Emergency Department Visits for Chronic Subdural Hematomas within 30 Days after Surgical Evacuation with and without Middle Meningeal Artery Embolization

Improved healthcare utilization and economic outcomes of chronic subdural hematoma treatment with middle meningeal artery embolization compared to conventional surgical drainage

BACKGROUND

Middle meningeal artery embolization (MMAE) emerges as an alternative to conventional surgical drainage (CSD) for chronic subdural hematomas (cSDH). Several studies have suggested that MMAE improves the cost efficacy of cSDH treatment. However, further comprehensive analyses of the outcomes and healthcare costs of MMAE are necessary.

METHODS

Merative MarketScan Research Database from 2017-2022 was used to compare demographics, reoperation rates, complications, healthcare utilization, and payments of patients being treated with CSD, CSD and adjunctive MMAE, or standalone MMAE for cSDH or nontraumatic subdural hemorrhage.

RESULTS

From 2017-2022, there were 2108 patients who underwent CSD (n = 2015), or CSD+MMAE (n = 23) or MMAE only (n = 70). The median age of the surgical group was 61 years (IQR 53-73 years), the surgery plus MMAE was 67 years (56-77 years) and the MMAE group was 65 years (55-77 years). Median hospital days were significantly longer for the CSD (6 (IQR 5-7) days) and CSD + MMAE (7 (IQR 6-7) days) groups compared to MMAE only (0 days(IQR 0-1)(p < 0.0001). Median index hospitalization payments were significantly higher for the CSD+MMAE group ($74,568) compared to both CSD ($39,658) (p = 0.003) and MMAE groups ($22,286) (p < 0.0001). The total median payments at six-month follow-up for the CSD group were higher compared to CSD+MMAE ($11494 vs $7300, p = 0.0017) but not compared to MMAE only ($10,680, p = 0.08).

CONCLUSIONS

The reduced complications, infection rate, hospital utilization, and costs observed in this study support MMAE as a promising treatment option in the arsenal for cSDH management.

Adjunct Middle Meningeal Artery Embolization Versus Surgery for Chronic Subdural Hematoma: A Systematic Review and Meta-Analysis

BACKGROUND

The procedure of middle meningeal artery embolization (MMAE) has emerged as a minimally invasive therapy for chronic subdural hematoma (CSDH). Previous studies comparing MMAE with conventional treatment for CSDH did not differentiate primary/upfront, adjunct, or rescue MMAE, and included both conservative and surgical treatment in the comparison group. We conducted a systematic review and meta-analysis to compare outcomes after adjunct MMAE (MMAE combined with surgical evacuation) versus surgery alone for CSDH.

METHODS

PubMed, Embase, Cochrane, Web of Science, and Scopus databases were searched to August 2023. Primary outcomes were treatment failure and reoperation. Secondary outcomes were complications, mortality, length of hospital stay, 30-day readmission, and follow-up modified Rankin Scale (mRS) > 2. Additional data from our institution was included.

RESULTS

12 published studies and our data yielded 57,165 patients, of whom 1,065 (1.9%) received adjunct MMAE and 56,100 (98.1%) surgery alone. Compared to surgery alone, adjunct MMAE was associated with lower rates of treatment failure (OR = 0.43 [0.23-0.83], p = 0.01), reoperation (OR = 0.45 [0.22-0.90], p = 0.02), and 30-day readmission (OR = 0.50 [0.34-0.73], p < 0.001). Length of hospital stay (MD = 2.49 [-0.51, 5.49], p = 0.10) was non-significantly longer in the adjunct MMAE group. Both groups had comparable rates of treatment-related complications (OR = 0.89 [0.52-1.53], p = 0.67), mortality (OR = 1.05 [0.75-1.46], p = 0.78), and follow-up mRS > 2 (OR = 0.91 [0.39-2.12], p = 0.83).

CONCLUSIONS

Adjunct MMAE reduces treatment failure, reoperation, and readmission rates without increasing morbidity and mortality. MMAE may be considered as an adjunct to surgical evacuation to reduce CSDH recurrence. Randomized trials will further establish the evidence for adjunct MMAE and its role in the management of CSDH.

Middle meningeal artery embolization alone versus combined with conventional surgery in the management of chronic subdural hematoma: A systematic review and meta-analysis

OBJECTIVE

To compare outcomes of middle meningeal artery embolization (MMAE) alone versus combined with conventional surgery in the management of chronic subdural hematoma (cSDH).

METHODS

A systematic literature search was performed on PubMed, Google Scholar, Scopus, and CINAHL, followed by a meta-analysis comparing recurrence rates, surgical rescue, mortality, in-hospital complications, and length of hospital stay was conducted. Mean differences and risk ratios were pooled using a random effects model, with subgroup analysis performed using Cochrane RevMan 5.4.1 software.

RESULTS

A total of 23 studies including 302,168 patients (62.5 % male, 37.5 % female) were analyzed, with most studies published between 2017 and 2024. Among these patients, 299,195 (99.0 %) were treated with conventional surgery, whereas 3113 underwent MMAE. MMAE patients showed a significantly lower recurrence rate compared to conventional surgery, with a 0.35 times lower risk of recurrence (95 % CI: 0.24-0.51, p<0.01). However, adjunctive MMAE was associated with a longer hospital stay (SMD: 2.61 [95 % CI: 2.46-2.76], p<0.01), though MMAE alone had a shorter stay compared to adjunctive MMAE. Additionally, MMAE demonstrated a lower risk of surgical rescue (0.29 times, p<0.01). While no significant difference was found in-hospital complications (RR: 1.01, 95 % CI 0.90-1.14, p=0.84) and mortality rates (RR: 0.88, 95 % CI 0.69-1.14, p=0.34).

CONCLUSION

MMAE stand-alone or adjunctive with conventional surgery presents a promising alternative to conventional surgery alone for chronic subdural hematomas due to lower recurrence and surgical rescue risk. Further prospective studies are needed to study the efficacy of this new approach.

Extensive Roles and Technical Advances of Middle Meningeal Artery Embolization for Chronic Subdural Hematoma

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.