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.

Use of reverse angle guide catheter with trans-radial approach in patients undergoing middle meningeal artery embolization.

Background: Trans-radial access (TRA) for MMA embolization has grown due to lower access site complications and greater patient satisfaction. Here, we describe the feasibility of utilizing a 6F Envoy Simmons 2 (6F-SIM2) as a guide catheter with TRA and compare outcomes with trans-femoral approach (TFA) in a single center case series. Methods: We performed a retrospective review of patients who underwent MMA embolization for management of chronic subdural hematoma (cSDH). TRA was performed by utilizing a combination of 6F 90cm Envoy (Codman & Shurtleff, Inc., Rayham, MA) Simmons 2 guide catheter and 5F 125cm Sofia (Microvention, Aliso Viejo, CA) intermediate catheter. Outcomes measured are Modified Rankin Score (mRS) at 90 days, inpatient mortality, post-embolization recurrence, fluoroscopy time and radiation exposure. Results: A total of 71 patients underwent 97 MMA embolization overall with 65 (67%) in trans-femoral access group, 11 (11.3%) in trans-radial access without use of Simmons 2 Guide catheter group and 21 (21.6%) in trans-radial access with use of Simmons 2 Guide catheter group. There were no direct access-related complications in either group. One patient had thromboembolic stroke in trans-femoral group. There was no difference in average procedure-related total fluro time or radiation dose among all three groups. Conclusion: Trans-radial approach using 6F-SIM2 guide catheter coupled with 5F Sofia intermediate catheter is safe and effective. It provides an alternative approach to access distal branches of bilateral anterior circulation in elderly patients with difficult anatomy undergoing MMA embolization.

Endovascular Treatment of Complex Distal Posterior Cerebral Artery Aneurysms with the Pipeline Embolization Device.

OBJECTIVE: To assess the safety and efficacy of the Pipeline Embolization Device (PED) for endovascular treatment of complex, distal posterior cerebral artery (PCA) aneurysms. METHODS: We conducted a retrospective review of patients who underwent endovascular treatment of complex PCA aneurysms with PED from November 2012 to December 2015. A total of 4 patients were identified and treated. Twelve-month angiographic and clinical follow-up was available for all patients. RESULTS: Mean aneurysm size (largest diameter) was 10.0 mm, and all aneurysms originated at the P2 segment or beyond. Technical success was achieved in all patients. All patients were treated with a single PED; adjunctive intrasaccular coil was also placed in one patient. All patients achieved a favorable postprocedural outcome (modified Rankin Scale score = 0) with no new neurologic deficits. No patients experienced neurologic complications or perforator infarction, and presenting symptoms resolved in all patients. Follow-up cerebral angiography at 12 months in 3 patients showed complete occlusion (Raymond-Roy Occlusion Classification class 1) and minimal residual aneurysm filling (Raymond-Roy Occlusion Classification class 2) in 1 patient. A small degree of focal stenosis was present in 2 patients within the PED at 12-month follow-up that was associated with mild decrease in flow within the distal PCA branches. CONCLUSIONS: PED use provides a practical and viable treatment option for complex, distal PCA aneurysms. Based on our limited institutional experience, PED use for treatment of complex, distal PCA aneurysms in select patients appears safe and effective.

Case report of a de novo brainstem arteriovenous malformation in an 18-year-old male and review of the literature.

De novo intracerebral arteriovenous malformations (AVMs) are exceedingly rare with only seven reported cases in the literature. Although generally considered congenital by nature, the lesions do not manifest themselves clinically until the third or fourth decades of life. However, with the advent of improved imaging modalities and more frequent surveillance, an increasing number of de novo cases are being found challenging the concept AVMs develop in the perinatal/antenatal period. Alternatively, this phenomenon could represent a distinct entity in which lesion development occurs after birth. A PubMed search of "de novo cerebral arteriovenous malformation" was performed in which seven reported cases were found. The mean age at diagnosis was 14.7 years with a mean follow-up imaging study of 5.8 years. Lesion location was supratentorial in all previously described cases. This case involves an 18-year-old male with congenital hydrocephalus and seizures diagnosed at 7 months of age. The patient underwent a ventriculoperitoneal shunt and was followed frequently by a neurologist. The last diagnostic imaging was an unremarkable MRI of the brain at age 12. Seven years later, the patient presented with an intracerebral hemorrhage. A CT angiogram demonstrated a large brainstem AVM with an intraparenchymal hemorrhage and intraventricular extension. This case is unique in that it is the first infratentorial de novo AVM. The congenital nature of AVMs is challenged with the increasingly described series of patients with previously documented normal radiographic imaging. This suggests there may be a subset of patients genetically predisposed to postnatal development of AVMs.

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.

Clinical characteristics and outcomes of neurogenic stress cadiomyopathy in aneurysmal subarachnoid hemorrhage.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (aSAH) is an often devastating form of stroke. Aside from the initial hemorrhage, cardiac complications can occur resulting in neurogenic stress cardiomyopathy (NCM), leading to impaired cardiac function. We investigated whether aSAH patients with NCM had poorer long term functional outcomes than patients without NCM. Mortality, vasospasm, and delayed ischemic complications were also evaluated. METHODS: A retrospective study of all patients admitted for aneurysmal subarachnoid hemorrhage (aSAH) from January 2006 to June 2011 (n=299) was conducted. Those patients who underwent an echocardiogram were identified (n=120) and were assigned to the NCM (n=49) category based on echocardiographic findings defined by a depressed ejection fraction (EF%) along with a regional wall motion abnormality (RWMA) in a non-vascular pattern. Primary outcome measures included in-hospital mortality and functional outcomes as measured by the Modified Barthel Index (mBI) at 3 months and one year. Secondary analysis determined if there was an association between NCM, cerebral vasospasm and delayed cerebral ischemia. RESULTS: 16% of aSAH patients developed NCM. Mortality was higher (p<.001) in the NCM group (n=23[46.9%]) than in the non-CM group (n=28[11.2%]). Patients with NCM had poorer functional outcomes as measured by the mBI at both 3 months (p=.002) and 12 months (p=.014). The Hunt-Hess score was predictive of functional outcome as measured by the mBI at both 3 months (p=.002) as well as at 1 year (p=.014). NCM was associated with both death (p=.047 CI, 1.012-7.288) and vasospasm (p=.008 CI, 1.34-6.66) after correction for Hunt-Hess grade. Tobacco use (p<.001) and a history of diabetes mellitus (p<.009) were also associated with vasospasm. NCM was associated with higher in-hospital mortality (p=.047) in multivariate analysis. CONCLUSION: NCM is seen in a substantial number of aSAH patients and when present, it is associated with higher mortality and poorer long-term functional outcomes. This finding may guide further prospective studies in order to determine if early recognition of NCM as well as optimization of cardiac output would improve mortality.

Multiple resting state network functional connectivity abnormalities in mild traumatic brain injury.

Several reports show that traumatic brain injury (TBI) results in abnormalities in the coordinated activation among brain regions. Because most previous studies examined moderate/severe TBI, the extensiveness of functional connectivity abnormalities and their relationship to postconcussive complaints or white matter microstructural damage are unclear in mild TBI. This study characterized widespread injury effects on multiple integrated neural networks typically observed during a task-unconstrained "resting state" in mild TBI patients. Whole brain functional connectivity for twelve separate networks was identified using independent component analysis (ICA) of fMRI data collected from thirty mild TBI patients mostly free of macroscopic intracerebral injury and thirty demographically-matched healthy control participants. Voxelwise group comparisons found abnormal mild TBI functional connectivity in every brain network identified by ICA, including visual processing, motor, limbic, and numerous circuits believed to underlie executive cognition. Abnormalities not only included functional connectivity deficits, but also enhancements possibly reflecting compensatory neural processes. Postconcussive symptom severity was linked to abnormal regional connectivity within nearly every brain network identified, particularly anterior cingulate. A recently developed multivariate technique that identifies links between whole brain profiles of functional and anatomical connectivity identified several novel mild TBI abnormalities, and represents a potentially important new tool in the study of the complex neurobiological sequelae of TBI.

The ARUBA trial: current status, future hopes.

BACKGROUND AND PURPOSE: Report on the status of an on-going National Institutes of Neurological Disorders and Stroke (NINDS)-supported clinical trial of management of unbled brain arteriovenous malformations. SUMMARY OF REVIEW: Begun in April 2007 with 3 centers, the trial has grown to 65 centers, and has randomized 124 patients through mid-June 2010 en route to the planned 400. The current literature continues to support the rationale for the trial. CONCLUSIONS: ARUBA is steadily approaching its monthly randomization goals and has already reached the number needed to test the maximum published interventional complication rates against the minimum hemorrhage rates for natural history.