Mazen Nofual, Conrad Liang, Paulio Yanez and Mark Calayag
Introduction: Chronic Subdural Hematoma (CSDH) is generally attributed to pathological changes in the arterial system of the dura mater. There are no case reports of CSDH due to cerebral cortical artery perforation.
Method: We report a case of spontaneous CSDH caused by cortical artery rupture that was identified on digital subtraction angiography and could be visualized on Computed Tomographic Angiography (CTA).
Result: A 56-year-old man presented with daily headache for three weeks with no history of trauma. Neurologic exam only showed subtle left pronator drift. A CT scan of the head showed a right CSDH with a midline shift. CTA was suspicious for a dilated vein in the subdural collection. Catheter cerebral angiogram demonstrated contrast extravasation from a small cortical branch of the middle cerebral artery with no aneurysm, arterial dissection, or vascular malformation. In retrospect, CTA findings represented contrast extravasation, not a dilated vein. Burr-hole mini-craniotomy was performed, and the hematoma was evacuated. The patient had complete clinical and radiographic recovery.
Conclusion: Ruptured cerebral cortical artery can cause CSDH. In atypical cases of CSDH, careful evaluation of selective internal carotid artery angiography is advised to look for alternative pathologies prior to proceeding with MMA embolization. CTA images may demonstrate active extravasation from a small cortical artery.