Literature ReviewSafety and Effectiveness of Embolization for Chronic Subdural Hematoma: Systematic Review and Case Series
Introduction
Chronic subdural hematoma (CSDH) is a common neurosurgical disease. Surgical evacuation is considered relatively straightforward, yet recurrence after drainage of a CSDH has challenged neurosurgeons for decades. The recurrence rates after surgical evacuation vary from 5% to 30%.1 This variation has been attributed to the complex pathophysiology of CSDH. The traditional theory of head trauma leading to the disruption of bridging veins has been widely contested in the past.2, 3, 4 It is now recognized that an inflammatory response of the dural layer, neovascularization, and the formation of inflammatory membranes are responsible for the accumulation of a CSDH.3 Although open surgical evacuation relieves mass effect immediately, it may not interrupt the causative features, and thus the CSDH may recollect. Moreover, surgery carries increased risk for patients receiving antiplatelet or anticoagulant therapy. Typically, patients must be weaned off antiplatelet or anticoagulant agents or the effect of these agents must be reversed before the surgical intervention. Moreover, the use of these agents postoperatively further increases the risk of hematoma recurrence.5
Embolization of the middle meningeal artery (MMA) has been proposed for the treatment of recurrent CSDH.6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 MMA embolization as a stand-alone therapy has also been suggested and reported in the literature.12, 19, 20 Most of these studies have small samples and do not provide conclusive evidence to support routine use of MMA embolization for CSDH. The purpose of this study was to systematically review the literature on the safety and effectiveness of MMA embolization for the treatment of CSDH and share our clinical experience with MMA embolization for the management of CSDH.
Section snippets
Methods
Our study included a systematic review of the literature and a retrospective review of cases of CSDH treated at our hospital. The literature review was registered online with PROSPERO (International Prospective Register of Systematic Reviews). The registration number was CRD42018102573. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed for reporting of the review. We searched PubMed (Public/Publisher Medline), CINAHL (Cumulative Index to
Literature Review
An initial search of the selected databases generated 169 articles (Figure 1). After removing duplicates and screening the abstracts of these articles, there were 22 articles. Seven articles (case reports) were excluded because of unavailability of an English translation. The systematic review included 15 studies of a cumulative 193 embolization procedures on 182 patients.6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22 Thirteen studies were retrospective (7 case series and 6 case
Material Used for Embolization
Polyvinyl alcohol (PVA) particles were used as the sole embolic agent in 8 studies. A coil or coils in addition to PVA were used in 2 other studies (comprising 7 patients).9, 17 Coils and a gelatin sponge were used in 4 patients in another study.14 Kang et al.11 embolized MMA with coils alone in the single patient described in their case report. N-butyl-2-cyanoacrylate was used in 2 studies (n = 8).10, 13 The embolic material used in each study is detailed in Table 4.
Discussion
To our knowledge, this is the first systematic review on MMA embolization for CSDH. The protocol was registered with PROSPERO and can be accessed online. PRISMA guidelines were followed when reporting the review. Most of the studies included in this systematic review are of low to moderate quality and small sample size. There is also a lack of a uniform treatment protocol. However, based on the available data, MMA embolization was safe and effective in the treatment and prevention of recurrent
Conclusions
In the literature, the rate of recurrence of CSDH after MMA embolization is 3.6%; no procedural complications of MMA embolization were reported. The results of our literature review and clinical experience suggest that the procedure is safe and effective for the treatment of CSDH with or without surgical evacuation.
Acknowledgments
We thank Paul H. Dressel, B.F.A. for preparing the illustrations and W. Fawn Dorr B.A. and Debra J. Zimmer for editorial assistance. Author contributions: conception and design, M.W. and K.V.; data acquisition, M.W. and P.W.; data analysis and interpretation, all authors; drafting the manuscript, M.W. and K.V.; critically revising the manuscript, all authors; final approval of the manuscript, all authors.
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Conflict of interest statement: M.W., K.V., P.V.W., E.H, none. J.M.D., research grant: National Center for Advancing Translational Sciences of the National Institutes of Health under award number KL2TR001413 to the University at Buffalo. speakers' bureau: Penumbra; Honoraria: Neurotrauma Science, LLC. A.H.S., financial interest/investor/stock options/ownership: Amnis Therapeutics, Apama Medical, BlinkTBI, Inc, Buffalo Technology Partners, Inc., Cardinal Health, CerebrotechMedical Systems, Inc, Claret Medical, Cognition Medical, Endostream Medical, Ltd, Imperative Care, International Medical Distribution Partners, Rebound Therapeutics Corp., Silk Road Medical, StimMed, Synchron, Three Rivers Medical, Inc., Viseon Spine, Inc.; consultant/advisory board: Amnis Therapeutics, Boston Scientific, Canon Medical Systems USA, Inc., Cerebrotech Medical Systems, Inc., Cerenovus, Claret Medical, Corindus, Inc., Endostream Medical, Ltd, Guidepoint Global Consulting, Imperative Care, Integra, Medtronic, MicroVention, Northwest University; DSMB Chair for HEAT Trial, Penumbra, Rapid Medical, Rebound Therapeutics Corp., Silk Road Medical, StimMed, Stryker, Three Rivers Medical, Inc., VasSol, W.L. Gore & Associates; national principal investigator/steering committees: Cerenovus LARGE Trial and ARISE II Trial, Medtronic SWIFT PRIME and SWIFT DIRECT Trials, MicroVention FRED Trial & CONFIDENCE Study, MUSC POSITIVE Trial, Penumbra 3D Separator Trial, COMPASS Trial, INVEST Trial.