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Objective: The efficacy of middle meningeal artery (MMA) embolization in the management of chronic subdural hematoma (cSDH) has been increasingly supported by recent randomized controlled trials. However, long-term data on the natural history of cSDH post-treatment remain limited. This study aims to evaluate the natural history and outcomes of cSDH over a 12-month period following MMA embolization., Methods: We conducted a retrospective analysis of 61 MMA embolization for the treatment of cSDH in 49 consecutive patients at a single institution between October 2019 and December 2022. Patients underwent MMA embolization as the primary treatment of cSDH, concurrently with surgical evacuation, or after initial surgical evacuation and subsequent recurrence. Clinical data, including patient demographics, hematoma maximal thickness, midline shift size, procedural details, and outcomes, were collected and analyzed. The primary outcomes assessed were time to resolution of hematoma maximal thickness, midline shift reduction and clinical improvement. Secondary outcomes included occurrence of complications, recurrence rate and the characteristics of the group of patients who needed surgical rescue. Tables and Kaplan-Meier curves were created, broken down by the percentage of reduction in current hematoma maximal thickness. Results for the primary, concurrent and recurrent groups were compared., Results: The mean age of included patients was 73 ± 10.8 years. Among them, 33 patients (67.3%) reported a history of previous trauma, with falls being the main mechanism of injury (65.3%). The majority of patients (77.5%) were male. The most frequent neurological symptom was headache (61.2%). The mean hematoma thickness and midline shift were 15.9±7.1 and 5.6±2.6 mm, respectively. There was a significant improvement in clinical symptoms within 1 month following middle meningeal artery embolization. Kaplan-Meier curves were generated for resolution of hematoma size and midline shift. At one month post procedure, only 25% of patients had at least a 25% reduction in hematoma size. However, by three months, 75% had a decrease in hematoma size by 50%. 85% of patients had complete resolution of hematoma by 7 months and all patients had resolution of hematoma by 12 months. Four patients underwent surgical rescue hematoma evacuation and the mean timeframe between the embolization and the surgical rescue was 2 weeks. Hematoma size and midline shift resolved faster for patients who underwent concurrent or rescue surgical evacuation of the hematoma in addition to embolization. No difference in results between the liquid embolics n-BCA and Onyx-18 was found., Conclusion: This study demonstrated a favorable resolution of subdural hematoma within 7 months in 85% of patients and in all patients by 12 months. By 3 months, 50% of patients had a decrease in hematoma size by 50% or more. A complete resolution of midline shift within 7 months, and a significant improvement in clinical symptoms within 1 month following middle meningeal artery embolization. Hematoma size and midline shift resolved faster for patients who underwent embolization for recurrent hematoma or concurrent surgical evacuation of the hematoma in addition to embolization., (Copyright © 2024. Published by Elsevier Inc.)

Testosterone supplementation has increased in recent years for both treatment of hypogonadism and recreational use. Strokes in young adults have similarly increased with a larger proportion of patients in this age group having a stroke due to early onset of cardiovascular risk factors or unrelated to conventional risks. Hormonal treatments are associated with increased stroke risk amongst women, with some studies indicating an increase in stroke risk as high as 40% when compared to non-users. However, less is known about male sex hormones and risks associated with increased stroke. Limited data evaluates the relationship between testosterone supplementation and stroke in young adults. In this review, we analyze the literature and plausible underlying pathophysiological mechanisms associated with increased risks in patients using exogenous testosterone. Furthermore, we highlight the gaps in research about safety and long-term effects on young patients., Competing Interests: AN owns stocks in Openwater. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Dengri, Koriesh, Babi, Mayberry, Goldstein, Pervez and Nouh.)

Background: Cryptogenic stroke (CS) is an exclusion diagnosis that accounts for 10-40% of all ischemic strokes. Patent foramen ovale (PFO) is found in 66% of patients with CS, while having a prevalence of 25-30% in the general population. The primary aim was to evaluate the risk of recurrent stroke following surgical PFO closure plus medical therapy vs. medical therapy alone amongst CS, an embolic stroke of undetermined source (ESUS), or transient ischemic attack (TIA). The secondary aim was to evaluate new-onset non-valvular atrial fibrillation, mortality, and major bleeding., Methods: We conducted an umbrella meta-analysis using PRISMA guidelines on English studies comparing surgical PFO closure plus medical therapy versus medical therapy alone for managing CS. We extracted data on interventions and outcomes and used random-effects models with generic inverse variance to calculate relative risks (RRs) with 95% confidence intervals for outcome calculations., Results: A comprehensive search yielded 54,729 articles on CS and 65,001 on surgical PFO closure, with 1,591 studies focusing on PFO closure and medical therapy for secondary CS, ESUS, or TIA prevention. After excluding non-meta-analyses, 52 eligible meta-analyses were identified, and eight studies were selected for outcome evaluation, excluding non-English, non-human, and studies before January 2019 as of August 31, 2021. Among a total of 41,880 patients, 14,942 received PFO closure + medical therapy, while 26,938 patients received medical therapy alone. Our umbrella meta-analysis showed that PFO closure plus medical therapy had a 64% lower risk of recurrent strokes than medical therapy alone (pooled RR: 0.36). PFO closure plus medical therapy was associated with 4.94 times higher risk of atrial fibrillation. There was no difference in the risk of death or bleeding between both groups., Conclusion: In patients with CS, PFO closure, in addition to medical therapy, reduces the risk of recurrence. More research is needed to assess the efficacy of early closure as well as specific risk profiles that would benefit from early intervention to reduce the burden of stroke., Competing Interests: The authors declare that there is no conflict of interest., (Copyright 2023, Patel et al.)

Over the years, medical education delivery has seen a change from teacher-centric to student-centric teaching-learning methods. Educators are constantly looking to develop interactive and innovative teaching-learning tools. One such supplementary tool is the use of the quiz for medical education. The Quiz has been used traditionally as a feedback assessment tool, but lately, it has found its way into the medical curriculum, mostly informally. The few available documented studies on the Quiz as a teaching and learning tool illustrate its acceptance and impact on the stakeholders. It could be one of the solutions to the endless search for a student-centric and engaging tool to deliver the medical curriculum. Commonly, the format for medical quiz is either on a case-based or image-based approach. Such an approach helps bridge the gap between traditional classroom teaching and clinical application. The Quiz is a readily acceptable tool that complements didactic lectures and improves students' learning and comprehension. Being an interactive student-centric tool, it enhances active student participation and encourages regular feedback mechanisms. It promotes healthy competition and peer-assisted learning by encouraging active discussion among students, hence improving student performance in standard examination techniques, along with teacher satisfaction. This literature review aims to enumerate the various formats of the Quiz, their role in improving the understanding and retention of knowledge among the students and assess their acceptability among the stakeholders., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Dengri et al.)