Extradural haemorrhage: is there a role for endovascular treatment?

The middle meningeal artery (MMA) is the most proximal and largest branch of the internal maxillary artery (IMA). It courses superiorly to the foramen spinosum making a sharp right angle bend entering the skull. The MMA has frontal, parietal and petrosal branches, the frontal branch being identified by its anterior convex curve along the greater wing of sphenoid. Trauma and a resultant extradural haematoma (EDH) demands urgent neurosurgical intervention to prevent imminent foramen magnum herniation and rapid demise. The seriousness of EDHs cannot be overstated and is a clear neurosurgical emergency requiring immediate definitive management. Historically craniotomy is the gold standard. But recent advances propose angiography and subsequent embolization as an alternative to craniotomy. We employed embolization to manage EDHs in two cases whose original clinical presentation did not demand urgent surgery. We discuss their subsequent management focusing on treatment choices and the potential role of endovascular techniques. We describe an alternative diagnostic protocol and embolic agents using Onyx and coils.