Endovascular management of acute epidural hematomas: clinical experience with 80 cases

Abstract

OBJECTIVE Small acute epidural hematomas (EDHs) treated conservatively carry a nonmeasurable risk of late enlargement due to middle meningeal artery (MMA) lesions. Patients with EDHs need to stay hospitalized for several days, with neurological supervision and repeated CT scans. In this study, the authors analyzed the safety and efficacy of the embolization of the involved MMA and associated lesions. METHODS The study group consisted of 80 consecutive patients harboring small- to medium-sized EDHs treated by MMA embolization between January 2010 and December 2014. A literature review cohort was used as a control group. RESULTS The causes of head injury were falls, traffic-related accidents (including car, motorcycle, and pedestrian vs vehicle accidents), and assaults. The EDH topography was mainly temporal (lateral or pole). Active contrast leaking from the MMA was seen in 57.5%; arteriovenous fistulas between the MMA and diploic veins were seen in 10%; and MMA pseudoaneurysms were found in 13.6% of the cases. Embolizations were performed under local anesthesia in 80% of the cases, with N-butyl-2-cyanoacrylate, polyvinyl alcohol particles, or gelatin sponge (or a combination of these), obtaining MMA occlusion and complete resolution of the vascular lesions. All patients underwent follow-up CT scans between 1 and 7 days after the embolization. In the 80 cases in this series, no increase in size of the EDH was observed and the clinical evolution was uneventful, without Glasgow Coma Scale score modification after embolization and with no need for surgical evacuation. In contrast, the control cohort from the literature consisted of 471 patients, 82 (17.4%) of whom shifted from conservative treatment to surgical evacuation. CONCLUSIONS This study suggests that MMA embolization is a highly effective and safe method to achieve size stabilization in nonsurgically treated acute EDHs.

Application of Absolute Alcohol in the Treatment of Traumatic Intracranial Hemorrhage via Interventional Embolization of Middle Meningeal Artery

“…To begin with, small EDHs are usually treated conservatively. Nevertheless, in some large samples of EDHs, it was found that the rate of re-expansion of hematoma after conservative treatment reached 5.5~65% ( 9 , 28 ). Sakai et al showed that 65% of small EDHs re-expansion in the first 24 h after trauma ( 29 ).…”

“…A prospective study evaluating 22 patients who had small EDHs showed that 32% of the patients underwent surgical evacuation because of late enlargement ( 30 ). Furthermore, most studies of EDHs suggest that EDHs are related to tearing or damage to the MMA, seen as contrast agent extravasation, pseudoaneurysm, or arteriovenous fistula in DSA ( 28 , 31 ). However, the best treatment option for EDH in larger or occipital and non-middle meningeal arterial blood supply areas remains surgery ( 32 ).…”

“…The reason why our patients did not use urokinase was that our patients had a relatively small amount of hematoma, MMA embolization and burr-hole drainage without urokinase was enough for preventing hematoma expansion and removing the occupying effect of hematoma. Peres et al and Ross et al demonstrated that MMA embolization was highly effective and safe to achieve size stabilization in non-surgically-treated AEDH ( 28 , 40 ).…”

“…If a dangerous anastomosis is observed, embolization injection should be performed carefully. Studies have reported the presence of extracranial–intracranial anastomoses of the external carotid artery with an average diameter of > 100 um ( 10 , 28 , 42 ). Generally, previous studies used embolization materials with a diameter much larger than the diameter of the anastomoses; therefore, no complications were seen related to the embolization material entering the intracranial blood vessels through the anastomosis and leading to cerebral infarction or cranial nerve dysfunction.…”

Craniofacial Trauma and Vascular Injury

“…To reduce the economic burden, effect of added radiation, and risk of sudden clinical deterioration, the MMA can be embolized. 39 Angiography may reveal laceration, pseudoaneurysm, or an AVF. Enlarging EDH can occur up to 30 days after trauma.…”