Outcomes of Particle versus Liquid Embolic Materials Used in Middle Meningeal Artery Embolization for the Treatment of Chronic Subdural Hematoma.

BACKGROUND: Early evidence suggests that middle meningeal artery (MMA) embolization is an efficacious minimally invasive neuroendovascular technique for the management of chronic subdural hematoma (cSDH). Particle and liquid embolic materials are commonly used to embolize the MMA; however, studies comparing the safety and outcomes between these 2 materials are limited. METHODS: Patients ≥18 years old who had MMA embolization for cSDH between July 15, 2020 and May 1, 2022 were retrospectively identified from a single-center database. The primary safety, radiation dosage, fluoroscopy time, and radiographic and clinical outcomes were compared between particle and liquid embolization. RESULTS: In a cohort of 116, 48 (41.38%) were treated with liquid embolic material and 68 (58.62%) were treated with particle. The median age of the cohort was 73 years in the particle group and 73.5 years in the liquid embolic group. There was no significant difference in radiation dose or duration among both groups. There was no reported mortality associated with the procedure. One patient experienced nondisabling ischemic stroke in the particle group. Based on imaging follow-up, 3 patients in the particle group and 1 in the liquid embolic group had asymptomatic recurrence. One patient in each group had symptomatic recurrence requiring hematoma evacuation. The index median size of hematoma was 12 mm in the particle group and 11 mm in the liquid embolic group. At approximately 1 month follow-up, the median size of hematoma reduced to 6 mm in both groups. CONCLUSIONS: Our series shows that liquid embolic and particle embolization are equally safe and effective among patients undergoing MMA embolization for management of cSDH.

Middle Meningeal Artery Embolization for Primary Treatment of a Chronic Subdural Hematoma in a Pediatric Patient: A Systematic Review of the Literature and Case Report.

BACKGROUND: Middle meningeal artery (MMA) embolization is becoming increasingly studied as a safe, effective treatment for chronic subdural hematoma (cSDH) in adults. Among pediatric patients, however, MMA embolization for cSDH has been rarely described, and the potential benefit of this approach for pediatric patients remains unknown. OBJECTIVE: To systematically review the literature and identify cases of pediatric MMA embolization for cSDH. We also report our experience with pediatric MMA embolization. METHODS: A systematic review of the literature was performed to identify cases of pediatric MMA embolization for cSDH. Inclusion criteria included English language availability and pediatric age defined as less than 18 years. A pediatric patient treated with MMA embolization was also identified at our institution. RESULTS: Five cases of pediatric MMA embolization for cSDH were identified in the literature. Two were associated with arachnoid cysts, 2 with antiplatelet/anticoagulation therapy, and 1 with abusive head trauma. There were no adverse events, and all patients demonstrated clinical and radiological improvement on follow-up. At our institution, a previously healthy 8-year-old male was found to have a right-sided acute-on-chronic SDH during a headache evaluation. A diagnostic angiogram was performed to rule out a dural arteriovenous fistula, and right-sided MMA embolization was performed concurrently. Rapid clinical and radiological improvement was observed, with complete resolution by 6 months. CONCLUSION: MMA embolization may represent a treatment option for pediatric patients with cSDH.

Rheumatoid Meningitis: Diagnostic and Therapeutic Observations.

A 75-year-old female with untreated rheumatoid arthritis presented with two weeks of behavioral changes and cognitive decline. A neurologic examination showed severe encephalopathy, brisk reflexes, and bilateral Babinski sign. A contrast-enhanced brain MRI demonstrated right meningeal enhancement and periventricular white matter disease. A computed tomographic angiogram (CTA) of the head and neck was negative for vasculitis. The cerebrospinal fluid (CSF) demonstrated lymphocytic pleocytosis. The patient's serum rheumatoid factor levels were elevated. A biopsy of the leptomeninges and cortex showed lymphocytic vasculitis of the cortical tissue and patchy lymphoplasmacytic infiltrates of dural small vessels consistent with rheumatoid meningitis. The patient received pulse-dose steroids followed by cyclophosphamide infusions. At her three month follow-up appointment, the patient's mental status had improved mildly. A follow-up brain MRI showed resolution of enhancement, but progression of subcortical bihemispheric white matter disease. Subsequently, the patient developed a respiratory infection and passed away. In rheumatoid arthritis, symptoms of encephalopathy, headaches, seizures, or focal neurologic deficits should raise suspicion for CNS involvement. This potentially treatable disease warrants prompt diagnosis.

A Novel Use of Direct Platelet Application During Surgery for Clopidogrel-Associated Intracerebral Hemorrhage.

BACKGROUND: Dual antiplatelet therapy is associated with increased rates of intracerebral hemorrhage, especially in the context of subarachnoid hemorrhage. We present a case of a spontaneous hemorrhage in a patient treated with a Pipeline stent for a ruptured dissecting vertebrobasilar aneurysm and the novel use of direct application of platelets during surgery to control bleeding. CASE DESCRIPTION: A 54-year-old previously healthy woman presented with an intradural right vertebral artery dissection with a ruptured 6-mm pseudoaneurysm. The patient was started on aspirin and clopidogrel and the vessel was reconstructed with 2 Pipeline Embolization Devices. On postbleed day number 14, she became obtunded with a blown right pupil; computed tomography of the head demonstrated a large right temporal intracerebral hematoma. The patient was taken emergently to the operating room for evacuation of the clot. Intraoperatively, satisfactory control of bleeding was not achieved despite transfusing several units of platelets intravenously. Ultimately, a mixture of Floseal and platelets applied directly to the hematoma wall allowed prompt hemostasis. At 3 months the patient was doing extremely well clinically and angiography demonstrated occlusion of the aneurysm. CONCLUSIONS: This is the first reported description of direct application of platelets to achieve intraoperative hemostasis. Platelets are activated by thrombin and collagen and the use of Floseal (a bovine-derived, gelatin matrix and human-derived thrombin) further potentiated the effectiveness of this strategy. With the increased incidence of intracerebral hemorrhage associated with dual antiplatelet therapy, this technique may provide a useful tool in the neurosurgical armamentarium.

Novel application of 3-dimensional rotational C-arm conebeam computed tomography angiography for metastatic hypervascular tumor mass in the spine.

STUDY DESIGN: This is a case report. OBJECTIVE: To report a 3-dimensional (3D) rotational C-arm conebeam computed tomography (CT) (DynaCT) angiography generating computed tomographic data concurrently with spinal angiographic datasets. This technology allowed 3D modeling of the anterior spinal arterial supply in juxtaposition to a hypervascular tumor mass, thus affording unprecedented guidance in presurgical planning. SUMMARY OF BACKGROUND DATA: An enhanced demonstration of spatial relationships between the vascular elements and their adjacent soft-tissue structures is needed to visualize the minute anterior spinal artery optimally. METHODS: A 76-year-old male with a history of renal cell carcinoma metastasis to the T6 vertebra 1 year prior, presented with worsening myelopathy caused by severe spinal cord compression at T6 level, and a plan for surgical decompression was established. Because of the hypervascular nature of this renal cell carcinoma metastasis, preoperative embolization was requested to minimize blood loss during the operation. A digital subtraction angiogram identified the major arterial contribution to the tumor to also supply the radiculomedullary branch to the anterior spinal artery. To further characterize this blood supply, a rotational DynaCT angiography was performed. RESULTS: The rotationally acquired data were processed generating volumetric CT datasets demonstrating the 3D relationships of the anterior spinal artery, the blood supply to the tumor and the adjacent soft-tissue and bony structures. A shared blood supply to both the tumor mass and the anterior spinal artery from the left T6 segmental artery was confirmed. The dual nature of this blood supply presented increased risk of ischemic spinal cord injury by possible nontarget embolization. Therefore, the embolization was deferred. CONCLUSION: The DynaCT angiography precisely characterized the complex blood supply of a hypervascular vertebral tumor mass in relation to a shared arterial supply to the thoracic spinal cord. The optimal visualization properly aided presurgical planning. LEVEL OF EVIDENCE: N/A.

Percutaneous endoscopic gastrostomy tube placement in left versus right middle cerebral artery stroke: effects of laterality.

BACKGROUND: Prolonged dysphagia after middle cerebral artery (MCA) territory strokes may require percutaneous endoscopic gastrostomy (PEG) tube feeding. OBJECTIVE: We examined the predictors of PEG placement among patients with MCA stroke. It was hypothesized that stroke laterality was a predictor. METHODS: A retrospective cohort study of existing data from Hartford Hospital Stroke Database was done. A total of 157 patients with acute ischemic MCA stroke were included. Patients were divided into the "PEG" group (n = 24) and "no PEG" group (n = 133). Existing demographic, clinical and swallowing data were compared between the 2 groups. RESULTS: Demographic data were similar between the groups. The "PEG" group had a higher admission National Institute of Health Stroke Scale (NIHSS) score, higher proportion of patients who had thrombolytic administration, in- hospital aspiration pneumonia and inability to be assessed on first swallow evaluation. Multivariate analysis revealed that all, except thrombolytic administration may predict PEG placement. CONCLUSION: Admission NIHSS score, in-hospital aspiration pneumonia and inability to undergo first swallow evaluation may predict PEG placement in patients with acute MCA stroke. Stroke laterality was not associated. This knowledge facilitates early identification of patients that may require PEG tube placement for early nutrition provision and discharge to rehabilitation.