PMC9168304_01
Imaging history of the patient before middle meningeal artery (MMA) embolization: the patient had bilateral biconvex lenticular hematoma (a). Bilateral burr hole irrigation was performed (b). Two months after his discharge, the hematoma was recurred (c), and MRI showed high DWI image (d). After the craniotomy for the right hematoma (e), the right side hematoma recurred in 2 weeks (f).
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F1
The head CT showed bilateral convex lenticular hematomas with relatively high density but no calcification [Figure 1a]. The bilateral hematomas showed almost no leakage of fluid, even after incision of the hematoma outer membrane, and the operation was completed after cleaning the hematoma cavity as much as possible through perforation and placing a drainage tube in the hematoma cavity [Figure 1b]. Although the CSDH had not increased significantly since the last time [Figure 1c], there was a compression of the brain parenchyma, so a craniotomy was proposed to remove the hematoma. Magnetic resonance imaging (MRI) showed high signal in diffusion-weighted imaging around the outer membrane of both bilateral hematomas [Figure 1d], so the possibility of infectious OSDH was considered at this time, and craniotomy under general anesthesia was planned for the right-sided hematoma [Figure 1e], which had greater hematoma volume. Two weeks after surgery, a CT scan showed recurrence of the right hematoma [Figure 1f].
Middle meningeal artery (MMA) embolization was performed. The left external carotid artery imaging showed the vascular foci feeding the hematoma mainly in the parietal region (a: white arrows), and embolization with 20% n-butyl-2-cyanoacrylate (NBCA) was performed (b: black arrows). The right external carotid artery imaging showed no abnormal vessels reaching the hematoma due to the postoperative craniotomy (c), but the remaining MMA branch was embolized with 20% NBCA (d).
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F2
The MMA embolization revealed that the left external carotid artery imaging showed the vascular foci feeding the hematoma [Figure 2a: white arrows], mainly in the parietal region, and embolization with 20% NBCA was performed [Figure 2b: black arrows]. The right external carotid artery selective imaging showed no abnormal vessels reaching the hematoma due to the postoperative craniotomy [Figure 2c], but the remaining MMA branch was embolized with 20% NBCA [Figure 2d].
The day after embolization, we performed craniotomy for the left hematoma. The findings of the left craniotomy were the same as those of the right craniotomy. Yellow outer membrane (a), hard hematoma (b), and complete exposure of the inner membrane after removal of hematoma (c).
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F3
The findings of the left craniotomy were the same as those of the right craniotomy: yellow outer membrane [Figure 3a], hard hematoma [Figure 3b], and complete exposure of the inner membrane after removal of hematoma [Figure 3c].
After the craniotomy for the left hematoma and drainage for the right hematoma (a), we followed computed tomography at postoperative day 7 (b), postoperative month 1 (c), and month 6 (d). Each side hematomas are almost disappeared.
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F4
The course of imaging findings after surgery is shown in [Figure 4]. The CT scan just after surgery shows a drain tube inserted into the right hematoma cavity [Figure 4a].We are taking CT scans of his head 1 week [Figure 4b], 1 month [Figure 4c], and six months after the surgery.