OBJECTIVE The incidence of already common chronic subdural hematomas (CSDHs) and other nonacute subdural hematomas (NASHs) in the elderly is expected to rise as the population ages over the coming ...decades. Surgical management is associated with recurrence and exposes elderly patients to perioperative and operative risks. Middle meningeal artery (MMA) embolization offers the potential for a minimally invasive, less morbid treatment in this age group. The clinical and radiographic outcomes after MMA embolization treatment for NASHs have not been adequately described in elderly patients. In this paper, the authors describe the clinical and radiographic outcomes after 151 cases of MMA embolization for NASHs among 121 elderly patients. METHODS In a retrospective review of a prospectively maintained database across 15 US academic centers, the authors identified patients aged ≥ 65 years who underwent MMA embolization for the treatment of NASHs between November 2017 and February 2020. Patient demographics, comorbidities, clinical and radiographic factors, treatment factors, and clinical outcomes were abstracted. Subgroup analysis was performed comparing elderly (age 65–79 years) and advanced elderly (age > 80 years) patients. RESULTS MMA embolization was successfully performed in 98% of NASHs (in 148 of 151 cases) in 121 patients. Seventy elderly patients underwent 87 embolization procedures, and 51 advanced elderly patients underwent 64 embolization procedures. Elderly and advanced elderly patients had similar rates of embolization for upfront (46% vs 61%), recurrent (39% vs 33%), and prophylactic (i.e., with concomitant surgical intervention; 15% vs 6%) NASH treatment. Transfemoral access was used in most patients, and the procedure time was approximately 1 hour in both groups. Particle embolization with supplemental coils was most common, used in 51% (44/87) and 44% (28/64) of attempts for the elderly and advanced elderly groups, respectively. NASH thickness decreased significantly from initial thickness to 6 weeks, with additional decrease in thickness observed in both groups at 90 days. At longest follow-up, the treated NASHs had stabilized or improved in 91% and 98% of the elderly and advanced elderly groups, respectively, with > 50% improvement seen in > 60% of patients for each group. Surgical rescue was necessary in 4.6% and 7.8% of cases, and the overall mortality was 8.6% and 3.9% for elderly and advanced elderly patients, respectively. CONCLUSIONS MMA embolization can be used safely and effectively as an alternative or adjunctive minimally invasive treatment for NASHs in elderly and advanced elderly patients.
Abstract
BACKGROUND
Middle meningeal artery (MMA) embolization has emerged as a promising treatment for chronic subdural hematoma (cSDH).
OBJECTIVE
To determine the safety and efficacy of MMA ...embolization.
METHODS
Consecutive patients who underwent MMA embolization for cSDH (primary treatment or recurrence after conventional surgery) at 15 centers were included. Clinical details and follow-up were collected prospectively. Primary clinical and radiographic outcomes were the proportion of patients requiring additional surgical treatment within 90 d after index treatment and proportion with > 50% cSDH thickness reduction on follow-up computed tomography imaging within 90 d. National Institute of Health Stroke Scale and modified Rankin Scale were also clinical outcomes.
RESULTS
A total of 138 patients were included (mean age: 69.8, 29% female). A total of 15 patients underwent bilateral interventions for 154 total embolizations (66.7% primary treatment). At presentation, 30.4% and 23.9% of patients were on antiplatelet and anticoagulation therapy, respectively. Median admission cSDH thickness was 14 mm. A total of 46.1% of embolizations were performed under general anesthesia, and 97.4% of procedures were successfully completed. A total of 70.2% of embolizations used particles, and 25.3% used liquid embolics with no significant outcome difference between embolization materials (P > .05). On last follow-up (mean 94.9 d), median cSDH thickness was 4 mm (71% median thickness reduction). A total of 70.8% of patients had >50% improvement on imaging (31.9% improved clinically), and 9 patients (6.5%) required further cSDH treatment. There were 16 complications with 9 (6.5%) because of continued hematoma expansion. Mortality rate was 4.4%, mostly unrelated to the index procedure but because of underlying comorbidities.
CONCLUSION
MMA embolization may provide a safe and efficacious minimally invasive alternative to conventional surgical techniques.
Graphical Abstract
Graphical Abstract
Background:
Chronic subdural hematoma (CSDH) is one of the most common neurosurgical diseases that affect elderly and fragile patients and as a consequence, management can be challenging. Surgery ...represents the standard treatment; however, alternative options are under investigation. Middle meningeal artery (MMA) embolization is considered a minimally invasive treatment although with poor evidence. In this review, we tried to summarize the findings about MMA embolization as a treatment for a CSDH to provide a useful guidance for clinical practice and for future speculative aspects.
Methods:
Literature review on PubMed until March 2021 was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. We conducted a research on PubMed with a various combinations of the keywords “CSDH” and “middle meningeal artery” and “embolization,” “refractory subdural hematoma,” and then we reviewed the references of the relevant studies as additional source of eligible articles.
Results:
Among the 35 studies eligible for this review, 22 were case series, 11 were case reports, one was a technical note, and 1 was a randomized trial. A total of 746 patients were found in the literature. Failure rate of MMA embolization was between 3.9 and 8.9% of the cases according the indication to treat CSDH (upfront vs. after surgery).
Conclusion:
The global impression deriving from the data available and the literature is that MMA embolization is a safe procedure with very low complications and with a low failure rate, both when associated with surgery or in case of a standalone treatment.
Subdural hematoma (SDH) is a common disease that is increasingly being managed nonoperatively. The all-cause readmission rate for SDH has not previously been described. This study seeks to describe ...the incidence of unexpected 30-day readmission in a cohort of patients admitted to an academic neurosurgical center. Additionally, the relationship between operative management, clinical outcome, and unexpected readmission is explored.
This is an observational study of 200 consecutive adult patients with SDH admitted to the neurosurgical ICU of an academic medical center. Demographic information, clinical characteristics, and treatment strategies were compared between readmitted and nonreadmitted patients. Multivariable logistic regression, weighted by the inverse probability of receiving surgery using propensity scores, was used to evaluate the association between operative management and unexpected readmission.
Of 200 total patients, 18 (9%) died during hospitalization and were not included in the analysis. Overall, 48 patients (26%) were unexpectedly readmitted within 30 days. Sixteen patients (33.3%) underwent SDH evacuation during their readmission. Factors significantly associated with unexpected readmission were nonoperative management (72.9% vs 54.5%, p = 0.03) and female sex (50.0% vs 32.1%, p = 0.03). In logistic regression analysis weighted by the inverse probability of treatment and including likely confounders, surgical management was not associated with likelihood of a good outcome at hospital discharge, but was associated with significantly reduced odds of unexpected readmission (OR 0.19, 95% CI 0.08-0.49).
Over 25% of SDH patients admitted to an academic neurosurgical ICU were unexpectedly readmitted within 30 days. Nonoperative management does not affect outcome at hospital discharge but is significantly associated with readmission, even when accounting for the probability of treatment by propensity score weighted logistic regression. Additional research is needed to validate these results and to further characterize the impact of nonoperative management on long-term costs and clinical outcomes.
To study the prognoses of patients with subdural hematoma (SDH) who were not operated on at the time of the first diagnosis and the causes of enlarged hematomas in some patients during the follow-up ...period.
The records, service files, and radiologic examination results of the patients with diagnoses of SDH were reviewed. The SDH patients were recorded under 5 different categories: acute SDH (ASDH), subacute SDH (SSDH), chronic SDH (CSDH), acute component with chronic SDH (A-CSDH), and subacute component with chronic SDH (S-CSDH). The symptoms, clinical findings, and progression in the patients were correlated with radiologic examinations.
A total of 291 patients received diagnoses of SDHs: 80 patients with acute, 29 patients with subacute, and 163 patients with chronic hematoma. Thirty-five patients had diagnoses of SDH with a combination of different components. It was determined that in the follow-up period, patients with A-CSDH showed the greatest increase in hematoma size over time and required surgical intervention the most often.
SDHs reveal different prognoses in different age groups. Multicomponent SDHs are within the group that shows the greatest increase in size in the follow-up period. SDHs and CSDHs cause recurrent hemorrhages by sustaining the tension on the bridging veins. The greater the hematoma volume, the greater the growth potential of the hematoma tends to be. CSDHs that do not manifest changes in volume for a long time can be monitored without surgical intervention as long as the clinical picture remains stable.
•The greater the hematoma volume, the greater the tension in the bridging veins.•Bicomponent hematomas tends to grow at higher rates.•Atrophy, anticoagulant, hematoma width, and septation in the hematoma are risk factors.
Endoscopic procedures are useful in chronic subdural hematoma especially when there are septations, solid/organized hematoma, and the presence of bridging or neovessels in the cavity. Visualizing the ...distal hematoma cavity by a rigid scope is challenging in large and curved ones due to the hindrance by the brain surface. Combining rigid endoscopy and brain retractor can overcome this limitation.
A retrospective study of 248 patients managed by endoscopic technique was performed and the relevant literature was reviewed.
The brain retractor was used in all patients. Average operative time, subgaleal drainage duration, and hospital stay were 56 minutes, 3.1 days, and 4.6 days, respectively. The average preoperative Glasgow coma scale (GCS) score was 12, which improved to 14 and 15 in 223 and 23 patients, respectively at discharge. There were solid clots, septations, bridging vessels, curved hematoma cavities, rapid expansion of the brain after partial hematoma removal, and recurrences in 59, 52, 15, 49, 19, and 2 patients, respectively. There were 2 deaths, without any procedure-related mortality.
Endoscope was very effective and safe in the management of chronic subdural hematoma, especially in about 51% patients with solid clots, septations, and bridging vessels which could have been difficult to treat by conventional burr hole. It can avoid craniotomy in such patients. Good visualization and complete hematoma removal were possible with the help of an endoscope and brain retractor in about 27% of patients which could have been difficult with a rigid endoscope alone.
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