Middle meningeal artery embolization to treat acute epidural hematoma, case report and literature review

Introduction: Treatment of acute epidural hematoma is surgery as soon as possible, elimination of the source of bleeding and evacuation of the hematoma. In case of small epidural hematoma, strict neurological and radiological follow-up is necessary. In a significant percentage of cases, open surgery must also be performed within a few days. In case of small epidural hematomas, embolization of the middle meningeal artery is considered as an alternative solution.

Aims: We review the literature on middle meningeal artery embolization and present our first treatment. Our case report is the first European report in which acute epidural hematoma was treated by embolization of middle meningeal artery. Our case is the first report in which a patient was treated with both open surgery and endovascular treatment for acute epidural hematoma within a year.

Methods: In 2022, a 56-year-old male patient with alcoholic liver failure who drank alcohol regularly suffered a severe skull injury and right-sided enormis epidural hematoma. We performed an immediate right fronto-temporo-parietal craniotomy for epidural and contusion hematoma evacuation. His preoperative GCS 5 state improved within a short time, and then he became asymptomatic. In June 2023, he repeatedly suffered a skull injury while intoxicated, CT confirmed an 11 mm wide acute epidural hematoma on the left parietal region. His GCS was 15. Due to poor liver enzyme values and poor blood coagulation parameters, we decided on endovascular treatment. Under local anesthesia, during a femoral puncture, selective catheterization of the left middle meningeal artery was performed and extravasation was detected.

Result: Selective embolization of the MMA was performed with 250-355 micron PVA particles. The intervention was without complications. The regression of the epidural bleeding was confirmed on CT scans taken on the 1st and 4th postoperative day. On the 10th day after the injury, the patient had no symptoms and was discharged home without any complaints. On a 1-month follow-up CT scan, the epidural bleeding was absorbed.

Conclusion: In case of small epidural hematomas, embolization of the middle meningeal artery is considered as an alternative solution. This intervention can be performed safely and successfully.