Images in Neurosurgery
Embolization of middle meningeal artery (MMA) for chronic subdural hematoma – a new treatment for an old disease – two case illustrations.
The first patient is a 74 year old female who presented with a left sided chronic subdural hematoma (SDH), secondary to a fall about a month prior to the presentation. She had experienced right sided weakness and difficulty with gait. Her exam was notable for memory impairment of recent events, a pronator drift and gait instability (Figure 1a). On CT imaging, she had a mixed density left convexity chronic subdural hematoma with 3 mm of midline shift. She underwent cerebral angiography and embolization. The internal carotid arteriogram shows the mass effect of the SDH (Figure 1a). Middle meningeal arteriogram AP and Lateral view (Figures 2b, c) demonstrated a robust supply to subdural membranes from the left MMA. Embolization was performed with a combination technique of distal penetration with polyvinyl alcohol (PVA) particles (150- 250 microns) followed by coil- embolization for permanent proximal trunk occlusion of the MMA. She improved clinically within a few days and on follow up at 3 months had a normal neurologic examination. CT scan at 3 months shows near total resolution of the hematoma (Figure 1b).
The second patient is 94 y/o male who presented to the ED in a similar manner and had a chronic SDH as seen on Figures 3a, b. He underwent embolization of his left MMA using particles and coils. He returned to his clinical baseline over a 4-week period and his CT scan at 3 months showed complete resolution of hematoma (Figures 3 c, d).