Ruptured traumatic pseudoaneurysm of the middle cerebral artery following minor trauma treated with an MCA-MCA bypass: A case report.

Background: Traumatic middle cerebral artery (MCA) pseudoaneurysms following minor head trauma are rare. Case Description: We report a case of a 76-year-old man who presented with a traumatic acute subdural hematoma and subarachnoid hemorrhage (SAH) from a ruptured distal right MCA pseudoaneurysm treated with evacuation of the hematoma, resection of the pseudoaneurysm, and an MCA-to-MCA bypass. Conclusion: Although traumatic pseudoaneurysms of the distal intracranial vessels are rare, patients with traumatic SAH would benefit from vascular imaging. Treatment of pseudoaneurysms of distal intracranial vessels may be treated with vessel occlusion or trapping/excision of aneurysm with revascularization.

Combined pterional burr hole and coagulation of middle meningeal artery for chronic subdural hematoma.

Background: There are many surgical techniques to treat chronic subdural hematomas (CSHs). However, they all have high recurrence rates. Recently, embolization of the middle meningeal artery (MMA) following surgical evacuation of CSH has reduced the recurrence rate. We investigated the feasibility of combining the surgical obliteration of the MMA at the same time as the placement of a burr hole for evacuation of the CSH. Case Description: We report on nine patients who underwent 11 of these combined procedure by the same surgeon in two hospitals, including clinical data and images during the perioperative and postoperative periods. Cardoso had previously reported details of the surgical technique. Two patients underwent bilateral procedures. Two patients had two burr holes because the hematomas did not extend caudally to the pterion, where the MMA enters the calvarium. Intraoperative fluoroscopy was used to locate the point of entry of the MMA into the calvarium in most cases, except in two instances when navigation was utilized. Conclusion: This small series of nine cases suggests the feasibility of using this combined procedure as an additional option to the treatment of CSHs, especially where endovascular treatment might not be readily available. Furthermore, it has the potential advantages of safety, efficacy, avoidance of a second endovascular procedure, faster disappearance of the subdural collection, lesser exposure to radiation, and cost containment. Larger prospective controlled series are needed to identify its potential usefulness.

Spinal Subdural Hematoma Secondary to Ruptured Internal Carotid Artery Ophthalmic Segment Aneurysm: A Case Report and Narrative Review.

Spinal subdural hematoma (SSDH) is a rare condition where the exact pathology is unclear; coagulopathy, bleeding disorders, trauma, and iatrogenic causes are frequently associated with SSDH. SARS-CoV-2 infection and COVID-19 vaccines are unusual causes of SSDH, as reported by multiple studies. Here, we present a rare case report and a narrative review of SSDH resulting from a ruptured cerebral aneurysm. A 53-year-old female presented with an acute, severe suboccipital headache and neck and back pain without radiculopathy. Investigations for cardiovascular diseases and brain images were unremarkable. Further investigation revealed an SSDH extending from T1 to S2. Negative spinal angiography led to a cerebral angiogram, identifying an internal carotid artery ophthalmic segment aneurysm that was successfully treated with endovascular stent-assisted coiling. This case scenario of anterior circulation cerebral aneurysmal rupture manifesting as an isolated SSDH is unique compared to previously reported cases of SSDH resulting from cerebral aneurysms. This case highlights the importance of considering aneurysmal rupture in SSDH cases with no apparent underlying pathology to prevent neurological deficits. Early detection and intervention in such cases can prevent serious neurological deficits and improve patient outcomes.

Comparison of outcomes and recurrence rates in patients undergoing single or double burr hole surgery for the treatment of chronic subdural hematoma in Bosnia and Herzegovina.

Introduction: Chronic subdural hematoma (CSDH) is a prevalent condition commonly seen in elderly individuals, often requiring neurosurgical intervention. Research question: This study investigates patient characteristics and recurrence rates in CSDH patients treated with single or double burr hole surgery in Bosnia and Herzegovina. Methods: A retrospective study was conducted on patients treated for CSDH between January 2018 and December 2022. The diagnosis of CSDH was confirmed through preoperative CT or MRI of the brain. Patients underwent either single or double burr hole surgery based on the neurosurgeon's decision. Preoperative and postoperative brain CT scans, along with clinical outcomes, were analyzed. Results: A total of 87 patients were included in the study, with 102 burr hole surgeries performed. Among these, 49 patients received single burr hole surgery, while 53 patients underwent double burr hole surgery. Recurrence of CSDH occurred in 8.8% of cases, with no significant difference observed between the groups. Notably, single burr hole surgery demonstrated comparable efficacy to double burr hole surgery in terms of subdural reduction and occurrence of pneumocephalus, while exhibiting fewer complications and shorter hospitalization. Discussion and conclusions: burr hole surgery, whether performed as a single or double procedure, is an effective treatment option for CSDH, as it leads to positive outcomes in both radiological and clinical assessments of patients following surgery. The population of Bosnia and Herzegovina receives good neurosurgical care for CSDH.

Hyperhomocysteinemia in a Patient With Subdural Hematoma and Subarachnoid Hemorrhage Secondary to a Traumatic Brain Injury.

Traumatic brain injury (TBI) is a significant global health issue, contributing substantially to mortality and disability. Serum biomarkers, such as homocysteine (Hcy), play a critical role in the prognosis of brain injuries, with hyperhomocysteinemia (HHcy) potentially leading to neurological disorders. We present the case of a 64-year-old patient admitted to the emergency department following a road traffic accident (RTA). Magnetic resonance imaging (MRI) revealed parietal subdural hematoma (SDH), right frontal contusion, and left subarachnoid hemorrhage (SAH). The patient underwent a craniotomy to address SAH and SDH. Initial Hcy levels were markedly elevated compared to post-operative levels. Hcy represents a rapid, non-invasive, and cost-effective diagnostic tool for assessing brain injury severity and guiding medical intervention. Early detection of HHcy could potentially mitigate vascular and neurological complications, thereby improving patient outcomes.

Thrombolytic therapy as a superior option: Insights from three cases of acute subdural hematoma following surgery for chronic subdural hematoma.

BACKGROUND: Chronic subdural hematoma (cSDH) ranks among the most prevalent neurosurgical conditions, with burr-hole drainage typically yielding favorable prognoses. Nevertheless, perioperative complications may arise, with remote intraparenchymal hemorrhage and subarachnoid hemorrhage occurring infrequently, while acute subdural hematoma (aSDH) remains a relatively common complication post-cSDH removal. The standard treatment for aSDH, typically large craniotomy, substantially elevates surgical risk. CASE DESCRIPTION: This study presents three cases of postoperative aSDH in elderly patients with cSDH, examining potential causative factors and proposing pertinent strategies. Three elderly patients, admitted urgently due to exacerbating symptoms, underwent preoperative assessment followed by emergency parietal burr-hole drainage. Regrettably, all three patients developed aSDH postoperatively. Various treatment approaches were employed: two cases received thrombolysis with 50,000 units of urokinase, while one case required a large craniotomy. Despite the patients achieving satisfactory outcomes without significant neurological deficits, this study advocates thrombolytic therapy as a potentially superior option for aSDH following cSDH surgery. CONCLUSION: Urokinase-mediated subdural thrombolysis enhances hematoma clearance rates, suggesting a shift towards minimally invasive treatments to mitigate greater trauma. However, the paucity of evidence necessitates extensive research to validate its safety and efficacy.

Anesthetic Management of a Neurosurgical Patient With Amyotrophic Lateral Sclerosis: A Case Report.

Amyotrophic lateral sclerosis (ALS) is a progressive form of neurological disorder that affects both the upper and lower motor neurons. Anesthesia management in these patients is always challenging as they can develop respiratory complications because of pre-existing muscle involvement. We report a middle-aged male with ALS posted for chronic subdural hematoma evacuation (CSDH) surgery. Surgery was done under scalp block with monitored anesthesia care. The choice of anesthesia in these patients should be one that interferes the least with the disease pattern while still providing optimal conditions for surgery.

Cost Savings on Inpatient Hospitalization for Middle Meningeal Artery Embolization in the Setting of Increased Case Volume and Low Complications Rate.

BACKGROUND: Middle meningeal artery(MMA) embolization for the treatment of chronic subdural hematomas(cSDH) is becoming increasingly prevalent. It is essential to optimize the safety and cost effectiveness of the post-procedural management. In this study, we examined our cases over time to determine the most appropriate post-procedural destination. METHODS: This is a retrospective study of patients who underwent MMA embolization for cSDH at our institution. The study cohort was divided into two groups based on the year of embolization. Baseline characteristics, post-procedural complications, and length of stay were compared. Patients with shorter ICU stay were also compared to those with longer stay. Univariate statistical analysis was performed. RESULTS: 92 MMA embolizations for cSDH have been performed at our institution, of which 36(39.1%) were done between 2019 and 2022 and 56(60.9%) after 2023. No patients experienced stroke, cranial nerve palsy, or intraparenchymal hemorrhage after embolization. All but 5 patients were admitted to the intensive care unit(ICU) post-embolization, of which 59(64.1%) were downgraded after one day. Factors associated with a longer ICU stay included pre-operative location(p = 0.002) and need for surgery(p = 0.02). Of those who came from home or non-monitored bed, 82% were downgraded from the ICU in less than 2 days. The average cost of one night in the ICU, IMC, and non-monitored unit was $3,671.75, $2,605.22, and $2,303.81 respectively. CONCLUSION: MMA embolization for cSDH is a safe procedure with low rate of procedure-related complications. In carefully selected patients, the necessity ICU admission post-operatively should be weighed against better hospital resource utilization.

Middle meningeal artery embolization following surgical evacuation of symptomatic chronic subdural hematoma improves outcomes, interim results of a prospective randomized trial.

BACKGROUND: Outcomes after surgical treatment of chronic subdural hematoma (cSDH) remain undesirable in a significant proportion of patients. We aimed to show the role of middle meningeal artery (MMA) embolization and to demonstrate its benefits. METHODS: Thirty-five patients with symptomatic cSDH were enrolled in a prospective randomized trial following evacuation surgery. Participants were randomized to embolization or control group (expectant management following surgical evacuation without embolization). Patients were followed throughout their hospitalization and outpatient follow-ups. The main goals of this planned interim analysis were to assess neurological outcome and resource utilization. RESULTS: The groups were comparable in terms of sex, age and follow-up retention rates. Side(s) of intervention(s) and hematoma size were similar. There was no statistical difference in neurological examination improvement at discharge, but at follow-up, we observed a decline in neurologic exam in the control group (p = 0.03). Control group participants required more re-interventions (p = 0.02) and were followed in clinic and during related readmissions for longer (p = 0.02). The number of imaging studies obtained in relation to the disease management was higher in the control group (p = 0.01). CONCLUSIONS: Our results suggest a beneficial role for the addition of MMA embolization to surgical intervention in the treatment of symptomatic chronic subdural hematoma. Neurological outcomes were significantly better in the embolization group. This contributed to less need for follow-up, re-interventions, and imaging studies.

ALARA principles in practice: reduced frame and pulse rates for middle meningeal artery embolization.

Objective: As the prevalence of neuroendovascular interventions increases, it is critical to mitigate unnecessary radiation for patients, providers, and health care staff. Our group previously demonstrated reduced radiation dose and exposure during diagnostic angiography by reducing the default pulse and frame rates. We applied the same technique for basic neuroendovascular interventions. Methods: We performed a retrospective review of prospectively acquired data after implementing a quality improvement protocol in which pulse rate and frame rate were reduced from 15 p/s to 7.5 p/s and 7.5 f/s to 4.0 f/s respectively. We studied consecutive, unilateral middle meningeal artery embolizations treated with particles. Total radiation dose, radiation per angiographic run, total radiation exposure, and exposure per run were calculated. Multivariable log-linear regression was performed to account for patient body mass index (BMI), number of angiographic runs, and number of vessels catheterized. Results: A total of 20 consecutive, unilateral middle meningeal artery embolizations were retrospectively analyzed. The radiation reduction protocol was associated with a 39.2% decrease in the total radiation dose and a 37.1% decrease in radiation dose per run. The protocol was associated with a 41.6% decrease in the total radiation exposure and a 39.5% decrease in exposure per run. Conclusions: Radiation reduction protocols can be readily applied to neuroendovascular interventions without increasing overall fluoroscopy time and reduce radiation dose and exposure by 39.2% and 41.6% respectively. We strongly encourage all interventionalists to be cognizant of pulse rate and frame rate when performing routine interventions.

A Case Report of Tranexamic Acid for the Treatment of Chronic Subdural Hematoma in an 86-Year-Old Patient.

Fibrinolytic and coagulative hyperactivity is proven to have a role in liquefaction and progression of chronic subdural hematoma (CSDH). Tranexamic acid was one of the pharmaceutical options that was explored, as it inhibits the hyper-fibrinolytic activity and reduces the vascular permeability in CSDH, leading to a gradual resolution of the hematoma. In this case study, we present a case of using tranexamic acid for CSDH treatment in an 86-year-old patient with co-morbidities. The complete resolution of the hematoma following using tranexamic acid in this case with no history of recurrence in two years follow-up supports its efficacy in CSDH treatment and may be considered as one of the strategies that help prevent surgeries.

Headache that will not go away...Third ED visit is the charm?

Subdural hematoma is an uncommon complication of epidural analgesia or diagnostic lumbar puncture. Headache is a common complaint for patients with either a subdural hematoma or a post-dural puncture headache. Because post-dural puncture headaches are commonly seen in the Emergency Department, the potential to miss more serious pathology arises. We present the case of a young female who suffered bilateral subdural hematomas following epidural analgesia during childbirth. She presented twice to the Emergency Department and was treated for a post-dural puncture headache before computed tomography imaging revealed the diagnosis on the third Emergency Department encounter. This case highlights the importance of exploring all potential diagnoses when a patient presents with a headache after either epidural analgesia or a diagnostic lumbar puncture, especially if the patient returns after unsuccessful treatment for a presumptive post-dural puncture headache.

Effectiveness of traditional herbal Kampo medicine Goreisan on chronic subdural hematoma recurrence: a meta-analysis.

Objectives: Our objective was to compare the effectiveness of Traditional Chinese herbal Kampo medicine Goreisan in improving recurrence in patients with chronic subdural hematoma (CSDH). Methods: Eligible randomized controlled trials prospective trials, and retrospective cohort studies were systematically identified through searches of PubMed, Cochrane Library, and CNKI from inception to March 2024. Following the application of predetermined inclusion and exclusion criteria to screen the available studies, main outcome measures were rigorously extracted. RevMan v5.4 software was utilized to evaluate the overall recurrence rate, employing a random-effects model to calculate pooled odds ratios with the Mantel-Haenszel estimation method. Inter-study heterogeneity was assessed using the Cochran Q (Chi-square) test and I2 statistics. Funnel plots were used to evaluate publication bias. Results: Among the 48 articles initially screened for citation, eight were ultimately selected for inclusion in the study. The results of our network meta-analysis indicate that patients with newly diagnosed Chronic subdural hematoma experienced a significantly reduced recurrence rate when treated with Goreisan compared to standard neurosurgical treatment (OR: 0.72; 95% CI 0.61-0.86; p = 0.00003). There was no statistically significant difference in the incidence rates of complications, including general fatigue, allergic reactions, hepatic dysfunction, and interstitial pneumonia (OR: 7.21; 95% CI 0.37-141.29; p = 0.19). Conclusion: Traditional medicine Goreisan was effective in reducing CDSH recurrence rates. For clinical treatment, it provides a high level of evidence-based medicine. It is also necessary to conduct multicenter randomized controlled trials with dose adjustments to determine whether Goreisan interventions improve neurological function or prognosis.

Grade III en-plaque meningioma mimicking subacute subdural hematoma: A case report.

INTRODUCTION: En-plaque meningioma (EPM) presents preoperative diagnostic challenges due to its atypical radiologic features. This case report describes the preoperative diagnostic challenges in identifying EPM that affected its operative management. CASE REPORT: A 58-year-old female patient presented to the emergency department with decreased consciousness and a history of a fall on the head two months earlier. For the past year, the patient also complained of worsening headaches. One week before, the patient also complained of nausea, vomiting, and fluctuating fever. Although a CT scan of the head showed a mass in the left temporoparietal region, the patient was initially diagnosed with subacute subdural hematoma (saSDH) and planned for SDH evacuation surgery using the burr hole technique. However, intraoperative findings revealed an extradural intracranial tumor, so the procedure was switched to tumor excision craniotomy, and based on histopathological examination, it was confirmed to be an anaplastic malignant meningioma, WHO grade III. DISCUSSION: EPM is one of the rare subtypes of meningioma with an atypical and radiologically variable appearance that often presents challenges in preoperative diagnosis. In this case, the patient's history of falling on the head and the CT scan of the head that resembles saSDH may obscure the preoperative diagnosis and affect the patient's management. CONCLUSION: EPM can manifest like other intracranial disorders. In this case, the patient's fall history may obscure the clinicians' diagnosis of the meningioma, leading to preoperative misdiagnosis with saSDH. Therefore, meticulous preoperative diagnosis is essential to determining the patient's medical treatment and outcome.

Risk Factors for the Recurrence of Chronic Subdural Hematoma.

Objective: Chronic subdural hematoma (CSDH) is commonly encountered in neurosurgery, and often occurs in elderly patients following a head injury. Despite favorable postoperative prognosis, recurrence remains common. Herein, we retrospectively analyzed the clinical and radiological data of patients at our institute to identify the risk factors for CSDH recurrence. Methods: We investigated 370 patients who underwent surgery for CSDH at our institute. The following data were analyzed: sex, age, antiplatelet/anticoagulant use, preexisting diseases, radiological parameters, and surgical techniques. A univariate analysis was subsequently performed to examine the association between these variables and CSDH recurrence. Variables with a p-value of <0.05 in univariate analysis were further subjected to a multivariate logistic regression model to identify independent risk factors of CSDH. Results: Of the 370 patients, 345 (93.2%) had no recurrence and 25 (6.8%) had recurrence. Univariate and multivariate analyses revealed that male sex, advanced age, bilateral hematoma, moderate or severe brain atrophy, separation type, gradation type, and burr hole trephination were independent risk factors for CSDH recurrence. Conclusion: Sex, age, bilateral hematoma, brain atrophy, hematoma density and architecture, and surgical techniques are all associated with CSDH recurrence.

Middle Meningeal Artery Embolization in the Treatment of Acute Subdural Hematoma: A Case Series Featuring Access Through a Carotid Stent.

The first objective of this case series was to describe the case of a patient with severe symptomatic left internal carotid artery stenosis after a recent stroke. Several days after stent placement by transcarotid artery revascularization, the patient developed a left-sided subdural hematoma. The patient then underwent embolization of the left middle meningeal artery (MMA) despite blocked access to the left MMA because of an internal carotid stent. The external carotid artery was accessed by passing a guiding catheter through the stent wall. We describe this method as "intrawall access." This allowed a coaxial system to deliver polyvinyl alcohol particles to the MMA for embolization. Embolization was successfully performed, with the stent integrity and blood flow through it remaining uncompromised. Overall, we demonstrated a new method of access through a previously placed internal carotid stent to gain neurointerventional access to the external carotid artery, which was jailed by a stent, for treating an acute subdural hematoma via MMA embolization. The second objective of this case series was to demonstrate the first MMA embolization in literature carried out in the acute or acute-on-subacute setting, in this case, and in four others.

Subdural hematoma due to skull base bone metastasis of epidermal growth factor receptor mutated non-small cell lung cancer.

Subdural hematoma due to skull base bone metastasis of lung cancer is rare but are oncological emergency, necessitating prompt identification when a headache develops with the progression of the malignancy.

Simultaneous resolution of arachnoid cyst and chronic subdural hematoma after middle meningeal artery embolization: illustrative case.

BACKGROUND: Arachnoid cysts are cerebrospinal fluid-filled spaces that are typically congenital and treated conservatively or with fenestration when symptomatic. Chronic subdural hematomas (cSDHs) can arise in the presence of arachnoid cysts due to fragile leptomeningeal vessels or veins within the cyst wall or cyst lumen, leading to bleeding and subsequent hematoma formation. Middle meningeal artery (MMA) embolization is regularly used for the treatment of cSDH as an alternative to craniotomy and evacuation. OBSERVATIONS: Here, the authors present the first known report of the simultaneous resolution of an arachnoid cyst and cSDH following MMA embolization in an adult. A 24-year-old male presented to the emergency department with 1 month of worsening headaches. Imaging revealed the presence of a cSDH and ipsilateral arachnoid cyst. The cSDH was treated with MMA embolization using coils exclusively. Follow-up imaging 4 months after embolization demonstrated simultaneous resolution of both the hematoma and the arachnoid cyst. LESSONS: MMA embolization has been used for the treatment of cSDH. In cases in which the hematoma is related to an arachnoid cyst, MMA embolization can also lead to the concurrent resolution of both pathologies. https://thejns.org/doi/10.3171/CASE24192.

Delayed Burr Hole Evacuation Compared With Acute Craniotomy for Acute Subdural Hematoma in Older Patients With Low-Energy Trauma.

Background Acute subdural hematomas commonly require emergent surgical decompression by craniotomy. There is currently limited research on alternative surgical strategies in the elderly population. This study investigates delayed surgical intervention for stable patients with low-energy trauma presenting with acute subdural hematomas. Methodology In this retrospective chart review, 45 patients over the age of 55 presenting with acute subdural hematomas with a Glasgow Coma Scale score greater than or equal to 13 in the setting of low-energy trauma were selected. Additionally, included patients had a maximal hematoma thickness of >10 mm and/or a midline shift size of >5 mm per the current Brain Trauma Foundations guidelines for surgical intervention of subdural hematomas. The study was performed at a large tertiary care center, with records being examined from 1995 to 2020. Comparison groups were immediate craniotomy (within 24 hours) or delayed burr hole (minimum of 48 hours passing since the initial presentation). Primary outcomes included minor complications, major complications, any complications, and any complications with mortality excluded. There was no significant difference in mortality between the two cohorts. Results The immediate craniotomy group consisted of 16 patients, while the delayed burr hole group consisted of 29 patients. The results demonstrated a statistically significant increase in the incidence of any complication including mortality (relative risk (RR) = 3.17, 95% confidence interval (CI) = 1.71-5.88, p < 0.0001), major complications (RR = 2.33, 95% CI = 1.07-5.07, p = 0.031), and minor complications (RR = 2.42, 95% CI = 1.02-5.74, p = 0.041) in the immediate craniotomy group compared to the delayed burr hole group. Conclusions Our study demonstrates the decreased risk of major and minor complications for delayed burr hole evacuation in stable patients >55 years old presenting with low-energy trauma and subdural hematoma. The results suggest that for this population of patients, it appears to be beneficial to delay surgery if the patient's clinical situation allows.