Organized chronic subdural hematoma treated with middle meningeal artery embolization and small craniotomy: Two case reports

✓ The authors present a case of refractory chronic subdural hematoma (CSH) in a 59-year-old man with coagulopathy due to liver cirrhosis. The patient was successfully treated by embolization of the middle meningeal artery after several drainage procedures. This new therapeutic approach to recurrent CSH is discussed.

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Middle meningeal artery embolization for chronic subdural hematoma: Endovascular technique and radiographic findings

Interventional Neuroradiology ◽

10.1177/1591019918769336 ◽

2018 ◽

Vol 24 (4) ◽

pp. 455-462 ◽

Cited By ~ 21

Author(s):

Thomas W Link ◽

Benjamin I Rapoport ◽

Stephanie M Paine ◽

Hooman Kamel ◽

Jared Knopman

Keyword(s):

Subdural Hematoma ◽

Case Reports ◽

Cranial Nerves ◽

Chronic Subdural Hematoma ◽

Middle Meningeal Artery ◽

Safe Alternative ◽

Selective Embolization ◽

Radiographic Findings ◽

Pathologic Process ◽

Meningeal Artery

Background and purpose Embolization of the middle meningeal artery (MMA) has recently been proposed as an alternative to surgery for treatment of chronic subdural hematoma (SDH), and several case reports have been published supporting its efficacy. It has been suggested that the primary pathologic process in chronic SDH is repeated microhemorrhaging into the subdural collection from fragile neovasculature within the SDH membrane that arises from distal branches of the MMA. Embolization could thus provide a means of eliminating this chronic rebleeding. Materials and methods Images were selected from MMA embolization procedures performed at our institution in order to illustrate the technique and theory behind its efficacy for treatment of chronic SDH. Results Images from MMA angiograms demonstrate the variability of MMA anatomy and help illustrate the importance of avoiding potential ophthalmic collaterals and branches supplying cranial nerves. The findings of irregular wispiness of the distal MMA vasculature, contrast outlining of the SDH membrane on angiography, and homogenous increased density within the SDH on postembolization head computed tomography are described. Conclusion MMA embolization may provide a safe alternative for treatment of chronic SDH, but careful angiographic assessment of MMA anatomy should be performed to avoid potential complications. The findings illustrated here lend support to the theory that the pathologic process of chronic SDH is repeated leakage of blood products from an inflamed, abnormal arterial neovasculature within the SDH membrane that arises from the MMA, and thus selective embolization could provide an effective treatment.

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Middle meningeal artery embolization for chronic subdural hematoma: an institutional technical analysis

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-016552 ◽

2020 ◽

pp. neurintsurg-2020-016552

Author(s):

Joshua S Catapano ◽

Andrew F Ducruet ◽

Candice L Nguyen ◽

Jacob F Baranoski ◽

Tyler S Cole ◽

...

Keyword(s):

Subdural Hematoma ◽

Complete Resolution ◽

Chronic Subdural Hematoma ◽

Middle Meningeal Artery ◽

Artery Embolization ◽

Embolic Material ◽

Ethylene Vinyl Alcohol ◽

Single Center Experience ◽

Meningeal Artery ◽

Single Branch

BackgroundRecently, middle meningeal artery (MMA) embolization has emerged as a potentially safe and effective method of treating chronic subdural hematoma (cSDH).ObjectiveTo report a single-center experience with MMA embolization and examines the type of embolic material used, the extent of penetration, and the number of MMA branches embolized.MethodsA retrospective analysis of all patients with MMA embolization from 2018 through 2019 was performed. A failed outcome was defined as either surgical rescue and/or greater than 10 mm of hematoma residual or reaccumulation following embolization.ResultsOf 35 patients, surgery had failed for 9 (26%) and initial conservative treatment had failed for 6 (17%). Of 41 MMA embolizations, including those in six patients with bilateral cSDH who underwent bilateral MMA embolization, 29 (72%) were performed using ethylene vinyl alcohol copolymer (Onyx), 7 (17%) using particles, and 5 (12%) using n-butyl cyanoacrylate. Both the anterior and posterior MMA divisions were embolized in 29 cases (71%); distal penetration of these branches was achieved in 25 embolizations (61%). Twenty-six (63%) cSDHs completely resolved. Complete resolution was seen in 22 of 29 hematomas (76%) in which both anterior and posterior MMA branches were occluded versus 4 of 12 (33%) following single-branch embolization (p=0.014). Embolization of one cSDH (2%) failed.ConclusionMMA embolization of cSDHs appears to be both safe and efficacious. Furthermore, embolization of both the anterior and posterior MMA branches may be associated with increased odds of complete resolution.

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