Cutting-edge treatments for Neurovascular Disorders (without the cutting)- Interventional Neuroradiology

1. INTERVENTIONAL NEURORADIOLOGY
CUTTING-EDGETREATMENTS
FOR NEUROVASCULAR DISORDERS
(WITHOUTTHE CUTTING)
Dr SHARATH KUMAR G G
MBBS, MD, DM (Neuroradiology)
Consultant- Neurointerventional Radiologist
Department of Radiology, Apollo Hospitals

2. CHANGE INTHE STANDARD OF CARE
MR CLEAN EXTEND-IA ESCAPE REVASCAT SWIFT PRIME

3. MECHANICAL STROKETHROMBOLYSIS
Patients eligible for intravenous r-tPA even if endovascular
treatments are being considered (Class I; Level Of Evidence
A). (Unchanged from the 2013 guideline)
Patients should receive endovascular therapy with a stent
retriever if they meet all the following criteria (Class I: Level of
Evidence A) ( New recommendation):
Prestroke mRS score 0 to 1,
Acute ischemic stroke receiving intravenous r-tPA within hours
of onset according to guidelines from professional medical
societies.
Causative occlusion of the ICA or Proximal MCA (M!),
Age > 18 years
NIHSS Score > 6
ASPECTS of > 6
Treatment can be initiated ( groin puncture) within 6 hours of
symptom onset
1.
2.
a.
b.
c.
d.
e.
f.
g.

4. STROKE:TIME LOST IS BRAIN LOST
neurons/minute!
2
MILLI
ONFast Accurate Sensitive Treatment
Facedrooping Armweakness Slurredspeech Timecounts

5. TIME WINDOW FOR INTERVENTION
IV. Thrombolysis
Mech. Thrombolysis
VBA. Thrombolysis
4.5 Hr
06 Hr
12 Hr
Vascular imaging is mandatory
If endovascular therapy is contemplated, a noninvasive
intracranial vascular study is strongly recommended during the
initial imaging evaluation of the acute stroke patient but should
not delay intravenous r-tPA if indicated.
(Class I; Level of Evidence A). (New recommendation)

6. A JOURNEY FROM GROINTO BRAIN

7. NEUROINTERVENTIONAL SUITE

8. CLINICAL CASES

9. CASE STUDIES - 01
Middle aged female with Dominant hemispheric
stroke arrives to ER within 60 minutes of aphasia and
right hemiplegia. CT showed hyperdense left MCA
and no evidence of bleeding.

10. INITIAL CT was
normal except for
the Hyperdense
MCA sign

12. DEPLOYMENT OF RETRIEVABLE STENT

13. Initial angiogram Time taken from puncture to
COMPLETE recanalisation is 30-40 minutes

14. ONTHE DAY OF DISCHARGE

15. CASE STUDIES - 02
Middle aged female with Right MCA stroke arrives to ER
within 60 minutes with dense left hemiplegia. Imaging
confirmed right M1 cut-off. Started IV tpa and patient started
waxing and waning Of weakness. Shifted to cathlab
immediately

17. OPENING AT
FIRST PASS BY
6 mm stent

18. SECOND PASS
with 4 mm stent
To M2 branch

19. Pre procedure Post procedure

20. CASE STUDIES - 03
Middle aged female with Right MCA stroke arrives to ER at
four hours disoriented with dense left hemiplegia. Imaging
confirmed right M1 cut-off. Started IV tpa and patient did not
show any improvement. Shifted to cath-lab immediately

22. Complete right
M1 cutoff

24. Immediate improvement
in power from zero to four

26. CASE STUDIES - 04
Middle aged female with altered sensorium arrives to ER at
six hours and CT showed hyperdense basilar artery. Started
IV tpa and patient did not show any improvement. Shifted to
cath-lab immediately.

27. Thrombosed vertebrobasilar arterial system

29. Clots

30. FINAL THOUGHTS
Endovascular stroke intervention has shown to be an effective and superior
standard of care in patients with large vessel occlusion.
The keys to success for a neurointerventional stroke center is a good
organization with proper clinical and neuroradiological patient selection.
The number of acute ischemic stroke patients is likely to increase and
there will consequently be a need for more neurointerventionalists in a not
too distant future.
This highlights the need for proper recruitment and standardized training.

31. CONCLUSION
Endovascular neurointervention is an interdisciplinary modality
of patient management, offering minimally invasive diagnostic
and therapeutic options to often challenging and difficult
neurovascular cases.

32. THANK YOU