Middle meningeal artery embolization for chronic subdural hematoma

Abstract

Objectives To assess recurrence rates, procedural outcomes and patient outcomes following middle meningeal artery (MMA) embolization for the treatment of chronic subdural hematomas (cSDH).Design Retrospective case series.Setting Two tertiary neurosurgical referral centers in Sydney, Australia.Participants 13 adult patients (mean age±SD, 68.5±9.5 years, 11 male) with 17 cSDHs (measuring 13.8±4.5 mm) undergoing MMA embolization alone (8/13) or with surgical evacuation (5/13) for cSDH. There were no exclusion criteria.Interventions Embolization was performed via femoral access, using either liquid embolic, polyvinyl alcohol particles, coils, or a combination of agents. Embolization was done either as the sole treatment or with surgical evacuation.Main outcome measures Primary outcomes were recurrence or increase in hematoma size requiring surgical evacuation. Secondary outcomes included procedural complications, hematoma size at follow-up, and patient clinical outcomes.Results No procedural complications occurred. 12 patients were discharged home at baseline neurological function, and one was discharged to an aged care facility with significant disability. At follow-up (mean=8.7 weeks), combined embolization with surgical evacuation led to hematoma size reduction (14.3±2.6 mm to 5.7±6.5 mm, p<0.01), while embolization alone showed a stable hematoma size (13.3±5.7 mm to 10.0±8.8 mm, p=0.20). Recurrence or increase in hematoma size requiring surgical evacuation occurred in 2/13 (15.4%) patients, one of whom received only unilateral embolization, and the other received partial coiling due to the presence of dangerous collaterals.Conclusions MMA embolization is a safe procedure that may reduce recurrence rates of cSDH when used as an adjunct to surgery or as a sole treatment. Possible reasons for treatment failure may include unilateral embolization, partial coiling, and absence of distal penetration of embolic agent. Large randomized control trials are currently in progress to assess the safety and efficacy of MMA embolization for this purpose.