Middle Meningeal Artery Embolization as an Alternative Strategy for Symptomatic CSF Hypovolemia related Chronic Subdural Hematoma: A Case Series

Background Chronic subdural hematoma (CSDH) secondary to cerebrospinal fluid (CSF) hypovolemia - most commonly from ventriculoperitoneal (VP) shunt overdrainage or spontaneous intracranial hypotension (SIH) - presents unique therapeutic challenges. In these cases, standard surgical evacuation may be contraindicated if intracranial pressure is not corrected, increasing the risk of complications. While middle meningeal artery embolization (MMAE) has emerged as a treatment option for refractory CSDH, its role in CSF hypovolemia-associated CSDH remains underexplored. Methods This retrospective study included seven patients with radiographically confirmed, symptomatic CSDH due to CSF hypovolemia. Etiologies included VP shunt overdrainage (n = 6) and SIH (n = 1). Prior to MMAE, all patients underwent definitive treatment of the underlying cause - either shunt adjustment or ligation, or targeted epidural blood patch. Embolization was performed using 250 µm microspheres via the middle meningeal artery. Patients were followed clinically and with serial CT imaging. Results All patients demonstrated neurological improvement within several days following embolization. Hematoma thickness progressively decreased over a period of 2 to 6 months, with complete or near-complete resolution in all cases. No patients experienced recurrence or required surgical evacuation. There were no procedural complications. Conclusion MMAE, when performed after correction of the underlying CSF hypovolemia, appears to be a safe and effective therapeutic option for CSDH. This approach may serve as an intermediate strategy between conservative treatment and surgical evacuation, particularly in patients at elevated risk due to intracranial hypotension.