J Cerebrovasc Endovasc Neurosurg.  2020 Mar;22(1):20-25. 10.7461/jcen.2020.22.1.20.

Middle meningeal artery embolizationto treat progressive epidural hematoma:a case report

• Park TJ
• Lee SP
• Baek J
• Ryou K
• Kim SH

• KMID: 2500070
• DOI: http://doi.org/10.7461/jcen.2020.22.1.20

Abstract

Progressive epidural hematoma is a form of acute epidural hematoma that gradually expands from a small initial hematoma; in cases that are clinically aggravated due to the presence of a mental illness or neurological condition, patients should be surgically treated for evacuation of the hematoma, but poorer outcomes are expected if the patient has several medical co-morbidities for surgery. We experienced two cases of progressive epidural hematoma which were successfully managed by endovascular treatment: an 85-year-old male with medical co-morbidities and a 51-year-old female with a poor-grade subarachnoid hemorrhage resulting from the rupture of a dissecting aneurysm of the vertebral artery. In both cases, a middle meningeal artery embolization was performed and contrast leakage was observed and controlled using cerebral angiography, halting the progression of their epidural hematomas. Thus, endovascular embolization of a middle meningeal artery may play a useful role in salvage therapy in certain complicated situations that limit treatment of the hematoma by surgical evacuation.

Keyword

Acute epidural hematoma; Endovascular treatment; Middle meningeal artery embolization; Progressive epidural hematoma

Figure

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  Fig. 1 (A) Initial brain computed tomography (CT) showing a left parietal linear skull fracture (white arrow). (B) Initial brain CT with minimal epidural hematoma (EDH) in a fractured site. (C) Pre-procedure brain CT showing increased EDH over time. (D) Three days post-procedure. (E) Brain CT performed two weeks post-procedure showing decreasing amount of EDH (F) Brain CT taken at a one month follow-up; the EDH is almost completely resolved.

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  Fig. 2 (A, B) Preoperative selective angiography of parietal branch of middle meningeal artery (MMA) with contrast leakage (black arrow). (C) Preoperative angiography of the external cerebral artery (ECA) showing contrast leakage (white arrow). (D) Postoperative ECA angiography showing resolved contrast leakage in the parietal branch of the MMA.

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  Fig. 3 (A) Post-external ventricular drainage (EVD) CT scan showing small epidural hematoma (EDH) at the EVD site. (B) Additional burr hole made lateral to the first burr hole (white arrow). The brain CT shows increasing size of the EDH with pneumocephalus. (C) Two days after EVD, the catheter to treat the EDH is removed. (D) Follow-up brain CT in one month after the procedure. The EDH is almost completely resolved, but brain CT shows multiple intracerebral hemorrhages due to thrombocytopenia.

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  Fig. 4 (A) Selective angiography of the MMA showing a contrast leakage site (black arrow). (B) Postoperative angiography of the ECA showing resolution of the contrast-leakage site. (C) Preoperative right vertebra artery (VA) angiography showing an aneurysm in the V4 segment (white arrow). (D) Angiography after trapping of the right VA with coil. MMA, middle meningeal artery; ECA, external carotid artery.

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