I’m proud to announce that Tallahassee Neurological Clinic (TNC) is participating the NEWTON2 trial, and we are currently enrolling patients. NEWTON2 is a phase 3 randomized trial evaluating intraventricular nimodipine (EG-1962) versus standard of care oral nimodipine in patients with subarachnoid hemorrhage due to ruptured brain aneurysms. This makes Tallahassee the only center in the region that provides full service cerebrovascular care and cutting edge stroke and brain aneurysm research.
Noncontrast CT scan of the head showing classic appearance of subarachnoid hemorrhage.
Participating in well designed clinical trials, such as NEWTON2, helps ensure that the care we provide in the future will be better than the care we provide today. I’m very proud that we are participating in this trial, as it helps advance our field within neurosurgery, and hopefully will improve outcomes for patients with subarachnoid hemorrhage.
TNC is the only neurosurgical group in the region with three endovascular neurosurgeons, who provide comprehensive care for ischemic stroke, hemorrhagic stroke, brain aneurysms, and carotid disease. We have an active clinical research division and have participated in numerous device and drug trials for neurosurgical patients.
TNC Endovascular Neurosurgeons. Left to right: Dr. Beaty, Dr. Oliver, and Dr. Lawson.
There is a great editorial in JNIS about stoke care at Comprehensive Stroke Centers and ongoing debate about how we as a medical community should address the inefficiencies in stroke care. Worth reading for anybody interested in stroke and stroke intervention. Click below to go to the article.
Carotid Artery Stenosis is a common cause of stroke. In fact, roughly 7 to 18% of all first time stroke is attributed to carotid artery stenosis in excess of 60%. That means that roughly 1 in 10 strokes is due to narrowing of the carotid artery.
There is debate regarding the best treatment for carotid artery stenosis. I won’t get into the relative risks and benefits of each in this post, but in general the treatment options for carotid stenosis include:
Medical Treatment – aggressive medical treatment usually involves aspirin, clopidogrel, a statin, as well as aggressive blood pressure and diabetes control. This may be the best option for asymptomatic carotid stenosis.
Carotid Endarterectomy (Surgery) – this is a surgical procedure in which an incision is made on the neck and the carotid artery is exposed. The artery is then temporarily occluded with clamps. The artery is then opened with a scalpel, the plaque is removed, and then the artery is repaired. This has been a common treatment for many decades, and is well studied with very good results.
Carotid Angioplasty and Stent (Endovascular Treatment) – this is an endovascular procedure to treat carotid disease. This is done awake in the
Pre-Treatment, severe >90% left internal carotid artery stenosis. The arrow denotes severe stenosis, or narrowing. This is seen as a tiny string of contrast at the arrow. The external carotid artery, which supplies blood to the face and scalp, fills much more rapidly than the internal carotid artery, which supplies the brain.
cath lab. A guide sheath is placed into an artery in the leg, it is navigated to the common carotid artery in the neck, and then the carotid narrowing is treated from within the blood vessel. The narrowed carotid artery is ballooned opened with a balloon catheter and a stent is placed to help keep the artery open. In the images to the right and below, there is a representative example of the treatment of left internal carotid stenosis with angioplasty and stent placement. In the image to the right, the narrowing is a tiny string of contrast at the arrow, which is causing severe limitation in flow into the left internal carotid artery. Below, you can see the post angioplasty and stent results, after the narrowing has been “ballooned open” and a stent placed.
Post carotid angioplasty and stent placement.Post treatment, unsubtracted and magnified to see stent inside left internal carotid artery.
Dr. Lawson treats carotid disease with all of the methods noted above; medical, surgical, and endovascular. All of his carotid procedures are tracked in a registry (the National Neurosurgery Quality and Outcomes Database, also known as QOD – Neurovascular module) to ensure quality and safety. Learn more about public quality data reporting at the Neuropoint Alliance.
Want to learn more? Download the American Stroke Association guidelines for the management of carotid disease here.
Click here to contact the office for an appointment.
I’m pleased to be one of the invited speakers to the Baptist Health Care Stroke Symposium in Pensacola, set for May 19, 2017. I’ll be speaking about Hemorrhagic Stroke as well as the role of the TMH Comprehensive Stroke Center in our community.
This conference is geared for all health care providers, including physicians, ARNPs/PAs, nurses, therapists, and EMTs/paramedics. CEUs are provided.
Tallahassee Neurological Clinic and Tallahassee Memorial Hospital have been selected as a site for the NEWTON2 trial, with Dr. Lawson as the local site primary investigator. This phase 3 trial is designed to study the efficacy of a novel substance compared to oral nimodipine for prevention of vasospasm in subarachnoid hemorrhage. This makes TNC and the TMH Comprehensive Stroke Center the only center in the region participating in phase 3 research in hemorrhagic stroke & subarachnoid hemorrhage treatments.
Institutional Review Board approval has not yet been granted, but we hope to finalize this in the next few months. The study is funded by Edge Therapeutics.
Why is it important that TMH is a Comprehensive Stroke Center?
Comprehensive Stroke Centers (CSCs) are the most advanced hospitals for providing stroke care. Not only have they demonstrated excellence at caring for ischemic stroke and administering TPA, Comprehensive Stroke Centers have gone the extra mile to specialize in stroke diagnosis and treatment, including treatment for all forms of stroke. The only facility in Northwest Florida, South Georgia, and Southeast Alabama with Comprehensive Stroke Center services is Tallahassee Memorial Hospital (TMH).
Primary Stroke Centers (PSCs) can be thought of as the minimum requirement for stroke care. PSCs are able to diagnose and treat ischemic stroke. Most PSCs in the region rely on teleneurology, or neurologists available by computer or telephone, to help diagnose and treat patients. Comprehensive Stroke Centers, on the other hand, have in house neurology and neurosurgery services. TMH has 4 employed hospital stroke neurologists as well as 4 board-certified neurosurgeons at Tallahassee Neurological Clinic.
Drs. Lawson and Oliver. Board-certified neurosurgeons with neuroendovascular certification (CAST certification) at the TMH Comprehensive Stroke Center.
Comprehensive Stroke Centers not only provide excellent care for ischemic stroke, but they also provide advanced stroke care services. This includes care for ruptured cerebral aneurysms, AVMs, and other forms of hemorrhagic stroke. CSCs perform cutting edge procedures, such as thrombectomy for ischemic stroke due to large vessel occlusion as well as brain aneurysm treatment. They generally qualify as high volume treatment centers for aneurysmal subarachnoid hemorrhage, which means they generally have better outcomes than other centers that treat brain aneurysms.
Dr. Lawson was one of the first 50 individuals certified in Neuroendovascular Surgery by the Society of Neurological Surgeons.
Endovascular Neurosurgery (also known as Neuroendovascular Surgery or Neurointerventional Surgery) is a cornerstone in the Comprehensive Stroke Center model of care. At TMH we have two board-certified neurosurgeons, Drs. Lawson and Oliver, who are also certified in Neuroendovascular Surgery by the Society of Neurological Surgeons (CAST Certification). TMH is the only facility in the region with such highly trained and experienced neurosurgeons. The CAST Neuroendovascular Certification is generally accepted as the highest level of certification for Neuroendovascular Surgery, and the Society of Neurointerventional Surgery endorses this CAST certification. No other physicians in the area have this certification, including those in Pensacola, FL, and Dothan, AL.
Drs. Lawson and Oliver are partners at Tallahassee Neurological Clinic, a multispecialty group practice of neurosurgeons, neurologists, and pain management physicians. Dr. Lawson has been in practice in Tallahassee since 2012, and he was the first neurosurgeon in the region to perform brain aneurysm coiling or thrombectomy for the treatment of acute stroke. He helped establish the TMH Neuroendovascular Lab and the TMH Comprehensive Stroke Center. Dr. Oliver joined Dr. Lawson in 2013. As of now they share call for Neuroendovascular services for the region. In 2017, we expect another endovascular neurosurgeon to begin in Tallahassee.
Fig. 1. Right MCA aneurysm prior to treatment.Fig. 2. Right MCA aneurysm at 6 months post treatment with a novel stent, placed at the TMH Comprehensive Stroke Center.
The neurosurgeons at TNC have a robust neurosurgical research component that includes research in stroke and brain aneurysm treatment. Neuroendovascular Surgery is a rapidly evolving field, and devices that were made just 10 years ago are now obsolete. Drs. Lawson and Oliver are active in Neuroendovascular research and have several open trials for novel devices and treatments. We feel that offering access to cutting edge medical research is a key component to a successful Comprehensive Stroke Center.
For more information about the TMH Comprehensive Stroke Center, click here.
Noncontrast CT scan of the head showing classic appearance of subarachnoid hemorrhage.
Subarachnoid Hemorrhage, or SAH, is a medical condition where there is bleeding into the subarachnoid space. This space is just outside of the brain and spinal cord, but inside the dura, or the tough covering over the brain and spinal cord. The subarachnoid space contains cerebrospinal fluid, or CSF, which protects the brain, as well as major blood vessels that supply the brain with oxygen and nutrients.
The most common cause of subarachnoid hemorrhage is trauma. When a patient strikes their head, such as in an automobile accident or fall, blood vessels in the subarachnoid space may tear and bleed, causing traumatic subarachnoid hemorrhage. This is usually treated with observation and placement of an intracranial pressure monitor, using the Guidelines for the Management of Severe Traumatic Brain Injury.
CT Angiogram (CT with contrast in arterial phase) shows 2 brain aneurysms.
Patients who present with subarachnoid hemorrhage who have not had a traumatic injury have spontaneous subarachnoid hemorrhage. This is commonly due to an abnormality of the blood vessels within the subarachnoid space that has caused them to rupture and bleed on their own. The most common vascular abnormality leading to subarachnoid hemorrhage is a cerebral aneurysm, or brain aneurysm, but other vascular conditions can also cause subarachnoid hemorrhage. When a patient comes to the hospital with subarachnoid hemorrhage, studies such as CT Angiography or Cerebral Angiography are performed to look for a brain aneurysm or malformation that may have caused the bleeding.
Aneurysmal Subarachnoid Hemorrhage is a medical emergency. It strikes roughly roughly 30,000 people annually in the United States. Many of these people are critically ill. Up to 40% of patients with subarachnoid hemorrhage from a ruptured aneurysm die, and many pass away quickly. Symptoms of SAH include sudden onset severe headache (the worst headache of my life, or thunderclap headache), nausea, vomiting, lethargy, coma, and sometimes focal neurological impairment. They may also develop seizures, elevated pressure in the brain or hydrocephalus, and aneurysm re-rupture. When patients arrive in the Emergency Department with SAH, they will often require intubation (placement of a breathing tube) and transfer to a specialized hospital, such as a Comprehensive Stroke Center (CSC).
SAH patients are then cared for in neurological intensive care units, usually at Comprehensive Stroke Centers. The goal of treatment is to support the patient, control blood pressure, and give medications to prevent a complication called vasospasm. About half of all SAH patients will need a ventricular drain to relieve hydrocephalus, a common complication of subarachnoid hemorrhage. The ventricular drain is a small catheter or tube that is placed into the fluid-filled spaces in the brain, the ventricles, which drains fluid to a collection system outside of the patient. This ventricular drain helps reduce the buildup of cerebrospinal fluid and helps relieve elevate intracranial pressure.
(1) Lateral angiogram demonstrating two aneurysms, with a microcatheter placed into the PCOM aneurysm for coil placement (embolization).
Once the patient with SAH is stabilized, the goal is to repair the aneurysm so that it cannot bleed again. Usually, this is done within the first 24 hours after admission to the hospital. Aneurysm repair does not generally change the condition of the patient, but it does prevent further bleeding from occurring. A brain aneurysm can be repaired in one of two ways, microsurgical clipping (open surgery) or endovascular embolization (often called coiling). Microsurgical clipping is done in the operating room, and a craniotomy is performed. The aneurysm is then “fixed” when a small titanium clip is placed across the bottom of the aneurysm (or neck), which prevents future bleeding. There are risks and benefits to each of these treatments, but most ruptured aneurysms at TMH are treated with endovascular embolization (coiling).
(2) Coils can be seen within the PCOM aneurysm.
Aneurysm embolization (coiling) is performed in a specialized cath lab, similar to a cardiac cath lab or interventional radiology suite, and is usually performed by an Endovascular Neurosurgeon. Small catheters are placed into the femoral artery in the groin and navigated up into the head, where aneurysms are treated from inside the blood vessels. Click here to learn more about Endovascular Neurosurgery.
The first 10-12 days after aneurysm rupture are usually spent in the ICU, and then the focus of care shifts towards rehabilitation. The average stay in the hospital is about 3 weeks. Many patients will require inpatient rehabilitation after aneurysmal subarachnoid hemorrhage. After a patient leaves the hospital, continued follow up with the neurosurgeon is critical.
TMH Stroke Team with American Stroke Association Award
Tallahassee Memorial Hospital received the American Stroke Association Get with the Guidelines Gold Plus recognition for excellence and consistency in compliance with stroke center quality measures. Great job team!
June 7, 2016 – TMH announces their new designation as a Comprehensive Stroke Center by the Agency for Healthcare Administration, making TMH the only Comprehensive Stroke Center in the region. TMH has received the American Stroke Association “Get with the Guidelines” Gold Plus recognition for stroke care, and we are proud to be the only hospital within hundreds of miles with the Comprehensive Stroke Center designation.
Dr. Lawson and his partner, Dr. Oliver, are the only board-certified neurosurgeons in the region with advanced certification in endovascular neurosurgery (CAST certification). They treat nearly 100 brain aneurysms per year, perform cutting edge thrombectomy procedures for the treatment of acute stroke, and countless other cerebrovascular procedures.
Together, TMH and Tallahassee Neurological Clinic are setting the standard for stroke and cerebrovascular care in Florida’s panhandle, south Alabama, and south Georgia.
Dr. Lawson presented a lecture on treatment of Acute Stroke and the MR CLEAN trial results at the TMH Cardiovascular Symposium. The second annual conference of its kind included over 100 medical attendees.
Dr. Lawson presented a lecture on treatment of Acute Stroke at the TMH Cardiovascular Symposium. This conference, the first of its kind in Tallahassee, included over 70 medical attendees.
In September of 2012 Tallahassee Memorial Hospital opened a state-of-the-art facility for performing complex neuro-endovascular procedures. One year later, 167 cases have been performed, dramatically improving the quality and availability of cerebrovascular care in the region.
Since the opening of this facility, we have successfully treated the following conditions:
Acute Stroke
Ruptured Brain Aneurysms
Unruptured Brain Aneurysms
Arteriovenous Malformations
Carotid Stenosis
Idiopathic Intracranial Hypertension
Dr. Lawson presented a lecture on treatment of Acute Stroke at the TMH Cardiovascular Symposium. This conference, the first of its kind in Tallahassee, included over 70 medical attendees.