Written by Alex Clark
Spoon Feed
Middle meningeal artery embolization in patients with nonacute subdural hematoma resulted in similar rates of symptomatic recurrence and expansion, with lower incidence of serious adverse events.
I’ve got the MAGIC…MT
An aging population with reliance on anticoagulants has increased the incidence of subdural hematomas (SDH) in the ED. Despite surgical evacuation methods such as burr-hole drainage and open craniotomy, as well as standard supportive medical care, symptomatic SDH recurrence and expansion remains high. One potential target focuses on the fragile subdural vasculature provided by the middle meningeal artery. Yesterday, we covered EMBOLISE, which showed reduced SDH recurrence.
The MAGIC-MT was a multicenter, open-label, blind endpoint, randomized control trial in China that examined middle meningeal artery embolization v.s. standard of care in patients previously living independently (modified Rankin 0-2), with symptomatic nonacute SDH and mass effect. Patients were in two groups: those warranting burr-hole drainage (~78% of patients) v.s. those who did not. Both groups (burr hole and not) were then randomized to embolization (n = 360) v.s. usual care (n = 362). The primary outcome showed no significant difference in symptomatic recurrence or progression of SDH within 90 days (6.7% vs 9.9%, (-3.3, 95%CI, -7.4 to 0.8; p=0.10)). However, the incidence of serious adverse events including death was significantly lower in the embolization group (6.7% vs. 11.6%, p=0.02).
This study is limited by a lack of blinding and generalizability. This includes location (single country in Asia), patient population (relatively healthy and low anticoagulant use), “standard of care” medical therapies (high use of glucocorticoids, low number of anticonvulsants), single-agent embolization material (Onyx liquid), and a niche patient cohort (no traumatic or acute SDH or craniotomy patients).
How does this change my practice?
Despite the limitations above, the MAGIC-MT RCT is one of several 2024 publications that supports the safety and potentially efficacy of middle meningeal artery embolization. More centers are offering this procedure, and as EPs we must be familiar with its pros and cons. The questions I’m asking: Is it safe in my patients? What about acute SDH? Is a burr-hole really necessary? The authors of MAGIC-MT lead me to believe some of these might be answered soon.
Source
Middle Meningeal Artery Embolization for Nonacute Subdural Hematoma. N Engl J Med. 2024 Nov 21;391(20):1901-1912. doi: 10.1056/NEJMoa2401201. PMID: 39565989
