Complete resolution of massive chronic subdural hematoma with refined layered middle meningeal artery embolization: A case report

BACKGROUND Chronic subdural hematoma (cSDH) is typically surgically managed; however, middle meningeal artery embolization (MMAE) has recently gained attention as a minimally invasive alternative. Optimal embolization techniques and patient selection criteria remain under investigation. Here, we present a refined embolization strategy - the layered embolization technique - which enhances distal penetration and procedural safety, representing a potential advancement in MMAE for cSDH. CASE SUMMARY A 78-year-old female with bilateral symptomatic cSDH and significant mass effect was unsuitable for surgery due to advanced age, comorbidities, and religious considerations. Standalone MMAE using a refined layered technique achieved complete hematoma resolution and full brain re-expansion within 3 months, without complications. The layered embolization technique involved initial deep penetration of the distal neovascular branches using low-concentration particles, followed by proximal vessel occlusion with standard-concentration particles under continuous fluoroscopic guidance. This controlled approach optimizes distal embolization, minimizes premature reflux, and facilitates complete hematoma clearance. Our case illustrates the potential for broader application of upfront MMAE, even in symptomatic cSDH with large hematomas. CONCLUSION Standalone MMAE using layered embolization is safe and effective for managing cSDH with significant mass effect in high-risk surgical candidates.