Endovascular Treatment of Chronic Subdural Hematomas through Embolization: A Pilot Study with a Non-Adhesive Liquid Embolic Agent of Minimal Viscosity (Squid).

Andrey Petrov,Hans Henkes,Pervinder Bhogal,Larisa Rozhchenko,Arkady Ivanov,Anna Petrova,Alexandru Cimpoca

doi:10.3390/jcm10194436

Abstract

Objective: Endovascular embolization using non-adhesive agents (e.g., ethylene vinyl alcohol copolymer with suspended micronized tantalum dissolved in dimethyl sulfoxide; Squid, Balt Extrusion) is an established treatment of brain arteriovenous malformations, dural arteriovenous fistulas, and hypervascular neoplasms. Middle meningeal artery (MMA) embolization is a relatively new concept for treating chronic subdural hematomas (CSDH). This study aimed to evaluate the safety and effectiveness of the use of Squid in the endovascular treatment of CSDH. Methods: Embolization was offered to patients with CSDH with minimal or moderate neurological deficits and patients who had previously undergone open surgery to evacuate their CSDH without a significant effect. Distal catheterization of the MMA was followed by embolization of the hematoma capsule with Squid 12 or Squid 18. Safety endpoints were ischemic or hemorrhagic stroke and any other adverse event of the endovascular procedure. Efficacy endpoints were the feasibility of the intended procedure and a ≥ 50% reduction of the maximum depth of the CSDH confirmed by follow-up computed tomography (CT) after >3 months. Results: Between November 2019 and July 2021, 10 patients (3 female and 7 male, age range 42–89 years) were enrolled. Five patients had bilateral hematomas, and five patients had previously been operated on with no significant effect and recurrent hematoma formation. The attempted embolization was technically possible in all patients. No technical or clinical complication was encountered. During a post-procedural follow-up (median 90 days), 10 patients improved clinically. A complete resolution of the CSDH was observed in 10 patients. The clinical condition of all enrolled patients during the so-far last contact was rated mRS 0 or 1. Conclusion: A distal catheterization of the MMA for the endovascular embolization of CSDH with Squid allowed for the devascularization of the MMA and the dependent vessels of the hematoma capsule. This procedure resulted in a partial or complete resolution of the CSDH. Procedural complications were not encountered.

Highlights

Introduction distributed under the terms andThe rupture of bridging intracranial veins can cause a hemorrhage in between the dura mater and the arachnoid
Embolization of the Middle meningeal artery (MMA) necessitates the injection of the vessel with a contrast medium, and contrast staining is often seen on the postoperative computed tomography (CT) scans, which indirectly confirms the connection between the MMA, the capsule, and the content of the chronic” subdural hematoma (CSDH) [2,3]
We present the first series of MMA embolizations for CSDH treatment with the exclusive usage of Squid (Balt Extrusion)

Summary

Introduction

The rupture of bridging intracranial veins can cause a hemorrhage in between the dura mater and the arachnoid (the subdural space). The term “chronic” subdural hematoma (CSDH) refers to a clinical onset 3 weeks after the presumed causing event. The first step in the pathophysiology of CSDH formation is the separation of the dural border cell layer, followed by inflammation and proliferation of dural border cells. The invasion of macrophages and granulation tissue formation results in a surrounding membrane. This membrane releases angioneogenetic factors, inducing the angioneogenetic formation of new vessels (“neovascularization”). It is believed that embolization of the MMA interferes with the final step of the pathophysiological cascade of CSDH formation [4,5,6]

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Discussion

Conclusion