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.
Fig. 1. CT Angiogram showing a large 1.1 cm aneurysm (yellow arrow), which explains this patient’s subarachnoid hemorrhage (not shown).Fig. 2. Diagnostic cerebral angiogram showing the right vertebral artery and basilar circulation. The large aneurysm is at the origin of the PICA vessel.
Aneurysm coiling is a minimally invasive technique for treating a brain aneurysm, where the entire procedure is performed from inside the blood vessel (an endovascular procedure). This is in contrast to the other method of treating brain aneurysm, surgical clipping. Traditionally, brain aneurysms were treated with open surgery, called clipping, where a small metal clip was placed at the neck of an aneurysm to prevent bleeding. Clipping has been the standard treatment of aneurysms since the 1960’s, and the procedure is highly invasive. Clipping involves making an incision on the scalp, removing part of the skull (a craniotomy), and then placing a clip at the base of the aneurysm.
In the 1990’s coiling was developed as a minimally invasive technique to treat brain aneurysms, and it was the first viable alternative to clipping surgery. Coiling “fixes” a brain aneurysm from inside the blood vessel, using long catheters and devices that are navigated to a brain aneurysm from a blood vessel in the patient’s leg. In much the same way that cardiologists treat heart disease with “heart catheterization” the endovascular neurosurgeon treats brain aneurysms with catheterization based endovascular procedures, or coiling.
At TMH we treat both ruptured brain aneurysms (see my post on
Fig. 3. Unsubtracted angiogram during balloon-assisted coil embolization of the ruptured PICA aneurysm. The blue line denotes the location of the parent vertebral artery as well as the small PICA blood vessel and the aneurysm. Coils can be seen in the aneurysm. The yellow line denotes the location of a balloon catheter that is helping to hold the coils in the aneurysm and protect the parent vertebral artery.
Subarachnoid Hemorrhage) as well as unruptured aneurysms. Patients who have a ruptured aneurysm have subarachnoid hemorrhage, and they are often critically ill and in the intensive care unit. Many patients who undergo coiling have unruptured aneurysms, or aneurysms that have not bled. The goal for these patients is to reduce or eliminate the risk of bleeding from the aneurysm in the future by treating high risk aneurysms with coiling.
The goal of coiling is to fill the aneurysm with platinum coils, or small devices that cause blood within the aneurysm to clot. This eliminates blood flow in the aneurysm and prevents future bleeding.
Most coiling procedures are done with the patient under general anesthesia using a biplane fluoroscopy unit. This specialized x-ray equipment is very similar to that seen in a cardiac cath lab, but it has additional features for cerebrovascular interventions.
The first step in any coiling procedure is to perform a diagnostic angiogram. This involves taking high resolution images of the blood vessels of the brain, to identify and understand the anatomy of an aneurysm. Next, a guide catheter is navigated from the femoral artery in the leg, up the aorta, and into one of the major blood vessels supplying the brain. The guide catheter is usually positioned in one of the carotid or vertebral arteries.
Fig. 4. Final result after balloon-assisted coiling with excellent embolization of the aneurysm.
After placing the guide catheter, a microcatheter is navigated within the guide catheter and then up into the blood vessels of the brain over a very small wire. This microcatheter is then carefully advanced into the aneurysm. Next, coils are placed within the aneurysm through the microcatheter. Once the aneurysm is treated, the catheters are removed and the patient is awakened.
Fig. 5a. Right middle cerebral artery aneurysm before stent-assisted coil embolization.Fig. 5b. Right middle cerebral artery aneurysm at 6-month follow up after stent-assisted coiling with an investigational stent. There is excellent occlusion of the aneurysm.
There have been numerous advances in coiling technology over the last 10-15 years. The pace of innovation in endovascular neurosurgery is astounding, as many of the devices on the market just 10 years ago are obsolete. At TMH, we are fortunate to be able to participate in advanced device trials, helping evaluate the next generation of medical devices. Drs. Lawson and Oliver perform traditional coiling as well as advanced stent-assisted coiling, balloon-assisted coiling, and embolization using flow diversion devices.
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.
