A Novel Case of Deep Temporal Artery (DTA) Embolization for Recurrent Subacute-Chronic Subdural Hematoma.

Subdural hemorrhage (SDH) is a common neurological disease. In past, SDHs were managed either conservatively (non-surgically) or with surgical evacuation (burr hole versus craniotomy) depending on the severity. Surgical evacuation has major challenges including high recurrence rate, stoppage and reversal of antiplatelet or anticoagulation agents, risk of general anesthesia and surgery in elderly patients with multiple comorbidities. Given the above challenges, embolization of the distal branches of the middle meningeal artery (MMA) has recently emerged as an excellent alternate to surgical evacuation or conservative management. To the best of our knowledge, there is no literature on the embolization of the deep temporal artery (DTA) for subacute-chronic SDH. We report the first case of recurrent subdural hematoma post MMA embolization that was successfully treated with embolization of DTA.

Retrieval of Migrated Coils From Distal Cerebral Vasculature Using Stent Retriever: A Case Series.

The incidence of coil dislocation during an endovascular embolization of intracranial aneurysm is low but it can lead to serious thrombo-embolic complications. Therefore, coil displacement/migration often requires either retrieval or fixation of the errant coil with a stent. There are no standard recommended methods of coil retrieval. We present a series of three cases in which off-label application of a stent retriever allowed successful retrieval of herniated coils.

Internal Carotid Artery Agenesis: A Rare Entity.

Congenital absence of the internal carotid artery (ICA) is an extremely rare entity that occurs due to insult during the embryonic development of the ICA. Various intracranial collateral pathways develop to compensate for the ICA agenesis. Patients can present with aneurysmal subarachnoid hemorrhage, stroke-like symptoms, or other neurological symptoms due to compression of brain structures from enlarged collateral pathways/aneurysms. We present two cases of ICA agenesis along with an extensive review of the literature. A 67-year-old man presented with fluctuating right-sided hemiparesis and aphasia, found to have left ICA agenesis. The left middle cerebral artery (MCA) is supplied by the basilar artery through the well-developed posterior communicating artery (PCOM). Left ophthalmic artery coming from the proximal left MCA. A 44-year-old woman presented with severe headaches, found to have right ICA agenesis with bilateral MCAs and anterior cerebral arteries (ACA) supplied by left ICA. A 17-mm anterior communicating artery (ACOM) aneurysm was discovered.

How Educators Can Help Prevent False Brain Death Diagnoses.

It is critical for brain death diagnosis to be accurate. Although standardized guidelines and institutional protocols for brain death determination exist, for many physicians, lack of understanding about brain death leads to confusion and muddles interactions with patients' loved ones at the end of life. Using a case-based approach, this article demonstrates what tends to go wrong in erroneous brain death diagnoses and clarifies what physicians and educators should do to help avoid these errors.

Safety and Clinical Outcomes after Transverse Venous Sinus Stenting for Treatment of Refractory Idiopathic Intracranial Hypertension: Single Center Experience.

BACKGROUND: Idiopathic intracranial hypertension (IIH) is a syndrome of elevated intracranial pressure of unknown etiology. Unilateral or bilateral transverse sinus (TS) or transverse-sigmoid junction stenosis is present in about 30%-93% of these patients. There is an ongoing debate on whether venous sinus stenosis is the cause of IIH or a result of it. The subset of IIH patients who continue to have clinical deterioration despite maximum medical therapy is termed as "refractory IIH." Traditionally, cerebrospinal fluid diversion surgeries (ventriculoperitoneal shunt and lumboperitoneal shunt) and optic nerve sheath fenestration (ONSF) were the mainstays of treatment for refractory IIH. In the last decade, venous sinus stenting (VSS) has emerged as a safe and effective option for treating refractory IIH patients with venous sinus stenosis. Through this study, we want to share our experience with venous stenting in refractory IIH patients with venous sinus stenosis associated with a significant pressure gradient (≥10 mm Hg). METHODS: Retrospective chart review of all the patients diagnosed with refractory IIH who underwent VSS or angioplasty at our comprehensive stroke center from November 2016 to March 2019. RESULTS: A total of seven refractory IIH patients underwent VSS or angioplasty within the specified period. The mean age was 39 years. Eighty-five percent of the patients were women (n = 6). The mean body mass index (BMI) was 37 kg/m2. Headache was the most common symptom (85%, n = 6) followed by transient visual obscurations (71%, n = 5) and pulsatile tinnitus (57%; n = 4). All patients had papilledema. Fifty-seven percent of patients (n = 4) had impaired visual field. Mean lumbar opening pressure was 40.6 cm H2O (SD = 9.66; 95% CI = 33.5-47.7). All patients were on maximum doses of acetazolamide ± furosemide. Six patients (85%) had dominant right transverse-sigmoid sinus. Fifty-seven percent of the patients had severe right transverse ± sigmoid sinus stenosis (n = 4) and the rest (43%) had bilateral TS stenosis (n = 3). Prestenting mean trans-stenosis pressure gradient was 18 mm Hg (SD = 6.16; 95% CI = 13.43-22.57). Six patients (85%) were treated with TS stenting and one (15%) with only angioplasty. Poststenting mean trans-stenosis pressure gradient was 4.8 mm Hg (SD = 6.6; 95% CI = -0.1-9.7). All patients were able to come off their medications with significant improvement in neurological and ophthalmological signs and symptoms. No procedure-related complications occurred. CONCLUSION: TS stenting ± angioplasty is a safe and effective means of treating refractory IIH with venous sinus stenosis associated with a significant pressure gradient (≥10 mm Hg).