- Our next presenter is Dr. John Dalfino. He's a neuroendovascular surgeon at Albany Medical Center. Dr. Dalfino specializes in the surgical and endovascular management of cerebrovascular disorders of the brain, including stroke, cerebral aneurysms, carotid and intercranial vessel disease. In addition to his cerebrovascular practice,
Dr. Dalfino has training in functional neurosurgery and spine surgery. He also performs surgical procedures for the diagnosis and treatment of epilepsy, pseudotumor cerebri, Chiari malformations, and degenerative spine disease.
I have worked with Dr. Dalfino for a number of years and I'm pretty sure I probably wouldn't have passed my VI board exam without his help. He took the time to sit down with me and go over cases, draw me multiple pictures of brain vessels, and explain different projections along with pathology.
I'd like you all to please help me join Dr. Dalfino. (audience applauding) - Can everyone hear me? Good, no? All right, I'm coming here from Albany Medical Center as Stefanie told you.
I've not given this talk before. I put this talk together so I have not given it live. It seems to run me somewhere between 30 minutes and two hours and 30 minutes, but-- (audience laughing) So I don't know, I'm gonna try to alter the timing
and we'll try to get through all the cases if I can. Albany Medical Center is not a bad place. It's the fourth best hospital in the capital region, just below our VA, who apparently does a great colonoscopy. (audience laughing) We have three neurointerventional people at Albany Med.
We are all neurosurgeons. That's me in the center. That's Alan Boulos, who's our chairman of our department, and Junichi Yamamoto joined in about 2008, and he's a neurosurgeon actually trained in Japan. You can see we're all well-liked in the community.
You can submit your own picture to UCompare, which is nice. (audience laughing) Next year, this is gonna be Dr. Ali Paul. She'll be our fourth neurointerventionalist, also a neurosurgeon, and also does both open and endovascular cases.
So the objectives of my talk today are gonna be to review the unique properties and vascular anatomy of the brain. I'm gonna talk a little bit about the differences between vascular intervention in the brain and elsewhere. And I'll show some examples
of both arterial and venous side cases.
So this is gonna be about the evolution of the brain. The human brain weighs 1,500 grams. In a normal size person, it's about 2% of the body mass. It consumes 20% of the blood supply, however, so it's a very thirsty organ.
It's fairly large compared to other mammals. It's bigger than other primates, and you can see that it has more gyrations. You see the sulcal pattern coming from, say, a macaque or a gorilla to the human brain. Does anyone know what the biggest brain is
in the animal kingdom, and with the most folds? Dolphin, but it doesn't seem to keep 'em out of a can of tuna. They can't swim out of those nets. So there's something different, all right. (audience laughing) Too far, I don't know.
Humans have gotten, our cranial vaults have gotten bigger over three million years, so the brain part. Our faces are the same size, but the brain part has gotten bigger. And another thing that's happened is that our carotid artery holes have gotten bigger,
so we think the carotid arteries have grown substantially. The carotid artery has doubled in cross-sectional area, but if you remember, this is the Neanderthal's carotid artery. You remember any physics, if you double the cross-sectional area, the radius,
so you get a 16-fold increase in flow, and so when you look at the carotid flow, say, between Neanderthals and Homo sapiens, our brain sizes are the same. They're both about 1,500 grams.
But the blood flow in humans is much higher. And since 50% of the brain metabolism is basically synaptic transmission, we think that we were probably smarter than the Neanderthals. The surface vessels of the brain aren't particularly important in angiography.
They are hard to identify in an angiogram and they're really more useful for open surgery. If you were to do a corrosion cast of the brain, it would look like this. This is where you basically fill all the blood vessels with resin,
dissolve away all the brain tissue, potassium hydroxide, and that's what you're left with. And it looks pretty vascular even compared to other vascular stuff like the heart and the kidneys. Blood supply to the brain, if you remember, is all off the arch, right?
So you have the two common carotid arteries. Left usually comes directly off the arch, although sometimes it will come off the innominate and be called a bovine origin. And you have your two vertebral arteries are always the first branches off of the subclavian arteries.
These vessels go up, and you'll see the carotid arteries go up to the neck, and about at C4 or so, they will bifurcate into an external carotid artery, which'll get branches off the neck, and the internal carotid artery, which goes directly up to the brain and pretty much
has no normal identifiable branches outside the skull. This is the circle of Willis, just showing you just from the arch to show you. I'm gonna give you a magnified view here of an MRA, and course, the circle of Willis is mostly the carotid arteries coming in.
You can see the middle cerebral artery here, anterior cerebral artery here, and this would be ACOM, and so you can come all the way across your anterior circulation. PCOM would be here, it's hard to see. And then you have your P1s, basilar artery,
all of that forms the circle of Willis. So how is the brain different than other organs? Well, you only have one, and you have the other organs that you have one, but you need this one, unlike a spleen or a part of your gut. And it does not have a dual blood supply,
although I guess maybe with the circle of Willis, you could make an argument that in some ways it does. But basically this means that if you have an embolus during a neuro case, the person's probably gonna have a severe complication.
We do have some advantages.
It is easy to see in the skull. You really don't have any significant motion inside the skull, so you don't have things like bowel and lungs in your way. The vascular anatomy in the brain is fairly predictable. Biplane fluoro's very effective in the skull,
basically 'cause you have the patient in head first and the head has the same dimensions in AP and lateral dimensions. And we're pretty far away from the radiation source, which is nice, which is probably why we step on the pedal more.
(audience laughing) So we tend to use a few things that are maybe different than some peripheral people. We use continuous flushes on most catheters. We use a lot of rotating hemostatic valves. We use anticoagulation during most of our procedures.
In a lot, we use anti-platelet drugs, and we use a lot of roadmapping and 3D rotational angiography, as you saw in the last talk.
So here's a carotid stenosis case. Carotid stenosis, when we talk about it,
typically refers to narrowing caused by atherosclerosis. And it usually occurs at the carotid bifurcation. Usually, symptomatic carotid disease presents either with a stroke or a TIA. Basically, the embolus that is formed on this plaque has to go somewhere.
If it goes to the brain, you have a stroke. If it goes to the ophthalmic artery, you have loss of vision. And that arrow was on something called a Hollenhorst plaque, which is basically an embolus to the eye. Asymptomatic carotid disease
is also found fairly frequently. This is usually when a primary care doctor hears a bruit in someone's neck during a screen test, or maybe the patient gets screened because they have cardiovascular disease or peripheral vascular disease, and oftentimes they are found incidentally on imaging
for other things, such as when we image for brain aneurysms. Initial studies usually include a lipid panel, and then we'll get a carotid ultrasound. You can see the normal ultrasound here and then this very severe narrowing on this ultrasound.
So this guy was 70 years old.
He had all the normal things you'd think a person would have when they have a stroke, diabetes, hypertension, hyperlipidemia. Found at home, had left sided weakness, mild aphasia. He had a carotid artery that looked like this. Here's a 3D reconstruction and this, I think, is an MRA.
He did have a stroke already, so this is a basal ganglia stroke here and a little bit in the temporal lobe out here, so right side. He wasn't sent to us immediately. He was controlled medically by controlling his hypertension. He had pretty mild symptoms
by the time he got to the hospital. Told him to quit smoking, he started a statin, and he started actually dual antiplatelet. He did aspirin and Plavix. We were a little worried about this guy at first. He did have a little bit of brain swelling.
You can see the basal ganglia here is kinda pressed in on the ventricle. So we ended up waiting to do this case for about two or three weeks. So here is a pre-treatment angiogram. I'm gonna kind of show a schematic view
on the right side there. So there's the vessel. That's where we think the plaque is, and here's the run. You can see that obviously, the carotid lumen here is very narrow. You see a little bit of stasis in the carotid artery
and pretty anemic flow throughout the entire thing. The ECA is getting the majority of the flow from the common. If you've seen these diagrams before, but basically, I'm injecting here on the left. The right carotid is the bad one, so passified blood is going into this artery.
Passified blood is gonna light up this side. In a normal patient, there's some competitive flow here, so most of the flow will stay on the ipsilateral side when you do an injection. So we wanna see, sorry, didn't play.
But we're gonna try this again with this one. So here, I'm gonna inject some contrast with this carotid as the bad one, and now you can see the contrast goes up and it fills both sides. I got a little bit of reflux here 'cause I think the catheter fell out.
Now here, the competitive flow doesn't work, right? This one's giving a lot more flow, so it overruns this one, and this is the pattern that you get. This is the cross-filling pattern that you see with bad carotid disease. There we go, so that's the cross-filling pattern.
I have a couple more of these that have less contamination from the other side we'll look at later, too. So how's a stent put in? I don't have a perfect cartoon animation, so I stole this one from Boston Scientific and shortened it. You can see we put a filter up first in the vessel.
We'd leave a wire behind, I went for a wire. It's a Monorail balloon. You do a pre-angioplasty to kinda leave a pathway. This is a WALLSTENT that you place in, and then we're gonna do a post-stent angioplasty and then remove the filter, and that's the basic procedure.
I have that in a little more detail coming up. All right, so here is the filter being deployed. You can see the area of stenosis. There's my filter. Of course, the filter really looks like that, but you're only seeing that part of it.
There's the wire. I know some of this stuff's hard to see from there, so I tried to color as much as I could. And that thing is basically there so when you do a balloon, that little embolus will go up and lodge in the balloon, lodge in the filter, not go somewhere into the brain.
Here's a carotid stent being deployed. These are all self-expandable stents. Every carotid stent that's FDA approved for the carotid bifurcation is self-expandable. There's a pretty good reason for that, right, these stents, you know, the carotid bulb,
when it is stretched with a balloon, oftentimes it will give a systole or a brief period of bradycardia. I think if you were to use a balloon-mounted stent there, you could really get a sustained problem, so the self-expandable stents kinda give up a little bit.
Here you can see the hourglass left by the stent, so it's then opened up here, it opened up here, and then inside the plaque, it looks like a little hourglass. So we're gonna fix that later. But already, it looks better.
You can see a little bit of the carotid bulb here, a lot of plaque kinda smooshed off to the side. All right, so now here's the balloon going up. There are the two markers on the balloon. There's the area of stenosis. I usually do this with just regular fluoro
'cause you really just need to see the stent. This balloon inflation is an eternity. Usually you do this very quickly, 'cause the patient may become asystolic, so we try to do this as rapidly as possible. I may have slowed this down just so I could show it better,
but basically now you're gonna see how much better the flow is. So there's your before and there's after. That's a pretty good result, I think. That's just a still picture of the same thing. So let me show you now the cross-filling.
So before and after, you can see here, right, so after the stent goes up, now the carotid competitive flow is good, so you don't see any of the cross-filling that you saw here. That'll be a common theme in a couple of cases that we show here.
So carotid stenting take home. Generally done using a distal embolic protection device. In fact, if you don't use a distal embolic device, it does not get paid for by Medicare. All current systems use self-expandable stents for the reason I gave, and we generally do
a pre and a post angioplasty during carotid stenting.
You can get carotid stenosis in other areas. This was sort of an unusual case where a person had stenosis at the origin of the carotid artery. He was a 50 year old. He had a history of carotid disease
but was having episodes of syncope. He actually got sent to me because he had an aneurysm. If you look at this CTA, that's the artery that we're looking at, that's the left carotid. They sent him for this, which I think is a hemodynamic aneurysm
because down here, he's got this plaque at the carotid origin right at the arch. So we did an angiogram. Here's a intercranial run. I actually did put a catheter in the origin a little bit by accident, but since we got in there,
we took the run, and not very good flow into the brain here. Here's the cross-filling that I keep harping on. So this carotid's really doing no work. All the blood flow's coming from the right, right to left. If you forgot what the other one looked like, it's up there. All right, so now there's the carotid origin.
You can see that pretty poor flow through there, maybe a calcified plaque. Kinda hard to visualize here, but you see that the flow here definitely isn't normal. Even if you don't agree that there's a big plaque here, you can't say that that flow is normal.
That's very slow, very dark as if it's getting held up. It's really not getting washed out properly. So here, we didn't, this worked out well because this guy, even though he had bad carotid disease, he had a type two arch, so we had a lot of options for access.
I ended up putting up a Cook Shuttle. And this thing, this is an Envoy, angle glide Envoy just to give a little bit of direction. There we go, and there's my wire. We did use a distal embolic protection device. This is a NAV6, I think,
basically the same thing as a filter wire. Here's the balloon-mounted stent across the lesion. You can see the two markers for the balloon. Ooh, I have it up there. And this is just before I inflate it. I didn't have the inflation,
so I just stuck this movie in there. This is basically every balloon-mounted stent where you have the stent inside the balloon, you inflate the balloon, take the balloon down, leave the stent behind. So imagine that was done,
and then there's the stent in place. I actually used one of these FLASH Ostial balloons. This is a two-stage balloon, has a regular balloon on the end of it. There is attached another balloon that's kinda wider, more circular balloon.
And when you inflate this thing, you're supposed to put this part in the stent and you inflate it to hold it in place, and then you inflate the bottom of it to try to open up the bottom of the stent. And this basically looks like this. It's supposed to look like this if you could see it.
So you inflate the balloon and the stent tines go out. Now in this particular case, it didn't make any difference. My stent was not low enough to benefit from that balloon much. I mean, I tried to do this and we put the balloon, and I think it slid the stent up a tad,
but we still had a pretty good radiographic result. You can see the vessel's wide open. No stagnation in the vessel from before and after. Here's a CTA that we did a month followup. You can see the stent is widely patent, and this guy did have some long-term followup.
Here's an arch angiogram. You can see the vessel's widely patent. And here's another before and after. You know, again, no cross-filling. You're probably thinking by now, so what, I get it. (audience laughing)
But I made all these slides, I feel like I need to show 'em. (audience laughing) The carotid looked much better. This is sort of interesting. You can see the carotid, the internal carotid artery above was very small.
You can see at a year, it's already gotten bigger, so it's kinda going back to its normal size. The aneurysm's still there. Maybe it's a little bit smaller? I suspect, actually, that the carotid artery will continue to get bigger
and this will just look like a normal carotid bulb. And he's obviously doing well, or I wouldn't have shown it.
Okay, so these are some venous cases.
Cerebral venous anatomy's actually simple. It's really only three big veins. This is the superior sagittal sinus. It runs from front to back in the midline. It breaks off into these two transverse sinuses, and these basically just connect right into the jugular.
We're gonna ignore this mess. This is the cavernous sinus and it's really not draining intercranial veins very much, and then there's a deep venous system, which I'm gonna show here. So here's the dural sinuses. Here's these cortical veins, and then that's the deep system
that drains basal ganglia, some of the brain stem, et cetera. These big veins are not real veins. They are actually leaflets of the dura, so unlike a normal vein, they're not really super compressible.
They have another function in addition to taking blood away. So this is the blood flow. They also have these organs called arachnoid villi, and these take the spinal fluid and basically dump spinal fluid into these veins. And they're pressure-dependent, so when the pressure
in the CSF is about six centimeters of water above pressure in this vein, CSF will drain out, and if the vein pressure's very high, you will not get drainage of spinal fluid. So imagine if you have a tumor in this area, that you not only obstruct the bloodflow,
but you also prevent spinal fluid from coming out, and those patients can develop hydrocephalous or high intercranial pressure.
All right, so here's a 50 year old man. I didn't put it in here, but this guy literally was 425 pounds.
He had bilateral papilledema on an eye exam for a workup for double vision. And he was sent to me because they found this tumor right here, and that tumor sits right next to the sagittal sinus. And so we did a little bit more work here.
This is CT angiogram. This software's actually our OR software. And this movie turned out a little slower and not as good as I thought, so I made this reconstruction. This is basically the tumor, and you can see it's pressing on the sagittal sinus here.
So I offered him a couple of options. Taking this tumor out, there are some issues. When it's right up against the vein, that vein needs to be reconstructed. It can be very difficult, there's often a lot of blood loss, and it oftentimes doesn't work well.
So I thought maybe we would stent the vein and if he needed the tumor out, the stent would act as a scaffold for the vein and we maybe wouldn't have to do a reconstruction. So here was a technique for that. Basically, we crossed the lesion first with a microcatheter.
This was, I think, a Renegade HI-FLO. There's the tumor there on the angiogram. And this is me pushing the wire and the catheter up past that lesion. I'll skip over that 'cause it's not that interesting. This is the venous angiogram.
So basically I took the catheter and put it past the tumor and then I measured the pressure inside the vein, and the pressure was 42, which is very high. And then I pulled the thing back and measured the pressure here, and it was 32, so I had a pressure gradient across that lesion.
Here's the microcatheter run. And you can see it's not super obstructive, but he definitely has a pressure gradient here. Here's a stent being pushed up. I used a Carotid WALLSTENT for this, basically 'cause it will go through a small guide catheter,
it's a 6 French guide catheter. You can see the stent going up here. See, it looks pretty looks pretty long, but actually, it foreshortens quite a bit in the vein. The veins are big, they're bigger than the carotid artery. Once the stent was deployed, you can sorta see it
on both sides, you don't see that big divot inside the vein anymore. I did do an angioiplasty. You can't see it well here, the vein looks fine. I didn't know, actually, if this angioiplasty would work. It's not plaque, right, this is a tumor,
so I thought maybe it would just bounce back. If you look here, you can see that little bit of an hourglass shape, and I'll show you the balloon going up here. The balloon actually did a fairly good job at opening the stent.
Think this is an eight millimeter Sterling balloon. So here's a before and here's an after. You can see the pressures again. Here's the pressure gradient here and here, there's no pressure gradient. The pressure has dropped down to 30.
I did a three-month followup, and you can see the stent is widely patent. Papilledema and headaches resolved, and we decided to just follow the tumor with MRI. It's really a small tumor, it's benign, so we'll just continue to follow it, and if it grows
over time, we'll talk to him about taking it out.
All right, so I'm gonna talk about, switch gears, and we'll talk about brain aneurysms. So I'm not gonna go too much into the epidemiology of this. I mean, it's probably covered in other people's stuff, but I'll just say a couple,
maybe things that you might find surprising. They're much more common in women. They do tend to run in families. Most common symptom is hemorrhage, and they do have a fairly high risk of rupture over seven millimeters, at least 1% per year, some are higher.
It used to be that we only discussed really two treatment options. You had clipping until 1990, basically, and then you had coiling, and every year there'd be another paper, which one's better. Coiling obviously has technology on its side,
and so now we're getting, in addition to coiling, we have bad transmitter. Okay, we got flow diverters. We have endolumenal devices like the web. Somebody once put this stuff in.
I don't think ever again has it been used and I haven't seen it in years. And then we have all these assist devices. We have stents, we have balloons. We have these endolumenal support devices. I think this is, it's not the, I always say FlowRider,
so I put this up here, it's the PulseRider. (audience laughing)
All right, so this is a case with a flow diverter called FRED. This was in a trial. This was an 82 year old lady.
She was previously healthy, but she got admitted with a TIA. Symptoms resolved, but she had this aneurysm, and I have to say I don't normally treat aneurysm in 82 year olds that are incidental, but this had a very strange shape, kinda like a snowman, and it looked nasty.
And so we talked to her about it and she wanted to have it treated. Basically, we went up there, we put an access system in. You could see, for an old lady, she's got decent carotids. Here is the pre-treatment angiogram. You can see maybe it looks a little different here,
doesn't look so much like a snowman, kinda like a snail. And here's a movie on how flow diverters work. I tried to shorten it up a little bit, so here's blood flow going into the aneurysm. You put up your catheter, deploy this flow diverter, which is basically just a very fine-meshed stent.
And then when you inject contrast in, it slows the contrast going through the aneurysm. It's supposed to hold the other vessels open so it could cover something like this, a PCOM. It's supposed to stay open and usually does, and then the aneurysm will shrink over time.
So I'll show you this example. Here's a FRED, you can see this system in here. This is where the vessel would be. I did this on a negative roadmap, so I had to draw the vessel. And I'll show you each of these.
These are the markers of the catheter, and these are the markers of the distal and proximal tines of the FRED device. These two markers at the bottom that just went up are the bumpers that hold the device in place. It's got the proximal bumper, or the distal bumper,
is connected to a delivery wire. That's the wire that you use to sort of hold the stent into the catheter, and then there's another pusher wire behind that that's a little stiffer. And then the stent is loaded partially over that wire, and then the whole thing goes inside a catheter.
And here's the device getting deployed. These are just single-frame shots so you can see. Stent's open here, and we kinda pull it back. Stent fell back just a tad there. And this stent has a nice helix in it that you can see really easily on fluoro.
And that's the device fully deployed. So here's the immediate film before you see the little snail head here, and it looks much better on the bottom. Oops, sorry, I ran through that one, but there we go. I guess the other one's not playing.
Here is, this is my ad for Siemens, so this is a axial DCT with a vessel fusion, so I did, this is a 20-second spin and this is the five-second DSA spin. And you can actually, I guess the movies aren't playing all of a sudden, but this is a MIP view
where you can see that the aneurysm is well-covered by the stint. Here is a 3D reconstruction. The blue yellow is kind of an inside joke. Alan Boulos can't see color, he can't see red and green so I make everything blue and yellow
to pick on his disability. (audience laughing) So here's a before and a one-month after. You can see quite a big difference between the aneurysm, right? It's already much smaller.
Here I overlaid them on top of each other in case you couldn't see it. Here's the stent at six months, it was patent, and here is one year post-procedure. You really see no filling at all of the aneurysm. Then I have a bunch of pictures showing that they're good.
So here's six months, one year gone. If you like 'em in linear form, that's that one, but basically, aneurysm's completely resolved. Okay, so that's FRED. FRED was, you know, a flow diverter that's really not out in the market, that's in a trial.
Pipeline is the one we use the most right now.
I'll show you a couple of interesting cases that are in some young people that you don't get to see very often. This is a 15 year old. He had two weeks of nausea, vomiting, and headache,
and then he was noted to have a medial deviation of the right eye, so we diagnosed him with a sixth nerve palsy. He had what appeared to be a mass in the cavernous sinus on the right side, but our radiologist was good. He read this as an aneurysm.
And when we got some additional imaging, oh, boy, let's see, he read this as an aneurysm and we treated it by putting in all of these Pipeline devices. So you can see four of them basically wrapping around the entire cavernous carotid down into the petrous carotid.
And this stent worked out pretty well. Here you can see this is where the Pipeline device is right here. You can see the aneurysm's well-covered. Here's an arterial phase shot. Obviously you see the aneurysm still, right,
it's not cured yet. This is right after the procedure. But if you go into the capillary phase, you're already starting to see that the aneurysm still fills, so there's some slowed filling
and you can see well into the venous phase that the aneurysm is still filling. One week post-procedure, you can see that the stent is open, that's the Pipeline device with the contrast inside of it. Here's where the aneurysm would've been on a similar shot and you can see that all that area is no longer enhancing.
And these are just pre and post-procedure CTAs, again showing all this stuff is gone on the new films. He missed his two-year appointment, I mean, he's 18 now and he, you know, he's just kinda of a woodsman sort of guy. He really doesn't feel like coming in, but we called him. He's doing fine clinically.
He stopped his anti-platelet drugs. He'll stay on aspirin for life, basically.
I wanted to show, with him, that the aneurysm gets smaller over time. I didn't have very good pictures of this one other than what you're gonna see here,
but this was a 12 year old who had sort of a similar but larger aneurysm. This was also Pipelined, but I had a problem with this Pipeline. I tried to Pipeline this aneurysm and the Pipeline deployed fine, but as you can see here,
the Pipeline fell back and it just looks like a volcano inside here. So I ended up sacrificing that artery. We did a test balloon occlusion with him under general anesthesia with neuromonitoring. It looked fine and I ended up sacrificing it,
so the aneurysm was cured. And you can see that the aneurysms do reduce in size. This was a one-year followup. And here is his current CTA, and you can see that all that mass effect has resolved. So these aneurysms, even these giant aneurysms,
can resolve over time, and the brain edema, the brain swelling, the mass effect goes away. This kid gained, when I met him, he was 65 pounds. He gained 35 pounds in his first three months 'cause he wasn't eating, basically a hypothalamic dysfunction,
and then he sprouted about a foot in the next year.
So lot of different ways to do an aneurysm. I really didn't have any pictures of these, so I did one last week where someone looked up, on my scheduled Pipeline case, the lady at the last second, her last anesthesia breath, tells everyone she has a soft metal allergy, and when they looked this up
in the Pipeline IFU, they decide that it's contraindicated for her to get a Pipeline, which was a good call. I think our techs did a great job. And then we had to think of some other way of doing it, so I offered to use a balloon, and this worked out okay. Here is my experimentation with iMovie.
So there's the aneurysm. All right, now here's the schematic for balloon-assisted coiling. There's the aneurysm, very wide-necked aneurysm. This is a Synchro2 soft and it's loaded in a Scepter XC balloon.
Obviously, you could use any balloon here. Scepter has three markers, a distal marker and then two markers on the balloon. Then the balloon itself is between those two markers, and then we have a microcatheter inside the aneurysm. I think I used the Headway Duo for this one.
And the idea is that you inflate this very compliant balloon and that gives you a scaffold to deploy your coils and then, if you're lucky, when you take the balloon down, the coils stay where they're supposed to. So here's my first attempt. I always try, this is a,
I don't know why I left this in here. This is me scarily getting into the aneurysm. Tougher catheterization than it looks on the screen. So now I have the catheter in place, and I'm gonna attempt to put the coil in without the balloon. I always try to do it without the balloon
because a lot of times, the coils will seat better than you think, and obviously when you put a balloon up, the brain is ischemic for a period of time. But you'll see here that the coil just will not stay in the aneurysm.
It's gonna keep popping into the parent vessel. You can see it down here, you can see it over there. I think this is sped up probably two or threefold. So now I'm gonna try again. I'm gonna put the balloon up this time. I'm gonna suggest to you, though,
that I had the balloon here a little too far distal. Doesn't look bad on that run, but it's a little, it's not really covering the base here. There's the coil, it's respecting the balloon there, but you can see this part is not gonna stay in. I actually lost access to the aneurysm here
'cause the coil came back, then I had to use the coil to get back in the aneurysm, and it was a pain in the neck. So then that was a fail. So I ended up pulling that coil back. Yeah, it wasn't for lack of trying, though. But you see this coil loop here still outside the aneurysm.
I didn't like that, and watch, when you take the balloon down, you see the coil moving. You don't wanna see that. That means your coil's just not stable. So I pulled the balloon back a little bit and I tried again. This one's a little better.
I still have a little loop here, pulled it back a couple times. This is the one I ended up keeping. Not bad here. Here's how we really do these. Usually I do the second coil on a negative roadmap.
You see it really fills in the front part of the aneurysm here. Just in case you wanted to see it without the roadmap. Just in case you wanted to see 'em compared. See, this is too much iMovie, but-- (audience laughing)
Whatever, you get to see something go in a couple of times. So here's the deployment, here's the final run. Not perfect, okay, I realize that there is a little bit of aneurysm filling. I might have another run, right back here. But I felt like we had done enough.
I really didn't have any backups for her, 'cause if I had to put another stent in, it would definitely be a nickel stent and she definitely mentioned nickel, so I think if anything, we'll talk to her about testing her for cobalt allergy and then putting in the Pipeline,
which is really a nickel-cobalt alloy. There's not supposed to be any significant amount of nickel in it. Alright, here's another ad for Siemens that I made by mistake, so this is a 3D angio,
pre-op, and then I fused the post-op CTA, and I'm gonna rotate the vessel so the aneurysm's mostly in relief, and then I'll fade in the CTA data to show you where the coils went. You can see they did a pretty good job there.
So in neurosurgery, we have to deal with a lot of vascular tumors, and my colleagues, a lot of these aren't my cases.
These are cases that I did in the last couple of weeks to embolize what were considered hypervascular tumors. This is a 47 year old male. He had 15 minutes of left-sided numbness and slurred speech while he was shoveling. He had this pre-op CTA that was positive
for this very big, not too vascular mass down here, but you'll see in a second that it's capped with this vascular area. And they thought this was probably a benign tumor, but it really needed to come out, and they asked me to take a look at this for embolization.
Here's a pre-op MRI, looks like a meningioma. It's kind of an interesting fill pattern. ICA run shows, here's a MRI overlay. You see this vessel coming in, this is an ACA collateral, so the bottom half of the tumor is fed by the internal circulation, internal carotid artery.
So just that bottom half, really. The top of the tumor was fed by the middle meningeal artery, which is the more common vascular target for us. And a pretty vascular tumor, really. So here's a position of the guide catheter.
I'm gonna skip this, 'cause it's not that interesting, but we did a pretty good job getting the catheter up here, I have to say. This was my fellow. The technique here was pretty good. This is a Duo microcatheter, a smaller version of the Duo.
It's a flow guided catheter. I sped this up about fourfold. It's a very, very trackable catheter. At this top part, you'll see this part where you're really letting the catheter go ahead of the wire, just using the wire
to kind of pull the slack out of the system, and that will eventually let the catheter just kind of jump forward to the aneurysm, to the tumor. Here's some Onyx going into the tumor. You could use a lot of different things. A lot of times, I'll use particles here,
but they won't go through the Duo. I thought this looked great. I also was out of Onyx at this point. Sometimes the techs don't order it. (audience laughing) And so I had to stop here and I thought this looked great at first, you know.
I was very happy with this, because I had no filling from the external. Yeah, and, I'm sorry to show that again. I flipped those images, so I moved 'em around, so before you could see really no filling from the external. And then even the right internal.
Look, you see no filling anymore of the tumor, probably 'cause I killed all the outflow. This is a venous problem here. This worked out very well. The surgeon who took it out said it didn't really bleed significantly
and felt it was a good embolization. I'll show you here, though, I did do a post-op MR. You can see the Onyx only went into that top compartment, and you can still see a lot of contrast enhancing tumor there. So I didn't think this was the best embo in the world,
but I think, functionally speaking, it got that very vascular part treated and that was the part they were most concerned about. I don't have any pathology yet, and here's just a picture showing they cut the tumor out.
So I got this case a couple weeks ago
and I just thought it would be an interesting case to show. This is a lady that has metastatic renal cell carcinoma. She was diagnosed 2015. She had a brain metastasis that was diagnosed a few months ago. This is a CT scan.
Here's the MRI showing this left temporal lesion that's probably responsible for all this edema. Small tumor, lot of edema, usually metastasis. But she had another lesion in the skull. That one, they resected this one and they radiated the other two lesions.
They did stereotactic radiosurgery, and it did not work. Here's that lesion, the picture you just saw. Here's a month later, here's 2 1/2 months later, so it grew rapidly. And you can see it went through the bone, right? This thing sits, this is our surgical planning software.
It flips the image because surgeons operate from the top, so it's still on the right. There's the tumor, it's got an epidural component, and then it's got this subdural component. If we put our little Google man on there, you can see it from the surface.
So we decided to just do a percutaneous embo for this. Basically we're gonna stick a needle in it and do an Onyx injection. If it wasn't just convenient, it was also, she had pretty bad access. These are iliac and femoral stents,
pretty bad vascular access. So here's the tumorgram, take some contrast and inject it into the tumor, so we stuck the needle in the tumor and you could see this extravasation into the tumor, and then we inject some Onyx.
And then we'll move the needle a little bit. Here is the Onyx in the front. I went a little deeper with the Onyx needle this time and we give some more. I just put this movie in 'cause you can actually see the Onyx going out of the syringe,
which I thought was kinda neat. It's neat 'cause it's not my hand. And you can see the Onyx down here. Again, Onyx did a decent job getting the epidural part of this. It did not do a great job penetrating through the dura,
probably because we didn't push the needle in deeply enough. I was okay with that, I think this turned out to be a pretty good embo. I really wanted to stop here, I was starting to get, I did a DCT to do all that, and you can actually see some subarachnoid hemorrhage here, or subarachnoid contrast.
I felt like we had probably done enough and we'd just let her go to surgery at that point. Here's a gross pathology, you can see all the Onyx in there, and if you ever do Onyx injections for a tumor, just remind the surgeons that it is flammable. Some of the used cauterate will spark.
Tell 'em after you do it (laughs). (audience laughing) Post-resection imaging looked good. You know, she's not cured. She still has metastatic renal cell cancer, but the tumor came out without a lot of blood loss,
and she did not have a stroke. So the percutaneous route, I don't use it a lot, but it's useful when you don't really have an intravascular route. It is fast when you can do it, and it can be effective. Usually, the skull's in the way,
so if you have an opportunity to try it, it's definitely a good way to do it. I think probably liquid agents are better than particles, but I'm happy to hear any comments if anyone has a thought about it.
I don't know if you know what trigeminal neuralgia is, but basically it's facial pain. We a lot of times do a surgical procedure to move the artery
off the nerve that's causing the problem, but it doesn't always work, so sometimes we'll use these injections to kind of demyelinate the nerve and reduce the pain for a while, at least. Usually we use fluoro views to do this, so basically,
you take a needle and you stick it in someone's cheek and you drive it into the skull base. And you're looking for a hole here called the foramen ovale, which would be right here. And this procedure can certainly be done under x-ray. There's your needle, kinda bullseye view,
top of the needle would be there, there's your view. But if you do a 3D, you really get a good sense as to exactly where that needle is going. You can see right here, that's where the needle goes in, right away from the mouth, he's intubated. So there's our needle there.
So there's the foramen ovale right there with a needle going into it. So now I do this procedure, I'm not getting a lot of spinal fluid back. There's supposed to be a little bit of spinal fluid once you get in the trigeminal cistern.
And there's the foramen ovale on the 2Ds. Here's the needle coming in, here are the teeth. You kinda have your finger in your mouth when you do this. You actually put it on the outside of their teeth to guide the needle so you don't go into the cheek. And then it enters the skull base, and it really ends,
it's supposed to end in that trigeminal cistern. I'm gonna put all this up just to tell you the guy did not do great with this procedure. He wasn't injured by it, but he didn't get any better, and I figured out why later when I merged some images together.
So this is the DCT and this is his preoperative MRI. This guy, by the way, already had a microvascular decompression, so he really had not many good options left. If you look at this carefully, here's your needle. It's coming in, there's the foramen ovale, right,
goes in there, and the MRI, I never quite reached this area. I have a couple of other better pictures of that. That is the trigeminal cistern. Again, here's the needle, just wasn't quite deep enough. So I made this trajectory and just never quite reached right there.
But by the fluoro landmarks, it looked like I was too deep. Just happened to be his anatomy. He just had a different type of skull base and the procedure really didn't work because we didn't have those reconstructions. And now, at least if I don't get everything I want now,
I try to do those fusions if we can. And it doesn't really take long. It's something you can do pretty rapidly. You can actually load the images the night before if you want to.
Alright, let me show the last case. It's a carotid blowout. 55 year old, this guy had laryngeal cancer, history of radiation and had had radiotherapy, and he was bleeding from his mouth and oropharynx.
I did an angiogram the day before the case I'm gonna show you. (coughs) That was the right internal carotid artery. Looked pretty ragged, but I didn't see any areas of extravasation. I ended up doing some, here's a cross-filling again.
Can't harp on that any more, right? I ended up doing this, they insisted that something was bleeding, so I went in and did this ascending cervical artery embo off the thyrocervical trunk with some coils, but I didn't feel like we really
accomplished much with this. Again, he wasn't injured by it, but then they said maybe his bleeding was a little bit better, but the next day, I get a call that he is basically bleeding out on the ICU. They're trying to pack him.
He's wide awake but he's trached, so they want me to bring him down and try to embolize the carotid artery. Here's the first run. (coughs) So he's definitely bleeding a lot at this point, and pointing at it as it pools on the floor. We knew we had cross-filling, so I had a feeling
I could probably sacrifice his carotid artery. I was a little concerned about just doing a proximal sacrifice. Here's all the images kinda laid up on each other. So imagine these are the vessels you're dealing with, right? If we just take it here, maybe the blood flow
will still get out and he's still bleed. And so I kinda wanted to go proximal distal to the lesion to try to make sure that he wasn't gonna bleed. So this was an ASCENT balloon, so basically I put this balloon up. It's a balloon catheter that you can coil through.
It's got the right markers for coiling. Here you can see that we stopped the bleeding. That's where the bleeding point was, and then I put some coils distal, so that's distal embolization. I wasn't showing off here.
The balloon's actually still inflated, but it must have come down a little bit. I did a run from the bottom and you can see there's no flow now through the carotid distally, but he's still bleeding, and you can see the balloon just barely on that run right here,
just incompletely inflated. So I pulled the balloon back a little bit, reinflated, now I have stopped the bleeding again. And then we placed some more coils, and then we put a AMPLATZER device in. Now when we do a run,
we have no flow. There's our cross-filling, and if we were gonna get bleeding, it would look like that, but we didn't. This guy, of course, he had malignant cancer, too, but he did live another year and a half,
so this gave him some time with his family. Are we over? Let's stop, I always have more stuff, so. All right, does anyone have any questions?
Yeah. (woman speaks faintly)
Depends, so they're supposed to last a few months, but the disease itself has ups and downs, so you just need to get 'em over the hump, and then a lot of times they'll restart their meds or they'll go into remission for a while. And so the functional lasting could be years.
You just wanna get 'em over the really miserable part so you can kinda reset their pain a little bit in the beginning. But months would be the answer. Yeah. - [Woman] I was wondering, so if we get a patient
(speaks faintly) be operated on, you had (speaks faintly) in that case, knowing that they (speaks faintly). - I joke a little bit about it. It's not that flammable. So when you use a Bovie or something that's on a lot of power, it will spark a little bit.
I mean, I do this on my own patients, too, and so the surgeon will see that and, you know, just prepare them to see some of the stuff, and it's not usually, to be honest with you, a big deal. We do it in AVMs all the time. You know, Onyx is FDA-approved for AVMs
and we use bipolars and AVMs all the time without much of a problem. So I don't wanna overstate the problem, but I think because the tumors get a lot of it, they notice it a little bit more. And they're not vascular surgeons,
so they're not only using bipolars. Some of them will use monopolar devices, too. All right, that's it, I guess we're done. (audience applauding)
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