Abstract 140: Additive Contralateral MMA Injection for Recurrent Previously Operated cSDH: Experience in 8 Consecutive Cases

Abstract

Introduction Middle meningeal artery (MMA) embolization has emerged as an adjunctive treatment in the management of chronic subdural hematomas (cSDH). After surgical cSDH evacuation, embolization offers enhanced resorption of cSDH fluid by infarcting the neomembranes at the capillary level. MMA embolization is typically performed on the side ipsilateral to the cSDH, but in the setting of recent surgical evacuation, the ipsilateral meningeal circulation is oftentimes disrupted and/or collateralized. In this situation, penetration of the membranes via an over‐the‐top contralateral injection may provide additional MMA occlusion and efficacy. Methods Consecutive cases of unilateral cSDH surgery with contralateral liquid embolic injection were retrospectively identified from a prospectively maintained database of the senior authors. Results Eight consecutive cases of recurrent cSDH after surgery were identified (average age = 76±3.5 years, all male). Five subjects (63%) had a previous craniotomy and 3 (38%) had previous burr holes. All subjects had a contralateral MMA embolization in addition to an ipsilateral MMA embolization with regards to their previous index surgery. Average recurrent cSDH thickness was 9.8±1.4mm, midline shift of 1.8±0.9mm. MMA branches embolized included both anterior and posterior (n=5, 63%) anterior only (n=2, 25%), and posterior only (n=1, 12.5%). The falx was penetrated in the contralateral MMA embolization in 3 (38%) cases. Injection of glue across the midline to previously non‐penetrated dura on the index surgery side was successfully achieved in all 8 cases. There were no periprocedural complications encountered. Conclusion The addition of contralateral MMA embolization for recurrent cSDH after previous surgery is a safe and potentially additive therapy that may increase the overall efficacy of MMA embolization in these challenging cases.