Volumetric resolution of chronic subdural hematomas treated with surgical evacuation versus middle meningeal artery embolization during immediate, early, and late follow up: propensity-score matched cohorts

Abstract

BackgroundLiterature on volumetric resolution and recurrence over time between surgical evacuation alone (SEA) and standalone middle meningeal artery embolization (MMAE) in comparable chronic subdural hematoma (cSDH) patients is limited.MethodsA retrospective database analysis of cSDH patients managed with either SEA or MMAE was conducted. Propensity-score matching was performed for axial and coronal lengths, maximum diameter, and midline shift. Volumetric measurements at multiple time intervals and recurrence were compared between the groups.Results48 matched hematoma pairs in patients with similar demographics, comorbidities, medications, and symptoms were obtained. Median volume was significantly lower at 24 hours in the SEA group (12.6 mL vs 52.7 mL, p<0.001) but not at remaining intervals. Median volume reduction was significantly greater in the SEA group at 24 hours (39.1 mL vs 8.8 mL in the MMAE group, p<0.001) and at 3–12 weeks (50.8 mL vs 23.7 mL, p<0.001), but not at remaining intervals. The SEA group had a significantly greater median hematoma resolution rate at 24 hours (39.1 mL/day vs 8.8 mL/day, p<0.001) and 3–12 weeks (1 mL/day vs 0.4 mL/day, p<0.001), but not at remaining intervals. Near-complete resolution at 3–12 weeks and 12–60 weeks was not significantly different between groups. Overall, the recurrence rate was significantly higher in the SEA group (22.9% vs 4.2%, p=0.01).ConclusionsIn comparable cSDH patients, SEA resulted in better volumetric outcomes in immediate postoperative and early follow-up periods, as expected. However, this difference was not significant at more distant follow-up intervals. Furthermore, surgical patients experienced a significantly higher rate of recurrence.

Timing of chronic subdural hematoma treatment affects middle meningeal artery embolization outcome

“…Regarding the timing of embolization, there are reports on treatment with embolization alone, failure at 1-3 recurrences, and embolization at 2-11 weeks after initial treatment. [3,5,6,10] In the present study, on average, 2.1 ± 0.6 times recurrences cases experienced MMAE 52.4 ± 35.4 days after the initial surgical treatment. Moreover, post-MMAE recurrence was more common in cases with a short time between the initial surgical treatment and MMAE and in cases with repeated recurrences during a short time interval.…”

“…MMA embolization alone reportedly reduces the hematoma after 3-12 weeks. [3] Even if the MMA is embolized early in CSDH development, the inflammatory cascade may cause further angiogenesis and bleeding, leading to recurrence. Even if the MMA is embolized, CSDH is not cured immediately.…”

Middle meningeal artery embolization for chronic subdural hematoma: a systematic review

“…In an evaluation of the efficacy of MMAE alone, Housley et al ( 37 ) compared the outcomes of 48 propensity-matched patients with cSDH who underwent either surgery alone or MMAE alone as initial treatment. There was a significant hematoma reduction in the surgery group immediately after surgery; after 12 weeks of treatment, however, there was no significant difference in hematoma reduction between the two groups.…”

“…There was a significant hematoma reduction in the surgery group immediately after surgery; after 12 weeks of treatment, however, there was no significant difference in hematoma reduction between the two groups. Furthermore, the recurrence rate was significantly lower in the MMAE group (22.9% vs. 4.2%) ( 37 ). Kim ( 5 ) compared the outcomes of 23 patients who received conventional treatment and 20 patients who received MMAE among 43 patients who developed recurrent cSDH after surgical treatment.…”

Extensive Roles and Technical Advances of Middle Meningeal Artery Embolization for Chronic Subdural Hematoma

“…In terms of timing, MMA embolization may be performed as the initial treatment for CSDH or at the time of CSDH recurrence, either alone or in combination with burr-hole irrigation. 38 - 40 ) Recurrence can be defined in various ways, including increased size, symptomatization, and reoperation. As in our institution, most reports have used liquid embolization materials, 41 ) and we have previously reported no complications or recurrences after MMA embolization using n-butyl-cyanoacrylate (NBCA).…”