Interventional Neurology and Acute Stroke Management
Dr. Boby Varkey Maramattom MD, DM

Fellow in Stroke & Critical Care Neurology (Mayo Clinic), Lourdes Hospital Neorointerventional procedures have become a standard procedure for most of the neurological disorders such as: 1. Mechanical and intra arterial thombolysis for acute ischemic and post operative strokes 2. Intra arterial thrombolysis for central retinal artery occlusions (CRAO) causing sudden blindness. 3. Thrombolysis for cerebral venous thrombosis 4. Carotid or vertebro-basilar angioplasty and stenting
5. Embolization for arterio-venous malformations. 6. Coiling for intracranial aneurysms. 7. Percutaneous Vertebroplasty for vertebral compression fractures,
osteoporotic fractures etc. To keep you updated as to the indications for referral, please keep this ready reference list on your desktop. A. Onset of acute ischemic stroke within 6 hours. Remember this time is critical. The time to treatment determines the success or failure of the procedure. Instant referral will reduce mortality and morbidity from strokes. B. Acute central retinal artery occlusion {CRAO} within 6 hours. C. Prior stroke with a critical carotid or vertebro-basilar stenosis. D. Symptomatic brain AVMs (arterio-venous malformations) E. Subarachnoid or intracerebral hemorrhage. F. Vertebral compression fractures causing severe pain or deformity. G. Transient ischemic attacks (TIAs) Ever since our state of the art, biplane digital cath lab [1st of its kind in South east asia] has been inaugurated, we have performed nearly 60 cerebral angiograms, 4 intra arterial thrombolysis and a few carotid stentings. World class faculty interact with our department and
renowned Neuro interventionalists from across the country and abroad coordinate with us and assist us in managing difficult cases. The department is headed by Neurointerventionalist, Dr Bobby Varkey . The department is geared for immediate action and open 24 hours. From casualty to the cath lab, the door to needle time is less than 30 minutes. In acute neurovascular problems please call our help line 4123456 extension 1531 (Neuro Stroke ICU) who will contact me immediately. Please remember ‘Timely referral saves a brain’. The following short examples are presented to refresh your knowledge of neurovascular interventions.
AVM EMBOLIZATION Arteriovenous Malformations (AVM's) are a condition in which there is an abnormal connection between arteries that normally supply brain tissue and veins. Embolization is a method of treating AVM's by placing tiny catheters next to the AVM and injecting materials under X-ray guidance to block the abnormal vessels. These materials can include coils or liquid adhesives and can cause significant reduction of the AVM size. Panel A shows the AVM, Panel B shows obliteration of the AVM

Role of Troponin in Chest Pain Evaluation and Rest Stratification
Dr. N. Balakrishnan MD, DM, Sr. Consultant & HOD, Cardiology, LHINC

Chest Pain is a very common presentation in an emergency room. It is important to recognize patient who need admission and urgent revascularization. The term Acute Coronary Syndrome (ACS) refers to this group of patients. It includes a spectrum of disorders viz. Unstable Angina, Non ST segment Elevation Myocardial Infarction (NSIMI), and ST segment Elevation Myocardial Infarction (STEMI). Unstable angina is the diagnosis in patients presenting with rest angina, recent onset angina or recent worsing of chronic stable angina. NSTEMI refers to group of patients presenting with angina with ECG changes other than ST segment elevation
and evidence of myocardial necrosis. Troponin has emerged as the most useful marker is early detection of myocardial necrosis. Both Troponin I and T has been found to be useful in diagnosis. Qualitative Troponin test identifies patients at high risk and need referral to a regional centre of excellence for the urgent coronary angiography and intervention. Quantitative tests gives a better idea of the risk and degree of myocardium at jeopardy. Values above 0.01 ng/ml are found to predict high mortality. In summary, Troponin is an extremely useful test in risk stratification in ACS. Patients with rest angina, nonspecific ECG changes and positive Troponin, benefit from an early interventional strategy.

MINIMALLY INVASIVE ANEURYSM TREATMENT - An aneurysm is a weakening in the wall of a blood vessel. This results in the formation of a balloon like
bulging in the wall. Depending on the clinical situation, there is a significant risk that an aneurysm may rupture and cause bleeding.Aneurysm coiling is a minimally invasive procedure using Guglielmi Detachable Coils (GDC) made of a fine platinum wire to fill the inside of the aneurysm thereby eliminating it from the circulation. A successful coiling will prevent future aneurysm rupture. This procedure is performed in our angiography suite. A fine catheter is threaded from the femoral artery in the groin the way to the inside of the aneurysm. Through this catheter the platinum wire GDC coil is then inserted. CAROTID STENTING - Carotid stenting is a new treatment that offers an effective means of reestablishing blood flow through blocked carotid arteries. The blockage can cause recurrent ischemic strokes or TIAs. Carotid stenting is a procedure in which a stent is fitted inside a carotid artery to increase the flow of blood blocked by plaques. The stent is inserted following angioplasty, in which a balloon-tipped catheter is guided into the blocked artery and inflated to re-open the artery. The stent acts as scaffolding to prevent the artery from collapsing or being closed by plaque after the procedure is completed. The smooth lining of the arterial wall eventually grows back to cover the stent and secure it, so the stent will not dislodge. Stents are left in place permanently, and because they are made from stainless steel or metal alloys, they will not rust or deteriorate. THROMBOLYSIS FOR STROKE AND CRAO - If a patient with ischemic stroke or CRAO is brought to hospital within 4-5 hours, an angiogram is performed. If the site of block is visualized, then microcatheters can be taken up to the site of the block and thrombolytic drugs and wires can be used to open up the block. However the timing of thrombolysis is crucial. If the patient reaches the hospital after 6 hours, then intraarterial thrombolysis may be contraindicated.
Hence early referral is essential.

Preventing heart failure after a heart attack : Hit hard and hit fast
Dr. Mohan Komaranchath MD, DM, Lourdes Hospital

Presentation Summary : Heart attacks are the leading cause of death in several countries world wide and are associated with severe morbidity and death. Though more people survive heart attack in the early 21st century than at other times in the past, the increased survival is associated with a higher incidence of heart failure, morbidity and suffering. The presen- tation deal with the important issue of limiting this major problem in the survivors of a heart attack. Limitation of the infarct size is the key to limiting post MI MORBIDITY. The key points in achieving this are : 1. Achieving an early reperfusion of the infarct related artery: as early as possible. 2. Completely restoring normal arterial flow. 3. Lowering myocardial metabolism to limit damage Early recognition of the infarct is paramount to minimizing damage,
followed by early administration of 325mg of soluble aspirin, 600 mg of clopidogrel, Streptokinase given within one hour is effective, but a single bolus of Tenecteplase has been shown to achieve almost double the patency rates of SK (60%) without the risk of allergy or hypotension. Primary angioplasty achieves 95% patency and is the modality of choice, especially in large, anterior infarcts, patients in shock, patients with diabetes and other risk factors. In summary, early recognition (hitting fast) and using the most effective drugs/angioplasty techniques is the best available treatment to limit heart failure after a heart attack.