Just like not all of dura is fed by the MMA, so is subdural hematoma embolization not limited to the same vessel.
Here is a large isodense subdural
A subdural “MMA” embolization — anything unusual here?
Headway duo in the MMA— typical membranes look
Lateral — see how some parietal region dura is not opacified — whats up with that?
PVA small particle embo (Contour 45-150 microns) of the petrosquamosal branch — important to go a bit distal in this one, past facial arcade — once u r near the inner skull table its fine
Next is frontoparietal branch PVA embo — on successive images look at how the territory becomes progressively devascularized — like a tree loosing leaves with only trunk left at the end. Followed by placement of single coil
Post — still there is subdural membrane hyperemia — interesting?
Supply comes from a transosseous branch fed by the occipital artery — its a pretty big territory. Even from this position we can embolize with Contours without too much concern about skin — but better to be closer still
Rotational VRs — progressive removal of bone mask image shows the transosseous branch
Final embo position — achieved by Headway Duo and .07 Hybrid — a winning combo. Even in this position there is no flow arrest — good for PVA, and no skin damage from here.
CCA post — of course we check ophthalmic beforehand — classic intradural ICA origin
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