Iatrogenic pseudoaneurysm of the middle meningeal artery during embolization of bilateral chronic subdural hematomas.

Summary/AbstractMiddle meningeal artery embolization has become an important treatment option for chronic subdural hematomas. While the treatment is safe, we present a unique case of development of an iatrogenic middle meningeal artery pseudoaneurysm during endovascular embolization with use of a dual-lumen balloon catheter used for injection of a liquid embolic agent. A 62-year-old man on Coumadin for portal vein thrombosis presented to the hospital with headache and supratherapeutic INR. Imaging revealed bilateral acute on chronic subdural hematomas. Given his medical comorbidities he underwent endovascular middle meningeal artery embolization. During the embolization, angiography revealed a pseudoaneurysm of the middle meningeal artery related to use of a dual-lumen balloon catheter. This pseudoaneurysm was successfully treated with ethylene vinyl alcohol embolization. Intracranial pseudoaneurysm related to balloon catheter use is a rare cause of iatrogenic pseudoaneurysm and could lead to life-threatening intracranial bleeding. Therefore, recognition and timely treatment are important.

Minimally invasive versus open transforaminal lumbar interbody fusion: comparison of clinical outcomes among obese patients.

OBJECT: Minimally invasive (MI) transforaminal lumbar interbody fusion (TLIF) has been demonstrated in previous studies to offer improvement in pain and function comparable to those provided by the open surgical approach. However, comparative studies in the obese population are scarce, and it is possible that obese patients may respond differently to these two approaches. In this study, the authors compared the clinical benefit of open and MI TLIF in obese patients. METHODS: The authors conducted a retrospective cohort study based on review of electronic medical records at a single institution. Eligible patients had a body mass index (BMI) ≥ 30 kg/m(2), were ≥ 18 years of age, underwent single-level TLIF between 2007 and 2011, and outcome was assessed at a minimum 6 months postoperatively. The authors categorized patients according to surgical approach (open vs MI TLIF). Outcome measures included postoperative improvement in visual analog scale (VAS), Oswestry Disability Index (ODI), estimated blood loss (EBL), and hospital length of stay (LOS). RESULTS: A total 74 patients (21 open and 53 MI TLIF) were studied. Groups had similar baseline characteristics. The median BMI was 34.4 kg/m(2) (interquartile range 31.6-37.5 kg/m(2)). The mean follow-up time was 30 months (range 6.5-77 months). The mean improvement in VAS score was 2.8 (95% CI 1.9-3.8) for the open group (n = 21) and 2.4 (95% CI 1.8-3.1) for the MI group (n = 53), which did not significantly differ (unadjusted, p = 0.49; adjusted, p = 0.51). The mean improvement in ODI scores was 13 (95% CI 3-23) for the open group (n = 14) and 15 (95% CI 8-22) for the MI group (n = 45), with no significant difference according to approach (unadjusted, p = 0.82; adjusted, p = 0.68). After stratifying by BMI (< 35 kg/m(2) and ≥ 35 kg/m(2)), there was still no difference in either VAS or ODI improvement between the approaches (both unadjusted and adjusted, p > 0.05). Complications and EBL were greater for the open group than for the MI group (p < 0.05). CONCLUSIONS: Obese patients experienced clinically and statistically significant improvement in both pain and function after undergoing either open or MI TLIF. Patients achieved similar clinical benefit whether they underwent an open or MI approach. However, patients in the MI group experienced significantly decreased operative blood loss and complications than their counterparts in the open group.

When negative rights become positive entitlements: complicity, conscience, and caregiving.

Clinicians have an obligation to ensure that patients with adequate capacity can make autonomous decisions. Thus, patients who choose to forego treatment and leave hospitals "against medical advice" are typically allowed to do so. But what happens when they require clinicians' assistance to physically leave? Is it incumbent upon clinicians to not only respect and fulfill patients' requests with which they disagree, but to physically assist in their fulfillment? We attempt to develop an ethical framework wherein clinicians can honor patients' wishes without necessarily sacrificing their own moral position.