Skip to main content

Advertisement

SpringerLink
Log in

Efficacy and safety of middle meningeal artery embolization in the management of refractory or chronic subdural hematomas: a systematic review and meta-analysis

  • Review Article - Vascular Neurosurgery - Other
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript

Abstract

Introduction

Refractory or chronic subdural hematomas (cSDH) constitute a challenging entity that neurosurgeons face frequently nowadays. Middle meningeal artery embolization (MMAE) has emerged in the recent years as a promising treatment option. However, solid evidence that can dictate management guidelines is still lacking.

Methods

We conducted a systematic review and meta-analysis (MA) in compliance with the PRISMA guidelines to evaluate the efficacy and safety of MMAE compared with conventional treatments for refractory or cSDH. Databases were searched up to March 2019. Using a random-effects model, meta-analyses of proportions and risk difference were conducted recurrence, need for surgical rescue, and complications.

Results

Eleven studies (177 patients) were included. Majority (116, 69%) were males with a weighted mean age of 71 + −19.5 years. Meta-analysis of proportions showed treatment failure to be 2.8%, need for surgical rescue 2.7%, and embolization-related complications 1.2%. Meta-analysis of risk-difference between embolized and non-embolized patients showed a 26% (p < 0.001, 95% CI 21%–31%, I2 = 0) lower risk of hematoma recurrence in MMAE. Similarly, in the embolized group, the need for surgical rescue was 20% less (p < 0.001, 95% CI = 12%–27%, I2 = 12.4), and complications were 3.6% less (p = 0.008, 95% CI 1%–6%, I2 = 0) compared to conventional groups.

Conclusions

Although MMAE appears to be a promising treatment for refractory or cSDH, drawing definitive conclusions remains limited by paucity of data and small sample sizes. Multicenter, randomized, prospective trials are needed to compare embolization to conventional treatments like watchful waiting, medical management, or surgical evacuation. More extensive research on MMAE could begin a new era in the minimally invasive management of cSDH.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Almenawer SA, Farrokhyar F, Hong C, Alhazzani W, Manoranjan B, Yarascavitch B, Arjmand P, Baronia B, Reddy K, Murty N, Singh S (2014) Chronic subdural hematoma management: a systematic review and meta-analysis of 34,829 patients. Ann Surg 259:449–457. https://doi.org/10.1097/SLA.0000000000000255

    Article  PubMed  Google Scholar 

  2. Aoki N (1990) Chronic subdural hematoma in infancy: clinical analysis of 30 cases in the CT era. J Neurosurg 73:201–205

    Article  CAS  PubMed  Google Scholar 

  3. Arbit E, Patterson RH Jr, Fraser RA (1981) An implantable subdural drain for treatment of chronic subdural hematoma. Surg Neurol 15:175–177

    Article  CAS  PubMed  Google Scholar 

  4. Ban SP, Hwang G, Byoun HS, Kim T, Lee SU, Bang JS, Han JH, Kim C-Y, Kwon O-K, Oh CW (2017) Middle meningeal artery embolization for chronic subdural hematoma. Radiology 286:992–999

    Article  PubMed  Google Scholar 

  5. Berghauser Pont LM, Dirven CM, Dippel DW, Verweij BH, Dammers R (2012) The role of corticosteroids in the management of chronic subdural hematoma: a systematic review. Eur J Neurol 19:1397–1403. https://doi.org/10.1111/j.1468-1331.2012.03768.x

    Article  CAS  PubMed  Google Scholar 

  6. Chihara H, Imamura H, Ogura T, Adachi H, Imai Y, Sakai N (2014) Recurrence of a refractory chronic subdural hematoma after middle meningeal artery embolization that required craniotomy. NMC Case Rep J 1:1–5

    Article  PubMed  PubMed Central  Google Scholar 

  7. Court J, Touchette CJ, Iorio-Morin C, Westwick HJ, Belzile F, Effendi K (2019) Embolization of the middle meningeal artery in chronic subdural hematoma–a systematic. Clin Neurol Neurosurg 105464

  8. Frati A, Salvati M, Mainiero F, Ippoliti F, Rocchi G, Raco A, Caroli E, Cantore G, Delfini R (2004) Inflammation markers and risk factors for recurrence in 35 patients with a posttraumatic chronic subdural hematoma: a prospective study. J Neurosurg 100:24–32

    Article  PubMed  Google Scholar 

  9. Gaist D, Rodríguez LAG, Hellfritzsch M, Poulsen FR, Halle B, Hallas J, Pottegård A (2017) Association of antithrombotic drug use with subdural hematoma risk. Jama 317:836–846

    Article  PubMed  Google Scholar 

  10. Gernsback J, Kolcun JP, Jagid J (2016) To drain or two drains: recurrences in chronic subdural hematomas. World Neurosurg 95:447–450. https://doi.org/10.1016/j.wneu.2016.08.069

    Article  PubMed  Google Scholar 

  11. Haines DE, Harkey HL, Al-Mefty O (1993) The “subdural” space: a new look at an outdated concept. Neurosurgery 32:111–120

    Article  CAS  PubMed  Google Scholar 

  12. Hashimoto T, Ohashi T, Watanabe D, Koyama S, Namatame H, Izawa H, Haraoka R, Okada H, Ichimasu N, Akimoto J (2013) Usefulness of embolization of the middle meningeal artery for refractory chronic subdural hematomas. Surg Neurol Int 4

    Article  PubMed  PubMed Central  Google Scholar 

  13. Hellwig D, Kuhn TJ, Bauer BL, List-Hellwig E (1996) Endoscopic treatment of septated chronic subdural hematoma. Surg Neurol 45:272–277

    Article  CAS  PubMed  Google Scholar 

  14. Hirai S, Ono J, Odaki M, Serizawa T, Nagano O (2004) Embolization of the middle meningeal artery for refractory chronic subdural haematoma: usefulness for patients under anticoagulant therapy. Interv Neuroradiol 10:101–104

    Article  PubMed  PubMed Central  Google Scholar 

  15. Ishihara H, Ishihara S, Kohyama S, Yamane F, Ogawa M, Sato A, Matsutani M (2007) Experience in endovascular treatment of recurrent chronic subdural hematoma. Interv Neuroradiol 13:141–144

    Article  PubMed  PubMed Central  Google Scholar 

  16. Ito H, Yamamoto S, Komai T, Mizukoshi H (1976) Role of local hyperfibrinolysis in the etiology of chronic subdural hematoma. J Neurosurg 45:26–31

    Article  CAS  PubMed  Google Scholar 

  17. Ivamoto HS, Lemos HP Jr, Atallah AN (2016) Surgical treatments for chronic subdural hematomas: a comprehensive systematic review. World Neurosurg 86:399–418. https://doi.org/10.1016/j.wneu.2015.10.025

    Article  PubMed  Google Scholar 

  18. Kalamatianos T, Stavrinou LC, Koutsarnakis C, Psachoulia C, Sakas DE, Stranjalis G (2013) PlGF and sVEGFR-1 in chronic subdural hematoma: implications for hematoma development. J Neurosurg 118:353–357

    Article  PubMed  Google Scholar 

  19. Kim E (2017) Embolization therapy for refractory hemorrhage in patients with chronic subdural hematomas. World Neurosurg 101:520–527

    Article  PubMed  Google Scholar 

  20. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 6:e1000100

    Article  PubMed  PubMed Central  Google Scholar 

  21. Link TW, Boddu S, Marcus J, Rapoport BI, Lavi E, Knopman J (2017) Middle meningeal artery embolization as treatment for chronic subdural hematoma: a case series. Oper Neurosurg 14:556–562

    Article  Google Scholar 

  22. Link TW, Boddu S, Paine SM, Kamel H, Knopman J (2018) Middle meningeal artery embolization for chronic subdural hematoma: a series of 60 cases. Neurosurgery. https://doi.org/10.1093/neuros/nyy521

    Article  Google Scholar 

  23. Link TW, Rapoport BI, Paine SM, Kamel H, Knopman J (2018) Middle meningeal artery embolization for chronic subdural hematoma: endovascular technique and radiographic findings. Interv Neuroradiol 24:455–462

    Article  PubMed  PubMed Central  Google Scholar 

  24. Liu W, Bakker NA, Groen RJ (2014) Chronic subdural hematoma: a systematic review and meta-analysis of surgical procedures. J Neurosurg 121:665–673. https://doi.org/10.3171/2014.5.JNS132715

    Article  PubMed  Google Scholar 

  25. Mandai S, Sakurai M, Matsumoto Y (2000) Middle meningeal artery embolization for refractory chronic subdural hematoma: case report. J Neurosurg 93:686–688

    Article  CAS  PubMed  Google Scholar 

  26. Matsumoto H, Hanayama H, Okada T, Sakurai Y, Minami H, Masuda A, Tominaga S, Miyaji K, Yamaura I, Yoshida Y (2018) Which surgical procedure is effective for refractory chronic subdural hematoma? Analysis of our surgical procedures and literature review. J Clin Neurosci 49:40–47

    Article  PubMed  Google Scholar 

  27. Middle Meningeal Artery Embolization for Treatment of Chronic Subdural Hematoma (2019) Retrieved from https://ClinicalTrials.gov/show/NCT03307395. (Identification No. NCT03307395). Weill Cornell Medical College, New York

  28. Mino M, Nishimura S, Hori E, Kohama M, Yonezawa S, Midorikawa H, Kaimori M, Tanaka T, Nishijima M (2010) Efficacy of middle meningeal artery embolization in the treatment of refractory chronic subdural hematoma. Surg Neurol Int 1

  29. Misra M, Salazar JL, Bloom DM (1996) Subdural-peritoneal shunt: treatment for bilateral chronic subdural hematoma. Surg Neurol 46:378–383

    Article  CAS  PubMed  Google Scholar 

  30. Nagahori T, Nishijima M, Takaku A (1993) Histological study of the outer membrane of chronic subdural hematoma: possible mechanism for expansion of hematoma cavity. No shinkei geka Neurol Surg 21:697–701

    CAS  Google Scholar 

  31. National Heart L, Institute B (2014) Quality assessment tool for observational cohort and cross-sectional studies. National Institutes of Health, Department of Health and Human Services, Bethesda

    Google Scholar 

  32. Orlin JR, Osen KK, Hovig T (1991) Subdural compartment in pig: a morphologic study with blood and horseradish peroxidase infused subdurally. Anat Rec 230:22–37

    Article  CAS  PubMed  Google Scholar 

  33. Poulsen FR, Munthe S, Søe M, Halle B (2014) Perindopril and residual chronic subdural hematoma volumes six weeks after burr hole surgery: a randomized trial. Clin Neurol Neurosurg 123:4–8

    Article  PubMed  Google Scholar 

  34. Qiu S, Zhuo W, Sun C, Su Z, Yan A, Shen L (2017) Effects of atorvastatin on chronic subdural hematoma: a systematic review. Medicine 96

  35. Rodziewicz G, Chuang W (1995) Endoscopic removal of organized chronic subdural hematoma. Surg Neurol 43:569–573

    Article  CAS  PubMed  Google Scholar 

  36. Santarius T, Kirkpatrick PJ, Kolias AG, Hutchinson PJ (2010) Working toward rational and evidence-based treatment of chronic subdural hematoma. Clin Neurosurg 57:112–122

    PubMed  Google Scholar 

  37. Sato M, Iwatsuki K, Akiyama C, Kumura E, Yoshimine T (2001) Implantation of a reservoir for refractory chronic subdural hematoma. Neurosurgery 48:1297–1301. https://doi.org/10.1097/00006123-200106000-00023

    Article  CAS  PubMed  Google Scholar 

  38. Shono T, Inamura T, Morioka T, K-i M, Suzuki SO, Ikezaki K, Iwaki T, Fukui M (2001) Vascular endothelial growth factor in chronic subdural haematomas. J Clin Neurosci 8:411–415

    Article  CAS  PubMed  Google Scholar 

  39. Srivatsan A, Mohanty A, Nascimento FA, Hafeez MU, Srinivasan VM, Thomas A, Chen SR, Johnson JN, Kan P (2018) Middle meningeal artery embolization for chronic subdural hematoma: meta-analysis and systematic review. World Neurosurg

  40. Stanisic M, Aasen AO, Pripp AH, Lindegaard K-F, Ramm-Pettersen J, Lyngstadaas SP, Ivanovic J, Konglund A, Ilstad E, Sandell T (2012) Local and systemic pro-inflammatory and anti-inflammatory cytokine patterns in patients with chronic subdural hematoma: a prospective study. Inflamm Res 61:845–852

    Article  CAS  PubMed  Google Scholar 

  41. Sun T, Boet R, Poon W (2005) Non-surgical primary treatment of chronic subdural haematoma: preliminary results of using dexamethasone. Br J Neurosurg 19:327–333

    Article  CAS  PubMed  Google Scholar 

  42. Takizawa K, Sorimachi T, Ishizaka H, Osada T, Srivatanakul K, Momose H, Matsumae M (2016) Enlargement of the middle meningeal artery on MR angiography in chronic subdural hematoma. J Neurosurg 124:1679–1683

    Article  PubMed  Google Scholar 

  43. Tanaka T, Fujimoto S, Saito K, Kaimori M (1997) Histological study of operated cases of chronic subdural hematoma in adults: relationship between dura mater and outer membrane. No shinkei geka Neurol Surg 25:701–705

    CAS  Google Scholar 

  44. Tempaku A, Yamauchi S, Ikeda H, Tsubota N, Furukawa H, Maeda D, Kondo K, Nishio A (2015) Usefulness of interventional embolization of the middle meningeal artery for recurrent chronic subdural hematoma: five cases and a review of the literature. Interv Neuroradiol 21:366–371

    Article  PubMed  PubMed Central  Google Scholar 

  45. Thotakura AK, Marabathina NR (2015) Nonsurgical treatment of chronic subdural hematoma with steroids. World Neurosurg 84:1968–1972

    Article  PubMed  Google Scholar 

  46. Toi H, Kinoshita K, Hirai S, Takai H, Hara K, Matsushita N, Matsubara S, Otani M, Muramatsu K, Matsuda S (2018) Present epidemiology of chronic subdural hematoma in Japan: analysis of 63,358 cases recorded in a national administrative database. J Neurosurg 128:222–228

    Article  PubMed  Google Scholar 

  47. Tunali S (2016) External carotid artery. In: Shoja MM, Loukas M (eds) Tubbs RS. John Wiley & Sons, Bergman's Comprehensive Encyclopedia of Human Anatomic Variation, pp 477–486. https://doi.org/10.1002/9781118430309.ch47

    Chapter  Google Scholar 

  48. Tyson G, Strachan WE, Newman P, Winn HR, Butler A, Jane J (1980) The role of craniectomy in the treatment of chronic subdural hematomas. J Neurosurg 52:776–781

    Article  CAS  PubMed  Google Scholar 

  49. Vinchon M, Noulé N, Soto-Ares G, Dhellemmes P (2001) Subduroperitoneal drainage for subdural hematomas in infants: results in 244 cases. J Neurosurg 95:249–255

    Article  CAS  PubMed  Google Scholar 

  50. Waqas M, Vakharia K, Weimer PV, Hashmi E, Davies JM, Siddiqui AH (2019) Safety and effectiveness of embolization for chronic subdural hematoma: systematic review and case series. World Neurosurg

  51. Weigel R, Hohenstein A, Schilling L (2014) Vascular endothelial growth factor concentration in chronic subdural hematoma fluid is related to computed tomography appearance and exudation rate. J Neurotrauma 31:670–673

    Article  PubMed  PubMed Central  Google Scholar 

  52. Weir B, Gordon P (1983) Factors affecting coagulation: fibrinolysis in chronic subdural fluid collections. J Neurosurg 58:242–245. https://doi.org/10.3171/jns.1983.58.2.0242

    Article  CAS  PubMed  Google Scholar 

  53. Xu CS, Lu M, Liu LY, Yao MY, Cheng GL, Tian XY, Xiao F, Wan Q, Chen F (2017) Chronic subdural hematoma management: clarifying the definitions of outcome measures to better understand treatment efficacy - a systematic review and meta-analysis. Eur Rev Med Pharmacol Sci 21:809–818

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Rutgers- Robert Wood Johnson Medical School & University Hospital, New Brunswick, NJ, USA

    Fareed Jumah, Ammar Jumah, Vinayak Narayan, Anil Nanda & Gaurav Gupta

  2. Department of Surgery, Dr. Ruth KM Pfau Hospital, Dow University of Health Sciences, Karachi, Pakistan

    Muhammad Osama

  3. Institute of Translational Medicine, University of Liverpool, Liverpool, UK

    Abdurrahman I. Islim

  4. Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK

    Abdurrahman I. Islim

  5. Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA

    Devi Prasad Patra, Jennifer Kosty & Rimal Hanif Dossani

Authors
  1. Fareed Jumah
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Muhammad Osama
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Abdurrahman I. Islim
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ammar Jumah
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Devi Prasad Patra
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Jennifer Kosty
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Vinayak Narayan
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Anil Nanda
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Gaurav Gupta
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Rimal Hanif Dossani
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

The following authors have contributed to the manuscript “Efficacy and Safety of Middle Meningeal Artery Embolization in the Management of Refractory or Chronic Subdural Hematomas: a Systematic Review and Meta-analysis” as follows:

• Conception and Design: Rimal Dossani, Fareed Jumah, Abdurrahman Islim, Gaurav Gupta, and Anil Nanda

• Data Acquisition: Fareed Jumah, Muhammad Osama, Ammar Jumah, and Vinayak Narayan

• Data Analysis: Fareed Jumah, Abdurrhaman Islim, Devi Patra, Vinayak Narayan

• Interpretation of Data: Fareed Jumah, Abdurrahman Islim, Jennifer Kosty, Devi Patra, and Vinayak Narayan

• Drafting Manuscript: Fareed Jumah, Muhammad Osama, Ammar Jumah, Jennifer Kosty, Rimal Dossani, Vinayak Narayan, and Gaurav Gupta

• Critical Revision of Manuscript: Rimal Dossani, Jennifer Kosty, Devi Patra, Abdurrahman Islim, Gaurav Gupta, Anil Nanda, Vinayak Narayan

• Final Approval of Manuscript: All authors

• Agreement to be accountable for all aspects of work: All authors

Corresponding author

Correspondence to Rimal Hanif Dossani.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

No informed consent was required for this study.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Vascular Neurosurgery - Other

Electronic supplementary material

ESM 1

(DOCX 12 kb)

ESM 2

(DOCX 17 kb)

ESM 3

(DOCX 19 kb)

ESM 4

(DOCX 19 kb)

ESM 5

(DOCX 17 kb)

ESM 6

(DOCX 19 kb)

ESM 7

(PNG 18 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Jumah, F., Osama, M., Islim, A.I. et al. Efficacy and safety of middle meningeal artery embolization in the management of refractory or chronic subdural hematomas: a systematic review and meta-analysis. Acta Neurochir 162, 499–507 (2020). https://doi.org/10.1007/s00701-019-04161-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00701-019-04161-3

Keywords

Search

Navigation