Neurointervention.  2024 Nov;19(3):174-179. 10.5469/neuroint.2024.00297.

Retrograde Middle Meningeal Artery Embolization through Mini Craniotomy for Subdural Hematoma Evacuation: A Technical Note

• Liang B
• Moskalik AD
• Yu N
• Goodrich DJ
• Lee G
• Cord BJ
• Waldau B

• KMID: 2560222
• DOI: http://doi.org/10.5469/neuroint.2024.00297

Abstract

This report introduces a novel surgical technique for middle meningeal artery embolization (MMAE) during a mini-craniotomy for subdural hematoma (SDH) evacuation. A patient with multiple health issues presented with a 14 mm right subacute SDH. During surgery, the MMA was retrogradely catheterized and embolized using Onyx 18. This approach, combining MMAE with hematoma evacuation, resulted in successful resolution of the SDH without complications. The procedure offers a more efficient workflow by integrating 2 interventions into 1, potentially reducing recurrence rates of SDH.

Keyword

Middle meningeal artery; Hematoma; Subdural; Chronic; Embolization; Craniotomy

Figure

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  Fig. 1. (A) Axial and (B) coronal views of computed tomography (CT) images of the head demonstrate a subacute subdural hematoma (SDH) that has partially liquefied 10 days after admission of the patient. (C) Intraoperativelateral skull X-ray. The white arrow points towards a prominent calvarial groove in which an middle meningeal artery (MMA) branch is expected to be found. (D) Lateral skull X-ray with sponge stick over the calvarial groove used to mark out the incision, note the pins of the radiolucent Mayfield head holder. (E, F) Direct catheterization of the frontal MMA branch on the dura at the craniotomy site. (G) Image of the anterior and posterior frontal MMA branches (black arrowheads). The black arrow points at the microcatheter. (H) Intraoperative digital subtraction angiography of the right middle meningeal artery. The black arrowhead points to the point from which the embolization was carried out. (I) Axial and (J) coronal views of CT images of the head demonstrate near resolution of the subacute on chronic SDH along the right cerebral convexity with improvement in midline shift on postoperative imaging. Onyx 18 cast can be seen in the main trunk of the right MMA. (K) Robust penetration of Onyx 18 embolic agent into right frontal branches of the MMA on the lateral skull X-ray. (L) Axial and (M) coronal views of a CT brain show near complete resolution of the right SDH 1.5 months after surgery.

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