Recurrence of a Refractory Chronic Subdural Hematoma after Middle Meningeal Artery Embolization That Required Craniotomy

Hideo Chihara, Hirotoshi Imamura, Takenori Ogura, Hidemitsu Adachi, Yukihiro Imai, Nobuyuki Sakai, Hideo Chihara, Hirotoshi Imamura, Takenori Ogura, Hidemitsu Adachi, Yukihiro Imai, Nobuyuki Sakai

Abstract

Middle meningeal artery (MMA) embolization has been performed to treat refractory chronic subdural hematoma (CSDH) with good reported outcomes. We have treated three cases of CSDH with MMA embolization to date, but there was a postoperative recurrence in one patient, which required a craniotomy for hematoma removal and capsulectomy. MMA embolization blocks the blood supply from the dura to the hematoma outer membrane in order to prevent recurrences of refractory CSDH. Histopathologic examination of the outer membrane of the hematoma excised during craniotomy showed foreign-body giant cells and neovascular proliferation associated with embolization. Because part of the hematoma was organized in this case, the CSDH did not resolve when the MMA was occluded, and the development of new collateral pathways in the hematoma outer membrane probably contributed to the recurrence. Therefore, in CSDH with some organized hematoma, MMA embolization may not be effective. Magnetic resonance imaging (MRI) should be performed in these patients before embolization.

Keywords: chronic subdural hematoma; craniotomy; middle meningeal artery embolization; refractory chronic subdural hematoma.

Conflict of interest statement

Conflicts of Interest Disclosure None declared. All authors who are members of The Japan Neurosurgical Society (JNS) have registered online Self-reported COI Disclosure Statement Forms through the website for JNS members.

Figures

Fig. 1
Fig. 1
a: Plain head computed tomography (CT) before embolization shows a chronic left subdural hematoma with an internal area of isodensity. b: Plain head CT 6 months after craniotomy for hematoma removal and capsulectomy shows no recurrence of the hematoma. c: During 2 years of subsequent follow-up, there has been no hematoma recurrence.
Fig. 2
Fig. 2
a, b: T1-weighted (a) and T2-weighted (b) head magnetic resonance imaging images before embolization show a mixture of a liquid hematoma component (T1- and T2-weighted: high signals) and an organized component (T1-weighted: isodense signal, T2-weighted: low signal).
Fig. 3
Fig. 3
a: Selective middle meningeal artery (MMA) angiography before embolization. There is an abnormal vascular network extending along the dura from the anterior and posterior branches. b: External carotid angiography after embolization. The MMA is completely embolized with polyvinyl alcohol and coils.
Fig. 4
Fig. 4
a: Craniotomy findings. There is no recanalization of the middle meningeal artery where embolization was performed. b: Dural incision findings. The hematoma has a four-layered structure, including an outer membrane, organized hematoma, liquid hematoma, and inner membrane.
Fig. 5
Fig. 5
Outer membrane of the hematoma (×100 magnification). Small branches from the middle meningeal artery that feed the dura are embolized with polyvinyl alcohol, and there are foreign-body giant cells (arrow). In addition, there is proliferation of new blood vessels (neovascularization) with a fragile structure (arrowhead).

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