Recurrence of chronic subdural hematoma caused by contralateral middle meningeal artery supply: a rare presentation

Abstract Background Chronic subdural hematoma (cSDH) is a prevalent neurological condition with a significant incidence and mortality rate, particularly among elderly individuals. Despite various treatments, the risk of recurrence persists. Here we present a rare case of cSDH recurrence potentially caused by neovascularization of the contralateral middle meningeal artery (MMA). Ultimately, the patient underwent craniotomy for hematoma removal and embolization of the contralateral MMA achieved excellent results. Case presentation A 74–year–old male was diagnosed with a cSDH involving the left frontal, temporal, parietal, and occipital regions. Initially, the patient underwent embolization of the frontoparietal branch of the MMA and single burr–hole craniostomy with drainage to resolve the cSDH. However, follow–up head CT and MRI scans revealed a fresh left subdural hemorrhage and a gradual increase in the amount of subdural hematomas. Digital subtraction angiography (DSA) demonstrated effective occlusion of the original left MMA but identified a newly discovered vascular network of the right MMA that crossed the midline to the left, with contrast agent leaking to the contralateral side. Superselective embolization of the right frontoparietal branch of the MMA was successfully performed. Subsequently, surgery to remove the intracranial hematoma was conducted. A postoperative CT re–examination confirmed that there was no recurrence of the hematoma. Conclusion This study indicates that cSDH recurrence may occur through the contralateral MMA supply. Regardless of the initial hematoma side, performing DSA of bilateral MMAs and selective embolization of the MMA with positive radiological findings are appropriate treatment options to reduce the cSDH recurrence rate.