Neurovascular Intervention

Navigation in neurovascular interventions is currently hindered by the fact that the vessel infrastructure and the instruments are only shown simultaneously in a single real-time image during the use of a roadmap. An image guidance system based on a single C-arm is proposed, which will enable a 3D-roadmap showing a blended image of a 3D-rotational angiography and a real-time fluoroscopy image. The images are combined using machine-based registration, employing sensors mounted on the patient table and the C-arm. The setup of the system and its implications for the interventional procedures are described. The feasibility of the system is discussed with respect to the desired accuracy of matching and speed. The 3D-roadmap is expected to enhance 3D-insight for the interventionist and will facilitate instrument navigation. Implementation of the system will lead to a reduction both of the X-ray dosage and of the use of contrast agent.

Neurovascular Surgery and
Neurosurgical Critical Care

Murat Gunel, MD
Chief

Program

Purpose/Goals

The Yale Neurovascular Program is committed to clinical excellence, superlative technical performance and innovation in diagnosis and therapy. The Program is entrusted with all facets of management of stroke and cerebrovascular disorders and the coordination of subsequent therapeutic strategies including surgery, interventional neuroradiology, stereotactic radiation (Gamma Knife Surgery), and rehabilitation. The Program is an integral part of the multi-disciplinary Yale Cerebrovascular Center, which includes the Vascular Neurology and Interventional Neuroradiology Programs. Together, these resources create a Neurovascular Program unique in breadth and depth nationally with latest techniques and modalities not available elsewhere in Southern New England. Among special services provided is the diagnosis and treatment of the following:

Aneurysms

á Microsurgery and Endovascular Coiling

á Vascular malformations

á Arteriovenous Malformations (AVM)

áMicrosurgery
áEmbolization
áGamma Knife Surgery

á Cavernous Malformations

á Acute stroke and occlusive disease management including
 

á Carotid disease- Carotid Endarterectomy and Stenting

The Neurovascular Surgery Program and NICU operate at the center of critical multidisciplinary interfaces related to cerebrovascular disease and acute brain injury.

In addition to the research collaborations, there are essential clinical collaborations integrating outpatient evaluations and the inpatient clinical service with the Vascular Neurology Program. A single phone number is used for patient access with clinical coordinators from both programs deciding whether the patient should be seen by a vascular neurosurgeon, a vascular neurologist or both, often arranged at the same clinic.

On the inpatient service, hemorrhagic stroke patients and cases with stroke and multisystem disease or elevated cranial pressure are managed jointly with the Neurology Service and the Stroke Service.

A weekly multidisciplinary Cerebrovascular Conference is an essential core of multidisciplinary case discussions, and includes participation from the vascular neurology, neurovascular surgery and vascular neuroradiology programs, as well as attendance by other services and by community referring physicians. Discussions are clinically based and allow refinements of ongoing inpatient and outpatient protocols. Weekly lectures allow discussion of a variety of related clinical and basic science topics and review of the relevant literature in regular journal clubs.

Other interactions with the Department of Surgery include collaboration in the Trauma Program where neurosurgical residents respond acutely to every case of major trauma for prompt neurologic evaluation. All neurosurgery residents have achieved certification by the Advanced Trauma Life Support course during this year. We also provide neurosurgical input at multidisciplinary trauma conferences and quality improvement seminars.

An ongoing collaboration with the Yale Section of Ear Nose and Throat Surgery allows the management of complex head and neck tumors involving the carotid artery. Controlled therapeutic occlusion of the internal carotid artery is frequently undertaken under a strict management protocol designed to minimize complications and study the consequences of this drastic neurovascular intervention. Collaborations with the Department of Diagnostic Radiology span the full range of clinical and research activities of our Program, including management of ischemic and hemorrhagic stroke, and close collaboration in the management of every case undergoing therapeutic neuroradiologic intervention.

The Multidisciplinary Yale AVM group includes the largest volume of clinical cases with hereditary hemorrhagic telangiectasia in the United States, and provides comprehensive multidisciplinary management of this rare entity.

• Interaction with Other Hospitals

Faculty from the Yale Neurovascular Program participate in clinical coverage at St. Mary's Hospital and Waterbury Hospital in Waterbury, and at Backus Hospital in Norwich for occasional weekends throughout the year. We provide consultative assistance to neurosurgeons in the community throughout Connecticut and the tri-state area, with the aim of referral of patients with complex cerebrovascular disease for advanced treatment at Yale. These clinical and programmatic collaborations are complemented by regular continuing medical education lectures provided at a number of Connecticut hospitals throughout the year.

• Neurosurgical critical care

The program is also entrusted with clinical operations and quality assurance in the Neurovascular-Neuroscience Intensive Care Unit (NICU) at Yale-New Haven Hospital, providing acute care for brain and spinal cord injury patients, acute stroke, and postoperative care of neurosurgical patients.

This clinical mission is complemented by an academic commitment to advancing knowledge and the quest for truth through basic and applied research, and the education of physicians and scientists at all levels about every facet of cerebrovascular disease and acute brain injury.

• Education

The Program participates in regular lectures to rotating medical students in neuroscience clerkship, addressing topics of stupor and coma, central nervous system injury, intracranial pressure, acute ischemic stroke and acute hemorrhagic stroke.

In addition, the Neurovascular Surgery Program at Yale has developed written curriculum objectives for resident training at the junior, assistant resident and senior resident level in cerebrovascular disease and neuro-critical care. These include specific knowledge-based objectives, as well as technical skills which must be achieved at every level of training. This curriculum was integrated in the neurosurgical residency training program at Yale during the current year, and has been used as a model for developing similar curricula at the national level, under the sponsorship of the Cerebrovascular Section of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. It is anticipated that these neurosurgical residency curriculum guidelines will form the basis of a multidisciplinary broad curriculum endorsed by national organizations.

The Program participates in a number of educational activities throughout the state. We are represented in the Connecticut Trauma Committee and in the local affiliate of the American Heart Association, and participate in their regular public information and regional scientific fora. Faculty from the Neurovascular Surgery Program present regular lectures at various community hospitals in Connecticut. Research Progress Interaction with Other Departments.