Middle meningeal artery (MMA) embolization for management of chronic subdural hematoma (cSDH)

 

 

We recently read the review article about this topic. We now summarize what we learn from this paper. 

 

By 2030, there will be > 60,000 new cases of SDH and mortality rate from cSDH is approximately 30%.

cSDHs have a tendency to persist and gradually increase in volume over time

The basic pathology is the formation of leaky vascular membrane, which incite a positive feedback cycle of continued hemorrhage, inflammation and angiogenesis.

There are 3 options of treatment for cSDH

1) Conservative Rx

For patients who are asymptomatic or minor symptoms with cSDH < 10 mm in greatest thickness and < 5 mm of midline shift.

2) Surgery

Traditional surgical approaches are twist drill hole, burr hole, and craniotmy based evacuation. Downside of surgery is recurrent rate about 10-20%. Patients have high morbidities which could potentially complicate cranial surgery. The most important one is the requirement of reversal of anti platelet and anticoagulant agents.

3) MMA embolization

The goal of embolization is to devascularize the subdural membranes to a sufficient extent such theat the balance is shifted from the continued leakage and accumulation of blood products towards reabsorption. 

Bottom line is the evidence support this treatment is composed largely by single center, retrospective, self adjudicated case series.   We need prospective randomized controlled trial !

Recent meta-analysis of 9 studies showed lower recurrence rate for sCDH after MMA embolization compared with surgery (2.1% vs 27.7%, OR=0.87)

Ban et al described 72 cases underwent MMA embolization (23, sole therapy and 45 prior surgery). In their series, 0/23  and 1/45 had treatment failure. Treatment failure= surgical rescue or reoperation after initial surgical management.  When they compared with case control data from the same hospital, treatment failure rate was 18.2% in patients initially managed surgically.

PVA particulate embolysate was the most commonly used for MMA embolization but this paper recommend liquid embolic agent. Liquid embolic agent is permanent, has better distal penetration, better thoroughness of the embolization and better observe during embolization. 

 

 

 

Reference

1) Fiorella D, Arthur A. Middle meningeal artery embolization for the management of chronic subdural hematoma J Neurointervent Surg 2019;Epub ahead of print ;0:1-4