A Patient's Guide to Cerebral Angiography

What is 'Cerebral Angiography' or a 'Brain Cath'?

It is a procedure which uses a dye (contrast material) and X-rays to visualize the arteries and veins in the neck and brain.

When is it performed?

This test is generally recommended by the doctor to evaluate patients with stroke, brain bleed, aneurysms,vascular malformations and brain tumors.

Who performs the procedure?

A specialist trained in neurointerventions can perform angiography. The specialist may be a neurosurgeon, neuro-radiologist or a neurologist.

How do I prepare for an angiogram?

Before scheduling the procedure, your doctor will check your kidney function and order other blood tests. Please inform your doctor about

1. Your allergies (specifically allergy to shellfish and iodine)
2. History of bleeding gums or easy bruising in the past
3. Your medications (specifically Metformin for diabetes mellitus)
4. Whether you are pregnant
5. You may be asked to not eat and drink anything for about 8-12 hours prior to the procedure

How is the procedure performed?

1. You will be asked to lie on a X-ray table.
2. Your head may be strapped using a tape to keep it still.
3. You may be given intravenous medications for pain and to put you to light sleep.
4. A numbing medication (local anesthesia) is given around the artery in the groin (femoral artery). You may have a transient stinging or burning sensation when the medication is injected in the groin.
5. A long catheter (a catheter is a long slender tube) is inserted through the artery in the groin and passed all the way up to the neck with the help of X-rays
6. Contrast dye is injected into the various arteries in the neck that carry blood to the brain and X-ray pictures taken to visualize the arteries and the veins and the blood flow pattern.
7. A diagnostic angiogram usually lasts about 30-45 minutes depending upon the specific arteries and veins that are being examined.
8. While the dye is being injected, you may feel a warm flushing sensation. You may also experience a metallic taste in the mouth for a few minutes.
9. After the angiogram, the doctor removes the tube from the groin and holds pressure over the artery in the groin to allow blood to clot and seal the hole in the artery.
10. Alternatively, your doctor may use a closure device to seal the hole in the artery.

How long do I have to stay in the hospital after the procedure?

A diagnostic cerebral angiogram is usually performed as an outpatient procedure. You will have to lay flat in the bed for about 3-6 hours after which you may be discharged home.

What precautions should I take after going home?

1. It is recommended not to drive or do any strenuous work for 1-2 days after the procedure. 
2. Do not exercise. 
3. You may walk around in the house. 
4. You may have some soreness in the groin for a couple of days. 
5. You may resume normal daily activity from the next day or the day after. 
6. You may take over-the-counter pain medications, if needed. 
7. If you are diabetic and take Metformin, do not take the medication for 24-48 hours following the procedure.
8. Immediately call the doctor's office if you experience

• severe itching all over the body
• rash over the groin or anywhere in the body
• swelling in the groin
• bleeding from the groin
• slurred speech
• weakness of an arm or leg

What are the risks of Cerebral Angiography?

1. There is a small risk of allergy to the contrast dye. If you have a history of allergy to the dye, your doctor may ask you to take some medications prior to the procedure to prevent any allergic reaction
2. There is a small risk of bleeding from the puncture site in the groin (1%-2%). Alternatively the bleeding may be under the skin forming a 'pseudo-aneurysm'. A swelling may be seen in the puncture site in the groin.
3. In about 0.5%-1% of the patients, a clot from within the catheter or a cholesterol plaque from one of the arteries in the neck may be dislodged and block an artery supplying the brain leading to stroke. With the advent of newer techniques, the incidence of a major or significant stroke following diagnostic angiography in experienced hands is very low.

From 'FAST' to 'FASTER'. The MR CLEAN Stroke trial: What does it mean to us?

The recently published MR CLEAN trial for interventional management of stroke is a major step towards management of acute ischemic stroke. The trial was conducted in Netherlands and compared medical management with medical management and interventional therapy. At the end of three months, a significantly greater proportion of patients in the interventional therapy group had good outcome than those in the medical treatment group (32.6% Vs 19.1%). Good functional outcome was 67% more likely in the interventional group.

This trial included patients with large artery strokes. Patients with large artery strokes have a clot occluding one of the major arteries that supply the brain such as the internal carotid artery or the middle cerebral artery. Such patients have a very high risk of disability and death. The currently approved treatment of such patients is tPA, a drug that is given intravenously and acts on the clot to dissolve it. However, tPA is able to dissolve only one-fifth of the clots. With the use of stentrievers, about 58% of the clots were removed leading to restoration of blood flow within the artery. A 'Stentriever' is a stent, a small wire cage, that is inserted from the groin through a catheter. When it reaches the clot in the brain, it expands and holds the clot. The stent is then pulled along with the clot.

With one person dying of stroke every 36 seconds in India, it is very essential to organize such stroke centers where appropriate treatment of acute stroke is undertaken in a protocol based manner. For, the general practitioners and neurologists, it is very important to collaborate with a stroke center with 24 x 7 availability of stroke neurologists, neurosurgeons and interventionists. Timely referral and treatment of acute stroke within 8 hours of onset of symptoms can potentially reverse the symptoms and prevent long term disability and death. The new phrase to identify and treat acute stroke is FASTER.

F - Face -Asymmetry of face
A - Arm - Arm weakness
S - Speech - Speech disturbance
T - Time - refer the patient to a stroke center immediately
E - Emergency - Treat stroke as an emergency
R - Restore - Restore blood flow in the vessel when appropriate

Breaking news! Proof of benefit of intra-arterial Stroke treatment!

In patients with acute ischemic stroke caused by proximal intracranial occlusion of the anterior circulation, intra-arterial treatment administered within 6 hours after stroke onset waseffective and safe.


http://www.nejm.org/doi/full/10.1056/NEJMoa1411587

Brain Aneurysms: What you should know

What is a Brain Aneurysm?

A brain aneurysm is a focal bulging of the wall of an artery that supplies blood to the brain. While most brain aneurysms remain silent, a few burst leading to bleed within the brain. The bleed may be so devastating that almost half of the people die and do not reach the hospital. Since most of the aneurysms rupture in the fourth through sixth decades of life, significant part of productive life is lost due to long term disability and death. Hence it is important for the people to know about the symptoms of brain aneurysms and possible treatment options. It is also important for general practitioners to be aware so that they can refer their patients to treatment centers that are capable of managing brain aneurysms.

What causes Brain aneurysms?

In most of the people, aneurysms are acquired. This means, that most people with brain aneurysms are not born with these and during their life time, the aneurysms form. High blood pressure, smoking, excessive alcohol intake are some of the risk factors that predispose an individual to aneurysm formation. Women are more likely to develop aneurysms than men and African-Americans and Finnish are more likely to have an aneurysmal rupture than people belonging to other races. An individual with a strong family history (at least 2 close relatives with brain aneurysms) also is a risk factor.

Rare hereditary conditions such as polycystic kidney disease are associated with brain aneurysms.

What are the symptoms?

Most aneurysms do not cause any symptoms. They are discovered incidentally during MRI or CT imaging for an unrelated cause. However, aneurysms can cause symptoms when they burst or occasionally, when they become big in size and press upon the surrounding brain structures. The most common symptoms of aneurysm rupture are

• sudden severe headache
• neck pain
• nausea and vomiting
• loss of consciousness
• intolerance to light
• seizures (fits)

Other symptoms may include blurred vision, double vision and changes in speech

How are aneurysms diagnosed?

There are several tests that the doctor may do to diagnose brain aneurysm rupture. CT scan, MRI, lumbar puncture (in which a needle is inserted in the spinal canal in the back and spinal fluid is drawn to look for blood products) and cerebral angiography. A cerebral angiogram is a test where a catheter is inserted through an artery in the groin and advanced all the way up to the neck. Dye is injected through the catheter and X-ray pictures taken.

How are aneurysms treated?

There are two ways in which aneurysms are treated. First, "Clipping", in which the aneurysm is closed from outside with a metal clip through open surgery. Second, "Coiling" in which thin metal threads called 'coils' are inserted in the aneurysm using a catheter in the same way as an angiogram is done. Both these treatment options are complimentary to one another and, depending upon the characteristics, the aneurysm may be suitable for clipping or coiling. If the aneurysm is very small and not ruptured, your neurosurgeon may also recommend observation depending upon the risk of rupture.

  

'Brain Attack' and 'Heart Attack': How are they different?

It is a common notion among people that 'brain attack' or 'stroke' and 'heart attack' are one and the same. There is also a profound lack of knowledge of common risk factors and symptoms of stroke. Inability of bystanders to recognize the common symptoms of stroke is a major hurdle in appropriate management of patients with stroke as golden hour is lost, specially in India where the pre-hospital services are not well organized. Treatment within the first 8 hours of onset of symptoms is most effective and prevents long term morbidity and mortality. It is estimated that one person dies of stroke every 36 seconds in India. In a study conducted among the rural population in Maharashtra in 2012, only 51% of the 373 respondents were able to correctly identify 'stroke' as a disorder of the brain, while 19% associated it with heart attack! Also, one third of the respondents (34%) did not know at least one risk factor for stroke. This phenomenon is seen in both developing and developed countries, although the proportions are lower in developed countries.

What are the similarities and differences between 'stroke' and 'heart attack'?

Heart attack refers to damage to the muscle of the heart, usually from a lack of blood flow. Most of the time, a blood clot forms in one of the arteries that supplies the heart muscle with blood, blocking the flow of blood. As the heart muscle starves, it begins to die, causing chest pain and other symptoms of heart attack.
A Stroke is a similar blockage in an artery in the brain or neck that supplies blood to the brain. When a clot forms in one of those arteries and stops blood flow, a section of the brain begins to die. When those cells die, the person loses whatever function those brain cells controlled. There is another category called the 'hemorrhagic stroke' in which a blood vessel bursts and bleeds in the brain.

While the common symptoms of a heart attack are chest pain, tightness and shoulder pain, the symptoms of stroke are completely different and may range from nothing to headache, paralysis of an arm or leg, unconsciousness, coma and death. Another type of stroke is a transient ischemic attack (TIA), essentially a “mini-stroke” caused by a temporary clot. TIA symptoms are identical to those of other kinds of strokes, but because they occur quickly and usually last less than five minutes, this brain attack often goes unnoticed.
While a TIA doesn’t usually cause permanent injury to the brain, it serves as a warning for patients and gives them time to seek further medical treatment in preventing ischemic or hemorrhagic strokes.

Because specific areas of the brain control certain functions, one can predict the effects of a stroke based on the location of the blockage. If the blockage occurs near the front of the brain, it can affect such things as organization skills, memory, communication, and problem solving. If it occurs lower down, near the brainstem, it can cause unconsciousness and an inability to breathe, swallow, or control elimination.if it occurs to one side near the temple, speech may be affected. In addition, which side (hemisphere) of the brain the stroke occurs on determines its side effects and which body functions are affected. The right side generally controls a person's emotions, creativity and abstract thinking. If the blockage occurs anywhere on the right side of the brain, it can cause the following symptoms:

• Paralysis or weakness on the left side of the body
• Disorientation
• Excessive talking
• An inability to perform routine tasks such as brushing the teeth, buttoning a shirt or tying shoelace

The left side controls more of speech, logic, perception and organization. If the stroke occurs anywhere on the left side of the brain, it can cause the following symptoms:

• Paralysis or weakness on the right side of the body
• Depression
• An inability to understand language
• Trouble speaking
• Memory problems
• Decreased attention span
   

 Heart attack and Stroke have many risk factors in common. They may be modifiable or non-modifiable. Some of the modifiable risk factors include

•  High Blood Pressure
• Heart Disease
• Diabetes Mellitus
• Cigarette smoking
• History of transient Ischemic Attacks (TIAs)
• High blood Cholesterol
• Lack of exercise, physical inactivity
• Obesity
• Excessive alcohol use
• Drug abuse 

 Some of the non-modifiable risk factors include

•  Age > 55 years
• Male gender
• Race (Asians and African-Americans have a greater risk than Caucasians)
• History of prior stroke
• Family history of stroke

The 'hub and spoke model' of health care: how can we apply to stroke care in India

India is ranked 119 out of 169 countries in Human Development Index (HDI). It spends about 4% of the Gross Domestic Product (GDP) on healthcare, which ranks among the countries with least spending on healthcare. As such, it is essential for the health care organizations in India to manage the expenditure on healthcare in a prudent manner. In continuation to my earlier article on 'telestroke', I will discuss the 'hub-and-spoke' model of stroke care and how it can help us to maximize the benefits of high tech care while minimizing unnecessary costs.

The 'hub-and-spoke' model

Organized inpatient stroke care at designated stroke centers has been shown to reduce mortality and morbidity when compared to treatment at non-specialist centers. With increasing complexity of stroke care, it has become impossible to provide specialist stroke services in every hospital in a specific area. Stroke care involves management by a dedicated stroke team consisting of vascular neurologist, neurosurgeon, neurointerventionist, intensivist, radiologist, anesthesiologist, specialist nurses, rehabilitation facilities and other trained medical personnel. It also requires the availability of cutting-edge technology at their disposal. Given that this requires millions of rupees, it is virtually impossible to have all these facilities in every hospital in a designated area. A simple but effective solution to this problem is to organize the stroke care in the form of a network of hospitals that depend on each other for caring for patients with stroke. In the hub and stroke model, a single hospital with all the specialist physicians and high-tech infrastructure forms the 'hub' and all the other hospitals with lesser complexity of care form the 'spokes'. The 'hub' hospital will be able to maximize the use of its infrastructure and specialized care facilities as patients from all the 'spoke' hospitals that require specialized care are concentrated here. Whereas, the 'spoke' hospitals will be able to maximize the facilities as they have the backup of the 'hub' hospital. In a study from Phoenix, Arizona, a patient with acute ischemic stroke treated at a 'network' hospital incurred $1,436 lower costs than another patient treated at a hospital outside the network.

In addition to the patients receiving the best possible care, the hospitals stand to gain financially as a patient treated at the 'hub' hospital goes back to the 'spoke' hospital for follow up and rehabilitation. That the hospitals are connected makes it easier for researchers to conduct studies for enhancing stroke care. It also makes the implementation of awareness campaigns easier at a larger scale.The 'hub and spoke' model also makes it easy to treat othe disease conditions coronary artery disease, etc.

In another study from the Mayo Clinic involving a network with 1,112 unique acute ischemic stroke patients per year, the study estimated that 45 patients per year would receive intravenous thrombolysis who would not have received it in the absence of a network, and 20 more patients per year would receive endovascular stroke therapies, resulting in 6.11 more discharges to home in a network than in the absence of a network. Researchers estimated cost savings in the network overall at $358,435 per year for the first year, increasing to $393,712 at the end of the fifth year. The hub facility bore the brunt of the costs, which researchers estimated at $405,121 per year, while each spoke saved $109,080 per year. The researchers suggested that with appropriate cost-sharing arrangements, over a five-year period all hospitals in the system could save an average of $44,804 per year. The researchers claimed that their model showed a target transfer rate of approximately 30 percent resulted in cost savings to the hub, the spokes, and the network overall.

Hence, it is high time that the above model of stroke care is planned and implemented in the various states in India. It is through this model that sustainable and cost-effective  stroke care can be offered to the people.

Source: http://www.strokeforum.com/acute-stroke-treatment/effectiveness-of-stroke-networks/_jcr_content/par/list_accordion/item_accordion/text_0/image.216472003.image.png

Can India deliver comprehensive stroke care?

In my previous articles, I talked about the extent to which stroke affects the people in India and how it is important for the country as a whole to take steps towards fighting this epidemic. One of the questions that often comes up during the discussion is how to overcome the high cost of infrastructure, manpower and the lack of awareness among the people. In the coming articles, I discuss the strategies that will help in establishing cost-effective comprehensive healthcare in general and stroke in particular.

Telestroke

Few countries in the world have experienced the explosive growth of internet usage that India is going through. India took more than ten years to grow from 10 million to 100 million internet users, three years to grow from 100 to 200 million; however, only a year to grow from 200 to 300 million users. According to a recent report 'Internet in India 2014', that is jointly published by the Internet and Mobile Association of India (IAMAI) and IMRB International, the number of internet users in India would reach 302 million by December 2014, registering a growth of 32 per cent over last year and surpassing the United States to become the country! It is also interesting to note that whereas the internet usage in urban India has grown by 29% in one year, that in rural India has grown by 39%. The primary use of internet in urban India is for search, online communication and social networking whereas that in rural areas is primarily entertainment followed by communication and social networking.

It will be, but foolish to not reap the benefits of telecommunication in healthcare and, India stands at a distinct advantage among the developing countries in this regard. Using telecommunications to connect stroke experts to the physicians and patients in rural areas dramatically improves the quality of care. With telestroke, patients in rural hospitals can have round-the-clock access to stroke specialists in specialized stroke centers. With telestroke, stroke specialists can clinically examine the patients in a remote hospital hundreds of kilometers away, view the CT and MRI scans and assist the physicians directly taking care of the patient in decision making. If the patient requires to be transferred to the specialized center, the transfer process can be expedited, thus cutting down the time to recanalization.

In Bavaria, Germany, telestroke units were introduced in 12 regional hospitals lacking neurology and neurosurgery departments. These 12 regional hospitals were linked to two stroke centers with 24 x 7 availability of vascular neurologists and neurosurgeons. Between 2003 and 2012, the percentage of patients with stroke treated at these hospitals increased from 19% to 78%. It also helped to provide immediate neurosurgical consultation in patients with hemorrhagic stroke. With the help of good internet and telecommunications, many district level and rural hospitals can be linked to the specialist stroke centers and patients cared for immediately at presentation. This will dramatically reduce the delay between the onset of symptoms and treatment. If tPA is to be administered, the medication can be administered and then the patient transported to a higher center. Another interesting finding from the German telestroke study was that the percentage of patients that actually were transferred to the specialized stroke center decreased over the ten years. The reason was that more and more patients were being treated at the peripheral hospitals and only those that genuinely required advanced care were treated at the referral center.

Low-cost strategies such as the use of video conferencing, smart phone apps that relay information to healthcare workers and assist the emergency medical services personnel to treat patients while being transferred to the hospital are very helpful and hospital systems should incorporate them while developing protocols for stroke care. Effective and innovative use of telecommunication systems is paramount to effective management of stroke in India.