Middle meningeal artery embolization of meningioma en plaque misdiagnosed as subdural hematoma: illustrative cases.

BACKGROUND: Meningioma en plaque (MEP) may rarely mimic subacute or chronic subdural hematoma (SDH) on noncontrast imaging. As middle meningeal artery (MMA) embolization becomes increasingly adopted for the management of SDH, misdiagnosis of an underlying dural tumor may delay definitive treatment and expose patients to interventions that could complicate subsequent resection. OBSERVATIONS: The authors present 2 cases of patients with MEP initially diagnosed as subacute SDH and treated with embolization. In both cases, embolization was performed prior to contrast-enhanced imaging, delaying recognition of the underlying tumor. Subsequent clinical and radiographic progression led to definitive diagnosis and surgical intervention. Intraoperatively, both lesions demonstrated marked cortical adherence and extensive invasion, resulting in challenging resections and postoperative neurological morbidity. These findings raise the possibility that embolization of an unrecognized MEP may alter tumor vascular dynamics and increase operative complexity. LESSONS: As MMA embolization becomes more widely used for presumed SDH, occult dural tumors such as MEP may increasingly be encountered as diagnostic pitfalls. In patients with atypical clinical presentation or unusual radiographic features, contrast-enhanced imaging should be obtained before or immediately after embolization to exclude an underlying neoplasm. Early recognition may prevent delays in care and avoid embolization-related vascular changes that could complicate definitive surgical treatment. https://thejns.org/doi/10.3171/CASE26492.