Middle meningeal artery branch transection combined with endoscope-assisted mini-craniotomy for high-risk chronic subdural hematoma: a retrospective case series

Background Chronic subdural hematoma (cSDH) associated with multiple risk factors for recurrence remains a challenging condition that often requires complex surgical management. Middle meningeal artery (MMA) embolization has shown enhanced effectiveness when combined with hematoma clearance surgery. Objective To evaluate the effect and feasibility of the combination of MMA transection and endoscopic-assisted mini-craniotomy for cSDH with a high risk of recurrence. Methods A total of 23 digital subtraction angiography (DSA) images were analyzed to map the main branches of MMA on lateral head. Hematoma-prone regions were delineated based on 36 cases of cSDH exhibiting a significant mass effect. Mini-bone window was designed based on main MMA branches maps and hematoma-prone areas. Twenty-five cSDH patients with multiple high-risk factors for recurrence underwent endoscopic-assisted mini-craniotomy. The procedure involved comprehensive hematoma removal, extensive inner membrane incision, and simultaneous transection of the responsible MMA branches. Clinical outcomes were assessed, and recurrence was evaluated 3 months after operation. Results For most cSDH cases (35/36), both MMA branches supplied the outer membrane. Of the 27 mini-craniotomy procedures performed, 26 successfully exposed and transected the both main MMA branches. All procedures achieved full exposure of the hematoma cavity by a rigid 0° high-definition endoscope through the mini-bone window. All patients experienced rapid improvement in their presenting symptoms after surgery, and no recurrence of cSDH was observed during the 3-month postoperative follow-up. Furthermore, no mortality and major procedure-related complications were detected. Conclusion For patients with cSDH and multiple risk factors for recurrence, middle meningeal artery branch transection combined with endoscope-assisted mini-craniotomy may represent a feasible surgical option, with favorable clinical outcomes and a low observed recurrence rate.