Cost Minimizing Thresholds and Recurrence Rates in Middle Meningeal Artery Embolization with Surgical Evacuation vs. Evacuation Alone

Introduction: Cost-minimization of middle meningeal artery embolization (MMAE) compared to traditional management approaches for persistent subdural hematomas (cSDH) is intriguing. This study aimed to evaluate our institutional experience and identify potential cost savings and cSDH recurrence rate thresholds that could influence the choice between these treatments.

Methods: All patients who underwent cSDH evacuation surgery (ES) plus MMAE (MMAE/ES) or ES alone from 2019-2022 were identified. We collected hospital-related costs for the initial admission and subsequent cSDH recurrences and conducted cost-minimization analyses. Base case scenario calculations were supplanted with one and two-way sensitivity analyses to study cost-minimizing variables.

Results: Demographics, comorbidities, and presenting symptoms did not significantly differ between patients receiving MMAE/ES and ES. Patients with MMAE/ES had longer operation times (72 min vs. 54 min, p=0.02) and a more substantial immediate post-operative hemorrhage volume reduction (-65% vs. 54%, p=0.04). No differences in 30-day complication rates, readmissions, or mortality were observed (all p>0.05). No patient in the MMAE/ES group experienced cSDH recurrence vs. 14% in the ES cohort (p < 0.01). The base case calculations indicated that ES alone is cost-minimizing than MMAE when there is no recurrence. Two-way sensitivity analyses revealed that with a 14% probability of redo surgery for the ES group, MMAE/ES becomes cost-minimizing when costs for MMAE/ES are kept below $20,000. Conversely, if ES costs exceed $32,000, MMAE/ES becomes more cost-minimizing. Also, if the ES revision rates are kept less than 20% and MMAE/ES costs remain below $20,000, MMAE becomes the cost-minimizing option.

Conclusion : Although MMAE/ES is surgically more effective for long-term management of cSDH than ES alone, ES remains the cost-minimizing option. However, provided increased ES revision rates, or decreased MMAE costs, MMAE becomes more cost-minimizing. These reported thresholds can help guide clinical and economic decision making per individual institutional costs and rates of revision.