Single Pterional Burr Hole Coupled with Coagulation of the Middle Meningeal Artery for Management of a Chronic Subdural Hematoma in a 98-Year-Old Patient: Illustrative Case

Patient: Male, 98-year-old Final Diagnosis: Chronic subdural hematoma Symptoms: Headache and vomiting Clinical Procedure: Burr hole drainage Specialty: Neurosurgery OBJECTIVE: Management of emergency care BACKGROUND: Chronic subdural hematoma (CSDH) is more common in older people, for which burr-hole drainage is a standard procedure. Middle meningeal artery (MMA) embolization was first proposed as an adjuvant therapy to prevent recurrence after surgical evacuation of CSDH and subsequently as the primary treatment modality. Disadvantages of MMA embolization include expensive procedural price, increased radiation exposure, and additional labor. MMA embolization also has the disadvantages of slow clinical response and prolonged time for radiographic clearance. CASE REPORT: A 98-year-old man presented with a symptomatic CSDH. A single pterional burr hole was placed over the origin of the calvarial portion of the MMA, thus allowing for the drainage of the CSDH and coagulation of the MMA. The procedure resulted in immediate cessation of symptoms, decrease of the hematoma size, disappearance of the hematoma at 4 weeks, and no recurrence. CONCLUSIONS: The location where the calvarial portion of the MMA leaves the outer sphenoid wing and enters the cranial vault can be reliably identified by means of external landmarks and confirmed by intraoperative fluoroscopy. Drainage of the CSDH and coagulation of the calvarial branch of the MMA can be achieved with a single procedure performed under local/conscious sedation. This report has shown that in cases of CSDH in the elderly, imaging is important to determine the optimum approach to hematoma drainage, which, in this case, required a pterional burr hole combined with MMA coagulation. This case report demonstrates feasibility of a novel procedure; further studies are needed to ascertain its usefulness.