In a recent two-and-a-half-hour procedure, Thomas J. Grobelny MD, of the medical center’s Neurosciences Institute, led a team in use of the substance to eliminate an aneurysm from the petrous-cavernous carotid artery on the right side of a patient’s head.

Called Onyx(R)HD 500, the glue-like liquid is delivered through a micro-catheter, a thin, tube-like device that has been threaded through a patient’s blood vessels to the site of the aneurysm. The liquid, which hardens upon contact with blood and other body fluids, is used to fill the aneurysm, effectively sealing it off by blocking the flow of blood to it.

The Onyx(R) material is intended for use with large aneurysms or those having wide openings, called “necks.”

Aneurysms form when a weakness in a blood vessel wall causes the vessel to balloon out and form a thin-walled, blood-filled pouch. If this pouch, or sac, develops in a brain blood vessel and bursts, a patient can sustain a devastating, even lethal, stroke as blood floods the brain tissue, said Dr. Grobelny.

Dr. Grobelny is a neurointerventionalist, namely a physician specializing in minimally invasive, endovascular neurosurgery.

The neurointerventional surgery team at Advocate Christ Medical Center has been a regional leader in the application of innovative, minimally invasive treatments for removal of brain aneurysms.

Just last year, the medical center became one of the first Chicago area institutions and only one in the Advocate Health Care system to use a specialized stent — the CORDIS ENTERPRISE(TM) Vascular Reconstruction Device and Delivery System. The advanced tool enables physicians to block off a brain aneurysm that has a wide neck separating it from the main blood vessel and to hold in place wire coils positioned inside the aneurysm. The wire coils facilitate clot formation, thereby stopping blood flow to the aneurysm and reducing the risk of rupture.

Also in 2007, the same team, under Dr. Grobelny’s leadership, achieved another “first” for the south and southwest suburbs and for Advocate Heath Care when it filled a patient’s potentially lethal brain aneurysm with coils that literally swelled up to eight times their original volume. The coils had been coated with a hydrogen polymer, which, in combination with water from surrounding body tissue, caused the coils to swell and fill the aneurysm.

“The highest technological advancements in minimally invasive brain aneurysm surgery are not simply the domain of university-based medical centers. These advancements are important treatment options available at major teaching hospitals like Advocate Christ Medical Center,” Dr. Grobelny stated.

In addition to its expertise in the treatment of brain aneurysms, the Christ Medical Center Neurosciences Institute also is a leader in the treatment of brain vascular malformations and stroke. In fact, last year, the Joint Commission, a national health care accrediting agency, awarded the medical center a two-year certification as a primary stroke center. Certification is given for “exceptional efforts to foster better outcomes for stroke care,” according to the Joint Commission.

Just two weeks after giving birth to a daughter last November, Michelle Larwood suffered a major stroke. One moment, the Los Angeles woman, 38, sat calmly in a doctor’s waiting room. The next, she recalls, “I couldn’t speak, and I couldn’t move my right side.” Neurologists at UCLA’s Stroke Center soon found the cause: a clot blocked the middle cerebral artery feeding the left side of her brain. Watching the blocked vessel on a monitor, an interventional radiologist snaked a tiny catheter tube through a leg artery and into her brain, penetrating the clot. Once he got it past the blockage, the doctor unfurled a tiny corkscrew and gently pulled, much like a sommelier easing a cork from a bottle of vintage merlot. It worked: a week later she was home with her husband and new daughter, Olivia. “I’m just so grateful,” she says.

Since 1996, a clot-busting drug called “tissue plasminogen activator,” or tPA, has been the sole FDA-approved treatment for strokes, and it can work wonders under some conditions. But even today few patients get its benefits. That’s because the intravenous drug is clearly effective only when given within three hours of a stroke’s onset. Even then, tPA can cause dangerous bleeding, so many patients whose strokes were caused by brain hemorrhage–or who had recent operations like Larwood’s caesar-ean section–aren’t eligible at all. As a result, just 3 percent of America’s 700,000 annual stroke victims get the tPA treatment. Stroke kills 170,000 Americans every year, and it’s the leading cause of long-term disability. Fortunately, the outlook is starting to change. Researchers are exploring several new treatments that, if successful, could make comebacks like Larwood’s commonplace.

Until recently no one dreamed of plucking clots from people’s brains, but experts now have high hopes for the technique. “Mechanical clot retrieval is a big step for strokes,” says Dr. Walter Koroshetz, director of acute- stroke service at Massachusetts General Hospital. “It gets away from using dangerous drugs.” The experimental device that helped Larwood was invented by Dr. Pierre Gobin of New York-Presbyterian Hospital. The so-called MERCI retriever (mechanical embolus removal in cerebral ischemia) consists of a nickel-titanium coil that straightens out in the catheter, then springs back to shape to capture the clot (chart). Proponents see several potential advantages. The device can be used up to eight hours after a stroke. It avoids the risk of drug-induced hemorrhage. And whereas tPA can take an hour or more to break down a clot, the device can remove one in minutes. “If you can physically remove something, you are not going to play around with tPA for two hours,” says Dr. Thomas Grobelny of St. Luke’s Hospital in Kansas City, Mo.
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It’s too soon to say how often the technique will work, but early results seem promising. In a multicenter trial with 28 patients, the device cleaned out the clot 46 percent of the time. Concentric Medical, which makes the device, has applied for FDA approval using data from more than 110 patients. Roughly 3 percent of them suffered complications such as bleeding from arterial damage.

No single therapy can work for every patient, but stroke doctors are pushing the envelope on other fronts. At Johns Hopkins, interventional radiologist Dr. Kieran Murphy is attacking a deadly form of stroke (vertebrobasilar) with a combination of tPA and stents. Using a catheter, he inserts a tubular stent to widen the blocked artery, restoring blood flow to the affected brain region. “Then we chase the clot with tPA,” says Murphy. Vertebrobasilar stroke normally kills nine out of 10 patients, but in a recent study four of the six patients who got Murphy’s two-hit treatment survived. Still other researchers are hoping that “neuroprotective” drugs, such as magnesium sulfate, may limit brain damage if administered promptly after a stroke. Researchers at UCLA are training paramedics to administer the drug to patients en route to the hospital. “We’ll find out whether magnesium can really help if it’s delivered within one to two hours,” says UCLA’s Dr. Sidney Starkman.

Better tools are critical, but there’s more to be done with the tools already in hand. In fact, researchers have shown that simple education can increase the use of tPA fivefold. Looking at hospitals in three rural Texas counties, a team led by Dr. Lewis Morgenstern of the University of Michigan Medical School noted that tPA treatments spiked from 2.2 percent to more than 11 percent of all stroke patients after his team had conducted an educational blitz to convince docs and patients that strokes were indeed treatable. Morgenstern believes similar campaigns would work in big cities, too, and he thinks the time is ripe. “Now that we have one therapy–and more coming around–it’s critical we have greater education and awareness of the need for quick treatment,” he says. Patients and their families can only hope for both.

On December 7, 2002, I was riding my horse in preparation for a horse show the next morning when all of a sudden I felt like I was going to pass out. I remember trying to slow the horse down and then I remember waking up on the ground in the dirt. I was terrified! When I woke up the first thing that I thought was that I was probably paralyzed. And, I knew something was really wrong. I am a healthly 34 year old, who teaches aerobics, runs, swims and works out on a regular basis.

Thank God I was surrounded by fantastic people. I had experienced a seizure and stopped breathing. My trainer did CPR on me and got me breathing again. My head and neck were killing me. I was actually lucky that I didn’t break my neck falling off the horse, but I had my helmet on and only ended up fracturing my skull.

I could hear everyone trying to get me to open my eyes and I heard them telling me that the life flight was almost there. I was so scared, especially when I heard the word life flight. I also remember, checking to make sure that I could think clearly and I could so I wasn’t sure what was wrong.

When I got to the emergency room everyone was just saying that I had fallen off the horse and landed on my head. But, I knew that I had passed out. Then, I started to vomit violently. A few hours later, they diagnosed me with a brain aneurysm and immediately drugged me up.

I was very, very lucky. I was a candidate for the coil procedure and spent about 8 days in ICU with no complications. However, I will tell you that it was truly a miserable and scary feeling to have something like this happen – especially being young and active. I kept thinking I can’t believe this happened to me – this is the kind of thing I only hear about on the news!

I guess the most important part of my story is that I want survivors to feel like they can communicate with me anytime regarding their experience. I know that probably the most difficult part of the process is healing and just having someone who has EXPERIENCED the same thing. Healing for me was not easy. Once I came off all the drugs, I had my first ever panic attack. It was so scary and my anxiety was horrible. I was lucky to find a great psychologist who was able to help. My neurosurgeon, although good, was not into helping me with my emotions.

I got plenty of rest and I immediately went back to exercising (lightly) and building my strength. Yoga has probably been the best part of my recovery. And, lots of vitamins! I went back to work after 6 weeks and it was hard. I have a very stressful job and I was scared! But, I feel very good now and I can’t believe I even had an aneurysm three months ago! If anyone has any questions or wants a friend to talk with,I am here!

Update: 15 September 2004

I wanted to thank everyone for their responses several weeks ago when I was seeking information regarding coiling follow up. At the same time, I wanted to share my results and, what I think to be, pertinent information.

First, I am very lucky to have Dr. Thomas Grobelny, who was featured in Newsweek and on Peter Jennings Evening News, perform my coiling and all my angiograms, he is incredible and Kansas City is lucky to have him! I had my angiogram and everything turned out to look good.

I finally, after almost two years, had follow up with my neurosurgeon, Dr. Camarata, who ended up being surprisingly nice ( I usually can’t talk to him because of his “Nazi” nurse — at least that is how I describe her). He told me that if you tolerate the coil after the first 18 months, you are pretty much in the clear (of course, no one bothered to tell me that–probably better if I didn’t know. He DID NOT recommend any follow up angiograms past this mark. He said that was it and that I should live my life. He said if I wanted to have it checked to wait until angiograms got much more user friendly.

Although my anxiety and fear feels better, I always have it in the back of my mind…no matter what doctor tells me. I am glad to be here and appreciate the family!

Update: 22 August 2006

It has been almost four years since I had a subarachnoid hemorrhage that was treated with coil. I was very, very lucky to survive and have really, no deficits. I was also blessed to have a very talented doctor. The frustration I have is the lack of follow-up with patients who appear to be normal after the procedure.

I continued to be shocked that I am not a case study or that I am not monitored in some capacity. Wouldn’t doctors want to track a patient who had a successful coiling? I did have two angiograms following the last two years of my procedure and was told that I was “good to go” – no follow-up was necessary. Again, I had really good doctors so I can’t really argue with them.

Additionally, there does appear to not really be a lot of documentation regarding follow-up treatments after successful coilings. I rarely hear or see anything from individuals that are doing fine after the procedure so it is hard for me to gauge. I have asked this question to the family before, however, even more time has passed and I often and still think about others after care and wonder if it is different or that maybe I am just obsessed!

Because I am concerned, I have set up an appt. with my neurosurgeon on Thursday to ask him the same questions – although, I think him and my husband think I have lost my mind. The doctor simply says I am fine and my husband tells me I don’t listen to the doctor! I would really appreciate hearing from anyone who has no complications from a coiling and what your follow-up treatment, if any, was or is.

FLOSSMOOR | On Dec. 13, 2006, U.S. Senator Tim Johnson suddenly began stuttering and became disoriented. Later that day, he had emergency surgery to repair bleeding inside his brain.

The 60-year-old Johnson, who still has not returned to the Senate, is undergoing speech therapy and using a wheelchair. If he resigns and South Dakota’s Republican governor appoints his replacement, control of the Senate would shift from Democrats to Republicans.

Johnson’s brain hemorrhage was caused by an arteriovenous malformation. An AVM usually is present at birth, but is almost always undiagnosed until there is a hemorrhage. AVMs in the brain or spinal cord affect about 300,000 Americans and kill about 3,000 per year.

An AVM nearly killed a senator and may cause a power shift, but Homewood-Flossmoor senior Ashley Berner plays soccer with it. She was told shortly after a March 29 angiogram that two surgeries could cure the AVM, but she postponed them until June to help her team.

H-F’s Ashley Berner delays surgery on her brain to play soccer

Berner remembers vividly what she thought when she was diagnosed on March 12 and told to stop all physical activity.

“I was nervous and scared,” she said. “I instantly thought about soccer because (the doctor) said I couldn’t play until I talked to more doctors. … I was very upset that I couldn’t practice. I wanted to be out there.”

The 18-year-old Berner is fortunate she was diagnosed.

Berner only went to a doctor this winter because athletes must pass physicals each season. Soccer is her passion. Last season, she became a star, scoring 18 goals — second-best on the Vikings — and making the Times All-Area team.

“She’s a difference-maker when she plays for us,” H-F coach Todd Elkei said.

While in the doctor’s office, Berner mentioned she had been having headaches. An MRI on March 3 revealed something abnormal in her brain.

“I was scared,” Ashley’s mother, Irene, said. “(My husband Philip and I) were very concerned about Ashley and didn’t want her to do anything that would put her in harm’s way and risk her health.”

The MRI led to the March 12 diagnosis of an AVM, a tangle of tiny veins and arteries that forces blood to flow straight back to the heart before it can bring oxygen and nutrients to the tissues.

Berner’s headaches probably were unrelated to the AVM, said Dr. Thomas Grobelny of the Chicago Institute of Neurosurgery and Neuroresearch.

Berner resumed practicing after a March 22 appointment with Grobelny. On March 29, she had an angiogram as dye was injected into her brain to ascertain how the AVM should be treated. It showed that the AVM was in the cerebellum.

“A hemorrhage in that area can be deadly,” Grobelny said.

Grobelny told Berner that she probably would need two operations to get rid of the AVM.

Many people postpone surgeries for decades, but Grobelny said there is a 1-to-2 percent risk each year of a hemorrhagic stroke. Ashley decided to act sooner rather than later because AVM patients’ risk of hemorrhage increases as they age.

“I want to get this out of the way so I don’t have to worry anymore,” Berner said.

Her first operation, an embolization, is slated for June 19 and should reduce the AVM’s size significantly. If it’s not eliminated, she will have gamma knife radiation surgery several weeks later. This surgery cures more than 90 percent of AVMs, Grobelny said.

Ashley could have had the embolization in April, but she chose soccer despite the risk of hemorrhage.

“I decided that I wanted to play my senior season,” she said. “I love the girls. We have an amazing team and we have a lot of potential this year. (Dr. Grobelny) said if soccer is what I love to do, I should go on with it.”

Grobelny said a lack of symptoms convinced him that an April operation was not needed.

“I don’t think she should stop enjoying doing what she is doing,” he said.

H-F’s season started on March 30. Berner missed one game.

“I was fired up to get out there,” she said. “I wasn’t conditioned properly. I went as hard as I could, but I pulled my calf.”

Teammates Maggie Hoskin and Zoe Lubeck said they were inspired by Berner’s return. Hoskin said her demeanor improved the second Berner stepped back onto the field.

“The whole team admires how determined she is to keep playing,” Lubeck said. “Most people who got that news would give up. Ashley just kept on playing.”

Berner didn’t score until H-F’s ninth game. She said the angiogram wasn’t a factor, but two weeks of no practice was. She played for shorter periods because she was out of shape.

“I was just getting back into the groove,” Berner said of her slow start. “I wasn’t that concerned.”

In the last month, Berner’s form has returned. She is fourth on the 16-4-1 team with seven goals and seven assists, and she has scored the winning goal twice.

She still has headaches, but Grobelny said 98 percent of them are not a serious medical problem. Ashley said she almost never thinks about her upcoming operations.

“It’s not a main concern right now,” she said. “I’ll worry about it when I get closer.”

THEY STRIKE OUT OF THE BLUE, INSIDIOUS AND DEADLY, KILLING BRAIN CELLS, DESTROYING LIVES. NOW A NEW WAVE OF RESEARCH OFFERS HOPE TO MILLIONS. INSIDE THE SEARCH FOR TREATMENTS THAT WORK
By Jerry Adler | NEWSWEEK
From the magazine issue dated Mar 29, 2004

Until the day he collapsed, John Kelly, 57–an exceptionally fit, nonsmoking, retired soldier–had never given a moment’s thought to strokes. His cholesterol was low; he worked out six days a week; no one in his family had ever had one. One morning in January he sat down on the edge of his bed, bent over to tie his shoes, and, he says, “kept right on going” until he toppled to the floor. A blood clot had cut circulation to a large region on the right side of his brain, which instantly began shutting down; muscles on the left side of his body, with no input from the nerves, went limp. Inside his head, a biochemical riot had begun, which if unchecked would lead in a few hours to a massive cell die-off, leaving him an invalid at best. Like many stroke victims, Kelly seemed barely aware of what was happening to him: the right side of the brain controls muscles on the left side of the body. But the speech center is in the left hemisphere, so Kelly could still talk. He asked his wife to help him finish dressing so he could go to work. She ran for the phone instead…

It will happen to 20 million people this year, two thirds of them 60 or older but some just in their 20s, and nothing, short of a massive coronary, kills as quickly. Of those who survive the initial attack–roughly 75 percent–nine in 10 will have long-term impairment of movement, sensation, memory or reasoning, ranging from slight to devastating.

The prevalence of strokes, which began leveling off around five years ago in the United States and Europe after a three-decade drop, may soon be on the rise, a result of an aging population and immigration. Strokes are particularly high among Hispanics and Africans. Rates are also expected to rise in many developing countries as they adopt Western lifestyles. And there is one other factor, says Dr. John Marler, associate director of the U.S. National Institute of Neurological Disorders and Stroke (NINDS): as we get better at treating heart attacks, “more people are surviving a myocardial infarction and going on to have a stroke.”

The two share identical risk factors, including high blood pressure, excess cholesterol and diabetes; the basic mechanism–blockage of a crucial artery–is usually the same. But progress against coronaries has not, until now, led to new treatments for stroke. While the last decade has seen big advances in long-term rehab for stroke victims, for most people who show up in the emergency room there is exactly one drug doctors can use to get blood flowing into their brains again–and only a few patients get even that. Still, promising research into how blood vessels function and how neurons die may lead to new treatments that can save the lives, and brains, of people like John Kelly. Says Dr. Joe Broderick, head of neurology at the University of Cincinnati: “We’re five to 10 years behind cardiology, but we’re going in the same direction.”

… An ambulance rushed Kelly to the local hospital, where doctors made a quick diagnosis and began an intravenous drip of tissue plasminogen activator (tPA). This is the only drug approved by the U.S. Food and Drug Administration for dissolving blood clots in stroke patients. The doctors watched and waited: Kelly’s condition was unchanged…

tPA is a powerful drug that can increase the chance of a full recovery by as much as 33 percent. But it must be given within three hours from the onset of symptoms; if it is given later, the risk of further damage outweighs the benefits. But first the patient has to get to the hospital. Unlike a heart attack, whose pain generally sends people to the hospital immediately, strokes can be subtle, especially if they strike the parts of the brain dealing with memory or cognition rather than movement or speech. The U.S. National Stroke Association says the average stroke patient waits more than 12 hours before going to the emergency room; some never get there.

And like any drug that counteracts clotting, tPA has the drawback that it can promote bleeding. It is useful only on the type of stroke Kelly had (“ischemic”), in which a clot blocks one or more of the arteries taking blood to the brain. But about 15 percent of strokes are “hemorrhagic,” resulting from a burst artery bleeding into the brain–in which case tPA is precisely the worst thing you can do. (There are no drugs to treat acute hemorrhagic stroke, which is fatal in up to 50 percent of cases.) Unfortunately, the symptoms of the two types of stroke can be identical. Only a brain scan can distinguish with certainty between them–so by the time doctors are ready to start treatment with tPA the three-hour time limit may have already passed. “You’re always looking at the clock on the wall,” says Dr. Anthony Furlan, a leading stroke researcher at the Cleveland Clinic. Rather than risk potentially fatal bleeding into the brain, doctors tend to err on the side of caution–which means fewer than 5 percent of stroke victims even get tPA at all.

Humans aren’t the only creatures with an interest in keeping blood liquid; they share it with the vampire bat, Desmodus rotundus. The thumb-size bats land on sleeping animals and make tiny cuts in their skin, lapping up the blood as it oozes out; an enzyme in their saliva keeps the wound from clotting. That suggests a possible new therapy. At a meeting of the American Stroke Association earlier this year, a group of international researchers reported on a study in which stroke victims were treated with a genetically engineered version of the bat’s active ingredient; they found that it could be used safely up to nine hours after a stroke began, and appeared to cause less collateral bleeding than tPA. “I’m not sure this will be the silver bullet,” says Furlan, who is leading a similar study in the United States. “But we’re optimistic.”

Even when given in time, clot-busting drugs don’t always work. Are there ways to enhance their effectiveness? Dr. Andrei Alexandrov, a neurologist at the University of Texas-Houston Medical School, made an unexpected discovery in 1999 while using diagnostic ultrasound to investigate how tPA restores blood flow to the brain. What he found was that the ultrasound machine, which was not intended as a treatment, helped break up the clots and made a dramatic difference in how patients recovered.

High-energy ultrasound has been used for years to bust up kidney stones, but nobody was crazy enough to use it anywhere near the brain. At the much gentler levels used for diagnosis, though, it seems to create just enough hydraulic pressure to get the tPA inside and around the clot, where it can go to work. “We’ve had cases where patients who couldn’t move suddenly regain the use of their body,” says Alexandrov. “They reach up with the arm that was paralyzed and try to remove the ultrasound device, saying they’re done and they’re going home.” In a study of 126 patients reported at the stroke conference, the combination of tPA and ultrasound restored blood flow in almost half the patients, compared with just 30 percent of those treated with tPA alone.

The most straightforward way to open an artery, of course, is to reach inside and clear it out. Also earlier this year, another team announced preliminary results from the use of the MERCI retriever. This is a corkscrew-shape device inside a catheter that can be maneuvered through the blood vessels to the site of a blockage; emerging from its sheath, the retriever grapples the clot and pulls it clear. In a clinical trial of 114 patients, the device successfully unblocked arteries in 61 of them–and of those, 20 recovered dramatically, many of them right on the table. The U.S. Food and Drug Administration is currently considering whether to approve this still-experimental device.

… St. Luke’s Hospital in Kansas City, Missouri, was one of the medical centers in the MERCI trial, and Kelly was lucky enough to be taken there next. Dr. Thomas Grobelny took an angiogram X-ray of his blood vessels. The results were discouraging; a massive clot, roughly two centimeters long, was blocking the intersection of two of the major arteries on the right side of the brain, the internal carotid and middle cerebral. A clot that size is virtually impervious to tPA. Grobelny inserted a needle into the femoral artery in Kelly’s thigh and snaked a catheter up to the right carotid, to the lower margin of the blockage. The tiny helical tool emerged from the end of the catheter and engaged the clot. A balloon on the catheter tip inflated, blocking the artery, so if the clot broke apart the blood flow wouldn’t simply drive pieces of it farther into Kelly’s brain. Grobelny began pulling…

Brain cells are voracious consumers of oxygen and glucose, both carried by the blood; when totally deprived of circulation they suffer irreversible damage in as little as five minutes. But a stroke usually cuts off blood flow to only a relatively small area of the brain, surrounded by a much larger region with diminished circulation. There, cells die more slowly. “Up to 24 hours, and even beyond that, damage continues in these marginal areas,” says Thomas Jacobs, the stroke program director at NINDS. The holy grail of stroke research over the last decade has been a means of slowing this secondary damage, keeping the brain as intact as possible until circulation can be restored. “We know the brain can survive a long time without oxygen,” says Dr. Patrick Lyden, director of the stroke center at the University of California, San Diego. “We see it every winter when some kid falls through the ice and is fished out 45 minutes later, and once he thaws out he’s fine.”

Without knowing precisely how cold protects brain cells, researchers have been trying for years to harness its benefits. But it isn’t easy to duplicate the effects of falling into a frozen pond, and the results have been mixed. In one experiment, Dr. Derk Krieger of the Cleveland Clinic used external cooling to reduce the body temperature of a group of stroke patients by nine degrees Fahrenheit for two days; it triggered violent shivering, which had to be counteracted by inducing paralysis, which required putting them on ventilators. On the whole, the group did better than the control patients who were not cooled, but the differences were small. Newer research is focused on endovascular cooling, using small catheters that can apply cooling directly to the blood vessels leading to the brain.

Perhaps the most important insight of recent years is that cells in the brain don’t just “starve to death” when blood flow is interrupted. Cell death is a process, a cascade of biochemical changes that lasts for hours and can, theoretically, be interrupted at several points in time to save the patient’s brain. “The analogy I use with patients is, you hit your hand with a hammer, and the injury is done, but you look at your hand and it looks the same, even if it hurts. But 48 hours later it’s black and blue and swollen,” says Dr. Lawrence M. Brass, a neurologist at the Yale School of Medicine in New Haven, Connecticut. You can alleviate some of that by applying ice; researchers are still looking for the best way to slow damage to the brain.

Better still would be a way to prevent strokes in the first place–beyond the universal prescription to stop smoking, to exercise and to control cholesterol, that is. Dr. John Hallenbeck, chief of the stroke branch of NINDS, is taking a unique approach, attempting to “immunize” blood vessels against stroke by focusing not on blood coagulation but on the artery walls themselves. Artery segments, for reasons still unclear, periodically become “activated”–a process akin to inflammation that promotes the formation of clots at those locations. Working with rats, Hallenbeck found that a naturally occurring molecule called E-selectin seems to dampen inflammation specifically in the lining of blood vessels, without affecting normal immune-system function. He called his results “startlingly successful” so far, but warns that the technique has not yet been tried in humans.

Another possible approach is to identify people at high risk for stroke, who could then be monitored and treated prophylactically. A classic warning sign for stroke risk, often overlooked, are “transient ischemic attacks,” or “mini-strokes”–episodes of diminished blood flow to the brain that don’t last long enough to cause permanent damage. The symptoms, which can last from a few seconds to as long as 24 hours, are the same as a stroke, including sudden numbness or weakness on one side of the body, trouble in seeing or speaking and loss of coordination. (Counterintuitively, Dr. Roger Simon, head of the Dow Neurobiology Laboratories in Portland, Oregon, has found that TIAs, although they may signal an impending stroke, also seem to play a protective role; animals with artificially induced TIAs tended to survive induced strokes with less brain damage.)

Another significant risk factor is atrial fibrillation, a disruption of the heart rhythm that affects one in 10 people over the age of 65. The condition has few obvious symptoms and often goes undetected, but can cause clots that can travel to the brain or other parts of the body–which appears to have been the case with Kelly, as his doctors discovered, some weeks later.

… Once the balloon was deflated, Grobelny could see blood flowing into the internal carotid, but a large chunk of clot remained, blocking the adjacent middle cerebral artery. So he went back in with the catheter, using it this time to inject a dose of tPA directly onto the clot, then skewering another fragment with the retriever. Four hours after Kelly fell onto his bedroom floor, blood was flowing again into all parts of his brain. Kelly still couldn’t move his left arm, but when Grobelny lifted it he felt a little resistance, as if his muscles were coming back to life. A few hours later, Kelly, now in intensive care, felt his nose itch. His right arm was tied down so he wouldn’t dislodge the IV line. He reached up with his left hand–and scratched his nose.

Special to the Tribune

February 18, 2009

Vivian Moore loves to play the 2-cent slot machines at Aurora’s Hollywood Casino. Although she can’t seem to finish a book, Moore, 67, jokes she can read an entire newspaper in one sitting and enjoys picking up the National Enquirer on occasion when someone—like Patrick Swayze—is featured.

The dove-haired grandmother also made history last week by becoming the first person in Chicago to undergo a highly confidential clinical trial for a device known as the Pipeline embolization device that is pending FDA approval and could potentially revolutionize treatment for brain aneurysms, neurosurgeons and medical experts say.

Less than three hours after surgery for an unruptured brain aneurysm, Moore was upright in her hospital bed at the Neurologic & Orthopedic Hospital of Chicago in Ravenswood telling her children how lucky she felt.

“Maybe you should go sky diving,” said her son Joe, 44, who lives in Ottawa. “Or bungee jumping,” said her daughter Dawn Schiro, 48, of Frankfort.

“We could put you on a Harley,” her son said. “Or take you to a monster truck rally,” Schiro said.

In reality, Moore just wanted some Jell-O. Preferably orange Jell-O, but anything but lime would do.

“I don’t feel any different,” said Moore, who lives in Lombard and is among about 100 brain aneurysm patients in the U.S. who have had the procedure. “I’m just glad it’s over and I made it through. I was so scared but I wanted to get it done. I wanted to make sure I’m here for my family. I didn’t want to die.”

Like many people, Moore discovered her brain aneurysm by accident. Three days before Thanksgiving, Moore began feeling dizzy. She called a neighbor and went to an Elmhurst hospital. While there, she almost passed out twice, pulling the emergency chain in the bathroom as she began to faint. The doctors told Moore her dizziness was likely the result of one the medications she was taking for other problems, which include high blood pressure. A CT scan during Moore’s hospital stay revealed she had a large brain aneurysm behind her left eye.

Moore soon learned that she’d had the aneurysm, a weakness in the blood vessel that causes a balloon-like bubble in one or more layers in the artery tissue, for years. According to some experts, 40 percent of all people die when it ruptures.

“I was shocked,” Moore said. “I just started to cry.”

Directed to Dr. Demetrius Lopes, an endovascular neurosurgeon at Rush University Medical Center (and the Neurologic & Orthopedic Hospital of Chicago) and Chicago Institute of Neurosurgery and Neuroresearch, Moore said Lopes told her the best option was to be part of a clinical trial and try an experimental device commonly called the Pipeline. The reason: the surgery is less invasive and typically takes half the time as traditional methods take, which is about three hours.

Additionally, Moore’s brain aneurysm was large at 12 millimeters and would likely rupture at some point given its size and location in the optic nerve, where traditional treatment methods could continue to cause it to compress against the nerves in the brain and create more problems, Lopes said.

“Dr. Lopes told me we could wait, but I wanted to get it over and done with,” Moore said.

According to Christine Buckley LeBlanc, executive director at the Hanover, Mass.-based Brain Aneurysm Foundation, it is estimated that 1 in 50 people in the U.S will develop a brain aneurysm. Women ages 35 to 60 are more likely to be affected than men. Although a lot is still unknown, experts say that smoking, high blood pressure, a traumatic head injury, drug use and a family history of brain aneurysm can be factors.

With most brain aneurysm patients who undergo surgery, the scull is drilled and brain tissue is moved in order to reach the problem area. In Moore’s case, the Pipeline—which looks like a tiny metal Chinese finger cuff—is inserted through the groin up into the brain via a stent. That creates a bridge or pipeline to redirect the flow of blood to help seal off the hole in the artery.

Since the pipeline device is made of tightly woven metal and can be added in multiple layers to adjust to individual needs, Lopes said it appears, in preliminary results, that the blood in the aneurysm won’t leak like it can in more traditional methods and that the brain nerves to continue to operate.

Lopes also said that patients in the clinical trial are recovering faster, typically leaving the hospital after one night’s stay and with a week of recovery. With traditional methods, the typical hospital stay is three to four days and the recovery period is four to eight weeks.

“In the past, we’d just fix aneurysms that were rupturing,” Lopes said. “And it didn’t really matter how you treated them, we were just trying to save people’s lives. Now, as technology has gotten better, we are seeing all these aneurysms that are unruptured and we are trying to be more proactive in our treatment. This could revolutionize treatment of certain types of brain aneurysms in the future.”

The Chicago Institute’s Dr. Thomas Grobelny and Dr. Harish Shownkeen, a interventional neuroradiologist at Central DuPage Hospital in Winfield, who are both part of the clinical trial, said the initial results look promising and could have a momentous impact on the treatment of brain aneurysms.

As for Moore, she said she ready to take the first cruise of her life now that she’s out of the hospital.

Likely to Alaska, she said.

Besides his expertise in endovascular surgery, Dr. Grobelny is best known for his compassion for others. During his residency in Radiology and Neuroradiology he was a jail physician at Rikers Island, New York, where he worked with prisoners during the initial terrorist attack on the World Trade Center in 1993. He encountered a wide variety of patients there and treated many inmates who preferred life in prison to living “on the outside.” He was most affected by one inmate who had been living in a discarded refrigerator under a bridge.
Educated in Poland, Dr. Grobelny has come a long way since his school days with Poland’s current wealthiest businessmen, Leszek Czarnecki. The two were classmates and on the high school swim team in Wroclaw, Poland. Today, they are still friends and Czarnecki, who started Poland’s largest leasing business and the Getin Bank, is credited with building the Sky Tower, the tallest residential building in Europe.

Dr. Grobelny attributes his success today as a stroke prevention specialist to his education in Poland’s fast track system for students excelling in math and physics and his unusual life experiences.

His expertise includes a full-range of neuroendovascular interventions, including coiling of aneurysms, stenting of narrowed blood vessels in the brain and neck, embolization of arteriovenous malformations, and the use of novel devices to treat acute stroke. Dr. Grobelny is also trained to use Gamma Knife radiosurgery to treat his patient afflicted with AVMs. In addition to the care of patients afflicted with neurovascular disorders, Dr. Grobelny’s experience also reflects the treatment of vertebral compression fractures using a procedure called kyphoplasty which almost immediately eliminates the back pain associated with this condition.
“I loved learning at an early age and I was encouraged by my teachers in high school,” Dr. Grobelny explains. “My passion for medicine and healing with the latest technology was sparked by my fellow students too.”

Grobelny began his medical training in 1980 where he attended the School of Medicine, Wroclaw, Poland. Shortly thereafter, he found himself a political refugee at a camp in Italy. Finally, in 1988 he was sponsored to come to the United States where he successfully passed U.S. qualifying medical license and English language fluency exams within one year. He performed his residency in Radiology at Columbia University, Harlem Hospital Center in New York City and completed fellowships in Endovascular Surgical Neuroradiology/Interventional Neuroradiology at Thomas Jefferson University Hospital, Philadelphia, PA and University of California at Los Angeles (UCLA) School of Medicine.

Grobelny is married to wife Eva whom he met in the middle of her OB/GYN internship in Poland. They were married in Poland and she was able to join him three long years after he immigrated to the U.S. They have one son, Bartosz, 24, who is in his third year of medical school at Thomas Jefferson School, Philadelphia (like his dad).

Dr. Grobelny is a resident of Chicago where he is an avid cyclist and Category 3 racer, often enjoying 5 a.m. training rides. Recently, he had the privilege of riding with 2006 Tour de France winner Floyd Landis along the Chicago lakeshore.

He joined CINN in March 2007 and has practices at the Neurologic & Orthopedic Hospital of Chicago and Advocate Christ Medical Center in Oak Lawn, Illinois. Dr. Grobelny is an active lecturer and researcher. His current research interest is in endovascular neuroresearch.

An intracranial aneurysm is a weakness in the wall of a blood vessel in the brain that balloons out, forming a thin-walled bubble or sac. Approximately 30,000 intracranial aneurysms present annually. Some 15,000 patients are treated and up to 4,000 of these individuals are likely to need vascular reconstruction.

View a minimally invasive approach to “wide neck” aneurysm repair using Cordis Enterprise Stent.

Today, many of these patients in most centers require open surgery-clipping an aneurysm requires opening the skull under general anesthesia, a three to four-day hospital stay and carries up to an approximate 12 percent probability of mortality/morbidity for patients. Another treatment which may be available to patients in select institutions is a less invasive neurovascular intervention. Most patients who undergo an elective neurovascular procedure stay in the hospital one or two days and recover fully after about a week.

Through a neuroendovascular intervention, Lopes and Grobelny will place the first Enterprise Vascular Reconstruction device in a 58-year-old female who was diagnosed with an aneurysm during an exam to treat her balance disturbance and tinnitus, or ringing in the ears.

With this procedure, they will fill the aneurysm with coils to help ensure blood from the vessel does not continue to fill up the sac. Some aneurysms, in particular wide-neck aneurysms, can be difficult to treat with coils alone. Because of this, doctors and researchers began using stents that act as a scaffold to reconstruct the blood vessel and support maintenance of the coils inside the aneurysm. The Enterprise system is a significant advance in this technology because it has a closed-cell, versus open cell, design that better ensures coils will not herniate through the stent and into the parent blood vessel. They will place the device over the neck of the aneurysm to keep the coils packed in, effectively remodeling the blood vessel, shutting off the aneurysm from blood flow and restoring more normal blood flow through the parent blood vessel.

According to Lopes, the introduction of the Enterprise stent is significant because it allows endovascular neurosurgeons to treat a larger number of aneurysms in a minimally invasive way that is not as risky as surgery. And, closing off these aneurysm is an effective way to prevent hemorrhagic stroke, which occurs when a cerebral aneurysm bursts and bleeds into brain tissue. In the U.S. , stroke is the third leading cause of death, behind heart disease and cancer. Each year, about 700,000 people suffer a stroke according to the American Heart Association.

“In the past, we couldn’t recommend surgery for patients with an aneurysm who were symptom free because the surgery itself was risky,” he said. “But, this new remodeling procedure now allows us to use the body’s circulatory system to navigate the device into the area where the aneurysm is without performing an open craniotomy.”

The clinical outcomes from the Cordis Enterprise Vascular Reconstruction Device Study, involving patients in Europe and the U.S. , were assessed by an independent core lab, establishing a new standard for clinical evidence in the treatment of intracranial aneurysms. Data from the independently evaluated clinical study suggest that the device is a promising assist device for the treatment of aneurysms, however, the effectiveness of the device for this use has not been demonstrated.

The Food and Drug Administration has granted Cordis, Inc. a Humanitarian Device Exemption and the company is working with top doctors, like Doctors Lopes and Grobelny, to carry out this promising approach to treating patients with aneurysms. In fact, Dr. Lopes and Dr. Grobelny are considered the foremost expert team in the world in treating complex aneurysms. HDEs are granted when a medical device is used to treat a disease that affects fewer than 4000 patients annually. In an effort to provide treatment for these types of conditions, humanitarian use devices are exempt from the efficacy requirements of devices intended to treat more common conditions.

The Neurologic & Orthopedic Hospital of Chicago is the country’s first freestanding acute care hospital dedicated exclusively to neuroscience and orthopedic services. It utilizes breakthrough technology and minimally invasive techniques as well as advanced procedures for neurosurgery, orthopedics, pain management, neuro-oncology, sports medicine, and rehabilitation.