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

Abstract

Background: Middle meningeal artery embolization (MMAE) is emerging as a promising treatment for chronic subdural hematoma (CSDH), serving both as an adjunct to surgery and as a primary therapeutic option depending on patient presentation. Due to its low recurrence rate and minimal complications, MMAE has gained increasing acceptance among clinicians in recent years. This report presents a case of diplopia following MMAE due to the presence of a potential anastomotic artery, aiming to enhance awareness of this complication.

Case summary: A 60-year-old male patient presented with a headache following head trauma, and cranial computed tomography revealed a left-sided CSDH. The patient underwent left MMAE; however, polyvinyl alcohol particles inadvertently flowed into the lacrimal artery through an anastomotic artery, resulting in diplopia due to impaired abduction of the left eye. The diplopia resolved by postoperative day 40. The patient's headache resolved by postoperative day 7, and the hematoma completely resolved by postoperative day 108.

Conclusion: Potential anastomotic arteries in the middle meningeal artery (MMA) can lead to serious complications. Superselective angiography of the MMA or its branches prior to embolization is essential. Performing embolization distal to potential anastomotic sites can reduce risks, and the presence of an anastomosis may warrant coil embolization or termination of the procedure.

Keywords: Anastomotic artery; Case report; Chronic subdural hematoma; Diplopia; Embolization; Middle meningeal artery.

Figure 1

Computed tomography and angiography. A: Brain computed tomography scan shows left chronic subdural hematoma; B: Middle meningeal artery (MMA) angiography revealed absence of detectable anastomotic artery along the anterior trunk; C: The tip of the microcatheter (white arrow) was placed distal to the main trunk of the anterior branch of the MMA for polyvinyl alcohol (PVA) injection; D: Lateral imaging of the microcatheter tip (white arrow) retracted due to intraoperative patient movement, revealing the anastomotic artery (black arrow) upon PVA injection; E: Anteroposterior view of PVA flowing through the long, tortuous sphenoidal artery (black arrow) to the lacrimal artery, which supplies the outer superior quadrant of the orbit; F: Reflux of PVA into the anastomotic artery (black arrow) during reinjection; G: Post-embolization contrast showing complete occlusion of the anterior and posterior branches of the MMA, with coils visible in the anterior branch (black arrow).