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Endovascular Management of Epistaxis (Nose Bleeding)

Epistaxis is characterized by hemorrhage or bleeding from the nose.
While the majority of the nose bleedings are self-limiting, those not responsive to
compression, nasal packing or other non-endovascular treatment options may need
endovascular management. This especially holds for bleeding from the backside (posterior
cavity) of the nose.
This article will talk about the management of the epistaxis in the posterior nasal cavity and
its management.

Causes

Some common causes of epistaxis include:

  • Hypertension
  • Blood vessels disorders
  • Fall and injury
  • Blood clotting disorders
  • Upper respiratory tract infections

However, in some cases, the cause of nose bleeding may not be known.

Management

Most cases of epistaxis are in the front side of the nose or in the anterior nasal cavity. They
are relatively easier to manage. However, the bleeding in the posterior nasal cavity is
challenging to manage.
Treatment options of the posterior nasal cavity bleeding include:

Non-Endovascular Management

Along with conventional measures, posterior nasal cavity bleeding needs anterior and
posterior packing to provide adequate compression. It also prevents the bleeding from
entering the food pipe.
However, this packing needs removal after 48 hours to prevent infection and other
complications.

Endovascular Management

In cases of recurrent or persistent epistaxis, endovascular management is an excellent option
with a success rate between 71%-100%. It is also a cheaper and comparatively safer option as
compared to surgery.
Your doctor will decide the need for general anesthesia based on your problem and the
underlying cause. They may advise blood tests to find out the underlying cause.
The next step is angiogram and embolization. The doctor will first carry out an angiogram for
evaluating your blood vessels. They will introduce an embolizing agent in the branches of the
blood vessels, causing epistaxis.
The doctor will take extra care in deciding the amount of embolizing agent as an additional
amount may result in blockage of the healthy blood vessel.
After the procedure, the doctor will decide to remove the nasal packaging depending on the
condition

Final Thoughts

About 95% of the epistaxis originate in the anterior nasal cavity and can easily be managed
with packaging and compression. However, the remaining 5% of the cases originate from the
posterior cavity and are more challenging to manage, needing endovascular treatment.
Endovascular embolization is a safe and effective option compared to surgery.

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“Vessel Wall Imaging” for detecting the Risk of Intracranial Aneurysm Bleeding

A ruptured aneurysm results in subarachnoid hemorrhage, which is a severe complication with high mortality rates. To prevent this risk, unruptured intracranial aneurysms (UIA) are managed endovascularly or surgically. However, these treatment options may have their own set of side effects.
So, patients are selected for these treatment options only when the benefits outweigh the risk. Your doctor will make this decision for you based on the aneurysm rupture risk. The risk can be predicted based on the patient’s age, size of the aneurysm, hypertension, location of the aneurysm, and history of subarachnoid hemorrhage.
This aneurysm rupture risk can be further refined using high-resolution vessel wall magnetic resonance imaging (HRVWI-MRI). For instance, usually, aneurysms smaller than 7mm are less prone to rupture. However, some patients with small aneurysms do report SAH from aneurysm rupture. So the HRVWI-MRI can detect the aneurysms which need urgent treatment.
Aneurysm wall enhancement on vessel wall imagining indicates arterial instability and an increased risk factor for aneurysm rupture.

Benefits

Silent saccular aneurysms are observed in about 4% of the normal population. A high-resolution vessel wall magnetic resonance imaging can help differentiate an unstable aneurysm from a stable one to decide the urgency for the treatment.

A thick circumferential pattern of aneurysmal wall enhancement has the highest specificity for differentiating between stable and unstable aneurysms (Circumferential aneurysmal wall enhancement is observed in almost 90% of the unstable aneurysms, allowing refined prediction of the aneurysm rupture risk).

It also aids in identifying the culprit aneurysm for SAH when multiple aneurysms are present.
It also aids in diagnosing the following conditions:

  • Eccentric wall thickening in atherosclerotic plaque
  • Concentric wall thickening in vasculitis
  • Minimally enhancing wall thickening in reversible cerebral vasoconstriction syndrome
  • Non-enhancing intracranial carotid stenosis in Moyamoya disease (non-atherosclerotic progressive vasculo-occlusive condition)

Pitfalls

As the investigation involves high-resolution imaging, additional time and money are involved.
Normal enhancement in large intracranial blood vessels near the skull base can be mistaken as arterial wall enhancement.
Brain Imaging Techniques for Stroke (Banner)
Imaging techniques are used to:

  • Detect or Exclude hemorrhage
  • Understand the extent of brain injury
  • Identify the underlying cause for stroke
  • Ruling out conditions that mimic stroke such as tumors

Imaging techniques commonly used are:

  • Computed tomography (CT)
  • Magnetic resonance imaging (MRI)
  • CT/MR angiography
  • CT Perfusion Imaging
  • Digital Subtraction Angiography (DSA)
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Brain Imaging Techniques for Stroke

Stroke, whether ischemic (due to blockage in brain’s blood supply) or hemorrhagic (due to bleeding in the brain), can result in long-lasting complications if not attended immediately. Early diagnosis of a stroke — including what type it is — can significantly reduce the patient’s chances of living with a disability.
Stroke is suspected clinically and can be confirmed with clinical examination and brain imaging techniques. They also help to find out the cause, part of the brain affected and bleeding in the brain. Finally these tests play in planning the treatment and possible outcomes.
The article talks about various imaging techniques used to confirm the presence of stroke.

Brain Imaging Techniques

The first-line tests to assess brain function and its blood supply include:

  • Magnetic resonance imaging (MRI): This test provides cross-sectional images of the brain. It helps in diagnosing a stroke and regions of the brain affected by the stroke. MRI is very sensitive and specific in differentiating ischemic lesions and identifying other conditions that may resemble a stroke.. MRI can uncover any brain damage within 20 minutes of beginning of stroke symptoms.
  • Computerized tomography (CT): it is more widely available in our country. It can very easily diagnose the hemorrhagic type of stroke. In ischemic stroke it may be normal for few hours however it can show us early signs of stroke or impending brain damage. It is more popular to diagnose stroke as it is easy to do, takes less time and is easily available.

Advanced Stroke and Neurovascular Imaging
In addition to the above first-line imaging techniques, the mentioned tests are advanced tools that provide additional and critical information about the complexity and location of the stroke.

  • CT angiography: This involves a CT scan along with a dye injected to obtain pictures of blood vessels in the brain. CT angiogram also helps locate blocked or narrow blood vessels, aneurysms, or other abnormal blood vessel formations.
  • CT perfusion: It is a type of CT test used as an adjunct with CT angiography to diagnose stroke. It aids in differentiating ischemic brain areas (penumbra) from the irrevocably damaged brain area (infarct core). Broadly speaking when patients of stroke come late to the hospital, this test can tell us whether giving treatment is going to be beneficial to the patient or not.
  • Magnetic resonance angiography (MRA): This type of test involves MRI to create two- or three-dimensional images of the structure of your blood vessels supplying the head and neck. This test does not involve any injection of the dye so is more useful in patients who have poor kidney function or history of drug allergy.
  • Digital Subtraction Angiography (DSA) / Catheter angiography: this is the gold standard test to detect problems of blood vessels of the brain. This test offers high-resolution images of the blood vessels of the brain, spine or head and neck. Catheter angiography is a minimally invasive technique where a small catheter is introduced in the artery supplying the brain. A dye is injected, and images are taken that show your blood vessels’ structure and the blood flow.
  • Transcranial Doppler (TCD): It is an ultrasound technique that allows your doctor to check the blood circulation within your brain. It is especially useful to detect delayed complications like vasospasm which can occur in hemorrhagic stroke patients
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Brain Stroke and COVID-19

Although COVID-19 typically affects the lung, it can also cause other complications involving almost all the body systems including brain. When it does affect brain, it is usually in the form of stroke. The reason behind this is the ability of this infection to increase the tendency of blood to clot.
Let’s understand more about it!

COVID-19 and Stroke

Various studies suggest that COVID-19 may increase the risk of stroke by 0.9% to 23% in COVID-19 positive patients. It may have the following types of manifestations:

  • Symptoms of stroke are seen in COVID-19, where the patient develops COVID-19 symptoms first and later develops stroke as a complication.
  • Some patients show the symptoms of stroke first and are later diagnosed with COVID-19. They are usually younger patients without any known risk factors for stroke.

Types Of Strokes Seen in COVID-19 Patients

The following types of strokes are commonly seen:

  • Ischemic stroke: Due to blockage of the blood vessel that causes stroke due to lack of oxygen supply to a part of the brain. This is the commonest type of stroke seen in these patients.
  • Hemorrhagic stroke: It is caused by rupture of a blood vessel supplying the brain that causes accumulation of blood in a part of the brain. This stroke sub type is reported rarely in COVID pts.

Cause of Stroke in These Patients

Experts believe that COVID-19 results in a prothrombotic stage, which means they have a tendency for the blood to become sticky or thicken, this leads to clot formation which causes obstruction in the blood supply to the brain. The lack of blood supply to the brain results in a stroke. It can affect single or multiple parts of the brain.

Difference Between COVID-19 related Stroke and Traditional Stroke

Usually, the risk factors for stroke include uncontrolled hypertension, smoking, diabetes, high cholesterol, heart disorders, and a sedentary lifestyle.
However, COVID-19 related strokes maybe seen in patients without these risk factors.
Besides, traditional stroke is uncommon in younger patients below 45 years of age. But younger age does not protect against COVID-19 related stroke. A study also suggests that younger patients have a more severe form of stroke because of large-vessel involvement.

Symptoms

Stroke is an emergency condition and may cause complications, including death, if immediate action is not taken.
So, it is essential to know the symptoms of stroke to identify one. Some common ones include (easily identified by a four-letter word FAST):

  • F: Face-Sudden onset facial weakness
  • A: Arm/leg weakness
  • S: Speech problems
  • T: Time- Don’t waste time at home

This is even more crucial during the pandemic as COVID-19 has overwhelmed healthcare systems, and delays may occur due to a lack of transfer facilities.

How Can Stroke Survivors Prevent Another Stroke in the Pandemic?

The most important thing to do is taking your medication for any condition, such as diabetes, blood pressure, and high cholesterol, regularly as advised by your doctor. Those individuals on physiotherapy need to continue the same at home.

Final Thoughts

While COVID-19 is seen as a lung infection, it may also cause blood clots that may result in a severe stroke. Knowledge that stroke can occur more frequently in COVID patients, taking precautions and seeking immediate care is essential to prevent associated complications.

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How to Prevent or Minimize the Plateau Phase After a Stroke

Stroke is a debilitating disease. Many stroke survivors are left with weakness of arms or legs or speech dysfunction. Rehabilitation helps stroke survivors to regain their muscle power and movement. It also allows them to perform activities more independently and adapt to the daily lifestyle.
However, there may be various ups and downs during this therapy. After a few months, the progress may halt or slow, which is known as the plateau phase. This phase is common for many survivors.
Fortunately, you can go through the plateau phase and regain more functions.

Stroke Recovery Plateau

A stroke recovery plateau is a phase where there is little or no recovery of functions after a period of rapid recovery progress. The phase may occur around three months after stroke when the body’s natural, spontaneous recovery stops too.
The phase may seem frustrating, and you may feel that you would not be able to make further progress. However, this is not the case. Experts believe that the plateau phase is not permanent.
So, if you are facing this plateau, don’t give up. Be patient and consistent, and you can still be able to enhance your progress.

Cause of the Recovery Plateau

Before we understand how you can get out of the plateau, let us know what the cause behind it is.
The shorter answer to this is neuroplasticity, which is your brain’s repair mechanism. After a stroke, your brain has a high level of plasticity, making it easier to recover lost function. So, high plasticity is the reason for spontaneous recovery after a stroke.
However, this heightened state does not last for long, and eventually, the brain becomes less pliable. When your brain loses the high plasticity, you notice a plateau.
Although plasticity is at a lower level, it is still present. This means it is possible to improve your functions after a plateau, but it will take more effort and time.

Here is What You Can Do?

Task-specific, repetitive exercises aid in engaging your brain’s plasticity. So, the ideal thing to do is continue your therapy patiently. It may be challenging to go through, especially when you do not see any result. But always remember, you can push through the plateau.
Here are a few ways that may help you to get started:

  • Get creative: Try learning a new skill such as painting or piano. This will help you to improve your mental and physical resilience. For instance, playing piano may help improve cognitive skills and motor functions without even you realizing it.
  • Find an accountable partner: Another way of going through a stroke plateau is to get a responsible partner. It could be anyone, your friend, a family member, or a therapist. They can remind and motivate you to do exercise daily.
  • Home therapy equipment: Many tools are available that can push and motivate you through a stroke plateau.

Final Thoughts

Plateau is a common but manageable aspect of stroke recovery. Studies have shown that stroke survivors regain their functions even decades after the stroke.
So, overcoming the plateau may be challenging but indeed possible. Carrying out your stroke recovery exercises is the best way to deal with the phase.

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Carotid-Cavernous Fistula

A carotid-cavernous fistula (CCF) is an atypical connection between the carotid artery (or its branches) and the cavernous sinus. The cavernous sinus is a large venous poch located behind your eye that receives blood from the orbit, brain, and pituitary gland. The carotid-cavernous fistula can be direct (high-flow) or indirect (low-flow).

Causes

The causes may be divided into two main types:

  • Traumatic (Direct): This may occur after a head injury, which can range from falls to penetrative wounds.
  • Spontaneous (Indirect): It may usually occur due to a spontaneous rupture of a cavernous carotid aneurysm. However, this type of fistula can also be due to a congenital abnormal connection between artery and vein that spontaneously opens due to atherosclerotic disease, collagen vascular disease, childbirth, or hypertension.

Symptoms

Direct CCF

Symptoms usually occur days or weeks after ahead injury. Common symptoms include:

  • Chemosis or red-eye syndrome
  • Pulsatile exophthalmos or protrusion of the eyeball
  • Ocular bruit or blood flow sounds from the eye
  • Other symptoms such as double vision or visual loss may also result

Indirect CCF
This type has a gradual onset and milder symptoms. The patient has a chronically red eye, but the ocular bruit is absent.

Instigations

The following tests may help:

CT Angiography

It is a non-invasive imaging investigation to evaluate a suspected CCF. CT angiography can detect exophthalmos, orbital congestion, enlarged superior ophthalmic vein, bulging cavernous sinus, intracranial hemorrhage, or enlargement or cavernous sinus.

Angiography (DSA)

Digital subtraction angiography is a gold standard imaging technique for CCF due to its high resolution. It may help detect the features of CCF, such as enlarged draining veins, shunting from the internal carotid artery to the cavernous sinus, and retrograde flow from the sinus into the ophthalmic veins.

Ultrasound

Doppler ultrasound may show arterialized ophthalmic veins.

Treatment

These fistulas can be managed through endovascular or microvascular neurosurgical techniques. However, the endovascular approach is usually preferred due to low morbidity.

Endovascular Therapy

Direct CCFs were usually managed by sealing the fistula with detachable balloons introduced through the blood vessel while preserving the internal carotid artery. Nowadays, treatment options include coiling of the fistula or placement of a stent through a trans-arterial route.
In cases where the trans-arterial route is ineffective or impossible, platinum coils are introduced through a transvenous approach. This can be done using the femoral route through the inferior petrosal sinus. Alternatively, the procedure can be done surgically through a superior ophthalmic vein.
Indirect CCFs usually resolve on their own. If not, manual carotid compression is the initial option for low-risk CCFs. This can manage about 30% of the indirect CCFs.
In patients where compression is not recommended, such as those with retrograde filling of the cortical venous system, a transvenous or trans arterial approach is used.

Surgical Treatment

This procedure involves a craniotomy and sealing the internal carotid artery proximal and distal to the fistula using clips. The sinus is then occluded with fascia, acrylate glue, or Surgicel to obstruct the blood flow.
The procedure may also involve connecting the external carotid artery to the middle cerebral artery using a vein or artery to prevent stroke.

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Cerebral AV malformations

Cerebral arteriovenous malformation (AVM) is a tangle of abnormal blood vessels connecting veins and arteries in your brain.
Arteries carry blood from the heart to other body parts, which get smaller until they turn into capillaries. Nutrients and oxygen exchange takes place in the capillaries. The blood then passes from capillaries to your heart through veins (Image A).

But in cerebral malformations, arteries directly connect to veins without capillaries in between, creating an area of high pressure. The veins cannot take this pressure and enlarge and bulge to accept extra blood (Image B).
AVMs can form anywhere in the body but is more common in the brain or spine. Even so, cerebral AVMs are rare and seen to affect less than 1% of the population.
AVMs in the brain are mainly silent and are picked up on scans for other health issues. However, when present, common symptoms are headaches and seizures.
Treating AVMs as soon as they are diagnosed lowers the risk of complications such as a stroke.

Symptoms

A cerebral AVM may not cause symptoms unless it ruptures. In almost half of the cases, brain hemorrhage is the first indication.
Some common symptoms include:

  • Severe headache
  • Seizures
  • Numbness or weakness in one part of the body
  • Difficulty speaking
  • Vision loss
  • Severe unsteadiness
  • Confusion

If left unattended, AVMs can damage the brain tissue. These can affect any age group. There are multiple types of AVM’s and depending upon the type different age groups are affected.
Galen defect, a severe type of brain AVM can cause symptoms immediately after birth. As a major blood vessel is involved in this AVM, it causes accumulation of fluid in the brain and brain swelling. Common symptoms include seizures, visible veins on the scalp, congestive heart failure, and failure to thrive. In contrast Dural AV fistulas, another type of cerebral AVM usually affects people of middle to old age.

Treatment

There are multiple treatment options for AVM, and their main goal is to prevent bleeding in the brain.
Your doctor will decide the ideal treatment option based on your health, age, and location of the AVM.
Medicines can be helpful to manage AVM symptoms such as headaches and seizures. However, surgery may be needed in the majority of cases. First step after an AVM is diagnosed on CT or MRI of the brain is to go a angiogram (DSA). This gives us information about the arteries/veins involved, type of AVM, actual size and if there are any danger signs which can predict the chances of bleeding inside the brain. Once this information is there following treatments can be planned.
Treatment options include:

  • Conservative management: some AVM’s which are incidentally detected and having low risk features on angiogram can be followed up for months to years on imaging. Only symptomatic treatment if required can be given.
  • Surgical removal: It is an ideal option if the AVM is very small and is at a location that is easily accessible surgically. Resection is usually done when the AVM can be removed with little risk of seizures or bleeding. As AVMs in the deeper brain parts have a higher risk of these complications, your doctor will recommend other options.
  • Endovascular embolization: It is a minimally invasive procedure involving the insertion of a flexible, thin tube (catheter) through a cut in the groin to deliver obstructive materials like glue into AVM and close the abnormal connection. This form of therapy is highly involved and carry low risk of complications.
  • Stereotactic radiosurgery: It uses a highly concentrated radiation beam that focuses on the site of AVM. The radiation beam damages the blood vessels and forms scar tissue, stopping the blood flow into the AVM. It is not a typical surgery as the procedure is cut-free. Radiosurgery is ideal for smaller, unruptured AVMs.
  • Combined approach: some AVM’s are tricky due to multiple reasons and no one form of therapy can cure them. In these cases combined approach like embolization followed by surgery or radiosurgery is carried out.
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Spinal AVM

Arteriovenous malformation (AVM) is a tangle of abnormal blood vessels connecting veins and arteries. When they occur in or around the spinal cord they are called Spinal AVM.
Typically, blood flows from the heart to the arteries, which get smaller until they turn into capillaries. Nutrients and oxygen exchange takes place in the capillaries. The blood then passes from capillaries to your heart through veins.

But in the AVM’s, arteries directly connect to veins, without capillaries in between, and form a knot of blood vessels. This creates an area of high pressure. The veins cannot take this pressure and enlarge and bulge to accept extra blood coming at high pressure. In this process they may exhibit pressure symptoms on the spinal cord resulting in disabilities or may bleed causing serious complications.

Spinal AVMs can be seen at any age depending upon their type. Typically when they are inside the spinal cord they present early and are commonly seen in the young children, and when they are around the spinal cord they present in the adults or older age group.

Symptoms

Manifestation of spinal AVM may be different in different patients depending on its location and size. While some may not have noticeable symptoms, others may have life-threatening symptoms.
When present, some common symptoms include:

  • Tingling or, numbness, in your legs or arms.
  • Problems with climbing stairs or walking.
  • Weakness on one or both the sides of your body.
  • Difficulty in passing urine or stools.

If left unattended, spinal AVM may cause the following symptoms:

  • Lack of sensation in your legs
  • Paralysis of arms/legs.
  • Difficulty moving your bowels or urinating.

Diagnosis

Spinal malformations can be challenging to diagnose as their signs and symptoms resemble other spinal disorders, such as spinal stenosis or other spinal infections.
Here are some tests that can help your doctor diagnose this condition:

  • Magnetic resonance imaging (MRI): it frequently raises the suspicion of underlying AVM. It also helps in assessing the damage caused to the spinal cord or if there is any bleeding due to AVM.
  • Digital Substraction Angiography (DSA): this is gold standard for spinal AVM diagnosis. Spinal angiography (DSA) also aids in identifying the blood vessels supplying the malformation, type of AVM and thus planning the right treatment approach.

Spinal Vascular Malformations Treatment

Treatment strategies and outcomes depend on the location, size, and blood flow to your spinal AVM, overall health, and neurological examination.
The primary goal of treatment is to lower the risk of bleeding and prevent or stop the progression of disability.
Pain-reliving medicines may reduce symptoms such as stiffness and back pain, but most patients will gradually need surgery.
Surgery
It helps in removing a spinal AVM from the surrounding tissues. Some common options include:

  • Conventional surgery: A surgeon makes an incision to remove the AVM. Care is taken to avoid damage to the spinal cord and its surrounding structures. This type of surgery is done when AVM is located in an area that is easily accessible and fairly small in size.
  • Endovascular embolization: It is a minimally invasive procedure involving the insertion of a flexible, thin tube (catheter) through a cut in the groin to deliver obstructive materials like glue or onyx into AVM and close the abnormal connection. At present this is the mainstay in the treatment of spinal AVM. Once diagnosed this form of surgery needs to be done at the earliest to prevent the progression of the deficits.
  • Radiosurgery: It uses a highly concentrated radiation beam that focuses on the site of AVM with the help of dedicated machines. The radiation beam damages the blood vessels and forms scar tissue that stops the blood flow into the AVM. The procedure is cut-free and painless. Radiosurgery is ideal for smaller, unruptured AVMs. The flip side to this treatment is that the effect of this treatment takes months to year to become evident unlike embolization where the AVM can be blocked right then during the treatment session.
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Vascular, Neuro, and Non-Vascular Interventional Radiology Procedures

Interventional radiology procedures are minimum invasive procedures guided by imaging techniques for diagnosis or treatment of various conditions.

Here are some commonly used procedures:

Vascular Interventional Radiology

Interventional radiology is an excellent option for patients suffering from pain or life-threatening conditions. Some arterial diseases that may benefit from IR are:

  • Peripheral artery disease: It is a condition with hardened arteries that may cause pain and decreased mobility.
  • Arterial aneurysms: In this disorder, a part of your blood vessel bulges and weakens. If this part of the blood vessel ruptures, it can result in internal bleeding.
  • Arterio-venous malformation: It is a condition with an abnormal tangle of blood vessels connecting arteries and veins, without capillaries in between, which disrupts normal blood flow and oxygen circulation.

In such cases, interventional radiologists may help manage symptoms by sealing off an aneurysm or restore blood flow in blocked arteries.

Some common procedures are:

  • Peripheral vascular disease stenting and angioplasty: If you have peripheral vascular disease, stenting and angioplasty help relieve painful symptoms and restore blood flow.
  • Endoleak embolization: If you have undergone an aortic aneurysm repair, there is an increased risk of filling blood in the aneurysm sac (endoleak). Endoleak embolization is a minimally invasive procedure where an interventional radiologist blocks the blood flow to the aneurysm using a catheter.
  • Visceral artery embolization: When a part of the abdominal artery supplying the kidney, intestines, spleen, and liver enlarges, it is known as a visceral aneurysm. In such cases, the interventional radiologist may manage it using visceral artery embolization.

Neuro Interventional Radiology

It involves endovascular treatment of arteriovenous malformation and aneurysm in the brain and stroke (explained below). The endovascular devices are inserted through peripheral vessels where they open blockages or stop bleeding.

  • Brain arteriovenous malformation: It is a tangle of abnormal blood vessels in the brain. Headaches and seizures are the most common symptoms of a brain AVM. Management includes surgical resection and endovascular embolization.

Learn more about the condition here.

  • Cerebral aneurysm: An aneurysm occurring in the brain is known as a cerebral aneurysm. An unruptured aneurysm may cause weakness, numbness, or paralysis on one side of the face. In comparison, a ruptured aneurysm may cause a headache, which is described as the worst headache of your life. Some treatment options include embolization, flow diversion devices, and microvascular clipping.
  • Stroke: It is a condition where the blood supply to a part of the brain is reduced or interrupted, preventing brain cells from getting nutrients and oxygen. A stroke is a medical emergency and needs immediate treatment. Some treatment options are endovascular embolization, surgical resection, and clipping.

Read more about stroke and its management here.

Non-Vascular Interventional Radiology

It is also known as interventional oncology, but it can also be useful for benign conditions. Non-vascular IR therapies are used to:

  • Treat cancer
  • Relieve effects of cancer on other systems such as liver or kidneys
  • Place feeding tubes
  • Drain collection of pus or fluid in the abdomen or chest
  • To manage collapsed spinal bones

Some common procedures include:

  • Kidney, liver, and other tumors: It involves destructive therapies (ablation) involving cold damage (cryotherapy) or heat damage (laser, ultrasound, radiofrequency, or microwave).
  • Tumor therapies: These therapies are intended to destroy or shrink tumors at their primary sites or areas where they have spread.
  • Uterine fibroids: These benign fibroids may cause pain and heavy menstrual bleeding. Blocking their blood supply by embolization causes these tumors to shrink.
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Cerebral Dural Arteriovenous Fistulas

Dural arteriovenous fistulas (d-AVFs) are malformations caused by abnormal connections between your artery and vein in the dura, an outer covering of the spinal cord or brain. These malformations usually appear later in life and are not seen to have a genetic tendency.
While there are many causes for these d-AVFs, blockage or narrowing of the brain’s venous sinuses is among the commonest causes.

Symptoms of Dural Arteriovenous Fistulas

Some patients with dural AVFs may not have any symptoms. But when present, they can be classified as benign or aggressive symptoms.
Aggressive symptoms
These symptoms can be due to hemorrhage/bleeding in the brain or non-hemorrhaging neurological deficits (NHND). Hemorrhagic symptoms include a sudden headache of varying intensity depending on the size and location of the bleeding.
On the other hand, symptoms of NHND develop gradually and cause symptoms based on its location. Some common symptoms include speech or language difficulty, seizures, dementia, face pain, pricking sensations, coordination problems, and apathy. Pressure symptoms can also be present such as nausea, vomiting, and headache.
Benign symptoms
Common symptoms include pulsatile tinnitus, a bruit behind the ear, and vision problems such as eye bulge, visual deterioration, and swelling in the eye lining.
Symptoms that indicate a medical emergency
If you have any of the mentioned symptoms, seek immediate medical care:

  • A sudden severe headache
  • Vomiting
  • Nausea
  • Paralysis of one side of the body
  • Difficulty in speaking
  • Double vision
  • Loss of vision
  • Loss of balance

Diagnosis

If you have symptoms of dural AVF, your doctor may ask for magnetic resonance imaging (MRI) and non-contrast head computerized tomography (CT).

  • MRI/CT: It can help determine the secondary changes in the brain due to d-AVF. However, it is difficult to see the dural AVF on MRI or CT. Enlarged blood vessels at specific sites can raise a suspicion of this condition.

DSA (Digital Subtraction Angiography / Catheter-based cerebral angiography):
This is the gold standard test to diagnose this condition. It not only can diagnose this but can also helps in making treatment plan and assessing the benign Vs. aggressive nature of this condition.
After the initial CT/MRI scan, your doctor may advise this angiography that will help to define:

  • Blood vessel structure of the fistula
  • Location and number of fistulae
  • Anatomy of blood vessels
  • The extent of blockage or narrowing in the dural sinus
  • If the affected veins are dilated and their extent

Treatment

  • Endovascular embolization: this is the mainstay in d-AVF treatment. It is a minimally invasive procedure involving the insertion of a flexible, thin tube (catheter) through a cut in the groin to deliver obstructive materials like glue into the AVF and close the abnormal connection. This form of therapy is highly evolved and carries a low risk of complications.
  • Stereotactic radiosurgery: It uses a highly concentrated radiation beam that focuses on the site of AVM. The radiation beam damages the blood vessels and forms scar tissue, stopping the blood flow into the AVF. It is not a typical surgery as the procedure is cut-free.
  • Surgical removal: It is an ideal option if the fistula is very small and is at a location that is easily accessible surgically. Resection is usually done when the AVF can be removed with little risk of seizures or bleeding.