Cost-minimizing thresholds and recurrence rates in surgical evacuation with adjunctive middle meningeal artery embolization versus evacuation alone

OBJECTIVE Cost-minimization approaches for the treatment of patients with chronic subdural hematoma (cSDH) are important given the increasing incidence of this pathology, particularly among elderly patients receiving antiplatelet and anticoagulation medications. The use of middle meningeal artery embolization (MMAE) as an adjunct to surgical evacuation has shown promise in reducing surgical recurrence; however, additional costs are involved with this procedure. Using their institutional experience, the authors identified thresholds for cost and the cSDH surgical recurrence rate that could influence treatment decisions in patients requiring surgical evacuation for cSDH. METHODS All patients who underwent cSDH evacuation surgery (ES) with concomitant MMAE or ES alone from January 2019 through August 2023 were identified. The authors collected hospital-related costs for the initial admission and any subsequent admissions to address surgical recurrence (rescue surgery [RS]) and conducted cost-minimization analyses. Base-case scenario calculations were supplemented with 1- and 2-way sensitivity analyses to study cost-minimizing variables. RESULTS Demographic characteristics, comorbidities, and presenting symptoms did not significantly differ between patients who received ES/MMAE (n = 44) and those who received ES (n = 100). ES/MMAE procedures required a mean ± SD 79.3 ± 34.8 minutes whereas ES alone required 54.3 ± 25.9 minutes (p < 0.01), and patients who underwent ES/MMAE had a greater immediate postoperative hemorrhage volume reduction (−62.5% ± 22.1% vs −54.3% ± 21.3%, p = 0.04). No differences in the rates of 30-day complications, readmissions, or mortality were observed (all p > 0.05), but the ES/MMAE cohort had no reoperations after initial surgery whereas 14% in the ES-alone cohort required RS (p < 0.01). The base-case calculations indicated that ES alone minimizes costs more than ES/MMAE when there is no RS. Two-way sensitivity analyses revealed that, given a 14% probability of RS for the ES-alone group and 0% for the ES/MMAE cohort, ES/MMAE becomes cost-minimizing when the costs for ES/MMAE are kept below $21,000. With these same failure rates and cost of ES/MMAE, if ES costs exceed $32,000, ES/MMAE becomes cost-minimizing. CONCLUSIONS Although ES/MMAE is more efficacious for the prevention of surgical recurrence in patients requiring surgical evacuation of cSDH than ES alone, ES alone remains the cost-minimizing option. However, in select situations, as with a low RS rate and low cost for ES/MMAE or a high RS rate and high cost for ES alone, then ES/MMAE also becomes the cost-minimizing option. These thresholds can be used in combination with institutional costs and RS rates to help guide clinical and economic decision-making.