Conditions

A catheter angiogram is an X-ray test that shows the blood vessels of your brain or spine in fine detail. A thin tube (a catheter) is guided through an artery at the wrist or groin to the vessel being studied, contrast dye is injected, and pictures are taken. Many people only need a CT or MRI scan first; angiography is used when more detail is needed, usually to plan treatment. You are usually awake, with local anaesthetic, although children and people who cannot lie still may have sedation or a general anaesthetic. You may feel warmth when the dye is injected. The test takes from under an hour to longer if the case is complex, and afterwards you rest for a few hours; many people go home the same day. Risks include bruising or bleeding where the catheter went in, a reaction to the dye, kidney strain in people with kidney disease, and a small risk of stroke, so tell the team about allergies, kidney problems, diabetes medicines, blood thinners and pregnancy. Ask your doctor: Do I need this test, or would a scan answer the question? Which route will you use? Which medicines should I stop?

A brain aneurysm is a weak spot in the wall of a brain artery that bulges like a small balloon. Most are found by chance, never burst and cause no symptoms, but a burst (ruptured) aneurysm is an emergency. Not everyone needs treatment: small, stable aneurysms are often just watched with repeat scans, and treatment is considered by size, location, shape, growth, your age and health, and whether you have had bleeding before. When treatment is advised, several options avoid opening the skull: coiling, where soft platinum coils fill the aneurysm so blood cannot enter; stent-assisted coiling, where a small mesh tube keeps the coils in place; a flow diverter, a fine mesh tube in the main artery that redirects blood away so the aneurysm usually shrinks over months; and a device inside the aneurysm, a small mesh basket that seals it. Surgery (clipping) is another option, and a team decides which is safest for you. After a stent or flow diverter you take blood-thinning tablets (antiplatelets) for a time and have follow-up scans, and stopping smoking and controlling blood pressure lower your risk. Stroke, bleeding and problems with the device are possible, and your doctor will explain the risks for your aneurysm. A sudden, severe headache unlike any before, sometimes with vomiting, a stiff neck, sensitivity to light or fainting, may mean an aneurysm has burst. Call emergency services.

An AVM (arteriovenous malformation) is a tangle of abnormal vessels where arteries connect straight to veins, skipping the normal fine vessels in between. People are born with it. It may be found after a bleed or a seizure, or by chance on a scan, and it can also occur in the spine. Not every AVM needs treatment: a team decides, using the AVM's size, position, drainage and bleeding history, and your general health. The options are observation, embolisation, surgery, radiosurgery (focused radiation), or a combination. A large study of AVMs that had not bled found that, over the first few years, people who had treatment for simple AVMs did worse than those who were watched, which is why treatment is chosen carefully for each person, depending on the AVM's architecture, bleeding history and risk. In embolisation, a catheter is guided through the vessels into the AVM and an embolic liquid is injected to block the abnormal vessels. It is often done in one or several sessions, depending on the size and complexity of the AVM, and is sometimes used on its own and sometimes to prepare the AVM for surgery or radiosurgery. Risks include bleeding, stroke, new weakness or vision or speech problems, and in rare cases death; the team will explain the risk for your AVM, and you will need follow-up scans. Get urgent help for a sudden severe headache, a seizure or sudden weakness.

Most strokes happen when a clot blocks an artery in the brain. When a large artery is blocked, mechanical thrombectomy can remove the clot: a catheter is guided through an artery, usually from the groin or wrist, up to the clot, and a small device then traps the clot or sucks it out. Brain scans decide who can have it at the hospital, along with how long ago symptoms began and the size of the brain damage already caused by the blocked artery. It has been shown to help selected people up to 24 hours after a stroke, and some people also receive clot-dissolving medicine first. Not everyone can have thrombectomy, and it does not help everyone who has it. The procedure may be done under local anaesthetic with sedation, or under general anaesthetic, and afterwards you are looked after in a stroke unit or intensive care. Risks include bleeding in the brain, damage to the artery, and the clot not being fully removed. Rehabilitation and long-term follow-up are provided by neurology and rehabilitation teams, while Dr. Aggour treats the first, urgent stage, in the first few hours, at the hospitals where he works.

A fistula is an abnormal direct link between an artery and a vein. A dural fistula sits in the covering around the brain or spinal cord, while a carotid-cavernous fistula sits behind the eye, where the carotid artery runs through a vein-filled space. The symptoms depend on where it is. Near the ear, it can cause a whooshing sound in time with your heartbeat (pulsatile tinnitus) and sometimes headache. Behind the eye, it can cause a red, swollen or bulging eye, double vision, eye pain or blurred vision. In the spine, it can cause slowly worsening leg weakness or numbness and bladder or bowel problems; this is often mistaken for other conditions, so tell your doctor if it is getting worse. Diagnosis uses MRI or CT scans, and often a catheter angiogram, which shows the abnormal flow best. In most cases a catheter is guided into the fistula and a liquid, coils or both are used to close the connection, while some low-risk fistulas are only watched. Risks include stroke, bleeding, and nerve or vision problems. Fistulas can return, so you will have follow-up imaging. Some fistulas can bleed. Call emergency services for a sudden severe headache.

Large veins inside the skull, called venous sinuses, drain blood from the brain. When one is narrowed (stenosed), pressure can build up, which can cause a whooshing sound in time with your heartbeat (pulsatile tinnitus) and, in some people, a condition called idiopathic intracranial hypertension (IIH), where pressure inside the head is raised for no clear reason. IIH causes headache that is often worse lying down or in the morning, brief greying-out of vision, double vision and a whooshing noise in the ear, and if untreated it can damage vision permanently. Not all tinnitus is due to sinus stenosis: most tinnitus has other causes, and a doctor needs to look for the cause of pulsatile tinnitus, which can include abnormal vessels, not just a narrowed vein. Assessment includes an eye examination, MR or CT scans of the veins, and sometimes a catheter test that measures pressure across the narrowing. In IIH, weight loss and medicines come first. Venous sinus stenting places a small mesh tube in the narrowed vein to hold it open, and it is considered for selected people with a proven narrowing and pressure difference, usually when other treatment has not worked. Stenting often improves swollen optic nerves and pulsatile tinnitus, while headache improves less reliably; the evidence so far comes more from observational studies than from randomised trials, so certainty is limited and trials are ongoing. Risks include bleeding, a clot in the stent, headache, and narrowing next to the stent, and you take blood-thinning tablets for a time afterwards. See an eye specialist urgently if your vision changes.

Fatty deposits (plaque) can narrow the arteries in the neck (the carotid arteries) or inside the skull. A narrowed artery can reduce the blood flow the brain needs and cause a mini-stroke (TIA) or a stroke. Many people have no symptoms until the first TIA or stroke, and the narrowing is often found by chance, for example when a doctor hears a sound over the neck artery. Treatment for everyone is medicines and lifestyle: antiplatelets, cholesterol medicine, blood pressure and diabetes control, stopping smoking, and exercise. If narrowing in the neck has caused symptoms, opening the artery lowers the chance of another stroke, and it works best soon after symptoms. Two ways are used: surgery to clean out the artery (endarterectomy), or a stent placed through a catheter, in which a balloon (angioplasty) opens the artery and the stent holds it open. Large studies found similar overall results with different risks, and your age and the anatomy of your artery help decide; stenting is a minimally invasive procedure compared with surgery. For narrowing inside the skull, studies found that intensive medical treatment worked better than stenting, so stenting is kept for selected people who keep having symptoms despite the best medicines. Risks include stroke, bleeding, the artery narrowing again, and effects on the heart, and you take antiplatelets for a time afterwards. A TIA can look like sudden loss of vision in one eye, brief weakness or numbness on one side, or brief trouble speaking. Treat it as an emergency even if it passes, because a stroke can cause permanent brain damage or even death.

Babies and children can have blood vessel problems of the brain and spine, including AVMs, fistulas, and rare malformations such as the vein of Galen malformation, a tangle where arteries connect straight into a large deep brain vein. Children are not small adults, and their management is different and specialised. In a vein of Galen malformation, newborns may have heart strain because of the large flow through the malformation, babies may have a growing head size because fluid collects, or seizures, and older children may have developmental delay. Embolisation closes the abnormal connections with a catheter, usually in stages, and the timing depends on how the baby's heart and brain are coping; the goal is often to reduce flow and protect the brain and heart, not always to close everything at once. Care involves a team of paediatric neurology, paediatric cardiology and intensive care, anaesthesia, neurosurgery and neuroradiology. Risks include bleeding, stroke, developmental problems and anaesthetic risks, and these are discussed with you individually. Questions for parents: What is the plan and timing? How will you protect my child's heart? What follow-up will be needed? Get urgent help if your child has a seizure, sudden weakness, repeated vomiting with unusual sleepiness, or breathing difficulty.

A chronic subdural haematoma is a slow collection of old blood between the surface of the brain and its outer covering. It often starts weeks after a head knock that seemed minor, or that was forgotten, but it can also happen spontaneously, and it is more common in older people and in people on blood thinners. The usual treatment is for a neurosurgeon to drain the blood through a small hole in the skull, although it can come back. Middle meningeal artery (MMA) embolisation blocks the artery that feeds the lining of the haematoma: a catheter is guided through an artery at the wrist or groin to the MMA, and tiny particles or liquid close it, with the aim of lowering the chance that the haematoma returns. It is an option for selected people, often those at higher risk of the haematoma returning or fragile patients not fit for surgery. It is not a replacement for surgery, and the decision is made with the neurosurgery team. Risks include bleeding or bruising where the catheter went in, stroke (rare), and the haematoma not shrinking. Signs to watch for, especially in an older relative: headache that is getting worse, confusion, memory or personality change, sleepiness, unsteady walking or falls, weakness on one side, and sometimes seizures. Get medical help promptly.

Embolisation closes blood vessels on purpose. A catheter is guided to the vessel, and tiny particles, coils or liquid block it. It is used where controlling blood flow helps. Most nosebleeds (epistaxis) stop with pressure, packing or cautery by an ear, nose and throat doctor. Embolisation is considered for a bleed that is severe or keeps coming back despite those steps, and the catheter blocks small branches of the artery supplying the nose. Risks are uncommon but real: stroke, facial pain or numbness, and damage to skin or tissue. Some tumours of the head, neck and brain have a rich blood supply, so embolisation before surgery can reduce bleeding during the operation, and it may also be used to relieve symptoms. After an injury to the head, face or neck, a damaged vessel may bleed or form a weak bulge, and embolisation can close it, sometimes as an emergency. The risks depend on the area, and the team will explain them before any planned procedure. Heavy nosebleed? Sit forward, pinch the soft part of the nose for 10 to 15 minutes, and go to an emergency department if it does not stop or you feel faint.