Middle Meningeal Artery Embolization for Acute Epidural Hematomas: A Promising Alternative to Traditional Surgery

Abstract

Background

Acute epidural hematoma (AEDH) is recognized as one of the most urgent neurosurgical conditions. Traditionally, the primary treatment for AEDH has involved craniotomy with surgical evacuation of the hematoma. However, with the widespread adoption of neurointerventional techniques, interest in their application to various forms of traumatic brain injuries has increased. Among these, embolization of the middle meningeal artery (MMA) has emerged as a minimally invasive treatment option for AEDH. This study evaluates the effectiveness of MMA embolization as a primary treatment for AEDH.

Methods

We conducted a retrospective review of patients treated for AEDH with embolization of the MMA at our institution from January 2019 to July 2024. Patient demographics, clinical presentation, procedural details, and outcomes were analyzed.

Results

MMA embolization was successfully performed in 20 patients with AEDH, with only 2 cases requiring subsequent burr-hole evacuation. The thickness of the AEDH was 10 mm or more in 47.8% of cases, and a midline shift was observed in 65.2% of cases. The most common angiographic findings included arteriovenous fistulas (AVFs) and contrast extravasation. N-butyl cyanoacrylate was used as the embolic material in all cases. In one case, Squid 12 was added to enhance penetration at sites of extravasation. No patients experienced recurrent AEDH postintervention.

Conclusion

MMA embolization is a promising minimally invasive treatment for AEDH, showing effectiveness as both a primary and adjuvant therapy. Future prospective multicenter studies are needed to validate preliminary findings and optimize treatment protocols for this high-risk patient population.

Keywords

traumatic brain injury - acute epidural hematoma - middle meningeal artery - embolization - arteriovenous fistula

Ethical Approval

The institutional review board approved the study design with a waiver of informed consent due to its retrospective nature.

Authors' Contributions

A.S.: Conceptualization, data curation, methodology, writing—original draft

K.B.: Conceptualization, data curation

A.A.: Conceptualization, writing—review and editing

D.S.: Supervision

A.S.: Supervision

R.M.: Data curation

D.I.: Data curation

Publication History

Received: 12 September 2024

Accepted: 16 April 2025

Accepted Manuscript online:
17 April 2025

Article published online:
18 November 2025

• References

• 1 Schulze A. [Unusual forms of epidural hematoma]. Zentralbl Neurochir 1957; 17 (01) 40-47
• 2 Zingesser LH, Schechter MM, Rayport M. Truths and untruths concerning the angiographic findings in extracerebal haematomas. Br J Radiol 1965; 38 (455) 835-847
• 3 Joyce E, Bounajem MT, Scoville J. et al. Middle meningeal artery embolization treatment of nonacute subdural hematomas in the elderly: a multiinstitutional experience of 151 cases. Neurosurg Focus 2020; 49 (04) E5
• 4 Stanishevsky AV, Babichev KN, Vinogradov EV. et al. Middle meningeal artery embolization for chronic subdural haematoma. Case series and literature review. J Neurosurg 2021; 85 (05) 71-79
• 5 Suzuki S, Endo M, Kurata A. et al. Efficacy of endovascular surgery for the treatment of acute epidural hematomas. AJNR Am J Neuroradiol 2004; 25 (07) 1177-1180
• 6 de Andrade AF, Figueiredo EG, Caldas JG. et al. Intracranial vascular lesions associated with small epidural hematomas. Neurosurgery 2008; 62 (02) 416-420 , discussion 420–421
• 7 Ross IB. Embolization of the middle meningeal artery for the treatment of epidural hematoma. J Neurosurg 2009; 110 (06) 1247-1249
• 8 Jussen D, Wiener E, Vajkoczy P, Horn P. Traumatic middle meningeal artery pseudoaneurysms: diagnosis and endovascular treatment of two cases and review of the literature. Neuroradiology 2012; 54 (10) 1133-1136
• 9 Lammy S, McConnell R, Kamel M, Rennie I, Al-Haddad S. Extradural haemorrhage: is there a role for endovascular treatment?. Br J Neurosurg 2013; 27 (03) 383-385
• 10 Ohshima T, Tajima H, Fujii K. et al. Combined endovascular and endoscopic surgery for acute epidural hematoma in a patient with poor health. Neurol Med Chir (Tokyo) 2012; 52 (11) 829-831
• 11 Kim DH, Lee JY, Jeon HJ, Cho BM, Park SH, Oh SM. Intraoperative endovascular embolization of middle meningeal artery and a pseudoaneurysm by using N-butyl 2-cyanoacrylate for hemostasis during operation of acute epidural hemorrhage. Korean J Neurotrauma 2015; 11 (02) 167-169
• 12 Son J, Iwakami T, Fujii N. A case of the growing epidural hematoma treated with the embolization of the middle meningeal artery. J Neuroendovasc Ther 2016; 10 (03) 134-137
• 13 Peres CMA, Caldas JGMP, Puglia P. et al. Endovascular management of acute epidural hematomas: clinical experience with 80 cases. J Neurosurg 2018; 128 (04) 1044-1050
• 14 Zhang Y, Li Q, Zhao R. et al. Novel minimally invasive treatment strategy for acute traumatic epidural hematoma: endovascular embolization combined with drainage surgery and use of urokinase. World Neurosurg 2018; 110: 206-209
• 15 Zussman BM, Goldschmidt E, Faraji AH, Salvetti DJ, Jankowitz BT. Middle meningeal artery embolization for the treatment of an expanding epidural hematoma. World Neurosurg 2019; 128: 284-286
• 16 Fan G, Wang H, Ding J. et al. Application of absolute alcohol in the treatment of traumatic intracranial hemorrhage via interventional embolization of middle meningeal artery. Front Neurol 2020; 11: 824
• 17 Park TJ, Lee SP, Baek J, Ryou K, Kim SH. Middle meningeal artery embolization to treat progressive epidural hematoma: a case report. J Cerebrovasc Endovasc Neurosurg 2020; 22 (01) 20-25
• 18 Babichev KN, Svistov DV, Kandyba DV, Savello AV, Martynov RS, Landik SA. Embolization of the middle shell artery in the treatment of small epidural hematomas. J Emerg Surg. 2021; 4 (05) 16-20