Friday, April 10, 2009


I have always been very concerned at the development of neuro-intervention in this country and worldwide. I had the good fortune of being at the ringside seat to see neuro-intervention begin and her early development It began almost as a spin-off from coronary angioplasty, by almost the same guys, who felt that any stenosis or blockage was fair game to unblocking and angioplasty. Evidence was grossly lacking and they just went ahead. Overtime, we saw a discipline developed, now looking for evidence. How many patients have suffered along the way, only God knows.
Anyway, in my reading, I have just come across the American Heart Association (AHA) and American Stroke Association ( ASA ) recommendation on neuro-interventional procedures. I cut and paste completely, so that my biasness will not come in.

This came out in a document entitled, " Indications for the performance of intracranial endovascular neurointerventional procedures". A scientific statement from the American Heart Association Council.
The following are some of the main recommendations in the new document.

  • Ruptured aneurysms: Endovascular coil occlusion of the aneurysm is appropriate if the aneurysm is deemed treatable by either endovascular coiling or surgical clipping (class I, level of evidence B).
  • Unruptured aneurysms: The authors deem it "reasonable" to consider endovascular occlusion for unruptured aneurysms if the aneurysm is thought to require intervention over conservative management and is amenable to endovascular treatment according to an endovascular specialist (class IIa, level of evidence B).
  • Intracranial stenosis: For symptomatic atherosclerotic stenosis greater than 70% and failing medical therapy, endovascular revascularization with angioplasty or stenting might be reasonable (class IIb, level of evidence B).
  • Acute ischemic stroke: For patients with a major stroke syndrome lasting six hours or less, and who are either ineligible for or who have failed intravenous thrombolysis, it is "reasonable to consider intra-arterial thrombolysis in selected patients" (class I, level of evidence B). For patients with a major stroke syndrome lasting eight or more hours, it "may be reasonable" to use mechanical disruption to restore blood flow in selected patients (class IIb, level of evidence B).
  • Cerebral arteriovenous malformation (AVM): For patients with hemorrhage referable to a pial AVM, endovascular treatment in combination with other therapies, such as surgery or radiosurgery, should be considered as a preoperative adjunct or palliative treatment to prevent recurrent hemorrhage (class IIb, level of evidence C). For those with neurologic symptoms or hemorrhage referable to a dural arteriovenous fistula, endovascular treatment alone might be curative or might be used in combination with other therapies, such as surgery or radiosurgery, as palliative treatment to prevent stroke or hemorrhage (class IIb, level of evidence C).

I do hope that practitioners doing neuro-intervention will based their therapy on good robust clinical evidence. The " oculo-stenotic " reflex should be curb as much as possible. " I can see, I think that I can do, so I will do" kind of logic should be avoided. It must havce evidence to show that it will help the patient. Each practitioner must draw their own line.

No comments: