Introduction Subdural hematomas (SDH), especially when recurring, pose a significant challenge in treatment. Middle Meningeal Artery (MMA) embolization has emerged as a promising method for managing chronic cases. Studies suggest its effectiveness in refractory cases with repeated recurrences. However, recurrence may still occur after embolization, necessitating further interventions like craniotomy, re-do ipsilateral MMA embolization of contra-lateral embolization.

Case Presentation An 85-year-old male with a history of recent falls presented to the emergency room for rapidly progressive left-sided weakness. His medical history included remote burr hole for a left-sided subdural hematoma, coronary bypass graft surgery, chronic renal insufficiency, and he was taking ASA. A CT scan revealed a large right-sided subdural hematoma (SDH) with significant mass effect, prompting surgical evacuation followed by transradial MMA embolization with 150–250 microns PVA particles (Contour, Boston Scientific) and coiling of a large meningo-lacrimal artery. Following this procedure, the patient showed neurological improvement and was discharged, with ASA discontinued. Follow-up CT scan at four weeks showed significant recurrent right SDH. Angiography of the right internal maxillary artery revealed complete occlusion of previously embolized right MMA. Angiography of the left MMA revealed multiple distal branches of the frontal and parietal division crossing the midline to supply convexal branches of the contralateral MMA and right sided SDH membranes. This was likely facilitated by patchy, segmental, and predominantly proximal distribution of the embolysate. The left MMA was then embolized with 150–250 microns PVA particles (Contour, Boston Scientific). At two months follow up, the SDH was almost completely resolved in head CT.

Conclusion Recurrent SDH after unilateral MMA embolization should prompt evaluation for contralateral MMA anastomosis. Contra-lateral MMA embolization should be considered as a viable treatment option.

Disclosures M. Asghariahmadabad: None. Y. Senol: None. A. Orscelik: None. L. Savastano: None.