Enhanced Hematoma Membrane on DynaCT Images During Middle Meningeal Artery Embolization for Persistently Recurrent Chronic Subdural Hematoma

OBJECTIVE: Chronic subdural hematoma (CSDH) is generally treated by burr-hole irrigation, but it can recur despite repeating these procedures. Embolization of the middle meningeal artery (MMA) has recently been proposed as a curative treatment for CSDH, but evidence for the indication and timing of MMA embolization is not definitive. The present study retrospectively analyzed the effects and safety of MMA embolization among patients with persistent CSDH recurrence. METHODS: We retrospectively assessed data from 381 consecutive patients who underwent burr-hole irrigation for CSDH between 2009 and 2017. Recurrent symptomatic ipsilateral CSDH in 71 (18%) patients was treated by a second burr-hole irrigation, and 20 of them had a further symptomatic CSDH recurrence thereafter. Those with persistent ipsilateral CSDH recurrence were treated by MMA embolization. Before the MMA embolization procedures, the amount of hematoma membrane enhancement determined using superselective MMA angiography-DynaCT imaging was classified into 3 stages. RESULTS: Embolization of the MMA proceeded without perioperative complications or further CSDH recurrence. The interval between recurrence and the amount of hematoma membrane enhancement significantly correlated (first to second and second to third treatments: P = 0.012 and P = 0.017, respectively). The frequency of bilateral CSDH was significantly higher and the recurrence interval between the first and second treatments was significantly shorter in the repeated recurrences group compared with the recurrence group (P = 0.023 and P = 0.006, respectively). CONCLUSIONS: Repeatedly recurrent CSDH can be safely treated and cured by MMA embolization. Hematoma membrane enhancement pattern using DynaCT images can predict repeated recurrences CSDH.