2013 Volume 36 Issue 2 Pages 206-210
Object: The continuous disruption of neovascuralization on outer membrane of subdural hematoma could be concerned in the refractory chronic subdural hematoma (rCSDH). The middle meningeal artery (MMA) mainly supplies to the membrane through the contacted dura matter. We hereby report a case of rCSDH with a risk factor of ischemic complication accompanied by embolization of MMA.
Patient: A 72-year-old female suffered severe headache due to left CSDH. She had been given a 10 mg of rivaroxaban against chronic atrial fibrillation. Twice symptomatic recurrences occurred after simple burrhole surgeries. Finally, embolization of MMA was additionally undergone with using coils following the third burrhole surgery. We chose some coils as an embolic material to avoid ischemic complication due to the migration of liquid embolic material, because recurrent meningeal artery (RMA) was shown on the angiogram prior to embolization. The hematoma disappeared at one month after the embolization.
Discussion: As long as it is easily to access to MMA, embolization of MMA is a simple and less invasive treatment under local anesthesia. However, MMA originated from stapedial artery, has some normal variations and occult anastomosis to internal carotid artery system (ophthalmic artery, inferior-lateral trunk on C4 portion) as known as dangerous anastomosis. RMA, one of these anastomotic arteries, generally connects between MMA at intracranial foramen spinosum and ophthalmic artery in ipsi-lateral orbit through superior orbital fissure. Therefore, the embolization, especially with using liquid embolic materials, should undergo at more distal portion of MMA as possible to avoid the accidental migration.
Conclusion: Deteriorate to rCSDH infrequently occurred in our clinical situation. The embolization was feasible treatment for patients with rCSDH. To recognize the anatomy of microvasculature is the most important for less complication regardless of embolic materials. Further discussion is necessary for both indication and timing of embolization.
