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Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations
Published on: October 20, 2017
Effectiveness of subdural evacuating port system (SEPS) and middle meningeal artery embolization (MMAE) for chronic
Jaims Lim1,2, Vinay Jaikumar1,2, Alexandra R Paul3
1Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.
Background:
Craniotomy for subdural hematoma (SDH) in elderly patients with comorbidities can be challenging. The Subdural Evacuating Port System (SEPS; Medtronic, Minneapolis, MN) offers a less invasive alternative, while middle meningeal artery embolization (MMAE) has shown effectiveness in preventing SDH recurrence. We evaluated the combined effectiveness of SEPS+MMAE for chronic SDH (cSDH) treatment.
Methods:
Retrospective database reviews were conducted. Demographic, comorbidity, procedural, and outcomes data were analyzed. cSDH resolution was tracked by measuring hematoma volumes on noncontrast computed tomograms pre-SEPS+MMAE, 24-48 hours post-SEPS+MMAE, and 6-8 weeks afterward (follow-up-SEPS+MMAE).
Results:
Our study included 114 patients (median age: 77 years (interquartile range (IQR): 69-83 years); men: women=74:40) with 134 cSDHs treated with SEPS+MMAE were included. Median pre-SEPS+MMAE cSDH volume was 122.9 mL (88-152.4 mL) with midline shift of 6 mm (3.4-9.5 mm). Most MMAE procedures were performed under general anesthesia (68.7%), utilizing the femoral approach (61.9%) and particle embolic agents (55.2%). In-hospital rescue craniotomy was required after 10 (7.5%) procedures. Median post-SEPS+MMAE and follow-up-SEPS+MMAE cSDH volume reductions were 71.1 mL (54.1-94.8 mL) and 23.4 mL (2-56.3 mL), respectively, resulting in 38.1% (22.1-52.9%) and 79.9% (51-97.8%) reductions, respectively. Of 109 patients with follow-up, 10 (9.2%) were readmitted for cSDH residual/recurrence within 90 days, eight (7.3%) required retreatment: five (4.6%) with craniotomy, three (2.8%) with SEPS. Hyperlipidemia (P=0.002), anticoagulant use (P=0.036), and larger pre-SEPS+MMAE cSDH volume (P<0.001) predicted greater SEPS-mediated clearance. Older age (P=0.03), coronary artery disease (P=0.004), membranes within cSDH (P=0.039), acute/subacute components in cSDH (P=0.047), and unilateral cSDH (P=0.017) predicted less SEPS-mediated clearance. Older age (P=0.006), acute/subacute components in cSDH (P=0.016), and longer follow-up (P=0.013) predicted higher MMAE effectiveness. Higher pre-SEPS+MMAE cSDH volume (P=0.047) and unilateral MMAE for bilateral cSDH (P=0.036) predicted lower MMAE effectiveness.
Conclusion:
SEPS+MMAE was an effective, safe treatment for cSDH.
