Middle meningeal artery embolization with subdural evacuating port system for primary management of chronic subdural hematomas

Carpenter, Austin B.; Rock, Mitchell; Dowlati, Ehsan; Miller, Charles A.; Jeffrey, C.; Liu, Ai‐Hsi; Armonda, Rocco A.; Felbaum, Daniel R.

doi:10.1007/s10143-021-01553-x

Cited by 17 publications

(14 citation statements)

References 36 publications

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“…MMA embolization is relatively novel, and reports to date consist largely of limited case series, 20,[71][72][73] often in comparison with historical controls. 74 One randomized study has been published, 53 with several more currently underway.…”

Section: Mma Embolizationmentioning

confidence: 99%

Management of Chronic Subdural Hematoma: A Systematic Review and Component Network Meta-analysis of 455 Studies With 103 645 Cases

et al. 2022

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BACKGROUND: Chronic subdural hematoma (CSDH) is a common neurosurgical condition with a high risk of recurrence after treatment. OBJECTIVE: To assess and compare the risk of recurrence, morbidity, and mortality across various treatments for CSDH. METHODS: A systematic review and meta-analysis was performed. PubMed/MEDLINE, EMBASE, SCOPUS, and Web of Science were searched from January 01, 2000, to July 07, 2021. The primary outcome was recurrence, and secondary outcomes were morbidity and mortality. Component network meta-analyses (CNMAs) were performed for surgical and medical treatments, assessing recurrence and morbidity. Incremental risk ratios (iRRs) with 95% CIs were estimated for each component. RESULTS: In total, 12 526 citations were identified, and 455 studies with 103 645 cases were included. Recurrence occurred in 11 491/93 525 (10.8%, 95% CI 10.2-11.5, 418 studies) cases after surgery. The use of a postoperative drain (iRR 0.53, 95% CI 0.44-0.63) and middle meningeal artery embolization (iRR 0.19, 95% CI 0.05-0.83) reduced recurrence in the surgical CNMA. In the pharmacological CNMA, corticosteroids (iRR 0.47, 95% CI 0.36-0.61) and surgical intervention (iRR 0.11, 95% CI 0.07-0.15) were associated with lower risk. Corticosteroids were associated with increased morbidity (iRR 1.34, 95% CI 1.05-1.70). The risk of morbidity was equivalent across surgical treatments. CONCLUSION: Recurrence after evacuation occurs in approximately 10% of cSDHs, and the various surgical interventions are approximately equivalent. Corticosteroids are associated with reduced recurrence but also increased morbidity. Drains reduce the risk of recurrence, but the position of drain (subdural vs subgaleal) did not influence recurrence. Middle meningeal artery embolization is a promising treatment warranting further evaluation in randomized trials.

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Section: Mma Embolizationmentioning

confidence: 99%

Management of Chronic Subdural Hematoma: A Systematic Review and Component Network Meta-analysis of 455 Studies With 103 645 Cases

et al. 2022

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“…Perioperative MMA embolization: The combined performance of MMA embolization and burr-hole craniotomy or Subdural Evacuation Port System (SEPS) insertion is an interesting concept [28]. Ng et al (2019) were able to show that a PVA embolization of the MMA after surgical evacuation results in faster absorption of the CSDH [29] the MMAs of 20 patients with nBCA after a second postoperative recurrence of their CSDHs and performed a third burr-hole surgery after the embolization.…”

Section: Discussionmentioning

confidence: 99%

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

Петров

Ivanov

Рожченко

et al. 2021

JCM

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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.

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“…Treatment failure Nine studies reported treatment failure [19][20][21][22][23][24][25][26][27] : 19 in the MMA embolization group (n = 337) and 264 events in the conventional management group (n = 1186). The relative risk of treatment failure in MMA embolization was significantly lower compared with conventional management (5.6% vs 22.2%, RR = 0.34 [0.14-0.82], P = .02, I 2 = 64%, P = .005; Figure 2a).…”

Section: Meta-analysis Of the Outcomes Primary Outcomesmentioning

confidence: 99%

“…Seven studies reported mortality, 20,21,[23][24][25][26][27] in which 11 and 26 events occurred in the MMA embolization (n = 209) and conventional management (n = 521) groups, respectively. Again, there was no difference in the risk of mortality between the groups (5.2% vs 4.9%, RR = 1.05 [0.51-2.14], P = .89, I 2 = 0%, P = .58; Figure 3c).…”

Section: Mortalitymentioning

confidence: 99%

“…6,[15][16][17][18] However, studies comparing the outcomes of MMA embolization relative to conventional therapy are limited and varied, with some studies demonstrating significantly lower treatment failure rates after MMA embolization, [19][20][21][22] and the others showing no benefit. [23][24][25][26][27] Therefore, this systematic review and meta-analysis sought to compare outcomes in cSDH in patients with MMA embolization and those without.…”

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confidence: 99%

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Middle Meningeal Artery Embolization Versus Conventional Management for Patients With Chronic Subdural Hematoma: A Systematic Review and Meta-Analysis

et al. 2023

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BACKGROUND:The results from studies that compare middle meningeal artery (MMA) embolization vs conventional management for patients with chronic subdural hematoma are varied. OBJECTIVE: To conduct a systematic review and meta-analysis on studies that compared MMA embolization vs conventional management. METHODS: Medline, PubMed, and Embase databases were searched. Primary outcomes were treatment failure and surgical rescue; secondary outcomes were complications, follow-up modified Rankin scale > 2, mortality, complete hematoma resolution, and length of hospital stay (day). The certainty of the evidence was determined using the GRADE approach. RESULTS: Nine studies yielding 1523 patients were enrolled, of which 337 (22.2%) and 1186 (77.8%) patients received MMA embolization and conventional management, respectively. MMA embolization was superior to conventional management for treatment failure (relative risk [RR] = 0.34 [0.14-0.82], P = .02), surgical rescue (RR = 0.33 [0.14-0.77], P = .01), and complete hematoma resolution (RR = 2.01 [1.10-3.68], P = .02). There was no difference between the 2 groups for complications (RR = 0.93 [0.63-1.37], P = .72), follow-up modified Rankin scale >2 (RR = 0.78 [0.449-1.25], P = .31), mortality (RR = 1.05 [0.51-2.14], P = .89), and length of hospital stay (mean difference = À0.57 [À2.55, 1.41], P = .57). For MMA embolization, the number needed to treat for treatment failure, surgical rescue, and complete hematoma resolution was 7, 9, and 3, respectively. The certainty of the evidence was moderate to high for primary outcomes and low to moderate for secondary outcomes. CONCLUSION: MMA embolization decreases treatment failure and the need for surgical rescue without furthering the risk of morbidity and mortality. The authors recommend considering MMA embolization in the chronic subdural hematoma management.

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Middle meningeal artery embolization with subdural evacuating port system for primary management of chronic subdural hematomas

Cited by 17 publications

References 36 publications

Management of Chronic Subdural Hematoma: A Systematic Review and Component Network Meta-analysis of 455 Studies With 103 645 Cases

Management of Chronic Subdural Hematoma: A Systematic Review and Component Network Meta-analysis of 455 Studies With 103 645 Cases

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

Middle Meningeal Artery Embolization Versus Conventional Management for Patients With Chronic Subdural Hematoma: A Systematic Review and Meta-Analysis

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