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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 45-49

Middle meningeal artery embolization in the management of chronic subdural haematoma: A case report and review of literature


Department of Neurosurgery, Apollo Hospitals, Chennai, Tamil Nadu, India

Date of Submission10-Aug-2020
Date of Acceptance01-Sep-2020
Date of Web Publication1-Oct-2020

Correspondence Address:
Dr. Srinivasan Paramasivam
Department of Neurosurgery, Apollo Hospitals, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcvs.jcvs_7_20

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  Abstract 


Chronic subdural hematoma (cSDH) is a common cranial neurosurgical condition with morbidity and mortality ranging from 2% to 5%. Conventional treatment includes conservative and surgical evacuation. Minimally invasive middle meningeal artery (MMA) embolisation is emerging as a potential treatment option. We report our case successfully managed by MMA embolization and review the literature. cSDH development and progression is related to the cycle of chronic inflammation and angiogenesis following the original hemorrhage due to trivial trauma. Due to growth factor, stimulation-initiating angiogenesis leading to growth of leaky blood vessels causing microhaemorrhages resulting in the progressive enlargement of subdural collection as the physiologic absorption capability is outpaced by the rate of collection. Strategies for the management of cSDH are aimed at interrupting the vicious cycle of its development and tilting the balance toward reabsorption of haemorrhage. Conservative management, medical treatment and surgical treatments are conventional treatment options with surgical evacuation considered as the gold standard option. However, challenges include recurrence and reversal of anti-platelets and anti-coagulants and its associated risk of ischaemic complications. cSDH being a pathology of meninges deriving blood the dura causing microhaemorrhages, it is prudent to seal off the vessels to tilt the balance towards resorption. MMA embolisation as a treatment option has been used with significant published data. It may be used as a stand-alone therapy in minimally symptomatic patients. Technical success rate is high both with polyviny alcohol and liquid embolic agents. Recurrence rate is consistently low in spite of significant patients having antiplatelets and anti-coagulants on board. It eliminates the ischemic complication due to stoppage of antiplatelets and anticoagulants. MMA embolization is also emerging as an adjunct to surgically evacuated cSDH that is considered high risk for recurrence.

Keywords: Burr hole evacuation, chronic subdural hematoma, craniotomy, middle meningeal artery embolisation, polyvinyl alcohol embolisation


How to cite this article:
Paramasivam S, Sudan H. Middle meningeal artery embolization in the management of chronic subdural haematoma: A case report and review of literature. J Cerebrovasc Sci 2020;8:45-9

How to cite this URL:
Paramasivam S, Sudan H. Middle meningeal artery embolization in the management of chronic subdural haematoma: A case report and review of literature. J Cerebrovasc Sci [serial online] 2020 [cited 2020 Nov 28];8:45-9. Available from: http://www.jcvs.com/text.asp?2020/8/1/45/296938




  Introduction Top


Chronic subdural hematoma (cSDH) is slow and progressive collection of blood in the subdural space commonly diagnosed in old age following trivial trauma. Its ever-increasing frequency is attributed to increased life expectancy and more frequent use of anti-coagulants and anti-platelet medications. It is expected to be the most common cranial neurosurgical condition in 2030 among adults.[1] Morbidity and mortality are low ranging from 2% to 5%,[2] but 6 month and 1 year mortality after the diagnosis of cSDH is estimated to be about 30% making this a sentinel health event marking a reduced life span compared to matched controls.[3],[4] Studies on the outcomes of cSDH have branded this a disabling and not a benign problem with increased mortality for up to 1 year after diagnosis.[5] Headache is the common symptoms of cSDH, followed by weakness, balance, gait disturbances, and cognitive decline.[6] Conventional treatment includes conservative management and surgical evacuation. cSDH being a disorder of blood vessels of the meninges, minimally invasive neuroendovascular management is a potential treatment option.


  Case Report Top


A 57-year old male without a significant past history had a trivial head trauma due to road traffic accident. The event was not significantly eventful, managed conservatively, reassured and he continued to do his routine. Three weeks later developed progressive, persistent right sided headache. He was evaluated with computed tomography (CT) scan brain plain that revealed right frontotemporoparietal hypodense collection with areas of hyperdensity and tentorial hyperdensity [Figure 1]. A diagnosis of cSDH was made. In view of mild but progressive symptoms, we treated him by super selective catheterisation and endovascular embolization of right middle meningeal artery (MMA) branches using polyvinyl alcohol (PVA) particles under conscious sedation [Figure 2]a and [Figure 2]b. Immediately following the procedure, he had relief of headache. He was discharged the following day. He resumed normal activities few days later. Follow-up evaluation at 1 month, he continued to be asymptomatic and CT scan brain revealed complete resolution of the cSDH [Figure 2]c, [Figure 2]d, [Figure 2]e, [Figure 2]f.
Figure 1: CT scan Brain in patient with trivial trauma 3 weeks ago and now presenting with headache. The scan shows right fronto temporopareital subdural hematoma with mass effect

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Figure 2: (a-b) Superselective catheterisation of the right middle meningeal artery showing diffuse enhancement of the subdural membrane (Arrow head in A). The lacrimal branch of middle meningeal vessel that anastomoses with ophthalmic artery, that needs to be preserved is shown in A and B (Asterisk). Following PVA embolization, the stump of middle meningeal artery is visualised (Arrow in B). (c-f) Follow up CT scan Brain at one month post procedure reveals complete resolution of the hematoma and the mass effect

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Development and progression of chronic subdural hematoma

cSDH development and progression are related to cycle of chronic inflammation and angiogenesis. Following the original haemorrhage due to trivial trauma, organisation of clot, fibrinolysis and liquefaction of clot ensues. The serous fluid intermixed with clotted blood, relies on neuroparenchymal counter pressure for resorption. The reorganisation and formation of vascular membranes that encapsulate the cSDH can prevent reabsorption. The clot breakdown products stimulate inflammation with the increased levels of interleukin-6, vascular endothelial growth factor and fibroblast growth factor leading to thickening of inner dural border cells initiating angiogenesis with ingrowth of immature capillaries which leak blood leading to microhaemorrhages. These microhaemorrhages lead to slow and progressive enlargement of subdural collection along with increased fibrinolysis, inflammation, membrane formation, angiogenesis and vascular proliferation cycle over and over again leading to sizable collection causing mass effect and clinical symptoms as the physiologic absorption capability is outpaced by the rate of collection.[6],[7],[8]

Conventional treatment options

Strategies for the management of cSDH are aimed at interrupting the vicious cycle of its development and tilting the balance towards reabsorption of haemorrhage. Therapy involves irrigation and removal of blood products resulting in changing the osmotic environment along with reducing the microhaemorrhages by altering angiogenesis. The procedure varies widely between individual physician and institutions with no guidelines for the management.

Conservative management is considered in patients with minor symptoms, small cSDH measuring <10 mm with minimal or no mass effect. Spontaneous resolution of symptomatic cSDH is relatively unusual and may be expected in a small cSDH that is asymptomatic.[9],[10] Medical treatment with steroids, platelet-activating factor antagonists and statins have been proposed with high failure rate requiring surgical bailout.[11],[12],[13] However, they need to be followed closely for the progression of symptom and sudden deterioration. This strategy requires prolonged hospitalisation, reduced activity and numerous serial imaging along with discontinuation of anti-platelets and anti-coagulants for prolonged period.

Surgical management include twist drill hole or burr hole evacuation and craniotomy and evacuation that may range from minicraniotomy to large craniotomy with or without excision of the membrane. Small comparative studies exist between various surgical techniques with each other, but no comprehensive study to compare surgery versus conservative management exists. Outcomes of treatment in general are favourable, but the major challenges are recurrence of cSDH that is reported to vary between 2% and 37% with most series reporting between 10% and 20%[5],[14],[15],[16] In a meta-analysis, recurrence or reoperation rate was 11.7% for burr hole evacuation, 19.4% for craniotomy, and 28.1% for twist drill craniostomy. Other challenges being reversal of anti-platelets and anti-coagulants and its associated risk of ischaemic complications. Overall, it is a disease of old age patients having comorbidities adds morbidity to cranial surgery,[17] and less invasive options are preferable for selected patients.[18]

Middle meningeal artery embolisation as a cure for chronic subdural hematoma

cSDH being a pathology of meninges deriving blood from the blood vessels of the dura and causing microhaemorrhages form the immature vessels formed form angiogenesis, it is prudent to seal off the vessels to tilt the balance towards absorption without further hemorrhage resulting in the resolution of the hematoma. MMA embolization as a sole therapy or as an adjunct to surgical evacuation has been used and various series have published the data. As early as 2000, Mandai et al. have published successful treatment of a refractory cSDH with MMA embolisation in a patient with coagulopathy due to liver cirrhosis.[19] Ban et al. have reported a detailed evaluation and in their series of 72 consecutive cases, 27 cases were primarily embolised and 45 were embolised prior to surgical evacuation. They compared their results with 439 historical controls treated conventionally. Treatment failure was defined as either requiring rescue surgery in conservative group, reoperation in surgical group or incomplete resolution or re-accumulation or more than 10 mm at 6 months follow-up CT scan. Compared with the same institution data, there was 83.6% failure rate in the conservative group and 18.2% in the surgical group. Comparative results favour embolisation with a success rate of 98.6% as against 72.5% in the control arm (P < 0.001).[18] Comparison of surgical retreatment versus endovascular embolisation in recurrent cSDH reported by El Kim et al. has shown higher rate of hematoma cure with shortened brain re-expansion time in embolisation group compared to conventional treatment. The recollection rate after the second procedure was 3.8% vs 33.3% in favour of embolisation group.[20]

Patients selected for embolisation were on antiplatelet or anticoagulant medications, and they were treated with embolisation without the need to stop the medications. Meta-analysis of nine case series has shown the recurrence rate after embolization to be as low as 2.1% as against 27.7% with conventional treatment (odds ratio [OR] = 087, 95% confidence interval [CI] 0.026–0.292, P < 0.001). Procedural complication rates were similar between the two groups 2.1% vs. 4.4%; OR = 0.563; 95% CI, 0.107–2.96; P = 0.497.[21] Subsequently, published three case series did not have any recurrence in the embolised patients.[1]

MMA embolisation can be done with either PVA particles or using liquid embolic agents. In most cases, embolisation using PVA particles of size 150–250 μ is possible and distal penetration can be achieved with good results and it is relatively cheap. The microcatheter in most situations is as large as the MMA and so only small amount of particles can be injected. However, if the microcatheter is wedged, liquid embolic material can be injected effectively having good distal penetration with casting of membrane along with back filling of adjacent vessels.[3] Unlike the PVA particles mixed with contrast, the liquid embolics are uniformly mixed with tantalum powder making the visibility better as it penetrates distal branches and it causes permanent occlusion of the vessel. Currently, most series reported are reported with PVA particles used as embolisation agent, and most cases are done under conscious sedation.

MMA embolisation as a treatment options for cSDH is promising with currently available literature. This is primarily chosen as a treatment option for minimally symptomatic cSDH with mass effect without motor deficit and radiologic progression of hematoma. The advantages are, it is minimally invasive, targets the root cause of the disease, performed under conscious sedation, in surgically high-risk groups such as those on anti-platelets, anti-coagulation without the need to stop it, those with thrombocytopenia and other co-morbidities. It is also used as an adjunct to surgery in patients with significant mass effect and motor deficit and has a higher risk of recurrence following surgery.


  Conclusion Top


Chronic subdural hematoma has various treatment options based on presentation and institutional preference. In addition to the conventional treatment options, MMA embolization has emerged as a potential alternate stand-alone treatment and adjunct to conventional treatment with high success rate and low recurrence rate.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Srivatsan A, Srinivasan VM, Thomas A, Burkhardt JK, Johnson JN, Kan P. Perspective on safety and effectiveness of middle meningeal artery embolization for chronic subdural hematoma. World Neurosurg 2019;127:97-8.  Back to cited text no. 1
    
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Edlmann E, Giorgi-Coll S, Whitfield PC, Carpenter KLH, Hutchinson PJ. Pathophysiology of chronic subdural haematoma: Inflammation, angiogenesis and implications for pharmacotherapy. J Neuroinflammation 2017;14:108.  Back to cited text no. 8
    
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Delgado-López PD, Martín-Velasco V, Castilla-Díez JM, Rodríguez-Salazar A, Galacho-Harriero AM, Fernández-Arconada O. Dexamethasone treatment in chronic subdural haematoma. Neurocirugia (Astur) 2009;20:346-59.  Back to cited text no. 11
    
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Hirashima Y, Kurimoto M, Nagai S, Hori E, Origasa H, Endo S. Effect of platelet-activating factor receptor antagonist, etizolam, on resolution of chronic subdural hematoma – A prospective study to investigate use as conservative therapy. Neurol Med Chir (Tokyo) 2005;45:621-6.  Back to cited text no. 12
    
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Chan DY, Chan DT, Sun TF, Ng SC, Wong GK, Poon WS. The use of atorvastatin for chronic subdural haematoma: A retrospective cohort comparison study. Br J Neurosurg 2017;31:72-7.  Back to cited text no. 13
    
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Ducruet AF, Grobelny BT, Zacharia BE, Hickman ZL, DeRosa PL, Andersen KN, et al. The surgical management of chronic subdural hematoma. Neurosurg Rev 2012;35:155-69.  Back to cited text no. 14
    
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Toi H, Kinoshita K, Hirai S, Takai H, Hara K, Matsushita N, et al. Present epidemiology of chronic subdural hematoma in Japan: Analysis of 63,358 cases recorded in a national administrative database. J Neurosurg 2018;128:222-8.  Back to cited text no. 17
    
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Ban SP, Hwang G, Byoun HS, Kim T, Lee SU, Bang JS, et al. Middle meningeal artery embolization for chronic subdural hematoma. Radiology 2018;286:992-9.  Back to cited text no. 18
    
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Mandai S, Sakurai M, Matsumoto Y. Middle meningeal artery embolization for refractory chronic subdural hematoma. Case report. J Neurosurg 2000;93:686-8.  Back to cited text no. 19
    
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21.
Srivatsan A, Mohanty A, Nascimento FA, Hafeez MU, Srinivasan VM, Thomas A, et al. Middle meningeal artery embolization for chronic subdural hematoma: Meta-analysis and systematic review. World Neurosurg 2019;122:613-9.  Back to cited text no. 21
    


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