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Letter: Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Series of 60 Cases

Feng, Zhou MD; Chen, Zhi MD, PhD

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doi: 10.1093/neuros/nyz137

To the Editor:

We read with great interest the recent article by Thomas et al,1 which described 60 cases of middle meningeal artery (MMA) embolization for chronic subdural hematoma (CSDH). This minimally-invasive therapy presents a safe and efficacious alternative to surgical evacuations for patients with CSDH.

Lately, we participated in a phase II clinical trial, which demonstrated that atorvastatin is safe and effective for nonsurgically treating CSDH.2 This clinical trial presents a safe and efficacious nonsurgical alternative for patients with CSDH, especially those who are not appropriate for surgery. Meanwhile, it was reported that administration of atorvastatin perioperatively was reported to be associated with a lower risk of CSDH recurrence rate.3 But atorvastatin is not efficacious for all CSDHs. About 11.2% patients of atorvastatin group switched to surgery in this trial.2 Previous study reported that the efficacious rate of atorvastatin on CSDH was about 75%.4 The suspected mechanism of CSDH is the intermittent bleeding of neovasculature in the outer membrane of the CSDH, whose blood flow was supplied by the MMA.5 Our previous studies demonstrated that statin can promote hematoma absorption after intracerebral hemorrhage and intraventricular hemorrhage.6,7 So the balance between hematoma absorption and bleeding of neovasculature might decide the therapeutic efficacy of atorvastatin on CSDH.

The mechanism that treating CSDH by embolization of the MMA was eliminating the blood supply from MMA.5 So we speculate that embolization of the MMA might be a salvage therapy for CSDH that has failed atorvastatin treatment. Further prospective study to combine MMA embolization with atorvastatin, simultaneous intercepting blood supply, and promoting absorption, is expected to improve the therapeutic efficacy of CSDH.


The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.


1. Link TW, Boddu S, Paine SM, et al. Middle meningeal artery embolization for chronic subdural hematoma: a series of 60 cases. Neurosurgery. published online: 2018(doi: 10.1093/neuros/nyy521).
2. Jiang R, Zhao S, Wang R, et al. Safety and efficacy of atorvastatin for chronic subdural hematoma in Chinese patients: a randomized clinical trial. JAMA Neurol. 2018;75(11):528-373.
3. Tang R, Shi J, Li X, et al. Effects of atorvastatin on surgical treatments of chronic subdural hematoma. World Neurosurg.2018;117:e425-e429.
4. Chan DY, Chan DT, Sun TF, et al. The use of atorvastatin for chronic subdural haematoma: a retrospective cohort comparison study. Br J Neurosurg. 2017;31(1):72-77.
5. Takizawa K, Sorimachi T, Ishizaka H, et al. Enlargement of the middle meningeal artery on MR angiography in chronic subdural hematoma. J Neurosurg. 2016;124(6):1679-1683.
6. Wang Y, Chen Q, Tan Q, et al. Simvastatin accelerates hematoma resolution after intracerebral hemorrhage in a PPARγ-dependent manner. Neuropharmacology. 2018;128:244-254.
7. Chen Q, Shi X, Tan Q, et al. Simvastatin promotes hematoma absorption and reduces hydrocephalus following intraventricular hemorrhage in part by upregulating CD36. Transl Stroke Res. 2017;8(4):362-373.
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