Dr. Shakir Husain MD, DM, FINR Consultant & Chief of Services Department of NeuroEndoVascular Therapy & Stroke. Program Director

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1 EGAS MUNIZ FELLOWSHIP INTERVENTIONAL NEUROLOGY & STROKE

2 Neurointervention is fast becoming an important subspecialty of neurosciences. There are many unexplored dimensions of these techniques, which may become useful in the management of stroke in the coming future. The next generations of neurologists will be playing an important and more useful role in the management of stroke and neurovascular diseases. In the recent past endovascular approach for the management of stroke and various complex neurovascular lesions has advanced significantly. Today this approach is preferred for the treatment of carotid, vertebral and basilar stenosis, brain aneurysms, cerebral and spinal arteriovenous malformations (AVM), dural cerebral and spinal arteriovenous fistulas (Dural AVF), vascular trauma, etc. Endovascular embolization of vascular tumors of the cranial base and other head and neck regions play an important role in the safe and radical surgical resection of these otherwise difficult to access locations. Intra-arterial thrombolysis and mechanical clot retrieval in acute stroke management has offered a new dimension for the treatment of ischemic stroke. Advancements in the techniques of neuro-imaging have contributed significantly to the understanding of ischemia of the brain and in case selection within window period. Stent assisted angioplasty of Carotids is seen as an alternative to its surgical counterpart, carotid endarterectomy, in the secondary prevention of stroke in high degree carotid stenosis. Vertebral, basilar, and middle cerebral arterial stenotic disease is now safely amenable to revascularization by stent angioplasty. Intracranial haemorrhage due to aneurysm, AVM, and dural AVF has always been a matter of great surgical concern. Surgical results of the treatment of these lesions located in difficult areas of the circle of Willis and eloquent area of the brain has been discouraging. Endovascular approach in such situation is very rewarding. Today endovascular treatment of ruptured aneurysm by coiling and other techniques is the preferred method over surgical clipping. Results of the randomized, double blind, multi-center ISAT trial published recently has shown superiority of endovascular coiling over surgical clipping. Endovascular embolization of AVM and dural AVFs is one of the best ways to eliminate these malformations from the circulation immediately to prevent them from re-bleed. Glue (NBCA) embolization offers a permanent obliteration of AVM in majority of the cases. Preoperative tumor embolization of vascular tumors like meningioma, juvenile angiofibroma, glomus tumors, haemangiomas etc. has been of great help to neurosurgeons. It causes tumor necrosis, and thus changes the consistency of the tumor from hard or firm to soft or less firm. It also reduces blood loss during surgery and offers better operative vision due to less blood in the operative field. Other applications of Neurointervention are treatment of vascular trauma, dealing with life threatening bleeding, treatment of vasospasm in SAH, intra-arterial chemotherapy, and vertebroplasty.

3 Dr. Shakir Husain MD, DM, FINR Consultant & Chief of Services Department of NeuroEndoVascular Therapy & Stroke Program Director He worked at GB Pant Hospital as senior research associate in the Department of Neurology and as a neurologist at St. Stephen's hospital, Indraprastha Apollo Hospital and VIMHANS in New Delhi before leaving for Zurich for a Fellowship in Interventional Neuroradiology. Dr Shakir Husain graduated from The RNT Medical College, Udaipur in 1986, completed residency in Internal Medicine at the same Institute to obtain MD(Internal Medicine) in He joined a postdoctoral programme in Neurology at G B Pant Hospital & Maulana Azad Medical College, New Delhi to obtain DM(Neurology) from Delhi University in He completed fellowship in Interventional Neuroradiology at the Institute of Neuroradiology, University Hospital Zurich, Zurich, Switzerland in He had visiting fellowships in Interventional Neuroradiology at Fondation Ophthalmique Adolphe de Rothschild, Paris and University Hospital Eppendorf, Hamburg, Germany. He is working as a Consultant Neurologist & Interventional Neuroradiologist at Sir Ganga Ram Hospital, New Delhi, India since May His clinical & research interests are in brain and spine interventions, especially carotid stenting and intracranial angioplasty & stenting, aneurysm coiling, brain and spinal AVM embolization. He is the author of several book chapters and original publications in various journals. He has designed a fellowship program in Stroke & Interventional Neurology and has been running it for past three years at Sir Ganga Ram Hospital, New Delhi. He is closely involved in the development of comprehensive Stroke and Neurointervention centers in Asia Pacific region in collaboration with the universities and major hospitals of this region

4 Neurointervention in Ischemic Stroke Intra-arterial Thrombolysis Mechanical Clot Retrieval (MCR) Carotid Angioplasty & Stenting (CAS) Vertebral Artery Stenting (VAS) Intracranial Angioplasty & Stenitng Carotid Angioplasty & Stenting Egas Muniz Fellowship in Interventional Neurology & Stroke

5 Neurointervention in Haemorrhagic Stroke Aneurysm Coiling Stent Assisted Coiling of wide neck aneurysm AVM Embolization Dural-AVF Embolization Egas Muniz Fellowship in Interventional Neurology & Stroke

6 The curriculum of the Neurointervention Department aims to make the trainees independent clinicians/consultants. The objectives of the training are that trainees should: Be acquainted with the current literature on relevant aspects of basic, investigative and clinical neurovascular practice. Have acquired performance skills and the ability to interpret relevant clinical investigations. Be able to diagnose, plan investigations and treat common conditions in the specialty by relevant current therapeutic methods. Be able to manage neurovascular and stroke emergencies. Be acquainted with allied and general clinical disciplines to ensure appropriate and timely referral. Be acquainted with relevant education delivery systems. Be able to identify, frame and carry out research proposals in their specialty. Emphasis will be given on Practical training other than on didactic lectures. Training imparted will be in the form of practical training in clinical neurology and neurointerventional procedures, departmental seminars, Journal Clubs, combined neurology and neurosurgical conferences, bedside case discussions, and video workshops. Total duration of Neurointervention training will be for one year, which comprises of o Theoretical Discussions o Observation of interventional procedures o Participation in various Neurointervention procedures and o Laboratory work on simulation modules on cerebral catheterization techniques, carotid stenting, brain aneurysm coiling etc. Observational aspects covers o o o o Learning Discipline of Neurovascular Catheterization Lab. ABC of Neurointervention Knowledge of Neurointervention materials and their handing Monitoring and management of events during interventional procedure Participation in seminar and symposium 1. Reviewing the important literature published in old and new journals and analyzing it critically. 2. Departmental seminar Once a month 3. Combined conference with neurosurgeons Once in two weeks 4. Journal Club (Neurology) Once in two weeks 5. Neurointerventional conference Once a month Practical part covers Hands-on carotid stenting simulator laboratory Insight of hardware selection, tips and tricks of carotid angiography and stenting. Step by step live carotid procedures including clinical diagnosis, carotid angiography with access demonstrating safe placement of catheters and manipulations of devices also with critical decision making. Performing cerebral and spinal digital subtraction angiography, brain aneurysm coiling, brain and spinal AVM embolization in part or complete. Active participation (as first assistant) in doing carotid stent angioplasty, vertebral, intracranial stenting, brain aneurysm coiling, brain and spinal AVM embolization and vascular trauma of head & neck. Clinical Research Work: The fellow is required to undertake a clinical research project and must complete and publish the results in an index journal before he is awarded the certificate of completion of the Fellowship. He will also be encouraged to participate and present papers in various national and international conferences.

7 COURSE AND CURRICULUM OF Interventional Neurology TRAINING 1. Anatomical and physiologic basic knowledge a) Basic knowledge in arterial angiographic anatomy of the brain, spine, spinal cord, head and neck b) Venous angiographic anatomy of the brain, spine, spinal cord, head and neck c) Collateral circulation d) Dangerous anastomosis e) Cerebral blood flow f) Cerebral Autoregulation g) Pharmacology of CNS vasculature 2. Technical aspects of Interventional Neurology, including: a) Catheter and delivery systems b) Embolic agents in cerebral, spinal, head and neck embolization c) Flow controlled embolization d) Complication of cerebral embolization e) Flow control between the extracranial and intracranial circulation f) Electrophysiological Monitoring g) Provocative testing (pre-therapeutic evaluation) h) Complications of head and neck, brain, and spine and spinal cord embolization i) Imaging of vascular systems 3. Pharmacology a) Contrast materials b) Provocative testing with anesthetics and barbiturates c) Anticoagulants d) Thrombolytic 4. Coagulation Cascade 5. Cerebral and spinal vascular pathology ( i.e. arteriovenous malformation, arteriovenous fistulas, cerebral aneurysms, ischemic stroke) a) Classification b) Clinical presentation c) Natural history d) Epidemiology e) Hemodynamic basis f) Indications for treatment g) Contraindications for treatment h) Therapeutic modalities i) Combined therapies 6. Revascularization for occlusive vascular diseases a) Arteriopathies b) Atherosclerotic lesions c) Techniques of revascularization: balloon angioplasty, thrombolytics, and stenting 7. Embolization for epistaxis or other causes of hemorrhage 8. Invasive functional testing

8 Dr. Shakir HUSAIN MD, DM(Neurology), FINR(Switzerland) Honorary Consultant & Chief of Services Stroke Neurology & Interventional Neuroradiology Dept. of NeuroEndoVascular Therapy & Stroke #2223, Superspecialty & Research Block Sir Ganga Ram Hospital Rajinder Nagar, New Delhi INDIA Tele : Mobile : drshakir@gmail.com, stent.carotid@gmail.com Academy of Neurovascular Intervention Stroke & NeuroIntervention Foundation