Combined Subdural Evacuation Port System (SEPS) and Middle Meningeal Artery Embolization (MMAE) for Subdural Hematomas: Insights from a Multicenter Study

Introduction: The increasing incidence of subdural hemorrhage (SDH) in older adults necessitates reevaluating surgical interventions. The Subdural Evacuation Port System (SEPS) is safer but has a higher recurrence risk. Middle Meningeal Artery Embolization (MMAE) reduces recurrence and treatment failures, making it a valuable adjunct to SEPS.

Methods: A retrospective review at four US cerebrovascular centers analyzed patients with SDH treated with combined SEPS and MMAE. We evaluated demographics, comorbidities, procedural details, and outcomes by comparing 3D-segmented CT volumes before treatment, 24-48 hours post-procedure, and at 6-8 weeks follow-up. Multivariate regression identified predictors of SDH volume reduction.

Results: We included 114 patients (Median age: 77 years [69-85.5]; Female=64.9%) with 154 SDH, of which 134 were treated with SEPS+MMAE. Notably, 109 (81.3%) SDHs were holohemispheric and 47 (35.1%) had an acute, subacute or acute/subacute component on chronic SDH. The median pre-SEPS+MMAE SDH volume was 122.9mL [88-152.4] with a midline shift of 6mm [3.4-9.5]. Majority of MMAE procedures were performed under general anesthesia (68.7%), utilizing the femoral approach (61.9%). The median post-SPES+MMAE and follow up-SEPS+MMAE volumes were 71.1mL [54.1-94.8] and 22mL [2-59.2] resulting in a 38.1% [22.1-52.9] and 80% [51.9-97.8] reduction compared to pre-SEPS+MMAE levels. Ten (9.2%) SDH required readmission for residual or recurrence within 90 days. Eight (7.3%) were retreated, five (4.6%) of which required a craniotomy. Younger age, anticoagulated status and larger SDH volumes predicted higher clearance with SEPS but negatively impacted MMAE efficacy. Additionally, unilateral MMAE compared to bilateral MMAE for bilateral SDH was less effective, underscoring the critical role of MMAE in optimizing SDH management.

Conclusion : This multicenter study represents the largest experience demonstrating individual and combined efficacy of SEPS and MMAE in managing SDH, with low recurrence and retreatment rates. The use of 3D-segmented volumes enhances the study's robustness by enabling precise measurement and tracking of SDH volume changes.