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Visish M. Srinivasan and Peter Kan

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Visish M. Srinivasan, Aditya Vedantam and Peter Kan

We present a case of a patient with an anterior communicating artery aneurysm treated by PulseRider-assisted coil embolization. PulseRider is a new device, FDA approved for treatment of broad-necked aneurysms of the basilar apex or internal carotid artery terminus. The aneurysm was broad-necked and involved the anterior communicating artery and was considered for traditional stent-assisted coiling as well as PulseRider-assisted coiling. The authors present the treatment plan and strategy and then fluoroscopic recording of the PulseRider delivery and subsequent coiling phase. Nuances of technique for this new device used in a challenging setting are discussed.

The video can be found here: https://youtu.be/ont7ggqgLH8.

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Visish M. Srinivasan, Anish N. Sen and Peter Kan

The authors present a case of a patient with a Barrow Type B carotid-cavernous fistula (CCF) who presented with severe symptoms of eye redness, diplopia, and proptosis. Due to the tortuosity and size of her angular vein and the lack of good flow/access via the inferior petrosal sinus, she was treated with a transvenous approach via a large, dilated superior ophthalmic vein for coil embolization of the CCF. The patient had a full angiographic and symptomatic cure. The authors present the treatment plan and strategy and the fluoroscopic recording of the treatment. Nuances of the technique are discussed.

The video can be found here: https://youtu.be/ABkGm17-cBU.

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Visish M. Srinivasan, Patrick J. Karas, Anish N. Sen and Jared S. Fridley

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Visish M. Srinivasan, Peter Kan and Edward A. M. Duckworth

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Visish M. Srinivasan, Gouthami Chintalapani, Edward A. M. Duckworth and Peter Kan

OBJECTIVE

The evaluation of the venous neurovasculature, especially the dural venous sinuses, is most often performed using MR or CT venography. For further assessment, diagnostic cerebral angiography may be performed. Three-dimensional rotational angiography (3D-RA) can be applied to the venous system, producing 3D rotational venography (3D-RV) and cross-sectional reconstructions, which function as an adjunct to traditional 2D digital subtraction angiography.

METHODS

After querying the database of Baylor St. Luke’s Medical Center in Houston, Texas, the authors reviewed the radiological and clinical data of patients who underwent 3D-RV. This modality was performed based on standard techniques for 3D-RA, with the catheter placed in the internal carotid artery and a longer x-ray delay calculated based on time difference between the early arterial phase and the venous phase.

RESULTS

Of the 12 cases reviewed, 5 patients had neoplasms invading a venous sinus, 4 patients with idiopathic intracranial hypertension required evaluation of venous sinus stenosis, 2 patients had venous diverticula, and 1 patient had a posterior fossa arachnoid cyst. The x-ray delay ranged from 7 to 10 seconds. The 3D-RV was used both for diagnosis and in treatment planning.

CONCLUSIONS

Three-dimensional RV and associated cross-sectional reconstructions can be used to assess the cerebral venous vasculature in a manner distinct from established modalities. Three-dimensional RV can be performed with relative ease on widely available biplane equipment, and data can be processed using standard software packages. The authors present the protocol and technique used along with potential applications to venous sinus stenosis, venous diverticula, and tumors invading the venous sinuses.

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Visish M. Srinivasan, Brent R. O'Neill, Diana Jho, Donald M. Whiting and Michael Y. Oh

External ventricular drainage (EVD) is one of the most commonly performed neurosurgical procedures. It was first performed as early as 1744 by Claude-Nicholas Le Cat. Since then, there have been numerous changes in technique, materials used, indications for the procedure, and safety. The history of EVD is best appreciated in 4 eras of progress: development of the technique (1850–1908), technological advancements (1927–1950), expansion of indications (1960–1995), and accuracy, training, and infection control (1995–present). While EVD was first attempted in the 18th century, it was not until 1890 that the first thorough report of EVD technique and outcomes was published by William Williams Keen. He was followed by H. Tillmanns, who described the technique that would be used for many years. Following this, many improvements were made to the EVD apparatus itself, including the addition of manometry by Adson and Lillie in 1927, and continued experimentation in cannulation/drainage materials. Technological advancements allowed a great expansion of indications for EVD, sparked by Nils Lundberg, who published a thorough analysis of the use of intracranial pressure (ICP) monitoring in patients with brain tumors in 1960. This led to the application of EVD and ICP monitoring in subarachnoid hemorrhage, Reye syndrome, and traumatic brain injury. Recent research in EVD has focused on improving the overall safety of the procedure, which has included the development of guidance-based systems, virtual reality simulators for trainees, and antibiotic-impregnated catheters.

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Michael G. Z. Ghali, Visish M. Srinivasan, Andrew Jea and Sandi Lam

Paul Louis Tessier is recognized as the father of craniofacial surgery. While his story and pivotal contributions to the development of the multidisciplinary practice of craniofacial surgery are much highlighted in plastic surgery literature, they are seldom directly discussed in the context of neurosurgeons. His life and legacy to craniosynostosis and neurosurgery are explored in the present paper.

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Visish M. Srinivasan, Stephen R. Chen, Kevin M. Camstra, Gouthami Chintalapani and Peter Kan

OBJECTIVE

Stroke is a major cause of disability and death in adults. Several large randomized clinical trials have shown the significant benefit of mechanical thrombectomy with modern stent retrievers in the treatment of large-vessel occlusions. However, large clots located at bifurcations remain challenging to treat. An in vivo model of these recalcitrant clots needs to be developed to test future generations of devices.

METHODS

Autologous blood was drawn from anesthetized swine via a femoral sheath. Blood was then mixed with thrombin, calcium chloride, and saline, and injected into silicone tubing to form cylindrical clots in the standard fashion. Matured clots were then delivered in an unfragmented fashion directly into the distal extracranial vasculature, at branch points where vessel sizes mimic the human middle cerebral artery, by using Penumbra aspiration tubing and the Penumbra ACE68 reperfusion catheter.

RESULTS

A total of 5 adult swine were used to develop the model. The techniques evolved during experiments in the first 3 animals, and the last 2 were used to establish the final model. In these 2 swine, a total of 8 autologous clots, 15–20 mm, were injected directly into 8 distal extracranial vessels at branch points to mimic a bifurcation occlusion in a human. All clots were delivered directly at a distal bifurcation or trifurcation in an unfragmented fashion to cause an occlusion. Ten revascularization attempts were made, and none of the branch-point occlusions were fully revascularized on the first attempt.

CONCLUSIONS

Using novel large-bore distal access catheters, large unfragmented clots can be delivered into distal extracranial vessels in a swine occlusion model. The model mimics the clinical situation of a recalcitrant bifurcation occlusion and will be valuable in the study of next-generation stroke devices and in training settings.

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Visish M. Srinivasan, Andrew P. Carlson, Maxim Mokin, Jacob Cherian, Stephen R. Chen, Ajit Puri and Peter Kan

OBJECTIVE

The Pipeline embolization device (PED) is frequently used in the treatment of anterior circulation aneurysms, especially around the carotid siphon, with generally excellent results. However, the PED has its own unique technical challenges, including the occurrence of device foreshortening or migration leading to prolapse into the aneurysm. The authors sought to determine the incidence of this phenomenon, the rescue strategies, and outcomes.

METHODS

Four institutional databases of neuroendovascular procedures were reviewed for cases of intracranial aneurysms treated with PEDs. Patient and aneurysm data as well as angiographic imaging were reviewed for all cases involving device prolapse into the aneurysm.

RESULTS

A total of 413 intracranial aneurysms were treated with PEDs during the study period, by 5 neurointerventionalists. Large and giant aneurysms (≥ 2 cm) accounted for 32 of these aneurysms. Among these 32 PEDs, prolapse into the aneurysm occurred in 3 patients, with 1 of these PEDs successfully rescued and the other 2 left in situ. No patients suffered any severe complications. The 2 patients in whom the PEDs were left in situ remained on antiplatelet therapy.

CONCLUSIONS

The PED may foreshorten or migrate during or after deployment, leading to prolapse into the aneurysm. This phenomenon appears to be associated with large and giant aneurysms, vessel tortuosity, short landing zones, and use of balloon angioplasty. Future study and follow-up is needed to further evaluate this phenomenon, but some of the observations and techniques described in this paper may help to prevent or salvage prolapsed devices.