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Abstract
Introduction Several recent RCT have demonstrated the benefit of middle meningeal artery embolization (MMAE) for chronic subdural hematoma (cSDH) with respect to minimizing risk of recurrence or need for repeat surgery. The procedure is typically performed via femoral or radial arterial access, and recently has been described via percutaneous access of the superficial temporal artery. This is the first described report of MMAE via direct percutaneous access of the external carotid artery ECA).
Methods A 70M presented with worsening HA and had progressive R>L acute on cSDH with R to L shift, after a fall 1 mo earlier. He underwent surgical evacuation of the larger R cSDH and was referred for MMAE. He also had a complex dissecting aortic aneurysm, with dissection flap extending into the innominate and both common carotid arteries via bovine arch. Due to risk of worsening the dissection or stroke via radial/femoral access, L MMAE was offered via direct LECA access. R MMAE was not offered given surgical evacuation with stable follow-up CT, and to mitigate unnecessary procedural risk. Informed consent was obtained. Under GA, the left neck was prepped and draped in sterile fashion. The L CCA, ICA, and ECA were identified with US. Small skin incision was made in the neck and the L ECA was accessed with a micropuncture needle under US guidance at the level of the proximal internal maxillary artery (IMA). The needle was exchanged over a .018’ wire for a 5F dilator, which was advanced into the left IMA and connected to an RHV and continuous flush. A Headway 21 microcatheter was advanced over a Synchro Select Soft .014’ wire into the L MMA. The anterior and posterior divisions of the MMA were embolized with 150–250 µ PVA particles followed by a single coil. Follow-up angiography demonstrated satisfactory occlusion. The 5F dilator was removed and hemostasis achieved with a 5F Celt closure device deployed under US guidance.
Results Patient recovered well with no new neuro symptoms and no neck hematoma. Follow-up CT at 3 mo showed near complete resolution of bilateral cSDH, and patient remained neuro intact.
Conclusion Several recent trials have demonstrated a clear benefit for MMAE in the management of cSDH. Traditional approaches via femoral or radial access are efficient and safe, and direct percutaneous STA access has recently been reported. Direct percutaneous ECA access for MMAE may prove a useful tool in certain high risk patient populations.
Disclosures T. Sivapatham: None.