Identification of middle meningeal artery confluence point in 3D CT scan images of Filipinos as pre-operative planning for management of chronic subdural hematoma: A cross-sectional morphometric study.

Chronic subdural hematoma (CSDH) is a frequent neurosurgical disorder, particularly in elderly patients and those receiving antithrombotic therapy. Although burr-hole drainage remains the standard treatment, recurrence occurs in 10–15% of cases. Middle meningeal artery (MMA) embolization has recently emerged as a minimally invasive technique targeting the vascular pathophysiology underlying hematoma persistence and recurrence. This review summarizes the rationale, technique, embolic materials, and clinical outcomes associated with MMA embolization for recurrent CSDH, with reference to a representative clinical case from our institution. A 63-year-old female with recurrent CSDH following burr-hole drainage underwent MMA embolization using polyvinyl alcohol (PVA) particles. The literature on the pathophysiology and endovascular management of CSDH was reviewed to contextualize this case. CSDH formation is driven by fragile neocapillaries and inflammatory cascades within vascularized membranes supplied by the MMA. Embolization interrupts this pathological cycle by reducing neovascular perfusion and inflammatory activity. Recent studies report recurrence rates of 4–5% after MMA embolization substantially lower than those following surgery along with low complication rates and earlier resumption of antithrombotic therapy. In our case, complete radiological resolution was achieved without adverse events. MMA embolization represents a paradigm shift in CSDH management by directly addressing the vascular mechanisms responsible for recurrence. It offers a durable, safe, and minimally invasive alternative or adjunct to surgery, particularly valuable for elderly or high-risk patients. Further randomized controlled trials are warranted to confirm its efficacy as a first-line or adjunctive therapy.

Introduction Chronic subdural hematoma is a disease encountered in elderly populations with cited frequencies of 1.7‐20.6 patients per 100,000 people yielding significant morbidity and mortality (Feghali). It is associated with a 5‐30% recurrence rate despite surgical evacuation (Kan). The pathophysiology involves a complex inflammatory reaction leading to angiogenesis and continued hematoma expansion (Holl). The traditional management of cSDH has historically been neurosurgical drainage either with craniotomy, Burr holes, or craniectomy (Mehta). These treatment techniques however, have been associated with higher rates of recurrence when compared to MMA embolization (Ironside). MMA embolization is a newer technique being offered to patients for management of cSDH that has proven to be highly effective (Catapano). Several recent studies comparing MMA embolization to traditional surgical treatment are beginning to show improved clinical outcomes, hospital days, recurrence rates, and complications (Srivatsan, Ban). Methods We collected all data regarding MMA embolization for patients with cSDH between March 2019 and August 2024 admitted to a single comprehensive stroke center in Thousand Oaks, CA. Demographic data, neurologic deficits, and radiologic reports were obtained through the electronic medical record. Procedural details were noted including any periprocedural complications, as well as the need for any surgical intervention. Repeat radiologic findings were reported, in addition to pertinent events that occurred during hospitalization and disposition. Major complications reported were periprocedural stroke, perioperative bleeding requiring transfusion, catheter detachment, and vascular dissection. Minor complications included contrast allergy and groin hematoma. Results 120 patients were admitted for cSDH and treated with MMA embolization. 34% of patients were female. Comorbidities include hypertension, diabetes mellitus, atrial fibrillation in 20%, 62%, and 14%, respectively. 30% of patients were receiving antithrombotics prior to the procedure (antiplatelets and dual oral anticoagulants). 39% were right‐sided SDH, 34% left‐sided SDH, and 27% bilateral SDH. Average size was 13.8mm and 4.8mm midlife shift. 71% of patients were treated with bilateral MMA embolization and 29% were treated with unilateral MMA embolization. Decision to treat bilateral or unilateral MMA embolization depended on neurointerventionalist preference. 52% of cases required surgical evacuation as well. There were 0 major complications and 0 minor complications. Average length of stay was 12 days and 42% of patients were discharged to home. Conclusions Our single center retrospective review of MMA embolization demonstrated that the procedure is safe indicated by our low complication rates. With the increased use of antithrombotic medications in an aging population, the frequency of chronic subdural hematomas is anticipated to expand, and MMA embolization offers a safe treatment option to prevent recurrence. This project contributes to growing fund of research for MMA embolization becoming the standard of care for cSDH.

The efficacy of middle meningeal artery (MMA) embolization in the management of chronic subdural hematoma (cSDH) has been increasingly supported by recent randomized controlled trials. However, long-term data on the natural history of cSDH post-treatment remain limited. This study aims to evaluate the natural history and outcomes of cSDH over a 12-month period following MMA embolization. We conducted a retrospective analysis of 61 MMA embolization for the treatment of cSDH in 49 consecutive patients at a single institution between October 2019 and December 2022. Patients underwent MMA embolization as the primary treatment of cSDH, concurrently with surgical evacuation, or after initial surgical evacuation and subsequent recurrence. Clinical data, including patient demographics, hematoma maximal thickness, midline shift size, procedural details, and outcomes, were collected and analyzed. The primary outcomes assessed were time to resolution of hematoma maximal thickness, midline shift reduction and clinical improvement. Secondary outcomes included occurrence of complications, recurrence rate, and the characteristics of the group of patients who needed surgical rescue. Tablesand Kaplan-Meier curves were created, broken down by the percentage of reduction in current hematoma maximal thickness. Results for the primary, concurrent, and recurrent groups were compared. The mean age of the patients included was 73 ± 10.8years. Among them, 33 patients (67.3%) reported a history of previous trauma, with falls being the main mechanism of injury (65.3%). The majority of patients (77.5%) were male. The most frequent neurological symptom was headache (61.2%). The mean hematoma thickness and midline shift were 15.9 ± 7.1 and 5.6 ± 2.6mm, respectively. There was a significant improvement in clinical symptoms within 1month following MMA embolization. Kaplan-Meier curves were generated for resolution of hematoma size and midline shift. At 1 month postprocedure, only 25% of patients had at least a 25% reduction in hematoma size. However, by 3 months, 75% had a decrease in hematoma size by 50%. About 85% of patients had complete resolution of hematoma by 7months, and all patients had resolution of hematoma by 12months. Four patients underwent surgical rescue hematoma evacuation and the mean timeframe between the embolization and the surgical rescue was 2weeks. Hematoma size and midline shift resolved faster for patients who underwent concurrent or rescue surgical evacuation of hematoma in addition to embolization. No difference in results between the liquid embolics N-butyl cyanoacrylate and Onyx-18 was found. This study demonstrated a favorable resolution of subdural hematoma within 7months in 85% of patients and in all patients by 12months. By 3months, 50% of patients had a decrease in hematoma size by 50% or more. A complete resolution of midline shift within 7months, and a significant improvement in clinical symptoms within 1month following MMA embolization. Hematoma size and midline shift resolved faster for patients who underwent embolization for recurrent hematoma or concurrent surgical evacuation of the hematoma in addition to embolization.

Introduction Chronic subdural hematomas (SDH) are common in older adults due to increased risks of falls, cerebral atrophy, and antithrombotic therapy, leading to higher bleeding risks. Current randomized clinical trials are evaluating the safety and efficacy of middle meningeal artery (MMA) embolization for chronic SDH. These trials, such as EMBOLISE, MAGIC‐MT, and STEM, have reported preliminary promising results using different embolic agents. This study examines the safety and efficacy of MMA embolization using liquid embolic materials and coils at a single institution, comparing outcomes with the aforementioned trials. Methods We conducted a retrospective review of 66 patients who underwent MMA embolization for subacute and chronic SDH at a single institution from February 2021 to March 2024. Data were collected from electronic medical records, including demographics, clinical data, imaging, procedural details, use of antiplatelet or anticoagulation medications, and outcomes at discharge and follow‐up. Patients aged 18 or older with subacute or chronic SDH who underwent MMA embolization were included. Follow‐up assessments were conducted at multiple intervals post‐procedure. Descriptive statistics were used for data analysis. Results The median age of the cohort was 71 years, with a predominance of males (64.71%) and African Americans (54.90%). Eighteen patients had prior SDH interventions, and 62.75% were on antithrombotic therapy before diagnosis. The median time from symptom onset to diagnosis was one day, with most SDHs being traumatic (60.78%). Elective MMA embolizations were performed in 64.71% of cases, primarily using a femoral approach. N‐butyl cyanoacrylate (n‐BCA) was used in 97.37% of procedures, and coils in 27.63%. Complications were rare, with two cases (3.92%) of MMA rupture and access site hematoma. The technical success rate was 97.37%. The median hospital stay was seven days, with most patients discharged home (70.59%). The in‐hospital mortality rate was 1.96%, with seven post‐discharge deaths unrelated to MMA embolization or SDH. The median follow‐up duration was 130 days, with two patients (3.92%) requiring repeat MMA embolization and three (5.88%) needing SDH evacuation. Compared to EMBOLISE, MAGIC‐MT, and STEM trials, our study showed a recurrence rate of 9.8% for all patients, with 6.45% in the MMA embolization alone group and 15% in the surgery with adjunctive MMA embolization group. EMBOLISE reported a 4.10% recurrence rate with surgical evacuation with adjunctive MMA embolization, MAGIC‐MT showed 1.90% recurrence with MMA embolization alone and 4.70% with surgery and adjunctive MMA embolization, and STEM found 19.10% recurrence with MMA embolization alone and 12.30% with surgery with MMA embolization. Discussion Our study suggests that selective distal embolization using n‐BCA is effective, with a low complication rate. Distal embolization may prevent cranial nerve injuries and strokes associated with proximal embolizations. The ongoing trials will provide further insights into optimal embolization sites and agents, and the timing for restarting anticoagulation. Conclusion MMA embolization using liquid embolic materials and coils is a promising treatment for subacute and chronic SDH, with low recurrence and complication rates. Comparison with current trials indicates favorable outcomes. Further research is needed to refine embolization techniques and optimize patient management strategies, potentially revolutionizing chronic SDH treatment.

Background: Symptomatic chronic subdural hematoma (SDH) is treated with surgical evacuation. SDH has a high incidence of recurrence despite evacuation, reported between 2% and 37%. Multiple case reports and case series demonstrate embolization of the Middle Meningeal artery (MMA) for the treatment of chronic SDH to be an adjunct treatment and a possible alternative to surgical evacuation. Method: Retrospective analysis of patients with chronic SDH who underwent MMA embolization at our community based, Comprehensive Stroke Center between April and August 2019 was done. MMA embolization was performed using 100-300 or 300-500 μm Embospheres. Results: 18 patients presented with chronic SDH, 55% female. Mean age and modified Rankin score was 70 (range: 48-95 years) and 1 (range: 0-3), respectively. 17 patients (94%) required a total of 20 MMA embolizations. 83% had unilateral MMA embolization and 17% had bilateral MMA embolizations. 100-300 μm Embospheres were used for the MMA embolization in 82% of the patients and 300-500 μm Embospheres in 18% of the patients. 33% had Burr hole prior to the procedure. 5% ( n= 1) patient had Burr hole evacuation after embolization due to Neurosurgeon preference, not neurological deterioration. 56 % patient received treatment to resume anticoagulation/antiplatelet and 44% received prophylactic embolization to prevent reaccumulation after Burr hole evacuation. Mean size of maximum diameter of SDH was 16.9 mm and 4.6 mm of midline shift on admission CT. Mean SDH size and midline shift at discharge was 13 mm and 2.27 respectively. 50% patients had 1 month follow up CT with mean SDH size was 8.2 mm (in comparison to 19.7 in these patients). 17 % (n=3) patients had complete resolution on 3 month follow up. The one patient treated with 300-500 μm Embospheres had an acute on chronic asymptomatic SDH on 1 month follow up CT, requiring accessory meningeal artery embolization with 100-300 μm Embospheres ultimately resulting complete resolution of the SDH at 1 month post embolization. Conclusion: Despite limited data available, Middle Meningeal artery embolization using 100-300 μm Embospheres leads to reproducible results to prevent recurrence of chronic subdural hematoma. A large randomized controlled study is needed to verify our results.

Background Chronic subdural hematoma (cSDH) is one of the most common neurosurgical conditions. Although surgical evacuation is still the gold standard for treatment, recent advances have led to the development of other management strategies, such as medical therapies and endovascular middle meningeal artery (MMA) embolization. Through this international survey, we investigated the global trends in cSDH management, focusing on medical and endovascular treatments. Design and participants A 14-question, web-based, anonymous survey was distributed to neurosurgeons worldwide. Results Most responders do not perform MMA embolization (69.5%) unless for specific indications (29.6%). These indications include residual cSDH after surgical evacuation (58.9%) or cSDH in patients on antiplatelet medications to avoid surgical evacuation (44.8%). Survey participants from teaching versus non-teaching hospitals (p = 0.002), public versus private hospitals (p = 0.022), and Europe versus other continents (p < 0.001) are the most users of MMA embolization. A large number of participants (51%) declare they use a conservative/medical approach, mainly to avoid surgery in patients with small cSDH (74.8%). Conclusions This survey highlights the current trends of cSDH management, focusing on conservative and MMA embolization treatment strategies. Most responders prefer a conservative approach for patients with small cSDHs not requiring surgical evacuation. However, in higher-risk scenarios such as residual hematomas after surgery or patients on antiplatelet medications, MMA embolization is regarded as a reasonable option by participants. Future studies should clarify the indications of MMA embolization, including appropriate patient selection and efficacy as a stand-alone procedure.

To the Editor: Subdural hematoma is one of the most diagnosed neurosurgical conditions in adults with an incidence rate reported to be 13.4 per 100 000 persons per year.1,2 Although mortality rates have decreased over the past several decades due to progressive advancements in diagnostics, novel treatment strategies are required to better manage patient outcomes.3 Middle meningeal artery (MMA) embolization is one such strategy that has recently emerged to reduce postoperative recurrence. This minimally invasive technique devascularizes the subdural membranes to prevent further bleeding and has proven viable and safe, especially among nonsurgical candidates.4 Here, we investigate the trends in the rates of middle meningeal artery embolization and mortality in patients with subdural hematoma. We queried the National Inpatient Sample database from 2016 to 2020 for patients with principal diagnosis of nontraumatic subdural hematoma (SDH) using the International Classification of Disease 10th Edition (ICD10) code I62. Cases at large urban teaching hospitals were selected. The yearly rate of inpatient mortality and MMA embolization was extracted. Trends in severity, as measured using variables suggestive of clinical severity (mechanical ventilation, hydrocephalus, treatment of hydrocephalus, coma, stupor, cranial nerve palsy, paralysis/paraparesis, and aphasia), were also explored. Multivariate regression analysis was performed to analyze the association between MMA embolization and mortality when controlling for age, socioeconomic status, race, and severity. All statistical analyses were performed using Statistical Product and Service Solutions (SPSS) Statistical Software, and significance was set to P < .05 (IBM Corp. Released 2020. IBM SPSS Statistics for Windows, version 28.0., IBM Corp). All data and ICD10 codes used in this study are available on reasonable request of the corresponding author. There were 173 165 patients with a principal diagnosis of SDH at large urban teaching hospitals from 2016 to 2020. We report an overall decrease in the mortality rate in 2020 (10.5%) as compared with 2016 (10.9%) (Figure 1). The mortality rate in 2016 and 2017 averaged 11.0%, whereas the mortality rate from 2018 to 2020 averaged 10.4%. On the other hand, severity trended upward throughout the years (Figure 2). The yearly rate of craniotomy and burr hole increased slightly from 1.18% to 1.46% and 8.36% to 9.12%, respectively. Notably, the rate of MMA embolization increased more than 10-fold from 2016 (0.2%) to 2020 (2.8%) (Figure 3). Most notable increase was post-2018, depicting its recent importance and success for managing subdural hematoma. Finally, when controlling for severity and demographics, MMA embolization was found to become protective against mortality in 2020, validating the trends stated above (Figure 4).Figure 1.: Yearly trends in mortality rate.Figure 2.: Yearly trends in severity.Figure 3.: Yearly trends in the rate of MMA embolization. MMA, middle meningeal artery.Figure 4.: Relationship between MMA embolization and mortality. MMA, middle meningeal artery.Surgical evacuation through craniotomy is one of the conventional treatments for chronic subdural hematoma. However, studies cite a 30-day mortality rate of 16.5% to 18% and high rates of adverse outcomes, including prolonged mechanical ventilation, return to the operating room, and prolonged length of stay, following craniotomy for subdural hematoma evacuation.3,5 Owing to a high rate of recurrence and perioperative complications associated with open surgery, MMA embolization is emerging to be not only an adjunct but also a stand-alone treatment option for chronic subdural hematoma.6,7 In a prospective study, Ban et al7 reported MMA embolization to be a superior option than conventional treatment options. In this same study, treatment failure for MMA embolization was reported to be only 1.4% as compared with 27.5% among patients who underwent surgical drainage. As we await the results of ongoing clinical trials, our analysis supports these findings and shows an overall inverse trend among the rate of MMA embolization and mortality throughout the United States, even when controlling for severity.

IntroductionSubdural hematomas (SDH), especially when recurring, pose a significant challenge in treatment. Middle Meningeal Artery (MMA) embolization has emerged as a promising method for managing chronic cases. Studies suggest its...

Middle meningeal artery (MMA) embolization has gained acceptance as a treatment for chronic subdural hematoma (cSDH) in adult patients but has not been well described in pediatric patients. Standard cSDH treatment has historically consisted of burr hole drainage with or without subdural drain placement. However, due to the high rate of recurrence and frequency of comorbidities within this population, as both pediatric and adult patients with cSDH frequently have concurrent cardiac disease and a need for anticoagulant therapies, MMA embolization has increasingly demonstrated its value as both an adjunctive and primary treatment. In this report, the authors present 3 cases of successful MMA embolization in medically complex children at a single institution. MMA embolization was used as a primary treatment modality and as an adjunctive therapy in the acute setting following surgical hematoma evacuation. Two patients were receiving anticoagulation treatment requiring reversal. Technical considerations specific to the pediatric population as well as those common to both the pediatric and adult populations are addressed. Further work is needed to define the optimal indications and outcomes for MMA embolization in children with cSDH.

Introduction/Purpose Middle meningeal artery (MMA) embolization has been shown to be a beneficial treatment for chronic subdural hematoma (1); however, anatomic variants of MMA can present challenges to the procedure. MMA embolization carries increased risk if there is an abnormal anastomosis between the MMA and ophthalmic artery given the risk of embolization into the ophthalmic artery and is therefore typically avoided in such cases (2). We present a case of a patient who presented with worsening chronic subdural hematoma and was found to have an ophthalmic artery that completely originated from his MMA and yet was able to undergo successful MMA embolization without complications. Materials/Methods We present a 72‐year‐old patient with a history of chronic subdural hematoma, asthma, left‐sided arachnoid cyst, hyperlipidemia, and migraines presenting for persistent severe headaches. He had a normal neurological exam. The patient had initially presented three months earlier for a ground‐level fall due to vasovagal syncope and was found to have a small right‐sided subdural hematoma. He was managed conservatively then and subsequently discharged. Interval CTH one month later showed an increased size of the SDH with a midline shift of 4mm. He subsequently re‐presented for headache (three months from the original fall), with repeat imaging showing expansion of his SDH to 2cm with 1cm midline shift. He had not had any recurrent traumatic falls and was not on any blood thinners during this time. He underwent an uncomplicated craniotomy with SDH evacuation. Results The patient subsequently underwent a digital subtraction angiography (DSA), which showed a meningio‐ophthalmic artery variant, with the ophthalmic artery fully originating from the middle meningeal artery. This variant greatly increases risk during MMA embolization given the origination of the ophthalmic artery directly and entirely from the MMA; occlusion of the MMA proximally likely results in retinal artery occlusion in this scenario. However, given the risk of re‐bleeding and re‐expansion of his cSDH, he underwent adjunctive right MMA embolization with coils placed distally to the ophthalmic‐MMA junction, confirmed on post‐embolization sequences during angiogram. He did not suffer any visual symptoms and remained with a normal neurological exam with full resolution of his headaches. Conclusion This case demonstrates the safety of MMA embolization for cSDH in a patient with a high‐risk variant, which has typically been deemed a contraindication. Using coils instead of a liquid embolization agent and embolizing distal to the ophthalmic‐MMA junction allows for safe completion of the procedure without complications. It is also unclear why this variant is more prevalent in patients with cSDH, and a causal relationship has not been established for the pathogenesis of subdural hematoma or risk of re‐bleeding

Chronic subdural hematoma (cSDH) is a common cranial neurosurgical condition with morbidity and mortality ranging from 2% to 5%. Conventional treatment includes conservative and surgical evacuation. Minimally invasive middle meningeal artery (MMA) embolisation is emerging as a potential treatment option. We report our case successfully managed by MMA embolization and review the literature. cSDH development and progression is related to the cycle of chronic inflammation and angiogenesis following the original hemorrhage due to trivial trauma. Due to growth factor, stimulation-initiating angiogenesis leading to growth of leaky blood vessels causing microhaemorrhages resulting in the progressive enlargement of subdural collection as the physiologic absorption capability is outpaced by the rate of collection. Strategies for the management of cSDH are aimed at interrupting the vicious cycle of its development and tilting the balance toward reabsorption of haemorrhage. Conservative management, medical treatment and surgical treatments are conventional treatment options with surgical evacuation considered as the gold standard option. However, challenges include recurrence and reversal of anti-platelets and anti-coagulants and its associated risk of ischaemic complications. cSDH being a pathology of meninges deriving blood the dura causing microhaemorrhages, it is prudent to seal off the vessels to tilt the balance towards resorption. MMA embolisation as a treatment option has been used with significant published data. It may be used as a stand-alone therapy in minimally symptomatic patients. Technical success rate is high both with polyviny alcohol and liquid embolic agents. Recurrence rate is consistently low in spite of significant patients having antiplatelets and anti-coagulants on board. It eliminates the ischemic complication due to stoppage of antiplatelets and anticoagulants. MMA embolization is also emerging as an adjunct to surgically evacuated cSDH that is considered high risk for recurrence.

Introduction : Middle meningeal artery (MMA) anatomy has very important surgical implications during endovascular and open based skull procedures. Various anatomical origins have been identified in the literature besides its most common origin as the largest branch of the maxillary artery. It runs parallel and close contact of the lateral skull face therefore during trauma to this area is prone to rupture resulting in subdural hemorrhage(SDH). In our case report, we present its peculiar origin from anterior inferior cerebellar artery which has never been reported before. The origin of MMA may reflects the risk involved with embolization therapy for chronic SDH. Methods : A case of MMA originated form AICA. A literature review was conducted of reports of MMA origins. Results : A 35‐year‐old male with a history of alcohol abuse presented to the ED after falling down from the stairs. In the ED, the patient had multiple episodes of seizures along with respiratory distress therefore was intubated due to concern of airway protection. CT head showed bilateral SDH. Patient underwent diagnostic angiogram for possible bilateral embolization of MMA. During the procedure, the left MMA origin was seen from the AICA whereas the right MMA arising from the external carotid artery. Embolization of the left MMA was aborted. Patient remained intubated and was later transferred to a long term care facility. Conclusions : In the last 80 years, the anatomy of the MMA has been part of the discussion of various literature. Seeger et.al, highlighted the embryological changes manifested as anastomosis between Sphenomaxillary artery and lateral pontine artery resulting in origin of MMA from Basilar artery along with absence of foramen spinosum. Since 1973, multiple literature highlighted the origin of MMA including the lacrimal artery, ICA, ascending pharyngeal artery, opthalmic and occipital arteries. Recently, In 2011 Kuruvuilla et.al showed the origin of MMA from posterior inferior cerebellar artery. MMA clinical significance can be seen in multiple diseases. Older populations with chronic subdural hematomas, embolization of MMA has shown to be a less invasive and cost effective procedure. In patients with anterior and middle cranial fossa meningiomas embolization of MMA has been a crucial part of management. Similarly, understanding of its anatomy is also important while treating MMA aneurysm or pseudoaneurysms. In our case, the origin of middle meningeal artery from AICA has been significant as it supplies the posterior fossa structures and was not reported in the literature before, hence the procedure was aborted. This anatomical variant has shown us a new light upon embryological evolution and has helped us widen the horizons of our approach towards brain vasculature. This finding will help the future Interventionists to develop new ways of embolization of the MMA and understanding its anatomy.

The results from studies that compare middle meningeal artery (MMA) embolization vs conventional management for patients with chronic subdural hematoma are varied. To conduct a systematic review and meta-analysis on studies that compared MMA embolization vs conventional management. Medline, PubMed, and Embase databases were searched. Primary outcomes were treatment failure and surgical rescue; secondary outcomes were complications, follow-up modified Rankin scale > 2, mortality, complete hematoma resolution, and length of hospital stay (day). The certainty of the evidence was determined using the GRADE approach. Nine studies yielding 1523 patients were enrolled, of which 337 (22.2%) and 1186 (77.8%) patients received MMA embolization and conventional management, respectively. MMA embolization was superior to conventional management for treatment failure (relative risk [RR] = 0.34 [0.14-0.82], P = .02), surgical rescue (RR = 0.33 [0.14-0.77], P = .01), and complete hematoma resolution (RR = 2.01 [1.10-3.68], P = .02). There was no difference between the 2 groups for complications (RR = 0.93 [0.63-1.37], P = .72), follow-up modified Rankin scale >2 (RR = 0.78 [0.449-1.25], P = .31), mortality (RR = 1.05 [0.51-2.14], P = .89), and length of hospital stay (mean difference = -0.57 [-2.55, 1.41], P = .57). For MMA embolization, the number needed to treat for treatment failure, surgical rescue, and complete hematoma resolution was 7, 9, and 3, respectively. The certainty of the evidence was moderate to high for primary outcomes and low to moderate for secondary outcomes. MMA embolization decreases treatment failure and the need for surgical rescue without furthering the risk of morbidity and mortality. The authors recommend considering MMA embolization in the chronic subdural hematoma management.

Chronic subdural hematoma (cSDH) is a common and challenging pathology to treat due to both the historically high recurrence rate following surgical evacuation and the medical comorbidities inherent in the aging patient population that it primarily affects. Middle meningeal artery (MMA) embolization has shown promise in the treatment of cSDHs, most convincingly to avoid surgical evacuation in relatively asymptomatic patients. Symptomatic patients requiring surgical evacuation may also benefit from perioperative MMA embolization to prevent cSDH recurrence. The goal of this study was to determine the utility of perioperative MMA embolization for symptomatic cSDH requiring surgical evacuation and to assess if there is a decrease in the cSDH recurrence rate compared to historical recurrence rates following surgical evacuation alone. Symptomatic cSDHs were evacuated using a subdural evacuating port system (SEPS) with 5-mm twist-drill craniostomy in an intensive care unit or by performing a craniotomy in the operating room, using either a small (silver dollar, < 4 cm) or large (≥ 4 cm) craniotomy. MMA embolization was performed perioperatively using angiography, selective catheterization of the MMA, and infusion of polyvinyl particles. Outcomes were assessed clinically and radiographically with interval head CT imaging. There were 44 symptomatic cSDHs in 41 patients, with 3 patients presenting with bilateral symptomatic cSDH. All cSDHs were evacuated using an SEPS (n = 18), a silver-dollar craniotomy (n = 16), or a large craniotomy (n = 10). Prophylactic MMA embolization was performed successfully in all cSDHs soon after surgical evacuation. There were no deaths and no procedural complications. There was an overall reduction of greater than 50% or resolution of cSDH in 40/44 (90.9%) cases, regardless of the evacuation procedure used. Of the 44 prophylactic cases, there were 2 (4.5%) cases of cSDH recurrence that required repeat surgical evacuation at the 1-year follow-up. These 2 cSDHs were initially evacuated using an SEPS and subsequently required a craniotomy, thereby representing an overall 4.5% recurrence rate of treated cSDH requiring repeat evacuation. Most notably, of the 26 patients who underwent surgical evacuation with a craniotomy followed by MMA embolization, none had cSDH recurrence requiring repeat intervention. Perioperative prophylactic MMA embolization in the setting of surgical evacuation, via either craniotomy or SEPS, may help to lower the recurrence rate of cSDH.

IntroductionAssessments of the Middle Meningeal Artery (MMA) Embolization have not been widely reported in community hospital settings. Moreover, there is a lack of clinical guidelines for repeated adult head CT...