A case of refractory chronic subdural hematoma and internal carotid artery stenosis sequentially treated with surgical drainage, middle meningeal artery embolization, and carotid artery stenting
- Department of Neurosurgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama,
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan.
Ryotaro Imai, Department of Neurosurgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan.
DOI:10.25259/SNI_505_2022Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Ryotaro Imai1, Takenori Akiyama2, Katsuhiro Mizutani2, Masahiro Toda2. A case of refractory chronic subdural hematoma and internal carotid artery stenosis sequentially treated with surgical drainage, middle meningeal artery embolization, and carotid artery stenting. 05-Aug-2022;13:342
How to cite this URL: Ryotaro Imai1, Takenori Akiyama2, Katsuhiro Mizutani2, Masahiro Toda2. A case of refractory chronic subdural hematoma and internal carotid artery stenosis sequentially treated with surgical drainage, middle meningeal artery embolization, and carotid artery stenting. 05-Aug-2022;13:342. Available from: https://surgicalneurologyint.com/surgicalint-articles/11764/
Background: Both chronic subdural hematoma (CSDH) and ischemic cerebrovascular disease are commonplace in the clinical context, and their combination is sometimes experienced. We describe a unique and challenging case in which both therapeutic interventions were indispensable and performed in a sequential manner. This report aims to discuss the management of hemorrhagic and ischemic conditions where CSDH and carotid artery stenosis coexist.
Case Description: An 83-year-old male presented with the left cerebral infarction due to the left internal carotid artery (ICA) stenosis. The coexisting left CSDH was surgically drained first. Then, the left middle meningeal artery (MMA) was endovascularly embolized to prevent hematoma recurrence under antiplatelet therapy, before the left carotid artery stenting (CAS) was successfully conducted. The subdural hematoma gradually grew but remained asymptomatic. However, he later presented with another stroke due to the progressive right ICA stenosis that had been conservatively treated initially. Emergency right CAS was required eventually.
Conclusion: Under the circumstances where CSDH is present but antiplatelet therapy is inevitable, MMA embolization could be a reasonable treatment option to avoid additional surgical procedures. Furthermore, early intervention should be considered even for asymptomatic carotid stenosis in terms of shortening the administration period of antiplatelet agents.
Keywords: Chronic subdural hematoma, Internal carotid artery stenosis, Middle meningeal artery embolization
Both chronic subdural hematoma (CSDH) and ischemic cerebrovascular disease are common, and thus, their comorbidity is not rare; however, surprisingly, few reports exist where surgical interventions for both of them were necessary or considered.[
An 83-year-old male with a history of CSDH, previously treated with surgical drainage twice, presented with transient right hemiparesis. Head computed tomography showed the expansion of the left CSDH over 2 years [
On admission, the expansion of the left chronic subdural hematoma was observed (b), compared to the finding 2 years before (a). Diffusion-weighted images showed the left watershed infarction between the anterior and middle cerebral arteries (c), which was resulted from the severe left carotid stenosis (d) with a T1 hyperintense plaque (e; arrowhead). Note that the contralateral carotid artery was also highly stenotic in the same degree. Intracranial large-vessel stenosis or occlusion was not present (f).
The transient right hemiparesis obviously resulted from the acute cerebral infarctions, which first required aspirin administration of 100 mg/day. Meanwhile, as the left CSDH expansion was expected under antiplatelet therapy, surgical drainage of the CSDH was concurrently performed. Furthermore, to avoid hematoma recurrence after upcoming carotid artery stenting (CAS) with long-term antiplatelet therapies, we conducted the left middle meningeal artery (MMA) embolization with platinum coils and n-butyl-2-cyanoacrylate (NBCA) 13 days after the evacuation [
After the evacuation of chronic subdural hematoma (CSDH), the left middle meningeal artery (MMA) embolization was conducted. Angiography showed stains of the hematoma membrane and two frontal branches of the MMA were identified as feeders: one running anteriorly (1) and another superiorly (2). The former was embolized with platinum coils since the anastomosis to the internal carotid artery (ICA) through the ophthalmic artery was present (a), whereas the latter was treated with n-butyl-2-cyanoacrylate (b). The stains completely disappeared after embolization (c). Afterward, the left CAS was performed using a distal balloon protection device (d and e). Computed tomography scans over time showed the gradual expansion of the left CSDH in 2 months since the surgical drainage (f and g).
The patient was discharged with no complications. The left CSDH, though still asymptomatic, gradually expanded in 2 months [
Diffusion-weighted images on the second admission showed acute cerebral infarction in the right middle cerebral artery territory (a). Magnetic resonance angiography revealed the right internal carotid artery occlusion and collateral circulation through the anterior communicating artery (b). The emergency right carotid artery stenting was necessary the next day (c and d), resulting in the flow restoration in the right cerebral hemisphere (e).
When both hemorrhagic and ischemic conditions coexist, we should assess how they will affect each other and progress in the future before formulating a treatment strategy. CSDH sometimes complicates or has a history of ischemic cerebrovascular diseases, and both of them tend to occur in middle-aged and older adults. The prevalence of CSDH incidentally combined with brain infarction or its history has been reported from 4% to 18%.[
Antithrombotic agents for cerebral ischemia are essential, while they increase the risk of CSDH growth. An infarction lesion is irreversible; meanwhile, the symptoms of CSDH can be reversible with drainage procedures. Thus, the treatment of ischemia should be a priority, unless the mass effect of CSDH is immediately fatal. In this case, the initial surgical evacuation of CSDH before antiplatelet agents became effective, was a reasonable strategy. However, surgery alone cannot always control CSDH. Additional treatment options include endovascular therapy. MMA embolization for CSDH was first reported in 2000[
In this case, additional MMA embolization did not have a complete curative effect on CSDH. As discussed above, the well-developed collateral circulation through the ECA system might have increased the vascularity of the dura and accounted for refractory CSDH. Furthermore, aspirin combined with clopidogrel increased the risk of CSDH.[
The right ICA was eventually occluded after clopidogrel discontinuation in the present case. Retrospectively, when and how to make an intervention for the right carotid stenosis, which was initially asymptomatic, is a considerable concern. Since DAPT longer than 3 months increases the risk of hemorrhagic complications,[
The case presented is unique in that both CSDH and ischemic cerebrovascular diseases required sequential interventions and challenging consideration of the treatment strategy. If CSDH is combined with cerebral ischemia requiring antiplatelet therapy, MMA embolization may contribute to avoiding additional surgical procedures for CSDH. The effect of MMA embolization on hematoma reduction still needs to be verified and the embolization should be conducted on the condition that dangerous anastomoses are not affected. At the same time, we should develop a treatment strategy so as to shorten the administration period of DAPT while CSDH is present. Thus, early intervention might be considered even for asymptomatic carotid stenosis. The overall treatment policy should be decided on a case-by-case basis.
The authors certify that they have obtained all appropriate patient consent.
There are no conflicts of interest.
1. Bakheet MF, Pearce LA, Hart RG. Effect of addition of clopidogrel to aspirin on subdural hematoma: Meta-analysis of randomized clinical trials. Int J Stroke. 2015. 10: 501-5
2. Coutts SB, Simon JE, Hudon ME, Demchuk AM. What is causing crescendo transient ischemic attacks?. Can J Neurol Sci. 2003. 30: 171-3
3. Gonugunta V, Buxton N. Warfarin and chronic subdural haematomas. Br J Neurosurg. 2001. 15: 514-7
4. Guha D, Coyne S, Macdonald RL. Timing of the resumption of antithrombotic agents following surgical evacuation of chronic subdural hematomas: A retrospective cohort study. J Neurosurg. 2016. 124: 750-9
5. Haldrup M, Ketharanathan B, Debrabant B, Schwartz OS, Mikkelsen R, Fugleholm K. Embolization of the middle meningeal artery in patients with chronic subdural hematoma-a systematic review and meta-analysis. Acta Neurochir (Wien). 2020. 162: 777-84
6. Kan P, Maragkos GA, Srivatsan A, Srinivasan V, Johnson J, Burkhardt JK. Middle meningeal artery embolization for chronic subdural hematoma: A multi-center experience of 154 consecutive embolizations. Neurosurgery. 2021. 88: 268-77
7. Kudo K, Naraoka M, Shimamura N, Ohkuma H. Chronic subdural hematoma (CSH) complicated by bilateral occipital lobe infarction: Two case reports. No Shinkei Geka. 2013. 41: 319-22
8. Link TW, Boddu S, Paine SM, Kamel H, Knopman J. Middle meningeal artery embolization for chronic subdural hematoma: A series of 60 cases. Neurosurgery. 2019. 85: 801-7
9. Maki Y, Hattori E, Satow T, Komuro T, Miyamoto S. Carotid artery stenting for symptomatic internal carotid artery stenosis associated with moyamoya disease. World Neurosurg. 2019. 123: 76-80
10. Mandai S, Sakurai M, Matsumoto Y. Middle meningeal artery embolization for refractory chronic subdural hematoma. Case report. J Neurosurg. 2000. 93: 686-8
11. Mori K, Maeda M. Surgical treatment of chronic subdural hematoma in 500 consecutive cases: Clinical characteristics, surgical outcome, complications, and recurrence rate. Neurol Med Chir (Tokyo). 2001. 41: 371-81
12. Otsuka T, Ito M, Kinkori T, Nishii T, Hayashi S, Kuwayama N. A case of refractory chronic subdural hematoma treated by repeated middle meningeal artery embolization. The difference between embosphere and n-butyl-2-cyanoacrylate (NBCA). No Kekkannai Chiryo. 2019. 4: 103-9
13. Saito H, Tanaka M, Hadeishi H. Angiogenesis in the septum and inner membrane of refractory chronic subdural hematomas: Consideration of findings after middle meningeal artery embolization with low-concentration n-butyl-2-cyanoacrylate. NMC Case Rep J. 2019. 6: 105-10
14. Srivatsan A, Mohanty A, Nascimento FA, Hafeez MU, Srinivasan VM, Thomas A. Middle meningeal artery embolization for chronic subdural hematoma: meta-analysis and systematic review. World Neurosurg. 2019. 122: 613-9
15. Yamada SM, Tomita Y, Takaya Y. Lacunar infarction caused by chronic subdural hematoma. Neurol Med Chir (Tokyo). 2020. 60: 397-401
16. Yoshikawa M, Yamamoto M, Shibata K, Ohta K, Kamite Y, Takahashi M. Hemichorea associated with ipsilateral chronic subdural hematoma case report. Neurol Med Chir (Tokyo). 1992. 32: 769-72
17. Zhang Q, Wang C, Zheng M, Li Y, Li J, Zhang L. Aspirin plus clopidogrel as secondary prevention after stroke or transient ischemic attack: A systematic review and meta-analysis. Cerebrovasc Dis. 2015. 39: 13-22