By Annie Alleman

Neurosurgeon Shakeel A. Chowdhry, MD, FAANS, FACS, FAHA, recently cared for a young woman at Endeavor Health Edward Hospital in Naperville who had a rare, giant thrombosed (or partially clotted) cerebral aneurysm that had ruptured. She was treated with complex surgical clipping using intraoperative angiography and recovered well, returning home to her husband and two children two weeks after her surgery.

Dr. Chowdhry is the Section Chief of Cerebrovascular and Endovascular Neurosurgery with Endeavor Health Medical Group and sat down with us to discuss innovations in stroke care.

Early training and a growing interest in neurosurgery

While he is passionate about stroke care, Dr. Chowdhry said he did not always plan on becoming a neurosurgeon. He initially considered orthopedic surgery; and it was in his third year of medical school and his rotation in neurosurgery at Georgetown that his focus changed. Dr. Chowdhry did his training at Case Western Reserve University in Cleveland, where he was drawn to cerebrovascular surgery.

“My father is a cardiac surgeon. That’s basically a blood vessel surgeon of the heart. I consider myself a blood vessel surgeon of the head. My brother is an interventional radiologist. I do a lot of things in the interventional radiology suite, such as aneurysm coilings, stroke thrombectomy and other catheter-based work. In that way, my practice overlaps a bit with that of my father and my brother.”

How stroke care has evolved

He notes that stroke care has transformed considerably since he became a doctor. That care continues to evolve, influenced by advancing technology as well as improved understanding of stroke.

The young woman Dr. Chowdhry recently cared for had experienced a bleeding, or hemorrhagic stroke, due to a ruptured aneurysm. Unlike most aneurysms, that rare aneurysm also had a significant clot burden making it a unique aneurysm requiring complex surgical treatment.

Dr. Chowdhry sees patients with ischemic strokes (strokes due to vessel blockage) and hemorrhagic strokes (strokes due to bleeding within the brain).

“I tend to see people in the acute situation that are suffering a stroke, but I also will see patients that have underlying conditions that increases their risk for stroke. Some surgeries are done after a stroke has occurred in order to limit or reverse the injury from the stroke. Others are done in patients with risk factors to treat the underlying problem and prevent a stroke from happening,” he said.

For example, Dr. Chowdhry noted that ischemic strokes can occur from heart issues where clots can travel to the brain and need to be removed emergently. Clots can also come from blockages in the artery of the neck which can be treated with removal (endarterectomy) or stenting. Bleeding strokes can be due to underlying disease, such as a cerebral aneurysm, arteriovenous malformation, or arteriovenous fistula. If these are identified early, they can be treated and mitigate the risk for stroke.

Most strokes are ischemic strokes in which a blood vessel is blocked. Treatment can include medication or use of a device to physically remove the blockage. When Dr. Chowdhry was in training, they used corkscrew devices to try to grab the clot or a device to try to morselize and aspirate it.

“The success rates were not excellent, and the procedures took a very long time,” he said. “The devices have improved and our ability to assess patients quickly and efficiently using advanced imaging has improved. So, instead of taking six hours for a stroke intervention they routinely take less than 30 minutes with high success rates.”

Improvements in the devices now allow for large catheters to essentially suction the clot out of the vessel to restore normal blood flow. The larger devices account in large part for the higher success rate. Stent retriever devices can also be used to remove the blockage by grabbing the clot and pulling it out of the blood vessel. Several improvements have been made with these devices, as well increasing their ease of delivery and success rate.

Reducing stroke risk

While lifestyle choices, like diet, exercise and smoking, play a role in cerebrovascular health, there are also genetic factors, Dr. Chowdhry said.

“Some people don’t take great care of themselves but do not end up with vascular problems — genetics does play a role in it,” he said. “Some people who do everything they possibly can right in life still have to deal with vascular disease because of a genetic predisposition to that.”

“With regards to vascular lesions, most of the aneurysms in the brain do not have a genetic or familial component. Only about 20 percent of them do. Similarly, most AVMs and fistulas are sporadic.”

Hardening of the arteries in the neck or issues with the way the heart pumps blood can increase the risk of stroke, he said.

Treating cerebrovascular disease

Treatment for cerebrovascular disease needs to be tailored to the patient and the disease because the various cerebrovascular diseases and conditions, such as stenosis, thrombosis, aneurysms, fistulas, AVMs and hemorrhagic strokes, require different treatment.

“All of these things, across the gamut, all have had advancements in the past five years that have changed care,” Dr. Chowdhry said. “The way we manage blood pressure is not necessarily different but there are a number of new medications that have come on the market that help with that. Our understanding of how the medications interact have changed too.”

“The importance of investing in our own health, particularly with things like blood pressure, are important but also we know that when it comes to things like congestive heart failure, there have been improvements in the control and management from a medication standpoint that change our risk of forming clots in the heart that can then go to the brain.”

Similarly, the management of atrial fibrillation (AFib), or abnormal rhythm of the heart, has changed, he said, including ablation techniques and anticoagulation options. Aggressive marketing and public exposure have raised awareness of the disease in the last 10 years, he said, citing a commercial with basketball legend Kareem Abdul-Jabbar.

Treatment advances for stenosis

When patients come in with carotid stenosis and are showing symptoms in the form of small strokes or TIAs, there are new ways to fix that carotid artery, Dr. Chowdhry said.

“One way is to open that artery itself and clean it out. It is the most classic way of doing it,” he said. “There are stents that can be placed in the vessel as well. The stent technology has progressed and changed over time. We have classically put the stent through an artery in the leg, but now we can do it often through an artery in the wrist. Sometimes, when needed, we can open the artery directly in the neck and put the stent in that way.”

If stenosis occurs in the brain and treatment with medication is not an option or has failed, there are new stents and balloon catheters to allow for opening the vessel more safely, he said.

“There are also surgical options to re-route blood vessels. This is one of the things I do too, in patients that are symptomatic from blood flow problems. We will take blood vessels that are outside the brain and connect them directly into the brain to provide blood flow to the brain to prevent strokes.”

When doing this type of surgery, marked enhancement in visualization with microscopes and exoscopes allows doctors to see the vessels in great detail, as the ones being sewn together can be under 1 millimeter (1/25^th of an inch) in size. There are ways to visualize blood flow in the vessels using infrared light as well.

Treatment advances for aneurysm

With regards to aneurysm treatment, there have been numerous developments over the recent years. “Initially, the thought was that you needed to fill the aneurysm to prevent it from bleeding. Coils would be put in one after another, over and over, until it was completely filled. If the aneurysm has a wide neck, sometimes this was not possible. Then stents came around to help hold those coils in place. That technology evolved so stents were later developed that would divert flow away from the aneurysm,” he said.

“Now we use devices with as much as metal as those flow diverting stents shaped into a compressive device that can be deployed directly into the aneurysm, such as the WEB device. There are a lot of variations, and all of this stuff is relatively new.”

Another device, called the Contour, is similar and is placed inside the aneurysm to treat it. This can be used on its own or with coils. At the same time, there have been significant enhancements in coil technology.

“The types of coils that are available now are significantly different in their behavior, so we have a lot more ability to control them and their position inside the aneurysm,” Dr. Chowdhry said. “Most recently, some of our significant improvements involve how we can get the treating devices into the head and ultimately to the site of treatment. The different catheters that we use have gotten so much better. Annually, there are different devices coming onto the market. Staying abreast of these allows us to continue to provide the best possible care for our patients.”

As for Dr. Chowdhry’s patient with the ruptured giant aneurysm, he noted that her rare aneurysm required a multimodality approach using open surgical and endovascular techniques. Dr. Chowdhry emphasized the importance of obtaining care for cerebrovascular disease at centers like Endeavor Health where high-level care using all treatment modalities and a large multidisciplinary cerebrovascular team allows for the best possible outcomes.

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