Written by Doug Wallace
Spoon Feed
This RCT describes a cutting-edge technique that entails embolization of the middle meningeal artery as an adjunctive therapy for operative SDH.
Therapeutic emboli
SDH is a common pathology with frequent indications for operative intervention. Operative treatment usually involves cranial decompression with burr holes or a craniotomy and high rate of recurrence and surgical complications. In this RCT, 400 patients were randomized to either “standard treatment” of surgery without embolization or surgery with embolization of the middle meningeal artery with an injectable liquid embolic system.
Hematoma recurrence requiring reoperation occurred in 4.1% of the embolization group versus 11.3% in controls (RR 0.36, 95%CI 0.11–0.80, P = 0.008). Functional deterioration at 90 days was comparable between groups (11.9% vs. 9.8%; risk difference 2.1%, 95%CI −4.8 to 8.9). The 90-day mortality appeared to be higher in the treatment group than in the control group (5.1% vs. 3.0%), but the difference was not attributed to the embolization procedure. Ischemic stroke is a known complication of embolization, and strokes related to the intervention occurred in 2 patients and were similar in the control group. Limitations of this study included significant lack of follow up (13%), which the authors ascribe to COVID and the age of the participants. They also mention a larger sample size is needed for this intervention to be adequately evaluated. Though not quite ready for primetime, this study highlights a cutting-edge and interesting technique for the treatment of operative SDH.
How will this change my practice?
While I won’t be embolizing meningeal arteries anytime soon, I might bring this technique up to my friendly neighborhood neurosurgeon next time they level a patient to the OR for SDH. Tomorrow, we will review MAGIC-MT, a similar RCT.
Source
Adjunctive Middle Meningeal Artery Embolization for Subdural Hematoma. N Engl J Med. 2024 Nov 21;391(20):1890-1900. doi: 10.1056/NEJMoa2313472. PMID: 39565988
