Intra-Arterial Bevacizumab as an Adjunct to Middle Meningeal Artery Embolization for Chronic Subdural Hematoma

Official title

Safety And Efficacy of Intra-aRterial BEV (IA-BEV) as an Adjunctive Treatment During Middle Meningeal Artery Embolization (MMAE) in Non-Surgical Chronic Subdural Hematoma (cSDH) Patients

Overview

This is a Phase 1, open-label, single-center, dose-escalation study evaluating the safety and tolerability of intra-arterial bevacizumab (IA-BEV) given as an adjunct to middle meningeal artery embolization (MMAE) in adults with non-surgical chronic subdural hematoma (cSDH). Up to 18 participants who are already scheduled to undergo MMAE as standard of care will receive a single dose of bevacizumab, delivered directly into the middle meningeal artery immediately before embolization, during the same procedure. Three dose levels (2.0, 3.5, and 5.0 mg/kg) will be tested using a standard 3+3 dose-escalation design to identify the maximum tolerated dose. The study will also collect imaging and blood biomarker data to help understand which patients may benefit most from this combined treatment approach.

Detailed description

Chronic subdural hematoma (cSDH) is a common and growing neurological condition, particularly in older adults, and standard surgical treatment carries meaningful perioperative risk. Middle meningeal artery embolization (MMAE) has emerged as an effective standalone or adjunctive treatment, but a meaningful proportion of patients do not achieve adequate hematoma resolution with embolization alone. Vascular endothelial growth factor (VEGF)-driven angiogenesis within the hematoma membrane is believed to underlie continued hematoma growth and treatment failure. Bevacizumab, an anti-VEGF monoclonal antibody, may interrupt this process when delivered directly into the middle meningeal artery at the time of embolization. This study will enroll up to 18 adults undergoing MMAE as standard of care, assigning them to one of three sequential dose cohorts (2.0, 3.5, or 5.0 mg/kg) of intra-arterial bevacizumab using a 3+3 dose-escalation design. The primary objective is to characterize the safety and tolerability of IA-BEV and identify a maximum tolerated dose. Secondary objectives include volumetric hematoma response, functional and neurological outcomes, and clinical event rates through 180 days. Exploratory objectives include correlating treatment response with Nakaguchi radiographic subtype, dual-energy CT membrane imaging biomarkers, and VEGF concentrations sampled from the middle meningeal artery at the time of the procedure.

Interventions

• Drug Bevacizumab (intra-arterial)
  Single intra-arterial infusion of bevacizumab (reference product or FDA-approved biosimilar) at 2.0, 3.5, or 5.0 mg/kg, delivered via microcatheter into the middle meningeal artery over 5-10 minutes, immediately before MMAE.

Primary outcome measures

• Incidence of dose-limiting toxicities [Time frame: 30 Days of Treatment]
• Incidence of SAE's [Time frame: 30 Days of Study Treatment]

Secondary outcome measures (7)

• Incidence of acute neurological worsening [Time frame: Within 24 hours post-procedure]
• Volumetric change in cSDH size [Time frame: 30, 90, and 180 days]
• Rates of surgical rescue, unplanned hospitalization, neurological death, and all-cause mortality [Time frame: Through 6 months]
• Functional status [Time frame: 30, 90, and 180 days]
• Neurological Status [Time frame: 30 and 180 days]
• Adverse events attributable to the MMAE procedure itself [Time frame: through study completion, an average of 1 year]
• Health-Related Quality of Life [Time frame: 30, 90, 180 Days]

Eligibility criteria

Inclusion criteria

• Age 18-85 years
• Scheduled to undergo MMAE as standard of care for cSDH, no concurrent surgical evacuation planned (prior surgery for the target cSDH allowed if ≥14 days elapsed)
• Radiographically confirmed cSDH meeting specified unilateral/bilateral density criteria
• cSDH volume 20-100 cc
• Midline shift <8 mm
• Markwalder Grade 1 or 2
• Subject or LAR able to provide written informed consent

Exclusion criteria

• Requires immediate/urgent surgical evacuation
• Prior large craniotomy, membranectomy, or MMAE for the current target cSDH
• Life expectancy <1 year
• Uncontrolled bleeding disorder (INR >1.7, aPTT >35s, platelets <100,000/μL)
• Concurrent intracranial hemorrhage outside the target subdural space
• Persistent neurological deficit from another acute/chronic neurological condition
• Pregnancy or lactation
• Known/suspected intracranial neoplasm or mass lesion
• Active alcohol/substance use disorder within 12 months
• Baseline mRS ≥3
• Uncontrolled severe hypertension (SBP >220 or DBP >120, or IV antihypertensive need within 24h pre-procedure)
• Thromboembolic event within 6 months (DVT, PE, TIA, stroke)
• Contraindication to VTE prophylaxis
• eGFR <60 mL/min/1.73m² or acute kidney injury at screening
• Known hypersensitivity to bevacizumab or its components

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

N/A

Model

Single group

Masking

Open label

Primary purpose

Treatment

Study locations

Center list to be confirmed — check the primary protocol.

Identifiers

NCT: NCT07729098 · SM-UMB · SM-UMB

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗