A Case of Acute Epidural Hematoma Successfully Treated with Middle Meningeal Artery Embolization

Abstract

We report a case of acute epidural hematoma (AEDH) successfully treated with middle meningeal artery (MMA) embolization. A 59-year-old man presented with headache 2 days after minor head trauma. Head computed tomography (CT) revealed a left-sided AEDH with an associated skull fracture. Although the patient had only mild disturbance of consciousness and no focal neurological deficits, the hematoma volume was significant. Given the absence of mass effect and to prevent further hematoma expansion, emergent MMA embolization was performed via a transradial approach under local anesthesia. Angiography demonstrated contrast extravasation from the MMA, which was successfully embolized using 20% n-butyl-2-cyanoacrylate. The patient's postoperative course was uneventful, and the hematoma showed near-complete resolution on follow-up CT 1 month later. This case highlights the potential utility of MMA embolization as a minimally invasive and effective treatment option for select AEDH cases that do not require emergency craniotomy.

 

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Keywords

acute epidural hematoma - middle meningeal artery embolization - endovascular treatment

Introduction

Acute epidural hematomas (AEDHs) are typically associated with skull fractures and, in cases with large hematoma volume or combined hematomas, craniotomy with hematoma evacuation is generally indicated.[1] Additionally, Knuckey et al reported that more than half of the cases in which fracture lines cross the middle meningeal artery (MMA) or venous sinuses required surgical evacuation.[2] However, recent advances in endovascular techniques, including MMA embolization (MMAE), have demonstrated efficacy in managing select cases of AEDH.[1] [2] [3] [4] [5] [6] [7] [8] We report a case of AEDH successfully managed with MMAE, resulting in favorable hematoma resolution without the need for craniotomy.

 

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Case Report

Patient: A 59-year-old male

Chief complaint: Headache

Past medical history: Unremarkable

Present illness: The patient experienced head trauma 2 days prior to presentation. He developed worsening headache on the day of admission and called emergency services.

Neurological findings on admission: The patient presented with mild disturbance of consciousness (Japan Coma Scale [JCS] I-1; Glasgow Coma Scale [GCS] E4V4M6). Pupils were 3.0 mm bilaterally with normal light reflexes, and no other neurological deficits were observed. Head computed tomography (CT) revealed a left AEDH with a maximum thickness of 40 mm and an estimated volume of 80 mL, along with a skull fracture ([Fig. 1]).

Fig. 1 Noncontrast axial (A, B) and coronal (C, D) computed tomography (CT) images revealed an acute epidural hematoma with a thickness of 40 mm and an estimated volume of approximately 80 mL. No midline shift was observed. The three-dimensional reconstruction (E) demonstrated a left parietal bone fracture, as indicated by the arrowhead. The fracture line was also visible on the two-dimensional (2D) images, as indicated by the arrowhead. Postoperative CT showing regression of the epidural hematoma (F).

Clinical course: Although the patient exhibited only mild disturbance of consciousness (JCS I-1), the large hematoma volume and presence of a skull fracture raised concern for potential neurological deterioration due to hematoma expansion. Emergency craniotomy was considered; however, an in-house anesthesiologist was not available, requiring external consultation. Transfer to another facility was also discussed, but given the relatively stable consciousness level and absence of mass effect on imaging, urgent MMAE was deemed appropriate to achieve hemostasis, especially in light of the hematoma volume and contrast extravasation observed on cerebral angiography. Emergency MMAE was performed the same day.

 

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Operative Findings

Under local anesthesia, embolization of the left MMA was performed via a right radial artery approach. A 4-Fr guiding sheath was advanced to the left external carotid artery. Digital subtraction angiography demonstrated contrast extravasation from the left MMA ([Fig. 2]). A microcatheter was navigated distally into the MMA, and 20% n-butyl-2-cyanoacrylate was injected. Subsequent angiography confirmed the disappearance of extravasation ([Fig. 3]).

Fig. 2 Super selective contrast images of middle meningeal artery (MMA). Anteroposterior view (A) and lateral view (B) revealed extravasation of contrast media.

Fig. 3 Embolization with n-butyl-2-cyanoacrylate (NBCA). Embolization of the middle meningeal artery (MMA) was performed using 20% NBCA (A and B). Post-transarterial embolization (TAE) angiography (C and D) showed disappearance of contrast extravasation. A postoperative computed tomography (CT) scan taken in the angiography suite (E) revealed contrast leakage into the hematoma cavity; however, there was no significant increase in hematoma volume.

 

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Postoperative Course

Following embolization, the patient had an uneventful course without rebleeding. The epidural hematoma showed a tendency toward resolution, and his primary complaint of headache gradually improved. One month after the procedure, follow-up CT demonstrated near-complete resolution of the hematoma, confirming the effectiveness of the MMAE ([Fig. 4]). His level of consciousness also improved to GCS E4V5M6, and the headache resolved. The patient was subsequently transferred to a rehabilitation unit for continued therapy.

Fig. 4 Follow-up computed tomography (CT) on postoperative day 1 (A) and day 30 (B). The CT on postoperative day 1 showed no hematoma enlargement. The CT on postoperative day 30 demonstrated a clear reduction in hematoma volume, indicating progressive resolution.

 

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Discussion

AEDHs are usually treated surgically if there is significant hematoma volume or associated mass effect.[1] Knuckey et al reported that when fracture lines crossed the MMA or venous sinuses, 55% of cases required craniotomy.[2] The general surgical indications for AEDH include a hematoma volume exceeding 30 mL, a thickness greater than 15 mm, a midline shift of more than 5 mm, or the presence of neurological deterioration.[9] In the present case, persistent bleeding from the MMA was observed. However, due to difficulties in arranging an operating room, along with the patient's relatively preserved level of consciousness and absence of mass effect on imaging, craniotomy was not performed. Instead, hemostasis was achieved with MMAE, which was considered effective in preventing potential neurological deterioration. The patient initially presented with only mild disturbance of consciousness (GCS E4V4M6). After MMAE, his level of consciousness improved to GCS E4V5M6. The reduction of the hematoma observed on postoperative CT was considered to be attributable to the embolization. According to Suzuki et al, the average time required for hematoma absorption following MMAE is approximately 20 days.[6] [10] In our case, follow-up CT performed 1 month after embolization confirmed resolution of the hematoma, consistent with previous reports ([Fig. 4]).

Recent studies have shown that endovascular treatment can be a viable option for AEDH, especially with technological advancements that allow better catheter navigation into distal vessels.[1] [2] [3] [4] [5] [6] [7] [8] Suzuki et al reported that in cases of conservatively manageable hematomas or bilateral lesions, MMAE offers a less invasive alternative with favorable outcomes.[6] Our patient also fell into this category and responded well to the embolization approach. Peres et al reported that epidural hematomas associated with skull fractures involving disruption of the MMA may experience delayed hematoma expansion due to secondary rebleeding. In cases where craniotomy is not deemed necessary, they recommend embolization of any abnormal vessels identified on angiography.[11] [12] In the present case, given the patient's relatively preserved consciousness and the inability to perform immediate craniotomy, MMAE was chosen and resulted in a favorable outcome. When comparing conservative management with MMAE, the former typically requires intensive monitoring in an intensive care unit setting. Should neurological deterioration occur—including decreased consciousness—emergency surgery becomes necessary. However, hematoma enlargement can sometimes be rapid, and even with timely intervention, prognosis may be poor. Therefore, MMAE may offer advantages in terms of early hematoma stabilization and reducing the need for repeated imaging. In our case, near-complete hematoma resolution was achieved 1 month after embolization, supporting the necessity and effectiveness of the endovascular intervention.[10] [11]

 

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Conclusion

We report a case of AEDH with persistent arterial bleeding that was successfully managed with MMAE. In selected cases without significant mass effect or severe neurological symptoms, endovascular treatment may serve as an effective, less invasive alternative to emergency craniotomy.

 

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Conflict of Interest

None declared.

• References

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Publikationsverlauf

Artikel online veröffentlicht:
18. September 2025