- Department of Neurological Surgery, Lebanese University, Faculty of Medical Sciences,
- Department of Neurological Surgery, Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Lebanon,
- Department of Oncology, Cleveland Clinic, Weston, Florida, United States,
- Department of Neurological Surgery, Al Rassoul Al-Azam Hospital,
- Head of Radiology Department, Zahraa Hospital University Medical Center,
- Department of Nuclear Medicine Radiobiology Radiopathology, Faculty of Medical Sciences, Lebanese University,
- Radiology Department, Bahman Hospital, Faculty of Medicine, Lebanese University,
- Head of Department of Radiology, Faculty of Medicine, Lebanese University, Bahman Hospital, Centre Hospitalier Vallee de la Maurienne-France, Beirut, Lebanon.
Ali Msheik, Department of Neurological Surgery, Lebanese University, Faculty of Medical Sciences, Beirut, Lebanon.
DOI:10.25259/SNI_1096_2022Copyright: © 2023 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Ali Msheik1, Youssef Fares2, Mohammad Mohanna3, Ahmad Aoude4, Mohamad Shkeir5, Feras Chehade6, Ali Kanj7, Assaad Mohanna8. Middle meningeal artery embolisation: The review of a new treatment for chronic subdural hematomas. 24-Feb-2023;14:66
How to cite this URL: Ali Msheik1, Youssef Fares2, Mohammad Mohanna3, Ahmad Aoude4, Mohamad Shkeir5, Feras Chehade6, Ali Kanj7, Assaad Mohanna8. Middle meningeal artery embolisation: The review of a new treatment for chronic subdural hematomas. 24-Feb-2023;14:66. Available from: https://surgicalneurologyint.com/surgicalint-articles/12175/
Background: This is a literature review aiming to provide an update about the recent findings related to the efficacy of middle meningeal artery embolization (MMAE) in the treatment of chronic subdural hematomas (cSDHs), comparison with conventional therapy and deduction of the current recommendations and indications.
Methods: The literature is reviewed using a search through the PubMed index using keywords. Studies are then screened, skimmed, and thoroughly read. 32 studies fulfilled the inclusion criteria and are included in the study.
Results: Five indications for the application of MMA embolization (MMAE) are deducted from the literature. The usage as a preventive measure after surgical treatment of symptomatic cSDHs in patients with a high risk of recurrence and the usage as a standalone procedure has been the most common reasons for indication of this procedure. Rates of failures for the aforementioned indications have been 6.8% and 3.8%, respectively.
Conclusion: The safety of MMAE as a procedure is regarded as a general theme in the literature and can be considered for future applications. Usage of this procedure in clinical trials with more patient segregation and timeframe assessment relative to surgical intervention are recommendations of this literature review.
Keywords: Burr hole, Chronic subdural hematomas, Elderly population, Inflammation, Middle meningeal artery embolization, Prevention, Recurrence
Definition of subdural hematoma
Chronic subdural hematoma (cSDH) is defined as a liquefied hematoma in the subdural space.[
Anatomy and histology
cSDHs are encapsulated flattened structures that form within the virtual dural space [
Drawn presentation showing the layers from the scalp to the cerebral cortex with a space-occupying subdural hematoma. Courtesy of the author Ali Msheik. (A) The arachnoid layer of the cerebral Dural membranes in coronal view, (B) The cerebral cortex, (C) The outer layer of the chronic subdural hematoma, (D): The content of the chronic subdural hematoma, (E) The inner layer of the chronic subdural hematoma, (i) Scalp, (ii) Periosteum layer of the skull, (iii): Skull bone, (iv) Dura matter, (v) Arachnoid layer of the Dural membranes in sagittal view.
Being of embryonic mesodermal origin, tear of the cell layer of the meninges dictates a similar response to wound healing.[
Correspondence of CT appearance with classification and prognosis
Postsurgical risk for recurrence and hematoma volume increase may be correlated to the CT scan features obtained before surgical intervention, that is, low risk is attributed to the homogenous appearance of cSDHs on CT scan.[
Causes of subdural hematoma
Tear of bridging veins as they traverse the dural cell layer is the most accepted cause of cSDHs.[
The transformation from hygroma
Formation of a cSDH as a progression from a subacute hygroma is another hypothesis advocated by Japanese neurosurgeons.[
Enlargement by osmotic and oncotic pressures
Indifference in osmolality and oncotic pressure between cSDH fluid, plasma, and CSF limits the credibility of the theory supporting the role of either in the enlargement of cSDHs.[
Epidemiology of cSDH
The incidence of cSDHs is not well known and varies between operated and non-operated cases. Ranging from 1.3 to 5.3/100,000/year for operative cases, the incidence naturally increases to 8.2 up to 48/3 of 17 100,000/year.[
Treatments for cSDH
Treatment of cSDH requires prior assessment of patients on an individual basis. The symptomatology of patients is key in determining the urgency and the indication for surgical intervention. Typically, patients received at the ED for trauma or acute development of neurological compromise are diagnosed or incidentally found to have cSDH.[
Correction of coagulopathy and thrombopathy
Reversal of coagulopathy instilled by OACs and antiplatelet medications, liver insufficiency, and other coagulation disease is essential for the prevention of further expansion of cSDHs and to allow control of blood loss after surgical evacuation of symptomatic cSDHs.[
Steroids and anti-epileptic medications are two main medical therapies adjuvant to surgical evacuation used in managing symptomatic cSDHs. In 2021 lesser recurrence of cSDH under the treatment with steroids were reported.[
The authors noted a lack of evidence of a significant reduction in the incidence of seizures in patients with cSDHs following the administration of anti-epileptic drugs.[
Conservative treatment is offered to patients whose morbid conditions hinder surgical intervention or to whom surgery will not add benefit compared to medical treatment. Patients with small asymptomatic cSDHs are managed conservatively.[
Symptomatic patients are ideal for treatment with surgical evacuation with an 80% success rate. Accomplished with minimal surgical risk, usually patients recover fast postoperatively and show the reverse neurological compromise instilled by the expanded hematoma.[
Prognosis and complications
Complications of cSDH surgical evacuation range from the ones associated with any surgery, that is, infection, bleeding and possible tissue damage to more specific ones related to the nature of the operation, that is, continuous bleeding, re-bleeding, tension pneumocephalus, seizures, intra-parenchymal bleeding, stroke, and possible brain tissue damage.[
Mortality due to cSDHs varies according to whether surgical intervention was held or not. Without surgical evacuation, mortality rises to 33%. However, it drops to 3% within 30 days of cSDHs evacuation.[
Future research areas
Surgical evacuation and brain decompression are the main goals of the treatment of symptomatic cSDHs. Postoperative adjuvant therapies are understudied in the literature inclusive of corticosteroids, ACE inhibitors, and tranexamic acid.[
Anatomy related to MMA embolization (MMAE)
It is believed that the MMA through its anterior and posterior branches, which supply the dural layers, can anastomose with the neovascular vessels. Hence, re-bleeding through these anastomoses can provoke the recurrence of a cSDH.[
Steps of MMAE
Embolization requires an endovascular approach through the femoral artery ipsilateral to the recurrent cSDH.[
The aim of the literature review
This literature review aims to provide an update on the recent findings related to the efficacy of MMA embolization. Answers that this review will provide connectivity to the following inquiries:
Is MMA embolization an adjunctive technique besides surgical intervention? Can MMA embolization replace surgery? In which patients? What are the indications for MMAE? How efficient is MMA embolization in the prevention of recurrence after surgical intervention and expansion of minimal cSDH not requiring surgical evacuation? What does the failure of MMA embolization to prevent the recurrence of cSDH re-bleeding suggest?
Is MMA embolization an adjunctive technique besides surgical intervention?
Can MMA embolization replace surgery? In which patients?
What are the indications for MMAE?
How efficient is MMA embolization in the prevention of recurrence after surgical intervention and expansion of minimal cSDH not requiring surgical evacuation?
What does the failure of MMA embolization to prevent the recurrence of cSDH re-bleeding suggest?
Primary revision: Identification
We reviewed the existing literature on PubMed until August 2022, in the English language. We performed the research with combinations of the keywords “MMA,” “middle meningeal artery embolization,” “embolization,” “refractory cSDH,” “chronic subdural hematoma recurrence”, and “cSDH outer layer.” All kinds of work were included. References of the relevant studies were considered as an additional source of articles. Pure literature reviews were not included. We focused on the cSDH and the embolization of MMA as means of treatment.
Secondary revision: Screening
The titles of the sequestered articles are screened. Causes of cSDH related to acute subdural and epidural hematomas and tumor-provoked cSDHs were excluded from the study. Studies inclusive of a pure methodological description of MMAE and MMA variable anatomy were excluded from the study.
Data sequestration: Inclusion and classification
As this literature review is the work of one author, data from the included studies were thoroughly read and analyzed. Referral to other recent literature reviews aided the guidance of the author and allowed further checking. The studies were classified according to the way MMAE was utilized. Hence, the patients were classified according to the indication of MMAE:
MMAE as a standalone therapy MMAE to prevent recurrence in symptomatic cSDHs MMAE in recurrent cSDHs without second surgery MMAE in patients with recurrent cSDHs after the second surgery.
MMAE as a standalone therapy
MMAE to prevent recurrence in symptomatic cSDHs
MMAE in recurrent cSDHs without second surgery
MMAE in patients with recurrent cSDHs after the second surgery.
297 records were identified after a search using the combination of the aforementioned keywords on PubMed. 36 records were exempted because of being duplicate records. 213 records were excluded after screening the titles and abstracts. 16 records were excluded after reading the full text [
32 records were finally reviewed [
Totally, 973 patients were included and categorized into five groups. The distribution of the patients is evident in
MMAE as a standalone procedure
Being a standalone procedure is an application of MMAE reported in 14 of the reviewed articles published starting from the year 2018 [
MMAE as a prevention of recurrence for symptomatic cSDHs
Of the 773 patients included in the studies, 516 (66.75%) were subject to a standalone MMAE procedure with 3.8% failure rate if compared to the total MMAE procedures done [
MMAE for recurrence of cSDHs
MMAE was applied for the recurrence of cSDHs either with a second surgery done or without any surgical intervention in 15 articles. Out of 556 patients included in those articles, 82 (14.74%) patients had MMAE procedures done without a second surgical intervention compared to 34 (6.29%) patients who received a second surgical intervention followed by an MMAE procedure. The only article reporting indicating MMAE for both reasons in the same study was Mino et al. in 2010.[
MMAE for recurrence without surgery
Besides Mino et al., of eight articles reporting MMAE procedures done for cSDHs recurrence without a second surgery, two were case reports, and six were case series [
MMAE after second surgery for recurrence
Besides Mino et al., only six articles reported applying MMAE procedures to patients for recurrence after the second surgery; two were case reports and four are case series [
Failure of MMAE
MMAE procedures categorized as a failure were either a procedure that has resulted in non-resorption of cSDHs, increase in the hematoma volume, or recurrence of the hematoma after resorption. Out of the 997 MMAE procedures, 22 procedures failed and 19 procedures were complicated [
Complications of MMAE
Only five complications were reported in the reviewed articles and it was noticed that all complications happened with patients whose MMAE procedures were indicated as either a standalone or a prophylactic procedure. The complications were worsening cSDHs, two CVAs, a focal seizure, and an episode of aphasia.
Comparison with conventional treatment
In the literature review published by Di Cristofori et al. in March 2022, the author reported that five studies cited a comparison between patients to whom MMAE was applied versus patients treated conventionally.[
Indications for MMA embolization through the literature
This review of literature unveiled the application of MMAE for the following indications: a standalone procedure, an adjuvant treatment at the time of first surgery, for prevention of recurrence after first surgical evacuation, as a treatment after recurrence after first surgical evacuation without second surgery and as a treatment after recurrence after second surgical evacuation. Keen attention ought to discriminate the first indication versus the other four indications. MMAE as a standalone procedure manages cSDHs by vascular compromise. Hence, further progression of cSDHs by standalone MMAE is valid. The other four scenarios target the mass effect imparted by the hematoma volume by surgical evacuation and target the vascular supply of the dural cell layer by MMAE, yet each is at a different stage regarding the surgical intervention and a number of recurrences. Therefore, this justifies the higher rate of standalone MMAE procedures failure compared to the other four modalities reported by Di Cristofori et al.[
Report of MMAE applications and results
The number of patients to whom MMAE was applied in the reviewed literature is conspicuous. Some articles reported the number of treated patients; others report the number of cSDHs yet not the number of patients. Bilateral cSDHs are reported as two cases and treatment of either has been reported by different modalities for different indications in the same individual. Limited is the report of segregation of patients according to whether the cSDHs is unilateral or bilateral. Risk factors of progression and recurrence, results of MMAE application, long-term outcomes, side effects, mortality, and morbidity need to be assessed for each of the two patient categories. This is not presented in the literature. Hence, results cannot be generalized. The heterogeneity of the data adds to the lack of parameters related to the number of patients within each category, the number of patients considered for each indication, the time between the surgical intervention and the MMAE procedure, and the type of MMAE material and technique specifications. Moreover, the categorization of patients according to morbid conditions, OACs administration and risk factor variance is missing in the articles, as a comparison among those groups is not derived.
Despite the aforementioned bias, discrimination between standalone MMAE and MMAE associated with surgical evacuation, regardless of the situation of either procedure, is paramount. Future application of MMAE associated with surgical evacuation is anticipated to provide better results versus standalone MMAE. This was noted previously in the results section. The mere fact that residual hematoma remains in the case of standalone MMAE constrains the efficacy of this application. This increases its failure rate as patients could fail to resorb the residual volume and re-bleeding could be a complication, especially in patients with OACs and anti-platelets intake. The necessity to surgically evacuate hematomas and consider MMAE later after surgical intervention appears as a better approach. Future consideration of studies addressing the adequate timeframe is highly recommended. This approach is anticipated to reduce the hospitalization period, and the costs of second surgical interventions, and promote a better prognosis with less morbidity and mortality, especially in the elderly population. Therefore, clinical trials inclusive of standalone MMAE applied to symptomatic yet poor surgical candidates and MMAE procedure applied at different timeframes to surgical candidates after surgical intervention versus conventional control groups are indispensable. The studies published by Nia et al. and Ng et al. are representative of the required studies.[
CSDH is a disease of the elderly who struggle with the eventual result of aging: comorbidities and chronic diseases. Treatment of this bleeding condition within the skull has been conventionally surgical. However, the recurrence of this condition and the risks implemented in the surgical evacuation of cSDHs renders less invasive procedures more appealing. Hence, the attention drives us toward MMAE. This literature review aimed to provide a walkthrough of the available data about MMAE application for the treatment of cSDHs. Anticipation of future applications of MMAE, the indications, and the foreseeable outcomes was speculated in light of the reported findings by articles over the past 22 years. As a result, application for the prevention of recurrence and as a primary modality of care has been the indication of choice. However, heterogeneity of the data limited this work and hindered the distinction between indication-specific MMAE failure rates. The safety of MMAE as a procedure is regarded as a general theme in the literature and can be considered for future application. We look forward to clinical trials with comparative themes to provide better population-specific deductions about this new technique.
Patient’s consent not required as there are no patients in this study.
There are no conflicts of interest.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.
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