• Hasitha Milan Samarage, Wi Jin Kim, David Zarrin, Keshav Goel, Anthony Chin-Hsiu Wang, Jeremiah Johnson, Naoki Kaneko, May Nour, Viktor Szeder, Satoshi Tateshima, Reza Jahan, Gary Duckwiler, and Geoffrey Philip Colby.
• Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA.
• Neurosurgery. 2022 Sep 1; 91 (3): 389-398.

BackgroundChronic subdural hematomas (CSDHs) are common in the elderly population and patients taking antiplatelet/anticoagulation medications. Middle meningeal artery (MMA) embolization has become an adjunctive treatment to observation and surgery. Despite many embolization techniques, best practices for optimal CSDH resolution remain unknown.ObjectiveTo report a retrospective case series of MMA embolization for CSDHs regarding rate of hematoma improvement and the significance of distal embolic penetration into the falx.MethodsRetrospective chart review was performed on all patients who underwent MMA embolization for CSDHs between January 2017 and June 2021. Patient demographics, clinical presentation, anticoagulant use, and radiographic features were collected. Pre-embolization and postembolization computed tomography scans were analyzed for volumetric changes and assessed for midline penetration of embolic material in the falx.ResultsMMA embolization was performed in 37 patients and 53 hemispheres. Older patients took longer to obtain complete resolution of CSDHs (r = 0.47, P = .03). Patients with larger pre-embolization (r = 0.57, P = .007) and postembolization (r = 0.56, P = .008) CSDH volumes took longer to completely resolve. Patients who had n-butyl cyanoacrylate embolization with midline penetration, as evidenced by the "bright falx" sign, had faster improvement rates than those who did not (5.64 cm 3 /d vs 1.2 cm 3 /d, P = .02).ConclusionDistal penetration of embolic material, particularly n-butyl cyanoacrylate, into the falx may lead to more rapid improvement of CSDH.Copyright © Congress of Neurological Surgeons 2022. All rights reserved.

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