Endovascular Neurosurgery is a super-specialty in which diseases of brain, craniofacial and spinal regions are treated by a minimal invasive technique as opposite to open surgical techniques. Alternative terminologies used for this modality of treatment are or Interventional Neuroradiology (INR) , Neuro-endovascular surgery and Surgical Neuro-angiography.
Originally developed in the 1980’s by neurological surgeons and radiologists, INR is made possible by dramatic advances in computer technology and state-of-the-art equipment. Essentially, interventional neuroradiology therapies are accomplished through microcatheters inserted in the groin area and, under X-ray guidance, threaded through the blood vessels leading into the brain. Interventional neuroradiologists currently employ a variety of minimally invasive procedures to accomplish a wide range of treatments including: aneurysm therapy by inserting platinum coils into the aneurysm bulge to prevent clotting and rupture; plugging (embolization) of vascular malformations; stroke treatment by delivering clot-busting drugs directly to the site of the blockage; and spinal treatments by injecting cement into a fractured vertebra in order to reinforce the bone.
Interventional neuroradiology is a subspecialty discipline overlapping the field of radiology, neurosurgery and neurology. Initially performing minimally invasive techniques utilizing x-ray fluoroscopy (“real-time” x-ray technology to monitor movement inside the body) and angiography (injection of x-ray contrast or “dye” to obtain pictures of blood vessel anatomy), radiologists have added ultrasound, computed tomography (CT), and even magnetic resonance imaging (MRI) to their arsenals. Such advanced technology allows the physician to visualize their operative procedures without making a skin incision to see inside the body.
Neuroendovascular center (at JPMC) is the first-ever unit which is working in public sector under the umbrella of Institute of Neurosurgery at Jinnah Postgraduate Medical Center Karachi-Pakistan. The endovascular unit will be especially focus for providing services to general public at a subsidized cost.
Society of Neurointerventional Surgery (SNIS)
http://www.snisonline.org/guest/guest.php
How an Endovascular Neurosurgeon can help:
As compared to open surgical techniques, endovascular treatments often involve less risk and result in less pain and a faster recovery period. Below is given a brief description of most commonly involved ailments which can be treated by endovascular treatment. The description is simplified for the purpose of understanding to physicians (non-specialized in INR), patients, their family memebers
Brain Aneurysm Treatment:
A brain aneurysm, also called a cerebral or intracranial aneurysm, is an abnormal bulging outward of one of the arteries in the brain. It is estimated that up to one in 15 people will develop a brain aneurysm during their lifetime.
Brain aneurysms are often discovered when they rupture, causing bleeding into the brain or the space closely surrounding the brain called the subarachnoid space, causing a subarachnoid hemorrhage. Subarachnoid hemorrhage from a ruptured brain aneurysm can lead to a hemorrhagic stroke, brain damage and death.
The main goals of treatment once an aneurysm has ruptured are to stop the bleeding and potential permanent damage to the brain and to reduce the risk of recurrence. Unruptured brain aneurysms are sometimes treated to prevent rupture.
The treatment of an aneurysm is often determined by its size. Traditional surgery is performed by a neurosurgeon, however, the patient may also have the option to select endovascular treatment or “coiling,” a less invasive option with fewer risks.
As in other endovascular treatments, a catheter is inserted in the groin area and threaded through the vessels to the site of the aneurysm. Detachable platinum coils are then dispensed through the catheter and placed carefully inside the aneurysm. The number of coils used depends on the size of the aneurysm.
As an aneurysm is really a “ballooning” in a weakened area of a vessel wall, the goal of “coiling” is to pack the aneurysm tightly to close off blood flow into the aneurysm thereby preventing its rupture. Occasionally, it is necessary to add more coils at a later time on follow up to complete treatment.
Certain aneurysms may be treated by blocking the artery from which the aneurysm arises using coils or detachable balloons. Additional new methods of aneurysm treatment are in development.
Hospitalization time varies from patient to patient. A 2 or 3-day hospitalization may be possible for certain patients who have not had a hemorrhage, but patients who have had a recent brain hemorrhage from a ruptured aneurysm may expect to be hospitalized at least 10-14 days minimum. A follow-up x-ray, MR scan, or an angiogram may be performed to evaluate the position of the coils.
Patients may be placed on a blood thinner such as aspirin after the procedure, which may be continued after discharge.
For Further details you may visit:
Brain Aneurysm Resources
Brain Arteriovenous Malformations (AVMs) Treatment:
Arteriovenous malformations (AVMs) are typically diagnosed by a CT scan or MRI upon presentation of symptoms that may include seizures, headache or stroke-like episodes. Once an AVM is confirmed, an angiogram or arteriogram is performed to identify the vessels involved in the malformation. Angiography is the only test currently available that provides sufficiently detailed information useful in planning and implementing therapy of most AVMs.
There are three major treatment methods that may be useful either alone or in combination to treat an AVM. The specific treatment for an individual is based on the patient’s history, symptoms, and anatomy of the AVM including its size, feeding arteries, draining veins, and location within the brain. Treatments include: endovascular embolization (closure of the AVM from within the blood vessels), open surgical removal of the AVM, radiosurgery or a combination of techniques.
Open surgical treatment involves removing a portion of the skull so that surgical instruments can be inserted to remove the AVM. Surgical treatment is often performed after embolization has closed portions of the AVM. The combination of embolization followed by surgical resection is frequently safer than surgical resection alone in treating an AVM.
Radiosurgery is a technique which uses focused beams of radiation to treat particular AVMs that are sufficiently small and located in appropriate areas of the brain. Despite the name, no opening of the skull is required. Instead, the radiation causes scarring in blood vessels of the AVM, thereby eliminating it. After treating the AVM with radiosurgery, a period of two to three years is required for the full effect of the treatment to be determined. In over 80% of cases where the AVM is sufficiently small, there is complete obliteration of the AVM.
Embolization is an endovascular technique (performed from within the blood vessels) to block the vessels of the AVM. In this procedure, a small catheter is threaded from the groin directly into the AVM vessels within the brain. Under X-ray guidance, material is injected through the catheter to permanently block and close off the vessels of the AVM. Materials used might include particles, small platinum coils, and/or liquid embolic agents similar to glue.
Embolization of an AVM is usually performed before treatment by either surgery or radiosurgery. Embolization is often able to decrease the size of the AVM making the surgery or radiosurgery much safer than would otherwise be the case. However, the blood flow from certain AVM’s may be totally blocked by embolization techniques, and no further therapy may be required.
Treatment of an AVM is directed toward preventing brain injury that could result from bleeding or re-bleeding. No treatment currently exists which can repair damage already done to the brain by the AVM. For example, seizures might continue after embolization or even complete removal of the AVM. Patients with neurological deficits resulting from AVM hemorrhage would likely still experience the same deficits after treatment of the AVM, although improvement may occur.
Dural Arteriovenous Fistula Treatment:
The treatment for a dural fistula depends on the vessels involved. Surgery or radiation therapy may be recommended. Often, these fistulae are treated through endovascular methods by placing a catheter into the blood vessels and injecting materials to block off the vessels, a procedure called embolization. Blockage of arteries, vein (sinus), or both may be needed. Multiple treatments may be needed to close the fistula.
Carotid Angioplasty and Stenting (Extracranial) Treatment:
If the carotid artery is minimally constricted due to blockage, medical treatment may be recommended. However, if significant blockage is present, surgery (endarterectomy) is usually performed. Designed to remove the plaque causing the constriction which in turn allows the blood to flow more freely, endarterectomy is becoming increasingly more common, and is often referred to as “the gold standard” treatment for carotid atherosclerosis. Endarterectomy is especially recommended for patients who have significant blockage.
In 2004, a minimally invasive treatment for carotid atherosclerosis called carotid stenting received FDA approval. This procedure is performed by opening the artery with a small tube and then inflating a balloon catheter to press the plaque into the sides of the artery wall. Similar to angioplasty, this procedure is also utilized in the heart (Angioplasty of blood vessels of heart in heart attack). Subsequently, a stent, or supportive tube, is then placed in the artery to cover the plaque and help keep the vessel open.
In deciding between surgery and stenting to treat carotid atherosclerosis, doctors consider the patient’s overall health condition. In cases where a patient is symptomatic and at high risk for surgery (experiencing poor health in general, manifesting a heart condition or experiencing a previous stroke), angioplasty and stenting has been proven in a recent trial to be at least as effective as surgery, inferring that Carotid Stenting and Angioplasty is an alternative to Carotid artery Surgery. Neither carotid stenting nor surgery may be a good option for patients with no symptoms from their stenosis.
In cases where a narrowing or stenosis is present in the vertebral artery, angioplasty and stenting are usually performed.
Brain Attack Coalition
http://www.stroke-site.org
American Stroke Association
http://www.strokeassociation.org
Stroke Information Directory
http://www.stroke-info.com
www.aneurysm-stroke.com
Intracranial Atherosclerosis Treatment:
Unlike atherosclerosis of the arteries leading to the brain (carotid and vertebral arteries), which often causes transient ischemic attacks (TIAs or ministrokes), intracranial atherosclerosis often is first found when a major stroke occurs. For this reason, it is important to treat intracranial atherosclerosis when it is found. This is accomplished by inserting a catheter into the groin and threading it up through the vessels to the site of the plaque. First, a balloon is deployed and expanded within the narrowing, pushing the plaque back against the artery walls (similar to angioplasty in the heart). As in the heart, stents may then be implanted to cover the plaque and keep the vessel open.
Although medical treatment may help decrease the chance of a stroke, it is not as effective as medical treatment for carotid artery disease. However, this form of treatment is becoming more common.
Meningioma Treatment:
Meningiomas can occur in people with certain inherited diseases, such as neurofibromatosis, however, most commonly they arise spontaneously. These tumors, although not malignant, are usually treated surgically; however, when they are very large, or have a large blood supply, surgical removal is riskier. When this is the case, they may be treated through endovascular methods by placing a catheter into the blood vessels supplying the tumor and injecting materials to block off the blood supply to the tumor. This procedure, called embolization, is usually performed within a few days prior to the surgery.
Head and Neck Tumor Treatment
Tumors of the head and neck (such as tongue or throat cancer) can cause bleeding into the throat or nosebleeds. Not infrequently, this bleeding can be difficult to control by surgery. When this is the case, endovascular methods can be used to treat these tumors and their bleeding by inserting a catheter into the blood vessels supplying the tumor and injecting materials to block off the blood supply to the tumor. This procedure, called embolization, can also be performed before a scheduled surgery if the surgeon is concerned that the large blood supply to the tumor will make surgery more difficult.
Additionally, certain tumors can be treated by placing a catheter into the artery supplying the tumor and injecting chemotherapy drugs directly into the mass, rather than dispensing the drugs intravenously. This treatment option depends on the kind of tumor, its size, and its location.
Paraganglioma Treatment:
While most paragangliomas are benign, their location, size, or growth may make treatment necessary. While it would be preferable to treat them surgically, this can be made more difficult by the fact that paragangliomas usually have a large blood supply. When this is the case, the tumor can be treated through endovascular methods by placing a catheter into the blood vessels supplying the tumor and injecting various materials to block off the blood supply to the tumor. This procedure, called embolization, is often done within a few days of an impending surgery.
Juvenile Nasopharyngeal Tumor Treatment:
The definitive treatment for juvenile nasopharyngeal tumors is surgical removal. This can be difficult depending on the size of the tumor and where it has spread. Additionally, these tumors usually have a large blood supply, which further complicates surgery. In order to decrease the amount of bleeding during surgery, endovascular treatment can be performed prior to surgery by inserting a catheter into the blood vessels supplying the tumor and injecting materials to block off the blood supply to the tumor. This procedure, called embolization, is usually done within a few days in advance of the impending surgery.
Nosebleed (Epistaxis) Treatment
Medical treatment of a nosebleed begins with local pressure and nasal spraying of decongestants, a process which causes the blood vessels to constrict. Nasal packing (and blood transfusion) may be needed if the bleeding does not stop. If these treatments do not work and the bleeding continues, the physician can possibly identify the site of bleeding by examination and cauterize the vessel. If the bleeding site cannot be found or does not respond to these treatments, or if the bleeding is too severe, then a procedure to block off the bleeding vessels may be required. In this case, a catheter is inserted into an artery at the groin, and is threaded through the vessels leading up to the ones supplying the nose. Once at the site, material is injected through the catheter to plug the bleeding vessel, allowing it to clot and heal.
Extracranial Vascular Malformations (including Cranio-facial Hemagiomas):
In the case of vascular malformations that do not resolve on their own, or, which cause symptoms, grow with age, or appear during adult life, there are a variety of treatments. Some of these are surgically removed, while others are treated with laser therapy. In some cases, they are treated through endovascular methods by placing a catheter into the blood vessels supplying the malformation and injecting various materials to block off the blood supply to the malformation. In some cases, another treatment option is utilized by placing a needle directly through the skin into the malformation and injecting material to block off the malformation termed as sclerotherapy.
Spinal Vascular Malformations Treatment:
Spinal vascular malformations often necessitate surgery, though this form of treatment can be very difficult and risky. Thus, most often this condition is treated first through endovascular methods by placing a catheter into the blood vessels supplying the malformation and injecting various materials through it to block off the blood supply. This procedure, called embolization, is often performed before surgery in order to decrease the blood flow supplying the malformation, making surgery much safer.
Extracranial and Paraspinal Vascular Malformations Treatment:
When vascular malformations do not disappear, or, cause symptoms, grow with age, or appear during adult life, a variety of treatment options may be considered. Some may be surgically removed, while others are treated with laser therapy. In other cases, vascular malformations are treated through endovascular methods by placing a catheter into the blood vessels supplying the malformation and injecting various materials to block off the blood supply to the abnormal vessels. This procedure is called embolization.
Another treatment option utilized by doctors involves placing a needle directly through the skin into the malformation and injecting material to block off the malformation.
Traumatic Vascular Lesions Treatment:
Some traumatic vascular lesions such as holes in the carotid artery with bleeding are best treated surgically. But in particular cases, surgery is not possible or is not safe. If there is bleeding from branches of a major artery such as the carotid artery, endovascular treatment can be performed by inserting a catheter into the damaged blood vessel(s) and injecting materials to block off the opening. If there is a hole in the main artery with a clot around it, this condition may be treated by inserting a stent (a metal device designed to hold a vessel open) through the catheter and placing it across the hole. Once the stent is secure, material can be injected into the hole and clot to close the hole completely. If a fistula is present, a catheter may be placed into the connection between the artery and vein and material may be injected to close the connection.
Sometimes, the only way to treat an injury to an artery is to block off the artery itself. If this is necessary, a catheter fitted with a small balloon can be placed into the vessel. The balloon is inflated, stopping the flow of blood. The patient is checked every few minutes to see if the blockage causes symptoms (similar to those of a stroke). This is called test occlusion. If there are no symptoms, material can be injected through the catheter to block the vessel.
Carotid-Cavernous Fistulae Treatment:
Because of their location, carotid-cavernous fistulae are difficult to treat surgically. Instead, endovascular treatments may be employed by placing a catheter into the blood vessels and injecting materials to block off the fistula and/or the vein. Sometimes, the same method is utilized so that the carotid artery itself may be blocked off to close the fistula. If this is necessary, tests are performed first to make sure that there is enough blood flow to the brain from the other arteries.
Vasospasm Treatment (Spasmolysis):
The use of drugs to help prevent vasospasm or spasm in the brain vessels has decreased the occurrence of this condition in recent years. Once vasospasm does occur (usually 4 to 12 days after an aneurysm has bled), several treatments may be used to re-open the vessels and prevent damage to the brain. These may include medical therapy to increase the blood pressure and improve blood flow to the brain, placement of a catheter in the arteries going to the brain in order to allow injection of a drug directly into the arteries to dilate (open) them, or placing a catheter fitted with a balloon into the vessels and stretching them open (angioplasty). The procedure or procedures that are used depend on how severe the spasm is and where in the blood vessels it occurs.
Acute Stroke Treatment (Intra-arterial Thrombolysis):
As a patient’s recovery from stroke is largely dependent on the amount of time that elapses between onset of symptoms and treatment, national efforts to educate the public center around one key message: stroke is a brain attack. Traditional treatments for ischemic stroke include tPA, a clot-busting drug given intravenously, which must be administered within three hours. In the last decade, intra-arterial (through the artery) catheter-based therapies were developed, extending the required treatment time to up to six hours. Designed to eliminate blockages in particular kinds of stroke, intra-arterial therapy is performed by inserting a catheter into the groin area and routing it through the blood vessels up to the blockage in the brain under X-ray guidance. Once the catheter is positioned, clot-busting drugs are delivered directly to the site of the blockage.
The most recent technological advancement in the treatment of stroke is the Merci® Retriever System manufactured by Concentric Medical. A tiny corkscrew-shaped device, the MERCI (Mechanical Embolus Removal in Cerebral Ischemia) Retriever is inserted through a catheter (as in other intra-arterial treatments) directly to the site of the clot. Once positioned, it is deployed to engage and ensnare the clot, pulling it back through the catheter and out of the body. Available at 120 hospital sites throughout the nation, the Merci Retriever can be used up to eight hours following symptom onset, and in some cases, even beyond this timeframe.
Ultimately, in the treatment of stroke, “time is brain.” If a patient gets to the hospital after too much time has elapsed, the damage is usually permanent and efforts to re-open the vessel may make things worse by causing a bleed in the brain.
Neuroscience Resources For Kids
http://faculty.washington.edu/chudler/vessel.html
Vertebral Body Compression Fracture Treatment (Percutaneous Vertebroplasty):
Vertebral body compression fractures may be treated with medications, surgically or with minimally invasive procedures known as vertebroplasty and kyphoplasty.
Vertebroplasty is designed to reinforce the fractured bone, thus eliminating the debilitating pain suffered by patients with compression fractures. Vertebroplasty is performed by first inserting a special needle into the affected vertebrae under fluoroscopic (x-ray) guidance. When the needle tip is in position, a cement mixture is injected into the affected vertebral body. When sufficient amounts of the cement are injected into the damaged bone, the needle is removed and gentle pressure is applied over the puncture site. No stitches are required and the patient is left only with a band-aid. The patient may then go home an hour or 2 after completion of the procedure. Almost all patients experience complete and immediate relief of the severe pain caused by the compression fracture.
Kyphoplasty is a technique originated in the late 1990?s and established in 2001. Also a minimally invasive procedure, kyphoplasty is conducted by inserting a balloon into the crushed vertebra via needle under X-ray guidance, expanding the balloon to create a cavity or void space within the bone tissue, and then withdrawing the balloon and inserting in its place a cement-like substance which ultimately serves to stabilize the vertebra.
Most patients undergo both of these procedures on an outpatient basis and are allowed to leave the hospital within a few hours of the procedure. Activities at home may be limited at first and slowly increased as tolerated. Strenuous activity such as heavy lifting should be avoided for up to one week; e.g., nothing heavier than a pocketbook or a small bag of groceries.
If the pain is not alleviated by either of these procedures, the patient should be re-evaluated for other possible causes by his/her referring physician. In some cases, similar pain can occur in a different location which may indicate that the patient has developed another fracture.
Depending on the specifics of the patient?s condition, he/she may be referred to a physical therapist or other rehabilitation services as needed.
Vertebral Body Tumors Treatment:
Depending on the type of tumor and the symptoms it is causing, different treatments can be used to treat vertebral body tumors. If there is collapse of the bone, a procedure called vertebroplasty may be performed by inserting a needle through the skin into the bone using x-ray guidance and injecting cement to strengthen the bone. If the tumor causes pressure on nerves or the spinal cord, surgery may be considered. In the event that the tumor has a large blood supply, which can complicate surgery, endovascular techniques may be employed by inserting a catheter into the blood vessels supplying the tumor and injecting materials to block off the blood supply to the mass. This procedure, called embolization, is usually performed within a few days of the impending surgery. If surgery is not recommended or possible, embolization may be performed to shrink the tumor.
In some cases, a needle can be placed directly into the tumor using x-ray guidance and material can be injected to kill the tumor. Some tumors are best treated with radiation therapy.
