AVM Embolisation: Treating Lobar Brain Bleeds

There are two distinct subsets. In the acute subset, the stroke is actively evolving and intervention has to happen locally — the thrombolytic drug window is 4.5 hours, and mechanical thrombectomy is 6 hours in all cases, extending to 24 hours in selected imaging-positive cases. Acute stroke care has to be developed in and around the patient's own locality; it can't depend on a distant specialist centre. The second subset is secondary prevention, where the stroke has already happened, the cause has been identified, and we're addressing it to prevent a future event. Those are the patients who can make a calculated decision to travel — most of our overseas patients fall into this category.

In haemorrhagic stroke, neurons aren't 100% dead — there's cytotoxic oedema, but if we can remove the blood and relieve the pressure on the brain, neurons can recover function. Our primary goal is to save the patient's life first; the first week to ten days after the bleed is life-threatening, so all effort goes into preventing death and disability, and neurological recovery happens over time through rehabilitation. That's different from ischemic stroke, where we're reversing the deficit on the table itself — rescuing neurons at the brink of death and restoring function immediately.

Not all intracranial haemorrhages require surgical evacuation — most are managed medically. When the bleed is causing raised intracranial pressure, because the brain is inside a closed skull and any extra volume risks herniation, we have to evacuate it. There are several techniques — minimally invasive surgery, stereotactic drainage, or open decompressive surgery — and that's the neurosurgeon's domain. Our endovascular role is in identifying and occluding the underlying vascular cause, the aneurysm or AVM, that caused the bleed in the first place.

Think of it like a blocked drainage system under a city. A surgeon's approach is to dig down from outside to reach the blockage. Our approach is to enter the drainage system from where it begins and navigate a map through the system to the blockage, clearing it from within — you don't have to dig the ground. Access is through a needle puncture in the groin or wrist, and from there the catheters track through the blood vessels all the way to the brain.

Age is not a criterion for us. We have treated patients in their 90s and even at 100 years of age and seen them recover. Age alone is never a reason to withhold intervention.

Deep bleeds, located in the brain's deep structures, are primarily caused by hypertension or diabetes. These hypertensive bleeds are treated with aggressive blood pressure control to prevent the haematoma from expanding, with surgical decompression reserved for large bleeds.

An AVM, or arteriovenous malformation, is a congenital vascular abnormality present since birth, unlike an aneurysm, which develops over a person's lifetime.

The abnormal vessels are occluded using an embolic material, an alcoholic compound that behaves like lava, filling and hardening within the malformation and achieving a complete cure rather than simply managing the bleed's effects.