Radiographic clearance of chronic subdural hematomas after middle meningeal artery embolization

2021 ◽  
pp. neurintsurg-2021-018073
Author(s):  
Joshua S Catapano ◽  
Andrew F Ducruet ◽  
Visish M Srinivasan ◽  
Kavelin Rumalla ◽  
Candice L Nguyen ◽  
...  
Keyword(s):  
Complete Resolution ◽  
Patient Characteristics ◽  
Middle Meningeal Artery ◽  
Multivariable Logistic Regression Analysis ◽  
Study Cohort ◽  
Subdural Hematomas ◽  
Improved Outcomes ◽  
Rapid Clearance ◽  
Meningeal Artery

BackgroundFew reports discuss variables associated with improved outcomes after middle meningeal artery (MMA) embolization for chronic subdural hematomas (cSDHs). We analyzed radiographic evidence of cSDH clearance after MMA embolization to elucidate optimal techniques, hematoma clearance rates, and suitable length of follow-up.MethodsPatients who underwent MMA embolization for cSDH from January 1, 2018 through December 31, 2020 were analyzed. Patient characteristics, demographics, and technical procedural details were examined. Outcomes for cSDHs analyzed included complete or near-complete resolution at 30, 90, and 180 days following embolization. A multivariable logistic regression analysis identified variables predictive of rapid clearance and resolution of hematomas at 90 days.ResultsThe study cohort comprised 66 patients with 84 treated cSDHs. The mean (SD) cSDH size differed significantly at 30-day (8.8 (4.3) mm), 90-day (3.4 (3.0) mm), and 180-day (1.0 (1.7) mm) follow-up (p<0.001). More cSDHs had complete or near-complete resolution at 180 days (92%, 67/73) than at 90 (63%, 45/72) and 30 days (18%, 15/84) post-embolization (p<0.001). Only distal embolysate penetration was independently associated with rapid clearance (OR 3.9, 95% CI 1.4 to 11.1; p=0.01) and resolution of cSDHs at 90 days (OR 5.0, 95% CI 1.7 to 14.6; p=0.003).ConclusionAlthough 63% of cSDHs with MMA embolization had complete or near-complete resolution by 90 days post-procedure, 92% reached this stage by 180 days. Therefore, 90-day follow-up may be insufficient to determine the effectiveness of MMA embolization for cSDHs, particularly compared with surgical evacuation alone. Also, distal MMA penetration may be associated with more rapid hematoma clearance.

Morphological changes in chronic subdural hematomas following upfront middle meningeal artery embolization: sequence, timing, and association with outcomes

2021 ◽  
pp. 1-14
Author(s):  
MirHojjat Khorasanizadeh ◽  
Yu-Ming Chang ◽  
Alejandro Enriquez-Marulanda ◽  
Satomi Mizuhashi ◽  
Mohamed M. Salem ◽  
...  
Keyword(s):  
Late Stage ◽  
Morphological Changes ◽  
Prognostic Significance ◽  
Intermediate Stage ◽  
Middle Meningeal Artery ◽  
Structural Features ◽  
Artery Embolization ◽  
Subdural Hematomas ◽  
Meningeal Artery

OBJECTIVE Middle meningeal artery embolization (MMAE) is an increasingly utilized approach for the treatment of chronic subdural hematomas (CSDHs). The course of morphological progression of CSDHs following MMAE is poorly understood. Herein, the authors aimed to describe these morphological changes and assess their prognostic significance for the outcomes on follow-up. METHODS A single-institution retrospective cohort study of CSDH cases treated by upfront MMAE, without prior or adjunctive surgical evacuation, was performed. Clinical outcomes, complications, and the need for rescue surgery on follow-up were recorded. Hematomas were categorized into 6 morphological subtypes. All baseline and follow-up head CT scans were assessed for CSDH structural appearance, density, and loculation. Changes in CSDH size were quantified via 3D reconstruction for volumetric measurement. RESULTS Overall, 52 CSDHs in 45 patients treated with upfront MMAE were identified. Hematomas were followed for a mean of 92.9 days. Volume decreased by ≥ 50% in 79.6% of the CSDHs. The overall rescue surgery rate was 9.6%. A sequence of morphological changes after MMAE was identified. Hematomas that diverged from this sequence (5.4%) all progressed toward treatment failure and required rescue surgery. The CSDHs were categorized into early, intermediate, and late stages based on the baseline morphological appearance. Progression from early to intermediate and then to late stage took 12.7 and 30.0 days, respectively, on average. The volume of early/intermediate- and late-stage hematomas decreased by ≥ 50%, a mean of 78.2 and 47.6 days after MMAE, respectively. Early- and intermediate-stage hematomas showed a trend toward more favorable outcomes compared with late-stage hematomas. The density of homogeneous hypodense hematomas (HSDHs) transiently increased immediately after MMAE (p < 0.001). A marked decrease in density and volume 1 to 3 weeks after MMAE in HSDHs was detected, the lack of which indicated an eventual need for rescue surgery. In HSDHs, a baseline mean density of < 20 HU, and a lower density than baseline by 1 month post-MMAE were predictors of favorable outcomes. The baseline hematoma volume, axial thickness, midline shift, and loculation were not correlated with MMAE outcomes. Loculated, trabecular, and laminar hematomas, which are known to have unfavorable surgical outcomes, had MMAE outcomes similar to those of other "surgical" hematomas. CONCLUSIONS The current study was the first to describe the nature, sequence, and timing of morphological changes of CSDHs after MMAE treatment and has identified structural features that can predict treatment outcomes.

A propensity-adjusted comparison of middle meningeal artery embolization versus conventional therapy for chronic subdural hematomas

2021 ◽  
pp. 1-6
Author(s):  
Joshua S. Catapano ◽  
Andrew F. Ducruet ◽  
Candice L. Nguyen ◽  
Tyler S. Cole ◽  
Jacob F. Baranoski ◽  
...  
Keyword(s):  
Treatment Failure ◽  
Conservative Management ◽  
Conventional Therapy ◽  
Surgical Intervention ◽  
Middle Meningeal Artery ◽  
Adjusted Analysis ◽  
Subdural Hematomas ◽  
Tertiary Center ◽  
Meningeal Artery

OBJECTIVEMiddle meningeal artery (MMA) embolization is a promising treatment strategy for chronic subdural hematomas (cSDHs). However, studies comparing MMA embolization and conventional therapy (surgical intervention and conservative management) are limited. The authors aimed to compare MMA embolization versus conventional therapy for cSDHs using a propensity-adjusted analysis.METHODSA retrospective study of all patients with cSDH who presented to a large tertiary center over a 2-year period was performed. MMA embolization was compared with surgical intervention and conservative management. Neurological outcome was assessed using the modified Rankin Scale (mRS). A propensity-adjusted analysis compared MMA embolization versus surgery and conservative management for all individual cSDHs. Primary outcomes included change in hematoma diameter, treatment failure, and complete resolution at last follow-up.RESULTSA total of 231 patients with cSDH met the inclusion criteria. Of these, 35 (15%) were treated using MMA embolization, and 196 (85%) were treated with conventional treatment. On the latest follow-up, there were no statistically significant differences between groups in the percentage of patients with worsening mRS scores. Of the 323 total cSDHs found in 231 patients, 41 (13%) were treated with MMA embolization, 159 (49%) were treated conservatively, and 123 (38%) were treated with surgical evacuation. After propensity adjustment, both surgery (OR 12, 95% CI 1.5–90; p = 0.02) and conservative therapy (OR 13, 95% CI 1.7–99; p = 0.01) were predictors of treatment failure and incomplete resolution on follow-up imaging (OR 6.1, 95% CI 2.8–13; p < 0.001 and OR 5.4, 95% CI 2.5–12; p < 0.001, respectively) when compared with MMA embolization. Additionally, MMA embolization was associated with a significant decrease in cSDH diameter on follow-up relative to conservative management (mean −8.3 mm, 95% CI −10.4 to −6.3 mm, p < 0.001).CONCLUSIONSThis propensity-adjusted analysis suggests that MMA embolization for cSDH is associated with a greater extent of hematoma volume reduction with fewer treatment failures than conventional therapy.

scholarly journals Endovascular Treatment of Chronic Subdural Hematomas through Embolization: A Pilot Study with a Non-Adhesive Liquid Embolic Agent of Minimal Viscosity (Squid)

2021 ◽  
Vol 10 (19) ◽  
pp. 4436
Author(s):  
Andrey Petrov ◽  
Arkady Ivanov ◽  
Larisa Rozhchenko ◽  
Anna Petrova ◽  
Pervinder Bhogal ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Complete Resolution ◽  
Middle Meningeal Artery ◽  
Endovascular Embolization ◽  
Neurological Deficits ◽  
Embolic Agent ◽  
Ethylene Vinyl Alcohol ◽  
Arteriovenous Fistulas ◽  
Subdural Hematomas

Objective: Endovascular embolization using non-adhesive agents (e.g., ethylene vinyl alcohol copolymer with suspended micronized tantalum dissolved in dimethyl sulfoxide; Squid, Balt Extrusion) is an established treatment of brain arteriovenous malformations, dural arteriovenous fistulas, and hypervascular neoplasms. Middle meningeal artery (MMA) embolization is a relatively new concept for treating chronic subdural hematomas (CSDH). This study aimed to evaluate the safety and effectiveness of the use of Squid in the endovascular treatment of CSDH. Methods: Embolization was offered to patients with CSDH with minimal or moderate neurological deficits and patients who had previously undergone open surgery to evacuate their CSDH without a significant effect. Distal catheterization of the MMA was followed by embolization of the hematoma capsule with Squid 12 or Squid 18. Safety endpoints were ischemic or hemorrhagic stroke and any other adverse event of the endovascular procedure. Efficacy endpoints were the feasibility of the intended procedure and a ≥ 50% reduction of the maximum depth of the CSDH confirmed by follow-up computed tomography (CT) after >3 months. Results: Between November 2019 and July 2021, 10 patients (3 female and 7 male, age range 42–89 years) were enrolled. Five patients had bilateral hematomas, and five patients had previously been operated on with no significant effect and recurrent hematoma formation. The attempted embolization was technically possible in all patients. No technical or clinical complication was encountered. During a post-procedural follow-up (median 90 days), 10 patients improved clinically. A complete resolution of the CSDH was observed in 10 patients. The clinical condition of all enrolled patients during the so-far last contact was rated mRS 0 or 1. Conclusion: A distal catheterization of the MMA for the endovascular embolization of CSDH with Squid allowed for the devascularization of the MMA and the dependent vessels of the hematoma capsule. This procedure resulted in a partial or complete resolution of the CSDH. Procedural complications were not encountered.

Utilizing dual energy CT to distinguish blood from contrast leakage following middle meningeal artery embolization for chronic subdural hematomas

2021 ◽  
pp. neurintsurg-2020-016953
Author(s):  
Mujtaba Zaki Naveed ◽  
Peter Wang ◽  
Ryan Lee ◽  
Mehdi Taghipour ◽  
Paul Brady
Keyword(s):  
Middle Meningeal Artery ◽  
Dual Energy ◽  
Dual Energy Ct ◽  
Head Ct ◽  
Subdural Hematomas ◽  
Alternative Treatment Option ◽  
Potential Alternative ◽  
Conventional Ct ◽  
Meningeal Artery

BackgroundRecently, middle meningeal artery (MMA) embolization has emerged as a potential alternative treatment option for chronic subdural hematomas (SDH). Imaging following MMA embolization often shows high density material in the subdural space, usually representing contrast leakage through the dura or, less commonly, hemorrhage. These cannot be reliably differentiated on conventional CT. Dual energy CT (DECT) provides the ability to differentiate materials that otherwise appear similar on conventional CT such as blood and iodine.MethodsA retrospective review was conducted to evaluate patients who underwent MMA embolization for SDH between May 2019 and April 2020. Post-procedural head CT performed on an IQon Elite Spectral CT detector-based DECT scanner enabled two-material decomposition to separate iodine from blood. The dual energy reconstructions used included the virtual non-contrast and iodine no-water images.ResultsFour representative illustrative cases were selected to highlight the ability of DECT to characterize new hyperdensity on head CT following MMA embolization as blood, contrast or a combination.ConclusionsDECT allows objective differentiation of contrast leakage from blood following MMA embolization. This technology can obviate the need for additional follow-up scanning and prolonged patient observation, which in turn can result in reduced costs and radiation exposure to patients.

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

Stroke ◽  
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.

Management and outcomes of isolated interhemispheric subdural hematomas associated with falx syndrome

2019 ◽  
Vol 131 (6) ◽  
pp. 1920-1925
Author(s):  
Daniel A. Tonetti ◽  
William J. Ares ◽  
David O. Okonkwo ◽  
Paul A. Gardner
Keyword(s):  
Neurological Deterioration ◽  
Neurological Deficits ◽  
Motor Deficits ◽  
Study Cohort ◽  
Venous Infarction ◽  
Nonsurgical Management ◽  
Subdural Hematomas ◽  
Poor Outcomes ◽  
Contemporary Management

OBJECTIVELarge interhemispheric subdural hematomas (iSDHs) causing falx syndrome are rare; therefore, a paucity of data exists regarding the outcomes of contemporary management of iSDH. There is a general consensus among neurosurgeons that large iSDHs with neurological deficits represent a particular treatment challenge with generally poor outcomes. Thus, radiological and clinical outcomes of surgical and nonsurgical management for iSDH bear further study, which is the aim of this report.METHODSA prospectively collected, single-institution trauma database was searched for patients with isolated traumatic iSDH causing falx syndrome in the period from January 2008 to January 2018. Information on demographic and radiological characteristics, serial neurological examinations, clinical and radiological outcomes, and posttreatment complications was collected and tallied. The authors subsequently dichotomized patients by management strategy to evaluate clinical outcome and 30-day survival.RESULTSTwenty-five patients (0.4% of those with intracranial injuries, 0.05% of those with trauma) with iSDH and falx syndrome represented the study cohort. The average age was 73.4 years, and most patients (23 [92%] of 25) were taking anticoagulants or antiplatelet medications. Six patients were managed nonoperatively, and 19 patients underwent craniotomy for iSDH evacuation; of the latter patients, 17 (89.5%) had improvement in or resolution of motor deficits postoperatively. There were no instances of venous infarction, reaccumulation, or infection after evacuation. In total, 9 (36%) of the 25 patients died within 30 days, including 6 (32%) of the 19 who had undergone craniotomy and 3 (50%) of the 6 who had been managed nonoperatively. Patients who died within 30 days were significantly more likely to experience in-hospital neurological deterioration prior to surgery (83% vs 15%, p = 0.0095) and to be comatose prior to surgery (100% vs 23%, p = 0.0031). The median modified Rankin Scale score of surgical patients who survived hospitalization (13 patients) was 1 at a mean follow-up of 22.1 months.CONCLUSIONSiSDHs associated with falx syndrome can be evacuated safely and effectively, and prompt surgical evacuation prior to neurological deterioration can improve outcomes. In this study, craniotomy for iSDH evacuation proved to be a low-risk strategy that was associated with generally good outcomes, though appropriately selected patients may fare well without evacuation.

Middle meningeal artery embolization for chronic subdural hematoma: an institutional technical analysis

2020 ◽  
pp. neurintsurg-2020-016552
Author(s):  
Joshua S Catapano ◽  
Andrew F Ducruet ◽  
Candice L Nguyen ◽  
Jacob F Baranoski ◽  
Tyler S Cole ◽  
...  
Keyword(s):  
Subdural Hematoma ◽  
Complete Resolution ◽  
Chronic Subdural Hematoma ◽  
Middle Meningeal Artery ◽  
Artery Embolization ◽  
Embolic Material ◽  
Ethylene Vinyl Alcohol ◽  
Single Center Experience ◽  
Meningeal Artery ◽  
Single Branch

BackgroundRecently, middle meningeal artery (MMA) embolization has emerged as a potentially safe and effective method of treating chronic subdural hematoma (cSDH).ObjectiveTo report a single-center experience with MMA embolization and examines the type of embolic material used, the extent of penetration, and the number of MMA branches embolized.MethodsA retrospective analysis of all patients with MMA embolization from 2018 through 2019 was performed. A failed outcome was defined as either surgical rescue and/or greater than 10 mm of hematoma residual or reaccumulation following embolization.ResultsOf 35 patients, surgery had failed for 9 (26%) and initial conservative treatment had failed for 6 (17%). Of 41 MMA embolizations, including those in six patients with bilateral cSDH who underwent bilateral MMA embolization, 29 (72%) were performed using ethylene vinyl alcohol copolymer (Onyx), 7 (17%) using particles, and 5 (12%) using n-butyl cyanoacrylate. Both the anterior and posterior MMA divisions were embolized in 29 cases (71%); distal penetration of these branches was achieved in 25 embolizations (61%). Twenty-six (63%) cSDHs completely resolved. Complete resolution was seen in 22 of 29 hematomas (76%) in which both anterior and posterior MMA branches were occluded versus 4 of 12 (33%) following single-branch embolization (p=0.014). Embolization of one cSDH (2%) failed.ConclusionMMA embolization of cSDHs appears to be both safe and efficacious. Furthermore, embolization of both the anterior and posterior MMA branches may be associated with increased odds of complete resolution.

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