New research published in the New England Journal of Medicine by Dr. Jared Knopman and colleagues at Weill Cornell Medicine and the University at Buffalo shows that a combination of surgery and embolization to treat subdural hematomas reduces the risk of recurrence and the need for follow-up surgeries. Chronic subdural hematomas are pools of blood that accumulate between the brain and its protective membrane due to trauma. Embolization is a minimally invasive procedure that stops the bleeding.
The EMBOLISE trial was a multi-center, randomized, clinical study that compared chronic subdural hematoma recurrence rates in patients treated with surgery and middle meningeal artery (MMA) embolization versus current standard of care with surgery alone.
The results of the study (Adjunctive Middle Meningeal Artery Embolization for Subdural Hematoma) were published November 20 in the New England Journal of Medicine. Researchers found that hematoma recurrence or progression resulting in another surgery occurred in about 4% of patients who underwent MMA embolization plus surgery, compared to more than 11% of those who received surgery alone.
“This trial provides evidence that adding MMA embolization should be a new standard of care for one of the most common neurosurgical conditions we see,” said Dr. Knopman, co-lead author and pioneer of MMA embolization. Dr. Knopman is director of Cerebrovascular Surgery and Interventional Neuroradiology and an associate professor of neurological surgery at Weill Cornell Medicine and a neurosurgeon at NewYork-Presbyterian/Weill Cornell Medical Center.
Subdural hematomas are common in elderly patients, who may develop a bleed after a fall or even a seemingly minor head injury. The standard of care has been surgery alone, a procedure in which the neurosurgeon makes a small opening in the skull to drain the blood. In about 15 percent of cases, however, the hematoma recruits other blood vessels to supply it and the patient requires an additional surgery.
In the MMA embolization procedure, a surgeon threads a small catheter into the middle meningeal artery that runs through the membranes covering the brain. The catheter delivers an embolic (clotting agent) to block blood vessels feeding the hematoma. “By reducing the chance of the subdural hematoma from coming back, the need for hospital re-admission and another operation can be avoided,” Dr. Knopman said.
Dr. Knopman and his colleagues are now determining what role MMA embolization could have in treating patients with chronic subdural hematomas that are not large enough for surgery. “If we embolize these patients early, we may decrease the number who need to be taken to surgery later,” he said.
The EMBOLISE study was sponsored by Medtronic, which produces Onyx, the blood flow-blocking agent that was used in the treatment group of the study.
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