Elsevier

World Neurosurgery

Volume 101, May 2017, Pages 520-527
World Neurosurgery

Original Article
Embolization Therapy for Refractory Hemorrhage in Patients with Chronic Subdural Hematomas

https://doi.org/10.1016/j.wneu.2017.02.070Get rights and content

Objective

There is no definite operative procedure for patients with intractable chronic subdural hematoma (CSDH). We describe the safety and efficacy of embolization treatment of the middle meningeal artery (MMA) for such cases.

Methods

Patients were divided into an embolization group (n = 20) and a conventional group (n = 23) based on the therapeutic approach to their CSDHs. The targets of the endovascular treatment were 26 recollected hematomas with increased risk of recurrence. To eliminate the arterial supply of the external membrane of CSDHs, 2 branches of the MMA were selected and occluded by injection of polyvinyl alcohol particles.

Results

Older age and antiplatelet drug use were comparatively related to the embolization group (P < 0.05). Among imaging study variables, severe brain atrophy and hematoma bilaterality were the risk factors for necessity of MMA embolization (P < 0.05). The complication rate and functional outcome were not significantly different between the 2 groups (P > 0.05). After multivariate analysis, early brain re-expansion (P = 0.003) and lesser hematoma recurrence (P = 0.024) remained independently associated with patients who underwent embolization therapy.

Conclusions

This pilot study indicated that perioperative MMA embolization could be offered as the least invasive and most effectual means of treatment for resistant patients of CSDHs with 1 or more recurrences.

Introduction

Chronic subdural hematoma (CSDH) is an increasing clinical occurrence in modern neurosurgical practice. Trephination and drainage are the gold standard for patients with space-occupying CSDHs. Treatment outcomes are good in most patients, but recollection of blood requiring reoperation sometimes occurs. In the reports on CSDHs treated by burr-hole surgery, 11%–28% of operative cases developed a recurrent hematoma.1, 2 Subdural drainage is the most widely accepted management for symptomatic recurrences; however, previous studies3, 4 have found that revision surgery was unsuccessful in some cases.

Furthermore, it is more difficult to treat patients with CSDHs in whom resolution cannot be achieved even after repeated craniostomy and irrigation procedures. This intractability is more commonly encountered in patients with coagulopathy, elderly patients with cerebral atrophy, and patients on antithrombotic drugs.5 Treatment for intractable CSDHs should concentrate on addressing the capillary feeders of hematomas that originate from the middle meningeal artery (MMA). However, only a few sporadic reports of achieving transarterial therapy for patients with recurrent CSDH have been published in the literature.6, 7 In this study, the MMA embolization method was applied to patients with uncontrolled hemorrhage in refractory CSDHs and the potential role of this strategy for preventing further recurrence of hematomas was examined.

Section snippets

Patient Selection

A review was carried out of 372 patients who were hospitalized for burr-hole surgery to evacuate newly diagnosed unilateral or bilateral CSDHs from January 2007 to December 2015. These patients received 1 or 2 burr-hole trephinations for subdural irrigation under general or local anesthesia. A silicon tube was pulled out when drainage became negligible. The recurrence of CSDHs was shown by the reappearance of neurologic manifestations and an increase in hematoma volume on computed tomography

Results

Demographic and clinical data are listed in Table 1. The embolization group was found to be associated with older age (P = 0.041) and antiplatelet medication (P = 0.038) but not with history of head trauma. On comparing the neurologic status on admission, no statistical difference was observed in either group. Hypertension, diabetes, and cerebral infarct were more frequently observed in the embolization group, but these factors did not reach statistical significance. Severe brain atrophy (P

Discussion

Managing CSDH is a straightforward process, but an unremitting hemorrhage is sometimes difficult to treat. This factor was shown in the present study because the cohort had underlying medical diseases that complicated the clinical course of CSDHs. Revision surgery for drainage and irrigation is the first-line treatment for recollected hematomas. However, a few surgeons have performed complex procedures, such as craniotomy and membranectomy, subdural shunt, reservoir placement, hollow screw

Conclusions

The perioperative application of MMA embolization can accelerate the brain re-expansion rate, lessen the incidence of recurrence, and contribute to excellent outcomes for surgical cases of CSDHs with refractory recurrent hemorrhages.

Acknowledgments

The author would like to thank Dr. Hyuckwon Chang for the cerebral angiography and interventional procedure.

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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