Stent-assisted Woven EndoBridge embolization for the treatment of pulsatile tinnitus caused by an ipsilateral high-riding jugular bulb.

PURPOSE: Pulsatile tinnitus can be caused by a high-riding jugular bulb (HRJB), characterized by the superior position of the jugular bulb in the petrous temporal bone. The anatomical position and morphology of this entity make it challenging for endovascular treatment. We report our experience with two patients successfully treated with a stent-assisted Woven EndoBridge (WEB; Microvention, Tustin, CA, USA) device. MATERIALS AND METHODS: We describe two cases of HRJB in patients presenting with disabling pulsatile tinnitus. Temporary balloon occlusion of the jugular bulb prior to the intervention reduced tinnitus intensity. Both patients were subsequently treated under general anesthesia with the WEB device deployed in the HRJB which was held by a stent deployed in the sigmoid sinus. RESULTS: Both procedures were successful with good positioning of the WEB device and no procedural complications. Both patients had complete resolution of pulsatile tinnitus immediately after the procedure. Follow-up imaging showed successful occlusion of the venous cavity with a widely patent stent. CONCLUSION: Among patients with pulsatile tinnitus caused by an ipsilateral HRJB, a stent-assisted WEB device seems to be a viable endovascular option with angiographic and clinical success.

Embolization of a pseudoaneurysm of the innominate artery with a Woven EndoBridge (WEB) device.

The Woven EndoBridge (WEB) is an intra-aneurysmal flow disruptor designed for the treatment of broad-based arterial aneurysms with a high safety and effectiveness profile.1, 2 It does not require concomitant antiplatelet therapy compared to other devices such as flow diverters or intracranial stents. Innominate artery pseudoaneurysms are a rare consequence of blunt traumatic injury, infection, or atherosclerotic disease.3, 4 We describe the case of an innominate artery pseudoaneurysm successfully treated with a WEB SL device instead of stenting, therefore alleviating the need for dual antiplatelet therapy. The treatment was successful and uneventful and postprocedural computed tomography angiography confirmed the complete occlusion of the pseudoaneurysm.

Organization of reward and movement signals in the basal ganglia and cerebellum.

The basal ganglia and the cerebellum are major subcortical structures in the motor system. The basal ganglia have been cast as the reward center of the motor system, whereas the cerebellum is thought to be involved in adjusting sensorimotor parameters. Recent findings of reward signals in the cerebellum have challenged this dichotomous view. To compare the basal ganglia and the cerebellum directly, we recorded from oculomotor regions in both structures from the same monkeys. We partitioned the trial-by-trial variability of the neurons into reward and eye-movement signals to compare the coding across structures. Reward expectation and movement signals were the most pronounced in the output structure of the basal ganglia, intermediate in the cerebellum, and the smallest in the input structure of the basal ganglia. These findings suggest that reward and movement information is sharpened through the basal ganglia, resulting in a higher signal-to-noise ratio than in the cerebellum.

Coronary balloon-assisted navigation of aspiration catheter for stroke thrombectomy.

In recent years, A Direct Aspiration First Pass Technique (ADAPT) has emerged as an effective and safe method of thrombectomy. Large trials have shown noninferiority of ADAPT compared to primary stent retriever approach, while new studies emphasize on its shorter procedural time with potentially fewer complications and costs.1,2. Failure of the A Direct Aspiration First Pass Technique (ADAPT) is often due to the inability to successfully navigate the aspiration catheter to the thrombus site. As a solution, several techniques have been considered such as the use of stiffer microcatheters or a wedge device.3 In Video 1, we present our technique of navigating aspiration catheters with the assistance of coronary balloons. This technique has been very successful in our experience of about 30 cases in the past 6 months. Thanks to its safety and efficacy, this technique has dramatically changed our technical management of acute ischemic stroke. It can increase the ADAPT success rate while potentially reducing procedural costs.

Stent retriever for Tandem Acute Revascularization Technique (START): a novel technique for the endovascular management of tandem occlusions.

Tandem occlusions, characterized by the simultaneous presence of an intracranial large vessel occlusion and extracranial carotid artery stenosis or occlusion,1 pose a unique endovascular challenge.2 3 Typically, the extracranial occlusion is a result of atherosclerotic plaque; however, dissections are also a possible cause. It is currently uncertain whether an intracranial first approach or an extracranial first approach should be employed.4 5 A new technique has been developed which allows for the simultaneous treatment of both the intracranial and the extracranial lesion.6 We describe a variation of this technique: the stent retriever for tandem acute revascularization technique (START), which consists of simultaneously treating the intracranial lesion with stent retriever and contact aspiration, and the extracranial lesion with balloon angioplasty. We present a technical video explaining all the steps of START.(video 1)neurintsurg;jnis-2023-021011v1/V1F1V1Video 1Description and example of the START.

Use of a Woven Endobridge device (WEB) for the treatment of an aneurysmal diverticulum of the transverse sinus causing pulsatile tinnitus.

Pulsatile tinnitus is a symptom with a potentially significant impact on the quality of life of patients.1 In some cases the pulsatile tinnitus is secondary to an arterial, arteriovenous, or a venous condition that can be treated endovascularly.2-5 One of the newly recognized entities that can cause pulsatile tinnitus is the presence of an ipsilateral aneurysmal diverticulum of the transverse sinus. The Woven EndoBridge (WEB) is an intra-aneurysmal flow disruptor for the treatment of broad-based arterial aneurysms with a high safety and effectiveness profile.3 The initial version of the WEB with a dual-layer structure evolved into a single-layer structure in two different versions (WEB SL, a barrel shape, and WEB SLS, a spherical shape).4 The WEB system does not require concomitant antiplatelet therapy, unlike other intraluminal devices such as flow diverters or intracranial stents. We describe a case of pulsatile tinnitus secondary to an aneurysmal diverticulum of the transverse sinus successfully treated with a WEB SL device instead of stent-assisted coiling, therefore alleviating the need for antiplatelets (video 1). The patient had an immediate clinical response with complete and persisting disappearance of her pulsatile tinnitus.neurintsurg;jnis-2023-020981v1/V1F1V1Video 1.

Distal to proximal snaring of a fractured microcatheter during dural AVF embolization.

Detachable-tip microcatheters are frequently used for endovascular embolization of arteriovenous shunts. Occasionally, the detachable tip can break during navigation resulting in the loss of the microcatheter tip in a vessel, which can lead to thrombo-embolic complications and also limit further navigation into the vessel to complete treatment. We present a case of dural AV-fistula embolization that was complicated by the accidental detachment and loss of the tip of a microcatheter during navigation to injection site. The proximal tip of the broken catheter was not visible and therefore we were unable to capture its proximal part with a Snare. Ultimately, we navigated a microcatheter distal to the broken segment and successfully snared the microcatheter fragment retrogradely. (Video 1).

A Following Wave Pattern of Suicide-Related Pediatric Emergency Room Admissions during the COVID-19 Pandemic.

The COVID-19 pandemic and response, which included physical distancing and stay-at-home orders, disrupted the daily lives of children and adolescents, isolating them from their peers, school, and other meaningful contacts. The present study aims to add to the accumulating evidence on the pandemic's impact on child and adolescent suicidal behavior. Data were extracted from Schneider Children's Medical Center of Israel's pediatric emergency room (ER) admissions for psychiatric consultation for suicidal-risk assessment between 1 January 2020, and 16 April 2022. We applied time-lagged cross-correlation analysis and a Granger causality test to assess the temporal relationships between COVID-19 infection waves and patterns of suicide-related ER admissions. The results revealed a significant lagged correlation between national COVID-19 infection rates and ER admission rates. The highest correlation was above 0.4 and was found with a lag of 80 to 100 days from infection rate to ER admission rate. The findings show that the effects of public crises change over time and may be lagged. This may have important implications for mental health services' readiness to serve growing numbers of children and adolescents at risk for suicide.

Tremor Relief and Structural Integrity after MRI-guided Focused US Thalamotomy in Tremor Disorders.

Background MRI-guided focused US thalamotomy of ventral intermediate nucleus of the thalamus is a treatment for tremor disorders. Purpose To evaluate white matter integrity before and after thalamotomy and its correlation with clinical outcome. Materials and Methods Participants with essential tremor (ET) or Parkinson disease (PD) undergoing thalamotomy were prospectively recruited between March 2016 and October 2018. Tremor and quality of life were assessed before, 1 month after, and 6 months after thalamotomy. Participants underwent T1-weighted, T2-weighted fluid-attenuated image recovery, and diffusion-tensor MRI before and 1 day, 7-10 days, 1-3 months, and 6 months or longer after treatment. Diffusivity and fiber tractography measures were calculated. Repeated measures analysis of variance with post hoc paired t test and Skillings-Mack test with post hoc Wilcoxon signed-rank test were used for normally and nonnormally distributed data, respectively, and Bonferroni method corrected for multiple comparisons. Results Twenty-two study participants with ET (mean age, 72 years ± 6 [standard deviation]; 14 men), 17 participants with PD (mean age, 65 years ± 8; 13 men), and a replication set of 17 participants with ET (mean age, 73 years ± 6; 10 men) were evaluated. Long-term damage was found in the ablated core (mean fractional anisotropy [FA] at baseline, 0.41 ± 0.10, and at ≥6 months, 0.23 ± 0.09; P < .001) and thalamus to red nucleus tract (mean number of tracts at baseline, 1663, and at ≥6 months, 1070; P = .003). Negative correlation was observed between motor thalamus FA 1 day after ablation and tremor improvement (ET: R = -0.52 [P = .03]; PD: R = -0.61 [P = .003]). Better tremor relief in ET was associated with lower fractional anisotropy before treatment (R = -0.5; P = .02). Conclusion MRI-guided focused US thalamotomy resulted in short- and long-term white-matter changes. Diffusion-tensor imaging provided evidence for long-term damage in the ablation core and in the thalamus and red nucleus tract, and a correlation between preablation fractional anisotropy in the motor thalamus and clinical outcome. © RSNA, 2020 Online supplemental material is available for this article.

CT-Ultrasound Fusion for Abdominal Aortic Aneurysm Measurement.

OBJECTIVE. To evaluate the potential for surveillance of abdominal aortic aneurysms without ionizing radiation exposure and without the risks of iodinated contrast administration, the accuracy of fusion of CT angiography (CTA) with ultrasound (US) was compared with conventional US in 14 patients. CONCLUSION. The mean measurement difference between conventional US and CTA was 0.50 cm, compared with 0.13 cm between CT-US fusion and CTA (p < 0.0005). CT-US fusion was more accurate than conventional US, reduces operator dependence, and is promising for accurate measurement of aortic aneurysms.

Using extracellular low frequency signals to improve the spike sorting of cerebellar complex spikes.

BACKGROUND: The challenge of spike sorting has been addressed by numerous electrophysiological studies. These methods tend to focus on the information conveyed by the high frequencies, but ignore the potentially informative signals at lower frequencies. Activation of Purkinje cells in the cerebellum by input from the climbing fibers results in a large amplitude dendritic spike concurrent with a high-frequency burst known as a complex spike. Due to the variability in the high-frequency component of complex spikes, previous methods have struggled to sort these complex spikes in an accurate and reliable way. However, complex spikes have a prominent extracellular low-frequency signal generated by the input from the climbing fibers, which can be exploited for complex spike sorting. NEW METHOD: We exploited the low-frequency signal (20-400 Hz) to improve complex spike sorting by applying Principal Component Analysis (PCA). RESULTS AND COMPARISONS: The low-frequency first PC achieves a better separation of the complex spikes from noise. The low-frequency data facilitate the detection of events entering into the analysis, and therefore can be harnessed to analyze the data with a larger signal to noise ratio. These advantages make this method more effective for complex spike sorting than methods restricted to the high-frequency signal (> 600 Hz). CONCLUSIONS: Gathering low frequency data can improve spike sorting. This is illustrated for the case of complex spikes in the cerebellum. Our characterization of the dendritic low-frequency components of complex spikes can be applied elsewhere to gain insights into processing in the cerebellum.

Autism-associated Nf1 deficiency disrupts corticocortical and corticostriatal functional connectivity in human and mouse.

Children with the autosomal dominant single gene disorder, neurofibromatosis type 1 (NF1), display multiple structural and functional changes in the central nervous system, resulting in neuropsychological cognitive abnormalities. Here we assessed the pathological functional organization that may underlie the behavioral impairments in NF1 using resting-state functional connectivity MRI. Coherent spontaneous fluctuations in the fMRI signal across the entire brain were used to interrogate the pattern of functional organization of corticocortical and corticostriatal networks in both NF1 pediatric patients and mice with a heterozygous mutation in the Nf1 gene (Nf1+/-). Children with NF1 demonstrated abnormal organization of cortical association networks and altered posterior-anterior functional connectivity in the default network. Examining the contribution of the striatum revealed that corticostriatal functional connectivity was altered. NF1 children demonstrated reduced functional connectivity between striatum and the frontoparietal network and increased striatal functional connectivity with the limbic network. Awake passive mouse functional connectivity MRI in Nf1+/- mice similarly revealed reduced posterior-anterior connectivity along the cingulate cortex as well as disrupted corticostriatal connectivity. The striatum of Nf1+/- mice showed increased functional connectivity to somatomotor and frontal cortices and decreased functional connectivity to the auditory cortex. Collectively, these results demonstrate similar alterations across species, suggesting that NF1 pathogenesis is linked to striatal dysfunction and disrupted corticocortical connectivity in the default network.

The Organization of Mouse and Human Cortico-Hippocampal Networks Estimated by Intrinsic Functional Connectivity.

While the hippocampal memory system has been relatively conserved across mammals, the cerebral cortex has undergone massive expansion. A central question in brain evolution is how cortical development affected the nature of cortical inputs to the hippocampus. To address this question, we compared cortico-hippocampal connectivity using intrinsic functional connectivity MRI (fcMRI) in awake mice and humans. We found that fcMRI recapitulates anatomical connectivity, demonstrating sensory mapping within the mouse parahippocampal region. Moreover, we identified a similar topographical modality-specific organization along the longitudinal axis of the mouse hippocampus, indicating that sensory information arriving at the hippocampus is only partly integrated. Finally, comparing cortico-hippocampal connectivity across species, we discovered preferential hippocampal connectivity of sensory cortical networks in mice compared with preferential connectivity of association cortical networks in humans. Supporting this observation in humans but not in mice, sensory and association cortical networks are connected to spatially distinct subregions within the parahippocampal region. Collectively, these findings indicate that sensory cortical networks are coupled to the mouse but not the human hippocampal memory system, suggesting that the emergence of expanded and new association areas in humans resulted in the rerouting of cortical information flow and dissociation of primary sensory cortices from the hippocampus.

The war against polypharmacy: a new cost-effective geriatric-palliative approach for improving drug therapy in disabled elderly people.

BACKGROUND: The extent of medical and financial problems of polypharmacy in the elderly is disturbing, particularly in nursing homes and nursing departments. OBJECTIVES: To improve drug therapy and minimize drug intake in nursing departments. METHODS: We introduced a geriatric-palliative approach and methodology to combat the problem of polypharmacy. The study group comprised 119 disabled patients in six geriatric nursing departments; the control group included 71 patients of comparable age, gender and co-morbidities in the same wards. After 12 months, we assessed whether any change in medications affected the death rate, referrals to acute care facility, and costs. RESULTS: A total of 332 different drugs were discontinued in 119 patients (average of 2.8 drugs per patient) and was not associated with significant adverse effects. The overall rate of drug discontinuation failure was 18% of all patients and 10% of all drugs. The 1 year mortality rate was 45% in the control group but only 21% in the study group (P < 0.001, chi-square test). The patients' annual referral rate to acute care facilities was 30% in the control group but only 11.8% in the study group (P < 0.002). The intervention was associated with a substantial decrease in the cost of drugs. CONCLUSIONS: Application of the geriatric-palliative methodology in the disabled elderly enables simultaneous discontinuation of several medications and yields a number of benefits: reduction in mortality rates and referrals to acute care facilities, lower costs, and improved quality of living.