SriHari Sundararajan

Neuroradiologist; Interventional Radiologist; Video gamer; Proud father

[SriHari Sundararajan @RadioloSri]

First WEB deployed as an attending! Super fortunate to have had proctor Eytan Raz @eytanraz! Microvention WEB SL 5x3 in oblong MCA bifurcation aneurysm, impressive dome stagnation s/p WEB, this aneurysm is #oneanddone. #irad #NeuroIR #neuroendovascular @SIRspecialists @SNISinfo

[JNIS @JNIS_BMJ]

🧠 WEB device protrusion was independently associated with a higher number of postprocedural DWI lesions after treatment of unruptured intracranial aneurysms.

📊 DWI lesions occurred in 44% of patients, with a significantly higher lesion burden in those with protrusion (4.6 vs 1.5; P=0.013).

Read more here: https://t.co/Kj3nuEu3ZB

[Andrew L Callen MD @AndrewCallenMD]

We see more and more lateral dural tear #CSFleaks with small epidural fluid missed because the correct MRI sequences were not obtained. 3DT2FS really shines in this context. Sometimes the 🔑 isn't new technology, but re-understanding how to look at existing data.

[Dr. Brandon Beaber @Brandon_Beaber]

Paramagnetic rim lesions (PRLs) [dark lesions on SWI sequences in multiple sclerosis] appear to be a phenomenon associated with relatively newer lesions. In this study, PRLs were only present in lesions formed within the last 5 years. https://t.co/FZTNebDNEQ

[JNIS @JNIS_BMJ]

🧠 How do you approach cervical carotid dissections associated with stroke? Labeyrie et al. show a technique that utilizes aspiration through a balloon guide catheter to expose the true lumen. Read more about it: https://t.co/BGiWyeMgsR

[Lea Alhilali, MD @teachplaygrub]

Just because you don’t see it, doesn’t mean it’s not there!!!

Just because you don’t see all cranial nerves on MRI doesn’t mean they aren’t there!

You must know their anatomy so you know when pathology might affect them.

Here is a figure w/the anatomy you NEED to know!

➡️Just remember this easy rule of four from Peter Gates:
There are:
🔸 4 cranial nerves from above the pons (including 2 from the midbrain)
🔸4 from the pons
🔸And 4 from the medulla oblongata!

Now you won't have be nervous when it comes to this nerve anatomy!

[Visish M. Srinivasan, MD @visishs]

Cool paper in @JNIS_BMJ - pushing the limits on ruptured blister aneurysms.

Can modern surface modified flow diverters allow us to safely use single antiplatelet therapy?

Using prasugrel or ticagrelor w/ tirofiban bridging seems to be a happy medium...

@SNISinfo @cvsection

[Lea Alhilali, MD @teachplaygrub]

Form follows function!!

Do you know functional neuroanatomy?

This post will help you to remember the functional neuroanatomy you need to function if you are reading brain MRIs!

Here’s how:

1. First start at the top
—At the top you will see a gyrus that looks like a thumbs sticking up. This is the superior frontal gyrus (SFG).
—Remember this bc you get a thumbs up when you do a superior job!

2. Next to the SFG is the middle frontal gyrus
—This looks like knuckles next your superior frontal gyrus thumb
—Remember this bc your MIDDLE finger is in your knuckles
—ALWAYS LOOK FOR THE KNUCKLES W/THE THUMBS UP!

3.Use the SFG to find the motor strip
—SFG has a motor & language component
—Motor component is first at the back (remember, you walk before you talk!)
—Motor component of SFG crashes into the motor strip
—Remember, when two cars crash, their MOTORS hit

4.Confirm its the motor strip by finding the hand omega
—Hand motor region looks like an upside down omega
—Remember Omega is a fancy watch brand you wear near your HAND!

Hopefully now you will be eloquent when it comes to this eloquent cortex!!!

[AshuJadhav @AshuPJadhav]

Alteplase for Acute Ischemic Stroke at 4.5 to 24 Hours https://t.co/mDenZ5Db6G

[JNIS @JNIS_BMJ]

Do you know what you are measuring? Dynamic head rotation can dramatically alter intracranial venous pressure measurements, indicating single position lumbar puncture opening pressure may not tell the whole story! https://t.co/BCDYPwGJkw #ICP #JugularStenosis #CerebralHemodynamics

[JNIS @JNIS_BMJ]

🚨 Do you ❤️/😱 pulsatile tinnitus? 🚨 Dive into the latest comprehensive review on diagnosing pulsatile tinnitus via non-invasive imaging modalities in @JNIS_BMJ. This article offers an insightful algorithm to guide clinicians through the diagnostic pathway. https://t.co/XV9c94hDrH

[Lea Alhilali, MD @teachplaygrub]

Time for you to meet your match!

T2/FLAIR mismatch sign in brain tumors can be very helpful.

But do you know how to use it?

Or do you go into a coma reading studies on gliomas?

Here’s what you need to know so you will never be overmatched when it comes to T2/FLAIR mismatch!

T2/FLAIR mismatch is when tumor is very bright on T2, but saturates on FLAIR imaging—usually centrally, w/a small remaining rim of bright signal.

It’s a very specific radiogenomic sign for an astrocytoma (IDH-mutant, 1p19q non-codeleted), as opposed to other low-grade gliomas

Here’s how to remember that:
Astrocytoma
Astro = astronomy. 
T2/FLAIR mismatch looks like a black hole, dark centrally with a bright rim, like the event horizon
Black holes are in ASTROnomy, T2/FLAIR mismatch is in ASTROcytomas

Oligodendroglioma
Oligo sounds “Ah, I’ll go”
I remember that in oligos the FLAIR will GO along with the T2
So FLAIR goes with T2 in oligos—so they look similar without mismatch

Why does this T2/FLAIR mismatch happen?
Pathologically it seems to be from microcysts in astrocytomas that a very bright on T2 (because they are tiny fluid filled cysts)
But these cysts saturate on FLAIR

Now you know how remember the T2/FLAIR mismatch sign!

Hopefully now you can catch every case of T2/FLAIR mismatch!

Time for you to meet your match!

[JNIS @JNIS_BMJ]

🚨 VSSS is safe and effective! 🚨

The River Stent Trial confirms venous sinus stenosis stenting (VSSS) is safe and effective treatment for idiopathic intracranial hypertension (IIH). Commentary discusses how clinical practices have evolved to prioritize noninvasive methods for post-stent evaluations. 🧠💡

Read the commentary now: https://t.co/8DXdt1WPZX in the pages of @JNIS_BMJ #NeuroIntervention #MedicalInnovation #IIH #VenousSinusStenting 🧠

[SriHari Sundararajan @RadioloSri]

Please join us today (February 25th) 8-9 pm EST for an exciting NeuroIR focused SIR Virtual Angio Club on the basics of stroke intervention @SIRspecialists @SIR_ECS @SIRRFS

Register here!

https://t.co/kzqvq1eYg6

[Lea Alhilali, MD @teachplaygrub]

Are you right when it’s bright?

Bright cortical signal on diffusion images is classically associated w/hypoxic-ischemic injury. 

But there are many mimics!

Do you know how to recognize the different patterns of cortical restricted diffusion? Here’s a figure & some pearls to help!

Cortical restricted diffusion many seen in a variety of conditions—many with VERY different pathophysiology & prognosis.

There are 6 main patterns:

(1) Cortex & deep gray

(2) Diffuse Cortex

(3) Focal Cortex

(4) Limbic

(5) Deep gray

(6) White matter

Here are some steps to help differentiate:

(1) Is the presentation acute or chronic?

(2) If it’s acute, toxic-metabolic & hypoxic-ischemic events account for the majority of cases. Seizure & encephalitis are less frequent and typically more focal

(3) In the chronic setting, isolated cortical involvement is almost diagnostic of CJD

Hopefully, this will clear up any confusion about the diffusion!

[Society of NeuroInterventional Surgery (SNIS) @SNISinfo]

Speakers Joseph Gemmete, MD, @Daryl_Goldman, @DrKazNIR, @RaghavMattay & @RadioloSri will sit down with moderators Dan Cohen-Addad, MD & @docroc99 to discuss this important topic.

[AJNR @TheAJNR]

"Lateral Spinal CSF Leaks in Patients with Spontaneous Intracranial Hypotension: Radiologic-Anatomic Study of Different Variants"

https://t.co/IUAN5BUH1z

#CSFLeak @WouterSchievink @The_ASSR

[Adam Grant @AdamMGrant]

Bosses who get results shouldn't earn a license to be cruel.

Berating and belittling aren’t signs of tough love—they’re hallmarks of abusive supervision. Treating people like dirt doesn't motivate them—it undermines them.

If you can't model respect, you don't deserve to lead.

[SriHari Sundararajan @RadioloSri]

https://t.co/n7b1HI9JR2

URL to paper

#urg

[SriHari Sundararajan @RadioloSri]

Honored to have our article on using sagittal CTA to identify the Sylvian triangle for M2,M3,M4 occlusions published (helps ID candidates for distal occlusion tx). Article dedicated to our NeuroIR mentor Dr. Irwin Keller who passed away last year. #neuroir #stroke #neuroradiology

[Lea Alhilali, MD @teachplaygrub]

How’s your core knowledge of corona radiata anatomy?

Feeling cornered if asked for detail about the corona radiata?

Knowing the white matter tracts here is important. Do YOU?

Learn how to remember these tracts w/this month’s @theAJNR SCANtastic!

https://t.co/wcKHoga3AL

At the level of the corona radiata, the ventricles look like a guy doing jumping jacks.

This jumping jacks guy can help you remember the anatomy.

➡️Corpus callosum:
🔸This is central, by the guy’s core.
🔸Remember the CORpus callosum is by the CORE

➡️Limbs of the internal capsule:
🔸These are by the arms and legs
🔸Remember the LIMBS are by the guy’s LIMBS
🔸There are the anterior, posterior, and retrolenticular limbs & the go in the order you expect
🔸Anterior is in front, posterior is behind it & what is RETRO is way behind. So the rentrolenticular is all the way back.

➡️Thalamic radiations:
Two regions of thalamic radiations are here.

🔷Anterior thalamic radiations are in the anterior coronal radiata & along the posterior ventricle are the posterior radiations.
🔸Anterior thalamic radiations are by the guys hands—remember ThaHANDic radiations by the HAND

🔷Posterior thalamic radiations are by the soles of the feet—remember ThaLANDic radiations are where you land when you do jumping jacks

➡️Superior longitudinal fasciculus:
🔸This where the toes of the feet would be
🔸So remember it’s the Superiro LONGitdinal FEETsiculus—it’s where the toes of the LONG FEET would end

Hopefully, now questions about corona radiata anatomy won't give you a coronary!