Duke Cerebrovascular Center offers specialized care and an unmatched range of treatments.

By Jeni Baker

Jennifer Tolan awoke the morning of May 6, 2008, to discover that the severe headache she’d had for several days was accompanied by frightening new symptoms. When she nearly dropped her newborn son, she knew something was terribly wrong.

The then-25-year-old mother of three was so weak on her left side that she couldn’t stand up. She wondered if she was having a migraine; a relative dialed 911. By the time Tolan arrived at nearby Beaufort County Hospital, she was completely paralyzed on her left side. A computed tomography (CT) scan revealed what appeared to be an intercranial occlusion, a blood clot in the brain.

“The doctor said that I was possibly having a stroke, and that I might need brain surgery,” recalls Tolan, of Washington, North Carolina “She said, ‘We've got to get you to Duke.’”

Easier said than done; Duke Life Flight helicopters were grounded due to severe weather. But coordination among Duke, Beaufort County, and Life Flight transfer center staff -- as well as a highway patrol escort -- made the 127-mile trip in a Life Flight ambulance happen within the critical time period for suspected stroke patients.

A MERCIful Intervention

When she arrived at Duke University Hospital, an angiogram confirmed Tolan’s intercranial occlusion, as well as a tear in her carotid artery.

“The dissection in Ms. Tolan’s carotid artery had developed a blood clot that traveled to her brain,” explains neurovascular surgeon Ali Zomorodi, MD. “The artery needed to be opened up, and because that must happen within eight hours of the onset of weakness, it was literally a race against the clock.”

Using the state-of-the-art MERCI (Mechanical Embolus Removal in Cerebral Ischemia) Retrieval System -- FDA-approved for treating ischemic strokes -- Zomorodi and Tony P. Smith, MD, director of Duke’s Divisions of Vascular/Interventional Radiology and Neurointerventional Radiology, performed a complex endovascular angioplasty procedure offered at few centers in the country.

In a nearly four-hour minimally invasive surgery, the surgeons threaded a microcatheter from Tolan’s groin to her brain. A balloon on the catheter pushed back the torn flap of the carotid artery, while a “corkscrew” on the catheter’s tip enabled them to grasp and remove the clot. A permanently placed stent will keep the artery flap pushed back to prevent future concerns.

“The manufacturer recently told us that Duke is the first center in the region successfully using MERCI with patients,” Zomorodi says. Tolan’s experience is unquestionably a success story.

“They said I could have died or been permanently paralyzed or brain dead, but I was walking about three days after my stroke, and got to go home about a week later,” she says. “I couldn’t have asked for a better place or nicer people -- and they didn’t even have to cut my hair!”

Pioneering Treatments for the Full Range of Neurovascular Conditions

The MERCI procedure is among many sophisticated therapies and services offered by Duke’s leading-edge Cerebrovascular Center. A component of the Division of Neurosurgery, the center is unique in that it treats patients suffering from the entire spectrum of cerebrovascular conditions -- those that affect the blood vessels in the brain and spinal cord. It is also among the country’s only programs to expertly treat patients with both microsurgical and minimally invasive endovascular procedures, as well as with radiosurgery.

“The Duke Cerebrovascular Center treats a large number of patients with cerebrovascular diseases, and as with all surgical procedures, the more you perform, the better the patient outcomes,” says director Gavin W. Britz, MD, MPH. FACS.

“This center offers treatment options that range from relatively simple procedures such as aneurysm clippings and coilings, embolizations, and microsurgical resection of AVMs to complicated procedures such as cerebral bypasses and cardiac stand-still surgeries for complicated aneurysms. Our team is simply outstanding.”

That team includes four neurosurgeons, two interventional neuroradiologists, one radiation oncologist, four neurologists, four anesthesiologists, and specially trained nursing staff.

The Cerebrovascular Center also delivers state-of-the-art interventions that include:

• Microsurgical clipping of aneurysms

• Endovascular coiling of aneurysms, including balloon remodeling and stent-assisted
• Embolization and microsurgical and radiosurgical treatment of arteriovenous malformations
• Angioplasty and stenting of intracranial stenosis for stroke prevention
• Cerebral bypasses for aneurysms and ischemia

Faculty members are engaged in a number of research initiatives as well, including basic-science studies of the mechanisms behind poor outcomes after aneurysm ruptures to outcomes studies of the latest endovascular devices used to treat cerebrovascular diseases.

“Research forms the basis of the program and provides the platform that will improve the outcome of these diseases in the future,” says Britz.

“Our efforts to build and maintain an absolutely first-tier program are ongoing,” Britz continues. “Our team of experts provides highly personalized care, and we are equipped to do whatever our patients need and prefer -- and do it at the highest skill level.”

The Cerebrovascular Center sees approximately 3,000 patients annually -- cerebral aneurysms alone make up 200-300 cases a year; strokes and transient ischemic attacks (TIAs or “mini strokes”) comprise another 200 -- and Britz says the need is great for its highly specialized services.

The Cerebrovascular Center also treats conditions that include:

• Dural fistulas
• Carotid and cerebral artery stenoses
• Cerebral, cavernous, and spinal arteriovenous malformations
• Arterial dissections 
• Moyamoya disease
• Intracranial atherosclerotic disease (ICAD), a condition responsible for 8-10 percent of ischemic strokes occurring in the United States each year

“Our practice is for patients who might benefit from a broad range of specialized, highly advanced neurosurgical services,” Britz says. “We are committed to providing patients with the state-of-the-art resources and treatment options that will lead to their best possible outcomes.”

Patient Tolan is a perfect example. “She continues to do very well neurologically and strength-wise, and her prognosis is excellent,” says Zomorodi. “Because so many Duke resources came together to help this patient, her outcome has been a resounding success.”

For more information, physicians should call 1-800-MED-DUKE (633-3853). Patients and consumers should call 1-919-668-0650.