Embolization of the middle meningeal artery in patients with chronic subdural hematoma-a systematic review and meta-analysis.

BACKGROUND: Chronic subdural hematoma (CSDH) remains a neurosurgical condition with high recurrence rate after surgical treatment. The primary pathological mechanism is considered to be repeated microbleedings from fragile neo-vessels within the outer hematoma membrane. The neo-vessels are supplied from peripheral branches of the middle meningeal artery, and embolization of MMA (eMMA) has been performed to prevent re-bleeding episodes and thereby CSDH recurrence. OBJECTIVE: To evaluate the published evidence for the effect of eMMA in patients with recurrent CSDH. Secondarily, to investigate the effect of eMMA as an alternative to surgery for primary treatment of CSDH. METHOD: A systematic review of the literature on eMMA in patients with recurrent CSDH was conducted. PubMed, Embase, and Cochrane databases were reviewed using the search terms: Embolization, Medial Meningeal Artery, Chronic Subdural Haematoma, and Recurrence. Furthermore, the following mesh terms were used: Chronic Subdural Haematoma AND embolization AND medial meningeal artery AND recurrence. Eighteen papers were found and included. No papers were excluded. The number of patients with primary CSDH and the number of patients with recurrent CSDH treated with eMMA were listed. Furthermore, the number of recurrences in both categories was registered. RESULTS: Eighteen papers with a total of 191 included patients diagnosed with CSDH treated with eMMA for primary and recurrent CSDH were identified. Recurrence rate for patients treated with eMMA for recurrent CSDH was found to be 2.4%, 95% CI (0.5%; 11.0%), whereas the recurrence rate for patients treated with eMMA for primary CSDH was 4.1%, 95% CI (1.4%; 11.4%). CONCLUSION: eMMA is a minimally invasive procedure for treatment of CSDH. Although this study is limited by publication bias, it seems that this procedure may reduce recurrence rates compared with burr hole craniostomy for both primary and recurrent hematomas. A controlled study is warranted.

Early decompressive surgery in patients with traumatic spinal cord injury improves neurological outcome.

BACKGROUND: The role and timing of a decompressive surgical intervention in patients with traumatic spinal cord injury (SCI) remain controversial. Given the impact of SCI on the individual and society, decompressive surgery to reduce the extent of tissue destruction and improving neurological outcome after initial spinal cord trauma are needed. OBJECTIVE: To evaluate any possible correlation between the time of a decompressive procedure after traumatic SCI and end-neurologic outcome for traumatic SCI patients. METHODS: A retrospective cohort study on patients with traumatic SCI in Western Denmark from 2010 to 2017. Data on date and time of injury and time of surgery and data on neurologic status at admission and one-year post-trauma were found in the Electronic Patients Journal (EPJ) and in paper journals. Patients were divided into 4 groups (< 6 h, < 12 h, < 24 h, and > 24 h) based on the time between injury and surgery. Further, patients were separated into two groups depending on whether they did or did not achieve neurological improvement one-year post-trauma. We used Fisher's exact test to compare the abovementioned groups to examine an eventual correlation between time from injury to operation and change in neurological outcome one-year post-trauma. RESULTS: Patients undergoing surgery < 24 h after trauma obtained a significantly better neurological outcome as compared with patients who underwent surgery > 24 h after trauma (p < 0.001). This result did not change for subgroups of incomplete SCI patients (p = 0.002). However, complete SCI patients operated < 24 h as compared with > 24 h did not obtain better outcome (p = 0.14). We did not find a statistically significant correlation when time from trauma to surgery was reduced further to < 6 or < 12 h post-trauma. Furthermore, stratification on patients undergoing surgery before and after 24 h was made regarding gender, completeness, and years of age. The groups did not differ concerning gender and SCI completeness, but significant difference in age was found (44 and 58 years of age, respectively, p < 0.001). The chance of improved outcome was significantly higher for patients < 50 years of age (42% versus 24%, p = 0.05). Patients under the age of 50 seemed to benefit from early intervention (50% improvement versus 23%); however, difference was not statistically significant (p = 0.08). In patients aged above 50, the trend was similar, but significant correlation was found (40% versus 16%, p = 0.05). CONCLUSION: The present study reports a beneficial effect of early decompression surgery, especially for incomplete SCI patients; however, surgical decision-making is complex, and all cases of acute spinal cord injury should be cautiously interpreted and handled on an individual basis.