Neurosurgeon Luis Savastano, MD, PhD, discusses middle meningeal artery embolization, a cutting-edge, outpatient procedure for subdural hematoma. Advantages over the traditional surgery include minimal risk, little or no need for sedation, and prevention of recurrence. Learn which patients are candidates.
Hello, I'm Luis Savastano and I am a neurosurgeon at the University of California San Francisco. We're going to be talking today about embolization of the middle meningeal artery for the treatment of Subra hematoma. Uh, this is a new but very common intervention that we are doing within the cerebrovascular neurosurgery group and neuron vascular surgery to start chronic subur hematomas are very common in elderly patients. Basically, the sub hematomas are expanding blood collections over the brain surface that are as common as 20 cases every 100,000 people when you are 65 years old or older in us every year, there are about 60,000 cases and of those one third are going to need surgery to drain. This hematoma is probably becoming the most common neurosurgical intervention that we're doing and it's becoming more and more prevalent for two main reasons. Number one, we have an aging population in the process, the brain, the brain shrinks and the the fluid starts to accumulate in the surface, especially when you are taking blood thinners or antipla agents such as aspirin. What you are seeing on the right of the screen is the common example of chronic subdural hematoma, which is this fluid collection, which is pushing on the brain and builds up between the brain and the skull. Classically, we have been draining these collections of fluid or blood by doing borehole surgery, which is a surgical intervention where we open one or more holes in the skull and then we irrigate the fluid collection out. This is how it looks in the or which is basically two boreholes being done. And then you can see how at the end of the intervention, we are putting in a drain within this subdural space, which is going to remain in the head for 2 to 3 days while the patient is in the intensive care unit to allow more of this uh fruit collection to drain out. And after surgery, this is a common uh appearance of uh basically the the barrels this intervention, as I mentioned is extremely common, but has one major problem, which is that one out of four patients, they're going to come back to the hospital within 30 days of admission. Um with a recurrent sub, that means that every four surgeries that we do one patient or 25% is going to come back to the hospital and require more surgeries. And the the reason for that is that there is an artery called artery that goes to the dura. And you can see here and in a contrast injection within the artery, you can see how the artery has multiple branches which are spanning the whole cranial circus. And then what happened is in elderly patients. When they start having small amount of blood, the blood creates inflammation, the inflammation creates more blood vessels and those blood vessels are very delicate and they are leaky. So what you can see here are a lot of membranes with very leaky blood vessels which over time they allow the hematoma to grow. And that is the main reason for the recurrent subdural hematoma after surgery. So the the problem here is that when we have this situation, we have more bleeding than reabsorption from this leaky membranes. And that drives hematoma formation. So when we are doing an embolization of the artery, which meaning including the artery, we are preventing further bleeding and the reabsorption keeps happening. So, over time, the Subra hematoma goes away. So this intervention is called middle meningeal artery embolization or M ma embolization. And these are the, basically the, the, the steps that we do during this intervention, we start by injecting a contrast into a tiny cat that we have navigated from the wrist or from the groin, all the way into the middle mening artery. And then you can see that all the arteries are open. Then from the inside of the artery, we deliver different uh embolization agents which can be particles or can be liquid uh substances that they are going to flow down stream and they're going to occlude all these branches. So what you are seeing here is after our embolization, how we have trimmed or occluded, all these arteries going to the dura. This intervention is usually outpatient, it's minimally invasive. So we need no sedation or minimal sedation. And as I mentioned, it's exclusively endovascular, meaning that we're putting our catheters in the radio or the femoral artery or the wrist or the groin. And through that, we can navigate following the arteries all the way to the skull. The goal is to permanently occlude the artery, the middle meningeal artery to prevent further bleeding. And as I mentioned, is a, a relatively uh a safe intervention with the risk of 1% or less and being minimally invasive. There is no really downtime for the patients. They don't have to recover from an open surgery like the surgery. There are three main indications to embolize the middle men artery. The first one is in patients that presents with the sub hematoma that have not had any other therapy. These subdural hematoma are usually larger than one centimeter. They have acute blood components. They are growing or the high risk of expansion. Patients are minimally symptomatic. So we can ay the artery and the patient will have enough time in the next few weeks to reabsorb the fluid collection without the need of surgery. The second indication is when we have patients that are symptomatic from the subdural, meaning that they need to have the clot evacuated with surgery. But we are concerned that they are at high risk of a recurrent subdural hematoma, for example, because they have brain atrophy or because they have liver or, or renal failure or because they have to go back on the blood thinner medication soon. So in those cases, we can do surgery and the M MA embolization at the same time, which at U CS F, we do by the same interventionist in the same room under one settings. And finally, one of the most common indications for M MA embolization is in patients that have had surgery from a previous subdural. And after a few weeks or few months, they return to our clinic with a recurrent subdural hematoma. And at that point, rather than doing a second surgery, we are embolize the middle mening artery just to give you two case examples. This is a case example of an upfront embolization which you can see that this was a 70 years old lady that had very low playlets in the setting of chemotherapy that presents with progressive headaches and difficulties walking. But she was still very functional. Uh You can see in the head city that there is a large Subra hematoma pushing on the brain, that patient was medically ill, but functionally she was doing well from the. So we decided just to do the M MA embolization, you can see that a few months after the fluid collection completely resolves. And the reason is because it stops bleeding and then eventually the bruise goes away as anywhere else in the body would do. This is another example when we have an elderly patient that was taking a anti coagulation. And you can see that after falling from a ladder, he had a very large subdural hematoma. This patient had surgery to evacuate this clot. But one month later, we can see that there is a now a chronic subdural that slowly grows over time. And at that point, we have not initiated anti coagulation yet. So that is a a good patient that would benefit from the M MA embolization, which was done in this case. And you can see that after a few months, the fruit collection has been completely reabsorbed despite being on warfarin. So in summary, M MA embolization is a highly effective intervention that can decrease more than 10 times the likelihood of a recurrent sub hematoma drainage, meaning decrease 10 times the likelihood of needing a second operation. The intervention can be a standalone therapy for selected patients which obviates the risk and the discomfort from open surgery. And in addition, by doing the M MA embolization, we can restart sooner the anti playlets or anti coagulation medication that the patient needs. M ma embolization is purely an endovascular intervention, minimally invasive that can be done as an outpatient procedure with minimal downtime at the bottom of the screen. You see our contact information. So please call fax or email with any questions, any time about any patient that we would like to discuss? Thank you. Have a good day.