Intra‐arterial Selective Bevacizumab Administration in the Middle Meningeal Artery for Chronic Subdural Hematoma: An Early Experience in 12 Hemispheres

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Abstract
Background: Chronic subdural hematoma (cSDH) has a rising incidence associated with an increasing burden of disability and mortality worldwide. Vascular endothelial growth factor plays an integral role in the inflammation and formation of subdural membranes responsible for the origin and propagation of cSDH. We report an early experience of intra‐arterial bevacizumab, a vascular endothelial growth factor receptor antagonist, to the middle meningeal artery of 12 hemispheres in 8 patients with cSDH. Methods: Eight patients with either unilateral or bilateral cSDH received intra‐arterial infusion of 2 mg/kg bevacizumab into the middle meningeal artery of each treated hemisphere. The primary outcome was hematoma recurrence or reaccumulation requiring surgical drainage or middle meningeal artery embolization within 3 months posttreatment. Results: Of 12 hemispheres treated, no treatment‐related complications were reported. Median duration of follow‐up was 5 months (interquartile range 3–7.5). By 3 months posttreatment, no patients experienced hematoma recurrence or reaccumulation. One patient required concurrent evacuation at the time of bevacizumab administration. There were no major strokes or mortality within 3 months. Four hemispheres (33.3%) demonstrated complete radiographic hematoma resolution by 3 months. All hemispheres achieved 50% reduction in hematoma size by 3 months. Conclusion: For all hemispheres treated, there was no hematoma recurrence or progression requiring surgical drainage or middle meningeal artery embolization within 3 months except 1 who required concurrent evacuation 24 hours after treatment. Our initial experience supports bevacizumab as a novel, potentially viable agent for cSDH treatment in select patients. Future studies in larger cohorts are necessary to confirm efficacy and safety and appropriate dosing.

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