Abstract
Aim: Middle Meningeal Artery (MMA) embolization has emerged as a viable neuroendovascular technique for the management of chronic subdural hematoma (SDH). Comparative analysis of various endovascular techniques for embolization is lacking. Guidance on operative techniques in situations of prior embolization failure is rare. Materials and Methods: In this case report, we present a patient with a chronic subdural hematoma that failed previous coil embolization of the MMA. Digital Subtraction Angiography showed the previously placed coil and continued distal flow to the dural membranes. Results: Onyx liquid embolization was completed successfully, effectively halting both anterograde flow to the MMA and retrograde flow from external circulation collaterals. Conclusion: This case report suggests that in situations of MMA embolization failure, follow-up angiography may be completed to determine if further embolization through other procedural techniques may be possible. The angiographic images contained here highlight the advantages of liquid embolization over coil embolization of the MMA in halting SDH angiogenesis.
Highlights
Middle Meningeal Artery (MMA) Embolization is a relatively new neuroendovascular intervention technique for addressing subdural hematoma (SDH), a notably tenacious pathology
Materials and Methods: In this case report, we present a patient with a chronic subdural hematoma that failed previous coil embolization of the MMA
While the exact pathogenesis of chronic SDH is thought to be a complex interplay of multiple factors, the benefit of MMA embolization is thought to be derived from occlusion of blood supply to the outer subdural membranes, which are made up of neovasculature arising from distal branches of the MMA [2,3,4]
Summary
Middle Meningeal Artery (MMA) Embolization is a relatively new neuroendovascular intervention technique for addressing subdural hematoma (SDH), a notably tenacious pathology. We present a unique patient with a chronic SDH previously treated unsuccessfully via burr holes and MMA coil embolization. Medical comorbidities, and prior unsuccessful surgical intervention, the patient was offered embolization of the MMA to prevent neovascularization and further right-sided subdural hematoma expansion. The previously placed coil was visualized at the bifurcation of the right middle meningeal artery with delayed but present anterograde filling in the distal anterior and posterior divisions (Figure 2). An Echelon 0.014 microcatheter with a straight tip was advanced over a Synchro 2 standard microwire past the non-occlusive, previously placed coil and into the distal parietal branch of MMA, followed by
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