Middle meningeal artery embolization before craniotomy for infected organizing chronic subdural hematoma: A case report and review of the literature

Abstract

Background: Organizing chronic subdural hematoma (OSDH) is intractable and its radical treatment remains controversial. Middle meningeal artery embolization has emerged as an adjunctive treatment to craniotomy for OSDH. Case Description: The patient is an 86-year-old man. He had been taking warfarin for atrial fibrillation and was referred to the department for the treatment of bilateral chronic subdural hematoma (CSDH), which was found on head computed tomography after a fall. Bilateral burr hole drainages were performed, but his hematomas were organized, so the hematomas could not be drained sufficiently. The patient was discharged from the hospital without any neurological symptoms. Two months later, the patient presented with persistent fever and headache and had recurrent bilateral CSDHs. The hematoma on the right side was larger. Based on the initial intraoperative findings, OSDH was suspected, and craniotomy was performed on the right hematoma. Propionibacterium acnes were detected in the hematoma culture, and antimicrobial therapy was started postoperatively. Since the right hematoma recurred on the 7th postoperative day, bilateral middle meningeal artery (MMA) embolization with 20% n-butyl-2-cyanoacrylate was performed, followed by craniotomy for the left hematoma and drainage for the right recurrent hematoma. Antimicrobials were administered for 2 weeks after the last operations. Six months after the operations, both bilateral hematomas had almost disappeared. Conclusion: Craniotomy is effective for the treatment of infected OSDH, and MMA embolization is useful to reduce the risk of bleeding complications in the perioperative period, and may also reduce the recurrence of CSDH.

Extensive Roles and Technical Advances of Middle Meningeal Artery Embolization for Chronic Subdural Hematoma

“… 10 , 14 ) This method has since been reported effective in cases with concomitant antithrombotic medications, 15 , 16 ) CSDH in elderly patients, 17 , 18 ) CSDH in cases of dural metastases from cancers of other organs, 19 , 20 ) and infectious CSDH. 21 ) Additionally, MMA embolization is considered a preferred therapeutic option for CSDHs with spontaneous intracranial hypotension to buy time before the epidural blood patch starts working. 22 , 23 ) Many reports show that MMA embolization is effective in children with congenital heart disease who are taking antithrombotic drugs and children with CSDH associated with head trauma.…”

Letter: Inverse Trends in Rates of Middle Meningeal Artery Embolization and Mortality in Subdural Hematoma in the United States

“…3,5 Owing to a high rate of recurrence and perioperative complications associated with open surgery, MMA embolization is emerging to be not only an adjunct but also a stand-alone treatment option for chronic subdural hematoma. 6,7 In a prospective study, Ban et al 7 reported MMA embolization to be a superior option than conventional treatment options. In this same study, treatment failure for MMA embolization was reported to be only 1.4% as compared with 27.5% among patients who underwent surgical drainage.…”