Interventional neurology is one of the leading and most fascinating division in the field of neurosciences. Interventional neurologists make use of image-guided, minimally invasive techniques to treat the complex and life-threatening diseases of the brain and spinal cord. These procedures are carried out in Cath lab under fluoro-guidance. The reason this field is getting so much attention is because it has completely changed the traditional norms of acute stroke treatment both ischemic and hemorrhagic type. With the advance in Interventional neurology, now doctors can perform highly complex surgeries without opening the brain through a small hole or cut in the femoral or radial artery. Procedures done by the interventional neurologists include:
• Stroke thrombectomy (removing clot from occluded brain vessel)
• Carotid stenting (opening narrowed and occluded blood vessels in neck and brain)
• Aneurysm Coiling including balloon and stent assisted procedures (occluding outpouching in the brain vessels)
• Flow-diverter stenting
• AVM and DAVF embolization in brain and spinal cord (occluding abnormal connection between arterial and venous circulation)
• Tumour embolization (to reduce blood flow before open surgery)
• Cerebral venous sinus thrombectomy (removing clot from large venous sinuses in brain)
• Cerebral venous sinus stenting
• Balloon test occlusion
• Facial AVMs etc.
ACUTE STROKE TREATMENT
Stroke is a ‘brain attack’, which suddenly strikes a part of, or whole of the brain causing sudden loss of function. A stroke is caused either due to a blood clot in a blood vessel to the brain or due to rupture of the blood vessel causing leakage of blood into the brain.
Every second lost can increase the life threatening Complications or chances of fatality. So, the need is to be quick and recognize to BE FAST
• Balance problems/dizziness?
• Eye problem like double vision or blurred vision?
• Is the Face drooping to one side?
• Can both Arms be raised?
• Is there Speech slurring?
• Then it is Time to call the ambulance
The 3 Cornerstones for Complete Recovery Are:
1. Identifying the warning signs
2. Rushing to the hospital within the golden window
3. Choosing the right medical facility with experienced and specialized doctors.
The moment one identifies a stroke, it is critical to choose an appropriate hospital, one that is fully capable of treating the stroke patient called A Stroke Ready Hospital/Comprehensive stroke Center. The ambulance should be manned by a trained team of paramedics and/or a doctor, who in real time will alert the Stroke team headed by the Stroke Physician.
On arrival, doctors use sophisticated imaging tools like multi-modal MRI or CT Brain and in some case (extended window patients beyond 6 hours of stroke onset) with perfusion imaging and select patients who will benefit from advanced clot busting or clot retrieval procedures using hyper-acute stroke pathways. Clot dissolving medication is infused into the vein to dissolve brain vessel clots to restore the flow.
Newer interventional treatments like the Clot retrieval procedures are done for large clots, too big to be dissolved by intravenous thrombolytics. They may also be done for clots in certain larger vessels. In what is also called mechanical thrombectomy, doctors thread a catheter through an artery in the groin up to the blocked artery in the brain. The stent opens and grabs the clot, allowing doctors to remove the stent with the trapped clot.
Mechanical retrieval can help patients upto 24 hours from the onset. However, the outcomes are best when done as soon as stroke strikes, so it is urgent to rush to a hyper-acute stroke centre as early as possible. Mechanical clot retrieval can also help where clot buster is deferred for various medical reasons.
After treatment the patient recovers in the” Stroke Unit” (a ward that cares almost exclusively for stroke patients) throughout their inpatient stay. Stroke unit also has few special Stroke ICU beds equipped with round the clock monitoring and stringent infection control. Stroke unit is run by stroke team which includes an interventional neurologist, neurologist, neurosurgeon, anesthesiologist and intensive care specialist, specialized stroke nurse, speech and swallow therapist, physiotherapist, occupation therapy, clinical psychologist and social worker.
Stroke units reduce death and disability through the provision of specialist multidisciplinary care for diagnosis, emergency treatments, normalization of homeostasis, prevention of complications, rehabilitation and secondary prevention. A standard patient pathway should include assessment of:
• neurological impairment
• vascular risk factors
• fluid balance and nutrition
• cognitive function
• mood disorders
• activities of daily living and rehabilitation goals
Intense rehabilitation is started almost immediately. Sophisticated equipment like the Robotic rehabilitation helps in efficient recovery of function of the limbs.
Good communication and shared decision making with patients and their families are key to high-quality stroke care. Patients with mild or moderate disability, who are medically stable, can continue rehabilitation at home with early supported discharge teams rather than needing a prolonged stay in hospital.