Middle meningeal artery embolization for chronic subdural hematoma [Neurosurgery Wiki]

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====== Middle meningeal artery embolization for chronic subdural hematoma ======

{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1h3SAs98aPqqd6VPxmYHdCUHneAgxPeyK42Ytv0rB-sus5CkEB/?limit=15&utm_campaign=pubmed-2&fc=20230707044946}}
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{{ middlemeningealartery.jpg}}

[[Middle meningeal artery embolization]] is effective for [[Chronic subdural hematoma recurrence]], and is considered an effective therapeutic method to stop hematoma enlargement and promote resolution
((Mandai S, Sakurai M, Matsumoto Y. Middle meningeal artery embolization for
refractory chronic subdural hematoma. Case report. J Neurosurg. 2000
Oct;93(4):686-8. PubMed PMID: 11014549.
))
((Takahashi K, Muraoka K, Sugiura T, Maeda Y, Mandai S, Gohda Y, Kawauchi M,
Matsumoto Y. [Middle meningeal artery embolization for refractory chronic
subdural hematoma: 3 case reports]. No Shinkei Geka. 2002 May;30(5):535-9.
Japanese. PubMed PMID: 11993178.
))
((Hirai S, Ono J, Odaki M, Serizawa T, Nagano O. Embolization of the Middle
Meningeal Artery for Refractory Chronic Subdural Haematoma. Usefulness for
Patients under Anticoagulant Therapy. Interv Neuroradiol. 2004 Dec 24;10 Suppl
2:101-4. Epub 2008 May 15. PubMed PMID: 20587257; PubMed Central PMCID:
PMC3522210.
))
((Tsukamoto Y, Oishi M, Shinbo J, Fujii Y. Transarterial embolisation for
refractory bilateral chronic subdural hematomas in a case with
dentatorubral-pallidoluysian atrophy. Acta Neurochir (Wien). 2011
May;153(5):1145-7. doi: 10.1007/s00701-010-0891-3. Epub 2010 Dec 2. PubMed PMID: 
21125409.
))
((Mino M, Nishimura S, Hori E, Kohama M, Yonezawa S, Midorikawa H, Kaimori M,
Tanaka T, Nishijima M. Efficacy of middle meningeal artery embolization in the
treatment of refractory chronic subdural hematoma. Surg Neurol Int. 2010 Dec
13;1:78. doi: 10.4103/2152-7806.73801. PubMed PMID: 21206540; PubMed Central
PMCID: PMC3011107.
))
((Hashimoto T, Ohashi T, Watanabe D, Koyama S, Namatame H, Izawa H, Haraoka R,
Okada H, Ichimasu N, Akimoto J, Haraoka J. Usefulness of embolization of the
middle meningeal artery for refractory chronic subdural hematomas. Surg Neurol
Int. 2013 Aug 19;4:104. doi: 10.4103/2152-7806.116679. eCollection 2013. PubMed
PMID: 24032079; PubMed Central PMCID: PMC3766342.)).


A pilot study indicated that perioperative [[middle meningeal artery]] (MMA) embolization could be offered as the least invasive and most effectual means of treatment for resistant patients of CSDHs with 1 or more recurrences
((Kim E. Embolization Therapy for Refractory Hemorrhage in Patients with Chronic
Subdural Hematomas. World Neurosurg. 2017 May;101:520-527. doi:
10.1016/j.wneu.2017.02.070. Epub 2017 Feb 27. PubMed PMID: 28249828.
)).

Chihara et al. have treated three cases of CSDH with MMA embolization to date, but there was a postoperative recurrence in one patient, which required a craniotomy for hematoma removal and capsulectomy. MMA embolization blocks the blood supply from the dura to the hematoma outer membrane in order to prevent recurrences of refractory CSDH. Histopathologic examination of the outer membrane of the hematoma excised during craniotomy showed foreign-body giant cells and neovascular proliferation associated with embolization. Because part of the hematoma was organized in this case, the CSDH did not resolve when the MMA was occluded, and the development of new collateral pathways in the hematoma outer membrane probably contributed to the recurrence. Therefore, in CSDH with some organized hematoma, MMA embolization may not be effective. Magnetic resonance imaging (MRI) should be performed in these patients before embolization
((Chihara H, Imamura H, Ogura T, Adachi H, Imai Y, Sakai N. Recurrence of a
Refractory Chronic Subdural Hematoma after Middle Meningeal Artery Embolization
That Required Craniotomy. NMC Case Rep J. 2014 May 9;1(1):1-5. doi:
10.2176/nmccrj.2013-0343. eCollection 2014 Oct. PubMed PMID: 28663942; PubMed
Central PMCID: PMC5364934.)).
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Perioperative prophylactic [[Middle meningeal artery embolization]] in the setting of surgical evacuation, via either craniotomy or  [[subdural evacuating port system]] (SEPS), may help to lower the recurrence rate of cSDH
((Schwarz J, Carnevale JA, Goldberg JL, Ramos AD, Link TW, Knopman J. Perioperative prophylactic middle meningeal artery embolization for chronic subdural hematoma: a series of 44 cases. J Neurosurg. 2021 May 21:1-9. doi: 10.3171/2020.10.JNS202856. Epub ahead of print. PMID: 34020417.)).

It can be used safely and effectively as an alternative or adjunctive [[minimally invasive]] [[chronic subdural hematoma treatment]] in elderly and advanced elderly patients
((Joyce E, Bounajem MT, Scoville J, Thomas AJ, Ogilvy CS, Riina HA, Tanweer O, Levy EI, Spiotta AM, Gross BA, Jankowitz BT, Cawley CM, Khalessi AA, Pandey AS, Ringer AJ, Hanel R, Ortiz RA, Langer D, Levitt MR, Binning M, Taussky P, Kan P, Grandhi R. Middle meningeal artery embolization treatment of nonacute subdural hematomas in the elderly: a multiinstitutional experience of 151 cases. Neurosurg Focus. 2020 Oct;49(4):E5. doi: 10.3171/2020.7.FOCUS20518. PMID: 33002874.)).

It has been proposed as a curative treatment for [[chronic subdural hematoma]] (cSDH), but [[evidence]] for the [[indication]] and [[timing]] is not definitive.

===== Complications =====

[[Middle meningeal artery embolization for chronic subdural hematoma complications]].


===== Trials =====

[[Middle meningeal artery embolization for chronic subdural hematoma trials]]


===== Systematic Reviews =====

[[Middle meningeal artery embolization for chronic subdural hematoma systematic reviews]].


===== Narrative reviews =====

The [[incidence]] and [[prevalence]] is expected to grow due to aging of the [[population]] and the increase in [[anticoagulation]] and anti-aggregation prescription [[drug]]s. Traditionally, it was accepted that the bleeding originates from bridging [[vein]]s that drain the brain towards the dural sinuses. However, recent findings exposed an additional underlying mechanism. Trauma leads to separation of the dural border cell layer which induces an inflammatory process that starts positive feedback of leaky blood vessels formation (angidysgensis), which causes blood product leakage that further increases the inflammation. For many years, the disease has been treated conservatively in cases of mild clinical and imaging features, or by surgical evacuation of the hematoma in more severe cases. The literature shows a consistent high recurrence rate of around 30% following a surgical removal of the blood. The newly discovered mechanism inspired the development of a novel treatment method for this entity. Endovascular embolization of the middle meningeal artery (MMA). This method has an excellent efficacy and safety profile, and it can be performed alone or in combination with surgical evacuation. A review of Milikovsky et al. presents the epidemiology and mechanisms underlying CSDH, in addition to possible treatment methods, and eventually discuss MMA embolization to increase the awareness of the medical community in [[Israel]] to this new approach
((Milikovsky DZ, Haim O, Basal S, Jonas Kimchi T, Sadeh U. [EMBOLIZATION OF MIDDLE MENINGEAL ARTERY AS A TREATMENT FOR CHRONIC SUBDURAL HEMATOMA]. Harefuah. 2025 Jan;164(1):35-38. Hebrew. PMID: 39931018.)).
===== Case series =====

[[Middle meningeal artery embolization for chronic subdural hematoma case series]]


===== Case reports =====

A 70-year-old male with [[ischemic heart disease]], [[diabetes mellitus]], and [[hypertension]] who presented with worsening [[headache]]s for the past three days, associated with gait [[imbalance]] and [[dizziness]]. The patient was vitally stable on examination with a Glasgow Coma Scale/Score (GCS) of 15/15; his pupils were reactive bilaterally; and his neurological examination was unremarkable. Non-contrast computed tomography (CT) of the head yielded acute and [[Chronic Subdural Hematoma]]. The patient was initially managed by [[middle meningeal artery embolization]], but one day later he developed a stroke. Hence, [[thrombectomy]] and burr hole craniotomy were performed to manage the stroke and evacuate the chronic subdural hematoma (CSDH). This paper presents this case as uncommon acute on chronic SDH presented with headache and vertigo, treated with embolization and with complications of stroke and pulmonary embolism
((Al-Thawwab N, Alfaraj D, Alenezi A. Delayed Recognition, Surgical Dilemmas, and Complications: A Case Report of Acute-on-Chronic Subdural Hematoma With Ischemic Stroke. Cureus. 2023 Dec 15;15(12):e50610. doi: 10.7759/cureus.50610. PMID: 38226134; PMCID: PMC10788661.)).
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A case of a 74-year-old male on aspirin with a history of recurrent symptomatic chronic right-sided subdural hematoma treated successfully with a SEPS and right middle meningeal artery embolization with poly vinyl alcohol (PVA) microparticles. The patient initially presented to the emergency department with headaches, difficulty walking, and left sided hemiparesis. CT Head showed a large chronic right-sided subdural hematoma measuring 2.7 cm thick with 1 cm of leftward shift. Patient underwent placement of a right-sided SEPS and the subdural hematoma decreased in size to 1.0 cm with 2 mm of leftward shift. The patient had resolution of headaches and neurological symptoms and was discharged home. Three months later, the patient returned to the emergency department with headache and left hand numbness. CT Head showed an acute on chronic right-sided subdural hematoma measuring 1.4 cm with 3 mm of leftward shift. Patient underwent right-sided SEPS placement. Repeat CT Head showed reduction in the subdural hematoma to 1.2 cm. The SEPS was removed and the patient had resolution of neurological symptoms. The patient then had a diagnostic cerebral angiogram with PVA microparticle embolization of the right middle meningeal artery. A SEPS was placed at the time of the angiogram to further reduce the size of the subdural hematoma.

Repeat CT Head after SEPS and middle meningeal artery embolization showed decrease in size of the subdural hematoma. Follow-up CT Head showed stability of the subdural hematoma and patient had no further neurological symptoms. Patient was discharged home.

Middle meningeal artery embolization is a useful endovascular technique for reducing the arterial supply to the membranes in chronic subdural hematomas. Middle meningeal artery embolization can reduce the recurrence rate of subdural hematomas
((https://jnis.bmj.com/content/10/Suppl_2/A98.1)).
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In [[1994]] a rare case of [[chronic subdural hematoma]] associated with a middle meningeal arteriovenous fistula was treated by a combination of embolization and burr hole drainage. This clinical situation might be missed in this era of computed tomography, when cerebral angiography is seldom indicated for the diagnosis of neuro-traumatic diseases. We should bear in mind the possibility of this clinical situation of a chronic subdural hematoma associated with a linear skull fracture crossing the middle meningeal groove in order to avoid possible hemorrhagic complications during surgery for chronic subdural hematoma
((Komiyama M, Yasui T, Tamura K, Nagata Y, Fu Y, Yagura H. Chronic subdural hematoma associated with middle meningeal arteriovenous fistula treated by a combination of embolization and burr hole drainage. Surg Neurol. 1994 Oct;42(4):316-9. doi: 10.1016/0090-3019(94)90400-6. PMID: 7974127.)).

===== References =====