Publications by authors named "Bharathi D Jagadeesan"

34 Publications

Editorial for "Tractometry Based Estimation of Corticospinal Tract Injury to Assess Initial Impairment and Predict Functional Outcomes in Ischemic Stroke Patients".

J Magn Reson Imaging 2021 Oct 19. Epub 2021 Oct 19.

Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA.

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http://dx.doi.org/10.1002/jmri.27961DOI Listing
October 2021

The social media conundrum.

J Neurointerv Surg 2021 Oct;13(10):861-862

Department of Radiology, Neurosurgery and Neurology, University of Minnesota, Minneapolis, Minnesota, USA.

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http://dx.doi.org/10.1136/neurintsurg-2021-018177DOI Listing
October 2021

Safety of the APOLLO Onyx delivery microcatheter for embolization of brain arteriovenous malformations: results from a prospective post-market study.

J Neurointerv Surg 2021 Oct 1;13(10):935-941. Epub 2021 Feb 1.

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Background: Catheter retention and difficulty in retrieval have been observed during embolization of brain arteriovenous malformations (bAVMs) with the Onyx liquid embolic system (Onyx). The Apollo Onyx delivery microcatheter (Apollo) is a single lumen catheter designed for controlled delivery of Onyx into the neurovasculature, with a detachable distal tip to aid catheter retrieval. This study evaluates the safety of the Apollo for delivery of Onyx during embolization of bAVMs.

Methods: This was a prospective, non-randomized, single-arm, multicenter, post-market study of patients with a bAVM who underwent Onyx embolization with the Apollo between May 2015 and February 2018. The primary endpoint was any catheter-related adverse event (AE) at 30 days, such as unintentional tip detachment or malfunction with clinical sequelae, or retained catheter. Procedure-related AEs (untoward medical occurrence, disease, injury, or clinical signs) and serious AEs (life threatening illness or injury, permanent physiological impairment, hospitalization, or requiring intervention) were also recorded.

Results: A total of 112 patients were enrolled (mean age 44.1±17.6 years, 56.3% men), and 201 Apollo devices were used in 142 embolization procedures. The mean Spetzler-Martin grade was 2.38. The primary endpoint was not observed (0/112, 0%). The catheter tip detached during 83 (58.5%) procedures, of which 2 (2.4%) were unintentional and did not result in clinical sequelae. At 30 days, procedure related AEs occurred in 26 (23.2%) patients, and procedure-related serious AEs in 12 (10.7%). At 12 months, there were 3 (2.7%) mortalities, including 2 (1.8%) neurological deaths, none of which were device-related.

Conclusion: This study demonstrates the safety of Apollo for Onyx embolization of bAVMs.

Clinical Trial Registration: CNCT02378883.
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http://dx.doi.org/10.1136/neurintsurg-2020-016830DOI Listing
October 2021

The next step in balloon assisted endovascular neurosurgical procedures: A case series of initial experience with the Scepter Mini balloon microcatheter.

Interv Neuroradiol 2021 Apr 8;27(2):298-306. Epub 2020 Nov 8.

Department of Neurology, Neurosurgery and Radiology, University of Minnesota, Minneapolis, MN, USA.

Background: The use of compliant dual lumen balloon microcatheters (CDLB) for the endovascular treatment of vascular malformations, wide neck aneurysms, and intracranial angioplasty (for vasospasm) is well documented. Navigation of 4 mm or larger CDLB within tortuous and small distal intracranial vessels can be challenging. Recently, the lower profile Scepter Mini balloon microcatheter (SMB) has been approved for use, with potential for improved intracranial navigation.

Objective: Discuss operative experience of Scepter Mini (Microvention, Aliso Viejo, CA).

Methods: We describe our initial experience with the SMB in a series of nine patients.

Results: The balloon microcatheter was used for delivery of liquid embolic in six patients (Case 1, 2, 6-9), adjunct support for delivery or positioning of the Woven Endobridge (WEB) device in two (Case 3,4), and gentle post-deployment repositioning of a WEB device in the last one (Case 5). We were able to successfully navigate the SMB over a 0.008 "micro wire to the target lesion in all the patients. We experienced initial difficulty with injecting liquid embolic in Case 2. We postulate that the SMB was in a tortuous segment of a dural vessel in this patient, and that it kinked on inflation with occlusion of the liquid embolic delivery lumen; this was overcome with slightly proximal repositioning and reinflation of the SMB.

Conclusion: Our initial experience shows that the SMB has potential to be useful in endovascular neurosurgical procedures requiring balloon assistance within smaller diameter blood vessels.
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http://dx.doi.org/10.1177/1591019920972884DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8050521PMC
April 2021

MR Imaging Safety in the Interventional Environment.

Magn Reson Imaging Clin N Am 2020 Nov 17;28(4):583-591. Epub 2020 Sep 17.

Radiology, Neurology and Neurosurgery, University of Minnesota, MMC 292, Mayo Memorial Building, 420 Delaware Street SE, Minneapolis, MN 55455, USA. Electronic address:

Interventional MR imaging procedures are rapidly growing in number owing to the excellent soft tissue resolution of MR imaging, lack of ionizing radiation, hardware and software advancements, and technical developments in MR imaging-compatible robots, lasers, and ultrasound equipment. The safe operation of an interventional MR imaging system is a complex undertaking, which is only possible with multidisciplinary planning, training, operations and oversight. Safety for both patients and operators is essential for successful operations. Herein, we review the safety concerns, solutions and challenges associated with the operation of a modern interventional MR imaging system.
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http://dx.doi.org/10.1016/j.mric.2020.07.007DOI Listing
November 2020

Thrombectomy in DAWN- and DEFUSE-3-Ineligible Patients: A Subgroup Analysis From the BEST Prospective Cohort Study.

Neurosurgery 2020 02;86(2):E156-E163

Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee.

Background: Because of the overwhelming benefit of thrombectomy for highly selected trial patients with large vessel occlusion (LVO), some trial-ineligible patients are being treated in practice.

Objective: To determine the safety and efficacy of thrombectomy in DAWN/DEFUSE-3-ineligible patients.

Methods: Using a multicenter prospective observational study of consecutive patients with anterior circulation LVO who underwent late thrombectomy, we compared symptomatic intracerebral hemorrhage (sICH) and good outcome (90-d mRS 0-2) among DAWN/DEFUSE-3-ineligible patients to trial-eligible patients and to untreated DAWN/DEFUSE-3 controls.

Results: Ninety-eight patients had perfusion imaging and underwent thrombectomy >6 h; 46 (47%) were trial ineligible (41% M2 occlusions, 39% mild deficits, 28% ASPECTS <6). In multivariable regression, the odds of a good outcome (aOR 0.76, 95% CI 0.49-1.19) and sICH (aOR 3.33, 95% CI 0.42-26.12) were not different among trial-ineligible vs eligible patients. Patients with mild deficits were more likely to achieve a good outcome (aOR 3.62, 95% CI 1.48-8.86) and less sICH (0% vs 10%, P = .16), whereas patients with ASPECTS <6 had poorer outcomes (aOR 0.14, 95% CI 0.05-0.44) and more sICH (aOR 24, 95% CI 5.7-103). Compared to untreated DAWN/DEFUSE-3 controls, trial-ineligible patients had more sICH (13%BEST vs 3%DAWN [P = .02] vs 4%DEFUSE [P = .05]), but were more likely to achieve a good outcome at 90 d (36%BEST vs 13%DAWN [P < .01] vs 17%DEFUSE [P = .01]).

Conclusion: Thrombectomy is used in practice for some patients ineligible for the DAWN/DEFUSE-3 trials with potentially favorable outcomes. Additional trials are needed to confirm the safety and efficacy of thrombectomy in broader populations, such as large core infarction and M2 occlusions.
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http://dx.doi.org/10.1093/neuros/nyz485DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8204769PMC
February 2020

Stent-Assisted Woven EndoBridge Implantation for Treatment of Wide-Necked Aneurysm Residual: Angiographic Video.

World Neurosurg 2019 Sep 19;129:276. Epub 2019 Jun 19.

Department of Neurology, Neurosurgery and Radiology, University of Minnesota, Minneapolis, Minnesota, USA.

Woven EndoBridge (WEB) is an intrasaccular flow-disrupting device that has recently been approved by the U.S. Food and Drug Administration (FDA) for treatment of wide-neck ruptured and unruptured aneurysms at arterial bifurcations. Successful and effective treatment of aneurysms with the WEB device requires accurate sizing. For optimal positioning of the WEB device within the aneurysm sac, the diameter of the device has to exceed by the mean diameter of the aneurysm by 1.0 mm. However, this predictably results in an increase in the height of the device. In shallow, wide-necked aneurysms, this increase in height of the WEB device could result in encroachment of the device on the parent artery or branch vessel origins. In these circumstances, the placement of an intracranial stent can prevent such encroachment. In this video, we demonstrate the operative technique of stent-assisted WEB device placement that was performed at our institution for the treatment of a recurrent basilar apex aneurysm (Video 1). This previously ruptured aneurysm had been treated initially with primary coil embolization, and the patient consented to endovascular treatment of her aneurysm recurrence. The video illustrates this procedure using a combination of fluoroscopic images, fluoroscopic cines, and digital subtraction angiograms.
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http://dx.doi.org/10.1016/j.wneu.2019.06.079DOI Listing
September 2019

Development of a Novel Canine Model of Ischemic Stroke: Skull Base Approach with Transient Middle Cerebral Artery Occlusion.

World Neurosurg 2019 Jul 19;127:e251-e260. Epub 2019 Mar 19.

Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA; Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA; Stem Cell Institute, University of Minnesota, Minneapolis, Minnesota, USA. Electronic address:

Objective: Although canine stroke models have several intrinsic advantages, establishing consistent and reproducible territorial stroke in these models has been challenging because of the abundance of collateral circulation. We have described a skull-base surgical approach that yields reproducible stroke volumes.

Methods: Ten male beagles were studied. In all 10 dogs, a craniectomy was performed to expose the circle of Willis. Cerebral aneurysm clips were temporarily applied to the middle cerebral artery (MCA), anterior cerebral artery (ACA), posterior cerebral artery, and/or ophthalmic artery (OA) for 1 hour, followed by cauterization of the distal MCA pial collateral vessels. Indocyanine green angiography was performed to assess the local blood flow to the intended area of infarction. The dogs' neurologic examination was evaluated, and the stroke burden was quantified using magnetic resonance imaging.

Results: High mortality was observed after 1-hour clip occlusion of the posterior cerebral artery, MCA, ACA, and OA (n = 4). Without coagulation of the MCA collateral vessels, 1-hour occlusion of the MCA and/or ACA and OA yielded inconsistent stroke volumes (n = 2). In contrast, after coagulation of the distal MCA pial collateral vessels, 1-hour occlusion of the MCA, ACA, and OA yielded consistent territorial stroke volumes (n = 4; average stroke volume, 9.13 ± 0.90 cm; no surgical mortalities), with reproducible neurologic deficits.

Conclusion: Consistent stroke volumes can be achieved in male beagles using a skull base surgical approach with temporary occlusion of the MCA, ACA, and OA when combined with cauterization of the distal MCA pial collateral vessels.
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http://dx.doi.org/10.1016/j.wneu.2019.03.082DOI Listing
July 2019

Gadolinium to the rescue for mechanical thrombectomy in acute ischemic stroke.

Interv Neuroradiol 2019 Jun 19;25(3):301-304. Epub 2018 Dec 19.

2 Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA.

Introduction: Mechanical thrombectomy in the setting of acute ischemic stroke (AIS) requires cerebral digital subtraction angiography (DSA), typically performed with iodinated contrast medium. We present a case of emergent cerebral DSA and mechanical thrombectomy using gadolinium-based contrast for cerebral DSA in a patient with a history of anaphylaxis to iodinated contrast agents (ICs).

Case Report: A 72-year-old man developed left ventricle assist device thrombus while on anticoagulation. During hospitalization he suffered right middle cerebral artery occlusion with a National Institutes of Health stroke scale score of 10. He had a history of anaphylaxis and the advanced directives revealed do not resuscitate/do not intubate status. We performed an emergent DSA as part of thrombectomy procedure using gadolinium-based contrast mixed in 1:1 proportion with normal saline. The images obtained were of adequate quality and the patient underwent successful thrombectomy with modified thrombolysis in cerebral infarction 2B recanalization.

Conclusion: Gadolinium-based contrast agents could be effective alternatives for cerebral DSA in patients undergoing mechanical thrombectomy for AIS who have a history of anaphylactic reaction to ICs.
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http://dx.doi.org/10.1177/1591019918815298DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6547216PMC
June 2019

Safety and Feasibility of Balloon-Assisted Embolization with Onyx of Brain Arteriovenous Malformations Revisited: Personal Experience with the Scepter XC Balloon Microcatheter.

Interv Neurol 2018 Oct 13;7(6):439-444. Epub 2018 Jul 13.

Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA.

Background/objective: Compliant dual-lumen balloon microcatheters have been used to perform balloon-assisted embolization (BAE) of brain arteriovenous malformations (AVMs) with ethylene vinyl alcohol copolymer (Onyx). However, vessel rupture and microcatheter retention have been reported from BAE using these microcatheters. Using an extra-compliant balloon microcatheter (Scepter XC; Microvention, Tustin, CA, USA) could help avoid pial vessel rupture during BAE. We herein report our experience using this balloon microcatheter for BAE.

Methods: This retrospective study included patients who underwent BAE of brain AVMs at our institution between June 2012 and March 2017.

Results: The extra-compliant Scepter XC balloon microcatheter was used for BAE of brain AVMs in 23 patients aged 44.3 ± 16.7 years (range 0-65 years). A total of 40 intracranial vessels (39 pial arteries and 1 pial vein) were catheterized and embolized during 30 separate sessions. In all instances, the balloon microcatheter could be successfully advanced to the AVM nidus. A mean volume of 2.4 ± 1.7 mL (range 0.65-4.6 mL) of Onyx was injected per session. There were no instances of vessel rupture, microcatheter retention, or stroke.

Conclusion: Utilization of the extra-compliant balloon microcatheter results in safe and effective BAE, which adds to the growing experience with BAE for AVM treatment.
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http://dx.doi.org/10.1159/000490579DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6216782PMC
October 2018

Embolization of a complex coronary to pulmonary artery fistula using balloon assisted liquid embolic injection: A novel technique.

Catheter Cardiovasc Interv 2018 12 18;92(7):E453-E455. Epub 2018 Jul 18.

Departments of Medicine, Cardiovascular, University of Minnesota, Minneapolis, Minnesota.

Complex Coronary artery to Pulmonary artery fistulas (CPFs) can be difficult to manage with embolization or ligation. An 88-year-old woman with exertional angina was found to have a complex precordial CPF, severe Mitral regurgitation, and Pulmonary Hypertension. CPF treatment was recommended prior to minimally invasive mitral valve replacement (to avoid postoperative myocardial ischemia from worsened steal). The CPF was supplied by multiple branches from the LAD and RCA, and formed a complex common varicosity with multiple drainage channels to the pulmonary artery. The CPF was treated by injecting a liquid embolic agent, Ethylene Vinyl Alcohol Copolymer (Onyx, Medtronic, MN), into two of the feeding arteries arising from the RCA through a Scepter C Dual lumen balloon micro catheter (Microvention, Aliso Viejo, CA. This resulted in complete obliteration of the fistula, and the patient subsequently underwent successful mitral valve replacement surgery.
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http://dx.doi.org/10.1002/ccd.27677DOI Listing
December 2018

Safety of cerebral angiography and neuroendovascular therapy in patients with chronic kidney disease.

Neuroradiology 2018 May 1;60(5):529-533. Epub 2018 Mar 1.

Department of Neurology, University of Minnesota Medical School and Hennepin County Medical Center, Minneapolis, MN, USA.

Purpose: Contrast-induced nephropathy is a common clinical concern in patients undergoing neuroendovascular procedures, especially in those with pre-existent kidney disease. We aimed to define the incidence of contrast-induced nephropathy in these high-risk patients in our practice.

Methods: We analyzed data retrospectively from patients undergoing neuroendovascular procedures at two academic medical centers over a 4-year period. Contrast-induced nephropathy was determined by an absolute increase in serum creatinine of 0.5 mg/dL or a rise from its baseline value by ≥ 25%, at 48-72 h after exposure to contrast agent after excluding other causes of renal impairment. High-risk patients were identified as those with pre-procedural estimated glomerular filtration rate < 60 mL/min irrespective of creatinine level, corresponding to stages 3-5 of chronic kidney disease.

Results: One hundred eighty-five high-risk patients undergoing conventional cerebral angiography and neuroendovascular interventions were identified. Only 1 out of 184 (0.54%) high-risk patients developed contrast-induced nephropathy. That one patient had stage 5 chronic kidney disease and multiple other risk factors.

Conclusion: We have observed a very low rate of renal injury in patients with chronic kidney disease, traditionally considered high risk for neuroendovascular procedures. Multiple factors may be responsible in the risk reduction of contrast-induced nephropathy in this patient population.
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http://dx.doi.org/10.1007/s00234-018-1996-2DOI Listing
May 2018

ACR Appropriateness Criteria Cranial Neuropathy.

J Am Coll Radiol 2017 Nov;14(11S):S406-S420

Specialty Chair, University of Cincinnati Medical Center, Cincinnati, Ohio.

Evaluation of cranial neuropathy can be complex given the different pathway of each cranial nerve as well as the associated anatomic landmarks. Radiological evaluation requires imaging of the entire course of the nerve from its nucleus to the end organ. MRI is the modality of choice with CT playing a complementary role, particularly in the evaluation of the bone anatomy. Since neoplastic and inflammatory lesions are prevalent on the differential diagnosis, contrast enhanced studies are preferred when possible. The American College of Radiology Appropriateness Criteria are evidencebased guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2017.08.035DOI Listing
November 2017

Salvage of Herniated Flow Diverters Using Stent and Balloon Anchoring Techniques: A Technical Note.

Interv Neurol 2017 Mar 11;6(1-2):31-35. Epub 2016 Nov 11.

Department of Radiology, Minneapolis MN, USA.

Background: The pipeline embolization device (PED; Medtronic, MN, USA) can sometimes herniate into the aneurysmal sac in an unexpected manner during or shortly after its deployment due to device foreshortening. In this report, we describe 2 endovascular techniques, which can be used to reposition a herniated PED construct into a more favorable alignment.

Summary: In a 67-year-old patient who had an intraprocedural herniation of a PED device into a giant cavernous aneurysm, a stent anchor technique was used to reverse the herniation, reorient the PED construct, and achieve successful flow diversion. In a different patient with a giant superior hypophyseal aneurysm, a balloon anchor technique followed by deployment of an LVIS Jr (Microvention, Tustin, CA, USA) stent was used to reverse the herniation into the aneurysmal sac.

Key Messages: Stent anchor and balloon anchor techniques as described here can be used to reposition PED constructs, which have unexpectedly herniated into the aneurysm sac during attempted flow diversion for the treatment of giant aneurysms.
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http://dx.doi.org/10.1159/000452284DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5465733PMC
March 2017

ACR Appropriateness Criteria Cerebrovascular Disease.

J Am Coll Radiol 2017 May;14(5S):S34-S61

Panel Chair, Emory University, Atlanta, Georgia.

Diseases of the cerebral vasculature represent a heterogeneous group of ischemic and hemorrhagic etiologies, which often manifest clinically as an acute neurologic deficit also known as stroke or less commonly with symptoms such as headache or seizures. Stroke is the fourth leading cause of death and is a leading cause of serious long-term disability in the United States. Eighty-seven percent of strokes are ischemic, 10% are due to intracerebral hemorrhage, and 3% are secondary to subarachnoid hemorrhage. The past two decades have seen significant developments in the screening, diagnosis, and treatment of ischemic and hemorrhagic causes of stroke with advancements in CT and MRI technology and novel treatment devices and techniques. Multiple different imaging modalities can be used in the evaluation of cerebrovascular disease. The different imaging modalities all have their own niches and their own advantages and disadvantages in the evaluation of cerebrovascular disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2017.01.051DOI Listing
May 2017

All that bleeds is not black: susceptibility weighted imaging of intracranial hemorrhage and the effect of T1 signal.

Clin Imaging 2017 Jan - Feb;41:69-72. Epub 2016 Oct 17.

Department of Radiology, Division of Neuroradiology, University of Minnesota, 420 Delaware St SE, Minneapolis, MN, 55455. Electronic address:

Purpose: To determine if intracranial hemorrhages (ICH) are always hypointense on Susceptibility weighted imaging (SWI) and to determine the effect of T1-signal intensity on the appearance of ICH in SWI series.

Methods: SWI and T1-signal intensities of ICH were retrospectively studied in a series of patients. SWI signal intensities were statistically correlated with T1-signal intensities.

Results: In a series of 57 MRI scans from 40 patients, ICH was hypointense in 19, mixed-intensity in 21, and hyperintense in 17. Hyperintensity of ICH on SWI was significantly associated with increased T1 signal (P<.001).

Conclusion: ICH can have a varied appearance on SWI.
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http://dx.doi.org/10.1016/j.clinimag.2016.10.009DOI Listing
January 2017

ACR Appropriateness Criteria Low Back Pain.

J Am Coll Radiol 2016 Sep 3;13(9):1069-78. Epub 2016 Aug 3.

Emory University, Atlanta, Georgia.

Most patients presenting with uncomplicated acute low back pain (LBP) and/or radiculopathy do not require imaging. Imaging is considered in those patients who have had up to 6 weeks of medical management and physical therapy that resulted in little or no improvement in their back pain. It is also considered for those patients presenting with red flags raising suspicion for serious underlying conditions, such as cauda equina syndrome, malignancy, fracture, and infection. Many imaging modalities are available to clinicians and radiologists for evaluating LBP. Application of these modalities depends largely on the working diagnosis, the urgency of the clinical problem, and comorbidities of the patient. When there is concern for fracture of the lumbar spine, multidetector CT is recommended. Those deemed to be interventional candidates, with LBP lasting for > 6 weeks having completed conservative management with persistent radiculopathic symptoms, may seek MRI. Patients with severe or progressive neurologic deficit on presentation and red flags should be evaluated with MRI. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (the RAND/UCLA Appropriateness Method and the Grading of Recommendations Assessment, Development, and Evaluation) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2016.06.008DOI Listing
September 2016

Endovascular management of a vein of Galen aneurysmal malformation in an infant with challenging femoral arterial access.

J Neurosurg Pediatr 2016 Aug 8;18(2):231-4. Epub 2016 Apr 8.

Departments of 1 Radiology.

A 5-month-old infant was to be treated with elective transarterial embolization for a vein of Galen aneurysmal malformation (VGAM). A team of endovascular surgical neuroradiologists, pediatric interventional radiologists, and pediatric cardiologists attempted conventional femoral arterial access, which was unsuccessful given the small caliber of the femoral arteries and superimposed severe vasospasm. Thereafter, eventual arterial access was achieved by navigating from the venous to the arterial system across the patent foramen ovale following a right femoral venous access. Embolization was then successfully performed. At a later date, the child underwent successful transvenous balloon-assisted embolization and eventual arterial embolization with cure of the VGAM.
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http://dx.doi.org/10.3171/2016.2.PEDS15652DOI Listing
August 2016

Midnight in the Garden of Yea or Nay.

J Neurointerv Surg 2017 07 16;9(e1):e12-e13. Epub 2015 Jul 16.

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http://dx.doi.org/10.1136/neurintsurg-2015-011936DOI Listing
July 2017

The role of percutaneous embolization techniques in the management of dural sinus malformations with atypical angioarchitecture in neonates: report of 2 cases.

J Neurosurg Pediatr 2015 Jul 24;16(1):74-9. Epub 2015 Apr 24.

Department of Radiology.

Dural sinus malformations (DSMs) are rare congenital malformations that can be midline or lateral in location. Midline DSMs have been reported to have a worse prognosis than lateral DSMs and have traditionally been more difficult to manage. The authors report 2 unusual manifestations of midline DSMs and their management with percutaneous transfontanelle embolization. The first patient (Case 1) presented at 21 days of life with a large midline DSM and multiple highflow dural and pial arteriovenous shunts. The child developed congestive cardiac failure and venous congestion with intracranial hemorrhage and seizures within a few weeks. The second patient (Case 2) presented with a large midline DSM found on prenatal imaging that was determined to be a purely venous malformation on postnatal evaluation. This large malformation resulted in consumptive coagulopathy and apneic episodes from brainstem compression. The patient in Case 1 was treated initially with endovascular embolization and eventually with curative percutaneous-transfontanelle embolization. The patient in Case 2 was treated with percutaneous transfontanelle embolization in combination with posterior fossa decompression and cranial expansion surgery.
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http://dx.doi.org/10.3171/2014.12.PEDS145DOI Listing
July 2015

ACR Appropriateness Criteria Dementia and Movement Disorders.

J Am Coll Radiol 2015 Jan;12(1):19-28

The Johns Hopkins Medical Institution, Baltimore, Maryland.

Neurodegenerative disease, including dementia, extrapyramidal degeneration, and motor system degeneration, is a growing public health concern and is quickly becoming one of the top health care priorities of developed nations. The primary function of anatomic neuroimaging studies in evaluating patients with dementia or movement disorders is to rule out structural causes that may be reversible. Lack of sensitivity and specificity of many neuroimaging techniques applied to a variety of neurodegenerative disorders has limited the role of neuroimaging in differentiating types of neurodegenerative disorders encountered in everyday practice. Nevertheless, neuroimaging is a valuable research tool and has provided insight into the structure and function of the brain in patients with neurodegenerative disorders. Advanced imaging techniques, such as functional neuroimaging with MRI and MR spectroscopy, hold exciting investigative potential for better understanding of neurodegenerative disorders, but they are not considered routine clinical practice at this time. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2014.09.025DOI Listing
January 2015

ACR Appropriateness Criteria Headache.

J Am Coll Radiol 2014 Jul 3;11(7):657-67. Epub 2014 Jun 3.

Washington University School of Medicine, St. Louis, Missouri, American Association of Neurological Surgeons, Rolling Meadows, Illinois/Congress of Neurological Surgeons, Schaumburg, Illinois.

Most patients presenting with uncomplicated, nontraumatic, primary headache do not require imaging. When history, physical, or neurologic examination elicits "red flags" or critical features of the headache, then further investigation with imaging may be warranted to exclude a secondary cause. Imaging procedures may be diagnostically useful for patients with headaches that are: associated with trauma; new, worse, or abrupt onset; thunderclap; radiating to the neck; due to trigeminal autonomic cephalgia; persistent and positional; and temporal in older individuals. Pregnant patients, immunocompromised individuals, cancer patients, and patients with papilledema or systemic illnesses, including hypercoagulable disorders may benefit from imaging. Unlike most headaches, those associated with cough, exertion, or sexual activity usually require neuroimaging with MRI of the brain with and without contrast to exclude potentially underlying pathology before a primary headache syndrome is diagnosed. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2014.03.024DOI Listing
July 2014

Endovascular balloon-assisted embolization of high-flow peripheral vascular lesions using dual-lumen coaxial balloon microcatheter and Onyx: initial experience.

J Vasc Interv Radiol 2014 Apr;25(4):587-92

Department of Radiology, University of Minnesota, 420 Delaware St. SE, MMC 292, Minneapolis, MN 55455.

Balloon-assisted embolization performed by delivering Onyx ethylene vinyl alcohol copolymer through a dual-lumen coaxial balloon microcatheter is a new technique for the management of peripheral vascular lesions. This technique does not require an initial reflux of Onyx to form around the tip of the microcatheter before antegrade flow of Onyx can commence. In a series of four patients who were treated with the use of this technique, the absence of significant reflux of Onyx was noted, as were excellent navigability and easy retrieval of the balloon microcatheter. However, in one patient, there was inadvertent adverse embolization of a digital artery, which was not caused by reflux of Onyx but could still be related to balloon inflation.
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http://dx.doi.org/10.1016/j.jvir.2013.11.013DOI Listing
April 2014

Modified balloon assisted coil embolization for the treatment of intracranial and cervical arterial aneurysms using coaxial dual lumen balloon microcatheters: initial experience.

J Neurointerv Surg 2014 Nov 23;6(9):704-7. Epub 2013 Oct 23.

Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA.

Introduction: Traditional balloon assisted coil embolization techniques for intracranial aneurysms require a single lumen balloon to remodel the aneurysm neck and a separate microcatheter to place coils. Here we report utilization of a single coaxial dual balloon microcatheter to achieve both coil placement and neck remodeling in a series of intracranial and cervical arterial aneurysms.

Materials And Methods: A series of five patients, including two with subarachnoid hemorrhage, presented to our institution with wide necked oblong aneurysms (8-30 mm maximum diameter). Coil embolization in four of these aneurysms was performed by advancing the tip of either a 4×10 mm Scepter C or a 4×11 mm Scepter XC balloon microcatheter (Microvention, Tustin, USA) into the aneurysm, inflating the balloon at the aneurysm neck, and placing the coils through the same microcatheter. In the fifth patient, who had a giant aneurysm at the top of the basilar artery, two Scepter XC balloon microcatheters were placed side by side and inflated simultaneously at the neck of the aneurysm; coil embolization was then successfully performed through both Scepter XC microcatheters.

Results: Coil embolization was successfully performed with this technique in all five aneurysms. There was no instance of aneurysm rupture, thromboembolic complications, occlusion of branch vessels near the aneurysm neck, or prolapse of coil loops into the parent vessel.

Conclusions: Aneurysmal neck remodeling and coil embolization can both be achieved using a single coaxial dual lumen balloon microcatheter in selected oblong intracranial and cervical arterial aneurysms.
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http://dx.doi.org/10.1136/neurintsurg-2013-010936DOI Listing
November 2014

Endovascular balloon-assisted embolization of intracranial and cervical arteriovenous malformations using dual-lumen coaxial balloon microcatheters and Onyx: initial experience.

Neurosurgery 2013 Dec;73(2 Suppl Operative):ons238-43; discussion ons243

*Department of Radiology; ‡Department of Neurosurgery; §Department of Neurology, University of Minnesota, Minneapolis, Minnesota.

Background: Ethylene vinyl alcohol copolymer (Onyx) is widely used for the embolization of arteriovenous malformations (AVMs) of the brain, head, and neck. Balloon-assisted Onyx embolization may provide additional unique advantages in the treatment of AVMs in comparison with traditional catheter-based techniques.

Objective: To report our initial experience in performing balloon-assisted AVM embolization for brain and neck AVMs with the use of the new Scepter-C and Scepter-XC coaxial dual-lumen balloon microcatheters.

Methods: Balloon-assisted transarterial embolization was performed in a series of 7 patients with AVMs (4 with brain AVMs, 1 with a dural arteriovenous fistula, and 2 with neck AVMs) by using Onyx delivered through the lumen of Scepter-C or Scepter XC coaxial balloon microcatheters. Following the initial balloon-catheter navigation into a feeding artery and the subsequent inflation of the balloon, the embolization was performed by using Onyx 18, Onyx 34, or both.

Results: A total of 12 embolization sessions were performed via 17 arterial feeders in these 7 patients. In 1 patient, there was an arterial perforation from the inflation of the balloon; in all others, the embolization goals were successfully achieved with no adverse events.

Conclusion: The balloon microcatheters showed excellent navigability, and there were no problems with retrieval or with the repeated inflation and deflation of the balloons. A proximal Onyx plug, which is crucial in many AVM embolizations, was not necessary with this technique. Additionally, fluoroscopy and procedural times seemed lower with this technique compared with conventional embolization methods.
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http://dx.doi.org/10.1227/NEU.0000000000000186DOI Listing
December 2013

Central-variant posterior reversible encephalopathy syndrome: brainstem or basal ganglia involvement lacking cortical or subcortical cerebral edema.

AJR Am J Roentgenol 2013 Sep;201(3):631-8

Department of Radiology, Hennepin County and University of Minnesota Medical Centers, 701 Park Ave, Minneapolis, MN 55415, USA.

Objective: Although posterior reversible encephalopathy syndrome (PRES) typically involves cortical or subcortical edema of the cerebrum, only individual cases have been described of a variant involving the central brainstem and basal ganglia and lacking cortical and subcortical edema. We evaluated FLAIR and T2-weighted images of 124 patients with confirmed PRES to determine the incidence of this uncommon variant, which we refer to as the "central variant"; to determine which structures are involved in this variant; and to determine the associated causes.

Conclusion: We found that five of the 124 patients (4%) with PRES had MR findings consistent with the central variant-that is, either brainstem or basal ganglia involvement and a lack of cortical or subcortical edema of the cerebrum. The thalami were involved in all five PRES patients with MR findings consistent with the central variant, but there was variable involvement of the posterior limb of the internal capsule (4/5), cerebellum (3/5), and periventricular white matter (3/5); in each patient, there was improvement both clinically and on MRI. The causes of PRES in these five patients were hypertension (n=2), cyclosporine (n=2), and eclampsia (n=1). The incidence of the central variant may be increasing because of an improving awareness of the diverse imaging patterns of PRES.
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http://dx.doi.org/10.2214/AJR.12.9677DOI Listing
September 2013

Differences in the basilar artery bifurcation angle among patients who present with a ruptured aneurysm at the top of the basilar artery and patients with perimesencephalic subarachnoid hemorrhage: a retrospective cross-sectional study.

Neurosurgery 2013 Jul;73(1):2-7

Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA.

Background: The angle of the basilar artery bifurcation of (BAB angle) is thought to influence the risk of the development and rupture of aneurysms at this site. It is, however, unknown whether the BAB angle also influences the incidence of angiographically negative perimesencephalic subarachnoid hemorrhage (PMSAH).

Objective: We performed a retrospective cross-sectional study comparing the BAB angle in a series of patients who presented with subarachnoid hemorrhage from a ruptured aneurysm at the top of the basilar artery (BSAH) with the BAB angle in a series of patients who presented with PMSAH.

Methods: Consecutive patients who presented to our institution with PMSAH or BSAH between January 1, 2005 and December 31, 2010 were studied. Patients with PMSAH were further subdivided into patients with classic PMSAH (CPMSAH) and those with nonclassic PMSAH (NCPMSAH) based on initial head computed tomography examinations. In each patient, the BAB angle was measured on the standard cranial anteroposterior projections after vertebral artery injections.

Results: A total of 21 patients with CPMSAH, 30 patients with NCPMSAH, and 31 patients with BSAH were studied. The BAB angle was significantly smaller in patients with CPMSAH (87.7 ± 17.1 degrees) and NCPMSAH (98.4 ± 21.1 degrees) compared with patients with BSAH (135.0 ± 30.8 degrees) (P < .001).

Conclusion: The significantly lower BAB angle in PMSAH patients compared with BSAH patients suggests that bleeding in PMSAH is either nonarterial in nature or is secondary to variations in hemodynamic arterial stress at the top of the basilar artery that need to be studied further with computational models.
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http://dx.doi.org/10.1227/01.neu.0000429837.45820.9cDOI Listing
July 2013

Diagnostic yield of computed tomography angiography and magnetic resonance angiography in patients with catheter angiography-negative subarachnoid hemorrhage.

J Neurosurg 2012 Aug 8;117(2):309-15. Epub 2012 Jun 8.

Division of Neuroradiology, Mallinckrodt Institute of Radiology, Washington University Schoolof Medicine, Saint Louis, Missouri, USA.

Object: The yield of CT angiography (CTA) and MR angiography (MRA) in patients with subarachnoid hemorrhage (SAH) who have a negative initial catheter angiogram is currently not well understood. This study aims to determine the yield of CTA and MRA in a prospective cohort of patients with SAH and a negative initial catheter angiogram.

Methods: From January 1, 2005, until September 1, 2010, the authors instituted a prospective protocol in which patients with SAH-as documented by noncontrast CT or CSF xanthochromia and a negative initial catheter angiogram- were evaluated using CTA and MRA to assess for causative cerebral aneurysms. Two neuroradiologists independently evaluated the noncontrast CT scans to determine the SAH pattern (perimesencephalic or not) and the CT and MR angiograms to assess for causative cerebral aneurysms.

Results: Seventy-seven patients were included, with a mean age of 52.8 years (median 54 years, range 19-88 years). Fifty patients were female (64.9%) and 27 male (35.1%). Forty-three patients had nonperimesencephalic SAH (55.8%), 29 patients had perimesencephalic SAH (37.7%), and 5 patients had CSF xanthochromia (6.5%). Computed tomography angiography demonstrated a causative cerebral aneurysm in 4 patients (5.2% yield), all of whom had nonperimesencephalic SAH (9.3% yield). Mean aneurysm size was 2.6 mm (range 2.1-3.3 mm). Magnetic resonance angiography demonstrated only 1 of these aneurysms. No causative cerebral aneurysms were found in patients with perimesencephalic SAH or CSF xanthochromia.

Conclusions: Computed tomography angiography is a valuable adjunct in the evaluation of patients with nonperimesencephalic SAH who have a negative initial catheter angiogram, demonstrating a causative cerebral aneurysm in 9.3% of patients.
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http://dx.doi.org/10.3171/2012.4.JNS112306DOI Listing
August 2012

Gradient echo plural contrast imaging--signal model and derived contrasts: T2*, T1, phase, SWI, T1f, FST2*and T2*-SWI.

Neuroimage 2012 Apr 28;60(2):1073-82. Epub 2012 Jan 28.

Department of Chemistry, Washington University in St. Louis, One Brookings Drive, Saint Louis, MO 63130, USA.

Gradient Echo Plural Contrast Imaging (GEPCI) is a post processing technique that, based on a widely available multiple gradient echo sequence, allows simultaneous generation of naturally co-registered images with various contrasts: T1 weighted, R2*=1/T2* maps and frequency (f) maps. Herein, we present results demonstrating the capability of GEPCI technique to generate image sets with additional contrast characteristics obtained by combing the information from these three basic contrast maps. Specifically, we report its ability to generate GEPCI-susceptibility weighted images (GEPCI-SWI) with improved SWI contrast that is free of T1 weighting and RF inhomogeneities; GEPCI-SWI-like images with the contrast similar to original SWI; T1f images that offer superior GM/WM matter contrast obtained by combining the GEPCI T1 and frequency map data; Fluid Suppressed T2* (FST2*) images that utilize GEPCI T1 data to suppress CSF signal in T2* maps and provide contrast similar to FLAIR T2 weighted images; and T2*-SWI images that combine SWI contrast with quantitative T2* map and offer advantages of visualizing venous structure with hyperintense T2* lesions (e.g. MS lesions). To analyze GEPCI images we use an improved algorithm for combining data from multi-channel RF coils and a method for unwrapping phase/frequency maps that takes advantage of the information on phase evolution as a function of gradient echo time in GEPCI echo train.
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http://dx.doi.org/10.1016/j.neuroimage.2012.01.108DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3303959PMC
April 2012

Diagnostic yield of repeat catheter angiography in patients with catheter and computed tomography angiography negative subarachnoid hemorrhage.

Neurosurgery 2012 May;70(5):1135-42

Division of Neuroradiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri, USA.

Background: The yield of repeat catheter angiography in patients with subarachnoid hemorrhage (SAH) who have negative initial catheter and computed tomography (CT) angiograms is not well understood.

Objective: To determine the yield of repeat catheter angiography in a prospective cohort of patients with SAH and negative initial catheter and CT angiograms.

Methods: From January 1, 2005, until September 1, 2010, we instituted a prospective protocol in which patients with SAH documented by noncontrast CT (NCCT) or cerebrospinal fluid (CSF) xanthochromia and negative initial catheter and CT angiograms were evaluated with repeat catheter angiography 7 days and 3 months after presentation to assess for causative vascular abnormalities.

Results: Seventy-two patients were included, with a mean age of 53.1 years (median, 53.5 years; range, 19-88 years). Forty-six patients were female (63.9%) and 26 male (36.1%). Thirty-nine patients had nonperimesencephalic SAH (54.2%), 29 patients had perimesencephalic SAH (40.3%), and 4 patients had CSF xanthochromia (5.5%). The first repeat catheter angiogram performed 7 days after presentation demonstrated a causative vascular abnormality in 3 patients (yield of 4.2%), 2 of which had nonperimesencephalic SAH (yield of 5.1%), and 1 had perimesencephalic SAH (yield of 3.4%). The second repeat catheter angiogram performed in 43 patients (59.7%) did not demonstrate any causative vascular abnormalities. No causative abnormalities were found in patients with CSF xanthochromia.

Conclusion: Repeat catheter angiography performed 7 days after presentation is valuable in the evaluation of patients with SAH who have negative initial catheter and CT angiograms, demonstrating a causative vascular abnormality in 4.2% of patients.
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http://dx.doi.org/10.1227/NEU.0b013e318242575eDOI Listing
May 2012
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