endovascular neurosurgery

1. Endovascular neurosurgery
By
Dr.Usman haqqani

2. • Endovasular Neurosurgery (Interventional
Neuroradiology) is a subspecialty of
radiology and neurousurgery in which
minimally invasive procedures are
performed using image guidance.

3. • Endovascular techniques are used to treat
– Cerebral aneurysm
– arteriovenous malformation (AVM)
– tumor embolization
– severesymptomatic vasospasm after
subarachnoid hemorrhage (SAH)

4. • Clinical trials have established benefit of
– intra-arterial thrombolysis (IAT) up to 6
hours after stroke symptom onset
– Mechanical revascularization therapy up to 8
hours after stroke symptom onset.

5. procedure

6. • The groin is prepared and draped
• The femoral pulse is palpated at the inguinal
crease, and local anesthesia is administered
• 5-mm incision is made parallel to the inguinal
crease.
• A Potts needle pointing to the patient’s opposite
shoulder.
• A J-wire is gently advanced through the needle
for 8 to 10 cm.
• The needle is exchanged for a regular 5-French
(F) 10-cm sheath that is secured with a silk stitch

7. • Guide catheters is advanced over guide
wire.
• The tip of the wire is observed under direct
fluoroscopic visualization.
• Slow twisting movements of the wire are
carried (observing the tip of the wire).

8. • Roadmapping (superpositioning of
previous contrast angiographic images
with “live” or real-time fluoroscopic
images) is done.

9. ISCHEMIC STROKE INTERVENTION
• Stroke remains the third most common cause of death in
industrialized nations and the single most common
reason for permanent adult disability
• consider of IV t-PA therapy 3 to 4.5 hours after stroke
symptom onset
• Early reocclusion following thrombolysis has been
demonstrated by transcranial Doppler imaging to occur
in 34% of patients receiving IV t-PA
• IV thrombolysis (IVT) is not as effective in
thromboembolic obstruction of large, proximal vessels,
as compared with more distal smaller vessels.

10. Mechanical
• candidates for endovascular
revascularization therapies currently
– Patients who do not meet the eligibility criteria for
thrombolytic therapy
– who fail to improve neurologically
– patients with reocclusion
• trials established a benefit of intra-arterial
thrombolysis (IAT) up to 6 to 8 hours after stroke
symptom onset, with an increase in
recanalization rates.

11. • The Merci retriever system has a flexible nitinol wire that assumes a
helical shape once it emerges from the tip of the microcatheter.
• A microcatheter containing this wire is passed distal to the
thrombus, the catheter is withdrawn, and the wire, in its helical
configuration, ensnares the clot for removal from the vasculature.

12. • Vessels amenable to embolectomy with the Merci device include the
– ICA
– M1 and M2 segments of the MCA
– VA, basilar artery
– posterior cerebral artery.
• The retriever is then retracted into the guide catheter under proximal flow
arrest.

15. • The Penumbra System
– The system primarily involves clot aspiration
using a microcatheter attached to a powered
aspiration pump that is capable of producing
25 mm Hg of suction.

16. • Despite aggressive revascularization with
mechanical therapies, only up to 45% of
patients recover to an mRS score of 0 to 2
at 3 months, and there is approximately an
8% to 10% procedure-related risk of
symptomatic ICH, a potentially detrimental
complication

17. Aneurysm intervention
• The incidence of aneurysmal subarachnoid
hemorrhage (SAH) is between 10 and 15 per
100,000 people per year.
• Endovascular treatment of intracranial
aneurysms has undergone multiple changes
since the introduction of Guglielmi detachable
coils for endosaccular occlusion of these
aneurysms in 1994.

18. • Observations of aneurysm recanalization after treatment
with bare platinum coils led to the introduction of coils
containing materials meant to enhance fibrosis within the
aneurysm and decrease the chance of recanalization.
Several “bioactive” coil systems are on the market
currently; some contain polyglycolic-polylactic acid
(PGLA) while others contain hydrogel.

19. • Using roadmapping, the microwire and
microcatheter are advanced to the target
vessel.
• tip of the microcatheter is initialy placed at
the neck of the aneurysm to allow the coil
to assume its spherical shape.

20. • Balloon-Assisted Coil Embolization
– It is the use of balloons to occlude the aneurysm neck
during coiling of wide-necked aneurysms

21. • trans-stent coiling
– the stent is placed across the neck of the
aneurysm and coil embolization is performed
after manipulation of a microcatheter. Trans-
stent coiling may be performed at the time of
the initial procedure or during a second
procedure (“staged technique”), typically 4 to
8 weeks after stenting.

23. • Y-stent
– This technique is most commonly used for
bifurcation aneurysms arising from the basilar
tip or carotid terminus.

24. Waffle-Cone Technique

25. Flow diverter
• Flow diverter is a kind of stent which can
be used with out use of coils.

26. Coiling of aneurysm:
Following diagrams show how aneurysm coiling is done
Coil mass inside aneurysm
prevents blood from
entering it

27. Coiling or Clipping?
Morbidity and Mortality:
ISAT TRIAL (for ruptured aneurysms): Dead or dependent at one year-
•
•
Surgical group: 30.6% patients were dead or dependent at one year
Endovascular group: 23.7% of patients were dead or dependent at one year
ISUIA trial (for unruptured aneurysms) Death and dependency at 1
year:
•
•
Surgical group: The 1-year morbidity and mortality rate
was 12.2%, and the mortality rate was 2.3%.
Endovascular treatment: The 1-year total morbidity
and mortality rates were 9.5% and 3.1%, respectively.