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This study aims to evaluate the length of stay (LOS) in patients who had adjunct middle meningeal artery embolization (MMAE) for chronic subdural hematoma after conventional surgery and determine the factors influencing the LOS in this population. A retrospective review of 107 cases with MMAE after conventional surgery between September 2018 and January 2024 was performed. Factors associated with prolonged LOS were identified through univariable and multivariable analyses. The median LOS for MMAE after conventional surgery was 9 days (interquartile range = 6–17), with a 3-day interval between procedures (interquartile range = 2–5). Among 107 patients, 58 stayed ≤ 9 days, while 49 stayed longer. Univariable analysis showed the interval between procedures, type of surgery, MMAE sedation, and the number of complications associated with prolonged LOS. Multivariable analysis confirmed longer intervals between procedures (odds ratio [OR] = 1.52; P < 0.01), ≥2 medical complications (OR = 13.34; P = 0.01), and neurological complications (OR = 5.28; P = 0.05) were independent factors for lengthier hospitalizations. There was a trending association between general anesthesia during MMAE and prolonged LOS (P = 0.07). Subgroup analysis revealed diabetes (OR = 5.25; P = 0.01) and ≥2 medical complications (OR = 5.21; P = 0.03) correlated with a LOS over 20 days, the 75th percentile in our cohort. The interval between procedures and the number of medical and neurological complications were strongly associated with prolonged LOS in patients who had adjunct MMAE after open surgery. Reducing the interval between the procedures and potentially performing both under 1 anesthetic may decrease the burden on patients and shorten their hospitalizations. [ABSTRACT FROM AUTHOR]

For maxillary gingival carcinomas, especially those in the molar region, surgical resection is often performed beyond the maxillary tuberosity. Bleeding from the posterior superior alveolar or maxillary artery into the pterygoid process is difficult to stop during partial maxillary resection. Advances in catheterization and materials have enabled the embolization of various vessels. In this report, we describe two cases of maxillary gingival cancer in which preoperative endovascular arterial embolization prevented bleeding due to unexpected vascular injury, allowing for a safe surgery with minimal blood loss. This technique effectively avoids emergency hemostasis for unexpected bleeding when resecting gingival cancers in the maxillary molar region.

Middle meningeal artery embolization (MMAE) is emerging as a safe and effective standalone intervention for non-acute subdural hematomas (NASHs); however, the risk of hematoma recurrence after MMAE in coagulopathic patients is unclear. To characterize the impact of coagulopathy on treatment outcomes, we analyzed a multi-institutional database of patients who underwent standalone MMAE as treatment for NASH. We classified 537 patients who underwent MMAE as a standalone intervention between 2019 and 2023 by coagulopathy status. Coagulopathy was defined as use of anticoagulation/antiplatelet agents or pre-operative thrombocytopenia (platelets <100,000/μL). Demographics, pre-procedural characteristics, in-hospital course, and patient outcomes were collected. Thrombocytopenia, aspirin use, antiplatelet agent use, and anticoagulant use were assessed using univariate and multivariate analyses to identify any characteristics associated with the need for rescue surgical intervention, mortality, adverse events, and modified Rankin Scale score at 90-day follow-up. Propensity score-matched cohorts by coagulopathy status with matching covariates adjusting for risk factors implicated in surgical recurrence were evaluated by univariate and multivariate analyses. Minimal differences in pre-operative characteristics between patients with and those without coagulopathy were observed. On unmatched and matched analyses, patients with coagulopathy had higher rates of requiring subsequent surgery than those without (unmatched: 9.9% vs. 4.3%; matched: 12.6% vs. 4.6%; both p < 0.05). On matched multivariable analysis, patients with coagulopathy had an increased odds ratio (OR) of requiring surgical rescue (OR 3.95; 95% confidence interval [CI] 1.68–9.30; p < 0.01). Antiplatelet agent use (ticagrelor, prasugrel, or clopidogrel) was also predictive of surgical rescue (OR 4.38; 95% CI 1.51–12.72; p = 0.01), and patients with thrombocytopenia had significantly increased odds of in-hospital mortality (OR 5.16; 95% CI 2.38–11.20; p < 0.01). There were no differences in follow-up radiographic and other clinical outcomes in patients with and those without coagulopathy. Patients with coagulopathy undergoing standalone MMAE for treatment of NASH may have greater risk of requiring surgical rescue (particularly in patients using antiplatelet agents), and in-hospital mortality (in thrombocytopenic patients). [ABSTRACT FROM AUTHOR]

BACKGROUND: Chronic subdural hematoma (CSDH) has significant patient morbidity and recurrence that drives the management towards less invasive procedures. We describe the different indications of middle meningeal artery embolization (MME) in management of CSDH. OBJECTIVE: We aimed to report and evaluate our institutional experience using MME in management of CSDH. PATIENTS AND METHODS: Retrospective analysis was conducted between 2020 and 2023, we reviewed the different indications of MME using different embolization material. Clinical and radiological outcomes were described 6 months and 1 year postoperatively. RESULTS: Twenty one CSDHs were treated in 16 patients (5 patients had bilateral CSDH). In patients with bilateral CSDH each hematoma was considered separately. Of the 21 hematomas, 7 (33.3%) were treated upfront without prior surgical treatment, 4 (19.1%) were treated for recurrence after prior surgical evacuation, and 10 (47.6%) were treated prophylactically following surgical evacuation. Post embolization, one hematoma needed to be evacuated due to failure of hematoma volume reduction. By the end of one year follow up, 50% reduction in hematoma size was achieved in 13 hematomas (62%), while total disappearance was evident in 7 hematomas (33.3%). Recurrence was noted in one patient on renal dialysis which was managed conservatively. The modified Rankin scale (mRS) improved after 6 months in comparison to the admission time from 3 ± 1.2 to 1.6 ± 0.63 with p value of 0.003. CONCLUSION: The MME is a safe and effective technique that should be considered in management of CSDH in patients with multiple morbidities and patients who have high risk of recurrence. [ABSTRACT FROM AUTHOR]

Copyright of Clinical Neuroscience / Ideggyógyászati Szemle is the property of LifeTime Media Kft. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Clinical Neuroscience / Ideggyógyászati Szemle is the property of LifeTime Media Kft. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Remarkable interest is rising around middle meningeal artery embolization (MMAE) as an emerging alternative therapy for chronic subdural hematoma (cSDH). The study aims to highlight a large center experience and the variables associated with treatment failure and build experimental machine learning (ML) models for outcome prediction. Material and Methods: A 2-year experience in MMAE for managing patients with chronic subdural hematoma was analyzed. Descriptive statistical analysis was conducted using imaging and clinical features of the patients and cSDH, which were subsequently used to build predictive models for the procedure outcome. The modeling evaluation metrics were the area under the ROC curve and F1-score. Results: A total of 100 cSDH of 76 patients who underwent MMAE were included with an average follow-up of 6 months. The intervention had a per procedure success rate of 92%. Thrombocytopenia had a highly significant association with treatment failure. Two patients suffered a complication related to the procedure. The best performing machine learning models in predicting MMAE failure achieved an ROC-AUC of 70%, and an F1-score of 67%, including all patients with or without surgical intervention prior to embolization, and an ROC-AUC of 82% and an F1-score of 69% when only patients who underwent upfront MMAE were included. Conclusion: MMAE is a safe and minimally invasive procedure with great potential in transforming the management of cSDH and reducing the risk of surgical complications in selected patients. An ML approach with larger sample size might help better predict outcomes and highlight important predictors following MMAE in patients with cSDH. [ABSTRACT FROM AUTHOR]

The study evaluates chronic subdural hematoma (cSDH) middle meningeal artery (MMA) embolization efficacy and safety. A prospective interventional study was conducted in Viet Duc Hospital from November 2021 to April 2024. All consecutive cSDH MMA embolization patients were included. Clinical and imaging data were collected before and one month after treatment. The study included 31 42-cSDH patients. Of these, 25.8% had hematoma evacuation, 83.9% were treated with surgery and embolization, and 16.1% with embolization alone. 92.9% of procedures used polyvinyl alcohol particles. The success rate was 92.9% and complications 7.1%. Asymptomatic external carotid artery vasospasm and MMA rupture occurred. Functional improvement occurred in 91.7% of patients one month after treatment. Significantly lower mean modified Rankin Scale (mRS) score (0.2±0.7 vs. 1.7±0.9; P=0.000) and higher proportion of patients with ≤2 mRS score (95.8% vs. 74.1%) were observed after treatment. Hematoma thickness decreased significantly (P=0.00) from 21.5±7.9 mm to 8.3±4.1 mm. The midline shift decreased significantly from 7.4±5.0 mm to 0.7±1.2 mm (P=0.00). Just one patient (4.2%) needed surgery. MMA embolization alone or with surgery appears to treat cSDH safely and effectively.

Introduction: Recent studies showed the connection between cerebrospinal fluid (CSF) and deep cervical lymph nodes (dCLN) via lymphatic vessels (LV)s. These LVs accompany dural sinuses, cranial nerves, and arteries. The present study aimed to show in addition to the main trunk of the middle meningeal artery (MMA) whether the anterior and posterior branches of MMA; the anterior (AMA) and posterior (PMA) meningeal arteries also have a role in brain lymphatic drainage in humans. Materials and method: Samples of the middle meningeal artery (MMA) and its two main branches (anterior and posterior), anterior and posterior meningeal arteries (AMA and PMA) were obtained from 3 cadavers and 6 autopsies. Podoplanin (PDPN) (lymphatic endothelial marker) and CD31 (vascular endothelial marker) immunohistochemistry (IHC) were applied to 5 μm thick transverse sections and counterstained with hematoxylin. Furthermore, western blotting techniques were applied to the same tissue samples in 3 autopsy cases to demonstrate the presence of PDPN. Results: We observed the presence of the LVs along the main trunk of MMA and its two branches, AMA, and PMA. The LVs along the MMA (main trunk) had a larger diameter range than its branches and the AMA and PMA. The diameter of LVs of the PMA was larger than AMA. Furthermore, fluid channels with varying diameters and densities were closely localized to the LVs. The western blot PDPN protein expression confirmed IHC results. Conclusion: The LVs along the main trunk, anterior and posterior branches of the MMA, AMA, and PMA also provide an extracranial pathway for thought drainage of waste from the brain tissue in humans. Thus, the organization of the extracranial transport of LVs of the brain should be well-defined for understanding the role of lymphatic drainage in various neurological diseases.

Copyright of Clinical Neuroscience / Ideggyógyászati Szemle is the property of LifeTime Media Kft. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objective: To perform a systematic review and meta-analysis evaluating the efficacy of middle meningeal artery embolization in terms of both clinical and radiographic outcomes, when performed with different embolic agents. Methods: A systematic literature review and meta-analysis was performed to evaluate the impact of embolic agents on outcomes for middle meningeal artery (MMA) embolization. The use of polyvinyl alcohol (PVA) with or without (±) coils, N-butyl cyanoacrylate (n-BCA) ± coils, and Onyx alone were separately evaluated. Primary outcome measures were recurrence, the need for surgical rescue and in-hospital periprocedural complications. Results: Thirty-one studies were identified with a total of 1,134 patients, with 786 receiving PVA, 167 receiving n-BCA, and 181 patients receiving Onyx. There was no difference in the recurrence rate (5.5% for PVA, 4.5% for n-BCA, and 6.5% for Onyx, with P=0.71) or need for surgical rescue (5.0% for PVA, 4.0% for n-BCA, and 6.9% for Onyx, with P=0.89) based on the embolic agent. Procedural complications also did not differ between embolic agents (1.8% for PVA, 3.6% for n-BCA, and 1.6% for Onyx, with P=0.48). Conclusions: Rates of recurrence, need for surgical rescue, and periprocedural complication following MMA embolization are not impacted by the type of embolic agent utilized. Ongoing clinical trials may be used to further investigate these findings. [ABSTRACT FROM AUTHOR]

Background: Anomalous origin of the middle meningeal artery (MMA) from the basilar artery is a rare congenital neurological variant that has been detected in both children and adults with diagnoses ranging from intracranial haemorrhage to ependymoma. This review aims to investigate the anatomical course of an anomalous basilar-middle meningeal artery and its clinical presentation. Methods: A systematic search was performed in PubMed using the keywords (middle meningeal artery) and (basilar artery). Ninety-four papers were identified, of which seven were included. One paper was further identified through cross-referencing. Results: The average age of presentation was 43 years with a male predominance (7/9). In most cases, the MMA arose between the superior cerebellar artery and the anterior inferior cerebellar artery (8/9) (versus 1 case between the anterior inferior cerebellar artery and the posterior inferior cerebellar artery). The anomaly mostly presented on the left side (6/11), but was bilateral in one case. Most of the cases showed a pontine artery branching from the basilar artery arising 5 mm to 10 mm proximal to the superior cerebellar artery, which would then assume the trajectory of the MMA. In three cases, the vessel increased in calibre near the trigeminal ganglion. Foramen spinosum absence in the anomalous side was noted in 3/6 of the patients. Conclusion: To avoid unexpected complications during neurosurgical and neuroradiointerventional procedures, it is essential to have a clear understanding of the anomalous routes of the MMA. This is especially important when it proves to be the only available route for embolization. [ABSTRACT FROM AUTHOR]

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]

Background: There are many surgical techniques to treat chronic subdural hematomas (CSHs). However, they all have high recurrence rates. Recently, embolization of the middle meningeal artery (MMA) following surgical evacuation of CSH has reduced the recurrence rate. We investigated the feasibility of combining the surgical obliteration of the MMA at the same time as the placement of a burr hole for evacuation of the CSH. Case Description: We report on nine patients who underwent 11 of these combined procedure by the same surgeon in two hospitals, including clinical data and images during the perioperative and postoperative periods. Cardoso had previously reported details of the surgical technique. Two patients underwent bilateral procedures. Two patients had two burr holes because the hematomas did not extend caudally to the pterion, where the MMA enters the calvarium. Intraoperative fluoroscopy was used to locate the point of entry of the MMA into the calvarium in most cases, except in two instances when navigation was utilized. Conclusion: This small series of nine cases suggests the feasibility of using this combined procedure as an additional option to the treatment of CSHs, especially where endovascular treatment might not be readily available. Furthermore, it has the potential advantages of safety, efficacy, avoidance of a second endovascular procedure, faster disappearance of the subdural collection, lesser exposure to radiation, and cost containment. Larger prospective controlled series are needed to identify its potential usefulness. [ABSTRACT FROM AUTHOR]

Background: Chronic subdural hematoma (cSDH) is a common sequela of traumatic brain injury. Middle meningeal artery embolization (MMAE) has shown promising results as an emerging minimally invasive alternative treatment. The purpose of this study is to examine the safety and efficacy of MMAE performed in patients with cSDH, acute-on-chronic, and subacute SDH with a traumatic etiology. Background: Chronic subdural hematoma (cSDH) is a common sequela of traumatic brain injury. Middle meningeal artery embolization (MMAE) has shown promising results as an emerging minimally invasive alternative treatment. The purpose of this study is to examine the safety and efficacy of MMAE performed in patients with cSDH, acute-on-chronic, and subacute SDH with a traumatic etiology. Results: In our patient population, 78% (39) either had lesions improve or completely resolved. The sample included 50 patients with a mean age of 74 years old. Statistically significant reductions in lesion size were found from pre- to post-procedure in the left lesions, right lesions, and midline shifts. The left lesions decreased from 13.88 ± 5.70 mm to 3.19 ± 4.89 mm at 3-6 months with P < 0.001. The right lesions decreased from 13.74 ± 5.28 mm to 4.93 ± 7.46 mm at 3-6 months with P = 0.02. Midline shifts decreased from 3.78 ± 3.98 mm to 0.48 ± 1.31 mm at 3-6 months with P = 0.02. No complications were experienced for bleeding, hematoma, worsening SDH, pseudoaneurysm, or stroke. Conclusion: Our pilot study from a single center utilizing MMAE demonstrates that MMAE is successful without increasing treatment-related complications not only for cSDH but also in acute-on-cSDH and SDH with a subacute component. [ABSTRACT FROM AUTHOR]

Background: Dural arteriovenous fistulas (AVFs) are reportedly induced by trauma. We report a rare case of traumatic AVF with a direct shunt from the middle meningeal artery (MMA) to the middle meningeal vein (MMV) and multiple drainage routes after head trauma. The patient was effectively treated with selective coil embolization alone without liquid embolic material. Case Description: A 56-year-old woman was admitted to the emergency department with mild disturbance of consciousness caused by a head contusion after alcohol consumption. She exhibited impaired consciousness with a Glasgow coma scale score of 14 (E4V4M6), complained of headache, and presented with a hemorrhage in the left ear. Computed tomography suggested a skull fracture and cerebral hemorrhage. Magnetic resonance imaging conducted on the 4th day after the injury indicated shunt disease with a feeder in the right MMA. Cerebral angiography on the 7th day suggested a direct shunt from the right MMA to the MMV aligned with the temporal bone fracture line, with multiple drainage route perfusion. Coil embolization was performed on the 14th day to occlude the shunt point selectively. In the final image, the MMA was absent, and the MMV, superior sagittal sinus, or pterygoid plexus was not visible through the shunt. Her symptoms improved, and she was discharged on the 20th day and did not exhibit recurrence at the 1-year follow-up. Conclusion: AVF with a direct shunt from the MMA to MMV after head trauma can be effectively and safely treated with coil embolization alone, despite the need for long-term postoperative follow-up. [ABSTRACT FROM AUTHOR]

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 membranous segmentation could have better outcomes after surgical treatment.

Objective: To investigate the efficacy and safety of MMA embolization in patients with CSDH who failed atorvastatin treatment. Methods: Seventeen CSDH patients who failed atorvastatin treatment from Jan 1, 2021 to Dec 31, 2021 were included in the study. All patients were treated with MMA embolization using polyvinyl alcohol (PVA) particles. Results: Twenty-six MMAs (unilateral embolization in 8 patients and bilateral embolization in 9 patients) were successfully embolized in all patients. Hematoma re-accumulated in only one patient (5.9%) after MMA embolization and was surgically evacuated. Procedural adverse events, mortality, or complications were not observed. At the last follow-up of an average of 51.5 days post MMA embolization, maximum hematoma thickness improved in 95.2% of CSDHs with a mean reduction of 52.1%, while mRS score improved in 94.1% of patients. In addition, 5 (29.4%) patients with unilateral hematoma underwent bilateral MMA embolization and hematoma absorbed completely in all 5 cases. Conclusions: MMA embolization may be a minimally invasive alternative to surgical evacuation for CSDH patients resistant to atorvastatin. In unilateral CSDH, bilateral superselective angiography and bilateral MMA embolization could be a useful and effective treatment strategy.

Background: Embolization of the middle meningeal artery (MMA) is a non-invasive procedure that is used as an alternative to surgical drainage in the treatment of subdural hematoma. The aim of our study is to represent the top-cited articles discussing the embolization of the MMA in treating chronic subdural hematoma (cSDH). Methods: Scopus database was used in June 2022 to search for the top 50 cited articles related to the embolization of the MMA in cSDH. Articles were assessed using bibliometric parameters, H-indices, impact factor, number of citations per article, and article type. The data was statically analyzed by using SPSS 23 along with Microsoft Excel. Results: Among the top 50 cited articles, the highest citation was 95 (article entitled "Middle meningeal artery embolization for chronic subdural hematoma"). The most productive year was 2020 with 13 articles, followed by 2021 with 11 articles. The United States of America (USA) contributed to 24 articles with 9 neurosurgical institutes. Most articles were case reports and case series (48%). Conclusion: This study collected the top 50 cited articles about embolization of the MMA in cSDH which can be used as a resource for clinicians in their practice and helps them to find the gap in the knowledge about this topic. [ABSTRACT FROM AUTHOR]

Traumatic middle meningeal artery (MMA)–middle meningeal vein (MMV) fistula (MMA-MMV fistula) and MMA pseudoaneurysm are the 2 main MMA-related vascular diseases occurring after blunt head trauma. These are rare but known causes of delayed intracranial hemorrhage. This study investigated predictors that may aid in the diagnosis of these diseases. In our department, screening digital subtraction angiography (DSA) is performed for patients with blunt head trauma accompanied by intracranial hemorrhage and skull or facial bone fracture. This study included 87 patients who underwent screening DSA without craniotomy from January 2019 to June 2023. The patients' clinical characteristics were retrospectively collected from the database. Statistical analysis was performed to examine the associations of various evaluation items with MMA-related vascular diseases. The first DSA examination revealed 34 MMA-MMV fistulas and 1 MMA pseudoaneurysm. The second follow-up DSA examination revealed 13 MMA-MMV fistulas and four MMA pseudoaneurysms. Temporal/parietal bone fracture (odds ratio, 5.33; P = 0.0005; 95% confidence interval, 1.95–14.60) was significantly associated with MMA-related vascular diseases. Endovascular treatments were performed in 9 patients. All procedures were successfully completed without complications; no delayed bleeding was observed. Temporal/parietal bone fracture in patients with blunt head trauma is a likely predictor of MMA-related vascular diseases. When initial head computed tomography reveals this pathology, we recommend careful imaging follow-up (e.g., DSA) and treatment as needed, while considering the possibility of MMA-related vascular diseases. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: The foramen spinosum (FS) is a pivotal passage for neurovascular structures within the skull base. We performed a detailed morphometric and morphological analysis of the FS to emphasize its clinical relevance. Materials & Methods: The study was performed on dried skull specimens obtained from the anatomical collections of the Institute of Anatomy and Institute of Forensic Medicine of the University of Ljubljana. The morphometric and morphologic features of FS in 126 whole human skulls and 15 skull halves were analyzed, including dimensions, shape, and other anatomical variations, as well as relationships to surrounding structures. Measurements were done with a digital sliding caliper. Results: The mean length and width of the FS were 2.45 ± 0.65 mm and 2.03 ± 0.53 mm on the right side and 2.49 ± 0.61 mm and 2.08 ± 0.48 mm on the left side. The most frequently observed shape was round (56.7%), followed by oval (28.2%), irregular (8.7%) and drop shaped (6.3%). Several anatomical variations were also noted, including FS duplication, confluences with other foramina, and FS obstruction due to marginal bony outgrowths. Conclusion: The FS exhibits notable interindividual differences in anatomical characteristics which should be considered during neurosurgical procedures and radiological interventions in the skull base. [ABSTRACT FROM AUTHOR]

Abstract Background Design and participants Results Conclusions Chronic subdural hematoma (cSDH) is one of the most common neurosurgical conditions. Although surgical evacuation is still the gold standard for treatment, recent advances have led to the development of other management strategies, such as medical therapies and endovascular middle meningeal artery (MMA) embolization. Through this international survey, we investigated the global trends in cSDH management, focusing on medical and endovascular treatments.A 14-question, web-based, anonymous survey was distributed to neurosurgeons worldwide.Most responders do not perform MMA embolization (69.5%) unless for specific indications (29.6%). These indications include residual cSDH after surgical evacuation (58.9%) or cSDH in patients on antiplatelet medications to avoid surgical evacuation (44.8%). Survey participants from teaching versus non-teaching hospitals (p = 0.002), public versus private hospitals (p = 0.022), and Europe versus other continents (p < 0.001) are the most users of MMA embolization. A large number of participants (51%) declare they use a conservative/medical approach, mainly to avoid surgery in patients with small cSDH (74.8%).This survey highlights the current trends of cSDH management, focusing on conservative and MMA embolization treatment strategies. Most responders prefer a conservative approach for patients with small cSDHs not requiring surgical evacuation. However, in higher-risk scenarios such as residual hematomas after surgery or patients on antiplatelet medications, MMA embolization is regarded as a reasonable option by participants. Future studies should clarify the indications of MMA embolization, including appropriate patient selection and efficacy as a stand-alone procedure. [ABSTRACT FROM AUTHOR]

Background: The conventional treatments for non-acute subdural hematoma (SDH) are facing the challenge of high hematoma recurrence and progression. A novel treatment of middle meningeal artery (MMA) embolization showed the potential role in decreasing the recurrence and progression rate of SDH compared to conventional treatments in multiple cohort studies. A randomized controlled trial is warranted to determine the effectiveness and safety of MMA embolization for non-acute hematoma and whether MMA embolization is superior to conventional treatments to lower the symptomatic recurrence and progression rate of non-acute SDH. Methods: This is an investigator-initiated, multi-center, prospective, open-label parallel group trial with blinded outcome assessment (PROBE design) assessing superiority of MMA embolization compared to conventional treatments. A total of 722 patients are planned to be randomized 1:1 to receive MMA embolization (intervention) or conventional treatments (control). The primary outcome is the symptomatic SDH recurrence/progression rate within 90 ± 14 days post-randomization. Discussion: This trial will clarify whether MMA embolization could reduce the recurrence or progression rate of symptomatic non-acute SDH compared to conventional treatment. Trial registration: ClinicalTrials.gov. Identifier: NCT04700345, Registered on 7 January 2021. [ABSTRACT FROM AUTHOR]

We sought to describe the resolution time of chronic subdural hematoma (CSDH) after middle meningeal artery embolization (MMAE) and potential variables that may affect hematoma resolution. A retrospective analysis was performed on CSDH patients between December 2018 and December 2021. Patient characteristics, radiologic manifestations, and data of hematoma resolution were recorded. Univariate and multivariate analyses were conducted to identify predictors of CSDH resolution time. A total of 53 patients were enrolled including 53 hematomas. Only 1 participant relapsed and did not require surgical evacuation. Hematoma resolution was observed in 27 (50.9%) at 4 months and 48 (90.6%) cases at the last radiologic follow-up. The median MMAE-to-resolution time was 19 weeks (interquartile range: 8–24). The burr-hole irrigation + MMAE group showed faster hematoma resolution than MMAE alone during early follow-up periods, but no significant difference was found at 6 months. Increased thickness of residual hematoma, excessive postoperative midline shift, high-density hematoma, mixed-density hematoma, separated hematoma, and anticoagulant or antiplatelet agents used were predictive of nonresolution at 4 months as determined by univariate analysis, whereas anticoagulant or antiplatelet agents used and high-density hematoma were not significant on multivariate analysis. No significant association was noted between hematoma resolution and comorbidities or other hematoma radiologic features. MMAE is an effective and minimally invasive treatment for CSDH with a lower recurrence rate. The median resolution time of CSDH following MMAE was 19 weeks (interquartile range: 8–24). Burr-hole irrigation contributed to early hematoma resolution but had no significant effect at 6 months. In addition, residual hematoma thickness, postoperative midline shift, and specific type of hematoma were associated with delayed hematoma resolution at 4 months. [ABSTRACT FROM AUTHOR]

Background: Chronic subdural hematoma (cSDH) is one of the most common diseases in neurosurgery. Middle meningeal artery embolization (MMAE) is reportedly an option to prevent recurrence or avoid surgery in patients with cSDH. This study was performed to review the evidence on MMAE for cSDH and evaluate its safety, efficacy, indications, and feasibility. Methods: We systematically reviewed the literature according to the PRISMA guidelines using an electronic database. The search yielded 43 articles involving 2,783 patients who underwent MMAE. Conclusion: This study shows that MMAE alone is, although not immediate, as effective as evacuation surgery alone in reducing hematoma. The study also shows that combined treatment has a lower recurrence rate than evacuation surgery alone. Because MMAE is a safe procedure, it should be considered for patients with cSDH, especially those with a high risk of recurrence. [ABSTRACT FROM AUTHOR]

BackgroundAnomalous origin of the middle meningeal artery (MMA) from the basilar artery is a rare congenital neurological variant that has been detected in both children and adults with diagnoses ranging from intracranial haemorrhage to ependymoma. This review aims to investigate the anatomical course of an anomalous basilar-middle meningeal artery and its clinical presentation.MethodsA systematic search was performed in PubMed using the keywords (middle meningeal artery) and (basilar artery). Ninety-four papers were identified, of which seven were included. One paper was further identified through cross-referencing.ResultsThe average age of presentation was 43 years with a male predominance (7/9). In most cases, the MMA arose between the superior cerebellar artery and the anterior inferior cerebellar artery (8/9) (versus 1 case between the anterior inferior cerebellar artery and the posterior inferior cerebellar artery). The anomaly mostly presented on the left side (6/11), but was bilateral in one case. Most of the cases showed a pontine artery branching from the basilar artery arising 5 mm to 10 mm proximal to the superior cerebellar artery, which would then assume the trajectory of the MMA. In three cases, the vessel increased in calibre near the trigeminal ganglion. Foramen spinosum absence in the anomalous side was noted in 3/6 of the patients.ConclusionTo avoid unexpected complications during neurosurgical and neuroradiointerventional procedures, it is essential to have a clear understanding of the anomalous routes of the MMA. This is especially important when it proves to be the only available route for embolization.

Middle meningeal artery embolization is an increasingly common procedure involved in the treatment of chronic subdural hematoma (cSDH) that can be an adjuvant intervention or an alternative to traditional medical or surgical therapies. Our review aims to summarize the mechanism, properties, and available clinical data for current and investigative embolic agents used for the treatment of cSDH. Pubmed, Scopus, and clinicaltrials.gov were searched for relevant studies and ongoing trials that examine middle meningeal artery embolization for cSDH. Particle agents, liquid embolic agents, and coil embolization are the common classes of embolic materials used in clinical practice and in ongoing trials. These embolic agents are not only mechanical occlusive materials; they have unique properties that address the angiogenic and proinflammatory mechanisms that propagate and sustain cSDH. Particle agents, such as polyvinyl alcohol and Embosphere (tris‐acryl gelatin microspheres) have been the most commonly used embolic agents given the long‐term evidence base regarding efficacy and established safety record. Liquid embolic agents such as cyanoacrylate glues and copolymer agents such as Onyx, Squid, and PHIL are increasingly common in clinical settings due to improved visualization on imaging, durable embolization, and better control of distal embolization. Coil embolization is used in conjunction with other embolic agents or as monotherapy in the setting of dangerous middle meningeal artery anastomoses. There are several ongoing randomized clinical trials and prospective cohort studies that will clarify the safety, efficacy, and use cases of particle agents, liquid embolic agents, and coil embolization for the treatment of cSDH.

Abstract Background The conventional treatments for non-acute subdural hematoma (SDH) are facing the challenge of high hematoma recurrence and progression. A novel treatment of middle meningeal artery (MMA) embolization showed the potential role in decreasing the recurrence and progression rate of SDH compared to conventional treatments in multiple cohort studies. A randomized controlled trial is warranted to determine the effectiveness and safety of MMA embolization for non-acute hematoma and whether MMA embolization is superior to conventional treatments to lower the symptomatic recurrence and progression rate of non-acute SDH. Methods This is an investigator-initiated, multi-center, prospective, open-label parallel group trial with blinded outcome assessment (PROBE design) assessing superiority of MMA embolization compared to conventional treatments. A total of 722 patients are planned to be randomized 1:1 to receive MMA embolization (intervention) or conventional treatments (control). The primary outcome is the symptomatic SDH recurrence/progression rate within 90 ± 14 days post-randomization. Discussion This trial will clarify whether MMA embolization could reduce the recurrence or progression rate of symptomatic non-acute SDH compared to conventional treatment. Trial registration ClinicalTrials.gov. Identifier: NCT04700345, Registered on 7 January 2021.

Abstract Background The ophthalmic artery is the first branch of the internal carotid artery. It arises from the supraclinoid segment of the internal carotid artery within the subarachnoid space and enters the orbit via the optic canal. However, due to complex embryogenesis, the ophthalmic artery can arise from different parts of the internal carotid artery or the distal branches of the external carotid artery. This is usually associated with a variation in the course of the ophthalmic artery through the superior orbital fissure instead of coursing through the optic canal. The ophthalmic artery and its branches vascularise the eyeball and its contents. Consequently, information about its morphologic variation is essential for treating clinical conditions such as central retinal artery occlusion, retinoblastoma chemoembolization, and ophthalmic artery aneurysm. Case presentation We report on two cases of the ophthalmic artery arising from the middle meningeal artery in one adult (33-year-old Indian female) and one pediatric (2-year-old African male) South African patient examined by digital subtraction angiography. The patients were diagnosed with arteriovenous malformations and bilateral retinoblastoma, respectively. Conclusions The ophthalmic artery plays a vital role in vision generation. Thus, its anatomy is of clinical interest to neurosurgeons, ophthalmologists, and interventional radiologists.

Background The foramen spinosum (FS) is a pivotal passage for neurovascular structures within the skull base. We performed a detailed morphometric and morphological analysis of the FS to emphasize its clinical relevance. Materials & Methods The study was performed on dried skull specimens obtained from the anatomical collections of the Institute of Anatomy and Institute of Forensic Medicine of the University of Ljubljana. The morphometric and morphologic features of FS in 126 whole human skulls and 15 skull halves were analyzed, including dimensions, shape, and other anatomical variations, as well as relationships to surrounding structures. Measurements were done with a digital sliding caliper. Results The mean length and width of the FS were 2.45 ± 0.65 mm and 2.03 ± 0.53 mm on the right side and 2.49 ± 0.61 mm and 2.08 ± 0.48 mm on the left side. The most frequently observed shape was round (56.7%), followed by oval (28.2%), irregular (8.7%) and drop shaped (6.3%). Several anatomical variations were also noted, including FS duplication, confluences with other foramina, and FS obstruction due to marginal bony outgrowths. Conclusion The FS exhibits notable interindividual differences in anatomical characteristics which should be considered during neurosurgical procedures and radiological interventions in the skull base.

Background: Embolization of the middle meningeal artery (MMA) is a non-invasive procedure that is used as an alternative to surgical drainage in the treatment of subdural hematoma. The aim of our study is to represent the top-cited articles discussing the embolization of the MMA in treating chronic subdural hematoma (cSDH). Methods: Scopus database was used in June 2022 to search for the top 50 cited articles related to the embolization of the MMA in cSDH. Articles were assessed using bibliometric parameters, H-indices, impact factor, number of citations per article, and article type. The data was statically analyzed by using SPSS 23 along with Microsoft Excel. Results: Among the top 50 cited articles, the highest citation was 95 (article entitled “Middle meningeal artery embolization for chronic subdural hematoma”). The most productive year was 2020 with 13 articles, followed by 2021 with 11 articles. The United States of America (USA) contributed to 24 articles with 9 neurosurgical institutes. Most articles were case reports and case series (48%). Conclusion: This study collected the top 50 cited articles about embolization of the MMA in cSDH which can be used as a resource for clinicians in their practice and helps them to find the gap in the knowledge about this topic.

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. 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. 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. 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. [ABSTRACT FROM AUTHOR]

Objective Pterion is an "H" shaped formation of sutures located in the temporal fossa of the skull. It is an important anatomical landmark and a craniometric point. The thinness of the skull and its inner relation with the middle meningeal artery make this anatomical landmark clinically significant. Variations in the pterion are imperative, especially for neurosurgeons in order to have the most suitable craniometric point to be minimally invasive. Materials and Methods One hundred pterions were studied to report the variations in the type and location of the pterion. Murphy's classification was used to classify the pterion into four types on the basis of bone articulation-sphenoparietal, frontotemporal, stellate, and epipteric. Results All four types of pterions were observed, sphenoparietal being the most common. No significant gender difference was observed in terms of type and laterality of various pterions. The mean distance between the center of pterion to the superolateral point of zygomaticotemporal (PZT) suture and the anterolateral point of the frontozygomatic (PFZ) suture were 3.91 ± 3.79 cm and 3.68 ± 3.79 mm, respectively. Correlation analysis showed a strong positive relation between PZT and PFZ sutures. Conclusion Accurate data on the morphology and morphometry of bony anatomical points are crucial, while performing intracranial surgery using them as recognizable landmarks. The morphometric parameters may help in determining the soundness of the pterion as an identifiable landmark for performing interventions like burr hole and other neurosurgical procedures in this area. [ABSTRACT FROM AUTHOR]

Background: The petrosal artery supplies several structures at the skull base and is often the focus of various neurointerventional procedures. Therefore, knowledge of its anatomy and variations is important to surgeons and interventionalists. Materials and methods: Twenty latex injected cadaveric heads (40 sides) underwent microsurgical dissection of the petrosal artery. Documentation of the course of the artery and its branches were made. Measurements of the petrosal artery’s length and diameter were performed using microcallipers. Results: A petrosal artery was identified on all sides. The mean length and diameter of the artery within the middle cranial fossa was 2.4 cm and 0.38 mm, respectively. Branches included the following: dural, ganglionic, V3 branches, branches extending through the foramen ovale, branches directly to the greater petrosal and lesser petrosal nerves, branches to the floor of the hiatus of the greater and lesser petrosal nerves, branch to the arcuate eminence, and superior tympanic artery. No statistically significant differences were noted between male and female specimens, but right-sided petrosal arteries were in general, larger in diameter than left sides. Conclusions: A thorough anatomical knowledge of the petrosal artery and to its relationship to the facial nerve and other neurovascular structures is necessary to facilitate effective endovascular treatment and to preclude facial nerve complications. [ABSTRACT FROM AUTHOR]

Introduction: Chronic subdural hematoma (CSDH) is common in elderly after a mild or trivial head injury. The concern for embolization is the period to wait, as compared to immediate relief of mass effect from surgery. Thus, a combination approach is advocated in our center when in doubt. We here reported our initial experience and observation with respect to time course of resolution. Method: We retrospectively reviewed all the patients with CSDH undergoing Onyx middle meningeal artery (MMA) embolization with curative intent and excluded patients for palliative treatment in a neurosurgical center in Hong Kong. Results: Four (50%) CSDH were treated with MMA embolization alone and 4(50%) CSDH were treated with both surgery and MMA embolization. For the 4 patients with MMA embolization alone, one(25%) achieved significant reduction at 6 weeks and 3(75%) achieved resolution at 3 months. For the 4 CSDH with both surgery and MMA embolization, all have resolution at the first follow-up imaging, two(50%) at 6 weeks and 2(50%) at 3 months. There were no procedure related complications, and there were no recurrence nor reoperation in all CSDH. Conclusion: MMA embolization is safe and feasible within the framework of surgery to cure and prevent recurrence.

Middle meningeal artery embolization (MMAE) for chronic subdural hematoma (CSDH) is a novel, minimally invasive treatment. The indications and treatment practices for MMAE are variable and remain controversial. This study aimed to evaluate a strategy involving sequential MMAE after burr hole surgery for treating recurrent CSDH. We performed a retrospective analysis of data from consecutive patients who had undergone MMAE using liquid embolic agents within approximately 2 weeks after burr hole surgery for recurrent CSDH from September 2020 to March 2022. We analyzed patient characteristics, procedural details, CSDH recurrence after MMAE, surgical rescue, and complications. Six of the nine patients who underwent MMAE for CSDH recurrence were male, and the median age was 85 (range, 70-94) years. Five of the nine patients were being administered antithrombotic agents. The median duration between the burr hole surgery and MMAE procedure was 10 (range, 3-25) days. Anterior and posterior convexity branches were targeted for embolization using low-concentration N-butyl cyanoacrylate (NBCA), and the abnormal vascular networks with a cotton wool appearance disappeared after embolization in all cases. The NBCA distribution was observed by high-resolution computed tomography during the procedure; in three of nine cases, the NBCA penetrated not only the MMA but also the inner membrane. No recurrence, surgical rescue, or complications were observed in any patient during the median follow-up period of 3 months. As a minimally invasive treatment for recurrent CSDH, sequential MMAE after burr hole surgery may be a safe and effective option for preventing recurrence.

Background: The ophthalmic artery is the first branch of the internal carotid artery. It arises from the supraclinoid segment of the internal carotid artery within the subarachnoid space and enters the orbit via the optic canal. However, due to complex embryogenesis, the ophthalmic artery can arise from different parts of the internal carotid artery or the distal branches of the external carotid artery. This is usually associated with a variation in the course of the ophthalmic artery through the superior orbital fissure instead of coursing through the optic canal. The ophthalmic artery and its branches vascularise the eyeball and its contents. Consequently, information about its morphologic variation is essential for treating clinical conditions such as central retinal artery occlusion, retinoblastoma chemoembolization, and ophthalmic artery aneurysm. Case presentation: We report on two cases of the ophthalmic artery arising from the middle meningeal artery in one adult (33-year-old Indian female) and one pediatric (2-year-old African male) South African patient examined by digital subtraction angiography. The patients were diagnosed with arteriovenous malformations and bilateral retinoblastoma, respectively. Conclusions: The ophthalmic artery plays a vital role in vision generation. Thus, its anatomy is of clinical interest to neurosurgeons, ophthalmologists, and interventional radiologists. [ABSTRACT FROM AUTHOR]

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. 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. 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. Our series shows that liquid embolic and particle embolization are equally safe and effective among patients undergoing MMA embolization for management of cSDH. [ABSTRACT FROM AUTHOR]

Abstract Background Chronic subdural hematoma (cSDH) is one of the most common neurosurgical disorders and the incidence is rising. The routine treatment is neurosurgical hematoma evacuation, which is associated with recurrence rates up to 10–25%. In recent years, endovascular embolization of the middle meningeal artery (eMMA) has garnered much attention due to recurrence rates as low as