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Recurrent Acute Subdural Hematoma Due to Middle Meningeal Artery Bleeding

Treated by Embolization

Huaqiang Ding, Xingyun Quan, Shuai Liao, Shengjie Liu, Liang Liu

PII: S1878-8750(19)32643-9
DOI: https://doi.org/10.1016/j.wneu.2019.10.028
Reference: WNEU 13499

To appear in: World Neurosurgery

Received Date: 12 September 2019

Revised Date: 3 October 2019
Accepted Date: 4 October 2019

Please cite this article as: Ding H, Quan X, Liao S, Liu S, Liu L, Recurrent Acute Subdural Hematoma
Due to Middle Meningeal Artery Bleeding Treated by Embolization, World Neurosurgery (2019), doi:
https://doi.org/10.1016/j.wneu.2019.10.028.

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© 2019 Published by Elsevier Inc.

Recurrent Acute Subdural Hematoma Due to Middle Meningeal

Artery Bleeding Treated by Embolization

Huaqiang Ding1, Xingyun Quan1, Shuai Liao1, Shengjie Liu1, Liang Liu1,2,3
1
Department of Neurosurgery, Affiliated Hospital of Southwest Medical University,
Luzhou, China
2
Neurosurgery Clinical Medical Research Center of Sichuan Province, China
3
Academician（Expert）Workstation of Sichuan Province

Corresponding Author:

Liang Liu

Department of Neurosurgery, Affiliated Hospital of Southwest Medical University,

Luzhou, China

Email:liulst@163.com
Introduction

An acute subdural hematoma (ASDH) is often due to the tearing of bridging veins or

the direct injury to cortical vessels after head trauma. Nontraumatic ASDHs are

associated with cerebral aneurysms, arteriovenous malformations, and tumors13.

ASDHs of the middle meningeal artery (MMA) origin is rare but also known1,2,11.

ASDHs with a significant mass effect still require evacuation, whether traumatic,

spontaneous, or iatrogenic. However, certain ASDHs should be managed individually.

MMA embolization has been described as an alternative treatment for new or

recurrent chronic subdural hematomas (CSDHs)3,12,20. MMA embolization for

epidural hematoma (EDH) has also been reported in some literatures6,14,18,21.

Nevertheless, only a few cases of ASDHs due to dural arteriovenous fistula, MMA

aneurysm or pseudoaneurysm treated via MMA embolization have been

reported8-10,15-17.

Herein, we present a case treated by MMA embolization to prevent further growth

of an expanding recurrent ASDH following surgical evacuation of a spontaneous

ASDH. We observed the relationship between the recurrent ASDH and MMA via

angiography and successfully performed endovascular treatment to spare this patient

from a second craniotomy.

Case report

A 56-year-old woman was admitted to our department with progressively worsening

headache and vomiting for approximately one week. She had no history of head

trauma or anticoagulation and antiplatelet medication. The Glasgow Coma Score on

admission was 14 (E3V5E6) and her examination was without focal deficits. A head

computed tomography (CT) scan revealed an ASDH on the right hemisphere with a

6mm midline shift (MLS) (Figure 1A). A CT angiography was performed and did not

show any intracranial vascular malformation. The patient was taken for a right-sided

craniotomy. At operation, we did not find an apparent bleeding point or vascular

malformation and the ASDH was evacuated successfully (Figure 1B) . 2 days after the

surgery, the patient exhibited impaired consciousness. A repeat CT scan showed a

recurrent ASDH with left-sided MLS along the right cerebral convexity (Figure 1C).

To clarify the causes of spontaneous ASDH and recurrent ASDH, we decided to

perform cerebral digital subtraction angiography (DSA) for the patient.

The procedure is performed under local anesthesia and a right-sided transfemoral

artery approach was used. No vascular abnormality was noticed during selective

angiography of the internal carotid and vertebral arteries and the left

external carotid artery. Selective angiography of the right external carotid artery and

MMA showed active contrast extravasation from the anterior branch of the right

MMA (Figure 2A and 2B) which was considered to be associated with the recurrent

ASDH. A microcatheter was advanced into the right MMA via the internal maxillary

artery, and the embolization of the MMA was performed by slowly infusing polyvinyl

alcohol particles (Onyx18) until the artery was occluded. MMA angiography

demonstrated elimination of flow into the right MMA and no further radiographic

extravasation (Figure 2C).

 CT scans 1day and 2 days after embolization demonstrated the progressive

decrease of the recurrent ASDH (Figure 3A and 3B). 1 week after embolization, a

repeat CT scan showed complete resolution of the right-sided ASDH and no

recurrence (Figure 3C). The patient was discharged without any neurologic deficits.

Discussion

Recurrent ASDHs are a common complication of ASDH evacuation. Desai et al.

found that the rate of postoperative hematoma after ASDH evacuation was 9.1% and

96% of them occurred in the subdural space7. In the paper by Chrastina et al. 27.9%

of reoperations after surgery for ASDH was reported, with recurrent or significant

residential SDH being the most frequent reason for reoperation5. Postoperative

ASDHs probably mainly result from bleeding in the bridging vein or the cortical

vessel but other possible etiologies, including unsuspected coagulopathies, vascular

injury and a vascular malformation also should be considered.

In our case, the recurrence of ASDH after craniotomy led to angiographic evaluation

to rule out an occult vascular lesion. Selective external carotid angiography

demonstrated active contrast extravasation of the anterior branch of the right MMA.

We suspect that iatrogenic injury to the MMA is the possible etiology for the

intradural bleeding during craniotomy because the lesion of MMA was not identified

on the preoperative CT angiography and no visible bleeding from MMA was found

intraoperatively. Furthermore, postoperative external carotid angiography showed the

lesion of MMA at the sphenoid ridge consistent in location with the bone partially

drilled off by our surgeons during operation. Although the rupture of the MMA may
lead to the formation of pseudoaneurysms, no aneurysms were found on angiography

in our patient. However, the possible dissection of the artery has been shown, which

can cause the absence of normal arterial layers.

Bleeding from the MMA usually causes acute epidural hematomas because it lies

on the outer surface of the dura. ASDHs associated with the intradural bleeding from

the MMA are very rare. To our knowledge, only several cases with this condition

have been reported. Korosue et al. and Aoki et al. reported an ASDH associated with

a ruptured nontraumatic and traumatic MMA aneurysm, respectively1,2. Gerosa et al.

reported the case of a traumatic MMA pseudoaneurysm as a cause of ASDH and

subarachnoid hemorrhage8. Kohyama et al. reported a case with ASDH and

intracerebral hemorrhage caused by spontaneous bleeding in the MMA after coil

embolization of a cerebral aneurysm11. All the cases were managed by emergency

craniotomy for evacuation of the hematoma.

Craniotomy or decompressive craniectomy is indicated for ASDHs with a

hematoma thickness >10 mm or midline shift >5 mm4. Small ASDHs in patients with

good neurologic status can be managed conservatively but the risks of enlargement

and evolution into CSDH exist, which may eventually require surgical evacuation19. If

there is a known origin of postoperative subdural bleeding, perhaps the repair of the

injured vessel would avoid reoperation. Pseudoaneurysms and active contrast

extravasation are common findings in patients with traumatic EDHs and MMA

embolization has been proved safe and useful for nonoperative EDHs6,14,18. Ross et al.

reported a case of postoperative EDH successfully controlled with MMA

embolization to obviated another craniotomy21. Postoperative ASDH treated by

embolization of MMA has not been reported previously.

In our patient, a cerebral DSA showed the notable image of contrast extravasation

from the peripheral branch of the MMA, which was thought to be the possible

etiology of the postoperative ASDH. Given the potential for the enlargement of the

recurrent ASDH, it is reasonable to treat it via embolization of the bleeding MMA.

Finally, it proved that the endovascular MMA embolization was safe and highly

effective to prevent the hematoma expansion for our patient.

Conclusions

Our case suggests that injured MMA may be one of the causes of recurrent ASDH

following neurosurgical operations and endovascular exploration and possible

treatment is necessary for such selected patients, especially for cases with an

unexplained ASDH.
Conflicts of interest: None.

Acknowledgements: None.

Funding: This research did not receive any specific grant from funding agencies in

the public, commercial, or not-for-profit sectors.

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Figure Legends

Figure 1. Pre- and postoperative computed tomography (CT) scans. (A), CT scan on

admission showed an acute subdural hematoma (ASDH) in the right hemisphere with

a 6mm midline shift (MLS). (B), CT scan performed 10 hours after surgery revealed

the ASDH evacuated and improvement in MLS. ( C), CT scan performed 2 days after

surgery demonstrated a recurrent ASDH with MLS at the site of operation.

Figure 2. Right external carotid artery angiography and middle meningeal artery

(MMA) embolization. (A), Selective right external carotid artery angiography showed

filling of anterior (a) and posterior (p) branches of the MMA and the lesion (arrow) in

the anterior branch. (B), Superselective right MMA angiography demonstrated active

extravasation of contrast and possible dissection of the artery (arrow). (C),

Angiography after MMA embolization showed resolution of contrast extravasation

and no filling of the MMA.

Figure 3. Postembolization CT scans. (A) and (B), Serial CT scans 1 day and 2 days

after embolization demonstrated a significant reduction of the ASDH and MLS. (C),

CT scan obtained 7 days after embolization showed complete absorption of the

ASDH.
Abbreviations list

ASDH: Acute subdural hematoma

CSDH: Chronic subdural hematoma

CT: Computed tomography

DSA: Digital subtraction angiography

EDH: Epidural hematoma

MLS: Midline shift

MMA: Middle meningeal artery
Conflicts of Interest: The authors have declared that no conflict of interest exists.