聚乙烯醇颗粒栓塞脑膜中动脉治疗慢性硬膜下血肿的临床价值初探

Polyvinyl alcohol particle embolization of middle meningeal artery in treating chronic subdural hematoma

目的初步探讨聚乙烯醇颗粒栓塞脑膜中动脉治疗慢性硬膜下血肿的疗效、安全性及手术经验。方法选择陆军军医大学第一附属医院神经外科自2021年5月至2022年8月收治的51例慢性硬膜下血肿患者(初次治疗25例、阿托伐他汀治疗无效19例、钻孔引流术后复发7例)为研究对象。患者术前行三维时间飞越法(3D TOF)MRA评估脑膜中动脉特征,无手术禁忌后于局麻下行单侧或双侧聚乙烯醇颗粒栓塞脑膜中动脉治疗。以术后血肿复发率及术后2个月血肿最大厚度减少>50%的患者比例为主要指标评估疗效,并观察并发症及手术相关不良事件发生情况,回顾性总结手术经验。结果51例患者术前3D TOF MRA所示的脑膜中动脉特征均与术中造影所示一致,其中16例单侧血肿患者术前3D TOF MRA示双侧脑膜中动脉增粗,经术中造影证实为双侧供血后行双侧脑膜中动脉栓塞。51例患者均顺利完成手术,其中单侧栓塞19例、双侧栓塞32例,总栓塞脑膜中动脉83侧。48例患者治疗后血肿吸收、症状改善,3例(5.9%)患者术后血肿复发,治疗成功率为94.1%。除复发患者外,共有39例患者完成术后2个月的随访,其中血肿最大厚度减少>50%的患者比例达100%。本组无死亡病例,患者无并发症及手术相关不良事件发生。结论聚乙烯醇颗粒栓塞脑膜中动脉治疗慢性硬膜下血肿安全有效。若单侧血肿患者术前MRA发现双侧脑膜中动脉供血可能,术中需考虑行双侧脑膜中动脉造影并行双侧栓塞。

Objective To investigate the efficacy,safety and surgical experience of middle meningeal artery embolization using polyvinyl alcohol particle in treating chronic subdural hematoma(CSDH).Methods A total of 51 CSDH patients(25 accepted first treatment,19 had invalid atorvastatin treatment,and 7 recurred after burr hole drainage)admitted to Department of Neurosurgery,First Affiliated Hospital of Army Medical University from May 2021 to August 2022 were enrolled.The characteristics of middle meningeal artery were evaluated by three-dimensional time-of-flight(3D TOF)MRA before embolization.With confirmation of no surgical contraindications,unilateral or bilateral embolization of the middle meningeal artery with polyvinyl alcohol particle was performed under local anesthesia.The hematoma recurrence rate and proportion of patients with reduction of maximum hematoma thickness>50%at 2 months after embolization were used as primary outcomes to evaluate the efficacy.Complications and embolization-related adverse events were recorded,and the experiences were retrospectively summarized.Results For all 51 patients,the characteristics of the middle meningeal artery shown in the preoperative 3D TOF MRA were consistent with those in the intraoperative angiography;16 patients with unilateral hematoma showed thickened bilateral middle meningeal arteries in preoperative 3D TOF MRA,bilateral blood supply was confirmed by intraoperative angiography and bilateral middle meningeal artery embolization was performed.Interventional embolization was successful in all 51 patients,including unilateral embolization in 19 and bilateral embolization in 32,with a total of 83 sides of embolizations.After embolization,hematoma was absorbed and symptoms improved in 48 patients,and hematoma recurrence was observed in 3 patients(5.9%),with an overall success rate of 94.1%.Excluding the 3 patients with hematoma recurrence,39 patients completed the 2-month follow-up,and these patients had the maximum hematoma thickness reduction>50%.No mortality,complications or surgery-related adverse events were observed in them.Conclusion Middle meningeal artery embolization with polyvinyl alcohol particle is safe and effective in treating CSDH;once bilateral middle meningeal artery blood supply is indicated by preoperative MRA in patients with unilateral hematoma,bilateral angiography and embolization should be considered during interventional treatment.