Introduction Chronic subdural hematoma (cSDH) is one of the most common neurological diseases, often causing significant morbidity especially in the elderly population. Recently, middle meningeal artery (MMA) embolization has emerged as a potentially safe and effective method of treating cSDH. Pertinent literature, however, remains limited. The current study reports our center’s experience with MMA embolization and examines the type of embolic material used, the extent of penetration, and MMA branches embolized.
Methods A prospectively maintained endovascular treatment database was retrospectively analyzed for all patients whom underwent MMA embolization from January 1st, 2018 to December 31st, 2019. Six patients without at least 30 days of follow-up were excluded. A failed outcome was defined as either surgical rescue and/or >10 mm of residual or reaccumulation after MMA embolization. Secondary outcomes included: complete and near-complete (<5 mm) resolution of the cSDH, mRS >2 on follow-up, and worse mRS on follow-up.
Results The 34 patients that met the inclusion criteria had an average age of 68±12 years. Twenty-four patients were male (71%). Twenty-three had suffered a preceding trauma (68%), and 13 were on antiplatelet or anticoagulant (38%) medications. Headache (N=14, 41%), focal neurological deficit (N=15, 44%), and altered mental status (N=11, 32%) were the most common presenting symptoms. Nine (26%) had failed surgery and 6 (18%) had failed conservative treatment. Transradial access was utilized for 20 patients (59%). One ischemic complication (3%) occurred in a patient with a type 3 arch who underwent transfemoral embolization. Average preoperative mRS was 2.0±1.4 and follow-up mRS was 1.8 ±1.4 with an average follow-up days of 110±72. Ten patients (29%) had a mRS >2 and 1 patient (3%) had a worse mRS on follow-up. A total of 40 MMA embolizations were performed (6 patients with bilateral cSDH had bilateral MMA embolization). Embolic agents included Onyx (N=27, 68%), particles (N=9, 20%), and NBCA (N=4, 10%). Both the anterior and posterior MMA branches were embolized in 27 (68%) and distal penetration of these branches was achieved in 23 (58%) patients. Twenty-two cSDHs (55%) completely resolved while 33 (83%) had either complete or near-complete resolution. Failed embolization occurred in only 3 cSDHs (8%), none in patients in whom both anterior and posterior MMA branches embolized (p=0.029).
Conclusion In our series, our procedure has evolved to transradial access for Onyx embolization which is both safe and efficacious. Furthermore, embolization of both the anterior and posterior MMA branches may be associated with a decrease risk of failed treatment. Future randomized control trials and/or large prospective studies are warranted, with attention to optimizing the procedural technique.
Disclosures J. Catapano: None. C. Nguyen: None. M. Pacault: None. T. Cole: None. J. Baranoski: None. D. Wilkinson: None. N. Majmundar: None. A. Ducruet: None. F. Albuquerque: None.
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