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[EMBOLIZATION OF MIDDLE MENINGEAL ARTERY AS A TREATMENT FOR CHRONIC SUBDURAL HEMATOMA]
Dan Zharia Milikovsky1, Oz Haim2, Sharif Basal2
1Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.
Insights
Chronic subdural hemorrhage (CSDH) is a common neurosurgical condition. A new endovascular embolization of the middle meningeal artery (MMA) treatment shows promise for reducing CSDH recurrence.
Area of Science:
- Neurosurgery
- Vascular Neurology
- Interventional Radiology
Background:
- Chronic subdural hemorrhage (CSDH) is a frequent neurosurgical condition with increasing incidence due to population aging and medication use.
- Traditional understanding of CSDH involved bridging vein rupture; however, recent research highlights dural border cell layer separation, inflammation, and angiogenesis as key mechanisms.
- High recurrence rates of approximately 30% persist with current surgical treatments for CSDH.
Purpose of the Study:
- To review the epidemiology and underlying mechanisms of chronic subdural hemorrhage.
- To discuss current and novel treatment strategies for CSDH.
- To raise awareness among the Israeli medical community regarding endovascular embolization of the middle meningeal artery (MMA) as a treatment option.
Main Methods:
- Literature review of CSDH epidemiology, pathophysiology, and treatment modalities.
- Analysis of recent findings on CSDH mechanisms, including inflammation and angiogenesis.
- Evaluation of endovascular embolization of the middle meningeal artery (MMA) as a therapeutic intervention.
Main Results:
- CSDH incidence is rising, driven by demographic and pharmacologic trends.
- A novel understanding of CSDH pathogenesis involves inflammatory processes and neovascularization.
- Endovascular embolization of the MMA presents a promising, effective, and safe treatment for CSDH, with potential for standalone or combined use.
Conclusions:
- CSDH requires updated understanding of its complex pathophysiology.
- Endovascular MMA embolization offers a potentially superior alternative or adjunct to traditional CSDH treatments.
- Increased awareness and adoption of MMA embolization can improve patient outcomes for CSDH.
Introduction:
Chronic subdural hemorrhage (CSDH) is one of the most common reasons for neurosurgical intervention. The incidence and prevalence of this condition is expected to grow due to aging of the population and the increase in anticoagulation and anti-aggregation prescription drugs. Traditionally, it was accepted that the bleeding originates from bridging veins 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. This review 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.
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