Embolization of the Middle meningeal artery in chronic subdural hematoma — A systematic review

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Highlights

  • MMAE is a promising, minimally invasive technique for patients suffering from cSDH.

  • Quality evidence is lacking regarding the effectiveness of MMAE.

  • Specific indications and contra-indications are yet to be determined.

Abstract

Chronic subdural hematomas (cSDH) are one of the most frequent reasons for consultation in neurosurgery. Multiple authors have proposed middle meningeal artery embolization (MMAE) as an option in cSDH patients to manage recurrence or avoid surgery altogether. Although many articles have been published on the matter, the current body of evidence still has to be evaluated before MMAE is integrated into clinical practice.

The goal of this study was to review the evidence on MMAE in cSDH to assess its safety, feasibility, indications and efficacy.

We performed a systematic review of the literature according to PRISMA guidelines using multiple electronic databases.

Our search yielded a total of 18 original articles from which data were extracted. A total of 190 patients underwent MMAE from which 81.3% were symptomatic cSDH. Over half (52.3%) of the described population were undergoing antithrombotic therapy. Most (83%) procedures used polyvinyl alcohol (PVA) particles and no complications were reported regarding the embolization procedures. Although the definition of resolution varied among authors, cSDH resolution was reported in 96.8% of cases.

MMAE is a feasible technique for cSDH, but the current body of evidence does not yet support its use as a standard treatment. Further studies with a higher level of evidence are necessary before MMAE can be formally recommended.

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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    Both authors contributed equally to study design, realization and completion and are both considered first authors.

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