Failure of MMA embolization due to deep and middle temporal artery supply in chronic subdural hematoma: the diagnostic value of 3D-RA

Chronic subdural hematoma (CSDH) is commonly managed with burr hole evacuation, yet recurrence remains frequent. Middle meningeal artery (MMA) embolization has emerged as a minimally invasive treatment. We describe the case of an 85-year-old man with refractory CSDH who developed multiple recurrences despite repeated surgical evacuation and MMA embolization. Three-dimensional rotational angiography (3D-RA) revealed atypical transosseous feeders from the anterior and middle deep temporal arteries and the middle temporal artery. Targeted embolization using N-butyl cyanoacrylate and coils resulted in durable hematoma resolution without further recurrence. This case highlights the importance of detailed vascular assessment with 3D-RA when MMA embolization fails.