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Background: Middle meningeal artery (MMA) embolization has been increasingly applied in adult populations for the treatment of chronic subdural hematomas (cSDH). There is a paucity of literature on the indications, safety, and outcomes of MMA embolization in the pediatric population. Summary: A systematic literature review on pediatric patients undergoing MMA embolization was performed. We also report the case of successful bilateral MMA embolization for persistent subdural hematomas following resection of a juvenile pilocytic astrocytoma. Persistent bilateral subdural hematomas following resection of a large brain tumor resolved following MMA embolization in a 13-year-old male. Indications for MMA embolization in the pediatric literature included cSDH (6/13, 46.2%), treatment or preoperative embolization of arteriovenous fistula or arteriovenous malformation (3/13, 23.1%), preoperative embolization for tumor resection (1/13, 7.7%), or treatment of acute epidural hematoma (1/13, 7.7%). Embolic agents included microspheres or microparticles (2/13, 15.4%), Onyx (3/13, 23.1%), NBCA (3/13, 23.1%), or coils (4/13, 30.8%). Key Messages: Whereas MMA embolization has primarily been applied in the adult population for subdural hematoma in the setting of cardiac disease and anticoagulant use, we present a novel application of MMA embolization in the management of persistent subdural hematoma following resection of a large space-occupying lesion. A systematic review of MMA embolization in pediatric patients currently shows efficacy; a multi-institutional study is warranted to further refine indications, timing, and safety of the procedure. [ABSTRACT FROM AUTHOR]

Sinus pericranii (SP) are abnormal vascular connections between extracranial scalp venous channels and intracranial dural sinuses. This vascular abnormality rarely results in significant sequelae, but in select cases, it can be symptomatic. We describe the case of a 7-year-old girl with an SP who experienced intermittent visual, motor, and sensory symptoms not previously described in the literature. Her symptoms resolved after surgical treatment of the SP. We propose a mechanism for her symptoms and the rationale for the role of neurosurgical intervention along with a review of the literature. [ABSTRACT FROM AUTHOR]

Introduction: Acute kidney injury (AKI) is associated with poor outcome in aneurysmal subarachnoid hemorrhage patients (aSAH). Frailty has recently been demonstrated to correlate with elevated mortality and morbidity; its impact on predicting AKI and mortality in aSAH patients has not been investigated. Objective: Evaluating risk factors and predictors for AKI in aSAH patients. Methods: aSAH patients from a single-center's prospectively maintained database were retrospectively evaluated for development of AKI within 14 days of admission. Baseline demographic and clinical characteristics were collected. The effect of frailty and other risk factors were evaluated. Results: Of 213 aSAH patients, 53 (33.1%) were frail and 12 (5.6%) developed AKI. Admission serum creatinine (sCr) and peak sCr within 48 h were higher in frail patients. AKI patients showed a trend towards higher frailty. Mortality was significantly higher in AKI than non-AKI aSAH patients. Frailty was a poor predictor of AKI when controlling for Hunt and Hess (HH) grade or age. HH grade ≥ 4 strongly predicted AKI when controlling for frailty. Conclusion: AKI in aSAH patients carries a poor prognosis. The HH grade appears to have superior utility as a predictor of AKI in aSAH patients than mFI. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Anterior cerebral artery (ACA) aneurysms are commonly encountered in clinical practice but can be challenging to treat. Flow diversion is a viable treatment in this population. METHODS: We retrospectively evaluated patients treated at our center from May 2017 to December 2020 who underwent flow diversion for an ACA aneurysm at or distal to the anterior communicating artery (ACOM). We defined ACA aneurysms as any aneurysm involving the ACOM itself, at the junction of the ACA with the ACOM (A1/A2), or in distal A2/A3 branches; both ruptured and unruptured aneurysms were included. Baseline and follow-up clinical and angiographic data were collected; the primary measure was elimination of the aneurysm on follow-up angiogram. Patients underwent flow diversion with a Pipeline stent. A single flow diverting stent was placed in the dominant ACA spanning from the A2 segment extending into the A1 segment; two patients required H-pipe technique. Distal aneurysms were treated with a single Pipeline device deployed across the parent vessel, covering the aneurysm. RESULTS: Two-seven patients underwent a total of 28 flow diversion procedures; median age was 57 and 16 (59.3%) were male. Thirteen (48.2%) patients presented with subarachnoid hemorrhage; of these, four were treated within 6 weeks of the index hemorrhage. Most patients (22; 81.5%) had significant ACA asymmetry. There was one postoperative intracerebral hemorrhage and one groin complication. Follow-up data were available for 19 patients, 15 (78.9%) of which showed no residual aneurysm and 17 (89.5%) had protection of the dome. CONCLUSION: Flow diversion of ACA aneurysms can be a primary treatment modality in an unruptured aneurysm or a complement to initial coil protection of a ruptured aneurysm. Further studies are needed to confirm these results. [ABSTRACT FROM AUTHOR]

While patients with angiogram-negative subarachnoid hemorrhages (ANSAH) have better prognoses than those with aneurysmal SAH, frailty's impact on outcomes in ANSAH is unclear. We previously showed that the modified frailty index (mFI-11) is associated with poor outcomes following ANSAH. Here, we compared the mFI-5, mFI-11, Charlson Comorbidity Index (CCI), and temporalis thickness (TMT) to determine which index was the best predictor of ANSAH outcomes and mortality rates. In this retrospective cohort analysis between 2014 and 2018, patients with non-traumatic, angiogram negative SAH (ANSAH) were identified. The admission mFI-5, mFI-11, CCI, and TMT were calculated for each patient. Primary outcomes were mortality rate, discharge location, and prolonged length of stay (PLOS; LOS >85th percentile). Multivariate logistic regression and receiver operating characteristic (ROC) curves were used to evaluate frailty as predictors of primary endpoints. We included 75 patients with a mean age of 55.4 ± 1.5 years. There were 4 patient deaths (5.3%), 53 patients (70.7%) discharged home, and 11 patients (14.7%) with PLOS. On ROC analysis, the mFI-5 had the highest discriminatory value for mortality (AUC = 0.97) while the mFI-11 was most discriminatory for discharge home (AUC = 0.85) and PLOS (AUC = 0.78). On multivariate analysis, the only independent predictor of mortality was the mFI-11 (OR = 0.46; 95%CI: 1.45–14.23; p = 0.009) while the mFI-5 was the best predictor of discharge home (OR = 0.21; 95% CI: 0.08–0.61; p = 0.004). On multivariate analysis, the only independent predictor of PLOS was the Hunt and Hess score (OR = 2.63; 95%CI: 1.38–5.00; p = 0.003). The CCI and TMT were inferior to either mFI for predicting primary endpoints. Increasing frailty is associated with poorer outcomes and higher mortality following ANSAH. The mFI-5 and mFI-11 were found to be superior predictors of discharge home and mortality rate. While larger prospective study is needed, frailty, as measured by mFI-11 and -5, should be considered when evaluating ANSAH prognosis. [ABSTRACT FROM AUTHOR]

Background Aneurysmal ruptures typically cause subarachnoid bleeding with intraparenchymal and intraventricular extension. However, rare instances of acute aneurysmal ruptures present with concomitant, non- traumatic subdural hemorrhage (SDH). We explored the incidence and difference in outcomes of SDH with aneurysmal subarachnoid hemorrhage (aSAH) as compared with aSAH alone. Methods Retrospective cohort study from 2012 to 2015 from the National (Nationwide) Inpatient Sample (NIS) (20% stratified sample of all hospitals in the United States). NIS database (2012 to September 2015) queried to identify all patients presenting with aSAH. From this population, the patients with concomitant SDH were identified. Results A total of 10 075 patients with both cerebral aneurysms and aSAH were included. Of these, 335 cases of concomitant SDH and aSAH were identified. There was no significant change in the rate of SDH in aSAH over time. SDH with aSAH patients had a mortality of 24% compared with 12% (p=0.003) in the SAH only group, and only 16% were discharged home vs 37% (p=0.003) in the SAH group. Conclusions There is a 3.5% incidence of acute SDH in patients presenting with non- traumatic aSAH. Patients with SDH and aSAH have nearly double the mortality, higher rate of discharge to nursing home and rehabilitation, and a significantly lower rate of discharge to home and return to routine functioning. This information is useful in counseling and prognostication of patients with concomitant SDH and aSAH. [ABSTRACT FROM AUTHOR]

PURPOSE: Aneurysmal recurrence represents a significant drawback of endovascular coiling, particularly in aneurysms that have previously ruptured. Given the high recurrence rate of coiled aneurysms and particularly the risk of posttreatment rupture in previously ruptured aneurysms that have been treated by coiling, the question of how best to treat ruptured aneurysms that recur postcoiling remains. MATERIALS AND METHODS: We conducted a retrospective analysis of twenty patients who underwent pipeline embolization of previously ruptured, coiled cerebral aneurysms. RESULTS: Pipeline embolization device (PED) treatment resulted in complete aneurysmal occlusion in 10 patients (62.5%) at first angiographic follow-up, and 11 patients (68.75%) at last follow-up. No PED-related complications were encountered and there were no peri-procedural or postprocedural hemorrhages, or symptomatic ischemic events following flow diversion. CONCLUSIONS: PED as a second-line treatment is a safe and effective modality for achieving aneurysmal occlusion in recurrent, previously ruptured, primarily coiled aneurysms. Additionally, a staged coil-to-PED approach may be considered for the management of acutely ruptured aneurysms to achieve aneurysmal obliteration in an effort to mitigate recurrence, and reduce the amount of postprocedural studies. [ABSTRACT FROM AUTHOR]