Treatment of Chronic Subdural Hematoma Using Endovascular Embolization of the Middle Meningeal Artery (Clinical Case)

Abstract

Chronic subdural hematoma is a common pathology predominantly observed in elderly individuals. Over the past decade, the overall incidence of chronic subdural hematomas has more than doubled. This increase is attributed to the aging population in most countries worldwide and advancements in the availability and quality of neuroimaging diagnostic technologies. Recent studies indicate that the primary pathological process in chronic subdural hematomas involves recurrent microhemorrhages into the subdural space from fragile newly formed vessels in the capsule of the chronic subdural hematoma, originating from the distal branches of the middle meningeal artery. Consequently, endovascular embolization of the middle meningeal artery may help prevent chronic recurrent bleeding into the subdural space and facilitate hematoma resorption. Objective ‒ to demonstrate the effectiveness of endovascular methods in the treatment of patients with chronic subdural hematomas through a clinical case. Clinical Case. Patient P., 85 years old, was hospitalized at the Stroke Center, Kharkiv Clinical Hospital of Railway Transport No. 1, Health Care Center Branch, JSC Ukrzaliznytsia with a suspected acute stroke. The patient lived alone and was brought to the hospital by her granddaughter, who found her with speech disturbances, weakness in the right limbs, behavioral disorders, and uncertain information about any recent trauma. Medical history includes hypertension, coronary heart disease, post-infarction (2010) cardiosclerosis, and diabetes mellitus in the subcompensation stage. Neurologically, her condition was of moderate severity, with a Glasgow Coma Scale score of 12‒13, elements of sensorimotor aphasia, right-sided hemiparesis, and negative meningeal signs. MRI of the brain revealed a chronic subdural hematoma in the left hemisphere of the brain with a significant mass effect, with a 5 mm rightward midline shift. During selective, superselective cerebral angiography, distal branches of the middle meningeal artery supplying the regions of the meninges and the capsule of the subdural hematoma in the left hemisphere were visualized. Endovascular embolization was performed with microinjections of Onyx-18 (Medtronic, USA) into the distal branches of the middle cerebral artery until the blood flow was blocked. In the postoperative period, a positive trend in the patient's neurological condition was observed. By the 12th day after endovascular embolization of the middle meningeal artery, there was a complete regression of neurological deficit. MRI of the brain one month after the intervention showed full resorption of the subdural hematoma, with no midline shift and no signs of brain compression. Conclusions. This clinical case demonstrates the potential of endovascular embolization methods to positively impact the outcomes of chronic subdural hematoma treatment.

Keywords

• chronic subdural hematoma; middle meningeal artery; endovascular embolization.