Middle meningeal artery embolization for symptomatic chronic subdural hematoma in the setting of severe transfusion-refractory thrombocytopenia: A case study and review of literature
- Division of Neurological Surgery, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii, United States.
Frances Tiffany Cava Morden, Division of Neurological Surgery, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii, United States.
DOI:10.25259/SNI_1051_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: Frances Tiffany Cava Morden, Clark Gianni Caballero, Maveric Abella, Andie Conching, Hannah Gang, Thomas Noh. Middle meningeal artery embolization for symptomatic chronic subdural hematoma in the setting of severe transfusion-refractory thrombocytopenia: A case study and review of literature. 30-Jun-2023;14:223
How to cite this URL: Frances Tiffany Cava Morden, Clark Gianni Caballero, Maveric Abella, Andie Conching, Hannah Gang, Thomas Noh. Middle meningeal artery embolization for symptomatic chronic subdural hematoma in the setting of severe transfusion-refractory thrombocytopenia: A case study and review of literature. 30-Jun-2023;14:223. Available from: https://surgicalneurologyint.com/surgicalint-articles/12388/
Background: Surgical decompression for the treatment of chronic subdural hematomas (cSDHs) is irrefutably effective; however, its utility in managing cSDH in patients with comorbid coagulopathy remains controversial. The optimal threshold for platelet transfusion in cSDH management is 3, according to guidelines from the American Association of Blood Banks GRADE framework. This threshold may be unachievable in refractory thrombocytopenia, though surgical intervention may still be warranted. We present a patient with symptomatic cSDH and transfusion-refractory thrombocytopenia successfully treated with middle meningeal artery embolization (eMMA). We also review the literature to identify management approaches for cSDH with severe thrombocytopenia.
Case Description: A 74-year-old male with acute myeloid leukemia presented to the emergency department with persistent headache and emesis following fall without head trauma. Computed tomography (CT) revealed a 12 mm right-sided, mixed density SDH. Platelets were 3 initially, which stabilized to 20,000 following platelet transfusions. He then underwent right eMMA without surgical evacuation. He received intermittent platelet transfusions with platelet goal >20,000 and was discharged on hospital day 24 with resolving SDH on CT.
Conclusion: High-risk surgical patients with refractory thrombocytopenia and symptomatic cSDH may be successfully treated with eMMA without surgical evacuation. A platelet goal of 20,000/mm3 before and following surgical intervention proved beneficial for our patient. Similarly, a literature review of seven cases of cSDH with comorbid thrombocytopenia revealed five patients undergoing surgical evacuation following initial medical management. Three cases reported a platelet goal of 20,000. All seven cases resulted in stable or resolving SDH with platelets >20,000 at discharge.
Keywords: Chronic subdural hematoma, Middle meningeal artery embolization, Platelet goal, Platelet transfusion, Thrombocytopenia
Chronic subdural hematoma (cSDH) is a common complication of acute myeloid leukemia (AML).[
Treatments for acute myeloid leukemia (AML) like chemotherapy and hypomethylating agents put patients at increased risk for thrombocytopenia and intracranial hemorrhage,[
Middle meningeal artery embolization (eMMA) for cSDH is an emerging treatment modality.[
To the best of our knowledge, there has been no report of a patient with AML, symptomatic cSDH, and transfusion-refractory thrombocytopenia treated with eMMA. We present a case of improving chronic SDH in the setting of AML-related thrombocytopenia by eMMA without surgical evacuation. We also performed a systematic review of the literature to identify management strategies for cSDH with severe thrombocytopenia.
A 74-year-old man with a history of AML presented to the emergency department (ED) for a complaint of nonresolving throbbing headache with nausea and vomiting after a witnessed fall without head trauma. He was on his second cycle of therapy with venetoclax and a hypomethylating agent.
At presentation to the ED, he had left upper extremity and left lower extremity drift with 4/5 left upper and lower extremity weakness, and scattered ecchymoses with a petechial rash. Laboratory studies were significant for severe thrombocytopenia of <2000/µL in the ED. Computed tomography of the head (hCT) revealed a right sided, mixed density 12 mm SDH with a 12 mm leftward midline shift and patchy acute subarachnoid hemorrhages [
Evolution of subdural hematoma (SDH) from presentation to 45 days later via head computed tomography (CT). (a) Head CT at initial presentation revealed a right-sided, mixed density 12 mm SDH with 12 mm midline shift to the left. (b) Cerebral angiogram visualizing middle meningeal artery. (c) Repeat head CT on hospital day 17 showing stable right SDH with resolving midline shift (5 mm to left).
Graphical depiction of patient’s platelet counts following initial presentation. The patient’s platelet count ranged from <2000/mm3 at initial presentation up to 48,000 5 days after presentation following multiple platelet transfusions. He underwent eMMA 7 days after presentation with platelet count of 20,000. He was discharged on 23 days after presentation and received outpatient platelet transfusions 3 times a week with a platelet goal of 20,000. His average platelet count was 14,000.
Fifty days after his initial presentation, the patient was readmitted for acute kidney injury secondary to severe tumor lysis syndrome, acute colitis, acute left pyelonephritis, anemia with hemoglobin of 7.8 g/dL, and thrombocytopenia with platelet count of 9000/µL. On hospital day 2, hCT showed a grossly stable SDH. He was considered a poor candidate for hemodialysis due to AML, discharged to hospice on hospital day 7, and passed 4 days later.
The optimal management of cSDHs in patients with concurrent thrombocytopenia remains obscure. In this review, we sought to find case reports or series similar to our patient to identify management strategies and treatment efficacy for cSDH with severe thrombocytopenia currently documented in the literature.
The preferred reporting items for systematic reviews and meta-analyses (PRISMA) reporting guideline were implemented for this review. A systematic search of PubMed and Web of Science data was conducted on October 13, 2021. The following search terms were utilized: thrombocytopenia OR pancytopenia; subdural; hematoma OR hemorrhage OR bleed*. Inclusion criteria required detection of isodense or hypodense areas in the subdural space on CT and report of individual patient data on platelet counts at intracranial cSDH confirmation, management of cSDH, platelet count following management, and outcome. Patients <18 years old and patients taking anticoagulants before cSDH presentation were excluded from the study. Reviews, editorials, and non-English articles were also excluded from the study. Two independent authors assessed the articles for inclusion and exclusion criteria.
Individual patient data on the following were collected: age, sex, risk factors/etiology of thrombocytopenia, location of SDH, size of SDH, presence of midline shift, platelet counts at the time of SDH confirmation and after management, management of SDH and thrombocytopenia, platelet goal for management, complications, recurrence of SDH, and outcome at last follow-up. These data were collected by one author and reviewed by another author.
Seven out of 242 studies met inclusion criteria.[
Preferred reporting items for systematic reviews and meta-analyses flow chart of systematic review conducted in October 2021. A total of 242 unique records were identified using PubMed and Web of Science databases. Initial title and abstract screening excluded 97 articles. Full-text screening found seven articles meeting inclusion criteria, n: Number.
Previous studies on safe platelet ranges for surgical management of SDHs focused on platelet transfusions for achieving platelet goals.[
The medical and surgical management varied widely among cases. Complications varied with two of the seven cases (Patient 1 and 4) having recurrence of the SDH after treatment. Patient 1 was diagnosed with concurrent ITP with the left-sided SDH and underwent left frontoparietal craniotomy with IV methylprednisolone and IVIG. Patient 4 had philadelphia chromosome positive ALL with bilateral SDH while receiving imatinib and dasatinib therapy and underwent trephination. Thrombocytopenia induced by hematologic disorders, such as ITP and ALL predisposed these patients to higher risk of recurrence after initial surgical management for SDH. Circulating autoantibodies due to the ITP present in Patient 1 led to a diminished recovery rate in endogenous platelet counts. ALL is known to lead to marrow failure contributing to decreased platelet count, making it difficult to recover adequate platelet numbers to prevent recurrent bleeding. This is the first report of eMMA for stabilization of cSDH without recurrence in the setting of refractory thrombocytopenia.
Once thought to be due to a singular event, the central pathology of SDHs is now being recognized as a cerebrovascular event with a cycle of hemorrhage, fibrosis, and angiogenesis.[
The MMA is believed to supply the outer membrane of a SDH,[
Although the exact mechanism of eMMA remains unclear, our findings support its use in populations with persistent refractory thrombocytopenia to prevent further bleeding. In this case, the patient’s cSDH was stable enough to be managed outside the hospital, so he spent his last moments with his loved ones as per his advanced directive. The overall treatment benefit among patients with substantial disease burden should also be emphasized in the management of cSDH.
Our case has shown the success of eMMA without surgical evacuation in successfully treating symptomatic cSDH in a high-risk surgical patient with refractory thrombocytopenia. Based on this case and a systematic review of seven cases of cSDH with comorbid thrombocytopenia, a platelet goal of 20,000/mm3 prior to any surgical intervention may be sufficient and more attainable than current platelet goals of 40,000-50,000/mm3. Though all patients included in this review had stable or resolving cSDH, further investigations are required to determine the utility of lowering the platelet threshold prior to neurosurgical intervention.
The authors certify that they have obtained all appropriate patient consent.
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.
The authors would like to acknowledge Andrea Siu for facilitating the logical aspects of this study. Thank you to the medical institution for assistance with data retrieval.
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