Abstract

Background: Traumatic cerebrovascular injury may result in epidural hematoma (EDH) from laceration of the middle meningeal artery (MMA), which is a potentially life-threatening emergency. Treatment ranges from surgical evacuation to conservative management based on a variety of clinical and imaging factors.

Case Description: A 14-year-old male presented to our institution after falling from his bicycle with traumatic subarachnoid hemorrhage and a right frontotemporal EDH. The patient did not meet criteria for surgical evacuation and endovascular embolization of the right MMA was performed. Rapid resolution of the EDH was observed.

Conclusion: This case corroborates the sparse existing literature for the potential role of endovascular embolization to treat acute EDH in carefully selected patients who do not meet or have borderline indications for surgical management.

Keywords: Endovascular procedures, Epidural hematoma, Meningeal arteries, Traumatic cerebral hematoma, Traumatic subarachnoid hemorrhage

INTRODUCTION

Traumatic epidural hematoma (EDH) is typically associated with a skull fracture and laceration of the meningeal artery.[ 18 , 36 , 41 ] Treatment decisions depend on the severity of the patient’s injury and neurological condition. In most scenarios, surgical evacuation is the treatment of choice, but in patients who do not meet surgical criteria, conservative management with serial imaging is performed to monitor the EDH.

The increasing use of endovascular therapies has reduced mortality rates associated with cerebrovascular injuries and disease.[ 7 , 31 ] However, few reports of embolization in the setting of EDH have been published, only two of which were performed in the United States.[ 32 , 42 ] We describe a rare case of blunt trauma causing subarachnoid hemorrhage (SAH) and frontotemporal EDH in a pediatric patient that was treated successfully through endovascular coil embolization of the right middle meningeal artery (MMA). The positive result in this case demonstrates the technical feasibility of performing embolization to expedite EDH regression in appropriately selected patients who do not meet or have borderline indications for surgery.

CASE REPORT

Patient history

A 14-year-old male presented to our facility after falling from his bicycle. He had lacerations on the right parietal area of his scalp and mild confusion that resolved quickly. He had lost consciousness for 1–2 min but remembered the events up to and through the traumatic incident. At the time of the original trauma, he had no associated vomiting, weakness, numbness, blurry vision, double vision, or neck pain and was not on blood thinning medication.

Clinical findings

At presentation, neurological examination was benign with no focal neurologic deficits. The patient then began to have large volume emesis and increasing lethargy in the emergency department (ED), although he remained clinically stable. A head CT was performed which showed an EDH in the right frontotemporal region, measuring up to 7 mm in transverse dimension, with additional thin subdural hemorrhage extending along the lateral margin of the right temporal lobe [ Figure 1 ]. Acute SAH and a small hemorrhagic contusion of the lateral left temporal lobe were also present, as well as a 3 mm thickness acute subdural hematoma along the left tentorial leaflet. There was evidence of an acute, nondepressed fracture of the anterior right parietal bone associated with a scalp laceration, propagating through the anterior squamous portion of the right temporal bone into the greater wing of the right sphenoid bone. After a discussion with the neurosurgery and ED teams, embolization was requested with no indication for open surgical evacuation. The patient’s parents provided consent for treatment and the patient was taken to the neuroangiography suite in stable condition.

Figure 1:

Preembolization coronal plane reformatted CT image demonstrating a small epidural hematoma over the right hemispheric convexity.

Therapeutic intervention

Following diagnostic angiography [ Figure 2 ], the right MMA was embolized with coils. Due to robust ophthalmic region anastomoses, polyvinyl alcohol particles were not used. With a 6 French catheter in the right external carotid artery (ECA), a microcatheter was used to subselectively catheterize the right MMA over a micro-guidewire. Microcatheter angiography confirmed appropriate catheter positioning before subsequent embolization. Embolization was performed by instilling three fibered microcoils through the microcatheter into the right MMA. The right ECA angiography demonstrated complete occlusion of the right MMA postembolization [ Figure 3 ]. At this point, the procedure was concluded and all catheters were removed from the patient. A total of 60 cc of Omnipaque 300 were administered. Total fluoroscopic time was 8.6 min, and Air Kerma dose was 469.41 mGy. A pediatric neurosurgeon was present from admission to the ED, throughout the embolization procedure, and after the procedure to monitor the patient. An operating room (OR) was kept on standby if emergent craniotomy was needed.

Figure 2:

Frontal (left) and lateral (right) microangiography of the right MMA without evidence of pseudoaneurysm or active extravasation.

Figure 3:

ECA angiography, lateral view, demonstrating coil occlusion of the MMA proximal trunk.

Follow-up and outcomes

There were no apparent complications, and the patient awoke from general anesthesia at his preprocedure neurologic baseline [ Figure 4 ]. The patient is neurologically intact with full recovery other than mild residual right lower extremity pain at 2-month follow-up.

Figure 4:

Postembolization coronal plane reformatted CT image postprocedure day 1 demonstrating markedly decreased size of the hematoma.

DISCUSSION

In this case, a traumatic cerebrovascular injury with EDH was quickly resolved following endovascular coil embolization in a pediatric patient. This case demonstrates the potential role of endovascular coil embolization to treat acute EDH in carefully selected patients.

Cerebrovascular injuries occur in approximately 1% of all blunt traumatic brain injuries[ 12 ] and represent emergency situations with high rates of mortality.[ 1 ] Such injuries typically present with carotid artery and vertebral artery injury,[ 2 , 14 ] requiring prompt treatment through carefully selected interventions. Patients with an EDH volume >30 mL, thickness >15 mm, a midline shift >5 mm, or clinical deterioration are typically offered surgical treatment;[ 4 ] however, endovascular therapy has been used with success in patients with EDH when open clot evacuation is not required. A review of the literature, including the present case, revealed 15 articles of embolization for EDH in 153 patients [ Table 1 ].[ 3 , 5 , 8 , 19 , 21 , 22 , 24 , 27 , 29 , 32 , 36 , 39 , 41 , 42 ] In 98.0% of cases (150/153), EDH occurred due to traumatic injury; 1 case (0.69%) was caused by a nontraumatic dural arteriovenous fistula.[ 39 ] The MMA was embolized in all cases (100%), leading to successful outcome with no complications in all but 1 complicated case, where the patient died of hypoxic injury and medical conditions 2 months after treatment for intracranial hemorrhage requiring an external ventricular drain.[ 27 ] Of note, only 2 of the embolization procedures in our literature review were performed in the United States, one of which was recently published in 2019.[ 32 , 42 ]

Table 1:

Literature review of epidural hematomas treated with embolization.

A recent study by Peres et al. reported results of 80 patients with acute, mainly temporal, EDH treated endovascularly.[ 29 ] The causes of head injury were falls, traffic-related accidents, and assaults. Contrast extravasation from the MMA was observed in 57.5% of patients. Embolizations were performed with N-butyl-2-cyanoacrylate, polyvinyl alcohol particles, or gelatin sponge (either alone or in combination), resulting in MMA occlusion and complete resolution in all cases. All patients had follow-up CT scans between 1 and 7 days postprocedure. No increase in size of the EDH was observed and the clinical evolution was uneventful, with no need for surgical evacuation. In addition, the author reported a historical cohort of 471 patients, 82 (17.4%) of whom were managed conservatively and eventually required surgical evacuation.

EDH occurs in approximately 6% of traumatic brain injuries in pediatric patients.[ 9 - 11 , 16 ] Management has not been standardized in this patient population through large prospective trials or professional society guidelines, particularly in patients with small EDH and no neurological deficits. Many studies in the pediatric population have reported high rates of good outcomes with conservative management.[ 6 , 9 , 10 , 17 , 20 , 25 , 26 ] Given the potential for EDH progression, repeated monitoring through CT imaging is routinely performed in cases managed conservatively. However, authors have recently argued against this practice in the absence of clinical signs, given the low percentage of patients with EDH progression and the risks associated with radiation exposure in young patients.[ 11 , 33 ] Radiation exposure from a head CT in pediatric patients ranges from 40 to 60 mGy per scan.[ 28 , 34 , 35 ] While endovascular procedures expose patients to significant radiation doses, this technique can quickly resolve EDH and reduce the need for repeated imaging over a prolonged period of time in carefully selected patients that are not otherwise candidates for surgery. Conservative management requires extended, close ICU monitoring for signs of clinical deterioration that may require emergent operative intervention. Hematoma expansion can be rapid enough that poor outcomes may occur even with prompt, much less delayed, OR management. Therefore, this technique may ultimately lead to cost savings with rapid hematoma stabilization, earlier discharge, and less repetitive imaging utilization.

Embolization procedures involving the MMA should only be performed by experienced neurointerventionalists familiar with head-and-neck vascular neuroanatomy, given the known potential anastomoses and variant collaterals between the MMA and the ophthalmic artery or facial arcade.[ 13 , 15 , 30 , 37 , 40 ] Embolization in these cases may lead to retinal or cranial nerve ischemic injury.[ 23 , 38 , 40 ] Thus, consideration of this technique as an alternative to conservative management assumes an acceptably low procedural complication rate at any given center. Randomized, controlled studies comparing embolization and conservative management could be considered for borderline surgical cases within acceptable clinical parameters.

CONCLUSION

This case demonstrates that a positive outcome and quick resolution can be achieved following embolization for acute traumatic EDH in appropriately selected patients. This technique may be considered for patients who do not meet or have borderline indications for surgical evacuation where the alternative of conservative serial imaging is expected to be prolonged.

Declaration of patient consent

Patient’s consent not required as patients identify is not disclosed or compromised.

Financial support and sponsorship

This work was supported by a grant from the United Hospital Foundation.

Conflicts of interest

Jillienne C Touchette is CEO and has ownership interest in Superior Medical Experts.

Acknowledgments

The authors acknowledge Superior Medical Experts for research and drafting assistance.

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