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6.17.2016

UM Neurologists and Neurointerventionalists Revolutionize Standard of Care for Acute Ischemic Stroke

More than 750,000 stroke cases occur in the United States every year, making it the fifth-leading cause of death and the leading cause of adult disability. Moreover, 85 percent of strokes are ischemic, occurring when the arteries to the brain become narrowed or blocked, causing severely reduced blood flow.

When treating a patient experiencing an acute ischemic stroke, time is the enemy. The University of Miami Miller School of Medicine’s Department of Neurology has one of the largest stroke centers in the country, and its physicians, part of UHealth – the University of Miami Health System, were among the first to introduce a rapid new procedure known as mechanical thrombectomy — a catheter-based system that uses a stent-like device to capture and remove the blockage — in South Florida. If the procedure is performed within six hours of the stroke’s onset, in combination with conventional intravenous clot-busting medication, symptoms are reversed in 60 to 70 percent of patients. The speed of response to the procedure is sometimes so dramatic that the patient shows immediate improvement in their motor paralysis or other stroke symptoms.

Two UHealth neurologists — Dileep Yavagal, M.D., associate professor of clinical neurology and neurological surgery, and chief of interventional neurology, and Ralph Sacco, M.D., M.S., professor and Chair of the Department of Neurology, and Olemberg Family Chair in Neurological Disorders — and Priyank Khandelwal, M.D., a former stroke fellow, now an interventional neurology fellow at Brigham & Women’s Hospital in Boston, published an article this month in the Journal of the American College of Cardiology that discussed the evolution of the procedure and the latest findings.

It was a year ago that Yavagal and coauthors from other stroke centers around the world published a seminal article in The New England Journal of Medicine that described the dramatic results obtained in large clinical studies of the combination treatment. Since then, designated Comprehensive Stroke Treatment Centers certified by The Joint Commission have begun employing this new approach. In addition to the 1,000 full-time neurointerventionalists in the U.S., more are being trained to use mechanical thrombectomy. Emergency medical services nationwide are also being trained to recognize stroke in the field and avoid delays in transport to certified stroke centers, since they are often first on the scene when a stroke occurs.

“The neuroendovascular and stroke teams at UHealth have led South Florida and the U.S. in bringing a revolutionary new disability-reducing standard of care for patients affected by acute strokes,” said Yavagal. “In addition to our research, our education efforts in the community and with emergency medical services have resulted in increased access for stroke patients to mechanical thrombectomy — a tripling of the number of acute stroke patients treated with the procedure, with or without clot-busting medication, at UHealth over the last year.”

The UHealth stroke neurology service has 10 faculty, and the neuroendovascular team includes Eric C. Peterson, M.D., assistant professor of clinical neurosurgery and Director of Neuroendovascular Surgery, and Yavagal, along with fellows, residents, nurses, technologists and stroke coordinators.

“There is considerable crossover between cardiology and neurology,” said Sacco. “Heart attacks and strokes share some of the same risk factors that can lead to blockages of arteries, as well as treatments that can prevent these conditions. Now treatments that have been used extensively to open up cardiac arteries, such as clot busters and stent catheters, are also advancing for acute stroke.”

Mauricio G. Cohen, M.D., associate professor of medicine and Director of the Cardiac Catheterization Laboratory, is especially interested in how the findings will affect heart patients.

“We traveled this same journey years ago, when we established interventional therapies — such as stents, which involve unclogging a blood vessel — as the standard for the care of patients with heart attacks,” he said. “We are now doing the same with strokes. At University of Miami Hospital, interventional neurologists and cardiologists work together and learn from each other. We may even start using stent retrievers in the heart. Patients can only win from this collaborative environment.”

Jose G. Romano, M.D., professor of clinical neurology, Chief of the Stroke Division and Medical Director of the Jackson Memorial Hospital Comprehensive Stroke Program, added: “The past decades have seen tremendous improvements in the understanding of the causes of stroke, its prevention and treatment. Just last year, six clinical trials demonstrated the usefulness of catheter-based approaches to restore blood flow to the brain in selected individuals. It is clear that having a multi-disciplinary team available at stroke centers is needed to adequately diagnose and select patients for these innovative and highly effective interventions.”

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