stroke and neurovascular interventions foundation

8/10/2019 Stroke and Neurovascular Interventions Foundation

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An Init iative of

Stroke and Neurovascular Interventions Foundation

Creating Stroke Awareness

Stroke and

Neurovascular Interventions


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Story telling by AL Services
http://www.alservices.in/http://www.alservices.in/


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Table of Contents

Stroke-An Infographic

1. About Stroke & Neurovascular Intervenons Foundaon

2. Stroke and Neurointervenon FAQ

3. Diseases & Treatments

4. Paent Stories

5. The Team

- The Founders Story

- Member Profiles

6 Annexures

- Media Gallery

- Useful Resources & Links

- Foundaon Brochure

Contact Us

d


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A stroke occurs when

blood flow to the brain is

blocked by clots in the

blood vessels or because

of a weakened blood

vessel rupturing bleeding

into the brain.

Dizziness

Difficulty walking, loss of walking l Sudden amnesia, mental impairment

Trouble speaking or understanding l Problems in one or both eyes l Intense, unexplained headache

Sudden ngling, numbness or weakness of the face, arm or leg, especially on one side of the body

WARNING SIGNS

STROKEO

FBAD

HEALTH

15mnpeople worldwide suffer a stroke each yeardie of stroke annually

are le permanently disabled

recover or funconally disabled

6.15mn

5mn

3.85mn

High blood pressure,high cholesterol and

triglycerides (blood fats),smoking, drinking alcohol,

physical inacvity, abdominalobesity (stomach fat), heart

disease, poor andover nutrion, diabetes,

and psychosocial stressors.

RIS

KFACTORS

TEST

MRI scan of the brainto show areas of braindamage due to lack of

blood flow.

Angiogram to evaluate thecalibre and patency(the condion of being open or unobstructed)

of the arteries in the neckand the brain.

A stroke is an emergency.

Take the paent to a hospital emergency at once.

Do not wait for the symptoms to improve

or waste me going to a neighbourhood clinic.

While waing for medical aenon, paents who are drowsy,

unresponsive or voming should be turned on their side toprevent them from choking on their tongue or vomit.

www.neurointervenonindia.com

www.facebook.com/NeurointervenonGurgaon

Stroke-An Infographic


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About Stroke & Neurovascular Interventions Foundation

On 29th October, all across the globe World Stroke Day is observed by various healthcare

instutes, organizaons and medical professionals by conducng different events, edu-

cang, and raising awareness among masses to minimize the death and disability caused

due to stroke. In 2010, stroke was declared as a public health emergency by World Stroke

Organizaon (WSO).

Dr. Vipul Gupta Head, Neurointervenonal Surgery, Medanta The Medicity along with

his colleagues have formed STROKE AND NEUROVASCULAR INTERVENTIONS FOUNDA-

TION to impart public educaon and increase awareness among common man and gen-

eral physicians for prevenon and treatment in stroke. The effort will be made to train

and empower the physicians to handle a medical emergency like stroke. The early treat -

ment is crical because at that stage the stroke may be reversible or the damage can be

limited. Every minute if stroke is untreated, the average paent loses 1.9 million (19

Lakh) neurons (brain cells).

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Every year millions of people become vicm of stroke. It is considered to be the third

most common cause of death and disability. The stascs states that one in six people

will have stroke in their lifeme and this toll will increase with flow of me, in countries

like India due to changing lifestyle, urbanizaon, stress, smoking, salt/alcohol intake.

However with the help of modern methods of minimally invasive neuro intervenon

techniques have revoluonized the treatment of carod stenosis, acute strokes, brain

aneurysm and AVMs many paents can achieve a complete recovery and lead a normal

life if they are detected early.

The prime focus of this foundaon is to educate masses through different media plat-

forms like WhatsApp, Facebook, Youtube and also through a special applicaon for

stroke. Along with this collaborave program with other agencies and training program

for healthcare professionals will also be part of its curriculum.

Dr. Vipul says; The increase in numbers of deaths due to stroke is majorly due to lack of

awareness. Therefore the foundaon will be helping the people and communies to

recognize the symptoms of stroke and prevent it from its consequences. Dr Gupta clari-

fies with early symptoms of stroke named as FAST that can help you to recognize the

stroke and could save you from further consequences. Here F stands for face drooping,

second A that stands for weakness in arms, then S reminds the sign of difficulty in

speaking and Tis for me to call for hospital emergency. Apart from these four there are

symptoms, which are beyond FAST includes trouble in understanding, severe

headache, dizziness, numbness in leg.Once the symptoms are recognized person shouldbe immediately taken to hospital parcularly stroke centres, where could be given a

stroke treatment.


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He further explains; If paent comes in first few hours (4.5 hrs), clot busng drug (t-PA)

cab be given. Blood vessel can also be opened by intervenon technique. Neurointer-

venonist goes through leg blood vessel and by special devices can take out the clot to

restore the blood flow, helping brain to recover. The intervenon can be done upto

8-hours and by these modern treatment methods paents have beer chances to recov-

er aer stroke.

The foundaon also highlights the prevenon from risk factors of stroke such as 80% of

strokes can be prevented by following seven simple ways by geng physically acve,healthy eang habits, saying no to smoking, controlling blood sugar levels, lowering cho-

lesterol and shedding out excess weight through regular exercise.


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Stroke and Neurointervention FAQ

How these techniques help in early treatment of stroke?

When a person suffers from stroke, some brain cells die immediately but the surround-

ing ssue can sll be revived. This zone which is called as penumbra is supplied with

blood that keeps these cells alive, although it is not enough for them to perform the

funcon. By giving IV t-PA drug or through neuro-intervenonal techniques, the blood

supply to the penumbra zone can be restored thereby aiding in the recovery from

stroke.

What are the risk factors involved? Are there any health complications

associated with it?

These procedures carry a small risk of bleeding in the brain, but studies have shown that

the overall rate of survival paents or recovery with these treatment methods is farbeer.

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How effective are these techniques in dealing with stroke?

It is dependent on the severity of the condion and the treatment that is employed to

treat the paent. Based on the selecon criteria (that depends on many factors), the

paents are selected for treatment. And among the selected ones, around 50% of thepaents have a good chance of recovery.

What is the cost of the treatment ?

The intravenous ssue type plasminogen acvator (IVtPA) procedure used to treat stroke

costs around 50-90 thousand, while intervenon techniques cost about Rs. 2 lakhs.

Videos

hps://www.youtube.com/watch?v=zRVw5-tqSKY

hps://www.youtube.com/watch?v=7sgULgi8IIE


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Diseases and Treatments

This chapter covers 5 major areas viz. Aneurysm, Carod Artery Stenosis, Stroke,

Thrombolysis in acute stroke and Arteriovenous malformaon.

To check out case studies, procedure videos, paent tesmonials

visit the website www.neurointervenonindia.com

ANEURYSM

CAROTID

ARTERY

STENOSIS

STROKE /

BRAIN ATTACK

THROMBOLYSIS

IN ACUTE

STROKE

ARTERIOVENOUS

MALFORMATION

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Aneurysm

What are intracranial aneurysms?

Intracranial aneurysms are localized pathological dilataons of cerebral arteries. Most

intracranial aneurysms are saccular or berry aneurysms, whereas dissecng, fusiform,

infecous, traumac, and oncoc aneurysms are much rarer. Saccular, or berry aneu-

rysms, correspond to lobulated focal outpouchings of the wall of the arteries of the circle

of Willis. Current opinions suppose that intracranial aneurysms result from a combina-

on of hemodynamic stresses and acquired degenerave changes within the arterial

wall.

How does aneurysm presents?

Aneurysms may present as

Rupture of the weak wall of such aneurysms mainly resulng in subarachnoid haemorrhage (SAH),

experienced as ''the worst headache of life'' by paents.

Mass effect, causing cranial nerve symptoms

Asymptomac, incidentally detected during imaging done for other reasons

It is accepted that about 3% to 5% of the populaon harbour an intracranial aneurysm.

One in every 20 strokes is caused by subarachnoid hemorrhage from rupture of intra-

cranial aneurysm,

Because the disease strikes a fairly young age and is oen fatal the loss of producvelife years is similar to that for cerebral infarcon or intra cerebral hemorrhage

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What are complicaons of SAH?

Many paents don't survive inial hemorrhage or suffer significant brain injury due to

the haemorrhage. Those who survive have high chance of repeat bleeding which can be

fatal in as high as 70-80% of cases. Even if the aneurysm is repaired before rebleeding,

15% of paents who survive the inial hemorrhage develop ischemic strokes or die from

the development of cerebral vasospasm. Non-Neurological Complicaons oen occur in

paents with SAH. These include fever, anemia, hypertension and hypotension, hyper-

glycemia, hypernatremia/hyponatremia, hypomagnesaemia, cardiac failure and arrhyth-

mias, and pulmonary edema and pneumonia. Therefore these paents needs intensive

care management so as avoid and mange such problems.

What are complicaons of SAH?

CT scan should be performed in suspected SAH. However, CT can be negave in some

cases parcularly if it is done few days aer the event.

Although MR is quite sensive if performed appropriately and interpreted by an experi-

enced radiologist, SAH is frequently missed.

Selecve cerebral angiography should be performed in paents with SAH to document

the presence and anatomic features of aneurysms.

MR angiography or CT angiography may be considered when convenonal angiographycannot be performed in a mely fashion.

What Are Management Recommendaons?

SAH is a medical emergency that is frequently misdiagnosed. A high level of suspicion for

SAH should exist in paents with acute onset of severe headache. Paent of SAH are tobe managed in ICU with good neuroanaesthec support and management. Early aneu-

rysm treatment should be performed to prevent repeat bleeding.


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Surgery (clipping) vs embolizaon (coiling)

Surgery has been the convenonal method of aneurysm treat-

ment. Surgery entails direct exposure of the aneurysm, the parent

vessel(s) and surrounding structures. The aneurysm is then

secured by the placement of a metallic clip along the neck thereby

excluding it from the circulaon. Problems with surgery include

invasiveness and trauma to normal brain parenchyma.

What Are Management Recommendaons?

Other treatment opon is of endovascular embolizaon (coiling)

of Aneurysms. In this treatment a microcatheter is placed from

one of the leg arteries in to the aneurysm, which is then occluded

with coils (usually detachable planum coils) so as to prevent

repeat bleeding. Advantages: Since coiling is a minimally invasive

technique it is less likely to result in injury to brain parenchyma.

It is associated with Internaonal Subarachnoid Aneurysm Trial

Study (ISAT)

Randomized, prospecve, internaonal controlled trial Compared policy of neurosurgi-

cal clipping with a policy of endovascular treatment in aneurysms deemed suitable for

either therapy.

9559 paents screened, 2143 (22.4%) were randomized and the difference in the risk ofdependency or death between the two groups was compared.

SURGICAL CLIPPING

COILING OF ANEURYSM


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Results: at 1 year, the outcome was much beer in the coiling group with relave risk

reducon of 22.6% as compared to surgical paents. The early survival advantage was

maintained for up to 7-years.

The risk of epilepsy was substanally lower in paents allocated to endovascular treat-

ment. The risk of late rebleeding was minimally higher (0.16%). The beer outcome in

coiling group was inspite of minimally increased risk of rebleeding.

According to recent American Stroke Associaon Guidelines- if both clipping and coiling

are possible, coiling is preferable over surgery

Are broad neck aneurysms amenable for coiling?

Most of the broad neck aneurysms can be treated by coiling, with use of 3D and complex

coils. These coils are stable even in broad neck aneurysms.

Some cases require balloon assistance or stent placement

Balloon assisted coiling for broad neck aneurysm- concept- a balloon is inflated tempo-rarily at the neck of the aneurysm to hold the coils

Stent assisted coiling of broad neck aneurysm- a stent is

placed across the neck of a broad neck aneurysm so as to hold

the coils and reconstruct the artery

COILING OF BROAD NECK ANEURYSM WITH COMPLEX COIL

BALLOON ASSISTED COILING

STENT ASSISTED COILING


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Carotid Artery Stenosis

What is the role of carod artery in stroke?

Stroke is third most common cause of death and disability. According to WHO Survey in

1990, out of 9.4 million deaths in India 6,19,000 were due to stroke. Most of the strokes

(approximately 75%) are ischameic in nature and large vessel disease accounts for

approximately 40% of ischaemic strokes. It has been esmated that approximately

20-30% of strokes may be caused by stenosis of carod artery.

What are the various means to diagnose Carod Artery Stenosis?

Carod Doppler- is a non-invasive & accurate modality to assess carod stenosis.

MR angiography (MRA)/CT angiography (CTA) - excellent quality imaging of carod

artery can be done by these relavely non-invasive methods.

Digital subtracon angiography (DSA)is the "Gold standard", however it is an invasive

invesgaon and is usually reserved to evaluate stenosis detected in non-invasive inves-

gaons as well when the non-invasive invesgaons are non-conclusive.

What are the treatment opons in Carod Artery Stenosis?

Medical treatment is done for the risk factors for atherosclerosis such as hypertension,

diabetes mellitus & dyslipidemia . Paents are also told to stop smoking. An-platelet

drugs (Dispirin, clopidogrel) are useful to prevent embolic events. Paents with marked

stenosis require revascularizaon which can be achieved by surgical (endarterectomy) orendovascular (angioplasty & stenng) means.


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What are the indicaons for carod revascularizaon (stenng/ endarterectomy)?

Carod stenosis more than 70%- should be revascularized

Carod stenosis (50%-69%)- Revascularizaon is recommended for paents who have

had recent transient ischaemic aack or stroke depending upon paent-specific factors

such as age, gender, co morbidies, and severity of inial symptoms

Carod stenosis less than 50%- No benefit of surgery is demonstrated in these paents

Asymptomac carod stenosis - Treatment of asymptomac carod stenosis is more

controversial. The guidelines indicate that paents benefit from treatment if the opera-

tor has a low complicaon rate.

How does carod stenng compare to surgical endarterectomy?

Paents who have coexisng medical problems or advanced age (>80) are beer suited

for stenng rather than endarterectomy. Paents having certain anatomical features

such as prior ipsilateral endarterectomy, prior neck irradiaon, contralateral internal

carod artery (ICA) occlusion & high cervical stenosis are also beer suited for stenng

as compared to endarterectomy.

Paents with marked tortuosity of the common carod artery and ICA or contraindica-

ons to an-platelet therapy may not be suitable candidates for endovascular therapy

What is a protecon device and what is its role in carod stenng?

Filter protecon devices are umbrella-shaped devices that are placed temporarily in the

internal carod artery beyond the site of stenosis during the procedure. These devices

have small pores designed to exclude parculate debris embolizaon to cranial circula-on during the procedure.

f h l h b l d l b


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Can stenosis of other cranial arteries such as vertebral and intracranial arteries be

treated?

Many cases of stroke occur due to stenosis in vertebral & intracranial atheroscleroc

disease. Recent studies have shown that these paents with intracranial stenosis have

high risk of stroke in spite of medical treatment. Recent advances in technology has

made angioplasty and stenng possible in these paents


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Stroke / Brain Attack

What is stroke (brain aack) and why should I know about it?

A stroke occurs due to brain damage because of decrease in blood supply to brain

because of a blockage in the blood vessel feeding the brain. Somemes it occurs when a

blood vessel bursts, leading to bleeding in the brain. Just as heart aack which occurs

due to decrease in blood supply to heart, stroke is a very serious condion and is also

referred to as "brain aack".

Is stroke (brain aack) an emergency?

If treatment is not started early enough in a brain aack paent, brain damage may be

very severe. New treatments are available which can significantly reduce the damage.

However, these treatments work best soon aer the brain aack

What causes stroke (brain aack)?

Brain aack is of two types-

"Ischaemic" brain aack is caused by decreased supply to brain due to blockage of

artery supplying blood to the brain. This blockage may occur because of clot forming

somewhere n the body floang into brain arteries and causing obstrucon. It can also

occur because of narrowing in the arteries giving blood supply to the brain.

"Haemorrhagic" brain aackoccurs due to bleeding in the brain due to hypertension,

rupture of aneurysms (areas of swelling in the blood vessels), vascular malformaons(areas of malformed blood vessels with increased flow in them) and many other causes.

Wh t th i k f t f t k (B i k)?


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What are the risk factors of stroke (Brain aack)?

Risk factors which one can't modify

Age-older you are, higher is the risk

Gender-males are more likely to have stroke

Race-Asians including Indians are more prone to stroke than western populaons

Family history of stroke and heart disease

Risk factors which can be modified

Hypertension- blood pressure more than 140/90 mmHg increases the risk for aack

significantly. Infact hypertension is called the "silent killer"Heart disease-diseases like atrial fibrillaon and other disorders increase the risk

Carod artery disease- carod arteries supply blood to brain and its narrowing can

predispose to brain aack

High cholesterol level-increases the risk

Smoking-smokers have higher risk, which decrease when one stops smoking

Diabetes-increases the risk, should be controlled by diet, oral drugs or insulin

Obesity-too much of weight, parcularly around the waist

Illegal drugs-intravenous drug abuse, cocaine abuse increase the risk

Physical inacvity

Transient ischaemic aacks (TIAs)are "mini strokes" that produce stroke like symptoms

but no lasng damage. However, paents having TIAs have a strong possibility of suffer-

ing from major stroke in future.

How do I know someone or myself is having stroke (brain aack)?


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How do I know someone or myself is having stroke (brain aack)?

Brain aack symptoms are:

Sudden numbness or weakness of the face, arm, leg (especially on one side of the body)

Sudden confusion, trouble speaking or understanding speech

Sudden trouble seeing in one or both eyes

Sudden trouble walking, dizziness, loss of balance or coordinaon

Sudden severe headache with no cause

If you suspect yourself or someone else to be having these symptoms, DONOT WAIT and

go to a hospital having emergency stroke treatment facilies.

Tests used to diagnose brain aack

CT (Computed tomography)-this tests involve taking a series of images of the brain to

detect stroke (brain aack). This test is usually the first invesgaon to be performed and

is parcularly useful to look for presence for bleeding (haemorrhagic brain aack).

MRI (Magnec resonance imaging)- This is very specialized test which uses magnec

properes of body to create very detailed images of brain as well as of blood vessels so

as to diagnose brain aack.

DSA- digital subtracon angiography)-This is the most accurate in diagnosis of most ofthe diseases of blood vessel. A small tube (catheter) is guided from the leg blood vessel

in to the blood vessel we wish to study followed by dye (contrast) injecons to obtain the

images. CT/MR angiography is also an opon in some cases.

Doppler ultrasound:in this ultrasound method is used to image the blood vessels and

the abnormalies in them.

Specialists involved in treatment of stroke


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Specialists involved in treatment of stroke

Stroke Neurologist- specializes in evaluang and medically managing ischaemic and

certain types of haemorrhagic strokes.

Neurosurgeon-performs surgical treatments such as hematoma evacuaon, aneurysmclipping or arteriovenous malformaon excision

Intervenonal neuroradiologist- specializes in minimally invasive treatment of brain

aack, such as carod stenosis stenng, intra-arterial thrombolysis, aneurysm emboliza-

on/coiling, arteriovenous malformaon embolizaon/gluing

Daignosc neuroradiologist- specializes in diagnosis of brain aack using modalies

such as CT, MRI, Doppler etc.

What are treatment opons in stroke (brain aack)?

Brain aack due to decreased blood supply (ischaemic stroke)Paents are given an-platelet drugs, which act as "blood thinners" so as to prevent clot

formaon. If paent reaches early enough to a hospital with acute stroke units, they can

be given thrombolyc drugs which act as clot busters and open up the blockage in the

arteries so as to save as much of brain as possible. The narrowing in the arteries which

have caused stroke can also be opened up by surgical or endovascular means.

Brain aack due to bleeding in the brain (haemorrhagic stroke)

Treatment opons will depend upon the cause and size of haemorrhage. Some paents

may need surgery to remove the clot, while other cases may need to be managed con-

servavely in ICU. Paent with bleeding due to swelling in blood vessels of brain knownas "aneurysms', will need to undergo repair of these swelling because they have a high

tendency to rebleed.

Specialized minimally invasive treatments of brain aack


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Specialized minimally invasive treatments of brain aack

Carod artery angioplasty/stenng- carod artery is a blood vessel which supplies

blood to brain and its narrowing can result in brain aack. The narrowing can be treated

by opening it up with a balloon followed by placing a metal mesh scaffolding (stent)

across it.

Intravenous/intrarterial thrombolysis-brain aack caused by decreased blood supply

to brain can be treated by giving drugs which can open up the blockade so as to save as

much of the brain as possible. These drugs can be given by intravenous route if a paent

comes to the hospital within three hours of onset of brain aack. These drugs can alsobe precisely given with in the area of blockade by placing a catheter (a small tube) from

one of the leg blood vessels in to the blocked vessel. This selecve (intra-arterial) treat-

ment can be given at least up to 6-hours aer the brain aack

Intracranial aneurysm coiling/embolizaton- aneurysms are localized swellings in the

blood vessels of brain which can rupture and cause bleeding. It is very crucial to seal

these swellings because they have tendency to rebleed. Minimally invasive treatment

can be performed by endovascular embolizaon/coiling of the aneurysm. In this treat-

ment a thin tube is placed from one of the leg arteries in to the aneurysm, which is then

filled up with metallic rings (coils).

What is the concept of thrombolysis? What is penumbra zone?

When blood flow to the brain stops, brain cells are deprived of oxygen and nutrients.

Stroke is a medical emergency because brain cells start dying quickly and the treatment

is most effecve when given promptly. Although some of the cells die within few min-

utes, surrounding zone though hypoperfused but are receiving just enough oxygen from

cerebral blood flow (CBF) to stay alive A compromised


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cerebral blood flow (CBF) to stay alive. A compromised

cell can survive for several hours in a low-energy state and

is referred to as "penumbra". If blood flow is restored

within this narrow window of opportunity then some of

these cells can be salvaged and become funconal again.

Blood flow to these cells can be achieved by administrang the clot-dissolving thrombo-

lyc agent t-PA by intravenous and intra-arterial routes.

What is stroke centre and why should a stroke paent go to these hospitals?Stroke centre- is a hospital or part of a hospital that (nearly) exclusively takes care of

stroke paents with specialized staff with team approach to treatment and care. Care in

stroke teams (including neurologists, neurosurgeons, intervenonal and diagnosc neu-

roradiologists) or by stroke units improve the outcome in these paents significantly.

What is the role of mechanical means of re-vascularziaon in acute stroke ?

One of the disadvantages of using thrombo-

lyc drugs is that there is risk of bleeding.

Another issue is that in large vessel blockage

thrombolyc drug is not effecve. These

drugs cannot be used in many situaon such

as recent surgery. To avoid these problems, mechanical means can be used to takeout

the clot and open up the blocked brain blood vessel. One such device is penumbra device

in which special catheter can be taken up to the clot which can then be aspirated.Medatna The Medicity is the first center in which such procedure was performed in

North India.


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Thrombolysis in Acute Stroke

A 64-year-old male presented with suddenonset hemiplegia and aphasia of 4-hours

duraon. since the me liit for intravenous therapy had already passed, paent was

taken up for intra-arterial recnalizaon. dsa revealed blocked le mca (a). microcthter ws

placed in mca and urokinase 95 millio units (b). was infused resulng in recnalizaon of

mca (c). paent acheived complete clinical recovery.

What is the concept of thrombolysis? What is penumbra zone?When blood flow to the brain stops, brain cells are deprived of oxygen and nutrients.

Stroke is a medical emergency because brain cells start dying quickly and the treatment

is most effecve when given promptly. Although some of the cells die within few min-

utes, surrounding zone though hypoperfused but are receiving just enough oxygen from

cerebral blood flow (CBF) to stay alive. A compromised cell can survive for several hours

in a low-energy state and is referred to as "penumbra". If blood flow is restored within

this narrow window of opportunity then some of these cells can be salvaged and

become funconal again. Blood flow to these cells can be achieved by administrang the

clot-dissolving thrombolyc agent t-PA by intravenous and intra-arterial routes.

Who are the right candidates for thrombolysis?

Paents who are able to reach hospital before major infarct has taken place and fulfill

the criteria for thrombolysis are the right candidates. Paents with hemorrhage or

well-established acute infarct on CT /MRI sequence are not the right candidates. Accord-ing to the criteria paent's having hypodensity in less than third of MCA territory on CT

scan are eligible for thrombolysis.

When is thrombolysis not done?


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y

Thrombolysis is not done in paents who are likely to have hemorrhage with use of

thrombolyc drugs. The contraindicaons include

- CNS lesion with high likelihood of hemorrhage s/p chemical thrombolyc agents (e.g.,

brain tumors, abscess, vascular malformaon, aneurysm, contusion)

- Established Bacterial endocardis

There are many relave contraindicaons including mild or rapidly improving deficits,

stroke within 3 months, history of intracranial hemorrhage and major surgery within

past 14 days. The complete is always checked beore performing the procedure.

What is likely benefit and risks of thrombolysis?

In the NINDS trial Favorable outcomes were achieved in 31% to 50% of paents treated

with rtPA, as compared with 20% to 38% of paents given placebo. The benefit was simi-

lar 1 year aer stroke. The major risk of treatment was symptomac brain hemorrhage,

which occurred in 6.4% of paents treated with rtPA and 0.6% of paents given placebo.

However, the death rate in the 2 treatment groups was similar at 3 months (17% versus

20%) and 1 year (24% versus 28%).In the NINDS trial there was 11-13% absolute increase

in the number of people who had minimal or no disability. When tPA was given within 3

hours of onset of symptoms, the number needed to treat for 1 more paent to have a

normal or near normal outcome was 8, and the number needed to treat for 1 more

paent to have an improved outcome was 3. These NNT are very impressive.

When is intra-arterial thrombolysis done ?At present intravenous therapy is not recommended beyond 3-hours, although in some

cases it may be done upto 4.4 hours. Intra-arterial thrombolysis can work up to 6-hours.

Therefore paents coming between 3 to 6 hours can benefit by intra-arterial therapy.


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p g y py

The window period can be further extended in cases of posterior circulaon stroke.

Paents with major vessel blockage such as internal carod, middle cerebral artery and

basilar artery are unlikely to respond to intravenous thrombolysis and can be treated

beer by intra-arterial means.

What is the role of mechanical means of re-vascularziaon in acute stroke ?

One of the disadvantages of using thrombolyc drugs is that there is risk of bleeding.

Another issue is that in large vessel blockage thrombolyc drug is not effecve. These

drugs cannot be used in many situaon such as recent surgery. To avoid these problems,

mechanical means can be used to takeout the clot and open up the blocked brain blood

vessel. One such device is penumbra device in which special catheter can be taken up to

the clot which can then be aspirated. Medatna The Medicity is the first center in which

such procedure was performed in North India.

What should one do if one sees a paent who is a possible candidate for thrombolysis?

One of the disadvantages of using thrombolyc drugs is that there is risk of bleeding.

Another issue is that in large vessel blockage thrombolyc drug is not effecve. These drugs

cannot be used in many situaon such as recent surgery. To avoid these problems, mechani-

cal means can be used to takeout the clot and open up the blocked brain blood vessel. Onesuch device is penumbra device in which special catheter can be taken up to the clot which

can then be aspirated. Medatna The Medicity is the first center in which such procedure was

performed in North India. One should get a CT scan done immediately to rule out a bleed. If

there is no bleed and paent is within the window period then one should transfer the

paent immediately to a centre with thrombolysis facilies. No an-platelet should be given

in these paent before thrombolysis. We should add anplatelet aer 24 hrs aer excluding

hemorrhage by repeat CT scan brain in thrombolysed paents.


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Arteriovenous Malformation

What is AVM disease?

An arteriovenous malformaon, or AVM for short, is a group of blood vessels that are

abnormally interconnected with one another. AVMs can occur in different organs of the

body, but brain AVMs are the most problemac. Another term for AVM is "arteriovenous

fistula."

What are the symptoms of disease?

About half of the paents find out they have an AVM only aer they suffer a brain hem-

orrhage. The other half are affected by, headaches, and stroke symptoms such as or

hemiparesis

How is it diagnosed?

Oen, the diagnosis of an AVM can be suspected by an expert radiologist with just CT

scan of the brain. Most physicians, however, feel more comfortable diagnosing AVMs

aer performing an MRI. However AVMs can be missed on non-invasive imaging and for

final diagnosis and evaluaon by cerebral angiography is mandatory. In cases when

bleeding has occurred, the AVM can be completely obscured by intracerebral bleeding,

requiring a to establish a final diagnosis.

Why does it develop?

Brain AVMs affect about 0.1% of the populaon, and are present at birth, but they rarely

affect more than one member of the same family. They happen roughly equally in men

and women. AVMs are thought to be due to abnormal development of blood vessels in


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utero and may be present since birth. An AVM is not a cancer, and does not spread to

other parts of the body. Dural AVFs, in adults are an acquired disorder that can occur

probably aer thrombosis of dural sinuses.

How is it treated?

There are 3 main modes of treatment. Endovascular embolizaon, micro neurosurgical

excision and radiosurgery. These are given alone or in combinaon. Which of them is

best for you is decided by our panel of experts aer discussing your detailed clinical and

radiological data. Your doctor will recommend the best treatment for you and this will be

determined by the size of your AVM and also the locaon. It is not uncommon to recom -

mend a combinaon of treatments.

Embolizaon

Under general anaesthesia a small catheter is advanced from the groin, into the brainvessels and then into the AVM. A liquid, non-reacve material (onyx) or glue is injected

into the vessels which block the AVM off. There is a small risk to this procedure and the

chances of completely curing the AVM using this technique depend on the size of the

AVM. It is frequently combined with the other treatments such as radiaon or surgery or

it can be staged in mulple sessions.

Radiaon Treatment

This treatment is also known as Radio surgery or Stereotacc Radiotherapy. A narrow

x-ray beam is focused on the AVM such that a high dose is concentrated on the AVM with

a much lower dose delivered to the rest of the brain. This radiaon causes the AVM toshrivel up and close off over a period of 2-3 years in up to 80% of paents. The risk of

complicaons is low. Unl the AVM is completely closed off, the risk of bleeding sll


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persists. This treatment can only be performed in small size AVM.

Surgery

This is the oldest method for treang AVMs. The AVM is surgically removed in an operat-

ing room under general anesthesia. Since AVMs do not grow back, the cure is immediate

and permanent if the AVM is removed completely. The risks of surgery are considered to

be high for AVMs that are located in deep parts of the brain with very important func -

ons. So surgery is usually indicated in those paent who are bled with large hematoma

or the AVM is superficial and in non eloquent part of the brain.

Are there any alternaves?

Other than above menoned modes of therapy no alternave is available. Only other

opon is to do nothing at all and just monitor the AVM. Your doctors may recommend

observaon if they feel that treatment can not be offered safely or when an AVM isdiscovered at a late age.

What will happen if it is le untreated?

There is risk of bleeding at the rate of 1-2 %/year aer the diagnosis. But risk is much

more if the AVm has bled or has a weak spot such as as aneurysm. Cumulave risk of

bleeding is high depending upon the expected life expectancy.

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Patient Stories

4


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Paents with acute ischaemic stroke or paralyc aacks usually face a life of dependancy


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with a huge psychological, social and financial burden. Acute stroke happens due to

blockage of blood supply. Although some brain cells die immediately, there is usually a

part of brain which can sll be revived if the blood supply is restored in next few hours.

This can be done by giving thrombolyc drugs (Intravenous thrombolysis) which act as

clot busters and open up the blockage in the arteries. This can result in reversal of stroke

and beer recovery. Direct delivery of drugs in the blocked artery (Intra-arterial or endo-

vascular) therapy can be more effecve when clot is large or when IV therapy cannot be

given. This is done by placing a catheter (a small tube) from one of the leg blood vessels

in to the blocked vessel followed by injecon of blockage (clot) dissolving drugs. Many

mechanical devices are also available which can be used to extract clot from the brain to

open the blood vessel. This selecve (intra-arterial) treatment can be given at least up to

8-hours aer the brain aack. First such case of mechanical recnalizaon using penum-

bra device in North India was done in Medanta, The Medicity. Recently first case of directstenng to open up a blocked vessel was performed in the hospital. All paents of stroke

are immediately assessed with CT angiography and perfusion (brain blood flow) imaging

using 256 slice CT scan to detect paents which have brain which can be revived and can

benefit with immediate treatment. We are the only centre in North India to use such

technology as a part of protocol.


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Executive collapses at work due to brain hemorrhage

Paent a 43 year old male working in an insurance company suddenly became uncon-

scious at work. He was taken to a nearby hospital which revealed brain haemorrhage. He

was shied to Medanta, The Medicity. Brain Angiography revealed a swollen blood

vessel (aneurysm) which had burst to cause the bleeding. He was at high risk of repeathaemorrhage and immediate repair of the leaking blood vessel was needed to safe his

life. This procedure was done by endovascular means through his leg blood vessel. A very

small tube (microcatheter) was placed in to the swollen damaged blood vessel and the

bleeding point was closed using planum coils (coiling). Paent has made almost com-

plete recovery and has gone back to his roune life.

Aneurysms are focal swelling of blood vessels, which can burst and cause bleeding in

brain. It is accepted that about 3% to 5% of the populaon harbour an intracranial aneu-

rysm and one in every 20 strokes is caused by rupture of intracranial aneurysm.

The aneurysm disease commonly strikes at prime of one's life at age of 40-50 yrs.

Alth h it i l th th f f t k b th di t ik


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Although it is less common then some other forms of stroke, because the disease strikes

a fairly young age and is oen fatal the loss of producve life years is similar to that for

cerebral infarcon or intracerebral hemorrhage. Many paents (up to 30%) do not

survive inial bleeding. Even the paents who survive more than 50% of paents do not

survive even for a month because the aneurysm bleeds again. Even the paents who

survive the inial bleeding, more than 50% of paents do not survive even for a month

because the aneurysm bleeds again. Open surgery "clipping" has been the convenonal

method of aneurysm treatment but has high chances of trauma to normal brain paren-

chyma. By endovascular method a microcatheter (a very thin tube) is placed into the

brain aneurysms through the leg blood vessel. Then the aneurysm is occluded by using

specialized coils. This procedure known as "coiling" has advantage of minimal injury to

normal brain and leading to beer outcomes. Studies have shown that paent recovery

is much beer with coiling rather than clipping. Medanta The Medicity has developed adedicated brain aneurysm program and more than 90% of brain aneurysms are treated

by endovascular means with very good clinical outcomes.

5


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The TEAM

Founders Story Dr Vipul Gupta


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Founder s Story Dr Vipul Gupta

Integrity First, Success Later

Do we lack role models in India, who have achievedmega success with integrity and without short cuts?

The role models are few, yet they exist nevertheless,

the path is tougher, yet there exists a path neverthe-

less. You dont need to escape abroad anymore and

rather find inspiraon to write your own success story

from professionals like Dr Vipul Gupta, who are worth

emulang. Who knows this may become your turning

point and you write your own mega success story,

inspired by him.

Neurosurgery and neurosurgeons, have always been awe-inspiring to me. Why not, the

mind and brain have always fascinated me (or rather all of us). So those who perform

intricate surgeries on this most delicate part of human body, are no less fascinang.

Dr Vipul Gupta is currently Addional Director & Head NeuroIntervenonal in

Medanta-The Medicity, one of Asias best mul-faculty super specialty hospitals located

in Gurgaon (Delhi NCR). He is a caring, skilled professional, dedicated to simplifying what

is oen a very complicated and confusing area of health care. No wonder, in a list of Top

10 Young Surgeons in the country prepared by The Hindustan Times,on doctors/sur-

geons with the cung edge, he is right at the top. It comes as no surprise that paents

come to him for treatment from different parts of North India, middle-east, Africa and

Central and South Asia.

What is Neuro Intervenon?

"Intervenonal Neuroradiology(Endovascular Neurosurgery)is a medical speciality in
http://www.medanta.org/about_an_overview.aspxhttp://www.hindustantimes.com/lifestyle/wellness/the-doctors-with-a-cutting-edge/article1-683143.aspxhttp://www.hindustantimes.com/lifestyle/wellness/the-doctors-with-a-cutting-edge/article1-683143.aspxhttp://www.medanta.org/about_an_overview.aspx


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Intervenonal Neuroradiology(Endovascular Neurosurgery)is a medical speciality in

which minimally invasive diagnosc and therapeuc procedures for cerebrovascular

disorders are performed under radiological guidance."

Background

Humble to the core, he aributes his success to his great mentors and the early exposure

to the best medical techniques and technologies in his snts abroad. He considers Dr AN

Jha (HOD-Neurosciences, Medanta), his best mentor, who besides mentoring him has also

extended him full support in creang systems, structures and processes in his department.

Vipul means large and plenty, and Dr Vipul is true to his name, large-hearted and a man

of abundance mentality.

Educated at the best instuons (DPS- RK Puram, Maulana Azad Medical College and later

post graduaon from Safdarjung Hospital) and trained at the best hospitals (AIIMS and

Max, Saket, New Delhi) in India and abroad, he has an admirable precision, which is so

crical in his profession.

A very emoonally stable person, who can be a dong father next minute, he believes,

Surgeons cant be emoonal. Only with a calm mind, you can think clearly. At 44, Gupta

heads neuro-intervenon at Medanta, and has a keen interest in creang systems and

processes. On the hobby front, he likes swimming, raing and rock-climbing. He points

out with a humourous note how he broke his knee twice at school in outdoor acvies

which forced him to lie in bed and study (and helped him crack MBBS entrance examina-

ons). He also loves listening to music and watching television in the evenings to relax.

Neurosurgery is tough, but I always knew the challenges. If I just wanted to save lives, I

could have treated diarrhoea. To be the best, you have to be unique, he points out.

A Doctor or a God?

He shared an interesng story yesterday of how he puts in his best efforts, yet brings


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He shared an interesng story yesterday of how he puts in his best efforts, yet brings

down the unrealisc expectaons of aendants/paents to realisc levels.

"An aendant with a paent walks in. He is a rich and educated man and has come in a

Mercedez Benz. In a panicky state, as the relave has been hit by a stroke, he inquires

about the surgery cost and also requests the doctor for a guaranteed cure. Dr Vipul

replies, Who do you visit, when your car needs repair? The gentleman replies, Of

course the authorized showroom of Merecedez.

Dr Vipul connues, So when your car needs repair, you go to the people who manufac-

tured/created it. And who created you and your relave? The aendant replies, God

of course Dr Vipul explains, So ideally for the repair of a human being, you need to go

to God herself. But I am not God, I will put the best of my efforts, without guarantees.

The aendant is able to understand the limitaons of the doctor. The doctor proceeds

for the surgery and the paent comes out of the operaon theater healed. And thepaent and the doctor live happily thereaer."(A happy ending here, but not always. The paents and aendants begin to treat him like a God, but he does not

want to be one.)

Medical Approach

He has an admirable precision, which is so crical in his profession. He holds high stan-


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p , p g

dards of integrity and ethics and does not shy away in discussing the ground realies

with the aendants of the paent. No wonder his reputaon and credibility has travelled

far and wide.

He emphasizes, We always perform surgeries in teams and team orientaon is very

crucial for success in our profession. Yet it is somemes a challenge as a leader to lead a

team of people of diverse backgrounds and cultures.

He specializes in intracranial aneurysms embolizaon (coiling), ArterioVenous malforma-

on (AVMs) and tumour embolizaon, Angioplasty and stenng of arterial stenosis

including carod stenng, Intra-arterial Thrombolysis for stroke and Percutaneous spinal

procedures such as vertebroplasty and other intervenonal procedures etc.

The Brainy Bale Goes OnHis primary focus area is Endovascular Neurosurgery. Before joining Medanta, he was the

Head Intervenonal Neuroradiology (Endovascular Neurosurgery) at Max Super Speciality

Hospital, Saket, New Delhi. He has also worked as Associate Professor in dept. of Neurora-

diology (AIIMS), New Delhi. He has done fellowship training in Vascular and Intervenonal

Neuroradiolgy from Foundaon Rothschild, Paris; Cleveland Clinic (USA) and in Italy.

He keeps travelling across North India to train the medicos especially the neurosciences

professionals. He has more than 45 publicaons in journals, 7 chapters in books and more

than 40 abstract (paper) presentaons in Indian and internaonal conferences. He has

been vising Professor in UMASS general Hospital, Boston, USA. He is a member of sever-

al professional bodies and is especially keen on creang stroke (brain aack) awareness.

Once a pioneer, always a pioneer

He was among the first in India to use dedicated intra cranial stents and 3D-DSA for


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g

aneurysm embolizaon, to perform intra cranial venous sinus stenng and one of the

few full me Neurointervenonists specializing in endovascular intervenons in

Stroke.

Here is a list of his fellowships, awards, achievements and other contribuons, which goon and on.

Fellowships

Foundaon Rothschild, Paris; Cleveland clinic (USA) and in ItalyAwards

1. IMA Award- Stroke Meeng Feb 2006

2. IMAAMS Disnguished Service Award - Annual Conference of IMAAMS, 2007

3. I.M.A. Academy of Medical Speciales- New Delhi, 09th December, 2007

4. Recognion Award- Max Healthcare Instute Limited- 2008

5. Best paper award- Joint Annual Conference of Neuroradiology, Vascular and Interven-

onal Radiology, Bangalore, India, 1999

6. Best poster award- 6th Annual conference of Indian Society of Vascular & Intervenonal

Radiology) and Indian Society of Neuroradiology, 2003

He has a slew ofachievements, academic contribuonsand of course paent storiesandtesmonials.

Neurosurgery is tough, but I always knew the challenges. If I just wanted to save lives, I

could have treated diarrhoea. To be the best, you have to be unique, he points out.

No grey areas here, but loads of Grey Maer

What surprised me the most about him is that he can discuss a philosophical subject
http://neurointerventionindia.com/achievement.htmlhttp://neurointerventionindia.com/experience.htmlhttp://neurointerventionindia.com/testimonial.htmlhttp://neurointerventionindia.com/video_testimonial.htmlhttp://neurointerventionindia.com/video_testimonial.htmlhttp://neurointerventionindia.com/testimonial.htmlhttp://neurointerventionindia.com/experience.htmlhttp://neurointerventionindia.com/achievement.html


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such as Indian culture and ethos as easily as he can discuss the precision and techniques

of neurosciences. He shared some very interesng observaons on the challenges of

creates systems and processes in India, where people trust people and relaonships,more than they trust the systems.

Enough of grey maer now, I think. With a dose of medical terminology and discussions

on brain, interrupted by a hundred phone calls, my brain is geng dizzy now. Let me rest

now and come back with more soon.

(Story wrien & edited by Dr Amit Nagpal and ALS team)

Not exhausted yet, find out more about Dr Vipul here

LinkedIn

Facebook Page

Website

Youtube channel

Medical Tourism Directory

Member Profiles
http://in.linkedin.com/pub/vipul-gupta/51/8a1/25ahttps://www.facebook.com/NeurointerventionGurgaonhttp://neurointerventionindia.com/profile.htmlhttps://www.youtube.com/channel/UC0mTNls5DSL05-MrzRK69Pghttp://www.medicaltourismco.com/india-hospitals/doctors/dr-vipul-gupta.phphttp://www.medicaltourismco.com/india-hospitals/doctors/dr-vipul-gupta.phphttps://www.youtube.com/channel/UC0mTNls5DSL05-MrzRK69Pghttp://neurointerventionindia.com/profile.htmlhttps://www.facebook.com/NeurointerventionGurgaonhttp://in.linkedin.com/pub/vipul-gupta/51/8a1/25a


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Dr Sumit Singh

A topper in DM neurology at All India Instutes of Medical Sciences (AIIMS), New Delhi,

Dr. Sumit Singh is the Head- Movement disorders & headache at Medanta the Medicity.He was awarded the BL Soni Gold Medal for being the best Resident in AIIMS where he

was an Associate Professor in neurology for 10 years. He started the first headache clinic

and the Neuromuscular disorders clinic in north India at AIIMS in 2002. He is a known

expert in Parkinsons disease and movement disorders. As a headache specialist he ini-

ated the use of botulinium toxin for the first me in the country, and extended its usage

in trigeminal Neuralgia.

He is one of the few botox injectors in India for Spascity, Limb dystonias, hemifacial

spasm, oral dyskinesias, spasmodic dysphonia and writers cramp. Dr Sumit had been


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with Deep Brain Smulaon Program for Parkinsons disease at AIIMS and has estab-

lished the same at Medanta the Medicity. He has innovated the plasma exchange proto-

cols for acute neuropathies, Myasthenic crisis, Polymyosis, and has introduced special

protocols for Mulple Sclerosis for the first me in the country. . Dr Sumit has more than

90 publicaons in Naonal and internaonal journals and has wrien several chapters in

books. His main areas of experse are Movement disorders, headache and Neuromuscu-

lar disorders.

Dr Gaurav GoelDr. Gaurav Goel is a Neuro-Intervenonist trained from presgious Montreal Neurologi-

cal Instute and Hospital in Canada. He specializes in the treatment of vascular disorders

of the brain and spine like coiling of aneurysms, embolizaon of the AVM (arterio-venous

malformaons), stenng in intracranial and extracranial atheroscleroc disease and

tumor embolizaon. He also has vast experience in newly developed flow diverter stents

for intracranial aneurysm. His primary area of interest remains in the treatment of acutestroke using mechanical and chemical thrombolyc agents. He also runs a very success-

ful spine pain management clinic, performing various spine procedures like nerve blocks,

facet blocks, epidural blocks, and vertebroplasty are being done to reduce the paents

pain, without the need for the surgery. He has managed more than 2000 of such cases

during his fellowship training program in Canada and has now brought this experse to

Medanta. Dr. Gaurav Goel is one of the very few DM neuro-radiologists in the countryand is a leading expert in the diagnosc neuro-imaging including the recent advances like

diffusion, MR/CT perfusion, MR/CT angiography and spectroscopy.

6


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Annexures


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Media Gallery


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Useful Resources & Links

Neuro Innovaons on Youtube

hps://www.youtube.com/channel/UC0mTNls5DSL05-MrzRK69Pg

Doctors Perspecves on Medical Profession and Life

hps://www.linkedin.com/today/author/184345126

Presentaons on Latest developments and Research in Neurointervenonhp://www.slideshare.net/vipulgupta35175/presentaons

NeuroIntervenon India

hp://www.neurointervenonindia.com/

Facebook Page

hps://www.facebook.com/NeurointervenonGurgaon

Healthy Living secon-Huffington Posthp://www.huffingtonpost.com/

A Health Blog

hp://www.ahealthblog.com/

Brain Anatomy

hp://brainanatomy.tk/

Your Brain Healthhp://yourbrainhealth.com.au/


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Foundation Brochure


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Contact Us

Dr. Vipul Gupta

Head- Neurovascular Intervenon Centre

Medanta Instute of Neurosciences

Medanta The Medicity

Sector 38, Gurgaon, Haryana - 122001, IndiaTelephone:+91-124-4141414 Extn: 6610

Mobile:+91-9810542372

Email: [email protected]

For Appointment: 9810332224

Dr. Gaurav GoelMBBS, MD, DM, Felloe ( intervenonal Neuro Radiology)

Consultant- Intervenonal Neuroradiology

Medanta Instute of Neurosciences

Mobile: +91-9650789820

Email:[email protected]


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Storytelling By

s e r v i c e s

LFrom Branding, the journey, toBonding, the destinationTM

+91 9810 337 995 l www.alservices.in l [email protected]

stroke and neurovascular interventions foundation

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