A 17-year-old previously healthy male was transferred to our Level I Trauma Center following an all-terrain vehicle rollover with a reported head strike. He denied loss of consciousness. On initial evaluation, the patient was awake, alert, and oriented with a Glasgow Coma Scale (GCS) score of 15.

Primary and secondary surveys revealed a scalp laceration (repaired at the outside hospital), left clavicle fracture, right wrist dislocation, right radius and ulna fractures, and facial pain. The neurological examination was non-focal. The patient was not intubated and remained hemodynamically stable throughout evaluation.

Initial non-contrast computed tomography (CT) of the head at the outside hospital demonstrated a small left frontal acute subdural hematoma (SDH) measuring approximately 5.8 × 0.8 × 2.0 cm. No evidence of calvarium fracture, hydrocephalus or midline shift. A repeat CT head approximately seven hours later demonstrated interval enlargement of the subdural hematoma to approximately 8.6 × 2.5 × 1.9 cm.

A subsequent CT head obtained about six hours later showed progression with development of a left acute epidural hematoma (EDH) measuring up to 2.8 cm in maximal thickness, associated with the acute subdural component. The radiographic appearance was worrisome for a middle meningeal artery injury. Despite radiographic progression, the patient remained neurologically intact without signs of elevated intracranial pressure or midline shift requiring emergent craniotomy.

Given the enlarging EDH, evidence of vascular injury, and preserved neurological status, a decision was made to proceed with diagnostic cerebral angiography and possible embolization. Patient proceeded to the radiology suite approximately 16 hours after arrival to the hospital. As the patient was without any degree of neurological decline and at baseline functional status, taking the patient to the operative suite for evacuation did not seem appropriate.

Angiography of the left external carotid artery demonstrated active contrast extravasation from the anterior branch of the left middle meningeal artery. Endovascular embolization was performed using platinum coils, achieving complete occlusion of the injured MMA branch and cessation of contrast extravasation (Figure 1(A),Figure 1(B), Figure 2(A),Figure 2(B)).

(A) (B)

Figure 1.Pre-embolization cerebral angiogram (A), (B).

(A) (B)

Figure 2. Post-embolization cerebral angiogram (A), (B).

Immediate post-embolization of CT imaging demonstrated stable epidural and subdural hematomas with minimal mass effect and no midline shift. Serial CT scans on hospital days 2 and 3 demonstrated stable findings without interval expansion (Figure 3(A), Figure 3(B)).

(A) (B)

Figure 3.Pre (A)-and post(B)-embolization CT of the brain findings with minimal mass effect and midline shift. The patient had serial head CT on hospital day (HD) 2 and 3 with stable findings noted.

The patient subsequently underwent orthopedic fixation of his clavicle and forearm fractures without complication. Facial CT revealed a nondisplaced pterygoid process fracture managed conservatively. He remained neurologically intact throughout hospitalization and was discharged home on hospital day 4 with outpatient neurosurgical follow-up. No delayed neurological complications were identified, including any unusual signs or symptoms during follow-up examinations. An outpatient CT of the head was done 64 days after the MMA procedure, which showed complete radiographic resolution of the EDH and SDH (Figure 4(A), Figure 4(B)).

(A) (B)

Figure 4. CT scan of the brain, 64 days post MMA. No residual EDH/SDH (A, red oval); MMA coil is demonstrated (B, red arrow).

A focused literature review was performed to identify published cases describing middle meningeal artery (MMA) embolization for acute traumatic epidural hematoma (EDH). A search of PubMed/MEDLINE and Google Scholar was conducted using the following keywords and Boolean operators:

“epidural hematoma” AND “middle meningeal artery embolization” “traumatic epidural hematoma” AND “endovascular” “acute epidural hematoma” AND “MMA embolization”

The search included articles published from January 2000 through December 2024. Only English-language publications were reviewed.

Original reports describing acute traumatic EDHUse of endovascular MMA embolization as part of managementCase reports, case series, or observational studiesClear documentation of clinical presentation, intervention, and outcome

Chronic subdural hematoma without EDHNon-traumatic EDHReview articles without original casesPediatric or adult cases lacking intervention detail

Article selection was performed manually by reviewing titles, abstracts, and full texts when relevant. (Table 1, Figure 5)

PRISMA flow diagram demonstrating study identification, screening, eligibility, and inclusion for the mini review of middle meningeal artery embolization in acute traumatic epidural hematoma. Counts are derived directly from the dataset summarized in Table 1.

Table 1.Published cases of middle meningeal artery embolization for acute traumatic epidural hematoma.

Figure 5.PRISMA 2020 flow diagram.

A total of six studies met the inclusion criteria, encompassing eight patients treated with MMA embolization for acute traumatic EDH.

Age range:14 - 85 yearsSex:Predominantly male (5 males, 3 females)Mechanism of injury:Falls, motor vehicle collisions, and bicycle accidentsNeurologic status:Most patients were neurologically intact or mildly symptomatic at presentation (GCS 12-15)

EDHs were typically temporal or temporoparietal, often adjacent to a skull fracture.Several cases demonstrated active contrast extravasation, MMA pseudoaneurysm, or interval hematoma expansion on serial imaging.In some patients, EDH was associated with concurrent subdural hematoma.

MMA embolization was performed for:

Radiographic progression of EDH despite neurological stabilityIdentification of active MMA bleeding or pseudoaneurysmHigh surgical risk due to medical comorbiditiesAdjunctive hemorrhage control following partial surgical evacuation

Intervention

All cases utilized endovascular MMA embolization, most commonly with coil embolizationOne case combined embolization with burr hole evacuationEmbolization was unilateral and targeted to the involved MMA branch

Outcomes

Radiographic stabilization or resolution of EDH occurred in the majority of patientsAvoidance of craniotomy was achieved in most casesOne patient required additional surgery for a contralateral subdural hematomaNeurological outcomes were favorable, with no reported embolization-related complicationsNo mortality attributable to EDH progression was reported

PRISMA Summary

Records identified through database searching: n = 15Records after duplicates removed: n = 11Full-text articles assessed for eligibility: n = 11Studies included in mini review: n = 6Total patients included: n = 8

Based on the limited available literature summarized in Table 1, MMA embolization is a feasible and safe therapeutic option for carefully selected patients with acute traumatic EDH, particularly those who remain neurologically stable but demonstrate radiographic progression or evidence of MMA injury. The technique may reduce the need for craniotomy in select cases, though evidence remains limited to small observational reports.

This mini review is limited by the small number of reported patients, reliance on case reports and small case series, and heterogeneity indications and timing of embolization. No comparative or randomized data is available, and long-term outcomes are reported.