Salem Mohamed M, Helal Ahmed, Gajjar Avi A, Sioutas Georgios S, Khalife Jane, Kuybu Okkes, Caroll Kate, Nguyen Hoang Alex, Baig Ammad A, Salih Mira, Baker Cordell, Cortez Gustavo, Abecassis Zack, Ruiz Rodriguez Juan F, Davies Jason M, Cawley C Michael, Riina Howard A, Spiotta Alejandro M, Khalessi Alexander A, Howard Brian M, Hanel Ricardo, Tanweer Omar, Tonetti Daniel A, Siddiqui Adnan H, Lang Michael J, Levy Elad I, Ogilvy Christopher S, Srinivasan Visish M, Kan Peter, Gross Bradley A, Jankowitz Brian T, Levitt Michael R, Thomas Ajith J, Grandhi Ramesh, Burkhardt Jan-Karl
Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia , Pennsylvania , USA.
Department of Neurosurgery, University of Colorado School of Medicine, Aurora , Colorado , USA.
Neurosurgery. 2024 Oct 17. doi: 10.1227/neu.0000000000003218.
Multiple preferences exist for embolic materials selection in middle meningeal artery embolization (MMAE) for chronic subdural hematoma with limited comparative literature data. Herein, we compare different embolic materials.
Consecutive patients undergoing MMAE for chronic subdural hematoma at 14 North-American centers (2018-2023) were classified into 3 groups: (a) particles, (b) Onyx, (c) n-butyl cyanoacrylate (n-BCA). The end points were unplanned rescue surgery, radiographic success (≥50% reduction in hematoma thickness at last imaging "minimum of 2 weeks"), and major complications. Initial unmatched analysis compared the 3 groups; subsequent propensity score matching (PSM) compared particles vs liquid embolics (groups b and c combined). Additional subgroup PSM analyses compared particles vs Onyx, particles vs n-BCA, and Onyx vs n-BCA. All matched analyses controlled for age, sex, concurrent surgery, previous surgery, hematoma thickness, midline shift, pretreatment antithrombotics, and baseline modified Rankin Scale.
Eight hundred and seventy-two patients (median age 73 years, 72.9% males) underwent 1070 MMAE procedures. Onyx was most used (41.4%), then particles (40.3%) and n-BCA (15.5%). Surgical rescue rates were comparable between particles, Onyx, and n-BCA (9.8% vs 7% vs 11.7%, respectively, P = .14). Similarly, radiographic success (78.8% vs 79.3% vs 77.4%; P = .91) and major complications (2.4% vs 2.3% vs 2.5%; P = .83) were comparable. The PSM comparing particles vs liquid generated 128 matched pairs; general anesthesia and bilateral procedures were significantly higher in particles (37.8% vs 21.3%; P = .004 and 39.8% vs 27.3%; P = .034, respectively). No differences in surgical rescue, radiographic improvement, or major complications were noted ( P > .05). Concurrently, PSM comparing particles vs Onyx, particles vs n-BCA, and Onyx vs n-BCA, resulted in 112, 42, and 40 matched pairs, respectively, without differences in surgical rescue, radiographic success, or major complications ( P > .05).
We found no differences in radiological improvement, surgical rescue, or major complications between embolic materials in MMAE. Current randomized trials are exclusively using liquid embolics, and these data suggest that future trials involving particles are likely to produce similar outcomes.
在慢性硬膜下血肿的脑膜中动脉栓塞术（MMAE）中，栓塞材料的选择存在多种偏好，但比较性文献数据有限。在此，我们比较不同的栓塞材料。
2018年至2023年期间，在北美14个中心接受MMAE治疗慢性硬膜下血肿的连续患者被分为3组：（a）颗粒，（b）Onyx，（c）正丁基氰基丙烯酸酯（n-BCA）。终点指标为计划外补救手术、影像学成功（最后一次成像“至少2周”时血肿厚度减少≥50%）和主要并发症。最初的非匹配分析比较了3组；随后的倾向评分匹配（PSM）比较了颗粒与液体栓塞剂（b组和c组合并）。额外的亚组PSM分析比较了颗粒与Onyx、颗粒与n-BCA以及Onyx与n-BCA。所有匹配分析均对年龄、性别、同期手术、既往手术、血肿厚度、中线移位、术前抗血栓治疗和基线改良Rankin量表进行了控制。
872例患者（中位年龄73岁，72.9%为男性）接受了1070次MMAE手术。Onyx使用最多（41.4%），其次是颗粒（40.3%）和n-BCA（15.5%）。颗粒、Onyx和n-BCA之间的手术补救率相当（分别为9.8%、7%和11.7%，P = 0.14）。同样，影像学成功率（78.8%、79.3%和77.4%；P = 0.91）和主要并发症发生率（2.4%、2.3%和2.5%；P = 0.83）相当。比较颗粒与液体栓塞剂的PSM产生了128对匹配对；颗粒组的全身麻醉和双侧手术显著更高（分别为37.8%对21.3%；P = 0.004和39.8%对27.3%；P = 0.034）。在手术补救、影像学改善或主要并发症方面未发现差异（P > 0.05）。同时，比较颗粒与Onyx、颗粒与n-BCA以及Onyx与n-BCA的PSM分别产生了112、42和40对匹配对，在手术补救、影像学成功或主要并发症方面没有差异（P > 0.05）。
我们发现MMAE中不同栓塞材料在影像学改善、手术补救或主要并发症方面没有差异。目前的随机试验仅使用液体栓塞剂，这些数据表明未来涉及颗粒的试验可能会产生类似的结果。
