Stroke and Interventional Neurology
The “Stroke and Interventional Neurology” (also known as Interventional Neurology / Endovascular Neurosurgery), is a subspecialty of Neurosciences specialises in advanced minimally invasive techniques used for the treatment of stroke and complex neurovascular diseases of the brain and spine.
Kims Alshifa Stroke and interventional neurology procedures are performed through a small hole in the skin, usually in the groin. Through this miniature portal, tiny catheters or tubes are placed and guided to their intended targets in the arteries and veins of the brain, head/neck, or spinal cord. The procedures are performed in sophisticated Neurointervention Suits with the help of cutting edge, sophisticated catheterisation
technologies like 3D-RA, Road-map, Vaso-CT, Flat Panel CT etc. (Neurointervention catheterisation laboratory) to precisely guide its catheters and devices into the arteries and veins of the highly sensitive neural structures of the brain and spinal cord. Once reached to the target point of the disease and precisely judged, micro-devices that are amongst the most innovative and advanced available to medicine are used to
accomplish minimally invasive neurointerventional procedures. Over the last more than 2 decades subspecialty of neurointervention has been in the front line of the management of complex vascular lesions of the brain and spine in the most effective and safest way.
Many of the vascular lesions of the brain and spine that were earlier considered difcult to treat or relatively unsafe, can now be efciently treated with low risk of these minimally invasive neurointervention procedures. Some of the diseases most suitable for this form of treatment includes cerebral aneurysms, brain and spinal arteriovenous malformations, brain and spinal dural arteriovenous stulas, carotid and intracranial atherosclerotic stenotic diseases and stroke due to sudden blockage of the brain artery, can be effectively diagnosed with cerebral and spinal angiograms and managed with endovascular techniques, without the need for open surgery.
Advantages of this technique:
- shorten hospital stay
- Quick recovery from the disease problem
- Accurate image interpretation and diagnosis
- Patient–centered imaging.
- State-of-the-art angiosuites with the ability to produce highest quality images to evaluate and treat cerebrovascular disorders.
- Advanced procedures regularly performed by the dedicated and experienced team of neurointerventionists
- Procedures & Treatments
- Diagnostic
Cerebral Angiography (DSA)
(for Stroke/Subarachnoid haemorrhage/Moya-Moya Disease/ Vasculitis/AVM/Aneurysm/CVT etc.)
Cerebral angiography is a diagnostic procedure commonly done for the diagnosis and evaluation of various vascular lesions of the brain like aneurysm, arteriovenous malformation, dural-AVM, occlusion of the brain artery, collateral circulation in brain artery occlusion to dene need for the intervention etc.
This procedure is generally performed under local anaesthesia. A needle puncture is done in the groin to access the artery of the groin(femoral artery) and then cannulated with a back-lock femoral sheath. Through this femoral sheath a catheter (thin, long tube) is navigated through the aorta into the brain arteries (carotid and vertebral arteries). Subsequent to this a dye (radio-opaque, water soluble iodinated contrast) is injected in the brain artery to cine imaging is performed to obtain pictures in various planes using advanced neurovascular cathlab. These images are then carefully analysed and if needed then three dimensional rotating angiograms can be performed in a few seconds time to obtain a very clear high resolution image which can pick up even micro aneurysm of 1mm in size.
Cerebral angiography (DSA) is generally a day-care procedure in which a patient arrives at the hospital on a scheduled day in an overnight fasting state and after initial clinical assessment and preparation including consent for the procedure, the patient is shifted to the Stroke and Interventional Cathlab. After the procedure the catheter is removed and the puncture site is given manual compression for a few minutes to stop bleeding from the punctured femoral artery. The patient is then shifted to the ICU/Day-care for monitoring and after 6 hours of the procedure, the patient is generally discharged to the home.
- Therapeutic
Mechanical Thrombectomy for Acute Stroke
Mechanical thrombectomy is a recently implied method to open the blocked artery of the brain in stroke cases where thrombolysis (clot-busting drug) has failed or is not suitable for its use to recanalise the blocked artery to reverse the stroke.
In cases of acute stroke which can be due to occlusion of main blood vessels of the brain, there is insufcient blood supply to the brain which causes permanent neurological damage if not opened in time. The thrombus(clot) can be removed using neurointervention techniques like suction thrombectomy or stent retrieval thrombectomy or it can be dissolved by intra-arterial administration of clot lytic drugs.
Carotid Stenting & Vertebral Stenting
Carotid atherosclerotic disease occurs when fatty deposits (plaques) clog the blood vessels that deliver blood to the brain and head (carotid arteries). Similarly the blockage can happen in the vertebral artery as well. The blockage increases the risk of stroke, a medical emergency that occurs when the blood supply to the brain is interrupted or seriously reduced. The rst sign that one has for this condition may be a stroke or transient ischemic attack (TIA). Mild and moderate stenosis (unto 70%) is treated with medical therapy but if stenosis increases to more than 70% in symptomatic cases and more than 80% in asymptomatic patients then only secondary prevention is recommended by surgery or intervention.
There are two options for dealing with this blockage in the brain arteries: 1- Surgery: carotid Endarterectomy, an old, conventional method and 2- Intervention: Carotid Stenting and angioplasty.
Both procedures are effective and safe in experienced hands, but carotid stenting is minimally invasive and a short hospital stay (2days) procedure and generally preferred nowadays. However, if blockage is highly calcic then we prefer surgery over intervention.
Brain Aneurysm Coiling
An aneurysm is a weakened area in the wall of an artery making it prone for rupture. If an aneurysm ruptures, it can cause life-threatening bleeding and brain damage. The goal of aneurysm treatment is to isolate an aneurysm from the normal circulation without blocking off any small arteries nearby or narrowing the main vessel by accessing the aneurysm from within the bloodstream either by surgical clipping or by endovascular Coiling.
Endovascular Coiling is minimally invasive and does not require opening of the skull to reach the aneurysm. The aneurysm is reached through a blood vessel in the groin endovascularly. A exible guiding catheter is advanced from the femoral artery to one of four arteries in the neck that lead to the brain and visualises the blood vessels of the brain by contrast injection. This provides us with a roadmap of the arteries. Subsequently a very tiny micro catheter is navigated through the guiding catheter into the aneurysm sac under Road-Map (A uoroscopic shadow of contrast superimposed over the live uoroscopy). Then through the micro catheter delicate platinum coils of different sizes and shape selected according to the morphology and diameter of aneurysm sac, are implanted one after the other till the aneurysm sac is fully lled with the coils and on contrast angiography no contrast is visible to enter the sac. The aneurysm is thus excluded from the circulation, effectively removing the risk of aneurysm rupture.
Flow Diversion by FD stent in complex and giant Aneurysms:
Flow diversion is a technique in which a device - Flow diverter stent (a soft, exible mesh tube) is placed into the blood vessel with the help of a catheter introduced through a groin vessel, where an aneurysm has formed.
This process immediately diverts the ow of blood away from the aneurysm itself thus gradually causing remodelling of the diseased vessel.
This helps to treat complex aneurysms which are difcult to treat previously by simple coiling or conventional neurosurgery.
Cerebral Arteriovenous malformation (AVM)
Arteriovenous malformations (AVMs) of the brain refer to abnormal connections between arteries and veins bypassing the normal capillary network to the brain parenchyma.
Brain AVMs commonly present with seizures or epilepsy which generally gets controlled with anti-epileptic drugs. However in some cases it may cause bleeding into or around the brain, most commonly in young adults which can cause headache or neurological decits. Left untreated, there is a risk that they may bleed again causing severe neurologic damage and even death.
Conventionally AVMs were treated with microsurgical excision. Surgical excision of these clusters of vessels is a bloody surgery and often incomplete due to obscuration of surgical led by bleeding when excision is done with knife /scissors. Moreover, some of the deeply located AVMs are difcult to exercise without any neurological morbidity.
here was always a need for an alternative treatment strategy in these complex and large vascular lesions. In the recent past two methods came into practice which are minimally invasive. 1- Stereotactic Radiosurgery (SRS9 or Gamma Knife/Cyberknife Radiosurgery. In this under highly sophisticated equipment Gamma rays radiation is given to the AVM nidus in a precisely dened way through multiple directions to avoid brain injury. This technique is effective in small AVM in about 80% cases over 2 years duration after SRS.
2- Endovascular AVM Embolisation: Embolization is a method of plugging the nidus of the AVM with glue or other liquid embolic agents like Onyx/Squid etc. under uoroscopic guidance by a small tube called a ow guided micro-catheter. This method may require multiple microcatheterization to achieve complete results. Sometimes complete AVM embolisation may not be achieved safely in one session and embolisation may be repeated for the second time in some cases. This requires enormous expertise and deep knowledge of the microvascular anatomy and is generally safe to perform in high volume centres by experienced neurointerventionist.
Tumor Embolisation & Chemoembolisation
Many brain tumors bleed heavily during surgery. This can make neurosurgery very difcult. This difculty can be eased by embolization (blocking) of the blood vessels feeding these tumors before surgery begins.
A cerebral tumor embolization is a procedure in which a catheter is placed into the patient's groin and carefully navigated into the blood vessels supplying the tumor under X-ray guidance. An angiogram is obtained by injecting X-ray dye into the blood vessel to examine the blood supply of the tumor and verify that it is safe to eliminate that vessel. Material is then injected through the catheter to block the blood vessel under X-ray guidance. Also chemotherapeutic drugs can be injected into the blood vessel supplying the tumor as an adjuvant or neoadjuvant therapy
Chronic Subdural Hemorrhage (SDH)
Embolisation
Chronic subdural hematoma (cSDH) is a debilitating condition with a high rate of recurrence after surgical evacuation.The new procedure, MMA embolization, involves guiding a catheter that is inserted into a blood vessel to the area of the brain that is supplying blood to the subdural hematoma. Particles or a special type of glue will be released to stop the bleeding that is causing the subdural hematoma, thus preventing recurrence.
Inferior Pterosal Sinus Sampling (IPSS) For Cushing’s Syndrome
Cushing disease results from excessive cortisol production due to elevated ACTH levels produced by a pituitary tumor. In contrast, Cushing syndrome includes all conditions of hypercortisolism due to either ACTH-dependent causes (eg, Cushing disease or ectopic ACTH secretion by a nonpituitary tumor) or ACTH-independent causes (eg, excessive autonomous secretion of cortisol from a hyperfunctioning adrenocortical tumor). Inferior petrosal sinus sampling (IPSS) is an invasive procedure in which adrenocorticotropic hormone (ACTH) levels are sampled from the veins that drain the pituitary gland; these levels are then compared with the ACTH levels in the peripheral blood to determine whether a pituitary tumor (as opposed to an ectopic source of ACTH) is responsible for ACTH-dependent Cushing syndrome. IPSS can reliably establish on which side of the pituitary gland the tumor is located.
Intracranial Venous Angiogram for Venous Sinus Stenosis and Venous Manometry
Cerebral DSA can be useful in assessing venous sinus stenosis which has implications in the etiopathogenesis of Idiopathic Intracranial Hypertension (IIH). Subsequent intracranial venous sinus manometry to assess the venous pressure gradient is important to guide the therapy in the form of Venous angioplasty and stenting, if needed.
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