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An Init iative of
Stroke and Neurovascular Interventions Foundation
Creating Stroke Awareness
Stroke and
Neurovascular Interventions
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Story telling by AL Services
http://www.alservices.in/http://www.alservices.in/8/10/2019 Stroke and Neurovascular Interventions Foundation
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Table of Contents
Stroke-An Infographic
1. About Stroke & Neurovascular Intervenons Foundaon
2. Stroke and Neurointervenon FAQ
3. Diseases & Treatments
4. Paent Stories
5. The Team
- The Founders Story
- Member Profiles
6 Annexures
- Media Gallery
- Useful Resources & Links
- Foundaon Brochure
Contact Us
d
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A stroke occurs when
blood flow to the brain is
blocked by clots in the
blood vessels or because
of a weakened blood
vessel rupturing bleeding
into the brain.
Dizziness
Difficulty walking, loss of walking l Sudden amnesia, mental impairment
Trouble speaking or understanding l Problems in one or both eyes l Intense, unexplained headache
Sudden ngling, numbness or weakness of the face, arm or leg, especially on one side of the body
WARNING SIGNS
STROKEO
FBAD
HEALTH
15mnpeople worldwide suffer a stroke each yeardie of stroke annually
are le permanently disabled
recover or funconally disabled
6.15mn
5mn
3.85mn
High blood pressure,high cholesterol and
triglycerides (blood fats),smoking, drinking alcohol,
physical inacvity, abdominalobesity (stomach fat), heart
disease, poor andover nutrion, diabetes,
and psychosocial stressors.
RIS
KFACTORS
TEST
MRI scan of the brainto show areas of braindamage due to lack of
blood flow.
Angiogram to evaluate thecalibre and patency(the condion of being open or unobstructed)
of the arteries in the neckand the brain.
A stroke is an emergency.
Take the paent to a hospital emergency at once.
Do not wait for the symptoms to improve
or waste me going to a neighbourhood clinic.
While waing for medical aenon, paents who are drowsy,
unresponsive or voming should be turned on their side toprevent them from choking on their tongue or vomit.
www.neurointervenonindia.com
www.facebook.com/NeurointervenonGurgaon
Stroke-An Infographic
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About Stroke & Neurovascular Interventions Foundation
On 29th October, all across the globe World Stroke Day is observed by various healthcare
instutes, organizaons and medical professionals by conducng different events, edu-
cang, and raising awareness among masses to minimize the death and disability caused
due to stroke. In 2010, stroke was declared as a public health emergency by World Stroke
Organizaon (WSO).
Dr. Vipul Gupta Head, Neurointervenonal Surgery, Medanta The Medicity along with
his colleagues have formed STROKE AND NEUROVASCULAR INTERVENTIONS FOUNDA-
TION to impart public educaon and increase awareness among common man and gen-
eral physicians for prevenon and treatment in stroke. The effort will be made to train
and empower the physicians to handle a medical emergency like stroke. The early treat -
ment is crical because at that stage the stroke may be reversible or the damage can be
limited. Every minute if stroke is untreated, the average paent loses 1.9 million (19
Lakh) neurons (brain cells).
1
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Every year millions of people become vicm of stroke. It is considered to be the third
most common cause of death and disability. The stascs states that one in six people
will have stroke in their lifeme and this toll will increase with flow of me, in countries
like India due to changing lifestyle, urbanizaon, stress, smoking, salt/alcohol intake.
However with the help of modern methods of minimally invasive neuro intervenon
techniques have revoluonized the treatment of carod stenosis, acute strokes, brain
aneurysm and AVMs many paents can achieve a complete recovery and lead a normal
life if they are detected early.
The prime focus of this foundaon is to educate masses through different media plat-
forms like WhatsApp, Facebook, Youtube and also through a special applicaon for
stroke. Along with this collaborave program with other agencies and training program
for healthcare professionals will also be part of its curriculum.
Dr. Vipul says; The increase in numbers of deaths due to stroke is majorly due to lack of
awareness. Therefore the foundaon will be helping the people and communies to
recognize the symptoms of stroke and prevent it from its consequences. Dr Gupta clari-
fies with early symptoms of stroke named as FAST that can help you to recognize the
stroke and could save you from further consequences. Here F stands for face drooping,
second A that stands for weakness in arms, then S reminds the sign of difficulty in
speaking and Tis for me to call for hospital emergency. Apart from these four there are
symptoms, which are beyond FAST includes trouble in understanding, severe
headache, dizziness, numbness in leg.Once the symptoms are recognized person shouldbe immediately taken to hospital parcularly stroke centres, where could be given a
stroke treatment.
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He further explains; If paent comes in first few hours (4.5 hrs), clot busng drug (t-PA)
cab be given. Blood vessel can also be opened by intervenon technique. Neurointer-
venonist goes through leg blood vessel and by special devices can take out the clot to
restore the blood flow, helping brain to recover. The intervenon can be done upto
8-hours and by these modern treatment methods paents have beer chances to recov-
er aer stroke.
The foundaon also highlights the prevenon from risk factors of stroke such as 80% of
strokes can be prevented by following seven simple ways by geng physically acve,healthy eang habits, saying no to smoking, controlling blood sugar levels, lowering cho-
lesterol and shedding out excess weight through regular exercise.
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Stroke and Neurointervention FAQ
How these techniques help in early treatment of stroke?
When a person suffers from stroke, some brain cells die immediately but the surround-
ing ssue can sll be revived. This zone which is called as penumbra is supplied with
blood that keeps these cells alive, although it is not enough for them to perform the
funcon. By giving IV t-PA drug or through neuro-intervenonal techniques, the blood
supply to the penumbra zone can be restored thereby aiding in the recovery from
stroke.
What are the risk factors involved? Are there any health complications
associated with it?
These procedures carry a small risk of bleeding in the brain, but studies have shown that
the overall rate of survival paents or recovery with these treatment methods is farbeer.
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How effective are these techniques in dealing with stroke?
It is dependent on the severity of the condion and the treatment that is employed to
treat the paent. Based on the selecon criteria (that depends on many factors), the
paents are selected for treatment. And among the selected ones, around 50% of thepaents have a good chance of recovery.
What is the cost of the treatment ?
The intravenous ssue type plasminogen acvator (IVtPA) procedure used to treat stroke
costs around 50-90 thousand, while intervenon techniques cost about Rs. 2 lakhs.
Videos
hps://www.youtube.com/watch?v=zRVw5-tqSKY
hps://www.youtube.com/watch?v=7sgULgi8IIE
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Diseases and Treatments
This chapter covers 5 major areas viz. Aneurysm, Carod Artery Stenosis, Stroke,
Thrombolysis in acute stroke and Arteriovenous malformaon.
To check out case studies, procedure videos, paent tesmonials
visit the website www.neurointervenonindia.com
ANEURYSM
CAROTID
ARTERY
STENOSIS
STROKE /
BRAIN ATTACK
THROMBOLYSIS
IN ACUTE
STROKE
ARTERIOVENOUS
MALFORMATION
3
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Aneurysm
What are intracranial aneurysms?
Intracranial aneurysms are localized pathological dilataons of cerebral arteries. Most
intracranial aneurysms are saccular or berry aneurysms, whereas dissecng, fusiform,
infecous, traumac, and oncoc aneurysms are much rarer. Saccular, or berry aneu-
rysms, correspond to lobulated focal outpouchings of the wall of the arteries of the circle
of Willis. Current opinions suppose that intracranial aneurysms result from a combina-
on of hemodynamic stresses and acquired degenerave changes within the arterial
wall.
How does aneurysm presents?
Aneurysms may present as
Rupture of the weak wall of such aneurysms mainly resulng in subarachnoid haemorrhage (SAH),
experienced as ''the worst headache of life'' by paents.
Mass effect, causing cranial nerve symptoms
Asymptomac, incidentally detected during imaging done for other reasons
It is accepted that about 3% to 5% of the populaon harbour an intracranial aneurysm.
One in every 20 strokes is caused by subarachnoid hemorrhage from rupture of intra-
cranial aneurysm,
Because the disease strikes a fairly young age and is oen fatal the loss of producvelife years is similar to that for cerebral infarcon or intra cerebral hemorrhage
-
-
-
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What are complicaons of SAH?
Many paents don't survive inial hemorrhage or suffer significant brain injury due to
the haemorrhage. Those who survive have high chance of repeat bleeding which can be
fatal in as high as 70-80% of cases. Even if the aneurysm is repaired before rebleeding,
15% of paents who survive the inial hemorrhage develop ischemic strokes or die from
the development of cerebral vasospasm. Non-Neurological Complicaons oen occur in
paents with SAH. These include fever, anemia, hypertension and hypotension, hyper-
glycemia, hypernatremia/hyponatremia, hypomagnesaemia, cardiac failure and arrhyth-
mias, and pulmonary edema and pneumonia. Therefore these paents needs intensive
care management so as avoid and mange such problems.
What are complicaons of SAH?
CT scan should be performed in suspected SAH. However, CT can be negave in some
cases parcularly if it is done few days aer the event.
Although MR is quite sensive if performed appropriately and interpreted by an experi-
enced radiologist, SAH is frequently missed.
Selecve cerebral angiography should be performed in paents with SAH to document
the presence and anatomic features of aneurysms.
MR angiography or CT angiography may be considered when convenonal angiographycannot be performed in a mely fashion.
What Are Management Recommendaons?
SAH is a medical emergency that is frequently misdiagnosed. A high level of suspicion for
SAH should exist in paents with acute onset of severe headache. Paent of SAH are tobe managed in ICU with good neuroanaesthec support and management. Early aneu-
rysm treatment should be performed to prevent repeat bleeding.
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Surgery (clipping) vs embolizaon (coiling)
Surgery has been the convenonal method of aneurysm treat-
ment. Surgery entails direct exposure of the aneurysm, the parent
vessel(s) and surrounding structures. The aneurysm is then
secured by the placement of a metallic clip along the neck thereby
excluding it from the circulaon. Problems with surgery include
invasiveness and trauma to normal brain parenchyma.
What Are Management Recommendaons?
Other treatment opon is of endovascular embolizaon (coiling)
of Aneurysms. In this treatment a microcatheter is placed from
one of the leg arteries in to the aneurysm, which is then occluded
with coils (usually detachable planum coils) so as to prevent
repeat bleeding. Advantages: Since coiling is a minimally invasive
technique it is less likely to result in injury to brain parenchyma.
It is associated with Internaonal Subarachnoid Aneurysm Trial
Study (ISAT)
Randomized, prospecve, internaonal controlled trial Compared policy of neurosurgi-
cal clipping with a policy of endovascular treatment in aneurysms deemed suitable for
either therapy.
9559 paents screened, 2143 (22.4%) were randomized and the difference in the risk ofdependency or death between the two groups was compared.
SURGICAL CLIPPING
COILING OF ANEURYSM
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Results: at 1 year, the outcome was much beer in the coiling group with relave risk
reducon of 22.6% as compared to surgical paents. The early survival advantage was
maintained for up to 7-years.
The risk of epilepsy was substanally lower in paents allocated to endovascular treat-
ment. The risk of late rebleeding was minimally higher (0.16%). The beer outcome in
coiling group was inspite of minimally increased risk of rebleeding.
According to recent American Stroke Associaon Guidelines- if both clipping and coiling
are possible, coiling is preferable over surgery
Are broad neck aneurysms amenable for coiling?
Most of the broad neck aneurysms can be treated by coiling, with use of 3D and complex
coils. These coils are stable even in broad neck aneurysms.
Some cases require balloon assistance or stent placement
Balloon assisted coiling for broad neck aneurysm- concept- a balloon is inflated tempo-rarily at the neck of the aneurysm to hold the coils
Stent assisted coiling of broad neck aneurysm- a stent is
placed across the neck of a broad neck aneurysm so as to hold
the coils and reconstruct the artery
COILING OF BROAD NECK ANEURYSM WITH COMPLEX COIL
BALLOON ASSISTED COILING
STENT ASSISTED COILING
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Carotid Artery Stenosis
What is the role of carod artery in stroke?
Stroke is third most common cause of death and disability. According to WHO Survey in
1990, out of 9.4 million deaths in India 6,19,000 were due to stroke. Most of the strokes
(approximately 75%) are ischameic in nature and large vessel disease accounts for
approximately 40% of ischaemic strokes. It has been esmated that approximately
20-30% of strokes may be caused by stenosis of carod artery.
What are the various means to diagnose Carod Artery Stenosis?
Carod Doppler- is a non-invasive & accurate modality to assess carod stenosis.
MR angiography (MRA)/CT angiography (CTA) - excellent quality imaging of carod
artery can be done by these relavely non-invasive methods.
Digital subtracon angiography (DSA)is the "Gold standard", however it is an invasive
invesgaon and is usually reserved to evaluate stenosis detected in non-invasive inves-
gaons as well when the non-invasive invesgaons are non-conclusive.
What are the treatment opons in Carod Artery Stenosis?
Medical treatment is done for the risk factors for atherosclerosis such as hypertension,
diabetes mellitus & dyslipidemia . Paents are also told to stop smoking. An-platelet
drugs (Dispirin, clopidogrel) are useful to prevent embolic events. Paents with marked
stenosis require revascularizaon which can be achieved by surgical (endarterectomy) orendovascular (angioplasty & stenng) means.
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What are the indicaons for carod revascularizaon (stenng/ endarterectomy)?
Carod stenosis more than 70%- should be revascularized
Carod stenosis (50%-69%)- Revascularizaon is recommended for paents who have
had recent transient ischaemic aack or stroke depending upon paent-specific factors
such as age, gender, co morbidies, and severity of inial symptoms
Carod stenosis less than 50%- No benefit of surgery is demonstrated in these paents
Asymptomac carod stenosis - Treatment of asymptomac carod stenosis is more
controversial. The guidelines indicate that paents benefit from treatment if the opera-
tor has a low complicaon rate.
How does carod stenng compare to surgical endarterectomy?
Paents who have coexisng medical problems or advanced age (>80) are beer suited
for stenng rather than endarterectomy. Paents having certain anatomical features
such as prior ipsilateral endarterectomy, prior neck irradiaon, contralateral internal
carod artery (ICA) occlusion & high cervical stenosis are also beer suited for stenng
as compared to endarterectomy.
Paents with marked tortuosity of the common carod artery and ICA or contraindica-
ons to an-platelet therapy may not be suitable candidates for endovascular therapy
What is a protecon device and what is its role in carod stenng?
Filter protecon devices are umbrella-shaped devices that are placed temporarily in the
internal carod artery beyond the site of stenosis during the procedure. These devices
have small pores designed to exclude parculate debris embolizaon to cranial circula-on during the procedure.
f h l h b l d l b
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Can stenosis of other cranial arteries such as vertebral and intracranial arteries be
treated?
Many cases of stroke occur due to stenosis in vertebral & intracranial atheroscleroc
disease. Recent studies have shown that these paents with intracranial stenosis have
high risk of stroke in spite of medical treatment. Recent advances in technology has
made angioplasty and stenng possible in these paents
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Stroke / Brain Attack
What is stroke (brain aack) and why should I know about it?
A stroke occurs due to brain damage because of decrease in blood supply to brain
because of a blockage in the blood vessel feeding the brain. Somemes it occurs when a
blood vessel bursts, leading to bleeding in the brain. Just as heart aack which occurs
due to decrease in blood supply to heart, stroke is a very serious condion and is also
referred to as "brain aack".
Is stroke (brain aack) an emergency?
If treatment is not started early enough in a brain aack paent, brain damage may be
very severe. New treatments are available which can significantly reduce the damage.
However, these treatments work best soon aer the brain aack
What causes stroke (brain aack)?
Brain aack is of two types-
"Ischaemic" brain aack is caused by decreased supply to brain due to blockage of
artery supplying blood to the brain. This blockage may occur because of clot forming
somewhere n the body floang into brain arteries and causing obstrucon. It can also
occur because of narrowing in the arteries giving blood supply to the brain.
"Haemorrhagic" brain aackoccurs due to bleeding in the brain due to hypertension,
rupture of aneurysms (areas of swelling in the blood vessels), vascular malformaons(areas of malformed blood vessels with increased flow in them) and many other causes.
Wh t th i k f t f t k (B i k)?
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What are the risk factors of stroke (Brain aack)?
Risk factors which one can't modify
Age-older you are, higher is the risk
Gender-males are more likely to have stroke
Race-Asians including Indians are more prone to stroke than western populaons
Family history of stroke and heart disease
Risk factors which can be modified
Hypertension- blood pressure more than 140/90 mmHg increases the risk for aack
significantly. Infact hypertension is called the "silent killer"Heart disease-diseases like atrial fibrillaon and other disorders increase the risk
Carod artery disease- carod arteries supply blood to brain and its narrowing can
predispose to brain aack
High cholesterol level-increases the risk
Smoking-smokers have higher risk, which decrease when one stops smoking
Diabetes-increases the risk, should be controlled by diet, oral drugs or insulin
Obesity-too much of weight, parcularly around the waist
Illegal drugs-intravenous drug abuse, cocaine abuse increase the risk
Physical inacvity
Transient ischaemic aacks (TIAs)are "mini strokes" that produce stroke like symptoms
but no lasng damage. However, paents having TIAs have a strong possibility of suffer-
ing from major stroke in future.
How do I know someone or myself is having stroke (brain aack)?
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How do I know someone or myself is having stroke (brain aack)?
Brain aack symptoms are:
Sudden numbness or weakness of the face, arm, leg (especially on one side of the body)
Sudden confusion, trouble speaking or understanding speech
Sudden trouble seeing in one or both eyes
Sudden trouble walking, dizziness, loss of balance or coordinaon
Sudden severe headache with no cause
If you suspect yourself or someone else to be having these symptoms, DONOT WAIT and
go to a hospital having emergency stroke treatment facilies.
Tests used to diagnose brain aack
CT (Computed tomography)-this tests involve taking a series of images of the brain to
detect stroke (brain aack). This test is usually the first invesgaon to be performed and
is parcularly useful to look for presence for bleeding (haemorrhagic brain aack).
MRI (Magnec resonance imaging)- This is very specialized test which uses magnec
properes of body to create very detailed images of brain as well as of blood vessels so
as to diagnose brain aack.
DSA- digital subtracon angiography)-This is the most accurate in diagnosis of most ofthe diseases of blood vessel. A small tube (catheter) is guided from the leg blood vessel
in to the blood vessel we wish to study followed by dye (contrast) injecons to obtain the
images. CT/MR angiography is also an opon in some cases.
Doppler ultrasound:in this ultrasound method is used to image the blood vessels and
the abnormalies in them.
Specialists involved in treatment of stroke
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Specialists involved in treatment of stroke
Stroke Neurologist- specializes in evaluang and medically managing ischaemic and
certain types of haemorrhagic strokes.
Neurosurgeon-performs surgical treatments such as hematoma evacuaon, aneurysmclipping or arteriovenous malformaon excision
Intervenonal neuroradiologist- specializes in minimally invasive treatment of brain
aack, such as carod stenosis stenng, intra-arterial thrombolysis, aneurysm emboliza-
on/coiling, arteriovenous malformaon embolizaon/gluing
Daignosc neuroradiologist- specializes in diagnosis of brain aack using modalies
such as CT, MRI, Doppler etc.
What are treatment opons in stroke (brain aack)?
Brain aack due to decreased blood supply (ischaemic stroke)Paents are given an-platelet drugs, which act as "blood thinners" so as to prevent clot
formaon. If paent reaches early enough to a hospital with acute stroke units, they can
be given thrombolyc drugs which act as clot busters and open up the blockage in the
arteries so as to save as much of brain as possible. The narrowing in the arteries which
have caused stroke can also be opened up by surgical or endovascular means.
Brain aack due to bleeding in the brain (haemorrhagic stroke)
Treatment opons will depend upon the cause and size of haemorrhage. Some paents
may need surgery to remove the clot, while other cases may need to be managed con-
servavely in ICU. Paent with bleeding due to swelling in blood vessels of brain knownas "aneurysms', will need to undergo repair of these swelling because they have a high
tendency to rebleed.
Specialized minimally invasive treatments of brain aack
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Specialized minimally invasive treatments of brain aack
Carod artery angioplasty/stenng- carod artery is a blood vessel which supplies
blood to brain and its narrowing can result in brain aack. The narrowing can be treated
by opening it up with a balloon followed by placing a metal mesh scaffolding (stent)
across it.
Intravenous/intrarterial thrombolysis-brain aack caused by decreased blood supply
to brain can be treated by giving drugs which can open up the blockade so as to save as
much of the brain as possible. These drugs can be given by intravenous route if a paent
comes to the hospital within three hours of onset of brain aack. These drugs can alsobe precisely given with in the area of blockade by placing a catheter (a small tube) from
one of the leg blood vessels in to the blocked vessel. This selecve (intra-arterial) treat-
ment can be given at least up to 6-hours aer the brain aack
Intracranial aneurysm coiling/embolizaton- aneurysms are localized swellings in the
blood vessels of brain which can rupture and cause bleeding. It is very crucial to seal
these swellings because they have tendency to rebleed. Minimally invasive treatment
can be performed by endovascular embolizaon/coiling of the aneurysm. In this treat-
ment a thin tube is placed from one of the leg arteries in to the aneurysm, which is then
filled up with metallic rings (coils).
What is the concept of thrombolysis? What is penumbra zone?
When blood flow to the brain stops, brain cells are deprived of oxygen and nutrients.
Stroke is a medical emergency because brain cells start dying quickly and the treatment
is most effecve when given promptly. Although some of the cells die within few min-
utes, surrounding zone though hypoperfused but are receiving just enough oxygen from
cerebral blood flow (CBF) to stay alive A compromised
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cerebral blood flow (CBF) to stay alive. A compromised
cell can survive for several hours in a low-energy state and
is referred to as "penumbra". If blood flow is restored
within this narrow window of opportunity then some of
these cells can be salvaged and become funconal again.
Blood flow to these cells can be achieved by administrang the clot-dissolving thrombo-
lyc agent t-PA by intravenous and intra-arterial routes.
What is stroke centre and why should a stroke paent go to these hospitals?Stroke centre- is a hospital or part of a hospital that (nearly) exclusively takes care of
stroke paents with specialized staff with team approach to treatment and care. Care in
stroke teams (including neurologists, neurosurgeons, intervenonal and diagnosc neu-
roradiologists) or by stroke units improve the outcome in these paents significantly.
What is the role of mechanical means of re-vascularziaon in acute stroke ?
One of the disadvantages of using thrombo-
lyc drugs is that there is risk of bleeding.
Another issue is that in large vessel blockage
thrombolyc drug is not effecve. These
drugs cannot be used in many situaon such
as recent surgery. To avoid these problems, mechanical means can be used to takeout
the clot and open up the blocked brain blood vessel. One such device is penumbra device
in which special catheter can be taken up to the clot which can then be aspirated.Medatna The Medicity is the first center in which such procedure was performed in
North India.
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Thrombolysis in Acute Stroke
A 64-year-old male presented with suddenonset hemiplegia and aphasia of 4-hours
duraon. since the me liit for intravenous therapy had already passed, paent was
taken up for intra-arterial recnalizaon. dsa revealed blocked le mca (a). microcthter ws
placed in mca and urokinase 95 millio units (b). was infused resulng in recnalizaon of
mca (c). paent acheived complete clinical recovery.
What is the concept of thrombolysis? What is penumbra zone?When blood flow to the brain stops, brain cells are deprived of oxygen and nutrients.
Stroke is a medical emergency because brain cells start dying quickly and the treatment
is most effecve when given promptly. Although some of the cells die within few min-
utes, surrounding zone though hypoperfused but are receiving just enough oxygen from
cerebral blood flow (CBF) to stay alive. A compromised cell can survive for several hours
in a low-energy state and is referred to as "penumbra". If blood flow is restored within
this narrow window of opportunity then some of these cells can be salvaged and
become funconal again. Blood flow to these cells can be achieved by administrang the
clot-dissolving thrombolyc agent t-PA by intravenous and intra-arterial routes.
Who are the right candidates for thrombolysis?
Paents who are able to reach hospital before major infarct has taken place and fulfill
the criteria for thrombolysis are the right candidates. Paents with hemorrhage or
well-established acute infarct on CT /MRI sequence are not the right candidates. Accord-ing to the criteria paent's having hypodensity in less than third of MCA territory on CT
scan are eligible for thrombolysis.
When is thrombolysis not done?
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y
Thrombolysis is not done in paents who are likely to have hemorrhage with use of
thrombolyc drugs. The contraindicaons include
- CNS lesion with high likelihood of hemorrhage s/p chemical thrombolyc agents (e.g.,
brain tumors, abscess, vascular malformaon, aneurysm, contusion)
- Established Bacterial endocardis
There are many relave contraindicaons including mild or rapidly improving deficits,
stroke within 3 months, history of intracranial hemorrhage and major surgery within
past 14 days. The complete is always checked beore performing the procedure.
What is likely benefit and risks of thrombolysis?
In the NINDS trial Favorable outcomes were achieved in 31% to 50% of paents treated
with rtPA, as compared with 20% to 38% of paents given placebo. The benefit was simi-
lar 1 year aer stroke. The major risk of treatment was symptomac brain hemorrhage,
which occurred in 6.4% of paents treated with rtPA and 0.6% of paents given placebo.
However, the death rate in the 2 treatment groups was similar at 3 months (17% versus
20%) and 1 year (24% versus 28%).In the NINDS trial there was 11-13% absolute increase
in the number of people who had minimal or no disability. When tPA was given within 3
hours of onset of symptoms, the number needed to treat for 1 more paent to have a
normal or near normal outcome was 8, and the number needed to treat for 1 more
paent to have an improved outcome was 3. These NNT are very impressive.
When is intra-arterial thrombolysis done ?At present intravenous therapy is not recommended beyond 3-hours, although in some
cases it may be done upto 4.4 hours. Intra-arterial thrombolysis can work up to 6-hours.
Therefore paents coming between 3 to 6 hours can benefit by intra-arterial therapy.
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p g y py
The window period can be further extended in cases of posterior circulaon stroke.
Paents with major vessel blockage such as internal carod, middle cerebral artery and
basilar artery are unlikely to respond to intravenous thrombolysis and can be treated
beer by intra-arterial means.
What is the role of mechanical means of re-vascularziaon in acute stroke ?
One of the disadvantages of using thrombolyc drugs is that there is risk of bleeding.
Another issue is that in large vessel blockage thrombolyc drug is not effecve. These
drugs cannot be used in many situaon such as recent surgery. To avoid these problems,
mechanical means can be used to takeout the clot and open up the blocked brain blood
vessel. One such device is penumbra device in which special catheter can be taken up to
the clot which can then be aspirated. Medatna The Medicity is the first center in which
such procedure was performed in North India.
What should one do if one sees a paent who is a possible candidate for thrombolysis?
One of the disadvantages of using thrombolyc drugs is that there is risk of bleeding.
Another issue is that in large vessel blockage thrombolyc drug is not effecve. These drugs
cannot be used in many situaon such as recent surgery. To avoid these problems, mechani-
cal means can be used to takeout the clot and open up the blocked brain blood vessel. Onesuch device is penumbra device in which special catheter can be taken up to the clot which
can then be aspirated. Medatna The Medicity is the first center in which such procedure was
performed in North India. One should get a CT scan done immediately to rule out a bleed. If
there is no bleed and paent is within the window period then one should transfer the
paent immediately to a centre with thrombolysis facilies. No an-platelet should be given
in these paent before thrombolysis. We should add anplatelet aer 24 hrs aer excluding
hemorrhage by repeat CT scan brain in thrombolysed paents.
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Arteriovenous Malformation
What is AVM disease?
An arteriovenous malformaon, or AVM for short, is a group of blood vessels that are
abnormally interconnected with one another. AVMs can occur in different organs of the
body, but brain AVMs are the most problemac. Another term for AVM is "arteriovenous
fistula."
What are the symptoms of disease?
About half of the paents find out they have an AVM only aer they suffer a brain hem-
orrhage. The other half are affected by, headaches, and stroke symptoms such as or
hemiparesis
How is it diagnosed?
Oen, the diagnosis of an AVM can be suspected by an expert radiologist with just CT
scan of the brain. Most physicians, however, feel more comfortable diagnosing AVMs
aer performing an MRI. However AVMs can be missed on non-invasive imaging and for
final diagnosis and evaluaon by cerebral angiography is mandatory. In cases when
bleeding has occurred, the AVM can be completely obscured by intracerebral bleeding,
requiring a to establish a final diagnosis.
Why does it develop?
Brain AVMs affect about 0.1% of the populaon, and are present at birth, but they rarely
affect more than one member of the same family. They happen roughly equally in men
and women. AVMs are thought to be due to abnormal development of blood vessels in
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utero and may be present since birth. An AVM is not a cancer, and does not spread to
other parts of the body. Dural AVFs, in adults are an acquired disorder that can occur
probably aer thrombosis of dural sinuses.
How is it treated?
There are 3 main modes of treatment. Endovascular embolizaon, micro neurosurgical
excision and radiosurgery. These are given alone or in combinaon. Which of them is
best for you is decided by our panel of experts aer discussing your detailed clinical and
radiological data. Your doctor will recommend the best treatment for you and this will be
determined by the size of your AVM and also the locaon. It is not uncommon to recom -
mend a combinaon of treatments.
Embolizaon
Under general anaesthesia a small catheter is advanced from the groin, into the brainvessels and then into the AVM. A liquid, non-reacve material (onyx) or glue is injected
into the vessels which block the AVM off. There is a small risk to this procedure and the
chances of completely curing the AVM using this technique depend on the size of the
AVM. It is frequently combined with the other treatments such as radiaon or surgery or
it can be staged in mulple sessions.
Radiaon Treatment
This treatment is also known as Radio surgery or Stereotacc Radiotherapy. A narrow
x-ray beam is focused on the AVM such that a high dose is concentrated on the AVM with
a much lower dose delivered to the rest of the brain. This radiaon causes the AVM toshrivel up and close off over a period of 2-3 years in up to 80% of paents. The risk of
complicaons is low. Unl the AVM is completely closed off, the risk of bleeding sll
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persists. This treatment can only be performed in small size AVM.
Surgery
This is the oldest method for treang AVMs. The AVM is surgically removed in an operat-
ing room under general anesthesia. Since AVMs do not grow back, the cure is immediate
and permanent if the AVM is removed completely. The risks of surgery are considered to
be high for AVMs that are located in deep parts of the brain with very important func -
ons. So surgery is usually indicated in those paent who are bled with large hematoma
or the AVM is superficial and in non eloquent part of the brain.
Are there any alternaves?
Other than above menoned modes of therapy no alternave is available. Only other
opon is to do nothing at all and just monitor the AVM. Your doctors may recommend
observaon if they feel that treatment can not be offered safely or when an AVM isdiscovered at a late age.
What will happen if it is le untreated?
There is risk of bleeding at the rate of 1-2 %/year aer the diagnosis. But risk is much
more if the AVm has bled or has a weak spot such as as aneurysm. Cumulave risk of
bleeding is high depending upon the expected life expectancy.
4
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Patient Stories
4
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Paents with acute ischaemic stroke or paralyc aacks usually face a life of dependancy
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with a huge psychological, social and financial burden. Acute stroke happens due to
blockage of blood supply. Although some brain cells die immediately, there is usually a
part of brain which can sll be revived if the blood supply is restored in next few hours.
This can be done by giving thrombolyc drugs (Intravenous thrombolysis) which act as
clot busters and open up the blockage in the arteries. This can result in reversal of stroke
and beer recovery. Direct delivery of drugs in the blocked artery (Intra-arterial or endo-
vascular) therapy can be more effecve when clot is large or when IV therapy cannot be
given. This is done by placing a catheter (a small tube) from one of the leg blood vessels
in to the blocked vessel followed by injecon of blockage (clot) dissolving drugs. Many
mechanical devices are also available which can be used to extract clot from the brain to
open the blood vessel. This selecve (intra-arterial) treatment can be given at least up to
8-hours aer the brain aack. First such case of mechanical recnalizaon using penum-
bra device in North India was done in Medanta, The Medicity. Recently first case of directstenng to open up a blocked vessel was performed in the hospital. All paents of stroke
are immediately assessed with CT angiography and perfusion (brain blood flow) imaging
using 256 slice CT scan to detect paents which have brain which can be revived and can
benefit with immediate treatment. We are the only centre in North India to use such
technology as a part of protocol.
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Executive collapses at work due to brain hemorrhage
Paent a 43 year old male working in an insurance company suddenly became uncon-
scious at work. He was taken to a nearby hospital which revealed brain haemorrhage. He
was shied to Medanta, The Medicity. Brain Angiography revealed a swollen blood
vessel (aneurysm) which had burst to cause the bleeding. He was at high risk of repeathaemorrhage and immediate repair of the leaking blood vessel was needed to safe his
life. This procedure was done by endovascular means through his leg blood vessel. A very
small tube (microcatheter) was placed in to the swollen damaged blood vessel and the
bleeding point was closed using planum coils (coiling). Paent has made almost com-
plete recovery and has gone back to his roune life.
Aneurysms are focal swelling of blood vessels, which can burst and cause bleeding in
brain. It is accepted that about 3% to 5% of the populaon harbour an intracranial aneu-
rysm and one in every 20 strokes is caused by rupture of intracranial aneurysm.
The aneurysm disease commonly strikes at prime of one's life at age of 40-50 yrs.
Alth h it i l th th f f t k b th di t ik
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Although it is less common then some other forms of stroke, because the disease strikes
a fairly young age and is oen fatal the loss of producve life years is similar to that for
cerebral infarcon or intracerebral hemorrhage. Many paents (up to 30%) do not
survive inial bleeding. Even the paents who survive more than 50% of paents do not
survive even for a month because the aneurysm bleeds again. Even the paents who
survive the inial bleeding, more than 50% of paents do not survive even for a month
because the aneurysm bleeds again. Open surgery "clipping" has been the convenonal
method of aneurysm treatment but has high chances of trauma to normal brain paren-
chyma. By endovascular method a microcatheter (a very thin tube) is placed into the
brain aneurysms through the leg blood vessel. Then the aneurysm is occluded by using
specialized coils. This procedure known as "coiling" has advantage of minimal injury to
normal brain and leading to beer outcomes. Studies have shown that paent recovery
is much beer with coiling rather than clipping. Medanta The Medicity has developed adedicated brain aneurysm program and more than 90% of brain aneurysms are treated
by endovascular means with very good clinical outcomes.
5
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The TEAM
Founders Story Dr Vipul Gupta
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Founder s Story Dr Vipul Gupta
Integrity First, Success Later
Do we lack role models in India, who have achievedmega success with integrity and without short cuts?
The role models are few, yet they exist nevertheless,
the path is tougher, yet there exists a path neverthe-
less. You dont need to escape abroad anymore and
rather find inspiraon to write your own success story
from professionals like Dr Vipul Gupta, who are worth
emulang. Who knows this may become your turning
point and you write your own mega success story,
inspired by him.
Neurosurgery and neurosurgeons, have always been awe-inspiring to me. Why not, the
mind and brain have always fascinated me (or rather all of us). So those who perform
intricate surgeries on this most delicate part of human body, are no less fascinang.
Dr Vipul Gupta is currently Addional Director & Head NeuroIntervenonal in
Medanta-The Medicity, one of Asias best mul-faculty super specialty hospitals located
in Gurgaon (Delhi NCR). He is a caring, skilled professional, dedicated to simplifying what
is oen a very complicated and confusing area of health care. No wonder, in a list of Top
10 Young Surgeons in the country prepared by The Hindustan Times,on doctors/sur-
geons with the cung edge, he is right at the top. It comes as no surprise that paents
come to him for treatment from different parts of North India, middle-east, Africa and
Central and South Asia.
What is Neuro Intervenon?
"Intervenonal Neuroradiology(Endovascular Neurosurgery)is a medical speciality in
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Intervenonal Neuroradiology(Endovascular Neurosurgery)is a medical speciality in
which minimally invasive diagnosc and therapeuc procedures for cerebrovascular
disorders are performed under radiological guidance."
Background
Humble to the core, he aributes his success to his great mentors and the early exposure
to the best medical techniques and technologies in his snts abroad. He considers Dr AN
Jha (HOD-Neurosciences, Medanta), his best mentor, who besides mentoring him has also
extended him full support in creang systems, structures and processes in his department.
Vipul means large and plenty, and Dr Vipul is true to his name, large-hearted and a man
of abundance mentality.
Educated at the best instuons (DPS- RK Puram, Maulana Azad Medical College and later
post graduaon from Safdarjung Hospital) and trained at the best hospitals (AIIMS and
Max, Saket, New Delhi) in India and abroad, he has an admirable precision, which is so
crical in his profession.
A very emoonally stable person, who can be a dong father next minute, he believes,
Surgeons cant be emoonal. Only with a calm mind, you can think clearly. At 44, Gupta
heads neuro-intervenon at Medanta, and has a keen interest in creang systems and
processes. On the hobby front, he likes swimming, raing and rock-climbing. He points
out with a humourous note how he broke his knee twice at school in outdoor acvies
which forced him to lie in bed and study (and helped him crack MBBS entrance examina-
ons). He also loves listening to music and watching television in the evenings to relax.
Neurosurgery is tough, but I always knew the challenges. If I just wanted to save lives, I
could have treated diarrhoea. To be the best, you have to be unique, he points out.
A Doctor or a God?
He shared an interesng story yesterday of how he puts in his best efforts, yet brings
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He shared an interesng story yesterday of how he puts in his best efforts, yet brings
down the unrealisc expectaons of aendants/paents to realisc levels.
"An aendant with a paent walks in. He is a rich and educated man and has come in a
Mercedez Benz. In a panicky state, as the relave has been hit by a stroke, he inquires
about the surgery cost and also requests the doctor for a guaranteed cure. Dr Vipul
replies, Who do you visit, when your car needs repair? The gentleman replies, Of
course the authorized showroom of Merecedez.
Dr Vipul connues, So when your car needs repair, you go to the people who manufac-
tured/created it. And who created you and your relave? The aendant replies, God
of course Dr Vipul explains, So ideally for the repair of a human being, you need to go
to God herself. But I am not God, I will put the best of my efforts, without guarantees.
The aendant is able to understand the limitaons of the doctor. The doctor proceeds
for the surgery and the paent comes out of the operaon theater healed. And thepaent and the doctor live happily thereaer."(A happy ending here, but not always. The paents and aendants begin to treat him like a God, but he does not
want to be one.)
Medical Approach
He has an admirable precision, which is so crical in his profession. He holds high stan-
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p , p g
dards of integrity and ethics and does not shy away in discussing the ground realies
with the aendants of the paent. No wonder his reputaon and credibility has travelled
far and wide.
He emphasizes, We always perform surgeries in teams and team orientaon is very
crucial for success in our profession. Yet it is somemes a challenge as a leader to lead a
team of people of diverse backgrounds and cultures.
He specializes in intracranial aneurysms embolizaon (coiling), ArterioVenous malforma-
on (AVMs) and tumour embolizaon, Angioplasty and stenng of arterial stenosis
including carod stenng, Intra-arterial Thrombolysis for stroke and Percutaneous spinal
procedures such as vertebroplasty and other intervenonal procedures etc.
The Brainy Bale Goes OnHis primary focus area is Endovascular Neurosurgery. Before joining Medanta, he was the
Head Intervenonal Neuroradiology (Endovascular Neurosurgery) at Max Super Speciality
Hospital, Saket, New Delhi. He has also worked as Associate Professor in dept. of Neurora-
diology (AIIMS), New Delhi. He has done fellowship training in Vascular and Intervenonal
Neuroradiolgy from Foundaon Rothschild, Paris; Cleveland Clinic (USA) and in Italy.
He keeps travelling across North India to train the medicos especially the neurosciences
professionals. He has more than 45 publicaons in journals, 7 chapters in books and more
than 40 abstract (paper) presentaons in Indian and internaonal conferences. He has
been vising Professor in UMASS general Hospital, Boston, USA. He is a member of sever-
al professional bodies and is especially keen on creang stroke (brain aack) awareness.
Once a pioneer, always a pioneer
He was among the first in India to use dedicated intra cranial stents and 3D-DSA for
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g
aneurysm embolizaon, to perform intra cranial venous sinus stenng and one of the
few full me Neurointervenonists specializing in endovascular intervenons in
Stroke.
Here is a list of his fellowships, awards, achievements and other contribuons, which goon and on.
Fellowships
Foundaon Rothschild, Paris; Cleveland clinic (USA) and in ItalyAwards
1. IMA Award- Stroke Meeng Feb 2006
2. IMAAMS Disnguished Service Award - Annual Conference of IMAAMS, 2007
3. I.M.A. Academy of Medical Speciales- New Delhi, 09th December, 2007
4. Recognion Award- Max Healthcare Instute Limited- 2008
5. Best paper award- Joint Annual Conference of Neuroradiology, Vascular and Interven-
onal Radiology, Bangalore, India, 1999
6. Best poster award- 6th Annual conference of Indian Society of Vascular & Intervenonal
Radiology) and Indian Society of Neuroradiology, 2003
He has a slew ofachievements, academic contribuonsand of course paent storiesandtesmonials.
Neurosurgery is tough, but I always knew the challenges. If I just wanted to save lives, I
could have treated diarrhoea. To be the best, you have to be unique, he points out.
No grey areas here, but loads of Grey Maer
What surprised me the most about him is that he can discuss a philosophical subject
http://neurointerventionindia.com/achievement.htmlhttp://neurointerventionindia.com/experience.htmlhttp://neurointerventionindia.com/testimonial.htmlhttp://neurointerventionindia.com/video_testimonial.htmlhttp://neurointerventionindia.com/video_testimonial.htmlhttp://neurointerventionindia.com/testimonial.htmlhttp://neurointerventionindia.com/experience.htmlhttp://neurointerventionindia.com/achievement.html8/10/2019 Stroke and Neurovascular Interventions Foundation
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such as Indian culture and ethos as easily as he can discuss the precision and techniques
of neurosciences. He shared some very interesng observaons on the challenges of
creates systems and processes in India, where people trust people and relaonships,more than they trust the systems.
Enough of grey maer now, I think. With a dose of medical terminology and discussions
on brain, interrupted by a hundred phone calls, my brain is geng dizzy now. Let me rest
now and come back with more soon.
(Story wrien & edited by Dr Amit Nagpal and ALS team)
Not exhausted yet, find out more about Dr Vipul here
Facebook Page
Website
Youtube channel
Medical Tourism Directory
Member Profiles
http://in.linkedin.com/pub/vipul-gupta/51/8a1/25ahttps://www.facebook.com/NeurointerventionGurgaonhttp://neurointerventionindia.com/profile.htmlhttps://www.youtube.com/channel/UC0mTNls5DSL05-MrzRK69Pghttp://www.medicaltourismco.com/india-hospitals/doctors/dr-vipul-gupta.phphttp://www.medicaltourismco.com/india-hospitals/doctors/dr-vipul-gupta.phphttps://www.youtube.com/channel/UC0mTNls5DSL05-MrzRK69Pghttp://neurointerventionindia.com/profile.htmlhttps://www.facebook.com/NeurointerventionGurgaonhttp://in.linkedin.com/pub/vipul-gupta/51/8a1/25a8/10/2019 Stroke and Neurovascular Interventions Foundation
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Dr Sumit Singh
A topper in DM neurology at All India Instutes of Medical Sciences (AIIMS), New Delhi,
Dr. Sumit Singh is the Head- Movement disorders & headache at Medanta the Medicity.He was awarded the BL Soni Gold Medal for being the best Resident in AIIMS where he
was an Associate Professor in neurology for 10 years. He started the first headache clinic
and the Neuromuscular disorders clinic in north India at AIIMS in 2002. He is a known
expert in Parkinsons disease and movement disorders. As a headache specialist he ini-
ated the use of botulinium toxin for the first me in the country, and extended its usage
in trigeminal Neuralgia.
He is one of the few botox injectors in India for Spascity, Limb dystonias, hemifacial
spasm, oral dyskinesias, spasmodic dysphonia and writers cramp. Dr Sumit had been
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with Deep Brain Smulaon Program for Parkinsons disease at AIIMS and has estab-
lished the same at Medanta the Medicity. He has innovated the plasma exchange proto-
cols for acute neuropathies, Myasthenic crisis, Polymyosis, and has introduced special
protocols for Mulple Sclerosis for the first me in the country. . Dr Sumit has more than
90 publicaons in Naonal and internaonal journals and has wrien several chapters in
books. His main areas of experse are Movement disorders, headache and Neuromuscu-
lar disorders.
Dr Gaurav GoelDr. Gaurav Goel is a Neuro-Intervenonist trained from presgious Montreal Neurologi-
cal Instute and Hospital in Canada. He specializes in the treatment of vascular disorders
of the brain and spine like coiling of aneurysms, embolizaon of the AVM (arterio-venous
malformaons), stenng in intracranial and extracranial atheroscleroc disease and
tumor embolizaon. He also has vast experience in newly developed flow diverter stents
for intracranial aneurysm. His primary area of interest remains in the treatment of acutestroke using mechanical and chemical thrombolyc agents. He also runs a very success-
ful spine pain management clinic, performing various spine procedures like nerve blocks,
facet blocks, epidural blocks, and vertebroplasty are being done to reduce the paents
pain, without the need for the surgery. He has managed more than 2000 of such cases
during his fellowship training program in Canada and has now brought this experse to
Medanta. Dr. Gaurav Goel is one of the very few DM neuro-radiologists in the countryand is a leading expert in the diagnosc neuro-imaging including the recent advances like
diffusion, MR/CT perfusion, MR/CT angiography and spectroscopy.
6
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Annexures
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Media Gallery
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Useful Resources & Links
Neuro Innovaons on Youtube
hps://www.youtube.com/channel/UC0mTNls5DSL05-MrzRK69Pg
Doctors Perspecves on Medical Profession and Life
hps://www.linkedin.com/today/author/184345126
Presentaons on Latest developments and Research in Neurointervenonhp://www.slideshare.net/vipulgupta35175/presentaons
NeuroIntervenon India
hp://www.neurointervenonindia.com/
Facebook Page
hps://www.facebook.com/NeurointervenonGurgaon
Healthy Living secon-Huffington Posthp://www.huffingtonpost.com/
A Health Blog
hp://www.ahealthblog.com/
Brain Anatomy
hp://brainanatomy.tk/
Your Brain Healthhp://yourbrainhealth.com.au/
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Foundation Brochure
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Contact Us
Dr. Vipul Gupta
Head- Neurovascular Intervenon Centre
Medanta Instute of Neurosciences
Medanta The Medicity
Sector 38, Gurgaon, Haryana - 122001, IndiaTelephone:+91-124-4141414 Extn: 6610
Mobile:+91-9810542372
Email: [email protected]
For Appointment: 9810332224
Dr. Gaurav GoelMBBS, MD, DM, Felloe ( intervenonal Neuro Radiology)
Consultant- Intervenonal Neuroradiology
Medanta Instute of Neurosciences
Mobile: +91-9650789820
Email:[email protected]
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Storytelling By
s e r v i c e s
LFrom Branding, the journey, toBonding, the destinationTM
+91 9810 337 995 l www.alservices.in l [email protected]