Archives: Servs posts

Mechanical Thrombectomy for Stroke

A stroke is a condition where the blood supply to the part of the brain is reduced or blocked, depriving brain cells of nutrients and oxygen. Because of this, the brain cells begin to die within a few minutes. Thus, stroke is a medical emergency that needs prompt treatment to prevent brain damage and other complications.Blood clots in a blood vessel supplying the brain are one of the most common causes of stroke. Fortunately, a minimally invasive procedure is available to remove these clots from the vessels: mechanical thrombectomy.Let’s understand more about this procedure and how it helps people with stroke.

Mechanical Thrombectomy

It is a type of minimally invasive procedure in which an interventional neuroradiologist removes the clot using special equipment. The doctor makes a very tiny hole or an incision in the groin or the wrist to access the blocked vessel.

The doctor threads a catheter through the artery to reach the clot under the guidance of fluoroscopy (continuous x-ray). Next, they can introduce a stent retriever (a stent-like device) to reach the clot through the catheter.

The stent retriever pushes through the blood clot, expanding the blood vessel. As the stent retriever captures the blood clot, the doctor will pull it out, removing the clot.

So, mechanical thrombectomy aids in stopping the damage entirely or to some extent by removing the clot that was clogging the artery supplying the brain.

Before doing the Mechanical Thrombectomy the doctor will use imaging techniques such as MRI and CT scans to help understand if mechanical thrombectomy can help.

Usually, this procedure needs to be carried out within 6 to 24 hours. In cases where the patient reaches the hospital within four and a half hours, a drug called tissue plasminogen activator (a drug to break down the clot) may be used in addition to this technique.

Benefits

The effect of the procedure is almost immediate. In some cases, the patient even becomes mobile again or starts speaking immediately. However, other patients may take weeks to months to improve.

Risks

Like any other procedure, mechanical thrombectomy may also have some risks. However, If done by a trained professional these risks are minimal. Some common ones include:

• Damage to the blood vessels
• Bleeding
• Infection
• Reactions or problems to anesthesia
• Clot traveling deeper into the vessel

Despite the risks, mechanical thrombectomy lowers the risk of stroke complications and improves the chances of survival. American Heart and Stoke association has recommended this treatment for the stroke patients. The procedure is thus widely used to manage stroke.

Brain hemorrhage is a medical condition that refers to bleeding in the brain and requires immediate attention.

The bony skull surrounds your brain making it a closed compartment. Therefore the bleeding inside the brain cause immediate rise in pressure and results in compression and damage to the brain tissues. Besides, if the compression is severe due to excessive bleeding, it prevents oxygen from reaching brain tissue and causes brain swelling (cerebral edema)

Let’s understand more about the causes, symptoms, and management of the condition.

Causes

Some common causes of brain hemorrhage are:

• Extremely high blood pressure
• Head injury
• A balloon like bulge in the brain artery (aneurysm)
• Bleeding disorders
• Blood vessel disorders
• Brain tumor
• Liver diseases

Symptoms

Common hemorrhage symptoms are severe headache, vomiting, loss of consciousness, weakness, numbness, tingling, or paralysis of the arm, leg, or face. Usually, these symptoms affect one side of the body.
Other symptoms include:

• Difficulty swallowing
• Loss of coordination or balance
• Confusion
• Slurred speech
• Unconsciousness
• Seizures

Types

There are various types of a brain hemorrhage based on the location of bleeding and include:

• Intracerebral hemorrhage (ICH): The bleeding is inside the brain. It is usually due to uncontrolled blood pressure.
• Subarachnoid hemorrhage: The bleeding is between the brain and a thin arachnoid membranes covering it. It is usually due to trauma or bleeding from the brain aneurysm.
• Subdural hemorrhage: The bleeding is between the internal layer of the dura (membrane covering the brain) and above the brain. It occure due to trauma or in old age without any significant trauma.
• Epidural hemorrhage: The bleeding is present between the brain and the skull. This is generally because of trauma and can be associated with a skull fracture.

Treatment

The treatment depends on the type and severity of the stroke. The early treatment involves stabilizing breathing and blood pressure. Once stabilized, the doctor will decide whether surgery is required or it can be managed with medicines. It all depends on the underlying cause of the bleeding.

The doctor will carry out several tests to understand the location or extent of bleeding, including a CT scan, MRI, eye examinationetc.

Various medicines reduce swelling of the area surrounding the hemorrhage, keep blood pressure under normal levels, and prevent seizures. If the patient is conscious, pain medicines may also be included.
If an aneurysm is found to the cause then it can be treated with Endovascular techniques like Coiling, Flow Diverters etc without opening the skull.

Prevention

One can not completely avoid the chances of having a brain hemorrhage. Some lifestyle modifications however allow you to reduce that risk, including:

• Treating underlying health conditions such as high cholesterol levels, diabetes, and hypertension.
• Being regular with your hypertension medications.
• Not taking aspirin or other blood thinners without doctors advise.
• Eating a healthy and balanced diet
• Being active and exercising regularly
• Quit smoking
• Avoiding excess consumption of alcohol

A cerebral aneurysm or a brain aneurysm is a balloon-like swelling in your brain’s blood vessels. It typically forms at a weak spot where the arterial wall bulges and fills with blood. As the aneurysm grows, it exerts pressure on the surrounding structures and may gradually rupture. It can be a life-threatening condition and may affect anyone irrespective of their age. A ruptured aneurysm may result in brain damage, stroke, or even death if not managed immediately.

The good news is that 50%-80% of the aneurysms do not rupture. Unruptured aneurysms are detected by chance during a scan for other health issues. The risk of rupture depends on the aneurysm size and location.

Cerebral aneurysm treatment & management options include observation and minimally invasive procedures. In some cases, cerebral aneurysm open surgery may be required.

Cerebral Aneurysm Symptoms

Aneurysms are unpredictable and may be silent unless they rupture. Ruptured or large aneurysms usually show symptoms and may need emergency medical care. Cerebral aneurysm warning signs and symptoms depend on whether they are ruptured or not.

An unruptured aneurysm may have the following symptoms:

• Severe, sudden headache, which could be described as the worst headache of your life
• Double or blurry vision
• Neck stiffness
• Drooping eyelid
• Sensitivity to light
• Loss of consciousness
• Dizziness
• Difficulty in walking
• Nausea or vomiting
• Loss of consciousness
• Seizures

A leaking aneurysm with minimal bleed may just cause a severe, sudden headache. If you have any of these symptoms, seek emergency medical attention immediately.

Cerebral Aneurysm Causes

Some common causes include:

• Brain injury
• Genetic conditions
• Severe infection
• Long-standing high blood pressure
• Smoking
• Autosomal dominant polycystic kidney disease, a condition that increases blood pressure and weakens blood vessels in the brain
• Marfan’s syndrome, a genetic disorder that alters the formation of connective tissue. It also creates a weakness in the blood vessel wall that can result in a brain aneurysm

The following causes may cause an existing aneurysm to rupture:

• Excessive Soda or coffee consumption
• Excessive exercise
• Startling
• Intense anger
• Straining while passing stools
• Sexual intercourse

Cerebral Aneurysm Risk Factors

While a cerebral aneurysm can affect anyone, certain factors increase your risk of getting it. Some common risk factors include:

• Atherosclerosis
• Smoking
• Older age
• Menopausal women
• Drug and alcohol abuse
• Head injury
• Coarctation of the aorta, a condition of congenital narrowing of the aorta
• Cerebral arteriovenous malformation
• Congenital problems affecting blood vessel walls, such as Ehlers-Danlos syndrome

Cerebral Aneurysm Treatment

Management of cerebral aneurysm include:

Observation

In some cases, the ideal treatment is to wait and watch. The doctor will ask you to control high blood pressure and quit smoking. Small(generally less than 3mm), asymptomatic, and unruptured aneurysms can be monitored with scans every year. If the aneurysms show a change in size or shape then they need to be treated.

Surgical Clipping

This procedure involves a cut in the skull under general anesthesia. The brain is retracted, and a small clip is placed on the neck of the aneurysm to prevent blood from entering it. The clip is made up of titanium and stays permanently in the brain.

Recovery time is usually between four to six weeks but may take longer.

Endovascular Coiling

It is a minimally invasive option and is performed during an angiogram. During this procedure, a catheter is introduced in the leg artery through a small cut in the groin, which is then passed to the aneurysm in the brain.

The doctor packs the aneurysm with platinum coils introduced through the catheter. These coils promote clotting, sealing the aneurysm, and preventing blood from entering it. Sometimes in addition to the coils balloon or stent assistance is required.

It may take up to two to four days for complete recovery. Coiling requires periodical monitoring through imaging for five years.

Endovascular flow diversion

When coiling and clipping are difficult due to the size or shape of the aneurysm, flow diversion can come in handy. A flow-diverter stent is a tightly woven mesh tube and is inserted in the main artery across the aneurysm.

The tight mesh stent prevents easy blood flow into the aneurysm, and blood flows through the artery predominantly with minimal flow inside the aneurysm. Lack of blood supply will cause the aneurysm to form thrombus/clot and it gradually disappears.

The recovery time is usually two to four days in an unruptured aneurysm.

Artery occlusion and bypass

This procedure is done very infrequently these days. This procedure is recommended when the aneurysm is inaccessible or large, or the blood vessel is damaged. It involves opening the skull and introducing clips to block the aneurysm and artery.

Now the surgeon bypasses the blood flow around the blocked artery by placing a graft. This graft is a small artery, usually taken from your leg, connected both above and below the occluded artery to allow blood flow through the graft.

Usually, it takes four to six weeks to recover, but it may even take longer.

Cerebral Aneurysm Prevention

Though the occurrence of aneurysms cannot be totally prevented certain lifestyle modifications aid in managing or preventing rupture of the aneurysm, such as:

• Eating a healthy diet of vegetables, fruits, whole-grain, low-fat dairy products, and lean meat.
• Quitting smoking
• Managing high cholesterol or high blood pressure
• Regular, but not excessive, exercise

An arteriovenous malformation (AVM) is a condition where the blood vessels in your brain or spine tangle abnormally. While some AVMs pose little or no risk to one’s health, others may be injurious when they bleed.

But the good news is that multiple treatment options are available, ranging from conventional wait and watch (observation) to surgery. Your doctor will decide the best treatment option for you, depending on the symptoms, type, and location of AVM.

What is an Arteriovenous Malformation?

Before heading towards the treatment option, let us first understand what AVM is.

The circulatory system consists of the heart and blood vessels. Three types of blood vessels make up the circulatory system: arteries, veins, and capillaries.

Typically, blood flows from the heart to the arteries, which get smaller until they turn into capillaries. Nutrients and oxygen exchange take place in the capillaries. The blood then travels from capillaries to your heart through veins.

But in AVM, arteries directly connect to veins, without capillaries in between, and form a knot of blood vessels. (Fig 1.) This creates an area of high pressure. The veins cannot take this pressure and enlarge and bulge to accept extra blood.

AVM is usually a congenital condition, meaning it is present at birth. Although AVM may develop everywhere in the body, it is commonly seen in the brain and spine, causing headaches and seizures.

Treatment for AVM

Treatment options for AVM include observation, embolization, radiosurgery, and surgery. The ideal treatment depends on the type and location of AVM, age, and physical health.

Observation

If there is no previous history of bleeding (hemorrhage), your doctor may decide to observe the condition and prescribe medicines to lower blood pressure or prevent seizure.

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.

The procedure time may vary for different cases, and the patient has to stay under observation in a hospital. Embolization is less invasive, reducing the risk of side-effects and promoting faster healing. It can be useful in inoperable or deep AVM.

Some disadvantages of the treatment include rebleeding and the risk of embolic stroke. Besides, multiple treatments may be needed.

Radiosurgery

It uses a highly concentrated radiation beam that focuses on the site of AVM. The radiation beam damages the blood vessels and forms a scar tissue that stops the blood flow into the AVM. The patient can go home on the same day. Usually, the AVM blood vessels close after six months to 2 years and are replaced with scar tissue. The procedure is cut-free and painless. Radiosurgery is ideal for smaller AVMs and may take longer to show results.

Conventional Surgery

It involves creating a surgical opening in the skull through which the AVM is cut from the normal brain tissue or shrunken. Various techniques, such as electrocautery and laser, are used for the same.
The patient may need to stay in the hospital between 5 to 7 days. The primary benefit of the procedure is immediate relief from the AVM.

Side-effects include damage to the nearby brain tissue, bleeding, and stroke.

Frequently Asked Questions

1. What is an AVM?
An AVM is an abnormal knot of blood vessels, mainly present in the brain and spine.

2. What is an AVM in the brain?
An AVM in the brain is a tangle of blood vessels connecting arteries and veins in the brain.

3. What happens if the AVM ruptures in the brain?
IF the AVM ruptures in the brain, the bleeding puts pressure on the brain’s surrounding tissues and blocks the brain’s blood flow.

4. What is the AVM rupture survival rate?
The survival rate after an AVM rupture ranges from 88-33%.

Get the Best Treatment for Arteriovenous Malformation in Faridabad from Dr. Vivek Gupta.

A stroke is a condition where a part of the brain is deprived of blood supply. It is a common disorder, and numbers suggest that one in six people will have a stroke at some point in time.

Ischemic stroke is one of the two types of strokes and is caused by the blockage of an artery supplying the brain. This blockage reduces the blood and oxygen supply to the brain cells, resulting in their damage or death. The blockage is due to a blood clot that prevents the blood from going into a portion of the brain.

Failure to timely restore circulation may permanently damage the brain. Here time is the most important factor, the upper limit of stroke treatment time window is 24 hours. Beyond this time only supportive treatment can be given and the chance of salvaging the brain tissue decrease drastically.

Acute Ischemic Stroke

Acute ischemic stroke (AIS) is a sudden loss of blood flow to an area of the brain associated with the loss of neurological functions. Thrombosis or embolism obstructs a blood vessel supplying a specific part of the brain.

During an ischemic stroke, the damage to the core area is irreversible, but that to the surrounding area (penumbra) can be reversed. Evidence-based treatments, such as endovascular clot retrieval or intravenous thrombolysis, can restore the blood circulation by removing the obstruction and are seen to improve the outcome when used for appropriate patients.

Acute Ischemic Stroke Symptoms

The acronym BE FAST (Balance, Eyes, Face, Arm, Speech, Time) is typically used to diagnose stroke. Loss of balance, difficulty in seeing, Face drooping, arm/leg weakness, and speech difficulty are signs that it is time to seek emergency treatment.

The symptoms depend on the location and severity of the stroke. Some people do not have any have multiple symptoms, while others may have only one symptom. However, most people have a combination of symptoms

Some common symptoms include:

• Weakness on one side of the body
• Difficulty in swallowing
• Change in alertness
• Loss of balance or dizziness
• Abnormal vision like seeing double or blurred

Acute Ischemic Stroke Risk Factors

Some factors that may increase your risk of getting a stroke are:

• Smoking
• Diabetes
• High blood pressure
• High cholesterol levels
• Atherosclerosis
• Atrial fibrillation
• Sickle cell anemia
• Congenital heart defects
• A history of heart attack/li>
• Clotting disorders
• Being overweight
• Alcohol or drug abuse
• Old age
• A family history of stroke

Acute Ischemic Stroke Causes

The leading cause of AIS is blockage of the artery supplying your brain with a plaque (fatty buildup) or clot.

Acute Ischemic Stroke Imaging and Intervention

The following tests aids in stroke imaging:

• Computed tomography scan
• Magnetic resonance imaging
• CT or MR angiography
• Cerebral Angiography(DSA)

Acute Ischemic Stroke Management

Acute ischemic stroke treatment mainly consists of the following therapies.

Clot buster drugs (Can be given till 4.5 hrs after stroke onset)

Clot-buster or thrombolytic medicines restore blood flow by dissolving the clot. The most common drug used for this purpose is tissue plasminogen activator or tPA. tPA is an enzyme found in your body and dissolve clots. Your doctor may inject tPA in your blood to speed up the process.

Individuals receiving tPA within the first three to four hours of stroke are more likely to recover faster with little or no disability.

Mechanical Thrombectomy(Can be given till 24 hrs of stroke onset)

Large blood clots that block large arteries may not dissolve fast enough with tPA. In such cases, a minimally invasive procedure, which uses clot retrieval devices to pull out the clot, leaving the artery open, is recommended.

This procedure is done during an angiogram, where a catheter is introduced in a blood vessel through a small hole in the groin. It is called Mechanical Thrombectomy.

Acute Ischemic Stroke Recovery

The recovery time is different for everyone and depends on the size and location of the brain area affected by the stroke. It may take from several hours to several months for complete recovery from acute ischemic stroke.

Two most important predictors of recovery are time and reopening of blood vessel status. The patients where treatment is given early (0-6 hrs) show better recovery as compared to patients who are treated late (12-24hrs). The second factor is re-opening of the blood vessels, the patients where full blood supply is restored either by t-PA injection or mechanical thrombectomy generally will do better than those in whom either partial or no restoration of blood supply is achieved.

Other factors like pre-existing conditions, age etc may also affect the recovery process.

Rehabilitation:

All stroke patients need supportive therapies like physiotherapy, speech therapy, swallowing therapy, etc which aid in better recovery and functional status.

Strokes can be of two types. An ischemic stroke results due to a lack of blood flow to the brain cells and tissues. Blockage of brain blood vessels due to clot is major cause of this stroke. Clot can arise from the heart or from the brain blood vessels. An ischemic stroke is the most typical type of stroke and accounts for 87% of stroke cases.Another type of stroke is a hemorrhagic stroke resulting from a ruptured blood vessel in the brain. The blood from the ruptured vessels accumulates and puts pressure on the surrounding brain areas and it can be fatal. Infact, only two-third of the patients of hemorrhagic stroke survive. A hemorrhagic stroke accounts for the remaining 13% of stroke cases and has a higher death rate than ischemic stroke.

However, the good news is that immediate/early treatment improves the odds of recovery.

Hemorrhagic Stroke Symptoms

• Sudden severe headache (Typically called ‘worst headache of your life’)
• Nausea and vomiting
• Loss of consciousness
• Numbness or weakness if the leg, arm, or face on one side of the body
• Dizziness
• Seizures
• Confusion
• Loss of balance
• Difficulty in talking or swallowing

Hemorrhagic Stroke Causes

There are multiple causes of hemorrhagic stroke, but the most common ones are:

• Uncontrolled Blood Pressure
  Prolonged and uncontrolled rise in BP may lead to bursting of tiny blood vessels of the brain causing a hemorrhagic stroke.
• Aneurysm
  It is a condition where a part of a blood vessel enlarges like a balloon due to a weak blood vessel wall. This bulging leads to the thinning of vessel walls and eventually cause them to rupture. It is the commonest cause of hemorrhagic strokes.
• Arteriovenous Malformation(AVM)
  It is a condition where blood vessels (arteries and veins) abnormally tangle without capillaries between them.The resultant blood vessels are weak and are prone to bleeding. This condition is usually present since birth.

Treatment for Hemorrhagic Stroke due to Brain Aneurysms

Medical Management
Once the bleeding is there in the brain, patients become very sick and require early hospital admission preferably in a dedicated neuro ICU. Here, medical management is given to decrease the symptoms of bleeding, manage increased blood pressure and in some cases ventilation if the patient has had severe bleeding. In addition to this, the cause of bleeding the aneurysm needs to be treated urgently because there is a very high chance of repeat bleeding.

Your physician may decide the best hemorrhagic stroke treatment based on the condition. Some common options include:

Endovascular Repair/coiling

In this form of treatment, the neurointerventional surgeon threads a catheter and thin wire through blood vessels into the aneurysm. A coil of platinum wire, which is as thick as a strand of your hair, is released into the area. The coil acts as a net, preventing blood from flowing into the aneurysm. Multiple coils are introduced inside the aneurysm till the time no blood flow is seen inside the aneurysm.

The procedure prevents rebleeding. In this type of treatment, there is no scar over the head and the entire treatment is done through a tiny hole in the groin or wrist. In general, this form of treatment is less risky then open surgery and recovery time is less.

Open Surgery/Clipping

In this form of treatment, the skull is opened up and the brain is separated to reach the site of the aneurysm. Once there the blood flow into the aneurysm is blocked with an aneurysmal clip that prevents it from bursting or bleeding further. Depending on the aneurysm’s size and location, surgery may or may not be a good option.

Coiling Versus Clipping

Both are established treatments for aneurysm treatment. The decision of which modality is better in a given case is based on, location of the aneurysm, size and configuration of the aneurysm, age, existing medical conditions and available local expertise. However, in general, coiling is safer when compared to open surgery in the majority of cases.

Hemorrhagic Stroke Recovery Time

Generally, after a ruptured/burst aneurysm is repaired patient would need 10-14 days additional stay in the hospital so that complications arising from blood collected in the brain can be managed. The duration of rehabilitation and recovery depends on the amount of bleeding, tissue damage and the severity of the stroke. You may need different therapies, depending on your needs. Some examples include occupational therapy, physical therapy, and speech therapy.