Post-Doctoral Research Fellow University of Pennsylvania Department of Neurosurgery Alexandria, Egypt
Introduction: Little is known regarding predictors of radiographic failure of MMA embolization (MMAE) treatment for chronic subdural hematomas (cSDH).
Methods: Consecutive patients undergoing MMA embolization for cSDH at 13 North-American centers (2018-2022) were included. Radiographic failure was defined as maximal hematoma thickness reduction of < 50% on last imaging, with a minimum of 2 weeks imaging follow-up. Multivariable logistic regression models were constructed to identify independent radiographic failure predictors, controlling for: age, gender, concurrent surgical evacuation, midline shift, hematoma thickness, pre-treatment baseline antiplatelet/anticoagulation therapy, follow-up imaging time categorized as: group 1 “2-4 weeks”, group 2 “4-6 weeks”, group 3 “6 weeks – 90 days”, group 4 “>90 days”.
Results: 530 patients underwent 636 MMAE procedures (mean age 72 years, 27.2% females) and were included [106 with bilateral treatments (20%)]. Pre-treatment median admission cSDH thickness was 15 mm; 31.3% and 21.8% of the patients were on antiplatelet and anticoagulation medications, respectively. Radiographic failure occurred in 26.3% of the cases. Independent predictors of radiographic failure included smaller MMA diameter ( < 1.5mm) (aOR 1.7; p=0.044), midline shift (aOR 1.10; p=0.02), and super-selective MMA catheterization (without targeting main MMA trunk) (aOR 2; p=0.029). Conversely, female gender (aOR 0.36; p=0.001), concurrent surgical evacuation (aOR 0.43; p=0.009), and longer imaging-time (utilizing group 1 as a reference: group 2: aOR 0.43; p=0.028, group 3: aOR 0.19, p< 0.001, group 4: aOR 0.1;p < 0.001) were protective against radiographic failure. Multiple subsequent sensitivity analyses were done by excluding the following:1) concurrent surgical group, 2) concurrent surgical group + cSDH thickness < 10mm, 3) cSDH with < 90 days imaging follow-up, all of which retained the aforementioned associations.
Conclusion : In this cohort, small MMA diameter ( < 1.5mm), midline shift and super-selective MMA catheterization were independently associated with radiographic failure. Conversely, female gender, concurrent surgical evacuation and longer imaging follow-up time were protective against radiographic failure.
