near the origin of the MMA, and the signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and contrast ratio (CR) were measured. Image sharpness was evaluated by measuring the full width at half maximum (FWHM) and the maximum intensity from the MMA vessel line profile. Qualitatively, the overall image quality, sharpness, and artifacts were evaluated using four-point Likert scales. The same evaluation was performed using PCD-CT with 0.2 mm ('0.2 mm') and virtual monoenergetic images (VMIs) ('45 keV', '55 keV', and '70 keV').

RESULTS

30 patients (19 males, 11 females; median age 65 years) were included. Quantitatively, the SNR (mean ± SD) for PCD-1024, PCD-512, and EID-512 were 16.9 ± 5.6, 20.3 ± 6.2, and 23.2 ± 7.8, respectively (P < 0.01 for PCD-1024 vs. EID-512). The CNR were 16.6 ± 4.5, 20.2 ± 5.5, and 44.4 ± 13.9. The CR were 0.74 ± 0.06, 0.74 ± 0.06, and 0.68 ± 0.08. The FWHM were 1.41 ± 0.17, 1.48 ± 0.15, and 1.77 ± 0.12, and the maximum intensity were 407.5 ± 71.7, 386.0 ± 72.5, and 218.2 ± 58.2 (P < 0.001 for PCD-1024 vs. EID-512 and PCD-512 vs. EID-512, respectively). Qualitatively, significant differences (P < 0.05) were identified among the PCD-1024, PCD-512, and EID-512 groups regarding the respective scores (median [IQR]) for overall image quality (4 [3-4], 3 [3-4], and 2 [2-3]), sharpness (4 [3-4], 3 [3-3], and 2 [2-3]), and artifacts (3 [3-3], 3 [2-3], and 2 [2-2]). In VMI analysis, quantitatively, 45 keV showed the highest values for SNR, CNR, CR, and maximum intensity; however, there were no differences in FWHM among the groups. Qualitatively, 0.2 mm was superior to the other groups in all evaluated aspects (P < 0.05).

CONCLUSION

PCD-1024 visualized the MMA better than both PCD-512 and EID-512. The 0.2 mm reconstruction was visually superior to the VMIs.

Efficacy and safety of middle meningeal artery embolization for nonacute subdural hematoma

BACKGROUND

This study aims to synthesise data from randomized controlled trials (RCTs) to evaluate the efficacy and safety of middle meningeal artery embolization (MMAE) in the treatment of nonacute subdural hematoma (SDH).

METHODS

We systematically searched electronic databases for RCTs comparing the efficacy and safety of MMAE with conventional treatment (usual care with or without surgery) for nonacute SDH. The primary efficacy outcome was treatment failure. Secondary efficacy outcomes included changes in hematoma volume, thickness, and functional independence. The primary safety outcome was severe adverse events, and the secondary safety outcome was mortality. Pooled analyses were conducted using risk ratios (RRs) and their 95% confidence intervals (CIs) with random effects model. Trial sequential analysis (TSA) employed to assess the robustness of the evidence.

RESULTS

Six RCTs with 1481 patients were included in the final analysis. Compared to conventional treatment groups, the proportion of treatment failure were lower in the adjunctive MMAE group (RR 0.48, [95% CI 0.34-0.68]), with TSA suggesting sufficient evidence. There was no significant difference in the risk of severe adverse events between the MMAE and conventional treatment groups (RR 0.85, [95% CI 0.63-1.15]). No significant differences were found in secondary outcomes. Further analysis showed that MMAE plus surgery also significantly reduced the proportion of treatment failure compared to surgery alone (RR 0.55, [95% CI 0.34-0.91]), without increasing severe adverse events. In the TSA, the cumulative z-line crossed the boundary for effect.

CONCLUSIONS

MMAE significantly reduces the risk of treatment failure in patients with nonacute SDH, without increasing the incidence of severe adverse events.

Embolization of the Middle Meningeal Artery for Chronic Subdural Hematoma

BACKGROUND

Patients receiving standard treatment for chronic subdural hematoma have a high risk of treatment failure. The effect of adjunctive middle meningeal artery embolization on the risk of treatment failure in this population remains unknown.

METHODS

We randomly assigned patients with symptomatic chronic subdural hematoma to undergo middle meningeal artery embolization as an adjunct to standard treatment (embolization group) or to receive standard treatment alone (control group). Either surgical or nonsurgical standard treatment had been chosen for each patient before randomization. The primary efficacy outcome was a composite of the following events: recurrent or residual chronic subdural hematoma (measuring >10 mm) at 180 days; reoperation or surgical rescue within 180 days; or major disabling stroke, myocardial infarction, or death from neurologic causes within 180 days. The primary safety outcome was a composite of major disabling stroke or death from any cause within 30 days.

RESULTS

Among 310 enrolled patients, 149 were randomly assigned to the embolization group and 161 to the control group; 189 patients were to receive surgical standard treatment and 121 nonsurgical standard treatment. The mean age of the patients was 73 years, and 70% were men. In the primary efficacy analysis, a primary-outcome event occurred in 19 of 120 patients (16%) in the embolization group, as compared with 47 of 129 patients (36%) in the control group (odds ratio, 0.36; 95% confidence interval, 0.20 to 0.66; P = 0.001). In the primary safety analysis, 4 of 144 patients (3%) in the embolization group and 5 of 166 patients (3%) in the control group either had a major disabling stroke or died within 30 days. Through 180 days, 12 patients (8%) in the embolization group and 9 patients (5%) in the control group had died, with death from neurologic causes occurring in 1 patient (1%) in the embolization group and in 3 patients (2%) in the control group.

CONCLUSIONS

Among patients with symptomatic chronic subdural hematoma, adjunctive middle meningeal artery embolization resulted in a lower risk of treatment failure than standard treatment alone, without resulting in an increased incidence of disabling stroke or death in the short term. Further study of longer-term safety outcomes is warranted. (Funded by Balt USA; STEM ClinicalTrials.gov number, NCT04410146.).

Antithrombotic resumption after middle meningeal artery embolization or surgery for chronic subdural hematoma: a systematic review and meta-analysis

BACKGROUND

The periprocedural management of antithrombotic medications in patients with chronic subdural hematoma (cSDH) after middle meningeal artery embolization (MMAE) or surgical evacuation is uncertain.

METHODS

A systematic review was conducted across Medline, Embase, and Web of Science databases. We pooled proportions and risk ratios (RRs) for the meta-analysis with the corresponding 95% CIs. Systemic and intracranial (including recurrence) bleeding complications and thromboembolic events were evaluated.

RESULTS

Of the 16 included studies with 4606 patients, 1784 were receiving antithrombotic medications. Antithrombotic therapy was resumed in 1231 patients (69.0%). Bleeding complications were similar between patients in whom antithrombotic therapy was resumed (14.1%, 95% CI 9.7% to 20.2%) and in those in whom it was discontinued (15.4%, 95% CI 7.4% to 29.3%). After MMAE, patients had similar rates of bleeding events (12.1%, 95% CI 4.9% to 27.0%) to patients with overall treated cSDH, and recurrence (RR 2.28, 95% CI 0.46 to 11.37) and reoperation (RR 1.07, 95% CI 0.40 to 2.917) risks were similar between the resumed and discontinued groups. Thromboembolic complications were significantly higher in the discontinued group (12.6%, 95% CI 6.5% to 23.0%) than in the resumption group (3.5%, 95% CI 1.8% to 6.9%). Earlier resumption (1 week to 1 month) was associated with a lower thromboembolic risk without increasing bleeding complications.

CONCLUSIONS

Post-procedural antithrombotic resumption may reduce thromboembolic events without significantly increasing bleeding risk. Early resumption of antithrombotics post-MMAE appears to be safe, although further data are required to confirm this observation. Future studies should aim to better define patient characteristics influencing decision-making in this context.

Endovascular Embolization and Atorvastatin Therapy for Recurrent Chronic Subdural Hematoma

Recurrent chronic subdural hematoma poses a significant clinical challenge. While craniotomy effectively removes the hematoma membrane, it is an invasive procedure associated with significant trauma. Recently, endovascular embolization of the middle meningeal artery has emerged as a promising minimally invasive alternative, demonstrating efficacy and a low recurrence rate in treating chronic subdural hematoma. Furthermore, postoperative administration of oral atorvastatin calcium may enhance hematoma absorption, thereby improving patient outcomes during the early recovery phase.