1. 1. An Initiative of Stroke and Neurovascular Interventions Foundation Creating Stroke Awareness Stroke and Neurovascular Interventions
2. 2. Story telling by AL Services
3. 3. Table of Contents Stroke-An Infographic 1. About Stroke & Neurovascular Interventions Foundation 2. Stroke and Neurointervention FAQ 3. Diseases & Treatments 4. Patient Stories 5. The Team - The Founders Story - Member Proles 6 Annexures - Media Gallery - Useful Resources & Links - Foundation Brochure Contact Us
4. 4. A stroke occurs when blood ow to the brain is blocked by clots in the blood vessels or because of a weakened blood vessel rupturing bleeding into the brain. Dizziness Diculty 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 tingling, numbness or weakness of the face, arm or leg, especially on one side of the body WARNING SIGNS STROKE OF BAD HEALTH 15mn people worldwide suer a stroke each year die of stroke annually are left permanently disabled recover or functionally disabled 6.15mn 5mn 3.85mn High blood pressure, high cholesterol and triglycerides (blood fats), smoking, drinking alcohol, physical inactivity, abdominal obesity (stomach fat), heart disease, poor and over nutrition, diabetes, and psychosocial stressors. RI SK FACTORS T EST MRI scan of the brain to show areas of brain damage due to lack of blood ow. Angiogram to evaluate the calibre and patency (the condition of being open or unobstructed) of the arteries in the neck and the brain. A stroke is an emergency. Take the patient to a hospital emergency at once. Do not wait for the symptoms to improve or waste time going to a neighbourhood clinic. While waiting for medical attention, patients who are drowsy, unresponsive or vomiting should be turned on their side to prevent them from choking on their tongue or vomit. www.neurointerventionindia.com www.facebook.com/NeurointerventionGurgaon Stroke-An Infographic
5. 5. About Stroke & Neurovascular Interventions Foundation On 29th October, all across the globe World Stroke Day is observed by various healthcare institutes, organizations and medical professionals by conducting dierent events, edu- cating, 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 Organization (WSO). Dr. Vipul Gupta Head, Neurointerventional Surgery, Medanta The Medicity along with his colleagues have formed STROKE AND NEUROVASCULAR INTERVENTIONS FOUNDA- TION to impart public education and increase awareness among common man and gen- eral physicians for prevention and treatment in stroke. The eort will be made to train and empower the physicians to handle a medical emergency like stroke. The early treat- ment is critical because at that stage the stroke may be reversible or the damage can be limited. Every minute if stroke is untreated, the average patient loses 1.9 million (19 Lakh) neurons (brain cells). 1
6. 6. Every year millions of people become victim of stroke. It is considered to be the third most common cause of death and disability. The statistics states that one in six people will have stroke in their lifetime and this toll will increase with ow of time, in countries like India due to changing lifestyle, urbanization, stress, smoking, salt/alcohol intake. However with the help of modern methods of minimally invasive neuro intervention techniques have revolutionized the treatment of carotid stenosis, acute strokes, brain aneurysm and AVMs many patients can achieve a complete recovery and lead a normal life if they are detected early. The prime focus of this foundation is to educate masses through dierent media plat- forms like WhatsApp, Facebook, Youtube and also through a special application for stroke. Along with this collaborative 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 foundation will be helping the people and communities to recognize the symptoms of stroke and prevent it from its consequences. Dr Gupta clari- es 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 diculty in speaking and Tis for time 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 should be immediately taken to hospital particularly stroke centres, where could be given a stroke treatment.
7. 7. He further explains; If patient comes in rst few hours (4.5 hrs), clot busting drug (t-PA) cab be given. Blood vessel can also be opened by intervention technique. Neurointer- ventionist goes through leg blood vessel and by special devices can take out the clot to restore the blood ow, helping brain to recover. The intervention can be done upto 8-hours and by these modern treatment methods patients have better chances to recov- er after stroke. The foundation also highlights the prevention from risk factors of stroke such as 80% of strokes can be prevented by following seven simple ways by getting physically active, healthy eating habits, saying no to smoking, controlling blood sugar levels, lowering cho- lesterol and shedding out excess weight through regular exercise.
8. 8. Stroke and Neurointervention FAQ How these techniques help in early treatment of stroke? When a person suers from stroke, some brain cells die immediately but the surround- ing tissue can still 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 function. By giving IV t-PA drug or through neuro-interventional 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 patients or recovery with these treatment methods is far better. 2
9. 9. How effective are these techniques in dealing with stroke? It is dependent on the severity of the condition and the treatment that is employed to treat the patient. Based on the selection criteria (that depends on many factors), the patients are selected for treatment. And among the selected ones, around 50% of the patients have a good chance of recovery. What is the cost of the treatment ? The intravenous tissue type plasminogen activator (IVtPA) procedure used to treat stroke costs around 50-90 thousand, while intervention techniques cost about Rs. 2 lakhs. Videos https://www.youtube.com/watch?v=zRVw5-tqSKY https://www.youtube.com/watch?v=7sgULgi8IIE
10. 10. Diseases and Treatments This chapter covers 5 major areas viz. Aneurysm, Carotid Artery Stenosis, Stroke, Thrombolysis in acute stroke and Arteriovenous malformation. To check out case studies, procedure videos, patient testimonials visit the website www.neurointerventionindia.com ANEURYSM CAROTID ARTERY STENOSIS STROKE / BRAIN ATTACK THROMBOLYSIS IN ACUTE STROKE ARTERIOVENOUS MALFORMATION 3
11. 11. Aneurysm What are intracranial aneurysms? Intracranial aneurysms are localized pathological dilatations of cerebral arteries. Most intracranial aneurysms are saccular or berry aneurysms, whereas dissecting, fusiform, infectious, traumatic, and oncotic 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- tion of hemodynamic stresses and acquired degenerative changes within the arterial wall. How does aneurysm presents? Aneurysms may present as Rupture of the weak wall of such aneurysms mainly resulting in subarachnoid haemorrhage (SAH), experienced as ''the worst headache of life'' by patients. Mass eect, causing cranial nerve symptoms Asymptomatic, incidentally detected during imaging done for other reasons It is accepted that about 3% to 5% of the population 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 often fatal the loss of productive life years is similar to that for cerebral infarction or intra cerebral hemorrhage - - -
12. 12. What are complications of SAH? Many patients don't survive initial hemorrhage or suer signicant 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 patients who survive the initial hemorrhage develop ischemic strokes or die from the development of cerebral vasospasm. Non-Neurological Complications often occur in patients 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 patients needs intensive care management so as avoid and mange such problems. What are complications of SAH? CT scan should be performed in suspected SAH. However, CT can be negative in some cases particularly if it is done few days after the event. Although MR is quite sensitive if performed appropriately and interpreted by an experi- enced radiologist, SAH is frequently missed. Selective cerebral angiography should be performed in patients with SAH to document the presence and anatomic features of aneurysms. MR angiography or CT angiography may be considered when conventional angiography cannot be performed in a timely fashion. What Are Management Recommendations? SAH is a medical emergency that is frequently misdiagnosed. A high level of suspicion for SAH should exist in patients with acute onset of severe headache. Patient of SAH are to be managed in ICU with good neuroanaesthetic support and management. Early aneu- rysm treatment should be performed to prevent repeat bleeding.
13. 13. Surgery (clipping) vs embolization (coiling) Surgery has been the conventional 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 circulation. Problems with surgery include invasiveness and trauma to normal brain parenchyma. What Are Management Recommendations? Other treatment option is of endovascular embolization (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 platinum 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 International Subarachnoid Aneurysm Trial Study (ISAT) Randomized, prospective, international controlled trial Compared policy of neurosurgi- cal clipping with a policy of endovascular treatment in aneurysms deemed suitable for either therapy. 9559 patients screened, 2143 (22.4%) were randomized and the dierence in the risk of dependency or death between the two groups was compared. SURGICAL CLIPPING COILING OF ANEURYSM
14. 14. Results: at 1 year, the outcome was much better in the coiling group with relative risk reduction of 22.6% as compared to surgical patients. The early survival advantage was maintained for up to 7-years. The risk of epilepsy was substantially lower in patients allocated to endovascular treat- ment. The risk of late rebleeding was minimally higher (0.16%). The better outcome in coiling group was inspite of minimally increased risk of rebleeding. According to recent American Stroke Association 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 inated 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
15. 15. Carotid Artery Stenosis What is the role of carotid 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 estimated that approximately 20-30% of strokes may be caused by stenosis of carotid artery. What are the various means to diagnose Carotid Artery Stenosis? Carotid Doppler - is a non-invasive & accurate modality to assess carotid stenosis. MR angiography (MRA)/CT angiography (CTA) - excellent quality imaging of carotid artery can be done by these relatively non-invasive methods. Digital subtraction angiography (DSA) is the "Gold standard", however it is an invasive investigation and is usually reserved to evaluate stenosis detected in non-invasive inves- tigations as well when the non-invasive investigations are non-conclusive. What are the treatment options in Carotid Artery Stenosis? Medical treatment is done for the risk factors for atherosclerosis such as hypertension, diabetes mellitus & dyslipidemia . Patients are also told to stop smoking. Anti-platelet drugs (Dispirin, clopidogrel) are useful to prevent embolic events. Patients with marked stenosis require revascularization which can be achieved by surgical (endarterectomy) or endovascular (angioplasty & stenting) means.
16. 16. What are the indications for carotid revascularization (stenting/ endarterectomy)? Carotid stenosis more than 70% - should be revascularized Carotid stenosis (50%-69%) - Revascularization is recommended for patients who have had recent transient ischaemic attack or stroke depending upon patient-specic factors such as age, gender, co morbidities, and severity of initial symptoms Carotid stenosis less than 50% - No benet of surgery is demonstrated in these patients Asymptomatic carotid stenosis - Treatment of asymptomatic carotid stenosis is more controversial. The guidelines indicate that patients benet from treatment if the opera- tor has a low complication rate. How does carotid stenting compare to surgical endarterectomy? Patients who have coexisting medical problems or advanced age (>80) are better suited for stenting rather than endarterectomy. Patients having certain anatomical features such as prior ipsilateral endarterectomy, prior neck irradiation, contralateral internal carotid artery (ICA) occlusion & high cervical stenosis are also better suited for stenting as compared to endarterectomy. Patients with marked tortuosity of the common carotid artery and ICA or contraindica- tions to anti-platelet therapy may not be suitable candidates for endovascular therapy What is a protection device and what is its role in carotid stenting? Filter protection devices are umbrella-shaped devices that are placed temporarily in the internal carotid artery beyond the site of stenosis during the procedure. These devices have small pores designed to exclude particulate debris embolization to cranial circula- tion during the procedure.
17. 17. 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 atherosclerotic disease. Recent studies have shown that these patients with intracranial stenosis have high risk of stroke in spite of medical treatment. Recent advances in technology has made angioplasty and stenting possible in these patients
18. 18. Stroke / Brain Attack What is stroke (brain attack) 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. Sometimes it occurs when a blood vessel bursts, leading to bleeding in the brain. Just as heart attack which occurs due to decrease in blood supply to heart, stroke is a very serious condition and is also referred to as "brain attack". Is stroke (brain attack) an emergency? If treatment is not started early enough in a brain attack patient, brain damage may be very severe. New treatments are available which can signicantly reduce the damage. However, these treatments work best soon after the brain attack What causes stroke (brain attack)? Brain attack is of two types- "Ischaemic" brain attack 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 oating into brain arteries and causing obstruction. It can also occur because of narrowing in the arteries giving blood supply to the brain. "Haemorrhagic" brain attack occurs due to bleeding in the brain due to hypertension, rupture of aneurysms (areas of swelling in the blood vessels), vascular malformations (areas of malformed blood vessels with increased ow in them) and many other causes.
19. 19. What are the risk factors of stroke (Brain attack)? 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 populations Family history of stroke and heart disease Risk factors which can be modied Hypertension- blood pressure more than 140/90 mmHg increases the risk for attack signicantly. Infact hypertension is called the "silent killer" Heart disease- diseases like atrial brillation and other disorders increase the risk Carotid artery disease- carotid arteries supply blood to brain and its narrowing can predispose to brain attack 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, particularly around the waist Illegal drugs- intravenous drug abuse, cocaine abuse increase the risk Physical inactivity Transient ischaemic attacks (TIAs) are "mini strokes" that produce stroke like symptoms but no lasting damage. However, patients having TIAs have a strong possibility of suer- ing from major stroke in future.
20. 20. How do I know someone or myself is having stroke (brain attack)? Brain attack 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 coordination 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 facilities. Tests used to diagnose brain attack CT (Computed tomography)- this tests involve taking a series of images of the brain to detect stroke (brain attack). This test is usually the rst investigation to be performed and is particularly useful to look for presence for bleeding (haemorrhagic brain attack). MRI (Magnetic resonance imaging)- This is very specialized test which uses magnetic properties of body to create very detailed images of brain as well as of blood vessels so as to diagnose brain attack. DSA- digital subtraction angiography)- This is the most accurate in diagnosis of most of the 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) injections to obtain the images. CT/MR angiography is also an option in some cases. Doppler ultrasound: in this ultrasound method is used to image the blood vessels and the abnormalities in them.
21. 21. Specialists involved in treatment of stroke Stroke Neurologist- specializes in evaluating and medically managing ischaemic and certain types of haemorrhagic strokes. Neurosurgeon- performs surgical treatments such as hematoma evacuation, aneurysm clipping or arteriovenous malformation excision Interventional neuroradiologist- specializes in minimally invasive treatment of brain attack, such as carotid stenosis stenting, intra-arterial thrombolysis, aneurysm emboliza- tion/coiling, arteriovenous malformation embolization/gluing Daignostic neuroradiologist- specializes in diagnosis of brain attack using modalities such as CT, MRI, Doppler etc. What are treatment options in stroke (brain attack)? Brain attack due to decreased blood supply (ischaemic stroke) Patients are given anti-platelet drugs, which act as "blood thinners" so as to prevent clot formation. If patient reaches early enough to a hospital with acute stroke units, they can be given thrombolytic 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 attack due to bleeding in the brain (haemorrhagic stroke) Treatment options will depend upon the cause and size of haemorrhage. Some patients may need surgery to remove the clot, while other cases may need to be managed con- servatively in ICU. Patient with bleeding due to swelling in blood vessels of brain known as "aneurysms', will need to undergo repair of these swelling because they have a high tendency to rebleed.
22. 22. Specialized minimally invasive treatments of brain attack Carotid artery angioplasty/stenting- carotid artery is a blood vessel which supplies blood to brain and its narrowing can result in brain attack. The narrowing can be treated by opening it up with a balloon followed by placing a metal mesh scaolding (stent) across it. Intravenous/intrarterial thrombolysis- brain attack 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 patient comes to the hospital within three hours of onset of brain attack. These drugs can also be 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 selective (intra-arterial) treat- ment can be given at least up to 6-hours after the brain attack 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 embolization/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 lled up with metallic rings (coils). What is the concept of thrombolysis? What is penumbra zone? When blood ow 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 eective when given promptly. Although some of the cells die within few min- utes, surrounding zone though hypoperfused but are receiving just enough oxygen from
23. 23. cerebral blood ow (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 ow is restored within this narrow window of opportunity then some of these cells can be salvaged and become functional again. Blood ow to these cells can be achieved by administrating the clot-dissolving thrombo- lytic agent t-PA by intravenous and intra-arterial routes. What is stroke centre and why should a stroke patient go to these hospitals? Stroke centre- is a hospital or part of a hospital that (nearly) exclusively takes care of stroke patients with specialized sta with team approach to treatment and care. Care in stroke teams (including neurologists, neurosurgeons, interventional and diagnostic neu- roradiologists) or by stroke units improve the outcome in these patients signicantly. What is the role of mechanical means of re-vascularziation in acute stroke ? One of the disadvantages of using thrombo- lytic drugs is that there is risk of bleeding. Another issue is that in large vessel blockage thrombolytic drug is not eective. These drugs cannot be used in many situation 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 rst center in which such procedure was performed in North India.
24. 24. Thrombolysis in Acute Stroke A 64-year-old male presented with suddenonset hemiplegia and aphasia of 4-hours duration. since the time liit for intravenous therapy had already passed, patient was taken up for intra-arterial recnalization. dsa revealed blocked left mca (a). microcthter ws placed in mca and urokinase 95 millio units (b). was infused resulting in recnalization of mca (c). patient acheived complete clinical recovery. What is the concept of thrombolysis? What is penumbra zone? When blood ow 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 eective 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 ow (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 ow is restored within this narrow window of opportunity then some of these cells can be salvaged and become functional again. Blood ow to these cells can be achieved by administrating the clot-dissolving thrombolytic agent t-PA by intravenous and intra-arterial routes. Who are the right candidates for thrombolysis? Patients who are able to reach hospital before major infarct has taken place and fulll the criteria for thrombolysis are the right candidates. Patients with hemorrhage or well-established acute infarct on CT /MRI sequence are not the right candidates. Accord- ing to the criteria patient's having hypodensity in less than third of MCA territory on CT scan are eligible for thrombolysis.
25. 25. When is thrombolysis not done? Thrombolysis is not done in patients who are likely to have hemorrhage with use of thrombolytic drugs. The contraindications include - CNS lesion with high likelihood of hemorrhage s/p chemical thrombolytic agents (e.g., brain tumors, abscess, vascular malformation, aneurysm, contusion) - Established Bacterial endocarditis There are many relative contraindications including mild or rapidly improving decits, 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 benet and risks of thrombolysis? In the NINDS trial Favorable outcomes were achieved in 31% to 50% of patients treated with rtPA, as compared with 20% to 38% of patients given placebo. The benet was simi- lar 1 year after stroke. The major risk of treatment was symptomatic brain hemorrhage, which occurred in 6.4% of patients treated with rtPA and 0.6% of patients 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 patient to have a normal or near normal outcome was 8, and the number needed to treat for 1 more patient 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.
26. 26. Therefore patients coming between 3 to 6 hours can benet by intra-arterial therapy. The window period can be further extended in cases of posterior circulation stroke. Patients with major vessel blockage such as internal carotid, middle cerebral artery and basilar artery are unlikely to respond to intravenous thrombolysis and can be treated better by intra-arterial means. What is the role of mechanical means of re-vascularziation in acute stroke ? One of the disadvantages of using thrombolytic drugs is that there is risk of bleeding. Another issue is that in large vessel blockage thrombolytic drug is not eective. These drugs cannot be used in many situation 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 rst center in which such procedure was performed in North India. What should one do if one sees a patient who is a possible candidate for thrombolysis? One of the disadvantages of using thrombolytic drugs is that there is risk of bleeding. Another issue is that in large vessel blockage thrombolytic drug is not eective. These drugs cannot be used in many situation 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. 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 rst 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 patient is within the window period then one should transfer the patient immediately to a centre with thrombolysis facilities. No anti-platelet should be given in these patient before thrombolysis. We should add antiplatelet after 24 hrs after excluding hemorrhage by repeat CT scan brain in thrombolysed patients.
27. 27. Arteriovenous Malformation What is AVM disease? An arteriovenous malformation, or AVM for short, is a group of blood vessels that are abnormally interconnected with one another. AVMs can occur in dierent organs of the body, but brain AVMs are the most problematic. Another term for AVM is "arteriovenous stula." What are the symptoms of disease? About half of the patients nd out they have an AVM only after they suer a brain hem- orrhage. The other half are aected by, headaches, and stroke symptoms such as or hemiparesis How is it diagnosed? Often, 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 after performing an MRI. However AVMs can be missed on non-invasive imaging and for nal diagnosis and evaluation 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 nal diagnosis. Why does it develop? Brain AVMs aect about 0.1% of the population, and are present at birth, but they rarely aect more than one member of the same family. They happen roughly equally in men
28. 28. and women. AVMs are thought to be due to abnormal development of blood vessels in 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 after thrombosis of dural sinuses. How is it treated? There are 3 main modes of treatment. Endovascular embolization, micro neurosurgical excision and radiosurgery. These are given alone or in combination. Which of them is best for you is decided by our panel of experts after 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 location. It is not uncommon to recom- mend a combination of treatments. Embolization Under general anaesthesia a small catheter is advanced from the groin, into the brain vessels and then into the AVM. A liquid, non-reactive material (onyx) or glue is injected into the vessels which block the AVM o. 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 radiation or surgery or it can be staged in multiple sessions. Radiation Treatment This treatment is also known as Radio surgery or Stereotactic 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 radiation causes the AVM to shrivel up and close o over a period of 2-3 years in up to 80% of patients. The risk of
29. 29. complications is low. Until the AVM is completely closed o, the risk of bleeding still persists. This treatment can only be performed in small size AVM. Surgery This is the oldest method for treating 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- tions. So surgery is usually indicated in those patient who are bled with large hematoma or the AVM is supercial and in non eloquent part of the brain. Are there any alternatives? Other than above mentioned modes of therapy no alternative is available. Only other option is to do nothing at all and just monitor the AVM. Your doctors may recommend observation if they feel that treatment can not be oered safely or when an AVM is discovered at a late age. What will happen if it is left untreated? There is risk of bleeding at the rate of 1-2 %/year after the diagnosis. But risk is much more if the AVm has bled or has a weak spot such as as aneurysm. Cumulative risk of bleeding is high depending upon the expected life expectancy.
30. 30. Patient Stories 4
31. 31. Sudden paralysis attack in a woman 62 year old lady had sudden onset of paralysis of left side of the body with diculty in speech. She was immediately bought to the Medanta, The Medicity hospital where she was found to be suering from acute stroke leading to complete left side paralysis. His immediate CT revealed that found that her major blood vessel in brain was occluded which was causing damage to her brain. Specialized imaging (CT based brain blood ow imaging) revealed that although some tissue was already dead, there was signicant part of his brain which could still be revived by restoring the blood supply. However if this was not done soon, those brain cells were likely to die in very short while. She was treated by intra-arterial thrombolysis. Through the leg artery a very small tube (microcatheter) was placed in the blocked brain vessel and clot dissolving drugs were given to open it up. She started to recover immediately and was completely all right in next 24 hours. She has now recovered complete power in left arm and leg with no diculty in speech and living a normal life.
32. 32. Patients with acute ischaemic stroke or paralytic attacks usually face a life of dependancy with a huge psychological, social and nancial 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 still be revived if the blood supply is restored in next few hours. This can be done by giving thrombolytic drugs (Intravenous thrombolysis) which act as clot busters and open up the blockage in the arteries. This can result in reversal of stroke and better recovery. Direct delivery of drugs in the blocked artery (Intra-arterial or endo- vascular) therapy can be more eective 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 injection 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 selective (intra-arterial) treatment can be given at least up to 8-hours after the brain attack. First such case of mechanical recnalization using penum- bra device in North India was done in Medanta, The Medicity. Recently rst case of direct stenting to open up a blocked vessel was performed in the hospital. All patients of stroke are immediately assessed with CT angiography and perfusion (brain blood ow) imaging using 256 slice CT scan to detect patients which have brain which can be revived and can benet with immediate treatment. We are the only centre in North India to use such technology as a part of protocol.
33. 33. Executive collapses at work due to brain hemorrhage Patient 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 shifted 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 repeat haemorrhage 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 platinum coils (coiling). Patient has made almost com- plete recovery and has gone back to his routine 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 population harbour an intracranial aneu- rysm and one in every 20 strokes is caused by rupture of intracranial aneurysm.
34. 34. The aneurysm disease commonly strikes at prime of one's life at age of 40-50 yrs. Although it is less common then some other forms of stroke, because the disease strikes a fairly young age and is often fatal the loss of productive life years is similar to that for cerebral infarction or intracerebral hemorrhage. Many patients (up to 30%) do not survive initial bleeding. Even the patients who survive more than 50% of patients do not survive even for a month because the aneurysm bleeds again. Even the patients who survive the initial bleeding, more than 50% of patients do not survive even for a month because the aneurysm bleeds again. Open surgery "clipping" has been the conventional 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 better outcomes. Studies have shown that patient recovery is much better with coiling rather than clipping. Medanta The Medicity has developed a dedicated brain aneurysm program and more than 90% of brain aneurysms are treated by endovascular means with very good clinical outcomes.
35. 35. The TEAM 5
36. 36. Founders Story Dr Vipul Gupta Integrity First, Success Later Do we lack role models in India, who have achieved mega 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 nd inspiration to write your own success story from professionals like Dr Vipul Gupta, who are worth emulating. 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 fascinating. Dr Vipul Gupta is currently Additional Director & Head NeuroInterventional in Medanta-The Medicity, one of Asias best multi-faculty super specialty hospitals located in Gurgaon (Delhi NCR). He is a caring, skilled professional, dedicated to simplifying what is often 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 cutting edge, he is right at the top. It comes as no surprise that patients come to him for treatment from dierent parts of North India, middle-east, Africa and Central and South Asia.
37. 37. What is Neuro Intervention? "Interventional Neuroradiology(Endovascular Neurosurgery)is a medical speciality in which minimally invasive diagnostic and therapeutic procedures for cerebrovascular disorders are performed under radiological guidance." Background Humble to the core, he attributes his success to his great mentors and the early exposure to the best medical techniques and technologies in his stints abroad. He considers Dr AN Jha (HOD-Neurosciences, Medanta), his best mentor, who besides mentoring him has also extended him full support in creating 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 institutions (DPS- RK Puram, Maulana Azad Medical College and later post graduation 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 critical in his profession. A very emotionally stable person, who can be a doting father next minute, he believes, Surgeons cant be emotional. Only with a calm mind, you can think clearly. At 44, Gupta heads neuro-intervention at Medanta, and has a keen interest in creating systems and processes. On the hobby front, he likes swimming, rafting and rock-climbing. He points out with a humourous note how he broke his knee twice at school in outdoor activities which forced him to lie in bed and study (and helped him crack MBBS entrance examina- tions). 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.
38. 38. A Doctor or a God? He shared an interesting story yesterday of how he puts in his best eorts, yet brings down the unrealistic expectations of attendants/patients to realistic levels. "An attendant with a patient walks in. He is a rich and educated man and has come in a Mercedez Benz. In a panicky state, as the relative 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 continues, So when your car needs repair, you go to the people who manufac- tured/created it. And who created you and your relative? The attendant 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 eorts, without guarantees. The attendant is able to understand the limitations of the doctor. The doctor proceeds for the surgery and the patient comes out of the operation theater healed. And the patient and the doctor live happily thereafter." (A happy ending here, but not always. The patients and attendants begin to treat him like a God, but he does not want to be one.)
39. 39. Medical Approach He has an admirable precision, which is so critical in his profession. He holds high stan- dards of integrity and ethics and does not shy away in discussing the ground realities with the attendants of the patient. No wonder his reputation and credibility has travelled far and wide. He emphasizes, We always perform surgeries in teams and team orientation is very crucial for success in our profession. Yet it is sometimes a challenge as a leader to lead a team of people of diverse backgrounds and cultures. He specializes in intracranial aneurysms embolization (coiling), ArterioVenous malforma- tion (AVMs) and tumour embolization, Angioplasty and stenting of arterial stenosis including carotid stenting, Intra-arterial Thrombolysis for stroke and Percutaneous spinal procedures such as vertebroplasty and other interventional procedures etc. The Brainy Battle Goes On His primary focus area is Endovascular Neurosurgery. Before joining Medanta, he was the Head Interventional 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 Interventional Neuroradiolgy from Foundation 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 publications in journals, 7 chapters in books and more than 40 abstract (paper) presentations in Indian and international conferences. He has been visiting Professor in UMASS general Hospital, Boston, USA. He is a member of sever- al professional bodies and is especially keen on creating stroke (brain attack) awareness.
40. 40. Once a pioneer, always a pioneer He was among the rst in India to use dedicated intra cranial stents and 3D-DSA for aneurysm embolization, to perform intra cranial venous sinus stenting and one of the few full time Neurointerventionists specializing in endovascular interventions in Stroke. Here is a list of his fellowships, awards, achievements and other contributions, which go on and on. Fellowships Foundation Rothschild, Paris; Cleveland clinic (USA) and in Italy Awards 1. IMA Award- Stroke Meeting Feb 2006 2. IMAAMS Distinguished Service Award - Annual Conference of IMAAMS, 2007 3. I.M.A. Academy of Medical Specialties- New Delhi, 09th December, 2007 4. Recognition Award- Max Healthcare Institute Limited- 2008 5. Best paper award- Joint Annual Conference of Neuroradiology, Vascular and Interven- tional Radiology, Bangalore, India, 1999 6. Best poster award- 6th Annual conference of Indian Society of Vascular & Interventional Radiology) and Indian Society of Neuroradiology, 2003 He has a slew of achievements, academic contributions and of course patient stories and testimonials. 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.
41. 41. No grey areas here, but loads of Grey Matter What surprised me the most about him is that he can discuss a philosophical subject such as Indian culture and ethos as easily as he can discuss the precision and techniques of neurosciences. He shared some very interesting observations on the challenges of creates systems and processes in India, where people trust people and relationships, more than they trust the systems. Enough of grey matter now, I think. With a dose of medical terminology and discussions on brain, interrupted by a hundred phone calls, my brain is getting dizzy now. Let me rest now and come back with more soon. (Story written & edited by Dr Amit Nagpal and ALS team) Not exhausted yet, nd out more about Dr Vipul here LinkedIn Facebook Page Website Youtube channel Medical Tourism Directory
42. 42. Member Profiles Dr Sumit Singh A topper in DM neurology at All India Institutes 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 rst 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 initi- ated the use of botulinium toxin for the rst time in the country, and extended its usage in trigeminal Neuralgia.
43. 43. He is one of the few botox injectors in India for Spasticity, Limb dystonias, hemifacial spasm, oral dyskinesias, spasmodic dysphonia and writers cramp. Dr Sumit had been with Deep Brain Stimulation 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, Polymyositis, and has introduced special protocols for Multiple Sclerosis for the rst time in the country. . Dr Sumit has more than 90 publications in National and international journals and has written several chapters in books. His main areas of expertise are Movement disorders, headache and Neuromuscu- lar disorders. Dr Gaurav Goel Dr. Gaurav Goel is a Neuro-Interventionist trained from prestigious Montreal Neurologi- cal Institute and Hospital in Canada. He specializes in the treatment of vascular disorders of the brain and spine like coiling of aneurysms, embolization of the AVM (arterio-venous malformations), stenting in intracranial and extracranial atherosclerotic disease and tumor embolization. He also has vast experience in newly developed ow diverter stents for intracranial aneurysm. His primary area of interest remains in the treatment of acute stroke using mechanical and chemical thrombolytic 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 patients 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 expertise to Medanta. Dr. Gaurav Goel is one of the very few DM neuro-radiologists in the country and is a leading expert in the diagnostic neuro-imaging including the recent advances like diusion, MR/CT perfusion, MR/CT angiography and spectroscopy.
44. 44. Annexures 6
45. 45. Media Gallery
46. 46. Useful Resources & Links Neuro Innovations on Youtube https://www.youtube.com/channel/UC0mTNls5DSL05-MrzRK69Pg Doctors Perspectives on Medical Profession and Life https://www.linkedin.com/today/author/184345126 Presentations on Latest developments and Research in Neurointervention http://www.slideshare.net/vipulgupta35175/presentations NeuroIntervention India http://www.neurointerventionindia.com/ Facebook Page https://www.facebook.com/NeurointerventionGurgaon Healthy Living section-Hungton Post http://www.hungtonpost.com/ A Health Blog http://www.ahealthblog.com/ Brain Anatomy http://brainanatomy.tk/ Your Brain Health http://yourbrainhealth.com.au/
47. 47. Foundation Brochure
48. 48. Contact Us Dr. Vipul Gupta Head- Neurovascular Intervention Centre Medanta Institute of Neurosciences Medanta The Medicity Sector 38, Gurgaon, Haryana - 122001, India Telephone: +91-124-4141414 Extn: 6610 Mobile: +91-9810542372 Email: drvipulgupta25@gmail.com For Appointment: 9810332224 Dr. Gaurav Goel MBBS, MD, DM, Felloe ( interventional Neuro Radiology) Consultant- Interventional Neuroradiology Medanta Institute of Neurosciences Mobile: +91-9650789820 Email: gaurav.goel@medanta.org
49. 49. Storytelling By s e r v i c e s LFrom Branding, the journey, toBonding, the destination TM +91 9810 337 995 l www.alservices.in l amit@alservices.in