COMBINING SPECIALITIES
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Combining Specialities
Team-working has been seen as an important essential in the delivery of modern medical care and quality, particularly in neurosurgery. With rapid development in newer techniques, a better understanding of tumour biology there has been constant up-gradation of neurosurgical services.
Neuro-anaesthesia, neuro-radiology, neuro-pathology, neuro-oncology, neuro-rehabilitation have become specialities by themselves. They all work together with a single aim of providing less risky, more beneficial and long term treatment options to the patients.
INTERVENTION NEURO-RADIOLOGY
It is a subspeciality of radiology, neurology and neurosurgery.Interventional neuroradiologists currently employ minimally invasive procedures to accomplish a wide variety of treatments including: stroke treatment by delivering clot-busting drugs directly to the site of the blockage, to open a stenosed blood vessel by angioplasty, aneurysm therapy by inserting platinum coils into the aneurysm sac, to name a few.
A. ANEURYSM COILING
Coiling involves approaching the aneurysm from inside the blood vessel, so that there is no need to open the skull. During endovascular coiling, a catheter is passed through the groin up into the artery containing the aneurysm. Platinum coils are then released. The coils induce clotting (embolization) of the aneurysm and, in this way, prevent blood from getting into it (and hence bleeding).The coils remain in the aneurysm; they are not removed.
Done by Dr Nishant Aditya.
Below is the example of Giant Aneurysm, which was treated by Dr Karapurkar, an interventional neuroradiologist and a neurosurgeon.
B. SSS THROMBOSIS
The superior sagittal sinus (SSS), also known as the superior longitudinal sinus is an unpaired large venous channel that drains blood from the lateral aspects of anterior cerebral hemispheres to the confluence of sinuses and ultimately to the heart. It is the major dural sinuses that receive a considerable amount of venous drainage of the brain. It causes brain stroke and could be life-threatening. A wide variety of diseases may be associated with thrombosis of SSS, including infectious diseases and noninfectious conditions such as vasculitis, hypercoagulable states like dehydration, and pregnancy, selected medications (eg, oral contraceptives, substance abuse), and unpredictable events (eg, head trauma).
It can be treated with anticoagulation even in the setting of intracranial hemorrhage (ICH) in most of the patients. In non responsive cases, where the thrombosis is extensive, the patient may require endovascular treatment (thrombectomy) as shown below. This procedure is done an interventional neuroradiologist.
Done by Dr Nishant Aditya.
C. AVM EMBOLISATION
Cerebral arteriovenous malformations (AVMs) are complex high-flow lesions that can result in devastating neurological injury when they haemorrhage. Embolization is a critical component in the management of many patients with cerebral AVMs. Embolization may be used as an independent curative therapy or more commonly in an adjuvant fashion prior to either microneurosurgery or radiosurgery.
Done by Dr Nishant Aditya.
ONYX A wide variety of agents have been used to embolize AVMs. Ethylene-vinyl alcohol copolymer (Onyx) is a more recently developed liquid embolic agent also used for the embolization of cerebral AVMs.
D. Internal Carotid artery (ICA) STENOSIS
The carotid arteries are located on each side of your neck. These are the main arteries supplying blood to your brain. They can be clogged with fatty deposits (plaque) that slow or block blood flow to the brain, which can lead to a brain stroke. Carotid angioplasty and stenting are procedures that open clogged arteries to restore blood flow to the brain. They’re often performed to treat or prevent strokes.
The procedure involves temporarily inserting and inflating a tiny balloon (angioplasty) into the clogged artery to widen the area so that blood can flow freely to your brain.
Carotid angioplasty is often combined with another procedure called stenting. Stenting involves placing a small metal coil (stent) in the clogged artery. The stent helps prop the artery open and decreases the chance of it narrowing again. Post procedure, the patient is usually prescribed blood thinners or antiplatelet medicines for at least six months or longer to prevent blockage of the stent.
Done by Dr Nishant Aditya, an interventional neuroradiologist.
E. CHEMICAL ANGIOPLASTY FOR VASOSPASM
Cerebral vasospasm—the narrowing of the cerebral arteries after SAH—is a common complication that occurs in up to 70% of patients. Cerebral vasospasm may be present in some patients even in the first 24 hours of the precipitating event but more frequently begins 3 to 4 days after an aneurysm rupture, reaching a peak after 7 to 10 days and resolving spontaneously after 21 days.
Cerebral vasospasm leading to delayed cerebral ischemia (DCI) and dysfunction continues to be a major complication and source of morbidity in cases of aneurysmal SAH. Carotid angioplasty is often combined with another procedure called stenting. Stenting involves placing a small metal coil (stent) in the clogged artery. The stent helps prop the artery open and decreases the chance of it narrowing again. Post procedure, the patient is usually prescribed blood thinners or antiplatelet medicines for at least six months or longer to prevent blockage of the stent.
F. CAROTIDO-CAVERNOUS FISTULA
Post-traumatic carotid-cavernous fistulas are due to a tear in the wall of the cavernous carotid artery, leading to shunting of blood into the cavernous sinus. These are generally high-flow fistula and rarely resolve spontaneously. There is severe conjunctival congestion, haemorrhagic chemosis, ptosis (drooping of the eyelid), and pulsatile proptosis (bulging of the eyeball) accompanied by a whistling sound. If not treated promptly, it can cause loss of vision.
Most cases require endovascular embolization (disconnection of the fistula between carotid artery and cavernous sinus).
Done by Dr Nishant Aditya, interventional neuroradiologist.
Done by Dr Nishant Aditya, interventional neuroradiologist.
2. STEREOTACTIC RADIOSURGERY
Radiosurgery is surgery using radiation, that is, the destruction of precisely selected areas of tissue using ionizing radiation rather than excision with a blade. It is not surgery in the traditional sense because there is no incision.Like other forms of radiation therapy (also called radiotherapy), it is usually used to treat cancer and many other benign conditions.
It is often a safer alternative to standard brain surgery (neurosurgery), which requires incisions in the scalp, an opening in the skull and membranes surrounding the brain, and dissection into brain tissue. This type of radiation treatment is usually performed when a tumor or other abnormality in the brain is difficult to reach with standard neurosurgery or for a residual tumour (after surgical excision), or if the patient isn’t healthy enough to undergo standard surgery or if he or she prefers a less invasive treatment.
Apart from malignant tumours, it is used to treat small (less than 2.5 cm) benign brain tumours, trigeminal neuralgia, AVMs, to name a few.
3. NEUROPATHOLOGY (Molecular Biology and targeted therapy)
Neuropathology is the study of diseases of the eyes and of the nervous system, which includes the: Brain. Spinal cord. Neuropathologists are increasingly becoming part of research teams looking into neurological diseases such as brain tumors, Alzheimer’s, Huntingdon’s, Parkinson’s, etc.
Until recently, diagnostics of brain tumors were almost solely based on morphology and immunohistochemical staining for relatively unspecific lineage markers.
Molecular biology is one such field, where the genetic study of the tumour (tumour markers) is done. Molecular markers are fragments of DNA, which are genetic signatures for discovering alterations in gene sequences, expression levels, and protein structures or functions. Genomics provides a comprehensive study of cancer, which helps in the molecular characterization of the tumors. Based on gene expression studies tumours that used to be considered as single entities so far, can now be grouped and can be treated differently (targeted therapy).
Targeted therapy toward specific genetic tumor alterations is still of limited use in the treatment of CNS tumors. Hopefully, future research will enable the development of new drugs that specifically target the genetic alterations that drive the progression of these aggressive tumors, thereby improving survival and quality of life.
Apart from rapid developments in diagnostics and intensive care units, following are the technologies useful to do safer neurosurgery.
4. HORMONE THERAPY FOR PITUITARY TUMOURS
Medication (drug therapy) is very effective for treating some hormone-producing pituitary tumors. The medication can stop a tumor from producing excess hormones or shrink it so it does not press on the pituitary gland or other parts of the nervous system.
These are a few medications used.
- 1.Bromocriptine and cabergoline for pituitary adenomas called prolactinomas, which produce excess of prolactin. These medications can treat prolactinomas by decreasing prolactin secretion and often shrink the tumor. The Possible side effects include drowsiness, dizziness, nausea, nasal stuffiness, vomiting, diarrhea or constipation, and occasionally confusion
- 2.Somatostatin analogs for pituitary adenomas that produce excess growth hormone. Somatostatin analog drugs decrease growth hormone production and may decrease the size of the tumor.
- 3.ACTH-producing tumors (Cushing syndrome). Medications to control excessive production of cortisol at the adrenal gland include ketoconazole, mitotane (Lysodren) and metyrapone (Metopirone). Side effects may include fatigue, nausea, vomiting, headaches, muscle aches, high blood pressure, low potassium and swelling.
Pasireotide (Signifor) works by decreasing ACTH production from a pituitary tumor. This medication is given as an injection twice daily. It is recommended if pituitary surgery is unsuccessful or cannot be done. Side effects are fairly common, and may include diarrhea, nausea, high blood sugar, headache, abdominal pain and fatigue.
Replacement of pituitary hormones
If a pituitary tumor or surgery to remove it decreases hormone production, you’ll likely need to take replacement hormones to maintain normal hormone levels. Some people who have radiation treatment also need pituitary hormone replacement.
5. TECHNOLOGICAL SUPPORT
- Neuronavigation
- Microscope
- CUSA
- IONM