We describe a unique case of central venous sinus thrombosis (CVST) caused by middle meningeal artery (MMA) Onyx embolization for the treatment of chronic subdural hematomas (SDH).
There are currently no specific guidelines for chronic SDH management, although MMA embolization is becoming a more widely used procedure.
Clinical case.
A 77-year-old male initially presented to our hospital after a fall with bilateral frontal contusions, traumatic subarachnoid hemorrhage, and bilateral subdural hematomas (SDH). Approximately one month later, he re-presented with altered mental status, confusion, and seizures. Neuroimaging showed worsening bilateral chronic subdural hematomas with mass effect. He underwent hematoma evacuation with bilateral burr holes and middle meningeal artery (MMA) Onyx embolization. Three weeks later, he re-presented with generalized tonic-clonic seizures, found to have an acute intraparenchymal hemorrhage, and extensive CVSTs with embolization material seen in the transverse and superior sagittal sinuses on CT Venogram.
Given the extent of the patient’s CVST and history of chronic subdural hematomas, there was a risk-benefit discussion regarding whether to start anticoagulation, the first-line treatment for CVST. After starting anticoagulation, the patient developed a worsening of his subdural hemorrhage. After goals of care discussions with the family, they elected for no further escalation of care given severe neurologic injury, and the patient was transitioned to hospice.
Our case report provides a novel description of CVST secondary to migration of the Onyx material into the dural venous sinuses after Onyx embolization for treatment of subdural hematoma that has not previously been described in the literature. This case highlights a potential complication of embolization material getting into the venous system and warrants further discussion on whether anticoagulation would be beneficial for this complication. This case also provides a forum for discussing the unique management of CVST, intraparenchymal hemorrhage, and chronic SDH.