Safety and Efficacy of Combined Middle Meningeal Artery and CSF Venous Fistula Embolization in Treatment of Spontaneous Intracranial Hypotension with Concurrent Subdural Fluid Collection.

INTRODUCTION: Fistulas forming between cerebrospinal fluid (CSF) and spinal veins is a common cause of spontaneous intracranial hypotension (SIH) with subdural fluid collections(SDFC). CSF-venous fistulas embolization (CVFE) can be performed with a combined middle meningeal artery embolization (MMAE) to close the fistula and treat the SDFC.

OBJECTIVE: Assess the safety and efficacy of combined MMAE and CVFE treatment.

METHODS: We performed a retrospective cohort study of 40 patients who underwent combined MMAE and CVFE or CVFE alone with SIH and SDFC at a single institution. Patients deemed nonsurgical candidates were excluded. Their demographics, clinical outcomes, and complications were reviewed.

RESULTS: 18 patients who underwent combined embolization were compared to 22 patients who underwent CVFE alone. The median age at embolization was 69 years for the CVFE only group and 66 years for the combined group. 19/22 (86%) patients experienced complete or significant improvement in symptoms in the CVFE only group versus 15/18 (83%) in the combined group. One patient in the dual embolization group had repeat SDFC while three patients in the CVFE only group had repeat SDFC. One patient in both groups experienced no improvement or worse clinical outcomes after the procedure. No patients in either group experienced any procedural complications.

CONCLUSION: Combined MMAE and CVFE was not found to have worse clinical outcomes or higher complication rates when compared to CVFE alone. In patients presenting with SDFC with CSF-venous fistula, combined embolization may be a potential therapy that can address all symptoms.