Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Series of 60 Cases.

BACKGROUND: Chronic subdural hematoma (SDH) is a particularly challenging pathology due to high recurrence rates (2%-37%) and complex medical comorbidities that tend to afflict the patient population. Recently, there have been several case series published describing the use of middle meningeal artery (MMA) embolization as an alternative to surgery for treatment of new or recurrent chronic SDH. OBJECTIVE: To describe our first 60 cases of MMA embolization for chronic SDH. METHODS: MMA embolization was performed using angiography, selective microcatheterization of the MMA, and infusion of polyvinyl alcohol particles. Outcomes were assessed clinically and with interval imaging studies at 1 d, 2 wk, and 6 wk postprocedure, and additional intervals as indicated. RESULTS: MMA embolization was performed successfully on 60 total SDHs in 49 patients. This includes upfront treatment for new (not previously treated) SDH in 42, for recurrence in 8, and prophylaxis (soon after surgical evacuation) in 10. There were 3 mortalities (unrelated to the procedure), and no procedural complications. Of the 50 nonprophylactic cases, there were 4 (8.9%) cases of recurrence requiring surgical evacuation, and 31 (68.9%) that had resolution or reduction in size >50% of SDH at longest follow-up. Overall, 41 (91.1%) were stable or decreased in size and able to avoid surgery. CONCLUSION: MMA embolization may represent a minimally-invasive alternative to surgery for new or recurrent chronic SDH, or as prophylaxis to reduce the risk of recurrence after surgery. Given our encouraging results with a 91% long-term success rate, a large scale clinical trial is warranted.

Middle Meningeal Artery Embolization for Recurrent Chronic Subdural Hematoma: A Case Series.

BACKGROUND: Embolization of the middle meningeal artery (MMA) has recently been proposed as an alternative to surgery for treatment of chronic subdural hematoma (SDH). There is increasing evidence that fragile neovasculature arising from distal branches of the MMA found within the membrane that forms around a chronic SDH is responsible for high recurrence rates due to chronic, repeated rebleeding. Embolization of the MMA could thus potentially eliminate the blood supply to this membrane and prevent further rebleeding. METHODS: The cases of 6 patients with 7 recurrent SDHs treated with MMA embolization with polyvinyl alcohol particles were retrospectively reviewed. RESULTS: MMA embolization was performed successfully in all 6 patients with no complications. Of the 7 SDHs treated, 1 required surgical reevacuation due to recurrence. The other 6 were able to avoid surgery, with reduction in size from 12 mm to 11 mm over 3 weeks, 14 mm to 9 mm over 9 weeks, 21 mm to 5 mm over 31 weeks, 17 mm to 9 mm over 12 weeks, 18 mm to 3 mm over 8 weeks, and 25 mm to 6 mm over 24 weeks. All patients had resolution of symptoms at longest follow-up. CONCLUSIONS: In this case series of 6 patients harboring 7 recurrent, chronic SDHs, 6 of the 7 were successfully treated with MMA embolization and able to avoid surgery for reevacuation, suggesting that this minimally invasive technique may represent an effective alternative to surgery.

Middle meningeal artery embolization for chronic subdural hematoma: Endovascular technique and radiographic findings.

Background and purpose Embolization of the middle meningeal artery (MMA) has recently been proposed as an alternative to surgery for treatment of chronic subdural hematoma (SDH), and several case reports have been published supporting its efficacy. It has been suggested that the primary pathologic process in chronic SDH is repeated microhemorrhaging into the subdural collection from fragile neovasculature within the SDH membrane that arises from distal branches of the MMA. Embolization could thus provide a means of eliminating this chronic rebleeding. Materials and methods Images were selected from MMA embolization procedures performed at our institution in order to illustrate the technique and theory behind its efficacy for treatment of chronic SDH. Results Images from MMA angiograms demonstrate the variability of MMA anatomy and help illustrate the importance of avoiding potential ophthalmic collaterals and branches supplying cranial nerves. The findings of irregular wispiness of the distal MMA vasculature, contrast outlining of the SDH membrane on angiography, and homogenous increased density within the SDH on postembolization head computed tomography are described. Conclusion MMA embolization may provide a safe alternative for treatment of chronic SDH, but careful angiographic assessment of MMA anatomy should be performed to avoid potential complications. The findings illustrated here lend support to the theory that the pathologic process of chronic SDH is repeated leakage of blood products from an inflamed, abnormal arterial neovasculature within the SDH membrane that arises from the MMA, and thus selective embolization could provide an effective treatment.