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Last, we agree with Dr Wang’s concluding remark that large- scale, prospective randomized controlled studies with predeter- e thank Dr Wang for the interest and careful review of mined outcome measures are required to validate the efficacy of Wour article “Emergency Department Visits for Chronic MMA embolization as frontline-versus-adjuvant therapy for the Subdural Hematomas within 30 Days after Surgical Evacuation treatment of cSDH. with and without Middle Meningeal Artery Embolization.” Disclosures: Dr Ducruet is a consultant for Medtronic, PLC (Dublin, Ireland), Middle meningeal artery (MMA) embolization is a promising Penumbra (Alameda, California), Stryker (Kalamazoo, Michigan), CERENOVUS (Johnson & Johnson Medical Devices Companies, Irvine, California), and Koswire treatment technique for chronic subdural hematomas (cSDHs) (Flowery Branch, Georgia). 3-6 that is efficacious and safe. The goal of the aforementioned study was to evaluate the treatment efficacy of MMA emboliza- REFERENCES 1. Wang L. Letter: Emergency department visits for chronic subdural tion using standardized outcome measures as determined by hematomas within 30 days after surgical evacuation with and with- emergency department visits and re-admissions within 30 days. out middle meningeal artery embolization. J Neurointerv Surg 2022. Using a retrospective study design, we demonstrated that surgical In press evacuation combined with MMA embolization in patients with 2. Catapano JS, Scherschinski L, Rumalla K, et al. Emergency depart- cSDH is associated with reduced 30-day emergency department ment visits for chronic subdural hematomas within 30 days after use compared with surgical evacuation alone. surgical evacuation with and without middle meningeal artery First, Dr Wang noted the potential impact on cSDH resolu- embolization. AJNR Am J Neuroradiol 2022;43:1148–51 CrossRef Medline tion and recurrence of postoperative medical management, 3. Kan P, Maragkos GA, Srivatsan A, et al. Middle meningeal artery including anticoagulation, antiplatelet, and statin therapy. embolization for chronic subdural hematoma: a multi-center expe- Although we did not collect data on medical therapy, we pro- rience of 154 consecutive embolizations. Neurosurgery 2021;88:268– vided data on comorbidities, including hypertension, diabetes, 77 CrossRef Medline coronary artery disease, cerebrovascular events, and coagulop- 4. Ng S, Derraz I, Boetto J, et al. Middle meningeal artery embolization athy, among others, and we found no significant differences as an adjuvant treatment to surgery for symptomatic chronic sub- between the 2 treatment groups. While we agree that postopera- dural hematoma: a pilot study assessing hematoma volume resorp- tive medical management may be implicated in the treatment tion. J Neurointerv Surg 2020;12:695–99 CrossRef Medline 5. Catapano JS, Ducruet AF, Nguyen CL, et al. A propensity-adjusted outcome of cSDH, the potential influence of these drugs remains comparison of middle meningeal artery embolization versus con- a subject of debate. For instance, Chang et al reported that anti- ventional therapy for chronic subdural hematomas. J Neurosurg platelet therapy adversely affected hematoma resolution at 2021 Feb 26. [Epub ahead of print] CrossRef Medline 6 months—a finding that became nonsignificant on multivariate 6. Catapano JS, Koester SW, Srinivasan VM, et al. Total 1-year hospital analysis. Other studies reporting similar findings have also cost of middle meningeal artery embolization compared to surgery expressed concern for an increased risk of thromboembolic for chronic subdural hematomas: a propensity-adjusted analysis. J events that must be weighed against the contentious risk of hema- Neurointerv Surg 2022;14:804–06 CrossRef Medline 8-10 7. Chang CL, Sim JL, Delgardo MW, et al. Predicting chronic subdural toma recurrence. hematoma resolution and time to resolution following surgical Likewise, there is controversary in the literature about evacuation. Front Neurol 2020;11:677 CrossRef Medline whether statins are predictors of cSDH recurrence. In an institu- 8. Guha D, Coyne S, Macdonald RL. Timing of the resumption of anti- tional study, Housley et al reported no differences in complete thrombotic agents following surgical evacuation of chronic sub- resolution and recurrence among patients with perioperative sta- dural hematomas: a retrospective cohort study. J Neurosurg 2016; tin therapy versus those without statin therapy. In consideration 124:750–59 CrossRef Medline of the ambiguity of postoperative medical management after 9. Poon MT, Rea C, Kolias AG; et al; British Neurosurgical Trainee cSDH treatment, we conclude that randomized controlled studies Research Collaborative (BNTRC). Influence of antiplatelet and anti- coagulant drug use on outcomes after chronic subdural hematoma are needed to decipher the role of postoperative medical thera- drainage. JNeurotrauma 2021;38:1177–84 CrossRef Medline peutics as independent predictors of treatment outcome and dis- 10. Scerrati A, Germano A, Trevisi G, et al. Timing of low-dose aspirin ease recurrence. discontinuation and the influence on clinical outcome of patients Second, Dr Wang raised concern that readmissions unrelated undergoing surgery for chronic subdural hematoma. World to the index procedure may be a potential source of bias. As Neurosurg 2019;129:e695–99 CrossRef Medline stated in the results, the readmission rate was largely higher 11. Housley SB, Monteiro A, Donnelly BM, et al. Statins versus nonsta- among patients with an operation alone compared with com- tin use in patients with chronic subdural hematomas treated with middle meningeal artery embolization alone: a single-center expe- bined therapy, and of those, most patients were re-admitted due rience. World Neurosurg 2022 Oct 15. [Epub ahead of print] to recurrence or a residual of cSDH. This finding stands in con- CrossRef Medline trast to only 1 patient who was re-admitted for hematoma recur- rence after adjuvant MMA embolization. Although we could not L. Scherschinski statistically compare these groups because of their small sample J.S. Catapano A.P. Jadhav size, it is unlikely that miscellaneous reasons for re-admission A.F. Ducruet introduced bias of any kind. We agree that longer follow-up of F.C. Albuquerque the groups would be of interest and merits future analysis. On behalf of all authors Department of Neurosurgery Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center http://dx.doi.org/10.3174/ajnr.A7754 Phoenix, Arizona AJNR Am J Neuroradiol 44:E3 Jan 2023 www.ajnr.org E3
American Journal of Neuroradiology – American Journal of Neuroradiology
Published: Jan 1, 2023
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