Early middle meningeal artery embolization for small acute epidural hematomas: a clinical study from a single center

Small acute epidural hematomas (EDHs) are generally managed conservatively; however, in certain instances, they may necessitate surgical evacuation owing to delayed hematoma expansion. This study aims to evaluate whether early embolization of the middle meningeal artery (MMA) can prevent hematoma progression in patients with small acute epidural hematomas accompanied by skull fractures involving meningovascular structures. We hypothesize that early MMA embolization could be a prophylactic strategy to prevent hematoma progression.

A retrospective study was conducted on 14 patients with small EDHs (volume <30 mL) and skull fractures intersecting MMA branches, who were treated via endovascular embolization at our center from October 2021 to August 2024. Onyx^™-18 was utilized for embolization after vascular injury detection via super-selective digital subtraction angiography (DSA). The study meticulously documented and analyzed clinical data, imaging findings, surgical outcomes, and prognosis.

Preoperative computerized tomography (CT) scans confirmed skull fractures at EDH sites, and preoperative angiography showed vascular lesions of the MMA (including active contrast leak or pseudoaneurysm) in all cases. All patients underwent the procedure under local anesthesia and obtained an MMA occlusion successfully, which was confirmed by subsequent angiography. All patients showed no hematoma expansion on follow-up CT scans and avoided craniotomy. All patients were discharged without neurological deficits.

This series establishes MMA embolization as a prophylactic approach for small acute EDHs with skull fractures intersecting MMA branches. Early super-selective angiography is crucial for detecting vascular injuries, and subsequent embolization guided by intraoperative findings may reduce monitoring burden and the risk of delayed expansion in selected patients.