Subdural Hematoma Research Articles

Newer treatment paradigm improves outcomes in the most common neurosurgical disease of the elderly: a literature review of middle meningeal artery embolization for chronic subdural hematoma.

Chronic subdural hematoma (cSDH) is one of the most prevalent neurosurgical diseases, especially in the elderly. Yet, its incidence is predicted to increase further, paralleling the growth of the geriatric population. While surgical evacuation is technically straightforward, it is associated with significant morbidity and mortality. In fact, 30% of patients are expected to have hematoma recurrence and to need repeat surgical evacuation, and 20% of patients are expected to lose independence and require long-term care. A pathophysiology more complex than originally presumed explains the disappointing results observed for decades. At its core, the formation of microcapillaries and anastomotic channels with the middle meningeal artery (MMA) perpetuates a constant cycle resulting in persistence of hematoma. The rationale behind MMA embolization is simple: to stop cSDH at its source. Over the last few years, this "newer" option has been heavily studied. It has shown tremendous potential in decreasing hematoma recurrence and improving neurological outcomes. Whether combined with surgical evacuation or performed as the only treatment, the scientific evidence to its benefits is unequivocal. Here, we aimed to review cSDH in the elderly and discuss its more recent treatment options with an emphasis on MMA embolization.

Factors associated with decisions to refer possible abusive head trauma to a hospital-based child protection team in Aotearoa New Zealand.

Aotearoa New Zealand has a high incidence of abusive head trauma (AHT) and a national children's hospital with an established multi-disciplinary child protection team (CPT). Staff concerned about possible AHT are expected to refer to the CPT, but there has been no research into the factors which might influence those referral decisions. To identify factors associated with decisions to refer head-injured children to the CPT, and to assess whether those factors are consistent with the literature. All children <5years old admitted from 2010 to 2019 with skull fracture or intracranial injury. Retrospective review comparing 25 variables in cases referred and not referred. Multivariable analysis estimated the independent role of each variable and modelled their combined contribution to decisions to refer. The area under the receiver operator characteristic curve (AUROC) and 95% CI were used to describe performance of the model. Of 631 head-injured children, 265 (42%) were referred and 121 (19%) diagnosed as AHT/undetermined. Variables associated with referral decisions were age<1year, p=.0001; injury inconsistent with the history, p<.0001; certain categories of history (motor vehicle accident, no history, history of abuse, fall <1m, blunt force and penetrating trauma), p<.0001; delayed presentation, p<.0001; past history of injury, p=.0001; social/behavioral concerns, p<.0001 and subdural hemorrhage, p=.01. The AUROC was 0.95 (95% CI 0.93, 0.97). Factors associated with referral are generally consistent with the literature. The percentage referred seems justified given the number diagnosed as AHT/undetermined.

A Patient With Rectal Cancer With Cranial Metastasis Resulting in Epidural Hematoma.

The incidence of colorectal cancer ranks third among all types of cancer. Effective treatment for colorectal cancer patients has not only improved their survival rate but it has also increased the possibility of tumor metastasis. It has been reported that the incidence of brain metastasis in colorectal cancer is low, but the improvement in patient survival and the lack of routine brain imaging may lower the actual incidence of brain metastasis in colorectal cancer. This article discusses a case of a patient with colorectal cancer brain metastasis, who was found to have a subdural hematoma as the main symptom.

Prognostic Factors of Recovery and Discharge Outcome in Adults after Moderate Traumatic Brain Injury

Abstract Background Traumatic brain injury (TBI) is a leading cause of mortality and morbidity particularly among young people. Identification of prognostic factors can be considerably helpful for clinical decision-making and prediction of outcome. Objective The aim of this study was to identify prognostic factors supposed to be of value in predicting functional outcome in moderate TBI patients. Materials and Methods This was a prospective case series study conducted from March 2023 to January 2024 involving 72 TBI patients with a Glasgow Coma Scale (GCS) score of 9 to 13. Demographic, clinical, laboratory, and management data were collected, analyzed, and correlated with patient outcomes. Based on the Extended Glasgow Outcome Scale (GOSE), patients were assigned to have either favorable outcome (GOSE score: 5–8) or poor outcome (GOSE score: 1–4). Results The mean age was 38.76 ± 18.30 years. The mean GCS score on admission was 11.68 ± 1.27. Surgical intervention was indicated in 29 patients (40.3%). The average length of hospital stay was 9.01 ± 7.88 days. Sixty-five patients (90.3%) had a favorable outcome and 7 patients (9.7%) had a poor outcome. Prognostic factors with significant impact on outcome included the GCS score on admission (p = 0.002); pupillary responses (p = 0.011); blood pressure (p = 0.005); acute subdural hematoma (ASDH) as a primary lesion (p = 0.049); and time to admission, comorbidities, blood glucose, hemoglobin%, oxygen saturation, coagulation profile, endotracheal intubation, and tracheostomy (p &lt; 0.001). Conclusion In moderate TBI patients, delayed hospital arrival, low GCS score, unequal pupils, pretrauma comorbidities, hypotension, hypoxia, anemia, endotracheal intubation, tracheostomy, and ASDH were associated with unfavorable functional recovery and could be considered as poor prognostic factors.

Diffusion-weighted imaging findings predictive of postoperative recurrence of chronic subdural hematoma

ObjectivesTo identify the brain magnetic resonance imaging (MRI) findings associated with the postoperative recurrence of chronic subdural hematoma (CSDH). MethodsWe examined 1099 consecutive patients admitted to our hospital with CSDH between 2005 and 2014. Of those, 1021 who underwent surgery for CSDH and were followed-up for >3 months after surgery were included. Preoperative brain MRI findings were classified as homogeneous, laminar, separate, or trabecular, according to the nature of the hematoma. Postoperative recurrence was defined in patients who required reoperation for ipsilateral hematoma growth within three months of surgery. The clinical and radiological factors associated with postoperative recurrence were evaluated using univariate and multivariate analyses. ResultsOf the 1021 CSDH patients with CSDH who underwent surgery, 91 (8.9%) experienced postoperative recurrence. Postoperative recurrence was significantly associated with male sex (p = 0.0004) and hematoma volume (p < 0.0001). Additionally, isotype or separate types of hematoma on computed tomography (CT) (p < 0.0001) and laminar/separate types of hematoma types on MRI (p = 0.0008) were significant. Multivariate analysis revealed odds ratios of 2.50 (95% CI, 1.45–4.61; p = 0.0007) for male sex and 3.05 (95% CI, 1.95–4.87; p < 0.0001) for iso/separate hematoma types in CT. Conversely, among the patients who underwent MRI, multivariate analysis revealed odds ratios of 4.33 (95% CI, 1.20–27.92; p = 0.001) for male sex and 4.88 (95% CI, 1.90–14.18; p = 0.023) for laminar/separate hematoma types. ConclusionWhile distinguishing the nature of hematomas is challenging with brain CT examination, detailed laminar/trabecular differentiation using MRI images may predict postoperative recurrence.

Adjunctive Middle Meningeal Artery Embolization for Subdural Hematoma

BackgroundSubacute and chronic subdural hematomas are common and frequently recur after surgical evacuation. The effect of adjunctive middle meningeal artery embolization on the risk of reoperation remains unclear.MethodsIn a prospective, multicenter, interventional, adaptive-design trial, we randomly assigned patients with symptomatic subacute or chronic subdural hematoma with an indication for surgical evacuation to undergo middle meningeal artery embolization plus surgery (treatment group) or surgery alone (control group). The primary end point was hematoma recurrence or progression that led to repeat surgery within 90 days after the index treatment. The clinical secondary end point was deterioration of neurologic function at 90 days, which was assessed with the modified Rankin scale in a noninferiority analysis (margin for risk difference, 15 percentage points).ResultsA total of 197 patients were randomly assigned to the treatment group and 203 to the control group. Surgery occurred before randomization in 136 of 400 patients (34.0%). Hematoma recurrence or progression leading to repeat surgery occurred in 8 patients (4.1%) in the treatment group, as compared with 23 patients (11.3%) in the control group (relative risk, 0.36; 95% confidence interval [CI], 0.11 to 0.80; P=0.008). Functional deterioration occurred in 11.9% of the patients in the treatment group and in 9.8% of those in the control group (risk difference, 2.1 percentage points; 95% CI, −4.8 to 8.9). Mortality at 90 days was 5.1% in the treatment group and 3.0% in the control group. By 30 days, serious adverse events related to the embolization procedure had occurred in 4 patients (2.0%) in the treatment group, including disabling stroke in 2 patients; no additional events had occurred by 180 days.ConclusionsAmong patients with symptomatic subacute or chronic subdural hematoma with an indication for surgical evacuation, middle meningeal artery embolization plus surgery was associated with a lower risk of hematoma recurrence or progression leading to reoperation than surgery alone. Further study is needed to evaluate the safety of middle meningeal artery embolization in the management of subdural hematoma. (Funded by Medtronic; EMBOLISE ClinicalTrials.gov number, NCT04402632.)

Middle Meningeal Artery Embolization for Nonacute Subdural Hematoma

BackgroundThe effect of embolization of the middle meningeal artery in patients with subacute or chronic subdural hematoma is uncertain.MethodsWe performed a multicenter, open-label, randomized trial in China, involving patients with symptomatic nonacute subdural hematoma with mass effect. Patients were assigned to undergo burr-hole drainage or receive nonsurgical treatment at the surgeon’s discretion, and patients in each group were then randomly assigned, in a 1:1 ratio, to undergo middle meningeal artery embolization with liquid embolic material or to receive usual care. Patients whose condition warranted craniotomy were excluded. The primary outcome was symptomatic recurrence or progression of subdural hematoma within 90 days after randomization. Secondary outcomes included clinical and imaging outcomes. The main safety outcome was any serious adverse event (including death).ResultsThe analysis included 722 patients, of whom 360 were assigned to the embolization group and 362 to the usual-care group. Burr-hole drainage was performed in 78.3% of the enrolled patients; among the patients who underwent burr-hole drainage, the procedure occurred after embolization in 99.6%. Symptomatic recurrence or progression of subdural hematoma within 90 days occurred in 24 patients (6.7%) in the embolization group and in 36 (9.9%) in the usual-care group (between-group difference, −3.3 percentage points; 95% confidence interval, −7.4 to 0.8; P=0.10). The incidence of serious adverse events was lower in the embolization group than in the usual-care group (6.7% vs. 11.6%, P=0.02).ConclusionsAmong patients with symptomatic nonacute subdural hematoma (of whom 78% underwent burr-hole drainage), middle meningeal artery embolization resulted in a 90-day incidence of symptomatic recurrence or progression similar to that with usual care but was associated with a lower incidence of serious adverse events. (Funded by Shanghai Shenkang Hospital Development Center and others; MAGIC-MT ClinicalTrials.gov number, NCT04700345.)

Bevacizumab: The future of chronic subdural hematoma.

Bevacizumab (BCZ), commercially known as Avastin, is a monoclonal antibody that targets vascular endothelial growth factor (VEGF). Initially recognized as a breakthrough in oncology, it has since gained FDA approval for various ocular conditions and more recently, for the treatment of glioblastoma multiforme (GBM). Bevacizumab's ability to inhibit excessive neovascularization suggests it may have a potential role in treating chronic subdural hematomas (cSDH). Recent studies have shown that the pathophysiology of cSDH is more complex than previously understood, with VEGF concentrations in subdural fluid significantly exceeding those in serum, contributing to the high recurrence rates. Intra-arterial administration of bevacizumab has shown promising results in recent case series against chronic subdural hematoma, and may be a viable alternative to middle meningeal artery embolization. If successful, this treatment could significantly decrease the rate of recurrence and result in lower rates of severe neurological complications such as visual loss. This literature review explores the connection between bevacizumab and cSDH, focusing on the pharmacological, safety, and delivery aspects of this approach while summarizing the current evidence supporting its use.

Characteristics and outcome of patients requiring Decompressive Craniectomy for Traumatic Brain Injury: a retrospective analysis.

Brain swelling after Traumatic Brain Injury (TBI) can elevate intracranial pressure, necessitating Decompressive Craniectomy (DC) as the preferred surgical intervention. This study aimed to analyze a large institutional database to identify clinical characteristics of patients requiring primary DC and their outcomes. We reviewed TBI patients admitted to our center from 2015 to 2021, utilizing a prospectively maintained registry. Data collected included demographics, injury mechanisms, admission findings, neuroimaging results, DC necessity, procedures during hospitalization, and functional outcomes at discharge and six-month follow-up. A total of 4,011 patients were analyzed, with 506 undergoing primary DC. Factors such as International Normalized Ratio, activated Partial Thromboplastin Time, subdural hematoma, midline shift, epidural hematoma, intracerebral hemorrhage, and the presence of compressed or absent basal cisterns were independently linked to the need for DC. Additionally, the requirement for DC correlated with an increased likelihood of tracheostomy. For patients requiring DC, older age, lower hemoglobin levels, higher Rotterdam scores, and the presence of compressed or absent basal cisterns were associated with unfavorable outcomes in mild to moderate TBI cases. In severe TBI patients, lower Glasgow Coma Scale scores and fixed pupils were linked to poor outcomes. This study represents one of the most comprehensive analyses of primary DC requirements and outcomes, revealing that the need for DC is associated with worse outcomes in TBI patients and identifying several independent predictors of outcomes across varying severity levels.

Imaging for management of chronic Subdural Hematoma- a review.

Imaging for management of chronic Subdural Hematoma- a review.

Embolization of the Middle Meningeal Artery for Chronic Subdural Hematoma.

Patients receiving standard treatment for chronic subdural hematoma have a high risk of treatment failure. The effect of adjunctive middle meningeal artery embolization on the risk of treatment failure in this population remains unknown. We randomly assigned patients with symptomatic chronic subdural hematoma to undergo middle meningeal artery embolization as an adjunct to standard treatment (embolization group) or to receive standard treatment alone (control group). Either surgical or nonsurgical standard treatment had been chosen for each patient before randomization. The primary efficacy outcome was a composite of the following events: recurrent or residual chronic subdural hematoma (measuring >10 mm) at 180 days; reoperation or surgical rescue within 180 days; or major disabling stroke, myocardial infarction, or death from neurologic causes within 180 days. The primary safety outcome was a composite of major disabling stroke or death from any cause within 30 days. Among 310 enrolled patients, 149 were randomly assigned to the embolization group and 161 to the control group; 189 patients were to receive surgical standard treatment and 121 nonsurgical standard treatment. The mean age of the patients was 73 years, and 70% were men. In the primary efficacy analysis, a primary-outcome event occurred in 19 of 120 patients (16%) in the embolization group, as compared with 47 of 129 patients (36%) in the control group (odds ratio, 0.36; 95% confidence interval, 0.20 to 0.66; P = 0.001). In the primary safety analysis, 4 of 144 patients (3%) in the embolization group and 5 of 166 patients (3%) in the control group either had a major disabling stroke or died within 30 days. Through 180 days, 12 patients (8%) in the embolization group and 9 patients (5%) in the control group had died, with death from neurologic causes occurring in 1 patient (1%) in the embolization group and in 3 patients (2%) in the control group. Among patients with symptomatic chronic subdural hematoma, adjunctive middle meningeal artery embolization resulted in a lower risk of treatment failure than standard treatment alone, without resulting in an increased incidence of disabling stroke or death in the short term. Further study of longer-term safety outcomes is warranted. (Funded by Balt USA; STEM ClinicalTrials.gov number, NCT04410146.).

Management of subarachnoid-pleural fistula following anterior transthoracic approach for the ossification of posterior longitudinal ligament in the thoracic spine.

Subarachnoid-pleural fistula is an abnormal communication between the subarachnoid and pleural spaces that can arise from blunt or penetrating trauma or as a complication of spinal surgery via the transthoracic approach. Uncontrolled cerebrospinal fluid (CSF) leakage with a fistulous condition after transthoracic spinal surgery could be more problematic than that after spinal surgery via the conventional posterior approach because of the negative pressure in the pleural cavity. The authors reported subarachnoid-pleural fistula management using chest and lumbar spinal drainage in five patients with several troublesome complications, such as intracranial subdural hematoma or severe respiratory dysfunction. Chest drainage was managed for 2-3 days by continuous low negative pressure, whereas lumbar spinal drainage was managed for 5-7 days, aiming at an output volume of 150-200 ml/day and higher than that of chest drainage. Additionally, when examining changes in the accumulated pleural fluid were examined by standing chest X-ray immediately before operation and 1 month after operation, the pleural effusions in four of the five patients were assimilated 1 month postoperatively. Compared with CSF management following standard posterior spinal surgery, management after the anterior transthoracic approach could be more troublesome because of intrapleural negative pressure. When chest and lumbar spinal drainage are used, it is important to consider that over-drainage of CSF could potentially cause severe respiratory dysfunction and intracranial subdural hematoma.

Expert consensus on diagnosis and treatment of spontaneous intracranial hypotension(2024)

Spontaneous intracranial hypotension is a disease characterized by orthostatic headache caused by spinal cerebrospinal fluid leakage. Patients have to remain bedridden, which significantly affects their quality of life. In severe cases, complications such as subdural hematomas may occur. Clinical practice reveals a high rate of misdiagnosis and insufficient implementation of diagnostic and treatment measures. To improve clinical physicians' understanding of spontaneous intracranial hypotension and to standardize the diagnosis and treatment, the Neurologist Branch of the Chinese Medical Doctor Association and the Headache and Sensory Disorders Committee of the Chinese Research Hospital Association organized experts to develop a total of 30 recommendations on the clinical identification, examination processes, diagnostic criteria, treatment, and follow-up of spontaneous intracranial hypotension based on domestic and international clinical practices and recent literature evidence after extensive discussions.

Paracetamol overdose associated with cortical blindness-complicated acute leukoencephalopathy: a case report

BackgroundParacetamol is one of the most used antipyretics and analgesics among pediatrics, and its overdose is highly encountered among pediatrics especially in the pre-school age. While it is well-known that paracetamol overdose may lead to toxicities including severe hepatic toxicity, some recent reports have highlighted its “in situ” toxicity on brain tissue at high doses, even in the absence of hepatotoxicity. This can result in acute leukoencephalopathy (AL), coma, or even death. This report describes a case of a child who developed cortical blindness-complicated AL, following a paracetamol overdose.Case presentationAn 18-month-old previously healthy girl accidentally ingested 300 mg/kg of paracetamol suspension. After ingestion, the child was in an initial bad condition that has gradually improved. Several days after ingestion, the patient lost her vision, and she remained blind since then despite a newer appreciation to light. The initial brain magnetic resonance imaging (MRI) suggested AL demonstrated as a faint high T2/fluid-attenuated inversion recovery (FLAIR) signal intensity in the cortical and subcortical regions of both parieto-occipital lobes with sulcal effacement and restricted diffusion. After around 3 months, the subsequent brain MRI showed involutional changes that were manifested as a brain volume loss in the same areas with evidence of gyri-form laminar necrosis in both parieto-occipital regions without restricted diffusion. Other brain MRI findings include right cerebral convexity hyperacute subdural hematoma with prominent subarachnoid spaces.ConclusionsThe child developed cortical blindness-complicated AL following a paracetamol overdose. It is well- known that AL may result from several toxins by their direct and/or indirect effect on the cerebral white matter. However, there is still no enough data in the literature clearly explaining the relation of paracetamol overdose to AL. The generally proposed effect of paracetamol on the brain is mainly justified by the excessive oxidative stress. Further studies at the cellular and genetic levels are still needed to investigate the exact association between paracetamol overdose and AL, as well as the underlying mechanisms involved.

Emergency neurosurgery for traumatic brain injury by general surgeons at local hospitals in Sweden: a viable option when time is brain

BackgroundTiming of surgical evacuation of mass lesions in traumatic brain injury (TBI) is crucial. However, due to geographical variations, transportation time to the nearest neurosurgical department may be long. To save time, general surgeons at a local hospital may perform the operation, despite more limited experience in neurosurgical techniques. This study aimed to determine whether patient outcomes differed between those who had undergone emergency neurosurgery at local hospitals by general surgeons vs. at university hospitals by neurosurgeons.MethodsA nationwide observational study was performed using data from the Swedish Trauma Registry (SweTrau) between 2018 and 2022. A total of 565 TBI patients (local hospitals, n = 21; university hospitals, n = 544) who underwent intracranial hematoma evacuation within 8 h after arrival at the hospital were included. Data on demography, admission variables, traumatic injuries, and outcome (Glasgow Outcome Scale [GOS]) at discharge were evaluated. Favourable vs. unfavourable outcomes were defined as GOS scores of 4–5 vs. 1–3.ResultsCompared with those treated at university hospitals, patients treated with intracranial hematoma evacuation at local hospitals had lower median Glasgow Coma Scale (GCS) scores (8 vs. 12, p < 0.001), higher rate of acute subdural hematomas (86% vs. 77%, p < 0.001), and lower rate of contusions (14% vs. 53%, p = 0.01). Being operated on at a local hospital was independently associated with higher mortality (p = 0.03) but with a similar rate of favourable outcome (p = 0.74) in multiple logistic regressions after adjustment for demographic and injury-related variables.ConclusionsAlthough a slightly greater proportion of patients who underwent emergency neurosurgery at local hospitals died, there was no difference in the rate of favourable outcome. Thus, in patients with impending brain herniation, when time is of the essence, evacuation of traumatic intracranial bleeding by general surgeons at local hospitals remains a highly viable option.

RECENT DEVELOPMENTS IN ENDOVASCULAR THERAPY FOR CHRONIC SUBDURAL HEMATOMAS USING LIQUID EMBOLIC AGENTS

Chronic subdural hematomas (cSDH) remain a significant challenge in neurosurgery, particularly among the elderly. Recent advancements in endovascular therapy, specifically the use of non-adhesive embolic agents, have shown promise in improving outcomes for these patients. This presentation will delve into the latest developments and clinical evidence surrounding this innovative approach. The discussion will include findings from recent randomized trials that have evaluated the efficacy and safety of embolisation with non-adhesive agents, both as a standalone treatment and in conjunction with traditional surgical methods. Technical outcomes from these studies will be analyzed, highlighting key differences in patient recovery, complication rates, and long-term results between the combined and isolated approaches. One of the focal points of the presentation will be the technical nuances of performing embolisation, emphasizing the procedural intricacies and the choice of embolic materials. Comparative data will be presented to illustrate the benefits of non-adhesive agents over other embolisation methods, particularly in terms of reducing re-bleeding rates and minimizing invasive interventions. Additionally, we will explore future implications of widespread adoption of this technique, including its potential to alter standard care practices and improve patient prognoses. Projections will be made regarding the impact on healthcare resources, patient quality of life, and overall survival rates. The presentation aims to provide a comprehensive overview of the current state and future potential of endovascular therapy for cSDH, offering valuable insights for neurosurgeons and interventional radiologists seeking to enhance their therapeutic arsenal.

Commentary: Embolic Materials Comparison in Meningeal Artery Embolization for Chronic Subdural Hematomas: Multicenter Propensity Score-Matched Analysis of 1070 Cases

Commentary: Embolic Materials Comparison in Meningeal Artery Embolization for Chronic Subdural Hematomas: Multicenter Propensity Score-Matched Analysis of 1070 Cases

Use of dexamethasone in patients with chronic subdural hematoma: a systematic review

Use of dexamethasone in patients with chronic subdural hematoma: a systematic review

Intracranial arachnoid cyst complicated with subdural hygroma in a 10-year-old child: A case report and literature review

Arachnoid cysts are abnormal collections of fluids within the arachnoid membrane after a doubling of the structure. These benign lesions represent only 1% of all intracranial space-occupying lesions. The affected patient can remain asymptomatic for several years, which is an incidental finding in most cases. Cysts have been reported to rupture after a minor head trauma, causing subdural hygroma or hematoma; however, spontaneous rupture complicated with subdural hygroma has been rarely reported. Herein, we report a rare case of a 10-year-old boy whose pregnancy follow-up, delivery, and parent&amp;rsquo;s medical history were unremarkable. The patient was admitted for a temporal arachnoid cyst complicated with subdural hygroma, which was determined to be caused by intracranial hypertensive syndrome. He was successfully treated through endoscopic arachnoid cyst fenestration, wherein a pathway was created for the cyst to communicate with the subarachnoid space through the basal cisterns. The choice of treatment for arachnoid cysts remains controversial. Endoscopic treatment is considered when an ipsilateral subdural hygroma is present. Intracranial hypertensive syndrome subsided immediately after surgery. No post-operative complications occurred. The child recovered uneventfully in the post-operative period and was discharged 5 days after surgery. He underwent a follow-up computed tomography 1 month later, confirming a progressive regression of the hygroma as well as arachnoid cyst.

Abstract 4129839: Successful Left Atrial Appendage Occlusion (LAAO) with WATCHMAN FLX via Transhepatic Approach

Left atrial appendage occlusion (LAAO) with the WATCHMAN FLX (Boston Scientific) has been proven to reduce stroke risk in patients with paroxysmal atrial fibrillation (PAF). Certain circumstances may preclude LAAO1. In this case, transhepatic vein access was used to successfully deploy a WATCHMAN FLX in a 72 year old male with PAF not on anticoagulation due to recent subdural hemorrhage and recurrent bilateral lower extremity deep venous thrombosis (DVT) post IVC filter placement. Recent attempt at LAAO was unsuccessful due to total occlusion of bilateral femoral veins (Figure 1 A-B) and inability to cross the IVC. Access to the inferior branch of the right hepatic vein was achieved by micropuncture technique at the right mid-axillary line at the level of the 12th rib, which was confirmed by venogram (Figure 2A). The 4F microsheath was upsized to 16F. Intraoperative TEE was used for device sizing and delivery (Figure 3A). The transseptal sheath and dilator were positioned in the right atrium at the level of the fossa ovalis (Figure 3B) before successfully crossing into the left atrium (Figure 2B). After confirming placement (Figure 3C), a pigtail catheter was positioned within the LAA (Figure 3D) and an angiogram was performed (Figure 2C). A 24 mm WATCHMAN FLX was partially unsheathed and positioned (Figure 3E). Repeat LAA angiogram was performed through the WATCHMAN delivery sheath (Figure 2D). A Tug test was performed. The device was released (Figure 3F). Repeat venogram was performed to confirm location (Figure 2E) of the access site, and coil embolization closure of the venotomy access site was performed (Figure 2F). The patient was discharged the following day on dual antiplatelet (aspirin, clopidogrel) without complication. Venous access via right hepatic vein is a viable option for LAAO using the WATCHMAN FLX device.