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1.  Thrombolysis, angioplasty and stenting of acute basilar artery occlusion in an octogenarian 
Radiology Case Reports  2015;3(2):157.
We present a case of an elderly male with sudden onset of a posterior circulation stroke that rapidly progressed to a deteriorating level of consciousness. Despite a dismal prognosis due to his age, the cause of his stroke, and his rapid clinical deterioration, he had an exceptional outcome. We attribute his favorable outcome to a number of factors including his good premorbid health, his timely presentation for definitive diagnosis and treatment, and rapid re-establishment and maintenance of flow in his occluded basilar artery using several endovascular techniques. The case report is exemplary of what may be achieved in elderly patients with acute posterior circulation stroke in contradistinction to what has been previously thought to be a universally fatal disease.
PMCID: PMC4896173  PMID: 27303519
CT, computed tomography; MRI, magnetic resonance imaging
2.  Unusual Presentation of a Dural Arteriovenous Fistula of the Superior Sagittal Sinus and Single Modality Therapy with Onyx 
Radiology Case Reports  2015;3(1):158.
Superior sagittal sinus (SSS) dural arteriovenous fistulas (DAVF) are rare and present unique challenges to treatment. Complex, often bilateral, arterial supply and involvement of large volumes of eloquent cortical venous drainage may necessitate multimodality therapy. We report a case of a DAVF of the SSS in a patient who presented uniquely with increasing dizziness and disequilibrium who was treated with a single modality, endovascular embolization with ethyl vinyl alcohol co-polymer (Onyx, EV3, Irvine, CA). The patient underwent staged embolization in 2 sessions with no complications. An angiographic cure was achieved and the patient's symptoms were ameliorated. Single modality therapy with endovascular embolization of a SSS DAVF can be achieved. Careful attention to technique during embolization with Onyx is required, but complete obliteration is possible without the need for adjunctive surgical resection.
PMCID: PMC4896129  PMID: 27303511
AVM, arteriovenous malformation; ACA, anterior cerebral artery; CT, computed tomography; DAVF, dural arteriovenous fistula; DMSO, dimethyl-sulfoxide; ECA, external carotid artery; ICA, internal carotid artery; MCA, middle cerebral artery; MMA, middle meningeal artery, MRI, magnetic resonance imaging; NBCA, N-butyl-cyanoacrylate
3.  What is the Role for Intra-Arterial Therapy in Acute Stroke Intervention? 
The Neurohospitalist  2015;5(3):122-132.
Intravenous recombinant tissue plasminogen activator continues to be first-line therapy for patients with acute ischemic stroke presenting within the appropriate time window, but one potential limitation is the low rate of recanalization in the setting of large artery occlusions. Intra-arterial (IA) treatment is effective for emergency revascularization of proximal intracranial arterial occlusions, but proof of benefit has been lacking until recently. Our goal is to outline the history of endovascular therapy and review both IA thrombolysis and mechanical interventions. In addition, we will discuss the impact of important trials such as the Third Interventional Management of Stroke (IMS3) trial, and the more recent trials Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN), Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE), Extending the Time for Thrombolysis in Emergency Neurological Deficits—Intra-Arterial (EXTEND-IA), and Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment (SWIFT PRIME) on acute stroke management and the implications for the practicing neurohospitalist.
PMCID: PMC4530425  PMID: 26288670
cerebrovascular disorders; carotid artery thrombosis; stroke; neurohospitalist; clinical specialty; cerebrovascular disease
4.  Automatic Monitoring of Localized Skin Dose with Fluoroscopic and Interventional Procedures 
Journal of Digital Imaging  2010;24(4):626-639.
This software tool locates and computes the intensity of radiation skin dose resulting from fluoroscopically guided interventional procedures. It is comprised of multiple modules. Using standardized body specific geometric values, a software module defines a set of male and female patients arbitarily positioned on a fluoroscopy table. Simulated X-ray angiographic (XA) equipment includes XRII and digital detectors with or without bi-plane configurations and left and right facing tables. Skin dose estimates are localized by computing the exposure to each 0.01 × 0.01 m2 on the surface of a patient irradiated by the X-ray beam. Digital Imaging and Communications in Medicine (DICOM) Structured Report Dose data sent to a modular dosimetry database automatically extracts the 11 XA tags necessary for peak skin dose computation. Skin dose calculation software uses these tags (gantry angles, air kerma at the patient entrance reference point, etc.) and applies appropriate corrections of exposure and beam location based on each irradiation event (fluoroscopy and acquistions). A physicist screen records the initial validation of the accuracy, patient and equipment geometry, DICOM compliance, exposure output calibration, backscatter factor, and table and pad attenuation once per system. A technologist screen specifies patient positioning, patient height and weight, and physician user. Peak skin dose is computed and localized; additionally, fluoroscopy duration and kerma area product values are electronically recorded and sent to the XA database. This approach fully addresses current limitations in meeting accreditation criteria, eliminates the need for paper logs at a XA console, and provides a method where automated ALARA montoring is possible including email and pager alerts.
PMCID: PMC3138926  PMID: 20706859
Peak skin dose; sentinal event; DICOM structured report dose; patient entrance reference point; fluoroscopy; interventional radiology; Joint Commission (JC); radiation dose; Digital Imaging and Communications in Medicine (DICOM)

Results 1-4 (4)