Direct puncture of the superficial temporal artery for ethylene vinyl alcohol embolization of a type 3 arteriovenous fistula with a dual lumen balloon.

Intracranial dural arteriovenous fistulas (dAVFs) may be difficult to treat by endovascular means, especially when the arterial feeders to the fistula are tortuous. 1 The usual main feeder to intracranial dAVFs is the middle meningeal artery, which may present very tight loops that are often difficult to cross with a microcatheter. 2 Direct puncture of a subcutaneous artery feeding the fistula indirectly via transosseous branches may be a valuable strategic option to overcome this limitation. 3 4 We report here the successful embolization of a Cognard type 3 parietal dAVF by direct puncture of the superficial temporal artery under roadmap guidance. The dAVF was subsequently embolized with ethylene vinyl alcohol via a dual lumen balloon, under balloon inflation. We highlight in this technical video 1 the potential difficulties and risks of direct puncture of the superficial temporal artery. We also stress the risk of delayed scalp necrosis using this technique. neurintsurg;13/5/493/V1F1V1Video 1.

Middle meningeal artery embolization reduces the post-operative recurrence rate of at-risk chronic subdural hematoma.

BACKGROUND: Embolization of the middle meningeal artery (MMA) has emerged as a potential treatment of chronic subdural hematomas (CSDHs). OBJECTIVE: To evaluate the impact on recurrence rate of postsurgical embolization of CSDH in patients with a higher than average risk of recurrence. METHODS: A monocentric retrospective study was performed on retrospectively collected data. From March 2018 to December 2019, embolization of the MMA was proposed as an adjunct postoperative treatment after burr-hole surgery in patients operated for a recurrent CSDH or a CSDH with an independent recurrence risk factor, including antiplatelet therapy, full anticoagulation therapy, coagulation disorder, hepatopathy, or chronic alcoholism. Patients who had undergone postoperative embolization were compared with a historic group of patients operated between March 2016 and March 2018, selected based on the same inclusion criteria. RESULTS: During the study period, 89 patients (with 74 unilateral and 15 bilateral CSDHs) were included and underwent an embolization procedure, leading to 91 out of a total of 104 MMA being embolized (88%). These were compared with 174 patients (138 unilateral and 36 bilateral CSDH) in the historic control group. One major procedure-related adverse event was registered. Four of the 89 patients (4%) required surgery for a CSDH recurrence in the embolization group, significantly less than the 24 of 174 patients (14%) in the control group (OR=0.28, 95% CI 0.07 to 0.86, p=0.02). CONCLUSIONS: Postsurgical embolization of the MMA may reduce the recurrence rate of CSDHs with a risk factor of recurrence.