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Recurrence of a Refractory Chronic Subdural Hematoma after Middle Meningeal Artery Embolization That Required
Hideo Chihara1, Hirotoshi Imamura1, Takenori Ogura1
1Department of Neurosurgery, Kobe City Hospital Organization, Kobe City Medical General Hospital, Kobe, Hyogo.
Insights
Middle meningeal artery (MMA) embolization shows promise for chronic subdural hematoma (CSH). However, recurrence can occur in cases with organized hematoma, necessitating further investigation before MMA embolization.
Area of Science:
- Neurosurgery
- Interventional Radiology
Background:
- Refractory chronic subdural hematoma (CSDH) presents a clinical challenge.
- Middle meningeal artery (MMA) embolization is an emerging treatment for CSDH.
Observation:
- Three CSDH cases treated with MMA embolization were analyzed.
- One patient experienced recurrence requiring craniotomy and capsulectomy.
Findings:
- Histopathology revealed foreign-body giant cells and neovascularization post-embolization.
- Organized hematoma components may impede resolution after MMA occlusion.
- Development of collateral pathways in the hematoma outer membrane can lead to recurrence.
Implications:
- MMA embolization may be less effective for CSDH with organized components.
- Pre-embolization magnetic resonance imaging (MRI) is recommended for patient selection.
- Further research is needed to refine patient selection criteria for MMA embolization in CSDH.
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.
