What is the preferred endovascular treatment for chronic subdural hematoma in elderly patients or those on anticoagulant or antiplatelet therapy, especially after recurrence following burr‑hole drainage, and how is middle meningeal artery embolisation performed?

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Endovascular Management of Chronic Subdural Hematoma

Primary Recommendation

Middle meningeal artery (MMA) embolization is a safe and effective treatment for chronic subdural hematoma (cSDH), particularly in elderly patients, those on anticoagulation/antiplatelet therapy, and cases with recurrence after burr-hole drainage, with recurrence rates as low as 6-7% compared to 30% with surgery alone. 1, 2, 3

Clinical Context and Patient Selection

Ideal Candidates for MMA Embolization

  • Elderly patients with multiple comorbidities who are poor surgical candidates 1, 2
  • Patients on anticoagulation or antiplatelet therapy who cannot safely discontinue these medications 4
  • Recurrent cSDH after burr-hole drainage (one or multiple recurrences) 5
  • Primary treatment option for symptomatic cSDH as an alternative to surgery 4
  • Bilateral cSDH requiring treatment 4

The pathophysiology underlying cSDH involves neovascularization from distal MMA branches supplying the dural layers, creating a cycle of recurrent hemorrhage. MMA embolization interrupts this cycle at its source by stopping the neovascularization process and blood flow to the hematoma membrane. 1, 2

Technical Procedure: How MMA Embolization is Performed

Procedural Approach

  • Anesthesia: Can be performed under local anesthesia or general anesthesia (46.1% of cases use general anesthesia in large series) 4
  • Access: Standard transfemoral arterial access with catheterization of the external carotid artery and selective catheterization of the MMA 4
  • Embolic agents: Two primary options with equivalent outcomes 4:
    • Polyvinyl alcohol (PVA) particles (used in 70.2% of cases) 4, 5
    • Liquid embolics such as Onyx or n-butyl cyanoacrylate (used in 25.3% of cases) 4
  • Technical success rate: 97.4% of procedures are successfully completed 4

Bilateral Treatment Considerations

  • Bilateral MMA embolization can be performed in the same session for bilateral cSDH 4
  • 15 patients in the largest multi-center series underwent bilateral interventions (154 total embolizations) 4

Clinical Outcomes and Efficacy

Radiographic Response

  • Median hematoma thickness reduction: 71% at mean follow-up of 95 days 4
  • Significant improvement rate: 70.8% of patients achieve >50% thickness reduction on imaging 4
  • Faster brain re-expansion compared to surgery alone 1

Recurrence Rates

  • MMA embolization recurrence rate: 6-7% across multiple studies 3, 4
  • Comparison to surgery alone: Traditional burr-hole drainage has 30% recurrence rate 2
  • Need for additional treatment: Only 6.5% of patients require further cSDH treatment within 90 days 4

Clinical Improvement

  • Functional improvement: 31.9% of patients show clinical improvement on National Institutes of Health Stroke Scale and modified Rankin Scale 4
  • No recurrence observed in patients treated for repeated recurrence after multiple surgeries 5

Safety Profile and Complications

Overall Complication Rate

  • Total complications: 6-6.5% across studies 3, 4
  • Procedure-related complications: Include continued hematoma expansion (6.5% of cases) 4
  • No side effects or complications from interventional treatment in smaller series with careful technique 5

Mortality

  • Mortality rate: 4.4%, mostly unrelated to the index procedure but due to underlying comorbidities in elderly patients 4

Treatment Algorithms

Algorithm for Primary Treatment Decision

For newly diagnosed symptomatic cSDH:

  1. Elderly patients (>70 years) with significant comorbidities → Consider MMA embolization as primary treatment 2, 4
  2. Patients requiring continued anticoagulation/antiplatelet therapy → MMA embolization preferred over surgery 4
  3. Younger, healthy patients with large hematomas and mass effect → Surgical evacuation remains standard, but consider adjunctive MMA embolization 2

Algorithm for Recurrent cSDH

After first recurrence following burr-hole drainage:

  1. Any recurrence → MMA embolization is treatment of choice 5
  2. Multiple recurrences (≥2) → MMA embolization is strongly indicated 5
  3. Continued recurrence after embolization (rare, 6-7% of cases) → Repeat surgical evacuation 3, 4

Combined Treatment Strategy

MMA embolization can be performed:

  • As standalone treatment for primary or recurrent cSDH 4
  • Combined with surgical evacuation to reduce recurrence risk 2
  • Timing: Can be performed before, during, or after surgical evacuation 2

Critical Pitfalls to Avoid

Common Errors

  • Delaying embolization in recurrent cases: Waiting for multiple recurrences before considering MMA embolization increases patient morbidity and healthcare costs 2
  • Discontinuing anticoagulation unnecessarily: MMA embolization allows treatment without stopping anticoagulation, whereas surgery typically requires temporary cessation 4
  • Assuming all elderly patients need surgery: Many elderly patients with cSDH are better served by MMA embolization given lower morbidity 2
  • Inadequate follow-up imaging: Follow-up CT imaging within 90 days is essential to document hematoma resolution 4

Technical Considerations

  • Careful attention to procedural technique is essential to minimize complications 5
  • Choice of embolic agent (particles vs. liquid embolics) does not significantly affect outcomes, allowing operator preference 4
  • Bilateral disease requires bilateral treatment for optimal outcomes 4

Anticoagulation and Antiplatelet Management

Continuation of Therapy

  • 30.4% of patients on antiplatelet therapy and 23.9% on anticoagulation at presentation can undergo MMA embolization safely 4
  • No need to discontinue therapy for the procedure, unlike surgical evacuation 4
  • This represents a major advantage in elderly patients with cardiovascular comorbidities requiring ongoing antithrombotic therapy 2

Follow-up Protocol

Imaging Schedule

  • Initial follow-up CT: Within 90 days to assess hematoma thickness reduction 4
  • Target outcome: >50% reduction in hematoma thickness 4
  • Mean follow-up duration: 95 days in largest series 4

Clinical Monitoring

  • Neurological examination: Serial assessments using standardized scales (NIHSS, mRS) 4
  • Symptom resolution: Monitor for headache improvement, neurological deficit resolution 4
  • Recurrence surveillance: Extended follow-up (4-60 weeks) to detect rare late recurrences 5

References

5
Research

Usefulness of interventional embolization of the middle meningeal artery for recurrent chronic subdural hematoma: Five cases and a review of the literature.

Interventional neuroradiology : journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences, 2015

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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