Ma Li, Hoz Samer S, Doheim Mohamed F, Fadhill Ali, Sultany Abdullah, Al-Bayati Alhamza R, Nogueira Raul G, Lang Michael J, Gross Bradley A
Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
Department of Neurology, University of Pittsburgh Medical Center Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
World Neurosurg. 2024 Dec;192:e513-e522. doi: 10.1016/j.wneu.2024.10.013. Epub 2024 Nov 2.
Middle meningeal artery embolization (MMAE) has revolutionized the armamentarium for chronic subdural hematoma (CSDH) treatment. Technical and angiographic benchmarks to guide procedural and clinical success are less well established.
A single-center database was reviewed to compare outcomes after standalone MMAE with and without resultant residual angiographic opacification of frontal and parietal (F/P) branches. Primary outcome was surgical rescue for CSDH progression. Secondary outcomes included the efficiency and accumulated efficacy of hematoma resolution. Effect sizes were adjusted via multivariable regression.
Of 147 standalone MMAE for CSDH, the overall rate of surgical rescue was 6.8%. Nonopacification of F/P branches via proximal middle meningeal artery or meningo-ophthalmic anastomosis was achieved after 83% of procedures and was associated with a 7-fold decreased rate of surgical rescue (3.3% vs. 24%, P = 0.001). At 90-day follow-up, a higher rate of hematoma resolution ≥50% was achieved if no residual opacification was identified (82% vs. 56%, P = 0.03). The median time to 50% hematoma resolution was 44 days for the no-residual group versus 71 days for the residual group (P < 0.001). The unfavorable effects of residual opacification of F/P branches were verified in a multivariate analysis: a higher risk of surgical rescue (adjusted odds ratio 24.6; P = 0.001) and poor hematoma resolution were both confirmed (adjusted hazard ratio 0.3; P = 0.001).
MMAE with nonopacification of F/P branches was associated with augmented efficacy. Nuanced MMAE adequately tackling culprit dural feeders should be considered for more effective procedures.
脑膜中动脉栓塞术（MMAE）彻底改变了慢性硬膜下血肿（CSDH）的治疗手段。用于指导手术和临床成功的技术及血管造影基准尚不完善。
回顾单中心数据库，比较单独进行MMAE且额叶和顶叶（F/P）分支血管造影有无残留造影剂充盈的患者的预后。主要结局是CSDH进展的手术补救情况。次要结局包括血肿吸收的效率和累积疗效。效应量通过多变量回归进行调整。
在147例单独进行的CSDH的MMAE中，手术补救的总体发生率为6.8%。83%的手术通过近端脑膜中动脉或脑膜眼动脉吻合实现了F/P分支无造影剂充盈，且与手术补救率降低7倍相关（3.3%对24%，P = 0.001）。在90天随访时，如果未发现残留造影剂充盈，则血肿吸收≥50%的发生率更高（82%对56%，P = 0.03）。无残留组血肿吸收50%的中位时间为44天，而残留组为71天（P < 0.001）。多变量分析证实了F/P分支残留造影剂充盈的不良影响：手术补救风险更高（调整后的优势比为24.6；P = 0.001）和血肿吸收不良均得到证实（调整后的风险比为0.3；P = 0.001）。
F/P分支无造影剂充盈的MMAE疗效更佳。为了获得更有效的手术效果，应考虑采用能精准处理硬膜供血动脉的细致MMAE术。
