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Vascular Disease and Abnormalities

vacular 1Blood vessel abnormalities in the brain normally cause no problem, and yet they are also the second most common cause of stroke.   Because they represent weaknesses in vessels, they can become a source of bleeding and thus stroke in the brain.   The presence of any blood leaked from vessels causes pressure on the brain and inflammatory reaction in brain tissue.

The two most common forms of these vascular abnormalities are aneurysms, which are balloon-like bulges in arteries where pressure has thinned the artery wall, and, less commonly, arteriovenous malformations (AVMs) which are tangles of faulty arteries and veins.   Both of these abnormalities can rupture and begin a bleeding (hemorraghic) stroke, which can represent a true life-or-death emergency.

These conditions are often identified before they become emergencies, through evaluation of various warning-sign symptoms that they cause such as:

  • seizures
  • headache
  • muscle weakness or numbness in a certain part of the body
  • or, in severe cases, paralysis, loss of vision or speech, confusion, unsteadiness.
CT angiogram, cerebral aneurysm

CT angiogram, cerebral aneurysm

Neurosurgeons may use either endovascular techniques or external surgical access to treat these conditions either before they cause a stroke (as a preventive step) or to stop stroke or prevent re-bleeding when one of these abnormalities has ruptured.   Depending on the specifics of each patient, the neurosurgery team may either choose to carefully monitor a vascular abnormality over time through CT scans and/or MR imaging, or proceed with an elective surgical procedure.   The imaging studies are important to making this determination.   If the rupture is small and produces only a modest amount of bleeding and pressure, bed rest may be the only form of care required.  However, bleeding is often significant enough that direct treatment is required.

Aneurysm Treatment

The neurosurgical team can clip an aneurysm or use a type of surgical glue to stop the flow of blood from it——or use a tiny coil device to embolize (clot) the blood flow.   Glue or coil procedures are done as catheter-based neurointerventional procedures taking advantage of imaging to guide the treatment.   Clipping involves making an external incision in the skull and brain to place a tiny clamp at the base of the aneurysm.

CT angiogram, AVM

CT angiogram, AVM

AVM Repair

If an AVM poses a risk for or is the cause of a stroke, or is causing severe symptoms that cannot be otherwise controlled, the team may use one of several approaches to repairing the malformation.   They may inject a surgical glue substance into the blood vessels of the AVM to block blood flow.   If this is not an option and the AVM is in an accessible location, they can use surgery to remove it or, sometimes, radiation to shrink the blood vessels of the AVM.

If a patient’s life is in danger from a bleeding vascular abnormality, the neurosurgical team may consider opening the skull to remove blood and release pressure on the brain, in a procedure called a decompression craniotomy.

Ultrasound of carotid artery

Ultrasound of carotid artery

Another vascular condition affecting blood flow in the brain are areas of narrowing or blockages to the carotid arteries that feed blood to the brain.   In this atherosclerotic condition, plaque lines and narrows the carotid artery and prevents proper blood flow.   The result can be ischemic stroke (due to lack of blood flow).   The neurosurgical team has approaches for revascularization (restoration of blood flow through a blocked artery) to treat this condition.   Using endovascular techniques, they may attempt to open compromised areas by inflating tiny balloons in them and sometimes placing tiny wire-mesh tubes called stents to maintain the opening.   They may also use catheters to cut away the plaque and remove it, in a procedure called atherectomy.   Finally, if these approaches are not possible or adequate, they may perform surgery on the artery through an incision on the outside of the neck and directly remove the plaque.

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