Intermittent Orbital Pain due to Hemodynamic Collapse of an Orbital Varix: A Case Report

Orbital varices typically present with symptoms related to dilation or thrombosis. We describe a rare presentation of an orbital varix with pain caused by hemodynamic collapse of the varix. A woman in the third decade presented with position-dependent orbital pain and enophthalmos. She was found to have an intraorbital varix and a separate pterygoid varix. The patient underwent endovascular treatment of the pterygoid varix using coils and sclerosing agents which altered the venous outflow from the orbital varix. The patient had immediate resolution of symptoms after the procedure. Our findings suggest that extraorbital venous outflow abnormalities may be the cause of symptoms in selected cases of orbital varices. By understanding the venous structures on cerebral angiography and treating the extraorbital component, orbital intervention may be avoided, reducing the risk of complications

Cessation and Resumption of Elective Neurointerventional Procedures during the Coronavirus Disease 2019 Pandemic and Future Pandemics

At the time of this writing, the coronavirus disease 2019 pandemic continues to be a global threat, disrupting usual processes, and protocols for delivering health care around the globe. There have been significant regional and national differences in the scope and timing of these disruptions. Many hospitals were forced to temporarily halt elective neurointerventional procedures with the first wave of the pandemic in the spring of 2020, in order to prioritize allocation of resources for acutely ill patients and also to minimize coronavirus disease 2019 transmission risks to non-acute patients, their families, and health care workers. This temporary moratorium on elective neurointerventional procedures is generally credited with helping to flatten the curve and direct scarce resources to more acutely ill patients; however, there have been reports of some delaying seeking medical care when it was in fact urgent, and other reports of patients having elective treatment delayed with the result of morbidity and mortality. Many regions have resumed elective neurointerventional procedures, only to now watch coronavirus disease 2019 positivity rates again climbing as winter of 2020 approaches. A new wave is now forecast which may have larger volumes of hospitalized coronavirus disease 2019 patients than the earlier wave(s) and may also coincide with a wave of patients hospitalized with seasonal influenza. This paper discusses relevant and practical elements of cessation and safe resumption of nonemergent neurointerventional services in the setting of a pandemic

Abstract Number ‐ 105: Development of Non‐Surgical Intracranial Access to the Subdural Space for Theranostic Applications in Neurology

Introduction The objective of this study was to test the hypothesis thattrans‐duralvenous sinus (tDVS)puncture from within the Superior Sagittal Sinus (SSS) is feasible. Furthermore, we determine the feasibility of accessing extravascular intracranial spaces overlying the cortex using an endovascular Inside‐Out (‘I/O’) tDVS. Aims: 1.Characterize puncture of the SSS using different size profiles and perform force measurements on benchtop and ex‐vivo models. 2.Identify the system requirements for endoluminal opposition to mediate controlled tDVSpenetration. 3.Demonstrate a system capable of tDVSpenetration and subdural‐meningeal access over the cortical convexity. Methods Silicone tube and 3D printed Superior Sagittal Sinus models were developed to assess different systems. Various re‐entry catheters (Cordis Outback, Philips Pioneer, BS Stingray LP CTO), as well as a modified construct (comprised of a 5Fr angio catheter, a BS OffroadLancet, and a distal‐end‐cut 0.014” microguidewire), were each tested on silicone tube models. To provide endoluminal apposition for controlledtDVSpenetration, various stents, stentrievers, non‐compliant balloon and compliant balloon catheters were assessed in conjunction with penetrator devices on tubular and ex‐vivo cadaveric models. To measure the force of various penetrator devices, a vector force gauge was used (3 trials by 2 independent operators). The Right Internal Jugular Vein access in a human cadaver was obtained by cut‐down and a purse string suture. Balloon microcatheters were advanced into the SSS under fluoroscopy. SSS catheterization with re‐entry devices required transcranial burr hole access due to inability to advance these beyond the jugular‐sigmoid junction. Results The Cordis Outback Re‐Entry device abuttedendoluminallyby a compliant balloon (Stryker Transform) most reliably enabled tDVSpuncture on ex‐vivo specimens (Figure 1). Only the compliant balloon provided adequate endoluminal radial support for penetrator deployment on silicon tube models, as well as enabled repositioning. The modified construct was also successful in penetrating the DVS, but required extensive manual manipulation for optimal positioning and apposition. The other support devices resulted either in kickback or insufficient radial support. In the cadaver, The Outback device markers were oriented to penetrate the SSS in a para‐sagittal trajectory after inflating the complaint balloon. The 22G cannula was deployed, and under fluoroscopy, an exchange‐lengthmicroguidewirewas advanced through the Outback and into subdural‐meningeal space. The Outback was then exchanged for a 0.021” microcatheter. Once in the subdural‐meningeal space, themicroguidewirewas withdrawn and contrast injections were performed to assess the space catheterized, which was confirmed as subdural (Figure 2). Conclusions •Controlled tDVS penetration from an endovascular locationis feasible with minimal force using a complaint endoluminal support structure. •Catheter access beneath the intracranial subdural meningeal space overlying the cortex may represent a viable route fortheranosticneurologic applications. •An in‐vivol study is needed to establish the feasibility and safety of tDVS access to the cortical surface

Intermittent Orbital Pain due to Hemodynamic Collapse of an Orbital Varix: A Case Report.

Orbital varices typically present with symptoms related to dilation or thrombosis. We describe a rare presentation of an orbital varix with pain caused by hemodynamic collapse of the varix. A woman in the third decade presented with position-dependent orbital pain and enophthalmos. She was found to have an intraorbital varix and a separate pterygoid varix. The patient underwent endovascular treatment of the pterygoid varix using coils and sclerosing agents which altered the venous outflow from the orbital varix. The patient had immediate resolution of symptoms after the procedure. Our findings suggest that extraorbital venous outflow abnormalities may be the cause of symptoms in selected cases of orbital varices. By understanding the venous structures on cerebral angiography and treating the extraorbital component, orbital intervention may be avoided, reducing the risk of complications

Endovascular repair of a complex renal artery aneurysm using PipelineTM Embolization Device (PED) assisted coil embolization.

BackgroundWe describe the treatment of a renal artery aneurysm with complex anatomy using coils and the PipelineTM Embolization Device (Medtronic, Irvine, CA), a flow-diverting stent typically used for the treatment of intracranial aneurysms.MethodsA 62-year-old female with history of an asymptomatic right renal artery aneurysm that was discovered incidentally 10 years ago was found to have enlargement of the aneurysm (1.9cm to 2.7cm) on a repeat surveillance CT scan. She was successfully treated with combined Pipeline Embolization Device and coil embolization of the aneurysm sac.ResultsPost-procedural angiography showed complete occlusion of the aneurysm with maintenance of perfusion to the entire kidney.ConclusionPipelineTM assisted coil embolization may be an option for parenchyma-sparing treatment of renal artery aneurysms with complex anatomy

Robotic assistant spinal angiography: a case report and technical considerations

Robotic-assisted technology has shown to be promising in coronary and peripheral vascular interventions. Early case reports have also demonstrated its efficacy in neuro-interventions. However, there is no prior report demonstrating use of the robotic-assisted platform for spinal angiography. We report the feasibility of the robotic-assisted thoracic and lumbar spinal angiography

Hemodynamic Effect of Unequal Anterior Cerebral Artery Flow Rates on the Anterior Communicating Artery Bifurcation: A Computational Fluid Dynamics Study

Computational fluid dynamics techniques were used to investigate the hemodynamic effect of unequal anterior cerebral artery flow rates on the anterior cerebral and anterior communicating artery (ACA-ACOM) bifurcation. Hemodynamics have long been implicated as a major factor in cerebrovascular disease. Using an idealized 2D symmetric model of the ACA-ACOM geometry, the flow field and wall shear stress (WSS) at the bifurcation regions are assessed for pulsatile inflows with left to right flow ratios of 1:1, 2:1, 3:1, and 4:1. Unequal flow rates through the ACA parent arteries result in bifurcation of the higher flow parent stream and a shifting of the impingement points along the A2-ACOM adjoining wall toward the contralateral ACA. Cross-flow through the ACOM is generally unstable and results in increased WSS at the impingement region from the higher flow parent artery and a double amplitude peak in the WSS at the contralateral bifurcation region from local recirculation effects. These results suggest that asymmetry in ACA flow rates result in increased hemodynamic stresses at the ACA-ACOM bifurcation regions and suggest a possible factor for vessel weakening and aneurysm formation

Nature’s Wastebasket: The Role of the External Carotid Artery in Acute Stroke

We describe a novel technical approach to acute stroke illustrated by the case of a 41 year old male who presented with tandem right common carotid artery (CCA) and M1 occlusions. His NIHSS was 17 and Alberta stroke programe early CT score (ASPECTs) was 8. Thrombectomy initially proved challenging due to large volume CCA thrombus that repeatedly occluded the aspiration catheters. However, by inflating a balloon distally and pulling clot into the adjacent ECA, we were able to quickly restore distal contrast flow to the intracranial circulation and achieve Thrombolysis In Cerebral Infarction/Arterial Occlusive Lesion (TICI2C/AOL3) revascularization