NeuroInterventional Medicine PLLC

03/27/2024

Neuroendovascular Case Study: A woman in her early 80’s presented 2 years ago with grade 3 SAH. DSA demonstrates 3 large irregular aneurysms (Left ICA Clinoid, Right ICA Ophthalmic, Right ICA pCOM). Which one Bled? We decided that the SAH pattern and Aneurysm’s morphologys were not definitive and decided to treat all 3. Using PTA Balloon Assisted Coil Embolization, which achieved greater than 90% embolization (with contrast stasis) in all of them. After extensive critical care as an inpatient, she ultimately made a Full and Complete recovery and return to Independent Life at Home and all her Activities of Daily Living. (Special Thanks to John Pile-Spellman for teaming up with me to Care for this Complex Patient!)

On Followup DSA at 2 Years, all 3 aneurysms remain well-embolized with no significant filling of the aneurysms. She continues to fully functional Independent Life and actively engages in outpatient physical therapy, exercise, as well as socializing with her fellow Seniors and enjoys reading and mahjong. Now in her mid-80’s, we will follow-up with MRA q2 years, but are confident her risks for recurrence are low.

Learning Points: Multiple Aneurysms are often observed in SAH patients. Often, it is difficult to determine which aneurysm has ruptured and is most Urgent to Treat. In these Cases, treatment of Multiple Brain Aneurysms at 1 time is occasionally required, and should be strongly considered to avoid the risks of catastrophic recurrent hemorrhages. Long term results with Coil Embolization remain very durable and achieve the goals of High Functioning Hemorrhage-Free Survival!

03/14/2024

Neuroendovascular Case Study: A man in his late 70's was experiencing a devastating Stroke secondary to Left ICA and MCA occlusion, which we were fortunate to successfully revascularize with Thrombectomy and Carotid Stenting of his Tandem Lesions (with Complete Clinical Recovery). His 3 mos CTA and Angio looked great. At 12 mos, however, he developed severe In-Stent Restenosis (ISR) of > 80%. Although asymptomatic, we elected to treat with repeat PTA using a Paclitaxel Drug Eluting Balloon (DEB), which alters the cytoskeletons in cells and irreversibly inhibits smooth muscle proliferation. 2 years after re-treatment (40 mos after initial Stroke), his Stented vessel remains widely Patent without recurrent Neointimal Hyperplasia. He remains asymptomatic and continues to be Fully Functional and Active!

Although symptomatic recurrent stenosis of Carotid Stents remains uncommon, we need to continue to diligently monitor our patients and explore innovative strategies to prevent life-threatening recurrent Strokes in these High-Risk patients. Drug Eluting Balloons have demonstrated improved Long-Term Patency in the Peripheral Vasculature as well as smaller Coronary Arteries, and remains an exciting option for these unusual high risk situations in the Cerebral Vasculature

Recent Cardiac AGENT IDE Randomized Controlled Trial Published in JAMA https://lnkd.in/epRQpc-d

01/17/2024

Excited to be Recognized by my Peers as Castle Connolly Top Doctor for 2024 (5 Years Running!). Privileged to Care for Patients in our Communities!

01/09/2024

Neuroendovascular Case Study: A woman in her early 50's experienced Grade 3 SAH secondary to a large Anterior Communicating Artery Aneurysm, which was successfully Coiled 13 years ago. She also underwent stent-assisted Coil embolization of a second smaller wide-necked aneurysm of the Right ICA 6 mos later (felt to be unruptured). She made a dramatic recovery after her initial SAH, returning to Work and all of her Activities of Daily Living. FU angiograms at 1 year, 3 year, and 13 years demonstrated complete stable Occlusion of both Aneurysms (and more importantly, she remains symptom-free in her mid 60's!)

Learning Points: Endovascular Techniques continue to provide Stable Long-Term Symptom Free Survival in most Brain Aneurysm SAH patients, even on extended delayed FU (>10 years), confirming Real-World experiences of the Original Landmark ISAT studies.

12/24/2023

The Best Holiday Blessings are Happy and Healthy Patients, Family, and Friends!

Wishing everyone our Best during the Holidays!

12/14/2023

Man in his 80's with a past medical history of Hypertension, ESRD - on HD, Aortic Stenosis, Hyperlipidemia, BPH, CAD s/p stents, on Aspirin, who presents acutely after fall hitting the back of his head without loss of consciousness. Per patient for the last 2 weeks he has been having gait difficulties and freezing up of gait, he denied any previous falls. CT head revealed an acute on chronic left subdural hemorrhage measure 2.7 cm with 7 mm midline shift. On exam, Neurologically intact, although has transient dysarthria/expressive aphasia lasting less than 5 minutes x 2 over his initial 24 hours of observation.

Considering his numerous high-risk comorbidities and "Stable" Exam, we elected to perform Left Middle Meningeal Artery (MMA) Embolization with MAC rather than Surgery (with GA). Superselective Embolization of the Parietal and then Frontal Divisions of the Left MMA were performed with Embopsheres (100-300 microns) until Stasis was achieved. He remained stabled, with improved headache and Discharged to Acute Rehab for Deconditioning within a Week. On his 2 month CT follow-up, there is greater than 80% Volume reduction of the SDH with resolution of Mass Effect/Midline Shift, and he is Home functionioning Indepdently mRS 0.

Learning Points: As we gain experience with MMA embolization, we are learning that we can successfully apply this Innovative Minimally Invasive Therapeutic Strategy to a wider population of minimally symptomatic and high-risk patients, often with dramatic results, avoiding the risks of GA and Invasive Surgery in many more Patients.

11/28/2023

50s y.o. male presents with a past medical history of hypertension. Patient reportedly woke normal around 5:30 AM. He describes while taking a shower around 6 AM, he noticed that he had some right eye blurriness. This was followed by left arm and leg weakness closing to feel off balance as well as feeling clumsier on the left side. He denies any recent head or neck trauma or pain/injury to the neck. (Although in retrospect, he later described regular chiropractic therapy). Initially drove himself to Urgent Care, but then realized he was getting worse, pulled over and called 911.

He presented as a code stroke and initial NIH was 4 with SBP in 190s. CT head did not reveal any evidence of acute ischemic changes or bleed and patient subsequently received Tenecteplase after blood pressure was controlled. CT perfusion was performed which showed a right holo-hemispheric mismatch. CTA demonstrated non-occlusive right distal cervical-petrous dissection with patent flow through the skull into the brain, albeit delayed. Initial plan was close post-thrombolytic monitoring, hemodynamic therapy, and no immediate Neuroendovascular neurointervention (low NIHSS, patent flow, No LVO). (Approx 9-10 AM)

At around 2pm, his exam worsened from an NIHSS of 4 to 18 (1 for commands, 2 for gaze, 4 for LUE, 4 for LLE, 1 for speech, 2 for face) for which a Code NI was re-activated. His dissection had progressed to complete occlusion (with orbital ECA collaterals to the cavernous ICA). Aspiration was non-productive. After extensive exploration to find the “True” Lumen with a Microcatheter, 2 Enterprise Stents were deployed from “normal to normal” vessel, restoring brisk ICA blood flow and “tacking” of the dissection flap (TICI 3 intracranial).

POD 1 – MRI demonstrates small distal right frontal punctate abnormalities, while CTP returned to normal. CTA reveals wide patency of the stented segments, and by POD 4, his NIHSS reduced to 2, ready for Discharge Home.

Learning points: Dissections often can be managed effectively with medical therapy (anti-platelets or anti-coagulation), however, they can occasionally rapidly progress to occlusion and profound ischemic syndromes. Emergent Neurointervention and Stenting may be considered early or at the first signs of neurologic decline with excellent results, and close neurologic monitoring should be performed in ALL patients.

11/17/2023

Excited to learn about the latest advances in Flow Diversion to treat our patients presenting with the most challenging Intracranial Brain Aneurysms! Great Hands-On Flow Model training with the Surpass Evolve by the experienced Stryker engineering and Clinical Support Teams. Dr. Italo Linfante MD, FAHA, FSVIN and Dr. Fawaz Al-Mufti generously shared their expertise and experience on expanding applications and providing us with valuable tips and tricks they have employed to treat many patients safely and effectively. Special thanks to our hosts Brian Huber and Tony Ratchford for making the quick trip to Miami fun and engaging, reconnecting with old friends and new.

07/13/2023

Great campaign by Society of NeuroInterventional Surgery to Celebrate the Diversity of Professional, Cultural, and Personal Experiences and Values we Share as a Community and with our Patients! Thank you to the Leadership teams!

“Today the campaign is featuring member Dr. Sundeep Mangla (). As he has grown relationships with friends, family, patients & colleagues, he believes "that we as humans share much more in common than we perceive as different."

“Today the campaign is featuring member Dr. Sundeep Mangla (). As he has grown relationships with friends, family, patients & colleagues, he believes "that we as humans share much more in common than we perceive as different."”

05/31/2023

A 60 y.o. woman reports awakening in the morning not feeling “normal” with gait unsteadiness, difficulty buckling a button with her left hand, and an observed left facial droop by her family. Upon further inquiry, she reported she had a similar episode of the left sided weakness approximately 3 weeks, placing her symptom onset between 9 hours and 3 weeks. Her initial NIHSS on examination was 3 with mild left facial droop with 5- power of the LUE and LLE. Her Initial CTA/CTP demonstrated severe high-grade 99% stenosis of the right Carotid bulb (ICA) with markedly diminished caliber and markedly delayed Perfusion (prolonged MTT and TMax, with diminished CBF, elevated CBV) and entire Right Hemisphere at Risk. MRI Diffusion confirmed Deep WM “Watershed” Strokes confirming Perfusion Failure. DSA confirms markedly delayed Perfusion of Right Hemisphere. After successful pre-dilatation or the “String”, successful PTA and Stenting was performed with complete restoration of her Perfusion, and complete Neurologic Recovery.

As we close out “Stroke Awareness Month” of May, we are reminded to stay vigilant when Patient’s present with mild and “stuttering” symptoms. Many are at high risk for experiencing a large and devastating Stroke, and a thorough evaluation with Early Intervention can be Critical in Preserving Healthy and Functional Lives for our Communities.

05/18/2023

Fun morning advocating with our Fellow Members of the Society of NeuroInterventional Surgery Get Ahead of Stroke® Campaign this morning at the Today Show with co-hosts Savannah Guthrie, Craig Melvin, and Sheinelle Jones.

Special Thanks to our Stroke Survivors for their Resilience and Marie Williams Denslow, Faith James, and Brenda Foster from SNIS for organizing the efforts. Tremendous turnout on a chilly May morning!

Stroke Awareness Stroke SurvivorsStroke Awareness & Support

05/16/2023

SNIS’s Get Ahead of Stroke® campaign is returning to the TODAY Show at Rockefeller Plaza on Thursday morning 5/18 from 6-9 am. Join us and Help Spread Stroke Awareness! (my signs are ready)