Meningo-meningeal arteriovenous fistula revealed immediately following middle meningeal artery microparticle embolization: Case report and literature review

We present a case of a meningo-meningeal arteriovenous fistula (MMAVF) discovered immediately following middle meningeal artery (MMA) microparticle embolization for the treatment of an acute subdural hematoma (SDH). An elderly patient presented with an SDH found during stroke workup. MMA embolization was elected due to his need for therapeutic anticoagulation. During the procedure, multiple MMAVFs appeared after microparticle embolization of the distal MMA branches. We aborted further microparticle embolization and performed coil embolization of the MMA trunk with cessation of flow. No clinical complication was noted postoperatively and no post-procedure hemorrhage was seen. Review of literature suggests that this phenomenon may be associated with microparticle embolization. We hypothesize the cause to be vessel rupture due to barotrauma during manual injection via the microcatheter. As MMA embolization becomes more common, this complication may become more recognized.