Recurrence Of Subdural Hematoma Research Articles

The relationship between serum coagulation parameters and the recurrence of chronic subdural hematoma.

The aim is to investigate the relationship between serum coagulation parameters (PT, APTT, D-D and FDP) before hospitalization and recurrence of chronic subdural hematoma (CSDH). 236 patients with CSDH who were diagnosed for the first time and had complete medical records were followed up for at least 90days. Fifty patients (21.2%) had relapsed. Univariate analysis was conducted including general data, imaging data and test results. Serum coagulation parameters (PT, APTT, D-D and FDP) were detected for all CSDH patients. The study identified several factors that exhibited a significant correlation with chronic subdural hematoma (CSDH) recurrence. These factors included advanced age (p = 0.01), hypertension (p = 0.04), liver disease (p = 0.01), anticoagulant drug use (p = 0.01), antiplatelet drug use (p = 0.02), bilateral hematoma (p = 0.02), and single-layer hematoma (p = 0.01). In addition, the presence of fibrin/fibrinogen degradation products (FDP) exceeding 5mg/L demonstrated a significant relationship with CSDH recurrence (P < 0.05). Notably, the combined assessment of D-dimer (D-D) and FDP exhibited a significant difference, particularly regarding recurrence within 30days after surgery (P < 0.05). The simultaneous elevation of serum FDP and D-D levels upon admission represents a potentially novel predictor for CSDH recurrence. This finding is particularly relevant for patients who experience recurrence within 30days following surgical intervention. Older individuals with CSDH who undergo trepanation and drainage should be closely monitored due to their relatively higher recurrence rate.

Recurrent subdural hemorrhages and evaluation of annual prostate screening

We report a 76-year old man who had cerebellar hemorrhage and recurrent subdural hematoma. Investigations revealed that these were metastases from cancer of the prostate. We discuss the need for annual prostate cancer assessment in our environment Key Message: The indications for annual examination of the prostatic specific antigen in elderly men should be appreciated.

(1383) - Follow Your Heart but Protect Your Brain: Management of Recurrent Subdural Hematomas in a Pediatric Patient with End-Stage Heart Failure

(1383) - Follow Your Heart but Protect Your Brain: Management of Recurrent Subdural Hematomas in a Pediatric Patient with End-Stage Heart Failure

Evolution of cerebrovascular imaging and associated clinical findings in children with Alagille syndrome.

Alagille syndrome (ALGS) is a multisystem autosomal dominant disorder with highly variable expression. Intracranial arterial and venous anomalies have a reported prevalence of 30-40% and can increase the risk of stroke by 16%. Few reports document the frequency and evolution of cerebrovascular abnormalities (CVAs) in children with ALGS. We aimed to define the spectrum, frequency, and evolution of CVAs in a series of children with ALGS using magnetic resonance angiography (MRA). We conducted a single-center, retrospective study in a large tertiary pediatric hospital. CVAs were grouped into 4 categories: 1) Stenosis or narrowing; 2) Aneurysms and ectasias; 3) Tortuosity; and 4) Vascular anomalies and anatomical variants. Thirty-two children met the inclusion criteria. The median age at initial diagnosis was 6 (3.8-10.3) years. Thirteen (40%) had follow-up MRI at a mean of 55 (31.5-66) months. Eighteen (56%) had CVAs; the most frequent fell into group 1 (n = 12, 37.5%). CVAs were stable over time, except for one patient with Moyamoya arteriopathy (MMA). One patient developed a transient ischemic attack secondary to an embolic event. Three (9.3%) had microhemorrhages at the initial diagnosis secondary to Tetralogy of Fallot. Another patient had recurrent subdural hematomas of unknown cause. CVAs were stable except in the presence of MMA. Vascular strokes, which are reported in older patients with ALGS, were not a common feature in children under 16 years of age, either at presentation or over the 31.5-66 month follow-up period.

Embolization of the middle meningeal artery for the prevention of chronic subdural hematoma recurrence in high-risk patients: a randomized controlled trial—the EMPROTECT study protocol

BackgroundMiddle meningeal artery (MMA) embolization has been proposed as a treatment of chronic subdural hematoma (CSDH). The benefit of the procedure has yet to be demonstrated in a randomized controlled...

Factors for predicting recurrence after burr hole drainage for chronic subdural hematoma: a retrospective study.

Chronic subdural hematoma (SDH) is a common disease in the neurosurgical field, and hematoma drainage through burr hole trephination has been widely considered the optimal treatment for SDH. Despite numerous investigations aimed at predicting recurrence rates and associated factors, studies have demonstrated inconsistent results. In this study, we aimed to comprehensively determine the predictive factors of chronic SDH recurrence in surgically treated patients. We retrospectively evaluated 578 consecutive patients who underwent single burr hole surgery for chronic SDH at our institute between January 2008 and December 2021. Various clinical and radiological factors in patients with and without recurrence were compared using univariate and multivariate logistic regression analyses. A total of 438 patients (531 hemispheres) were analyzed. Fifty-four (10.17%) of the 531 hemispheres had recurrence of chronic SDH within 6months. Male sex (adjusted odds ratio (aOR) = 3.48; 95% confidence interval (CI), 1.42-8.49), bilateral hematomas (aOR = 2.14; 95% CI, 1.05-4.35), laminar hematoma type (aOR = 2.87; 95% CI, 1.23-6.71), > 30-cm3 volume of postoperative residual hematoma (aOR = 2.99; 95% CI, 1.01-8.83), and preoperative blood glucose level of ≥ 150mg/dL (aOR = 2.11; 95% CI, 1.10-4.05) were identified as independent factors associated with recurrence in multivariate logistic regression analysis. The present study revealed that male patients and those who had bilateral hematomas, laminar hematoma type, a large volume of hematoma after surgery, and a high preoperative blood glucose level had a higher probability of experiencing recurrent chronic SDH. We recommend close monitoring of patients 6months postoperatively to detect subsequent chronic SDH recurrence.

A Study to Detect Risk Factors of Chronic Subdural Hematoma Recurrence

Introduction: Chronic subdural hematoma (CSDH) is a common type of intracranial hemorrhage in elderly patients. The risk factors for recurrence of chronic subdural hematoma (CSDH) after surgical evacuation has not been completely understood until now, but several risk factors for recurrence have been reported. Meanwhile, the definitive risk factors have not been defined until now. The aim of this study was to study the potential risk factors, including preoperative, operative and post-operative ones for CSDH recurrence. Materials and Methods: The study population comprised of all &gt; 18 year age group patients who were operated for chronic subdural hematoma in Neurosurgery Department of tertiary care center. It was prospective cohort study. Patients who met inclusion criteria, postoperative outcomes were assessed at discharge, then at one month and three months afterwards in the neurosurgery OPD. Both the treatment options i.e. BHC Burr hole craniotomy and minicraniotomy as required as per CT scan or MRI findings. Results: 7 patients (10.7%) had recurrence, of CSDH. All the reoccurrences occurred in burr hole operated patients. There was no recurrence in mini craniotomy operated group. Conclusions: Many risk factors for recurrence of CSDH have been found, including old age, cerebral atrophy, large hematoma, bilateral hematomas, hematoma density, inflammation markers, alcohol ingestion, bleeding tendency, and some technical aspects of surgery such as irrigation with small amount of fluid, not excising thick membrane preventing brain expansion.

Intraoperative Irrigation and Risk of Chronic Subdural Hematoma Recurrence.

In most neurosurgical centers, irrigation is an essential part of the surgical procedure for chronic subdural hematoma (CSDH). However, it is unknown whether the volume of irrigation fluid affects the risk of CSDH recurrence. This study aimed to investigate a potential association between the volume of irrigation fluid used during burr hole evacuation of CSDH and the risk of CSDH recurrence. This study is a subanalysis of 2 randomized trials (Drain Time & Drain Time 2) designed to investigate the effect of drainage duration on the recurrence of CSDH. Intraoperative irrigation volume was measured, and patients were followed for 90 days for recurrent CSDH. A total of 525 patients with CSDH were included. There was no significant difference in the volume of irrigation fluid used between patients with recurrence (mean = 938 mL, SD = ±552) and without recurrence (mean = 852 mL, SD = ±454) ( P -value = .15). Patients with recurrent CSDH had larger primary CSDH volumes (mean = 134 cm 3 , SD = ±69) than patients without recurrence (mean = 119 cm 3 , SD = ±58) ( P = .04). Multiple logistic regression analysis revealed no association between irrigation volume and recurrence, also when stratified for hematoma size. There was no significant association between irrigation volume and recurrent CSDH within 90 days in patients undergoing burr hole surgery for CSDH.

Recurrent subdural hematoma as presentation of neonatal biliary atresia: A case report

Biliary atresia is a congenital disorder of progressive and obliterative cholangiopathy, the most common cause of neonatal cholestasis, it can cause secondary vitamin-K deficiency bleeding due to the malabsorption of lipids and lipid-soluble vitamins due to cholestasis. We report a 46-day-old child presenting with cholestatic features complicated by subdural hematoma (SDH) and cerebral edema. On investigations, she was found to be having primary biliary atresia, for which she was operated but had a recurrence of the SDH on the opposite side.

Comparative analysis of the results of surgical treatment of chronic subdural hematomas by craniotomy and burr hole surgery

A chronic subdural hematoma is a disease of the elderly. The analysis of a series of more than 200 surgical interventions for chronic subdural hematoma over a 5‑year period is presented. The clinical picture and neurosurgical treatment are considered with a special emphasis on the surgical technique. Material and methods. In the period from 2017 to 2022, a retrospective analysis of 120 patients (74 men and 46 women, with a mean age of 77.4 years [ranging from 24 to 89 years]) suffering from chronic subdural hematoma was performed. Results. 88 craniotomies and 32 burr holes were performed. Forty-two patients after craniotomy (28 %) required surgical revision, in contrast to 6 patients after burr hole surgery (14 %). Craniectomy was performed as a last resort after at least 3 previous evacuations. Conclusion. Craniotomy seems to have a higher chronic subdural hematoma recurrence rate; therefore, burr hole surgery should be a preferable technique. Craniectomy may be a good therapy option for complicated recurrent chronic subdural hematomas.

Renin-angiotensin-aldosterone system inhibitors as a risk factor for chronic subdural hematoma recurrence: A matter of debate

ObjectivesChronic subdural hematoma (cSDH) is a common central nervous system condition. Recent reports indicate that cSDH affects long-term prognosis; however, its definitive risk factors remain unknown. An antihypertensive drug, renin–angiotensin–aldosterone system inhibitors (RAASi), can affect vascular permeability and cell proliferation processes, which may suppress the recurrence of cSDH. However, several studies have reported negative results to this effect. Therefore, we aimed to evaluate antihypertensive drugs, including RAASi, as risk factors for recurrent cSDH. Materials and methodsA total of 203 consecutive cases of surgically treated cSDH were retrospectively reviewed. Clinical and radiological parameters were compared between the groups with and without cSDH recurrence to identify risk factors. ResultsOf the included cases, 68 (33.5%) used RAASi and 37 (18.2%) developed recurrence within 60 days of surgery. In the multiple logistic regression analysis adjusted by composite risk score, the odds ratios (95% confidence interval) of RAASi, calcium channel blockers, diuretics, β and α blockers, for the recurrent risk of cSDH after surgery were 2.49 (1.16, 5.42), 1.79 (0.84, 3.82), 1.83 (0.62, 4.87), 0.90 (0.28, 2.44), and 0.96 (0.21, 3.20), respectively. The Cox proportional hazard model also demonstrated that RAASi-use was an independent risk factor for cSDH recurrence. ConclusionsPresent series suggests RAASi-use as a risk factor for cSDH recurrence, although the role of RAASi-use in cSDH remains debatable. Further studies for deeper understanding of the microenvironment of hematoma and the surroundings are preferable. (235 words)

Recurrent Subdural Hematoma: An Institutional Experience.

Background Chronic subdural hematoma (CSDH) is a common neurosurgical problem, which offers a good outcome following surgery. In many cases, burr hole irrigation and drainage under local anesthesia can provide satisfactory results. However,recurrencecan be a cause for concern for both the surgeon and the patient. While recurrence is not a frequent phenomenon, studies have reported rates of up to 31.6%. Aims and objectives In this study, our objective is to examine a comprehensive range of potential risk factors and provide valuable insights into identifying patients at a higher risk of recurrence to aid in surgical decision-making. Methodology This study employed a prospective and retrospective design, conducted between 2017 and 2021, at Sri Ramachandra Institute of Higher Education and Research. The study received ethical approval from the Institutional Ethics Committee. The research aimed to assess patients who underwent surgery for CSDH, with a particular focus on those who experienced recurrence. Results The average age of patients with recurrence was 71.5 years compared to 65.2 years in the no-recurrence group, but this difference did not show a significant statistical correlation. A significant male predominance was observed, with 27 men and four women affected (out of a total of 147 men and 73 women in the study), resulting in a statistically significant p-value of 0.01.On multivariate analysis, heterogenous subtypes were a significant predictor of recurrence (OR: 8.88, 95% CI: 6.96-16.54, p = 0.01).The mean midline shift in those with recurrence was 11.4 mm compared to 7.09 mm in those without recurrence. This was a statistically significant correlation with a p-value of 0.02.Regarding those with recurrence, 24 patients underwent evacuation using two burr holes, with one placed in the frontal region and another in the parietal region. All of these patients had a subdural drain placed, which was removed on postoperative day 2. The remaining eight patients underwent a mini-craniotomy for evacuation.We had four cases of refractory CSDH, all of whom underwent the second evacuation using burr holes. Three of them underwent evacuation via craniotomy, while the family of the fourth patient did not give consent for the procedure. Conclusion Patient-related factors such as gender, bilateral presentation, and the presence of hypertension and radiological factors such as the presence of heterogenous subtype and a significant midline shift are clues towarda higher chance of recurrence.

Pachymeningeal en plaque metastasis from gastric cancer mimicking subdural hematoma: illustrative case.

Pachymeningeal metastasis associated with gastric cancer, especially in its early stages, is extremely rare. The authors describe a 77-year-old man with a past medical history of lung cancer and previously treated chronic subdural hematoma who was admitted to their hospital because of hematemesis and newly diagnosed gastric cancer. He became unconscious during the hospitalization. The preoperative brain imaging studies had the appearance of recurrent subdural hematoma and extracranial tumor with skull invasion. Craniotomy revealed pachymeningeal carcinomatosis and en plaque metastasis of tumor. The histopathology of the tumors was consistent with metastatic gastric adenocarcinoma. This is the first reported case of metastatic gastric cancer as a pachymeninges-based en plaque entity. This report highlights the rare radiological presentation and operative findings in this case. The authors also summarize those case reports associated with dural metastasis arising from gastric cancer.

Biofluid Biomarkers in the Prognosis of Chronic Subdural Hematoma: A Systematic Scoping Review.

The present systematic scoping review aimed at mapping and analyzing the available literature on biological fluid (biofluid) biomarkers showing promise in the prediction of chronic subdural hematoma (cSDH) recurrence and the prognosis of neurological/functional patient outcome. Twenty-three studies published between 2003 and 2023 investigating a diverse range of biomarkers in hematoma fluid and/or the circulation in 3749 patients were included. Immune cell populations and inflammatory/anti-inflammatory cytokines comprised the most studied category of biomarkers displaying significant findings. A notable time trend in biomarker studies was a recent shift in research focus towards the analysis of circulating biomarkers. Several biomarkers were indicated as independent predictors of cSDH recurrence and/or functional/neurological outcome, including circulating fibrinogen degradation products (FDP), brain natriuretic peptide (BNP-1) and high-density lipoprotein (HDL), as well as blood urea nitrogen (BUN) and the ratios of blood neutrophil to lymphocyte (NLR) or red blood cell distribution width to platelet count (RPR). While studies on cSDH prognostic biomarkers have gained, in recent years, momentum, additional multicenter prospective studies are warranted to confirm and extend their findings. The identification of prognostic biofluid biomarkers in cSDH is an active field of research that may provide future tools, guiding clinical decisions and allowing for the design of treatments based on risk stratification.

A low prognostic nutritional index is associated with chronic subdural hematoma recurrence.

Chronic subdural hematoma (CSDH) is a common neurosurgical condition. Inflammation has been found to play an essential role in the formation of CSDHs, and the prognostic nutritional index (PNI), a nutritional and inflammatory baseline marker, plays a role in predicting the prognosis of many diseases. We aimed to identify the relationship between PNI and CSDH recurrence. This study retrospectively analyzed 261 CSDH patients who underwent burr hole evacuation in Beijing Tiantan Hospital from August 2013 to March 2018. The PNI was calculated as 5 ∗ lymphocyte count (109/L) + serum albumin concentration (g/L), and these markers were obtained from the peripheral blood test on the day of discharge from the hospital. Recurrence was defined as operated hematoma enlargement accompanied by newly emerging neurological disorders. The comparison of baseline characteristics demonstrated that patients with bilateral hematoma and low levels of albumin, lymphocytes, and PNI were more likely to be recurrent. After adjusting for age, sex, and other important variables, decreased PNI levels were associated with an increased risk of CSDH (OR, 0.803, 95% CI: 0.715-0.902, p = 0.001). The addition of PNI to conventional risk factors significantly improved the risk prediction of CSDH (net reclassification index: 71.12%, p = 0.001; integrated discrimination index: 10.94%, p = 0.006). A low PNI level is associated with an increased risk of CSDH recurrence. As an easily obtainable nutritional and inflammatory marker, PNI may play a significant role in predicting the recurrence of CSDH patients.

Significant Correlation between Structural Changes in the Net-like Appearance on Postoperative Cranial Magnetic Resonance Images and Hematoma Recurrence in Cases of Chronic Subdural Hematoma.

Organized hematoma, which exhibits a net-like appearance on imaging studies, is one of the predisposing factors for the recurrence of chronic subdural hematoma. Patients who are positive for the net-like appearance are often treated with only burr hole surgery. We investigated the relationship between postoperative structural changes in the net-like appearance and the recurrence rate of chronic subdural hematoma. Of the 949 patients with chronic subdural hematoma treated with primary burr hole surgery between January 2010 and April 2021 at our hospital, 268 who were considered positive for the net-like appearance on T2- and T2 star-weighted magnetic resonance images were extracted. We followed the structural changes in the net-like appearance postoperatively and subsequently classified the patients into three groups: decreasing type, shifting type, and no change and deterioration type. The relationship between each structural change and the recurrence rate in the three groups was investigated. Postoperative recurrence requiring surgery occurred in 3.5% of the subjects with decreasing type, 0% with shifting type, and 100% with deterioration type of the net-like appearance (P < 0.05), indicating differences in the recurrence rates according to postoperative structural changes in the magnetic resonance images (MRI) features of chronic subdural hematoma. Our results indicate that the risk of postoperative chronic subdural hematoma recurrence can be predicted by focusing on the structural changes in the postoperative net-like appearance on MRI.

551 Middle Meningeal Artery Embolization Embolic Agents – A Systematic Review &amp; Meta-Analysis

INTRODUCTION: Middle meningeal artery (MMA) embolization is increasing in popularity and is thought to lower the rate of subdural hematoma recurrence and need for surgical rescue. Multiple embolic agents have been utilized, but the most effective agent has not been identified. METHODS: Clinical outcomes of embolization using polyvinyl alcohol (PVA) with or without (+/-) coils, N-butyl cyanoacrylate (n-BCA) +/- coils, and Onyx alone were separately evaluated. Outcome measures were the need for surgical rescue and in hospital periprocedural complications. RESULTS: 30 studies were identified with a total of 646 patients, with 449 receiving PVA +/- coils, 134 receiving n-BCA +/- coils, and 60 patients receiving onyx alone. Composite rates for need for surgical rescue following embolization were 4.6% (95% Confidence Interval: 2.5% to 6.7%) for PVA +/- coils, 3.7% (CI: 0.6% to 6.8%) for n-BCA +/- coils, and 9.0% (CI: 1.9% to 5.4%) for Onyx alone. However, meta-regression revealed no significant difference between n-BCA and PVA based embolization (P = 0.728), between n-BCA and Onyx alone (P = 0.177), nor between PVA based and Onyx (P = 0.323) concerning need for surgical rescue. In regard to periprocedural complication rates, there was a pooled composite rate of 1.5% (CI: 0.3% to 2.7%) for PVA +/- coils, 3.1% (CI: 0.2% to 6.1%) for n-BCA +/- coils, and 2.7% (CI: 0% to 6.7%) for Onyx embolization. Similarly, meta-regression indicated no significant difference between PVA and n-BCA based therapy (P = 0.318), between n-BCA and Onyx embolization (P = 0.869), nor between PVA based and Onyx (P = 0.574). CONCLUSIONS: Rates of periprocedural complications and need for surgical rescue following MMA embolization are not influenced by the type of embolic agent utilized.

Middle Meningeal Artery Embolization in the Management of Chronic Subdural Hematoma: a Comprehensive Review of Current Literature

Chronic subdural hematoma (cSDH) is a common intracranial hemorrhagic disorder with a high incidence rate among the elderly. While small, asymptomatic cSDH may resolve spontaneously, surgical intervention has been the treatment of choice for larger, symptomatic cases. Surgical evacuation of cSDH may be associated with high rates of recurrence, and even asymptomatic cSDH cases tend to progress. Over the last few years, middle meningeal artery (MMA) embolization has proven to be a safe non-invasive treatment of choice with favorable outcomes and a low recurrence rate. The ensuing paper discusses current treatment modalities for cSDH and reviews existing literature on the anatomy of MMA and its embolization as a treatment option for cSDH. Recent studies show that traumatic head injury leading to subdural hemorrhage can induce neovascularization that may initiate a cycle of recurrent subdural hematoma. Distal branches of MMA supply blood to the dural layers. Several studies have revealed that embolization of the MMA can stop the neovascularization process and blood flow. In addition, patients who underwent MMA embolization had a significantly quicker brain re-expansion and lower recurrence rate. Although the management of cSDH is still very much a dilemma, recent research findings bring MMA embolization to light as a promising treatment alternative and adjunctive therapy.

Correlation between Blood Type 0 and Risk of Chronic Subdural Hematoma Recurrence: A Single Center Retrospective Cohort Study

Chronic subdural hematoma (cSDH) is a common disease in the neurological and neurosurgical world. The recommended treatment for cSDH patients with moderate or severe neurological symptoms is surgical evacuation, but cSDH frequently recurs. The patient's ABO blood type may influence the outcome. This study aims to evaluate the correlation between cSDH recurrence and blood type O. We performed a retrospective analysis of the data of patients with cSDH who were surgically treated. Recurrence was defined as the need for re-operation within the first 12 weeks after the initial surgery. We analyzed standard demographic data, duration and type of surgery, ABO blood types, and the re-operation rate. Univariate and multivariate analyses were conducted. A total of 229 patients were included. The recurrence of hematoma was identified in 20.5% of patients. Blood type O was found to be significantly associated with cSDH recurrence leading to re-operation within 12 weeks (p = 0.02, OR 1.9, 95% CI 1.1-3.5). Thrombocyte aggregation inhibition and oral anticoagulants were not predictors of cSDH recurrence. Patients with blood type O in our cohort were identified to be at higher risk of cSDH recurrence and may, therefore, be a more vulnerable patient group. This finding needs further evaluation in larger cohorts.

Embolic Agent Choice in Middle Meningeal Artery Embolization as Primary or Adjunct Treatment for Chronic Subdural Hematoma: A Systematic Review and Meta-analysis.

Middle meningeal artery embolization is an emerging treatment option for chronic subdural hematomas. Our aim was to assess outcomes following middle meningeal artery embolization by different techniques, including in comparison with traditional surgical methods. We searched the literature databases from inception to March 2022. We selected studies reporting outcomes after middle meningeal artery embolization as a primary or adjunctive treatment for chronic subdural hematoma. We analyzed the risk of recurrence of chronic subdural hematoma, reoperation for recurrence or residual hematoma, complications, and radiologic and clinical outcomes using random effects modeling. Additional analyses were performed on the basis of whether middle meningeal artery embolization was used as the primary or adjunct treatment and by embolic agent type. Twenty-two studies were included with 382 patients with middle meningeal artery embolization and 1373 surgical patients. The rate of subdural hematoma recurrence was 4.1%. Fifty (4.2%) patients underwent a reoperation for a recurrent or residual subdural hematoma. Thirty-six (2.6%) experienced postoperative complications. The rates of good radiologic and clinical outcomes were 83.1% and 73.3%, respectively. Middle meningeal artery embolization was significantly associated with decreased odds of subdural hematoma reoperation (OR = 0.48; 95% CI, 23.4-99.1; P = .047) compared with surgery. The lowest rates of subdural hematoma radiologic recurrence, reoperation, and complications were observed among patients receiving embolization with Onyx, whereas good overall clinical outcome occurred most commonly with combined polyvinyl alcohol and coils. A limitation was the retrospective design of studies included. Middle meningeal artery embolization is safe and effective, either as a primary or adjunctive treatment. Treatment using Onyx seems to yield lower rates of recurrence, rescue operation, and complications whereas particles and coils produce good overall clinical outcomes.