Preemptive Surgical Coagulation of the Middle Meningeal Artery via Keyhole Approach to Prevent Contralateral Epidural Hematoma Expansion and Intraoperative Brain Swelling: A Comparative Case Report.

Acute intraoperative brain swelling in the course of decompressive surgery of traumatic brain injury (TBI) is a disastrous complication, which is usually fueled by the rapid growth of a contralateral epidural hematoma (EDH) after the tamponade effect has been released. We report 2 patients with almost identical bilateral TBI profiles (left subdural hematoma/contusion and right thin EDH with skull fracture) who were treated using opposite approaches. In the control case, left-sided decompression with gradual opening of the dura led to massive intraoperative cerebral edema due to rapid expansion of the contralateral EDH, which eventually caused death. The preemptive approach was used in the intervention case: the right-sided EDH was operated on first through a keyhole craniotomy, and the middle meningeal artery (MMA) was cauterized and divided at the foramen spinosum. The next left-sided decompression was easy without any swelling of the brain, and the patient made a good recovery (GCS 15). Preemptive surgical coagulation of the MMA at the foramen spinosum is an effective, safe method to avoid contralateral EDH expansion during decompression.