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CC BY-NC-ND 4.0 · Asian J Neurosurg
DOI: 10.1055/s-0045-1811245
Case Report

A Case of Burr Hole Drainage and Middle Meningeal Artery Embolization for Chronic Subdural Hematoma Associated with Spontaneous Intracranial Hypotension

Authors

  • Akihiro Shimoi

    1   Department of Neurosurgery, Institute of Brain and Blood Vessels, Gunma-ken, Isesaki, Japan

  • Kazuma Kowata

    1   Department of Neurosurgery, Institute of Brain and Blood Vessels, Gunma-ken, Isesaki, Japan

  • Keisuke Yoshida 

    1   Department of Neurosurgery, Institute of Brain and Blood Vessels, Gunma-ken, Isesaki, Japan

  • Hironori Takahashi

    1   Department of Neurosurgery, Institute of Brain and Blood Vessels, Gunma-ken, Isesaki, Japan

  • Kazunori Akaji

    1   Department of Neurosurgery, Institute of Brain and Blood Vessels, Gunma-ken, Isesaki, Japan
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Abstract

Idiopathic intracranial hypotension (IIH) is an uncommon condition characterized by cerebrospinal fluid leakage, which may lead to complications such as chronic subdural hematoma (CSDH). Management of recurrent CSDH in the context of IIH remains a therapeutic challenge. A 50-year-old man presented with bilateral CSDH associated with symptoms of IIH. Initial conservative treatment was followed by burr hole drainage due to deteriorating consciousness. Despite temporary improvement, hematoma recurrence necessitated repeat drainage. Subsequently, bilateral middle meningeal artery embolization (MMAE) was performed. The patient showed rapid clinical recovery, and no recurrence was observed at 3-month follow-up. MMAE may be an effective and minimally invasive treatment option for recurrent CSDH associated with IIH, especially when surgical intervention poses risks or proves insufficient. Early recognition of IIH and tailored intervention strategies are essential for optimal outcomes.


 

Keywords

burr hole drainage - chronic subdural hematoma - intracranial hypotension - middle meningeal artery embolization - hematoma

Introduction

We report a case of spontaneous intracranial hypotension (SIH) associated with chronic subdural hematoma (CSDH), in which bilateral middle meningeal artery embolization (MMAE) was performed following recurrence after burr hole drainage.


 

Case Presentation

  • Patient: 50-year-old male.

  • Medical history: unremarkable.

Clinical Course

The patient had been experiencing headaches for about 1 month prior to presentation. Two weeks before admission, he visited a local clinic where bilateral CSDH was diagnosed. He was treated conservatively with herbal medicine and analgesics, but worsening headache led to emergency transport to our hospital.


 

On Admission

The patient was alert, with normal pupillary light reflexes and no motor weakness. Blood tests were unremarkable. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed thin bilateral CSDHs ([Figs. 1] and [2]). Lumbar puncture revealed a low opening pressure of 4 cmH2O, and SIH was diagnosed. Although spinal imaging was planned, the diagnosis was made based on low cerebrospinal fluid (CSF) pressure and posture-related headache.

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Fig. 1 Bilateral CSDH on initial head CT. CSDH, chronic subdural hematoma; CT, computed tomography.
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Fig. 2 Bilateral CSDH on initial MRI. CSDH, chronic subdural hematoma; MRI, magnetic resonance imaging.

Conservative treatment with bed rest and intravenous fluids (2,000 mL/day) was initiated. Although symptoms initially improved, the patient developed impaired consciousness on the 7th day of hospitalization. CT at that time showed no significant hematoma enlargement ([Fig. 3a]), but burr hole drainage was performed ([Fig. 3b]). Consciousness improved, and the patient was discharged home.

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Fig. 3 (a) CT prior to first drainage. (b) CT after first burr hole drainage. (c) CT showing recurrence. (d) CT after MMAE showing no recurrence. CT, computed tomography; MMAE, middle meningeal artery embolization.

On the 14th day after discharge, he was re-admitted due to recurrence of headache and impaired consciousness. CT showed recurrence of CSDH, and burr hole drainage was performed again the same day ([Fig. 3c]). Consciousness improved postoperatively to the level seen at the initial discharge.

On the 21st day of re-admission, bilateral MMAE was performed ([Figs. 4],[5],[6],[7]). A total of 0.5 mL of 12.5% n-butyl cyanoacrylate (NBCA) was injected into the left middle meningeal artery (MMA), and 0.1 mL of 12.5% NBCA into the right MMA, achieving sufficient embolization. Postoperative CT showed no recurrence of hematoma and regression of the existing hematoma. The patient's headache resolved, and he was discharged 7 days after embolization. No recurrence of symptoms or hematoma has been observed to date ([Fig. 3d]).

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Fig. 4 Right MMA angiography before embolization. MMA, middle meningeal artery.
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Fig. 5 Right MMA after embolization. MMA, middle meningeal artery.
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Fig. 6 Left ECA angiography before embolization. ECA, external carotid artery.
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Fig. 7 Left MMA after embolization. MMA, middle meningeal artery.

 

 

Discussion

CSDH is reported in 10 to 69% of patients with SIH.[1] [2] [3] Treatment options include conservative therapy, surgical evacuation, and epidural blood patching, alone or in combination. Bed rest and hydration remain the cornerstone of treatment for CSDH associated with low CSF pressure.[4]

SIH is caused by decreased CSF volume or leakage and is characterized by orthostatic headache.[4] There are reports suggesting that decreased CSF production may be linked to vitamin A deficiency.[5]

In SIH-related CSDH, spontaneous resolution after epidural blood patching has been reported.[6] [7] [8] Burr hole drainage is indicated in the presence of neurological symptoms, altered consciousness, or hematoma thickness over 1 cm.[3] In our case, drainage was necessary due to impaired consciousness.

Although we found no direct evidence in the literature linking MMAE to resolution of CSDH in SIH, some studies report that CSDH can worsen even after clinical improvement of SIH, leading to irreversible hematoma formation.[9] Similarly, in our case, impaired consciousness appeared despite improvement in SIH symptoms, suggesting continuous bleeding from the hematoma capsule and low likelihood of spontaneous resolution.

In bilateral CSDH associated with SIH, a combined strategy of epidural blood patch followed by burr hole drainage or MMAE should be considered. Diagnostic imaging with contrast-enhanced MRI is critical when SIH is suspected. The optimal timing of MMAE—whether prior to or following burr hole drainage—remains unclear. However, in cases where hematoma volume is small or drainage poses a risk, embolization of the hematoma capsule via MMAE may be a valid alternative.[10] [11] [12]

In the present case, epidural blood patch was not feasible due to logistical constraints, and symptoms were mild at onset. Initial conservative treatment was followed by burr hole drainage upon symptom exacerbation. Recurrence was managed with repeat drainage and MMAE. Although hematoma resolution may have occurred naturally through repeated drainage, the absence of recurrence post-MMAE suggests that embolization contributed to the favorable outcome.


 

Conclusion

In patients with bilateral CSDH associated with SIH, where hematomas are thin and burr hole drainage carries a risk of complications, preemptive MMAE or, where feasible, epidural blood patching should be considered.


 

 

Conflict of Interest

None declared.


Address for correspondence

Akihiro Shimoi, MD
Department of Neurosurgery, Institute of Brain and Blood Vessels
Gunma-ken, Isesaki 372-0006
Japan   

Publication History

Article published online:
15 September 2025

© 2025. Asian Congress of Neurological Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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Fig. 1 Bilateral CSDH on initial head CT. CSDH, chronic subdural hematoma; CT, computed tomography.
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Fig. 2 Bilateral CSDH on initial MRI. CSDH, chronic subdural hematoma; MRI, magnetic resonance imaging.
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Fig. 3 (a) CT prior to first drainage. (b) CT after first burr hole drainage. (c) CT showing recurrence. (d) CT after MMAE showing no recurrence. CT, computed tomography; MMAE, middle meningeal artery embolization.
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Fig. 4 Right MMA angiography before embolization. MMA, middle meningeal artery.
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Fig. 5 Right MMA after embolization. MMA, middle meningeal artery.
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Fig. 6 Left ECA angiography before embolization. ECA, external carotid artery.
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Fig. 7 Left MMA after embolization. MMA, middle meningeal artery.