Middle Meningeal Artery Embolization

For most of his life, David Moss maintained peak physical condition. He took up running at the age of 40, completing 17 marathons within 12 years before retiring from the sport. However, on April 26, 2023 — three days after celebrating his 86th birthday — Moss awakened during the night and rose from bed. He forgot to remove his CPAP mask, passed out and, despite the mask protecting his face, the bridge of his nose forcefully struck the door jamb. Moss and his wife Susan, quickly headed to Eisenhower Health’s Tennity Emergency Department where he underwent an initial assessment that involved examining for neurological and cardiovascular symptoms. To avoid a wait time in the emergency department, Moss opted to sign himself out with a proviso from clinicians that he seek medical assistance the next day.

“At the time, I was feeling better,” Moss recalls. “The only real pain I had at that point was a sore neck because of the apparent whiplash when my head hit the door jamb.”

A visit to his primary care physician yielded no signs or symptoms pointing to a stroke or seizure and Moss felt better. But during an ear irrigation visit in early May, the otolaryngologist observed an indentation on Moss’s head from the CPAP; a further check noted sinus damage. A subsequent CT scan revealed chronic bilateral subdural hematomas. Often the result of a head injury, a subdural hematoma occurs when liquefied blood collects and clots between the brain’s surface and the outer layer, called the dura.

Moss immediately reached out to Eisenhower Board Certified Neurosurgeon Farhad Limonadi, MD, who had successfully treated Moss for a previous acoustic neuroma (a noncancerous tumor on the vestibular nerve in the ear). Dr. Limonadi’s colleague, Alfred Shen, MD, Board Certified in Neurosurgery, admitted Moss to the hospital.

A brain MRI indicated the hematomas were stable and Moss remained asymptomatic. As a result, Dr. Shen put Moss on observation and medication to reduce the risk of stroke or seizure. However, following a brain CT scan two weeks later, Dr. Shen recommended that Moss undergo a middle meningeal artery (MMA) embolization to treat the hematomas.

Board Certified Neurointerventional Radiologist Brian Herman, MD, performed the embolization on May 26, 2023. A minimally invasive procedure, MMA involves inserting a microcatheter through the groin and directing it into the middle meningeal arteries. Employing biplanar imaging, a state-of-the-art medical technology that uses two rotating cameras, Dr. Herman infused small particles through the tubes to block the blood flow, and shrink and eventually eradicate the hematomas.

“The embolization involves reducing the upstream pressure on the vessels that are likely responsible for the hemorrhage, so that the subdural bleeds can heal and hopefully not recur,” says Dr. Herman.

Although stroke and vision loss are risks associated with MMA embolization, complications are less common than traditional interventions and the post-surgical outcome is highly favorable.

“Middle meningeal artery embolization is a progressive, less invasive approach that is becoming more common and it has also been shown to be successful in preventing recurrent subdural hematomas,” explains Dr. Herman. “Because it’s a newer technique, it’s important for people who are diagnosed with subdural hematomas to discuss the procedure with their physician as a potential treatment option,” he adds.

The surgery went smoothly and Moss spent two nights in the hospital recovering before being discharged home. 

“Dr. Herman called me on the Monday following surgery to see how I was doing, which I thought was very impressive,” says Moss. “I told him that I felt great.”

Moss notes that he is on the mend overall. Although recovering his physical strength and stamina has taken some time, he’s happy to be playing golf again. The great news is that a series of CT scans since the surgery has shown a decrease in the size of the subdural hematomas. 

“At some point, I would love to thank Dr. Herman personally,” he says. 

For more information or to contact Eisenhower Neuroscience Institute, call 760.837.8020 or visit EisenhowerHealth.org/Neuro.