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Middle Meningeal Artery Embolization for Nonacute Subdural Hematoma
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- This open-label, randomized, clinical trial (MAGIC-MT) investigated whether middle meningeal artery (MMA) embolization in patients with subacute or chronic subdural hematoma as an adjunctive therapy to standard of care (burr hole drainage) or nonsurgical treatment provided better prevention of symptomatic hematoma recurrence and progression (primary outcome) at 90 days. Although there was a trend toward benefit, the results showed similar hematoma recurrence and progression or better functional outcomes (measured by the modified Rankin Scale) with MMA embolization and with the control intervention. A lower incidence of serious adverse events (death, etc) was observed in the MMA embolization group.
- This trial failed to make a convincing case for MMA embolization as an adjunctive therapy to burr hole drainage (close to 80% of the patients underwent it) in patients with subacute to chronic subdural hematoma. It is possible that the beneficial trends did not reach statistical significance owing to the small sample size.
abstract
This abstract is available on the publisher's site.
Access this abstract nowBACKGROUND
The effect of embolization of the middle meningeal artery in patients with subacute or chronic subdural hematoma is uncertain.
METHODS
We performed a multicenter, open-label, randomized trial in China, involving patients with symptomatic nonacute subdural hematoma with mass effect. Patients were assigned to undergo burr-hole drainage or receive nonsurgical treatment at the surgeon's discretion, and patients in each group were then randomly assigned, in a 1:1 ratio, to undergo middle meningeal artery embolization with liquid embolic material or to receive usual care. Patients whose condition warranted craniotomy were excluded. The primary outcome was symptomatic recurrence or progression of subdural hematoma within 90 days after randomization. Secondary outcomes included clinical and imaging outcomes. The main safety outcome was any serious adverse event (including death).
RESULTS
The analysis included 722 patients, of whom 360 were assigned to the embolization group and 362 to the usual-care group. Burr-hole drainage was performed in 78.3% of the enrolled patients; among the patients who underwent burr-hole drainage, the procedure occurred after embolization in 99.6%. Symptomatic recurrence or progression of subdural hematoma within 90 days occurred in 24 patients (6.7%) in the embolization group and in 36 (9.9%) in the usual-care group (between-group difference, -3.3 percentage points; 95% confidence interval, -7.4 to 0.8; P = 0.10). The incidence of serious adverse events was lower in the embolization group than in the usual-care group (6.7% vs. 11.6%, P = 0.02).
CONCLUSIONS
Among patients with symptomatic nonacute subdural hematoma (of whom 78% underwent burr-hole drainage), middle meningeal artery embolization resulted in a 90-day incidence of symptomatic recurrence or progression similar to that with usual care but was associated with a lower incidence of serious adverse events.
Additional Info
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Middle Meningeal Artery Embolization for Nonacute Subdural Hematoma
N. Engl. J. Med 2024 Nov 21;391(20)1901-1912, J Liu, W Ni, Q Zuo, H Yang, Y Peng, Z Lin, Z Li, J Wang, Y Zhen, J Luo, Y Lin, J Chen, X Hua, H Lu, M Zhong, M Liu, J Zhang, Y Wang, J Wan, Y Li, T Li, G Mao, W Zhao, L Gao, C Li, E Chen, X Cheng, P Zhang, Z Wang, L Chen, Y Zhang, B Tian, F Shen, Y Lei, Y Wu, Y Li, G Duan, L Xu, N Lv, J Yu, X Xu, Z Du, H Zhang, J Hu, Z Li, Q Yuan, Y Zhou, G Wu, L Zhang, C Gao, D Dai, X Wu, Y Zhang, H Jiang, R Zhao, J Su, Y Xu, JM Ospel, CBLM Majoie, M Goyal, Q Li, P Yang, Y Gu, Y MaoFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Middle Meningeal Artery Embolization for Subdural Hematoma
Subdural hematomas (SDHs) are increasingly prevalent in the elderly population, with increasing incidence rates posing significant clinical management challenges. Traditionally, standard surgical treatments such as craniotomy or burr hole drainage have been the mainstay of therapy. However, these procedures are often associated with a high risk of treatment failure and recurrence, necessitating the exploration of alternative, less invasive approaches.1 One such approach is middle meningeal artery (MMA) embolization, which has emerged as a promising adjunctive treatment. This nonsurgical intervention is recommended for patients with SDHs owing to its potential to reduce blood supply to the inflamed vascular membranes, thereby reducing the risk of hematoma recurrence compared with conventional surgical methods.1,2
Recent randomized controlled trials have provided valuable insights into the efficacy of MMA embolization. One study enrolled 310 patients with chronic SDH, with 149 assigned to the embolization group and 161 assigned to the control group. The embolization group (median age, 73 years) underwent MMA embolization using the Squid agent. The results were compelling: 97% of the embolization group underwent the procedure with a remarkable 99% success rate and an average duration of 80 minutes. In comparison, 99% of patients in the control group underwent traditional surgical treatments such as burr hole or subdural evacuating port system drainage, which took an average of 50 minutes. Notably, 16% of the embolization group required reintervention compared with 36% of the control group, highlighting the potential benefit of MMA embolization in reducing the need for reintervention.1
Similarly, in the study by Liu et al (2024), 722 patients were randomized to either the MMA embolization group (360 patients) or the usual care group (362 patients); the median age was 69 years, and the Onyx liquid embolic system was used for embolization.3 The success rate of MMA embolization was 98.3%, with a slightly lower rate of symptomatic recurrence or progression of SDH in the embolization group (6.7%) compared with the usual care group (9.9%). Although the difference was not statistically significant (P = .10), the study showed a lower incidence of serious adverse events in the embolization cohort. This suggests that, although MMA embolization may not dramatically reduce recurrence rates among patients with nonacute SDH, it may minimize complications associated with the procedure.3
Supporting these findings, a study involving 400 patients—197 in the embolization group and 203 in the control group—demonstrated the efficacy of MMA embolization.2 In this study, recurrence or progression of hematoma leading to reoperation was observed in only 4.1% of patients in the embolization group compared with 11.3% of patients in the control group (relative risk, 0.36; P = .008). Although the 90-day mortality rate was higher in the embolization group (5.1%) than in the control group (3.0%), the treatment group reported significantly fewer adverse effects, particularly those related to the procedure.2
Collectively, these studies suggest that MMA embolization as adjunctive therapy significantly reduces the need for reoperation in patients with SDHs. However, the variation in mortality outcomes across trials raises important questions about the safety profile of this procedure. Although some studies report a higher mortality rate in the embolization group, others show a comparable mortality rate between the two groups, albeit with fewer adverse events.2 This discrepancy warrants further investigation to better understand the long-term safety and efficacy of MMA embolization for SDHs.1-3
In conclusion, the use of MMA embolization as an adjunctive treatment for SDHs shows considerable promise, particularly in reducing the risk of recurrence and adverse complications. However, the mixed results regarding mortality and the need for further research into the safety and efficacy of this technique are critical to ensure its widespread clinical adoption. As these studies suggest, although MMA embolization may offer a valuable alternative to traditional surgical methods, more rigorous studies are needed to refine its role in the management of SDHs and ensure favorable patient outcomes.
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