Interventional Neurosurgery

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Interventional Neurosurgery

Interventional neurosurgery / endovascular neurosurgery

Neurosurgeons at Columbia Asia Hospitals have a team of highly qualified and experienced neurosurgeons who specialise in interventional neurosurgery / endovascular neurosurgery. The services are available for both adult and paediatric patients. We aim at excellence in care through the practice of evidence-based medicine and treatment according to international protocols. The consultants performing these procedures are trained in some of the best institutes across the globe.

Diseases which can be treated by endovascular technique:

  • Aneurysm coiling: standard coiling, stent-assisted coiling, balloon-assisted coiling, flow diverters
  • Acute stroke management: intra-arterial tPA injection, use of mechanical clot retrievers(solitaire system, merci system, penumbra system)
  • AVM management: glue injection of the AVM / onyx injection of the AVM
  • Carotid artery stenting: standard carotid stenting, stenting with distal protection device, angioplasty of the carotid arteries
  • Vertebral artery stenosis: angioplasty, stenting
  • Intracranial arterial occlusion: arterial angioplasty, angioplasty and stenting procedures
  • Embolisation of dural arteriovenous fistulas
  • Carotico-cavernous fistula management
  • Management of vasospasm
  • Balloon occlusion test for carotid occlusions
  • Tumour embolisations: meningiomas, nasopharyngeal angiofibroma, haemangiomas, head and neck tumours, glomus jugularae
  • Head and neck vascular malformations: venous angioma of the face, mandibular vascular malformations, maxillary vascular malformations, orbital vascular malformations
  • Embolisation for epistaxis (nasal bleeding)
  • Deep venous thrombosis management: intravenous tPA instillation, mechanical extraction of clots
  • Spinal cord vascular malformations and fistulas
  • Spinal tumours embolisations
  • Management of vascular trauma: dissections, transections of vessels
  • WADA test (intra carotid sodium amobarbital procedure)
  • Inferior petrosal sinus sampling for Cushings's syndrome diagnosis

1. Brain aneurysm treatment

A brain aneurysm, also referred to as a cerebral aneurysm or intracranial aneurysm, is a weak bulging spot on the wall of a brain artery very much like a thin balloon or weak spot on an inner tube. As the artery wall becomes gradually thinner from the dilatation, the blood flow causes the weakened wall to swell outward. The aneurysm may rupture at any point when the pressure inside the blood vessel increases and blood will escape into the brain. A ruptured brain aneurysm commonly requires urgent and advanced surgical treatment.

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Risk factors that doctors and researchers believe contribute to the formation of brain aneurysms: common causes include smoking, high blood pressure or hypertension, congenital (resulting from an inborn abnormality in artery wall), family history of brain aneurysms, drug use (particularly cocaine), tumours and trauma to the brain.

Clinical features:

An unruptured aneurysm will cause problems by pressing on areas in the brain. When this happens, the person may suffer from severe headaches, blurred vision, changes in speech and neck pain, depending on what areas of the brain are affected and how big the aneurysm is. Symptoms of a ruptured brain aneurysm are sudden, severe headaches that are different from past headaches, neck pain, nausea and vomiting, fainting or loss of consciousness and seizures.

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Management:

Traditionally, aneurysms were treated by clipping, but more recently majority of the aneurysms are treated by a new technique called coiling.

Coiling of aneurysms is done through a small needle placed in the groin. Through the needle special wires and tubes are passed and aneurysms are cured by placing platinum coils inside aneurysms. The patient will be discharged in the evening and can resume regular activities from the next day.

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2. Brain AVM treatment

AVM stands for arterio-venous malformation. An AVM is a tangle of abnormal and poorly formed blood vessels (arteries and veins).

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They have a higher rate of bleeding than normal vessels. AVMs can occur anywhere in the body. Brain AVMs are of special concern because of the damage they cause when they bleed.

The cause is not known. AVMs are thought to be due to abnormal development of blood vessels in utero and may be present since birth. Most AVMs are not inherited. An AVM is not a cancer and does not spread to other parts of the body.

Symptoms of an AVM:

Symptoms depend on the location and size of the AVM. Common problems include:

  1. Seizures: An AVM in the brain may act as an irritant resulting in abnormal electrical activity.
  2. Headache: may be mild or quite disabling. Sudden, severe headaches can be caused by bleeding. These headaches are often followed by nausea, vomiting , neurological problems or a decreasing level of consciousness.7

     

  3. Stroke-like symptoms: Brain AVMs may cause stroke-like symptoms by depriving the nearby brain tissue of oxygen and nutrients.
    • Weakness or paralysis on one side of the body
    • Numbness and tingling
    • Problems with vision, hearing, balance, memory and personality changes8

       

  4. Bleeding: This is the most serious complication of an AVM. It is the main reason for recommending treatment. Bleeding from an AVM will occur in about 4 out of 100 people with a brain AVM. Approximately 50% of the bleeds are significant with permanent disability in half of these cases and death in the other half.9

     

Note: It is important to know that an AVM can be present and not produce any symptoms

Treatment:

One option is to do nothing at all and just monitor the AVM. Your doctors may recommend observation if they feel that treatment cannot be offered safely or when an AVM is discovered at a late age.

Endovascular embolisation

Under general anaesthesia a small catheter (plastic tube) is passed from the groin, into the brain vessels and then into the AVM. Liquid, non-reactive glue is injected into the vessels which block the AVM. There is a small risk to this procedure and the chances of completely curing the AVM using this technique depends on the size of the AVM. The patient will be discharged the next day and can resume normal activities in a few days.

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Surgery

This is the oldest method for treating AVMs. The AVM is surgically removed in an operating room under general anaesthesia. Since AVMs do not grow back, the cure is immediate and permanent if the AVM is removed completely.

3. Carotid artery diseases

A pair of carotid arteries on either side of neck supply blood to the brain. Over a period of time, in vulnerable patients these arteries start getting blocked from inside and cause reduced blood supply to brain and cause a stroke, similar to what happens in the heart leading to a heart attack.

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In carotid stenosis, there will be progressive narrowing of the carotid arteries in the neck by a process called atherosclerosis. As we age, hypertension and small injuries to the blood vessel wall can allow plaque to build-up. Plaque is a sticky substance made of fat, cholesterol, calcium and other fibrous material. Over time, plaque deposits inside the inner wall of the artery can form a large mass that narrows the lumen, the inside diameter of the artery and also harden the artery.

Risk factors: Ones that have been linked to the development of carotid stenosis include:

Typically, the carotid arteries become diseased a few years later than the coronary arteries. People who have coronary artery disease and atherosclerosis elsewhere (such as peripheral artery disease or PAD) have a higher risk of developing carotid artery disease.

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Symptoms:

There may not be any symptoms of carotid artery disease (asymptomatic carotid stenosis). However, there are warning signs of a stroke (symptomatic): sudden loss of vision or blurred vision in one or both eyes, weakness and / or numbness on one side of the face, or in one arm or leg, or one side of the body, slurred speech, difficulty talking or understanding what others are saying, loss of coordination or imbalance while walking, dizziness or confusion, difficulty swallowing etc.

A transient ischemic attack (also called TIA or 'mini-stroke')

It is one of the most important warning signs of a stroke. A TIA occurs when a blood clot briefly blocks an artery that supplies blood to the brain. The symptoms of a TIA are temporary and may last a few seconds / minutes or a few hours. TIAs are strong predictors of future strokes; a person who has experienced a TIA is 10 times more likely to suffer a major stroke than someone who has not experienced a TIA.

Management:

Carotid angioplasty / stenting

It is a minimally invasive endovascular procedure that compresses the plaque and widens the lumen of the artery. Procedure is done local anaesthesia and the patient is discharged in the evening and can resume normal activities from the next day.

Carotid endarterectomy

It is a surgical procedure that removes the plaque build-up from the inner lining of the carotid artery. Carotid endarterectomy requires general anaesthesia. An incision is made in the neck, the artery is opened, the plaque is removed, and the artery is closed again.

4. Brain vascular atherosclerotic diseases Similar to carotid stenosis, atherosclerotic blockage of blood vessels can occur inside the brain vessels. They are dealt similarly with angioplasty and stenting.

5. Vascular diseases of spine and spinal cord Vascular malformations of the spine and spinal cord are considered uncommon lesions. Variety of vascular lesions can occur in the spinal cord causing pain, weakness, loss of limb power and paralysis.151617

These are complex lesions which have high complications with surgery. They can now be safely managed with endovascular techniques with the patients under local anaesthesia and with constant talking to patients during procedures.