Middle meningeal artery embolization for the treatment of unilateral large chronic subdural hematoma patients with significant midline shift: A single-center experience

Abstract

Background: The amount of midline shift (MLS) considered safe for middle meningeal artery embolization (MMAE) in patients with chronic subdural hematoma (CSDH) has not been established. Whether MMAE could be used as upfront treatment for unilateral large CSDH patients with significant MLS (>1 cm) has not been reported.

Objective: To investigate the efficacy and safety of MMAE in unilateral large CSDH patients with MLS > 1 cm.

Methods: Eleven carefully selected CSDH patients with mild or moderate symptoms and significant MLS > 1 cm from 1 May 2021 to 31 August 2022 were included in the study. All patients were treated with MMAE using polyvinyl alcohol (PVA) particles. Outcomes were assessed clinically and with interval imaging studies at follow-up.

Results: All 19 MMAs (unilateral embolization in three patients and bilateral embolization in eight patients) were successfully embolized. All 11 patients were followed for subsequent months, and there was no recurrence and enlargement of CSDH. Procedural adverse events, mortality, or complications were not observed. The average time to achieve a 50% reduction in MLS was approximately four weeks, while it took approximately eight weeks to achieve a 50% reduction in maximal volume. All 11 patients showed improvement in their neurological symptoms at three days post-operation, including four hemiplegic patients.

Conclusions: MMAE may demonstrate safety in carefully selected CSDH patients with significant midline shift (MLS > 1 cm), particularly in those who are not suitable for surgery, thus providing a potential alternative approach.

Keywords: 3D-TOF MRA; Chronic subdural hematoma; interventional embolization; middle meningeal artery; midline shift.

Figure 1.

Box-plot analysis of MLS improvement during follow-up of a CSDH after treatment with MMAE. The box plots summarize the distribution of MLS at each follow up over time, which demonstrates the significant time effect among 11 patients who underwent MMAE for a CSDH.

Figure 2.

Box-plot analysis of hematoma volume improvement during follow-up of a CSDH after treatment with MMAE. The box plots summarize the distribution of hematoma volume at each follow up over time, which demonstrates the significant time effect among 11 patients who underwent MMAE for a CSDH.

Figure 3.

Box-plot analysis of mRS improvement during follow-up of a CSDH after treatment with MMAE. The box-plot summarizes the distribution of mRS at each follow up over time, which demonstrates the significant time effect among 11 patients who underwent MMAE for a CSDH.

Figure 4.

Illustrative case. (A) Head MRI demonstrated a large right CSDH with MLS > 1 cm; (B) TOF MRA showed significant enlargement of bilateral MMA (arrows); (D, E) Frontal and lateral right MMA superselective angiography on ipsilateral of CSDH demonstrated an enlarged MMA; (G, H) Left MMA superselective angiography demonstrated frontal division of the MMA anastomosing with branches of the contralateral MMA (arrowheads); (F, I) Post-embolization angiography presented bilateral MMA branches occlusion; (C) CT scan four months post-embolization demonstrated almost complete resolution of CSDH.