Nonopacification of Frontal and Parietal Branches After Middle Meningeal Artery Embolization: A Radiographic Benchmark

Abstract

BackgroundMiddle meningeal artery embolization (MMAE) has revolutionized the armamentarium for chronic subdural hematoma (CSDH) treatment. Technical and angiographic benchmarks to guide procedural and clinical success are less well-established. MethodsA single-center database was reviewed to compare outcomes after standalone MMAE with and without resultant residual angiographic opacification of frontal and parietal (F/P) branches. Primary outcome was surgical rescue for CSDH progression. Secondary outcomes included the efficiency and accumulated efficacy of hematoma-resolution. Effect sizes were adjusted via multivariable regression. ResultsOf 147 standalone MMAE for CSDH, the overall rate of surgical rescue was 6.8%. Non-opacification of F/P branches via proximal MMA or meningo-ophthalmic anastomosis, was achieved after 83% of procedures and was associated with a 7-fold decreased rate of surgical rescue (3.3% vs. 24%, P=0.001). At 90-day follow-up, a higher rate of hematoma-resolution ≥ 50% was achieved if no residual opacification was identified (82% vs. 56%, P=0.03). The median time-to-50%-hematoma-resolution was 44 days for the no-residual group versus 71 days for the residual group (P<0.001). The unfavorable effects of residual opacification of F/P branches were verified in a multivariate analysis: a higher risk of surgical-rescue (adjusted OR 24.6; P=0.001) and poor hematoma resolution were both confirmed (adjusted HR 0.3; P=0.001). ConclusionMMAE with non-opacification of F/P branches was associated with augmented efficacy. Nuanced MMAE adequately tackling culprit dural feeders should be considered for more effective procedures.