Background and objectives: Middle meningeal artery embolization (MMAE) has become a pivotal intervention in managing chronic subdural hematomas (cSDHs). This systematic review synthesizes past, recent, and ongoing clinical trials to assess MMAE's role in cSDH treatment. Methods: A systematic review was conducted using PRISMA guidelines, incorporating PubMed, ClinicalTrials.gov, and reverse bibliography searches to identify clinical trials evaluating MMAE for cSDH. Inclusion criteria included randomized and nonrandomized trials reporting outcomes, such as recurrence rates and procedural safety. Case reports, retrospective reviews, and opinion pieces were excluded. Results: Seven published and 15 ongoing trials were identified. Landmark randomized controlled trials (RCTs), including EMBOLISE, STEM, and MAGIC-MT, demonstrated reductions in hematoma recurrence and surgical rescues with MMAE, establishing its role as both an adjunctive and standalone therapy. Ongoing trials, such as EMPROTECT and CHESS, investigate diverse embolic agents, procedural strategies, and patient populations to optimize MMAE outcomes. However, challenges remain, including variability in patient selection criteria, embolic materials, and endpoints. Conclusion: MMAE is an innovative and minimally invasive approach that has reshaped cSDH management. Evidence supports its efficacy and safety as an adjunct to surgery and a potential standalone therapy for select patients. Future research should focus on long-term outcomes, subgroup analyses, and standardization of protocols to further refine its application and integration into clinical practice.

Background: Radiation necrosis (RN) is a delayed and potentially debilitating complication of radiotherapy for central nervous system (CNS) tumors. It presents significant diagnostic and therapeutic challenges due to the variable clinical manifestations and overlap with tumor recurrence. Although advances in radiotherapy have improved tumor control, RN remains incompletely understood and inadequately addressed. This narrative review synthesizes current evidence on RN pathophysiology, risk factors, diagnostic strategies, and management approaches. Methods: A literature search was conducted for English-language literature published between January 1990 and December 2024. Studies were included if they addressed RN incidence, diagnosis, treatment, or novel preventive strategies in CNS tumor populations. Relevant findings were synthesized to produce a narrative review summarizing pathophysiology, diagnostic challenges, and treatment strategies. Results: RN results from radiation-induced neurovascular injury, inflammation, and vessel permeability, with incidence ranging from 3 to 26% depending on tumor type, location, and treatment parameters. Risk is influenced by dose, fractionation, cumulative exposure, re-irradiation, and adjuvant therapies. Advanced modalities such as SRS, HFSRT, brachytherapy, proton therapy, and IORT reduce but do not eliminate RN risk. Diagnosis remains challenging despite advanced MRI and PET techniques, with histopathology as the gold standard. Management includes corticosteroids, bevacizumab, surgery, LITT, and experimental therapies. Connectomics-based planning shows promise in minimizing RN by sparing critical brain networks. Conclusions: RN is a clinically significant and multifactorial complication of CNS radiotherapy. Precision treatment modalities and advanced imaging have improved prevention and detection, but diagnostic uncertainty and recurrence risk persist. Integration of connectomics into treatment planning may offer future promise of a reduction in RN-related morbidity by preserving structural and functional network integrity.

Background/Objectives: Nonacute subdural hematomas (naSDHs) are a prevalent intracranial pathology, particularly in older people, due to increased brain atrophy, fall risk, and anticoagulant use. This study examines the impact of frailty on the surgical outcomes of craniotomy for naSDH over 20 years. Methods: Data from the Nationwide Inpatient Sample (NIS) from 2000 to 2021 were analyzed, including 251,597 patients who underwent cranial decompression for naSDH. Patients were selected using specific ICD codes. Frailty was calculated using the modified frailty index (mFI-5 and mFI-11) and the Charlson Comorbidity Index (CCI). Outcomes were compared using descriptive statistics and multivariable regression models. Results: 251,597 patients underwent craniotomy, with a mean age of 69.2 years. The cohort exhibited significant comorbid conditions, reflected in a mean Charlson Comorbidity Index (CCI) of 3.8, and a high frailty prevalence, with 23.49% of patients classified as frail and 20.14% as severely frail. The CCI demonstrated the highest predictive value for adverse outcomes, with an area under the curve (AUC) of 0.6346 for mortality and 0.6804 for complications. Frailty indices (mFI-5 and mFI-11) were also strongly associated with increased mortality (p < 0.001), complications (p < 0.001), and extended length of stay (p < 0.001). Age was not a significant predictor of outcomes. Conclusions: This study highlights the moderate impact of frailty on surgical outcomes for naSDH.

Introduction: Chronic subdural hematomas (cSDH) are increasingly recognized as a major cause of morbidity in aging populations. Procedural Innovations such as middle meningeal artery embolization (MMAE) are becoming more widely adopted for cSDH treatment. While embolization reduces hematoma recurrence, the economic cost of different embolic agents remains unclear. This study evaluates inpatient procedural costs associated with particulate versus liquid embolic materials in MMAE for cSDH. Methods: A retrospective cohort study was conducted at a Comprehensive Stroke Center, including patients who underwent MMAE for cSDH between January 2019 and January 2024. Actual hospital expenditure data was used to assess total procedural and material-specific costs. Clinical outcomes, such as modified Rankin Scale (mRS) scores and 90-day retreatment rates, were compared between embolic agent groups. The primary independent variable was the embolic agent, categorized as particulate or liquid embolics (liquid including Onyx and nBCA). Results: 114 patients were included, with 18 (15.8%) treated with liquid embolics and 96 (84.2%) treated with particulate embolization. Baseline demographics and procedural variables were largely similar across groups. Procedural costs trended higher for liquid embolization than particulates ($27,419.50 ± $15,851.84 vs. $24,731.24 ± $23,195.37, p = 0.639). Material-specific costs were substantially greater for liquid ($3703.17 ± $1797.85) than to particulates ($152.74 ± $75.91, p < 0.0001). Functional outcomes (mRS at discharge, 30 days, and 90 days) and 90-day retreatment rates were not significantly different between groups. Subgroup analyses of hospital costs and access site also showed no significant differences. Conclusions: Particulate embolic agents offer a cost-effective alternative to liquid embolics for MMAE in cSDH, achieving comparable clinical outcomes at a significantly reduced material cost. Cost-conscious embolic selection may help sustain procedural expansion as MMAE adoption grows.

Introduction: Large vessel occlusion (LVO) strokes are a significant cause of disability and death globally. Endovascular mechanical thrombectomy (EVT) has improved outcomes for LVO patients. However, the impact of pre-existing frailty on outcomes for patients undergoing EVT remains understudied. Methods: This study utilized the National Inpatient Sample (NIS) database to identify patients aged 18 and older who underwent EVT for LVO of the internal carotid artery (ICA) or middle cerebral artery (MCA) from 2016 to 2021. Frailty was assessed using the modified Frailty Index-5 (mFI-5), mFI-11, Charlson Comorbidity Index (CCI), and Risk Analysis Index (RAI). Outcomes analyzed included mortality, complications, length of stay (LOS), discharge disposition, and cost of care. Results: We analyzed 57,260 EVT admissions. Patients classified as highly frail by the CCI had the highest in-hospital mortality (odds ratio (OR) 1.13, p < 0.0001). High frailty identified by mFI-5 was associated with a higher likelihood of postoperative complications (OR 1.41, p < 0.0001) and extended LOS (OR 1.23, p < 0.0001). High frailty by the administrative RAI was linked to nonhome discharge (OR 1.31, p < 0.0001), with mFI-5 showing similar predictive value (OR 1.30, p < 0.0001). High frailty, as determined by the CCI, incurred the highest estimated cost of care (p < 0.0001). Conclusions: Frailty assessment using mFI-5 is a practical predictor of patient outcomes in LVO thrombectomy, including complication rates, extended LOS, and discharge disposition. The CCI remains the most predictive for mortality, though it is more complex to calculate. We emphasize that frailty, as measured by the mFI-5, is one of many factors to consider when deciding on EVT for LVO.

This study analyzed the capability of GPT-4o to properly identify knee osteoarthritis and found that the model had good sensitivity but poor specificity in identifying knee osteoarthritis; patients and clinicians should practice caution when using GPT-4o for image analysis in knee osteoarthritis.