Interventional neuroradiology

Last updated

Interventional neuroradiology (INR) also known as neurointerventional surgery (NIS), endovascular therapy (EVT), endovascular neurosurgery, and interventional neurology is a medical subspecialty of neurosurgery, neuroradiology, intervention radiology and neurology specializing in minimally invasive image-based technologies and procedures used in diagnosis and treatment of diseases of the head, neck, and spine. [1]

Contents

History

Endovascular modalities for intracranial aneurysms StentingCoils.png
Endovascular modalities for intracranial aneurysms

Diagnostic angiography

Cerebral angiography was developed by Portuguese neurologist Egas Moniz at the University of Lisbon, in order to identify central nervous system diseases such as tumors or arteriovenous malformations. He performed the first brain angiography in Lisbon in 1927 [3] by injecting an iodinated contrast medium into the internal carotid artery and using the X-rays discovered 30 years earlier by Roentgen in order to visualize the cerebral vessels. In pre-CT and pre-MRI, it was the only tool to observe the structures within the skull and was also used to diagnose extravascular pathologies.

Subsequently, European radiologists further developed the angiographic technique by replacing the traumatic direct puncture with catheterization: in 1953, Swedish physician Sven Seldinger introduced the technique of arterial and venous catheterization still in practice, [4] dubbed the Seldinger Technique. In 1964, the Norwegian radiologist Per Amudsen was the first to perform a complete brain angiography with a transfemoral approach, as it is performed today; he then moved to San Francisco to teach the technique to American neuroradiologists. [5] These two stages, at the basis of modern invasive vascular diagnostics, prepared the way for later therapeutic developments.

The first treatments: balloon occlusion

The first to carry out a true endovascular procedure was Charles Dotter, the father of angioplasty and considered by many as the father of all interventional radiology, as well as the first doctor to have performed endovascular treatment. On January 16, 1964, he performed a therapeutic angioplasty of a superficial femoral artery in an 82-year-old woman with an ischemic leg refusing amputation. [6] The artery remained open for the next two and a half years, after which the woman died of pneumonia.

The concept of using balloons to treat cerebrovascular lesions was inspired by a 1959 May Day celebration in Moscow’s Red Square. While watching children use tether lines to manipulate helium balloons, Fedor Serbinenko, a Russian neurosurgeon, began to envision small balloons moving through tortuous arteries. [7] In the 1970s Fedor Serbinenko developed a technique for closing intracranial aneurysms with balloons that were released into the internal carotid artery by occluding the lumen. The first treatment was performed in 1970 in Moscow, with the occlusion of an internal carotid to treat a carotid-cavernous fistula. He can be considered, therefore, the first interventional neuroradiologist. This technique was subsequently refined by neuroradiologists all over the world and mainly in France, where interventional neuroradiology developed and flourished.

Parallel to the development of catheters, in the radiology and neuroradiology units, image technology dramatically improved: Charles Mistretta in 1979 invented digital subtraction angiography (DSA), the technique currently in use. It consists of performing skull radiography under basic conditions which are then "subtracted" to the image after contrast media injection, to provide an image where only brain vessels are displayed, with great improvement in the diagnostic potential.

Coils replace balloon occlusion

Between the end of the 1980s and the beginning of the '90s, INR was suddenly revolutionized after the work of two Italian physicians: Cesare Gianturco and Guido Guglielmi. The first combined a deep knowledge of diagnostic radiology with a great ability to solve technical and manual problems. He invented Gianturco's coils, which he used to make the first attempts to embolize arteries and aneurysms. [8] Gianturco also patented the first endovascular stent approved by the American FDA; [8] a device with a great legacy. In the second half of the 1980s, Sadek Hilal was the first in Columbia University to use coils to treat brain aneurysms; but this technique was inaccurate and dangerous because the coils were released with little control with great risk of occluding the vessel from which the aneurysm originated (parent vessel). [9] The coil embolization was revolutionized by the work of Guido Guglielmi in UCLA, who realized that electricity could function as a controlled release mechanism for coils; in 1991 he published two works dealing with the embolization of brain aneurysms by means of detachable platinum coils [10] (Guglielmi's coils). The treatment of aneurysms was thus made more accessible and safe.

New techniques: Sole stenting and flow diversion stents

From the early 2000s, intracranial stents were used to prevent the coils inside the aneurysmal sac from protruding into the parent artery. [11] [12] Flow diversion devices were later developed, with the function of reconstructing the vessel's normal anatomy without directly closing the aneurysm neck and therefore preserving side branches and preventing ischemia. [13] The sole stenting [14] procedure involves the insertion of a stent only (without any coils) into the vessel that has an aneurysm. [15]

Not just hemorrhages: the treatment of ischemic stroke

The Souers Stroke Institute was founded in 1991 at Saint Louis University, and its first director, Camilo R. Gomez, M.D., is often credited with founding interventional neurology as a subspecialty in the United States [16] .

Between January and June 2015, five major randomized trials were published in the New England Journal of Medicine (NEJM) with the collaboration of interventional neuroradiologists and stroke neurologists (in the Netherlands, [17] Canada, [18] Australia, [19] US [20] and Spain [21] ) regarding the role of mechanical thrombectomy in the treatment of ischemic stroke, demonstrating that if it is performed in centers with proven experience, intra-arterial mechanical thrombectomy is more effective than traditional treatment (intravenous thrombolytic injection). The promising results of these mechanical thrombectomy trials were highlighted by the NEJM in an editorial, which concluded with the statement: "Endovascular equipoise no longer exists. It's about time." [22]

Thrombectomy is currently recommended by the guidelines written by the main American (AHA/ASA) [23] and European (ESO-ESNR-ESMINT) [24] societies of stroke neurologists and interventional neuroradiologists.

Diseases and conditions

Endovascular repair of cerebral aneurysm GDCcoilAneurysm.jpg
Endovascular repair of cerebral aneurysm
Intra-cranial angioplasty and stent of basilar artery stenosis IntraCranialAngioplastyStentBasilarArtery.jpg
Intra-cranial angioplasty and stent of basilar artery stenosis

The following is a list of diseases and conditions typically treated by neurointerventionalists.

See also

Related Research Articles

<span class="mw-page-title-main">Intracranial aneurysm</span> Cerebrovascular disorder

An intracranial aneurysm, also known as a cerebral aneurysm, is a cerebrovascular disorder in which weakness in the wall of a cerebral artery or vein causes a localized dilation or ballooning of the blood vessel.

<span class="mw-page-title-main">Aneurysm</span> Bulge in the wall of a blood vessel

An aneurysm is an outward bulging, likened to a bubble or balloon, caused by a localized, abnormal, weak spot on a blood vessel wall. Aneurysms may be a result of a hereditary condition or an acquired disease. Aneurysms can also be a nidus for clot formation (thrombosis) and embolization. As an aneurysm increases in size, the risk of rupture, which leads to uncontrolled bleeding, increases. Although they may occur in any blood vessel, particularly lethal examples include aneurysms of the circle of Willis in the brain, aortic aneurysms affecting the thoracic aorta, and abdominal aortic aneurysms. Aneurysms can arise in the heart itself following a heart attack, including both ventricular and atrial septal aneurysms. There are congenital atrial septal aneurysms, a rare heart defect.

<span class="mw-page-title-main">Interventional radiology</span> Medical subspecialty

Interventional radiology (IR) is a medical specialty that performs various minimally-invasive procedures using medical imaging guidance, such as x-ray fluoroscopy, computed tomography, magnetic resonance imaging, or ultrasound. IR performs both diagnostic and therapeutic procedures through very small incisions or body orifices. Diagnostic IR procedures are those intended to help make a diagnosis or guide further medical treatment, and include image-guided biopsy of a tumor or injection of an imaging contrast agent into a hollow structure, such as a blood vessel or a duct. By contrast, therapeutic IR procedures provide direct treatment—they include catheter-based medicine delivery, medical device placement, and angioplasty of narrowed structures.

<span class="mw-page-title-main">Vascular surgery</span> Medical specialty, operative procedures for the treatment of vascular disorders

Vascular surgery is a surgical subspecialty in which vascular diseases involving the arteries, veins, or lymphatic vessels, are managed by medical therapy, minimally-invasive catheter procedures and surgical reconstruction. The specialty evolved from general and cardiovascular surgery where it refined the management of just the vessels, no longer treating the heart or other organs. Modern vascular surgery includes open surgery techniques, endovascular techniques and medical management of vascular diseases - unlike the parent specialities. The vascular surgeon is trained in the diagnosis and management of diseases affecting all parts of the vascular system excluding the coronaries and intracranial vasculature. Vascular surgeons also are called to assist other physicians to carry out surgery near vessels, or to salvage vascular injuries that include hemorrhage control, dissection, occlusion or simply for safe exposure of vascular structures.

<span class="mw-page-title-main">Subarachnoid hemorrhage</span> Bleeding into the subarachnoid space

Subarachnoid hemorrhage (SAH) is bleeding into the subarachnoid space—the area between the arachnoid membrane and the pia mater surrounding the brain. Symptoms may include a severe headache of rapid onset, vomiting, decreased level of consciousness, fever, weakness, numbness, and sometimes seizures. Neck stiffness or neck pain are also relatively common. In about a quarter of people a small bleed with resolving symptoms occurs within a month of a larger bleed.

Mechanical thrombectomy, or simply thrombectomy, is the removal of a blood clot (thrombus) from a blood vessel, often and especially endovascularly as an interventional radiology procedure called endovascular thrombectomy (EVT). It thus contrasts with thrombolysis by thrombolytic medications, as either alternative or complement thereto. It is commonly performed in the cerebral arteries as treatment to reverse the ischemia in some ischemic strokes. Open vascular surgery versions of thrombectomy also exist. The effectiveness of thrombectomy for strokes was confirmed in several randomised clinical trials conducted at various medical centers throughout the United States, as reported in a seminal multistudy report in 2015.

<span class="mw-page-title-main">Cerebral angiography</span> Angiography that produces images of blood vessels in and around the brain

Cerebral angiography is a form of angiography which provides images of blood vessels in and around the brain, thereby allowing detection of abnormalities such as arteriovenous malformations and aneurysms. It was pioneered in 1927 by the Portuguese neurologist Egas Moniz at the University of Lisbon, who also helped develop thorotrast for use in the procedure.

<span class="mw-page-title-main">Carotid artery stenosis</span> Medical condition

Carotid artery stenosis is a narrowing or constriction of any part of the carotid arteries, usually caused by atherosclerosis.

<span class="mw-page-title-main">Carotid-cavernous fistula</span> Medical condition

A carotid-cavernous fistula results from an abnormal communication between the arterial and venous systems within the cavernous sinus in the skull. It is a type of arteriovenous fistula. As arterial blood under high pressure enters the cavernous sinus, the normal venous return to the cavernous sinus is impeded and this causes engorgement of the draining veins, manifesting most dramatically as a sudden engorgement and redness of the eye of the same side.

<span class="mw-page-title-main">Watershed stroke</span> Medical condition

A watershed stroke is defined as a brain ischemia that is localized to the vulnerable border zones between the tissues supplied by the anterior, posterior and middle cerebral arteries. The actual blood stream blockage/restriction site can be located far away from the infarcts. Watershed locations are those border-zone regions in the brain supplied by the major cerebral arteries where blood supply is decreased. Watershed strokes are a concern because they comprise approximately 10% of all ischemic stroke cases. The watershed zones themselves are particularly susceptible to infarction from global ischemia as the distal nature of the vasculature predisposes these areas to be most sensitive to profound hypoperfusion.

<span class="mw-page-title-main">Vertebral artery dissection</span> Tear of the inner lining of the vertebral artery

Vertebral artery dissection (VAD) is a flap-like tear of the inner lining of the vertebral artery, which is located in the neck and supplies blood to the brain. After the tear, blood enters the arterial wall and forms a blood clot, thickening the artery wall and often impeding blood flow. The symptoms of vertebral artery dissection include head and neck pain and intermittent or permanent stroke symptoms such as difficulty speaking, impaired coordination, and visual loss. It is usually diagnosed with a contrast-enhanced CT or MRI scan.

<span class="mw-page-title-main">Carotid stenting</span>

Carotid artery stenting is an endovascular procedure where a stent is deployed within the lumen of the carotid artery to treat narrowing of the carotid artery and decrease the risk of stroke. It is used to treat narrowing of the carotid artery in high-risk patients, when carotid endarterectomy is considered too risky.

<span class="mw-page-title-main">Endovascular aneurysm repair</span> Surgery used to treat abdominal aortic aneurysm

Endovascular aneurysm repair (EVAR) is a type of minimally-invasive endovascular surgery used to treat pathology of the aorta, most commonly an abdominal aortic aneurysm (AAA). When used to treat thoracic aortic disease, the procedure is then specifically termed TEVAR for "thoracic endovascular aortic/aneurysm repair." EVAR involves the placement of an expandable stent graft within the aorta to treat aortic disease without operating directly on the aorta. In 2003, EVAR surpassed open aortic surgery as the most common technique for repair of AAA, and in 2010, EVAR accounted for 78% of all intact AAA repair in the United States.

Joshua B. Bederson is an American neurosurgeon, Leonard I. Malis, MD/Corinne and Joseph Graber Professor of Neurosurgery, and System Chair of Neurosurgery at the Mount Sinai Health System in New York City. He is a Fellow of the American College of Surgeons, and an attending neurosurgeon at The Mount Sinai Hospital.

<span class="mw-page-title-main">Endovascular coiling</span>

Endovascular coiling is an endovascular treatment for intracranial aneurysms and bleeding throughout the body. The procedure reduces blood circulation to the aneurysm through the use of microsurgical detachable platinum wires, with the clinician inserting one or more into the aneurysm until it is determined that blood flow is no longer occurring within the space. It is one of two main treatments for cerebral aneurysms, the other being surgical clipping. Clipping is an alternative to stenting for bleeding.

Camilo Ramiro Gomez, is an American neurologist, medical educator, and researcher. He is one of the first 100 vascular neurologists certified by the American Board of Psychiatry and Neurology (ABPN), and one of the founders of the subspecialty of interventional neurology in the United States.

<span class="mw-page-title-main">Flow diverter</span>

A flow diverter is an endovascular prosthesis used to treat intracranial aneurysms. It is placed in the aneurysm's parent artery, covering the neck, in order to divert blood flow and determine a progressive thrombosis of the sac. Flow diverting stents consist of structural Cobalt-chrome or Nitinol alloy wires and often a set of radiopaque wires woven together in a flexible braid.

<span class="mw-page-title-main">Demetrius Klee Lopes</span> American neurosurgeon

Demetrius Klee Lopes is a cerebrovascular neurosurgeon specializing in neuroendovascular therapy. At Advocate Health, he serves as medical director of the cerebrovascular and neuroendovascular program and is co-director of their stroke program.

Alexander Coon is an American neurosurgeon who is the Director of Endovascular and Cerebrovascular Neurosurgery at the Carondelet Neurological Institute of St. Joseph's and St. Mary's Hospitals in Tucson, Arizona. He was previously the Director of Endovascular Neurosurgery at the Johns Hopkins Hospital and an assistant professor of neurosurgery, Neurology, and Radiology at the Johns Hopkins Hospital. He is known for his work in cerebrovascular and endovascular neurosurgery and his research in neuroendovascular devices and clinical outcomes in the treatment of cerebral aneurysms, subarachnoid hemorrhage, and AVMs.

Elad I. Levy is an American neurosurgeon, researcher, and innovator who played a major role in the development and testing of thrombectomy, which improved quality of life and survival of stroke patients. He has focused his career and research on developing evidence based medicine and literature showing the benefits of thrombectomy for the treatment of stroke. He is currently Professor of Neurosurgery and Radiology, and the L. Nelson Hopkins, MD Professor Endowed Chair of the Department of Neurosurgery at the State University of New York at Buffalo (SUNY).

References

  1. ↑ Chen, M.; Nguyen, T. (2008). "Emerging Subspecialties in Neurology: Endovascular surgical neuroradiology". Neurology. 70 (6): e21–e24. doi: 10.1212/01.wnl.0000299086.22147.89 . PMID   18250282. S2CID   26791160.
  2. ↑ Zenteno, M (March 2012). "Endovascular approach in the management of intracranial aneurysms. Part 1: basic concepts and devices". Gac Med Mex. 148 (2): 169–79. PMID   22622317.
  3. ↑ Artico, M (2017). "Egas Moniz: 90 Years (1927-2017) from Cerebral Angiography". Front Neuroanat. 11: 81. doi: 10.3389/fnana.2017.00081 . PMC   5610728 . PMID   28974927.
  4. ↑ Seldinger, Sven Ivar (1953-05-01). "Catheter Replacement of the Needle in Percutaneous Arteriography: A new technique". Acta Radiologica. 39 (5): 368–376. doi: 10.3109/00016925309136722 . ISSN   0001-6926. PMID   13057644.
  5. ↑ Rosenbaum, Arthur E.; Eldevik, O. Petter; Mani, John R.; Pollock, Arliss J.; Mani, Richard L.; Gabrielsen, Trygve O. (2001-03-01). "In Re: Amundsen P. Cerebral angiography via the femoral artery with particular reference to cerebrovascular disease. Acta Neurol Scand 1967; Suppl. 31:115". American Journal of Neuroradiology. 22 (3): 584–589. ISSN   0195-6108. PMC   7976838 . PMID   11237988.
  6. ↑ Busch, U (Mar 2014). "50 years ago: Charles Dotter and the first percutaneous transluminal angioplasty". RöFo (in German). 186 (3): 294–5. doi: 10.1055/s-0034-1368886 . PMID   24557558.
  7. ↑ Alaraj, A (Feb 2014). "Balloons in endovascular neurosurgery: history and current applications". Neurosurgery. 74 (Suppl 1): S163-90. doi: 10.1227/NEU.0000000000000220 . PMID   24402485.
  8. 1 2 LaGumina, Salvatore J.; Cavaioli, Frank J.; Primeggia, Salvatore; Varacalli, Joseph A. (2003). The Italian American Experience: An Encyclopedia. Routledge. p. 451. ISBN   9781135583330.
  9. ↑ Group, British Medical Journal Publishing (1963-03-16). "Obliteration of Intracranial Aneurysms by Pilojection". Br Med J. 1 (5332): 700. doi:10.1136/bmj.1.5332.700-a. ISSN   0007-1447. S2CID   30623125.
  10. ↑ Currie, S; Mankad, K; Goddard, A (Jan 2011). "Endovascular treatment of intracranial aneurysms: review of current practice". Postgraduate Medical Journal. 87 (1023): 41–50. doi:10.1136/pgmj.2010.105387. PMID   20937736. S2CID   30220296.
  11. ↑ Fessler, Richard D. (January 2000). "Intracranial Stent Placement to Trap an Extruded Coil During Endovascular Aneurysm Treatment: Technical Note". Neurosurgery. 46 (1): 248–253. doi:10.1093/neurosurgery/46.1.248. PMID   10626961.
  12. ↑ Biondi, Alessandra (September 2007). "Neuroform Stent-Assisted Coil Embolization of Wide-Neck Intracranial Aneurysms". Neurosurgery. 61 (3): 460–469. doi:10.1227/01.NEU.0000290890.62201.A9. PMID   17881956. S2CID   24343785.
  13. ↑ Krishna, Chandan (Oct–Dec 2014). "The Expanding Realm of Endovascular Neurosurgery: Flow Diversion for Cerebral Aneurysm Management". Methodist Debakey Cardiovascular Journal. 10 (4): 214–219. doi:10.14797/mdcj-10-4-214. PMC   4300059 . PMID   25624975.
  14. ↑ Zenteno, M (Feb 2010). "Ten-year follow-up of giant basilar aneurysm treated by sole stenting technique: a case report". J Med Case Rep. 4: 64. doi: 10.1186/1752-1947-4-64 . PMC   2843709 . PMID   20175900.
  15. ↑ Zenteno, MA (Jul 2005). "Sole stenting bypass for the treatment of vertebral artery aneurysms: technical case report". Neurosurgery. 57 (1 Suppl): E208. doi: 10.1227/01.neu.0000163683.64511.24 . PMID   15987592. S2CID   41571535.
  16. ↑ "Neurology Fellowships".
  17. ↑ Berkhemer, Olvert A.; Fransen, Puck S.S.; Beumer, Debbie; van den Berg, Lucie A.; Lingsma, Hester F.; Yoo, Albert J.; Schonewille, Wouter J.; Vos, Jan Albert; Nederkoorn, Paul J.; Wermer, Marieke J.H.; van Walderveen, Marianne A.A. (2015-01-01). "A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke". New England Journal of Medicine. 372 (1): 11–20. doi:10.1056/NEJMoa1411587. hdl: 2066/153000 . ISSN   0028-4793. PMID   25517348. S2CID   9499117.
  18. ↑ Goyal, Mayank; Demchuk, Andrew M.; Menon, Bijoy K.; Eesa, Muneer; Rempel, Jeremy L.; Thornton, John; Roy, Daniel; Jovin, Tudor G.; Willinsky, Robert A.; Sapkota, Biggya L.; Dowlatshahi, Dar (2015-03-12). "Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke". New England Journal of Medicine. 372 (11): 1019–1030. doi: 10.1056/NEJMoa1414905 . ISSN   0028-4793. PMID   25671798.
  19. ↑ Campbell, Bruce C.V.; Mitchell, Peter J.; Kleinig, Timothy J.; Dewey, Helen M.; Churilov, Leonid; Yassi, Nawaf; Yan, Bernard; Dowling, Richard J.; Parsons, Mark W.; Oxley, Thomas J.; Wu, Teddy Y. (2015-03-12). "Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection". New England Journal of Medicine. 372 (11): 1009–1018. doi: 10.1056/NEJMoa1414792 . ISSN   0028-4793. PMID   25671797. S2CID   4688893.
  20. ↑ Saver, Jeffrey L.; Goyal, Mayank; Bonafe, Alain; Diener, Hans-Christoph; Levy, Elad I.; Pereira, Vitor M.; Albers, Gregory W.; Cognard, Christophe; Cohen, David J.; Hacke, Werner; Jansen, Olav (2015-06-11). "Stent-Retriever Thrombectomy after Intravenous t-PA vs. t-PA Alone in Stroke". New England Journal of Medicine. 372 (24): 2285–2295. doi: 10.1056/NEJMoa1415061 . ISSN   0028-4793. PMID   25882376.
  21. ↑ Jovin, Tudor G.; Chamorro, Angel; Cobo, Erik; de Miquel, María A.; Molina, Carlos A.; Rovira, Alex; San Román, Luis; Serena, Joaquín; Abilleira, Sonia; Ribó, Marc; Millán, Mònica (2015-06-11). "Thrombectomy within 8 Hours after Symptom Onset in Ischemic Stroke". New England Journal of Medicine. 372 (24): 2296–2306. doi:10.1056/NEJMoa1503780. hdl: 2445/125710 . ISSN   0028-4793. PMID   25882510.
  22. ↑ Furlan, Anthony J. (2015-06-11). "Endovascular Therapy for Stroke — It's about Time". New England Journal of Medicine. 372 (24): 2347–2349. doi:10.1056/NEJMe1503217. ISSN   0028-4793. PMID   25882509.
  23. ↑ American Heart Association, Stroke Council (Mar 2018). "2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association". Stroke. 49 (3): e46–e110. doi: 10.1161/str.0000000000000158 . PMID   29367334. S2CID   4972922.
  24. ↑ Sacks, D (Apr 2018). "Multisociety Consensus Quality Improvement Revised Consensus Statement for Endovascular Therapy of Acute Ischemic Stroke". J Vasc Interv Radiol. 29 (4): 441–453. doi: 10.1016/j.jvir.2017.11.026 . PMID   29478797.


This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.