Bevacizumab Infusion into Middle Meningeal Arteries for Chronic Subdural Hematoma: Insights from 35 Hemispheres in 25 Patients

Bevacizumab is an anti-vascular endothelial growth factor antibody that may disrupt the pro-inflammatory cascade driving chronic subdural hematoma (CSDH) development, expansion, and recurrence. This expanded case series describes clinical and radiographic outcomes of intra-arterial infusion of bevacizumab into the middle meningeal artery for treatment of chronic subdural hematoma in 35 hemispheres of 25 patients. Adult patients with asymptomatic or mild symptoms and either unilateral or bilateral CSDH with mixed-density appearance or presence of membranes infused with intra-arterial bevacizumab in one or both middle meningeal arteries under fluoroscopic guidance were included. The primary outcome was the percent reduction in CSDH size from baseline to 90-day follow-up. Of 25 included patients, median age was 77 years (IQR 68-86). Of 35 treated hemispheres, 80% (28/35) hemispheres demonstrated greater than 50% CSDH resolution, and 25.7% (9/35) hemispheres had 100% resolution by 90 days. There were no rescue interventions for symptomatic recurrence, new stroke or neurological deterioration, or mortality by 90 days. In conclusion, intra-arterial bevacizumab infusion demonstrates potential as a novel endovascular approach to CSDH in select patients.