Abstract
Middle meningeal artery embolization (MMAE) is emerging as a safe and effective standalone intervention for non-acute subdural hematomas (NASHs); however, the risk of hematoma recurrence after MMAE in coagulopathic patients is unclear. To characterize the impact of coagulopathy on treatment outcomes, we analyzed a multi-institutional database of patients who underwent standalone MMAE as treatment for NASH. We classified 537 patients who underwent MMAE as a standalone intervention between 2019 and 2023 by coagulopathy status. Coagulopathy was defined as use of anticoagulation/antiplatelet agents or pre-operative thrombocytopenia (platelets <100,000/μL). Demographics, pre-procedural characteristics, in-hospital course, and patient outcomes were collected. Thrombocytopenia, aspirin use, antiplatelet agent use, and anticoagulant use were assessed using univariate and multivariate analyses to identify any characteristics associated with the need for rescue surgical intervention, mortality, adverse events, and modified Rankin Scale score at 90-day follow-up. Propensity score-matched cohorts by coagulopathy status with matching covariates adjusting for risk factors implicated in surgical recurrence were evaluated by univariate and multivariate analyses. Minimal differences in pre-operative characteristics between patients with and those without coagulopathy were observed. On unmatched and matched analyses, patients with coagulopathy had higher rates of requiring subsequent surgery than those without (unmatched: 9.9% vs. 4.3%; matched: 12.6% vs. 4.6%; both p < 0.05). On matched multivariable analysis, patients with coagulopathy had an increased odds ratio (OR) of requiring surgical rescue (OR 3.95; 95% confidence interval [CI] 1.68-9.30; p < 0.01). Antiplatelet agent use (ticagrelor, prasugrel, or clopidogrel) was also predictive of surgical rescue (OR 4.38; 95% CI 1.51-12.72; p = 0.01), and patients with thrombocytopenia had significantly increased odds of in-hospital mortality (OR 5.16; 95% CI 2.38-11.20; p < 0.01). There were no differences in follow-up radiographic and other clinical outcomes in patients with and those without coagulopathy. Patients with coagulopathy undergoing standalone MMAE for treatment of NASH may have greater risk of requiring surgical rescue (particularly in patients using antiplatelet agents), and in-hospital mortality (in thrombocytopenic patients).
| Original language | English (US) |
|---|---|
| Pages (from-to) | 1375-1383 |
| Number of pages | 9 |
| Journal | Journal of neurotrauma |
| Volume | 41 |
| Issue number | 11-12 |
| DOIs | |
| State | Published - Jun 18 2024 |
Funding
E.I.L. received consulting fees from Clarion, GLG Consulting, Guidepoint Global, Imperative Care, Medtronic, StimMed, Misionix, and Mosiac; lecture payments from Clarion, GLG Consulting, Guidepoint Global, Imperative Care, Medtronic, StimMed, Misionix, and Mosiac; expert testimony payment from Renders Medical; has patents planned, issued, or pending for Ultrasonic surgical blade; is on the advisory board for Stryker, NeXtGen Biologics, MEDX, Cognition Medical, Endostream Medical, and IRRAS; is a stockholder of NeXtGen Biologics, RAPID Medical, Claret Medical, Cognition Medical, Imperative Care, Rebound Therapeutics, StimMed, and Three Rivers Medical; and is the chief medical officer for Haniva Technology. A.H.S. received a grant from the National Institutes of Health (NIH); consulting fees from Amnis Therapeutics, Apellis Pharmaceuticals, Boston Scientific, Canon Medical Systems, Cardinal Health 200, Cerebrotech Medical Systems, Cerenovus, Cerevatech Medical, Cordis, Corindus, Endostream Medical, Imperative Care, InspireMD, Integra, IRRAS AB, Medtronic, MicroVention, Minnetronix Neuro, Peijia Medical, Penumbra, Piraeus Medical, Q'Apel Medical, Rapid Medical, Serenity Medical, Silk Road Medical, StimMed, Stryker Neurovascular, Three Rivers Medical, VasSol, and Viz.ai; is a stockholder of Adona Medical, Amnis Therapeutics, Bend IT Technologies, BlinkTBI, Borvo Medical, Cerebrotech Medical Systems, Cerevatech Medical, Cognition Medical, Collavidence, CVAID, E8, Endostream Medical, Galaxy Therapeutics, Imperative Care, InspireMD, Instylla, International Medical Distribution Partners, Launch NY, Neurolutions, NeuroRadial Technologies, NeuroTechnology Investors, Neurovascular Diagnostics, Peijia Medical, PerFlow Medical, Piraeus Medical, Q'Apel Medical, QAS.ai, Radical Catheter Technologies, Rebound Therapeutics, RIST Neurovascular, Sense Diagnostics, Serenity Medical, Silk Road Medical, Sim & Cure, SongBird Therapy, Spinnaker Medical, StimMed, Synchron, Three Rivers Medical, Truvic Medical, Tulavi Therapeutics, Vastrax, VICIS, Viseon, and Whisper Medical; has received payments related to Cerenovus EXCELLENT and ARISE II Trials; Medtronic SWIFT PRIME, VANTAGE, EMBOLISE, and SWIFT DIRECT Trials; MicroVention FRED Trial & CONFIDENCE Study; MUSC POSITIVE Trial; Penumbra 3D Separator Trial, COMPASS Trial, INVEST Trial, MIVI Neuroscience EVAQ Trial; Rapid Medical SUCCESS Trial; and InspireMD C-GUARDIANS IDE Pivotal Trial. A.M.S. has received grants or contracts from Medtronic, Stryker, Penumbra, Avail, and RapidAI; consulting fees from Stryker, Penumbra, RapidAI, and Terumo; is on the medical advisory board of the Brain Aneurysm Foundation; and is a stockholder of Avail Med. A.A.K. has received consulting fees from Medtronic; payment for expert testimony from Procopio US Attorney; is on the advisory board of Route 92 and Medtronic; has a leadership role in the Congress of Neurological Surgeons and American College of Surgeons; and is a stockholder of Ospitek, Synaptive, and Proximie. R.H. has received grants or contracts from NIH, Interline Endowment, Microvention, Stryker, CNX, and Balt; consulting fees from Medtronic, Balt, Stryker, Q'Apel Medical, Codman Neuro (J&J), Cerenovus, Microvention, Imperative Care, Phenox, and Rapid Medical; is on the advisory board of MiVI, eLum, Three Rivers, Shape Medical, and Corindus; is associate editor of the endovascular section for Neurosurgery Journal; and is a stockholder of InNeuroCo, Cerebrotech, eLum, Endostream, Three Rivers Medical, Scientia, RisT, Blink TBI, and Corindus. B.A.G. has received consulting fees from Medtronic and Microvention. J.M.D. has received institutional grants or contracts from the NIH, NSF SBIR, University at Buffalo Center for Advanced Technology, Buffalo Translational Consortium, Cummings Foundation, NVIDIA, and Google; royalties from RIST Neurovascular; lecture payment from Medtronic; is on the advisory board for NIH Strokenet; has a leadership role in the cerebrovascular section of the Congress of Neurological Surgeons; and is a stockholder of QAS.ai, RIST Neurovascular, Cerebrotech, Synchron, and Hyperion. A.J.T. receives consulting fees from Stryker, Medtronic, and Cerevasc. M.R.L. has received unrestricted educational grants from Medtronic and Stryker; consulting fees from Medtronic, Metis Innovative, Aeaean advisers, and Stereotaxis; is on the data safety monitoring board for Arsenal; has equity interests in Hyperion Surgical, Proprio, Aperture, Cerebrotech, Synchron, Fluid Biomed, and Stereotaxis; and is on the editorial board on the Journal of NeuroInterventional Surgery and Frontiers in Surgery. P.T.K. has received grants from the NIH (1U18EB029353-01), Medtronic (ERP-2019-12070), Siemens (CON30434), and Joe Niekro Foundation (CON30914); consulting fees from Stryker Neurovascular, Imperative Care, Cerenovus, and Microvention; and is on the editorial board of the Journal of Neurointerventional Surgery. J.K.B. receives consulting fees from Q`Apel Medical, Stryker, Medtronic, Cerenovous, and Microvention. R.G. receives consulting fees from Medtronic Neurovascular, Balt Neurovascular, and Cerenovus. The other authors have nothing to disclose.
Keywords
- anticoagulant
- antiplatelet agent
- aspirin
- chronic subdural hematoma
- coagulopathy
- middle meningeal artery
- middle meningeal artery embolization
- non-acute subdural hematoma
- thrombocytopenia
ASJC Scopus subject areas
- Clinical Neurology