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

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  • 1 Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
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OBJECTIVE

Middle 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.

METHODS

A 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.

RESULTS

A 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).

CONCLUSIONS

This 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.

ABBREVIATIONS

cSDH = chronic subdural hematoma; MMA = middle meningeal artery; mRS = modified Rankin Scale.

Illustration from Kim et al. (pp 1164–1172). Copyright Eui Hyun Kim. Published with permission.

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  • 1

    Balser D, Farooq S, Mehmood T, et al. Actual and projected incidence rates for chronic subdural hematomas in United States Veterans Administration and civilian populations. J Neurosurg. 2015;123(5):12091215.

    • Search Google Scholar
    • Export Citation
  • 2

    Ducruet AF, Grobelny BT, Zacharia BE, et al. The surgical management of chronic subdural hematoma. Neurosurg Rev. 2012;35(2):155169.

  • 3

    Fiorella D, Arthur AS. Middle meningeal artery embolization for the management of chronic subdural hematoma. J Neurointerv Surg. 2019;11(9):912915.

    • Search Google Scholar
    • Export Citation
  • 4

    Mehta V, Harward SC, Sankey EW, et al. Evidence based diagnosis and management of chronic subdural hematoma: a review of the literature. J Clin Neurosci. 2018;50:715.

    • Search Google Scholar
    • Export Citation
  • 5

    Foreman P, Goren O, Griessenauer CJ, et al. Middle meningeal artery embolization for chronic subdural hematomas: cautious optimism for a challenging pathology. World Neurosurg. 2019;126:528529.

    • Search Google Scholar
    • Export Citation
  • 6

    Miranda LB, Braxton E, Hobbs J, Quigley MR. Chronic subdural hematoma in the elderly: not a benign disease. J Neurosurg. 2011;114(1):7276.

    • Search Google Scholar
    • Export Citation
  • 7

    Ban SP, Hwang G, Byoun HS, et al. Middle meningeal artery embolization for chronic subdural hematoma. Radiology. 2018;286(3):992999.

  • 8

    Brennan PM, Kolias AG, Joannides AJ, et al. The management and outcome for patients with chronic subdural hematoma: a prospective, multicenter, observational cohort study in the United Kingdom. J Neurosurg. 2017;127(4):732739.

    • Search Google Scholar
    • Export Citation
  • 9

    Knopman J, Link TW, Navi BB, et al. Rates of repeated operation for isolated subdural hematoma among older adults. JAMA Netw Open. 2018;1(6):e183737.

    • Search Google Scholar
    • Export Citation
  • 10

    Rovlias A, Theodoropoulos S, Papoutsakis D. Chronic subdural hematoma: surgical management and outcome in 986 cases: a classification and regression tree approach. Surg Neurol Int. 2015;6:127.

    • Search Google Scholar
    • Export Citation
  • 11

    Hashimoto T, Ohashi T, Watanabe D, et al. Usefulness of embolization of the middle meningeal artery for refractory chronic subdural hematomas. Surg Neurol Int. 2013;4:104.

    • Search Google Scholar
    • Export Citation
  • 12

    Kang J, Whang K, Hong SK, et al. Middle meningeal artery embolization in recurrent chronic subdural hematoma combined with arachnoid cyst. Korean J Neurotrauma. 2015;11(2):187190.

    • Search Google Scholar
    • Export Citation
  • 13

    Link TW, Boddu S, Paine SM, et al. Middle meningeal artery embolization for chronic subdural hematoma: a series of 60 cases. Neurosurgery. 2019;85(6):801807.

    • Search Google Scholar
    • Export Citation
  • 14

    Link TW, Rapoport BI, Paine SM, et al. Middle meningeal artery embolization for chronic subdural hematoma: Endovascular technique and radiographic findings. Interv Neuroradiol. 2018;24(4):455462.

    • Search Google Scholar
    • Export Citation
  • 15

    Link TW, Schwarz JT, Paine SM, et al. Middle meningeal artery embolization for recurrent chronic subdural hematoma: a case series. World Neurosurg. 2018;118:e570e574.

    • Search Google Scholar
    • Export Citation
  • 16

    Matsumoto H, Hanayama H, Okada T, et al. Which surgical procedure is effective for refractory chronic subdural hematoma? Analysis of our surgical procedures and literature review. J Clin Neurosci. 2018;49:4047.

    • Search Google Scholar
    • Export Citation
  • 17

    Edlmann E, Giorgi-Coll S, Whitfield PC, et al. Pathophysiology of chronic subdural haematoma: inflammation, angiogenesis and implications for pharmacotherapy. J Neuroinflammation. 2017;14(1):108.

    • Search Google Scholar
    • Export Citation
  • 18

    Kolias AG, Chari A, Santarius T, Hutchinson PJ. Chronic subdural haematoma: modern management and emerging therapies. Nat Rev Neurol. 2014;10(10):570578.

    • Search Google Scholar
    • Export Citation
  • 19

    Nagahori T, Nishijima M, Takaku A. Histological study of the outer membrane of chronic subdural hematoma: possible mechanism for expansion of hematoma cavity. Article in Japanese. No Shinkei Geka. 1993;21(8):697701.

    • Search Google Scholar
    • Export Citation
  • 20

    Takizawa K, Sorimachi T, Ishizaka H, et al. Enlargement of the middle meningeal artery on MR angiography in chronic subdural hematoma. J Neurosurg. 2016;124(6):16791683.

    • Search Google Scholar
    • Export Citation
  • 21

    Tanaka T, Kaimori M. Histological study of vascular structure between the dura mater and the outer membrane in chronic subdural hematoma in an adult. Article in Japanese. No Shinkei Geka. 1999;27(5):431436.

    • Search Google Scholar
    • Export Citation
  • 22

    Saito H, Tanaka M, Hadeishi H. Angiogenesis in the septum and inner membrane of refractory chronic subdural hematomas: consideration of findings after middle meningeal artery embolization with low-concentration n-butyl-2-cyanoacrylate. NMC Case Rep J. 2019;6(4):105110.

    • Search Google Scholar
    • Export Citation
  • 23

    Ivamoto HS, Lemos HP Jr, Atallah AN. Surgical treatments for chronic subdural hematomas: a comprehensive systematic review. World Neurosurg. 2016;86:399418.

    • Search Google Scholar
    • Export Citation
  • 24

    Weigel R, Schmiedek P, Krauss JK. Outcome of contemporary surgery for chronic subdural haematoma: evidence based review. J Neurol Neurosurg Psychiatry. 2003;74(7):937943.

    • Search Google Scholar
    • Export Citation
  • 25

    Decaux O, Cador B, Dufour T, et al. Nonsurgical treatment of chronic subdural hematoma with steroids: two case reports. Article in French. Rev Med Interne. 2002;23(9):788791.

    • Search Google Scholar
    • Export Citation
  • 26

    Delgado-López PD, Martín-Velasco V, Castilla-Díez JM, et al. Dexamethasone treatment in chronic subdural haematoma. Neurocirugia (Astur). 2009;20(4):346359.

    • Search Google Scholar
    • Export Citation
  • 27

    Dran G, Berthier F, Fontaine D, et al. Effectiveness of adjuvant corticosteroid therapy for chronic subdural hematoma: a retrospective study of 198 cases. Article in French. Neurochirurgie. 2007;53(6):477482.

    • Search Google Scholar
    • Export Citation
  • 28

    Sun TF, Boet R, Poon WS. Non-surgical primary treatment of chronic subdural haematoma: preliminary results of using dexamethasone. Br J Neurosurg. 2005;19(4):327333.

    • Search Google Scholar
    • Export Citation
  • 29

    Thotakura AK, Marabathina NR. Nonsurgical treatment of chronic subdural hematoma with steroids. World Neurosurg. 2015;84(6):19681972.

    • Search Google Scholar
    • Export Citation
  • 30

    Waqas M, Vakhari K, Weimer PV, et al. Safety and effectiveness of embolization for chronic subdural hematoma: systematic review and case series. World Neurosurg. 2019;126:228236.

    • Search Google Scholar
    • Export Citation
  • 31

    Kim HC, Ko JH, Yoo DS, Lee SK. Spontaneous resolution of chronic subdural hematoma: close observation as a treatment strategy. J Korean Neurosurg Soc. 2016;59(6):628636.

    • Search Google Scholar
    • Export Citation
  • 32

    Horikoshi T, Naganuma H, Fukasawa I, et al. Computed tomography characteristics suggestive of spontaneous resolution of chronic subdural hematoma. Neurol Med Chir (Tokyo). 1998;38(9):527533.

    • Search Google Scholar
    • Export Citation
  • 33

    Hirai S, Ono J, Odaki M, et al. Embolization of the middle meningeal artery for refractory chronic subdural haematoma. usefulness for patients under anticoagulant therapy. Interv Neuroradiol. 2004;10(suppl 2):101104.

    • Search Google Scholar
    • Export Citation
  • 34

    Ishihara H, Ishihara S, Kohyama S, et al. Experience in endovascular treatment of recurrent chronic subdural hematoma. Interv Neuroradiol. 2007;13(suppl 1):141144.

    • Search Google Scholar
    • Export Citation
  • 35

    Mandai S, Sakurai M, Matsumoto Y. Middle meningeal artery embolization for refractory chronic subdural hematoma. Case report. J Neurosurg. 2000;93(4):686688.

    • Search Google Scholar
    • Export Citation
  • 36

    Mino M, Nishimura S, Hori E, et al. Efficacy of middle meningeal artery embolization in the treatment of refractory chronic subdural hematoma. Surg Neurol Int. 2010;1:78.

    • Search Google Scholar
    • Export Citation
  • 37

    Takahashi K, Muraoka K, Sugiura T, et al. Middle meningeal artery embolization for refractory chronic subdural hematoma: 3 case reports. Article in Japanese. No Shinkei Geka. 2002;30(5):535539.

    • Search Google Scholar
    • Export Citation
  • 38

    Tempaku A, Yamauchi S, Ikeda H, et al. Usefulness of interventional embolization of the middle meningeal artery for recurrent chronic subdural hematoma: five cases and a review of the literature. Interv Neuroradiol. 2015;21(3):366371.

    • Search Google Scholar
    • Export Citation
  • 39

    Tsukamoto Y, Oishi M, Shinbo J, Fujii Y. Transarterial embolisation for refractory bilateral chronic subdural hematomas in a case with dentatorubral-pallidoluysian atrophy. Acta Neurochir (Wien). 2011;153(5):11451147.

    • Search Google Scholar
    • Export Citation
  • 40

    Kim E. Embolization therapy for refractory hemorrhage in patients with chronic subdural hematomas. World Neurosurg. 2017;101:520527.

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