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A subset of patients with chronic subdural hematoma (CSDH) remains refractory to standard treatment with hematoma drainage by burr-hole craniotomy and irrigation. We recently reported the usefulness of middle meningeal artery (MMA) embolization for intractable CSDH in patients with multiple intractable risk factors. We present the midterm outcomes of MMA embolization in patients with intractable CSDHs. Seventeen consecutive patients (average age, 76.4 years; 12 men [71%]) underwent MMA embolization of CSDH from January 2014 to July 2017. Earlier interventions included embolization using N -butyl-2-cyanoacrylate (although trisacryl gelatin microspheres were used in recent cases), followed by burr-hole craniotomy and irrigation in all cases. None of the patients experienced perioperative complications or postoperative recurrence. The modified Rankin Scale scores, which were unfavorable at admission, improved significantly at discharge but were comparable to those at the time of hospitalization when measured during the follow-up period. Although the patients required rehospitalization at other departments for unrelated causes, none required rehospitalization in our department. Despite the known unfavorable outcomes of patients with intractable CSDHs, MMA embolization was not associated with recurrent CSDH or rehospitalization in our department in the current case series. MMA embolization should be considered a preferred therapeutic option for intractable CSDHs. [ABSTRACT FROM AUTHOR]

Objective This study aimed to examine whether there is a difference in the difficulty of extirpation after use of Embosphere versus n-butyl 2-cyanoacrylate (NBCA) for the embolization of meningiomas. Methods Study subjects were 20 patients with meningioma who underwent embolization using either NBCA or Embosphere from April 2012 to December 2016. The difficulty of extirpation was compared and assessed in terms of objective indices, such as operative duration, perioperative bleeding, and Simpson grade, and in terms of subjective indices such as “impression on operative field” and “hardness of tumors” that the surgeon assessed using 3-point scales (dry, moderate, bloody, and soft, moderate, hard, respectively). Pathologic findings, including ischemia, necrosis, and inflammatory changes, were assessed. Results No significant differences were found between the 2 groups regarding the mean values of operative duration ( P = 0.27), perioperative bleeding ( P = 0.23), and Simpson grade ( P = 0.39). On the other hand, there was a significant difference with respect to the “impression on operative field” and “hardness of tumors,” with reports of dry (54%; P = 0.034) and soft (81%; P = 0.0001), respectively, in the Embosphere group exceeding those of the NBCA group. The pathologic findings showed that although ischemic change ( P = 0.43) and necrosis ( P = 0.79) were observed in both groups, perivascular inflammation was observed only in the NBCA group ( P = 0.006). Conclusions No relative merits were found regarding objective indices, whereas the Embosphere group had superior “ease of extirpation” as reported by the surgeon. [ABSTRACT FROM AUTHOR]

Background: Lenticulostriate artery (LSA) aneurysms are uncommon. Most reported cases have been surgically treated. There are only three reports of LSA aneurysms treated with endovascular techniques., Case Description: We report the case of a 49-year-old man who presented with a hemorrhage in the basal ganglia. An angiogram revealed a distal LSA aneurysm in the setting of moyamoya disease. The patient's aneurysm was successfully embolized by the use of Onyx 18. In this report, we present the first case of onyx embolization of a LSA aneurysm and review all the previous cases that were managed with endovascular techniques., Conclusion: Treatment of these lesions with either surgery or endovascular therapy is challenging and requires specialized expertise. Given the risks of surgery, we believe that LSA aneurysms are best treated by endovascular means, especially in the setting of moyamoya disease., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: Dural arteriovenous fistulas (DAVFs) are arteriovenous shunts from a dural arterial supply to a dural venous channel, typically supplied by pachymeningeal arteries and located near a major venous sinus. A retrospective review was conducted to present the results of endovascular obliteration of DAVFs, with particular emphasis of newer liquid embolic agents, including Onyx-18 (MV3, Irvine, California, USA)., Methods: A review of the literature was performed, and a presentation of the number of treatments, complications, and outcomes is included here. The number of arterial embolizations and need for transvenous embolization, open surgery, and radiosurgery was assessed as well as normalization of retrograde cortical venous drainage., Results: Thirty-nine patients (22 men and 17 women) underwent endovascular treatment of DAVFs at our institution from 2001 to 2009. Ages ranged from 39 to 71 years (mean, 48 years). Seventy-nine percent of patients had retrograde cortical venous drainage. The average number of embolizations in all patients was 2.1. Twelve patients underwent 40 embolization treatments with Onyx, with an obliteration rate of 75% and cortical venous drainage obliteration rate of 85%. Seventy-one percent (28/39) of patients had complete treatment of the fistula: 21 by purely endovascular treatment and 7 with endovascular therapy followed by craniotomy, as well as seven patients who underwent stereotactic radiosurgery after embolization., Conclusions: Endovascular management of DAVFs is a safe and effective method of treating these complex lesions., (Copyright © 2013 Elsevier Inc. All rights reserved.)