Brain and Spine

Neuro Interventions – Brain

  1. CEREBRAL DSA

Condition

Cerebral DSA means Digital Subtraction Angiography of brain vessels. There are several indications of a cerebral DSA like a) Patients with rupture of brain vessels causing brain hemorrhage especially if patient has no history of trauma; if patient is young, not hypertensive or if hemorrhage in atypical location. b)  Patients with blockage of brain vessels causing brain ischemia.

Treatment

Femoral artery in groin is punctured and sheath (short hollow tube) is placed in femoral artery. Then, a catheter (long thinner hollow tube) is taken through the sheath in both carotid arteries and an angiogram is done. Then, the catheter is taken in both the vertebral arteries and an angiogram is done. Finally the catheter and the sheath are removed.

 

  1. ACUTE ARTERIAL ISCHEMIC STROKE (AIS) OR BRAIN ATTACK

Condition

Acute arterial ischemic stroke (AIS) means permanent blockage of blood supply to the brain causing ischemic symptoms which does not recover spontaneously. Transient ischemic attack (TIA) means temporary blockage of blood supply to the brain causing ischemic symptoms which recover spontaneously over few minutes. TIA is usually a precursor of a major stroke. All acute ischemic strokes should be treated urgently. TIME IS BRAIN, so the earlier we open the artery, the better are its final results.

Treatment

AIS can be treated either by IV Thrombolysis or Mechanical Thrombectomy. Due to the limitations and ineffectiveness of IV Thrombolysis, Mechanical Thrombectomy is preferred in large vessel occlusion. There are two methods of mechanical thrombectomy: Stent Retrieval and Aspiration. Both can be used together as well.

Stent Retrieval – Femoral artery in groin is punctured and the sheath is placed in femoral artery. Then, through that, a guiding catheter is placed into neck vessel. Then, the stent device is taken through the guiding catheter into the occluded brain artery and thrombus is caught. Stent device with captured thrombus is taken out. Finally, the guiding catheter and the sheath are removed.

Aspiration Technique – Femoral artery in groin is punctured and the sheath is placed in femoral artery. Then, through that, a guiding catheter is placed into neck vessel. Then, the aspiration catheter is taken through the guiding catheter into the occluded brain artery. Aspiration is started and thrombus is sucked out. Finally, the aspiration catheter, the guiding catheter and the sheath are removed.

 

  1. ANEURYSMAL SUBARACHNOID HEMORRHAGE (SAH)

Condition

Aneurysm is localized, abnormal out pouching of the wall of an artery. The wall of aneurysm is weak and it can rupture to cause hemorrhage. Rupture of intracranial aneurysm will cause subarachnoid hemorrhage. All aneurysms should be treated, otherwise they will rebleed. Aneurysmal SAH is an emergency. It should be treated at the earliest-as risk of rebleed and death is 50% in the first month.

Treatment

Brain aneurysms can be treated either by surgical clipping or endovascular coiling. However, coiling is preferred as it has significantly less risk and better results than later. Endovascular coiling is minimally invasive technique in which we don’t need to open the skull (brain covering), rather microcatheter is used to reach aneurysm from groin (femoral) artery.

While performing endovascular coiling, Femoral artery in groin is punctured and the sheath is placed in femoral artery. Then, through that, a guiding catheter is placed into the neck vessel. Microcatheter is taken through the guiding catheter in the aneurysm and first coil is deployed within aneurysm. Then aneurysm is tightly packed with multiple coils, one after another so that it stops filling anymore. Finally, the microcatheter, the guiding catheter and the sheath are removed.

 

  1. BRAIN ARTERIO-VENOUS MALFORMATION (BAVM)

Condition

Brain AVM is direct connection between brain arteries and veins through abnormal bunch of vessels. These abnormal vessels tend to bleed and cause intracranial hemorrhage. Patients with BAVM present with Intracranial hemorrhage, Seizures, Focal neurological deficit, Venous hypertension and raised intracranial pressure. Intracranial bleed is an indication to treat BAVM.

Treatment

BAVMs can be treated either by Surgery, Embolization or Radiotherapy. However, embolization is the preferred option as immediate complete cure can be achieved with less risk. To perform BAVM embolization, Femoral artery is punctured and the sheath is placed in femoral artery. Then, through that, a guiding catheter (thick tube) is placed into neck vessel. The microcatheter (thin tube) is taken through the guiding catheter in the feeding artery distal to normal arteries. BAVM is embolized with liquid embolic agent. Finally, the microcatheter, the guiding catheter and the sheath are removed.

 

  1. VASCULAR BRAIN TUMOUR EMBOLIZATION

Condition

Vascular brain tumour embolization means blocking the blood vessels supplying highly vascular brain tumours. Indications for embolization of brain tumours are – Pre-operative embolization of Vascular tumours like Meningioma, Hemangiopericytomas, Glomus tumours, etc. Preoperative embolization is the preferred in these brain tumours as it not only helps to decrease blood loss, but also decrease operative time significantly. Plus, due to a blood-less operative field, the tumour can be removed completely thus decreasing residual and recurrence rates significantly.

Treatment

Preoperative embolization followed by surgery is treatment of choice for treating vascular brain tumours. Eg. meningioma which is supplied by branches of Middle Meningeal Artery (MMA). For performing its embolization, femoral artery is punctured and the sheath is placed in femoral artery. Then, through that, a guiding catheter (thick tube) is placed into the neck vessel. Microcatheter (thin tube) is taken through the guiding catheter in the branch of MMA supplying tumour. Tumour is embolized with Poly Vinyl Alcohol (PVA) particles and made avascular. Finally, the microcatheter, the guiding catheter and the sheath are removed.

 

  1. CAROTID ARTERY STENTING (CAS)

Condition

Stroke is one of the leading cause of death and disability in India. Carotid artery stenosis causes approximately 10-15% of all ischemic strokes. Atherosclerotic plaque in cervical carotid artery is the most common cause of carotid artery stenosis. Plaque disruption and atheroembolization into the intracranial circulation is the most common mechanism for stroke. CAS means opening of this narrowed/stenosed neck carotid artery by placing a stent. Indications for treating carotid artery stenosis in symptomatic patients are – one or more TIAs in 6 months + carotid artery stenosis >50% or Progressive stroke + carotid artery stenosis >50%. Sometimes carotid artery stenosis is detected incidentally. In such asymptomatic patients also if stenosis is >70% it should be treated, as there is significantly high risk of stroke if left untreated.

 

Treatment

Carotid artery stenosis can be treated either by Carotid Endarterectomy (CEA) or by Carotid artery stenting (CAS). However CAS is preferred over CEA especially in patients with multiple comorbidities, contralateral ICA occlusion, postoperative or post radiotherapy status, high bifurcation and young patients (<70yrs). For performing CAS, femoral artery is punctured and the sheath is placed in the femoral artery. Then, through that, a guiding catheter (thick tube) is placed into the neck vessel. Then, stenosis is crossed with the wire and the filter is placed distally. Stenosis is dilated with a balloon and stent is deployed across stenosis. The stent is then dilated with balloon. Finally, the filter with wire, the guiding catheter and the sheath are removed.

 

  1. CAROTID-CAVERNOUS FISTULA (CCF)

Condition

CCF is a direct connection between cavernous part of Internal carotid artery (ICA) and Cavernous sinus. It drains into cavernous sinus tributaries. So the arterial pressure from ICA is directly transmitted to cavernous sinus tributaries like ophthalmic veins and cerebral veins. Patients usually have history of trauma and they with CCF present with — redness and proptosis of eye, loss of vision, occasional intracranial venous hypertension, raised intracranial pressure and intracranial hemorrhage.

Treatment

CCF is treated by endovascular embolization/obliteration of fistula.  For this femoral artery is punctured and the sheath is placed in femoral artery. Then, through that, a guiding catheter (thick tube) is placed into the neck vessel. Through the guiding catheter, a balloon catheter (thin tube with balloon) is taken in ICA across the rent and a microcatheter (thin tube) is taken in cavernous sinus. The balloon is inflated to protect ICA and CCF is embolized with coils and liquid embolic agent. After fistula is obliterated (keeping ICA patent), the microcatheter, the balloon catheter, the guiding catheter and the sheath are removed.

 

  1. DURAL ARTERIOVENOUS SHUNTS (DAVS)

Condition

Dura mater is the outermost covering of brain, lying just beneath the bony skull. Dural AVS is a direct connection between the brain dural arteries and the veins through abnormal bunch of vessels, situated in dura mater. It drains into the cerebral veins. So the arterial pressure from dural arteries is directly transmitted to the cerebral veins causing cerebral venous hypertension. Patients with DAVS present with – Intracranial hemorrhage, focal neurological deficit, venous hypertension and raised intracranial pressure, seizures.

Treatment

Dural AVS is best treated by endovascular embolization. For this, femoral artery is punctured and the sheath is placed in the femoral artery. Then, through that, a guiding catheter (thick tube) is placed into the neck vessel. A microcatheter (thin tube) is taken through the guiding catheter in the feeding artery. DAVS is embolized with liquid embolic agent. Finally, the microcatheter, the guiding catheter and the sheath are removed.

 

  1. INTRACRANIAL ANGIOPLASTY & STENTING (IAS)

Condition

Intracranial artery stenosis is the narrowing of an artery inside the brain, that can lead to ischemic stroke. IAS means opening of this narrowed/stenosed intracranial artery by a balloon dilatation and placing a stent. Indications of IAS in these patients are — recurrent TIAs and progressive stroke, even after aggressive medical management.

Treatment

Intracranial stenosis is first treated by aggressive medical management including lifestyle changes. But in some cases inspite of this, patient develop recurrent TIAs or progressive stroke. In such cases IAS is treatment of choice. For this, femoral artery is punctured and the sheath is placed in femoral artery. Then, through that, a guiding catheter (thick tube) is placed into the neck vessel. Then, stenosis is crossed with the wire. Stenosis is dilated with balloon. Stent is deployed across stenosis. Finally, the wire, the guiding catheter and the sheath are removed.

 

  1. VEIN OF GALEN MALFORMATION (VOGM)

Condition

VOGM is a rare type of an arteriovenous shunt which usually presents in infants. In VOGM, there is a direct connection between the brain arteries and the vein of Galen. They are of two types: Mural and Choroidal. Child with VOGM presents with cardio-respiratory failure in neonatal period. Later on, child presents with focal neurological deficit, venous hypertension and raised intracranial pressure or seizures.

Treatment

VOGM is best treated by endovascular embolization. For this, femoral artery is punctured and the sheath is placed in the femoral artery. VOGM is supplied by choroidal branch of anterior and posterior cerebral arteries. First the guiding catheter (thick tube) is placed in the carotid artery and a microcatheter (thin tube) is taken through the guiding catheter in the choroidal branch of the anterior cerebral artery and it is embolized with glue. Then, the guiding catheter (thick tube) is placed in the proximal vertebral artery and the microcatheter (thin tube) is taken through the guiding catheter in choroidal branch of posterior cerebral artery and it is embolized with glue. Finally, the microcatheter, the guiding catheter and the sheath are removed.