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Middle Meningeal Artery Embolization of a Pediatric Patient With Progressive Chronic Subdural Hematoma
Tomoyoshi Shigematsu1, Evelyn Dier1, Kurt A Yaeger1
1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Insights
Middle meningeal artery (MMA) embolization successfully treated chronic subdural hematoma (CSDH) in an infant, avoiding surgery. This minimally invasive approach offers a safe option for pediatric CSDH management.
Area of Science:
- Interventional neuroradiology
- Pediatric neurosurgery
- Vascular interventions
Background:
- Chronic subdural hematoma (CSH) treatment in adults often involves middle meningeal artery (MMA) embolization for high-risk patients.
- Limited data exists on MMA embolization for CSDH in the pediatric population.
- This case highlights the potential of MMA embolization in infants.
Observation:
- A 5-month-old infant with dilated cardiomyopathy developed a stroke due to left ventricular thrombus, complicated by an enlarging chronic subdural hematoma (CSH).
- The CSH delayed necessary heart transplantation.
- The infant underwent bilateral middle meningeal artery (MMA) embolization using n-butyl-cyanoacrylate (n-BCA).
Findings:
- The MMA embolization procedure was technically successful, closing distal arteries and subdural vasculature.
- The CSH significantly improved post-embolization.
- The patient subsequently underwent a successful heart transplant and maintained normal neurological development.
Implications:
- Middle meningeal artery (MMA) embolization may be a safe and effective minimally invasive treatment for pediatric chronic subdural hematoma (CSDH).
- This technique is particularly valuable for pediatric patients with CSDH who are at high risk for surgical complications or hematoma recurrence.
- MMA embolization could be a crucial alternative to surgical management in select pediatric cases.
Background And Importance:
Evidence suggests middle meningeal artery (MMA) embolization benefits adult patients with chronic subdural hematoma (CSDH) at high risk for recurrence or hemorrhagic complications. Yet, there has not been any report discussing MMA embolization in the pediatric population. Thus, we present a case of an infant with CSDH successfully managed with MMA embolization without surgical management.
Clinical Presentation:
A 5-mo-old girl with idiopathic dilated cardiomyopathy underwent surgical implantation of a left ventricular assist device for a bridge to heart transplantation. This was complicated by left ventricular thrombus causing stroke. She was placed on dual antiplatelet antithrombotic therapy on top of bivalirudin infusion. She sustained a left middle cerebral artery infarction, but did not have neurological deficits. Subsequent computed tomography scans of the head showed a progressively enlarging asymptomatic CSDH, and the heart transplant was repeatedly postponed. The decision was made to proceed with MMA embolization at the age of 7 mo. Bilateral modified MMA embolization, using warmed, low-concentration n-butyl-cyanoacrylate (n-BCA) from distal microcatheter positioning, allowed the embolic material to close the distal MMA and subdural membranous vasculature. The patient underwent successful heart transplant and the CSDH improved significantly. She remained neurologically asymptomatic and had normal neurological development after the MMA embolization.
Conclusion:
MMA embolization may represent a safe and effective minimally invasive option for pediatric CSDH, especially for patients at high risk for surgery or hematoma recurrence.
