Subdural hematoma: Preventing recurrence with a three-step Onyx embolization

Patient situation

A 61-year-old patient presented externally with a several-day history of right leg weakness.

MRI identified a left-sided space-occupying chronic subdural hematoma as the underlying cause.

He was transferred for surgical management of the cSDH.

On the same day, a burr hole trepanation was performed with hematoma evacuation and drainage placement.

Embolization of the middle meningeal artery to prevent cSDH recurrence was performed during the same hospital stay.

Treatment chosen

Set up

• General anaesthesia
• Right femoral artery puncture (5-French short sheath)
• 5F Envoy Catheter
• Marathon Microcatheter
• Chikai 008 Microwire
• 2 Vials Onyx18 liquid embolic agent

After visualization of the internal and external carotid arteries, the Envoy catheter was placed in the maxillary artery.

ECA

MMA

Step 1 – The frontal branch

Navigation of the first frontal branch using a Marathon microcatheter.

Occlusion with Onyx18.

Step 2 – The parietal branch

Occlusion with Onyx18.

Step 3 – The petrosquamosal branch

Occlusion of the petrosquamosal branch due to its collateral supply to the dorsal parietal branch.

Final result

After the occlusion of three branches of the middle meningeal artery.

 

Outcome

The patient was discharged without neurological deficits the day after embolization. A follow-up CT scan three weeks later showed a markedly reduced residual hematoma.

Post-embolization CT scan

Three-week follow-up CT scan

Supported by Medtronic