Angiographic classification of chronic subdural hematoma.

Background and purpose:

Chronic subdural hematoma (cSDH) is a challenging pathology with high recurrence rate after surgical treatment and may seriously affect the patient’s quality of life. Membrane formation with angiogenesis plays an important role in the evolution of the disease, providing a promising target for endovascular therapy. Our goal is to categorize angiographic patterns of chronic subdural hematoma for standardized reporting purposes.

In our retrospective analysis of prospective data collection, we analyzed angiographic properties of all high recurrence risk patients with cSDH, who were treated by embolization in our hospital between February 2019 and June 2020. Altogether 17 patients were included in the analysis. 

Based on superselective angiography of the middle meningeal artery (MMA) in the two standard, AP and lateral views, three distinct categories of dural supply were defined: normal vascular pattern (Grade I), cottonwool appearance without enlargement of the MMA branches (Grad II) and strong cottonwool like staining with dilatative remodelling of the MMA branches (Grade III).

The proposed grading system of the angiographic appearance of cSDH, representing the pathophysiological evolution of the disease should be correlated to therapeutic success rates and could be applied in future clinical studies.

Unusual Anatomic Variation: Intradural Conjugation of the Hypoplastic Left ICA and the Enlarged Accessory Meningeal Artery.

The precise definition of the accessory meningeal artery was not available until 1961. It can originate from the maxillary artery or middle meningeal artery and supplies the meatus and membranous portion of the auditory tube, the lateral pharyngeal muscle, and the medial pterygoid muscle; Laterally, it supplies the lateral pterygoid muscle, the extracranial part of the mandibular nerve, the pterygoid venous plexus, and the sphenoid periosteum. Here, we present a 70-year-old male patient who applied to the neurosurgery clinic with complaints of chronic headaches and dizziness. Magnetic resonance angiography and computed tomography angiography showed hypoplasic appearance of the left internal carotid artery and an enlarged accessory meningeal artery variant merging with its ophthalmic segment.

Dural Tail Sign and Middle Meningeal Artery Hypertrophy in Glioblastoma: A Rarity?

BACKGROUND: Dural tail sign and increased caliber of branches of the external carotid artery (ECA) are common findings in meningioma and they have been rarely reported in intra-axial lesions. Anyway, some cases of glioblastoma (GBM) are reported in the literature, mostly superficially localized, characterized by these 2 findings and therefore, misdiagnosed with meningioma. The aim of this study is to verify the prevalence of dural tail sign and hypertrophy of middle meningeal artery (MMA) in a large cohort of GBMs. METHODS: 180 GBM patients were retrospectively evaluated. Deep or superficial localization of GBM was established and the presence of dural tail sign and hypertrophy of the ipsilateral MMA were assessed. The rate of tumor necrosis and the incidence of dural metastases during the radiological follow-up were also evaluated. Inter-rater reliability was calculated using Cohen's K-test. RESULTS: Dural tail sign and enlarged MMA were evident in 30% and 19% of 96 superficial GBM, respectively. Deep GBM did not present those signs. Only one patient developed dural metastasis at follow-up and no differences in terms of tumor necrosis and hypoxic biomarkers expression were evident among GBMs with and without dural and vessel signs. CONCLUSIONS: Dural tail sign and hypertrophy of the MMA in superficial GBM are more common than expected. They probably represent reactive rather than a neoplastic infiltration. Knowing these radiological signs may be important in terms of neurosurgery planning and avoiding excessive bleeding. Anyway, this hypothesis should be confirmed by a prospective neurosurgery studio.

Time-of-flight magnetic resonance angiography for detection of postoperative recurrence in patients with chronic subdural hematoma.

PURPOSE: Chronic subdural hematoma (CSDH) is associated with postoperative recurrence. Although various factors are involved in postoperative recurrence of CSDH, blood flow, especially in the middle meningeal artery (MMA), is considered to play an important role. We investigated whether the degree of signal intensity (SI) of the MMA on time-of-flight magnetic resonance angiography (TOF MRA) and various clinical factors are involved in recurrence of CSDH. METHODS: The maximum SI of both MMAs was measured on TOF MRA images within 1 month before or after the initial surgery. RESULTS: In total, 185 patients (20 with and 165 without recurrence of CSDH) were included in the analysis. The SI ratio and dementia were significant predictors of recurrence of CSDH (SI ratio: odds ratio [95% confidence interval (CI)] = 1.71 [1.32, 2.22], p < 0.0001; dementia: odds ratio [95% CI] = 7.41 [1.83, 30.1], p = 0.005). The estimated regression coefficients in the final model were 6.14 for the SI ratio and 1.28 for dementia. The risk score was derived according to these regression coefficients as follows: score = 5 × SI ratio + 1 (dementia: yes). With a score of 5, the predicted probability of recurrence was 2% [95% CI 0.7, 5.7], whereas with scores of 8 and 10, the probability was 43.3% [27.0, 61.1] and 89.5% [65.7, 97.5], respectively, which increased the risk of recurrence. CONCLUSION: Patients with an increased SI ratio of the affected MMA on TOF MRA who underwent surgery for CSDH were significantly more likely to experience recurrence.

Middle Meningeal Artery Aneurysm in a Giant Meningioma.

Nontraumatic perilesional aneurysms are thought to occur because of high-flow demands of feeding arteries and neoangiogenesis of hypervascular lesions, most commonly in vascular malformations, but they can rarely be associated with tumors as well. Most of these perilesional aneurysms are from intracranial vasculature associated with branches off the internal carotid artery. We report the unique case of a middle meningeal artery aneurysm associated with a giant convexity meningioma seen on a preoperative angiogram.

Larger Middle Meningeal Arteries on Computed Tomography Angiography in Patients with Chronic Subdural Hematomas as Compared with Matched Controls.

Chronic subdural hematomas (CSDHs) are one of the most prevalent head-trauma-related conditions. The middle meningeal artery (MMA) may participate in the pathophysiology of CSDHs. The aim of this study was to determine whether CSDHs are associated with large MMAs. Patients referred for CSDH embolization and having undergone a computed tomography angiography (CTA) before embolization were retrospectively included. For each CSDH patient, two age- and sex-matched controls with a CTA performed during the study period were selected. Size comparisons of the MMA were performed between MMAs ipsilateral to CSDHs, on the contralateral side, and in controls. Comparison was also made with angiographic measurements from CSDH embolization procedures. Seventy-five patients with CSDH with available CTAs prior to embolization were enrolled and 146 MMAs were measured. One hundred fifty controls were included and 288 MMAs were measured. The median diameter of the 94 MMAs ipsilateral to a CSDH (1.5 mm; interquartile range [IQR] 1.3-1.7) was significantly larger than that of control MMAs (1.28 mm; IQR 1.15-1.4) (p < 0.001). The median diameter of 52 MMAs on the side of a unilateral CSDH (1.6 mm; IQR 1.4-1.8) was larger than that of the 52 contralateral MMAs (1.4 mm; IQR 1.25-1.6) (p < 0.001). Among the characteristics of patients with CSDH, multiple surgeries were associated with significantly larger MMAs (>1.7 mm; p = 0.01). MMAs ipsilateral to CSDHs appear to be significantly larger as compared with contralateral MMAs and MMAs in a control population, suggesting the involvement of the MMA in the pathophysiology of CSDH.

Efficacy and safety of middle meningeal artery embolization in the management of refractory or chronic subdural hematomas: a systematic review and meta-analysis.

INTRODUCTION: Refractory or chronic subdural hematomas (cSDH) constitute a challenging entity that neurosurgeons face frequently nowadays. Middle meningeal artery embolization (MMAE) has emerged in the recent years as a promising treatment option. However, solid evidence that can dictate management guidelines is still lacking. METHODS: We conducted a systematic review and meta-analysis (MA) in compliance with the PRISMA guidelines to evaluate the efficacy and safety of MMAE compared with conventional treatments for refractory or cSDH. Databases were searched up to March 2019. Using a random-effects model, meta-analyses of proportions and risk difference were conducted recurrence, need for surgical rescue, and complications. RESULTS: Eleven studies (177 patients) were included. Majority (116, 69%) were males with a weighted mean age of 71 + -19.5 years. Meta-analysis of proportions showed treatment failure to be 2.8%, need for surgical rescue 2.7%, and embolization-related complications 1.2%. Meta-analysis of risk-difference between embolized and non-embolized patients showed a 26% (p < 0.001, 95% CI 21%-31%, I2 = 0) lower risk of hematoma recurrence in MMAE. Similarly, in the embolized group, the need for surgical rescue was 20% less (p < 0.001, 95% CI = 12%-27%, I2 = 12.4), and complications were 3.6% less (p = 0.008, 95% CI 1%-6%, I2 = 0) compared to conventional groups. CONCLUSIONS: Although MMAE appears to be a promising treatment for refractory or cSDH, drawing definitive conclusions remains limited by paucity of data and small sample sizes. Multicenter, randomized, prospective trials are needed to compare embolization to conventional treatments like watchful waiting, medical management, or surgical evacuation. More extensive research on MMAE could begin a new era in the minimally invasive management of cSDH.

Double Ophthalmic Arteries Arising from the Internal Carotid Artery and the Accessory Meningeal Artery: A Case Report of a New Anatomic Variation.

BACKGROUND: Variant origin of the ophthalmic artery (OA) is uncommon. The majority of variant origins are from the middle meningeal artery and from the infraclinoid segment of the internal carotid artery. An OA arising from the accessory meningeal artery is an extremely rare vascular variation that has not been described previously in the English literature. CASE DESCRIPTION: We report the first case of double origin of the OA from the supraclinoid segment of the internal carotid artery and from the accessory meningeal artery branch of the maxillary artery. A 33-year-old woman was referred to our clinic with suspicion of a middle cerebral artery aneurysm. She had nonspecific neurologic symptoms. The patient underwent cerebral magnetic resonance imaging and magnetic resonance angiography. CONCLUSIONS: Being aware of variant origin of the OA from the accessory meningeal artery is very important for transarterial chemoembolization in the external carotid artery territory. Reconstructed images from magnetic resonance angiography are very useful to reveal the variant origin of the OA.

A novel lethal recognizable polymicrogyric syndrome caused by ATP1A2 homozygous truncating variants.

Polymicrogyria is a heterogeneous malformation of cortical development microscopically defined by an excessive folding of the cortical mantle resulting in small gyri with a fused surface. Polymicrogyria is responsible for a wide range of neurological symptoms (e.g. epilepsy, intellectual disability, motor dysfunction). Most cases have a supposed environmental clastic vascular or infectious origin but progress in genomics has revealed new monogenic entities. We report four cases from two independent families sharing a common recognizable lethal syndromic polymicrogyria of autosomal recessive inheritance. Beyond diffuse polymicrogyria detected prenatally, pathological examination revealed a common pattern associating meningeal arterial calcifications, necrotic and calcified areas in basal ganglia, dentato-olivary dysplasia and severe hypoplasia/agenesis of the pyramidal tracts. In all affected cases, exome sequencing showed a pathogenic homozygous nonsense ATP1A2 variant. This resulted in absence of immunodetectable ATP1A2 protein in two brains analysed. ATP1A2 encodes the alpha-2 isoform of the Na+/K+-ATPase, which is highly expressed in brain tissues and has previously been related to familial hemiplegic migraine (MIM#602481) and alternating hemiplegia of childhood (MIM#104290). Through the description of this genetic entity, we emphasize the possibility of dual mode of transmission for disease-causing genes and provide the key neuropathological features that should prompt geneticists to test for mutations in the ATP1A2 gene.

Endovascular Treatment of Transverse-Sigmoid Sinus Dural Arteriovenous Fistulas: A Single-Center Experience with Long-Term Follow-Up.

BACKGROUND: Endovascular treatment of transverse-sigmoid sinus dural arteriovenous fistulas (TSDAVFs) remains challenging because of their complex anatomic factors. The aim of our study was to evaluate the long-term efficacy and safety of endovascular treatment of TSDAVFs. METHODS: From January 2008 to December 2014, 44 patients with TSDAVFs were treated endovascularly at our institution. The clinical and angiographic data were retrospectively collected, and the occlusion rate, complications, and clinical outcomes were analyzed. RESULTS: Overall, 44 patients (26 males and 18 females) were identified, with a mean age of 47 years (range, 13-68 years). Of the 44 patients, 5 presented with Cognard type I fistula, 12 with type IIa, 6 with type IIb, 13 with type IIa+IIb, 2 with type III, and 6 with type IV. Complete (n = 29) or near-complete (n = 7) occlusion of the fistula was achieved in 36 patients (82%). Two patients experienced a transient neurological deficit (cranial nerve VII). In 31 patients with angiographic follow-up (range, 2-40 months) data available, the occlusion remained in 25, 2 previously minimal residual fistulas were completely occluded, 3 residual fistulas were unchanged, and 1 fistula recurred. Two patients with cortical venous reflux who had received incomplete treatment died of intracranial hemorrhage during the follow-up period. Of the 37 patients with clinical follow-up (mean, 33.6 months) data available, clinical cure was achieved in 29, residual symptoms remained unchanged in 7, and symptoms had deteriorated in 1. CONCLUSIONS: Favorable and durable outcomes were achieved with endovascular treatment of TSDAVFs. TSDAVFs with cortical venous reflux carry a high risk of hemorrhage and require curative treatment.

Chronic Dilatation of Superficial Temporal Artery and Middle Meningeal Artery Associated with Development of Collateral Circulation After Bypass Surgery for Moyamoya Angiopathy.

OBJECTIVES: Dilatation of the superficial temporal artery (STA) and middle meningeal artery (MMA) were occasionally observed after bypass surgery for moyamoya angiopathy. The purpose of this study was to examine the correlation between angiographic outcomes and magnetic resonance imaging (MRI), specifically focusing on the postoperative dilatation ratio of the STA (rSTA) and MMA (rMMA). METHODS: Fifty-six hemispheres in 36 consecutive patients who underwent revascularization for moyamoya angiopathy were evaluated. All patients underwent angiography and MRI before surgery and during the chronic phase. Angiographic outcomes were classified as good or poor according to the extent of the blood supply through direct or indirect bypass. The rSTA and rMMA was calculated in time-of-flight magnetic resonance angiography (MRA). The signal changes of ivy signs and flow voids in basal ganglia were also evaluated. RESULTS: Postoperative collaterals through direct and indirect bypass was good in 30 (53.6%) and 33 (58.9%) patients, respectively. The mean rSTA and rMMA were 36.04 ± 28.79% and 29.15 ± 22.01%, respectively. Ivy signs and flow voids were decreased in 9 (16.1%) and 26 (46.4%) patients, respectively. Univariate analyses demonstrated no significant correlation between the angiographic outcomes and postoperative signal changes on MRI. However, rSTA was significantly correlated with good collaterals through direct bypass (P = 0.04), whereas rMMA was significantly correlated with good collaterals through indirect bypass (P < 0.001). CONCLUSIONS: MRA may be an alternative to angiography. Both rSTA and rMMA estimated the development of collaterals after bypass surgery for moyamoya angiopathy.

Delayed Intracerebral Hemorrhage After Pseudoaneurysm of Middle Meningeal Artery Rupture: Case Report, Literature Review, and Forensic Issues.

BACKGROUND: Traumatic pseudoaneurysm of the middle meningeal artery (PMMA) is rare. Its rupture is associated with high mortality, so an early diagnosis is recommended for this risky condition. In the absence of a specific guideline, computed tomography (CT), digital subtraction angiography, and CT angiography (CTA) are proposed for its diagnosis. CTA is the technique of choice even if it is almost never performed, especially in mild head injury. We report a rare case of a delayed rupture of PMMA, analyzed from a forensic point of view. METHODS: Fifteen days after mild blunt head trauma, characterized by temporal fracture and a small hemorrhage near the rim, a wide intraparenchymal hemorrhage (IPH) occurred. The onset of IPH was marked by neurologic deterioration and arm paralysis. Immediate head CT showed IPH, and CTA showed PMMA. Prompt surgery could not help patient survival. The goal of autopsy was to formulate the cause of death and to individuate potential medical negligence. RESULTS: In the literature, 16 cases of 54 are related to PMMA (26%) and are associated with IPH. IPH can be acute or delayed. Eight cases of acute IPH and 8 cases of delayed IPH (including our case), both coexisting with PMMA, are described. The literature review showed that the association of temporal rim fracture and a small hemorrhage nearby is highly predictive of PMMA formation. CONCLUSIONS: Therefore, in the presence of these 2 risk factors after heat trauma, CTA is strongly suggested.

Middle Meningeal Artery Embolization for Chronic Subdural Hematoma.

Purpose To evaluate the effect of middle meningeal artery (MMA) embolization on chronic subdural hematoma (CSDH) and compare the treatment outcomes of MMA embolization and conventional treatment. Materials and Methods All consecutive patients 20 years or older with CSDH were assessed for eligibility. CSDHs with a focal location, a thickness of 10 mm or less, no mass effect, or underlying conditions were excluded. Seventy-two prospectively enrolled patients with CSDH underwent MMA embolization (embolization group; as the sole treatment in 27 [37.5%] asymptomatic patients and with additional hematoma removal for symptom relief in 45 [62.5%] symptomatic patients). For comparison, 469 patients who underwent conventional treatment were included as a historical control group (conventional treatment group; close, nonsurgical follow-up in 67 [14.3%] and hematoma removal in 402 [85.7%] patients). Primary outcome was treatment failure defined as a composite of incomplete hematoma resolution (remaining or reaccumulated hematoma with thickness > 10 mm) or surgical rescue (hematoma removal for relief of symptoms that developed with continuous growth of initial or reaccumulated hematoma). Secondary outcomes included surgical rescue as a component of the primary outcome and treatment-related complication for safety measure. Six-month outcomes were compared between the study groups with logistic regression analysis. Results Spontaneous hematoma resolution was achieved in all of 27 asymptomatic patients undergoing embolization without direct hematoma removal. Hematoma reaccumulation occurred in one (2.2%) of 45 symptomatic patients receiving embolization with additional hematoma removal. Treatment failure rate in the embolization group was lower than in the conventional treatment group (one of 72 patients [1.4%] vs 129 of 469 patients [27.5%], respectively; adjusted odds ratio [OR], 0.056; 95% confidence interval [CI]: 0.011, 0.286; P = .001). Surgical rescue was less frequent in the embolization group (one of 72 patients [1.4%] vs 88 of 469 patients [18.8%]; adjusted OR, 0.094; 95% CI: 0.018, 0.488; P = .005). Treatment-related complication rate was not different between the two groups (0 of 72 patients vs 20 of 469 patients [4.3%]; adjusted OR, 0.145; 95% CI: 0.009, 2.469; P = .182). Conclusion MMA embolization has a positive therapeutic effect on CSDH and is more effective than conventional treatment. © RSNA, 2017.

Posterior meningeal artery DMSO injection resulting in reproducible asystole prior to Onyx therapy of a dural arteriovenous fistula: a previously undescribed variant of the trigeminocardiac reflex or a new phenomenon?

We describe a case of reproducible asystole during endovascular treatment of a posterior fossa dural arteriovenous fistula. Catheterisation of the posterior meningeal artery, a branch of the vertebral artery in this patient, followed by dimethyl sulfoxide injection prior to Onyx administration resulted in two episodes of asystole.To the best of our knowledge, this is the first reported case of asystole occurring during endovascular intervention in the posterior meningeal artery. This may represent a previously undescribed variant of the trigemino-cardiac reflex (TGCR) caused by chemical stimulation of small areas of trigeminally innervated posterior fossa dura. Alternatively, this may represent a newly identified phenomenon with chemical stimulation of regions of posterior fossa dura innervated by branches of the vagus nerve leading to increased parasympathetic activity and resultant asystole.In either case, it is important to recognise the potential for such episodes in this vascular territory to allow case planning and management.

T cell function is dispensable for intracranial aneurysm formation and progression.

Given the social importance of intracranial aneurysm as a major cause of a lethal subarachnoid hemorrhage, clarification of mechanisms underlying the pathogenesis of this disease is essential for improving poor prognosis once after rupture. Previous histopathological analyses of human aneurysm walls have revealed the presence of T cells in lesions suggesting involvement of this type of cell in the pathogenesis. However, it remains unclear whether T cell actively participates in intracranial aneurysm progression. To examine whether T cell is involved in aneurysm progression, intracranial aneurysm model of rat was used. In this model, aneurysm is induced by increase in hemodynamic force loaded on bifurcation site of intracranial arteries where aneurysms are developed. Deficiency in T cells and pharmacological inhibition of T cell function were applied to this model. CD3-positive T cells were present in human aneurysm walls, whose number was significantly larger compared with that in control arterial walls. Deficiency in T cells in rats and pharmacological inhibition of T cell function by oral administration of Cyclosporine A both failed to affect intracranial aneurysm progression, degenerative changes of arterial walls and macrophage infiltration in lesions. Although T cells are detectable in intracranial aneurysm walls, their function is dispensable for macrophage-mediated inflammation and degenerative changes in arterial walls, which presumably leads to intracranial aneurysm progression.

Unusual case of intracranial dural AV fistula presenting with acute myelopathy.

We present a case of intracranial arteriovenous fistula with perimedullary venous drainage presenting with acute myelopathy, which is an unusual presentation of this uncommon condition. Subsequent catheter angiogram defined the arterial feeders from the meningohypophyseal trunk and petrosal branch of the middle meningeal artery. The patient was successfully embolised, resulting in complete obliteration of the fistula, and significant resolution of brainstem and cervical cord changes along with clinical improvement.

[Pial synangiosis for moyamoya disease. The Bordeaux experience]. / Traitement de la maladie de Moya-Moya par synangiose piale. L'expérience bordelaise.

BACKGROUND: Different surgical methods may be used for the treatment of moyamoya disease. The authors report their experience with pial synangiosis revascularization. MATERIAL AND METHODS: We reviewed the clinical, surgical as well as radiographic records of all patients who underwent cerebral revascularization surgery using pial synangiosis for a symptomatic moyamoya disease at a single institution, Bordeaux University Hospital. RESULTS: Over a 6-year period (2007-2013), 17 procedures were performed in 9 patients. Median age at presentation was 11.5 years and six patients presented with an ischemic event. As regards previous medical history, five patients were diagnosed with moyamoya syndrome. Median time between the symptoms onset and the first surgical procedure was 5.9 months. The average age of the first surgery was 11.8 years and the median time between the two synangiosis was 3.5 months. One patient died of a malignant ischemic stroke after the second procedure. At long-term follow-up, no patient experienced any symptoms recurrence. CONCLUSION: Pial synangiosis typically results in an increase in collaterals from the superficial temporal artery or middle meningeal artery to the brain. It is a simple and effective surgical technique to prevent further moyamoya manifestation and to stabilize or improve the neurologic prognosis.

Enlargement of the middle meningeal artery on MR angiography in chronic subdural hematoma.

OBJECT The middle meningeal artery (MMA) is suspected to play an important role in the development of chronic subdural hematoma (CSDH). The aim of this study was to clarify whether the MMA was enlarged in patients with CSDHs. METHODS The authors retrospectively assessed 55 patients in whom CSDH was diagnosed between 2010 and 2014 and who underwent MR angiography (MRA) after the onset of CSDH. The authors compared MMA diameters between hemispheres with and without CSDHs on MR angiograms. A case-control study was also performed with 55 sex- and age-matched patients with incidental unruptured aneurysms as controls. RESULTS In 55 patients with CSDHs, the diameters of the 79 MMAs on the CSDH side were significantly larger than the diameters of the 31 MMAs on the non-CSDH side (p < 0.05). In 24 patients with bilateral CSDHs, no significant difference was found between the MMA diameters on the larger hematoma side and those on the smaller hematoma side. In 13 patients who underwent MRA before the onset of the CSDH, the MMAs on MR angiograms acquired after onset of the CSDH were significantly larger than those on MR angiograms acquired before the CSDH onset (p < 0.05). The diameters of the MMAs in 55 patients with CSDHs were significantly larger than those of the MMAs in the 55 control patients (p < 0.05). CONCLUSIONS The MMA is enlarged with development of a CSDH. Information about the MMA observed on MRA in patients with CSDHs may be useful in developing a strategy for future treatment of CSDHs.