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Letter to the Editor
Middle meningeal artery embolisation in the treatment of chronic subdural haematoma
Embolización de la arteria meníngea media en el tratamiento del hematoma subdural crónico
M. Gelabert-Gonzáleza,b,
Corresponding author
miguel.gelabert@usc.es

Corresponding author.
, A. Doval-Rodrígueza, P. Román-Penaa, B. Rodríguez-Botanaa
a Servicio de Neurocirugía, Hospital Clínico Universitariode Santiago de Compostela, Santiago de Compostela, La Coruña, Spain
b Departamento de Cirugía y Especialidades Médico-Quirúrgicas, Universidad de Santiago de Compostela, Santiago de Compostela, La Coruña, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with interest the manuscript &#8220;Endovascular embolisation of the middle meningeal artery to treat chronic subdural haematomas&#58; effectiveness&#44; safety&#44; and the current controversy&#46; A systematic review&#44;&#8221; recently published in <span class="elsevierStyleItalic">Neurolog&#237;a</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> We would like to comment on the article based on our experience in the diagnosis and treatment of chronic subdural haematoma &#40;CSH&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Firstly&#44; the article gives the impression that middle meningeal artery &#40;MMA&#41; embolisation is frequently performed to treat CSH&#44; whereas this is in fact an exceptional procedure that has not been validated to date by any study with a high level of evidence&#59; therefore&#44; huge controversy surrounds its true usefulness&#46; The aim of embolisation is to eliminate blood supply to the internal membrane of the haematoma through neoformed microvessels&#44; which generate microbleeds to a bordering space between the arachnoid mater and the dura mater&#44; known as the dural border cell layer&#46; This layer is of reduced thickness&#44; and due to the effect of bleeding and the lack of collagen it may open into 2 walls that are liable to separate&#44; facilitating blood accumulation&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In our opinion&#44; the series published&#44; none of which are prospective or randomised&#44; provide insufficient data and evidence to establish routine performance of this technique in neurosurgery departments&#46; The use of MMA embolisation reported in the published series is far from comparable to the current gold standard for the treatment of CSH&#58; burr-hole&#44; washing out&#44; and external drain&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Most publications do not provide enough information on the type of patients treated&#46; It would be relevant to specify the presence of widely known prognostic factors in CSH&#44; such as clinical status &#40;assessed with the Glasgow Coma Scale or the Markwalder Grading Scale&#41;&#44; the internal structure of the haematoma &#40;assessed by CT studies&#41;&#44; etc&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">We do not agree that MMA embolisation is an appropriate technique for the primary treatment of patients presenting high risk for surgery and general sedation&#44; or that endovascular therapy may be performed under light sedation&#44; decreasing anaesthetic risk&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Local anaesthesia was used in 91&#46;1&#37; of cases in our series of 1000 patients with CSH treated with burr-hole&#44; washing out&#44; and drain&#44; and in 88&#46;5&#37; of cases in our series with 200 elderly patients &#40;&#62; 85 years&#41;&#44; with no need to modify the anaesthesia used due to the comorbidities of the patients&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Finally&#44; we agree with the authors that MMA embolisation may be used safely in cases of recurrent CSH or as first option in patients with limited brain shift and good clinical status&#44; since the technique&#44; unlike surgery&#44; takes some time to reduce the haematoma and to resolve compression and brain shift&#46;</p></span>"
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