J Korean Neurosurg Soc.  2022 Nov;65(6):868-874. 10.3340/jkns.2022.0061.

Efficacy of Middle Meningeal Artery Embolization in Treatment Resistant Spontaneous Intracranial Hypotension Caused Subdural Hematoma : Report of Two Cases and Review of the Literature

• Evran S
• Kayhan A
• Saygı T
• Ozbek MA
• Kilickesmez O

• KMID: 2535848
• DOI: http://doi.org/10.3340/jkns.2022.0061

Abstract

Spontaneous intracranial hypotension (SIH) most commonly manifests as bilateral subdural hematoma (SH). SIH cases mostly resolve spontaneously but further treatment would be needed via blind epidural blood patch (EBP). Cerebrospinal fluid (CSF) leakage in EBP-refractory cases can be treated surgically only if the localization of CSF leakage is detectable but it cannot be possible in most of the cases. Also surgical evacuation of SH secondary to SIH (SH-SIH) is not favorable without blocking the CSF leakage. Thus the management of these patients is a challenge and alternative treatment options are needed. Although middle meningeal artery embolization (MMAE) is an effective treatment option in non-SIH SH, there is no report about its application in the treatment of SH-SIH. We present two cases of SH-SIH which their clinical and radiological findings were completely resolved by bilateral MMAE treatment.

Keyword

Intracranial hypotension; Embolization; Meningeal arteries; Subdural hematoma

Figure

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  Fig. 1. Preoperative magnetic resonance imaging (MRI) of epidural blood patch (ebP)-refractory case 1. A : Axial T2-weighted MRI shows bilateral widening of subdural spaces and subdural hematoma (SH) (arrows). b : Axial T2-weighted MRI at the level of the uncus shows obliteration of bilateral sylvian and basal cisterns (red arrows) and bilateral uncal herniation especially on the left side (blue arrow). c : coronal fluid-attenuated inversion recovery MRI shows bilateral SH (red arrows), shrinkage of lateral ventricles (blue arrows), obliteration of the third ventricle and bilateral uncal herniation especially on the left side (yellow arrow). d : Sagittal T1-weighted MRI shows shrinkage of corpus callosum (red arrows), reduction of pontomesencephalic angle, mesencephalic compression due to transtentorial herniation, and tonsillar herniation (blue arrow). e : Sagittal enhanced T1- weighted MRI shows epidural venous congestion extending to c4 level (red arrows). f : Axial enhanced T1-weighted MRI shows increase of pachymeningeal enhancement (red arrows) and bilateral SH (blue arrows).

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  Fig. 2. Angiographic images of middle meningeal artery embolization (MMAe). A : Pre embolization lateral image of the right middle meningeal artery (MMA) (arrow). b : Post embolization lateral image shows end-branch pruning of the right MMA (arrows). c : Pre embolization lateral image of the left MMA (arrow). d : Post embolization lateral image shows end-branch pruning of the left MMA (arrows).

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  Fig. 3. Post embolization magnetic resonance imaging (MRI) of epidural blood patch (ebP)-refractory case 1. A : Axial T2-weighted MRI at the level of centrum semiovale shows total regression of subdural hematoma (SH) and better sulcus-gyrus differentiation (arrows). b : Axial T2-weighted MRI at the level of the third ventricle shows enlarging of the third ventricle and bilateral sylvian cisterns (arrows). c : coronal T2-weighted MRI shows enlarging of the lateral and third ventricles (blue arrows), total regression of SH and improving of bilateral uncal herniation (red arrows). d : Sagittal T2-weighted MRI shows regression of the shrinkage of corpus callosum and increment of the pontomesencephalic angle (arrows).

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  Fig. 4. Preoperative computed tomography (cT) scans of epidural blood patch (ebP)-refractory case 2. A : Axial cT image at the level of centrum semiovale shows bilateral subdural hematoma (SH) and difficulty of sulcus-gyrus differentiation (arrows). b : Axial cT image at the level of basal cisterns shows obliteration in sylvian and basal cisterns (red arrows) and third ventricle (blue arrow). c : coronal cT image shows bilateral SH (red arrows), shrinkage of lateral ventricles (blue arrows), and obliteration of the third ventricle (yellow arrow).

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  Fig. 5. Post embolization computed tomography (cT) scans of epidural blood patch (ebP)-refractory case 2. A : Axial cT image at the level of centrum semiovale shows total regression of the subdural hematoma and better sulcus-gyrus differentiation (arrows). b : Axial cT image at the level of the third ventricle shows enlarging of the third ventricle (blue arrow) and bilateral sylvian cisterns (red arrows). c : coronal cT image shows enlarging of the lateral and third ventricles (blue arrows) and bilateral sylvian cisterns (red arrows) and also total regression of SH.

Reference

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