Dr. Sidharth Ghosh

CV Junction

Cerebrovascular disorders are a group of diseases related to the vessels of the brain. There are many different types and following are a few examples:

Aneurysms:
Aneurysms are balloon like weakness in the vessels that carry blood to the brain. The walls of these balloons or aneurysms are thin and can break due to the pressure of flowing blood. This results in blood seeping in and around the brain and this is how they are most often diagnosed. These are called ruptured aneurysm. A ruptured aneurysm is an emergency and definitive treatment i.e. either surgery or endovascular coiling has to be undertaken as soon as possible, because there exists very high likelihood it rupturing again which in itself is fatal. Before this treatment a DSA (digital subtraction angiogram) has to be done to plan appropriate treatment.

Rarely aneurysms are discovered on scans that were done for some other reason and accidently aneurysm is found and these are called unruptured aneurysms. Current consensus is that if they are more than 5 mm in size they should be treated. If smaller than 5 mm they have to be followed up with regular scans.

Very rarely they may be diagnosed if they grow to large size and compress adjacent structures, and they without exception require treatment.

The gold standard of treatment till few years back was open surgery and clipping of aneurysm, which basically involves putting a metal clip at the base of the aneurysm and thereby removing the aneurysm from the blood vessel. Now the option of coiling is also available. This procedure is carried out by putting a needle in the femoral artery (in the thigh) and then passing a small tube (catheter) into the aneurysm and then depositing wires which coil inside (hence called coiling) the aneurysm and remove it from the circulation.

It must be understood that both procedures have their advantages and disadvantages and there are some aneurysms which are best clipped by surgery and there are some that are best coiled. There are also instances when both procedures give equally good results. The cost of coiling is many times more than clipping and therefore affordability also influences the choice of treatment.

At our centre we offer both treatments to patients. For further information please contact us.

AVM (Arteriovenous malformation):
AVM is an abnormal connection between an artery (vessel carrying blood from heart to other parts of body) and vein (vessel carrying blood for body parts back to heart). This connection is via a abnormal tuft of vessels (called nidus). These may be small to giant. They are diagnosed in one of many ways- bleeding, fits, neurological symptoms, etc. Once diagnosed, they require treatment because they have tendency to bleed inside the brain which can be life threatening, or they steal blood meant for normal brain, or they exert pressure on normal brain.

Treatment options include surgery, stereotactic radiosurgery, gamma knife, or cyberknife.

Open surgery and removal of AVM can be done for small or medium size AVM which are located close to surface of brain or in brain area which does not serve critical functions. Advantage of open surgery is that the risk of bleeding is immediately abolished. In experienced hands results of surgery are excellent.

Stereotactic radiosurgery, Gamma knife or cyberknife is a special method of delivering focused high dose radiation therapy to a lesion (tumor,AVM etc.). This is not really surgery but radiation therapy. For AVM they are very frequently used because it avoids open surgery and results are excellent. Not all AVM can be given this treatment. Generally those less than 3 cm in size are most suited.

There is a group of AVM which are called giant AVM because of their large size. These are technically neither suitable for surgery nor for radiation therapy. They still have to be treated, because they pose risk to life from bleeding and cause disability due to fits and neurological deficit. These can be successfully treated with a combination of surgery and/or radiation therapy with embolization. Embolization is a procedure where a tube is passed to the AVM from inside the vessel and glue is deposited to close the AVM. Embolization alone does not cure it in most cases hence a multimodality treatment is needed, which is offered at our centre.

Moya-moya disease:
This is a rare disease, and is caused by narrowing of main arteries (vessels carrying blood from heart to brain) inside the skull. This leads to insufficient blood supply to the brain and the brain tries to get blood from alternative channels (called collaterals). With time the narrowing becomes worse and the alternative channels (collaterals) cannot supply sufficient blood to brain. This causes multiple strokes- in fact this disease is one of the commonest causes of childhood strokes. Bleeding into brain from the fragile collateral vessels is also not uncommon. This disease affects both children and adults.

The treatment of this disease is surgery and surgery only. Unfortunately due to lack of awareness the patients keep taking medicines which do not really help control the disease. Surgery is the best treatment, and in most cases is simple and effective. Some cases require surgery in form of creating vascular bypass to increase blood flow to brain. Both type of procedures are performed at our centre, whichever is appropriate for a patient.

Stroke:
Stoke or brain attack is probably as common as heart attack, but people lack awareness of this disease and often delay treatment. Time is golden in treatment of stroke and results are best when treatment is started within six hours of stroke.

Strokes are of two types:

Ischemic stroke: This occurs when a artery (vessel carrying blood to brain from heart) is suddenly blocked be a clot. This can lead to symptoms like inability to speak, slurring of speech, irrelevant talking, paralysis of one side of body, altered behaviour or consciousness or even coma. The treatment is giving blood thinning medicine (anti-coagulants) to try and dissolve the clot. This can be done only within 6 hours of the stroke hence it is must to realise this is an emergency requiring immediate treatment. Surgery is needed in some select cases where the pressure (intracranial tension) inside the skull becomes high due to swelling of brain (edema). In such cases a decompressive craniectomy (surgery to reduce pressure in skull) may be life saving.

Some patients suffer strokes mini-strokes or temporary strokes (transient ischemic attacks) due to fat deposition (plaque) and narrowing of carotid artery (main blood vessel to head). It has been conclusively proven by numerous international trials that removal of plaque (carotid endarterectomy) by surgery reduces risk of major stroke and death. However, due to lack of awareness most patients are not offered this excellent surgical procedure. Very recently stent placement has also become a viable option in some cases.

Hemorrhegic stroke: This occurs due to bleeding inside the brain and can happen due to many causes. Most common are high BP (hypertension) and blood thinning medicines. Treatment involves taking steps to control the cause of bleeding immediately. The blood clot itself if small can be treated with medicines, but larger blood clots have to be removed by surgery to reduce pressure (intracranial pressure) inside the skull. In some countries blood clot breaking medicines (thrombolytics) are placed inside the clot to dissolve it using stereotactic methods, or by using endoscope. These methods are not universally accepted as standard procedures for treating intracranial hemorrhage (blood clot inside brain).