The Use of Middle Meningeal Artery Embolization to Treat Chronic Subdural Hematoma in the Pediatric Population: A Review of the Literature.

Chronic subdural hematoma (cSDH) is rare in the pediatric population and typically arises from various causes. These include trauma (accidental, non-accidental, or birth-related injuries), coagulopathies (such as hemophilia or von Willebrand disease), vascular malformations (such as arteriovenous malformations), and complications from previous surgeries. These diverse etiologies contribute to the complexity of managing this condition. Although middle meningeal artery (MMA) embolization is proven effective in adults, limited studies have investigated its applicability in pediatrics. This study aims to assess the efficacy, safety, and outcomes of MMA embolization in the pediatric age group, guiding future research and treatment strategies. A systematic review of the literature was conducted using PubMed, Web of Science, and Embase. No restrictions were applied regarding publication status or follow-up duration. The inclusion criteria were studies that integrated MMA embolization as a treatment for cSDH in pediatric patients. Data extracted included patient sample and characteristics, cSDH etiology and characteristics, prior intervention, procedural technique and indication, and clinical and radiological outcomes. Twelve studies were included in the review, comprising a total of 14 patients. There were no randomized clinical trials or large-scale cohort studies. The included literature consisted of 11 case reports and one case series, and the results described a clinical and radiological outcome in a varied mix of patients with different characteristics and backgrounds for cSDH. No neurological complications attributed to MMA embolization were reported. Follow-up showed resolved or decreased size of cSDH in all patients except for one, who experienced hematoma expansion despite treatment. MMA embolization may be considered a primary or adjuvant treatment modality for cSDH in the pediatric population. However, further research is needed to investigate the impact of different etiologies on outcomes and to highlight long-term complications and results.

Comparison of surgical techniques for the treatment of chronic subdural hematomas: A single­center case series.

Chronic subdural hematoma (CSDH) is one of the most challenging realities in the neurosurgical world. The aim of the present study was to compare different surgical techniques, such as burr hole evacuation with subperiosteal drain or subdural drain and mini-craniotomy, and to review the diverse outcomes on the post-operative clinical state of patients. The present study was a retrospective cohort study with 122 patients with CSDH treated at a single center. The patients were separated into three groups according to the surgical technique used as follows: group 1, two burr holes with the placement of a subperiosteal drain; group 2, single burr hole per hematoma with the placement of an intradural drain; and group 3, mini-craniotomy. The duration of hospitalization, hematoma recurrence, complications, Glasgow coma scale at discharge and mortality were reported as outcome measures. A total of 3 patients succumbed following hematoma evacuation; of these 2 patients were from group 2 and 1 patient was from group 3. The patients from groups 1 and 3 exhibited a significantly lower odds ratio (OR) of hematoma recurrence than patients in group 2 (OR, 0.76; P<0.01; and OR, 0.8; P<0.01, respectively). The patients in group 1 exhibited a significantly lower probability of having a depressed level of consciousness on discharge (OR, 0.249; P=0.031). Group 2 was associated with a statistically significant prolongation of hospitalization. On the whole, the present study demonstrates that multiple burr hole hematoma evacuation with subperiosteal drain placement and mild suction is a very promising technique with very beneficial post-operative outcomes, such as zero mortality, a low CSDH recurrence risk, a reduced period of hospitalization and an improved post-operative quality of life.

Endoscopic Evacuation of Acute Subdural Hematomas: A New Selection Criterion.

Introduction Acute subdural hematomas (ASDHs) have a high mortality rate and unfavorable outcomes especially in the elderly population even after surgery is performed. The conventional recommended surgeries by the Brain Trauma Foundation in 2006 were craniotomies or craniectomies for ASDH. As the world population ages, and endoscopic techniques improve, endoscopic surgery should be utilized to improve the outcomes in elderly patients with ASDH. Materials and Methods This was a single-center retrospective report on our series of six patients that underwent endoscopic ASDH evacuation (EASE). Demographic data, the contralateral global cortical atrophy (GCA) score, evacuation rates, and outcomes were analyzed. Results All patients' symptoms and Glasgow Coma Scale improved or were similar after EASE with no complications. Good outcome was seen in 4 (66.7%) patients. Patients with poor outcome had initial low Glasgow Coma Scale scores on admission. The higher the contralateral GCA score, the higher the evacuation rate ( r = 0.825, p ≤ 0.043). All the patients had a GCA score of ≥7. Conclusion EASE is at least not inferior to craniotomy for the elderly population in terms of functional outcome for now. Using the contralateral GCA score may help identify suitable patients for this technique instead of just using a cut-off age as a criteria.

Mini-Craniotomy for Chronic Subdural Hematoma: A Reliable Surgical Option.

Introduction Chronic subdural hematoma (SDH) is one of the most common conditions encountered in the neurosurgical practice. Surgical modalities like twist drill craniostomy, burr hole evacuation, mini-craniotomy, and craniotomy are practiced in the management of chronic SDH. Mini-craniotomy without excision of membranes may help to achieve best results with decreased complication rate. Materials and Methods Patients with chronic SDH operated from September 2013 to September 2022 were included in the study. Mini-craniotomy (40-60 mm) was done and cruciate incision was given over the dura. Dura was left wide open by reflecting and suturing the cut edges of the dural leaflets to the craniotomy edge allowing to evacuate subdural space under vision during surgery and to allow any residual collection to drain out freely in the postoperative period. A drain was placed between the inner membrane and the bone flap. Preoperative and postoperative clinical and radiological parameters were recorded. Complications, recurrence, and residual collections were noted. Results Seventy-seven patients were included in the study. Mean age was 57.32 years. Median Glasgow Coma Scale (GCS) at presentation was 13 while median GCS at discharge was 15. Two patients with preexisting comorbidities expired after surgery due to medical causes. No recurrences were noted. Fourteen patients had residual collections which resolved by 6 weeks. Two patients had wound infection. One of these patients later needed a bone flap removal due to osteomyelitis. Conclusion Mini-craniotomy without membranectomy is a good option for complete evacuation of chronic SDH under vision mainly avoiding the complication of membranectomy. It is not associated with increased complications rate. It needs fewer follow-ups as brain expansion can be established radiologically in a short period.

Timing of chronic subdural hematoma treatment affects middle meningeal artery embolization outcome.

Background: Chronic subdural hematoma (CSDH) is a condition that tends to recur frequently. Although middle meningeal artery embolization (MMAE) is an effective CSDH treatment, there is currently no consensus regarding the optimal timing for embolization. Methods: In this single-center and retrospective study, we reviewed 72 cases with 1st-time recurrent CSDH from January 2018 to July 2023 and identified those treated with MMAE to examine its effect and the impact of differences in the timing of treatment. Results: Of the 72 cases with CSDH recurrence for the 1st time (mean age: 80.4 ± 9.7 years; men: 62 [86.1%]; mean first recurrence interval: 33 ± 24 days), 27 (37.5%) experienced a second recurrence. The mean first recurrence interval was shorter in cases with a second recurrence compared to cured cases: 24.3 ± 18.6 versus 38.3 ± 25.6 days, respectively (P = 0.005). MMAE was performed in 17 (23.6%) cases (mean age: 82 ± 6.2 years; men: 14 [82.4%]). The mean time from initial surgical treatment to embolization was 52.4 ± 35.4 days, and the mean recurrence interval before MMAE was 24.9 ± 19.6 days. Six cases (35.3%) experienced post-embolization recurrence and required surgical treatment. The mean recurrence interval before MMAE was shorter in cases with recurrence after MMAE (15 ± 6.4 vs. 30 ± 22.1 days, P = 0.023). The time from initial surgical treatment to embolization was significantly shorter: 31.3 ± 12.8 versus 63.9 ± 38.9 days (P = 0.039). Conclusion: Cases with a short first recurrence interval were more likely to experience a second recurrence. Repeated recurrences within a short time increased the likelihood of post-embolization recurrence. MMAE performed early following the initial surgical treatment increased the recurrence risk.

Craniectomy versus craniotomy: What can we do for acute subdural hematoma?

Compared with hematoma evacuation craniotomy, decompressive craniectomy has a higher incidence of intracranial complications and no outcome benefit over craniotomy, which gives surgeons a safer decision-making options during surgery.

Subdural hematoma due to skull base bone metastasis of epidermal growth factor receptor mutated non-small cell lung cancer.

Subdural hematoma due to skull base bone metastasis of lung cancer is rare but are oncological emergency, necessitating prompt identification when a headache develops with the progression of the malignancy.

Successful Management of Acute Subdural Hematoma in Deep Brain Stimulation Patient: A Case Report and Literature Review.

Deep brain stimulation (DBS) has emerged as an important therapeutic option for several movement disorders; however, the management of acute complications, such as acute subdural hematoma (ASDH), remains challenging. This is the case of a 71-year-old woman with Parkinson's disease who developed ASDH 12 years after bilateral DBS placement. On admission with altered consciousness, imaging revealed significant displacement of the DBS electrodes because of the hematoma. Emergent craniotomy with endoscopic evacuation was performed with preservation of the DBS system. Postoperatively, complete evacuation of the hematoma was confirmed, and the patient experienced significant clinical improvement. ASDH causes significant electrode displacement in patients undergoing DBS. After hematoma evacuation, the electrodes were observed to return to their proper position, and the patient exhibited a favorable clinical response to stimulation. To preserve the DBS electrodes, endoscopic hematoma evacuation via a small craniotomy may be useful.

Grade III en-plaque meningioma mimicking subacute subdural hematoma: A case report.

INTRODUCTION: En-plaque meningioma (EPM) presents preoperative diagnostic challenges due to its atypical radiologic features. This case report describes the preoperative diagnostic challenges in identifying EPM that affected its operative management. CASE REPORT: A 58-year-old female patient presented to the emergency department with decreased consciousness and a history of a fall on the head two months earlier. For the past year, the patient also complained of worsening headaches. One week before, the patient also complained of nausea, vomiting, and fluctuating fever. Although a CT scan of the head showed a mass in the left temporoparietal region, the patient was initially diagnosed with subacute subdural hematoma (saSDH) and planned for SDH evacuation surgery using the burr hole technique. However, intraoperative findings revealed an extradural intracranial tumor, so the procedure was switched to tumor excision craniotomy, and based on histopathological examination, it was confirmed to be an anaplastic malignant meningioma, WHO grade III. DISCUSSION: EPM is one of the rare subtypes of meningioma with an atypical and radiologically variable appearance that often presents challenges in preoperative diagnosis. In this case, the patient's history of falling on the head and the CT scan of the head that resembles saSDH may obscure the preoperative diagnosis and affect the patient's management. CONCLUSION: EPM can manifest like other intracranial disorders. In this case, the patient's fall history may obscure the clinicians' diagnosis of the meningioma, leading to preoperative misdiagnosis with saSDH. Therefore, meticulous preoperative diagnosis is essential to determining the patient's medical treatment and outcome.

Comparison between the use of subdural and subgaleal drainage in treatment of chronic subdural hematoma.

BACKGROUND AND OBJECTIVES: Chronic subdural hematoma (CSDH) is one of the most common pathologies in our daily practice. The standard treatment is the evacuation making a burr-hole and placement of a subdural drainage, which has shown to decrease its recurrence. However, this procedure can entail risks such as parenchymal damage, infection, or the onset of seizures, prompting the consideration of subgaleal drainage as an alternative. Our objective is to compare the use of subdural and subgaleal drainage in a cohort of patients undergoing intervention for CSDH, as well as to analyze the differences in complication rates and recurrence between the two groups. METHODOLOGY: A retrospective analytical observational study was conducted, analyzing 152 patients diagnosed with CSDH who underwent intervention at our center from January 2020 to April 2022. Patients in whom drainage was not placed were excluded. In all patients, a burr-hole was performed and the type of drainage was chosen by the neurosurgeon. RESULTS: Out of the 152 patients, subdural drainage was placed in 80 cases (52.63%), while subgaleal drainage was used in 72 cases (47.37%). There were no significant differences in the recurrence rate (30% in the subdural drainage group vs. 20.83% in the subgaleal drainage group; p = 0.134) or in the complication rate (7.5% in the subdural drainage group vs. 5.5% in the subgaleal drainage group; p = 0.749). CONCLUSIONS: Subgaleal drainage shows similar clinical outcomes with a recurrence and complication rate comparable to subdural drainage, suggesting it as a safe and effective alternative to subdural drainage in the treatment of CSDH.

Headache that will not go away...Third ED visit is the charm?

Subdural hematoma is an uncommon complication of epidural analgesia or diagnostic lumbar puncture. Headache is a common complaint for patients with either a subdural hematoma or a post-dural puncture headache. Because post-dural puncture headaches are commonly seen in the Emergency Department, the potential to miss more serious pathology arises. We present the case of a young female who suffered bilateral subdural hematomas following epidural analgesia during childbirth. She presented twice to the Emergency Department and was treated for a post-dural puncture headache before computed tomography imaging revealed the diagnosis on the third Emergency Department encounter. This case highlights the importance of exploring all potential diagnoses when a patient presents with a headache after either epidural analgesia or a diagnostic lumbar puncture, especially if the patient returns after unsuccessful treatment for a presumptive post-dural puncture headache.

Traumatic Parafalcine Subdural Hematoma: A Case Report.

Parafalcine subdural hematoma is a rare subtype of intracranial hematoma. Brain hemorrhage, or hematomas, can occur in the brain or within the three layers that cover the brain. A subdural hematoma is trapped blood that develops between the inner layers and the tough outer covering called the dura. Typically, this is due to the tearing of the subdural or bridging veins. The patient in this report is an 85-year-old male who came to the emergency department following a fall on the second day with complaints of headache, neck pain, bilateral leg weakness, nausea, and vomiting. A computed tomography scan was performed in the emergency department, demonstrating an acute parafalcine subdural hematoma measuring 11 mm in thickness. This report will discuss the findings of interhemispheric hematomas and the rare parafalcine subtype and shed light on the diagnostic approach, medical and surgical treatment modalities, and prognosis.

Effectiveness of hinge craniotomy as an alternative to decompressive craniectomy for acute subdural hematoma.

BACKGROUND: Acute subdural hematoma (ASDH) is a life-threatening condition, and hematoma removal is necessary as a lifesaving procedure when the intracranial pressure is highly elevated. However, whether decompressive craniectomy (DC) or conventional craniotomy (CC) is adequate remains unclear. Hinge craniotomy (HC) is a technique that provides expansion potential for decompression while retaining the bone flap. At our institution, HC is the first-line operation instead of DC for traumatic ASDH, and we present the surgical outcomes. METHODS: From January 1, 2017, to December 31, 2022, 372 patients with traumatic ASDH were admitted to our institution, among whom 48 underwent hematoma evacuation during the acute phase. HC was performed in cases where brain swelling was observed intraoperatively. If brain swelling was not observed, CC was selected. DC was performed only when the brain was too swollen to allow replacement of the bone flap. We conducted a retrospective analysis of patient demographics, prognosis, and subsequent cranial procedures for each technique. RESULTS: Of the 48 patients, 2 underwent DC, 23 underwent HC, and 23 underwent CC. The overall mortality rate was 20.8% (10/48) at discharge and 30.0% (12/40) at 6 months. The in-hospital mortality rates for DC, HC, and CC were 100% (2/2), 21.7% (5/23), and 13.0% (3/23), respectively. Primary brain injury was the cause of death in five patients whose brainstem function was lost immediately after surgery. No fatalities were attributed to the progression of postoperative brain herniation. In only one case, the cerebral contusion worsened after the initial surgery, leading to brain herniation and necessitating secondary DC. CONCLUSIONS: The strategy of performing HC as the first-line operation for ASDH did not increase the mortality rate compared with past surgical reports and required secondary DC in only one case.

Focal motor weakness and recovery following chronic subdural hematoma evacuation.

OBJECTIVE: The incidence of chronic subdural hematomas (cSDHs) is expected to climb precipitously in the coming decades because of the aging populous. Neurological weakness is one of the most common presenting neurological symptoms of cSDH. Yet, the recovery rates of motor strength recovery are seldom documented, as neurological outcomes have predominantly focused on broader functional assessment scores or mortality. In this study, the authors performed one of the first detailed analyses on functional motor weakness and recovery in patients who underwent cSDH evacuation. METHODS: Patients who underwent evacuation of a cSDH at a tertiary academic medical center between November 2013 and December 2021 were retrospectively identified using ICD-9 and ICD-10 billing codes. The presence of focal motor weakness was subcategorized by location as upper extremity (UE) or lower extremity (LE). Postoperative improvement, worsening, or resolution of weakness was recorded at the time of discharge. Statistical analysis included univariate and backward stepwise multivariable logistic regression modeling. RESULTS: A total of 311 patients were included in the analysis. Patients were significantly more likely to experience UE weakness than LE weakness (29% vs 18%, p < 0.001). Forty-one percent (43/104) had both UE and LE weakness present. Risk factors for the development of focal motor weakness at the time of presentation were older age (OR 1.02, p = 0.03), increased cSDH size (OR 1.04, p = 0.02), and the presence of a unilateral cSDH (OR 2.32, p = 0.008). The majority of patients (68%, 71/104) experienced motor strength improvement following cSDH evacuation, with 58% (60/104) having complete resolution of weakness. Multivariable logistic regression analysis revealed that longer symptom duration was associated with lower rates of improvement (OR 0.96, p = 0.024). Older age was also associated with reduced resolution of weakness (OR 0.96, p = 0.02). CONCLUSIONS: This study represents one of the first in-depth analyses investigating the rates of motor strength weakness and recovery following cSDH evacuation. Nearly two-thirds of all patients had complete resolution of their weakness by the time of discharge, and more than three-quarters had partial improvement. Risk factors for impaired neurological recovery were longer symptom duration prior to treatment and older age.

[Az arteria meningea media embolisatio szerepe a krónikus subduralis haematoma kezelési algoritmusában, legújabb evidenciák és saját tapasztalataink]. / Az arteria meningea media embolisatio szerepe a krónikus subduralis haematoma kezelési algoritmusában, legújabb evidenciák és saját tapasztalataink.

Chronic subdural hematoma is one of the most common diseases requiring a neurosurgical operation that affect elderly and fragile patients. In addition to standard neurosurgical operations (trepanation and craniotomy), embolization of the meningeal artery media is an alternative solution. Several review aerticles have confirmed the very high rate of success and safety of the endovascular treatment. We present the technical details and results of our 10 consecutive selective media meningeal artery embolization procedures for residual chronic subdural hematomas. Our interventions were performed without complications and all resulted in complete recovery. 

Assessment of cerebrovascular alterations induced by inflammatory response and oxidative-nitrative stress after traumatic intracranial hypertension and a potential mitigation strategy.

The rapid perfusion of cerebral arteries leads to a significant increase in intracranial blood volume, exposing patients with traumatic brain injury to the risk of diffuse brain swelling or malignant brain herniation during decompressive craniectomy. The microcirculation and venous system are also involved in this process, but the precise mechanisms remain unclear. A physiological model of extremely high intracranial pressure was created in rats. This development triggered the TNF-α/NF-κB/iNOS axis in microglia, and released many inflammatory factors and reactive oxygen species/reactive nitrogen species, generating an excessive amount of peroxynitrite. Subsequently, the capillary wall cells especially pericytes exhibited severe degeneration and injury, the blood-brain barrier was disrupted, and a large number of blood cells were deposited within the microcirculation, resulting in a significant delay in the recovery of the microcirculation and venous blood flow compared to arterial flow, and this still persisted after decompressive craniectomy. Infliximab is a monoclonal antibody bound to TNF-α that effectively reduces the activity of TNF-α/NF-κB/iNOS axis. Treatment with Infliximab resulted in downregulation of inflammatory and oxidative-nitrative stress related factors, attenuation of capillary wall cells injury, and relative reduction of capillary hemostasis. These improved the delay in recovery of microcirculation and venous blood flow.

Therapeutic efficacy of drilling drainage combined with intraoperative middle meningeal artery occlusion in the management of chronic subdural hematoma: a clinical study.

BACKGROUND: The bone holes in the skull during surgical drainage were accurately located at the site of the MMA. The MMA was severed, and the hematoma was removed intraoperatively; furthermore, surgical drainage removed the pathogenic factors of CSDH. This study aimed to describe and compare the results of the new treatment with those of traditional surgical drainage, and to investigate the relevance of this approach. METHODS: From December 2021 to June 2023, 72 patients were randomly assigned to the observation group and the control group. The control group was treated with traditional surgical drainage, while the observation group was treated with DSA imaging to accurately locate the bone holes drilled in the skull on the MMA trunk before traditional surgical drainage. The MMA trunk was severed during the surgical drainage of the hematoma. The recurrence rate, time of indwelling drainage tube, complications, mRS, and other indicators of the two groups were compared, and the changes of cytokine components and imaging characteristics of the patients were collected and analyzed. RESULTS: Overall, 27 patients with 29-side hematoma in the observation group and 45 patients with 48-side hematoma in the control group were included in the study. The recurrence rate was 0/29 in the observation group and 4/48 in the control group, indicating that the recurrence rate in the observation group was lower than in the control group (P = .048). The mean indwelling time of the drainage tube in the observation group was 2.04 ± 0.61 days, and that in the control group was 2.48 ± 0.61 days. The indwelling time of the drainage tube in the observation group was shorter than in the control group (P = .003). No surgical complications were observed in the observation group or the control group. The differences in mRS scores before and after operation between the observation group and the control group were statistically significant (P < .001). The concentrations of cytokine IL6/IL8/IL10/VEGF in the hematoma fluid of the observation and control groups were significantly higher than those in venous blood (P < .001). After intraoperative irrigation and drainage, the concentrations of cytokines (IL6/IL8/IL10/VEGF) in the subdural hematoma fluid were significantly lower than they were preoperatively. In the observation group, the number of MMA on the hematoma side (11/29) before STA development was higher than that on the non-hematoma side (1/25), and the difference was statistically significant (P = .003). CONCLUSION: In patients with CSDH, accurately locating the MMA during surgical trepanation and drainage, severing the MMA during drainage, and properly draining the hematoma, can reduce the recurrence rate and retention time of drainage tubes, thereby significantly improving the postoperative mRS Score without increasing surgical complications.

Importance of repeated computed tomography on pediatric traumatic acute posterior fossa subdural hematoma: A case study.

Traumatic acute posterior fossa subdural hematoma (PFSDH) is a rare and potentially fatal condition in which the progressed hematoma compresses the brainstem or causes secondary hydrocephalus. Hence, vigilant monitoring of clinical and radiological findings is crucial to detect the typical sudden deterioration, which can occur in the early stages. However, managing pediatric PFSDHs poses additional challenges due to risks associated with radiation exposure from repeat computed tomography (CT) examinations, potentially impeding crucial diagnostic insights. Here, we present a rare pediatric case of fatal acute traumatic PFSDH. Despite undergoing a timely initial CT scan that indicated the presence of PFSDH, the patient experienced sudden deterioration 15 h later and eventually died. No follow-up CT examinations were conducted during this critical period. This case underscores the challenges in managing pediatric PFSDHs, particularly concerning the benefits of repeated CT examinations in initially stable patients.

Organized Chronic Subdural Hematoma (OCSDH) Mimicking Meningioma.

Organized chronic subdural hematoma (OCSDH) is a relatively rare condition that forms over a longer period of time compared to chronic subdural hematoma and is sometimes difficult to diagnose with preoperative imaging. We resected an intracranial lesion in a 37-year-old Japanese man; the lesion had been increasing in size for >17 years. The preoperative diagnosis based on imaging findings was meningioma; however, pathological findings revealed OCSDH. Clinicians should be aware that OCSDH mimics other tumors and consider surgical strategies for this disease.

Factors Associated with Extended Hospitalization in Patients Who Had Adjuvant Middle Meningeal Artery Embolization After Conventional Surgery for Chronic Subdural Hematomas.

BACKGROUND: This study aims to evaluate the length of stay (LOS) in patients who had adjunct middle meningeal artery embolization (MMAE) for chronic subdural hematoma after conventional surgery and determine the factors influencing the LOS in this population. METHODS: A retrospective review of 107 cases with MMAE after conventional surgery between September 2018 and January 2024 was performed. Factors associated with prolonged LOS were identified through univariable and multivariable analyses. RESULTS: The median LOS for MMAE after conventional surgery was 9 days (interquartile range = 6-17), with a 3-day interval between procedures (interquartile range = 2-5). Among 107 patients, 58 stayed ≤ 9 days, while 49 stayed longer. Univariable analysis showed the interval between procedures, type of surgery, MMAE sedation, and the number of complications associated with prolonged LOS. Multivariable analysis confirmed longer intervals between procedures (odds ratio [OR] = 1.52; P < 0.01), ≥2 medical complications (OR = 13.34; P = 0.01), and neurological complications (OR = 5.28; P = 0.05) were independent factors for lengthier hospitalizations. There was a trending association between general anesthesia during MMAE and prolonged LOS (P = 0.07). Subgroup analysis revealed diabetes (OR = 5.25; P = 0.01) and ≥2 medical complications (OR = 5.21; P = 0.03) correlated with a LOS over 20 days, the 75th percentile in our cohort. CONCLUSIONS: The interval between procedures and the number of medical and neurological complications were strongly associated with prolonged LOS in patients who had adjunct MMAE after open surgery. Reducing the interval between the procedures and potentially performing both under 1 anesthetic may decrease the burden on patients and shorten their hospitalizations.