Embolization Proves Its Mettle for Subdural Hematoma

PHOENIX — For chronic or subacute subdural hematoma, embolization of the heart meningeal artery (MMA) lowered recurrence, three randomized trials showed.

Two trials with the Onyx liquid embolic system and one with the Squid liquid embolic system have been reported with what one presenter called “very constant” findings at the closing unhurried-breaking science session of the American Stroke Affiliation Global Stroke Convention.

The manner has been weak sporadically off-stamp for subdural hematoma, although acquainted to neurointerventionalists attributable to exercise in dural arteriovenous fistulas and arteriovenous malformation, noted session co-moderator Tudor G. Jovin, MD, of the Cooper Neurological Institute in Camden, New Jersey.

“This is mountainous recordsdata, these three trials, because they are setting up this route of as a customary of care,” he instructed MedPage This day. “Level one proof modified into as soon as lacking, and I admire this would possibly well trade practice and trade guidelines.”

“I would map the analogy with the thrombectomy trials of 2015. There have been some products and services that have been doing it, but it wasn’t the customary of care,” he mentioned. “It would possibly well maybe maybe be as impactful because the 2015 trials have been for thrombectomy.”

Surgical medicine with craniotomy or by drilling a burr hole to drain the hematoma seems to have been in exercise for hundreds of years, basically basically basically based on archaeological proof. Conservative medical administration with therapies adore tranexamic acid administration, steroids, or statins is frequent as neatly.

Nonetheless, put up-surgical recurrence rates are up to 20% in many sequence. A most up-to-date systematic review showed a 36% nonsuccess rate for conservative therapy.

“As that fluid has gathered on the floor of the mind, you are inclined to develop membranes,” noted Jason Davies, MD, PhD, of the Yell College of New York at Buffalo. “Chances are high you’ll maybe need got inflammatory cells that stretch in that have a educated-angiogenic role. You starting up to get ingrowth of neovascularity from the overlying dura, and these vessels are inclined to be slightly poorly formed and to be leaky. And so what occurs is that these membranes starting up having repeated microhemorrhages, fluid exudates, and they in reality gather on a lifetime of their very have.”

“So the understanding is, if we are able to devascularize these membranes by interrupting the blood vessels, we are able to dry up the membranes, interrupt that cycle, and expectantly slit the recurrence rates and increase scientific outcomes for the patient,” he explained.

Onyx Outcomes

Davies reported intervening time outcomes from the EMBOLISE trial cohort present process surgical administration. The trial — designed to succor an utility to the FDA for an expanded indication — also has an arm that randomized patients who elected conservative administration without surgical operation; that recordsdata will possible be reported at a later date.

In the surgical cohort, subdural hematoma recurrence or progression requiring surgical drainage thru 90 days came about in 4.1% of patients randomized to embolization with the Onyx liquid embolization system, compared with 11.3% handled with surgical operation on my own (RR 0.36, 95% CI 0.11-0.80, P=0.0081).

The quantity wished to treat modified into as soon as about 14, or correct 12 in a modified intent-to-treat diagnosis with the exception of for patients handled outside the protocol.

Deterioration in neurologic characteristic modified into as soon as identical between groups (11.9% and 9.8%, respectively, P=0.0022 for non-inferiority).

The surgical cohort in the trial integrated 400 patients at 60 products and services across the U.S. Inclusion standards required a premorbid modified Rankin Score (mRS) of 0-3, diagnosis of subacute or chronic subdural hematoma on MRI or CT imaging with corroborating scientific indicators, and characteristics that ruled out commentary on my own. Radial get admission to and native anesthesia have been inspired for the route of.

All embolization procedures accomplished technical success for the blueprint vessel, with 1.1% reflux to non-blueprint vessels. Excessive unfavorable events (AEs) connected to the embolization route of came about in 2% of patients internal 30 days, but now not one of many four cases have been deemed connected to Onyx.

Neurologic death in the principle 90 days have been better than twice as frequent in the embolization crew (4.6% vs 2.0%), but when it comes to all have been attributable to the subdural hematoma with none connected to Onyx or the embolization route of. No ipsilateral visual complications or excessive intracerebral hemorrhage connected to Onyx or the embolization route of came about both.

One limitation modified into as soon as about 10% of overlooked hospital visits at 90-day be conscious-up given the timing of the trial across the COVID-19 pandemic (December 2020 to August 2023) with a slightly ancient, elderly inhabitants. The frequent age modified into as soon as around 71 in the behold.

“We imagine MMA embolization must gentle be understanding of as an adjunct for patients who endure surgical drainage of chronic or subacute subdural hematomas,” concluded co-presenter Jared Knopman, MD, of Weill Cornell Treatment in New York City. “We’re very excited by these outcomes.”


A second trial from China, MAGIC-MT, also showed a 4.93-share level slit value in symptomatic recurrence or progression of subdural hematoma or death internal 90 days after randomization to MMA embolization utilizing Onyx compared with in the community obvious care administration on my own (7.2% vs 12.2%, P=0.02).

Ying Mao, MD, PhD, of Huashan Hospital and Fudan College in Shanghai, reported that the trial integrated 727 symptomatic non-acute subdural hematoma patients with a shift in midline structure or deformation of native cerebral cortex. It had inclusion standards connected to the EMBOLIZE trial, Mao noted. It likewise allowed native doctors to mediate on conservative administration or burr hole drainage, on the opposite hand both groups have been randomized into the identical trial cohort, in inequity to EMBOLIZE.

Symptomatic subdural hematoma recurrence (most thickness >10 mm) or re-operation internal 90 days modified into as soon as numerically much less frequent with embolization in the 78% of patients who underwent burr-hole drainage (4.7% vs 5.2%).

For these managed conservatively, symptomatic subdural hematoma progression showed a elevated impact of embolization, with rates of 1.7% versus 4.7%. Diversified factors connected to a elevated medicine own have been identified head trauma, smaller midline shift, and smaller hematoma quantity.

Security findings in reality showed vastly fewer excessive AEs internal 90 days in the embolization crew (6.7% vs 11.6%, P=0.02). Embolization-connected complications came about in 0.8% of patients, with one case of facial nerve paralysis and two of inequity agent allergy.

SQUID Outcomes

A novel liquid embolization system, dubbed Squid, better than tripled the chance of medicine success compared with customary administration, reported Adam Arthur, MD, of Semmes-Murphey Neurological Hospital in Memphis, Tennessee, who called the outcomes “very constant” with what had already been offered at the unhurried-breaking science session.

Embolization with Squid yielded a 15.5% failure rate internal 180 days compared with 39.2% utilizing customary administration on my own (OR 3.60, 95% CI 1.91-6.78) when failure modified into as soon as outlined 3 options: residual or re-accumulation to as a minimum a 10-mm thick hematoma, re-operation or surgical rescue, or any novel predominant tournament (disabling stroke, myocardial infarction, or death from any neurological motive).

Notably, patients who had MMA embolization at the side of conservative administration in reality had a decrease possibility of medicine failure than these who acquired surgical operation on my own (19.1% vs 25.4%). The lowest possibility modified into as soon as viewed in these who acquired the combined surgical operation-plus-embolization approach (12.3%), whereas fully 59.2% had failure with non-surgical administration on my own.

The STEM pivotal trial randomized 310 patients (stratified by surgical administration, which 189 elected, or non-surgical care).

Contributors have been ages 30 and older and had premorbid mRS 0-1 in the prior 365 days. Their chronic subdural hematoma wished to be symptomatic and measure as a minimum 10 mm at its thickest level and exert native cortical pulling down or midline shift.

No deaths in the trial have been attributed to the route of or tool, and 30-day all-motive mortality modified into as soon as identical between medicine arms. The right predominant disabling stroke came about in the retain a watch on crew.

Of the a complete lot of endpoints for which recordsdata will possible be reported later, Arthur noted that mRS shift, health center length of contend with, and neurocognitive scores will possible be of particular interest.

“Again, we’re trying at an older patient inhabitants and looking out to back them to retain independence and retain cognitive competence later in lifestyles,” he concluded.

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EMBOLISE modified into as soon as backed by Medtronic.

Davies disclosed relationships with NIH, NSF SBIR, UB CAT, Buffalo Translational Consortium, Cummings Foundation, Nvidia, Google,, Rist Neurovascular, Cerebrotech, Synchron, Hyperion, Medtronic, Microvention, Imperative Care, Xenter, RapidPulse, Canon, Johnson & Johnson, and StrokeNet.

MAGIC-MT modified into as soon as supported by the Shanghai Shenkang Hospital Construction Heart, Shanghai Municipal Successfully being Commission, and Covidien/Medtronic.

Mao disclosed relationships with Medtronic.

STEM modified into as soon as backed by BALT USA.

Arthur disclosed relationships with Arsenal, Cerenovus, Medtronic, Microvention, Neuros, Penumbra, Perfuze, Scientia, Siemens, Stryker, Bendit, EndoStream, Magneto, Mentice, Neurogami, Neuros, Perfuze, RevBio, Scientia, Serenity, Synchron, Tulavi, Vastrax, and

Jovin disclosed relationships with Cerenovus, Route 92, Galaxy Therapeutics, Methinks, Anaconda ,, Kandu Successfully being, StataDX, FreeOx Biotech, Stryker, and Medtronic.

Main Offer

Global Stroke Convention

Offer Reference: Davies JM, et al “The EMBOLISE behold: Embolization of the heart meningeal artery with onyx liquid embolic system in the medicines of subacute and chronic subdural hematoma” ISC 2024; Summary LB28.

Secondary Offer

Global Stroke Convention

Offer Reference: Mao Y, et al “The MAGIC-MT trial: Managing non-acute subdural hematoma utilizing liquid presents: A Chinese randomized trial of center meningeal artery medicine” ISC 2024; Summary LB29.

Further Offer

Global Stroke Convention

Offer Reference: Arthur A, et al “STEM (The Squid trial for the embolization of the MMA for the medicines of CSDH)” ISC 2024; Summary LB31.

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