WHAT IS NEUROINTERVENTION ?

HOW IS IT PERFORMED ?

Neuro interventional procedures also known as endovascular neurointervention (means procedures performed by staying within the blood vessels) are typically performed using tiny needle prick at the groin region and the Physician insert a small pipe known as catheter using fluoroscopic image guidance and it is threaded to the target region of the brain and spine using imaging technology.

No incision& no cut open surgical approaches are used during these procedures by the Physician. Neurointerventional procedures are hence typically less invasive than traditional surgical interventions, and result in significant shorter hospital stays and faster recovery times for patients.

Neurointerventional procedures are used to address conditions such as brain aneurysms, arteriovenous malformations (AVMs), carotid artery stenosis, acute strokes, preoperative head-neck & spine vascular tumor embolisation, middle meningeal artery embolisation for chronic recurrent subdural hematomas, brain-spine dural arteriovenous fistulas and cerebral venous sinus stenting among others. Neuro Interventional Radiologist plans his procedures after studying the patient’s Neuro images (Preoperative CT /or MRI) thoroughly.

The goal of these procedures is to improve blood flow to the brain, or to repair damaged blood vessels or other structures within the nervous system.

ACUTE STROKE INTERVENTIONS

The incidence of stroke in India is relatively high and is a major cause of death and disability. According to WHO, stroke is the second leading cause of death globally with an estimated of 17 million cases per year. 1 in 4 develop stroke and every 4 minutes one individual succumbs to stroke. Awareness about stroke is very poor among public and they not only fail to recognise symptoms of stroke but also not aware of Stroke ready hospitals close to their residence.

Stroke happens when there is sudden blockage of the blood vessel by the clot known as ischemic stroke (80% of the cases) or due to bursting of the blood vessel known as hemorrhagic stroke (20% of cases).

The goal of acute stroke intervention in ischemic stroke is to restore blood flow to the brain, to limit the damage from the stroke and prevent further injury.

Acute stroke intervention refers to the medical treatments and procedures that are performed as soon as possible after a stroke occurs. It is highly time sensitive treatment and time saved is brain saved!

There are two types of treatment: Intravenous injection of clot busting drug known as IV. Thrombolysis and second one is endovascular procedure known as Mechanical Thrombectomy.

Effective acute stroke intervention can help to reduce the risk of long-term disability and increase the chances of recovery.

Thrombolysis is one of the most common acute stroke intervention procedures performed within the first 4.5 hours of an ischemic stroke. This involves administering medication such as tissue plasminogen activator (tPA) to dissolve the blood clot that is obstructing a blood vessel in the brain.

Another acute stroke intervention procedure is mechanical thrombectomy, which involves inserting a catheter into an artery in the groin and threading it up to the clot in the brain to mechanically remove or break up the blood clot. Mechanical thrombectomy is a minimally invasive neurointerventional procedure used to treat ischemic strokes caused by blood clots that occur within a blood vessel in the brain. It involves using a thin catheter that is inserted through an artery in the groin and threaded up to the blocked vessel in the brain. Once the catheter reaches the clot, a stent-like device is deployed to break up or remove the clot, restoring blood flow to the brain.

Mechanical thrombectomy is typically performed within the first few hours of an ischemic stroke, when the best chance for recovery is possible. It is considered the gold standard treatment for ischemic strokes caused by large vessel occlusions and has been shown to be highly effective in reducing disability and improving outcomes. Recovery time after mechanical thrombectomy is usually much faster than traditional stroke treatments and patients are typically discharged sooner. However, not all patients with stroke will be candidates for thrombectomy and it is important to receive prompt medical attention as the ideal therapeutic window is narrow.

The urgency and complexity of acute stroke require a multidisciplinary team approach including emergency medical staff, neurologists, interventional neuroradiologists, clinical laboratory, imaging specialists, and rehabilitation professionals. Advances in acute stroke intervention techniques have helped to improve outcomes for patients with both ischemic and hemorrhagic strokes.

WHAT IS GOLDEN HOUR STROKE?

The “golden hour stroke” refers to the critical period of time after a stroke occurs in which medical treatment needs to be administered as quickly as possible. This period generally lasts for the first 6 hours after a stroke and in exceptional cases it’s up to 24 hours. During this time, the brain is losing millions of neurons due to a lack of oxygen and blood flow, and immediate treatment can help to limit the damage.

During the golden hour stroke, it is important for people to recognize and respond to stroke symptoms quickly. The most common symptoms of stroke include sudden numbness or weakness of the face, arm, or leg, sudden confusion or trouble speaking, sudden vision or balance problems, and sudden severe headache.

Treatment during the golden hour stroke may involve medication to dissolve the blood clot (if the stroke is ischemic & if patient reaches hospital in first 4.5 hours), or Endovascular intervention treatments such as mechanical thrombectomy (first 24 hours of ischemic stroke). The quicker the treatment is administered, the greater the chance of recovery and reduction of disability. For these reasons, it is critical to seek medical attention immediately if anyone is experiencing stroke symptoms during the golden hour stroke.

A stroke-ready hospital is a medical facility that has the infrastructure, staff, and resources necessary to provide rapid and effective care for patients who have experienced a stroke. Stroke-ready hospitals are typically equipped to provide time-critical interventions, including administering clot-busting drugs such as tissue plasminogen activator (tPA) and performing mechanical thrombectomy.

To become a stroke-ready hospital, a medical facility must meet certain criteria and guidelines set by national stroke organizations. This includes having a dedicated stroke team of healthcare professionals, including neurologists, radiologists, and emergency department staff trained in stroke care. The hospital must also have imaging capabilities, including CT scans, MRI scans, and angiography, available 24/7.

Having stroke-ready hospitals in the community help ensure that patients receive timely treatment and support optimal recovery. If someone experiences symptoms of stroke, it is essential to call emergency services immediately to receive a prompt and precise response that could lead to a higher quality of life for the patients and improve clinical outcomes.

What is Comprehensive stroke center (CSC)?

It is a specialized hospital facility that provides the most advanced and comprehensive level of medical care for patients who have experienced a stroke. CSCs are equipped with the latest technology and have a multidisciplinary team of highly skilled medical professionals specializing in stroke care, including neurosurgeons, neurologists, internventional neuroradiologists, , neuroradiologists, and rehabilitation specialists.

To be designated as a comprehensive stroke center, hospitals need to meet certain criteria set by national stroke organizations, which incorporate highly specialized stroke services. This includes having a stroke team available 24/7, advanced imaging equipment for stroke diagnosis, and specialized treatment options such as thrombectomy.

Comprehensive stroke centres provide a full range of essential clinical services like stroke prevention, acute stroke management, rehabilitation, and ongoing long-term care following discharge. The multidisciplinary team approach in a comprehensive stroke center ensures that patients receive personalized, evidence-based care, and optimal medical management to help reduce the risk of future strokes.

Having CSCs in the community helps to ensure effective and prompt treatment for patients with complex or severe stroke cases, resulting in improved quality of life, reduced disability, and higher chances of recovery. Apollo hospitals, Bangalore is not only Stroke ready but also a comprehensive stroke center. Strike the stroke by calling our 24×7 Emergency

What is brain aneurysm?

Aneurysm coiling is a minimally invasive neurointerventional procedure used to treat aneurysms in the brain. It involves inserting a catheter through a small incision in the groin and threading it up to the aneurysm via an artery in the body. Once the catheter reaches the site of the aneurysm, tiny metal coils are delivered through the catheter and into the aneurysm. The coils are then packed tightly into the aneurysm, promoting blood clots to form and sealing off the aneurysm from the bloodstream. This effectively stops blood flow into the aneurysm, eliminating the risk of a rupture.

Aneurysm coiling is a safer and less invasive alternative to traditional surgical treatments for aneurysms, such as open craniotomy and clipping. It is typically performed using conscious sedation or general anesthesia and allows for a faster recovery. The procedure often results in shorter hospital stays and less risk of complications.

Aneurysm coiling is best suited for small to medium-sized aneurysms that are located in areas of the brain that are considered hard to reach or difficult to access using traditional surgery. The success rate of aneurysm coiling is high, with most patients treated being able to return to their normal daily activities relatively quickly.

What is carotid stenting?

Carotid stenting is a minimally invasive procedure used to treat carotid artery disease when carotid endarterectomy, the surgical removal of plaque build-up from the inner walls of the carotid arteries is not possible due to anatomy or medical reasons. Carotid artery disease is caused by the buildup of plaque in the carotid arteries, which can restrict blood flow to the brain and can lead to ischemic stroke.

The procedure involves inserting a small, flexible catheter through an artery in the groin and threading it up to the carotid artery affected by the plaque build-up. Once the catheter reaches the region affected by the build-up, a small balloon at the end is inflated to widen the carotid artery. In addition, a stent placement may secure the artery and prevent restenosis.

Carotid stenting is a less invasive and less risky procedure when compared with traditional surgery to remove plaque from the carotid arteries, known as a carotid endarterectomy. Carotid stenting requires a shorter hospital stay and reduced recovery time.

What is brain AVM & it’s management?

AVM (arteriovenous malformation) embolization is a minimally invasive neuro interventional procedure used to treat abnormal connections between arteries and veins in the brain or spine. AVMs are typically characterized by a tangle of blood vessels that develop abnormally, and can cause serious health problems, for example, bleeding, seizures, and neurological deficits.

AVM embolization involves introducing a catheter into an artery near the site of the AVM and then threading it into the vessels around the malformation. Tiny particles known as embolic agents, such as coils or liquid glue, are injected through the catheter to block the blood flow to the abnormal vessels. This causes the small blood vessels to convert into connective tissue gradually, which helps reduce the risk of rupture.

AVM embolization may be done as the sole treatment or in combination with other treatments, such as surgery or radiation therapy, depending on the size, location, and severity of the AVM.

The minimally invasive nature of the procedure often results in shorter hospital stays and less risk of complications. AVM embolization can help to reduce the risk of bleeding and relieve symptoms, addressing patients’ seizures or headaches. However, complete AVM obliteration is not always possible, and multiple embolization treatments or a combination approach may be necessary. The need for embolisation, surgical AVM resection, or radiation therapy depends on multiple factors and must be assessed and determined by a multidisciplinary team of physicians, including interventional neuroradiologists, neurosurgeons, and neurologists working together to develop a comprehensive plan of care.

What is Cerebral Venous Sinus Thrombosis and does intervention has a role  in management ?

The blood flows out of the brain through venous channels called the cortical veins and venous sinuses. In certain patients due to various causes these veins may get blocked causing symptoms ranging from head ache, seizures to drowsiness and coma. These patients are managed initially with blood thinners. Some of them who does not respond well to medication and who have a heavy clot burden these clots in the veins can be removed using minimally invasive Neurointervention procedure. These interventions are life saying in them and will speed up their recovery process.

What is chronic subdural hematoma and its management ?

Chronic subdural hematoma(CSDH) is blood getting collected between the layers of the dura on the surface of the brain. Dura are membranes which cover the surface the brain and are supplied by middle meningeal artery. CSDH develops following a trivial trauma or spontaneously and progressively increases in size due to repeated bleeding into the hematoma compressing the brain and causing various symptoms. The symptoms may range from headache to drowsiness and coma. These hematomas can be managed by minimally invasive Neurointervention procedure where we enter the middle meningeal artery and block it avoiding surgery and breaking open the skull in most of the patients. Some of the patient may require surgery due to the large size of the hematoma but even in such patients blocking the middle meningeal artery has an important role as it prevents repeated collection which these hematomas are prone for in spite of surgery.

What are pain management procedures a Neurointerventionist can offer?

Pain in various parts of the body are mediated through the nerves which carry the pain sensation to the brain. There are image guided techniques performed with high precision where we can block these nerves carrying pain and give an immediate and significant pain relief to the patient. These techniques include:

Transforaminal nerve block, intercostal nerve block and epidural steroid injections. These are minimally invasive techniques for reduction of pain caused by irritation of the nerves due to degenerative disease or tumors or post viral infection.

Facet joint steroid injection: Pain relief measure in patients with severe degenerative facet joint arthropathy.

Radiofrequency Ablation for Trigeminal Neuralgia: Percutaneous daycare procedure performed to relieve pain in patients with trigeminal neuralgia, which is sever episodic pain caused by the irritation of the nerve supplying in the face.

What are the other procedures performed by the Neurointerventinist?

Tumor Embolisation: Pre-operative tumor embolization is performed in tumors of the head, neck, brain, and spine to reduce the bleeding from these tumor during surgery.

Embolisation of bleeders: Endovascular treatment of bleeders in head, neck and spine caused by tear or damage to the blood vessels due to trauma, infection or tumor.

Digital subtraction myelography(DSM): Diagnostic test to detect CSF leak in patients with intracranial hypotension.

Image guided biopsies of soft tissue/bone tumors and lymphnodes in the skull base, neck and face

Biopsies of vertebral lesions, intervertebral disc lesions and paravertebral soft tissue lesions.

Epidural blood patch: Treatment for patient with intracranial hypotension caused due to CSF leak in the spinal cord.

Vertebroplasty for benign and pathological compression fractures: Procedure performed to strengthen the vertebral body with cements in patient with fracture of the vertebral body.