Our Experiences With Neurovascular Intervention at King Edward VII Memorial Hospital, Mumbai 1976-1996
Keywords: Embolization, history, KEM hospital, neurovascular intervention
Seth G S Medical College and KEM Hospital [Figure 1] were inaugurated in 1925. The then huge sum of Rs 5,75,000/was donated by the Bombay Municipal Corporation and 50,000 square yards of land by the Government. The successors of Seth Gordhandas Sunderdas of the Mulji Jetha family donated Rs 1,20,000/for the foundation of a medical college. The donors made a precondition that the professors and teachers should all be properly qualified independent Indians not in Government service.
The Department of Neurosurgery at the KEM Hospital and Seth G S Medical College, Mumbai was started by Dr. R. G Ginde in 1953. However, he left in frustration as he did not get support from the Bombay Municipal Corporation.
In 1956 Dr. H M Dastur [Figure 2] returned from UK after finishing his training under Sir Wylie McKissock at the Atkinson Morley Hospital. He built up the Department of Neurosurgery at the above institutions. Dr. Anil Desai joined him as Honorary Neurologist and helped expand the services. Dr. Sunil Pandya joined the department in 1966 as Assistant Professor. Dr. R D Nagpal joined the department as a houseman in 1965 and later rose to become Professor. A separate Neurosurgery Operation Theatre, Neuroradiology Division, attached OPD and adjacent pediatric, female and male wards were carved out of the main hospital building on the second floor. Dr. Dastur left the KEM Hospital to join the newly commissioned Jaslok Hospital in 1974.
Dr. Pandya then took over as Head of Department. I joined the department as a houseman in 1972 and passed MS Neurosurgery in 1975 and was promoted as Lecturer in 1976.
In 1974 Dr. Pandya went to the UK under a Commonwealth Fellowship program and was able to study transfemoral select cerebral and spinal angiography performed by Dr. George du Boulay and Dr. Brian Kendall. On his return to India in 1975 he was gifted many diagnostic catheters and guide wires for transfemoral cerebral angiography by Dr. du Boulay.
The Neuroradiology Division of the Department of Neurosurgery at KEM Hospital in 1975 was equipped with an Elema-Schonander skull table which had a box for changing films to allow cerebral angiography and a 90-90 tilting table for myelography. Angiography, ventriculography, pneumo-encephalography and myelography were performed by the staff and residents of the neurosurgery department. Angiography was performed by direct puncture of the carotid artery in the neck. Vertebral angiography was performed by puncturing between transverse processes of the 5th and 6th cervical vertebrae. It was difficult and failed at times.
In 1975 we requested Dr. Mutjaba (Chotu) Tayabali [Figure 3], a reputed radiologist at the Breach Candy Hospital, to teach us transfemoral cerebral angiography. Dr. Tayabali had trained in radiology and angiography in the UK. He promptly obliged and visited our department at least once a week for the purpose for many months. He gifted our department a mechanical injector for angiography of the arch and abdominal aorta. The injection was purely mechanical with no control. Pressing the foot pedal released the piston and the contrast was delivered under pressure. The volume of contrast could be controlled but not the pressure or rate of injection.
With the catheters and wires gifted by Professor G du Boulay angiography was started at the KEM Hospital in 1976 under the guidance of Dr. Tayabali. Dr. Pandya was the first to be trained. He was followed by Dr. Nagpal and later by me. The angiography initially was performed under fluoroscopy on the 90-90 table. Later the fluoroscopy was replaced by the safer and clearer imaging on Old Delft intensifier.
In 1978 the NeuroDiagnost machine was acquired for the department. The quality of fluoroscopy of the NeuroDiagnost allowed transfemoral catheterization of all the branches of the internal carotid artery (ICA) and, more importantly, the vertebral artery (VA) and the external carotid artery (ECA). Acquisition of images continued on the changing box of Elema-Schonander skull table as special films were not available for the film changer of the NeuroDiagnost machine. Photographic subtraction was done by superimposing plain films on the post-contrast films. The catheters had excellent torque but would only allow the passage of guide wires. Initially only diagnostic procedures were performed.
Dr. Homi Dastur had started embolisation through the internal carotid artery to obliterate carotid artery – cavernous sinus fistulas (CCF) by making a cutdown in the common carotid artery. A piece of muscle anchored to a black silk stitch was floated through the opening in the common carotid artery (CCA) and manipulated till the bruit ceased. The black silk was then cut at the arteriotomy site.
By 1977 pre-operative embolisation of arterio-venous malformation in the brain had commenced in our department. Methyl methacrylate spheres, described by Luessenhop in 1960, of various sizes were imported by us and floated up for the pre-operative embolization of large brain AVMs. During embolization of a brain AVM in a young female patient, some of the spheres instead of travelling to the nidus stacked up in the distal M1 trunk and branches. This resulted in occlusion of the MCA. The procedure was being done under local anesthesia (LA). The patient developed immediate contra-lateral hemiplegia. She was shifted to the OT. The MCA was incised and the spheres milked out. Though blood flow was restored, the patient succumbed. It was decided to suspend further embolization of brain AVM by this technique.
Gel foam particles were used for embolization of vascular tumors. They were floated through an arteriotomy in the CCA. Later angiography through an intra-arterial catheter was followed by embolization with the injection of a slurry of tiny pieces of gel foam. Indications for embolization were vascular tumors like nasopharyngeal angiofibroma, meningioma, chemodectoma, metastases etc. A paper in Journal of Neurosurgery described a fatal outcome after embolization of a functioning glomus jugulare tumor in 1978.
By now I had developed an inclination and special aptitude for endovascular therapy of cranial and spinal lesions. It became necessary for me to train abroad in selective and superselective angiography and safe embolization techniques.
Professor B. Ramamurthi, the eminent neurosurgeon in Madras, was approached for help. He wrote to Professor B Pertuiset, at the Pitie Group of Hospitals, Paris, for suggestions. Professor Pertuiset recommended Professor Luc Picard [Figure 4] of the Department of Diagnostic and Therapeutic Neuroradiology at University Hospital, Nancy, France.
Professor Picard graciously accepted me for a period of two months, but pointed out that no financial support was possible. However, he offered accommodation in the residents' quarters and the facility of the hospital canteen. I received financial help from the R. D. Birla Smarak Kosh of Bombay Hospital, and an interest free loan from the Bombay Municipal Corporation. This enabled me to spend 6 months (September 1980 to March 1981) in France - two months each under Professor Bernard Pertuiset at Pitie Group of Hospitals studying vascular neurosurgery, Professor Gerard Guiot of Foch Hospital, Suresnes, a suburb of Paris, for trans-sphenoid surgery and Professor Luc Picard for interventional neuroradiology (INR). The department for INR in Nancy, was equipped with two bi-plane Neurolabs with film changers. Photographic subtraction was the norm. There was no real time subtraction or road map. The department possessed two computerised tomographic (CT) scanners. There was no magnetic resonance imaging (MRI).
At Nancy all transfemoral procedures, diagnostic and therapeutic, were performed using short introducer sheath through which catheters could be exchanged without the use of exchange wires. Interventions were performed by direct puncture in the neck and placement of short sheath in common carotid artery.
At that time, the procedures performed were:
I was allowed to do diagnostic angiography and assist at all procedures.
After completing my stint in France, I went to University Hospital, London, Ontario, Canada to spend 3 weeks as an observer in the neurosurgery department. Professor Charles Drake, the doyen of vascular neurosurgery, was the head of the department. Professor Gerard Debrun, the formidable interventional neuroradiologist from France, James Fox and Fernando Vinuela formed the INR department.
One very important lesson which played a significant part in embolization of AVMs was witnessed here. Prof. Debrun navigated a microcatheter into a posterior choroidal branch (PChoA) of the posterior cerebral artery (PCA). To everyone's horror it got stuck there. It could not be pushed or pulled without injuring the basilar artery (BA). Professor Drake was called in. He suggested angiography through the other groin. There was no compromise of the circulation. It was decided to cut the catheter in the groin and bury the proximal end in the groin. This was done uneventfully. The microcatheter thus extended from left PChoA through PCA, VA, subclavian, aorta all the way to the groin.
This lesson was extremely useful because at KEM everything was reused. This was necessary as funds were scarce and importing expensive catheters, guide wires and other necessities for selective angiography was out of question. Spasm of delicate cerebral arteries was fairly common and catheters getting stuck was a major issue. Often just waiting for ten minutes and the use of intra-arterial papaverine would release the catheter. But sometimes it would remain firmly stuck. I was forced to leave behind a few catheters with no detriment to patients. Patients were placed on anti-platelet drugs for 3 months. Some patients even underwent subsequent embolization through the same feeders.
In early 1980s guiding catheters were not available. Angiography was done through the groin using 5F or 6F catheters and the guide wires were Teflon 038. Detachable balloons were introduced through the neck by direct puncture. On two occasions a non-detachable Fogarty balloon was used to obliterate a carotid artery – cavernous sinus fistula (CCF). To keep the balloon inflated the catheter was clamped, the hub was cut and its tip closed by holding over spirit lamp and crushed with artery forceps and buried in the neck leaving the ICA open. Particulate embolization was done through 5F and 6F catheters placed in internal maxillary artery (IMA). On my return to India, I was gifted catheters, vascular sheaths, detachable balloons, Fogarty catheters, sheets of lyophilized dura by Professor Picard.
Up to 1980, at KEM, diagnostic angiography was performed by changing catheters as required, using long wires, through the groin puncture. Vascular sheath was not used. Using a short sheath with irrigation via pressure bag simplified angiography and interventions.
Over the next several years all the above procedures were performed at the KEM Hospital on the Neurodiagnost machine with the angiography done on the film changer box. Most of the materials were reused after proper cleaning and sterilization. Initially the materials were sterilized by placing tablets of formaldehyde in sealed polyethylene bags and later with ethylene oxide gas. Catheters were made of polyurethane and were fragile. Three catheters fractured during use. One broke in the right CCA with its tip in the ECA after embolising a naso-pharyneal angiofibroma. It was extracted through an arteriotomy. Another fractured in the left cervical VA. Since it was the non-dominant VA it was ligated at C2, distal to the catheter, to prevent embolism. The third catheter was extracted from the right subclavian artery using a Dormia basket.
Balloon embolization of CCF and giant carotid aneurysms was done by percutaneous carotid puncture. Tumor embolization using gel foam was done using 5F or 6F catheters through the femoral route. Dural AVFs were embolised using lyophilized dura. Most procedures were done under LA.
Professor Picard's Visits to our Department
In 1982 Professor Luc Picard was invited to deliver an oration at the annual conference of NSI in Cuttack. On his way he stopped over in Mumbai. He demonstrated spinal angiography and embolization of a spinal cord AVM. He also gave some lectures that benefited the faculties of all the medical colleges in the city.
First national workshop conducted by Professor Picard
In 1985 a workshop was conducted at the KEM hospital [Figure 5](a and b) with live demonstration and 2-way audio-visual communication. Neurosurgeons and radiologists from across the country attended. Didactic lectures were given and some procedures performed. Test occlusion followed by parent artery occlusion (PAO) for giant aneurysm, CCF treatment with detachable balloon and spinal cord AVM embolization were demonstrated. The lectures included, among other topics, brain AVM embolization using silastic spheres. Prof N K Mishra, of AIIMS attended the workshop as a delegate. Dr R V Phadke had his first exposure to INR during this workshop. He later went on to Head INR at SGPGI, Lucknow.
Dr. Arya and I Visit France
In 1987 Professor Picard invited me for further training for 3 months under a Post-Doctoral Exchange Program of the French Government. Professor B Y T Arya, Professor of Neuroradiology, NIMHANS, Bangalore was also a co-trainee. I was introduced to Professor Jacques Moret [Figure 6] during this visit. Professors Picard and Moret used to treat brain AVM together because by now selective catheterization of feeders and embolization with liquid embolic agent, Isobutyl 2 Cyano-Acrylate (IBC) was being done. Alternate fortnights, on Mondays and Tuesdays, patients were treated at Nancy and in Professor Moret's department at Fondation Ophthalmique de Rothschilde Hospital in Paris. Professor Picard would travel to Paris and Professor Moret would travel to Nancy.
I witnessed the first ever treatment of an aneurysm of the middle cerebral artery treated by Prof. Moret, using a detachable balloon which was filled with contrast.
During this training schedule Professor Picard arranged for me to attend two important meetings. 1. A multinational conference in Bordeaux on the new modality of imaging, MRI and its applications. 2. A multinational meeting in Venice, Italy on Advances in Cerebro-Vascular Surgery and INR.
The highlight of the Venice meeting was a presentation by Professor Guido Guglielmi on the treatment of experimental aneurysms using platinum coils. These were later named after him as Guglielmi detachable coils (GDC). The advantage of using the coil was that it could be removed if it was too large or too small or too long and to detach it at will only after satisfactory position had been obtained. GDC later revolutionized the treatment of aneurysms.
For both meetings, and the Paris trips registration, travel and hotel were funded by Professor Picard.
Once again, on my return, I was gifted various materials like catheters, adaptors, 2 ml and 1 ml Luer Lock syringes, balloons etc., Professor Moret had gifted a home-made syringe [Figure 7] for coiling silastic tubing for brain AVM, which I used for many years.
By now new techniques had evolved, much better materials were available. Transfemoral telescoping large bore guide catheters were used routinely replacing cervical carotid punctures. Instead of silastic spheres liquid embolic material (Isobutyl-2-cyanoacrylate, IBC, Glue) was injected for brain and spinal cord AVM. Five-meter rolls of 1.5 F and 1.8F supple silastic tubing was cut into 150 cm lengths. They were coiled in a special syringe and propelled into the feeder by injecting into the side arm of the syringe. The high blood flow would carry the microcatheter into the feeder. Later a small balloon with a hole at the tip to permit calibrated leak of contrast and glue, was attached to the tip to allow some directional control of the microcatheter and to achieve better control of the injection of glue, which would other-wise fly into the draining veins. At this time standard concentration of glue was 66%. Today the standard concentration is 20% for common AVM and 90% for high flow AV Fistula. The small hole at the tip allowed partial inflation for better navigation and also to reduce or slow flow to allow better penetration of the glue.
Thin-walled guiding catheters now became available. 6F-9F and 5F-8F mother–baby (Ingenor, Rue Orfila, Paris, France) catheters to allow trans-femoral catheterization of carotid and VA allowed deployment of balloons. Tumors were embolised with PVA (poly vinyl alcohol) particles.
Over the next several years the new techniques were employed at the KEM Hospital. Several hundred cases of giant aneurysms, CCF, intracranial and spinal AVM, dural AVF, intracranial and juxta-cranial tumors were treated thus.
In 1989 the second live workshop on INR was conducted at KEM Hospital with live demonstrations and two-way audio-visual communications. Professor Luc Picard and Jacques Moret were the faculty. During the workshop lectures were given. Several patients were treated. The highlight was the embolization of a brain AVM and of aneurysm on a persistent trigeminal artery. The aneurysm was treated by a detachable balloon mounted on a special catheter developed by Professor Moret and inflated with HEMA (hydroxyethyl-methacrylate) which replaced the contrast. This was a technique developed by Professor Moret. The workshop was attended by radiologists, neurosurgeons and neurophysicians from across India.
By now the first generation of Magic catheters were available. The Moret-Picard (MP) 1.5F catheter was the favourite. The catheter was still flow directed but the tip could be shaped on steam, could be torqued and flipped to allow catheterization of tortuous small vessels. AVM embolization targeting the nidus was now possible. Isobutyl-2-cyanoacrylate had been withdrawn because it was carcinogenic but N-butyl-2 cyanoacrylate (NBCA) was now available and the injection could be better controlled.
Initially all diagnostic procedures were done under LA. Most extracranial procedures and balloon test occlusion were also done under LA. Soon all intracranial procedures were done under neuroleptanalgesia. Dr. D B Deval, Professor of Neuro Anesthesia, mastered neuroleptanalgesia using fentanyl and droperidol. Angiography for SAH and spinal procedures were done under general anesthesia (GA). All procedures, diagnostic and therapeutic, were done with anesthetists in attendance.
At the KEM, initially, all AVMs were treated with glue embolization. But as all catheters were disposable and meant for single use, most patients could not afford them. The aim of embolization was to facilitate surgery. It was decided to embolise using silk threads. 3/0 Mersilk could be injected through 1.8F and 5/0 through 1.5F Magic catheters. Multiple feeders were embolised, using the same microcatheter, in the same sitting under neuroleptanalgesia. Embolisation was followed by surgical excision.
Upto 1991 all procedures were done on the Neurodiagnost machine which did not have subtraction or road map.
In 1991, a portable C-arm with roadmap and real-time subtraction was imported for the department. The table was cannibalized from a discarded cathlab and was used with the C-Arm. The number of procedures now multiplied and were much safer.
Tumor embolization with gel foam particles and PVA was common. CCF and giant carotid aneurysms were treated with detachable balloon by the transfemoral route. Embolisation of cirsoid aneurysms of the scalp (which are high flow A-V Fistula between branches of ECA and scalp veins) was by direct puncture and injection of concentrated glue. These were large and sometimes presented with exsanguinating hemorrhage. The AVF was obliterated with glue but it resulted in scalp necrosis. Hence surgical excision and scalp flap rotation was carried out 2 days later in conjunction with our plastic surgery colleagues. Large glomus tumors, carotid body tumors, nasopharyngeal angiofibromas were embolised by direct puncture and glue injection on blank roadmap. One large, very vascular malformation of the tongue had presented with exsanguinating hemorrhage. Preliminary urgent tracheostomy was performed. Direct puncture embolization was done by filling the malformation with histoacryl. Subsequently glossectomy was achieved with 10 cc blood loss. Low flow malformations, venous and mixed veno-lymphatic and large venous varices were obliterated by direct puncture and injection of sclerosant. For the first few venous varices absolute alcohol was injected. Later STD (sodium tetradecyl sulphate) an excellent, inexpensive sclerosant proved effective.
Giant aneurysms were treated by PAO (parent artery occlusion) after doing test occlusion with a balloon (BTO). Inexpensive wedge pressure balloon catheter was used to perform test occlusion. The appropriate ICA was occluded above the carotid body. A second catheter was introduced from the other groin and with the ICA occluded, angiography of the opposite ICA and dominant VA were done to compare arterial, capillary and venous phases. If the patient passed the BTO and the aneurysm was below the ophthalmic artery the ICA was occluded with pushable, non-retrievable occlusion coils. These coils are radio-opaque, made of steel or platinum and have Dacron cross hairs to promote occlusion.
In 1994 tungsten coils were invented which could be delivered inside the aneurysm through fine microcatheters. However these thin pushable coils were non-retrievable. Two circle of Willis (COW) aneurysms and another on a feeding artery of an AVF were closed uneventfully. However when treating a mid-basilar artery aneurysm, two coils went in uneventfully. The third coil prolapsed into the BA and could not be retrieved. Thrombus around the coil dissolved with local heparin and urokinase but reformed and enlarged, occluding the BA. The patient succumbed the next day. Follow up of the treated patients one year later, showed that the coils had got reabsorbed and the aneurysm partially recanalised. Later there were multiple reports of dissolution of the tungsten coils. After the catastrophe, embolization with tungsten coils was never attempted by us.
Between 1982 and 1996 several papers were presented at annual meetings of the Neurological Society of India on various subjects, such as aneurysms, AVMs, CCF, Vein of Galen malformation,,,, to state association of Oto-Laryngology for embolization of nasopharyngeal angiofibroma, glomus tumors and dural AVF causing tinnitus and to Maharashtra State Ophthalmology Association on CCF.
The World Federation of Interventional and Therapeutic Neuroradiology was founded in 1990 at Val d'Isere, France. The first meeting was held along with that of the Working Group in Interventional Neuroradiology (WIN). In 1991 I was invited to attend the WIN meeting held in Val d'Isere, France by Professor Picard. He sponsored the registration fee, hotel and local expenses. At this meeting I was elected a member of the recently formed World Federation of Interventional and Therapeutic Neuroradiology (WFITN). Professors Moret and Picard sponsored the membership and requested that the membership fee be waived. I expressed my inability to pay the fee of USD150 since it was several times my salary and would not be refunded by my institution. Professor Moret promptly offered to pay the fees and he did. I have been a member of WFITN since 1991 and have attended many meetings. After the meeting I spent one month as an observer in Professor Moret's department learning newer techniques.
In 1994 (Symposium Neuroradiologicum), the World Federation of Neuro Radiology, meeting was organized in Kumamoto, Japan by Professor M Takahashi. The registration fee was waived and local expenses borne by the organizers. I was invited to present a paper 'treatment of CCF with detachable balloons'. Poster presentations were also made, at this meeting on 1. Embolisation of skull base tumors fed by ICA, 2. PAO for giant aneurysms of the ICA.
In 1994 I was invited to attend the first meeting of the newly founded Asian & Australasian Federation of Interventional & Therapeutic Neuro Radiology (AAFITN) [Figure 8] which was held in Beijing soon after the WFITN meeting. The meeting was organized by Professor Ling Feng and I was elected Founder Member, representing India. Professor Ling Feng of Beijing, China was the President, Prof Waro Taki of Kyoto, Japan was the secretary and Dr John Kwok of Hong Kong was the treasurer of AAFITN.
In 1995 I was invited to the IIIrd WFITN meeting held in Kyoto Japan. I presented a paper on treatment of 'Giant Aneurysms with Parent Artery Occlusion' and 'Embolisation of brain AVM using silk thread'.
Neurosurgery residents would assist at procedures. But none of them were keen to take up Neuro-Intervention. After 1987 Dr. Ravi Ramakantan, Professor of Radiology, KEM Hospital, used to come and help especially for embolization of brain AVM with glue and for difficult cases of AV Fistula. He was instrumental in getting the portable C-Arm with DSA and road map for the department. Several innovative techniques evolved from this association with him. A 5-year-old child presented with a high flow CCF. Detachable balloons mounted on micro-catheter could only be navigated through large bore 8F and 9F guide catheters which could not be used in a child. He suggested a 5F femoral sheath be slit, and the cocooned balloon mounted on the microcatheter in a 5F Head Hunter (HH) catheter be advanced into the groin 5F sheath and the slit sheath removed [Figure 9]. Torquing of the HH would allow positioning of the catheter in the ICA. The balloon would be positioned in the cavernous sinus by required gentle push, inflation, deflation. The fistula was closed successfully by inflating-deflating the balloon until the balloon was positioned in the cavernous sinus closing the CCF. Bilateral direct type I CCF patient was treated with single detachable balloon on either side with almost immediate regression of proptosis, chemosis and improvement of vision [Figure 10].
In 1992 Dr. Ravi started a rotation of radiology residents for a month in INR in the department of neurosurgery. In late 1994, Dr. Uday Limaye was deputed to the department of INR as a full-time associate.
In 1996 I retired from KEM Hospital, Seth GS Medical College to join Indraprastha Apollo Hospital, New Delhi. Professor Uday Limaye then took over Neuro Intervention at K. E. M. Hospital and with strong support from Dr Ravi Ramakantan, over the subsequent decade built up a world-class department of NeuroIntervention.
Prof. Sunil Pandya, Former Head of Department of Neurosurgery and Prof. Ravi Ramakantan, Former Head of Department of Radiology, KEM Hospital and Seth G. S. Medical College, helped in the preparation of the manuscript.
Financial support and sponsorship
Conflicts of Interest
There are no conflicts of interest
[Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 1], [Figure 1]