This document discusses recent advances in neurointerventional treatment of hemorrhagic and ischemic stroke. It summarizes treatments for aneurysms, carotid artery stenosis, intracranial atherosclerosis, and cerebral arteriovenous malformations. Endovascular coiling is now the primary treatment for aneurysms in over 90% of cases. For carotid artery stenosis, stenting and endarterectomy are considered equivalent treatment options. Mechanical thrombectomy devices have improved recanalization rates for large vessel occlusions in acute ischemic stroke compared to intravenous thrombolysis alone. A multidisciplinary team approach including neurointervention, neurosurgery, and neurocritical care is emphasized.
Neurointerventional Therapy for Brain Aneurysms and Acute Stroke Allina Health
By Yasha Kadkhodayan, MD. Overview of interventional neuroradiology approaches to brain aneurysm and stroke care, discussion of processes in place at Abbott Northwestern to enhance the delivery of stroke care.
Neurointerventional Therapy for Brain Aneurysms and Acute Stroke Allina Health
By Yasha Kadkhodayan, MD. Overview of interventional neuroradiology approaches to brain aneurysm and stroke care, discussion of processes in place at Abbott Northwestern to enhance the delivery of stroke care.
Mechanical thrombectomy for acute ischemic stroke (temporary stroke) is a minimally invasive endovascular procedure to remove blood clots from larger vessels in the brain.
Who is it recommended for?
Mechanical thrombectomy is indicated for patients who:
1. Had an Acute ischemic stroke due to LAO
2. Has failed intravenous thrombolysis
3. Have temporarily or permanent disabilities with the the below mentioned.
Complications:
a. Paralysis or loss of movement in muscles
b. Difficulty when talking or swallowing
c. Memory loss or difficulty in processing thoughts, reasoning or making decisions/judgements
d. Pain or numbness in affected parts
e. Change in moods, behaviour and self-care ability.
However, consulting physicians and surgeons decide if Mechanical thrombectomy for Acute Ischemic (temporary) Stroke is a suitable option for the patient. The decision is made based on various factors, such as age, severity of the stroke, time and test results. Eligible patients should receive intravenous alteplase without delay even if mechanical thrombectomy is being considered.
Recovery after Mechanical thrombectomy:
Recovery of the patient depends on:
1. Overall condition
2. Severity of the stroke
3. Severity of the symptoms
Patients are seen usually walking within 24 hours.of the procedure, but if the injury is severe then doctors recommend a couple of days rest with physiotherapy and rehabilitation.
Benefits of Mechanical thrombectomy for acute ischemic stroke are:
1. Greater Efficacy
2. Cost Effective
3. Larger Treatment window (up to 24 hours)
4. Short Hospital stay and rehabilitation
Mechanical thrombectomy for acute ischemic stroke (temporary stroke) is a minimally invasive endovascular procedure to remove blood clots from larger vessels in the brain.
Mechanical thrombectomy for acute ischemic stroke (temporary stroke) is a minimally invasive endovascular procedure to remove blood clots from larger vessels in the brain.
Who is it recommended for?
Mechanical thrombectomy is indicated for patients who:
1. Had an Acute ischemic stroke due to LAO
2. Has failed intravenous thrombolysis
3. Have temporarily or permanent disabilities with the the below mentioned.
Complications:
a. Paralysis or loss of movement in muscles
b. Difficulty when talking or swallowing
c. Memory loss or difficulty in processing thoughts, reasoning or making decisions/judgements
d. Pain or numbness in affected parts
e. Change in moods, behaviour and self-care ability.
However, consulting physicians and surgeons decide if Mechanical thrombectomy for Acute Ischemic (temporary) Stroke is a suitable option for the patient. The decision is made based on various factors, such as age, severity of the stroke, time and test results. Eligible patients should receive intravenous alteplase without delay even if mechanical thrombectomy is being considered.
Recovery after Mechanical thrombectomy:
Recovery of the patient depends on:
1. Overall condition
2. Severity of the stroke
3. Severity of the symptoms
Patients are seen usually walking within 24 hours.of the procedure, but if the injury is severe then doctors recommend a couple of days rest with physiotherapy and rehabilitation.
Benefits of Mechanical thrombectomy for acute ischemic stroke are:
1. Greater Efficacy
2. Cost Effective
3. Larger Treatment window (up to 24 hours)
4. Short Hospital stay and rehabilitation
Mechanical thrombectomy for acute ischemic stroke (temporary stroke) is a minimally invasive endovascular procedure to remove blood clots from larger vessels in the brain.
Terapi Endovaskuler, Standar Baru Manajemen Stroke Iskemik Akut? Ersifa Fatimah
Konon, plenary pertama International Stroke Conference (ISC) 2015 yang digelar di Nashville, Tennessee bulan Februari lalu merupakan sesi ISC terseru selama beberapa tahun terakhir. Sebagaimana diberitakan dalam Medscape (Hughes, 2015), para presenter terpaksa memberi jeda beberapa saat untuk menyambut applause dari audiens. Suatu kejadian langka dalam partemuan saintifik. Adalah MR CLEAN, ESCAPE, EXTEND-IA, dan SWIFT PRIME yang menjadi topik hangat lantaran keempat studi ini dirilis dengan hasil yang positif dramatis hingga diprediksi bakal menjadikan terapi endovascular sebagai standar baru dalam manajemen stroke iskemik akut. Sehebat apakah 4 studi yang “menyejarah” dalam tatalaksana stroke iskemik akut ini? Bagaimana bila studi-studi ini diadopsi dan diaplikasikan dalam praktik sehari-hari di sentra kita?
Note: Esai ini ditulis saat SWIFT PRIME fulltext belum published (akhir Maret-awal April 2015). Update & beberapa revisi dibuat menjelang presentasi tanggal 18 Mei 2015.
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"Revolutionizing Stroke Care: Endovascular Therapy and Neuro Intervention in Acute Ischemic Stroke with Dr. Ganesh"
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CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
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Navigating the Health Insurance Market_ Understanding Trends and Options.pdfEnterprise Wired
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Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
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How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
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Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
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QA Paediatric dentistry department, Hospital Melaka 2020Azreen Aj
QA study - To improve the 6th monthly recall rate post-comprehensive dental treatment under general anaesthesia in paediatric dentistry department, Hospital Melaka
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
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
7. 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
8. 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)
23. Day 6 Confused, slightly weak on right side
CT perfusion for vasospasm mgt
24. Day 7
Continuous intra-arterial dilatation
Continuous Intra-arterial Dilatation With Nimodipine and Milrinone for Refractory Cerebral Vasospasm.
Anand S, Goel G, Gupta V.
J Neurosurg Anesthesiol. 2013 Jun 14. [Epub ahead of print]
25. ISAT Randomized, prospective,
international trial
Clipping vs coiling
9559 patients screened,
2143 randomized
at 1 year, the difference
in the risk of dependency
or death between the two
groups was 6.9% and the
relative risk reduction was
22.6% (in the coiling
group)
ISAT follow-up, Lancet 2009- death at 5 years lower
The Barrow Ruptured Aneurysm Trial
Compared clipping vs coiling in SAH patients.
Poor outcome - 33.7% in clipping vs 23.2% in coiling
26. Guidelines for the Management of Aneurysmal SAH: SpecialWriting
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
27. Our protocol
Interventionist part of
neurosurgery team
DSA & if possible
embolization
Neuro labwith 3D, CT
NS ICU monitoring
(TCD/CTP).
Vasospasm- IAVD
N- 540 (Jan 2014)
Embolization
Surgery
91%
9%
Good outcome
FND
Mortality
Mgt. outcome in good grade patients- 90 % mRS 0-2
(Submitted for publication)
32. Patient with recurrent TIAs…..stenting done the
next day
Should be done as soon as
possible…maximum stroke risk in first few
weeks
33. 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 2011-
Endarterectomy and stenting are alternatives
(Class I evidence)
Early intervention is advisable
34. Pivotal randomized trials
Issues-
Use of embolic protection devices
Lead in/training phase/experience required
MI as point of evaluation
Cranial nerve injuries and local complications
35. Long-term mortality
after peri-
procedural events:
No association with
minor stroke, but
strong association
of MI
Neurological Residual
Deficit Rates by NIHSS
Associated with Minor
Strokes, Equal at 6 months
37. Treatment protocol at Medanta
Active endovascular (INR)- 50/year- mostly
symptomatic; Cardiology – 20/year
Active endarterectomy (CTVS,VS)- 80-90/many
incidental combined with CABG
We offer both options - thrombus, excessive
tortuosity/kinking, diffuse disease- send to CEA
“It is not the procedure but expertise matters”
38. 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
39.
40. ISCHAEMIC stroke- brain attack
Intravenous
thrombolysis
*Time limitation-
<3-4.5 hrs
• Not effective in large
vessel occlusion
• Many contraindications
Role of I/A therapy
Chemical thrombolysis
Mechanical
recanalization
42. Issues with IV tPA
Time factor (<4.5 hrs)
C.I. – anti-coagulants, recent surgery, wake-up
strokes….
<10% eligible
Large vessel disease
Time to recanalize
43. •Distal MCA – 44%
•Proximal MCA - 30%
•Terminal ICA - 6%
•Tandem cervical ICA/MCA -27%
•Basilar artery- 30%
Prerecombinant tissue plasminogen activator, National Institutes of
Health Stroke Scale score, systolic blood pressure, glucose, and
Thrombolysis in Brain Ischemia flow grade at the occlusion site were
the negative independent predictors for complete recanalization in the
final model.
44. • 53 studies, 2066 patients
• Sp.- 24%, IV tPA- 46%, IA- 64%, Mechanical- 84%
• Good outcome more in recanalized patients (OR- 4.4)
• Less mortality in recanalized patients
48. •68/M, DM, HTN, CAD, underwent PTCA to
LAD
•Admitted for surgery of aortic
stenosis.
•Double anti-platelets was stopped
•Patient developed acute onset right
side weakness with aphasia.
IV- tPA given, no improvement
49.
50. Procedure time 28-minutes
Patient made complete neurological recovery next day
51. Case 2
41 y.o. male
Stroke in sleep
Left sided weakness with facial palsy
NIHSS 14
Last well seen at 10:30 PM
Presented to emergency at 5:08 AM (six and half hours after)
55. Patient made gradual recovery
Left LL 4/5 and UL 3/5
Improved by 30 day follow up
56.
57.
58. Results
Total No. of patients= 42 (M-19, F- 23)
Time of arrival: 30 min- 840 min (mean 203.8 minutes)
NIHSS at admission: 5-22 (Mean 14.33)
MVO 39, IV tPA- 19
Good recanalization(TICI 2b or 3) in 57.1%
mRS 0-2 =52.3%, 3-5 = 34.4%, 6 = 9.5%)
Recanalization V/s Outcome
59. Mechanical recanalization in acute stroke
LVO, IV tPA C.I./not -effective
Stent retrievers – good recanalization; < 1-hr
Case selection and speed are crucial
Previous trials failed (older devices, delay, case
selection)
IMS III – subanalysis- CTA guided cases-
significant benefit
Many randomized trials going on…..answer in
few years
61. AVM- treatment options
Embolization
Radiosurgery (GK, LINAC, Cyberknife)- Dr Aditya Gupta
Surgery – Dr AN Jha, Dr Aditya Gupta
Embolization
Glue (NBCA) vs Onyx embolization
74. STROKE AND NEUROVASCULAR
INTERVENTIONS FOUNDATION
Newsletter
Interesting case studies via social media
Updates regarding treatment protocols
Stroke training course for physicians
Advanced stroke and neurointervention
simulator courses
You tube channel
Opinion regarding cases via tablets/smart
phones