Standalone middle meningeal artery embolization versus middle meningeal artery embolization with concurrent surgical evacuation for chronic subdural hematomas: a multicenter propensity score matched analysis of clinical and radiographic outcomes

Huanwen Chen; Mohamed M Salem; Marco Colasurdo; Georgios S Sioutas; Jane Khalife; Okkes Kuybu; Kate T Carroll; Alex Nguyen Hoang; Ammad A Baig; Mira Salih; Mirhojjat Khorasanizadeh; Cordell Baker; Aldo Mendez Ruiz; Gustavo M Cortez; Zack Abecassis; Juan Francisco Ruiz Rodríguez; Jason M Davies; Sandra Narayanan; C Michael Cawley; Howard Riina; Justin Moore; Alejandro M Spiotta; Alexander Khalessi; Brian M Howard; Ricardo A Hanel; Omar Tanweer; Daniel Tonetti; Adnan H Siddiqui; Michael Lang; Elad I Levy; Tudor G Jovin; Ramesh Grandhi; Visish M Srinivasan; Michael R Levitt; Christopher S Ogilvy; Brian Jankowitz; Ajith J Thomas; Bradley A Gross; Jan Karl Burkhardt; Peter Kan

doi:10.1136/jnis-2023-020907

Standalone middle meningeal artery embolization versus middle meningeal artery embolization with concurrent surgical evacuation for chronic subdural hematomas: a multicenter propensity score matched analysis of clinical and radiographic outcomes

J Neurointerv Surg. 2023 Nov 6:jnis-2023-020907. doi: 10.1136/jnis-2023-020907. Online ahead of print.

Authors

Huanwen Chen^#^{1

2}, Mohamed M Salem^#³, Marco Colasurdo⁴, Georgios S Sioutas³, Jane Khalife⁵, Okkes Kuybu⁶, Kate T Carroll⁷, Alex Nguyen Hoang⁸, Ammad A Baig⁹, Mira Salih¹⁰, Mirhojjat Khorasanizadeh¹⁰, Cordell Baker¹¹, Aldo Mendez Ruiz⁶, Gustavo M Cortez¹², Zack Abecassis¹³, Juan Francisco Ruiz Rodríguez¹³, Jason M Davies¹⁴, Sandra Narayanan¹⁵, C Michael Cawley¹⁶, Howard Riina¹⁷, Justin Moore¹⁰, Alejandro M Spiotta¹⁸, Alexander Khalessi¹⁹, Brian M Howard^{20

21}, Ricardo A Hanel²², Omar Tanweer²³, Daniel Tonetti²⁴, Adnan H Siddiqui^{25

26}, Michael Lang²⁷, Elad I Levy²⁸, Tudor G Jovin²⁹, Ramesh Grandhi¹¹, Visish M Srinivasan³⁰, Michael R Levitt⁷, Christopher S Ogilvy³¹, Brian Jankowitz³², Ajith J Thomas²⁴, Bradley A Gross³³, Jan Karl Burkhardt³, Peter Kan³⁴

Affiliations

¹ National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA.
² Neurology, MedStar Georgetown University Hospital, Washington, District of Columbia, USA.
³ Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
⁴ Interventional Radiology, Oregon Health and Science University, Portland, Oregon, USA.
⁵ Department of Neurosurgery, Cooper Medical School of Rowan University, Camden, New Jersey, USA.
⁶ Department of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Kansas, USA.
⁷ Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA.
⁸ Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.
⁹ Neurosurgery, Buffalo State, The State University of New York, Buffalo, New York, USA.
¹⁰ Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
¹¹ Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA.
¹² Neurosurgery, Lyerly Neurosurgery, Jacksonville, Florida, USA.
¹³ Department of Neurosurgery, University of Washington, Seattle, Washington, USA.
¹⁴ Neurosurgery and Biomedical Engineering, Toshiba Stroke and Vascular Research Institute, University at Buffalo, State University of New York, Buffalo, New York, USA.
¹⁵ Department of Neurology, Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA.
¹⁶ Neurosurgery, Emory University, Atlanta, Georgia, USA.
¹⁷ Neurosurgery, NYU, New York, New York, USA.
¹⁸ Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.
¹⁹ Department of Neurological Surgery, University of California San Diego, La Jolla, California, USA.
²⁰ Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.
²¹ Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA.
²² Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA.
²³ Department of Neurosurgery, NYU Langone Health, New York, New York, USA.
²⁴ Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA.
²⁵ Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.
²⁶ Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA.
²⁷ Department of Neurosurgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA.
²⁸ Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.
²⁹ Neurology, Cooper University Hospital, Camden, New Jersey, USA.
³⁰ University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA.
³¹ Department of Neurosurgery, BIDMC, Boston, Massachusetts, USA.
³² Neurosurgery, University of Pennsylvania, Camden, Pennsylvania, USA.
³³ Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
³⁴ Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, Texas, USA ptkan@utmb.edu.

^# Contributed equally.

PMID: 37932033
DOI: 10.1136/jnis-2023-020907

Abstract

Background: Middle meningeal artery embolization (MMAE) has emerged as a promising therapy for chronic subdural hematomas (cSDHs). The efficacy of standalone MMAE compared with MMAE with concurrent surgery is largely unknown.

Methods: cSDH patients who underwent successful MMAE from 14 high volume centers with at least 30 days of follow-up were included. Clinical and radiographic variables were recorded and used to perform propensity score matching (PSM) of patients treated with standalone MMAE or MMAE with concurrent surgery. Multivariable logistic regression models were used for additional covariate adjustments. The primary outcome was recurrence requiring surgical rescue, and the secondary outcome was radiographic failure defined as <50% reduction of cSDH thickness.

Results: 722 MMAE procedures in 588 cSDH patients were identified. After PSM, 230 MMAE procedures remained (115 in each group). Median age was 73 years, 22.6% of patients were receiving anticoagulation medication, and 47.9% had no preoperative functional disability. Median midline shift was 4 mm and cSDH thickness was 16 mm, representing modestly sized cSDHs. Standalone MMAE and MMAE with surgery resulted in similar rates of surgical rescue (7.8% vs 13.0%, respectively, P=0.28; adjusted OR (aOR 0.73 (95% CI 0.20 to 2.40), P=0.60) and radiographic failure (15.5% vs 13.7%, respectively, P=0.84; aOR 1.08 (95% CI 0.37 to 2.19), P=0.88) with a median follow-up duration of 105 days. These results were similar across subgroup analyses and follow-up durations.

Conclusions: Standalone MMAE led to similar and durable clinical and radiographic outcomes as MMAE combined with surgery in select patients with moderately sized cSDHs and mild clinical disease.

Keywords: Embolic; Hemorrhage; Subdural.