0:00

You can do venous stenting, as I alluded to in select cases. Um,

0:04

this is one of those select cases.

0:06

This is a 46 year old lady who came to me with pap edema. Um,

0:09

her b m I was on the higher side, but it wasn't really that suspicious. I mean,

0:13

and she didn't really look that big to me. I mean, I'm, I'm from the south.

0:16

I mean, she seemed like normal kinda, I mean, so I was like, I don't really,

0:20

I don't,

0:20

my spider sense was tingling and this is more of a venous sinus problem on her.

0:24

Um, but you can see in this patient she does have slit like ventricles. Um,

0:27

she does have, um, dilation of the optic nerve sheath.

0:30

It's easier to see on the right side here. Um,

0:32

she also has a partially empty cell,

0:35

and what we can see is that she has basically diffuse sinus narrowing with a

0:39

little bit of superimposed narrowing at the sigmoid transverse junction

0:42

bilateral, which is a common location for arachnoid granulations.

0:45

And that's usually the, the, um,

0:47

non-commitment contributing factor in these patients.

0:49

She did have a high opening pressure, I believe it was, um,

0:52

in the mid to high thirties, if I'm remembering right. Um,

0:55

so we did an M R V on this patient,

0:57

and you can see she does have some degree of diffuse sinus narrowing with some

1:00

distension of the cortical veins. Uh, and then she has actually, um,

1:03

focal arachnoid granulations at both sigmoid transverse junction, um,

1:07

causing superimposed, um, uh, um, uh, stenosis,

1:11

but still because of her b m i being a little on the higher side, we,

1:13

we would have to call this more potentiator as opposed to a, a mimicker.

1:17

And in this case, she definitely needs venous sinus pressure measurements,

1:20

which is what we did.

1:21

We catheterize the venous sinuses all the way across the toula,

1:24

usually from one jugular, and essentially measure the pressures on a pullback.

1:27

Um, she had a six to one gradient with an absolute gradient of 21 millimeters

1:31

mercury, which is very high. Um, anybody with a,

1:34

a gradient of greater than three to one or eight millimeters,

1:37

mercury usually predicts, uh, uh, stent responsiveness or,

1:40

or revascularization responsiveness.

1:42

So she ultimately did undergo stenting and didn't require anything else

1:46

required. No more di pressures dropped to normal. Uh,

1:48

pap edema resolved everything, um, resolved and she's,

1:51

she's doing well with no headaches. Now at this point. Um,

1:54

I usually treat these patients just like arterial stents. I put 'em on aspirin,

1:57

Plavix for three months, and then after that, just lifelong baby aspirin. And I,

2:01

knock on wood, I haven't had any patients who've had, um,

2:04

significant repeat narrowing. I,

2:05

I typically just for those who are interventionalists, i, i for, i,

2:09

I typically use, um, the silver biliary stent. I mean, it's just,

2:13

it's really easy to open. And if you have trouble getting there,

2:15

I normally just use our stroke catheters to get a guide up there.

2:18

So I'll use like a, you know, like a,

2:20

a neuron max guide catheter or B M X 96, and then I'll put like, um,

2:25

either a a, uh, red 62 or a 68 through it, and then some sort of,

2:30

you know, microcatheter wire. And I, I typically use the Roadrunner wire though,

2:34

but once you get the neuron max into the head, um, it,

2:36

it's very easy to deploy one of these stents if you, if you,

2:39

if that's what your goal is. So, um,

2:40

but the stroke catheter system is basically just used to get the guide there and

2:44

then the road runner exchange wire will, will easily take the, uh,

2:47

silver stent into position if that's, if that's what needs to happen. Um,

2:51

so this is that same patient after um, uh, a few months.

2:55

We did an M R V prior to taking her off the aspirin. Platos,

2:58

you can see the stents y be patent.

2:59

It's harder to see the signal through the stent, um,

3:01

because obviously the stent, um, obscures M R I a little bit, but it,

3:04

it's a pretty good, uh, result overall and you can see the stent appears patent,

3:08

uh, also on the, on the, um, uh, the, uh, two d time of flight.

3:13

But, um, I think that one thing that is a little bit easier if you do a

3:17

A C T V ri, you can see it a little bit easier, but I tend not to like to do,

3:19

uh, ionizing radiation of these younger patients and,

3:22

and give 'em contrast if I don't have to. So I, I typically start with an M R V,

3:26

and if I'm not, if I'm not worried based on the m v and the symptoms,

3:29

I usually just

3:29

Stop at that point.