O-030 Super-selective middle meningeal artery embolization for chronic subdural hematoma using n-BCA with the sugar push technique: single center experience of 61 consecutive patients

Background Middle meningeal artery (MMA) embolization has emerged as a promising treatment modality for patients with chronic subdural hematoma (SDH). Onyx, particles, or coils are the most used embolic materials. Therefore, the safety and efficacy of n-butyl cyanoacrylate (n-BCA) embolization in these patients are not fully understood. We present the technical feasibility and efficacy of n-BCA embolization in the largest consecutive cohort to date. Methods This study is a retrospective analysis of a prospectively maintained database of consecutive patients with chronic or recurrent SDH treated with MMA embolization using diluted n-BCA with the ‘Sugar- Rush’ technique. Briefly, a 2.1 Fr microcatheter was used to selectively catheterize the distal frontal and posterior branches of the MMA. A 5-Fr intermediate catheter was advanced proximal to the origin of the MMA in the internal maxillary artery and used for Dextrose 5% (Sugar- Rush) injection via a 60 ml syringe while the primary operator was injecting n-BCA through the microcatheter. Complete obliteration of frontal and posterior branch of the MMA and lack of SDH recurrence in 3-6 months follow up CT scan were defined as efficacy outcomes. Cranial nerve palsy, vision loss, transient neurologic deficit and stroke were defined as safety outcomes. Results A total of 61 patients were identified with a mean (±SD) age of 62.5± 9. Seventy eight percent of the patients were male. Median (IQR) NIHSS score was 1 (3), 67% of the patients had midline shift and 36% had bilateral SDH. Forty nine percent of the patients had craniotomy, burr hole or Subdural Evacuating Port System (SEPS) placement prior to embolization. The embolization was performed under MAC anesthesia in 39 (64%) patients and radial access in 29 (48%) patients. In 6 patients (10%), coil embolization of the origin of the frontal or posterior branch was performed as super-selective catheterization of the branch was unsuccessful due to tortuous anatomy. Complete obliteration of frontal and posterior branches was achieved in 100% of the cases. In 25% of the patients, n-BCA penetrated the contralateral side. Follow up CT scan at 3-months and 6- months were available in 91% of the patients. Recurrent SDH was seen in only 1 patient on the side contralateral to treatment. No incidence of cranial nerve palsy, vision loss, or stroke occurred. One patient suffered a transient neurological deficit. Conclusion MMA embolization using diluted n-BCA with concomitant Dextrose 5% injection (Sugar-Rush) is associated with a high degree of distal penetration and complete branch occlusion and minimal risk of cranial nerve palsy or other thrombo-embolic complications. Clinical trials are warranted to compare long-term efficacy of this procedure with standard of care management. Disclosures S. Majidi: None. S. Matsoukas: None. R. De Leacy: None. P. Morgenstern: None. R. Soni: None. H. Shoirah: None. T. Shigematsu: None. J. Bederson: None. A. Berenstein: None. J. Mocco: None. J. Fifi: None. C. Kellner: None.