Middle meningeal artery embolization for recurrent subdural hematoma in an extra-intracranial anastomosis patient on anticoagulant medication: A case report.

Symptomatic chronic subdural hematoma (cSDH) is amongst the most frequent neurological diseases with an upward trend due to an aging society and development in the field of anticoagulation therapies. Lately, subgaleal drainages and middle meningeal artery (MMA) embolization have been introduced to the standard armamentarium as treatment options for cSDH patients. Vascular anomalies, such as internal carotid artery (ICA) occlusion with spontaneous extra-intracranial anastomoses, usually lead to forfeiting embolization treatment from patients. This report presents a case of a 67-year-old male with a repeated recurrence of cSDH in conjunction with a history of middle cerebral artery territory stroke and consecutive platelet inhibition therapy. The patient was initially treated with a burr hole plus subgaleal and subdural drainage upon revision surgery. Due to repeated recurrence, MMA embolization was considered, even though an extra-intracranial anastomosis was present on angiography. The patient was deemed to be fully recovered three months after intervention and no further intervention was needed. We can conclude that MMA embolization is a feasible option also in patients with recurrent cSDH after territorial infarction secondary to ICA occlusion with present extra-intracranial anastomoses.