Middle Meningeal Artery Embolization in Chronic Subdural Hematoma: Implications of Pathophysiology in Trial Design.
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ABSTRACT:
SUBMITTER: Moshayedi P
PROVIDER: S-EPMC7481478 | biostudies-literature | 2020
REPOSITORIES: biostudies-literature
Publications
Middle Meningeal Artery Embolization in Chronic Subdural Hematoma: Implications of Pathophysiology in Trial Design.
Moshayedi Pouria P Liebeskind David S DS
Frontiers in neurology 20200827
<b>Background:</b> Chronic subdural hematoma (cSDH) is a debilitating condition with a high rate of recurrence after surgical evacuation. <b>Summary:</b> This review is focused on middle meningeal artery (MMA) embolization to treat cSDH. We discuss the underlying pathophysiology of chronic subdural hematoma and how cessation of arterial flow may resolve a venous hemorrhage. We also present the current evidence for MMA embolization and the roadmap for future trials. <b>Conclusion:</b> Frequent mu ...[more]
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Project description: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. 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. 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. 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.
| S-EPMC7915255 | biostudies-literature
Project description:BackgroundMiddle meningeal artery embolization (MMAE) has been used as an effective minimally invasive treatment for chronic subdural hematoma (cSDH). The demographics and clinical outcomes after MMAE treatment for cSDH have not yet been studied using a national database.MethodsWe queried all MMAE cases up to October 7, 2020, from the TriNetX Analytics Network. We identified patients >18 years old who underwent MMAE for treatment of cSDH. Patient demographics, baseline characteristics, comorbidities, and clinical outcomes were evaluated within 180 days after MMAE. Analyses of 180-day mortality and recurrence were performed after propensity score matching to control for baseline characteristics and comorbidities.ResultsThe study included 191 patients (mean age 71.2 ± 13.5 years, 73.3% male, 69.6% White, 13.6% Black/African American, and 16.8% other race). Essential hypertension (71.3%), heart disease (62.8%), type 2 diabetes mellitus (27.2%), nicotine dependence (23.6%), chronic kidney disease (19.4%), and overweight/obesity (19.4%) were among the most prevalent comorbidities. At presentation, 20.4% and 40.3% of patients were on antiplatelet and anticoagulation therapy, respectively. Outcomes within 180-day follow-up were 6.3% (1.0%-5.8% when propensity matched) for mortality (12 patients), 7.3% for craniotomy/craniectomy after MMAE (14 patients), 0.52%-5.2% for burr hole procedures (1-10 patients), and no patients with low vision/blindness.ConclusionsMMAE is a safe and effective minimally invasive procedure for treatment of cSDH. This is the first analysis of patients undergoing MMAE for cSDH using a national database.
| S-EPMC8384691 | biostudies-literature
Project description:BackgroundChronic subdural hematoma (cSDH) is the most common complication of mild traumatic brain injury demanding neurosurgery in high-income countries. If undetected and untreated, cSDH may increase intracranial pressure and cause neurological deficiencies. The first-line intervention of choice is burr hole trepanation and hematoma evacuation. However, any third patient may experience rebleeding, demanding craniotomy with excess morbidity. Adjunct endovascular embolization of the frontal and parietal branches of the middle meningeal artery (MMA) is a promising approach to avoid relapse and revision but was hitherto not studied in a randomized trial.MethodsMEMBRANE is an investigator-initiated, single-center, randomized controlled trial. Male, female, and diverse patients older than 18 years scheduled for surgical evacuation of a first cSDH will be assigned in a 1:1 fashion by block randomization to the intervention (surgery plus endovascular MMA embolization) or the control group (surgery alone). The primary trial endpoint is cSDH recurrence within 3 months of follow-up after surgery. Secondary endpoints comprise neurological deficits assessed by the modified Rankin Scale (mRS) and recurrence- or intervention-associated complications during 3 months of follow-up. Assuming a risk difference of 20% of rebleeding and surgical revision, a power of 80%, and a drop-out rate of 10%, 154 patients will be enrolled onto this trial, employing an adaptive O'Brien-Fleming approach with a planned interim analysis halfway.DiscussionThe MEMBRANE trial will provide first clinical experimental evidence on the effectiveness of endovascular embolization of the MMA as an adjunct to surgery to reduce the risk of recurrence after the evacuation of cSDH.Trial registrationGerman Clinical Trials Registry (Deutsches Register Klinischer Studien [DRKS]) DRKS00020465. Registered on 18 Nov 2021.Clinicaltrialsgov NCT05327933 . Registered on 13 Apr 2022.
| S-EPMC9396835 | biostudies-literature
Project description:BackgroundThe conventional treatments for non-acute subdural hematoma (SDH) are facing the challenge of high hematoma recurrence and progression. A novel treatment of middle meningeal artery (MMA) embolization showed the potential role in decreasing the recurrence and progression rate of SDH compared to conventional treatments in multiple cohort studies. A randomized controlled trial is warranted to determine the effectiveness and safety of MMA embolization for non-acute hematoma and whether MMA embolization is superior to conventional treatments to lower the symptomatic recurrence and progression rate of non-acute SDH.MethodsThis is an investigator-initiated, multi-center, prospective, open-label parallel group trial with blinded outcome assessment (PROBE design) assessing superiority of MMA embolization compared to conventional treatments. A total of 722 patients are planned to be randomized 1:1 to receive MMA embolization (intervention) or conventional treatments (control). The primary outcome is the symptomatic SDH recurrence/progression rate within 90 ± 14 days post-randomization.DiscussionThis trial will clarify whether MMA embolization could reduce the recurrence or progression rate of symptomatic non-acute SDH compared to conventional treatment.Trial registrationClinicalTrials.gov. Identifier: NCT04700345, Registered on 7 January 2021.
| S-EPMC10503047 | biostudies-literature
Project description:BackgroundChronic subdural hematoma (cSDH) is one of the most common neurosurgical disorders and the incidence is rising. The routine treatment is neurosurgical hematoma evacuation, which is associated with recurrence rates up to 10-25%. In recent years, endovascular embolization of the middle meningeal artery (eMMA) has garnered much attention due to recurrence rates as low as < 5%. Several randomized controlled trials are planned or ongoing. In most of these trials, conventional neurosurgical treatment with or without adjunctive endovascular embolization is compared. The proposed trial aims to conduct a head-to-head comparison between neurosurgical and endovascular treatment as stand-alone treatments.MethodsThe trial is academically driven and funded within existing public healthcare systems and infrastructure. Patients with uni- or bilateral cSDH, presenting with mild-to moderate symptoms, and admitted to neurosurgery on clinical grounds will be offered participation. Subjects are randomized 1:1 between conventional neurosurgical treatment (control) and endovascular embolization of the middle meningeal artery (intervention). Primary endpoint is reoperation due to clinically and/or radiologically significant recurrence within 3 months. Secondary endpoints include safety, technical success rate, neurological disability, and quality of life.DiscussionThere are mounting retrospective data suggesting eMMA, as sole treatment or as an adjunctive to neurosurgery for cSDH, is safe and effective with a reoperation rate lower than neurosurgical hematoma evacuation alone. If randomized controlled trials confirm these findings, there is a potential for a paradigm shift in the treatment of cSDH where a minimally invasive procedure can replace open surgery in a large and oftentimes old and fragile patient cohort.Trial registrationClinicalTrials.gov, ClinicalTrials.gov Identifier NCT05267184 . Registered March 4, 2022.
| S-EPMC9641832 | biostudies-literature
Project description:Aneurysms of meningeal middle artery (MMA) are extremely rare. These aneurysms are of two types: true aneurysm and pseudoaneurysm. The true type is usually seen with pathologic conditions. Pseudoaneurysms, on the other hand, are associated with a skull fracture. Epilepsy caused by MMA aneurysm has never been described to our knowledge. We report a case of true aneurysm isolated from MMA revealed by epilepsy.A 57-year-old patient with a history of high blood pressure developed epilepsy which was treated by valproic acid. Initial scalp electroencephalography (EEG) showed seizure activity arising from the right temporal area. Epilepsy had become drug-resistant. Cerebral angiography revealed an aneurysm of the right middle meningeal artery without any other intraparenchymal anomaly. The interrogation did not reveal any history of family aneurysm. The patient underwent surgery with coagulation of the aneurysm and the MMA. The aneurysm was intradural in contact with the temporal cortex, and the surrounding brain tissues were preserved. The operative follow-up was favorable with amelioration of convulsions with a single antiepileptic. We planned to stop antiepileptic treatment according to electroencephalograms.Aneurysms of the MMA are rare. Their mode of revelation by seizures is unusual. The factors of rupture are not known. When isolated, their physiopathology is identical to that of the aneurysms of the Willis polygon. Their management uses the same techniques as for other cerebral aneurysms.
| S-EPMC5551285 | biostudies-other
Project description:Chronic subdural hematoma (cSDH), previously considered fairly benign and easy to treat, is now viewed a possible sign of incipient clinical decline. We investigated case-fatality, excess fatality and need for reoperations following operated cSDH in a nationwide setting focusing on patient-related characteristics. Finnish nationwide databases were searched for all admissions with operated cSDH as well as later deaths in adults (≥ 16 years) during 2004-2017. There were 8539 patients with an evacuated cSDH (68% men) with a mean age of 73.0 (± 12.8) years. During the follow-up, 3805 (45%) patients died. In-hospital case-fatality was 0.7% (n = 60) and 30-day case-fatality 4.2% (n = 358). The 1-year case-fatality was 14.3% (95% CI = 13.4-15.2%) among men and 15.3% (95% CI = 14.0-16.7%) among women. Comorbidity burden, older age, and alcoholism were significantly associated with fatality. One-year excess fatality rate compared to general Finnish population was 9.1% (95% CI = 8.4-9.9) among men and 10.3% (95% CI = 9.1-11.4) among women. Highest excess fatality was observed in the oldest age group in both genders. Reoperation was needed in 19.4% (n = 1588) of patients. Older age but not comorbidity burden or other patient-related characteristics were associated with increased risk for reoperation. The overall case-fatality and need for reoperations declined during the study era. Comorbidities should be considered when care and follow-up are planned in patients with cSDH. Our findings underpin the perception that the disease is more dangerous than previously thought and causes mortality in all exposed age groups: even a minor burden of comorbidities can be fatal in the post-operative period.
| S-EPMC9054845 | biostudies-literature
Project description:Background: Evidence suggests that hyperdense (HD) chronic subdural hematomas (CSDHs) have a higher recurrence than hypodense (LD) chronic subdural hematomas. The value of mean hematoma density (MHD) has been proven to be associated with postoperative recurrence. The MHD levels in homogeneous CSDHs likely underestimate the risk of recurrence in HD homogeneous subtypes. Methods: This study investigated 42 consecutive CSDH cases between July 2010 and July 2014. The area of the hematoma was quantified to determine the MHD level using computer-based image analysis of preoperative brain CT scans. Results: In terms of the MHD distribution of the four types of CSDHs (homogeneous, laminar, separated, and trabecular), wide 95% CI (11.80-16.88) and high standard deviation (4.59) can be found in homogeneous types, reflecting a high variability in the MHD levels between cases (from low to high density). The categorization of homogeneous types into LD and HD (type five) displayed a minor standard deviation in the MHD levels for LD and HD subtypes (1.15, and 0.88, respectively). MHD values demonstrated concentrated distributions among the respective five types, compared to the four-type setting. Conclusions: In the current research, we provide a consideration that if LD and HD hematomas are separated from homogeneous CSDHs, the variability of the MHD quantification can potentially be reduced, thereby avoiding the possibility of undetected high-risk groups.
| S-EPMC9689778 | biostudies-literature
Project description:Background: Traumatic brain injury is a common condition in neurosurgery. Traditional methods of treatment include conservative treatment and surgical evacuation using burr-holes or craniotomy; however, studies have reported problems such as high re-expansion rates after conservative treatment of epidural hematoma and high postoperative recurrence rates of subdural hematoma. Solutions to these problems are lacking, and research into new treatment methods is ongoing. Among the potential new treatments, middle meningeal arterial embolization is an option. This study involved patients with acute epidural hematoma and chronic subdural hematoma. The purpose was to evaluate the use and effects of absolute alcohol to embolize the middle meningeal artery to treat intracranial hematoma. Material and Methods: A retrospective description study was 12 cases of intracranial hematoma who treated with absolute alcohol interventional therapy from our hospital between June 2018 and October 2019. Five patients with acute epidural hematoma and seven patients with chronic subdural hematoma were treated using absolute alcohol to embolize the middle meningeal artery. Patients' clinical data, imaging results, surgical results, and prognosis were recorded and analyzed. Results: All patients underwent absolute alcohol embolization of the middle meningeal artery, in combination with burr-hole drainage. All imaging data were confirmed preoperatively. We successfully used absolute alcohol to embolize the middle meningeal artery intraoperatively and confirmed these results by postoperative angiography. All patients achieved symptomatic relief without complications, and no recurrence or re-expansion was seen with follow-up computed tomography. Our study has been registered in the Chinese Clinical Trial Registry (http://www.chictr.org.cn, ChiCTR1800018714). Conclusion: The use of absolute alcohol to embolize the middle meningeal artery could be used as an attempt to treat acute epidural hematoma and chronic subdural hematoma.
| S-EPMC7438730 | biostudies-literature
Project description:Background: Several pharmacological treatments have been used to treat patients with chronic subdural hematoma (CSDH), although little is known about the comparative effectiveness of different classes of medication. We performed a Bayesian network meta-analysis to compare and rank the efficacy and safety of five drug regimens to determine the best treatment for this group of patients. Methods: We systematically searched PubMed, Medline, clinicaltrials.gov, the Cochrane database, and Embase to identify relevant randomized clinical trials (RCTs) comparing drug treatments in adult patients with CSDH. A network meta-analysis was conducted using a Bayesian framework. Random- and fixed-effects models were used to pool the network results, and the preferred model was selected by comparing the deviance information criteria (DIC). Efficacy outcomes included recurrence requiring surgery, changes in hematoma volume, and a good recovery. The safety outcomes were treatment-related adverse events and all-cause mortality. Results: In this Bayesian network meta-analysis, available data were obtained from 12 eligible trials, including 2,098 patients and 5 techniques. Compared to placebo, atorvastatin (RR: 0.45, 95% CrI: 0.24-0.81) and dexamethasone (RR: 0.38, 95% CrI: 0.22-0.63) were similarly effective in reducing recurrence requiring surgery by 55% and 62%, respectively. Dexamethasone (RR: 0.46, 95% CrI: 0.23-0.91) was more effective in reducing recurrence requiring surgery than goreisan. Additionally, atorvastatin reduced the hematoma volume to a greater extent than placebo (MD: -7.44, 95% CrI: -9.49 to -5.43) or goreisan (MD: -14.09, 95% CrI: -23.35 to -4.82). Moreover, tranexamic acid (MD: -12.07, 95% CrI: -21.68 to -2.29) reduced the hematoma volume to a greater extent than goreisan. No significant differences were detected between drugs and placebo with regard to a good recovery. In terms of safety, dexamethasone (RR: 1.96, 95% CrI: 1.20-3.28) increased the risk of mortality compared to placebo. Conclusion: These findings suggest that dexamethasone is the best treatment to reduce recurrence and atorvastatin is the best treatment to reduce hematoma volume in patients with CSDH. However, clinicians should pay close attention to the elevated risk of all-cause mortality and potential adverse events caused by dexamethasone. Future well-designed RCTs with more participants are needed to verify these findings. Clinical Trial Registration: http://osf.io/u9hqp.
| S-EPMC8280518 | biostudies-literature