Dual-Lumen Balloon Assisted Onyx Embolization of Middle Meningeal Artery for Chronic Subdural Hematoma

BACKGROUND AND PURPOSE: Middle meningeal artery embolization (MMAE) with liquid embolic agents (LEAs) is increasingly used to manage chronic subdural hematoma (CSDH). Conventional microcatheters require distal wedge positioning of the microcatheter tip or proximal plug formation to prevent reflux and achieve effective distal penetration. Dual-lumen balloon microcatheters limit reflux and enable controlled LEA injection, which may improve procedural efficiency. The evidence base for dual-lumen balloons in CSDH is limited. MATERIALS AND METHODS: This single-center retrospective study included consecutive adults with CSDH treated from December 2021 to September 2025. The Scepter XC dual-lumen balloon microcatheter was used to arrest antegrade flow and control Onyx-18 delivery, first distal to the anterior branch origin and then from the MMA trunk into the posterior branch. Outcomes included >50% hematoma thickness reduction and complete resolution on computed tomography (CT), recurrence, retreatment, complications, hospital stay, and procedure time. RESULTS: 152 patients were identified; 33 (21.7%) underwent concomitant surgery and 108 (71.1%) standalone MMAE. Median follow-up was 3 months. This technique achieved >50% hematoma thickness reduction in 90.4% and complete resolution in 70.6% at 3 months or last follow-up. There were no serious adverse events definitely associated with the dual-lumen balloon technique. Overall postprocedural complications occurred in 4 patients (2.6%): transient facial palsy in 2 (1.3%), transient diplopia in 1 (0.7%), and bilateral watershed territory cerebral infarctions without long-term neurological deficits in 1 (0.7%). Median hospital stay was 2 days (IQR 1-4), and median procedure duration was 31.5 minutes (IQR 24.3-48.8). None of the patients who completed follow-up experienced CSDH recurrence or required retreatment. CONCLUSIONS: Scepter XC-assisted Onyx-18 MMAE was technically feasible and associated with high rates of CSDH resorption and resolution, with a safety profile similar to other MMAE techniques and no serious adverse events directly attributable to dual-lumen balloon microcatheter use.