Chapters
Introduction and Objectives | Endovascular Management of Neurovascular Diseases: Ischemic and Hemorrhagic Strokes
Introduction and Objectives | Endovascular Management of Neurovascular Diseases: Ischemic and Hemorrhagic Strokes
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Acute Ischemic Stroke | Endovascular Management of Neurovascular Diseases: Ischemic and Hemorrhagic Strokes
Acute Ischemic Stroke | Endovascular Management of Neurovascular Diseases: Ischemic and Hemorrhagic Strokes
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Slurred Speech, Left face, Arm weakness | IV tPA | 77 | | Endovascular Management of Neurovascular Diseases: Ischemic and Hemorrhagic Strokes
Slurred Speech, Left face, Arm weakness | IV tPA | 77 | | Endovascular Management of Neurovascular Diseases: Ischemic and Hemorrhagic Strokes
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Left sided weakness, Visual field deficity, slurred speech | Angioplasty, Stent  | 72 | Male | Endovascular Management of Neurovascular Diseases: Ischemic and Hemorrhagic Strokes
Left sided weakness, Visual field deficity, slurred speech | Angioplasty, Stent | 72 | Male | Endovascular Management of Neurovascular Diseases: Ischemic and Hemorrhagic Strokes
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Hemorrhagic Stroke | Endovascular Management of Neurovascular Diseases: Ischemic and Hemorrhagic Strokes
Hemorrhagic Stroke | Endovascular Management of Neurovascular Diseases: Ischemic and Hemorrhagic Strokes
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Ruptured aneurysm| Coil Embolization  | 51 | Female | Endovascular Management of Neurovascular Diseases: Ischemic and Hemorrhagic Strokes
Ruptured aneurysm| Coil Embolization | 51 | Female | Endovascular Management of Neurovascular Diseases: Ischemic and Hemorrhagic Strokes
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Intracerebral Hemorrhage | Endovascular Management of Neurovascular Diseases: Ischemic and Hemorrhagic Strokes
Intracerebral Hemorrhage | Endovascular Management of Neurovascular Diseases: Ischemic and Hemorrhagic Strokes
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Conclusion | Endovascular Management of Neurovascular Diseases: Ischemic and Hemorrhagic Strokes
Conclusion | Endovascular Management of Neurovascular Diseases: Ischemic and Hemorrhagic Strokes
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Transcript

Thank you very much Michael for giving me this opportunity and thank you everybody for having me it's a great honor to be here. So again I'd like to thank you for your patience and attention and restructuring the schedule today so thank you.

So I want to talk about some of the key things that we do in the neuro world. Neuro world is about two broad concepts. If there's a blood clot you want to get rid of it. If there's a blood vessel abnormality that is either at risk or has caused

hemorrhage you want to trying and take care of it. So the talk is going to exemplify many different cases that fall in one of these two categories. And when this happens...either the blood clot or hemorrhage... you really have a stroke. And the sooner

you can treat it the less disability the brain suffers. Because time is brain and stroke is a neurologic emergency. ...It's not on....can you hear me now... Okay well let me say stroke is a neurological emergency and the two categories of

strokes that fall into that are ischemic and hemorrhagic. So I'll be presenting different examples of cases that we deal with and these run the gamut and I've tried to highlight by picking cases that exemplify what we do. So both

ischemic and hemorrhagic strokes are brain emergencies. And recent studies have shown that an ischemic stroke you can actually revolutionize patient's outcome by selecting patients and using modern technology to treat

them. Intracerebral hemorrhage is no different and Dr. Gaughen actually set the stage for aneurysms as being an example of that. I'll show you some cases there. It's important to recognize that you don't

stop the subarachnoid hemorrhage when it comes to hemorrhagic disease you also have been intracerebral hemorrhage. And there are multiple underlying vascular abnormalities that actually cause our intracerebral hemorrhage and it's

important to be vigilant and pay attention and pick up these entities that you can treat. So stroke is a

world problem. And stroke is very much a problem in the US. And this is us...and the more purple we are the higher the risk

of death stroke. And though these numbers are from census data from 2007-2009 this purple color and intensity of this purple color has not changed. This map has really not changed. So this tells us how serious this problem is. And we need to

do everything we can to identify patients quickly and get them to the right place so that they can get the right treatment. So this is a cartoon that lays out what we're dealing with when we talk about different types of stroke. This is a

blood vessel cartoon which is blocked up. And when either it's blocked here or the blockage breaks off and occludes an artery in the brain you have a ischemia and infarct. And you have an ischemic stroke. Hemorrhagic stroke in this

cartoon there's an aneurysm that ruptures and blood leaks out in the brain and now we have a hemorrhagic stroke. But they're not fifty-fifty in disease prevalence. We have way more four times more ischemic disease than

hemorrhagic disease that contributes to stroke. But they're both equally important for obvious reasons. If you suffer a stroke the number...the amount of disability that you have is very severe. It is the leading cause of

disability in the U.S. We spend about 80 billion dollars...80 million dollars...every year paying for various aspects of stroke care. So it's it's a problem that's very important to all of us. So talking about ischemic stroke one of the key things

in our minds we are dealing with this is where did the clot comes from. Did it come from the heart did it come from the aortic arch did it come from a plaque that's sitting in the carotid bifurcation or is the

intracranial vasculature already at atherosclerotic and becoming norrow and forming an in-situ thrombus. These are just some examples and the prevalence of this is in this chart. The vast majority of them...more than a third of

them...we still don't know where the clot comes and that requires a lot of investigation on the back end when the patient is admitted. One-in-six are because of carotid disease. One-in-five because of a clot that forms in the

heart or somehow gets to the heart. And one-quarter of them are because of very small blood vessels that are getting smaller and smaller due to long-standing issues like high blood pressure diabetes cholesterol and smoking. And there is still

a fair segment where you don't really know why they had the stroke. So ischemic stroke is not one disease. Its causes are varied. And based on symptoms timing how they present that all goes into your thought process as to how you're going to treat

them. Ultimately regardless of where the clot came from the problem that you're dealing with that time is ticking away when the brain is suffocating for oxygen and energy. This is an example of a brain that is

got ischaemia and infarct. The dark areas are areas of the brain that are dead. So when this patient comes to the emergency room and can't speak and can't move part of the brain is already dead. What we're trying to save by attending

to the patient in a timely fashion is the areas and various shades of blue from turning into dark. So we're trying to penumbra. Okay. The most striking way to think about it is if there is something that's on fire

there's already damaged that's happened. What you're trying to prevent is the damage from spreading further and becoming irreversible. Same idea applies here and each minute that passes where the brain does not have

oxygen is a problem because you're losing two million neurons each minute that you don't have blood flow. And the brain ages for every hour that it's not reperfused about four years. So this is a very

important concept because time is brain. And that's what we're trying to do to save when you're trying to reperfuse these patients with various technologies. So here's the case. Somebody that we

treated. 77-year old guy comes in with slurred

speech. Left side of the face left side of the arm they're both weak. Patient was last known well sometime at night and has hypertension cholesterol. Has had a history of heart attack and heart failure takes Plavix.

There is a standardized way of assessing these patients symptom severity and that's called the NIH Storke Scale. It goes from 0 to 42 points and this patient's number of points is 12. And it's an under-representation of the severity of

the patient's symptoms because the way you measure this is weighted for right sided symptoms rather than left sided symptoms. Anyway the patient gets IV tPA to thrombolyze because if the patient came in

within a three to four and a half hour window. He was eligible and he got tPA. The tPA reduces the disability score from 12 to 9. It did not decrease any further. Why is that. Well it's like saying that the kitchen fire extinguisher should be

able to be as equally effective as a fire truck that comes to put out a very massive fire. Small fire in your kitchen can be handled by the kitchen fire extinguisher. But if you have a building on fire that kitchen fire extinguisher isn't

going to do anything. So in this case the way to think about this is the clot is big for what tPA can be expected to handle. So the pointer is not working and I don't think you can see the arrow. But the circle on the picture that shows

the CT scan of that patient's brain is dusky within the circle compared to other areas. Dusky brain is brain that is ischemic. It is on its way to die unless you do something. The scan on the other side with the arrow

pointing to is the blockage of a blood vessel that supplies that area of the brain. So if you can open up the blockage in a timely fashion you can prevent that dusky brain turning into completely dark brain which means it's dead brain.

Ok so people have looked at this and said okay tPA is a good medicine its FDA approved for patients who come in with stroke symptoms of who don't have bleeding in the head who could be having ischemic strokes. It works. But just like

the example that I used it can't be expected to be effective for every clot size. And that's that that's what the figure shows. ICA MCA Stem MCA division and MCA branch are all different distances from where the carotid bifurcates. Ok.

The farther out you go in the blood vessels branch the smaller it gets. Which means a small clot will cause a small branch to be occluded but not a large branch to be occluded. So therefore if you have a small clot in a small branch

tPA has a better chance of breaking that clot up than a large clot which is stuck in a more proximal branch. And that's intuitive. But somebody actually looked at those numbers and they said well you know what what we thought

turns out to be true. If you give tPA to all comers with ischemic stroke it has a less than one in three chance of being effective and opening that blood vessels. And if you look at the location of the blood clot to where

the branches as you go farther out into smaller branches and block that blood vessel and then give tPA the more effective tPA is for the smaller clot than it is for the larger clot. So that's intuitive and that's what this study shows. So this

explains why maybe the gentleman who came to our ED...77-year old man...didn't fully respond to tPA. So if this were about 12 years ago we would have used the device that's on the left called MERCI device. It's like a cork screw on a

catheter end of a wire end which is fed through the catheter to the area the blockage and you engage the clot and you pull it out. As you move along the timeline more and more devices started to become available for thrombectomies.

So the next device is Penumbra. You've heard that device in the previous talk. And it has that little separator wire that's got a little bulb which distrupts the clot mechanically as the other catheter goes up and down which is

connected to a suction device. They were effective but by the time they actually open the blood vessel that didn't seem to make a whole lot of difference. Not as effective. Patients didn't do all that well despite having spent the time. So the

field continue to work towards something that was more effective in opening up blood vessels. Then came 2011 there abouts when 2012 two devices came out that are both called stent retriever both Solitaire and Trevo and the picture is

what you see. It's a collapsible stent that you cannot leave. It's not a detachable stent that you advance against the clot beyond the clot and unsheath. And engage the clot so that you can retrieve the whole stent back.

And when you retrieve it back you find that the clot has also been retrieved. Ok so there are two devices they're both FDA approved. And there is now overwhelming data that mechanical thrombectomy is very successful and

effective in opening up these large vessel occlusions. There's one more device that has since undergone a iteration in development and that's the Penumbra 5MAX ACE and there are few additional devices. They're nothing

more than if you think about it like a Dyson vacuum cleaners. it's a large-bore aspiration catheter that you go ahead and park in the face of the clot turn on the suction canister which is connected to this

aspiration catheter and you engage the clot with this vacuum and the aspiration catheter. Wait a few minutes and then retrieve the clot back. So with these new technologies we have actually seen great improvement in how

we can benefit our patient. So what we did in the 77-year old gentleman is you can see there is that arrow showing on this side of the screen where there is blockage. You see that the central blood vessels fill but the ones going

towards the side of the screen the MCA branches don't. On the other side where there's the circle that's the lateral view showing that the branch is going to the top of the head fill but the ones going towards the side of the head

right over here they don't fill. So in this case we went ahead and deploy a stent retriever. I can't remember whether it was Solitaire or Trevo it was one of the two. And the red line on that image outlines where the stent is spanning

between from the distal end to the proximal end where the clot is. After five minutes we removed the stent retriever and what you see is fragments of clot that are brought back. And now that blood vessel that was included is

fully open as you can see where the arrow shows. And the circle outlines what was missing its now fully filled in. So this gentleman comes back to see me in clinics a month later. Walking in no deficits. How representative is this

of the results that we saw in the trials. There were five major trials. Now there are more that have all shown that somebody who comes in has a large blood vessel occlusion like this gentleman did if you treat them in this fashion

there is a roughly sixty to seventy percent chance that they will be independent after such treatment. Previously the independent score was at best high thirties. So this is a big revolution in the way we treat the

ischemic stroke patients. Now there are other this is not just a one-off there may be such examples that we see daily. You have a blood vessel here that's the carotid artery and it stops at the skull base.

Beyond that there is no blood flow. So we use not just a stent retriever but a combination of stent retriever and aspiration catheters and after using these devices in multiple passes were completely able to open up that blood

vessel. Ok. What this patient was left with was that area that's demarcated in a circle that's all the stroke that he has. And he actually walked out of the hospital. And what we pulled out is laid out on

the bottom and those are the different clot fragments each time we did this procedure we recovered. And it measures several centimeters actually. So again this patient also went some from very high disabling numbers to actually no

deficit at the time of discharge. Here is

another example you can see the arrow is pointing to the blockage and after doing...in this case we just did suction thrombectomy. You can see that the configuration of

the clot mirrors the bifurcation. And that's what we pulled out with suction thrombectomy and this patient also did very well. The unique thing about this patient is that four days ago the patient had

CABG for symptomatic coronary artery disease. So when the patient was discovered in the morning 15 minutes prior to discovery with stroke symptoms she was fine. Talking moving everything. 15 minutes later somebody

walked in she was doing nothing. Couldn't move couldn't talk. So we couldn't give her tPA because she post surgical. The risk would be unacceptable. So we brought her in and this is what we found and we did aspiration thrombectomy and that's

what we pulled out. And she went from a stroke score of 22 which is very severe for a stroke score of 1 the next day. So again examples that show that we now have a very effective way to treat ischemic strokes. The key here is that it

needs to be timely identified. And that's that's what you know it's still a work-in-progress nationwide but now we have technologies to treat these people that improves outcome and decreases mortality.

do have a strokes. They didn't come to you in proper time. Is there something that we can do to prevent their strokes? That's called medicines. That what we normally do. But there's some patients where you see

that the carotid arteries are still pretty narrow. It may have contributed to their stroke maybe they're outside the time window for you to be able to treat them with these. But now you know you have an

opportunity to treat the carotid disease it doesn't cause another stroke. That was the case that you have in front of you. A 72 year old man who came in with weakness in the left side couldn't see had slurred speech. He

unfortunately came a day after. So we couldn't offer him anything other than medical management. But a month later he came back so that he could have the carotid artery addressed. You can see on that picture that's a reconstructed

picture that shows the narrowing of the blood vessel with the arrow. There's hardly any flow across that narrowing. And the 2D reconstruction here with the coronal picture show that there is a huge atherosclerotic buildup to the point

where there is no flow. And the key to treat this is no small undertaking. Because if you go ahead and you angioplasty that atherosclerotic lesion you can actually send all the debris upstairs.

You could say that you could use a distal protection device but you would have to get through that narrowing. And when you do that you're going to dislodge all the debris upstairs. So in this case we wound up using a proximal flow arrest

device so that when you go ahead and do the angioplasty and lay the stent there is no forward flow to shower all that emboli. And that's exactly what we did. So here is the before and with that degree of stenosis the very next picture

shows you how much blood flow is going to the brain. (Thank you so much) So this is the narrowing. With that narrowing this is all the brain that this blood vessel is able to supply. The brain is starving for oxygen. Once we did the

procedure and you can see the outline of the stent here that looks like a very nice result. What does the brain look like. This branch wasn't even seen before. These branches were not even seen before. Now they're all open. So again there are

things that we might be able to do provided that the patient comes to us in a reasonably timely fashion to treat them from very their ischemic stroke and prevent the future risk of a stroke. So I'm going to

switch gears here and talk about

hemorrhagic stroke. Hemorrhagic stroke just like ischemic stroke comes in different flavors. So I'm going to talk about 2 key ones here today and they're all non-traumatic. The one shown here is a intraparenchymal hemorrhage. Meaning the hemorrhage is in the

substance of the brain. This starshaped hemorrhage is pretty classic for a subarachnoid hemorrhage which is within the folds of the brain not inside the brain but within the folds of the brain. And they both have a very high mortality

rate. Half the patients don't make it to the hospital. So let's start with the aneurysms. You've heard some about aneurysms today. An aneurysm is like a blister on a blood vessel wall that develops over time due to various

risk factors such as uncontrolled hypertension smoking binge-drinking recreational drug use...just a few of them that are known to be influential in their formation and growth. Back in the day you would have to have

an open brain surgery where they'd have to shave your hair make an incision peel the scalp back drill a hole in the bone and then go ahead and put this clip across the neck of the aneurysm excluded from

filling with blood. But since the advent of endovascular treatment you can do this transfemorally by taking a catheter parking it...microcatheter... into the aneurysm and deploying coils which are like miniature metal

slinkies so that you replaced the majority of the volume of the aneurysm with coils which prevents....which minimizes greatly entry of blood. And if you diminish pulsatile flow into the aneurysm you decrease the risk of

re-rupture.

lady with progressive worsening headache and altered mental status. And her blood pressure was very severe 239/132. She's had a very poor GCS score

that was continuing to get worse. And here is that blood pattern that I just talked with you about. A star pattern hemorrhage which we recognize a sub- arachnoid hemorrhage. When we did a CTA we found this bifurcation aneurysm at the

left MCA. So we went ahead and here is the aneurysm. And if you're used to looking at this we can appreciate that this aneurysm has multiple compartments. This double density here is a bubble on the anterior aspect of this aneurysm. This double

density behind this blood vessel is another pouch of this aneurysm behind this blood vessel. So we went ahead and put coils in the aneurysm and excluded it from circulation. So we can do that for

patients who come in with ruptured aneurysms.

They come in in very bad shape they're easy to recognize at least by how severe they are. There are patients who may have aneurysms that have not yet ruptured but still are having symptoms and these symptoms show an impending

rupture of an aneurysm. This and the next example show you exactly that. This is a 51-year old lady with two weeks of headaches double vision droopy eyelid. And she came in. Her CT scan looked okay.

However a CTA showed this PCOM aneurysm... this bubble right here. And that bubble was pushing on the nerve that's passing right onto it. That's why she was having her symptoms. That's actually a hallmark of an

impending aneurysm rupture. Because with each pulsation that's pushing on the nerves and that's telling you that the vessel wall around the aneurysm is getting weaker and could rupture any minute. So it's important to recognize this and she

was recognized in a timely fashion. Here's the aneurysm on the angiogram AP view and here's the lateral view...looks like a boot shape. And we went ahead and coiled this. So here are some...a magnified view of how the coils look within the

aneurysm. Here's the microcatheter that goes up and around into the aneurysm fundus and coils are deployed that way. This is the final result which shows you that the coil volume has replaced the blood

volume within the aneurysm with very little filling within the aneurysm itself. How did she do with her double vision. Well this is what you look like. There's a difference between eyelid sizes on

the left side compared to the right side. Two weeks later he already had significant improvement in the degree of the droopiness of the eyelid and the double-vision. Six months later the double-vision fully gone and she

actually had full movement of eyes. So again another success story that you see. We can offer endovascularly these patients who come in with aneurysms which had ruptured which had not ruptured and those that were discovered incidentally. You

all heard Dr. Gaughen talk about the pipeline device as a treatment option for aneurysms that are certain shape size and location. Well this lady here had almost eight weeks of double vision. Couldn't move her

eyes and the problem with her was that this eye couldn't look to the left. You can see that in this picture. She thought it would go away and waited several weeks before saying "okay it's not going away I

need to seek attention". So when she came she had a CT angiogram and the subsequently a diagnostic angiogram which shows this huge aneurysm here. This is the lateral view of the same thing. And I will play you a video and I think the video illustrates

how blood flows into the aneurysm. Contrast flows this way. It enters the aneurysm swirls in comes out goes wherever it's supposed to go. So this aneurysm would be a good aneurysm for this paitent to have the pipeline embolization device

placement. However she came in with not enough time to put her on two antiplatelet agents so that you couldn't get her therapeutic to tolerate the pipeline stent. Remember what Dr. Gaughen had said that they need to be able to tolerate Aspirin Plavix or two

antiplatelet agents in order for this to actually work. So we went ahead and said let's take the risk of rupture from the this aneurysm by putting in some coils so that it doesn't fill with as much blood and doesn't keep pulsating against the

DI that controls the eye muscles. Then we brought her back in after he became therapeutic. And what you see here is you won't be able to appreciate the stent itself... the pipeline devices itself because the

coils are there and that makes it very difficult for you to see where the pipeline device was place...but this is the outline of how the pipeline device was laid across the neck of the aneurysm that courses along the blood vessels. And the

idea of pipeline as Dr. Gaughen had said... if you want to put a seive that looks like it's jailing fence rolled around to make a stent and use that kind of a seive to interrupt the flow of water you would get dribble on the other side. And that

slows down the blood flow and you would form a clot. The tighter that mesh the more effective that will be. So pipeline embolization device is a much tighter mesh and that's what's shown down here. So that's the kind of

thing that she got put. And now time that's passed between here and here is about six months. So I had no expectation that this lady double vision would have improved but she came back after this procedure three weeks later and now she not only has...is

able to look all the way to the left she does not have double vision anymore. So again a very impressive result that we were able to see in this patient. The

last few minutes i'm going to talk about intracerebral hemorrhage. The other kind of

of hemorrhage that I showed you where the hemorrhage is in the soft tissue of the brain. Very high mortality rate. Very important to pick them up. Very important to look for an underlying blood vessel abnormality because if you do maybe you can treat it from happening again. If you don't these

patient's can re-bleed and that contributes to a very high degree of mortality. So take a look in any manner that's represented here. You have a lobar hemorrhage a basal ganglia hemorrhage temporal lobe hemorrhage a convexity parenchymal

hemorrhage. And the location of the hemorrhage doesn't tell you the underlying cause even though people used to think that it did. And up to one out of every two patients has an underlying vascular abnormalities

and this was not felt to be this high previously. That's because people were not looking for anything underneath. They thought it was due to hypertension or amyloid. So there are certain things that you can look for on the CT scan that

clues you in to there being something else underneath. Like a spot of calcium or dilated blood vessels on a CTA or a blood vessel coursing through where the hematomas is or an aneurysm that doesn't look like a star pattern bleeder or a subarachnoid bleed

but this huge pool of blood eccentric in one part of the brain. So these are just various examples that you might see that can clue you in as to there being something structurally abnormal in these scans. So here's a

patient that came to us. 76 year old man still working still very active. He presented with a seizure and when he got a CT scan you see this big left frontal lobe hemorrhage with a lot of swelling around it. We did the

angiogram we found this AVM. AVM you know is an abnormal connection between arteries and veins in an organ with a nidus that is at the crux of the vascular malformation. So this is a lateral view where you

can see branches from this artery both supply normal brain and also the AVM. So this patient came back from the hemorrhage and is now going to be treated with radiation treatment given that parts of these blood vessels supply normal brain.

Otherwise we would take it out endo- vascularly. This example is such an example where we did take it out endo- vascularly. So this is a 61 year-old gu he was a school school security guard came in with this hemorrhage. Very odd looking

hemorrhage. Had headache and some memory loss. So we did do the angiogram. We didn't find anything when he first came so we went back and look again at three months. When we did that you can see that this artery here supplies branches

and here it's actually filling early an arterialized vein which drains into one of the sinuses. You really shouldn't be seeing any of this in an arterial phase which is what the rest of the scan shows.

So we went ahead and took progressively smaller catheters and ultimately this microcatheter that we parked as close to the fistula point of this vascular malformation and from here injective a substance that would fill that connection

so you would not be able to continue... you would prevent the shunting from happening anymore thereby decreasing the risk of re-rupture again. So here is the video that should show that and here's the microcatheter and

at the end of it is glue or NBCA. And I'll play that again because it goes pretty quickly and it is that quick. In fact I've slowed this down for the purposes of the video. Here it come. And there's the glue cast which looks like what you see before we actually

embolized. And after the embolization the final rung looks like this. Where previously you had this fistula right here you no longer see it and the cast formed by the NBCA is in the location where

the patient initially had the bleed. Untreated this has a rupture...re-rupture risk anywhere upwards of fifty percent. So if you didn't look for this you wouldn't be able to identify it and treat this. And this guy who was

independent would loose his independent or his life if this were to happen again. So he's actually back in school doing his job and doing very well actually. Here's a 33-year old guy with another hemorrhage

and came in headache and weakness in the right side and some confusion. He had some funny looking features on a CT scan so we undertook an angiogram. This angiogram shows a blood vessel going to an AVM right here with pseudoaneurysms

within this AVM. These pseudoaneurysms is what ruptured. That area is difficult to get surgically so we went ahead and put in a microcatheter and did something very similar to what I showed you. So what you're seeing here is the glue

cast that's pretty much what the blood vessel looks like. And here's the 3D of the same. Here's the AVM with pseudoaneurysms. The glue cast shows you the same appearance of the blood vessel because that's what we took down. And again this video

ok the video is not going to play but effectively it shows the glue going from here to the pseudoaneurysm and filling back to this point right about here. How did that patient do. Well there is

the...you saw the rupture in the previous scan right here. Not all of it is the malformation. Only part of it is because of blood just ruptured everywhere from the AVM. So the glue cast itself is within the

crux of the AVM itself. And this is the post-treatment injection where you don't...you see very little of this AVM left at this point and we expect it might actually thrombose in due time. Here's another pattern of blood.

This is actually multi-compartment hemorrhage in the 62 year-old lady who presented with headache nausea and dizziness. She actually had an AVM with some flow related aneurysms and this was sitting right in the hematoma bed. So we went ahead

put in microcatheters...catheter through which microcatheters were advanced and coiled off the aneurysm. She also had two additional flow related aneurysms. These aneurysms are actually very malignant. They don't tolerate all

that excess flow through the vascular bed. And they are at very high risk of bleeding especially in a patient whose already had rupture. So here is the other artery that's supplying feeders to this AVM with

very dysplastic segment and aneurysms here. So we went ahead and injected Onyx...this is the cast that's left behind by that... which is within these magnified views of the aneurysm and dysplastic segment and the pseudoaneurysm. And she'd done well

after surviving the hemorrhage and the treatment and she has come back to clinic and she's contemplating getting the AVM treated. So in conclusion

intracerebral hemorrhage like the other types of stroke is a neurological

emergency. You're not going to find an underlying vascular abnormality and if you look for it. And if you do find it its...many of these are treatable like the aneurysm the AVM the fistula...these are treatable entities. And

where you find aneurysms even when they don't present the present with subarachnoid hemorrhage if they present in other ways clinically treating them can minimize or reverse the symptoms that they're having. So time of brain. And thank you for your attention.

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