Endovascular Techniques

Some of the most recent advances in stroke therapy relate to the development of new catheters for interventional neuroradiology procedures. There are now catheters that can inflate a balloon within an area of stenosis to open a lumen within an atherosclerotic area of the vessel (cerebral angioplasty). Angioplasty and intraarterial papaverine injections have recently been used to successfully manage vasospasm following subarachnoid hemorrhage. A small loop or snare may be guided to the site of a thrombus using a catheter so that the thrombus may be removed directly through the catheter. Mechanical disruption of the clot or embolectomy (removal of the embolus) may allow recanalization of the vessel, with restoration of CBF. Thin wires may be inserted through the catheter to achieve recanalization through a recently occluded

Figure 9 Intravascular coil within an aneurysm. This is a drawing showing how a catheter may be used to insert a detachable coil into an aneurysm. The wall of the vessel is cut away so that the catheter can be seen within the lumen. The coil is inserted through the catheter, and this partly occupies the aneurysm cavity. The coil may be detached so that it remains in the aneurysm permanently. A similar technique may be utilized to insert balloons into giant aneurysms (not shown) (drawing by Adam Bourgoin).

Figure 9 Intravascular coil within an aneurysm. This is a drawing showing how a catheter may be used to insert a detachable coil into an aneurysm. The wall of the vessel is cut away so that the catheter can be seen within the lumen. The coil is inserted through the catheter, and this partly occupies the aneurysm cavity. The coil may be detached so that it remains in the aneurysm permanently. A similar technique may be utilized to insert balloons into giant aneurysms (not shown) (drawing by Adam Bourgoin).

arterial segment. Catheters may deploy intravascular stents that remain in the vessel lumen to maintain vascular patency. Glue may be administered through the catheter to occlude feeder vessels within a large AVM. Test occlusion of such vessels using a balloon (or anesthetic injection into the vessel) may prove that sacrificing the vessel surgically (e.g., to remove an AVM) would not produce unacceptable complications. Balloons or coils (Fig. 9) may be deployed into a large aneurysm to promote coagulation within the lumen of the aneurysm. If blood cannot enter the lumen, the risk of rupture is substantially reduced. Specially formed catheters allow cannulation of small branches of intracranial arteries. Intraarterial throm-bolysis may be applied specifically to the vessels that are occluded. Recently, TCD has been used to agitate the clot following thrombolytic administration, and this technique increases the rate of recanalization. These and other evolving endovascular techniques promise to revolutionize the management of acute stroke.

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