BACKGROUND AND OBJECTIVES: Despite effective surgical evacuation, chronic subdural hematoma (cSDH) recurrence rates remain high. Middle meningeal artery (MMA) embolization has emerged as a promising adjunct significantly reducing recurrence rates but adding procedural risk, logistical complexity, and cost. Thus, single-stage cSDH evacuation with direct surgical MMA occlusion through a single pterional/frontotemporal burr hole could offer a practical alternative. This study assesses the applicability of this approach on routine preoperative imaging and evaluates both neuronavigation-guided and landmark-based localization of the MMA bifurcation. METHODS: In this single-center study, preoperative noncontrast cranial computed tomography scans of patients undergoing burr hole trepanation for cSDH were analyzed. We assessed osseous MMA anatomy, visibility, and dominance of the MMA bifurcation; its spatial relationship to the cSDH; and distances from 3 external craniometric landmarks Stephanion, Bregma, and external auditory canal (EAC)-zygomatic root plane. RESULTS: Twenty patients with 26 cSDHs were included. A distinct osseous groove indicating the MMA bifurcation was identifiable in all cases (100%). The bifurcation overlapped with the hematoma in 18/26 (75%) and projected onto the region of maximal thickness in 5/26 (21%). Mean craniocaudal and anteroposterior distances from the Stephanion to the bifurcation were 27.3 ± 12.3 mm and 8.8 ± 5.5 mm; from the Bregma 113.9 ± 18.2 mm and 16.1 ± 8.6 mm, respectively. In the sagittal plane, the mean perpendicular distance from the EAC-zygomatic line to the bifurcation was 52.4 ± 10.8 mm, and the mean distance from EAC to the MMA bifurcation along this line was 29.9 ± 10.8 mm. CONCLUSION: Anatomic localization of the MMA bifurcation using standard noncontrast cranial computed tomography and external craniometric landmarks is feasible. Furthermore, the bifurcation overlaps the hematoma in most patients. These findings support the technical plausibility of surgical MMA occlusion via a strategically placed pterional burr hole (or an additional burr hole for occlusion if no overlap) as a straightforward alternative to endovascular embolization in selected patients with cSDH.
Alakmeh et al. (Wed,) studied this question.