Stand-Alone Middle Meningeal Artery Embolization for Treatment of Giant Chronic Subdural Hematoma in Elderly Frail Patients: A Case Series

ABSTRACT BACKGROUND Previous case series have demonstrated safety and efficacy of middle meningeal artery (MMA) embolization as both adjuvant and stand-alone treatment of chronic subdural hematoma (cSDH). The safety and efficacy of stand-alone MMA embolization for treatment of giant (>150 ml) cSDH in specifically elderly, frail patients is not well studied. OBJECTIVE To evaluate the safety and efficacy of stand-alone MMA embolization for treatment of giant cSDH in elderly, frail patients in whom traditional surgical intervention was deemed high risk. METHODS We reviewed the records of consecutive patients referred for MMA embolization and identified patients ≥ 75 yr with modified Frailty Index (mFI) ≥ 2 who underwent stand-alone MMA embolization for cSDH treatment with at least one follow-up imaging study. RESULTS A total of 42 patients were referred for MMA embolization with 5 patients meeting inclusion age and frailty criteria. The average age was 82.2 ± 6.8 yr. The median mFI was 3.0 (interquartile range (IQR) 2-4). Four patients were either on aspirin or thrombocytopenic. The average initial cSDH volume was 187.8 ± 31 ml with average initial midline shift of 8.0 ± 2.1 mm. The average length of stay was 4 ± 1.1 d. The average cSDH volume decrease on follow-up imaging was 68.5% ± 11.9%. Follow-up average midline shift decreased by 70% to 2.4 ± 1.4 mm. There were no peri-procedural or in-hospital complications. CONCLUSION In frail, elderly patients with giant cSDH, stand-alone MMA embolization was effective in reducing cSDH volume and improving presenting symptoms without complications.

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Abstract TP38: Efficacy of Middle Meningeal Artery Embolization for Chronic Subdural Hematoma

Stroke ◽

10.1161/str.51.suppl_1.tp38 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Ashish Kulhari ◽

Amrinder Singh ◽

Siddhart Mehta ◽

Farah Fourcand ◽

Jawad.F. Kirmani ◽

...

Keyword(s):

Subdural Hematoma ◽

Complete Resolution ◽

Chronic Subdural Hematoma ◽

Middle Meningeal Artery ◽

Burr Hole ◽

Midline Shift ◽

Artery Embolization ◽

Burr Hole Evacuation ◽

Meningeal Artery

Background: Symptomatic chronic subdural hematoma (SDH) is treated with surgical evacuation. SDH has a high incidence of recurrence despite evacuation, reported between 2% and 37%. Multiple case reports and case series demonstrate embolization of the Middle Meningeal artery (MMA) for the treatment of chronic SDH to be an adjunct treatment and a possible alternative to surgical evacuation. Method: Retrospective analysis of patients with chronic SDH who underwent MMA embolization at our community based, Comprehensive Stroke Center between April and August 2019 was done. MMA embolization was performed using 100-300 or 300-500 μm Embospheres. Results: 18 patients presented with chronic SDH, 55% female. Mean age and modified Rankin score was 70 (range: 48-95 years) and 1 (range: 0-3), respectively. 17 patients (94%) required a total of 20 MMA embolizations. 83% had unilateral MMA embolization and 17% had bilateral MMA embolizations. 100-300 μm Embospheres were used for the MMA embolization in 82% of the patients and 300-500 μm Embospheres in 18% of the patients. 33% had Burr hole prior to the procedure. 5% ( n= 1) patient had Burr hole evacuation after embolization due to Neurosurgeon preference, not neurological deterioration. 56 % patient received treatment to resume anticoagulation/antiplatelet and 44% received prophylactic embolization to prevent reaccumulation after Burr hole evacuation. Mean size of maximum diameter of SDH was 16.9 mm and 4.6 mm of midline shift on admission CT. Mean SDH size and midline shift at discharge was 13 mm and 2.27 respectively. 50% patients had 1 month follow up CT with mean SDH size was 8.2 mm (in comparison to 19.7 in these patients). 17 % (n=3) patients had complete resolution on 3 month follow up. The one patient treated with 300-500 μm Embospheres had an acute on chronic asymptomatic SDH on 1 month follow up CT, requiring accessory meningeal artery embolization with 100-300 μm Embospheres ultimately resulting complete resolution of the SDH at 1 month post embolization. Conclusion: Despite limited data available, Middle Meningeal artery embolization using 100-300 μm Embospheres leads to reproducible results to prevent recurrence of chronic subdural hematoma. A large randomized controlled study is needed to verify our results.

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Stand-Alone Middle Meningeal Artery Embolization for Treatment of Giant Chronic Subdural Hematoma in Elderly Frail Patients: A Case Series

Neurosurgery ◽

10.1093/neuros/okaa025_s169 ◽

2021 ◽

Vol 89 (Supplement_2) ◽

pp. S6-S6

Author(s):

Gregory J Cannarsa ◽

Joshua Olexa ◽

Timothy Chryssikos ◽

Aaron P Wessell ◽

Ashish Sharma ◽

...

Keyword(s):

Subdural Hematoma ◽

Case Series ◽

Chronic Subdural Hematoma ◽

Middle Meningeal Artery ◽

Artery Embolization ◽

Frail Patients ◽

Meningeal Artery

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Transradial middle meningeal artery embolization for chronic subdural hematoma using Onyx: case series

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-016185 ◽

2020 ◽

pp. neurintsurg-2020-016185

Author(s):

Gary B Rajah ◽

Muhammad Waqas ◽

Rimal H Dossani ◽

Kunal Vakharia ◽

Andrew D Gong ◽

...

Keyword(s):

Subdural Hematoma ◽

Conscious Sedation ◽

Case Series ◽

Chronic Subdural Hematoma ◽

Antiplatelet Agents ◽

Middle Meningeal Artery ◽

Complication Rates ◽

Femoral Access ◽

Guide Catheter ◽

Meningeal Artery

BackgroundMiddle meningeal artery (MMA) embolization is an emerging therapy for the resolution of subacute or chronic subdural hematoma (CSDH). CSDH patients are often elderly and have several comorbidities. We evaluated our experience with transradial access (TRA) for MMA embolization using predominantly Onyx under conscious sedation.MethodsData for consecutive patients who underwent transradial MMA embolization for CSDH during a 2-year period (2018–2019) were analyzed from a single-center, prospectively-maintained database. Patient demographics, comorbidities, ambulatory times, subdural hematoma resorption status, and guide catheter type were recorded. Conversion to femoral access and complication rates were also recorded. Univariate and multivariate analyses were performed.ResultsForty-six patients (mean age, 71.7±14.4 years) were included in this study. Mean CSDH size was 14±5.5 mm. Most (91.3%) TRA embolizations were performed with 6-French 0.071-inch Benchmark guide catheters (Penumbra). MMA embolization was successful in 44 patients (95.7%) (including two cases of TRA conversion). Twenty-one (48%) patients had a severe Charlson Comorbidity Index (>5). Symptomatic improvement was noted in 39 of 44 patients (88.6%). Mean length of stay was 4±3 days. Patients were ambulated immediately postprocedure. At mean follow-up (8±4 weeks), 86.4% of patients had complete or partial CSDH resolution. Persistent use of antiplatelet agents after the procedure was associated with failed or minimal CSDH resorption (5 of 6, 83.3% vs 9 of 38 23.7% with complete or near-complete resolution; P=0.009).ConclusionTransradial Onyx MMA embolization under conscious sedation is safe and effective for CSDH treatment. TRA may be especially useful in elderly patients with numerous comorbidities.

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Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Series of 60 Cases

Neurosurgery ◽

10.1093/neuros/nyy521 ◽

2018 ◽

Vol 85 (6) ◽

pp. 801-807 ◽

Cited By ~ 23

Author(s):

Thomas W Link ◽

Srikanth Boddu ◽

Stephanie M Paine ◽

Hooman Kamel ◽

Jared Knopman

Keyword(s):

Subdural Hematoma ◽

Large Scale ◽

Case Series ◽

Chronic Subdural Hematoma ◽

Middle Meningeal Artery ◽

Recurrence Rates ◽

Surgical Evacuation ◽

Procedural Complications ◽

Previously Treated ◽

Meningeal Artery

Abstract BACKGROUND Chronic subdural hematoma (SDH) is a particularly challenging pathology due to high recurrence rates (2%-37%) and complex medical comorbidities that tend to afflict the patient population. Recently, there have been several case series published describing the use of middle meningeal artery (MMA) embolization as an alternative to surgery for treatment of new or recurrent chronic SDH. OBJECTIVE To describe our first 60 cases of MMA embolization for chronic SDH. METHODS MMA embolization was performed using angiography, selective microcatheterization of the MMA, and infusion of polyvinyl alcohol particles. Outcomes were assessed clinically and with interval imaging studies at 1 d, 2 wk, and 6 wk postprocedure, and additional intervals as indicated. RESULTS MMA embolization was performed successfully on 60 total SDHs in 49 patients. This includes upfront treatment for new (not previously treated) SDH in 42, for recurrence in 8, and prophylaxis (soon after surgical evacuation) in 10. There were 3 mortalities (unrelated to the procedure), and no procedural complications. Of the 50 nonprophylactic cases, there were 4 (8.9%) cases of recurrence requiring surgical evacuation, and 31 (68.9%) that had resolution or reduction in size >50% of SDH at longest follow-up. Overall, 41 (91.1%) were stable or decreased in size and able to avoid surgery. CONCLUSION MMA embolization may represent a minimally-invasive alternative to surgery for new or recurrent chronic SDH, or as prophylaxis to reduce the risk of recurrence after surgery. Given our encouraging results with a 91% long-term success rate, a large scale clinical trial is warranted.

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Usefulness of interventional embolization of the middle meningeal artery for recurrent chronic subdural hematoma: Five cases and a review of the literature

Interventional Neuroradiology ◽

10.1177/1591019915583224 ◽

2015 ◽

Vol 21 (3) ◽

pp. 366-371 ◽

Cited By ~ 40

Author(s):

Akira Tempaku ◽

Shigeru Yamauchi ◽

Hidetoshi Ikeda ◽

Nobuyuki Tsubota ◽

Hironori Furukawa ◽

...

Keyword(s):

Subdural Hematoma ◽

Chronic Subdural Hematoma ◽

Middle Meningeal Artery ◽

Interventional Treatment ◽

Careful Attention ◽

Review Of The Literature ◽

Hematoma Formation ◽

Polyvinyl Alcohol Particles ◽

Meningeal Artery

Purpose Although several strategies against recurrent chronic subdural hematoma (CSDH) have been proposed, no consensus has been established. Recently, middle meningeal artery (MMA) embolization has been proposed as radical treatment for recurrent CSDH. We wanted to estimate the usefulness of MMA embolization for recurrent CSDH. Methods From February 2012 to June 2013, 110 patients with CSDH underwent single burr-hole surgery with irrigation and drainage. Among these patients, 13 showed recurrent hematoma formation and were retreated surgically. Furthermore, repeated recurrence of CSDH was observed in six patients. Five of these six patients underwent middle meningeal artery (MMA) embolization with polyvinyl alcohol particles. All five patients with interventional treatment were observed for four to 60 weeks. Results No more recurrence of CSDH was observed in any of the patients. During the follow-up period, no patients suffered from any side effects or complications from the interventional treatment. Conclusion MMA embolization with careful attention paid to the procedure might be a treatment of choice for recurrent CSDH.

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Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Multi-Center Experience of 154 Consecutive Embolizations

Neurosurgery ◽

10.1093/neuros/nyaa379 ◽

2020 ◽

Cited By ~ 1

Author(s):

Peter Kan ◽

Georgios A Maragkos ◽

Aditya Srivatsan ◽

Visish Srinivasan ◽

Jeremiah Johnson ◽

...

Keyword(s):

Subdural Hematoma ◽

Anticoagulation Therapy ◽

Surgical Techniques ◽

Chronic Subdural Hematoma ◽

Middle Meningeal Artery ◽

Primary Treatment ◽

Thickness Reduction ◽

Hematoma Expansion ◽

Meningeal Artery

Abstract BACKGROUND Middle meningeal artery (MMA) embolization has emerged as a promising treatment for chronic subdural hematoma (cSDH). OBJECTIVE To determine the safety and efficacy of MMA embolization. METHODS Consecutive patients who underwent MMA embolization for cSDH (primary treatment or recurrence after conventional surgery) at 15 centers were included. Clinical details and follow-up were collected prospectively. Primary clinical and radiographic outcomes were the proportion of patients requiring additional surgical treatment within 90 d after index treatment and proportion with > 50% cSDH thickness reduction on follow-up computed tomography imaging within 90 d. National Institute of Health Stroke Scale and modified Rankin Scale were also clinical outcomes. RESULTS A total of 138 patients were included (mean age: 69.8, 29% female). A total of 15 patients underwent bilateral interventions for 154 total embolizations (66.7% primary treatment). At presentation, 30.4% and 23.9% of patients were on antiplatelet and anticoagulation therapy, respectively. Median admission cSDH thickness was 14 mm. A total of 46.1% of embolizations were performed under general anesthesia, and 97.4% of procedures were successfully completed. A total of 70.2% of embolizations used particles, and 25.3% used liquid embolics with no significant outcome difference between embolization materials (P > .05). On last follow-up (mean 94.9 d), median cSDH thickness was 4 mm (71% median thickness reduction). A total of 70.8% of patients had >50% improvement on imaging (31.9% improved clinically), and 9 patients (6.5%) required further cSDH treatment. There were 16 complications with 9 (6.5%) because of continued hematoma expansion. Mortality rate was 4.4%, mostly unrelated to the index procedure but because of underlying comorbidities. CONCLUSION MMA embolization may provide a safe and efficacious minimally invasive alternative to conventional surgical techniques.

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Chronic subdural hematoma recurrence due to contralateral neovascularization following middle meningeal artery embolization

Interventional Neuroradiology ◽

10.1177/15910199211065197 ◽

2021 ◽

pp. 159101992110651

Author(s):

Zachary S Hubbard ◽

Sami Al Kasab ◽

Guilherme B Porto ◽

Alejandro Spiotta

Keyword(s):

Subdural Hematoma ◽

Chronic Subdural Hematoma ◽

Middle Meningeal Artery ◽

Artery Embolization ◽

Diagnostic Investigation ◽

Neurologically Intact ◽

Radiographic Result ◽

Radiographic Improvement ◽

Meningeal Artery

Introduction Chronic subdural hematoma (CSDH) is one of the most commonly encountered neurosurgical diseases. Middle meningeal artery embolization (MMAE) is a technique for the management of CSDH that has elicited promising results. Despite the encouraging results of MMAE, recurrence does occur. One uncommon mechanism for recurrence of CSDH is by means of neovascularization of the contralateral middle meningeal artery (MMA). We describe two cases of CSDH recurrence by means of contralateral middle meningeal artery neovascularization treated with contralateral MMAE. Methods We identified two cases of recurrent subdural hematoma secondary to neovascularization following treatment with contralateral MMAE. Results Two patients initially treated with MMAE were identified with CSDH recurrence secondary to contralateral MMA neovascularization. There was no traumatic or coagulopathic contribution to CSDH recurrence. In both cases, patients underwent contralateral MMAE. Both patients were neurologically intact with radiographic improvement of CSDH at follow up. Conclusions Re-accumulation of SDH following MMAE by means of contralateral MMA neovascularization is a rare subtype of subdural hematoma (SDH) recurrence following MMAE. Within the context of re-accumulation of SDH following MMAE, catheter angiography is an important diagnostic investigation to elucidate the etiology of the recurrence. Furthermore, when angiography reveals neovascularization of the contralateral MMA, embolization of the contralateral MMA achieves good clinical and radiographic result.

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Middle Meningeal Artery Embolization as Treatment for Chronic Subdural Hematoma: A Case Series

Operative Neurosurgery ◽

10.1093/ons/opx154 ◽

2017 ◽

Vol 14 (5) ◽

pp. 556-562 ◽

Cited By ~ 16

Author(s):

Thomas W Link ◽

Srikanth Boddu ◽

Joshua Marcus ◽

Benjamin I Rapoport ◽

Ehud Lavi ◽

...

Keyword(s):

Subdural Hematoma ◽

Symptomatic Relief ◽

Case Series ◽

Chronic Subdural Hematoma ◽

Middle Meningeal Artery ◽

Maximum Diameter ◽

Recurrence Rates ◽

Surgical Evacuation ◽

Initial Injury ◽

Meningeal Artery

Abstract BACKGROUND Traditional treatment for symptomatic subdural hematoma (SDH) has been surgical evacuation, but recurrence rates are high and patients often harbor complex medical comorbidities. Growth and recurrence is thought to be due to the highly friable nature of the vascularized membrane that forms after initial injury. There have been reported cases of middle meningeal artery (MMA) embolization for treatment of recurrent SDH after surgical evacuation with the goal of eliminating the arterial supply to this vascularized membrane. OBJECTIVE To present the first known case series of MMA embolization as upfront treatment for symptomatic chronic SDHs that have failed conservative management in lieu of surgical evacuation. METHODS Five patients with symptomatic chronic SDHs underwent MMA embolization using PVA microparticles at our institution. Size of SDH was recorded in maximum diameter and total volume. RESULTS Four patients underwent unilateral and 1 underwent bilateral MMA embolization successfully. All cases had significant reduction in total volume of SDH at longest follow-up scan: 81.4 to 13.8 cc (7 wk), 48.5 to 8.7 cc (3 wk), 31.7 and 88 to 0 and 17 cc (14 wk, bilateral), 79.3 to 24.2 cc (8 wk), and 53.5 to 0 cc (6 wk). All patients had symptomatic relief with no complications. Histologic analysis of the chronic SDH membrane in a separate patient that required surgery revealed rich neovascularization with many capillaries and few small arterioles. CONCLUSION MMA embolization could present a minimally invasive and low-risk initial treatment alternative to surgery for symptomatic chronic SDH when clinically appropriate.

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