Combined interventional and craniotomy surgery for meningioma apoplexy complicated by acute subdural hematoma: a case report and literature review.

BACKGROUND

Spontaneous hemorrhage from meningiomas causing intracranial hematomas is rare (1%-2% of cases), and concurrent acute subdural hematoma (ASDH) is even rarer, which is easily misdiagnosed and may lead to inadequate preoperative planning. Combined endovascular-craniotomy hybrid surgery enables precise diagnosis and treatment, serving as an effective approach for complex intracranial lesions.

CASE PRESENTATION: A 34-year-old married female was admitted with a 4-day history of sudden headache. Cranial CT showed left temporal lobe hemorrhage and left frontoparietotemporal-occipital ASDH; CTA indicated a left temporal mass, subdural hematoma, sigmoid sinus compression, cerebral edema, and tortuous superficial vessels. Emergency hybrid surgery was conducted. Digital subtraction angiography (DSA) first ruled out intracranial vascular malformations and confirmed that the left temporal lesion was supplied by the temporal branch of the left middle meningeal artery (ball-holding sign). Given the tumor's location at the cerebral convexity with a relatively superficial distribution, combined with the potential risk of ischemic complications and aggravated cerebral edema secondary to preoperative endovascular embolization, preoperative embolization of tumor-feeding arteries was therefore omitted. Direct craniotomy was subsequently adopted as the definitive surgical approach. A left subtemporal craniotomy was subsequently performed, achieving gross total resection of the tumor (2 × 3 × 4 cm) and complete evacuation of the hematoma. Postoperative pathology confirmed angiomatous meningioma (WHO Grade Ⅰ) with hemorrhage. The patient recovered well without complications or neurological deficits, and no recurrence was noted at 1-year follow-up.

CONCLUSION

Combined endovascular-craniotomy hybrid surgery achieves integrated diagnosis and treatment through simultaneous endovascular evaluation and craniotomy, improving the efficiency and accuracy in the management of meningioma-related stroke complicated with ASDH. Preoperative endovascular embolization may be added for large, hypervascular tumors to reduce bleeding, but clinicians should remain vigilant for ischemic risks. Rational application of this hybrid surgery effectively improves patient prognosis.