Luciano Bambini Manzato

Introduction: Chronic subdural hematoma (cSDH) is increasingly prevalent among older adults due to population aging and widespread antithrombotic use. Although burr-hole drainage remains the standard treatment, recurrence rates are substantial. Middle meningeal artery embolization (MMAE) has emerged as an adjunctive strategy to disrupt dural neovascularization and prevent rebleeding. Objectives: To assess the efficacy and safety of MMAE combined with standard therapy versus standard therapy alone, with stratification by timing of intervention. Methods: Randomized controlled trials (RCTs) were searched in PubMed, Scopus, and Cochrane Central up to July 2025. Adults with confirmed cSDH were included. The primary outcome was hematoma recurrence or persistence. Secondary outcomes were reoperation, hematoma resorption, serious adverse events, neurological death, mortality, functional independence, and hospital stay. Risk of bias was assessed with RoB-2, and analyses followed PRISMA guidelines (PROSPERO CRD420251112841). Results: Seven RCTs (1,889 patients) were included. Compared with standard therapy, MMAE significantly reduced recurrent or residual cSDH (RR 0.63; 95% CI 0.46–0.85) and reoperation (RR 0.39; 95% CI 0.28–0.56) without increasing serious adverse events (RR 0.87; 95% CI 0.72–1.06), neurological death, mortality, or poor functional outcomes. Hematoma resorption did not differ significantly. Subgroup and sensitivity analyses confirmed the robustness of the results across age, intervention timing, and follow-up duration. Conclusion: MMAE combined with standard therapy significantly reduces recurrence and reoperation in cSDH without increasing adverse events or mortality. Benefits appear independent of procedural timing, though larger RCTs with extended follow-up are warranted to define long-term outcomes and optimal use.

Background: Migraine is the most common neurological problem in primary care affecting 18% of women and 6% of men, while chronic migraine affects 2% of the population and refractory migraine is estimated to affect between 5% and 30% of migraine sufferers. The dura is a well-vascularized structure, which is densely innervated by pain fibers. Intra-arterial administration of lidocaine in the middle meningeal artery (MMA) has been used for refractory migraine, promoting pain relief. Patients with chronic headaches who underwent embolization of the MMA for the prevention of chronic subdural hematoma recurrence experienced complete resolution of pain. Methods: Based on this data, we treated 10 patients consecutively with chronic and refractory migraine with a high degree of disability assessed by headache impact test (HIT-6) who experimented with pain relief with lidocaine injection and subsequently underwent definitive bilateral occlusion of the MMA with biological glue. Results: Mean age was 48.2 ± 14.4, with 90% being female, all patients confirmed primary headache in the lidocaine suppression test (LST) and after bilateral occlusion was observed worsening of pain between 0 h and 6 h (−0.9 (95% CI −2.2–0.6, P = 0.193) with complete improvement at discharge within 24 h. In the 30-day follow-up, we observed a significant improvement in HIT-6, 30.5 (95% CI 25.5–35.5, P < 0.001) that lasted up to 6 months. No neurological or technical complications were observed. Conclusions: Patients with chronic or refractory migraine, rigorously selected through the LST, may benefit from bilateral occlusion of the MMA for a period of up to 6 months, without additional risks. Despite the positive results, we must emphasize the preliminary nature of these findings, especially given the small sample size. A multicenter, randomized study is needed to prove the efficacy and safety of this new treatment and it may be an alternative for a specific subset of patients.

Introduction The management of chronic subdural hematoma (CSDH) faces a high recurrence rate. Cohort studies have demonstrated a reduction in recurrence with middle meningeal artery embolization (MMAE). This study aims to demonstrate that this therapy is a safe and effective treatment and that, when combined with surgical drainage, it is superior to surgical treatment alone in reducing the recurrence rate. Methods This is a single-center, prospective, randomized study designed to evaluate the superiority of surgery followed by MMAE in reducing the recurrence rate of CSDH compared to surgery alone. A total of 76 hematomas were randomized in a 1:1 ratio to receive surgery followed by MMAE or conventional surgical treatment, with 69 patients evaluated at the end of the study. The primary outcome assessed was the recurrence rate of these hematomas within 90 days post-randomization. Results A total of 76 chronic subdural hematomas were included in this study, with 43 randomized to the control group and 33 to the intervention group. Hematoma recurrence within 90 days occurred in 1 patient (4.2%) in the intervention group compared to 4 patients (12.5%) in the control group (Absolute Risk Reduction, 8.3%; p = 0.379). The 90-day mortality rate was 6.1% in the intervention group and 11.6% in the control group (p = 0.434). No differences were observed in hospitalization duration or severe complication rates. Conclusions In symptomatic patients who underwent surgical treatment for CSDH drainage, the addition of MMA embolization showed a trend toward reducing the recurrence rate and 90-day mortality.

Traumatic carotid artery dissection (TCAD) usually occurs after a direct cervical trauma or blunt trauma that causes hyperextension and excessive rotation of the neck. The most frequent presentation of TCAD is stroke, with 80% of patients developing a stroke in the first week after the trauma. Recent data indicate that symptoms start later in non-survivors (19.5 hours after trauma) compared with survivors (12.5 hours). In this case report, a young boy, 14 years-old, developed TCAD after he fell from his bike. He developed ischemic stroke symptomatology in the eighth day of hospitalization, with full recovery of symtoms after acetylsalicylic acid (AAS) administration. The use of antithrombotic medication is recommended, aiming for better neurological outcomes and prevention of stroke in TCAD patients, as highlighted by our case. However, the treatment recommendations are based on observational studies and expert opinion, owing to the lack of concrete data on the treatment of carotid artery blunt trauma. New studies and data are required to improve diagnosis and treatment of TCAD.

BACKGROUND AND PURPOSE: The development of flow diverters has changed the endovascular approach to intracranial aneurysms. On the basis of good results, the indications for flow diverters have expanded to include aneurysms of different shapes, locations, and sizes. The objective of the study was to report on the performance of the Flow Re-Direction Endoluminal Device (FRED) in intracranial aneurysm treatment at early and medium-term follow-up. MATERIALS AND METHODS: This single-arm, multicentric, prospective, observational study assessed aneurysm treatment with the FRED. The primary outcome was complete aneurysm occlusion at 6 and 12 months, and the secondary outcome was to evaluate the safety of the FRED with respect to stroke and death rates. RESULTS: Between June 2016 and August 2018, a total of 100 consecutive patients with 131 aneurysms were treated in 107 procedures. Total occlusion rates were 91% and 95% at 6 and 12 months. There was 1 death, and the total final morbidity rate was 1.8%. The complication rate was 4.6%. CONCLUSIONS: As reported previously, the FRED has proved to be a safe and effective tool, with high occlusion rates. The design of the stent makes it more difficult to perform balloon angioplasty compared with similar devices. A branch arising from the aneurysm sac was found to be a predictor of nonocclusion at 12 months, though larger series are needed to estimate the magnitude of the association.

Objective The aim of this trial was to compare the efficacy of closed-cell stents with Casper stents during carotid angioplasty stenting (CAS). Methods This was a randomized superiority trial in which 88 patients were enrolled. The primary end points were the incidence, number, and size of new ischemic brain lesions after CAS under distal embolic protection devices (EPD). The secondary end points included stroke, transient ischemic attack (TIA) and myocardial infarction (MI). Ischemic brain lesions were assessed by a diffusion-weighted magnetic resonance image (DW-MRI). Neurological outcomes were evaluated by means of the National Institutes of Health scale score (NIHSS) and the modified Rankin scale (mRS). Results Compared with closed-cell stents (n = 47), Casper stents (n = 41), resulted in no significant reduction in the incidence (44.7% versus 39%, P = 0.592), number (1.3 ± 1.8 versus 0.9 ± 1.5, p = 0.444), and size (3.9 ± 5.8 mm versus 2.8 ± 4.1 mm, p = 0.353) of new ischemic brain lesions. The global rate of stroke/TIA/MI was (2/88, 2.3%). Two TIA occurred during the hospitalization period, one in each group (1/41, 2.4% vs 1/47, 2.1%). One patient of the Casper group had an asymptomatic in-stent thrombosis. One patient of the control group had a MI (1/47, 2.1%) after discharge. Conclusion The Casper stents did not show superiority in the rate of incidence, number and size of new silent ischemic brain lesions detect by DW-MRI when compared to close cell stents during CAS under distal EPD.

Lhermitte-Duclos disease (LDD), or cerebellar dysplastic gangliocytoma, is a rare type of cerebellar tumor, from unknown origin. Patients can be asymptomatic for several years, but there are usually imprecise neurological signs for long periods.

Stent infection is extremely rare, especially in stents placed in the internal carotid artery (ICA). Treatment in these cases remains controversial and no consensus has been reached, resulting in high mortality in all cases. We report the case of a 78-year-old man undergoing stent placement in the left ICA who, 20 days later, presented with infection at the stent site and a large pseudoaneurysm. The primary infectious focus was the teeth. The patient was treated with antibiotics and placement of a Casper stent, a dual layer braided metal stent with micro-mesh, intended to determine flow diversion and arterial wall reconstruction. Although the procedure was able to reduce the pseudoaneurysm, the patient eventually died of sepsis. We believe that the use of dual layer stents, with a flow-diverting effect, may be a treatment option in selected cases. However, further studies are needed to confirm this hypothesis.