Middle meningeal artery embolization for recurrent subdural hematoma from ventriculoperitoneal shunt overdrainage: a pediatric case report

Abstract

Background
Subdural hematoma (SDH) is a recognized complication following ventriculoperitoneal shunt (VPS) placement, primarily caused by excessive cerebrospinal fluid (CSF) drainage. This overdrainage can result in ventricular collapse and traction of the bridging veins, leading to hemorrhage. Management remains challenging, requiring a balance between evacuating the hematoma, maintaining adequate CSF diversion, and in refractory cases, adjunctive endovascular techniques.


Case description
A 13-year-old boy with obstructive hydrocephalus underwent VPS placement with initial valve setting of 100 mmH₂O. Three months later, he developed bilateral subdural hematomas (40 mm right, 22 mm left) with 11 mm midline shift. Despite valve adjustment to 160 mmH₂O and two bilateral craniotomies evacuating over 650 mL, collections recurred with radiological progression and chronic neomembrane formation. The course was complicated by pneumocephalus requiring external ventricular drainage and hyperbaric oxygen therapy. Bilateral middle meningeal artery embolization was performed as salvage therapy. At 6-month follow-up, clinical stabilization was achieved without additional interventions, though residual asymptomatic collections persisted (32 mm right, 16 mm left). The patient developed Parinaud syndrome as sequela of acute hydrocephalus but had no other focal deficits.


Conclusions
Recurrent subdural hematomas following VPS placement due to overdrainage, though uncommon, represent a clinically significant complication in pediatric patients. This case demonstrates that when conventional management fails—including valve pressure adjustment and surgical evacuation—middle meningeal artery embolization may serve as a potential salvage therapy to achieve clinical stabilization in select cases. However, radiological resolution may be incomplete, and neurological sequelae can occur despite optimal management. Prevention through appropriate initial valve selection (150–200 mmH₂O in school-aged patients) is paramount. A stepwise, individualized, multidisciplinary approach combining neurosurgical and endovascular techniques is essential in managing these complex cases.