Gurmeen Kaur

BACKGROUND: Chronic subdural hematoma is a complex but commonly treated neurosurgical condition, particularly affecting the elderly. Traditional treatment involves open surgeries, but middle meningeal artery embolization (MMAE) has emerged as an effective, minimally invasive adjunctive. The objective of this study is to assess the safety and efficacy of MMAE in combination with surgery using real-world data. METHODS: This retrospective cohort study analyzed data from the TriNetX Research Network. Outcomes of mortality, reoperation, and hospital readmission were studied using Cox proportional hazard models controlling for age, sex, indications of severity, type of surgical intervention, antiplatelet/anticoagulant use, comorbidities, and hospitalization events. Patients were followed for up to 6 years. RESULTS: This study included 38 049 patients with chronic subdural hematoma, of which 486 received surgery with MMAE and 5362 received surgery monotherapy. At 90 days after surgery, mortality was 5.2% in the MMAE group and 7.7% in the surgery monotherapy group ( P =0.0467). After 6 years, mortality was 11.2% in the MMAE group and 19.0% in the surgery monotherapy group ( P P =0.173). Patients with MMAE had significantly lower rates of rehospitalization at 1 year (2.1% versus 4.4%; P =0.0195), even after adjustment (hazard ratio, 0.414 [95% CI, 0.203–0.845]; P =0.015). CONCLUSIONS: Among patients with chronic subdural hematoma who received surgery, patients receiving adjunctive MMAE experienced lower mortality rates out to 6 years of follow-up, but the difference was not significant after full adjustment. Beginning 1 year after surgery, patients receiving combination therapy had significantly lower long-term rehospitalization compared with patients receiving surgery monotherapy. Future prospective studies will help identify strengths and weaknesses of this highly promising treatment modality.

Super large-bore aspiration catheters have emerged as promising tools for endovascular thrombectomy (EVT) in acute ischemic stroke (AIS) due to large vessel occlusion (LVO). The Route 92 Reperfusion System utilizes super large-bore catheters with specialized delivery mechanisms to maximize first-pass effect (FPE) and reperfusion rates. To evaluate the efficacy and safety of the Route 92 super large bore reperfusion System in treating AIS-LVO. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we searched five databases from inception through December 2025. Studies evaluating Route 92 Reperfusion System outcomes in AIS-LVO patients were included. Primary outcomes were FPE and functional independence (modified Rankin Scale (mRS) 0–2). Secondary outcomes included successful reperfusion (modified thrombolysis in cerebral infarction (mTICI) scores), symptomatic intracranial hemorrhage (sICH), mortality, and adverse events. Random-effects models were used for all analyses. Seven studies comprising 490 patients were included. In comparative analyses, Route 92 (0.088”) demonstrated significantly higher FPE rates (risk difference (RD): 0.18, number needed to treat (NNT) = 6, p = 0.001) and near-complete reperfusion (RD: 0.23, NNT = 4, p = 0.0005) compared to other techniques. Single-arm analyses showed 56% achieved FPE, 94% achieved near-complete to complete reperfusion, and 43% achieved functional independence at follow-up. The system demonstrated favorable safety with 3% sICH rate and 20% mortality. National Institutes of Health Stroke Scale (NIHSS) scores improved significantly (mean difference (MD): -9.55, p < 0.00001). The Route 92 Reperfusion System achieves high rates of FPE and successful reperfusion with acceptable safety profiles. Future RCTs is warranted to support these findings.

BACKGROUND: Acute ischemic stroke affecting the middle cerebral artery (MCA) remains a major global cause of death and disability. However, it remains unclear whether the laterality of MCA strokes independently influences inpatient outcomes. Despite the fact that the National Institutes of Health Stroke Scale score is heavily weighted toward left-sided acute ischemic stroke, we hypothesize that right MCA strokes (R-MCASs) are associated with worse inpatient outcomes because they would require more severe deficits to amount to a comparable National Institutes of Health Stroke Scale score for a left MCA stroke. METHODS: A retrospective cross-sectional analysis was conducted using data from the National Inpatient Sample between 2015 and 2022. This nationally representative sample included adult patients (aged ≥18 years) in the United States hospitalized primarily for MCA strokes and with reported National Institutes of Health Stroke Scale scores. Patients were stratified into R-MCAS and left MCA stroke. Outcomes included odds of inpatient mortality, routine discharge, complications, and receipt of reperfusion therapy. Propensity score–based inverse probability of treatment weighting is adjusted for confounding factors. Multivariable logistic regression evaluated adjusted odds ratios (aORs) and 95% CIs for all outcomes. RESULTS: Among 489 360 acute ischemic stroke hospitalizations, 263 495 (53.8%) were left MCA stroke, and 225 865 (46.2%) were R-MCAS. Following inverse probability of treatment weighting, R-MCASs were significantly more likely to receive endovascular thrombectomy (aOR, 1.26 [95% CI, 1.22–1.30]; P P =0.018). R-MCAS was associated with significantly increased odds of cerebral edema/herniation (aOR, 1.53 [95% CI, 1.47–1.59]; P P P P P P <0.001). CONCLUSIONS: Patients with R-MCAS were more likely to receive endovascular thrombectomy and less likely to receive intravascular thrombolysis. R-MCASs were also associated with worse discharge disposition and increased likelihood of inpatient mortality. The National Institutes of Health Stroke Scale bias toward assessment and valuation of patients’ language abilities may place patients with R-MCAS at increased risk of adverse poststroke outcomes and complications. Recognition of the subtle signs of nondominant hemisphere strokes may lead to more rapid detection, effective treatment, and improved outcomes.

Introduction/Purpose Cerebral venous thrombosis (CVT) is a rare condition that presents significant treatment challenges and has traditionally been managed with anticoagulation. However, for patients who fail anticoagulation or present with severe symptoms, endovascular thrombectomy (EVT) has emerged as a favorable treatment option. Objective The primary aim of this study is to evaluate the outcomes, complications, and comorbidities associated with EVT in patients with CVT. Methods A query of the 2015-2019 National (Nationwide) Inpatient Sample (NIS) was performed for patients admitted to hospitals with ICD-10 diagnosis codes for CVT. The usage of endovascular thrombectomy was identified using ICD-10 procedure codes. Demographic information, baseline comorbidities, complications, and discharge dispositions were compared between patients who underwent EVT and those who were managed medically. A multivariate logistic regression was performed to determine independent predictors of outcomes, while controlling for age, gender, cerebral edema/herniation, hemorrhage, mechanical ventilation, Elixhauser Comorbidity Index, and National Institute of Health Stroke Scale (NIHSS) severity. Odds ratios (OR) were calculated for each complication/outcome. Statistical significance was set at an alpha level of 0.05. All statistical analyses were performed using Statistical Product and Service Solutions (SPSS) Statistical Software Version 29. Results A total of 36,005 patients diagnosed with CVT were identified from 2015(Q4)-2019; of those, 325 (0.9%) underwent EVT. Patients who underwent EVT were older (49.28±19.08years vs 43.62±23.29 years, p < 0.001), more likely to be female (61.5% vs. 54.8%, p = 0.016), and had higher rates of comorbidities, such as diabetes mellitus (18.5% vs. 13.5%, p = 0.012), hypertension (47.7% vs. 31.3%, p < 0.001), and obesity (13.8% vs. 8.1%, p < 0.001). These patients also presented with more severe neurological symptoms, including higher NIHSS scores (13.15 vs. 6.17, p < 0.001), coma (30.8% vs. 11.2%, p < 0.001), and cerebral edema (43.1% vs. 15.5%, p < 0.001). Patients who instead received medical management had higher rates of sepsis (4.7% vs 1.5%, p = 0.008), and were more likely to undergo subsequent decompressive craniectomy (1.9% vs 0%, p = 0.011). Patients undergoing EVT had a higher incidence of in-hospital mortality (15.4% vs. 4.6%, OR 1.627, p = 0.007), were less likely to be discharged routinely (29.2% vs. 57%, OR 0.599, p < 0.001), and more likely to be transferred to a skilled nursing facility (44.6% vs. 20%, OR 3.22, p < 0.001). They also experienced higher rates of concomitant conditions, such as pulmonary embolism (7.7% vs. 3%, p < 0.001) and hemiplegia (33.8% vs. 10.5%, p < 0.001). Conclusions In this nationally-representative analysis, patients with CVT who underwent EVT were older, had higher income, were more likely to be female, and presented with more severe neurological conditions. Our results indicate that EVT in patients with CVT is associated with significant risks, including higher rates of inpatient mortality. Although our analysis attempts to adjust for confounding differences, it remains challenging to fully account for the increased baseline morbidity in patients undergoing EVT. As a result, the poorer outcomes observed in this cohort potentially reflect the severity of illness in these patients rather than the risks associated with EVT itself. Nonetheless, EVT remains an important treatment option for patients who fail medical management. Careful patient selection and tailored management strategies are essential to minimize risks and improve outcomes in this high-risk population. Further studies should focus on developing precise patient selection criteria to better identify which patients with CVT are most likely to benefit from EVT.

Background and purpose: Historically, overall outcomes for patients with high-grade subarachnoid hemorrhage (SAH) have been poor. Generally, between physicians, either reluctance to treat, or selectivity in treating such patients has been the paradigm. Recent studies have shown that early and aggressive care leads to significant improvement in survival rates and favorable outcomes of grade V SAH patients. With advancements in both neurocritical care and end-of-life care, non-treatment or selective treatment of grade V SAH patients is rarely justified. Current paradigm shifts towards early and aggressive care in such cases may lead to improved outcomes for many more patients. Materials and methods: We performed a detailed review of the current literature regarding neurointensive management strategies in high-grade SAH, discussing multiple aspects. We discussed the neurointensive care management protocols for grade V SAH patients. Results: Acutely, intracranial pressure control is of utmost importance with external ventricular drain placement, sedation, optimization of cerebral perfusion pressure, osmotherapy and hyperventilation, as well as cardiopulmonary support through management of hypotension and hypertension. Conclusions: Advancements of care in SAH patients make it unethical to deny treatment to poor Hunt and Hess grade patients. Early and aggressive treatment results in a significant improvement in survival rate and favorable outcome in such patients.

BACKGROUND AND PURPOSE: Embolization of the middle meningeal artery for treatment of refractory or recurrent chronic subdural hematomas has gained momentum during the past few years. Little has been reported on the use of the n-BCA liquid embolic system for middle meningeal artery embolization. We present the technical feasibility of using diluted n-BCA for middle meningeal artery embolization. MATERIALS AND METHODS: We sought to examine the safety and technical feasibility of the diluted n-BCA liquid embolic system for middle meningeal artery embolization. Patients with chronic refractory or recurrent subdural hematomas were prospectively enrolled from September 2019 to June 2020. The primary outcome was the safety and technical feasibility of the use of diluted n-BCA for embolization of the middle meningeal artery. The secondary end point was the efficacy in reducing hematoma volume. RESULTS: A total of 16 patients were prospectively enrolled. Concomitant burr-hole craniotomies were performed in 12 of the 16 patients. Two patients required an operation following middle meningeal artery embolization for persistent symptoms. The primary end point was met in 100% of cases in which there were no intra- or postprocedural complications. Distal penetration of the middle meningeal artery branches was achieved in all the enrolled cases. A 7-day post–middle meningeal artery embolization follow-up head CT demonstrated improvement (>50% reduction in subdural hematoma volume) in 9/15 (60%) patients, with 6/15 (40%) showing an unchanged or stable subdural hematoma. At day 21, available CT scans demonstrated substantial further improvement (>75% reduction in subdural hematoma volume). CONCLUSIONS: Embolization of the middle meningeal artery using diluted n-BCA and ethiodized oil (1:6) is safe and feasible from a technical standpoint. The use of a dextrose 5% bolus improves distal penetration of the glue.