Cerebrovascular Treatment

Preserve Mental Capacity

Ischemic strokes account for about 85% of all stroke types and are caused by a blockage of blood flow in an artery leading to brain tissue. When the blockage occurs, the brain tissue that is not getting enough blood flow will start to become permanently injured. Restoring blood flow to brain tissue at risk of injury is the first priority in an ischemic stroke. The first treatment to try and open the vessel is the use of medication to break the clot up. This medication is called intravenous recombinant tissue-type plasminogen activator (r-tPA) or alteplase. The earlier this medication is administered the more likely it can open the vessel before there is permanent brain tissue loss.

Neuroendovascular Reperfusion Therapy

In some cases, the blockage may not be opened up with the use of tPA (alteplase) alone. Many strokes occur as the result of blockage of a large artery and there is more brain tissue at risk of injury. In these types of stroke, the symptoms are likely to be the even more severe. For some patients that have a large vessel occlusion, a second line therapy must be considered. This is called mechanical endovascular reperfusion therapy.

As in the use of intravenous tPA, mechanical endovascular reperfusion therapy must be provided as early as possible to provide the most benefit to those who are suffering an ischemic stroke.

How May We Help?

Contact us: (864) 797-7435

Our Care Team

Imran Chaudry, MD
Quill Turk, DO
Raymond Turner, MD
Jan Vargas, MD
Annette Davis, ANCP

Diseases we treat

  • Acute ischemic stroke
  • Hemorrhagic stroke
    • Subarachnoid hemorrhage
    • Intracerebral hemorrhage
    • Subdural hemorrhage
  • AVMs
  • Dural fistulas
  • Idiopathic intracranial hypertension
  • Intracranial tumors (tumor embolization)
  • Carotid stenosis
  • Compression fractures
  • Congenital vascular malformations

Acute Ischemic Stroke

An acute ischemic stroke occurs when a blood clot blocks an artery that brings blood to the brain. Deprived of oxygen and nutrients the brain cells start to die at a rate of two million neurons per minute, increasing the risk permanent brain damage, disability or death. Recognizing stroke symptoms and acting fast to get medical attention can save a life and minimize disability.

Stroke Surgery

During a mechanical thrombectomy, a small catheter (small plastic tube) is placed into a vessel over the wrist or hip. Using X-ray guidance additional catheters are advanced through the blood vessels of the body to the blocked vessels of the head. Once the catheters are advanced to the blockage, either a special stent is used to remove the clot or a technique called ADAPT is used to remove the clot using aspiration (or vacuum). Doctors at Prisma Health-Upstate were the pioneers of this technique which has been shown to be just as effective as a stent but safer, faster and less expensive. The goal is to remove the clot and restore blood flow to the affected part of the brain.

After the procedure, patients usually spend a couple of days in the neurocritical care unit and then in a step-down unit and, if needed, rehabilitation. Mechanical thrombectomy is considered to be a breakthrough in stroke treatment. Removing the blood clots from the brain leads to better outcomes for stroke patients, including greater independence and mobility.

Hemorrhagic stoke

A hemorrhagic stroke occurs when there is bleeding in the brain.  This bleeding maybe into the substance of the brain called an intracerebral hemorrhage or into the spaces around the brain called a subarachnoid hemorrhage. Both of these can be treated with minimally invasive methods.

Subarachnoid hemorrhage

A subarachnoid hemorrhage is usually caused by a ruptured aneurysm or AVM. An aneurysm is a weak spot on a blood vessel and looks like a sac or a ballooning out from the vessel wall. An AVM (arteriovenous malformation) is an abnormal tangle of vessels with high flow from the arteries to the veins. Both can be treated by traditional open surgery where an incision is made in the skin, a small window is made in the skull by removing part of the bone and then either an aneurysm clip is placed across the aneurysm neck, or the AVM is removed. However, newer, minimally invasive methods have been shown to be equally effective and better tolerated by patients. An aneurysm can be treated by a number of different minimally invasive techniques:

  • Aneurysm coiling: a small catheter (plastic tube) is placed into a vessel over the wrist or hip.  Longer catheters are advanced into the vessel with the aneurysm.  From there smaller catheters are advanced all the way into the aneurysm sac and then the aneurysm is filled up with “coils” that block off the aneurysm.
  • Flow diverting stents: similar to a coiling a procedure, in this procedure a special stent is placed in the main vessel across the aneurysm opening. The stent causes blood flow to be diverted away from the aneurysm causing the aneurysm to occlude over time.
  • Next Generation devices: The physicians at Prisma Health-Upstate have worked closely with many companies developing newer techniques to treat aneurysms, many of which are unavailable at other institutions in the state. These newer devices have the advantage of being quicker, efficacious and safer for you.
  • WEB: this device is used in a similar fashion as coils. A small catheter is placed into the aneurysm. Through this catheter a special single device is placed into the aneurysm occluding it over time.
  • PulseRider: A special “T” shaped stent that is used to treat very complex aneurysms through the blood vessels that otherwise would require open brain surgery. The physicians at Prisma Health-Upstate have the regions highest experience with this device and are responsible for training surgeons around the world on its usage.

AVM treatment:
There are three major treatment methods that may be useful either alone or in combination to treat an AVM. The specific treatment for an individual is based on the patient’s history, symptoms, and anatomy of the AVM including its size, feeding arteries, draining veins, and location within the brain. Treatments include: endovascular embolization (closure of the AVM from within the blood vessels), open surgical removal of the AVM, radiosurgery or a combination of techniques.

  • Radiosurgery is a technique which uses focused beams of radiation to treat particular AVMs that are sufficiently small and located in appropriate areas of the brain. Despite the name, no opening of the skull is required. Instead, the radiation causes scarring in blood vessels of the AVM, thereby eliminating it. After treating the AVM with radiosurgery, a period of two to three years is required for the full effect of the treatment to be determined. In over 80% of cases where the AVM is sufficiently small, there is complete obliteration of the AVM.
  • Embolization is an endovascular technique (performed from within the blood vessels) to block the vessels of the AVM. In this procedure, a small catheter is threaded from the groin directly into the AVM vessels within the brain. Under X-ray guidance, liquid “glue” is injected through the catheter to permanently block and close off the vessels of the AVM. Embolization of an AVM is usually performed before treatment by either surgery or radiosurgery. Embolization is often able to decrease the size of the AVM making the surgery or radiosurgery much safer than would otherwise be the case. However, the blood flow from certain AVM’s may be totally blocked by embolization techniques, and no further therapy may be required.
  • Open surgical resection involves removing a portion of the skull so that surgical instruments can be inserted to remove the AVM. Surgical treatment is often performed after embolization has closed portions of the AVM. The combination of embolization followed by surgical resection is frequently safer than surgical resection alone in treating an AVM.

Intracerebral hemorrhage (ICH)
An intracerebral hemorrhage is bleeding in the brain. This is most commonly caused by uncontrolled hypertension.

Intracerebral hemorrhage treatment
When small, ICH can be managed medically. However large bleeds (hematoma) compress vital structures of the brain and the blood itself is toxic to the brain.  These large may need to be removed surgically. Your doctors at Prisma Health-Upstate may elect to perform a minimally invasive procedure to remove the hematoma. Studies shows that if you can remove the hemorrhage in a minimally invasive manner, the patients will leave the hospital sooner and achieve a better outcome. The team at Prisma Health-Upstate were early pioneers of this surgery and have the one of the highest experiences with this surgery in the US. Due to this expertise, they have access to the latest FDA approved devices and are currently one of only a handful of hospitals in the country that have the latest technology to treat this disease.

These procedures are performed through a small dime sized-hole in the skull. Using image guidance, small camera is used to see as the bleed is controlled and the blood clot is removed.

Idiopathic Intracranial Hypertension
Idiopathic intracranial hypertension (IIH) also known as pseudotumor cerebrii or benign intracranial hypertension is a disease that most commonly affects obese females in their 40s. Patients commonly present with frequent headaches, visual changes (blurred vision, double vision) and occasionally ringing in their ears. Left untreated visual changes may progress to blindness. These symptoms are due to raised intracranial pressure. Treatment revolves around reducing the pressure of the CSF (the fluid that covers the brain).

Treatment for IIH:

  • Medical therapy: medicines such as acetazolamide maybe given to reduce the production of CSF.
  • CSF diversion: a shunt may be placed into the spaces of the brain and then tunneled to the abdomen to help drain off the CSF fluid to reduce the pressure.
  • Sinus stenting: Newer studies have shown the increase in pressure maybe due to a narrowing in one of the dural sinuses (large vein) and that a procedure called sinus stenting maybe better than a diversion procedure to reduce the intracranial pressure. In this procedure a small stent is placed into the dural sinus (large veins of the head) to improve flow of CSF and reduce the overall pressure inside the head. This procedure has been shown to reduce headaches in up to 80% of patients and arrest the deterioration of visual changes in almost all patients.

Congenital Vascular Anomalies

What are congenital vascular anomalies?
The congenital vascular anomalies can essentially be divided into two groups: tumors and malformations.  Tumors are characterized by cellular growth and these lesions can grow at a rapid pace. The malformations however do not grow, per se, but grow in conjunction with the growth of the child.

Tumors Malformations
Hemangiomas Lymphatic Malformation

Venous Vascular Malformations

Arteriovenous Malformations

What are Hemangiomas?
Hemangiomas are the most common benign tumor of infancy and occur in up to 10% of Caucasian infants and are 3-5 times more common in females. The majority of hemangiomas occur in the head and neck area. Less than 25% occur in the trunk and 15% occur in the arm or legs. Hemangiomas while most commonly grow on the skin, can grow on any internal organ such as the liver, gastrointestinal tract, lung and even the brain.

Hemangiomas are usually first noticed shortly after birth. Rarely, they can be present at birth. Hemangiomas have a classic rapid period of growth (proliferative phase) followed by a period of regression (imvolution phase). Large hemangiomas and hemangiomas that have not regressed should be treated.

What do hemangiomas look like?
Hemangiomas vary from small raised redish lesions to large firm masses.

What is a congenital vascular malformation?
Vascular malformations are benign lesions of the lymphatics, arteries and veins. All vascular malformations are present at birth although they may not be visible.  Vascular malformations, unlike hemangiomas, do not have a rapid period of growth but grow slowly though out life, growing in conjunction with the growth of the child.  The most common types of vascular malformations are:

  1. Capillary malformations or port wine stains.
  2. Venous malformations: these are soft bluish lesions that are commonly seen on the lips, tongue and cheek.
  3. Lymphatic malformations: these are a collection of abnormal channels and cystic spaces that contain clear fluid. They are also known as “cystic hygromas”
  4. Arteriovenous malformations are abnormal connections between arteries and veins resulting in high flow pulsating masses.

How are hemangiomas and vascular malformations different?
All vascular malformations are present at birth while most hemangiomas appear shortly after birth. Hemangiomas have a period of rapid growth (over months) and then regress (over years), while vascular malformations grow slowly and never disappear. Vascular malformations can experience periods of rapid growth during times of infection and hormonal change (puberty and pregnancy).

How are Hemangiomas and vascular anomalies treated?
The majority of small hemangiomas disappear on their own; most small hemangiomas can be treated conservatively, that is with careful observation. Large hemangiomas or hemangiomas in cosmetically sensitive locations that are disfiguring or those that hinder important functions such as vision or breathing should be evaluated by a vascular anomalies specialist. Treatment may consist of medical therapy with propranalol, surgery, embolization or sclerotherapy.

Treatment of the vascular anomalies depends on the type. Laser therapy can be used to treat capillary malformations. Arteriovenous malformations are treated with embolization while lymphatic malformations and venous malformations can be treated with sclerotherapy.

What is sclerotherapy?
Sclerotherapy is a minimally invasive, image guided treatment used to treat certain types of vascular anomalies. It involves injecting a special material, called a sclerosant, directly into a vascular anomaly in order to bring about scarring.

Who treats hemangiomas and congenital vascular anomalies?
Hemangiomas are can be treated by pediatricians, pediatric ENT, dermatologists, plastic surgery and radiology.