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Christopher L Sistrom, MD
The incidence of already common chronic subdural hematomas CSDHs and other nonacute subdural hematomas NASHs in the elderly is expected to rise as the population ages over the coming decades. Surgical management is associated with recurrence and exposes elderly patients to perioperative and operative risks. Middle meningeal artery MMA embolization offers the potential for a minimally invasive, less morbid treatment in this age group.
The clinical and radiographic outcomes after MMA embolization treatment for NASHs have not been adequately described in elderly patients. In this paper, the authors describe the clinical and radiographic outcomes after cases of MMA embolization for NASHs among elderly patients.
Patient demographics, comorbidities, clinical and radiographic factors, treatment factors, and clinical outcomes were abstracted. Seventy elderly patients underwent 87 embolization procedures, and 51 advanced elderly patients underwent 64 embolization procedures. Transfemoral access was used in most patients, and the procedure time was approximately 1 hour in both groups. NASH thickness decreased significantly from initial thickness to 6 weeks, with additional decrease in thickness observed in both groups at 90 days.
Surgical rescue was necessary in 4. MMA embolization can be used safely and effectively as an alternative or adjunctive minimally invasive treatment for NASHs in elderly and advanced elderly patients. As such, NASHs have become an ever more prevalent diagnosis, rising in concert with the aging population. There is still no definitive consensus on the most appropriate treatment for NASHs, particularly in the elderly, and, as such, there remains wide variation in practice, ranging from conservative management to operative intervention.
Middle meningeal artery MMA embolization is a newly recognized technique used as an alternative or adjunctive minimally invasive treatment for NASHs. Early studies have uniformly demonstrated favorable outcomes with better efficacy and safety compared with conventional surgical evacuation. MMA embolization has yet to be adequately studied among the elderly. The purpose of this study was to analyze a cohort of elderly patients who underwent MMA embolization for NASH treatment at 15 academic centers across the US and describe the clinical and radiographic outcomes in this population.
Each center obtained appropriate local institutional review board approval before data collection. Patient charts were reviewed for demographics, clinical data, and radiographic data, including age, sex, race, comorbidities, prior NASH, prior NASH evacuation, use of antiplatelet or anticoagulant medications, midline shift, laterality of hematoma, maximum hematoma width on axial imaging, and presence of membranes. Treatment data were also recorded, including embolization success, NASH treatment indication upfront, recurrent, or prophylactic with concurrent surgical intervention , access location transfemoral vs transradial , type of anesthesia general anesthesia vs moderate sedation , procedure duration, and type of embolysate used coils, liquid embolic, particles, or a combination.
The need for retreatment, adverse events, and mortality were assessed at the latest recorded follow-up. Statistical analysis in the form of Student t-tests was conducted to compare midline shift and maximum subdural width between the two age groups, as well as to compare preprocedural width and width at 6-week and day follow-ups.
Seventy elderly patients underwent a total of 87 embolization attempts 17 bilateral , and 51 advanced elderly patients underwent a total of 64 embolization attempts 13 bilateral Table 1. The average age for the elderly and advanced elderly patients differed significantly at Both groups were predominantly white and male.
Comorbid conditions were similar, with hypertension being the most common, followed closely by hyperlipidemia, coronary artery disease, and diabetes mellitus. The initial maximum subdural width was significantly greater in the advanced elderly group Boldface type indicates statistical significance. The 3 cases with failed attempts occurred in the younger group Table 3.
NASH treatment was performed in three settings. The average procedure duration was nearly identical between the groups at just over 1 hour. None of these were significantly different between the groups. At the 6-week follow-up, the maximum subdural width was not significantly different between groups At the day follow-up, a similar trend was observed, with NASH thickness similar between the groups 4. At the longest follow-up of at least 6 weeks, the majority of patients in each group showed NASH improvement.
Worsening of the NASHs was infrequently observed in 8. This year-old female patient on a regimen of coumadin for a recent pulmonary embolism in the setting of antiphospholipid syndrome presented with headache and a supratherapeutic international normalized ratio of 4.
The hematoma measured Adverse events were rare, at 2. The need for surgical rescue, defined by post-MMA embolization burr holes or craniotomy for worsening or persistent symptoms, did not differ between the two groups, with 4. Mortality was not significantly different between the groups, at a rate of 8.
Three patient deaths 2. The remaining 5 patient deaths 4. In this study, we describe the clinical and radiographic outcomes in a robust series of elderly patients undergoing embolization procedures to treat NASHs.
To the best of our knowledge, this is the first such report of MMA embolization for subdural treatment in elderly patients. Our subgroups were fairly equivalent in clinical, radiographic, and outcome measures, although the advanced elderly group was significantly more likely to be taking antiplatelet or anticoagulant medication and had greater initial NASH width with less initial midline shift. Upfront hematoma treatments were slightly more common in the advanced elderly group, but the difference did not reach statistical significance.
Our study provides additional evidence reinforcing the results from other recent large, single-center MMA embolization cohorts. In , Link et al. Their cohort included 42 upfront, 8 recurrent, and 10 prophylactically treated subdural hematomas, and they reported comparable outcomes to those in our present study, with subdural stability or improvement in Ban et al.
Enrollment criteria included CSDH thickness of at least 10 mm, and the average subdural maximum width was slightly larger than that in our patient cohort at At the 6-month follow-up, there were no cases of surgical rescue for those treated with embolization alone and in only 1 2.
Recent systematic reviews have corroborated these excellent outcomes. Surgery for CSDHs in the elderly carries unique challenges regarding effectiveness, recurrence rates, surgical complications, and medical perioperative complications. Good outcome Glasgow Outcome Scale score of 5 only occurred in Rohde et al. Still others have reported unique perioperative risks that need to be monitored for in the elderly, such as a higher risk of postoperative acute subdural hematoma requiring treatment, 34 higher risk of postoperative infection after craniotomy, 12 higher risk of mortality, 31 and decreased likelihood of a good functional outcome postoperatively.
A retrospective review of patients aged 60 years or older treated with burr hole craniotomy for CSDHs saw a higher frequency of cardiac complications, and thus longer hospitalization, in those receiving general anesthesia when compared with local anesthesia. Endovascular MMA embolization offers several advantages over conventional open surgery for subdural evacuation that make it a particularly attractive minimally invasive treatment option in elderly patients.
Percutaneous transradial or transfemoral access are both generally well tolerated under local anesthesia with a low risk of complications. Most patients in our study underwent transfemoral access; however, transradial access may soon prove to be a superior approach because it has been shown to be associated with a lower risk of major bleeding and vascular complications, shorter time to ambulation, and, in some instances, an improved ability to navigate tortuous cerebrovascular anatomy.
Procedure times are also short; in the present study, the average duration was just over an hour in both subgroups.
Postoperative bed rest is still practiced by clinicians as a way to allow brain reexpansion after subdural drain placement, but after MMA embolization, this is unnecessary as there is no subdural drain.
Patients are typically ambulatory within a few hours after embolization, and in select asymptomatic patients, discharge to home may be appropriate after a short period of observation. Finally, infection risk is greatly reduced without the need for skin incision, craniotomy, and subdural drain placement. A significant limitation of this study is that it is a nonrandomized, retrospective chart review of prospectively collected data and, as such, only demonstrates associations rather than causation.
We also were unable to control for confounding variables, such as initial hematoma width, midline shift, and preprocedure antiplatelet or anticoagulation medication use. A unique strength of this cohort is the inclusion of 15 academic centers across the US.
This helps increase the generalizability and external validity of our results; however, the wide variety of embolization agents used may make it challenging to draw meaningful conclusions as to which type of embolization is most effective in elderly patients.
To the best of our knowledge, this study presents the outcomes on the largest cohort of elderly patients to have undergone MMA embolization for treatment of NASH. MMA embolization appears to be both a safe and efficacious minimally invasive treatment option for NASHs in the elderly.
Riina: consultant for Medtronic and speakers bureau for Stryker. Spiotta: consultant for Penumbra, Terumo, and Stryker; and support of non—study-related clinical or research effort from Penumbra and Stryker. Gross: consultant for Medtronic and MicroVention. Khalessi: consultant for Medtronic and Cerenovus. Hanel: consultant for Medtronic. Levitt: consultant for Medtronic; ownership in Synchron, Cerebrotech, eLoupes, and Metis Innovative; and support of non—study-related clinical or research effort from Medtronic, Stryker, and Philips Volcano.
Taussky: consultant for Covidien, Medtronic, and Stryker Neurovascular. Analysis and interpretation of data: Grandhi, Joyce, Bounajem, Scoville. Reviewed submitted version of manuscript: Grandhi, Joyce, Bounajem, Binning. Approved the final version of the manuscript on behalf of all authors: Grandhi.
Statistical analysis: Scoville. Video Abstract. Yang W , Huang J. Chronic subdural hematoma: epidemiology and natural history. Neurosurg Clin N Am. Actual and projected incidence rates for chronic subdural hematomas in United States Veterans Administration and civilian populations. J Neurosurg. Current Population Reports. US Census Bureau ; Mori K , Maeda M. Surgical treatment of chronic subdural hematoma in consecutive cases: clinical characteristics, surgical outcome, complications, and recurrence rate.
Neurol Med Chir Tokyo. Epidemiology of chronic subdural hematomas. Article in Japanese. No Shinkei Geka. Chronic subdural hematoma in the elderly. Article in German.
Embolic Agent
For Medicare patients, procedures using ONYX liquid embolic system are required to be performed in the hospital inpatient setting. It does not constitute legal advice or a recommendation regarding clinical practice. Information provided is gathered from third-party sources and is subject to change without notice due to frequently changing laws, rules and regulations. Medtronic makes no guarantee that the use of this information will prevent differences of opinion or disputes with Medicare or other payers as to the correct form of billing or the amount that will be paid to providers of service.
Publications and Presentations
The University of Florida Academic Health Center - the most comprehensive academic health center in the Southeast - is dedicated to high-quality programs of education, research, patient care and public service. The College of Medicine , the largest of six colleges at the University of Florida Academic Health Center, opened in with a mission to increase Florida's supply of highly qualified physicians, provide advanced health-care services to Florida residents and foster discovery in health research. Founded in , the University of Florida College of Nursing is the premier educational institution for nursing in the state of Florida and is ranked in the top 10 percent of all nursing graduate programs nationwide. The UF College of Nursing continually attracts and retains the highest caliber of nursing students and faculty with a passion for science and caring. Ranked among the top schools of pharmacy nationally, the college supports research, service and educational programs enhanced with online technologies. The UF College of Veterinary Medicine is Florida's only veterinary college and provides many unique educational programs for students and services aimed at helping pets, wildlife and endangered species. We offer a a four-year Doctor of Veterinary Medicine programs as well as M. Co-located with the Shands Jacksonville Hospital, the Jacksonville Health Science Center excels in education, research and patient care that expresses our abiding values of compassion, excellence, professionalism and innovation.
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LINC 2019 presentations
The venue with a special flair: The Philharmonie Essen in the historic Saalbau Essen is embedded in the ensemble of the city garden and the Aalto Theatre, right in the center of the city. By exceptional central location, the versatile space on offer and the first-class hotels in the immediate vicinity, the Philharmonie Essen is the ideal place for your event in a unique atmosphere. Please keep in mind that due to rules and regulations we can provide your CME credits and certificate only if you have filled in the evaluation form which you can request by email from the congress organization, Denise Thom d. Jan Gralla Thrombectomy : which patients to exclude? Jean Raymond Risk of treatment of unruptured aneurysms :is it really so low? Ludovic Drouet Discussion How dangerous is the combination Aspirin and Ticagrelor in unruptured aneurysms?
Preoperative Onyx Embolization of Meningiomas Fed by the Ophthalmic Artery: A Case Series
Over the past two decades, transcatheter arterial embolization has become the first-line therapy for the management of upper gastrointestinal bleeding that is refractory to endoscopic hemostasis. Advances in catheter-based techniques and newer embolic agents, as well as recognition of the effectiveness of minimally invasive treatment options, have expanded the role of interventional radiology in the management of hemorrhage for a variety of indications, such as peptic ulcer bleeding, malignant disease, hemorrhagic Dieulafoy lesions and iatrogenic or trauma bleeding. Transcatheter interventions include the following: selective embolization of the feeding artery, sandwich coil occlusion of the gastroduodenal artery, blind or empiric embolization of the supposed bleeding vessel based on endoscopic findings and coil pseudoaneurysm or aneurysm embolization by three-dimensional sac packing with preservation of the parent artery. Transcatheter embolization is a fast, safe and effective, minimally invasive alternative to surgery when endoscopic treatment fails to control bleeding from the upper gastrointestinal tract. This article reviews the various transcatheter endovascular techniques and devices that are used in a variety of clinical scenarios for the management of hemorrhagic gastrointestinal emergencies. Upper gastrointestinal bleeding UGIB is defined as originating in the distal esophagus, stomach and duodenum proximal to the ligament of Treitz. Other less common causes include benign and malignant tumors, ischemia, gastritis, arteriovenous malformations such as Dieulafoy lesions, Mallory-Weiss tears, trauma and iatrogenic causes[ 1 , 2 ]. Effective treatment requires timely and accurate diagnosis location and etiology and, unlike lower gastrointestinal bleeds, most patients have undergone endoscopic examination and treatment prior to their referral to interventional radiology.
Curriculum Vitae
Either your web browser doesn't support Javascript or it is currently turned off. In the latter case, please turn on Javascript support in your web browser and reload this page. Free to read. The type and composition of an embolic agent have a relevant influence on the performance of endovascular embolization.
This site is running Profiles RNS version v3. Login to edit your profile add a photo, awards, links to other websites, etc. Awards and Honors. Van V. Halbach and his colleagues of the Interventional Neurovascular Radiology Section developed clinical and basic science research protocols designed to perfect innovative techniques to treat life threatening neurovascular disorders.
The incidence of already common chronic subdural hematomas CSDHs and other nonacute subdural hematomas NASHs in the elderly is expected to rise as the population ages over the coming decades. Surgical management is associated with recurrence and exposes elderly patients to perioperative and operative risks. Middle meningeal artery MMA embolization offers the potential for a minimally invasive, less morbid treatment in this age group. The clinical and radiographic outcomes after MMA embolization treatment for NASHs have not been adequately described in elderly patients. In this paper, the authors describe the clinical and radiographic outcomes after cases of MMA embolization for NASHs among elderly patients. Patient demographics, comorbidities, clinical and radiographic factors, treatment factors, and clinical outcomes were abstracted. Seventy elderly patients underwent 87 embolization procedures, and 51 advanced elderly patients underwent 64 embolization procedures.
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