rteriovenous malformations are abnormal clusters of blood vessels which can be seen in any part of the human body.

They are congenital in nature. In he brain ,AVM's may have no symptoms at all and the abnormality may be picked during a brain scan for another reason. However, one the commonest presentations is with a bleed in the brain resulting in paralysis or unconsciousness . Another form of presentation can be seizures . Its also known that AVM,s can at time's result in frequent head aches termed "vascular headaches". When detected, AVMs are ideally treated to prevent bleeding in future.

Procedure Details
Patients with AVM's may have no symptoms at all and the abnormality may be picked during a brain scan for another reason. However one the commonest presentations is with a bleed in the brain resulting in paralysis or unconsciousness . Another form of presentation can be seizures . Its also known that AVM,s can a time result in frequent head aches termed "vascular headaches".

Diagnosis
The Diagnosis or a vascular malformation is usually made on CT or MR. However,Angiography is a mandatory investigation to not only confirm the diagnosis but to also understand the character and morphology of the malformation . Its also important to measure the size of the AVM since the management would depend on this.

Treatment options.
The three options that are available in the management of AVM'S are aopen bendovascular c- radio surgery . Often multiple modalities have to be used to cure an AVM. Open surgery is reserved for large AVM'S .However, it is a risky procedure and has to be performed by surgeons specially trained to do these procedures . Here, the skull is opened and the malformation located and the abnormal cluster of vessels delicately excised. Endovascular(embolization) therapy surgery therapy

is performed like Angiography .through a small skin puncture a catheter is navigated under imaging control and placed in the blood vessel that supplies the region of the brain that has the AVM. Another thinner and softer tube is then navigated right up to the AVM and a special medical glue "onyx" is then slowly injected to fill abnormal spaces in the vascular malformation . This procedure may have to done in two three sittings if it is large smaller AVM's can be treated in one sitting. Stereo-tactic radio-surgery is another form of treatment which is used in small AVM's especially when the risk of bleeding is low. Although the term surgery is used the procedure involves no surgery at all. The treatment is a highly specialized form of radiotherapy where multiple beams are focused on a single point . It is a procedure that describes accurate, precise delivery of ionizing radiation in a single fraction to an intra-cranial lesion with the intent of eradicating or stabilizing the focus of disease. SRS may be a viable alternative to conventional surgery for brain lesions such as brain mets, Arteriovenous Malformations (AVM), Gliobastoma Multiforme (GBM), Meningioma and Acoustic Neuroma (AN). However after this procedure it may take months to years before the AVM is finally obliterated and thus may not play a role when the AVM has a very high chance of bleeding.

Complications of Embolization
Even though this procedure is safer than open surgery the following complications are possible - rupture of the AVM during embolization, clot formation in a normal blood vessel during the procedure or glue occluding a normal vessel. All these can lead to permanent disability or may even prove fatal.

About the Procedure

Aneurysms are small outpouchings from of vessel wall. It is believed that the vessel is weak at this area. This small outpouching has a tendency to grow reducing an extremely friable or which is liable to burst at any moment. When an aneurysm ruptures in the brain, the patient experiences headache of such severity that it is termed thunder clap headache.Close to 20 % of patients never reach the hospital at all. Another 20% will die in the next two weeks unless the aneurysm is treated.Aneurysms which have bled have a very high likelihood of bleeding again in the

next few days and definite treatment for the same should be given at the earliest. Endovascular coiling is an innovative technique where, this weak area in the blood vessel of the brain is repaired by packing this this outpouching with multiple medical coils which obliterates the sac completely. The procedure is done by a small puncture in the blood vessel of the thigh without opening the brain and skull.

Procedure Details SAH and Aneurysm

When an aneurysm ruptures in the brain, the patient experiences headache of such severity that it is termed thunder clap headache.Close to 20 % of patients never reach the hospital at all. Another 20% will die in the next two weeks unless the aneurysm is treated.Aneurysms which have bled have a very high likelihood of bleeding again in the next few days and definite treatment for the same should be given at the earliest.

Management
Till a few years ago the only treatment available for intracranial aneurysm was open surgery . Here the skull was opened and the connection between the abnormal sac and the main vessel excluded by placing a specially designed surgical clip . However this surgery is risky and also difficult in certain locations ,particularly in the elderly and when the patient is semi or unconscious. In the mid Nineties a revolutionary treatment was developed by Dr. Guglielmi, an Italian neuro-radiologist, where a fine tube is inserted from a needle puncture in the leg . This tube is navigated under advanced image guidance into the aneurysm and the sac delicately packed with very fine soft platinum wires shaped to look like coils that match the size of the aneurysm . Several such coils may be required to close an aneurysm ,this basically depends on the size of the abnormal sac. The actual procedure may vary depending on the size of the junction between the sac and the normal blood vessel (neck). When this is small only coils are used , when its moderately large a balloon may be used to help packing the aneurysm.When the neck is really wide, a metal tubular mesh(stent) is first deployed across the neck and then the coils packed.(animation). Although there is no major external surgery ,the procedure is ideally performed under general anesthesia to keep the blood pressure under control and to also to ensure that the patient does not move.

Post Procedure
Following the procedure the patient may return to the room or the ICU . This depends on the severity of the initial bleed.A patient

who has SAH is also prone for vaso-spasm where the blood vessels of the brain may contract as a result of the blood that has leaked out and at times this can prove fatal especially if the initial bleed is large. Every patient who has coiling performed is advised to undergo followup angiography after six months, since in about 5-18% patients a part of the aneurysm may reopen in some this may be significant and additional coils may be required for stability.

Complications
Even though this procedure is safer than open surgery, during the acute stage the following complications are possible - rupture of the aneurysm during coiling, clot formation in a normal blood vessel during the procedure or coils occluding a normal vessel.All these can lead to permanent disability or may even prove fatal.

About the Procedure

Because the brain relies on only two sets of major arteries for its blood supply, it is very important that these arteries are healthy. Then one of these blood vessels or its branches are suddenly blocked the brain tissue in that area stops functioning. If this block can be removed within the first 6 hours then, most of this tissue can be salvaged and the patient may have full recovery. It is not only important to remove this block but it is also mandate lead to ascertain the cause of this block. Sometimes narrowing in the blood vessel that leads to the brain [stenosis] can be the underlying reason for this block. Since stenotic segments are prone to generate blood clots which can then flow into the cerebral circulation leading to stroke. Today thanks to interventional radiology techniques a small catheter can be navigated right into the block and special proximal injected to dissolve and salvage the dying brain tissue. Further, the narrowing in the blood vessels can also be treated by angioplasty and stenting.

Procedure Details "Brain Attack" is another name of Stroke.

The brain is the most important organ in the body. It cannot last for more than a few minutes without blood supply unlike any other organ in the body once the brain tissue dies one cannot do a procedure like a transplant to get back its normal function. Thus

it is extremely important to recognize the warning signs of stroke and also to treat stroke at the earliest in the center that is it equipped to handle stroke

WARNING

SIGNS

There are also warning signs of an impending ischemic stroke, and stroke often does not strike unannounced. PRIOR STROKE Stroke can strike a person twice. Suffering one stroke, regardless of its severity increases your chances of suffering a second stroke. TIA (Transient Ischemic Attack) A TIA is a temporary Cerebrovascular disruption that leaves no permanent damage. These are recognizable events and can be predictor of a future, more devastating stroke. One of the common causes of TIA is narrowing of the blood vessel that supplies the brain it can either be in the vertebral or carotid artery. Of the two carotid stenosis is commoner.

CAROTID

STENOSIS

Carotid artery disease refers to plaque building up on the artery wall. The bodys natural reaction is to heal over it much like a scab forming over a cut. This condition is called arteriosclerosis artheroma is the plaque material that builds up, and sclerosis refers to the bodys reaction to harden the material. The material accumulates and narrows the artery. The narrowing is referred to as stenosis Certain features of stenosis such as the size of the artery and location of the blockage, or certain medical conditions in your history may call for different treatment called carotid Stenting. In this procedure, a small tube like support called stent is threaded in to the narrowing artery from a hole made in the groin(in the same way the angiography catheter is inserted). The stent is then expanded and opens the narrowing, restoring normal blood supply to the brain. Today carotid stenting is a safe procedure especially if it is performed by placing a small filter in the blood vessel prior to stenting following the procedure this filter was removed. There is enough evidence to suggest that carotid stenting with filter protection is as safe as open surgery.

SYMPTOMS OF STROKE
The single most important factor in treating an acute stroke is time. Stroke is an emergency. Stroke victims need urgent medical care. Symptoms of Ischemic stroke include: VISUAL DISTURBANCES, INCLUDING BLOCKED OR LOSS OF VISION IN ONE EYE, BLURRY VISION OR GRAYING It seemed like someone was pulling a shade over one of my eyes WEAKNESS, NUMBNESS OR CLUMSINESS IN ONE ARM OR HAND OR LEG. My arm wouldnt do what I wanted it to do I couldnt hold on to my coffee cup

 I couldnt lift up my arm/leg. My arm felt tingly LANGUAGE PROBLEMS, INCLUDING SLURRED SPEECH I just couldnt say anything She sounded drunk My family couldnt make sense of what I was saying FACIAL DROOP/WEAKNESS The left side of my face was sagging DIZZINESS, STUMBLING I couldnt walk straight Symptoms of Hemorrhagic Stroke include: SEVERE OR SUDDEN HEADACHE I have the worst headache of my life LOSS OF CONSCIOUSNESS AND/OR VOMITING If there is any doubt whether you, or someone around you, is experiencing a stroke, seek immediate medical attention.

TREATMENT OF ISCHEAMIC STROKE

A thrombotic stroke occurs when a build up of plaque and blood clot, called a thrombus, blocks an artery to the brain and stops blood flow. An embolic stoke occurs when a piece of plaque or thrombus travels from its original site and blocks an artery down stream. The material that has moved is called an embolus. How much of the brain is damaged or effected depends on exactly how far downstream in the artery the blockage occurs. EARLY TREATMENT CAN SAVE LIFE AND RESCUE THE BRAIN There are new treatments available to help rescue cells in the first 6 hours, we can treat stroke and stop permanent brain damage by giving a clot dissolving drug intra-venously in the first 3 hours (TPA) or actually taking a small tube from the brain into the blocked blood vessel and we can dissolve the clot with drugs like urokinase within 3 to 6 hours of stroke. However, before drug therapies can be given, a CT scan must be obtained to rule out any bleeding in the brain. This takes precious time. The sooner you get to the hospital, the better chance you have for a good outcome. All stroke victims must come in time to the

hospital to make them eligible for this therapy which will make the difference between complete recovery and permanent disability.

About the Procedure

Click on the image to view animation Turn on speakers The brain receives its blood supply from two sets of blood vessels,the Carotids in the front, and the Vertebral arteries at the back. If any of these vessels become narrow, then the patient may experience a condition termed TIA. In TIA one may experience a transient loss of consciousness , weakness in the limb.or blurring of vision. Narrowing of these vessels are generally caused by deposition of fat and fibrous tissue due to atherosclerosis. It can also be rarely seen due to inflammation of the blood vessels or arteritis. Till recently these patients had open surgery as the only option. However thanks to interventional radiology this narrow segment in the vessel can be safely opened through a small skin puncture by a procedure cord carotid / vertebral angioplasty and stenting.

Procedure Details
The brain can be considered to be the most vital organ of the body. Unlike any other organ the brain requires a continuous supply of blood. Severe damage can take place if this organ does not have oxygen for more than a few minutes. One of the common causes of stroke is a occlusion of a blood vessel supplying a vital part of the brain. They are commonly caused by a small blood clot that develops at the site of narrowing in the carotid or vertebral arteries, which are the main blood vessels that supply the brain. the clot then detaches it self and migrates into the smaller intracranial vessels along the direction of flow. Narrowing of these vessels are commonly caused by atherosclerosis. In this condition deposition of fat and fibrous tissue results in reduction in size of the lumen which in turn produces turbulence of blood across this segment. Another reason a blood vessel can be narrow is secondary to a type of inflammation called arteritis. This is commonly seen in young women. Often carotid stenosis may have no symptoms at all and may be detected during a

Doppler ultrasound of the neck. At times the patient may experience intermittent numbness or weakness of one half of the body or of a single extremity. Patients also may experience blurring or blindness in one eye which may last for a few seconds. This condition is called TIA. Color Doppler evaluation of the neck vessels is a simple and accurate way to establish the diagnosis of carotid stenosis. Once this diagnosis is made ,the patient should ideally receive treatment which could either be surgical or a non- surgical -carotid stentingand if the stenosis is more than 65% . Technique

Carotid stenting involves taking a fine tube [catheter] under imaging guidance through small puncture in the blood vessel of the thigh into the suspected blood vessel that supplies the brain. This is performed under sophisticated imaging guidance. An angiogram is performed to confirm the diagnosis that is made by Doppler. After this a fine wire which has a specialized medical filter is navigated across the narrow segment and placed beyond it in the normal vessel. The narrow segment is then dilated with a balloon catheter. The balloon is then exchanged for a fine metalmesh (stent). Further balloon dilatation is performed if the lumen continues to be narrow after stenting. Following the procedure the filter is captured in a specialized tube and removed. The puncture site in the groin is then compressed till hemostasis is achieved or an Angio-Seal device is used to prevent further bleeding. There is enough evidence in the literature to conclusively said that carotid stenting is in no way inferior to open surgery for carotid stenosis. Narrowing of the vertebral artery can also be treated in the same way. Here, unlike carotid stenting interventional radiology is the only way reestablished normal flow. Surgery of the vertebral arteries is difficult and dangerous.