Adjunctive middle meningeal artery embolization may reduce the recurrence of subdural hematomas

1. In this randomized controlled trial, middle meningeal artery embolization plus surgical evacuation was associated with a lower risk of hematoma recurrence or progression in patients with a symptomatic subacute or chronic subdural hematoma.

2. The 90-day mortality appeared to be higher in the treatment group than the control group, thus, further studies are needed to evaluate the safety of middle meningeal artery embolization for management of subdural hematoma.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Surgical evacuation is often indicated for the treatment of subacute and chronic subdural hematoma. The inflammatory response to these bleeds often produces vascularized membranes that can prevent resorption and contribute to the recurrence of the hematoma. Recurrence after surgery happens in 8 to 20% of patients. Retreatment after recurrence can lead to clinical deterioration and poor clinical outcomes. Middle meningeal artery embolization is a non-surgical procedure that reduces blood flow to the inflamed dural vascular membranes. Many preliminary studies indicate that middle meningeal artery embolization may reduce the risk of hematoma recurrence. This study aimed to compare subdural hematoma recurrence in patients with a symptomatic subacute or chronic subdural hematoma who underwent either middle meningeal artery embolization plus surgery or surgery alone. In this study, patients were randomly assigned to undergo middle meningeal artery embolization plus surgery (treatment group) or surgery alone (control group). The primary endpoint was hematoma recurrence or progression that led to repeat surgery within 90 days of the index treatment. The secondary endpoint was the deterioration of neurologic function at 90 days, as assessed by the Rankin scale. Results from this study found that hematoma recurrence or progression leading to repeat surgery occurred more in the control group compared to the treatment group. Mortality at 90 days was slightly higher in the treatment group than in the control group. Overall, this study found that among patients with symptomatic subacute or chronic subdural hematoma who require surgical evacuation, middle meningeal artery embolization plus surgery was associated with a lower risk of hematoma recurrence or progression than surgery alone.

Click here to read the study in NEJM

In-Depth [randomized controlled trial]: This randomized controlled trial compared hematoma recurrence or progression in patients with a symptomatic subacute or chronic subdural hematoma who underwent either middle meningeal artery embolization plus surgery (treatment) or surgery alone (control). Adult patients who had CT evidence of subacute or chronic subdural hematoma required surgical evacuation and had neurological symptoms were eligible for this study. Patients were excluded if they had a life expectancy of less than one year, a modified Rankin score of 4 or 5 before the hematoma developed, or if they had severe neurological symptoms, such as stupor, severe focal signs, or coma. A total of 400 patients were randomly assigned in a 1:1 ratio to either the treatment group (n=197) or the control group (n=203). Middle meningeal artery embolization was performed with biplane digital subtraction angiography, where a catheter was inserted into the artery and an embolic agent was injected. Results from this study found that hematoma recurrence or progression leading to repeat surgery occurred in eight patients (4.1%) in the treatment group and 23 patients (11.3%) in the control group (relative risk, 0.36; 95% Confidence Interval [CI], 0.11 to 0.80; p = 0.008). Functional deterioration occurred in 11.9% of patients in the treatment group and 9.8% of patients in the control group (risk difference, 2.1 percentage points; 95% CI, -4.8 to 8.9). Mortality at 90 days was 5.1% in the treatment group and 3.0% in the control group. By 180 days, four patients (2.0%) in the treatment group had experienced a serious adverse event related to the embolization procedure. Overall, results from this randomized controlled trial found that among patients with symptomatic subacute or chronic subdural hematomas that required surgical evacuation, middle meningeal artery embolization plus surgery was associated with a lower risk of hematoma recurrence or progression and reoperation than surgery alone.

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