辅助脑膜中动脉栓塞与单独手术治疗慢性硬膜下血肿：随机对照试验的荟萃分析和试验序列分析

IF 1.9 4区医学 Q3 CLINICAL NEUROLOGY

Journal of Clinical Neuroscience Pub Date : 2025-05-12 DOI:10.1016/j.jocn.2025.111307

João Pedro Fernandes Gonçalves, Gabriel Souza Medrado-Nunes, Gabriel Teles de Oliveira Piñeiro, Felipe Asaf Borges Millard, Marcos Paulo Rodrigues Oliveira, Nara Samara Silva Felipe dos Santos, Thaís Barbosa de Oliveira, Pedro Henrique Ferreira Sandes, Luiz Paulo Oliveira-Martins, Marivaldo Yslan Silveira-Leal, Júlia Xavier, Luísa Dias Moreno Aravena, Pedro Antonio Pereira de Jesus

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引用次数: 0

摘要

脑膜中动脉栓塞（MMAE）作为慢性硬膜下血肿（cSDH）手术引流的辅助手段进行了研究。先前比较MMAE与常规治疗cSDH的荟萃分析包括观察性和随机研究。为了提供更可靠的评估，我们对随机对照试验进行了荟萃分析，以评估辅助MMAE与单独手术治疗的结果。方法我们检索PubMed、EMBASE和Cochrane CENTRAL数据库，以比较截至2024年12月辅助脑膜中动脉栓塞与单独手术治疗的研究。评估的结果包括治疗失败、再手术、并发症、死亡率、功能结局和住院时间。采用R软件（4.3.2版）进行统计分析。采用I2统计量评估异质性。使用Cochrane随机试验偏倚风险工具评估偏倚风险。结果纳入6项研究，1422例患者，其中700例（49.2%）接受了辅助脑膜中动脉栓塞。栓塞组的平均年龄为64.2 ~ 77.4岁，单纯手术组的平均年龄为70 ~ 74.4岁。在这些患者中，435人（54.5%）有过已知的头部创伤，315人（22.1%）使用过抗血小板或抗凝血药物。随访时间为90 ~ 180天。与单纯手术治疗相比，辅助脑膜中动脉栓塞治疗失败的发生率降低(RR 0.482；95% CI 0.328 ~ 0.708；p & lt;0.001;I2 = 0%)和再手术(RR 0.333；95% CI 0.212 ~ 0.521；p & lt;0.001;I2 = 0%)，但didńt可降低任何原因死亡率的发生(RR 0.970；95% CI 0.400 ~ 2.353；p = 0.946；I2 = 39.6%)，最后一次随访时功能依赖(RR 1.000；95% CI 0.726 - 1.377；p = 0.705；I2 = 0%)，或停留时间(MD 0.576；95% CI - 0.085 ~ 1.238；p = 0.088；i2 = 0%)。此外，在手术后的并发症方面没有发现差异(RR 0.902；95% CI 0.688 ~ 1.182；p = 0.455；I2 = 0%)，栓塞相关并发症发生率较低(RR 0.013；95% CI 0.006 ~ 0.027；i2 = 0%)。试验序贯分析认为样本量足以证明治疗失败和再次手术，但建议需要进一步的试验来证明手术相关并发症的差异。结论与单纯手术相比，脑膜中动脉栓塞可显著降低复发和再手术率，不良事件发生率低。然而，对功能结局和死亡率的影响仍不确定，需要进一步研究以阐明其长期益处。

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Adjunct middle meningeal artery embolization versus surgery alone for chronic subdural hematoma: A meta-analysis and trial sequential analysis of randomized controlled trials

Introduction

Middle meningeal artery embolization (MMAE) has been studied as an adjunct to surgical evacuation for chronic subdural hematoma (cSDH). Previous meta-analyses comparing MMAE with conventional treatment for cSDH included both observational and randomized studies. To provide a more robust assessment, we performed a meta-analysis of randomized controlled trials to evaluate the outcomes of adjunct MMAE compared to surgical treatment alone.

Methods

We searched PubMed, EMBASE, and Cochrane CENTRAL databases for studies comparing adjunct middle meningeal artery embolization to surgical treatment alone until December 2024. The outcomes assessed were treatment failure, reoperation, complications, mortality, functional outcome, and length of hospital stay. Statistical analysis was performed via R software (version 4.3.2). Heterogeneity was assessed with I² statistics. The risk of bias was assessed using the Cochrane Risk of Bias Tool for Randomized Trials.

Results

We included 6 studies with 1,422 patients, of whom 700 (49.2 %) received adjunct middle meningeal artery embolization. The mean age ranged from 64.2 to 77.4 years in the embolization group and from 70 to 74.4 years in the surgery-only group. Among the patients, 435 (54.5 %) had previous known head trauma, and 315 (22.1 %) were on antiplatelets or anticoagulants. The follow-up ranged from 90 to 180 days. Adjunct middle meningeal artery embolization reduced the occurrence of treatment failure compared to surgical treatment alone (RR 0.482; 95 % CI 0.328 to 0.708; p < 0.001; I² = 0 %) and reoperation (RR 0.333; 95 % CI 0.212 to 0.521; p < 0.001; I² = 0 %), however, didńt reduce the occurrence of any cause mortality (RR 0.970; 95 % CI 0.400 to 2.353; p = 0.946; I² = 39.6 %), functional dependence at the last follow-up (RR 1.000; 95 % CI 0.726 to 1.377; p = 0.705; I² = 0 %), or the length of stay (MD 0.576; 95 % CI −0.085 to 1.238; p = 0.088; I² = 0 %). Furthermore, no differences were found regarding complications secondary to the surgical procedure (RR 0.902; 95 % CI 0.688 to 1.182; p = 0.455; I² = 0 %), and the occurrence of embolization-related complication was low (RR 0.013; 95 % CI 0.006 to 0.027; I² = 0 %). Trial sequential analysis judged the sample size sufficient for treatment failure and reoperation but suggested that further trials are needed to prove differences in surgical-related complications.

Conclusion

Our results confirm that middle meningeal artery embolization significantly reduces recurrence and reoperation rates compared to surgery alone, with low adverse event rates. However, the impact on functional outcomes and mortality remains uncertain, warranting further studies to clarify its long-term benefits.

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来源期刊

Journal of Clinical Neuroscience 医学-临床神经学

CiteScore

4.50

自引率

0.00%

发文量

402

审稿时长

40 days

期刊介绍： This International journal, Journal of Clinical Neuroscience, publishes articles on clinical neurosurgery and neurology and the related neurosciences such as neuro-pathology, neuro-radiology, neuro-ophthalmology and neuro-physiology. The journal has a broad International perspective, and emphasises the advances occurring in Asia, the Pacific Rim region, Europe and North America. The Journal acts as a focus for publication of major clinical and laboratory research, as well as publishing solicited manuscripts on specific subjects from experts, case reports and other information of interest to clinicians working in the clinical neurosciences.