Interventional neuroradiology

Interventional neuroradiology is a specialized discipline that relies on performing minimally invasive, image-guided procedures for diagnostic or therapeutic purposes, either endovascularly (passing probes through the vascular tree) or percutaneously, for certain diseases of the brain, head and neck, and spine.

Spinal column

• Herniated disc: leakage of intervertebral disc material that crushes on a nerve root and can cause pain.
• Pain originating from the spine: cervical, dorsal, lumbar: arthrosis and inflammation of nerves or joints in the spine can cause pain.
• Vertebral fractures: fractures or crushing of vertebrae, caused by trauma, osteoporosis, or tumors.

Brain

• Cerebral aneurysms: an aneurysm is a bulge along the walls of an artery; aneurysms that occur in the arteries of the brain are called cerebral aneurysms and can cause intra-cranial bleeding.
• Carotid stenosis: a condition due to narrowing of the carotid artery due to atherosclerosis, which can impair blood flow to the brain.
• Cerebral vascular malformation: congenital diseases of the cerebral circulatory system, which can cause bleeding.
• Arteriovenous fistula: an abnormal communication between an artery and a vein in the cranial box, which can cause neurological disorders and bleeding.
• Cerebral strokes: acute occlusion of a cerebral blood vessel that causes a sudden neurological deficit (inability to move or feel a body part, speech or vision disturbance).

Procedures

To obtain a more precise diagnosis, to complement diagnostic neuroradiology techniques, invasive interventional neuroradiology techniques are necessary in some cases.

• Cerebral angiography: an invasive diagnostic investigation to study the morphology of cerebral arteries and veins and the pathologies involving them. It is performed by inserting a catheter into a leg (groin) or arm artery to inject contrast medium directly into the arteries of the neck or brain and obtain high-precision images of the cerebral circulation.
• Vertebral biopsy: insertion of a special needle through the skin to reach the affected vertebra using image guidance to take a small sample of bone, which is then examined under a microscope to clarify the nature and cause of the pathology.
• Soft tissue biopsy of the head-neck region: insertion of a special needle through the skin to reach the affected region by image guidance, for taking a small tissue sample which is then examined under a microscope to clarify the nature and cause of the pathology.
• Spinal interventional procedures
  • Procedures are performed percutaneously under the guidance of CT and/or fluoroscopic images.
  • In many cases, procedures can be performed under local anesthesia or mild sedation, with a short day hospital stay.

Treatments

Spinal Interventional Surgery
Through a percutaneous access of a few millimeters, under the guidance of CT and/or fluoroscopic images, one or more access cannulas are inserted to reach the region to be treated; there are different procedures depending on the pathology to be treated:

• Vertebroplasty and kyphoplasty: minimally invasive procedures to treat certain types of spinal fractures (so-called "insufficiency or compression fractures") or to strengthen vertebrae weakened by osteoporosis or tumors.
• Spinal tumor ablation: probes are inserted through the needle inserted into the vertebra to remove and/or destroy part of the tissue present in the vertebral lesion and inject bone cement to strengthen the tumor-affected vertebra; complementary treatment and not a substitute for chemotherapy and/or radiation cancer treatments.
• Osteoplasty: placement of a special needle inside a cancerous bone lesion with subsequent injection of bone cement for the purpose of pain reduction.
• Spinal infiltration: in cases of back pain or pain along the course of a nerve that originates from a recognizable site in the spine, when conventional medical, physical and pharmacological therapies do not provide benefit, the more targeted action of image-guided infiltrative therapy, which involves the administration of a drug precisely at the affected site, may be used.
• Disc decompression: employed to treat certain herniated discs that give symptoms. It is important that the indication for this treatment be determined by a medical specialist in the field, as not all hernias need treatment, nor can all hernias be treated in this way.

Endovascular interventional procedures
These procedures are performed by means of probes (catheters and microcatheters) inserted into an artery in the leg or arm and then reaching the cerebral circulation where the treatment is performed.These procedures are intended to complement or be an alternative to open cranial neurosurgical interventions.These procedures include:

• Embolization and/or stenting interventions: the treatments of cerebral aneurysms, fistulas, cerebral vascular malformations; they consist of reaching the cerebral vessels through the peripheral arteries and filling the aneurysmal sac or abnormal vessels with platinum filaments, particles, sticky substances or by placing stents that exclude the aneurysm from the cerebral circulation.
• Carotid stenting surgery: to treat atherosclerotic stenosis (narrowing) of the carotid arteries that carry blood flow to the brain. By means of a catheter, the narrowing in the artery is dilated and a retina or stent is placed to keep the vessel open; thereby restoring necessary blood flow to the brain.
• Revascularization with mechanical thrombectomy or fibrinolysis for acute cerebral stroke: thrombectomy is an operation that is performed on an emergency basis by inserting a catheter into the femoral artery in the groin to the intra-cranial circulation to remove or dissolve the thrombus occluding an artery in the brain.
• Devascularizationof brain and head-neck region tumors: the tumor is devascularized by catheterization and embolization of each nutrient artery.

Collaborations

The Interventional Neuroradiology Service collaborates with:

• Imaging Institute of Italian Switzerland.
• Neuroradiology Service of the Inselspital of Bern.

The advantages of the minimally invasive approach over the surgical approach

These procedures stand as an adjunct or alternative to open neurosurgical interventions, with the following advantages:

• Possible reduction in complication rates.
• Reduction in infection rates.
• Reduced recovery and hospitalization times.

It is important that the indication for such treatments be made by a multidisciplinary team, as not all pathologies can be treated with these techniques and in some cases surgery or other treatments are more indicated and offer better results.

How to perform an interventional neuroradiology procedure

Preparation
Before proceeding with the procedure, the patient is summoned for an interview with the interventional neuroradiologist, who will explain the procedure and preparation in detail.

Conduct

• Some procedures are performed on an outpatient basis and under local anesthesia: the patient can return to his or her home a few minutes after the procedure.
• For more invasive procedures, the patient is admitted as an outpatient for a few hours and the examination is performed with anesthesiological support. In some cases a short hospitalization of one or two nights is advisable.
• For cerebral endovascular treatments, the patient is observed for 24 hours in intensive care and then transferred to the ward.

Timely treatments
Vascular interventional neuroradiology has ready 24-hour availability for cerebral revascularization treatment in case of stroke or embolization in urgency of arterial bleeding or other vascular disease requiring prompt intervention.