1) Neurovascular diseases like stroke are a major cause of death and disability worldwide. Advances in neuroimaging and endovascular neurointerventions now allow minimally invasive treatments for conditions like aneurysms and acute ischemic strokes. 2) Recent clinical trials have shown the benefits of endovascular therapies like stent retrievers for acute ischemic stroke. This represents a dramatic change in stroke management from older failed trials testing earlier devices. 3) A neurointerventionist, neurologist, neurosurgeon and radiologist working as a integrated team is key to utilizing the latest minimally invasive treatments for various neurovascular conditions like aneurysms, arteriovenous malformations and carotid artery stenosis.

1. Vipul Gupta
Head, Neurointerventional Surgery
Interventional Neuroradiology
NEUROVASCULAR & STROKE CENTRE
Interventions in stroke:Interventions in stroke:
A new eraA new era

2. Neurovascular diseases…
Stroke…. Third most common cause of death
 Most common reason for disability
 Appx. 1 in 4 people die within 1 year
 30%–50% do not regain functional
independence
 Annual incidence rate of stroke in India
currently is 145 per 100,000 population
 10 - 15% occur in < 40 years
WHO estimates suggest that by 2050, 80% stroke
cases in the world would occur in low and middle
income countries mainly India and China

3. Endovascular
neurointerventions !!! Disease states different
 End- organ different- every area
important
 Reactive organ- reperfusion-
bleed
 Arteries different
 Access difficult- tortuosity

4. Neurointervention Cath Lab- Biplane
flat panel, 3D imaging, Road map,
Dyna CT
NEUROINTERVENTION EVOLUTION…….

5. Neurointerventions…
 SAH- aneurysms, vasospasm
 Intracerebral hemorrhage- AVMs
 TIA- major vessel stenosis E/C & I/C
 Stroke- revascularization
 Diagnosis- Imaging
 Interventional hardware
 Integrated approach

6. ANEURYSMS- basic facts
• Subarachnoid hemorrhage (SAH).
• One in every 20 strokes , at the
prime of ones life (commonly
between 40-50yrs).
• Up to 40-50% patients do not
survive even for a month mostly
because of the rerupture of the
aneurysm
• With proper treatment up to 90%
of patient who reach hospital
before any major damage has
happened will lead an independent
and productive life
Initial CT Scan
Rebleeding after 1 day

7. Clipping vs coiling…
Initially
 Surgically inappropriate
Tremendous changes in last 15-yrs
Cerebral Aneurysms-
• Image-guidance (3-D , Dyna-CT)
• Coil, catheter, balloons, stents
• Drugs- aspirin, clopidogrel, abciximab
• Appx. 90% by endovascular
• Intra-arterial vasospasm mgt.
• HELP and Cerecyte studies – mRS 0-2 in
87% (80% in ISAT)

8. ISAT
 Randomized,
prospective,
international trial
 Clipping vs coiling
 ISAT follow-up, Lancet 2014- at 9
yrs, outcome better
 Guidelines for the Management of Aneurysmal SAH: Special Writing
Group of the Stroke Council, ASA/AHA Stroke 2009
 Amenable to both endovascular coiling and neurosurgical
clipping, endovascular coiling can be beneficial (Class I, Level
of Evidence B).
Metanalysis- Stroke 2013, AJNR 2013
• Ruptured aneurysms- better outcomes
after endovascular management

10. 3 D

11. Balloon assisted coiling

12. Very small aneurysms

13. Stent assisted coiling

14. Flow diverters
(stents)- no coils

15. Vasospasm- 15-25% morbidity and mortality

17. Our protocol
 Interventionist part of neurosurgery
team
 DSA & if possible embolization
 Neuro lab with 3D, CT
 NS ICU monitoring (TCD/CTP).
 Vasospasm- IAVD
 N- 706 (Sept 2014)
 Data of consecutive patients

18. Our protocol
Embolization
Surgery
91%
9%
Good outcome
FND
Mortality
Mgt. outcome in good grade patients- 90 % mRS 0-2

19. CAROTID ARTERY STENOSIS-
20-25% STROKES BY MAJOR VESSEL
STENOSIS

20. Symptomatic StenosisSymptomatic Stenosis
• Non-invasive >70%Non-invasive >70%
• Catheter angiography >50%Catheter angiography >50%
• Peri-procedural risk <6%Peri-procedural risk <6%
Asymptomatic StenosisAsymptomatic Stenosis
• >70% Stenosis>70% Stenosis
• Periprocedural complication risk is lowPeriprocedural complication risk is low
• Life expectancy >5 yrLife expectancy >5 yr
• >80% stenosis- tend to be treated>80% stenosis- tend to be treated
Revascularization indications-Revascularization indications-
ASA/AHA guidelines 2011ASA/AHA guidelines 2011

22. Patient with TIAs…..stenting done the next day
Should be done as soon as possible…
maximum stroke risk in first few weeks

23. CAS vs CEA- CREST – NEJM 2011
•2502 patients- Outcome largely same
•More MI in surgery ; more minor strokes in CAS
•Stenting better in 70yrs and less age group
•Nerve palsies not included in end-points
•Less than 1% major stroke
ASA/AHA guidelines 2014-
Endarterectomy and stenting are alternatives (Class I evidence)
<70 yrs, stenting may be preferable

24. Intracranial atherosclerosis
 Intracranial arterial stenosis is responsible for 6% to
10% of ischemic strokes in whites and 22% to 26% of
ischemic strokes in Asians
SAMPRIS Trial- stenting not to be
done as routine in acute stroke
•Recurrent symptom
•Subocclusive stenosis

26. ISCHAEMIC stroke- brain attack
Penumbra
• At 60 min, about 90%
• At 2 h about 80 %
• At 3 h about 60% and
• At 4.5 h about 40% of
patients
 Thereafter ?
• Maybe 30% at 9 h
• And less than 20%
beyond 12 h

27. Issues with IV tPA
 Time factor
 Large vessel disease
 Time to recanalize
 C.I. – anti-coagulants, recent surgery, wake-up
strokes….
 < 5 % qualify

28. CT, CTA, CTP….
CT perfusion imaging
MTTCBF CBV
CBV – 2ml/gm- infarcted core;
CBF, MTT - hyoperfusion area

29. Concept of Penumbra
CBF/MTT CBV
Matched
No penumbra
CBF/MTT
CBV
penumbra
CTA & CTP vs MR DWI & PWI

30. PENUMBRA, 2007MERCI, 2004
STENTREIVERS- SOLITAIRE (2012), TREVO…..

32. Clinical … Left hemiplegia, left UL and LL 0/5
 5:14AM

33. 6:22AM

34. 8:07 AM
Patient made gradual recovery
Left LL 4/5 and UL 3/5 - 30 day
follow up mRS at 90 days- 0

35.  63 /M, AVR, Coumadin
 INR of 2.5
 RT hemiparesis - 2/5 in leg
and 0/5 in arm
 Global aphasia
CBF CBV
Solitaire stent was deployed

36. Evidence – 2014-2015
 IMS-III, MR RESCUE & Synthes – failed- no
appropriate imaging and old devices
 Recent trials – imaging for MVO & stent-
retreviers
 MR CLEAN – strongly positive
 ESCAPE – stopped bcs of efficacy
 EXTEND –IA – positive
DRAMATIC CHANGE IN MGT OF STROKE

37. Clinical-
 Bleeding
 Seizures
 Neurological deficit
 Headaches
 Incidental
Cerebral ArteriovenousCerebral Arteriovenous
malformationsmalformations

38. AVM- treatment options
 Embolization
 Radiosurgery (Gamma Knife, LINAC,
Cyberknife)
 Surgery
Embolization
Glue (NBCA) vs Onyx embolization

44. Conclusion
 Advances in Neuroimaging and
neurointervention
 Critical role in mgt of SAH-
aneurysm, Acute stroke, TIA-
carotid stenosis, ICH-AVMs
 Latest trials have proven the
role in acute stroke
 Neurointerventionist,
neurologist, neurosurgeon and
radiologist as a team

45. STROKE AND NEUROVASCULAR
INTERVENTION FOUNDATION
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 RG Singh, Sachin Bhawsar

46. Thank you