Middle Meningeal Artery Embolization Using Combined Particle Embolization and n-BCA with the Dextrose 5% in Water Push Technique for Chronic Subdural Hematomas: A Prospective Safety and Feasibility Study

Abstract

Background and purpose: Embolization of the middle meningeal artery for treatment of refractory or recurrent chronic subdural hematomas has gained momentum during the past few years. Little has been reported on the use of the n-BCA liquid embolic system for middle meningeal artery embolization. We present the technical feasibility of using diluted n-BCA for middle meningeal artery embolization.

Materials and methods: We sought to examine the safety and technical feasibility of the diluted n-BCA liquid embolic system for middle meningeal artery embolization. Patients with chronic refractory or recurrent subdural hematomas were prospectively enrolled from September 2019 to June 2020. The primary outcome was the safety and technical feasibility of the use of diluted n-BCA for embolization of the middle meningeal artery. The secondary end point was the efficacy in reducing hematoma volume.

Results: A total of 16 patients were prospectively enrolled. Concomitant burr-hole craniotomies were performed in 12 of the 16 patients. Two patients required an operation following middle meningeal artery embolization for persistent symptoms. The primary end point was met in 100% of cases in which there were no intra- or postprocedural complications. Distal penetration of the middle meningeal artery branches was achieved in all the enrolled cases. A 7-day post-middle meningeal artery embolization follow-up head CT demonstrated improvement (>50% reduction in subdural hematoma volume) in 9/15 (60%) patients, with 6/15 (40%) showing an unchanged or stable subdural hematoma. At day 21, available CT scans demonstrated substantial further improvement (>75% reduction in subdural hematoma volume).

Conclusions: Embolization of the middle meningeal artery using diluted n-BCA and ethiodized oil (1:6) is safe and feasible from a technical standpoint. The use of a dextrose 5% bolus improves distal penetration of the glue.

FIG 1.

Treatment course of a 77-year-old man with bilateral cSDH. Noncontrast axial head CT reveals bilateral subacute-on-chronic SDHs on admission (A). Diagnostic cerebral angiogram reveals robust filling of the MMA (B). The MMA was then embolized using n-BCA diluted with D5W (C). Postprocedural spin sequence reveals the glue cast left in the MMA (D). Noncontrast head CT at 3 months reveals significant resolution of the patient's SDHs (E and F).

FIG 2.

Imaging course of a 75-year-old woman with bilateral cSDHs managed by unilateral burr-hole evacuation followed by bilateral MMA embolization. Noncontrast head CT images were obtained on presentation (A), postoperatively (B), 1 week postembolization (C), and 4 months postembolization (D).