Stroke and

Neurovascular Inter ventions

An Initiative of
Stroke and Neurovascular Interventions Foundation
Creating Stroke Awareness

Story telling by

AL Services

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

www.neurointerventionindia.com
www.facebook.com/NeurointerventionGurgaon

HEALTH
BAD
F
O

WARNING SIGNS
Sudden tingling, numbness or weakness of the face, arm or leg, especially on one side of the body
Trouble speaking or understanding l Problems in one or both eyes l Intense, unexplained headache

A stroke occurs when

Diculty walking, loss of walking l Sudden amnesia, mental impairment

blood ow to the brain is

blocked by clots in the
blood vessels or because

Dizziness

15mn

of a weakened blood
vessel rupturing bleeding
into the brain.

people worldwide suer a stroke each year

6.15mn die of stroke annually

5mn are left permanently disabled
3.85mn recover or functionally disabled
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.

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.

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.

O
FACT RS
K
S

RI

STR
OK
E

Stroke-An Infographic

T
ES
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.

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, educating, 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 FOUNDATION to impart public education and increase awareness among common man and general 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 treatment 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).

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 platforms 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 claries 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.

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. Neurointerventionist 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 recover 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 cholesterol and shedding out excess weight through regular exercise.

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 surrounding 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.

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

Diseases and Treatments

ANEURYSM

ARTERIOVENOUS
MALFORMATION

THROMBOLYSIS
IN ACUTE
STROKE

CAROTID
ARTERY
STENOSIS

STROKE /
BRAIN ATTACK

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
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 aneurysms, 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 combination 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 intracranial 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

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, hyperglycemia, hypernatremia/hyponatremia, hypomagnesaemia, cardiac failure and arrhythmias, 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 experienced 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 aneurysm treatment should be performed to prevent repeat bleeding.

Surgery (clipping) vs embolization (coiling)

Surgery has been the conventional method of aneurysm treatment. 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.
SURGICAL CLIPPING

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)

COILING OF ANEURYSM

Randomized, prospective, international controlled trial Compared policy of neurosurgical 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.

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 treatment. 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.

COILING OF BROAD NECK ANEURYSM WITH COMPLEX COIL

Some cases require balloon assistance or stent placement

BALLOON ASSISTED COILING
Balloon assisted coiling for broad neck aneurysm- concept- a balloon is inated temporarily 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
STENT ASSISTED COILING

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 investigations 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.

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 operator 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 contraindications 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 circulation during the procedure.

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

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.

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 suering from major stroke in future.

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.

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 embolization/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 conservatively 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.

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) treatment 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 treatment 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 minutes, 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.
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 neuroradiologists) 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 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.

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 minutes, 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. According to the criteria patient's having hypodensity in less than third of MCA territory on CT
scan are eligible for thrombolysis.

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 similar 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.

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, 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. 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.

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 hemorrhage. 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

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 recommend 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

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 operating 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 functions. 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.

Patient Stories

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.

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 endovascular) 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 penumbra 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.

Executive collapses at work due to brain hemorrhage

Patient a 43 year old male working in an insurance company suddenly became unconscious 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 complete 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 aneurysm and one in every 20 strokes is caused by rupture of intracranial aneurysm.

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 parenchyma. 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.

The TEAM

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 nevertheless. 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/surgeons 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.

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 examinations). 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.

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 manufactured/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.)

Medical Approach
He has an admirable precision, which is so critical in his profession. He holds high standards 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 malformation (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 Neuroradiology (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 several professional bodies and is especially keen on creating stroke (brain attack) awareness.

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 Interventional 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.

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

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 initiated the use of botulinium toxin for the rst time in the country, and extended its usage
in trigeminal Neuralgia.

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 established the same at Medanta the Medicity. He has innovated the plasma exchange protocols 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 Neuromuscular disorders.
Dr Gaurav Goel
Dr. Gaurav Goel is a Neuro-Interventionist trained from prestigious Montreal Neurological 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 successful 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.

Annexures

Media Gallery

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/

Foundation Brochure

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: drvipulgupta25@gmail.com
For Appointment: 9810332224
Dr. Gaurav Goel
MBBS, MD, DM, Felloe ( interventional Neuro Radiology)
Consultant- Interventional Neuroradiology
Medanta Institute of Neurosciences
Mobile: +91-9650789820
Email: gaurav.goel@medanta.org

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