(1566) Traumatic Subdural Complicated by Cardiac Arrest During Middle Meningeal Artery Embolization

Introduction: Middle meningeal artery (MMA) embolization has shown promise as an emerging minimally invasive treatment for the prevention of future hematoma expansion and hemorrhage. The prevention of continued subdural bleeding makes MMA embolization an attractive procedure in the setting of chronic subdural hematoma. Although an endovascular procedure, MMA embolization does have significant risk. As a developing intervention, cardiovascular risks are less well described.

Description: An 81-year-old male presented to the hospital for decompensated heart failure and new-onset atrial fibrillation requiring anticoagulation. His hospitalization was complicated by bradycardia from second-degree atrioventricular block with sinus pauses following transesophageal echocardiogram for cardioversion. After an in-hospital fall resulting in traumatic acute on chronic subdural hematoma (SDH) he was transferred to the trauma service. Anticoagulation was reversed, and he underwent successful craniotomy with hematoma evacuation with neurosurgery. After stable repeat computed tomography (CT) scans of the head, he was offered MMA embolization five days post-operatively. Once successfully under anesthesia, ethylene vinyl alcohol (EVOH) copolymer dissolved in dimethyl sulfoxide (DMSO) (OnyxTM Liquid Embolic System, Medtronic, Minneapolis, MN, USA) was prepared for administration. DMSO delivery provoked bradycardia, asystole and ensuing cardiac arrest. Advanced cardiac life support (ACLS) was performed with return of spontaneous circulation (ROSC). He became hypotensive leading to a second arrest shortly after with subsequent ACLS and ROSC; the embolization procedure was aborted, and patient returned to the intensive care unit. Post cardiac arrest neurologic function remained intact, and he was liberated from the ventilator. Before discharge to acute rehab, he had a dual-chamber pacemaker implanted. No further attempts were made for middle meningeal artery embolization.

Discussion: Middle meningeal artery embolization continues to show promise as a therapeutic option for prevention of recurrent subdural hematomas. Despite encouraging long-term data, adverse effects such as hemodynamically significant bradycardia with DMSO administration must be thoroughly considered.