
56-year-old women from Thrissur got a new lease of life after Amrita Hospital Doctors performed lifesaving endovascular neurosurgery to reconstruct in the major blood vessel injury in the brain to prevent the risk of developing life-threatening hemorrhage or stroke. In a first for Kerala, for a blood vessel injury in private sector Amrita Hospital used a ‘flow diverter device’, a new-generation stenting device, to repair and divert blood flow away from the injured segment of the blood vessel. This Flow diverter device was first used in the Private sector in Kerala in 2014 in Amrita Hospital for a Brain aneurysm and is now regularly being used for blood vessel diseases in the brain in most Neurointerventional centres. But for an emergency life threatening bleed in the injured blood vessel, it is for the first time. Amrita Hospital, Kochi, one of the handful of hospitals in the country and in Kerala, to have a Neurosurgery department with an Endovascular division.
Dr N. R. Sreehari (Associate Professor, Division of Vascular and Endovascular Neurosurgery) said, “The patient had life threatening blood vessel injury involving a major segment of the left internal carotid artery. If left untreated the injured internal carotid artery could have led to life threatening hemorrhage or major disabling stroke. We performed the reconstruction for arterial injury using endovascular arterial flow diverter (one of the latest version- SILK VISTA), after ICU stabilization of the patient`s vitals. It is a very difficult procedure and technically demanding as the Blood vessel segment to repair was long tortuous. She had two complex curvatures in the blood vessel in the injured area which made the navigation of the device very difficult. Another challenge was to work inside the injured blood vessel as we could not use blood thinning agents before the device deployment as there is risk of massive re-bleeding.”
Thanks to the combined effort of the neuro endovascular, neuro endoscopy, ENT, and neuro anesthesia team at Amrita Hospital, a near total reconstruction of the internal carotid artery was done and the damaged segment of the artery was repaired. The surgery done on January 21, 2022, lasted 1 1⁄2 hours. The patient was observed closely in the ICU for 48 hours and was taken up for the removal of the ‘nasal pressure pack’ and sealing of bleeding from inside the nose. The surgical team was led by Dr N. R. Sreehari (Neurovascular and Endovascular Surgery) with Dr Ayyadurai R. (Neuroendoscopy), Dr. Unnikrishnan (ENT surgeon) ,Dr Sajesh K. Menon (HOD Neurosurgery), Dr Mathew George, Dr Eldo Issac and Dr Gokul Das S.( Neuroaneasthesia team).
For the patient, Ms. Prabha Manoharan, a mother of two, it all started with a partial vision loss in one of her eyes about three months ago. It was considered a cataract problem. Hence, she underwent a surgery for the removal of the cataract. But the vision could not be restored. Later, a Neurologist in a local hospital using an MRI scan diagnosed what her exact problem was: a brain tumor (Tuberculum Sellae Meningiomas) near the pituitary gland that was infiltrating a vessel supplying blood to the brain and eyes and thus impairing her vision.
To remove the tumor, the local hospital performed a transnasal endoscopic surgery, a minimally invasive technique that allows a surgeon to go through the nose to operate on areas at the base of the skull. But the patient developed severe bleeding from the nose during the procedure. Immediately, the surgeon detected the problem and aborted the surgery and performed ‘nasal packing’, an emergency procedure to control the bleeding from the nose. The patient was rushed to Amrita Hospital for emergency endovascular treatment.
Endovascular neurosurgery means “doing surgery from inside the blood vessel” also described as Pinhole neurosurgery. Endovascular neurosurgery is a less invasive procedure to treat problems affecting the blood vessels supplying the brain and the spinal cord. It is performed using long, thin tubes called catheters that are inserted in small needle puncture in the peripheral blood vessel in the groin or arms and are guided through the blood vessels. In this case, the endovascular treatment was done through groin puncture in the femoral artery to reconstruct an injured internal carotid artery of the patient.
At Amrita, the patient underwent an urgent cerebral angiogram that showed the origin of the bleeding: left Internal carotid artery. The injury involved a tear in the wall of the artery (long segment dissection) causing the wall of artery to bulge (pseudo aneurysm). This type of artery rupture will lead to a life-threatening bleed or major stroke.
Repairing or reconstructing arteries and restoring the normal blood supply calls for enormous surgical expertise. However, if the blood vessels in question are giving the major blood supply to the brain (known as internal carotid arteries), and the procedure recommended is a minimally invasive surgery, then it demands the highest level of competence in ‘endovascular’ neurosurgery and adoption of advanced techniques.
Post operation, blood transfusion and close monitoring of blood pressure and neurological status was ensured. Since the patient was stable after the procedure, she was discharged without any issues on January 24, 2022.
Today, the patient recovered completely. She needs follow up treatment for the tumor after the blood vessel is fully healed. This will take 3-6 months. Ms. Prabha now requires follow-up with medications for six months. After the re-surgery for the tumor, she will be able to lead a normal life.