Background Middle meningeal artery embolization (MMAE) has emerged as a promising therapy for chronic subdural hematomas (cSDHs). The efficacy of standalone MMAE compared with MMAE with concurrent surgery is largely unknown. Methods cSDH patients who underwent successful MMAE from 14 high volume centers with at least 30 days of follow-up were included. Clinical and radiographic variables were recorded and used to perform propensity score matching (PSM) of patients treated with standalone MMAE or MMAE with concurrent surgery. Multivariable logistic regression models were used for additional covariate adjustments. The primary outcome was recurrence requiring surgical rescue, and the secondary outcome was radiographic failure defined as <50% reduction of cSDH thickness. Results 722 MMAE procedures in 588 cSDH patients were identified. After PSM, 230 MMAE procedures remained (115 in each group). Median age was 73 years, 22.6% of patients were receiving anticoagulation medication, and 47.9% had no preoperative functional disability. Median midline shift was 4 mm and cSDH thickness was 16 mm, representing modestly sized cSDHs. Standalone MMAE and MMAE with surgery resulted in similar rates of surgical rescue (7.8% vs 13.0%, respectively, P=0.28; adjusted OR (aOR 0.73 (95% CI 0.20 to 2.40), P=0.60) and radiographic failure (15.5% vs 13.7%, respectively, P=0.84; aOR 1.08 (95% CI 0.37 to 2.19), P=0.88) with a median follow-up duration of 105 days. These results were similar across subgroup analyses and follow-up durations. Conclusions Standalone MMAE led to similar and durable clinical and radiographic outcomes as MMAE combined with surgery in select patients with moderately sized cSDHs and mild clinical disease.

Introduction: Chronic subdural hematoma (CSDH) is associated with high recurrence rates. Middle meningeal artery embolization (MMAE) has emerged as a promising treatment option. In this systematic review and meta-analysis, we aimed to assess the safety and efficacy of MMAE for CSDH using liquid embolic agents and compare them with particles. Methods: We systematically reviewed all studies describing MMAE for CSDH with liquid embolic agents, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Additionally, we included a cohort of patients from our institution using liquid and particle embolic agents. Data were analyzed using random-effects proportions and comparisons meta-analysis, and statistical heterogeneity was assessed. Results: A total of 18 studies with 507 cases of MMAE with liquid embolic agents (including our institutional experience) were included in the analysis. The success rate was 99% (95% confidence interval [CI]: 98–⁠100%), all complications rate was 1% (95% CI: 0–⁠5%), major complications rate was 0% (95% CI: 0–⁠0%), and mortality rate was 1% (95% CI: 0–⁠6%). The rate of hematoma size reduction was 97% (95% CI: 73–⁠100%), complete resolution 64% (95% CI: 33–⁠87%), radiographic recurrence 3% (95% CI: 1–⁠7%), and reoperation 3% (95% CI: 1–⁠7%). No significant differences in outcomes were found between liquid and particle embolic agents. Sensitivity analyses revealed that liquid embolic agents were associated with lower reoperation rates in upfront MMAE (risk ratio 0.13, 95% CI: 0.02–⁠0.95). Conclusion: MMAE with liquid embolic agents is safe and effective for the treatment of CSDH. Outcomes are comparable to particles, but liquids were associated with a decreased risk of reoperation in upfront MMAE. However, further studies are needed to support our findings.

OBJECTIVE: Stent-assisted coil (SAC) embolization has been the mainstay endovascular treatment for bifurcation aneurysms. The recent introduction of the Woven EndoBridge (WEB) device has presented an alternative endovascular treatment modality for these aneurysms. Direct comparisons of outcomes between these two modalities are limited in the literature. Here, the authors compared the outcomes of bifurcation aneurysms treated with SAC and WEB devices. METHODS: This retrospective single-center study comprised 148 bifurcation aneurysms that were treated endovascularly with SAC or WEB devices between 2011 and 2019. The primary outcome was complete occlusion of the aneurysm at 6 months on catheter angiography. RESULTS: The SAC and WEB cohorts comprised 85 and 63 aneurysms, respectively. The baseline characteristics were well balanced after inverse probability weight (IPW) adjustment, except for smoking status. The 6-month complete occlusion rate was higher in the WEB cohort than the SAC cohort (67.4% vs 40.6%; unadjusted OR [95% CI] 3.014 [1.385–6.563], p = 0.005). However, this difference in complete occlusion rates did not remain significant after IPW adjustment and multiple imputations. The neck remnant rate was lower in the WEB cohort than the SAC cohort (20% vs 50%; OR [95% CI] 0.250 [0.107–0.584], p = 0.001), and this difference remained significant after IPW adjustment (OR [95% CI] 0.304 [0.116–0.795], p = 0.015) and multiple imputations. CONCLUSIONS: Use of SAC and WEB demonstrated comparable 6-month complete occlusion rates for bifurcation aneurysms. WEB appeared to be associated with a lower rate of neck remnant at 6 and 12 months compared with SAC. WEB was also associated with fewer complications and decreased retreatment rates compared with SAC.

No statistically significant differences in outcomes were found based on whether the middle meningeal artery embolization was performed before or after surgery or early or late after surgery.

This study evaluates the effectiveness of artificial intelligence (AI) models in generating accurate, high-quality medical illustrations for vascular neurosurgery. It aims to develop a systematic framework for producing and assessing AI-generated medical images. Four AI models-DALL-E, Copilot, Gemini, and Midjourney-were tested to generate illustrations of neurovascular structures and procedures (e.g., aneurysms, endovascular techniques). The study had three stages: (1) Proof of concept, in which each model generated images for nine neurovascular topics, evaluated using a standardized rubric; (2) A focused comparison using simple vs. advanced prompt strategies with Gemini; and (3) Validation of the best strategy with neurosurgery trainees and attendings. Images were scored from 1 (worst) to 5 (best) across eight domains: Accuracy, Location, Size/Scale, Color, Complexity, Educational Value, Relevance, and Aesthetic Quality. Gemini consistently outperformed other models in Stage 1, particularly in accuracy, color, and educational value. In Stage 2, advanced prompting significantly improved image quality across nearly all topics (e.g., fusiform aneurysm score rose from 22.4 to 35.0, p = 7E-08). In Stage 3, 85 % of respondents indicated they would use the saccular aneurysm image in a manuscript without modification. However, complex anatomy like anterior cerebral arteries scored lower in accuracy (2.18) and educational value (2.20). AI-generated illustrations, especially from Gemini, show strong potential in neurosurgical education and communication. While advanced prompting improves output quality, challenges remain in consistently rendering complex anatomy. This study outlines a reproducible framework for clinical integration of AI-generated medical images.