1. An Initiative of Stroke and Neurovascular Interventions
Foundation Creating Stroke Awareness Stroke and Neurovascular
Interventions
2. Story telling by AL Services
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Patient Stories 4
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. 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. 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. 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. The TEAM 5
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. 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. 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. 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. 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. 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. 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. 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. Annexures 6
45. Media Gallery
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. Foundation Brochure
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:
[email protected] For Appointment: 9810332224 Dr. Gaurav
Goel MBBS, MD, DM, Felloe ( interventional Neuro Radiology)
Consultant- Interventional Neuroradiology Medanta Institute of
Neurosciences Mobile: +91-9650789820 Email:
[email protected]
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 [email protected]