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Published on: October 15, 2021
The CSDH Grading Scheme for Middle Meningeal Artery Embolization: Stratified Risk of Surgical Rescue
Li Ma1, Rachel C Jacobs1, Prateek Agarwal1
1Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
Background And Objectives:
Prospective stratification of surgical rescue risk after middle meningeal artery embolization (MMAE) for chronic subdural hematomas (CSDHs) can facilitate a follow-up approach and optimize patient expectations. In this study, we have identified factors, identifiable at the time of presentation, for MMAE failure in a summative fashion using a grading scheme.
Methods:
The scheme includes 4 domains defined on presentation (1 point for each): Coagulation/platelet abnormality, Scan findings (midline shift >6 mm, hemispheric hematoma with thickness ≥15 mm, or acute components), Deficits (attributable focal neurological deficits [FNDs]), History (comorbidities requiring antithrombotic agents during the reabsorption of hematomas), making up "CSDH." The predictive performance for risk of surgical rescue was assessed using calibration curve and C-index in an institutional cohort. In a test dataset of 100 cases, its accuracy was further compared with 2 regression models.
Results:
Of 298 CSDHs undergoing stand-alone MMAE, 9.4% required surgical rescue (n = 28): 5.4% if Grade 1 (0-1 point, 87% cases), 29% if Grade 2 (2 points, 11% of cases), and 67% if Grade 3 (3 points or more, 2% of cases). The CSDH score demonstrated both external accuracy and discrimination (C-index 0.81, 95% CI 0.74-0.87). Accuracy persisted in the test data (area under the receiver-operating characteristic curves [AUROC] 0.85, 95% CI 0.74-0.95) compared with a least absolute shrinkage and selection operator regression model (FNDs, hemispheric hematoma, acute component, midline shift >6 mm, age, and hemodialysis; AUROC 0.79, 95% CI 0.66-0.92, P = .46) and a logistic regression model (FNDs, hemispheric hematoma, acute component, and thrombocytopenia; AUROC 0.75, 95% CI 0.61-0.89, P = .22).
Conclusion:
Comprehensive assessment of CSDH imaging features, neurological deficits, and predisposing hemorrhagic factors may delineate appropriate candidates for stand-alone MMAE.
Insights
A new CSDH score predicts surgical rescue risk after middle meningeal artery embolization (MMAE). Higher scores indicate increased risk, aiding treatment decisions for chronic subdural hematomas (CSDHs).
Area of Science:
- Neurosurgery
- Interventional Radiology
- Medical Imaging
Background:
- Chronic subdural hematomas (CSDHs) often require intervention.
- Middle meningeal artery embolization (MMAE) is an emerging treatment for CSDHs.
- Predicting the need for surgical rescue after MMAE is crucial for patient management.
Purpose of the Study:
- To develop and validate a grading scheme for predicting surgical rescue risk after MMAE in CSDH patients.
- To identify factors at presentation that indicate MMAE failure.
Main Methods:
- A 4-domain grading scheme was developed, assessing coagulation, scan findings, neurological deficits, and patient history.
- The scheme's predictive performance was evaluated using calibration curves and C-index in an institutional cohort.
- Accuracy was compared against regression models in a separate test dataset.
Main Results:
- The CSDH score demonstrated strong predictive accuracy (C-index 0.81) and discrimination.
- Surgical rescue rates increased significantly with higher CSDH scores (Grade 1: 5.4%, Grade 2: 29%, Grade 3: 67%).
- The CSDH score outperformed traditional regression models in a test dataset (AUROC 0.85).
Conclusions:
- The CSDH score effectively stratifies surgical rescue risk after MMAE.
- Comprehensive assessment of imaging, deficits, and hemorrhagic factors can guide MMAE candidacy.
- This tool can optimize patient selection and follow-up strategies for CSDH treatment.
