While using a burr hole is the gold standard for surgical evacuation of a subdural hematoma, a recurrence rate of up to 33 percent after surgical intervention has been reported in patients. Interventional neurologist Shahram Majidi, MD, explains how middle meningeal artery embolization (MMAE) has emerged as a promising treatment modality for patients with chronic subdural hematoma and presents cases from Mount Sinai where this technique was applied.
Chapters (Click to go to chapter start) Background on subdural hematoma and current treatment/management options Method for collecting data on the use of MMAE to treat subdural hematomas at Mount Sinai Results of Mount Sinai’s trial What the trial means for treatment of subdural hematomas in the future Q&A/Discussion low rate of hematoma in solution and surgical evacuation through their whole or craniotomy remains as a gold standard treatment for symptomatic patients. However high rate of recurrence, more than up to more than 30% has been reported following surgical intervention. In the past several years, middlemen angel ordering globalization has emerged as a promising treatment modality for patients with chronic subdural hematoma, both as an adjunctive treatment after surgical evacuation or stand alone treatment. Ah Regarding how middlemen angel artery complication works in this setting, Prior animal studies and microscopic evaluation had demonstrated that after initial hemorrhages and subdural hematoma there is an inflammatory response stars, which includes the dural border, so layer proliferation and angiogenesis. This results in the formation of an immature and reaching vocabulary and a membrane around the subdural hematoma. This fragile vascular membrane serves as a source of progressive Cambridge and therefore recurring subdural in this patient. The middleman angel globalization has been shown to perhaps decrease the rate of recurrent lead likely by the vascular rising This subdural membrane and therefore breaking this vicious cycle of vascular proliferation and progressive membrane leakage. So, some anatomical consideration for uh embolization every embolization care cases starts with careful uh and geographic review of the vascular anatomy, the most common configuration of the middleman angel or anatomy starts with mm. A taking off from the proximal segment of the imax. As you see in this lateral view of the external carotid artery injection cst a imax and middle managers ordinary taking up. However, in rare cases, middlemen angel artery can originate from atomic ordinary or rarely or directly from the internal credit artists in those cases embolization of the development, injured artery might not safe for this purpose. So after identifying the middlemen angel arguing, we do uh super selective micro cast the injection of the artery. Here in this lateral view of the development in general are you see the frontal branch of the middlemen, angel artery and also posterior branch of the artery. There are two branches that uh we study carefully regarding the dangerous anastomosis. One is here as you see the arrows showing this haziness here. These are petros all branches they contribute to the facial nerve. So embolization proximal to this branch as the risk of causing facial nerve policy. And here when we go towards the frontal branch you see this small branch going forward towards the eyes. So this is orbital or meaning galaxy mall branch. So again embolization needs to be avoided um in vicinity of this branch so there safe embolization plan is to advance the micro catheter beyond these two dangerous and esteem. Asus and carefully watch the embolization material and avoid any reflects to this too branches in the past several years. Various techniques has been utilize and describe for subdural hematoma and realization of the main. The majority of the previously reported cases is used uh tv a embolization particles. The advantage of these particles are they're inexpensive. They do not elicit any pain response. Therefore the procedure can be done under Mac sedation. However, they are invisible. So it is a little challenging to see where exactly Then small particles are going. They also tend to make comes at bifurcation. Therefore it may not necessarily fully penetrate the subdural memory. The other amount of material which has been used or coil uh coils can be used for proximal occlusion of the main trunk of the artery. They're straightforward and fast to use the low risk because you're not gonna uh migrate uh or diffuse into the dangerous anastomosis. However, as you can imagine, they're not gonna fully d vascular arise. The subdural membrane and the membrane itself might still continue to get blood supply from collateral ah circulation. And recently liquid anabolic material has been also used for uh this purpose uh including uh onyx. Uh So the advantage of using liquid and metallic materials such as onyx is we can it can be used through smaller catheter which can be advanced. More pistol. In the middle men in geology, they're easily visible. So we can see where the embryonic material is going and you can stop when we see it is going towards the dangerous anastomosis. However, the mso injection is painful for the patient and most of the time you need to do our next injection under general anesthesia. And we can also use uh clue or NBC liquid anabolic material for nme embolization. Again it can be used through smaller catheters. The group is easily visible and the advantages it doesn't elicit pain. So therefore the procedure can be done under MAC sedation and these patients. Some of them has multiple comorbidities and general anesthesia might not be the most favorable platform and similar to the annex glue also offers permanent inclusion of distal with the potential ordering branch. NBC. A gluten problem arises when it contacts ionic substance like blood. It is typically mixed with the title to make its radio packed and also using a diluted NBC, able to delay the timing of the polymer Ization. NBC A does not problem arise in non ionic environment so therefore the rate of polymer ization flow and depth of penetration can be modified using diluted blue as well as concurrent infusion of The five and Water Solution. This technique has been previously utilized in a VM. Embolization of rural A. V. Fistula and it's called sugar push technique. So we hypothesized that if we advance the micro catheter very distal in the frontal or the Syrian branch of middleman angel artery. And while injecting dilute with glue, the second operator start injecting D five uh and water that will provide the glue the environment go further distantly into the middle manager artery branches and fully penetrate the subdural membrane. We started this technique in 2019 and here we are reporting are experience regarding safety and efficacy of just Take me for this patient Reviewed our prospectively collected institutional database and identify the op patient who underwent middle manager or the embolization with this technique during 2019 and 2020 inclusion criteria was aged 18 or older chronic regarding subdural hematoma and middle managers are the embolization using diluted glue and sugar push technique and presence of follow up cat scan and one leg. And up to six months after the intervention. In terms of the technique that we use tri axle system was used in our patients. This is the lateral the view of external credit artery angiography. Here. Down here you see them guide catheter has been part in the proximal segment of the C. C. A. And then up here the arrow shows the intermediate catheter which is like the origin of the imax. And after we advanced the micro catheter up to the either frontal or the Syrian branch off ah middlemen angel artery. Uh The intermediate category further advance into the origin of the middle manager artery to effectively arrest the blood flow to the artery And then maximize the impact of d. five. While the first operator is injecting NBC. A. Through micro catheter. The second operator injecting high volume uh D. Five. True Intermediate Catheter via 60 cm. Syringe to clear the M. M. A. From the blood and provide this non irony environment. NBC. A. So it will go much history in cases where the digital catheterization of the middle manager artery was not possible due to torches Anatomy. Uh We decided to put some coin and just close the proximal segment of the artery as a rescue plan. Outcome measures included primary efficacy outcome, which was the rate of recurrent symptomatic subdural hematoma which required surgical evacuation imaging efficacy outcome include the complete or near complete resolution of hematoma. It's near complete, defined as 90% or greater decrease in the size of it. Subdural hematoma and six month old law scan and primary safety outcome defined as the rate of cranial nerve policy or trump and Malik even resulting in tia or stroke and also access site complications such as hematoma or scheming complications. We also define and geographic outcomes as the rate of subdural hematoma member and penetration by blue. The rate of NBC A cast reaching the midline and the ap view. And also the rate of the time that NBC. A cast crossing the midline to the contra lateral side. So we identified 61 patients during this time period which was Which were being treated by this technique. The mean age was 62, 78% of them are male. Their initial and I struck scale score was one 25 patients were on anti platelets and nine patients were on anti gravity totals of 22 patients had bilateral subdural hematoma. 49% of the patients had surgical evacuation using either craniotomy their whole or steps prior to embolization. The normalization procedure was performed through radial access In 29 patients. Almost half of the patients and under Max edition and 64% of the patient complete closure of both frontal and parietal branches of middlemen and hardly was achieved in all cases. I've known in six occasions we have to use coal embolization to take the trunk of the frontal branch of the middlemen. Angel artery because the characterization of the branch was not possible to touch is an atom In 84% of the patients, the NBC a penetrated to this subdural membrane and more than half of the patients that reaches the midline. And in one out of four patients, NBC a cast cross the midline to the control lateral. That's right. This is an example of one of the patients of any one year old gentleman who presented with recurrent left subdural hematoma. As you see on the left side, can scan he underwent middlemen in geology embolization using diluted glue. As you see here, the arrows are showing the blue cast and the frontal and the Syrian branch of middlemen. In john hartley. Here in the middle scan, you see the one month follow up and on the right hand side. You see six month follow up which is showing a near complete resolution of subdural hematoma. We'll be showing some examples of our cases here. On the left side. You see super selective and geographic round of the main trunk of the right middle managerial artery lateral view here is the tip of the micro catheter obviously injecting glue from this position is not safe as we see the petrochemical plant and also collaterals to the eyes. So we advance the micro catheter up too much distal location and they for the Syrian branch of the military men. And john hardy as you see in the right hand side with this arrow showing the tip of the micro catheter. And at this point this is safe to uh start a glue injection. As you see in the middle of the picture. NBC injection being performed and and blue is crossing the midline to the controller had all side and we are very higher than any dangerous anastomosis in that pizza was bone or two or die. Another example on the left side is a super selective and geographic run of the frontal branch of the middleman and ordinary the arrow points the tip of the micro catheter again very higher than any collateral through the eyes. And you see some blush rooms there subdural membrane on the right side. You see the actual NBC injection with sugar push technique and And you see how diffuse sleep glue is filling the entire branch and crossing into the control lateral managerial or three branches. Another example. Super selective and geographic run of the frontal branch of the government in geology. Again the arrow is showing the tip of the micro catheter way higher than any dangerous anastomosis. And on the right side you see the actual glue injection taking the total dismantle of the mm a membrane, the subdural membrane this time. Super selective and geographic run of the frontal branch of the left middle men in geology arrows showing the tip of the micro canister. And you see that membrane blush in this patient. That left subdural hematoma on the right side. You see the blue injection. Sorry. You see how the glue is painting the entire branches of the frontal branch and also crossing to the control adult side. Very safe with this technique there is almost never reflects to the proximal anatomy because there is it heavy sugar push um providing the environment to the balloon to go forward. In fact, sometimes we see that glue is going too far because frontal branch of middlemen injured artery and go to the interior 1000 artery. Which actually can go down to the economic artists. So what we watch here just to make sure it doesn't go too far. So all patients underwent post embolization cat scan at one week and one month and a 86% of the patient had three month follow up scan and close to 40% of the patient had Var log scan at six months. So we encountered three Patients with recurrence of a hematoma which is 5% of the cases. One of his patients had a new subject him to him at the control annual side at six month. Follow up to underwent NBC embolization of the contra lateral side and remained stable at one month. Follow up the other two patients had worsened mass effect from their known subdural hematoma after normalization during the hospital state. And underwent a craniotomy and their whole placement or their health placement, hematoma evacuation of the 23 patients with follow up scan at six months, 96% had near complete or complete resolution of previously known subdural hematoma regarding the safety outcome. No cranial nerve policy vision. Last or ischemic stroke was seen in our home again. The distal pistol positioning of the micro catheter. And you think I loaded with Sugar Bush technique made the procedure extremely safe and the rate of cranial nerve policy. Original last. Uh huh. Zero one of our patients though had a transient episodes of alter mental status and Mr. Eric speech after procedure which resolved following in a few hours and then regarding the exercise complication. Bomb patient had growing hematoma which was managed conservatively with no intervention movement. So the alcohol is the largest series to date of mm hmm realization for subdural hematoma. Using NBC. A. In this course we demonstrated that diluted NBC A. With simultaneous large volume D. Five injection result in more distal and diffused penetration of NBC A. To the subdural membrane. It can be performed under MAC sedation and VR. Trans radial access as half of our cases or gone through this axis. The point here is uh using this technique. Uh We can offer minimum unusual artery embolization as an outpatient procedure. The patients come to get the procedure done under max edition through radial access will go back home same day, back to normal life. Uh From next day. The recurrent rate in our Cohort was 5%, which is comparable to previously published studies. And as mentioned, there's no procedure related vision loss, cranium, their policy or stroking count. So do you believe that unlike particles and we see a permanently vascular rise, the target vasculature there therefore provides a more durable benefit and also with direct visualization of the anabolic agents. As you see you saw in the prior slide, it's easier to control the depth and distribution of the embolization and avoid reflux into dangerous anastomosis. Announced to this small and more diffuse penetration of the membrane can be consistently achieved with this technique. The limitations of our studies, approximately 20% of our patient did not have a six month follow up or cat scan. Therefore, a cautious interpretation of the long term benefit. Our our proposed technique is warranted and also, although a very high rate of technical success in this comprehensive revascularization of the M. M. A. The vasculature was achieved in our cohort. Whether this taking call approach has any superior benefit and regarding outcome and decreasing the rate of recurrence of neural. In comparison to other techniques such as uh particles. Calls for onyx needs to be studied in randomized clinical setting regarding the future directions. Uh We are in the process of proposing a standardized creating system for middlemen, angel or re embolization using liquid anabolic material which can be clue or onyx. Uh They believe this uh This standardized creating system bull will help us to further understand the clinical and outcome significance of deep penetration of the anabolic material and comprehensive revascularization of the mm a branches in this patient. This grading system is from 1- five. One is when there is just a proximal ligation of the proximal trunk of the middle manager artery. Similar to what we can achieve that using cold two is when the branch ministry operation occurred without reaching the midlife three is when the branch penetration with the symbolic material achieved. And also the symbolic material reaches the midline four. Grade 4 is when uh symbolic material crosses the midline to the control adult side. So this is 1-4. And if there is a subdural membrane identified during them, micro catheter injection. And if there is this membrane penetration of the of the embryonic material, that injection will get extra points for that. So that son Most of the injection that I should do. They will qualify to either four or 5. Trading based on this grading system. We are in the process of finalizing this grading system and 100 consecutive patients that we have done here at Sinai. And it will be finalizing the manuscript in the near future. And also you're participating into ongoing randomized clinical trials. Um One is uh membrane studies which is middle manager Archie embolization for the treatment of subdural hematoma at NBC A. And this is a multi center randomized clinical trial dR Conner is the National Society. And also there is another trial called symbolized embolization of the middle artery with onyx for some patients. So I believe these two couldn't cut trials will have significant importance in terms of helping us to study the actual benefit of middlemen. Angel artery embolization and subdural hematoma patient. As as this study has the medical management or surgical innovation or plus minus embolization. This will also give us the opportunity to compare and outcome of using liquid anabolic material and subdural hematoma embolization to the historic database of using uh particles. I think that I'm gonna stop here and take questions. It's much from up there you go. If anybody has any questions. Nice job sarah. Um that was a really really cool presentation. And I appreciate you doing that for us. Um a couple of questions actually. So when you look at the recurrent subdural hematoma patients and and the percentage is quite small. Which is nice. Do you see recapitalization of the middle managerial artery. I mean has that been looked at in bye you guys or others. So that's a good question. This has been shown with the particles uh and coins. However, we haven't seen a recapitalization after using the liquid anabolic materials. In fact I do recall the case of recurrence. This was out of this database uh that that came to me and I did the second embolization in the second embolization. Those um and middle managerial artery branches were gone. There was no collateral formations. However, I did contra lateral ah middle managerial embolization for that patient. So reconciliation can happen with the collaterals. But those branches that we take with glue or onyx, they will be gone permanently. That's why the case that we are making more diffused and comprehensive revascularization of the membrane with permanent mobilization material like glue might have advantage of avoiding any reorganization. Do you think so. Along those lines, I was going to ask you, you know why the liquid onyx versus the particles and you know the images you showed us? The particles seem to travel further. Uh Does the liquid, the onyx kind of doesn't migrate that far. Is that kind of the impression? Is that a correct impression? Well. But but all onyx can also go further. We have different Dilution of Onyx two Types of Annex 18 or 34. And there are some techniques that we can use and facilitate panics going a little further uh with ah particles also can be used for deep penetrations. However, the the disadvantages number one, we really do not see the actual particles. That's why we mix the particle with some contrast. So we see where the actual food is going and we use different sizes of particles, smaller particles can go much deeper into the membrane of the hematoma. However, using the park together again, there is risk of re canonization. It's not going to cause permanent occlusion number two. As I mentioned earlier. They don't. They tend to make some clamps and they aggregate and they may actually include the bifurcation before reaching the actual membrane of the subdural. Thank you. Good job. Thanks jerome. That was an awesome talk. I really enjoyed it. Um Just had a question relating to the use of the symbolic material with the products of their own membranes. So the membranes can be very difficult frustrating to deal with when you're trying to do an evacuation in the operating room. I was wondering if, given your scale that you showed, is there any data to suggest that the spread of the symbolic material when it reaches or you're seeing spread to the chronic subdural membranes? Are those patients having better outcomes than when they aren't reached? Or there is not spread there? And conversely, is the spread of the symbolic material to those membranes causing significant regression of the membranes? Or is it just uh observed that the overall some drug is smaller? Yeah. Yeah, exactly. So this this was a theory and hypothesis that we had if we do it if you use penetration of the member a theoretically we d vascular arise this uh immature capillaries and it may help with decreased rate of recurrence. The data in this area is still evolving? You do not have a definite answer. However, in the past few months there was data came from Darryl. They actually demonstrated in their database that more deeper penetration of the symbolic material, more diffused uh embolization and distal penetration of the branches been associated with lower rates of recurrence. We need a larger database to show that but the evidence is uh starting to appear. Thank you. Thanks. I just had a comment or question trump great job. Thank you for presenting that. And one thing to respond to dr hydroponics is I actually have I had the benefit of seeing them Emma after tumor embolization. And I've seen that in some cases of onyx that sometimes there are little channels that that blood still kind of seeps through. So it doesn't you know maybe maybe for some reason these tumors they have a more hypertrophic mm A or something like that. But definitely see a little bit. So maybe a thrombosis over time like you said. But I've definitely had been able to see it from the other side which is I think it's kind of interesting. My question is when you do these cases technically, are there any indicators for you that there is going to be a higher level of success. And then the guest kind of goes to Trevor's question. Remember we had talked a while back about seeing um Seeing the glue across the midline was one thing that may be suggestive of success. Um But have you noticed anything else that may have correlated may correlate or is it just too soon to know? Well, they can't be done. Don't have actual data to support that. But when when we do see that uh flashy membrane leaky membrane in the micro cancer injection and that followed by glue penetration into that membrane and crossing the midline. That's well, that's that's that's a sign that we think that we really are taking down this uh supply to the subdural membrane. Again, the tortoise that will help to decrease the recurrence rate. However, you need a larger database to actually show that. As I said, we can we can use coil to take down the trump versus use the aggressive embolization with this technique that I described. Probably this is superior to that. But we need to wait for actual data similar to what we see in the tumor embolization. Sometimes in tumor normalization when they were facing a dangerous and esteem. Asus I can and um norman ngl branches or sending differential. Sometimes you up to just coil the feeding artery to the tumor vs. Using liquid anabolic material. But then then in follow up M. R. I. And also when we follow up with the surgeons later after using coil there there's still significant uh blood supply to the tumor from other collaterals. So the same concept I guess work here if we only take the trunk of the mm a do approximately civilization the membrane itself. That leaky membrane still will get the supply from the other collateral simulation. The other concepts that that you're on working on it. Again, we need more data is to perform bilateral middle managerial authority embolization even in patients with unilateral subdural hematoma. Again, the theory is with bilateral embolization with symbolic material crossing the midline to the other side. You're you're basically providing a comprehensive takedown of the middlemen, injure an artery branches and collaterals. And that potentially we will have further outcome benefits. Again, we need to wait for larger database to to prove that. Yeah. Um And last last kind of question is have you used any adjuvant devices like balloons that can help achieve those technical results? Or is that also still kind of limited? I guess the question is, do balloons matter? The balloon does matter when you're using Onix. So for Onix we have a small balloon. My balloon ride micro catheters inflate the balloon. And then that will help uh inject the onyx and onyx will go more distantly with this technique. Sugar push technique. No balloon is required. Ah And as I showed you became consistently achieve very distal embolization. Isn't this thing by the way? Our results are being published in the journal neurosurgery next month. It is impressed. Thanks. Thank you. I think jorge had a question. Yes. Thank you doctor material. Very, very nice presentation. My question to you is um there is there is a recent study showing because the cost effectiveness um you know um achieved with a middle manager larry embolization for these patients borehole evacuation. My question to you is where does the where does the diluted glue sugar push technique? You know, stand in terms of how much does it cost for the patient compared to maybe Onix or or you know, coils or particles and maybe even uh surgical approaches open. Thanks. Great question uh forehead. Well the surgical evacuation sometimes is inevitable independent of cost. So symptomatic patients gonna need surgical evacuation no matter what but regarding the cost effectiveness. That's a that's a great point. So Onix and blue they are much more expensive compared to particles. Ah uh So therefore it will be very nice to have a head to head analysis of this techniques and should see if it is really superior to particles. However, he believed that bit with NBC A not being painful for the patient. Easy procedure under MAC. You can offer this procedure procedure on their outpatient fashion. The patients come no need for hospitals. They will go home the same day. That might upset some of the because awesome. Thank you. And then we also have a question in the Q. And A box. What is the mechanism why the chronic subdural hematoma does not re accumulated 90% of cases after drainage. Yeah. Well uh again, the mechanism of the recurrence. Uh as we know from the prior experimental studies are just this membrane development and uh immature uh neo angiogenesis. In some cases it does not so perhaps in inflammatory processes, not as robust as observation, and also sometimes, and middle managers artery as being taken during the during the surgical evacuation. That might also contribute to ah the lower rate of recurrence in those patients. Okay, thanks very much for um I don't see any more questions, so I think we'll wrap it up. Thanks everybody. Have a good day.