Skip to main content
SpringerLink
Log in

Middle meningeal artery patency after surgical evacuation for chronic subdural hematoma

  • Research
  • Published:
Neurosurgical Review Aims and scope Submit manuscript

Abstract

Background

Chronic subdural hematoma (CSDH) often requires surgical evacuation, but recurrence rates remain high. Middle meningeal artery (MMA) embolization (MMAE) has been proposed as an alternative or adjunct treatment. There is concern that prior surgery might limit patency, access, penetration, and efficacy of MMAE, such that some recent trials excluded patients with prior craniotomy. However, the impact of prior open surgery on MMA patency has not been studied.

Methods

A retrospective analysis was conducted on patients who underwent MMAE for cSDH (2019–2022), after prior surgical evacuation or not. MMA patency was assessed using a six-point grading scale.

Results

Of the 109 MMAEs (84 patients, median age 72 years, 20.2% females), 58.7% were upfront MMAEs, while 41.3% were after prior surgery (20 craniotomies, 25 burr holes). Median hematoma thickness was 14 mm and midline shift 3 mm. Hematoma thickness reduction, surgical rescue, and functional outcome did not differ between MMAE subgroups and were not affected by MMA patency or total area of craniotomy or burr-holes. MMA patency was reduced in the craniotomy group only, specifically in the distal portion of the anterior division (p = 0.005), and correlated with craniotomy area (p < 0.001).

Conclusion

MMA remains relatively patent after burr-hole evacuation of cSDH, while craniotomy typically only affects the frontal-distal division. However, MMA patency, evacuation method, and total area do not affect outcomes. These findings support the use of MMAE regardless of prior surgery and may influence future trial inclusion/exclusion criteria. Further studies are needed to optimize the timing and techniques for MMAE in cSDH management.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Data availability

Deidentified data will be available from the corresponding author upon reasonable request.

References

  1. Liu W, Bakker NA, Groen RJM (2014) Chronic subdural hematoma: a systematic review and meta-analysis of surgical procedures. J Neurosurg 121:665–673

    Article  PubMed  Google Scholar 

  2. Moshayedi P, Liebeskind DS (2020) Middle meningeal artery embolization in chronic subdural hematoma: implications of pathophysiology in Trial Design. Front Neurol 11:923

    Article  PubMed  PubMed Central  Google Scholar 

  3. Shapiro M, Walker M, Carroll KT, Levitt MR, Raz E, Nossek E, Delavari N, Mir O, Nelson PK (2021) Neuroanatomy of cranial dural vessels: implications for subdural hematoma embolization. J Neurointerv Surg 13:471–477

    Article  PubMed  Google Scholar 

  4. Di Cristofori A, Remida P, Patassini M, Piergallini L, Buonanno R, Bruno R, Carrabba G, Pavesi G, Iaccarino C, Giussani CG (2022) Middle meningeal artery embolization for chronic subdural hematomas. A systematic review of the literature focused on indications, technical aspects, and future possible perspectives. Surg Neurol Int 13:94

    Article  PubMed  PubMed Central  Google Scholar 

  5. Sattari SA, Yang W, Shahbandi A, Feghali J, Lee RP, Xu R, Jackson C, Gonzalez LF, Tamargo RJ, Huang J, Caplan JM (2023) Middle Meningeal Artery Embolization Versus Conventional Management for Patients With Chronic Subdural Hematoma: A Systematic Review and Meta-Analysis. Neurosurgery

  6. Salah WK, Baker C, Scoville JP, Hunsaker JC, Ogilvy CS, Moore JM, Riina HA, Levy EI, Spiotta AM, Jankowitz BT, Michael Cawley C 3rd, Khalessi AA, Tanweer O, Hanel R, Gross BA, Kuybu O, Hoang AN, Baig AA, Khorasanizadeh MH, Mendez AA, Cortez G, Davies JM, Narayanan S, Howard BM, Lang MJ, Siddiqui AH, Thomas A, Kan P, Burkhardt J-K, Salem MM, Grandhi R (2023) Middle meningeal artery embolization as a perioperative adjunct to surgical evacuation of nonacute subdural hematomas: an multicenter analysis of safety and efficacy. Interv Neuroradiol J Peritherapeutic Neuroradiol Surg Proced Relat Neurosci. ;15910199231162664

  7. Court J, Touchette CJ, Iorio-Morin C, Westwick HJ, Belzile F, Effendi K (2019) Embolization of the Middle meningeal artery in chronic subdural hematoma - A systematic review. Clin Neurol Neurosurg 186:105464

    Article  PubMed  Google Scholar 

  8. Koo TK, Li MY (2016) A Guideline of selecting and reporting Intraclass correlation coefficients for Reliability Research. J Chiropr Med 15:155–163

    Article  PubMed  PubMed Central  Google Scholar 

  9. Fiorella D, Hirsch JA, Arthur AS (2021) Embolization of the middle meningeal artery for the treatment of chronic subdural hematoma: considerations for pragmatic trial design. J Neurointerv Surg 13:295–297

    Article  PubMed  Google Scholar 

  10. Schirmer CM, Siddiqui AH (2019) Commentary: middle meningeal artery embolization for chronic subdural hematoma: a Series of 60 cases. Neurosurgery 85:E1004–E1005

    Article  PubMed  Google Scholar 

  11. Rudy RF, Catapano JS, Jadhav AP, Albuquerque FC, Ducruet AF (2023) Middle Meningeal Artery Embolization to Treat Chronic Subdural Hematoma. Stroke Vasc Interv Neurol [Internet]. ;3:e000490. https://doi.org/10.1161/SVIN.122.000490

  12. Salem MM, Kuybu O, Nguyen Hoang A, Baig AA, Khorasanizadeh M, Baker C, Hunsaker JC, Mendez AA, Cortez G, Davies JM, Narayanan S, Cawley CM, Riina HA, Moore JM, Spiotta AM, Khalessi AA, Howard BM, Hanel R, Tanweer O, Levy EI, Grandhi R, Lang MJ, Siddiqui AH, Kan P, Ogilvy CS, Gross BA, Thomas AJ, Jankowitz BT, Burkhardt J-K (2023) Middle meningeal artery embolization for chronic subdural hematoma: predictors of clinical and radiographic failure from 636 embolizations. Radiology. ;222045

  13. Sadasivan C, Dashti N, Marfoglio S, Fiorella D (2023) In vitro comparison of middle meningeal artery embolization with Squid liquid embolic agent and contour polyvinyl alcohol particles. J Neurointerv Surg

  14. Kan P, Maragkos GA, Srivatsan A, Srinivasan V, Johnson J, Burkhardt J-K, Robinson TM, Salem MM, Chen S, Riina HA, Tanweer O, Levy EI, Spiotta AM, Kasab S, Al, Lena J, Gross BA, Cherian J, Cawley CM, Howard BM, Khalessi AA, Pandey AS, Ringer AJ, Hanel R, Ortiz RA, Langer D, Kelly CM, Jankowitz BT, Ogilvy CS, Moore JM, Levitt MR, Binning M, Grandhi R, Siddiq F, Thomas AJ (2021) Middle meningeal artery embolization for chronic subdural hematoma: a Multi-center experience of 154 consecutive embolizations. Neurosurgery 88:268–277

    Article  PubMed  Google Scholar 

  15. Catapano JS, Ducruet AF, Nguyen CL, Baranoski JF, Cole TS, Majmundar N, Wilkinson DA, Fredrickson VL, Cavalcanti DD, Albuquerque FC (2021) Middle meningeal artery embolization for chronic subdural hematoma: an institutional technical analysis. J Neurointerv Surg 13:657–660

    Article  PubMed  Google Scholar 

  16. Samarage HM, Kim WJ, Zarrin D, Goel K, Chin-Hsiu Wang A, Johnson J, Kaneko N, Nour M, Szeder V, Tateshima S, Jahan R, Duckwiler G, Colby GP (2022) The Bright Falx sign-Midline Embolic Penetration is Associated with faster resolution of chronic subdural Hematoma after Middle Meningeal artery embolization: a Case Series. Neurosurgery 91:389–398

    Article  PubMed  Google Scholar 

  17. Khorasanizadeh M, Shutran M, Garcia A, Enriquez-Marulanda A, Moore J, Ogilvy CS, Thomas AJ (2022) Middle meningeal artery embolization for treatment of chronic subdural hematomas: does selection of embolized branches affect outcomes? J Neurosurg. ;1–9

  18. Weinberg JH, Akhter A, Zakeri A, Tanweer O, Zyck S, Tjoumakaris S, Jabbour P, Kan P, Peng J, Youssef P (2023) Middle meningeal artery embolization for membranous versus non-membranous subdural hematomas: a retrospective and multicenter cohort study. World Neurosurg

  19. Chen H, Salem MM, Colasurdo M, Sioutas GS, Khalife J, Kuybu O, Carroll KT, Hoang AN, Baig AA, Salih M, Khorasanizadeh M, Baker C, Mendez Ruiz A, Cortez GM, Abecassis Z, Ruiz Rodríguez JF, Davies JM, Narayanan S, Cawley CM, Riina H, Moore J, Spiotta AM, Khalessi A, Howard BM, Hanel RA, Tanweer O, Tonetti D, Siddiqui AH, Lang M, Levy EI, Jovin TG, Grandhi R, Srinivasan VM, Levitt MR, Ogilvy CS, Jankowitz B, Thomas AJ, Gross BA, Burkhardt JK, Kan P (2023) Standalone middle meningeal artery embolization versus middle meningeal artery embolization with concurrent surgical evacuation for chronic subdural hematomas: a multicenter propensity score matched analysis of clinical and radiographic outcomes. J Neurointerv Surg

  20. Gomez-Paz S, Akamatsu Y, Salem MM, Enriquez-Marulanda A, Robinson TM, Ogilvy CS, Thomas AJ, Moore JM (2021) Upfront middle meningeal artery embolization for treatment of chronic subdural hematomas in patients with or without midline shift. Interv Neuroradiol J Peritherapeutic Neuroradiol Surg Proced Relat Neurosci 27:571–576

    Google Scholar 

  21. Khorasanizadeh M, Chang Y-M, Enriquez-Marulanda A, Mizuhashi S, Salem MM, Gomez-Paz S, Siddiq F, Kan P, Moore J, Ogilvy CS, Thomas AJ (2021) Morphological changes in chronic subdural hematomas following upfront middle meningeal artery embolization: sequence, timing, and association with outcomes. J Neurosurg. ;1–14

  22. Saway BF, Roth W, Salvador CD, Essibayi MA, Porto GBF, Dowlati E, Felbaum DR, Rock M, Withington C, Desai SK, Hassan AE, Tekle WG, Spiotta A (2023) Subdural evacuation port system and middle meningeal artery embolization for chronic subdural hematoma: a multicenter experience. J Neurosurg 139:131–138

    PubMed  Google Scholar 

  23. Salih M, Shutran M, Young M, Vega RA, Stippler M, Papavassiliou E, Alterman RL, Thomas A, Taussky P, Moore J, Ogilvy CS (2023) Reduced recurrence of chronic subdural hematomas treated with open surgery followed by middle meningeal artery embolization compared to open surgery alone: a propensity score-matched analysis. J Neurosurg 139:124–130

    PubMed  Google Scholar 

Download references

Acknowledgements

None.

Funding

None.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

    Georgios S. Sioutas, Oleg Shekhtman, Mert Marcel Dagli, Mohamed M. Salem, Sonia Ajmera, Sandeep Kandregula, Jan-Karl Burkhardt, Visish M. Srinivasan & Brian T. Jankowitz

Authors
  1. Georgios S. Sioutas
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Oleg Shekhtman
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Mert Marcel Dagli
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Mohamed M. Salem
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Sonia Ajmera
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Sandeep Kandregula
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Jan-Karl Burkhardt
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Visish M. Srinivasan
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Brian T. Jankowitz
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors made substantial contributions. Study conception/design: GSS and BTJ. Data acquisition: GSS, OS, MMD, MMS, SA, SK. Data analysis: GSS. Data interpretation: all authors. Manuscript drafting: GSS. Illustration: SK. Manuscript critical revision for important intellectual content: all authors. Approval of final version of manuscript: all authors. Guarantor of the study: BTJ.

Corresponding author

Correspondence to Brian T. Jankowitz.

Ethics declarations

Competing interests

The authors declare no competing interests.

Ethical approval

The study was approved by the University of Pennsylvania Institutional Review Board with a waiver of informed consent.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sioutas, G.S., Shekhtman, O., Dagli, M.M. et al. Middle meningeal artery patency after surgical evacuation for chronic subdural hematoma. Neurosurg Rev 47, 145 (2024). https://doi.org/10.1007/s10143-024-02383-3

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s10143-024-02383-3

Keywords

Search

Navigation