Middle Meningeal Artery Embolization versus Surgery in Patients with Chronic Subdural Hematoma-No More Fence Sitting?

BACKGROUND: Endovascular treatment of patients with chronic subdural hematoma using middle meningeal artery (MMA) embolization could become an alternative to surgical hematoma evacuation. The aim of the study was to compare methods and identify parameters to help determine the correct treatment modality. METHODS: We retrospectively reviewed 142 cases conducted internally; 78 were treated surgically and 64 were treated using MMA embolization. We analyzed the treatment failure rate and complications, and using a binary logistic regression model, we identified treatment failure risk factors. RESULTS: We found a comparable treatment failure rate of 23.1% for the surgery group and 21.9% for the MMA embolization group. However, in the MMA embolization group, 11 cases showed treatment failure due to early neurological worsening with a need for concomitant surgery. We also found a recurrence of hematoma in 15.4% of cases in the surgery group and 6.3% of cases in the MMA embolization group. CONCLUSION: Both modalities have their advantages; however, correct identification is crucial for treatment success. According to our findings, hematomas with a maximal width of <18 mm, a midline shift of <5 mm, and no acute or subacute (hyperdense) hematoma could be treated with MMA embolization. Hematomas with a maximal width of >18 mm, a midline shift of >5 mm, and no membranous segmentation could have better outcomes after surgical treatment.

Efficacy of Mechanical Thrombectomy using Penumbra ACETM Aspiration Catheter Compared to Stent Retriever SolitaireTM FR in Patients with Acute Ischemic Stroke.

BACKGROUND: Mechanical thrombectomy is the standard therapy in patients with acute ischemic stroke (AIS). The primary aim of our study was to compare the procedural efficacy of the direct aspiration technique, using Penumbra ACETM aspiration catheter, and the stent retriever technique, with a SolitaireTM FR stent. Secondarily, we investigated treatment-dependent and treatment-independent factors that predict a good clinical outcome. METHODS: We analyzed our series of mechanical thrombectomies using a SolitaireTM FR stent and a Penumbra ACETM catheter. The clinical and radiographic data of 76 patients were retrospectively reviewed. Using binary logistic regression, we looked for the predictors of a good clinical outcome. RESULTS: In the Penumbra ACETM group we achieved significantly higher rates of complete vessel recanalization with lower device passage counts, shorter recanalization times, shorter procedure times and shorter fluoroscopy times (p < 0.001) compared to the SolitaireTM FR group. We observed no significant difference in good clinical outcomes (52.4% vs. 56.4%, p = 0.756). Predictors of a good clinical outcome were lower initial NIHSS scores, pial arterial collateralization on admission head CT angiography scan, shorter recanalization times and device passage counts. CONCLUSIONS: The aspiration technique using Penumbra ACETM catheter is comparable to the stent retriever technique with SolitaireTM FR regarding clinical outcomes.

Giant internal carotid aneurysm: endovascular parent artery occlusion after failed treatment using a flow diverter-case report.

Treatment of giant aneurysms is challenging. While parent vessel reconstruction is the primary therapeutical target, the parent artery occlusion (PAO) is considered the next treatment option. We report a case of a 56-year-old woman with a right-sided non-ruptured giant aneurysm of the cavernous internal carotid artery. After failed aneurysm treatment by vessel remodeling through a flow diverter stent, we decided upon aneurysm coiling and PAO. Prior to the procedure, a successful balloon occlusion test (BOT) was performed, and in the second stage, just before occluding the parent artery, the BOT with induced hypotension was repeated. We achieved a good angiographic result and successful outcome without neurological deficit. In the case of failed treatment of giant aneurysm by vessel reconstruction, PAO is a therapeutical option. Prior to the vessel occlusion, a BOT with induced arterial hypotension challenge should be performed.

Intraoperative ventricular volume restoration by intraventricular Ringer solution injection in a normal-pressure hydrocephalus patient with traumatic bilateral acute subdural hematoma and ventricular system collapse caused by cerebrospinal fluid shunt overdrainage: illustrative case.

BACKGROUND: The authors report a case of a patient with normal-pressure hydrocephalus treated with a ventriculoperitoneal shunt who developed a traumatic hemispheric bilateral acute subdural hematoma caused by quick cerebrospinal fluid (CSF) overdrainage. The authors present active ventricular CSF volume restoration as a novel treatment option. CSF overdrainage in patients with shunts may facilitate acute subdural hematoma formation even in cases of minor head trauma. Therapeutic options include CSF shunt function restriction or ligation, hematoma evacuation, or a combination of both. OBSERVATIONS: In this case, the authors performed emergency surgery with hematoma evacuation through a bilateral craniotomy and actively restored the volume of the ventricular system with a slow intraventricular injection of 37°C warmed Ringer solution through a shunt burr hole reservoir. LESSONS: In addition to hematoma evacuation and restriction of shunt function, the intraoperative restoration of ventricular volume could be a treatment option to prevent postoperative rebleeding or a space-occupying air collection in the subdural space. The risk of possible complications, such as ventricular or parenchymal bleeding, shunt dysfunction, or infections, requires further investigation. Restoration of the ventricular CSF volume by intraventricular injection of Ringer solution was in this case an efficient treatment method to prevent subdural rebleeding and a space-occupying air collection after subdural hematoma evacuation.