Neurovascular Diseases and Strokeat the University of Michigan

Collaborative Care for Neurovascular DiseasesAt the University of Michigan, neurovascular services are comprised of a comprehensive team of stroke and neurovascular specialists. It is due to this team of neurologists, neurosurgeons, neurointerventional radiologists, emergency medicine physicians, physiatrists, nurse practitioners, physical and occupational therapists, speech and language pathologists and nurses and their quality of care for patients that the Joint Commission has awarded us the distinction of Comprehensive Stroke Center.

This collaborative team also allows us to treat the complete spectrum of neurovascular diseases in both adults and children, and regularly partner with other clinical areas when needed. We provide comprehensive care for any patient with these pathologies:

• Brain aneurysm

• Adult and pediatric brain and spine arteriovenous malformations (AVMs)

• Adult and pediatric brain and spine arteriovenous fistulae (AFVs)

• Ischemic stroke and transient ischemic attack

• Carotid blowout syndrome

• Carotid stent/placement/endarterectomy

• Epistaxis

• Head, neck and face vascular malformations

• Hemorrhagic stroke

• Hypervascular head and neck tumor embolization

• Intra-arterial chemotherapy for orbital tumors

• Meningioma pre-surgical embolization

As our knowledge base in specific body organ systems continues to advance, it is physically impossible for isolated physician groups to stay at the cutting edge of all aspects of disease in these organ systems on their own. Treatment of

Healing the Brain

2 | Neurovascular Diseases and Stroke at the University of Michigan

Figure 1: Left internal carotid angiogram shows occlusion of the left middle cerebral artery.

Figure 2: Left internal carotid angiogram after thrombectomy with stent retriever shows a widely patent left middle cerebral artery.

Figure 1 Figure 2

diseases of the nervous system, in particular neurovascular diseases, has enjoyed tremendous advances in understanding and technology in the last couple of decades. Our subspecialty experts work together to understand diseases at the molecular level and to develop technology to improve treatment. We believe that bringing all of our endeavors under the neurosciences umbrella is ideal for the best patient outcomes.

Endovascular and Surgical Treatment of Neurovascular DiseasesSince 1998, the Neurovascular Program has continued to grow and has become one of a select few of its kind in the country that offers both endovascular and surgical treatment for patients. Our neurovascular team includes two neurosurgeons dually trained in neuro endovascular surgery and open cerebrovascular surgery, and two neurointerventional radiologists uniquely trained in interventional neuroradiology and endovascular neurosurgery. Our neurointerventional suite with an integrated CT scanner and biplane fluoroscopy is the first of its kind in the nation and makes it possible for our team of radiologists, neurosurgeons and other specialists to work closely together to detect and repair brain aneurysms, AVMs, cavernous malformations (CVMs), AVFs, carotid stenosis, and other neurovascular conditions. Complex patient cases are presented at a weekly multidisciplinary conference where clinical issues and plans for treatment are reviewed by a panel of experts that ensures patients receive the optimal treatment.

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“I am proud and honored to be part of a team, one of a few in

the world, which offers a breadth of treatment options and

depth of experience for neurovascular diseases such as

brain aneurysms and stroke. ”

B. Gregory Thompson, MDProfessor, Department of Neurosurgery;Professor, Department of Radiology

4 | Neurovascular Diseases and Stroke at the University of Michigan

CoilsOur team has extensive experience in placing endovascular coils for aneurysm repair, reducing the chance of rupture. In some cases, stents or balloons are inserted in conjunction with a coil to hold it in place.

Intra-Arterial Chemotherapy In the past couple of years, our neurointerventional radiologists have treated orbital tumors, with intra-arterial chemotherapy for both adult and pediatric patients. This procedure is performed in conjunction with ophthalmology and pediatric oncology departments. This therapy provision here at U-M is the first of its kind in the state of Michigan.

Onyx Liquid EmbolicLiquid embolic agent is typically used for AVM embolization where arterial feeders are occluded/blocked to cut off blood supply. This prevents the risk of hemorrhage from these AVMs.

Pipeline™ StentFlow diverter stents like Pipeline enable treatment of aneurysm by parent vessel restoration without the need for coil embolization. U-M is one of the few programs in the region to offer this type of stent.

Stereotactic RadiosurgeryThis procedure along with endovascular embolization and microsurgical excission is an effective treatment for AVM.

Surgical ClippingIf an aneurysm cannot be repaired with an endovascular procedure, surgeons can perform a craniotomy and place a metal clip across the base of the aneurysm.

Our team has also pioneered new techniques for vessel reconstruction on unclippable aneurysms.

Carotid Stent Placement / EndarterectomyCurrent evidence suggests equivalence of both modalities in the treatment of carotid atherosclerotic disease. Surgical removal of carotid plaque and stent placement.

Patients with symptomatic carotid stenosis, who are at increased risk of stroke, are evaluated individually to determine if carotid stenting, carotid endarterectomy or medical treatment is most appropriate.

“Some neurovascular diseases that we

treat are very rare — like spinal dural fistula

and carotid cavernous fistula. Here at U-M,

we have the expertise and the resources

necessary to tackle and comprehensively

care for patients with these diseases. Being a

referral center for these conditions, we have

developed a substantial volume of experience

over the past 10 years in treating them. As

a consequence, we believe that these rare

conditions have become relatively common

for our expert group of physicians.”

Neeraj Chaudhary, MD, MRCS, FRCRAssistant Professor, Department of Radiology;Assistant Professor, Department of Neurosurgery

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Neurovascular Diseases ResearchThe Neurovascular Program team participates in and often leads cutting-edge research for neurovascular diseases. We are dedicated to bringing the latest in research, diagnosis and treatment to patients with these diseases, and are continuously working to offer the least invasive options that yield the best outcomes.

Our main research focus is to increase our understanding of brain aneurysm formation and healing. We have a basic science laboratory fully equipped with various neurovascular animal models along with sophisticated imaging capabilities. This enables us to perform bench research that could be translated to human subjects.

Other research areas of interest for our team include:

• Cerebral vasospasm—translating findings from basic science to bedside.

• Spinal cord vascular malformations and their natural history.

• Head and neck tumors—presurgical embolization (adults mainly; no equivalent in pediatric population), including carotid body tumor, paragangliomas, and juvenile nasal angiofibroma (JNA).

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About

600 endovascular procedures are performed at U-M every year.

Approximately

50% are diagnostic cerebral angiograms (including both adult and pediatric patients)

Approximately

300 are interventional procedures

Our team treats approximately 300 aneurysm patients each year—the most aneurysm cases in the state, and one of the reasons why our program is a top referral center nationwide.

The American Association of Neurological Surgeons estimates that every year 30,000 people in the United States experience a ruptured cerebral aneurysm, and up to six percent of the population may be living with an unruptured aneurysm.

AP left vertebral angiogram shows a large right P2 segment aneurysm.

6 | Neurovascular Diseases and Stroke at the University of Michigan

Voice for Many

An estimated 30,000 people in the United States experience a ruptured cerebral aneurysm every year, and up to six percent of the population may be living with an unruptured aneurysm. Survivors describe the rupture as the worst headache you can imagine. Sudden in onset, it is often followed by vomiting, unconsciousness, and in some cases, disability or death.

Last October, Donna Poole was on her way to see a neurologist referred to her by her primary care physician because of some unusual symptoms she had been experiencing after surviving a stroke three years earlier. At that appointment Donna learned that she had a brain aneurysm. By November, she was meeting with University of Michigan neurosurgeon Gregory Thompson, M.D.

Dr. Thompson explained that sometimes he recommends a wait and see approach with aneurysms, but not in Donna’s case. Due to the wide neck of her aneurysm and its location, he determined that a right-sided supraorbital craniotomy for aneurysm clipping would be the best course of treatment.

Donna’s surgery took place in February. Her aneurysm was so close to rupturing during the procedure that Dr. Thompson and his team decided to use a temporary clip before placing three permanent clips to deprive the aneurysm of its blood supply. Donna was home just 48 hours later, taking on the role of aneurysm survivor and advocate with gusto ever since.

“Unlike many aneurysm survivors I do not have serious handicaps, but I am not exactly as I was before. They tell me that it takes 18 months for complete healing, so I fully expect to make more progress.

“I am a voice. I speak for those whose lives ended with a ruptured aneurysm. I speak for those who lived but can no longer talk, read, write, walk, or see. I speak for caregivers too weary to talk in any language but tears.

“I am grateful to the skilled doctors and nurses, especially Dr. Thompson, my gifted and gracious surgeon, and to my husband, children, church and online support family—868 members and growing! Most of all I am happy to be alive. I celebrate love and laughter every day. My aneurysm was, in many ways, a gift to me. It reminded me, in a way I will never forget, that life is too short for anything but love.”

Donna Poole and her granddaughter

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Comprehensive Critical and Preventive Stroke Care

Stroke Program At the University of Michigan, the Stroke Program is recognized by the Joint Commission as a Comprehensive Stroke Center and includes a specially trained multidisciplinary team of experts that collaborates care for patients who are at risk for stroke or have had a stroke in the past. Our team includes faculty from emergency medicine, neurology, neurosurgery and neurointerventional radiology, along with vascular surgeons, cardiologists, internists and physiatrists. We work with patients throughout their hospital stay and outpatient clinic follow-up visits.

In-Patient Stroke Care In our state-of-the-art Stroke Unit and 15-bed Neuro-ICU, patients receive care by specially trained neuroscience nurses, in addition to vascular neurologists, neurointensivists and neurosurgeons. Physical therapists, occupational therapists, and speech language pathologists are available to start a patient’s rehabilitation process seven days a week. While stroke patients are in the hospital, providers work together to determine the cause of the stroke, start the rehabilitation process, and develop a plan to prevent future strokes.

Stroke Clinic The stroke clinic is located within the Samuel and Jean Frankel Cardiovascular Center, which allows our team to collaborate with cardiologists, neurosurgeons, neuroradiologists and vascular surgeons most efficiently. Together we take the latest scientific data and develop an individualized stroke prevention plan for each patient. This may range from lifestyle changes to surgical treatment in order to decrease stroke risk.

“I enjoy working at UMHS because I can work with a

comprehensive multidisciplinary team that cares for stroke

patients. From nurses to therapists to physicians, we are

all dedicated to helping patients and their families achieve

the best possible outcomes. We have the knowledge and

resources to treat the most complex stroke patients.”

Eric Adelman, MDAssistant Professor, Department of Neurology

8 | Neurovascular Diseases and Stroke at the University of Michigan

Stroke ResearchAs a regional and national referral center for stroke care, our providers participate in various research projects relating to stroke recognition, education, treatment and epidemiology. Through these projects, patients have access to research studies that allow them to receive cutting-edge care.

Some of our research efforts include:

• SHINE – evaluating glucose control after acute stroke

• Therapy – exploring what is the best way to treat acute stroke: IV tPA or IV tPA plus IA treatment

• WILMA – attempting to reduce stroke disparities in older women using medical alert devices

• Post-stroke depression – studying the psycho-social effects of stroke in patients

• Brain Attack Surveillance in Corpus Christi (BASIC) Project – analyzing the biological and social risk factors for stroke among Mexican Americans

• SHARE – preventing stroke by encouraging healthy habits in Corpus Christi, Texas in partnership with the Catholic Church

• PRAISE – encouraging people to call 911 when they develop stroke symptoms. This intervention is being done in churches in Flint, MI

• MISTIE III – evaluation of minimally invasive mechanism of evacuation intracerebral hemorrhage (catheter placed within clot with administration of tPA into clot)

• FEAT – utilization of 18 framing coils in the prevention of recurrence of coiled cerebral aneurysms

• HEAT – utilization of hydrocoils in the prevention of recurrence of coiled aneurysm

Lateral right internal carotid angiogram shows a large AVM within the right parietal lobe.

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Our highly trained teams of faculty, nurses and support staff specialize in the care of patients with neurovascular diseases and stroke.

Our FacultyNeurology Faculty

Eric Adelman, MDAssistant Professor, Neurology

Lewis Morgenstern, MDProfessor, Neurology

Darin Zahuranec, MDAssistant Professor, Neurology

Lesli Skolarus, MD Assistant Professor, Neurology

Michael Wang, MD, PhDAssociate Professor, Neurology

Devin Brown, MDAssociate Professor, Neurology

James Burke, MDAssistant Professor, Neurology

10 | Neurovascular Diseases and Stroke at the University of Michigan

Neurosurgery Faculty Neurointerventional Radiology Faculty

Neurointensivists

Aditya Pandey, MDAssistant Professor, Neurosurgery;Assistant Professor, Radiology

Neeraj Chaudhary, MD, MRCS, FRCRAssistant Professor, Radiology; Assistant Professor, Neurosurgery

Teresa Jacobs, MDAssociate Professor, Neurosurgery and Neurology

B. Gregory Thompson, MDProfessor, Neurosurgery; Professor, Radiology

Joseph Gemmete, MDAssociate Professor, Radiology; Associate Professor, Neurosurgery

Venkatakrishna Rajajee, MBBSAssociate Professor, Neurosurgery and Neurology

Kyle Sheehan, MDClinical Lecturer, Neurosurgery

“It is an honor to take care of individuals, and when referring physicians

give us this opportunity we treat it as a privilege. Collaborative

efforts allow us to provide the latest technologies and techniques in

managing our patients.”

Aditya S. Pandey, MDAssistant Professor, Department of Neurosurgery;Assistant Professor, Department of Radiology

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Emergency Medicine FacultyOur specialists who respond to acute stroke calls in the emergency room and in the hospital

If you would like to consult with a member of the Neurovascular Diseases or Stroke teams, or refer a patient directly, please contact M-LINE 24 hours a day, seven days a week.

M-LINE (800) 962-3555

NEUROVASCULAR DISEASES

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STROKE

UofMHealth.org/stroke

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Executive Officers of the University of Michigan Health System:Michael M.E. Johns, M.D., Interim Executive Vice President for Medical Affairs; James O. Woolliscroft, M.D., Dean, U-M Medical School; T. Anthony Denton, J.D., MHA, Interim Chief Executive Officer, U-M Hospitals and Health Centers; Kathleen Potempa, Ph.D., Dean, School of Nursing. The Regents of the University of Michigan: Mark J. Bernstein, Julia Donovan Darlow, Laurence B. Deitch, Shauna Ryder Diggs, Denise Ilitch, Andrea Fischer Newman, Andrew C. Richner, Katherine E. White, Mark S. Schlissel, M.D., Ph.D. (ex officio). The University of Michigan, as an equal opportunity/affirmative action employer, complies with all applicable federal and state laws regarding nondiscrimination and affirmative action. The University of Michigan is committed to a policy of equal opportunity for all persons and does not discriminate on the basis of race, color, national origin, age, marital status, sex, sexual orientation, gender identity, gender expression, disability, religion, height, weight, or veteran status in employment, educational programs and activities, and admissions. Inquiries or complaints may be addressed to the Senior Director for Institutional Equity, and Title IX/Section 504/ADA Coordinator, Office of Institutional Equity, 2072 Administrative Services Building, Ann Arbor, Michigan 48109-1432, 734-763-0235, TTY 734-647-1388. For other University of Michigan information call 734-764-1817. © 2014, The Regents of the University of Michigan.

RBD11319184

William Meurer, MD Assistant Professor, Emergency Medicine

William Barsan, MDProfessor, Emergency Medicine

Phillip Scott, MDAssociate Professor, Emergency Medicine

Robert Silbergleit, MDAssociate Professor, Emergency Medicine

Neurovascular DiseasesTaubman Health Care Center1500 E. Medical Center DriveAnn Arbor, MI 48109

StrokeFrankel Cardiovascular Center 1500 E. Medical Center Drive Ann Arbor, MI 48109

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“Multidisciplinary collaboration is at the core of the care we provide our patients here at the University of Michigan. We have the latest imaging equipment and endovascular devices available to optimize patient outcomes.”

Joseph Gemmete, MDAssociate Professor, Department of Radiology;Associate Professor, Department of Neurosurgery