Endovascular Neurosurgery

Head doctor: Prof. José Cohen
Secretary, tel: 02-677-6956

This exciting new field has recently been developed at Hadassah with the recruiting of Prof. José Cohen to the faculty. Prof. Cohen is a renowned expert in these sophisticated procedures, including embolization of cerebral aneurysms, ateriovenous malformations and fistulae, thrombolysis for acute stroke and carotid and cerebral arterial stenting. This competency helps in treating various brain diseases that originate from or are related to vascular cerebral blood vessels.

Using fine microcatheters, the neurosurgeon ia able to reach and perform actions in the arteries of the brain, where entry is via a small hole pricked in the thigh. In this way it is possible to reopen blocked arteries and treat damaged arteries without the need for open skull surgery.

Stroke is the third leading cause of death, and the major cause of disability in Israel. A considerable number of patients suffering from this condition could benefit from the new endovascular techniques, the use of stents and new medications.

The use of these endovascular techniques may also be the optimal treatment in cases of brain aneurysms, cases of AVM (arterio-venous malformations), certain intracranial tumors and some diseases of the spinal cord.

Endovascular treatment of brain aneurysms
The treatment of brain aneurysms using balloons was initially reported at the beginning of the 1970s. However, after the development of detachable coils in 1991, the balloon treatment option was soon abandoned, and it is limited today only for use in selected cases.

The method of treatment of a blockage using detachable coils involves inserting a microcatheter via a transfemoral approach, namely access through the femoral artery. From there, the catheter is passed through to the arterial system of the skull, and directly into the aneurysm. Soft platinum coils are transferred into the aneurysm and disconnected, until complete blockage of the aneurysm is attained. This approach is still progressing and evolving, and occasionally different coils (microstents) are inserted for use, as well as various clotting factors.

Catheterization for the treatment of intracranial ischemic lesions
Patients in whom medication has failed to treat the symptoms of cerebral ischemia are candidates for treatment via the renewal of blood flow - revascularization therapy, wthether by catheterization with a balloon or by grafting a stent. The majority of these patients are very sensitive to invasive treatment, and suffer from extensive atherosclerotic illness that affects different vascular areas.

Therefore, sophisticated methods have been developed that involve minimal invasiveness. These techniques have had high success rates.

The use of a stent is acceptable in most cases where the atherosclerotic damage is in the extra-cranial arterial system: in the carotid artery or vertebral arteries. Innovative measures that protect the brain help with the catheterization process.

Arterio-venous malformations (AVM) treatment and treatment of fistulas
The goal of embolization is to block the AVM or the fistula. However, in the treatment of multiple defects or abnormalities of large size, the embolization is part of an integrated treatment plan that may also include surgery or radiosurgery. This integrated approach has enabled the treatment of defects that were previously thought to be impossible to fix.

Pre-operative Embolization in Tumors
With the goal of reducing blood loss during surgery and reducing the duration of surgery, pre-operative embolization is performed in selected tumors of the central nervous system. These are generally tumors that are abundant in blood vessels, such as meningiomas, pre-gangliomas or angiofibromas.

Introduction of chemotherapeutic drugs directly into the tumor is a promising field that only just begun.

Patients who have recently suffered vertebral fractures, especially fractures resulting from osteoporosis, often suffer from back pain of different severity levels. Patients whose back pain does not respond to medication and rest are good candidates for spinal catheterization (vertebroplasty).

This process is performed under sedation and includes the insertion of material deep into the damaged vertebrae bodies. The process usually takes about one to two hours, and almost 90% of patients have significant relief or disappearance of pain thereafter.

Thrombolytic intra-arterial therapy for stroke
Patients arriving at the hospital with the initial stages of ischemic stroke can today benefit from immediate and local treatment for clot dissolution (thrombolytic treatment). Similarly to emergency catheterization for an infarction, the blocked cerebral artery can be reopened by this treatment, but treatment must be given within six hours of the onset of symptoms.

Stroke is a devastating disease of the brain, and it is a leading cause of mortality, as well as impairing quality of life, in developing countries. In order to improve emergency treatment in stroke, we recommend that the public relate and respond to strokes as an emergency incident.

Time may help us to save your brain!

Signs that should raise the suspicion of a stroke

  • Weakness or sudden numbness of the face, arm or leg (especially on one side of the body).
  • Sudden appearance of confusion, disturbance in speech, a phrase, or understanding words (Aphasia)
  • Sudden appearance of slurred words and inaccurate expression of words (Dysarthria)
  • A sudden disturbance in vision in one or both eyes
  • Loss of vision in one eye
  • Loss of vision on one side
  • Sudden appearance of double vision
  • A sudden disturbance in walking or dizziness, loss of balance or coordination
  • Severe headache that appears suddenly and without a known cause.
  • Sudden decline in the state of consciousness.

Case Study No. 1
A 68 year old man complains of recurrent right eye blindness.
Diagnosis: severe narrowing of the right carotid artery. The brain does not receive an adequate blood supply.
Treatment: Opening of the catheterization by stenosis. The artery was reopened, and the brain gets a good blood supply.

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