Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: Predictors of Clinical and Radiographic Failure from 636 Embolizations

Background Knowledge regarding predictors of clinical and radiographic failures of middle meningeal artery (MMA) embolization (MMAE) treatment for chronic subdural hematoma (CSDH) is limited. Purpose To identify predictors of MMAE treatment failure for CSDH. Materials and Methods In this retrospective study, consecutive patients who underwent MMAE for CSDH from February 2018 to April 2022 at 13 U.S. centers were included. Clinical failure was defined as hematoma reaccumulation and/or neurologic deterioration requiring rescue surgery. Radiographic failure was defined as a maximal hematoma thickness reduction less than 50% at last imaging (minimum 2 weeks of head CT follow-up). Multivariable logistic regression models were constructed to identify independent failure predictors, controlling for age, sex, concurrent surgical evacuation, midline shift, hematoma thickness, and pretreatment baseline antiplatelet and anticoagulation therapy. Results Overall, 530 patients (mean age, 71.9 years ± 12.8 [SD]; 386 men; 106 with bilateral lesions) underwent 636 MMAE procedures. At presentation, the median CSDH thickness was 15 mm and 31.3% (166 of 530) and 21.7% (115 of 530) of patients were receiving antiplatelet and anticoagulation medications, respectively. Clinical failure occurred in 36 of 530 patients (6.8%, over a median follow-up of 4.1 months) and radiographic failure occurred in 26.3% (137 of 522) of procedures. At multivariable analysis, independent predictors of clinical failure were pretreatment anticoagulation therapy (odds ratio [OR], 3.23; P = .007) and an MMA diameter less than 1.5 mm (OR, 2.52; P = .027), while liquid embolic agents were associated with nonfailure (OR, 0.32; P = .011). For radiographic failure, female sex (OR, 0.36; P = .001), concurrent surgical evacuation (OR, 0.43; P = .009), and a longer imaging follow-up time were associated with nonfailure. Conversely, MMA diameter less than 1.5 mm (OR, 1.7; P = .044), midline shift (OR, 1.1; P = .02), and superselective MMA catheterization (without targeting the main MMA trunk) (OR, 2; P = .029) were associated with radiographic failure. Sensitivity analyses retained these associations. Conclusion Multiple independent predictors of failure of MMAE treatment for chronic subdural hematomas were identified, with small diameter (<1.5 mm) being the only factor independently associated with both clinical and radiographic failures. 

Comments：

This is a retrospective study that aimed to identify predictors of middle meningeal artery embolization (MMAE) treatment failure for chronic subdural hematoma (CSDH). The study included consecutive patients who underwent MMAE for CSDH at 13 U.S. centers from February 2018 to April 2022. The study defined clinical failure as hematoma reaccumulation and/or neurologic deterioration requiring rescue surgery, and radiographic failure as a maximal hematoma thickness reduction less than 50% at last imaging (minimum 2 weeks of head CT follow-up).

The study included 530 patients with a mean age of 71.9 years, and 636 MMAE procedures were performed. The study found that clinical failure occurred in 6.8% of patients over a median follow-up of 4.1 months, and radiographic failure occurred in 26.3% of procedures. The study identified multiple independent predictors of failure of MMAE treatment for CSDH. Small MMA diameter (<1.5 mm) was the only factor independently associated with both clinical and radiographic failures. Other factors associated with clinical failure included pretreatment anticoagulation therapy and non-use of liquid embolic agents. Factors associated with radiographic failure included midline shift, superselective MMA catheterization (without targeting the main MMA trunk), and shorter imaging follow-up time. Conversely, female sex and concurrent surgical evacuation were associated with non-failure. Sensitivity analyses retained these associations. The study provides important insights into the predictors of MMAE treatment failure for CSDH and can help guide clinical decision-making in this patient population.