gms | German Medical Science

Objective: Chronic subdural hematoma (cSDH) often requires neurosurgical evacuation. The recurrence rates after burr hole craniotomy and twist drill craniostomy (TDC) are high, especially in patients under antiplatelet therapy. Middle meningeal artery embolization (MMAE) has surged as an endovascular intervention, used nowadays either as a stand-alone procedure or as a complementary approach to the neurosurgical evacuation of the cSDH, aiming to reduce the recurrence rate. However, neither the optimal timing for MMAE, nor the safety profile regarding patients taking anti-platelet therapy has been addressed. We had the hypothesis, that MMAE before planned TDC reduces the recurrence rate in a subgroup of patients who received anti-platelet drugs.

Methods: We prospectively collected clinical and radiological data of patients who presented between December 2019 and September 2021 with cSDH and were assigned primarily to a MMAE, as they were under anti-platelet medication. Surgical evacuation (twist drill craniostomy [TDC]) was performed consecutively. Pre- and postinterventional volumetric measurement of hematoma were performed and correlated with clinical course.

Results: Nineteen patients were included in the study. 5 (26,3%) of the 19 patients showed a significant increase in the volume of subdural hematoma immediately after MMAE (mean of differences (volume after MMAE – volume before) = 18.4 ±5.3 cm3; 95% CI= 3.7 to 33.12 cm3; p=0.025). All 5 patients showed a clinical deterioration that ranged from worsening of the hemiparesis to decreasing level of consciousness, which urged a surgical evacuation. The remaining patients showed neither a significant difference in the volume of subdural hematoma nor neurological deterioration after MMAE (mean of differences (after MMAE – before MMAE) = -6.9±3 cm3; 95% CI= -14.74 to 0.9 cm3; p=0.072).

Conclusion: In this small series, we found a significant rate of increase in the volume of cSDH following MMAE, accompanied with clinical deterioration among patients who were under anti-platelet therapy at presentation. Our results suggest the strategy of MMAE as a primary treatment in patients under anti-platelet therapy should be re-evaluated. These results need further verification in larger clinical series.