scholarly journals Contrast enhancement of chronic subdural hematomas after embolization of the middle meningeal artery

2019 ◽  
Vol 25 (5) ◽  
pp. 596-600 ◽  
Author(s):  
Pouya Entezami ◽  
Alan Boulos ◽  
Alexandra Paul ◽  
Emad Nourollahzadeh ◽  
John Dalfino
Keyword(s):  
Contrast Enhancement ◽  
Treatment Option ◽  
Subdural Hematoma ◽  
Middle Meningeal Artery ◽  
Endovascular Embolization ◽  
Interesting Phenomenon ◽  
Subdural Hematomas ◽  
Surgical Evacuation ◽  
New Treatment ◽  
Meningeal Artery

Chronic subdural hematomas are a common neurosurgical presentation. They are difficult to treat, and current interventions – namely surgical evacuation – are not without complications or recurrences. Embolization of the middle meningeal artery is a promising new treatment option for this pathology. We have noted an interesting phenomenon in our patients following endovascular embolization, which is that the subdural hematoma is stained with contrast following the procedure. This ties into the basic physiology of chronic subdurals, which parasitize the middle meningeal artery during the process of membrane formation and neovascularization, which has previously been reported.

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.

scholarly journals Embolization of the Middle Meningeal Artery Effectively Treats Refractory Chronic Subdural Hematoma: A Systematic Review

2014 ◽  
Vol 21 (3) ◽  
pp. 251-258
Author(s):  
Alfotih Gobran ◽  
Fang-Cheng Li ◽  
Xin-Ke Xu ◽  
Shang-Yi Zhang
Keyword(s):  
Subdural Hematoma ◽  
Chronic Subdural Hematoma ◽  
Middle Meningeal Artery ◽  
Endovascular Embolization ◽  
Common Disease ◽  
Old People ◽  
Repeat Surgery ◽  
Repeated Surgery ◽  
Surgical Treatments ◽  
Meningeal Artery

AbstractChronic subdural hematoma (CSDH) formation mechanism is very complex, and has not entirely understood. It represents a frequent type of intracranial hemorrhage, and is very common disease in Neurosurgery practice, especially in older patients. Various surgical treatments have been proposed for the treatment of CSDH. The rate of recurrence in CSDH after surgery ranges from 5% to 30%, repeated surgery must be considered. But in some cases subdural collections are still persistent. Endovascular embolization of the middle meningeal artery (MMA) is an option for treatment of refractory CSDH. We review all cases that were treated with embolization to assess the effect of this intervention. Our review revealed 6 papers with a total enrollment of 14 patients were treated with MMA embolization for refractory chronic subdural hematoma without any postoperative complication or recurrence. In this study we suggest MMA embolization as an alternative for treatment of non-curable CSDH, especially for old people with systematic diseases, who cannot tolerate repeat surgery.

Total 1-year hospital cost of middle meningeal artery embolization compared to surgery for chronic subdural hematomas: a propensity-adjusted analysis

2021 ◽  
pp. neurintsurg-2021-018327
Author(s):  
Joshua S Catapano ◽  
Stefan W Koester ◽  
Visish M Srinivasan ◽  
Kavelin Rumalla ◽  
Jacob F Baranoski ◽  
...  
Keyword(s):  
Hospital Cost ◽  
Middle Meningeal Artery ◽  
Additional Treatment ◽  
Mean Difference ◽  
Total Hospital Cost ◽  
Total Hospital ◽  
Adjusted Analysis ◽  
Subdural Hematomas ◽  
Surgical Evacuation ◽  
Meningeal Artery

BackgroundMiddle meningeal artery (MMA) embolization results in fewer treatment failures than surgical evacuation for chronic subdural hematomas (cSDHs). We compared the total 1-year hospital cost for MMA embolization versus surgical evacuation for patients with cSDH.MethodsData for patients who presented with cSDHs from January 1, 2018, through May 31, 2020, were retrospectively reviewed. Patients were grouped by initial treatment (surgery vs MMA embolization), and total hospital cost was obtained. A propensity-adjusted analysis was performed. The primary outcome was difference in mean hospital cost between treatments.ResultsOf 170 patients, 48 (28%) underwent embolization and 122 (72%) underwent surgery. cSDHs were larger in the surgical (20.5 (6.7) mm) than in the embolization group (16.9 (4.6) mm; P<0.001); and index hospital length of stay was longer in the surgical group (9.8 (7.0) days) than in the embolization group (5.7 (2.4) days; P<0.001). More patients required additional hematoma treatment in the surgical cohort (16%) than in the embolization cohort (4%; P=0.03), and more required readmission in the surgical cohort (28%) than in the embolization cohort (13%; P=0.04). After propensity adjustment, MMA embolization was associated with a lower total hospital cost compared to surgery (mean difference −$32 776; 95% CI −$52 766 to −$12 787; P<0.001). A propensity-adjusted linear regression analysis found that unexpected additional treatment was the only significant contributor to total hospital cost (mean difference $96 357; 95% CI $73 886 to $118 827; P<0.001).ConclusionsMMA embolization is associated with decreased total hospital cost compared with surgery for cSDHs. This lower cost is directly related to the decreased need for additional treatment interventions.

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.

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.

scholarly journals Recurrence and Coniglobus Volumetric Resolution of Subacute and Chronic Subdural Hematoma Post-Middle Meningeal Artery Embolization

Diagnostics ◽  
2021 ◽  
Vol 11 (2) ◽  
pp. 257
Author(s):  
Ambooj Tiwari ◽  
Adam A. Dmytriw ◽  
Ryan Bo ◽  
Nathan Farkas ◽  
Phillip Ye ◽  
...  
Keyword(s):  
Subdural Hematoma ◽  
Chronic Subdural Hematoma ◽  
Middle Meningeal Artery ◽  
Volumetric Analysis ◽  
Primary Therapy ◽  
Curative Therapy ◽  
Complete Obliteration ◽  
Embolization Treatment ◽  
Long Term Follow Up ◽  
Meningeal Artery

Objective: To study the efficacy of middle meningeal artery (MMA) embolization for the treatment of chronic subdural hematoma (SDH) and characterize its post-embolization volumetric resolution. Methods: Ten patients diagnosed with 13 cSDH underwent MMA embolization. SDH volumes were measured from time of initial discovery on imaging to pre-operative, post-operative, short-term and long-term follow-up. Time between procedure to obliteration was also measured. Volumetric analysis was done using the coniglobus formula, and recurrence rate as well as resolution timeline was defined using best-fit models. Results: Out of 10 patients, five were recurrent lesions, three were bilateral and seven unilateral cSDH. Average and median pre-operative volumes were 105.3 cc and 97.4 cc, respectively. Embolization on average was performed 21 days after discovery. Sixty percent of patients had concurrent antiplatelets or anticoagulation use. Forty percent underwent embolization treatment as the primary therapy. Recurrence was not seen in any patients treated with embolization. There were no peri- or post-operative complications. Five patients experienced complete or near-complete obliteration, while those with partial resolution showed a composite average of 75% volumetric reduction in 45 days. Post-embolization, the volumetric resolution followed an exponential decay curve over time and was independent of initial volume. Conclusion: MMA embolization contributed to a marked reduction in SDH volume post-operatively and can be used as a curative therapy for primary or recurrent chronic SDH.

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