Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: Rationale, Technique, and Results

Abstract

rosurgical condition that has a poor natural history. With an inhospital mortality of 16.7%, 1-year mortality of 32%, and only 21.1% of admitted patients returning home, cSDH remains a disabling and deadly disease. The incidence of cSDH greatly increases with age, with some estimates being as high as 18 per 100,000 individuals between the ages of 71 and 80 years. With an aging population and increased use of antiplatelet and anticoagulation medications, the incidence of cSDH is expected to exceed 60,000 new cases per year by the year 2030. Management strategies for cSDH vary widely and are subject to provider and institutional preferences. Traditional management avenues for cSDH have involved conservative management and open surgery. Conservative management has included observation, the use of corticosteroids, statins, osmotically active agents, platelet-activating factor inhibitors, and plasminogen activator inhibitors. Statins, in particular, have been demonstrated to be beneficial for patients with cSDH in recent randomized clinical trials. Surgical management includes options such as twist drill craniostomy at the bedside and open surgical drainage via burr holes or formal craniotomy. In a randomized clinical trial performed in 2009, the use of drains after burr hole drainage was associated with reduced recurrence and mortality at 6 months, thereby justifying the use of drains after burr hole drainage of cSDH. In general, patients who are asymptomatic or have minor symptoms with smaller hematoma volumes typically warrant conservative management, whereas patients with more severe symptoms and larger hematoma volumes require operative intervention. The success rate of each method in resolving the hematoma is variable, although surgical intervention is generally favorable in this regard and offers the advantage of an immediate decompressive effect. However, the recurrence rate of cSDH even after surgical evacuation is variable and may be as high as 37% by some estimates.