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Hoenning A, Lemcke J, Rot S, Stengel D, Hoppe B, Zappel K, Schuss P, Mutze S, Goelz L. Middle Meningeal Artery Embolization Minimizes Burdensome Recurrence Rates After Newly Diagnosed Chronic Subdural Hematoma Evacuation (MEMBRANE): study protocol for a randomized controlled trial. Trials 2022; 23:703. [PMID: 35996195 PMCID: PMC9396835 DOI: 10.1186/s13063-022-06506-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 07/01/2022] [Indexed: 11/10/2022] Open
Abstract
Background Chronic subdural hematoma (cSDH) is the most common complication of mild traumatic brain injury demanding neurosurgery in high-income countries. If undetected and untreated, cSDH may increase intracranial pressure and cause neurological deficiencies. The first-line intervention of choice is burr hole trepanation and hematoma evacuation. However, any third patient may experience rebleeding, demanding craniotomy with excess morbidity. Adjunct endovascular embolization of the frontal and parietal branches of the middle meningeal artery (MMA) is a promising approach to avoid relapse and revision but was hitherto not studied in a randomized trial. Methods MEMBRANE is an investigator-initiated, single-center, randomized controlled trial. Male, female, and diverse patients older than 18 years scheduled for surgical evacuation of a first cSDH will be assigned in a 1:1 fashion by block randomization to the intervention (surgery plus endovascular MMA embolization) or the control group (surgery alone). The primary trial endpoint is cSDH recurrence within 3 months of follow-up after surgery. Secondary endpoints comprise neurological deficits assessed by the modified Rankin Scale (mRS) and recurrence- or intervention-associated complications during 3 months of follow-up. Assuming a risk difference of 20% of rebleeding and surgical revision, a power of 80%, and a drop-out rate of 10%, 154 patients will be enrolled onto this trial, employing an adaptive O’Brien-Fleming approach with a planned interim analysis halfway. Discussion The MEMBRANE trial will provide first clinical experimental evidence on the effectiveness of endovascular embolization of the MMA as an adjunct to surgery to reduce the risk of recurrence after the evacuation of cSDH. Trial registration German Clinical Trials Registry (Deutsches Register Klinischer Studien [DRKS]) DRKS00020465. Registered on 18 Nov 2021. ClinicalTrials.gov NCT05327933. Registered on 13 Apr 2022.
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Affiliation(s)
- Alexander Hoenning
- Center for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany.
| | - Johannes Lemcke
- Department of Neurosurgery, BG Klinikum Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
| | - Sergej Rot
- Department of Neurosurgery, BG Klinikum Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
| | - Dirk Stengel
- BG Kliniken - Klinikverbund der Gesetzlichen Unfallversicherung gGmbH, Leipziger Pl. 1, 10117, Berlin, Germany
| | - Berthold Hoppe
- Institute of Laboratory Medicine, BG Klinikum Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
| | - Kristina Zappel
- Center for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
| | - Patrick Schuss
- Department of Neurosurgery, BG Klinikum Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
| | - Sven Mutze
- Department of Radiology and Neuroradiology, BG Klinikum Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany.,Institute for Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany
| | - Leonie Goelz
- Department of Radiology and Neuroradiology, BG Klinikum Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany.,Institute for Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany
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Yang L, Li N, Yang L, Wang D, Qiang S, Zhao Z. Atorvastatin-Induced Absorption of Chronic Subdural Hematoma Is Partially Attributed to the Polarization of Macrophages. J Mol Neurosci 2021; 72:565-573. [PMID: 34569007 DOI: 10.1007/s12031-021-01910-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 09/02/2021] [Indexed: 11/25/2022]
Abstract
As one of the main types of secondary craniocerebral injury, the onset, progression, and prognosis of chronic subdural hematoma (CSDH) are closely related to the local inflammation of intracranial hematoma. Atorvastatin is reported to be effective in the conservative treatment of CSDH. This study aimed to clarify whether atorvastatin regulated the inflammatory responses in CSDH by interfering with the function of macrophages. The rat CSDH model was prepared by repeated intracranial blood injection with velocity gradient, and MRI was applied to calculate the intracranial hematoma volume. Changes in rat nerve functions were evaluated by foot-fault and Morris water maze tests. Flow cytometry was applied to detect the number of total macrophages and the percentage of M1 or M2 macrophages. The expression of inflammatory factors was examined by ELISA and western blot. Western bolt was applied to detect the expression of proteins involved in the colony-stimulating factor 1 receptor (CSF-1R) signaling pathway. Our results showed that atorvastatin significantly accelerated the absorption of hematoma and improved the nerve functions of CSDH rats. In addition, atorvastatin treatment effectively suppressed the expression of TNF-α, IL-6, and IL-8 and promoted the expression of IL-10. The total number of macrophages was decreased, and the percentage of M2 macrophages was increased in the intracranial hematoma following atorvastatin treatment. Furthermore, atorvastatin increased the levels of M2-related genes and surface markers in BMDMs stimulated by lipopolysaccharides and IFNγ, and activated the CSF-1R signaling pathway. In conclusion, our study shows that atorvastatin could alleviate the symptoms of CSDH and promote hematoma ablation by polarizing macrophages to M2 type and regulating the inflammatory responses.
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Affiliation(s)
- Liang Yang
- Department of Neurosurgery, the Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang 050000, Hebei, China
| | - Nan Li
- Department of Gynecology, the Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang 050000, Hebei, China
| | - Lijun Yang
- Department of Neurosurgery, the Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang 050000, Hebei, China
| | - Dong Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, No. 154 Anshan Road, Tianjin, 300052, China
| | - Shuke Qiang
- Department of Neurosurgery, the Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang 050000, Hebei, China
| | - Zongmao Zhao
- Department of Neurosurgery, the Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang 050000, Hebei, China.
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Joyce E, Bounajem MT, Scoville J, Thomas AJ, Ogilvy CS, 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. Middle meningeal artery embolization treatment of nonacute subdural hematomas in the elderly: a multiinstitutional experience of 151 cases. Neurosurg Focus 2020; 49:E5. [DOI: 10.3171/2020.7.focus20518] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 07/17/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe incidence of already common chronic subdural hematomas (CSDHs) and other nonacute subdural hematomas (NASHs) in the elderly is expected to rise as the population ages over the coming decades. Surgical management is associated with recurrence and exposes elderly patients to perioperative and operative risks. Middle meningeal artery (MMA) embolization offers the potential for a minimally invasive, less morbid treatment in this age group. The clinical and radiographic outcomes after MMA embolization treatment for NASHs have not been adequately described in elderly patients. In this paper, the authors describe the clinical and radiographic outcomes after 151 cases of MMA embolization for NASHs among 121 elderly patients.METHODSIn a retrospective review of a prospectively maintained database across 15 US academic centers, the authors identified patients aged ≥ 65 years who underwent MMA embolization for the treatment of NASHs between November 2017 and February 2020. Patient demographics, comorbidities, clinical and radiographic factors, treatment factors, and clinical outcomes were abstracted. Subgroup analysis was performed comparing elderly (age 65–79 years) and advanced elderly (age > 80 years) patients.RESULTSMMA embolization was successfully performed in 98% of NASHs (in 148 of 151 cases) in 121 patients. Seventy elderly patients underwent 87 embolization procedures, and 51 advanced elderly patients underwent 64 embolization procedures. Elderly and advanced elderly patients had similar rates of embolization for upfront (46% vs 61%), recurrent (39% vs 33%), and prophylactic (i.e., with concomitant surgical intervention; 15% vs 6%) NASH treatment. Transfemoral access was used in most patients, and the procedure time was approximately 1 hour in both groups. Particle embolization with supplemental coils was most common, used in 51% (44/87) and 44% (28/64) of attempts for the elderly and advanced elderly groups, respectively. NASH thickness decreased significantly from initial thickness to 6 weeks, with additional decrease in thickness observed in both groups at 90 days. At longest follow-up, the treated NASHs had stabilized or improved in 91% and 98% of the elderly and advanced elderly groups, respectively, with > 50% improvement seen in > 60% of patients for each group. Surgical rescue was necessary in 4.6% and 7.8% of cases, and the overall mortality was 8.6% and 3.9% for elderly and advanced elderly patients, respectively.CONCLUSIONSMMA embolization can be used safely and effectively as an alternative or adjunctive minimally invasive treatment for NASHs in elderly and advanced elderly patients.
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Affiliation(s)
- Evan Joyce
- 1Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, Utah
| | - Michael T. Bounajem
- 1Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, Utah
| | - Jonathan Scoville
- 1Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, Utah
| | - Ajith J. Thomas
- 2Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christopher S. Ogilvy
- 2Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Howard A. Riina
- 3Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - Omar Tanweer
- 3Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - Elad I. Levy
- 4Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York
| | - Alejandro M. Spiotta
- 5Department of Neurosurgery, Medical College of South Carolina, Charleston, South Carolina
| | - Bradley A. Gross
- 6Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | - Alexander A. Khalessi
- 9Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Aditya S. Pandey
- 10Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Andrew J. Ringer
- 11Mayfield Clinic, TriHealth Neuroscience Institute, Good Samaritan Hospital, Cincinnati, Ohio
| | - Ricardo Hanel
- 12Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida
| | - Rafael A. Ortiz
- 13Department of Neurosurgery, Lenox Hill Hospital, New York, New York
| | - David Langer
- 13Department of Neurosurgery, Lenox Hill Hospital, New York, New York
| | - Michael R. Levitt
- 14Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Mandy Binning
- 15Department of Neurosurgery, Drexel University College of Medicine, Philadelphia, Pennsylvania; and
| | - Philipp Taussky
- 1Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, Utah
| | - Peter Kan
- 16Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Ramesh Grandhi
- 1Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, Utah
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