{
  "abstract": "Background Randomized clinical trials have demonstrated that middle meningeal artery embolization (MMAe) reduces reoperation rates in surgically treated patients with subacute/chronic subdural hematoma (SDH). The effect of embolization on outcomes beyond reoperation remains to be determined. We analyzed the impact of reoperation and healthcare encounters among patients enrolled in the EMBOLISE trial.Methods Symptomatic subacute/chronic SDH patients were randomized to surgical evacuation alone (control) or surgical evacuation plus Onyx MMAe (treatment). Changes in modified Rankin Scale (mRS) scores, frequency of unscheduled follow-up visits, and radiographic evolution of hematomas in patients with versus without reoperation were analyzed.Results A total of 197 patients were randomly assigned to the treatment group and 203 to the control group. Patients who required reoperation compared with those who did not exhibited a ~threefold higher incidence of mRS >2 (37.0% vs 12.9%, P=0.0025) and an ~2.5 fold increase in mRS worsening (22.2% vs 9.5%, P=0.0503) at 180 days. In patients who did not receive MMAe, there was a ~threefold fold increase in rate of SDH recurrence/progression even among those who did not require reoperation (14.3% vs 5.3%, P=0.0045) and a ~twofold increase in unscheduled physician follow-up visits (27.1% vs 14.7%, P=0.0031).Conclusion Among patients with symptomatic subacute/chronic SDH, reoperation was associated with increased rates of mRS worsening and higher mRS scores at follow-up. Adjunctive Onyx MMAe resulted in lower rates of hematoma recurrence/progression and fewer unscheduled physician follow-up visits. Thus, in addition to reducing surgical reoperation rates, adjunctive MMAe led to improved clinical outcomes and reduced healthcare encounters.",
  "authors": [
    {
      "affiliations": [
        "Neurological Surgery, NewYork-Presbyterian Weill Cornell Medical Center, New York, New York, USA"
      ],
      "name": "Jared Knopman"
    },
    {
      "affiliations": [
        "Neurosurgery and Bioinformatics and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA",
        "Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA"
      ],
      "name": "Jason M Davies"
    },
    {
      "affiliations": [
        "Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA",
        "Neurosurgery and Brain Repair, Tampa General Hospital, Tampa, Florida, USA"
      ],
      "name": "Maxim Mokin"
    },
    {
      "affiliations": [
        "Neuroscience, University of Texas Rio Grande Valley, Harlingen, Texas, USA"
      ],
      "name": "Ameer E Hassan"
    },
    {
      "affiliations": [
        "Neurosurgery and Engineering Science & Mechanics, Penn State University, Hershey, Pennsylvania, USA"
      ],
      "name": "Robert E Harbaugh"
    },
    {
      "affiliations": [
        "Neurological Surgery, Surgery, Radiology, and Neurosciences, University of California San Diego, La Jolla, California, USA"
      ],
      "name": "Alexander Khalessi"
    },
    {
      "affiliations": [
        "Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany"
      ],
      "name": "Jens Fiehler"
    },
    {
      "affiliations": [
        "Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA",
        "Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA"
      ],
      "name": "Elad I Levy"
    },
    {
      "affiliations": [
        "Neurosurgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA"
      ],
      "name": "Bradley A Gross"
    },
    {
      "affiliations": [
        "Department of Neurosurgery, University of Utah Health, Salt Lake City, Utah, USA"
      ],
      "name": "Ramesh Grandhi"
    },
    {
      "affiliations": [
        "Radiology, Providence Little Company of Mary Medical Center San Pedro, Torrance, California, USA",
        "Pacific Neuroscience Institute LLC, Santa Monica, California, USA"
      ],
      "name": "Jason Tarpley"
    },
    {
      "affiliations": [
        "Neurosurgery, Providence Little Company of Mary Medical Center Torrance, Torrance, California, USA",
        "Neurosurgery, Pacific Neuroscience Institute LLC, Santa Monica, California, USA"
      ],
      "name": "Walavan Sivakumar"
    },
    {
      "affiliations": [
        "Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA"
      ],
      "name": "Mark Bain"
    },
    {
      "affiliations": [
        "Neurosurgery, Rush University, Chicago, Illinois, USA"
      ],
      "name": "R Webster Crowley"
    },
    {
      "affiliations": [
        "Neurosurgery, North Shore University Hospital, Great Neck, New York, USA"
      ],
      "name": "Thomas W Link"
    },
    {
      "affiliations": [
        "Neurological Surgery, Neurology, Radiology, Otolaryngology, and Neuroscience, University of Kentucky, Lexington, Kentucky, USA"
      ],
      "name": "Justin F Fraser"
    },
    {
      "affiliations": [
        "Neurological Surgery, Radiology, Neurology, Mechanical Engineering, and Stroke & Applied Neuroscience Center, University of Washington School of Medicine, Seattle, Washington, USA"
      ],
      "name": "Michael R Levitt"
    },
    {
      "affiliations": [
        "Neurosurgery, Memorial Hermann Texas Medical Center, Houston, Texas, USA",
        "Neurosurgery, The University of Texas Health Science Center at Houston Vivian L Smith Department of Neurosurgery, Houston, Texas, USA"
      ],
      "name": "Peng Roc Chen"
    },
    {
      "affiliations": [
        "Cerebrovascular Surgery, Baptist Neurological Institute, Lyerly Neurosurgery, Jacksonville, Florida, USA"
      ],
      "name": "Ricardo A Hanel"
    },
    {
      "affiliations": [
        "Neuroendovascular Surgery, Neuroradiology, Atrium Health Carolinas Medical Center, Charlotte, North Carolina, USA",
        "Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA"
      ],
      "name": "Joe D Bernard"
    },
    {
      "affiliations": [
        "Neurology and Interventional Neurology, The University of Toledo Medical Center, Toledo, Ohio, USA",
        "Neurology and Interventional Neurology, ProMedica Physicians Group, Toledo, Ohio, USA"
      ],
      "name": "Mouhammad Jumaa"
    },
    {
      "affiliations": [
        "Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA"
      ],
      "name": "Patrick P Youssef"
    },
    {
      "affiliations": [
        "Orlando Health Neuroscience Institute Neurosurgery Group, Orlando Health Orlando Regional Medical Center, Orlando, Florida, USA"
      ],
      "name": "Marshall C Cress"
    },
    {
      "affiliations": [
        "Diagnostic Radiology and Neuroradiology, Prisma Health, Greenville, South Carolina, USA"
      ],
      "name": "Mohammad Imran Chaudry"
    },
    {
      "affiliations": [
        "Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA"
      ],
      "name": "Hakeem J Shakir"
    },
    {
      "affiliations": [
        "Neurosurgery, Baylor Scott & White Health, Temple, Texas, USA"
      ],
      "name": "Walter S Lesley"
    },
    {
      "affiliations": [
        "Neurosciences, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA"
      ],
      "name": "Joshua Billingsley"
    },
    {
      "affiliations": [
        "Neurosurgery and Radiology, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA"
      ],
      "name": "Jesse Jones"
    },
    {
      "affiliations": [
        "Department of Neurosurgery, University of Florida, Gainesville, Florida, USA"
      ],
      "name": "Matthew J Koch"
    },
    {
      "affiliations": [
        "Neurosurgery, Albany Medical Center, Albany, New York, USA"
      ],
      "name": "Alexandra R Paul"
    },
    {
      "affiliations": [
        "Neurological Surgery, Keck Medicine of USC, Los Angeles, California, USA"
      ],
      "name": "William J Mack"
    },
    {
      "affiliations": [
        "Neurosurgery, Radiology, and Neurology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA"
      ],
      "name": "Joshua W Osbun"
    },
    {
      "affiliations": [
        "Neurosurgery, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA"
      ],
      "name": "Kathleen M Dlouhy"
    },
    {
      "affiliations": [
        "Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA"
      ],
      "name": "Jonathan A Grossberg"
    },
    {
      "affiliations": [
        "Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA"
      ],
      "name": "Christopher P Kellner"
    },
    {
      "affiliations": [
        "Neuroendovascular, Neurointerventional Radiology, Goodman Campbell Brain and Spine, Carmel, Indiana, USA"
      ],
      "name": "Daniel H Sahlein"
    },
    {
      "affiliations": [
        "Neurosurgery, Westchester Medical Center, Valhalla, New York, USA"
      ],
      "name": "Justin Santarelli"
    },
    {
      "affiliations": [
        "Neurosurgery, Geisinger Commonwealth School of Medicine, Wilkes-Barre, Pennsylvania, USA",
        "Geisinger Health, Danville, Pennsylvania, USA"
      ],
      "name": "Clemens M Schirmer"
    },
    {
      "affiliations": [
        "Division of Neurosurgery, Corewell Health West Michigan, Grand Rapids, Michigan, USA",
        "Neurosurgery, Michigan State University College of Human Medicine, East Lansing, Michigan, USA"
      ],
      "name": "Paul Mazaris"
    },
    {
      "affiliations": [
        "Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA"
      ],
      "name": "Jesse J Liu"
    },
    {
      "affiliations": [
        "Neurology, McLaren Flint Hospital, Flint, Michigan, USA",
        "Neurology, McLaren Macomb Hospital, Mount Clemens, Michigan, USA"
      ],
      "name": "Aniel Q Majjhoo"
    },
    {
      "affiliations": [
        "Aurora Neuroscience Innovation Institute, Aurora Health Care, Milwaukee, Wisconsin, USA"
      ],
      "name": "Thomas Wolfe"
    },
    {
      "affiliations": [
        "Neurointerventional Radiology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA"
      ],
      "name": "Neil V Patel"
    },
    {
      "affiliations": [
        "Neurosurgery, University of Colorado Denver, Denver, Colorado, USA"
      ],
      "name": "Christopher D Roark"
    },
    {
      "affiliations": [
        "Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA",
        "Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA"
      ],
      "name": "Adnan H Siddiqui"
    },
    {
      "affiliations": [],
      "name": "On behalf of the EMBOLISE Investigators"
    }
  ],
  "title": "EMBOLISE randomized surgical trial for subdural hematoma: clinical benefits beyond reoperation with middle meningeal artery embolization",
  "uid": "de1f8dfb-7706-5ec2-a19e-8087b52d6994"
}