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Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations
Published on: October 20, 2017
Adjunct Middle Meningeal Artery Embolization Versus Surgery for Chronic Subdural Hematoma: A Systematic Review and
Zheting Zhang1, Jia Xu Lim2, David Wen3
1Lee Kong Chian School of Medicine, Nanyang Technological University, 11 Mandalay Road, Singapore, 308232, Singapore. zzhang059@e.ntu.edu.sg.
Background:
The procedure of middle meningeal artery embolization (MMAE) has emerged as a minimally invasive therapy for chronic subdural hematoma (CSDH). Previous studies comparing MMAE with conventional treatment for CSDH did not differentiate primary/upfront, adjunct, or rescue MMAE, and included both conservative and surgical treatment in the comparison group. We conducted a systematic review and meta-analysis to compare outcomes after adjunct MMAE (MMAE combined with surgical evacuation) versus surgery alone for CSDH.
Methods:
PubMed, Embase, Cochrane, Web of Science, and Scopus databases were searched to August 2023. Primary outcomes were treatment failure and reoperation. Secondary outcomes were complications, mortality, length of hospital stay, 30-day readmission, and follow-up modified Rankin Scale (mRS) > 2. Additional data from our institution was included.
Results:
12 published studies and our data yielded 57,165 patients, of whom 1,065 (1.9%) received adjunct MMAE and 56,100 (98.1%) surgery alone. Compared to surgery alone, adjunct MMAE was associated with lower rates of treatment failure (OR = 0.43 [0.23-0.83], p = 0.01), reoperation (OR = 0.45 [0.22-0.90], p = 0.02), and 30-day readmission (OR = 0.50 [0.34-0.73], p < 0.001). Length of hospital stay (MD = 2.49 [-0.51, 5.49], p = 0.10) was non-significantly longer in the adjunct MMAE group. Both groups had comparable rates of treatment-related complications (OR = 0.89 [0.52-1.53], p = 0.67), mortality (OR = 1.05 [0.75-1.46], p = 0.78), and follow-up mRS > 2 (OR = 0.91 [0.39-2.12], p = 0.83).
Conclusions:
Adjunct MMAE reduces treatment failure, reoperation, and readmission rates without increasing morbidity and mortality. MMAE may be considered as an adjunct to surgical evacuation to reduce CSDH recurrence. Randomized trials will further establish the evidence for adjunct MMAE and its role in the management of CSDH.
Insights
Adjunct middle meningeal artery embolization (MMAE) combined with surgery significantly lowers chronic subdural hematoma (CSDH) recurrence and reoperation rates. This minimally invasive approach offers comparable safety to surgery alone, reducing patient readmissions.
Area of Science:
- Neurosurgery
- Interventional Radiology
- Vascular Surgery
Background:
- Chronic subdural hematoma (CSDH) management often involves surgical evacuation.
- Middle meningeal artery embolization (MMAE) is an emerging minimally invasive therapy for CSDH.
- Previous research lacked differentiation between primary, adjunct, or rescue MMAE strategies.
Approach:
- Systematic review and meta-analysis of studies published up to August 2023.
- Searched PubMed, Embase, Cochrane, Web of Science, and Scopus databases.
- Included institutional data, comparing adjunct MMAE with surgery alone for CSDH.
Key Points:
- Adjunct MMAE significantly reduced treatment failure (OR=0.43), reoperation (OR=0.45), and 30-day readmission (OR=0.50) compared to surgery alone.
- No significant differences observed in treatment-related complications, mortality, or functional outcomes (mRS > 2).
- Length of hospital stay was non-significantly longer in the adjunct MMAE group.
Conclusions:
- Adjunct MMAE is effective in reducing CSDH recurrence, reoperation, and readmission rates.
- The procedure demonstrates comparable safety to surgery alone, without increased morbidity or mortality.
- Further randomized trials are warranted to solidify the role of adjunct MMAE in CSDH management.
