• Journal of Korean Neurosurgical Society
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• 제56권5호
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• pp.423-427
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• 2014

Traumatic pseudoaneurysms of the middle meningeal artery (MMA) are rare phenomenon, which are usually associated with head trauma such as an underlying skull fracture. They were usually known to cause acute or delayed epidural hematomas but can be associated with subdural, subarachnoid, or even intracerebral hemorrhage. Sometimes, a high mortality rate was reported in these circumferences. But the natural course of these pseudoaneurysms is not well recognized. The indication and guideline of treatment for pseudoaneurysm are also unclear. This report describes a rare case of angiographically progressive change of traumatic pseudoaneurysm of the middle meningeal artery for one week, which was treated with endovascular embolization.

• Journal of Korean Neurosurgical Society
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• 제42권5호
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• pp.416-418
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• 2007

Hematomas caused by ruptured traumatic pseudoaneurysms of the middle meningeal artery (MMA) usually present with extradural hematomas, whereas intradural intraparenchymal hematomas are extremely rare. We report a case of traumatic pseudoaneurysm of the MMA giving rise to an intracerebral hematoma after head trauma. A 70-year-old man suffered a massive intracerebral temporoparietal hemorrhage after a head injury. CT angiogram of the brain revealed a large hematoma in the right middle cranial fossa extending to the right sylvian fissure. Cerebral angiogram also revealed a pseudoaneurysm of the MMA, which was successfully treated surgically. Although traumatic MMA pseudoaneurysm producing intracerebral hematoma (ICH) is rare, it should be considered as a possible cause of intracerebral hematoma.

• Journal of Cerebrovascular and Endovascular Neurosurgery
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• 제26권1호
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• pp.11-22
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• 2024

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.

• Journal of Korean Neurosurgical Society
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• 제63권4호
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• pp.532-538
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• 2020

Traumatic arteriovenous fistulas (AVFs) involving the external carotid artery are exceedingly rare in young adults. Since an AVF is the most common life-threatening cause for pulsatile tinnitus (PT), meticulous evaluation and treatment of patients with PT is crucial. Here, we present two traumatic AVF cases treated with coil embolization leading to no residual fistulous connections followed by an immediate and complete resolution of PT. A 20-year-old man developed left ear tinnitus three months after a traumatic brain injury involving the right temporal bone fracture. Cerebral angiography demonstrated an enlarged left middle meningeal artery (MMA) and a fistular point at the posterior branch of the MMA draining to the middle meningeal vein (MMV) and the left pterygoid plexus, suggesting an AVF. Another 18-year-old girl developed left tinnitus, left exophthalmos, and conjunctival injection 6 months after a traffic accident involving no demonstrable abnormal findings in the radiologic exam. Magnetic resonance angiography demonstrated a markedly dilated left MMA draining to the MMV, left cavernous sinus, and left superior ophthalmic vein. In both cases, coil embolization was performed with total obliteration of the fistular point.

• Journal of Korean Neurosurgical Society
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• 제57권1호
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• pp.54-57
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• 2015

A 66-year-old woman presented with intermittent paraparesis and generalized tonic-clonic seizure. Cerebral angiography demonstrated dural arteriovenous fistula (AVF) involving superior sagittal sinus (SSS), which was associated with SSS occlusion on the posterior one third. The dural AVF was fed by bilateral middle meningeal arteries (MMAs), superficial temporal arteries (STAs) and occipital arteries with marked retrograde cortical venous reflux. Transfemoral arterial Onyx embolization was performed through right MMA and STA, but it was not successful, which resulted in partial obliteration of dural AVF because of tortuous MMA preventing the microcatheter from reaching the fistula closely enough. Second procedure was performed through left MMA accessed by direct MMA puncture following small decortications of cranium overlying the MMA using diamond drill one week later. Microcatheter could be located far distally to the fistula through 5 F sheath placed into the MMA and complete obliteration of dural AVF was achieved using 3.9 cc of Onyx.

• Journal of Korean Neurosurgical Society
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• 제65권6호
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• pp.868-874
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• 2022

Spontaneous intracranial hypotension (SIH) most commonly manifests as bilateral subdural hematoma (SH). SIH cases mostly resolve spontaneously but further treatment would be needed via blind epidural blood patch (EBP). Cerebrospinal fluid (CSF) leakage in EBP-refractory cases can be treated surgically only if the localization of CSF leakage is detectable but it cannot be possible in most of the cases. Also surgical evacuation of SH secondary to SIH (SH-SIH) is not favorable without blocking the CSF leakage. Thus the management of these patients is a challenge and alternative treatment options are needed. Although middle meningeal artery embolization (MMAE) is an effective treatment option in non-SIH SH, there is no report about its application in the treatment of SH-SIH. We present two cases of SH-SIH which their clinical and radiological findings were completely resolved by bilateral MMAE treatment.

• Journal of Cerebrovascular and Endovascular Neurosurgery
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• 제25권4호
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• pp.380-389
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• 2023

Objective: Middle meningeal artery embolization (MMAe) has burgeoned as a treatment for chronic subdural hematoma (cSDH). This study evaluates the safety and short-term outcomes of MMAe patients relative to traditional treatment approaches. Methods: In this retrospective large database study, adult patients in the National Inpatient Sample from 2012-2019 with a diagnosis of cSDH were identified. Cost of admission, length of stay (LOS), discharge disposition, and complications were analyzed. Propensity score matching (PSM) was utilized. Results: A total of 123,350 patients with cSDH were identified: 63,450 without intervention, 59,435 surgery only, 295 MMAe only, and 170 surgery plus MMAe. On PSM analysis, MMAe did not increase the risk of inpatient complications or prolong the length of stay compared to conservative management (p>0.05); MMAe had higher cost ($31,170 vs. $10,768, p<0.001) than conservative management, and a lower rate of nonroutine discharge (53.8% vs. 64.3%, p=0.024). Compared to surgery, MMAe had shorter LOS (5 vs. 7 days, p<0.001), and lower rates of neurological complications (2.7% vs. 7.1%, p=0.029) and nonroutine discharge (53.8% vs. 71.7%, p<0.001). There was no significant difference in cost (p>0.05). Conclusions: MMAe had similar LOS and decreased odds of adverse discharge with a modest cost increase compared to conservative management. There was no difference in inpatient complications. Compared to surgery, MMAe treatment was associated with decreased LOS and rates of neurological complications and nonroutine discharge. This nationwide analysis supports the safety of MMAe to treat cSDH.

• Journal of Cerebrovascular and Endovascular Neurosurgery
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• 제25권2호
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• pp.214-223
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• 2023

Embolization of the middle meningeal artery (MMA) is a safe and effective adjunct in the treatment of chronic subdural hematoma. While prior authors describe the use of coils to assist embolization by preventing reflux through eloquent collaterals, we de- scribe the use of coils to further open the MMA, allowing the administration of greater amounts of embolisate for a more robust embolization. The objective of this study was to demonstrate that helical coils can safely open the MMA following the administration of polyvinyl alcohol (PVA) particles. This allows for more embolisate to be administered into the MMA for more effective treatment. A retrospective review was conducted at our institution including intraoperative images and postoperative clinical and radiographic follow up. Failure rates using MMA embolization with PVA and helical coil augmentation were compared to failure rates in the literature of MMA embolization with PVA or ethylene vinyl-alcohol copolymer alone. A total of 8 cases were reviewed in which this technique was implemented. There were no immediate complications after treatment. All patients that underwent helical coil embolization following the administration of PVA had increased amount of embolisate delivered into the MMA. All patients at follow up had resolution of the subdural hematoma on outpatient imaging. Helical coil embolization allows for more embolisate administration into the MMA and provides a technical advantage for patients that fail traditional techniques of embolization. Case series are taking place to further test this hypothesis and identify the ideal patient population that may gain maximal yield from this novel technique.

• Journal of Cerebrovascular and Endovascular Neurosurgery
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• 제25권1호
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• pp.28-35
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• 2023

Objective: The purpose of this study was to evaluate the effectiveness of middle meningeal artery embolization (MMAE) in elderly high-risk patients with symptomatic chronic subdural hematoma (CSDH) in terms of reduction in hematoma volume and recurrence rate. Methods: We retrospectively reviewed data prospectively collected from nine patients who underwent 13 MMAE for CSDH between June 2017 and May 2022. The volume of the subdural hematoma was measured using a computer-aided volumetric analysis program. Hematoma volume changes during the follow-up period were analyzed and clinical outcomes were evaluated. Results: The mean follow-up period was 160 days (range, 46-311 days). All procedures were technically successful and there were no procedure-related complications. Of the 13 MMAE, 84% (11 out of 13 hemispheres) showed mean 88% of reduction on follow-up volumetric study with eight cases of complete resolution. There was one refractory case with MMAE which had been performed multiple burr-hole trephinations, for which treatment was completed by craniotomy and meticulous resection of multiple pseudomembranes. There was no recurrent case during the follow-up period, except for refractory case. Conclusions: MMAE for CSDH in selected high-risk elderly patients and relapsed patients might be effective. Despite the small cohort, our findings showed a high rate of complete resolution with no complications. Further prospective randomized trials are warranted to evaluate its usefulness as a primary treatment option for CSDH.

• Journal of Korean Neurosurgical Society
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• 제50권3호
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• pp.260-263
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• 2011

Intracranial dural arteriovenous fistulas (DAVFs) are abnormal arteriovenous connections that lie within the dura. Intraosseous DAVFs involving diploic venous system are extremely rare. A 46-year-old woman presented with headache and right pulsatile tinnitus for three weeks. The tinnitus started after yelling. Digital subtraction angiography revealed DAVF within the basal portion of right parietal bone along the middle meningeal artery (MMA) groove. The fistula was fed by frontal branch of right MMA and drained into right transverse sigmoid sinus junction through dilated middle meningeal vein. The intraosseous DAVF involving diploic vein was successfully obliterated with Onyx embolization via transarterial route.