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Treatment of cerebrovascular pathology in the Neurosurgery Wedau-Center in Duisburg

See the interview with Professor Brassel

Director of the Radiology and Neuroradiology Clinic Prof. MD Friedhelm Brassel.

Professor Brassel is an outstanding neuroradiologist and a pioneer of this area. Many methods of research and treatment of vascular neuroradiology were invented under the direction of Professor Brassel. For over 30 years he has successfully embolised complicated cerebral aneurysm and angioma to rescue thousands of patients.

 

What is Radiology and Neuroradiology?

Total rengenology (radiology) is known as a part of diagnostic medicine with a lot of its directions. Nowadays, this discipline has been changed from diagnostic into therapeutic. For example, Interventional Radiology and Neuroradiology make it possible to avoid an open brain operation.

In some cases, only the radiologist may reach the inaccessible area by introducing a catheter into the artery or vein. However, this inaccessible area is not available for obvious reasons. The patient's life directly depends on experience and genius of the radiologist.

Many angiomas, aneurysms and vascular brain malformations can be treated through the introduction of the catheter into the vessel without surgical intervention. This thin catheter is introduced through the femoral artery of the anesthetized patient and conducted in the vessels to the needed point of the impact in the body.


1. The introduction of the catheter through the femoral artery on the right (the left image)

2. The complex device of the internal world of the brain vessels (the average image)

3. Branches of the external carotid artery (the right image)


The treatment of vascular brain diseases has been greatly improved and the patients' mortality from diseases such as angioma and aneurysm has been consequently reduced due to the rapid development of neuroradiology in Europe over the past 30 years.

There is a great need for close contact between the neurosurgery clinics in spite of advances in neuroradiology. For example, there are some complications during the disease followed by the cerebral haemorrhage. Experienced neurosurgeons are really needed in this case. Professor Hassler, director of neurosurgery Wedau-Clinic, is an experienced surgeon in the angioma, aneurysms and malformations. He has numerous publications about this medicine field.

The Neuroradiology and General Radiology clinic offers the following services:

A full range of roentgen diagnostics and treatment carried out in the hospital.

Such examinations as hagiography and minimally-invasive effects take place in a hospital environment (including therapeutic and diagnostic puncture, biopsy, angiography and vascular embolization, as well as embolization of the fistula, aneurysm, and tumors).

Percutaneous transluminal angioplasty, implantation of intravascular prostheses in case of the arterial stenosis, local thrombolytic therapy and various methods of vascular recanalization of different parts of the body are very popular in addition to the impact on the cerebral vessels. You can read more about the methods of treatment in the Neuroradiology clinic on the page with the title “Methods”.

Methods of treatment of vascular pathologies

There are many treatment methods in Neuroradiology. Let us explain the methods of the influence on the vascular diseases of the brain and spinal cord.

In some cases, only the radiologist may reach the inaccessible area by introducing a catheter into the artery or vein. However, this inaccessible area is not available for obvious reasons. The patient's life directly depends on experience and genius of the radiologist.

Many angiomas, aneurysms and vascular brain malformations can be treated through the introduction of the catheter into the vessel without surgical intervention. This thin catheter is introduced through the femoral artery of the anesthetized patient and conducted in the vessels to the needed point of the impact (see the image below).

1.The introduction of the catheter through the femoral artery on the right

 

2. The size of the catheter (functional conductor) conducted through the vessels until the cerebral vessels

The Neuroradiologist must pass all the necessary vessels till the necessary “point of impact” while not damaging the vessel wall. This is achieved by continuous control by use of X-ray equipment removing unnecessary components by means of a computer, while seeing only the vessels and the catheter.

Installation for angiography by Siemens in our clinic:

We should not overestimate the value of the equipment. In particular, experience of the doctor and his professional ability are valued in the field of neuroradiology and surgery. Professor Brassell, a pioneer in his discipline, takes a large part in the development of modern catheters, stents and systems for angiography.

Do you know that more than 70 percent of aneurysm may be treated by non-surgical means? Do you know that the majority of strokes can be avoided due to well-timed diagnosis and adequate therapy? We will talk about this in this article. There are some examples of specific cases to understand the article in a better way.

There are 2 main areas:

1.Methods of recanalization are applied in such diseases as vascular atherosclerosis and thromboembolism.

2.Methods of embolization (occlusion) are applied in case of the angioma, aneurysms, embolization of tumors and other vascular malformations.

  • Local intraarterial fibrinolysis (thromboclasis)
  • Intravascular removal of the thrombus by means of the catheter
  • Intracranial and extracranial angioplasty by use of balloon-dilators or stents
  • Coiling
  • Combination of coiling and stents
  • Partikelembolisation (PVA)
  • Liquid embolisate (e.g. Ethibloc ®, Onyx ®)

Methods of the vascular recanalization

Thrombolysis, fibrinolysis

An intravascular catheter is brought to the thrombus that damaged the bloodstream, and then the lytic substance is introduced.

This method makes it possible to reach perfect results. Sometimes the combined treatment is necessary. Some examples of practices help you understand the technique better. Unfortunately, the time for the application of this method is limited. Thrombolysis can be carried out in the first 6 hours after the cerebral crisis. It means that there must be necessary equipment in your city. In some cases, the patient with incomplete thrombosis can still be saved.

1. Basilar Artery Thromboembolism (A case from the practice of Professor Brassel, images a, b, c)

a)The 50-year-old patient suddenly sank into a coma..
The reason was basilar artery thromboembolism. Computer tomogram.

b)Angiography images of the same patient for conducting local fibrinolysis. The arrow indicates the place of thromboembolism.

c)Angiography images after local fibrinolysis. The arrow indicates the vessel in which the blood re-flows..

2. Middle Cerebral Artery Thromboembolism (A case from the practice of Professor Brassel)

Right-sided hemiplegia with aphasia (denial of right-side limb function with speech disturbance) was developed in the 68-year-old patient. The reason was a thrombus in the middle cerebral artery. The images A, B, C, and D below show the stages of diagnosis and treatment.

a) The arrow on the Angiogram indicates “stop”, namely where artery thrombosis occurred

b) The introduction of the catheter into the thrombotic artery and local lysis of the thrombus

c) The MRA image (non-invasive magnetic resonance angiography) the day after Thrombolysis. The patient could walk again, paresis is minimal.

d)The MR image of the brain 1 week after Thrombolysis. The arrow indicates the minimal area of infarct. The patient became free of speech disturbance and toe paralysis.


3. Internal Carotid Artery Thromboembolism (A case from the practice, images A, B, C and D)

The 40-year-old patient with sudden loss of consciousness and paralysis of limbs on right side

a) CT of the brain in the acute period of the disease

b) The combination of effects on the thrombus by mechanical removal of thrombus while fibrinolysis

c) The mechanical removal of the thrombus by use of the intravascular catheter

d) The right image shows the control Angiogram and CT image of the patient a few days later. Recanalization was successful, the zone of infarction is minimal, and the patient can speak again. The limb paresis is moderate

In normal cases, carotid artery thrombosis is an extensive malignant infarction inevitably leading to irreversible neurological consequences or death of the patient.

Angioplasty (Implantation of balloons and stents)

These techniques are among the most popular and necessary in the prevention and treatment of cerebral vascular diseases. The common problem in case of arterial stenosis is atherosclerosis.

Especially late in life there are often the cases of sudden weakness of the limbs or speech disturbance (these are the first symptom of this disease). In fact, the symptoms may be indicated in the form of visual impairment and dizziness. Unfortunately, young people sicken of this disease, and the doctors must often treat the 35-40-year-old patients with very serious or fatal diagnoses.

 Balloon vessel dilation affected by atherosclerosis. Readers know the technique from the field of cardiology.

This method allows you to pass through the plaque and expand the vessel lumen.

Sometimes balloon dilation is not sufficient, in such cases the installation of the stent is necessary (a metal frame made of special alloy which does not allow narrowing a vessel).


Installation of the stent into the neck and brain vessels

This is the stent in a state of readiness before the introduction into the vessel. As you can see, it does not open and is almost the same thickness as the catheter (the image below).

Here you can compare the stent in a state of compression and disclosure. The difference in diameter is visible. This allows the opened stent to keep a constant diameter of the vital vessel.

There is only the stent after removal of the catheter from the vessel (the image below). The stent is a self-unpacked metal frame keeping the constant diameter of the vessel in a dangerous place, thereby preventing the risk of the stroke.

Modern stents are made of a special alloy keeping the form of the vessel and growing flexibly inside it without recession.

There is a real revolution in the stent market. The fight is for the strength, elasticity, size and favorable prices. And the further this area is developing, so more and more neuroradiologists can help people.

Let us explain methods of angioplasty by the examples of the practice of Professor Brassel

1. Middle cerebral artery stenosis (A case from the practice of Professor Brassel)

The 55-year-old patient with recurrent symptoms of weakness of limbs and speech disturbance (PRINT-symptoms) (images A, B, C and D)

a) Narrowing of the middle cerebral artery is shown here

b) The implantation of the stent

c) Angiography imaging 20 months after the implantation of the stent. Ischemia attacks do not recur anymore.

2. Double internal carotid artery stenosis (A case from the practice of Professor Brassel)

The 60-year-old patient complains of a long “a pulsating noise” in the left ear and dizziness. The patient wouldn't get an extensive cerebral infarction due to the well-timed angiogram. It is possible to expand the vessel by the balloon or the stent in the case of timely detection of such pathologies.

Look at the images below.


a) On the MRI-angiography there are strongly stenosed vessels of the internal carotid artery led to the patient's noise in the ears and dizziness

b) The installation of the stents is shown

c) The arrow shows the stent (in the form of the reticulum inside the vessel)

d) Angiography after 15 months. Stenosis has disappeared. There is no noise in the ears and dizziness.


Coiling (treatment of aneurysm)

Often, we get know this diagnosis after the death of a close friend or relative. Today, the chances of treatment of such patients are very high. There are great possibilities of aneurysm treatment without open surgery in connection with the development of medicine in the field of neuroradiology.

Coiling

Dr. Guido Guglielmi, an Italian neurosurgeon, applied this technique for the first time in 1990. This is the common method of noninvasive (without surgery) treatment of aneurysm. The main point of this method is that the platinum coil forming the beam and keeping all aneurysms is introduced into the aneurysm. This leads to the thrombosis in the aneurysmal bag and, as a consequence, the formation of the connective tissue to prevent bleeding. The Images A, B, C and D show a special catheter for coiling and the method of its application:

 

a) The image shows a catheter with coils extruded in the form of wire

b) The coil in the spread state in the vessel (aneurysm), the upper image.

c) Here you see how the coil is conducted through the catheter and introduced into the aneurysm, thus closing it. The surgery is not needed in this case. 


Today, there are various models of coils. E.g., “biologically active coils” (the right image)

Treatment of “problem” aneurysm

Most aneurysm might be closed by using the said above coiling method. But there are problematic cases, too. Look at the images below:

a) The lower image shows that the coil package literally “tips out” of the aneurysm inside the vessel. This can cause an acute stroke in the patient.

b) The solution of this problem is proposed here. First, the stent is introduced into the main artery, and the coiling is conducted through the stent openings. So the surgery is not necessary.

c) The vessel after treatment. You see the intravascular stent and closed aneurysm.

Treatment of problem aneurysm (a case from the practice of Professor Brassel)

The 45-year-old patient with subarachnoid hemorrhage from the large basilar artery aneurysm
In this case, there are two main problems:

1st problem: a neurosurgeon cannot reach aneurysm for obvious anatomic reasons, in other words only a neuroradiologist is able to help a patient.

2nd problem: basilar artery stenosis (narrowing of the vessel) at the location of the aneurysm

Take a look at the process of the neuroradiological surgery below (images A, B and C)


a) There is a huge basilar artery aneurysm with basilar artery stenosis (before the surgery)

b) A stent with subsequent coiling is installed (the image from the surgery)

c) Angiography of the same patient after a year. The image shows well that the aneurysm is fully cured and there is no artery stenosis.

Liquid embolisate (treatment of vascular fistula and angioma)

Liquid embolisate is used mainly to treat vascular fistula and angioma. What are there formations?

A normal artery is always divided into the small arterioles at first, then it passes into the capillaries and then into a vein.

However, the arteries directly flow into the vein in case of such diseases as vascular fistula and artery angioma. This causes a disturbance of the bloodstream by means of the blood redistribution in other arteries. Such a vessel “steals” the blood from the healthy one, thereby causing the inanition in the neighboring nerve cells. This is reflected in the specific neurological symptoms which are very different depending on the location of angioma in the brain.

Additional danger is that such formations have tendency to hemorrhage, so it is necessary to make diagnosis and treatment on time.

a) Angioma looks like this. In this case there are no capillaries, and the whole blood immediately flows into a severely stretched vein that can burst.

b) The scheme of possible variants of vascular shunts

The task of the neuroradiologist is very serious. At the surgical table the doctor has to analyze all the arteries and veins, as well as the way of their interaction not to close down a vital artery by an embolisate. Tragic consequences are possible in the case of an incorrect analysis. Treatment of cerebral angioma and fistula is the “highlight” in Neuroradiology. Only experienced professionals may treat patients with this diagnosis.

Let's go back to the methodology. Liquid embolisate was invented to close arterioles and even capillaries because it is not always possible to get into so many small vessels by a catheter.

This technique makes it possible to “turn off” angioma completely without an open skull operation. The partly embolised angioma can be operated much easier.

Angioma is very hard to reach and is thus inoperable in many cases.

Look at the examples below.

a) The catheter through which the liquid embolisate is injected

b) The embolisate completes as a “sponge” all the smaller spaces switching the specific vessel from the bloodstream.

c) 4 months after embolization. The embolisate “Ethibloc” is replaced by the connective tissue.



Angioma (an example from the practice of Professor Brassel)

The 25-year-old patient complained of frequent headaches in the past 10 years. The pills helped badly. Vascular malformation was suggested during magnetic resonance imaging of the brain. It was confirmed by angiography.

 

a) Angioma on the image is indicated by the arrow. The image before embolization

b) The normal bloodstream is after embolization of vessels angioma. Angioma is totally “turned off”; the patient's headaches have disappeared.


Dural arteriovenous fistula (an example from the practice of Professor Brassel)

Dural arteriovenous fistula is considered one of the most severe diseases. Treatment can be surgical or neuroradiological depending on the localization.

The images A, B and C show the 35-year-old patient with complaints of diplopia, exophthalmos, and changes in the eye sclera.


a) The photo of the patient with complaints of diplopia. The eye sclera changed noticeably. The eye stands visibly forward (exophthalmos)

b) Here you can see how the fistula is “turned off” by use of transvenous embolization (the catheter is carried out through venous channels to the point of impact of the embolisate).

c) The image shows the draining vein before embolization (indicated by the arrow). The vein has disappeared after embolization; the patient has no complaints anymore.

 


Neurosurgeon Dr. Bitter is an author. The materials are kindly provided by Professor MD Brassel.



If you have any questions about treatment of cerebral vascular abnormalities (aneurysm, angioma, malformations, and arteriovenous fistula),
please call us +49 (2283) 77-369-0 or write us a mail