Case: 18M MCA Aneurysm | Without A Scalpel: Neuro Intervention
Case: 18M MCA Aneurysm | Without A Scalpel: Neuro Intervention
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Here's another interesting case, another young person. This is an 18 year old male college student. Basically, he had a seizure. Lab work was unremarkable. Yeah, all right, he coulda had a lot of things, right?

Obviously I wouldn't be showing you any of those things, but we're looking at AVMs, tumors, cavernomas, congenital lesions, abscesses. Here's the initial CT. You can see a lesion here, kinda strange, right? It's very round, doesn't look like it's in a place

where an aneurysm would be. We saw this, you can see this lesion, again, very round. Sort of enhances a little bit but not a lot. Here it almost looks like a cavernoma, and I think that was our preferred diagnosis at the time. This sort of has a cavernoma look, appearance to it.

Cavernomas typically present with seizures, so that was our working diagnosis, but, if you look carefully at the MRA, there's maybe a little bit of irregularity in this vessel. And pretty much everybody gets a CTA now, and this is what we found.

So on the CTA, you can see a much more prominent irregularity. He's got this inflow vessel here and outflow vessel here. We wanted to look at them more carefully, so we told 'em we would do an angiogram. Here's that lesion, looks a little bit more significant

on the angiogram, a little bigger. Kinda hangs out in the venous phase, which probably explains why it enhances. This was our 3D spin, 3D CT reconstruction here. So we want to do this, we decided to do this

through an endovascular procedure. Basically we put a catheter up in the middle cerebral artery and we did a microcatheter run right proximal to the vessel. We did this procedure awake. We microcatheterized him awake, and then while he was awake, we injected, one at a time,

Brevital and Amytal into that vessel. Brevital is basically a barbiturate, puts the gray matter to sleep. Lidocaine works to inhibit the white matter firing. The idea is that you basically numb that part of the brain to see how eloquent it is, and we didn't notice any changes,

neurological changes in him, so we felt that this would be a safe vessel to embolize. And we didn't plan on doing any distal embolization, so we just wanted to make sure what was the worst-case scenario for embolization for him. So that's the distribution of the drug

going into the microcatheter. Here's the first coil, microcatheter and coil in the aneurysm. There's my microcatheter, there are the coils. You can see I started to coil this thing, catheter's still here.

Here's the coil mass. There's where the rest of that vessel was supposed to be. And the reason I'm showing you this is a lot of times, when you do a proximal takedown of an aneurysm like this, sorry.

Thanks, nope, there it goes. All right, so I tried to do a microcatheter angiogram so you could see the aneurysm's fully occluded even with the microcatheter. No filling of the aneurysm. I'm gonna try to show these pial collaterals, so now,

I had some graphics on here but I'm gonna just point, 'cause I think it's easier to see. So that vessels's still backfilling. You see how the vessel comes? You see the contrast is not going directly through the aneurysm.

It's coming through these pial collaterals, and you see that little bit of flow coming right to the tip of the aneurysm, so he really had no, there was really no significant loss of vasculature in him. And I can prove that, there's aneurysms,

there's my backward pial collateral. Well, that was a post-op MRI. It's not a movie, but you'll have to take my word for it, there was no stroke. And he did well.

as well as the chemical. In thermal RFA, the target is to get the nerve to 70 to 90 degrees, which basically then disrupts the axonal continuity.

You get this Wallerian degeneration of the nerve because you disrupt the myelin, and the axon, and the endoneurium. Basically you're doing what the surgeon does by basically stopping that conduction of the nerve. Pulsed RFA is a newer way of addressing this

and this is not entirely well understood. Basically you're doing a non-lethal ablation affecting what's called modulations. You're modulating the nerve by passing an electric current across the nerve. And what that's supposed to do is reset the nerve.

There's actually genetic changes that occur in the dorsal root ganglion based on doing this modulation. I will tell you that if I ask my colleagues on this esteemed panel, how does pulsed RFA work, they would all give me kind of funny looks, I suspect. Because it really isn't totally understood right now.

Cryoablation is similar to thermal RFA where you basically are damaging the nerve

in that case. The next subject, which is splenic steal syndrome, which is a very complex subject.

Splenic steal syndrome, or NOHAH, that's non-exclusive hepatic artery hyperprofusion basically means that the hepatic artery's open, but there's slow flow in it, so it's not anatomical. This is a hemodynamic problem. It is not an anatomical defect.

It's not a thrombosis, it's not an aneurysm, it is not a stricture, it is not a kink. The artery is a wide open pump, but flow is going through it very slowly. The idea on this is to go as proximal as possible and is to impede flow, slow down the flow,

not necessarily shut it off, but slow down the flow significantly. Go proximal as possible to allow collaterals to keep the spleen alive. It is not a splenic artery embolization where you use particles.

We've talked a little bit or touched on some of the traditional blocks, Demetrius has kind of run through some of those, so I won't be covering those. But the concept is that basically you put your needle

in the space, you inject a little contrast to make sure you're in a safe position and then you give a combination of lidocaine and a longer acting agent like bupivacaine with a steroid and then that's the block. Once you've done that and diagnosed that that's actually

addressed the problem and is addressing the pain, you can then move on to the neurolysis and ablation where you're sort of more permanently blocking that. We started incorporating some of the more complex sympathetic blocks into our practice which really, many of the pain specialists out there

shy away from because they're much more heavily reliant on imaging and that's where we shine, and that's where you all come in to help us to use the guidance techniques that William talked about to sort of get us to some of these more difficult places to reach.

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