Research Talk - Thomas Link - Northwell -North Shore

October 27, 2021

ID7085

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00:10Perfect we can see your slides right.
00:18OK.
00:21So hi, my name is Tom Lincoln neurosurgeon
00:25heavy endovascular based practice
00:27here at North Shore in Long Island.
00:31One of the major centers
00:32in the north wall system.
00:34I was asked to talk today about
00:36middle meningeal artery embolization
00:37for chronic subdural hematoma.
00:39A little bit of a change of subject.
00:42In the stroke net conference here,
00:44but I think.
00:46Uhm, it becomes.
00:48It's becoming more and more relevant
00:50really in as more and more places are
00:53doing this kind of intervention and a
00:56vascular option for subdural hematoma,
00:58we have a few clinical trials going on here.
01:00As one of them is multi institutional
01:03will get into at the end.
01:06So it's kind of a lot to get in,
01:09get through in 15 minutes,
01:11but so I might go pretty quickly
01:13through some parts of this,
01:14but a little bit of the background
01:16here so you know why do we need other
01:19methods to treat subdural hematoma
01:21and and one of the major issues
01:23with it is that it's classically
01:25very difficult pathology to treat,
01:26so there's very high recurrence rates.
01:28Literature says anywhere
01:30between kind of 10 to 30% or so,
01:33and it tends to affect.
01:35Older and sicker patients, and as we know,
01:39the population is aging in general,
01:41so this is increasing incidence.
01:42In general,
01:43chronic subdural hematoma that is,
01:45and this tends to affect
01:47patients who are older,
01:48have many comorbidities,
01:49tend to be on anticoagulation
01:51and any platelet agents.
01:53So it's certainly helpful to have a less
01:56invasive option compared to surgery.
01:58So just to go through
02:00why we think this works.
02:02So what happens when you have
02:04sort of this blood clot that
02:06forms in the subdural space?
02:07And traditionally this is this
02:09is initially caused by the
02:11tearing of bridging veins and
02:13acute hemorrhage in this space.
02:15But the the brain's reaction to it
02:17really is an inflammatory reaction
02:19where you have infiltrate infiltration
02:22of inflammatory cells you have.
02:24If I burn a lysis of the clot,
02:25it's trying to break it down into a
02:27more liquid type substance and and really,
02:30there's this in capsulation of this hematoma.
02:34And formation of a membrane around
02:36and also through it which we
02:38see in surgery in these chronic
02:40kind of membranous flocculated,
02:42subdural hematomas membrane itself
02:45becomes vascularized so there's
02:48no release of all these vascular
02:50endothelial growth factors.
02:51And if you take some of this membrane
02:53at surgery and send it to pathology
02:56we actually have found that these
02:58vessels within this membrane itself
03:00inflammatory cells and there's
03:02high staining for veg F so.
03:04It really turns out that
03:06chronic subdural hematoma,
03:07as opposed to acute,
03:08is really it really becomes an
03:10arterial pathology because the the
03:12new vascularization of this membrane
03:14leads to these leaky kind of fragile
03:17vessels that repeatedly bleedin sort of
03:20ooze into this collection over time.
03:22And while some chronic
03:24subdural's go away over time,
03:26the body is able to resorb it,
03:27others don't,
03:28and the thought now is that it's
03:29this repeated sort of kind of
03:31rebleeding into this collection
03:33that leads to the persistence.
03:34And recurrence, and many of these cases.
03:37So you see here,
03:38and generally when you have
03:39a subdural that persists,
03:41the thought is that this process outweighs
03:44the brains ability to resore bit.
03:46And where does this the vasculature
03:48come from in this membrane or the
03:50only place it can come from is is
03:52the adjacent dura and which comes
03:53from the middle meningeal artery,
03:55so essentially by shutting down
03:57the blood supply to the from
03:59the middle meningeal artery.
04:00To this membrane you arrest
04:02this process of this repeated.
04:04Bleeding and you can.
04:05You can in effect tip the
04:07scales there to now allow the
04:09rain to be able to resolve it.
04:11So that that's the theory behind
04:13how this works, and there's some
04:15support to a lot of this in in,
04:17in the angiography and
04:18and some of the imaging.
04:19So you know when you do a
04:22selective middle meningeal artery.
04:24A angiography you could see we have
04:26this kind of distal what we call a
04:28cotton wool like appearance of the
04:30of the distal branches of the man.
04:32This wispy NIS that you see where
04:35there could be supply to some of
04:37this vast new vascularised membrane.
04:39Uhm, you see this kind of
04:41leakiness into the subdural space,
04:43and in many times when you do the
04:45post-op scan after an embolization,
04:47you actually get this kind of
04:49subtle increased in density
04:51in the entire subdural space.
04:54Which the thought is that
04:55this is actually contrast.
04:56That kind of leaks in through
04:59this this leaky vasculature.
05:00And then finally, one of my favorite images.
05:03If you look at an AP projection of a
05:06selective and then a injection here,
05:08it really outlines perfectly what you see.
05:10This entire subdural hematoma
05:12on the kernel image here.
05:13So it's you really see this membrane
05:16surrounding the the hematoma
05:18that's being supplied by the.
05:21So when I was a fellow training
05:23at at Cornell with Doctor Nachman,
05:25who really kind of pioneered this,
05:27we started back in 2016 or so.
05:30Here's the example of the first
05:32five patients that we treated
05:33as primary treatment.
05:35So you know, prior to this,
05:38it really only been described
05:40internationally as kind of salvage
05:42therapy for multi recurrent subdural's.
05:44This was used for patients that essentially
05:48we were able to get to avoid surgery.
05:51Altogether,
05:51so one might say initially well,
05:54many sub tools go away on their own.
05:56So how do you know that these
05:57hematomas wouldn't have just went away?
05:59Well, these patients were selected
06:00because they show that they failed
06:02conservative management already,
06:04so this was progression of their subdural's.
06:07Despite observations, steroids, etc.
06:10And we did the embolization.
06:12You see, many of them.
06:14The subdural completely went away over time,
06:16and others it almost entirely went away.
06:18And all five were able to avoid
06:21any further surgical intervention.
06:23So we we went along and then
06:24the first 60 cases that we did,
06:26we published a couple of years ago and
06:29and really show that there are three
06:31major categories where this can be useful.
06:33So number one,
06:34it can be used instead of surgery
06:36in certain patients that are meet
06:38certain criteria which we can get into.
06:41It can be used as to treat recurrence
06:43after surgical evacuation and even there
06:45might be this prophylactic used to it.
06:48So say you have someone who
06:49has surgery and maybe you think
06:51they're high risk for recurrence.
06:53So you could sort of fend it off by
06:55doing this immediately after surgery,
06:57and in this study of 60 patients
06:59we were able to help
07:0191% of these patients avoid any
07:04further surgical treatment.
07:05And that's what we defined
07:07as the the primary endpoint.
07:09And really, you know,
07:10almost 70% overall also had a
07:13reduction in size greater than 50%.
07:15So, uhm. This is just describing
07:17a little bit more technique.
07:20There's been a few other larger
07:21studies now and and really two of the
07:24best papers that I chose to share.
07:25Here's one that was published
07:27last year where they did.
07:28It was a multicenter but
07:29non randomized trial.
07:30So there 154 embolization
07:32is done in 138 patients.
07:35There they defined a 93.5% success rate.
07:38Again, same thing,
07:39the primary endpoint being did any
07:42any of these patients require an
07:44additional treatment which would
07:45be surgery so very successful?
07:48And in this multicenter trial,
07:50right around that 70% mark again.
07:52Also for greater than 50%
07:54reduction in size overall.
07:56Uhm complication rate low.
07:58I mean they wrote 9% because
08:00that included those that actually
08:03failed treatment and headaches.
08:05So if you if you knock those two out
08:07there was there was one temporary
08:09facial droop in one seizure so overall
08:12kind of about 1.4% complication rate.
08:14There are dangers,
08:15collaterals,
08:16meaning potential collaterals from the Emma.
08:18To say the optomec artery which
08:20is well described and it's just
08:22something that we have to be
08:24careful about and lookout for.
08:26Uhm,
08:26and then here is a single
08:28center prospective study where
08:30embolization was done for patients
08:32that they considered high risk
08:35for recurrence after surgery.
08:36So 91 sub drills in 89 patients
08:39after surgery got embolization.
08:42And they compared this to 174
08:44historical controls and they saw
08:46that in the patients that got
08:49embolization there was only a
08:514% recurrence rate or needing an
08:53additional intervention compared to
08:5514% in their historical controls.
08:57So this suggests that it could
09:00be very effective for helping to
09:02prevent recurrence in in subbed roles.
09:05Here at Northwell at Northshore,
09:07we've had similar experience.
09:09We've done about 80 patients here,
09:11and this doesn't include the Lenox
09:12Hill experience where doctors are
09:14really there is doing them as well.
09:16We've had three patients fail,
09:18meaning they came back with growth
09:21of their residual subdural requiring
09:24further surgery.
09:25So essentially 96% success rate.
09:27There was one complication out of
09:30all 77 that could be considered major.
09:33There was a partial kind of
09:34partial blurry vision. In one eye.
09:38And there were three mortality's,
09:39all unrelated symbolisation.
09:40Just you know,
09:41these are a lot of these are sick
09:43patients with some more advanced lymphoma,
09:45multi multi system organ failure.
09:49Uhm,
09:49and I include this chart because it
09:51really helps to show how this works overtime.
09:54So certainly this can't be done
09:56for patients that need you know
09:59urgent relief of pressure from
10:01from a large collection.
10:03This is something that works overtime,
10:05so even if you look at this
10:07chart at the two week Mark,
10:08most of the time there's not that
10:10much of a reduction in size yet,
10:12but certainly you want to
10:13see that it's not getting
10:14any bigger and then by six weeks you
10:16really start to see this drop off in
10:18size and by three months many of them.
10:20And in our experience,
10:21over 90% have significant reduction in size.
10:24Many of them resolved completely.
10:27Uhm, so you know where could this be useful?
10:30So certainly you have these
10:32patients that have chronic subdural
10:33hematomas that are not going away,
10:35or even getting bigger,
10:36but haven't quite gotten to the
10:38point yet where it's causing so much
10:39Mass Effect that they need surgery.
10:41This is a great option to sort
10:42of fend it off,
10:43and in many times help it go away.
10:45Patients that you might want to avoid
10:47surgery for for whatever reason,
10:49whether they have significant comorbidities.
10:51Patients that need to be restarted
10:54on antiplatelets or anticoagulation
10:56very quickly.
10:56Those are some of the options,
10:58so just a few quick illustrative cases.
11:02Here's a patient with diffuse
11:03large B cell lymphoma that had
11:05this small subdural that was just
11:07being watched over time.
11:08It's platelets were very low.
11:09Here was as low as 34,000,
11:11so he's not a good surgical candidate.
11:14Overtime it got bigger and bigger to the
11:16point where it started causing worsening
11:18symptoms and had acute hemorrhage into it.
11:20Again, bad surgical candidate with
11:22this severe thrombocytopenia.
11:24So we tried this embolization procedure.
11:26Just a few before and after Ma injections.
11:30And if you look at the post-op scan
11:32compared to about six months later,
11:34he had this MRI and it was
11:37completely resolved.
11:37So great option for this
11:39poor surgical candidate.
11:41Uh,
11:41here's a a patient work that's
11:43very relevant to this conference.
11:45A patient who is 70 and had many T as
11:47well as a small stroke in the past,
11:50and he's been managed by neurologist
11:51on aspirin and Plavix.
11:53Because of that started to develop
11:55some kind of intermittent mild word
11:57finding difficulty and was found to
11:59have this acute on chronic subdural here.
12:01Again,
12:01not a great candidate and someone
12:03you certainly want to get back on
12:05their antiplatelets very quickly
12:06because of his stroke history.
12:08So if you watch overtime,
12:10here's the two weeks cans getting smaller,
12:12six weeks and three months.
12:14Even smaller,
12:14almost completely resolved this
12:16tiny tiny bit left,
12:17and we were able to restart his
12:19both of his antiplatelets pretty
12:20quickly and able to prevent him from
12:23having any further ischemic events.
12:25Uhm?
12:25So just quickly 'cause I'm running
12:28out of time.
12:29Just another quick case.
12:31Examples and 91 year old who was
12:33on Coumadin who had a Burr hole
12:35that it then ended up getting this
12:38embolization procedure effort
12:40expanded further.
12:41You could just see overtime how this
12:43slowly goes away up to three months
12:46all the way on the right there.
12:48Uhm?
12:48Few other case examples I'll skip
12:51through for the sake of time
12:53and then certainly are when when
12:55this is done postoperatively,
12:56the curve looks a little bit different.
12:58You see this initial drop
12:59off in size because of
13:00the surgery and then you hope to
13:02see the slow tapering down overtime
13:04where that residual less left
13:06after surgery continues to go away.
13:09So you know, can this be used after
13:12surgery to help prevent a recurrence?
13:14And certainly not every patient is the same.
13:17So this example on the left there
13:18was a patient having seizures are
13:20relatively smaller subdural and
13:22his brain re expanded nicely and
13:24there's not much residual left.
13:26He's at a much lower risk for recurrence,
13:28probably then say this patient on
13:29the right who had bilateral large
13:31collections and then post op.
13:32The brain just doesn't really
13:34re expand and you have all this
13:35error and a lot of residual.
13:37This is somebody who would probably
13:38benefit from anything that you
13:40can do to help prevent this.
13:41This recurrence.
13:44Uh, to quote some, you know we
13:46did have a few failures and that
13:48could be a topic for another time.
13:50It could be related to variations
13:52in the anatomy of the of the MA and
13:55and the degree to which you are
13:57able to affectively embolize them.
13:59Uhm, so generally you have various
14:01techniques that you can use micro
14:04particles which are injected,
14:06you know, kind of distally into the
14:08distal branches or liquid embolic's.
14:10Some are good for different
14:12situations depending on anatomy.
14:15Uhm, and certainly you
14:16know that last note there.
14:18This is not again meant to be done in
14:21patients that require urgent evacuation.
14:23Uhm, so a few of the trials going on.
14:25We are here apart of the EMBOLIZED trial,
14:27which is a multicenter, randomized trial.
14:30That national PSRR, Dr.
14:32Norman from Cornell,
14:33Dr Davies from Buffalo,
14:35where there's two cohorts based on size,
14:38the smaller size or randomized,
14:40either observation only or embolization
14:43only and then the larger size
14:45greater than 15 millimeters or
14:46randomized to surgery only versus
14:49embolization plus surgery.
14:50So overall, they're up to about 88 patients.
14:53In total,
14:54we're hoping to get up to 400 and you know,
14:56hopefully this will provide better
14:58evidence for using this again either.
15:01Upfront as treatment instead of surgery,
15:03or in addition, as an agent.
15:06Therapy. In addition to surgery.
15:08We also started at a postoperative
15:10trial here ourselves.
15:12So for the patients that don't
15:14qualify for that trial and need
15:16to go to more urgent surgery.
15:18Randomized to the surgery only versus
15:21surgery followed by embolization.
15:23You know, up to a week afterwards.
15:25Uhm?
15:27We're going to have ourselves here at
15:28North Shore, as well as Lennox Hill,
15:30about to be involved,
15:31and hopefully this will again
15:33provide better evidence for whether
15:34this can be useful to help prevent
15:37recurrence after surgery.
15:38For patients that require surgery.
15:41So that's kind of a whirlwind
15:43tour through this.
15:44Thank you for inviting me and
15:45thank you for listening.
15:47Thank you so much,
15:49Doctor Link a really excellent
15:51presentation and definitely a hot topic.
15:53MMA embolization so you know.
15:56I know at Brown here we do some
16:00MMA embolization and I'm sure
16:02other sites and the RCC do so so
16:05you know if we can help with any
16:08preliminary data or anything or
16:10if you have thoughts about a small
16:13scale study and within the RCC I
16:15think this would be a great idea.
16:18Uhm, for the sake of time,
16:20where two men