Abstract
INTRODUCTION
Refractory chronic subdural hematomas (cSDH) constitute a challenging entity that neurosurgeons face frequently nowadays, especially in fragile elderly populations. Middle meningeal artery embolization (MMAE) has emerged in the past years as a promising treatment option. However, solid evidence is still lacking due to paucity of studies and small sample sizes.
METHODS
We conducted a systematic review and meta-analysis (MA) in compliance with the PRISMA guidelines to evaluate the efficacy and safety of MMAE compared with conventional treatments for refractory or SDH. Four databases were searched up to March 2019. Using a random-effects model, meta-analyses of proportions and risk difference were conducted on outcomes including recurrence, need for surgical rescue, and complications
RESULTS
A total of 12 studies (177 patients) were included. Majority (69%) were males with weighted mean age of 71 + −19.5 yr. Rate of chronic alcoholism was 15%, cerebral atrophy 39%, use of anticoagulants/antiplatelets 52%, and history of head trauma 55%. Weighted mean hematoma thickness was 17.9 + −13.3 mm. In embolized patients across 12 studies, proportion MA showed rate of treatment failure to be 2.9% (95% CI = 0.5%-5.2%, I2 = 0%), need for surgical rescue 2.7% (95% CI = 0.4%-5%, I2 = 0%), and embolization-related complications 1.2% (95% CI 0.3%-2.7%, I2 = 0%). Meta-analysis of risk-difference between embolized and nonembolized patients in three double-armed cohort studies showed a 26% lower risk of failure in MMAE (95% CI 21%-31%, I2 = 0, Cochran Q = 0.64) that was statistically significant (P < 0.001). Similarly, in the embolized group, the need for surgical rescue was 20% less (95% CI = 12%-27%, I2 = 12.4, Cochran Q = 2.28) and complications 3.6% less (95% CI 1%-6%, I2 = 0, Cochran Q = 0.31) than in conventional groups, both of which achieved statistical significance
CONCLUSION
Although MMAE appears to be a promising treatment for refractory or cSDH, drawing definitive conclusions remains limited by paucity of data. Large, prospective trials are needed to compare embolization to conventional treatments, like watchful waiting, medical management, or surgical evacuation. More extensive research of MMAE could begin a new era in the minimally invasive management of cSDH.
Endovascular embolisation of the middle meningeal artery to treat chronic subdural haematomas: effectiveness, safety, and the current controversy. A systematic review