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Endovascular neurosurgery
The document provides an overview of endovascular neurosurgery, highlighting its importance as a minimally invasive approach for diagnosing and treating diseases related to the head, neck, and spine. It details common procedures such as interventions for ischemic stroke, carotid angioplasty, and intracranial aneurysm treatment, along with advancements in techniques like embolization. Current references and guidelines in endovascular practices are also mentioned, emphasizing the evolving landscape of neurosurgical methods.
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Similar to Endovascular neurosurgery
Endovascular neurosurgery
- 2.
- 3. Aims • Introduction toendovascular neurosurgery • Importance of endovascular neurosurgery • Basic know how of endovascular neurosurgery • Commonly performed neuro-endovascular procedures • Video illustrations • Current advancements
- 4. Introduction • Subspecialty ofNeurosurgery which specializes in minimally invasive image-based technologies and procedures used in diagnosis and treatment of diseases of the head, neck, and spine • Greater developments over the past two decades • Incorporation into neurosurgery curriculum • Important alternate therapeutic option to open surgery or medical therapy
- 5. General Principles • Preproceduralevaluation • Detailed neurovascular history & exam • Baseline investigations • Antiplatelet therapy • Aspirin / Clopidogrel / Eptifibatide • Contrast agents • iohexol / iodixanol / iopromide
- 6. General Principles • FemoralArtery Puncture
- 7. Intervention for Ischemicstroke • Candidates • Time window: 6 -8 hours *PROACT/Penumbra trials • Techniques: • Pharmacological => t-PA • Mechanical: • Microwire (Merci & Penumbra) • Stent-assisted or stent-platform-based
- 8. Intracranial atherosclerosis • 8%to 10% of ischemic strokes are attributable to intracranial atherosclerosis • Need for treatment? • The WASID trial found an 11% to 12% first-year risk of ischemic stroke in territory attributable to the patient symptoms • majority of strokes (73%) in WASID patients were in the territory of the stenotic artery • Endovascular Tools and Technique • The Wingspan Stent System
- 9. Carotid angioplasty andstenting • 30% of ischemic strokes. • Carotid endarterectomy is the conventional procedure • Patients who are unfit for endarterectomy are suitable candidates for CAS • The Technique: • Preprocedural aortic arch angiogram • Selective carotid angiography to assess stenosis severity • Femoral puncture and CAS
- 10. Intracranial aneurysm treatment •Endovascular coiling is the conventional minimally invasive procedure • Balloon assisted coiling • Self-expanding stent assisted coiling • Onyx embolization • Onyx is composed of an ethylene vinyl alcohol copolymer dissolved in DMSO and suspended in micronized tantalum powder (for visualization under fluoroscopy) • Investigational procedure, not licensed
- 11. Recent advancements 1. AVMembolization with Onyx 2. Vascular tumors embolization • Polyvinyl alcohol • Gelfoam • Coils • Trisacryl gelatin microspheres 3. Ischemic Vasospasm • Balloon angioplasty 4. Epistaxis
- 12. References 1. Sabareesh KN,Adnan HS, Hopkins LN. Endovascular Neurosurgery. Principles of Neurological surgery. 3rd ed.. P 362-338 2. del Zoppo GJ, Higashida RT, Furlan AJ, et al. PROACT: a phase II randomized trial of recombinant pro-urokinase by direct arterial delivery in acute middle cerebral artery stroke. PROACT Investigators. Prolyse in acute cerebral thromboembolism. Stroke. 1998;29:4-11. 3. Levy EI, Siddiqui AH, Crumlish A, et al. First Food and Drug Administration-approved prospective trial of primary intracranial stenting for acute stroke: SARIS (Stent-Assisted Recanalization in acute Ischemic Stroke). Stroke. 2009;40:3552-3556. 4. Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart disease and stroke statistics—2010 update: a report from the American Heart Association. Circulation. 2010;121:e46-e215. National 5. Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333:1581-1587. 6. Yadav JS, Wholey MH, Kuntz RE, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med. 2004;351:1493-1501. 7. Report of the WHO Task Force on Stroke and Other Cerebrovascular Disorders, 1989. Recommendations on stroke prevention, diagnosis, and therapy. Stroke. 1989; 20:1407-1431. 8. Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart disease and stroke statistics—2010 update: a report from the American Heart Association. Circulation. 2010;121:e46-e215. 9. Broderick JP. William M. Feinberg Lecture: stroke therapy in the year 2025: burden, breakthroughs, and barriers to progress. Stroke. 2004;35:205-211. 10. National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333: 1581-1587.
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Editor's Notes
- #5 The treatment of neurovascular diseases has been completely revolutionized with the introduction and growth of endovascular neurosurgery Endovascular neurosurgery is becoming a primary treatment alternative to conventional open surgery for multiple neurovascular pathological conditions, including carotid and vertebral atherosclerotic stenosis, cervical vessel dissections, acute and chronic cerebral ischemia, intracranial aneurysms, arteriovenous malformations (AVMs), and dural arteriovenous fistulas (dAVFs). Endovascular revascularization has resulted in recanalization rates as high as 70% to 100% for acute large vessel occlusions responsible for ischemic stroke in patients in whom intravenous (IV) tissue plasminogen activator (t-PA) therapy has failed or was contraindicated. Neuroendovascular surgery is being increasingly integrated into the neurosurgical training curriculum. It is essential for future neurosurgeons to have a basic understanding of endovascular techniques and tools and have them as an option for treating cerebrovascular pathological conditions.
- #6 The patient is asked whether there is a history of reaction to iodinated contrast material. Femoral, dorsalis pedis, and posterior tibial pulses should be examined to identify iliofemoral disease and for comparison after the intervention. Laboratory test results, including renal function and coagulation parameters, should be reviewed. Oral foods and flu- ids, except medications, are withheld for 6 hours prior to the angiogram or intervention Midazolam and fentanyl are the common drugs used for conscious sedation Intraprocedural monitoring is done with electrocardiograms, blood pressure readings, pulse oximetry, and frequent neurological examinations The groin is prepared and draped in the usual sterile fashion. The femoral pulse is palpated at the inguinal crease, and local anesthesia is administered via infiltration of 2% lidocaine (5-10 mL) at the site of the planned groin incision A 5-mm incision is made parallel to the inguinal crease A Potts needle with the bevel facing upward is advanced at a 45-degree angle to the skin, pointing to the patient’s opposite shoulder On posteroanterior fluoroscopy, the femoral artery is located approximately 1 cm medial to the center of the femoral head. Roadmapping (superpositioning of previous contrast angiographic images with “live” or real-time fluoroscopic images) should be used when engaging the vertebral arteries (VAs) and the internal carotid artery (ICA) and external carotid artery (ECA). A loading dose of heparin is administered intravenously (70 units/kg) after groin puncture, and 5 minutes later, the activated coagulation time is obtained Iohexol, a nonionic contrast agent, is the agent most commonly used for cerebral angiography.
- #9 Approximately 8% to 10% of ischemic strokes are attributable to intracranial atherosclerosis. The most definitive study of symptomatic intracranial ste- nosis thus far is the prospective Warfarin versus Aspirin for Symptomatic Intracranial Disease (WASID) trial, which found an 11% to 12% first-year risk of ischemic stroke in territory attributable to the patient symptoms The majority of strokes (73%) in WASID patients were in the territory of the stenotic artery
- #12 It is important for a neurosurgeon to be “completely” trained (both in microsurgery and endovascular neurosurgery) if he or she wishes to specialize in treating cerebrovascular diseases. At present, multiple trials are attempting to establish the superiority of one of these treatment options over the other.
- #13 It is important for a neurosurgeon to be “completely” trained (both in microsurgery and endovascular neurosurgery) if he or she wishes to specialize in treating cerebrovascular diseases. At present, multiple trials are attempting to establish the superiority of one of these treatment options over the other.