endovascular neurosurgery

endovascular neurosurgery

1. Endovascular neurosurgery By Dr.Usman haqqani

2.   Endovasular  Neurosurgery (Interventional Neuroradiology) is a subspecialty of radiology and neurousurgery in which minimally invasive procedures are performed using image guidance .

3. Endovascular techniques are used to treat Cerebral aneurysm arteriovenous malformation (AVM) tumor embolization severe symptomatic vasospasm after subarachnoid hemorrhage (SAH)

4. Clinical trials have established benefit of intra-arterial thrombolysis (IAT) up to 6 hours after stroke symptom onset M echanical revascularization therapy up to 8 hours after stroke symptom onset .

5. procedure

6. The groin is prepared and draped The femoral pulse is palpated at the inguinal crease, and local anesthesia is administered 5-mm incision is made parallel to the inguinal crease. A Potts needle pointing to the patient’s opposite shoulder. A J-wire is gently advanced through the needle for 8 to 10 cm . The needle is exchanged for a regular 5-French (F) 10-cm sheath that is secured with a silk stitch

7. Guide catheters is advanced over guide wire. The tip of the wire is observed under direct fluoroscopic visualization . Slow twisting movements of the wire are carried (observing the tip of the wire).

8. Roadmapping ( superpositioning of previous contrast angiographic images with “live” or real-time fluoroscopic images ) is done.

9. ISCHEMIC STROKE INTERVENTION Stroke remains the third most common cause of death in industrialized nations and the single most common reason for permanent adult disability consider of IV t-PA therapy 3 to 4.5 hours after stroke symptom onset Early reocclusion following thrombolysis has been demonstrated by transcranial Doppler imaging to occur in 34% of patients receiving IV t-PA IV thrombolysis (IVT) is not as effective in thromboembolic obstruction of large , proximal vessels, as compared with more distal smaller vessels.

10. Mechanical candidates for endovascular revascularization therapies currently Patients who do not meet the eligibility criteria for thrombolytic therapy who fail to improve neurologically patients with reocclusion trials established a benefit of intra-arterial thrombolysis (IAT) up to 6 to 8 hours after stroke symptom onset, with an increase in recanalization rates.

11. The Merci retriever system has a flexible nitinol wire that assumes a helical shape once it emerges from the tip of the microcatheter . A microcatheter containing this wire is passed distal to the thrombus, the catheter is withdrawn, and the wire, in its helical configuration, ensnares the clot for removal from the vasculature .

12. Vessels amenable to embolectomy with the Merci device include the ICA M1 and M2 segments of the MCA VA, basilar artery posterior cerebral artery. The retriever is then retracted into the guide catheter under proximal flow arrest.

13. The Penumbra System The system primarily involves clot aspiration using a microcatheter attached to a powered aspiration pump that is capable of producing 25 mm Hg of suction.

14. Despite aggressive revascularization with mechanical therapies, only up to 45% of patients recover to an mRS score of 0 to 2 at 3 months, and there is approximately an 8% to 10% procedure-related risk of symptomatic ICH, a potentially detrimental complication

15. Aneurysm intervention The incidence of aneurysmal subarachnoid hemorrhage (SAH) is between 10 and 15 per 100,000 people per year . Endovascular treatment of intracranial aneurysms has undergone multiple changes since the introduction of Guglielmi detachable coils for endosaccular occlusion of these aneurysms in 1994.

16. Observations of aneurysm recanalization after treatment with bare platinum coils led to the introduction of coils containing materials meant to enhance fibrosis within the aneurysm and decrease the chance of recanalization. Several “bioactive” coil systems are on the market currently; some contain polyglycolic-polylactic acid (PGLA) while others contain hydrogel.

17. Using roadmapping , the microwire and microcatheter are advanced to the target vessel . tip of the microcatheter is initialy placed at the neck of the aneurysm to allow the coil to assume its spherical shape.

18. Balloon-Assisted Coil Embolization It is the use of balloons to occlude the aneurysm neck during coiling of wide-necked aneurysms

19. trans-stent coiling the stent is placed across the neck of the aneurysm and coil embolization is performed after manipulation of a microcatheter . Trans-stent coiling may be performed at the time of the initial procedure or during a second procedure (“staged technique”), typically 4 to 8 weeks after stenting.

20. Y-stent This technique is most commonly used for bifurcation aneurysms arising from the basilar tip or carotid terminus.

21. Waffle-Cone Technique

22. Flow diverter Flow diverter is a kind of stent which can be used with out use of coils.

23. Coiling of aneurysm: Following diagrams show how aneurysm coiling is done Coil mass inside aneurysm prevents blood from entering it

24. Coiling or Clipping? Morbidity and Mortality: ISAT TRIAL ( for ruptured aneurysms ): Dead or dependent at one year- • • Surgical group: 30.6% patients were dead or dependent at one year Endovascular group: 23.7% of patients were dead or dependent at one year ISUIA trial ( for unruptured aneurysms ) Death and dependency at 1 year: • • Surgical group: The 1-year morbidity and mortality rate was 12.2%, and the mortality rate was 2.3%. Endovascular treatment: The 1-year total morbidity and mortality rates were 9.5% and 3.1%, respectively.