PDF icon Download PDF
Open Access
CC BY 4.0 · J Neurol Surg Rep 2025; 86(02): e116-e121
DOI: 10.1055/a-2603-9286
Invited Report

Overcoming Challenging Vascular Anatomy in Chronic Subdural Hematoma: Direct Carotid Bulb Access and Contralateral Middle Meningeal Artery Embolization

Saarang Patel
1   Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
,
Zachary Hoglund
1   Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
,
Chandrasekhar Palepu
2   Department of Neurosurgery, School of Medicine, St. George's University, Grenada, West Indies
,
Kyle W. Scott
1   Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
,
Visish M. Srinivasan
1   Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
› Author Affiliations
› Further Information
Also available ateRefMedOne
  Permissions and Reprints
Preview

Abstract

Background

Middle meningeal artery (MMA) embolization is an emerging intervention for subdural hemorrhage. Few cases discuss the utility of contralateral MMA embolization due to challenging ipsilateral MMA anatomy for this indication.

Case Presentation

A 90-year-old male presented after 6 days of slurred speech and severe headache. A head computed tomography (CT) revealed a left-sided 13-mm subdural hemorrhage, and neck CT angiography revealed left internal carotid artery stenosis at 50%. The carotid stenosis was treated with a standard carotid endarterectomy at the carotid bulb. Despite direct catheterization of the external carotid artery, selective catheterization of the MMA was not feasible. Instead, coils were placed in the left internal maxillary artery spanning the left MMA origin, and the right MMA was selectively embolized using a standard transradial approach. Postoperative CT showed a reduction in subdural hematoma (SDH) size, and the patient was discharged in stable condition on postoperative day 6.

Conclusion

This case presents a rescue or salvage maneuver for MMA embolization for SDH with a favorable safety profile and outcome.

Keywords

neurosurgery - vascular - hematoma - carotid bulb access - middle meningeal artery embolization


Publication History

Received: 18 February 2025

Accepted: 29 April 2025

Accepted Manuscript online:
09 May 2025

Article published online:
27 May 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

 

  • References

  • 1 Catapano JS, Ducruet AF, Nguyen CL. et al. Middle meningeal artery embolization for chronic subdural hematoma: an institutional technical analysis. J Neurointerv Surg 2021; 13 (07) 657-660
    Search in Google Scholar
  • 2 Srivatsan A, Mohanty A, Nascimento FA. et al. Middle meningeal artery embolization for chronic subdural hematoma: meta-analysis and systematic review. World Neurosurg 2019; 122: 613-619
    Search in Google Scholar
  • 3 Catapano JS, Nguyen CL, Wakim AA, Albuquerque FC, Ducruet AF. Middle meningeal artery embolization for chronic subdural hematoma. Front Neurol 2020; 11: 557233
    Search in Google Scholar
  • 4 Desir LL, Narayan V, Ellis J. et al. Middle meningeal artery embolization in the management of chronic subdural hematoma: a comprehensive review of current literature. Curr Neurol Neurosci Rep 2023; 23 (04) 109-119
    Search in Google Scholar
  • 5 Nakagawa I, Kotsugi M, Yokoyama S. et al. Extensive roles and technical advances of middle meningeal artery embolization for chronic subdural hematoma. Neurol Med Chir (Tokyo) 2023; 63 (08) 327-333
    Search in Google Scholar
  • 6 Ironside N, Nguyen C, Do Q. et al. Middle meningeal artery embolization for chronic subdural hematoma: a systematic review and meta-analysis. J Neurointerv Surg 2021; 13 (10) 951-957
    Search in Google Scholar
  • 7 Kocharian G, Zappi KB, Carnevale J, Schwarz J, Knopman J. Recent advances and future directions in middle meningeal artery embolization for chronic subdural hematomas. Curr Pain Headache Rep 2022; 26 (08) 657-665
    Search in Google Scholar
  • 8 Zhang Z, Lim JX, Wen D, Wong CP, Lim WEH, Chia GS. Adjunct middle meningeal artery embolization versus surgery for chronic subdural hematoma: a systematic review and meta-analysis. Neurosurg Rev 2024; 47 (01) 876
    Search in Google Scholar
  • 9 Clinicaltrials.gov. Accessed December 27, 2024 at: https://clinicaltrials.gov/study/NCT04095819
  • 10 Clinicaltrials.gov. Accessed December 27, 2024 at: https://clinicaltrials.gov/study/NCT04270955?tab=table
  • 11 Clinicaltrials.gov. Accessed December 27, 2024 at: https://clinicaltrials.gov/study/NCT04372147?tab=table
  • 12 Hoenning A, Lemcke J, Rot S. et al. Middle meningeal artery embolization minimizes burdensome recurrence rates after newly diagnosed chronic subdural hematoma evacuation (MEMBRANE): study protocol for a randomized controlled trial. Trials 2022; 23 (01) 703
    Search in Google Scholar
  • 13 Clinicaltrials.gov. Accessed December 27, 2024 at: https://clinicaltrials.gov/study/NCT04410146?tab=table
  • 14 Muhammad N, Ramayya A, Burkhardt JK, Srinivasan VM. Urgent carotid endarterectomy with distal mechanical thrombectomy. J Neurointerv Surg 2025; jnis-2024-021662
    Search in Google Scholar
  • 15 Senol YC, Asghariahmadabad M, Cooke DL, Savastano LE. A case of recurrent subdural hematoma after unilateral MMA embolization that resolved after contralateral MMA embolization. Interv Neuroradiol 2024: 15 910199241267342
    Search in Google Scholar
  • 16 Edlmann E, Giorgi-Coll S, Whitfield PC, Carpenter KLH, Hutchinson PJ. Pathophysiology of chronic subdural haematoma: inflammation, angiogenesis and implications for pharmacotherapy. J Neuroinflammation 2017; 14 (01) 108
    Search in Google Scholar
  • 17 Lima V, Schechtman N, Araujo Junior D. et al. Middle meningeal artery embolization with n-butyl cyanoacrylate (NBCA) for the treatment of chronic subdural hematoma – technical note. Interdiscip Neurosurg 2022; 29: 101558
    Search in Google Scholar
  • 18 Chen C-C, Chen C-T, Wu Y-M. et al. Direct carotid artery exposure for acute cerebral infarction in hybrid angiography suite: indications and limitations. Front Surg 2022; 8: 819053
    Search in Google Scholar
  • 19 Shin DS, Yilmaz A, Ozkul A, Yeo DK, Hwang S-C, Kim B-T. Direct carotid exposure for neuroendovascular approaches. J Neurol Surg A Cent Eur Neurosurg 2016; 77 (06) 505-510
    Search in Google Scholar
  • 20 Abe T, Sakata H, Ezura M, Endo H, Tominaga T. Direct carotid puncture for endovascular surgery of intracranial aneurysms: technical note for avoiding complications. Surg Neurol Int 2022; 13: 69
    Search in Google Scholar
  • 21 Funakoshi Y, Hatano T, Ando M. et al. Use of direct carotid artery puncture access for flow diverter embolization combined with coil embolization: a case report. J Neuroendovasc Ther 2019; 13 (03) 143-148
    Search in Google Scholar
  • 22 Mokin M, Snyder KV, Levy EI, Hopkins LN, Siddiqui AH. Direct carotid artery puncture access for endovascular treatment of acute ischemic stroke: technical aspects, advantages, and limitations. J Neurointerv Surg 2015; 7 (02) 108-113
    Search in Google Scholar
  • 23 Sivapatham T. E-104 direct percutaneous external carotid artery access for middle meningeal artery embolization. SNIS 21st annual meeting electronic poster abstracts. July 2024:
  • 24 Takano I, Matsumoto Y, Fujii Y. et al. Carotid surgical cut-down technique for neuroendovascular therapy. Interv Neuroradiol 2019; 25 (03) 348-352
    Search in Google Scholar
  • 25 Ross IB, Luzardo GD. Direct access to the carotid circulation by cut down for endovascular neuro-interventions. Surg Neurol 2006; 65 (02) 207-211 , discussion 211
    Search in Google Scholar
  • 26 Rutledge C, Baranoski JF, Catapano JS, Jadhav AP, Albuquerque FC, Ducruet AF. Republished: Resolution of an enlarging subdural haematoma after contralateral middle meningeal artery embolisation. J Neurointerv Surg 2023; 15 (03) e2
    Search in Google Scholar
  • 27 Hubbard ZS, Al Kasab S, Porto GB, Spiotta A. Chronic subdural hematoma recurrence due to contralateral neovascularization following middle meningeal artery embolization. Interv Neuroradiol 2022; 28 (06) 639-643
    Search in Google Scholar
  • 28 Abdelsalam A, Ramsay IA, Luther EM. et al. Middle meningeal artery embolization for chronic subdural hematoma using n-butyl cyanoacrylate with a D5W push technique: a multicentric North American study of 269 patients. Oper Neurosurg (Hagerstown) 2024;
    Search in Google Scholar
  • 29 Marvin E, Laws LH, Coppens JR. Ruptured pseudoaneurysm of the middle meningeal artery presenting with a temporal lobe hematoma and a contralateral subdural hematoma. Surg Neurol Int 2016; 7 (3, Suppl 2): S23-S27
    Search in Google Scholar
  • 30 Campos JK, Meyer BM, Zarrin DA. et al. Immediate procedural safety of adjunctive proximal coil occlusion in middle meningeal artery embolization for chronic subdural hematomas: experience in 137 cases. Interv Neuroradiol 2024: 15 910199231224003
    Search in Google Scholar
  • 31 Msheik A, Fares Y, Mohanna M. et al. Middle meningeal artery embolisation: the review of a new treatment for chronic subdural hematomas. Surg Neurol Int 2023; 14: 66
    Search in Google Scholar