CLINICAL ARTICLE J Neurosurg 128:1044–1050, 2018 A cute epidural hematoma (EDH) is one of the most dramatic and urgent traumatic brain injuries (TBIs). Patients frequently present with sudden neurological deterioration. In these cases, the most com- mon cause is a tearing of the middle meningeal artery (MMA) near the foramen spinosum. In such circumstanc- es, rapid clinical deterioration requires prompt surgical evacuation before the onset of brain dysfunction. 4 Small EDHs have not been adequately studied thus far, and their incidence, natural history, clinical relevance, and ideal management remains to be well established. 5,7,27 However, late enlargement of previously small hematomas is a well-recognized clinical occurrence. 25 One of the most hazardous events in the rupture of intracranial vessels is the relatively slow but continuous expansion of the hema- toma and sudden neurological deterioration. Traditionally, these patients need to stay in the hospital for several days or weeks under conservative management, including close neurological supervision and several repeated CT scans. 9 Recently, endovascular management of intracranial ABBREVIATIONS AVF = arteriovenous fistula; EDH = epidural hematoma; GCS = Glasgow Coma Scale; MMA = middle meningeal artery; NBCA = N-butyl-2-cyanoacry- late; OphA = ophthalmic artery; PVA = polyvinyl alcohol; SAH = subarachnoid hemorrhage; SDH = subdural hematoma; TBI = traumatic brain injury. SUBMITTED May 31, 2016. ACCEPTED November 7, 2016. INCLUDE WHEN CITING Published online April 14, 2017; DOI: 10.3171/2016.11.JNS161398. Endovascular management of acute epidural hematomas: clinical experience with 80 cases Carlos Michel A. Peres, MD, 1 Jose Guilherme M. P. Caldas, MD, PhD, 2 Paulo Puglia Jr., MD, 2 Almir F. de Andrade, MD, PhD, 3 Igor A. F. da Silva, MD, 3 Manoel J. Teixeira, MD, PhD, 3 and Eberval G. Figueiredo, MD, PhD 3 1 Hospital Universitário Francisca Mendes, Manaus; and Divisions of 2 Neuroradiology and 3 Neurosurgery, University of São Paulo School of Medicine, São Paulo, Brazil OBJECTIVE Small acute epidural hematomas (EDHs) treated conservatively carry a nonmeasurable risk of late en- largement due to middle meningeal artery (MMA) lesions. Patients with EDHs need to stay hospitalized for several days, with neurological supervision and repeated CT scans. In this study, the authors analyzed the safety and ef fcacy of the embolization of the involved MMA and associated lesions. METHODS The study group consisted of 80 consecutive patients harboring small- to medium-sized EDHs treated by MMA embolization between January 2010 and December 2014. A literature review cohort was used as a control group. RESULTS The causes of head injury were falls, traf fc-related accidents (including car, motorcycle, and pedestrian vs vehicle accidents), and assaults. The EDH topography was mainly temporal (lateral or pole). Active contrast leaking from the MMA was seen in 57.5%; arteriovenous fstulas between the MMA and diploic veins were seen in 10%; and MMA pseudoaneurysms were found in 13.6% of the cases. Embolizations were performed under local anesthesia in 80% of the cases, with N-butyl-2-cyanoacrylate, polyvinyl alcohol particles, or gelatin sponge (or a combination of these), obtaining MMA occlusion and complete resolution of the vascular lesions. All patients underwent follow-up CT scans between 1 and 7 days after the embolization. In the 80 cases in this series, no increase in size of the EDH was observed and the clinical evolution was uneventful, without Glasgow Coma Scale score modifcation after embolization and with no need for surgical evacuation. In contrast, the control cohort from the literature consisted of 471 patients, 82 (17.4%) of whom shifted from conservative treatment to surgical evacuation. CONCLUSIONS This study suggests that MMA embolization is a highly effective and safe method to achieve size stabi- lization in nonsurgically treated acute EDHs. https://thejns.org/doi/abs/10.3171/2016.11.JNS161398 KEY WORDS epidural hematoma; traumatic brain injury; middle meningeal artery; pseudoaneurysm; embolization; endovascular treatment; vascular disorders J Neurosurg Volume 128 • April 2018 1044 ©AANS 2018, except where prohibited by US copyright law Unauthenticated | Downloaded 07/18/21 03:39 PM UTC