Question 1

How does a GP, neurologist or neurosurgeon know when to refer a patient to a neurointerventionist?

Dr. Tariq Matin · Accepted Answer

Neurointervention is still largely unknown in medical circles, and people do not understand what it can do. Since ischemic stroke forms the major share of our work, awareness is needed not only among doctors but in the community. The FAST acronym captures it: sudden facial drooping, arm weakness and speech disturbance mean a stroke is evolving. A stroke in evolution needs an immediate CT scan; nothing can be diagnosed clinically alone, because the stroke may be haemorrhagic or ischemic. Sudden loss of a function the patient had before, such as lifting the arm or speaking, points to an ischemic stroke. A sudden, severe headache that the patient calls the worst of their life, or sudden seizures, also call for neuroimaging with CT or MRI. Whenever a neurological function is suddenly lost, whether a physician or a member of the community notices it, the patient must be rushed to a neuro care centre.

Question 2

What is the window of opportunity for intervention, particularly for cross-border cases where travel is involved?

Dr. Tariq Matin · Accepted Answer

There are two subsets. In the acute subset, the stroke is still evolving and brain damage is happening, and this is when we intervene. Acute stroke care has to be developed in and around the patient's own locality; it cannot depend only on a few good centres. The window is 4.5 hours for a clot-busting drug and 6 hours for neurointervention in all cases, extending to 24 hours in certain patients selected on imaging. The second subset is secondary prevention: patients in whom a vascular cause, an occlusive or stenotic lesion, has been found, and treating it may prevent a further stroke. These patients can take a calculated decision and be transferred. Intracranial angioplasty, for example, is a genuinely complex procedure that needs a good centre and experienced hands. Most of our overseas ischemic stroke patients come for revascularization as secondary prevention.

Question 3

An overseas patient had an aneurysm coiled in India some time after a bleed. Was that treatment to prevent a future stroke?

Dr. Tariq Matin · Accepted Answer

That is a haemorrhagic stroke, specifically the subarachnoid haemorrhage subset. Subarachnoid haemorrhage is often so devastating that patients are in poor condition or do not even reach hospital alive. Our role for overseas patients begins after the acute phase: they have stabilised, survived and not rebled, but the aneurysm remains like a ticking bomb that can rupture at any time, and second ruptures are usually massive and devastating. These patients are transferred so that the aneurysm can be treated.

Question 4

In haemorrhagic stroke, after intervention, to what degree do symptoms reverse?

Dr. Tariq Matin · Accepted Answer

Haemorrhagic stroke has two aspects: securing the point from which the bleeding happened, and clearing the blood in which the brain is soaked. If we achieve both, we have controlled the disease. The neurons are not completely dead, and if they can be brought back, function returns. In haemorrhagic stroke our primary aim is to save the patient's life, because the next week to ten days are life-threatening; rehabilitation follows. This differs from ischemic stroke, where we try to reverse the symptoms on the table. In haemorrhagic stroke, once loss of life has been prevented, brain function recovers over time, depending on how large the bleed was and how severe the disease.

Question 5

Does the same happen in ischemic stroke?

Dr. Tariq Matin · Accepted Answer

No. In acute ischemic stroke, while the stroke is still evolving, our intervention reverses it: we bring neurons back from the brink of death to function. The results are far more remarkable. The patient I showed earlier could not move his limb, and the next day he could move it and was walking freely without disability. In ischemic stroke the intervention reverses the symptoms. In haemorrhagic stroke we are preventing death and disability; because the neurons have not completely died, they recover, and the patient regains function once further damage has been prevented.

Question 6

Can patients with long-standing stroke benefit from these interventions?

Dr. Tariq Matin · Accepted Answer

Whenever a stroke happens, ischemic or haemorrhagic, the cause must be established: it may lie in the heart, the blood or the vessels. If the cause is identified and the right preventive measures are deployed, we can help in most cases, though not all, since nothing in medicine is 100%. In a haemorrhagic stroke due to a hypertensive bleed, for example, we must confirm that it really is hypertensive; aggressively controlling the patient's blood pressure then reduces the chance of a second bleed.

Question 7

When evaluating an intracranial haematoma that needs evacuation, is it done manually or with robotic or stereotactic guidance?

Dr. Tariq Matin · Accepted Answer

Not every intracerebral haemorrhage goes under the scalpel or receives endovascular treatment. The bleed is diagnosed on neuroimaging, CT or a good MRI. Two questions then follow: why the bleeding happened, and whether it is raising intracranial pressure. The brain sits inside the closed box of the skull and cannot accommodate anything extra, so a large volume of blood pushes on the normal brain, which can herniate and leave the patient brain dead. In those cases the blood must be removed, by minimally invasive surgery, drainage procedures or decompressive surgery. That is where the neurosurgeon's role comes in.

Question 8

How do you gain access to occluded vessels in the deeper structures of the brain?

Dr. Tariq Matin · Accepted Answer

There are catheters, wires and tools to get there, and it is not that difficult. A neurosurgeon has to go from the outside in, while we go from the inside. Think of a blocked drainage pathway under a city. The surgical way is to work out where to dig and go deep into the ground to clear it. If instead you know the drainage system from where it starts, you can enter it, follow the map to the blockage and remove it, without digging the ground at all.

Question 9

Lay people fear any brain intervention, medical, surgical or neurointerventional. Has medical science advanced enough to change that?

Dr. Tariq Matin · Accepted Answer

We cannot claim to be 100% safe or free of complications. Complications do occur; that is normal, but they must remain within standard operating procedures. Even taking paracetamol, which seems innocuous, can cause a complication, so no treatment can be called 100% safe. Neurointerventional and surgical procedures are evolving with precision and technology, and complication rates are going down significantly. They are not as frightening as they were 10 or 20 years ago.

Question 10

How do you help older patients, over 70 years of age?

Dr. Tariq Matin · Accepted Answer

We have treated patients of almost 90 and 100 years and helped them recover. Age is not a criterion for us.

Question 11

How do coils help a patient?

Dr. Tariq Matin · Accepted Answer

A neurointerventionist does two things: open a blockage or seal a leak. A blockage is an ischemic stroke; a leak is a haemorrhagic stroke, with blood escaping from the vessels. When the leak comes from an aneurysm, a round balloon-like structure from which the blood is coming out, we go inside it and deposit thrombogenic coils so that a clot forms and occludes the bleeding point while the normal vessels are preserved. The normal vessel is protected with the balloon-assisted, stent-assisted or simple coiling techniques I showed.

Question 12

What are the risk factors for developing aneurysms?

Dr. Tariq Matin · Accepted Answer

It is a difficult question, because no one fully understands it. Hypertension is one risk factor, and smoking is a major contributing factor. Blood strikes the vessel wall and weakens it until it bulges into an aneurysm, while the body tries to heal the wall. Either the blood is pushing hard because of raised blood pressure, systemically or just at that point, or a weakness has developed in the wall, from exogenous factors such as tobacco smoke or endogenous factors such as a genetic weakness of the collagen. The body's repair mechanism is hindered, and the aneurysm develops over time. This differs from an arteriovenous malformation, which is a developmental lesion present since birth, though not genetic. Aneurysms form de novo over time through the interplay of these dynamic factors.

Question 13

What is severe carotid stenosis?

Dr. Tariq Matin · Accepted Answer

Carotid stenosis usually refers to the carotid bifurcation in the neck, where the common carotid artery divides into two: one branch supplies the face, and the internal carotid artery goes into the brain. The narrowing in question is at the origin of the internal carotid artery. Beyond a certain degree, the stenosis is called significant, and a patient who has had symptoms from it needs a revascularisation procedure, either carotid endarterectomy or carotid angioplasty with stenting. Severe stenosis means narrowing of more than 70%, that is, 70% to 99%.

Question 14

What is the window of time to reverse symptoms before the patient is permanently devastated?

Dr. Tariq Matin · Accepted Answer

In ischemic stroke, it is 4.5 hours with a thrombolytic drug and 6 hours with mechanical thrombectomy, and up to 24 hours in a few patients. In haemorrhagic stroke, the patient needs to be treated as early as possible.

Question 15

What is your approach when an aneurysm has a wide neck or complex anatomy that makes conventional coiling difficult?

Dr. Tariq Matin · Accepted Answer

We move on to remodelling techniques: balloon-assisted coiling, stent-assisted coiling and intrasaccular devices, of which we use three or four. The technology is evolving, and we have more and more tools to deal with complex aneurysms; there are many ways to treat them.

Question 16

How do you decide between coiling, stent-assisted coiling, flow diversion, and surgical clipping for an aneurysm?

Dr. Tariq Matin · Accepted Answer

We work as a team with our neurosurgical colleagues, with a close and harmonious relationship; they have very skilled surgical hands. Under the newer guidelines, for an aneurysm amenable to both treatments, endovascular coiling is preferable, but we do not force that decision on a patient. We hold a multidisciplinary meeting before deciding, then explain everything to the family: the complexity of each procedure and the costs involved. The family decides after that informed meeting, so it is a joint decision. Most patients opt for an endovascular procedure. The choice between coiling, stent-assisted coiling and flow diversion depends on the aneurysm's morphology. Our interventionists and fellows review the case together on screen, reach a conclusion, discuss it with the neurosurgical team, and then, as a team, discuss it with the family before starting treatment.

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