Embolization of the Middle meningeal artery in chronic subdural hematoma — A systematic review
Introduction
Chronic subdural hematomas (cSDH) have an incidence of up to 58.1 per 100 000 person-year in patients over 65 years old and often require neurosurgical attention [1]. Traditionally, cSDH are treated through burr hole evacuation and irrigation, however recurrence is frequent and ranges from 11 to 37% [[1], [2], [3]]. The prevalence of recurrence is over-represented in patients undergoing antithrombotic therapy [4,5]. A recent meta-analysis found that anticoagulated patients had over twice the risk of recurrence compared to patients not taking any antithrombotic medication, whereas another study found that patients on antiplatelet therapy had 4 times the risk [4,5]. Hence, in patients affected with a cSDH, the resumption of antithrombotic medications is usually not considered safe until the hematoma has resolved [6].
The pathophysiology of cSDH involves the formation of neo-membranes from dura mater inflammatory remodeling. This distinguishes cSDH from acute SDH and led to the recent suggestion that cSDH should rather be called membrane-associated SDH [7]. The membrane and newly formed capillaries are fed through the dura mainly by distal branches of the middle meningeal artery (MMA) [8]. Strategies tested to non-invasively address this growth have included dexamethasone [3] as well as tranexamic acid [9]. Recently, several case reports and two prospective studies suggested that embolization of the MMA could inhibit the influx of blood into this membrane and thus prevent the accumulation of the hematoma in the subdural space [[10], [11], [12]]. The goal of this study was to systematically review all published cases of MMA embolization (MMAE) in cSDH to assess the procedure’s safety, feasibility, indications and efficacy.
Section snippets
Study design and search strategy
We performed a systematic review according to the PRISMA guidelines [13]. An electronic literature search on the 12th of August 2018 was performed on Medline, Pubmed and Scopus for indexed studies, using and combining the main following key concept terms: “chronic subdural hematoma”, “embolization” and “middle meningeal artery”. Detailed search strategy design is available upon request. A final search was performed the 9th of November 2018 and any supplemental articles meeting the inclusion and
Results
Our search strategy yielded 217 articles. Of those, 89 were duplicates and 106 were excluded based on their abstract not meeting selection criteria. Twenty-Two English articles were selected for full-text review and 5 more articles were excluded (Fig. 1). No additional studies in French or in English were found in the reference lists of these reports. One article which was published in November 2018 was added after the initial literature search [11]. Eighteen articles were included in the final
Discussion
The cSDH population is elderly and frail. Given the 11–37% [[1], [2], [3]] recurrence rate reported after surgical cSDH evacuation, the development of minimally invasive alternatives to surgery could be valuable. The treatment options for cSDH have been extensively studied and debated. The success of conservative management is low (ranging from 3 to 18%) [29,30]. Several medical options have been investigated, such as angiotensin-converting enzyme (ACE) inhibitors [31], statins [32], and
Conclusion
MMAE is a feasible intervention in the cSDH population, although no conclusion can be reached concerning its safety or efficacy. Eighteen articles, graded “very low” to “low”, involving 190 patients, have been published to date; therefore, the level of evidence supporting MMAE is currently too low to routinely recommend this procedure in clinical practice. Formal prospective, randomized, controlled trials are required before MMAE can be introduced into routine clinical practice.
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History and current progress of chronic subdural hematoma
2021, Journal of the Neurological SciencesCitation Excerpt :Compared with conservative management, MMA embolization was associated with lower rates of CSDH recurrence and surgical rescue. The details of embolization agents were not systematically described; however most patients underwent MMA embolization with polyvinyl alcohol (PVA) particles (83%), followed by n-buthyl-2-cyanoacrylate (NBCA) (9%), coils (3%) (Fig. 3) [115]. In other systematic review regarding MMA embolization, the hematoma resolution rate was estimated to be as high as 96.8%, with recurrence ranging from 2.1% to 4.1% and procedural complication rates from 0% to 3.6% [116].
Thirty- and 90-Day Readmissions After Treatment of Traumatic Subdural Hematoma: National Trend Analysis
2020, World NeurosurgeryCitation Excerpt :One particular procedure that is increasing in popularity is middle meningeal artery embolization (MMAE) for chronic SDH. In a recent systematic review of 190 patients who underwent MMAE for chronic SDH, Court et al30 reported no procedural complications and a 96.8% resolution of the chronic SDH. Further studies are necessary to better understand the role of MMAE in the management of traumatic SDH (including chronic SDH).
Analysis of middle meningeal artery embolization for the treatment of chronic, acute on chronic, and subacute subdural hematomas
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Both authors contributed equally to study design, realization and completion and are both considered first authors.