Making Strides in the Treatment of Hemorrhagic Stroke

Comprehensive Stroke Center Facts

  • The Joint Commission and the American Heart Association/American Stroke Association certified NewYork-Presbyterian as a Comprehensive Stroke Center in June 2016.
  • Awarded for a two-year period, the recognition shines a light on the long-term experience and highly specialized expertise of NewYork-Presbyterian’s stroke teams.
  • In addition to recently launching the first mobile stroke treatment unit on the East Coast, NewYork-Presbyterian, has neurointensive care units, 24/7 neurosurgical and endovascular care, advanced imaging, and treatment capabilities for patients with ischemic and hemorrhagic stroke.
  • NewYork-Presbyterian physicians continue to be at the forefront of treatment and technology used in the care of patients with hemorrhagic stroke caused by bleeding aneurysms and arteriovenous malformations (AVMs), with outcomes among the best in the country.

"Our Neuro ICU was one of the first of its kind in the country to provide neurosurgical and neurological expertise for the sickest of patients. We work incredibly close with neurosurgery, neurology, and interventional radiology. A lot of the care that we provide is aimed at minimizing secondary worsenings. If you can imagine a patient in a coma, there might be a storm going on in their brain, but you don’t see it. We want to detect any changes as soon as possible."

— Jan Claassen, MD, Ph.D.
Medical Director of the Neurological ICU and Director of Critical Care Neurology at NewYork-Presbyterian/Columbia

The physicians who comprise NewYork-Presbyterian’s stroke teams agree that collaborations among neurosurgeons, neurologists, neurointerventionalists, neurointensivists, and neuroradiologists are a key factor in the successful outcomes achieved in their patients with stroke.

“NewYork-Presbyterian has a large group of physicians specializing in stroke who see each other every day, consult with each other, and share information, all of which is extremely beneficial to our patients,” says Robert A. Solomon, MD. A pioneer in the treatment of cerebral aneurysms, 2017 marked Dr. Solomon’s 20th anniversary as Neurosurgeon-in-Chief at NewYork-Presbyterian/Columbia University Medical Center. “Whether it’s intensive care or endovascular treatment, stereotactic radiosurgery or open micro-neurosurgery, we can provide the highest quality stroke care.”

“Close, collaborative working relationships among the hospital’s neurosurgeons, neurologists, and neuro-related specialists are the norm at each of the hospital’s campuses — not only for stroke but also for all neurological disorders and injuries,” emphasizes Matthew E. Fink, MD, Neurologist-in-Chief, NewYork-Presbyterian/Weill Cornell Medical Center. “We trust each other, and we are willing to listen and defer to each other. This results in a quality of care that is virtually without peer.”

“It is important to distinguish between an ischemic stroke that turns hemorrhagic versus a hemorrhage or a hematoma in the brain,” says Randolph S. Marshall, MD, MS, Chief of the Stroke Division, NewYork-Presbyterian/Columbia. “They have overlapping pathophysiology, but the management can be different depending on the type of hemorrhagic stroke. The common thread is hypertension. However, the key for hemorrhagic stroke is to find out if there is some other cause. In younger people, or those without a history of hypertension, you have to do additional testing to see what might be the cause of bleeding, and in particular, to rule out an underlying arteriovenous malformation.”

New Directions in Surgical and Endovascular Techniques

NewYork-Presbyterian neurosurgeons, endovascular surgeons, and neurologists led by internationally renowned leaders in these fields are pursuing the development and evaluation of new techniques, devices, and technology to treat complex hemorrhagic stroke. “Developments in surgical and endovascular approaches are providing great potential for improving recovery of patients with hemorrhagic stroke,” says Philip E. Stieg, PhD, MD, Neurosurgeon-in-Chief at NewYork-Presbyterian/Weill Cornell, who edited the definitive textbook on AVMs, Intracranial Arteriovenous Malformations.

“Advances in surgical treatment involve more minimally invasive approaches with less retraction on the brain so that we can prevent any secondary injuries,” says Dr. Stieg. “New clip configurations – smaller clips and mini clips – increase the diversity of aneurysm types that we can clip. For patients who develop severe brain swelling and herniation after removal of a clot, we can perform a hemicraniectomy to allow the swelling to move outward rather than inward. This buys us time. The portion of the skull that is removed is reconstructed with a plastic prosthesis using advanced 3D remodeling techniques based on an individual’s CT scan. Once the brain swelling is reduced, we replace the removed section.”

NewYork-Presbyterian’s multidisciplinary stroke teams encompass expertise in surgical, endovascular, and radiosurgical techniques for the treatment of AVMs. “Together we craft a personalized approach and develop the best plan for repair for each patient – one that offers the lowest risk and the highest benefit we can achieve,” says E. Sander Connolly, Jr., MD, Surgical Director of the Neurointensive Care Unit at NewYork-Presbyterian/Columbia. “A patient may require a bypass, a stent, coiling, or clipping, but what’s really important to know is that whatever treatment is decided, it will be performed by a super subspecialist.”

However, Dr. Connolly is quick to note that team members are very conservative in their approach to minimally symptomatic lesions — whether related to an unruptured aneurysm or unruptured AVM. “Sometimes patients feel that when they are referred to a large academic medical center for care, they will automatically hear, ‘You need an operation.’ However, that couldn’t be further from the truth. I would say that 10 percent or less of the patients referred to us for these minimally symptomatic lesions will be recommended for an invasive therapy. Most patients will only need to be followed.”

Ruptured aneurysms are increasingly being treated endovascularly with either coils or stents. Endovascular surgeons at Columbia University Medical Center and Weill Cornell Medicine are lead investigators in trials of a new stent and delivery system that may provide a mechanism to treat wide-necked intracranial aneurysms with coils and reduce the chance of rupture. The LVIS HUD is a stent mesh tube placed across the neck of the aneurysm and intended to remodel the blood vessel and provide support for the coils placed inside the aneurysm. The purpose is to close off the aneurysm neck and lower the chance of rupture.

NewYork-Presbyterian's neurosurgeons and neurologists are also participating in the international MISTIE III trial, which is focused on intracerebral hemorrhage for which there is currently no effective treatment. MISTIE is a series of clinical trials evaluating approaches to remove an intracerebral hemorrhage from the brain quickly. The MISTIE III trial is investigating the treatment of intracerebral hemorrhage with minimally invasive surgery and intermittent dosing of the clot-busting drug alteplase, a recombinant tissue plasminogen activator (rtPA). The study premise is that by removing the blood clot faster, injury to the brain will be reduced and the patient’s long-term prognosis will improve.

“This trial is evaluating a minimally invasive surgical technique involving stereotactic placement of a catheter — instilled with the thrombolytic drug — directly into an intracerebral hemorrhage to aspirate the congealed blood clot,” says Dana Leifer, MD, Director of the Stroke and Neuroscience Step-Down Unit at NewYork-Presbyterian/Weill Cornell. “This may seem somewhat paradoxical because tPA is a drug that dissolves blood clots. But when administered after the bleeding has stopped and when the hemorrhage is very thick and has a jelly-like consistency, the tPA dissolves the clot so that the blood drains out through the catheter. The catheter is kept in place for a period of up to three days. Preliminary studies have shown that we can considerably decrease the volume of the hemorrhage with this technique and that it appears to have some potential benefit regarding outcome.”

NewYork-Presbyterian’s interventional neuroradiologists and endovascular neurosurgeons also have extensive experience with flow-diverting stents to treat unruptured large and giant aneurysms at the skull base. “We are always among the first to obtain the newest technology that comes into the constantly evolving field of endovascular neurosurgery,” says Jared Knopman, MD, a neurosurgeon and interventional neuroradiologist at NewYork-Presbyterian/Weill Cornell. “New devices and new techniques are continually being developed, making the field safer and allowing us to do procedures that we could not do years ago.”

Until these devices became available, suitable treatment for these anatomically challenging conditions did not exist. More recently, technological advances and clinical trial results suggest that flow diverters now can be safely and effectively used in treating ruptured aneurysms, posterior circulation aneurysms, and distal anterior circulation aneurysms that are difficult to treat with conventional clipping or coiling.

Dr. Jared Knopman and Dr. Halinder S. Mangat

Dr. Jared Knopman and Dr. Halinder S. Mangat

Philip M. Meyers, MD, and Sean D. Lavine, MD, serve as Clinical Co-Directors of Neuroendovascular Services at NewYork-Presbyterian/Columbia. Dr. Meyers points to institutional experience as key to successful outcomes. “Good outcomes are associated with a large volume of cases, low treatment risk, and highly specialized cerebrovascular experts with a sole focus on the treatment of cerebral aneurysms. All of these elements are present at NewYork-Presbyterian. It’s why our patients do so well and among the reasons leading to the Hospital’s designation as a Comprehensive Stroke Center.”

A radiologist with subspecialty training in interventional neuroradiology and endovascular neurosurgery, Dr. Meyers has for years championed the need for the development of technical standards and clinical guidelines for the field and served as chair of the Society of NeuroInterventional Surgery’s Committee on Guidelines and Standards. More recently, he and Dr. Sander Connolly served as members of the Writing Group commissioned by the American Heart Association/American Stroke Association to develop evidence-based recommendations for the management of patients with unruptured intracranial aneurysms, which were published in Stroke in 2015.

A Focus on Neurointensive Care

“In the past decade, there has been major recognition that care of patients with neurological injury is unique and should be led by specialized teams,” says Halinder S. Mangat, MD, Medical Director of the Neurological Intensive Care Unit at NewYork-Presbyterian/Weill Cornell. Dr. Mangat provides specialized expertise in advanced clinical neurovascular physiology monitoring techniques using invasive devices such as cerebral oximetry and cerebral microdialysis, which measure chemicals released into the brain.

“Scientific evidence shows that patients with neurological injuries have better outcomes when cared for on a dedicated unit,” notes Dr. Mangat. “When patients are unconscious and ventilated, we can perform a number of assessments in addition to EEG monitoring to determine their condition and whether there has been a change in status. If a patient is in a deep coma, we can use more aggressive monitoring that involves placing probes in the brain to look at cerebral blood flow, intracranial pressure, and oxygen levels. Few hospitals have this capability to study brain metabolism in real time.”

Dr. Philip M. Meyers and Dr. Jan Claassen

Dr. Philip M. Meyers and Dr. Jan Claassen

“Our Neuro ICU was one of the first of its kind in the country to provide neurosurgical and neurological expertise for the sickest of patients,” says Jan Claassen, MD, PhD, Medical Director of the Neurological ICU and Director of Critical Care Neurology at NewYork-Presbyterian/Columbia. Dr. Claassen is an internationally recognized expert in neurological intensive care with particular expertise in brain hemorrhages. “We work incredibly close with neurosurgery, neurology, and interventional radiology. A lot of the care that we provide is aimed at minimizing secondary worsenings. If you can imagine a patient in a coma, there might be a storm going on in their brain, but you don’t see it. We want to detect any changes as soon as possible.

“For example,” continues Dr. Claassen, “a hemorrhagic stroke patient with a subarachnoid hemorrhage may develop a vasospasm. You often can’t detect this in a poor grade patient, and it significantly impacts outcome. We have devised several monitoring techniques, non-invasive as well as invasive, to identify this complication in real time to intervene and prevent damage from occurring. We feel it is important for local physicians and local emergency rooms to know that we have a team capable of supporting their complex stroke patients through the more advanced care that NewYork-Presbyterian offers.”

Reference Articles