Christopher C. Young

Background/Objective: Hematologic cancer patients are at high risk of developing chronic subdural hematomas (cSDH), and traditional treatment with surgery is potentially risky in this patient population, with associated coagulopathy and thrombocytopenia. Neurointerventional endovascular middle meningeal artery embolization (MMAE) is emerging as a novel minimally invasive treatment method for cSDH, and its efficacy and complication profile has not been evaluated in patients with hematologic cancers. Methods: We conducted a retrospective cohort study of adults with hematologic malignancies and cSDH between 2015 and 2025 and compared the efficacy and safety of treatment with MMAE versus open surgery. Variables were abstracted from the medical records. Primary outcomes were necessity for rescue treatment within 180 days after the index procedure and time to restart systemic cancer therapy among patients whose treatment was held due to subdural hematoma. Inverse probability of treatment weighting (IPTW) was applied using covariate-balancing propensity scores to address confounding by indication. Time-to-event outcomes were analyzed using weighted Cox proportional hazards models and Kaplan–Meier methods. Results: A total of 67 patients with hematologic malignancies and cSDH were included (37 treated with MMAE and 30 with surgical evacuation). After IPTW, baseline covariates were well balanced between groups. MMAE was associated with a significantly lower risk of requiring rescue treatment than surgery (HR, 0.19; 95% CI, 0.05–0.81). This association persisted after accounting for the competing risk of death (Fine–Gray subdistribution HR, 0.21; 95% CI, 0.06–0.77). Prolonged Activated Partial Thromboplastin Time was associated with a higher risk of requiring rescue treatment. The median time to resume systemic therapy was significantly shorter following MMAE (13.5 days; 95% CI, 9–26) than after surgery (27.0 days; 95% CI, 22–50) (p = 0.005). Conclusions: In patients with hematologic malignancies and symptomatic cSDH, MMAE was associated with fewer rescue interventions and earlier resumption of systemic therapy compared with surgical evacuation, suggesting that embolization may represent an effective and minimally invasive treatment strategy that preserves continuity of oncologic care in this high-risk population.

BACKGROUND: To evaluate possible associations between anti-VEGF (vascular endothelial growth factor) therapy and cSDH (chronic subdural hematoma) outcomes. METHODS: We conducted a cohort study using the TriNetX Research Network, comparing patients with cSDH taking anti-VEGF agents to controls through propensity score matching. Outcomes measured were assessed at 6 months and 1 year follow-up and included cSDH rebleeding, endovascular or surgical cSDH treatment, mortality, headaches, stroke, arterial hypertension, proteinuria, and major bleeding (noncranial). RESULTS: After propensity matching, 737 patients were included in both anti-VEGF and control cohorts at 6 months, and 722 patients in each cohort at 1 year. Baseline characteristics were well balanced. At 6-months, the anti-VEGF group had significantly lower odds of rebleeding (odds ratio [OR], 0.204 [95% CI, 0.159–0.26]; P P =0.002), and mortality (OR, 0.778 [95% CI, 0.615–0.990]; P =0.037). At 1-year, reduced odds persisted for rebleeding (OR, 0.158 [95% CI, 0.122–0.200]; P P P =0.007), and mortality (OR, 0.677 [95% CI, 0.520–0.880]; P =0.003). Arterial hypertension was higher in the anti-VEGF group at 6 months (OR, 1.240 [95% CI, 1.000–1.530]; P =0.048), but not 1 year (OR, 1.110 [95% CI, 0.904–1.350]; P =0.330). No significant differences were observed in headache, stroke, proteinuria, or major bleeding at either time point. CONCLUSIONS: Anti-VEGF therapy is associated with significantly reduced rebleeding, reintervention rates, and mortality in patients with cSDH at both 6 months and 1 year. A transient increased incidence of arterial hypertension was noted at 6 months, but other major adverse events were not significantly different. Further randomized, prospective studies are warranted to confirm these results and optimize treatment strategies.

Background: Spinal arteriovenous fistulas (SAVFs) are direct communication between arteries and veins without intervening abnormal vessel nidus, which often results in venous congestion and spinal cord dysfunction. Ventrally located SAVF can be challenging to treat through traditional open or endovascular approaches. Case Description: We describe a hybrid (open/endovascular) procedure in a 72-year-old male with a Takai Type IVb SAVF presenting with paraparesis and sphincter dysfunction. Imaging revealed a conus medullaris SAVF in which the main fistulous connection was located ventrally. The conventional endovascular approach was deemed risky, and open surgery failed in the first attempt. The SAVF was resolved using a hybrid approach: under direct visualization, an engorged dorsal vein was punctured with an Angiocath, and a fluoroscopy-guided microcatheter was advanced through it to reach and embolize the ventral perimedullary fistulous connection. After surgery, his progressive neurological decline stabilized, radiographic spinal cord edema improved, and follow-up angiography confirmed obliteration of the fistula. Neurological function remained at the preoperative baseline. Conclusion: This approach may be a treatment for selected cases of type IVb SAVF. Easily accessible feeding vessels are coagulated and cut; the inaccessible ones can be embolized endovascularly during the same procedure.