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100 Interesting
Case Studies in
Neurointervention:
Tips and Tricks

Vipul Gupta
Ajit S. Puri
Rajsrinivas Parthasarathy
Editors

123
100 Interesting Case Studies
in Neurointervention: Tips and Tricks
Vipul Gupta • Ajit S. Puri
Rajsrinivas Parthasarathy
Editors

100 Interesting
Case Studies in
Neurointervention:
Tips and Tricks
Editors
Vipul Gupta Ajit S. Puri
Neurointerventional Surgery, Stroke Unit Division of Neurointerventional Surgery
Artemis Agrim Institute of Neuroscience University of Massachusetts Medical
Gurgaon Center
India Worcester
MA
Rajsrinivas Parthasarathy USA
Department of Vascular Neurology and
Neurointerventional Surgery
Artemis Agrim Institute of Neuroscience
Gurgaon
India

ISBN 978-981-13-1345-5    ISBN 978-981-13-1346-2 (eBook)

https://doi.org/10.1007/978-981-13-1346-2

Library of Congress Control Number: 2018965218

© The Editor(s) (if applicable) and The Author(s) 2019

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, express or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Co-publishing partnership between Byword Books Private Limited and Springer Nature India
Private Limited
This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd.
The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore
189721, Singapore
Dedicated to my family
My inspiration, G
My children Nainika and Nilay
—Dr. Vipul Gupta
Preface

Neurointervention has come a long way in last two decades. Recent positive
trials in acute stroke (to me the “holy grail” of neurointervention) and device
evolution in aneurysmal management have brought this field to the fore with
increasing role in neurosurgical as well as neurological disorders.
However, the training programs have not kept pace in spite of increasing
need for more neurointerventionists. There is dearth of evolved centers (with
adequate volume, quality, and teaching) running training programs in South
and Southeast Asia. Not just this at times training done in West may not suit
the clinical and financial profile of the patients in this region.
During my career, I have worked in close association with neurosurgeons
and neurologists of high repute and on many occasions explained “Tips and
Tricks” I use to manage particularly difficult cases. I was encouraged by my
colleagues to collate these discussions succinctly into a book for the benefit
of young aspiring neurointerventionists. This book is the result of their per-
sistent prompting and unstinting support.
Book is designed as a practical teaching atlas, a quick reference for neuro-
interventionists when handling challenging situations. Format we have used
explains the technique employed – “the how I do it,” the decision-making
process, alternate clinical management options, and pre- and post-procedure
images. At the end of each case, there is a “Tip and Trick” section wherein I
share my personal experience in an attempt to shorten the learning curve for
my young colleagues in the field of neurointervention.
I sincerely hope that you find this book a useful tool in your armamentar-
ium and more importantly it enables you to better your technical and clinical
outcomes.

Gurgaon, India Dr. Vipul Gupta

vii
Acknowledgments

From the bottom of my heart, I thank my coeditors Dr. Rajsrinivas Parthasarthy

and Dr. Ajit S. Puri who were pivotal not only in writing cases but also in
reviewing the case material provided by other authors. I am indebted to my
coauthors who took time out of their busy schedules to contribute cases for
the book. A special mention of my colleagues and dear friends Dr. Aditya
Gupta and Dr. Sumit Singh for their support during this period; I am pro-
foundly grateful to Dr. Swati Chinchure, Dr. Milind Sawant, and Dr. Anshul
Mahajan who helped in reviewing the cases. Our patients played a big role in
our learning and gave consent for the images to be used for academic pur-
pose. And lastly, full credit to my editors Dinesh Sinha and Naren Aggarwal
for their patience and support.

ix
Contents

Part I Aneurysms

1 Basilar Top Aneurysm with Extreme Tortuosity:

Triaxial Technique����������������������������������������������������������������������������   3
Vipul Gupta
2 Aneurysm Embolization in Patient with Tortuous Aorta������������   7
Vipul Gupta
3 Cerebral Aneurysm with Tortuous Access: Distal Access
Catheter Placement Using Coaxial Technique������������������������������ 11
Rajsrinivas Parthasarathy and Vipul Gupta
4 Interrupted Aortic Arch: Access—Direct
Carotid Puncture������������������������������������������������������������������������������ 15
Rajsrinivas Parthasarathy and Vipul Gupta
5 Giant Cavernous Aneurysm: Parent Vessel Occlusion
After Balloon Occlusion Test���������������������������������������������������������� 19
Vipul Gupta
6 Dual Microcatheter Technique ������������������������������������������������������ 23
Ajit S. Puri and Rajsrinivas Parthasarathy
7 Balloon-Assisted and Dual Microcatheter Technique
(Geometry Assessment and Catheter Shaping)���������������������������� 27
Ajit S. Puri and Rajsrinivas Parthasarathy
8 Embolization of Internal Carotid Artery (ICA) Aneurysm
Incorporating Origin of Posterior Communicating Artery �������� 31
Vipul Gupta
9 Aneurysm with Probable Near the Neck Rupture:
Endovascular Management������������������������������������������������������������ 35
Vipul Gupta
10 Small Lobulated Aneurysm: Balloon-Assisted Coiling���������������� 37
Vipul Gupta
11 Balloon-Assisted Coiling of Large Internal Carotid
Artery (ICA) Bifurcation Aneurysm: Assessment of Neck���������� 41
Vipul Gupta

xi
xii Contents

12 Aneurysm with a Branch Arising from the Sac:

Balloon over Inflation Technique���������������������������������������������������� 45
Vipul Gupta
13 Multilobulated Broad-Neck Aneurysm:
End-Hole Technique������������������������������������������������������������������������ 49
Vipul Gupta
14 ICA Bifurcation Aneurysm: Balloon Placement
Through Anterior Communicating Artery������������������������������������ 53
Vipul Gupta
15 Double Balloon Technique for Wide-Neck Aneurysms���������������� 57
Rajsrinivas Parthasarathy and Vipul Gupta
16 Dissecting Aneurysm of MCA: Stent-Assisted Coiling���������������� 61
Vipul Gupta
17 Stent-Assisted Coiling of Dissecting Aneurysm of Posterior
Cerebral Artery�������������������������������������������������������������������������������� 65
Vipul Gupta
18 Use of Open-Cell Nitinol Stents for Aneurysms with
Branch at Base (Ophthalmic and Anterior Choroidal
Artery Aneurysms, etc.)������������������������������������������������������������������ 67
Ajit S. Puri and Rajsrinivas Parthasarathy
19 Microstent-Assisted Aneurysm Sac Catheterization�������������������� 71
Rajsrinivas Parthasarathy and Vipul Gupta
20 Microstent-Assisted Coiling of Dissecting Aneurysm
of the Left MCA Bifurcation���������������������������������������������������������� 75
Rajsrinivas Parthasarathy and Vipul Gupta
21 Shelfing Technique for Stent-­Assisted Coiling of
Bifurcation Aneurysms�������������������������������������������������������������������� 79
Vipul Gupta
22 Y Stenting and Coil Embolisation of Broad-Based
Aneurysm Using LVIS Jr. Stents���������������������������������������������������� 83
Ajit S. Puri and Rajsrinivas Parthasarathy
23 Balloon-Assisted Catheter Access in Large
and Giant Aneurysms���������������������������������������������������������������������� 89
Ajit S. Puri and Rajsrinivas Parthasarathy
24 Stent Retriever-Assisted Access������������������������������������������������������ 93
Ajit S. Puri and Rajsrinivas Parthasarathy
25 Quadri-axial Technique to Gain Access for Flow Diverter
Deployment�������������������������������������������������������������������������������������� 99
Rajsrinivas Parthasarathy and Vipul Gupta
26 Multiple Blister Aneurysm of ICA: Management
by Pipeline Device���������������������������������������������������������������������������� 103
Vipul Gupta
Contents xiii

27 Long Flow Diverter (FD) in Partly Thrombosed Basilar

Trunk Aneurysms���������������������������������������������������������������������������� 107
Aviraj Deshmukh, Rajsrinivas Parthasarathy, and Vipul Gupta
28 Pipeline Flex Embolization Device for Treatment
of Pericallosal Artery Aneurysm���������������������������������������������������� 111
Ajit S. Puri and Rajsrinivas Parthasarathy
29 Feeding Artery Recurrent Aneurysm Treated
with a p64 Flow Diverter ���������������������������������������������������������������� 115
Hans Henkes and Marta Aguilar Pérez
30 “Catheter Push” Technique to Open Flow Diverter �������������������� 123
Vipul Gupta
31 “Catheter Pull” Technique to Open Flow Diverter���������������������� 127
Vipul Gupta
32 “Balloon-Push” Technique to Open Flow Diverter���������������������� 131
Vipul Gupta
33 Endovascular Techniques for Achievement of Better Flow
Diverter Wall Apposition: Telescopic Device Placement�������������� 135
Ajit S. Puri and Rajsrinivas Parthasarathy
34 pCONus Reconstruction for Basilar Top Aneurysm�������������������� 139
Hans Henkes and Marta Aguilar Pérez
35 Recurrent Wide-Necked Bifurcation Aneurysm:
Treatment Using PulseRider® as an Adjunctive Device���������������� 143
Helen Cliffe and Tufail Patankar
36 Wide-Necked Bifurcation Aneurysm: Treatment
with Woven EndoBridge (WEB) Device���������������������������������������� 147
Helen Cliffe and Tufail Patankar
37 Glue Occlusion of Dissecting Aneurysm After
Induced Cardiac Asystole���������������������������������������������������������������� 151
Hans Henkes
38 Anterior Communicating (ACOM) Artery Aneurysm;
Acute Angle Between A1 and A2: Microwire Shaping ���������������� 157
Rajsrinivas Parthasarathy and Vipul Gupta
39 Broad Neck Dysplastic Anterior Communicating Artery
Aneurysm: Compartmental Packing �������������������������������������������� 161
Vipul Gupta
40 Broad Neck Basilar Top Aneurysm:
Understanding the Neck������������������������������������������������������������������ 165
Vipul Gupta
41 Aneurysm Rupture During Coiling: Key Actions������������������������ 169
Vipul Gupta
xiv Contents

42 Aneurysm Rupture During Coiling: Use of Balloon�������������������� 173

Vipul Gupta
43 Coil Rupture During Balloon-­Assisted Coiling���������������������������� 175
Vipul Gupta
44 Aneurysm Rupture After Flow Diversion
with a Braided Stent������������������������������������������������������������������������ 177
Vipul Gupta
45 Prolapse of Coil Loop: Balloon-­Repositioning Technique����������� 181
Vipul Gupta
46 Coil Prolapse: Balloon-­Repositioning
and Coil Fixation Technique ���������������������������������������������������������� 185
Vipul Gupta
47 Coil Prolapse: Emergency Stent Placement���������������������������������� 189
Vipul Gupta
48 Coil Migration During Coiling: Retrieval by Snare �������������������� 193
Vipul Gupta
49 Thrombus Formation During Coiling:
Heparinization Protocol������������������������������������������������������������������ 195
Vipul Gupta
50 Delayed Thromboembolism After Balloon-Assisted Coiling�������� 197
Vipul Gupta
51 Air Embolism During Coiling Procedure�������������������������������������� 201
Vipul Gupta
52 Coil Retrieval: Stent-Assisted Retrieval Techniques�������������������� 205
Rajsrinivas Parthasarathy and Vipul Gupta
53 Wire Retrieval Method: Stent- and Snare-Based
Retrieval Technique ������������������������������������������������������������������������ 213
Vipul Gupta
54 Very Small (Less Than 2 mm) Aneurysm with Severe
Vasospasm: Pretreatment Dilatation���������������������������������������������� 217
Vipul Gupta
55 Severe Diffuse Vasospasm: B/L Intraarterial Vasodilatation
Followed by Coiling ������������������������������������������������������������������������ 221
Rajsrinivas Parthasarathy and Vipul Gupta
56 Intraarterial Dilatation in Subarachnoid
Haemorrhage-­Induced Vasospasm������������������������������������������������ 225
Rajsrinivas Parthasarathy and Vipul Gupta
57 Continuous Intra-arterial Dilatation in
Refractory/Malignant Vasospasm�������������������������������������������������� 229
Rajsrinivas Parthasarathy and Vipul Gupta
Contents xv

58 CT Perfusion Imaging to Diagnose Vasospasm After

Subarachnoid Hemorrhage������������������������������������������������������������ 235
Rajsrinivas Parthasarathy and Vipul Gupta

Part II Arteriovenous Malformation

59 Cavernous Sinus Dural Arteriovenous Fistula (AVF):

Trans-­venous Approach Through Inferior Petrosal Sinus ���������� 243
Vipul Gupta
60 Cavernous Dural Arteriovenous Fistula (AVF):
Angio-CT-Guided Fistula Site Localization���������������������������������� 247
Vipul Gupta
61 Coil Embolization of Direct Carotid Cavernous
Fistula (CCF)������������������������������������������������������������������������������������ 251
Vipul Gupta
62 Combined Trans-arterial and Balloon-Assisted
Transvenous Onyx Embolization of Dural AVF���������������������������� 255
Vipul Gupta
63 Dural AVF with Venous Aneurysm Causing Mass Effect:
Management Strategy���������������������������������������������������������������������� 261
Vipul Gupta
64 Dural AVF Draining into an Isolated Sac:
Embolization Technique������������������������������������������������������������������ 265
Vipul Gupta
65 Dural AVF Embolization-Tortuous Access: Wire Loop
Technique������������������������������������������������������������������������������������������ 271
Vipul Gupta
66 Transvenous Onyx Embolization of the Dural AVF���������������������� 275
Vipul Gupta
67 Dural AVF with Progressive Edema and Mass Effect������������������ 279
Rajsrinivas Parthasarathy and Vipul Gupta
68 Dural AVF Embolization Using Proximal Balloon
Catheter Occlusion Technique�������������������������������������������������������� 285
Vipul Gupta
69 Small Cerebral AVM: Onyx Embolization������������������������������������ 289
Vipul Gupta
70 Cerebral Hematoma with a Micro-­AVM: Intra-Arterial
DynaCT Angiography-Guided Surgical Excision ������������������������ 293
Vipul Gupta
71 AVM with Haematoma: Embolization and Surgery
in Single Session ������������������������������������������������������������������������������ 297
Vipul Gupta
xvi Contents

72 Cerebral Hematoma with AVM: Intra-Arterial DynaCT

Angiography-Guided Targeted Embolization
and Balloon-Assisted Catheterization�������������������������������������������� 299
Vipul Gupta
73 High-Flow Pial AVF: Safety Considerations—Detachable
Tip Microcatheter and Proximal Balloon
Occlusion Technique������������������������������������������������������������������������ 303
Aviraj Deshmukh, Rajsrinivas Parthasarathy, and Vipul Gupta
74 Acutely Ruptured Arteriovenous Malformation (AVM)
with Venous Aneurysm: En Passage
Feeder—Endovascular Strategy ���������������������������������������������������� 309
Aviraj Deshmukh, Rajsrinivas Parthasarathy, and Vipul Gupta
75 Cerebral AVM Embolization: Postoperative Bleeding
Due to Draining Vein Occlusion – Part 1�������������������������������������� 315
Vipul Gupta
76 Cerebral AVM Embolization: Postoperative Bleed
Due to Draining Vein Occlusion—2������������������������������������������������ 321
Vipul Gupta
77 Vein of Galen Aneurysmal Malformation: Emergency
Embolization for Cardiac Failure�������������������������������������������������� 327
Rajsrinivas Parthasarathy and Vipul Gupta
78 Cerebral Proliferative Angiopathy: Differentiation
from Arteriovenous Malformation (AVM)������������������������������������ 333
Vipul Gupta
79 Spinal Arteriovenous Fistula from Anterior Spinal Artery:
Embolization Technique������������������������������������������������������������������ 337
Vipul Gupta
80 Spinal Dural Arteriovenous Fistula (AVF)������������������������������������ 343
Vipul Gupta

Part III Stroke and Carotid Disease

81 Acute Mechanical Thrombectomy Using Stent Retriever

with Balloon Guide Catheter: Proximal Flow Arrest
and Reversal ������������������������������������������������������������������������������������ 349
Ajit S. Puri, Aviraj Deshmukh, and Rajsrinivas Parthasarathy
82 ADAPT Technique for Stroke Thrombectomy������������������������������ 353
Ajit S. Puri, Aviraj Deshmukh, and Rajsrinivas Parthasarathy
83 Solumbra Technique������������������������������������������������������������������������ 357
Ajit S. Puri, Aviraj Deshmukh, and Rajsrinivas Parthasarathy
84 Aspiration Retriever Technique in Stroke (ARTS) ���������������������� 359
Ajit S. Puri and Rajsrinivas Parthasarathy
Contents xvii

85 Terminal ICA Occlusion: The Utility of 6 mm × 30 mm

Retrievable Stents���������������������������������������������������������������������������� 363
Mohammed A. Almekhlafi and Mayank Goyal
86 Atherosclerotic BA Occlusion:
The Need to Detach the Stents�������������������������������������������������������� 367
Mohammed A. Almekhlafi and Mayank Goyal
87 Anterior Cerebral Artery Branch Occlusion�������������������������������� 371
Mohammed A. Almekhlafi and Mayank Goyal
88 Stroke in Evolution Due to Critical MCA Stenosis���������������������� 375
Mohammed A. Almekhlafi and Mayank Goyal
89 Intracranial Atherosclerotic Disease (ICAD):
Submaximal Angioplasty���������������������������������������������������������������� 379
Srinivasan Paramasivam
90 Tandem Occlusions (Antegrade First Technique with Stent)����������383
Mohammed A. Almekhlafi and Mayank Goyal
91 Intracranial Occlusion with Tandem Carotid Stenosis:
Distal to Proximal Approach���������������������������������������������������������� 387
Ajit S. Puri and Rajsrinivas Parthasarathy
92 Intracranial Occlusion with Tandem Carotid Stenosis:
Retained Filter���������������������������������������������������������������������������������� 391
Rajsrinivas Parthasarathy and Vipul Gupta
93 Acute ICA Dissection: Stent-­Assisted Recanalization������������������ 395
Vipul Gupta and Rajsrinivas Parthasarathy
94 Extensive Stent Reconstruction for Long-Segment
Symptomatic Dissections ���������������������������������������������������������������� 399
Ajit S. Puri and Rajsrinivas Parthasarathy
95 Carotid Stenosis with Thrombus���������������������������������������������������� 403
Vipul Gupta and Swati D. Chinchure
96 Difficult to Cross Carotid Stenosis: Microcatheter
Exchange Technique������������������������������������������������������������������������ 407
Vipul Gupta
97 Carotid Stenting with Tortuous Arch�������������������������������������������� 411
Vipul Gupta
98 Acute Thrombosis of Carotid Stent������������������������������������������������ 415
Vipul Gupta
99 Carotid Stenosis with Recurrent TIA’s: Emergency Stenting�������� 417
Vipul Gupta
100 Sub-occlusive Carotid Stenosis with Slow Flow in ICA
with Dissection of Cervical ICA During the Procedure �������������� 421
Vipul Gupta
About the Editors

Vipul Gupta is the director of Neurointerventional Surgery and co-director

of Stroke Unit at Artemis Agrim Institute of Neurosciences, Artemis Hospitals,
India. He trained in interventional neuroradiology from All India Institute of
Medical Sciences, Delhi. He is a pioneer in the field in India, and his main
focus has been on designing new techniques to suit individual patient man-
agement challenges. Besides, he is a passionate teacher and has taught and
trained young neurointerventionalists from across the country through curric-
ulum-based fellowship program, national conferences, and focused work-
shops. He has published in acclaimed journals and written book chapters. He
is the current secretary of the Society of Therapeutic Neurointervention,
India.

Rajsrinivas Parthasarathy is one of the few neurologists trained in vascular

neurology and neurointerventional surgery. He is a “Royal college of
Physicians” of “UK” certified neurologist and has completed his training
from prestigious institutes in Yorkshire deanery, UK. His fellowship training
included cerebrovascular diseases (1 year) and interventional neuroradiology
(2 years). He is an avid researcher who has published “original research” in
highly commended journals.

Ajit S. Puri is the director of the Integrated Cerebrovascular Program and

Neurointerventional Radiology at the University of Massachusetts Medical
School. Dr. Puri received advanced fellowship training in diagnostic neurora-
diology and neurointerventional surgery from Harvard Medical School—
Brigham and Women’s Hospital, Boston Children’s Hospital, and Beth Israel
Deaconess Medical Center. He is highly published, written numerous articles
in prestigious journals, authored several book chapters, and is a frequent
speaker at national and international neurointerventional surgery meetings.

xix
Contributors

Mohammed A. Almekhlafi, MSc, FRCPC Department of Neurology,

Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
Swati D. Chinchure, DMRD, DNB, DAM (Neuroradiology) Medanta
Institute of Neurosciences, Medanta Hospital, Vijay Nagar, Indore, India
Helen Cliffe, MA(Cantab) MBBChir FRCR Leeds Teaching Hospitals
NHS Trust, Leeds, UK
Aviraj Deshmukh, MD, DM Neurointerventional Surgery, Artemis Agrim
Institute of Neuroscience, Gurgaon, India
Mayank Goyal, MD, FRCPC Department of Radiology, Seaman Family
MR Research Centre, Foothills Medical Centre, Calgary, AB, Canada
Vipul Gupta, MD Neurointerventional Surgery, Stroke Unit, Artemis Agrim
Institute of Neuroscience, Gurgaon, India
Hans Henkes Neuroradiological Clinic, Klinikum Stuttgart, Stuttgart,
Germany
Srinivasan Paramasivam, M Ch., MRCS Ed., FINR (USA) Neuro
Endovascular Surgery, Apollo Hospitals, T. Nagar, Chennai, India
Rajsrinivas Parthasarathy, CCT(UK) Neuro, Fellow Stroke-INR Vascular
Neurology and Neurointerventional Surgery, Artemis Agrim Institute of
Neuroscience, Gurgaon, India
Tufail Patankar, PhD, FRCR Leeds Teaching Hospitals NHS Trust,
Leeds, UK
Marta Aguilar Pérez Neuroradiological Clinic, Klinikum Stuttgart,
Stuttgart, Germany
Ajit S. Puri, MD, DM Radiology, and Neurosurgery, Division of
Neurointerventional Surgery, Neurointerventional Fellowship Program,
University of Massachusetts Medical Center, Worcester, MA, USA

xxi
Abbreviations

2D Two-dimensional
3D Three-dimensional
ACA Anterior cerebral artery
ACOM Anterior communicating artery
AICA Anterior inferior cerebellar artery
BA Basilar artery
CCA Common carotid artery
ECA External carotid artery
EVD External ventricular drain
FD Flow diverter
ICA Internal carotid artery
LVA Left vertebral artery
MCA Middle cerebral artery
MRI Magnetic resonance imaging
PCA Posterior cerebral artery
PCOM Posterior communicating artery
PICA Posterior inferior cerebellar artery
RVA Right vertebral artery

xxiii
 Part I
Aneurysms
 Basilar Top Aneurysm
with Extreme Tortuosity: Triaxial
Technique
Vipul Gupta
Case
An Eighty four year old lady presented with sub-
arachnoid haemorrhage (Hunt & Hess Grade II;
Fisher Grade 3). Angiogram (Fig. 1.1) revealed a
small basilar top aneurysm with a broad neck.
The aneurysm was lobulated, and the neck was
more towards the origin of left PCA. Both verte-
bral arteries were extremely tortuous with loops
just beyond the origin and at the V2 segments.
Issue
• A stable microcatheter position is desirable to
safely coil small ruptured aneurysms. When
guiding catheter is too proximal or not stable,
microcatheter movements cannot be controlled
and can result in rupture during catheterisation
or coiling. Therefore, the key challenge is to
safely navigate the guiding catheter as distally
as possible beyond the loops.
Management
The procedure was performed under general
anaesthesia. A bolus of 3000 IU of heparin was
given at the start of procedure. A long sheath (6F,
V. Gupta
Neurointerventional Surgery, Stroke unit, Artemis
Agrim Institute of Neuroscience, Gurgaon, India
e-mail: vipul.gupta@artemishospitals.com
© The Author(s) 2019
V. Gupta et al. (eds.), 100 Interesting Case Studies in Neurointervention: Tips and Tricks,
https://doi.org/10.1007/978-981-13-1346-2_1
1
raphe) was placed in left subclavian artery to pro-
vide support and stability to the guiding catheter.
A flexible guiding catheter Neuron (Penumbra,
Alameda, California, USA) was then navigated
into the left vertebral artery. To take it across the
loops, a soft inner catheter (Penumbra 0.041″,
Alameda, California, USA) was taken up to the
V3 segment over a microcatheter Prowler 21
(Codman & Sheurtleff, Inc. USA) and Traxcess
0.014 (MicroVention, Tustin, California, USA)
microwire as shown in Fig. 1.2. The placement of
Penumbra catheter provided support for the
Neuron guiding catheter to take it across the
proximal loops and was placed in desired posi-
tion of distal segment of the V2 vertebral artery.
Thereafter, a balloon catheter (Scepter XC
4 × 11 mm, MicroVention, Tustin, California,
USA) was placed in the left PCA following
which the sac was catheterised using an Echelon
10 microcatheter (ev3 Inc., Irvine, California,
USA). The aneurysm was embolised with multi-
ple soft coils resulting in complete aneurysm
occlusion. The final check angiogram revealed
complete occlusion with coil loops in all of the
lobules of the sac (Fig. 1.2e).
Tips and Tricks
1. It is absolutely critical to obtain a stable and
distal guiding catheter location in patients
with proximal tortuosity. This is particularly
3
4 V. Gupta

a c d

Fig. 1.1 (a and b) 3D reconstructed and DSA angiogram images showing small, lobulated and broad neck basilar top
aneurysm. (c and d) Subclavian artery injections showing marked tortuosity and loops in both vertebral arteries

important in cases with small and friable
aneurysms.
2. The long sheath in our case provided the nec-
essary support to aid distal placement of guid-
ing catheter.
3. A soft-tipped guiding catheter is preferred as
it can be taken across the loops without injur-
ing the vessel wall. It usually is navigated over
an inner snugly fitting coaxial catheter to both
provide the necessary support and eliminate
the space between the outer and inner catheter
to avoid wall injury particularly at bends. The
inner catheter was in turn placed over a
microcatheter.
4. In old patients with tortuous anatomy, the
difficulty encountered during placing the
catheter systems predisposes to thrombo-
embolism, and therefore adequate hepa-
rin levels should be maintained during the
procedure.
1 Basilar Top Aneurysm with Extreme Tortuosity: Triaxial Technique 5

a b c d

Fig. 1.2 (a and b) Road map images depicting placement
of guiding catheter. A long sheath (white arrows) was
placed in the left subclavian artery, and a Neuron 6F guid-
ing catheter (black arrows) was navigated over a Penumbra
0.041 catheter (curved arrows). (c) Balloon microcatheter
placement in left PCA. (d) Showing balloon-assisted coil-
ing. (e) Final DSA image showing complete occlusion of
aneurysm. Coil mass in in situ showing coil loops in all
the lobules of aneurysm

Park MS, Stiefel MF, Fiorella D, et al.

Suggested Reading
Chaudhary N, Pandey AS, Thompson BG, et al. Utilization
of the Neuron 6 French 0.053 inch inner luminal diameter
guide catheter for treatment of cerebral vascular pathol-
ogy: continued experience with ultra distal access into the
cerebral vasculature. J Neurointerv Surg. 2012;4:301–6.
Intracranial placement of a new, compliant guide
catheter: technical note. Neurosurgery. 2008;63:
E616–7.
Simon SD, Ulm AJ, Russo A, et al. Distal intracranial
catheterization of patients with tortuous vascular anat-
omy using a new hybrid guide catheter. Surg Neurol.
2009;72:737–40.
 Aneurysm Embolization in Patient
with Tortuous Aorta
Vipul Gupta
Case
A 68-year-old female presented with sudden
onset right third nerve palsy. MRI revealed a
right internal carotid artery (ICA) aneurysm.
DSA revealed a lobulated broad-neck ICA aneu-
rysm (Fig. 2.1a). The patient had congenital
kyphoscoliosis with excessive tortuosity of the
aorta (Fig. 2.1b, c). The management plan was to
perform a stent-assisted coil embolization.
Issue
1. Difficulty in placement of guiding catheter
due to excessive tortuosity.
2. Guide catheter can become unstable during
the procedure.
Management
The patient was loaded with antiplatelet agent
(ecosprin 300 mg and clopidogrel 300 mg) the
evening before the procedure. An 8F short
V. Gupta
Neurointerventional Surgery, Stroke unit,
Artemis Agrim Institute of Neuroscience,
Gurgaon, India
e-mail: vipul.gupta@artemishospitals.com
© The Author(s) 2019
V. Gupta et al. (eds.), 100 Interesting Case Studies in Neurointervention: Tips and Tricks,
https://doi.org/10.1007/978-981-13-1346-2_2
2
sheath was placed in the right femoral artery.
Following that, a 6F long sheath (arrow) was
placed in the right common carotid artery
(Fig. 2.2a) using a coaxial catheter (Slipcath 5.5
F, Cook). Once the long sheath was placed, a
guiding catheter (Envoy 6F) (Codman &
Shurtleff, Inc. USA) was placed in the right ICA
(Fig. 2.2b). Thereafter, stent-assisted coil embo-
lization was performed after trapping the micro-
catheter in the aneurysm (Fig. 2.2c). Almost
complete occlusion of the aneurysm was
achieved (Fig. 2.2d, e).
Tips and Tricks
1. In patients with excessively tortuous access, it
is advisable to place a long sheath so that the
guiding catheter is stable.
2. In cases with excessive angulations, a flexible
long sheath such as Arrow may be easier to
navigate than a stiffer one.
3. Using a coaxial catheter helps in these cases.
Once a flexible coaxial catheter is in place, it
is easier to navigate the long sheath.
7
8 V. Gupta

a b c

Fig. 2.1 DSA was done along with 3D angiogram. A broad-neck lobulated ICA aneurysm was seen (a). Marked tortuos-
ity of the aorta and arch vessels was noticed on pig tail run (b). Arrows in (c) outline the course of diagnostic catheter

a b c

Fig. 2.2 A long sheath (arrows, a) was placed in right (arrow, b). Stent-assisted coiling was performed (c) with
common carotid artery with coaxial catheter. A guiding complete occlusion of aneurysm (d, e)
catheter (arrowhead, b) was placed through the sheath
2 Aneurysm Embolization in Patient with Tortuous Aorta 9

Suggested Reading Park MS, Stiefel MF, Fiorella D, et al. Intracranial place-
ment of a new, compliant guide catheter: technical
note. Neurosurgery. 2008;63:E616–7.
Chaudhary N, Pandey AS, Thompson BG, et al. Utilization
Simon SD, Ulm AJ, Russo A, et al. Distal intracranial
of the Neuron 6 French 0.053 inch inner luminal diameter
catheterization of patients with tortuous vascular anat-
guide catheter for treatment of cerebral vascular pathol-
omy using a new hybrid guide catheter. Surg Neurol.
ogy: continued experience with ultra-distal access into the
2009;72:737–40.
cerebral vasculature. J Neurointerv Surg. 2012;4:301–6.
 Cerebral Aneurysm with Tortuous
Access: Distal Access Catheter
Placement Using Coaxial
Technique
Rajsrinivas Parthasarathy and Vipul Gupta
Case
A 56-year-old lady presented with a sudden onset
of headache and loss of consciousness. Plain CT
brain scan on admission revealed diffuse SAH
with intraventricular extension. Cerebral angiog-
raphy revealed a saccular wide-neck paraclinoid
aneurysm of left ICA measuring 4.2 × 3.6 mm.
Left ICA was tortuous with a loop in the cervical
segment. Balloon-assisted coiling was planned.
Issues
1. Tortuous course of access artery posing a
challenge for placement of guide catheter in
the distal ICA.
2. Small aneurysms are difficult to catheterize
with a higher chance of rupture during the
procedure particularly in the presence of prox-
imal tortuosity.
R. Parthasarathy (*)
Vascular Neurology and Neurointerventional Surgery,
Artemis Agrim Institute of Neuroscience,
Gurgaon, India
V. Gupta
Neurointerventional Surgery, Stroke unit, Artemis
Agrim Institute of Neuroscience, Gurgaon, India
e-mail: vipul.gupta@artemishospitals.com
© The Author(s) 2019
V. Gupta et al. (eds.), 100 Interesting Case Studies in Neurointervention: Tips and Tricks,
https://doi.org/10.1007/978-981-13-1346-2_3
3
Management
Endovascular embolization of the aneurysm was
done via right transfemoral route under general
anesthesia. A 6F long sheath (Flexor Check-Flo
Introducer, Cook Medical, Bloomington, USA)
was introduced into the left CCA. DAC
070/105 cm (Concentric Medical, Inc.,
Mountain View, CA) was navigated over DAC
044/115 cm (Concentric Medical, Inc.,
Mountain View, CA) and 0.035″ Terumo guide
wire (Terumo Corporation, Tokyo, Japan) across
the tortuous ICA. It was done by progressive
advancement of DAC 044 over Terumo wire for
a distance followed by navigation of DAC 070
over DAC 044. The snugly fitting smaller profile
inner catheter provided the necessary support
and eliminated the dead space between the inner
and outer thereby allowing for smooth advance-
ment across bends without injuring the arterial
wall (Fig. 3.1).
With distal tip of DAC 070 in the proximal
cavernous ICA, DAC 044 and Terumo guide wire
were removed. A 4 × 11 mm Scepter XC balloon
(Microvention, Inc., Tustin, CA) was placed
across the neck of aneurysm, and aneurysm was
embolized with detachable coils using Echelon-10
microcatheter (Micro therapeutics, Inc., ev3
Neurovascular, Irvine, California). Post-
procedure angiogram shows complete oblitera-
tion of the aneurysm (Fig. 3.2).
11
12
a b
d e
Fig. 3.1 Left CCA angiogram (a) reveals extreme tortu-
ous course of left ICA, and left ICA angiogram (b) reveals
small wide-neck paraclinoid aneurysm. With road map
(c–e), DAC 044 (white bold arrow) was advanced into
ICA over Terumo wire (black arrow) followed by advance-
Tips and Tricks
1. Placement of guide catheter in the distal ICA
helps to provide stability which is particularly
important in the coiling of small aneurysms.
2. Triaxial system of navigation across tortuous
artery helps to minimize the trauma to the
vessel.
R. Parthasarathy and V. Gupta
c
f
ment of DAC 070 (black bold arrow) over DAC 044 in a
stepwise manner. On reaching cavernous ICA (f), DAC
044 and Terumo wire were removed. Coaxial system of
distal access catheters helped to navigate tortuous loop in
the cervical ICA
3. Using DAC 070/105 cm with inner longer
DAC 044/115 cm coaxially helps in the navi-
gation through tortuous arteries.
4. Because of braided wall design, these distal
access catheters offer flexibility to navigate
difficult access arteries and provide enough
stability to support microcatheters.
3 Cerebral Aneurysm with Tortuous Access: Distal Access Catheter Placement Using Coaxial Technique 13

a b

Fig. 3.2 Road map image (a) shows balloon inflated of the aneurysm. Distal position of the DAC 070 helped to
across the neck of aneurysm and coils within the aneu- provide stable support for microcatheter during aneurysm
rysm. Subtracted image (b) shows complete obliteration coiling

technical note. J Neurointerv Surg. 2011;3(2):

Suggested Reading 172–6.
Lin L-M, et al. Pentaxial access platform for ultra-distal
Hauck EF, et al. Use of the outreach distal access cath- intracranial delivery of a large-bore hyperflexible
eter as an intracranial platform facilitates coil DIC (distal intracranial catheter): a technical note.
embolization of select intracranial aneurysms: Neurosurgery. 2016;6:29–34.
 Interrupted Aortic Arch:
Access—Direct Carotid Puncture
Rajsrinivas Parthasarathy and Vipul Gupta
Case
A 40-year-old male presented with subarachnoid
haemorrhage from a ruptured ACOM aneurysm.
He was diagnosed with an interrupted aortic
arch while being investigated for refractory
hypertension.
Issue
• Access to the right ICA in a patient with inter-
rupted arch
• Blood pressure management
Management
Balloon-assisted coiling was planned to treat this
large broad-based ACOM aneurysm (Fig. 4.1).
Both brachial approaches were deemed not suit-
able due to the acute angle origin of the right
CCA from the right approach and reverse origin
from the left approach. Therefore, for access, a
direct carotid puncture was undertaken.
R. Parthasarathy (*)
Vascular Neurology and Neurointerventional Surgery,
Artemis Agrim Institute of Neuroscience,
Gurgaon, India
V. Gupta
Neurointerventional Surgery, Stroke unit, Artemis
Agrim Institute of Neuroscience, Gurgaon, India
e-mail: vipul.gupta@artemishospitals.com
© The Author(s) 2019
V. Gupta et al. (eds.), 100 Interesting Case Studies in Neurointervention: Tips and Tricks,
https://doi.org/10.1007/978-981-13-1346-2_4
4
Steps for Carotid Puncture
• 21 G Venflon was used to puncture the right
common carotid artery under ultrasound
guidance.
• Following that, the inner stylet was removed
and an injection taken to define the anatomy
of the bifurcation (Fig. 4.2a).
• Then a guidewire from a 5F micropuncture
(Cook Medical, Bloomington, USA) set was
introduced through the Venflon into the ECA.
• The Venflon was exchanged with a 4F dilator
into the ECA.
• A 0.035 Terumo wire was then introduced
through the dilator, and the dilator was
exchanged with a 5F dilator followed by a 6F
11 cm short sheath (Fig. 4.2b, c).
• Following that, Envoy 6F guiding catheter
was taken through the carotid sheath and
parked in the petrous right ICA (Fig. 4.2d).
A Scepter XC 4 × 11 balloon was parked
across the neck of the aneurysm, and the sac was
catheterized using Echelon-10 microcatheter.
The sac was embolized with multiple detachable
coils. Post-procedure Xper CT revealed no
haemorrhage.
15
16 R. Parthasarathy and V. Gupta

a b

Fig. 4.1 (a) Interrupted aortic arch; (b, c) ACOM aneurysm neck view and end on view

a b c d e

Fig. 4.2 (a) Injection through 21 G venflon; (b) 0.035′ Carotid artery. (e) The set up on the surface showing a 6F
Terumo wire in the ECA; (c) Injection through the 6F sheath and the Envoy guiding catheter
sheath; (d) 6F envoy guiding catheter in the Internal
Another random document with
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 Pilgrims and Puritans

The Pilgrims and Puritans who reached our “stern and rock-bound
coast” early in the 17th century did not approve of music, except for
the singing of five hymn tunes! The first book printed in America was
the Bay Psalm Book (1640) at Cambridge, Massachusetts. Its
heading was:
“The Psalmes in Metre: Faithfully translated for the Use,
Edification, and comfort of the Saints in publick and private,
especially in New England.”
“Spiritual Songs” were not at first included, but later about fifty
English hymn tunes, sung in unison were used. It went into many
editions, found its way to England and Scotland, and was preferred
by many to all others.
Music was forbidden as a trade in New England and a dancing
master was fined for trying to start a class. The early settlers thought
“to sing man’s melody is only a vain show of art” and objected to
tunes because “they are inspired”! So the Puritans were forbidden to
invent new tunes. You can understand that an art could not easily
flourish in such stony ground.
Mr. Oscar G. Sonneck, an authority on the history of American
music, says in his book, Early Concert-life in America: “The
Puritans, the Pilgrims, the Irish, the Dutch, the Germans, the
Swedes, the Cavaliers of Maryland and Virginia and the Huguenots
of the South may have been zealots, adventurers, beggars,
spendthrifts, fugitives from justice, convicts, but barbarians they
certainly were not.... Possibly, or even probably, music was at an
extremely low ebb, but this would neither prove that the early
settlers were hopelessly unmusical nor that they lacked interest in
the art of ‘sweet conchord.’... What inducements had a handful of
people, spread over so vast an area, struggling for an existence,
surrounded by virgin forests, fighting the Redman, and quarreling
amongst themselves, to offer to musicians? We may rest assured that
even Geoffrey Stafford, ‘lute and fiddle maker’ by trade and ruffian
by instinct, would have preferred more lucrative climes and
gracefully declined the patronage of musical Governor Fletcher had
he not been deported in 1691 to Massachusetts by order of his
Majesty King William, along with a batch of two hundred other
Anglo-Saxon convicts.
“There were no musicians by trade, ... and as the early settlers
were not unlike other human beings in having voices, we may take it
for granted that they used them not only in church, but at home, in
the fields, in the taverns, exactly as they would have done in Europe
and for the same kind of music as far as their memory or their supply
of books carried them. That the latter, generally speaking, cannot
have been very large, goes without saying.... Instruments were to be
found in the homes of the wealthy merchants of the North and in the
homes of the still more pleasure seeking planters of the South.
Indeed, there can be little doubt that the nearest approach to a
musical atmosphere ... was to be found in the South rather than in
the North. Still, we might call the period until about 1720 the
primitive period in our musical history.
“After 1720 we notice a steadily growing number of musicians who
sought their fortunes in the Colonies, an increasing desire for organs,
flutes, guitars, violins, harpsichords, the establishment of ‘singing-
schools,’ an improvement in church music, the signs of a budding
music trade from ruled music paper to sonatas and concertos, the
advent of music engravers, publishers and manufacturers of
instruments, the tentative efforts to give English opera a home in
America, the introduction of public concerts, in short the beginnings
of what may properly be termed the formative period in our musical
history, running from 1720 until about 1800.”
The first organ in America came from London in 1713 for the
Episcopal Church of Boston, but it remained unpacked for seven
months, as many objected to an organ at divine services. The fate of
music hung in the balance with the Puritans but fortunately it won
out.
Rev. James Lyon, a graduate of Princeton University, “Patriot,
preacher and psalmodist,” published in 1792 a collection of psalms,
anthems and hymns, called Urania, to which he added a few of his
own compositions and a dozen or so pages of instructions for his
singing-school in Philadelphia. Other collections followed.
 William Billings

William Billings, born in Boston, in 1746, was one of our first

composers. He took his music seriously, was self-taught, and wrote
his first music on leather with chalk, in the tannery where he worked.
He was queer and was laughed at, but he was so sincere in his love of
music that he won friends who encouraged him to publish (in 1770) a
new psalm-book, The New England Psalm Singer, or American
Chorister. As singing-schools had been formed to learn how to read
and to sing the church music, the time was ripe for more difficult
music than had been allowed by the Pilgrim Fathers. Billings,
although he knew nothing about it, tried some experiments in
counterpoint, and introduced some “fugue-tunes,” which really were
not fugues at all, into his hymns. That he enjoyed the result may be
seen from this quotation: “It has more than twenty times the power
of the old slow tunes, each part straining for mastery and victory, the
audience entertained and delighted, ... sometimes declaring for one
part, and sometimes for another. Now the solemn bass demands
their attention, next the manly tenor; now the lofty counter, now the
volatile treble. Now there; now here again, O ecstatic! Rush on, you
sons of harmony!”
In the preface to his book we find the first American musical
declaration of independence, for he states that Nature and not
Knowledge must inspire thought, and that “it is best for every
composer to be his own carver.” But later he showed a bigness of
spirit, for he writes humbly: “Kind Reader, no doubt you remember
that about ten years ago I published a book ... and truly a most
masterly performance I then thought it to be. How lavish was I of
encomiums (praise) on this my infant production!... I have
discovered that many of the pieces were not worth my printing or
your inspection.”
This second book was called Billings’ Best because it became very
popular. Many of his tunes were sung around the camp-fires of the
Revolutionary Army, and even the Continental fifers played one of
his airs. He was a fiery patriot, and when Boston was occupied by the
British, he paraphrased the 137th Psalm, and wrote:
By the rivers of Watertown, we sat down;
Yea, we wept as we remembered Boston!

This was the time when the young Mozart was astonishing the
courts of Europe, and the Colossus Beethoven was born!
For a long time there was prejudice against instrumental music in
New England, so the first concerts gave selections from Handel’s
Messiah and Haydn’s Creation, which after all were oratorios.
Later William Billings’ singing class in Stoughton, Massachusetts,
founded in 1774 to study and perform psalm tunes and oratorios
became the Stoughton Musical Society in 1786 and was looked upon
as the earliest musical organization in America. It is still in existence.
But Mr. Sonneck discovered that in Charleston, South Carolina, the
St. Cecilia Society was founded twenty-four years earlier.
The next important society founded was the Boston Handel and
Haydn. It is still alive and has had great influence on musical life not
only in its native city but throughout America. After the war of 1812,
a musical jubilee was held in Boston. It was so successful, that a
society was formed from the fifty members of the Park Street Church
choir and others interested in “cultivating and improving a correct
taste in the performance of sacred music.” This was the Handel and
Haydn, which has lived up to its intention. The young society showed
American spirit and asked Beethoven to write a work for it! The
Colossus was pleased with this recognition from over the seas, and in
one of his note books had written “The oratorio for Boston.”
 Music in Benjamin Franklin’s Philadelphia

Although New England was the cradle of music, Philadelphia was

the art center in the second half of the 18th century, and went ahead
of Boston in culture, because it was not held down by Puritan laws.
In 1741 Benjamin Franklin published Dr. Watt’s hymns, and later
invented an instrument called the harmonica,—not the little
mouthorgan. Franklin’s instrument was a set of thirty-five circular
glasses arranged on a central rod, tuned to play three octaves and
enclosed in a case that looked like a spinet. There is one in New York
City at the Metropolitan Museum of Art. Try rubbing the edge of
your tumbler with a moist finger and you will hear the sound this
instrument made.
In Goldsmith’s Vicar of Wakefield, we read that fashionable ladies
“would talk of nothing but ... pictures, taste, Shakespeare and the
musical glasses.” These had been invented by no less a person than
Gluck! He played a concerto on twenty-six drinking glasses,
accompanied with “the whole band,” and claimed he could play
anything that could be performed on a violin or harpsichord! It was
after hearing them in London, that Franklin improved upon them
and made his harmonica.
 Francis Hopkinson, “First American Poet-Composer”

On whom should fall the title of first American composer? William

Billings was born before Francis Hopkinson (1757–1791), but in 1759,
Hopkinson wrote a secular song, My Days Have Been so Wondrous
Free, eleven years before Billings’ New England Psalm Singer saw
the light of day. Billings was the product of New England Psalmody,
was an uncouth self-taught son of the people. Hopkinson was born in
Philadelphia, was a college bred man, lawyer, poet, essayist, patriot,
composer, harpsichord player, organist, and inventor.
He was an intimate friend of Franklin, Washington, Jefferson and
Joseph Bonaparte; a member of the Continental Congress, and one
of the signers of the Declaration of Independence.
He wrote in the style of Carey and Dr. Arne in England, and we
have eight songs dedicated to “His Excellency George Washington,
Esquire,” and in the dedication Hopkinson says: “With respect to this
work ... I can only say that it is such as a lover, not a master, of the
arts can furnish.”
The Beggar’s Opera was presented in New York in 1750 and in
Philadelphia in 1759. In 1787, Washington went to a puppet opera in
Philadelphia. In 1801 selections from Handel’s Messiah were given in
the hall of the University of Pennsylvania. We hear of Francis
Hopkinson’s playing on the first organ in Christ Church,
Philadelphia, and as early as 1749, John Beals, a “musick-master
from London” comes to the Quaker city to teach “violin, hautboy,
(oboe) flute and dulcimer,” and advertises as ready to play for balls
and entertainments. So we see Philadelphia growing up rapidly, with
opera, oratorio, instrumental music and music teachers!
Franklin and Washington often commented on the unusually fine
music that they heard in the town of Bethlehem (Pennsylvania).
Today the early appreciation of music is continued in the yearly Bach
Festival held in the Moravian Church under the direction of
Frederick Wolle. Musicians from everywhere attend these
remarkable performances at Bethlehem.
Trinity Church in New York had an organ in 1741, although there
were concerts at least ten years earlier. An English schoolmaster,
William Tuckey, was the first to train choir boys for the services
about 1756.
 Early Opera

We should hardly expect to find French and Italian operas in

America before the 1800s, but way down south in New Orleans in
1791, a troupe was giving performances of parts of operas and
vaudeville, and perhaps an occasional opera of Grétry or Boieldieu.
From 1810, the company performed opera regularly, and until
recently, there was French opera in New Orleans.
Every time an opera company came to New York, The Beggar’s
Opera was played, along with other Ballad-Operas. In 1796, there
were two operas by Americans, Benjamin Carr and Pellisier, but all
details have been lost.
Mr. Elson says, “At the beginning of the 19th century Charleston
and Baltimore entered the operatic field, and travelling troupes came
into existence, making short circuits from New York through the
three large cities, but avoiding Boston, which was wholly given over
to Handel, Haydn, and psalms.”
The first time that New York heard Home, Sweet Home was on
November 12, 1823, in a melodrama by John Howard Payne, Clari,
the Maid of Milan. Payne, an American, wrote the words, and Henry
Carey, the English composer, the music.
The first grand opera that New York heard was Weber’s Der
Freischütz. It was probably a very crude performance as they made
many changes to suit public taste, but it was a great success,
especially the melodramatic scenes.
In 1825, Manuel Garcia, a Spanish tenor, came to New York with
his family of singers, including his daughter, who afterwards became
the famous Mme. Malibran. He gave The Barber of Seville and ten
other Italian operas which were a revelation to the new world. They
called Garcia the “Musical Columbus.”
After this, New York was never without some opera venture. One
company followed another, and although the people seemed to enjoy
the novelty for a while, they never gave it whole-souled patronage.
The first opera written (1845) by an American was Leonora by
William H. Fry (1813–1864). It was performed in Philadelphia, and
thirteen years later in New York. It was in the Balfe and Donizetti
style. He composed symphonies and wrote for the New York Tribune
on musical subjects, and did much to make people realize the benefit
of music.
In 1855 George Bristow composed the second American opera, Rip
Van Winkle. He and Fry started a crusade against the German
musicians who had come over to America after the revolution of
1848, fearing that they would extinguish the feeble American flame
of composing.
 Orchestras

The father of American orchestras was a German oboe player,

Gottlieb Graupner. When Haydn went to London to direct the largest
orchestra formed, up to that time, Graupner played with him.
Graupner went to Boston (1799), and at once formed the first
American orchestra. About the same time in New York, a society
called the “Euterpian” was founded; it gave one concert a year for
thirty years! From 1820 to 1857 there was in Philadelphia, a “Musical
Fund Society”; its object was to improve musical taste and to help
needy musicians. It gave the first performance in America of
Beethoven’s First Symphony, as well as choral works.
In Boston the last concert of the Philharmonic Orchestra as
Graupner’s band was called, took place in 1824, and another more
important orchestra was formed sixteen years later. Before the
Boston Symphony came, an orchestra was given to the city by the
Harvard Musical Association. It was controlled by a group of people
brought up on Handel, Haydn and Beethoven, who would not permit
their idols to be replaced by such anarchists as Berlioz and Wagner!
Many of the young foreign orchestral players wanted the new works
by the “anarchists,” so they seceded from the Harvard Musical
Association and called themselves the Philharmonic Society. As there
were not enough people interested in classical music to support two
orchestras they were soon replaced by the Boston Symphony
Orchestra, which was put on a permanent basis by Colonel Henry L.
Higginson, who founded it and supported it during his lifetime.
Georg Henschel conducted the first concert in 1881, and the Boston
Symphony Orchestra has always been one of the greatest musical
institutions in America. The conductors have been Wilhelm Gericke,
Arthur Nikisch, Max Fiedler, Karl Muck, Henri Rabaud, Pierre
Monteux, and Serge Koussevitzky.
The New York Philharmonic Society, born in 1842, was founded
through the efforts of a violinist, Uriah Hill, its first conductor, and it
always gave works of value. Among its conductors have been:
Theodore Thomas, Dr. Leopold Damrosch, Anton Seidl, Walter
Damrosch, Emil Paur, Wassili Safonoff, Henry Hadley, Gustav
Mahler, Theodore Spiering, Josef Stransky, Willem Mengelberg,
Willem van Hoogstraten, Wilhelm Furtwängler, and Arturo
Toscanini, a genius among conductors.
Theodore Thomas (1835–1905), who was born in Germany but
came to this country at the age of ten, was the first great musician to
live in America and to advance the condition and standards. He gave
this country its first taste for the aristocrat of music, chamber music,
and with William Mason, the pianist, presented Schumann and
Brahms to America. They were young radicals, and wanted to make
everybody love the music they loved. Thomas introduced Wagner,
too, and can’t you imagine the discussions the Wizard’s music raised
when even Europe was torn in its opinions of the master innovator?
Franz Liszt sent Thomas parts of the scores which the young
conductor tried out even before they had been played in Europe. He
had an orchestra of his own in 1864 that ran a close race with the
Philharmonic Society in New York, and he took it out on tour, giving
other cities the chance to hear orchestral music. Theodore Thomas
was a musical missionary! In 1877 and 1879 he was conductor of the
New York Philharmonic, and in 1890 the Chicago Orchestra was
formed where he remained until his death in 1905. Frederick Stock
followed Thomas, and the Chicago Orchestra has helped to cultivate
music in the Middle West.
 The Damrosch Family

In 1871, a German conductor, destined to develop music came to

New York and after a few months, sent for his family. This was Dr.
Leopold Damrosch, who founded the Oratorio Society (1873), and
the New York Symphony Society (1877), which was merged with the
Philharmonic in 1928. The Oratorio Society, for many years directed
by Walter Damrosch, is today conducted by a gifted American, Albert
Stoessel.
In the early years feeling ran high between the followers of
Theodore Thomas and Dr. Damrosch, and many stories are told of
the rivalry in playing new European scores. One of Damrosch’s
greatest early triumphs was the performance of Berlioz’s Damnation
of Faust. He also gave the first performance of Brahms’ First
Symphony.
During this time, Dr. Damrosch’s young son, Walter, was playing
second violin, learning through experience, his father’s profession,
and he is today the conductor of the New York Symphony Society,
and a commanding figure in America.
Dr. Damrosch was also a pioneer in introducing Wagner to us. Two
years after the Metropolitan Opera House was built (1882), Dr.
Damrosch was made director and conductor of German opera. He
imported some of the great Wagnerian singers, Madame Materna,
Marianne Brandt, Mme. Seidl-Kraus, Anton Schott, and others.
Wagner opera had come to stay. After a short illness, Dr. Damrosch
died (1885) and his son Walter, then nineteen years of age, fell heir
to the position of conductor of German opera at the Metropolitan
Opera House, and of the Oratorio Society. Through Walter
Damrosch’s efforts, Lilli Lehmann, the foremost Wagnerian singer,
was engaged for the Metropolitan; he also engaged Emil Fischer,
basso, Max Alvary, tenor, Anton Seidl, conductor, and Mme. Lillian
Nordica (Lillian Norton), one of the first Americans at the
Metropolitan.
Walter Damrosch composed the popular American song, Danny
Deever on the poem by Rudyard Kipling. One never can think of this
stirring song, without remembering David Bispham, who sang it into
fame. Bispham was another native, who was for years a member of
the Metropolitan Opera Company, and an oratorio singer. Damrosch
is the composer of two grand operas, The Scarlet Letter on a text
from Nathaniel Hawthorne’s novel, and Cyrano de Bergerac, of
Edmond Rostand’s, made into a libretto by W. J. Henderson. He also
wrote incidental music to three Greek Tragedies Iphigenia in Aulis,
Medea and Electra, first performed in the open air theatre of the
University of California, in Berkeley, by Margaret Anglin and her
company.
Damrosch married the daughter of James G. Blaine in 1890, and
soon after, he started an opera venture which for several years visited
the large cities and brought Wagner into many places where his
music had been merely a hearsay. He has been a pioneer in
championing the cause of modern composers, and many well known
European works have had their first American performances at his
New York Symphony concerts.
Dr. Frank Damrosch, older brother of Walter, is an important
educator, the head of the Institute of Musical Art, and was once
conductor of the Oratorio Society, and of the “Musical Art Society” in
which were sung unaccompanied all the lovely motets and madrigals
of Palestrina, Lassus, and many others. Dr. Frank Damrosch also
founded the People’s Choral Union in which working men and
women were taught singing and became members of a chorus of
twelve hundred voices which performed the classic oratorios. He also
founded the Young People’s Concerts, which have brought to young
people of New York the finest music the world has produced. For
several years, Mr. Walter Damrosch has had these in charge, and his
talks explaining the works performed are quite as enjoyable as the
music.
 The Mason Family

Another famous family in American music is the Mason family,

dating back to Lowell Mason (1792–1872) who was born at Medfield,
Massachusetts. His principal work was a collection of hymn tunes
which he harmonized, and won him the title of “Father of American
Church Music.” He was president and conductor of the Handel and
Haydn Society, and was a born teacher. He travelled from one society
to another in distant cities, training choruses, giving encouragement
and advice. He moved to New York in 1851.
Lowell Mason’s third son, Dr. William Mason (1829–1908), was
also a pioneer. In his long life he saw music grow in America from
crude beginnings and reach a height that seems almost unbelievable,
in one short century. He not only heard but played, piano concertos
with orchestras as fine as those he found in Europe when he went to
study with Moscheles, Hauptmann, Richter, and Franz Liszt. Mason
was one of the young artists permitted to be a friend as well as a
pupil of the kindly Music Master. Dr. Mason and Theodore Thomas
were the first to give chamber music concerts, and thus introduced
many masterpieces of Brahms and Schumann, for as “modernists”
they loved to bring new compositions to the public. Dr. Mason in his
whole-hearted love of his art, and sincerity and geniality is worthy of
our deepest respect and admiration. He composed about fifty piano
pieces, and with W. S. B. Mathews he arranged a piano method that
was very popular and successful. We feel sure that if you search in
that old box of music that mother used to study, you will find a copy.
No doubt she played his Silver Spring, Reverie Poetique and Danse
Rustique.
Daniel Gregory Mason, one of the foremost composers, lecturers
and writers on music, is a nephew of Dr. William Mason. He was
born in 1873, was graduated from Harvard University in 1895. His
compositions include many works in large form, sonatas, a string
quartet on Negro themes, a piano quartet, a symphony, a fugue for
piano and orchestra, a Russian Song Cycle, piano pieces; Mr. Mason
has written many valuable books on musical subjects and on Music
Appreciation, and is at present professor of music at Columbia
University.
 Gottschalk—the Picturesque

We have been telling you about the composers in the northern part
of the United States, and those who had come from Germany like the
Damrosch family, but here is one composer and gifted pianist who
brought a new color into American music. Louis Moreau Gottschalk
(1829–1869), born in New Orleans, was the child of an English
father and Creole mother, thus mixing Spanish, French and English
blood. He was an infant prodigy; he played the piano at four, the
organ at six, and at thirteen he went to Paris to study. He was praised
by Chopin, and appeared in concerts with Hector Berlioz. He
charmed everyone who heard him, and was the first American
pianist to receive European honors. The Infanta of Spain made a
cake for him and a celebrated bull-fighter gave him a sword! He
toured Cuba and North and South America, giving more than a
thousand concerts. But the life was too hard on him and he died at
the age of forty in Rio Janeiro, Brazil.
The Last Hope, Ojos Creollos (Creole Eyes), Banjo, Souvenirs of
Andalusia are among the most popular of his ninety compositions
for piano, which showed the strong influence of life in Louisiana, his
love of sunshiny Spain, and his study in France. Here we find
rhythms closely related to ragtime and jazz, as well as the slow
fascinating Spanish dance. Today his works are forgotten, but for
many years they were played throughout the land.
 Stephen Collins Foster

Stephen Collins Foster (1826–1864), for whom we have claimed

the right to be called a composer of folk songs, was born in
Lawrenceville (Pittsburgh), Pennsylvania, on the fiftieth anniversary
of our Declaration of Independence. The understanding he showed
of the Negro came to him because his parents were Southerners. He
showed talent for music when he was very young, and taught himself
to play the flageolet when he was seven years old. He was very self-
willed and did not like discipline, so he taught himself practically all
he knew of music. His first composition, Tioga Waltz for four flutes,
was written when he was a school boy. It was first played in school,
with Stephen in the lead. His first song, Open thy Lattice, Love, was
published in 1842. For several years, five boys met at the Foster
home, and Stephen taught them to sing part songs. He composed
many pieces for them, among them Oh, Susannah, Old Uncle Ned
and Old Black Joe.
About 1830, an actor, Thomas Rice, had the idea of dressing up
like an old negro porter in Pittsburgh, from whom he borrowed the
clothes, and singing a song he had heard from a negro stage driver:
Turn about and wheel about, and do jist so,
And ebery time I turn about, I jump Jim Crow.

The song, accompanied by a dance, took the audience by storm,

especially when the porter appeared on the stage, half dressed, and
demanded his clothes, because the whistle of the steamboat had just
blown and the old fellow had to “get back on the job.” So “Daddy”
Rice became the father of “Negro Minstrels,” and travelled all over
America and even England, singing and dancing negro songs. A few
years later Stephen Foster sent his Oh, Susannah to a travelling
minstrel troupe, and the song took “like wild fire.” He decided to
write songs as a profession, in spite of his family who thought he had
wasted time “fooling around” with music, and insisted on his going
to work.
While Oh, Susannah is a “rollicking jingle,” Old Uncle Ned is the
“first of the pathetic negro songs that set Foster apart from his
contemporaries and gave him a place in musical history,” says
Harold Vincent Milligan. “In this type of song, universal in the
appeal of its naïve pathos he has never had an equal.”
Another claim he has as a folk song composer, is that he never
studied as most people do who want to be composers. He knew very
little about harmony and less of counterpoint, and his is “music that
has come into existence without the influence of conscious art, as a
spontaneous utterance, filled with characteristic expression of the
feelings of a people.” (H. E. Krehbiel.) Perhaps he was right when he
said that he was afraid that study would rob him of the gift of
spontaneous melody that was his to such a marked degree, because
he was not naturally a student and might never have carried his
studies far enough. At any rate we have every reason to be grateful
for the simple direct songs which are dear to us and as near to our
hearts as any folk song of any age or country whose author has been
forgotten!
He was sweet-natured, irresponsible, refined and sensitive, but
easily influenced. His publishers made $10,000 out of his songs, but
he made little and spent much. He married in 1850, but the union
was not happy.
During his last years spent in New York, he was poverty-stricken
and miserable, and sold his songs, as soon as they were written, for a
few dollars in order to live. It seems too bad to have to say that much
of his money and his life were squandered thoughtlessly.
Curiously enough, his favorite poet was Edgar Allan Poe, whose
life resembled his own in many sad details. He loved to go up and
down in the Broadway stages, often thinking out his melodies as he
rode. This reminds us of Walt Whitman, who rode up and down Fifth
Avenue alongside his friend Pete Dooley, the driver of the stage
coach!
Stephen Foster died in New York in 1864 as the result of an
accident in which he had severed an artery. He was saved from burial
in Potter’s Field, by the arrival of his brothers and his wife, and he
was buried in Pittsburgh beside his parents whom he had
immortalized in The Old Folks at Home.
 CHAPTER XXXI
America Comes of Age

For many years Boston was a center of musical life.

At the close of the Civil War a school was well under way in New
England, which we might call the classical period of American music.
 B. J. Lang

Although Benjamin J. Lang (1837–1909) never published his

compositions and never allowed them to be heard, he had much
influence on Boston’s musical life, having been conductor of the
Handel and Haydn and of the St. Cecilia societies, and the piano
teacher of such musicians as Arthur Foote, William Apthorp,
Ethelbert Nevin and Margaret Ruthven Lang, his daughter.