Background Middle meningeal artery embolization (MMAE) has emerged as a promising therapy for chronic subdural hematomas (cSDHs). The efficacy of standalone MMAE compared with MMAE with concurrent surgery is largely unknown.
Methods cSDH patients who underwent successful MMAE from 14 high volume centers with at least 30 days of follow-up were included. Clinical and radiographic variables were recorded and used to perform propensity score matching (PSM) of patients treated with standalone MMAE or MMAE with concurrent surgery. Multivariable logistic regression models were used for additional covariate adjustments. The primary outcome was recurrence requiring surgical rescue, and the secondary outcome was radiographic failure defined as <50% reduction of cSDH thickness.
Results 722 MMAE procedures in 588 cSDH patients were identified. After PSM, 230 MMAE procedures remained (115 in each group). Median age was 73 years, 22.6% of patients were receiving anticoagulation medication, and 47.9% had no preoperative functional disability. Median midline shift was 4 mm and cSDH thickness was 16 mm, representing modestly sized cSDHs. Standalone MMAE and MMAE with surgery resulted in similar rates of surgical rescue (7.8% vs 13.0%, respectively, P=0.28; adjusted OR (aOR 0.73 (95% CI 0.20 to 2.40), P=0.60) and radiographic failure (15.5% vs 13.7%, respectively, P=0.84; aOR 1.08 (95% CI 0.37 to 2.19), P=0.88) with a median follow-up duration of 105 days. These results were similar across subgroup analyses and follow-up durations.
Conclusions Standalone MMAE led to similar and durable clinical and radiographic outcomes as MMAE combined with surgery in select patients with moderately sized cSDHs and mild clinical disease.
Data availability statement
Data are available upon reasonable request.
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HC and MMS contributed equally.
Contributors HC, MMS, MC, JKB, and PK conceived the study idea. MMS and JKB designed the study. MMS, GSS, JK, OK, KTC, ANH, AAB, MS, MK, CB, AMR, GMC, ZA, JFRR, JMD, SN, CMC, HR, JM, AMS, AK, BMH, RAH, OT, DT, AHS, ML, EIL, TGJ, RG, VMS, MRL, CSO, BJ, AJT, BAG, JKB, and PK acquired the data. HC, MC, and PK analyzed the data and wrote the manuscript. MMS, DT, RG, MRL, and JKB revised the manuscript. All authors approved the final manuscript for publication. PK is guarantor and accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.
Disclaimer Dr. Huanwen Chen is an employee of the National Institutes of Health, and thus the United States Government. The opinions expressed in this article are the author's own and do not reflect the view of the National Institutes of Health, the Department of Health and Human Services, or the United States Government.
Competing interests AMS: grants or contracts from Penumbra, Microvention, Medtronic, and Stryker; consulting fees from Penumbra, Terumo, and Rapid AI; co-founder of the STAR collaboration; stock or stock options in Avail Medical. AHS: grants or contracts from NIH and Brain Aneurysm Foundation; consulting fees from Amnis Therapeutics, Apellis Pharmaceuticals, Boston Scientific, Canon Medical Systems USA, Cardinal Health 200, Cerebrotech Medical Systems, Cerenovus, Cordis, Corindus, Endostream Medical, Hyperfine Operations, Imperative Care, InspireMD, Integra, IRRAS AB, Medtronic, MicroVention, Minnetronix Neuro, Peijia Medical, Penumbra, Piraeus Medical, Q’Apel Medical, Rapid Medical, Serenity Medical, Silk Road Medical, StimMed, Stryker Neurovascular, VasSol, and Viz.ai; patents planned, issued, or pending for patent No US 11,464,528 B2; stock or stock options in Adona Medical, Bend IT Technologies, BlinkTBI, Borvo Medical, Cerebrotech Medical Systems, Code Zero Medical, Cognition Medical, Collavidence, CVAID, E8, Endostream Medical, Galaxy Therapeutics, Hyperion Surgical, Imperative Care, InspireMD, Instylla, Launch NY, Neurolutions, NeuroRadial Technologies (sold to Medtronic in 2021), Neurovascular Diagnostics, Peijia Medical, PerFlow Medical, Piraeus Medical, Q’Apel Medical, QAS.ai, Radical Catheter Technologies, Rebound Therapeutics (purchased in 2019 by Integra Lifesciences), Rist Neurovascular (purchased in 2020 by Medtronic), Sense Diagnostics, Serenity Medical, Silk Road Medical, Sim & Cure, Spinnaker Medical, StimMed, Synchron, Tulavi Therapeutics, Vastrax, Viseon, Whisper Medical, and Willow Medtech; national PI/steering committees for Cerenovus (EXCELLENT and ARISE II trial), Medtronic (SWIFT-PRIME, VANTAGE, EMBOLISE, and SWIFT DIRECT trials), MicroVention (FRED trial and CONFIDENCE study), MUSC (POSITIVE trial), Penumbra (3D Separator trial, COMPASS trial, INVEST trial, MIVI neuroscience EVAQ trial), Rapid Medical (SUCCESS trial), and InspireMD (C-GUARDIANS IDE Pivotal trial).TGJ: consulting fees from Stryker, Silk Road Medical, Blockade Medical, FreeOx Biomedical, Route 92, Neurotrauma Science, Viz.ai, Corindus, Anaconda, Medtronic, Contego, Methinks DAWN, AURORA, and Stryker Neurovascular. RG: consulting fees from Medtronic, Stryker, Cerenovus, Balt, and Rapid Medical. MRL: grants or contracts from NIH, The Aneurysm and AVM Foundation, Society of NeuroInterventional Surgery, and Congress of Neurosurgeons; consulting fees from Metis Innovative and Aeaean Advisers; support for attending meetings and/or travel from Penumbra; participated on the DSMB of Arsenal Medical; serves on the editorial boards of Journal of NeuroInterventional Surgery and Frontiers in Surgery; equity interest in Hyperion Surgical, Proprio, Apertur, Cerebrotech, Synchron, Fluid Biomed, and Stereotaxis; unrestricted educational grants from Medtronic and Stryker. CSO: DSMB for Medtronic (EMBOLISE) and Contour. BAG: consultant for Medtronic, Stryker, and Microvention. PK: grants or contracts from NIH, Siemens, Medtronic, and Joe Niekro Foundation; consulting fees from Stryker Neurovascular and Imperative Care; editorial board of Journal of NeuroInterventional Surgery; stock or stock options in Vena Medical.
Provenance and peer review Not commissioned; externally peer reviewed.
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