Recurrence and Coniglobus Volumetric Resolution of Subacute and Chronic Subdural Hematoma Post-Middle Meningeal Artery Embolization.

Ambooj Tiwari,Ryan Bo,Adam A Dmytriw,David Turkel-Parrella,Nathan Farkas,Jeffrey Farkas,David S Gordon,Karthikeyan M Arcot,Phillip Ye

doi:10.3390/diagnostics11020257

Abstract

Objective: To study the efficacy of middle meningeal artery (MMA) embolization for the treatment of chronic subdural hematoma (SDH) and characterize its post-embolization volumetric resolution. Methods: Ten patients diagnosed with 13 cSDH underwent MMA embolization. SDH volumes were measured from time of initial discovery on imaging to pre-operative, post-operative, short-term and long-term follow-up. Time between procedure to obliteration was also measured. Volumetric analysis was done using the coniglobus formula, and recurrence rate as well as resolution timeline was defined using best-fit models. Results: Out of 10 patients, five were recurrent lesions, three were bilateral and seven unilateral cSDH. Average and median pre-operative volumes were 105.3 cc and 97.4 cc, respectively. Embolization on average was performed 21 days after discovery. Sixty percent of patients had concurrent antiplatelets or anticoagulation use. Forty percent underwent embolization treatment as the primary therapy. Recurrence was not seen in any patients treated with embolization. There were no peri- or post-operative complications. Five patients experienced complete or near-complete obliteration, while those with partial resolution showed a composite average of 75% volumetric reduction in 45 days. Post-embolization, the volumetric resolution followed an exponential decay curve over time and was independent of initial volume. Conclusion: MMA embolization contributed to a marked reduction in SDH volume post-operatively and can be used as a curative therapy for primary or recurrent chronic SDH.

Highlights

In spite of effective treatment of subdural hematoma, recurrence is seen in approximately 10–20% cases over an average interval of 1–8 weeks [1,2,3,4,5]
Micro-hemorrhage from fragile neovascular channels formed within the hematoma membrane is the putative contributor to its collection or recurrence. [2,11] This angiogenesis is often associated with the middle meningeal artery (MMA), whose consequent hypertrophy is often used as a surrogate for this pro-angiogenic response [12]
A total of 60% underwent embolization for recurrent subdural hematoma (SDH), while 40% received it as a primary treatment

Summary

Introduction

In spite of effective treatment of subdural hematoma, recurrence is seen in approximately 10–20% cases over an average interval of 1–8 weeks [1,2,3,4,5] This is primarily due to the pathophysiology of the neo-membrane formed within the hematoma. Burr hole drainage resolves the volumetric pressure of the hematoma, it does not address the underlying pathophysiology of inflammation, neovascularization and re-hemorrhage [6,7] This may be at play in cases associated with higher rates of recurrence: patients with cerebral atrophy, congenital or acquired coagulation disorders (chronic renal failure), use of antiplatelet or anticoagulant drugs and delayed time to treatment [7,8,9]. Micro-hemorrhage from fragile neovascular channels formed within the hematoma membrane is the putative contributor to its collection or recurrence. [2,11] This angiogenesis is often associated with the middle meningeal artery (MMA), whose consequent hypertrophy is often used as a surrogate for this pro-angiogenic response [12]

Methods

Results

Conclusion