Middle Meningeal Artery Embolization as a First-Line Therapy for Chronic Subdural Hematoma

Chronic subdural hematoma (cSDH) is a common neurovascular condition, particularly among elderly or anticoagulated patients. Its recurrence after surgical evacuation remains a major challenge. Middle meningeal artery embolization (MMAE) has recently emerged as a minimally invasive and durable alternative treatment, targeting the vascular networks that sustain hematoma membranes. We describe a patient with metastatic prostate cancer who developed a spontaneous cSDH and underwent first-line MMAE due to high surgical risk. Angiography revealed multifocal patchy dural enhancement resembling tumor blush, which was later confirmed on MRI to represent leptomeningeal metastasis. To our knowledge, the middle meningeal angiographic appearance of leptomeningeal disease seen in this case is previously unpublished. Embolization using 100-300 μm embospheres and coils achieved complete occlusion of the vessel and clinical improvement without recurrence. This case highlights the growing role of MMAE as a safe, effective first-line therapy for cSDH, supported by recent clinical trials demonstrating significant reductions in recurrence compared with conventional management. This report also underscores the importance of correlating angiographic findings with MRI when unique neoplastic vascular patterns are suspected.