Pediatric middle meningeal artery embolization for chronic subdural hematoma: A case report

Abstract

Background: The most common neuroradiological finding in pediatric nonaccidental trauma (NAT) is subdural hematoma (SDH). Management options for pediatric SDH range from conservative clinical surveillance to craniotomy or decompressive craniectomy. The middle meningeal artery (MMA) indirectly feeds the hematoma; thus, MMA embolization is an alternative or adjunct to current surgical treatments in adults. Herein, we present, to the best of our knowledge, the first reported case of successful MMA embolization in a pediatric patient as an adjunct to current standard treatment for chronic SDH (cSDH). Case Description: An 18-month-old male with a history of NAT presented at 5 months of age with an acute right parietal skull fracture and bilateral SDH treated with burr hole drainage. He was lost to follow-up until 15 months of age with an increased head circumference and new dysconjugate gaze. Imaging revealed a right-sided cSDH and underwent craniotomy. Six-week follow-up revealed significant improvement in the SDH but cSDH remained at the periphery of the craniotomy’s reach. The patient symptoms continued. The right-sided MMA embolization was offered as option to avoid repeat craniotomy. Follow-up CTs at 2 weeks, 3 months, and 6 months postprocedure revealed decrease of cSDH size and density. At 8-month follow-up, the patient continued to meet developmental milestones with near resolution of his dysconjugate gaze. Conclusion: This case report details the first successful use of MMA embolization in the treatment of pediatric cSDH as an adjunct to standard treatment. Further investigation of MMA embolization in pediatrics should be made to expand options available for cSDH in this patient population.

Primary Middle Meningeal Artery Embolization for a Chronic Subdural Hematoma After Non-Accidental Trauma in a Child: A Case Report

“…Our case bears a resemblance to the study by Farber et al on a child who developed a chronic subdural from non-accidental trauma. However, unlike in their case, our patient's chronic subdural was treated entirely with embolization without concurrent hematoma evacuation [3]. Shigematsu et al report a single case of standalone MMA embolization for chronic subdural hematoma occurring secondary to antiplatelet and anticoagulant medication use while she was undergoing preparation for an eventual heart transplant [4].…”

“…MMA embolization is an evolving treatment option for chronic subdural hematoma. As of the writing of this paper, there are 15 clinical trials actively recruiting patients [3][4][5]. Embolization is theorized to stop a self-propagating cycle beginning with inflammation followed by angiogenesis of leaky capillaries, resulting in exudate formation and ultimately hematoma expansion [2].…”

“…Embolization is theorized to stop a self-propagating cycle beginning with inflammation followed by angiogenesis of leaky capillaries, resulting in exudate formation and ultimately hematoma expansion [2]. It has not been well studied in the pediatric population, with only two prior case reports in the literature to the best of our knowledge, as further described in Table 1 [3,4]. Our case bears a resemblance to the study by Farber et al on a child who developed a chronic subdural from non-accidental trauma.…”

“…Middle meningeal artery (MMA) embolization is a developing therapy that has been shown to aid the resorption of chronic subdural hematomas in the adult population and aid in preventing recurrence [2]. Its use in children has been reported only once in the literature, primarily in an adjunctive fashion to surgical therapy [3]. We review the literature and report the first case of utilizing MMA embolization as a standalone treatment to address chronic subdural hematoma after non-accidental trauma.…”

Endovascular Treatment of Chronic Subdural Hematomas through Embolization: A Pilot Study with a Non-Adhesive Liquid Embolic Agent of Minimal Viscosity (Squid)

“…The penetration of the embolic agent deep into the dependent vasculature of the MMA is considered crucial by most authors. The following embolic agents have been used and were reported together with good results: Polyvinyl alcohol particles (PVA) [ 2 , 28 , 29 , 37 , 38 ] Embospheres [ 39 , 40 ] n-butyl cyanoacrylate (nBCA) [ 25 , 36 , 39 , 41 ] PVA and nBCA [ 42 , 43 ] Absolute alcohol [ 44 ] Onyx [ 35 , 45 , 46 ] Phil: Pending Squid: Pending Coils [ 37 , 47 ]. …”