Definitions
Embolism refers to the migration of any substance not native to the blodd vessel coming from some other source.e.g tumor embolism wherein fragments of tumor invade the blodd vessel and carry on with the blood flow to occlude some other vessel. The process is called embolism, the material transported is called embolus (plural: emboli)
 Embolization is a non-surgical, minimally-invasive procedure performed by an interventional radiologist and interventional neuroradiologists. It involves the selective occlusion of blood vessels by purposely introducing embolic material into the target blodd vessel.
The medical dictionary definition of embolisation is "therapeutic introduction of various substances into the circulation to occlude vessels, either to arrest or prevent hemorrhaging; to devitalize a structure, tumor, or organ by occluding its blood supply; or to reduce blood flow to an arteriovenous malformation." 
Usage
Embolisation is used to treat a wide variety of conditions affecting different organs of the human body. 

• Arteriovenous malformations (AVMs) and other vascular malformations
• Aneurysm
• Gastrointestinal bleeding
• Epistaxis
• Primary post-partum hemorrhage
• Surgical hemorrhage
• Post traumatic hemorrhage
• uterine fibroids
• Kidney lesions

• Liver lesions, typically hepatocellular carcinoma (HCC). Treated either by particle infarction or transcatheter arterial chemoembolization (TACE).
• Portal venous hypertension

In interventional neuroradiology practice, embolisation means dealing with vascular lesions of the brain and spine including AVM, Dural AVF, aneurysms, tumors (pre-operative) etc.

1. An adjunctive goal (eg, preoperative, adjunct to chemotherapy or radiation therapy)
2. A curative goal (eg, definitive treatment such as that performed in cases of aneurysms, arteriovenous fistulae [AVFs], arteriovenous malformations [AVMs], and traumatic bleeding)
3. A palliative goal (eg, relieving symptoms, such as those of a large AVM, which cannot be cured by using embolotherapy alone)

Embolization Materials And Substances

Detachable balloon - Treats AVF and previosuly aneurysms, also to occlude blodd vessels in rare instances where the vessel need to be sacrificed e.g dissections, large aneurysms, carotid bloqout syndrome etc. These balloons are simply implanted in a target vessel, then filled with saline through a one-way valve. The blood stops and endothelium grows around the balloon until the vessel fibroses. Unfortunately, the balloon may be hypertonic relative to blood and hence rupture and fail, or it may be hypotonic and shrink, migrating to a new location.


 

Onyx^® LES

• Onyx is comprised of EVOH (ethylene vinyl alcohol) copolymer dissolved in DMSO (dimethyl sulfoxide), and suspended micronized tantalum powder to provide contrast for visualization under fluoroscopy.
• The Onyx Liquid Embolic System (LES) consists of a 1.5 ml vial of Onyx, a 1.5 ml vial of DMSO, and three 1 ml Onyx delivery syringes.
• A DMSO compatible delivery micro catheter that is indicated for use in the neuro vasculature (e.g. Marathon^™, Rebar^® or UltraFlow^™ HPC catheters) is used to access the embolization site. 
• Onyx is available in two product formulations, Onyx 18 (6% EVOH) and Onyx 34 (8% EVOH). 

Onyx^® HD-500

Onyx^{® 500} is a non-adhesive liquid embolic agent used for the embolization of brain aneurysms.

Procedure

The procedure is a minimally invasive alternative to surgery. The purpose of embolization is to prevent blood flow to an area of the body, which effectively can shrink a tumour or block an aneurysm etc.

The procedure is carried out as an endovascular procedure by a consultant radiologist in an interventional suite. It is common for most patients to have the treatment carried out with little or no sedation, although this depends largely on the organ to be embolized. Patients who undergo cerebral or spinal embolization are usually given a general anesthetic.

Access to the organ in question is acquired by means of a guidewire and catheter(s). Depending on the organ this can be very difficult and time consuming. The position of the correct artery or vein supplying the pathology in question is located by digital subtraction angiography (DSA). These images are then used as a map for the radiologist to gain access to the correct vessel by selecting an appropriate catheter and or wire, depending on the 'shape' of the surrounding anatomy.

Sometimes, direct percutaneous access to the lesion adn organ can be made e.g in liver, face etc. In such cases, multiple fine needles and inserted and placed inside the lesions and the embolic material injected directly.

Advantages

• Minimally invasive
• No scarring
• Minimal risk of infection
• No or rare use of general anesthetic
• Faster recovery time
• High success rate compared to other procedures
• Preserves fertility and anatomical integrity

Disadvantages

• User dependent success rate
• Risk of emboli reaching healthy tissue
• Not suitable for everyone
• Recurrence more likely

What are Angioplasty and Stenting ?
Angioplasty with or without vascular stenting is a minimally invasive procedure performed to improve blood flow in the body's arteries and veins. In an angioplasty procedure, imaging techniques are used to guide a balloon-tipped catheter, a long, thin plastic tube, into an artery or vein and advance it to where the vessel is narrow or blocked. The balloon is then inflated to open the vessel, deflated and removed. During angioplasty, a small wire mesh tube called a stent may be permanently placed in the newly opened artery or vein to help it remain open. There are two types of stents: bare stents (wire mesh) and covered stents (also commonly called stent grafts).
What are some common uses of the procedures?
Angioplasty with or without vascular stenting is commonly used to treat conditions that involve a narrowing or blockage of arteries or veins throughout the body, including:

1. narrowing of large arteries (aorta and its branches) due to atherosclerosis, or hardening of the arteries, a gradual process in which cholesterol and other fatty deposits, called plaques, build up on the artery walls.
2. peripheral artery disease (PAD), a narrowing of the arteries in the legs or arms. In patients with PAD, angioplasty alone or angioplasty with stenting may be used to open up a blocked artery in the pelvis, leg or arm.
3. renal vascular hypertension, high blood pressure caused by a narrowing of the kidney arteries. Angioplasty with stenting is a commonly used method to open one or both of the arteries that supply blood to the kidneys. Treating renal arterial narrowing is also performed in some patients to protect or improve the kidney function.
4. carotid artery disease, a narrowing of the neck arteries supplying blood to the brain.
5. coronary artery disease, a narrowing of the coronary arteries that carry blood and oxygen to the heart muscle.
6. venous narrowings involving the central veins. In some cases, stenting of the narrowed vein is also needed.
7. narrowing in dialysis fistula or grafts. When there is decreased flow in the graft or fistula so that is not adequate for dialysis, angioplasty is generally the first line of treatment. Stenting may also be needed in some cases.
8. intracranial arteries and veins

How should I prepare?
You should report to your doctor all medications that you are taking, including herbal supplements, and if you have any allergies, especially to local anesthetic medications, general anesthesia or to contrast materials (also known as "dye" or "x-ray dye"). Your physician may advise you to stop or add some medications for a specified period of time before your procedure. Also inform your doctor about recent illnesses or other medical conditions. Women should always inform their physician and x-ray technologist if there is any possibility that they are pregnant. Many imaging tests are not performed during pregnancy so as not to expose the fetus to radiation. If an x-ray is necessary, precautions will be taken to minimize radiation exposure to the baby. See the Safety page for more information about pregnancy and x-rays. You may be instructed to not eat or drink anything for several hours before your procedure. You may need to stay overnight at the hospital following your procedure. You will be given a gown to wear during the procedure. What does the equipment look like?


In these procedures, x-ray imaging equipment, a balloon catheter, sheath, stent and guide wire are used. The equipment typically used for this examination consists of a radiographic table, an x-ray tube and a television-like monitor that is located in the examining room or in a nearby room. When used for viewing images in real time (called fluoroscopy), the image intensifier (which converts x-rays into a video image) is suspended over a table on which the patient lies. When used for taking still pictures, the image is captured either electronically or on film. A guide wire is a thin wire used to guide the placement of the diagnostic catheter, angioplasty balloon catheter and the vascular stent. A sheath is a vascular tube placed into the access artery, such as the femoral artery in the groin, that allows catheter exchanges easily during these complex procedures. ( In interventional neuroradiology, we routinely use femoral artery access as opposed to cardiac interventions where radial artery access has gained significantly widespread reach. A balloon catheter is a long, thin plastic tube with a tiny balloon at its tip. A stent is a small, wire mesh tube. Balloons and stents come in varying sizes to match the size of the diseased artery. Stents are specially designed mesh, metal tubes that are inserted into the body in a collapsed state on a catheter and then expanded inside the vessel to prop the walls open. In some cases the stent may have a synthetic fabric covering. Other equipment that may be used during the procedure includes an intravenous line (IV) and equipment that monitors your heart beat and blood pressure.
How does the procedure work?
Using image guidance, an inflatable balloon mounted at the tip of a catheter is inserted through the skin into an artery and advanced to the site of an arterial blockage where the balloon is inflated and deflated. In this process, the balloon expands the artery wall, increasing blood flow through the artery. A stent may be placed at the treatment site to hold the artery open
How is the procedure performed?
Image-guided, minimally invasive procedures such as angioplasty and vascular stenting should only be performed by a specially trained interventional radiologist in an interventional radiology suite or occasionally in the operating room. This procedure is often done on an outpatient basis. However, some procedures may require admission. Please consult with your physician. You will be positioned on the examining table. You will be connected to monitors that track your heart rate, blood pressure and pulse during the procedure. A nurse or technologist will insert an intravenous (IV) line into a vein in your hand or arm so that sedative medication can be given intravenously. You may also receive general anesthesia. The area of your body where the catheter is to be inserted will be shaved, sterilized and covered with a surgical drape. Your physician will numb the area with a local anesthetic. A very small nick is made in the skin at the site. A sheath is first inserted into the artery. Guided by x-rays, the catheter is then inserted through the skin and maneuvered through the artery until it reaches the site of the blockage. Once the catheter is in place, contrast material will be injected into the artery and an angiogram will be taken of the blocked artery to help identify the site of the blockage. With x-ray guidance, a guide wire will then be moved to the site, followed by the balloon-tipped catheter. Once it reaches the blockage, the balloon will be inflated for a short period of time. The same site may be repeatedly treated or the balloon may be moved to other sites. Additional x-rays will be taken to determine how much the blood flow has improved. When your physician is satisfied that the artery has been opened enough, the balloon catheter, the guide wire and catheter will be removed. Many angioplasty procedures also include the placement of a stent, a small, flexible tube made of plastic or wire mesh to support the damaged artery walls. Stents can be self-expandable (opens up itself upon deployment) or balloon expandable (balloon needed to open the stent). Balloon expandable stents are typically placed over a balloon-tipped catheter so that when the balloon is expanded, it pushes the stent in place against the artery wall. When the balloon is deflated and removed, the stent remains permanently in place, acting like a scaffold for the artery. Self-expandable stents are easy to deploy, but may require additional angioplasty with balloon to obtain satisfactory dilation (opening) of the diseased vessel. Covered stents or stent-grafts have additional advantages over bare stents and are becoming more commonly used. Drug-coated (also called drug-eluting) stents have recently been approved for clinical use in the coronary (heart) arteries by the U.S. Food and Drug Administration (FDA). These stents are coated with a medication that is slowly released to help keep the blood vessel from re-narrowing, a condition called restenosis. However, for neuro patients these are still not available, and are used off-label. If a sheath was inserted into your arm or wrist, it will be removed. At the end of the procedure, the catheter will be removed and pressure will be applied to stop any bleeding. The opening in the skin is then covered with a dressing. No sutures are needed. You may need to lie in bed with your legs straight for several hours. In some cases, your physician may use a device that seals the small hole in the artery, called a "closure device", which will allow you to move around more quickly. When the procedure is completed, you will be moved to a recovery room or to a hospital room. Your intravenous line will be removed. The length of the procedure varies depending on the time spent evaluating the vascular system prior to any therapy, as well as the complexity of the treatment.
 What will I experience during and after the procedure?
Devices to monitor your heart rate and blood pressure will be attached to your body. You will feel a slight pin prick when the needle is inserted into your vein for the intravenous line (IV) and when the local anesthetic is injected. If the case is done with sedation, the intravenous (IV) sedative will make you feel relaxed and sleepy. You may or may not remain awake, depending on how deeply you are sedated. You may feel slight pressure when the catheter is inserted but no serious discomfort. As the contrast material passes through your body, you may get a warm feeling. It is common for patients to feel some mild discomfort when the balloon is inflated because the artery is being stretched. Discomfort is more prominent when veins are dilated. Your discomfort should lessen as the balloon is deflated. The catheter insertion site may be bruised and sore. For several hours, your catheter site will be checked for bleeding or swelling and your blood pressure and heart rate will be monitored. Bleeding risk at the vascular entry site when veins are treated is less likely, therefore, you may be discharged earlier if the procedure is performed for vein disease, for example, dialysis fistula. Your physician may prescribe medication to relax your arteries, to protect against spasm of the arteries and to prevent blood clots. If a contrast material was used during the procedure, you will urinate often to rid your body of this material. You may be asked to drink extra fluids. After you return home, you should rest and drink plenty of fluids. You should avoid lifting heavy objects and strenuous exercise for at least 24 hours. You should avoid smoking permanently (since this is a major cause of atherosclerosis). If bleeding begins where the catheter was inserted, you should lie down, apply pressure to the site and call your physician. Any change in color in your leg, pain or a warm feeling in the area where the catheter was inserted should be promptly reported to your physician. After an angioplasty or stent placement procedure you may be instructed to take one or more medications (such as aspirin, or blood thinners such as Plavix®, Lovenox® or Coumadin®) for a period of time. These medications can prevent blood clots from forming at the site of arterial treatment during healing. The effect of Coumadin will be monitored with frequent blood tests. Magnetic resonance imaging (MRI) can probably be done immediately following stent placement, but make sure that you notify the MRI department that you have recently had a stent. Although stents used today may be considered safe for MRI, you may need several weeks after stent placement for MRI to be safe. Metal detectors will not affect a stent.
Who interprets the results and how do I get them?
The interventional radiologist can advise you as to whether the procedure was a technical success by comparing the pre- and post-procedure angiograms.
 What are the benefits vs. risks?
Benefits Compared to surgical interventions such as bypass surgery, balloon angioplasty and stent placement are much less invasive and relatively low-risk, low-cost procedures. These procedures are performed using local anesthesia; no general anesthetic is required in the majority of patients. No surgical incision is needed-only a small nick in the skin that does not have to be stitched closed. You will be able to return to your normal activities shortly after the procedure.
 Risks Major complications following angioplasty are uncommon. However, inserting the catheter can lead to injury of the artery. The balloon also poses a risk of blood clots or tearing the artery. When angioplasty is performed alone, blockages can recur, although most of these arteries can be opened again successfully. This can also occur when a stent is placed in the artery at the time of the angioplasty. Heavy bleeding from the catheter insertion site may require special medication or a blood transfusion. There is a risk of stroke when angioplasty and/or stenting are performed on the carotid artery. A relatively rare complication associated with balloon angioplasty is abrupt vessel closure, or occlusion. This blockage in the area treated by the balloon angioplasty typically occurs within 24 hours of the procedure. If it happens, treatment with medication into the artery to dissolve clots followed by angioplasty or stenting may be appropriate. In some cases, emergency bypass surgery may be needed. Other rare complications include heart attack and sudden cardiac death. Any procedure where the skin is penetrated carries a risk of infection. There is a very slight risk of an allergic reaction if contrast material is injected. Any procedure that involves placement of a catheter inside a blood vessel carries certain risks. These risks include damage to the blood vessel, bruising or bleeding at the puncture site, and infection. Contrast material used during these procedures may cause renal failure, a decrease in kidney function, particularly if there is already some degree of decreased kidney function. Your physician generally checks your renal function before this procedure in order to lower this risk.
 What are the limitations of Angioplasty and Vascular Stenting? 
 Angioplasty with vascular stenting is just one way to treat narrowed or blocked arteries. Medications and exercise are often the first step in treating atherosclerosis. Regardless of which artery is blocked, angioplasty does not reverse or cure the underlying disease of atherosclerosis. It is extremely important for patients to make lifestyle changes, including eating a healthy diet that is low in saturated fat, exercising and not smoking. Individuals with diabetes, high blood pressure and/or high cholesterol need to follow the treatment plan prescribed by their healthcare providers. Angioplasty may have to be repeated if the same artery becomes blocked again, a condition called restenosis. If a stent is placed at the time of the angioplasty, the chance of restenosis may be reduced but can still occur. Only about half of patients with renal vascular hypertension caused by atherosclerosis have their blood pressure successfully treated or improved by angioplasty/stenting. By the time the procedure is done, many of these patients have disease in small arteries within the kidney that does not respond to angioplasty. Angioplasty and vascular stenting for peripheral artery disease (PAD) affecting arteries in the pelvis and legs are less successful when there are multiple leg vessels that are narrowed or when small vessels have to be opened. Patients with PAD can benefit from smoking cessation, eating a proper diet, exercising regularly and controlling blood cholesterol. Angioplasty and stent placement in the carotid artery has been approved by the FDA, but there is not much long-term data to know how well this works, or if there are potential complications that can develop from stents being placed in the carotid arteries. A dedicated filter device may be used during stent placement to try and help keep blood clots and other plaques from passing into the brain during the procedure, thereby lowering the risk of stroke. Surgical repair has been done for many years and has been proven effective and safe when done by skilled surgeons. You should discuss with your physician what the potential risks and benefits of carotid artery stenting are in your particular situation.
 Watch a video of of carotid stenting
Watch an animated video of intracranial stenting using Wingspan stent system

What is coiling?

In the 1990s, coiling was introduced as a way of treating ruptured and unruptured aneurysms without the need for a craniotomy (an operation to open the head to expose the brain). Coiling involves approaching the aneurysm from inside the blood vessel, avoiding the need to open the skull. Small platinum coils are inserted into the aneurysm through the arteries that run from the groin to the brain. The coils remain in the aneurysm: they are not removed. They prevent blood flowing into the aneurysm and therefore reduce the risk of a bleed or a re-bleed. Blood then clots around the coils sealing off the weakened area. It is one of the most commonly performed and most rewarding procedures in interventional neuroradiology practice.

What happens before the procedure?

The coiling procedure is similar to an angiogram (an X-ray test to take pictures of the blood vessels) and involves a very small tube (catheter) being fed up to the brain via blood vessels from the groin.
However, it is much more complex and is usually carried out under general anaesthesia in the interventional neuroradiology department.
This means you must not eat or drink anything for four to six hours before the procedure. The staff on the ward will advise you on this.
Before you leave the ward, a nurse might shave a small area of your groin at the entry site through which the coils will be passed. If you are well enough, and if you prefer, you might be able to shave yourself.
On arrival at the radiology department, an anaesthetist will give you a general anaesthetic and you will be asleep throughout the procedure.

What happens during the procedure?

The room will have several large pieces of high-technology scanning equipment which are needed to perform the coiling.
The interventional neuroradiologist will make a small incision in your groin through which they will insert the catheter into your femoral artery. This is then guided through other blood vessels in your body until it reaches your neck and then into your brain.
Using a guide wire and microcatheter, one by one, one or more coils are slowly inserted into the aneurysm. The coils are made of platinum, are twice the width of a human hair, and can vary in length. The number of coils needed depends on the size and shape of the aneurysm. The largest coil is inserted first and then smaller coils are inserted until the aneurysm is filled. Usually, several coils will be used.
After the whole aneurysm gets filled up by coils, the interventional neuroradiologist will remove the catheter. Occasionally, the entry point in the groin will need to be sealed or stitched. It might be slightly painful and there might be some bruising.
Coiling is a complex and delicate procedure that will take at least three hours and often longer.

What happens after the procedure?

You will probably spend some time in the high dependency unit – usually at least two hours. During this time, regular neurological observations will be performed by the nursing staff. This is to check that you are waking up properly from the anaesthetic. It involves asking you simple questions, testing the strength of your arms and legs, and shining a light in your eyes. Your blood pressure, heart rate, respiratory rate, and oxygen levels will also be monitored.
The nurse will check the small wound in your groin for any bleeding and also check the pulse in your foot. This is to ensure that your blood circulation to your legs has not been affected.
It might be that the opening in your artery in your groin is plugged closed after the procedure. This is done with a device called an angioseal.
You will have to lie flat, or at an angle of no more than 30 degrees, for at least six hours following the procedure. This helps with your blood pressure and prevents any excess pressure on the artery which could increase the chance of bleeding at the puncture site in your groin.
Depending on your recovery after this time, you will be able to sit up gradually. The nurses will assist you with this.
Throughout this time, the nurses on the ward will continue to monitor you and carry out neurological observations. Pain-killers will be given for any discomfort or headaches you might be experiencing. You are also likely to have a drip to prevent dehydration, and possibly a urinary catheter.
Because you are restricted to bed rest, you will have to wear pressure stockings to help prevent blood clots forming in your legs (deep vein thrombosis).

What are the risks of coiling?

It is likely that the benefits of coiling will strongly outweigh any possible risks, and your doctor will have discussed this with you fully before you give your consent to go ahead with the procedure. However, as with any invasive procedure, there are certain risks associated with coiling. Possible complications include stroke-like symptoms such as weakness or numbness in an arm or leg, problems with speech, or problems with vision.
There is also a risk of bleeding, infection or arterial damage at the entry site in the groin.  In all the risk is not more than 3-4% and the risk of death is<1%.

How successful is coiling?

Research is still being conducted to explore the benefits and risks of coiling. Various studies have been published. The largest is the International Subarachnoid Haemorrhage Trial (ISAT) which was established to explore the effectiveness of coiling compared to the clipping of ruptured aneurysms during a craniotomy. The trial involved different neurosurgical centres and a total of 2,143 patients participated. The ISAT trial showed that the long-term risks of further bleeding are low for both coiling and clipping, and the results positively supported coiling as a treatment for ruptured aneurysms, both in terms of survival and in the reduction of long-term disability.

Can the coils move?

Once the coils are securely in place they will not move out of the aneurysm.

Will I need more coils?

Although the coils do not move, they might settle into the space within the aneurysm. This might mean that more coils are required to block off the aneurysm fully. This is why you will have a follow-up angiogram. Although in literature, about 15-20% patients have some refilling of the aneurysm, in our practice most of them do not need any further treatment. Around one in 20 patients require further treatment.
Is it safe to coil aneurysms with difficult morphology?
The interventional neuroradiology practice has evolved rapidly along with the necessary expertise and the technological advances such that the things unthinkable of 10 years ago can be done now. e.g coiling of aneurysms with multiple sacs.
For aneurysms with large size or wide necks, balloon or stent support may be used. A wide variety of them are available now.
Balloon assisted coiling
Stent assisted coiling
Combined balloon and stent assisted coiling
An example of balloon assisted coiling is below.


Fig: Balloon assisted coiling. A and B, Frontal (A) and lateral (B) arterial phase images from digital subtraction angiography (DSA) of the left internal carotid artery (ICA) show a large wide-necked aneurysm of the ophthalmic segment.
C and D, Road-mapped live subtraction images of the left ICA (lateral projection) show placement of the first coil. Note the herniation of a coil loop (arrow) through the neck of the aneurysm into the left ICA (C). In D, the balloon (thick arrow) has been inflated across the aneurysmal neck, permitting the framing coils to be deployed within the aneurysm. Arrowheads identify the indwelling 0.010-inch guidewire within the balloon microcatheter. An unextruded segment of a GDC (thin arrow) identifies the course of the coil-delivery microcatheter.
E and F, Frontal (E) and lateral (F) unsubtracted radiographs show deployment of a subsequent GDC. The images serve to orient the viewer with respect to the course of the ICA in relation to the aneurysmal base. The balloon (slanted arrow, E and F) has been inflated within the paraclinoid segment of the ICA, which sweeps lateral to medial across the face of the aneurysmal neck. The supraclinoid segment courses medial to the lower portion of the aneurysmal fundus and is partially obscured by the aneurysm in lateral projection. A small niche of aneurysm lying posterior to the ICA could not be angiographically thrown off the ICA by any of the views attempted. In this respect, the inflated balloon defines the boundary of the ICA lumen and assists the operator in coiling the aneurysmal base. The final segment of coil 14 (thin arrow, E) has been deployed in F. Note the alignment of the delivery wire marker with the proximal microcatheter marker (curved arrow, F). An indwelling 0.010-inch guidewire (arrowhead, E and F) identifies the course of the balloon microcatheter.
G, Mid-arterial phase image (frontal projection) from the immediate posttreatment left ICA DSA after deployment of the 18th GDC within the aneurysm. Coils are present throughout the aneurysmal base; however, minor opacification through the coil interstices is evident.
H and I, Frontal (H) and lateral (I) arterial phase images from the follow-up angiogram 18 months later confirm stable occlusion of the aneurysm.

New materials are being devised day to day e.g bioactive material coated coils which expand after deployment so as to prevent any chance of recurrence.

• Full blood count
• Blood glucose
• Blood urea, electrolytes
• Chest radiograph
• ECG
• CT scan
• Blood coagulation profile

• Arterial Hypertension ( high BP)
• Cigarette smoking
• Diabetes mellitus
• Hyperlipedaemia
• Polycythaemia
• Thrombocythaemia
• High alcohol intake
• Positive family history
• Oral contraceptives
• Trauma

• Antinuclear factor
• Anti-bodies to double-stranded DNA
• Anti-cardiolipin antibodies
• Lupus anti-coagulant
• Cholesterol

• Careful nursing
  Regular turning of a patient to avoid pressure sores; skin kept dry and clean
• Care of airway
  Oropharyngeal tube with regular suction of secretions if the patient is unconscious
• Fluid balance
  Nasogastric feeding if patient cannot swallow; bladder catheterisation if incontinent
• Physiotherapy
  Start immediately to prevent joint contractions; to clear chest secretions; to promote recovery of strength and coordination
• Speech and occupational therapy
  Start once acute stage over to assess functional problems and to encourage recovery skills

1. Ischemic stroke: Clot busting medications can be given intravenously to dissolve the clot in the arteries so that blood flow is restored. Prior to it the physician evaluates the patient for suitability for ‘thrombolysis’. In certain patients, intraarterial therapy (done by interventional neuroradiologists) can be done to dissolve or retrieve the clot out of the blood vessel. Some patients may not be found suitable for either therapy however and they will be put on blood thinning drugs( antiplatelets or anticoagulants)
2. Hemorrhagic stroke: Depending upon the type of hemorrhage the physician will decide the further active treatment e.g for subarachnoid hemorrhage; a DSA is done which usually shows an aneurysm and can be treated by interventional neuroradiologists by endovascular coiling. If there is a large intraparenchymal hemorrhage then open surgery to remove the clot and relieve pressure on the normal areas of the brain can be undertaken (craniotomy) by a neurosurgeon.

How can stroke be prevented?

• Knowing and controlling blood pressure
• Finding out if you have atrial fibrillation
• Not smoking
• Lowering cholesterol, sodium, and fat intake
• Following a healthy diet
• Drinking alcohol only in moderation
• Treating diabetes properly
• Exercising regularly. Moderate aerobic fitness can reduce stroke risk,
• Managing stress
• Not using drugs
• Taking preventive medications such as anti-platelet and anticoagulant drugs to prevent blood clots
• Cholesterol lowering drugs can prevent stroke recurrence
• Secondary prevention of stroke: means ‘to prevent re happening of stroke after the patient has recovered from the present episode’. The patient will undergo some form of angiography (CTA, MRA or DSA) to have a look at the blood vessels If any narrowing is found then ‘angioplasty’ and ‘stenting’ may be offered by the interventional neuroradiologist.