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

Neurosurgery ◽  
2018 ◽  
Vol 85 (6) ◽  
pp. 801-807 ◽  
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.

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

2017 ◽  
Vol 14 (5) ◽  
pp. 556-562 ◽  
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.

Perioperative prophylactic middle meningeal artery embolization for chronic subdural hematoma: a series of 44 cases

2021 ◽  
pp. 1-9
Author(s):  
Justin Schwarz ◽  
Joseph A. Carnevale ◽  
Jacob L. Goldberg ◽  
Alexander D. Ramos ◽  
Thomas W. Link ◽  
...  
Keyword(s):  
Recurrence Rate ◽  
Subdural Hematoma ◽  
Chronic Subdural Hematoma ◽  
Middle Meningeal Artery ◽  
High Recurrence Rate ◽  
Recurrence Rates ◽  
Asymptomatic Patients ◽  
Surgical Evacuation ◽  
Silver Dollar ◽  
Meningeal Artery

OBJECTIVE Chronic subdural hematoma (cSDH) is a common and challenging pathology to treat due to both the historically high recurrence rate following surgical evacuation and the medical comorbidities inherent in the aging patient population that it primarily affects. Middle meningeal artery (MMA) embolization has shown promise in the treatment of cSDHs, most convincingly to avoid surgical evacuation in relatively asymptomatic patients. Symptomatic patients requiring surgical evacuation may also benefit from perioperative MMA embolization to prevent cSDH recurrence. The goal of this study was to determine the utility of perioperative MMA embolization for symptomatic cSDH requiring surgical evacuation and to assess if there is a decrease in the cSDH recurrence rate compared to historical recurrence rates following surgical evacuation alone. METHODS Symptomatic cSDHs were evacuated using a subdural evacuating port system (SEPS) with 5-mm twist-drill craniostomy in an intensive care unit or by performing a craniotomy in the operating room, using either a small (silver dollar, < 4 cm) or large (≥ 4 cm) craniotomy. MMA embolization was performed perioperatively using angiography, selective catheterization of the MMA, and infusion of polyvinyl particles. Outcomes were assessed clinically and radiographically with interval head CT imaging. RESULTS There were 44 symptomatic cSDHs in 41 patients, with 3 patients presenting with bilateral symptomatic cSDH. All cSDHs were evacuated using an SEPS (n = 18), a silver-dollar craniotomy (n = 16), or a large craniotomy (n = 10). Prophylactic MMA embolization was performed successfully in all cSDHs soon after surgical evacuation. There were no deaths and no procedural complications. There was an overall reduction of greater than 50% or resolution of cSDH in 40/44 (90.9%) cases, regardless of the evacuation procedure used. Of the 44 prophylactic cases, there were 2 (4.5%) cases of cSDH recurrence that required repeat surgical evacuation at the 1-year follow-up. These 2 cSDHs were initially evacuated using an SEPS and subsequently required a craniotomy, thereby representing an overall 4.5% recurrence rate of treated cSDH requiring repeat evacuation. Most notably, of the 26 patients who underwent surgical evacuation with a craniotomy followed by MMA embolization, none had cSDH recurrence requiring repeat intervention. CONCLUSIONS Perioperative prophylactic MMA embolization in the setting of surgical evacuation, via either craniotomy or SEPS, may help to lower the recurrence rate of cSDH.

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

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.

scholarly journals Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Case Series

2021 ◽  
Vol 16 (1) ◽  
pp. 21-25
Author(s):  
Mosaab Alsuwaihel ◽  
Dana El-Mughayyar ◽  
Brian Archer ◽  
George Kolyvas ◽  
Najmedden Attabib
Keyword(s):  
Subdural Hematoma ◽  
Case Series ◽  
Chronic Subdural Hematoma ◽  
Middle Meningeal Artery ◽  
Artery Embolization ◽  
Meningeal Artery

scholarly journals Middle meningeal artery embolization for the treatment of chronic subdural hematoma. A case series

2021 ◽  
Vol 1 ◽  
pp. 100643
Author(s):  
C. Christoforou ◽  
T. Schrammel ◽  
J. Gerhardt ◽  
M. Hartmann ◽  
Y.-M. Ryang
Keyword(s):  
Subdural Hematoma ◽  
Case Series ◽  
Chronic Subdural Hematoma ◽  
Middle Meningeal Artery ◽  
Artery Embolization ◽  
Meningeal Artery

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

Neurosurgery ◽  
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

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

2018 ◽  
Vol 118 ◽  
pp. e570-e574 ◽  
Author(s):  
Thomas W. Link ◽  
Justin T. Schwarz ◽  
Stephanie M. Paine ◽  
Hooman Kamel ◽  
Jared Knopman
Keyword(s):  
Subdural Hematoma ◽  
Case Series ◽  
Chronic Subdural Hematoma ◽  
Middle Meningeal Artery ◽  
Artery Embolization ◽  
Meningeal Artery

Middle meningeal artery embolization for chronic subdural hematoma in cancer patients with refractory thrombocytopenia

2021 ◽  
pp. 1-5
Author(s):  
Sungho Lee ◽  
Aditya Srivatsan ◽  
Visish M. Srinivasan ◽  
Stephen R. Chen ◽  
Jan-Karl Burkhardt ◽  
...  
Keyword(s):  
Platelet Count ◽  
Cancer Patients ◽  
Subdural Hematoma ◽  
Prospective Trial ◽  
Chronic Subdural Hematoma ◽  
Middle Meningeal Artery ◽  
Artery Embolization ◽  
Technical Success Rate ◽  
Surgical Evacuation ◽  
Meningeal Artery

OBJECTIVE Surgical evacuation of chronic subdural hematoma (SDH) in cancer patients is often contraindicated owing to refractory thrombocytopenia. Middle meningeal artery embolization (MMAE) recently emerged as a potential alternative to surgical evacuation for patients with chronic SDH. The goal of this study was to evaluate the safety and efficacy of MMAE for chronic SDH in cancer patients with refractory thrombocytopenia. METHODS A multiinstitutional registry was reviewed for clinical and radiographic outcomes of cancer patients with transfusion-refractory thrombocytopenia and baseline platelet count < 75 K/µl, who underwent MMAE for chronic SDH. RESULTS MMAE was performed on a total of 31 SDHs in 22 patients, with a mean ± SD (range) platelet count of 42.1 ± 18.3 (9–74) K/µl. At the longest follow-up, 24 SDHs (77%) had reduced in size, with 15 (48%) showing > 50% reduction. Two patients required surgical evacuation after MMAE. There was only 1 procedural complication; however, 16 patients (73%) ultimately died of cancer-related complications. Median survival was significantly longer in the 16 patients with improved SDH than the 6 patients with worsened SDH after MMAE (185 vs 24 days, p = 0.029). Length of procedure, technical success rate, SDH size reduction, and complication rate were not significantly differ between patients who underwent transfemoral and transradial approaches. CONCLUSIONS Transfemoral or transradial MMAE is a potential therapeutic option for thrombocytopenic cancer patients with SDH. However, treatment benefit may be marginal for patients with high disease burden and limited life expectancy. A prospective trial is warranted to address these questions.

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

2021 ◽  
Vol 2 (1) ◽  
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 ◽  
Midline Shift ◽  
Safety And Efficacy ◽  
Presenting Symptoms ◽  
Frail Patients ◽  
Meningeal Artery

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 (&gt;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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