Concurrent Middle Meningeal Artery Embolization for Treatment of Chronic Subdural Hematomas

Introduction: Non-acute subdural hematomas (NASHs) are expected to be the most common cranial neurosurgery pathology by the year 2030. Treatment with surgical evacuation may be necessary, but rates of recurrence after surgery as high as 30% have been reported. Minimally invasive middle meningeal artery embolization (MMAe) during the perioperative period has been posited as an adjunct to decrease recurrence after surgical evacuation of NASH. We evaluated the safety and efficacy of MMAe in a multi-institutional cohort.

Methods: Data from 145 patients (median age 73 years) with NASH who underwent surgical evacuation and concurrent MMA embolization were retrospectively collected from 15 institutions. The primary outcome was rates of NASH recurrence requiring repeat surgical intervention. We collected clinical data including anticoagulant/antiplatelet use, prior NASH treatment, and perioperative platelet counts; treatment data including anesthesia type, type of embolic agent, length of hospital stay, and access type; and radiographic data including NASH laterality, presence of subdural membranes or dangerous collaterals, MMA size, and median NASH width at initial presentation, after evacuation, and at 90-day follow-up. Outcomes data collected included mortality, and modified Rankin Scale (mRS) score at last follow-up.

Results: The median preoperative hematoma width was 18 mm, and subdural membranes were present on imaging in 87% of patients. At 90-day follow-up, the median NASH width was 6 mm, and 51% of patients had ≥50% decrease of NASH size. At last clinical follow up, 87% had the same or improved mRS score. Eight percent of treated NASHs had recurrence requiring additional surgery. The all-cause mortality rate was 6%.

Conclusion : This study provides evidence from a multi-institutional cohort that performing MMAe in the perioperative period as an adjunct to surgical evacuation is a safe and effective means to reduce surgical recurrence in patients with NASHs