Interventional radiology is a new subspecialty in West Africa that uses minimally invasive image-guided techniques to treat diseases of the body's vascular and non-vascular systems. The presentation aims to provide an overview of interventional radiology, highlight common procedures relevant to the environment, and discuss procedures performed at the speaker's center. Interventional radiologists can treat conditions like stroke through procedures such as angioplasty, stent placement, thrombolysis, and aneurysm coiling to restore blood flow and remove blood clots. Stroke treatment is time-sensitive, so certified stroke centers are needed to ensure standardized care and improved patient outcomes.

1. Prof. Dr Ahmed Ahidjo
Professor of Radiology
Consultant Diagnostic and Interventional Radiologist
Department of Radiology
University of Maiduguri Teaching Hospital
PMB 1414, Borno State, Nigeria
Email: ahmedahidjo@hotmail.com
Interventional Radiology

2. INTRODUCTION
Interventional Radiology is a new
subspecialty in the West African sub
region, hence the need to educate the
our community on its benefits and
available services.

3. The aim of this presentation is to;
 Highlight on the overview of interventional
radiology
 Point out the most common interventional
radiology procedures relevant to our environment
 Enlighten our board members on the
interventional radiology procedures that are
performed in our centre and the peculiarity of an
interventional radiologist working in this
environment.

4. Interventional radiology is a
vibrant and rapidly evolving
specialty due to in large part to the
ingenuity and creativity of its
practitioners.
Vascular and Interventional
Radiology has been referred to as
"The Surgery of the 21st Century."

5. The specialty of interventional
radiology has never been and never
will be static, boring or easily
characterized.
It comprises a unique combination of
imaging, technology, procedures and
clinical variety, for treatment of
patients, there is hardly a more
exciting specialty!

6. Along with the satisfaction of
performing interventions comes the
responsibility:
to see patients in clinics
render consultations
recommend a course of action
perform the procedure
follow up treatment outcomes

7. The procedures that once require the
services of surgeons or surgical incisions
have been replaced by interventional
radiologists to percuteneous image
guided techniques.
Interventional Radiology procedures
are performed across all body system
and can be broadly classified as vascular
or non-vascular.

8. The major categories of vascular
interventions are:
angioplasty and stenting
embolization
thrombolysis and thrombectomy
haemodialysis access
venous interventions
foreign body removal

9. Although angiography machine is the basic
equipment used by all interventionists,
other imaging modalities are also used
ultrasound
fluoroscopy
CT
MRI

10. NEURO-INTERVENTION
 Interventional neuroradiology (IR)is medical subspecialty developed in
1980s neuroradiologists and neurosurgeons
 Used to treat cerebrovascular, head and neck, and spinal disease by
using minimally invasive techniques.
 Since then there has been dramatic advances in IR which have been
made possible by similarly rapid advances in neuroimaging particularly
digital subtraction cerebral angiography and development of
revolutionary medical devices.
 Many medical conditions which could not be treated effectively 15-20
years ago can now be treated curatively using current endovascular
techniques.
 New technology and devices introduced within the past 5 -10 years have
allowed IRs to increase the number of life-threatening CVDs which can
be treated effectively.
10

11. TREATMENT OPTIONS IN INTERVENTIONAL NEURORADIOLOGY
 Diagnostic catheter angiography is firstly performed to:
 define the vascular anatomy
 determine if stenosis or occlusion is present
 rule out cerebral aneurysms
 arteriovenous malformation
11

12. Normal DSA carotid angiogram: a) Lateral view b) AP view
a b
12

13.  Acute management of ruptured and unruptured cerebral
aneurysms
 coil embolization
 balloon-assisted coiling
 stent-assisted coiling
13

14.  Diagnosis and/or embolization of AV malformations – either
ruptured or not ruptured.
AV malformation: Before and after embolization
14

15. (A) Acute middle cerebral artery occlusion (arrow). (B) Placement
of the stent retriever with immediate flow restoration. Distal marker
of the device (thin black arrow), the thrombus is pressed to the
vessel wall (thick black arrow). (C) Successful recanalization of
the artery.
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16. STROKE
 Stroke occurs when blood supply to a
vascular territory of the brain is suddenly
interrupted (ischaemia) or when blood
vessel is ruptured (haemorrhagic).
 The location is mostly supratentorial-90%
(70% cerebral mantle and 20% basal
ganglia and internal capsule) ,

17. Epidemiology
 Stroke is a main cause of death worldwide and is one of the
most common causes of disability in developed countries.
 Most patients are above 40 years
 Only 3% of cases occurs in younger people, mostly due t:o
 cardiac diseases
 hematological disease
 vascular dissection

18. RADIOLOGICAL
INVESTIGATIONS
1. Emergency CT scan of the brain
2. Xenon-enhanced CT-assessment of cerebral blood flow
3. MRI
4. Angiography
5. Ultrasonography

19. Angiographic methods currently
used include:
1. Magnetic resonance angiography (MRA)
2. CT angiography
3. Sonographic vascular imaging
4. Intravenous digital subtraction angiography (IV DSA)
5. Direct intra-arterial angiography.

20. Conventional Angiography
 Conventional angiography of cerebral vessels
was the gold standard examination
 It is recommended primarily when Doppler
ultrasonography and MRA/CTA yield
discordant results or if they are not feasible

21. Angiography:
May show narrowed or occluded vessel
supplying the area, delay filling and
emptying of involved vessel and early
draining vein

22. TREATMENT
 Some stroke symptoms can be reversed with prompt
diagnosis and treatment, healthcare providers should use
standardized protocols to improve outcomes.
 The Brain Attack Coalition recommends the following key
interventional components be integrated into hospital-
based programs to improve patient outcomes:
 treatment by healthcare personnel with expertise in
neurosurgical and endovascular techniques
 advanced neuroimaging techniques, such as magnetic resonance
imaging, computed tomography, and angiography
 surgical and endovascular techniques, including intracranial
aneurysm clipping and coiling, carotid endarterectomy, and intra-
arterial thrombolytic therapy
 specific infrastructure and program elements, such as intensive
care and stroke registry

23. TIME IS BRAIN
 The earlier the patient present to hospital
the better the outcome.
 Indeed, animal experimental and clinical
evidence shows that the time to treatment
is the primary determinant of outcome.

24. TIME IS BRAIN-IV THROMBOLYSIS
 In 1995, the National Institute of Neurological Disorders and
Stroke (NINDS) study group reported that patients with
acute ischemic stroke who received alteplase (0.9 mg per
kilogram of body weight) within 3 hours after the onset of
symptoms were at least 30% more likely to have minimal or
no disability at 3 months than those who received placebo.
 Alteplase is a tissue plasminogen activator (tPA). It works
by helping to break down unwanted blood clots.

25. IV THROMBOLYSIS
 The potential for clot recanalisation with intravenous
thrombolysis is markedly dependent on the site of the
occlusion.
 It is more successful in distal middle cerebral artery
occlusions than in recanalisation of larger vessels such
as the internal carotid artery (ICA) or proximal (M1)
segment of the middle cerebral artery.

26. IV THROMBOLYSIS
 Unfortunately, only 2% to 3% of ischemic stroke victims
meet I.V. tPA criteria. Patients can’t receive tPA if they:
 have had recent surgery
 received recent blood thinner therapy increasing
prothrombin time
 have suffered a hemorrhagic stroke
 have nonthrombotic emboli
 are younger than age 18
 have rapidly improving symptoms.
 Because of the small number of patients presenting to
emergency departments within the treatment window
who meet I.V. tPA eligibility requirements, additional
treatment options have been developed.
 These include endovascular stenting, balloon
angioplasty, intra-arterial thrombolytics, and clot or
plaque retrieval.

27. INTERVENTIONAL RADIOLOGY TREATMENT
OPTIONS
 Cerebrovascular interventional radiology
treatments expand the treatment options for
acute ischemic stroke victims.
 Recent innovations include:
 MERCI Retriever®
 Penumbra System®
 intra-arterial tPA
 Each offers a longer treatment window and can be
used in some patients ineligible for I.V. tPA.

28. RETRIEVAL DEVICE
 Approved in 2004, the Mechanical Embolus Removal in
Cerebral Ischemia (MERCI) Retriever is the first mechanical
device for use in endovascular procedures in stroke
patients.
 With a treatment window of up to 8 hours from symptom
onset, the MERCI Retriever is most successful when used in
larger cerebral vessels, such as:
 vertebral arteries
 basilar artery
 internal carotid arteries
 middle cerebral artery
 The corkscrew-shaped device is threaded directly into the
clot.
 The interventional radiologist or neurosurgical
interventionist threads the microcatheter into the femoral
artery, advances the device to the site of the clot, deploys
the retriever into the clot to capture it, inflates a balloon
to occlude blood flow, and pulls the clot through the
catheter.

30. THROMBO-ASPIRATION DEVICE
 Another innovation, approved in 2008, is a
thrombo-aspiration device called the
Penumbra System.
 Offering an 8-hour window from onset of
acute ischemic stroke symptoms, it has been
82% successful in recanalization.
 Introduced through percutaneous angiography,
the system is threaded into the cerebral
circulation to the area of the clot; the
interventional radiologist deploys a separator
to break up the clot and the Penumbra device
then sucks the clot out.

32. INTRA-ARTERIAL/DIRECT THROMBOLYSIS
 Another new treatment is intra-arterial tPA
administration, often used in conjunction
with the MERCI Retriever or the Penumbra
System.
 Tissue plasminogen activator (abbreviated
tPA or PLAT) is a protein involved in the
breakdown of blood clots
 When delivered intra-arterially directly to
the site of the clot, tPA has the same clot-
busting potential as when given I.V., but
with a longer treatment window—6 hours
from symptom onset.

34. Interventional Radiology for
Hemorrhagic Stroke
 In hemorrhagic stroke, interventional radiological
treatment such as coiling has established itself as a
standard procedure for treating aneurysms
 Moreover, in some cases of arteriovenous malformations
(AVM), interventional embolization may be a treatment
option as well
 Stenting, balloons
 Excellent imaging during intervention is indispensable
for safe and efficient vascular therapy. Interventional
radiology suites should therefore reflect the therapeutic
requirements of the interventional imaging technique
and the skills of the interventional team

35. DSA Before and after
thrombolysis

37. Preangioplasty Post angioplasty

38. Embolisation of
Caroticocavanous fistula

39. Coil embolisation of
aneurysm

40. Embolisation of Aneurism

41. Embolisation of AVM

48. STROKE CENTERS
Certified primary stroke centers should meet the following
requirements:
 use standardized methods of delivering care based on the
Brain Attack Coalition recommendations
 support patients’ self-management activities
 provide treatments and interventions tailored to meeting
patients’ individual needs
 promote the flow of patient information across care settings
 analyze standardized performance measure data to promote
continual process-improvement
 demonstrate application of and compliance with clinical
practice guidelines

49. SUMMARY
 Stroke is a major cause of morbidity and mortality in Nigeria
and worldwide.
 Interventional Radiology plays important roles in modern
diagnosis and treatment of stroke patients.
 CT, MRI and Angiography are essential imaging modalities for
diagnosis and treatment of stroke.
 Establishment of designated stroke national center and other
accredited zonal centers in Nigeria will assist in improving
health care service to stroke patients.