Leading the Way in Cerebrovascular Care

When 17-year-old Isabella’s heart went into arrhythmia, it triggered her implanted defibrillator. The device kick-started her heart, but it also pushed a blood clot caused by her arrhythmia into her brain. It blocked a blood vessel and caused a stroke.

Immediately, a cascade of time-sensitive events set into motion. Isabella needed quick care. She was an otherwise healthy cross-country runner at Ballard High School. But she was also on the heart transplant list. That fact made swift intervention even more critical.

“Isabella couldn’t move one side of her body, so the wonderful pediatric neurologists at Seattle Children’s immediately sent her to us,” says UW Medicine neurological surgeon Michael Levitt, MD. “We got into her artery, removed the blood clot and she got better right there on the table. She was out of the hospital in time to go to her prom. Plus, our fast work meant she avoided any lasting signs of stroke and was able to get the heart transplant she needed.”

Close internal collaborations like this between UW Medicine neurological surgeons and neurologists lead to successful stroke treatments, as well as therapies for a wide variety of cerebrovascular conditions.

Providing expert clinical care

Like Isabella, hundreds of patients come to UW Medicine for ischemic or hemorrhagic stroke care every year, Levitt says. Other patients need care for brain aneurysms or blood vessel problems, such as arteriovenous or cavernous malformations, which can lead to stroke. These cerebrovascular conditions can be complicated, but our providers adopt a straightforward approach to addressing them.

“At the simplest level, vascular surgery is just like plumbing. Blood vessels are the pipes to the brain. If they’re blocked, you open them up. If they’re leaking, you close them off,” Levitt says. “The only difference is that the instruments we use are very small and the stakes are very high.”

As the first certified Joint Commission Comprehensive Stroke Center in Washington, Harborview Medical Center offers the most advanced cerebrovascular surgical services available:

  • Minimally invasive endovascular treatment and microsurgery for brain aneurysms
  • Gamma Knife® radiosurgery and microsurgery for arteriovenous malformations and cavernous malformations
  • Intravenous therapies and mechanical thrombectomy for stroke
  • Surgical treatment for Moyamoya disease

Harborview patients also have access to advanced medical interventions, says UW Medicine vascular neurologist Arielle Davis, MD. Our providers administer the clot-busting medication Tenecteplase to patients with acute ischemic stroke. Recent research has shown this drug is non-inferior to alteplase and is easier to deliver both in the hospital and during transport for cases requiring transfer for thrombectomy. For patients with a large vessel occlusion, mechanical thrombectomy offers a potentially larger impact on patient functional outcomes. While not always the case, in the most dramatic scenarios, successful thrombectomy can transform an aphasic and hemiplegic patient into someone who can walk out of the hospital, thanking staff.

However, some of our most significant clinical work comes through our preventive efforts.

“We have an eye toward primary or secondary prevention therapies, such as effective hypertension screening and treatment. These efforts have the potential for making a huge impact on patients,” Davis says. “Up to 50% of the attributable risk of stroke is due to hypertension. So, aggressive primary and secondary prevention remains essential and critical.”

Conducting leading-edge research

In addition to being clinical leaders, our neurological surgery and neurology experts are at the forefront of research, Levitt says.

“We’re very active in both neurology and neurological surgery investigations,” he says. “We’re using cutting-edge approaches to try to restore or reverse some of the damage caused during a stroke.”

  • Autologous mitochondrial transplant for stroke: The lack of blood flow during stroke damages mitochondria in brain cells, so our neurological surgery researchers are investigating whether injecting a patient’s own mitochondria into blood vessels during stroke treatment can help control or reverse brain damage.
  • Immune and inflammatory responses: Neurology researchers are examining immune and inflammatory responses to cerebrovascular disease. They aim to identify intervention targets that could prevent stroke or improve patient outcomes.
  • Observational research: Using funding from the National Institutes of Health, our investigators are conducting observational research around the effects of palliative care for patients with severe brain injury, obstructive sleep apnea treatment after stroke, computer simulations of brain aneurysms and advanced imaging for improved ischemic stroke phenotyping.

Working together

Our streamlined neurological surgery and neurology partnerships make it easier to use our high-quality clinical care and research efforts to help patients, Davis says. Opportunities to work together can arise in the moment or on a planned schedule.

“I truly value the close collaborations between our two departments,” she says. “We can discuss patients in real time, at all hours of the day or night, to quickly review their history and imaging. It all helps us make the best clinical treatment decisions.”

During emergency stroke cases, UW Medicine activates an interdisciplinary stroke team of neurological surgeons, neurologists, imaging technicians, interventional and neuroradiologists, anesthesiologists, laboratory staff, neurocritical nurses and pharmacists. Patients quickly get a head CT scan — in an average of six minutes — before going to the surgical suite. The goal, Levitt says, is to start stroke treatment as quickly as possible.

“We’re like a NASCAR pit crew,” he says. “Everyone knows their job.”

Although these teams work like well-oiled machines, there’s always room for improvement. That’s why the neurological surgery and neurology teams come together weekly for a stroke conference. They review and discuss clinical cases, pinpointing where they can make changes that will boost patient care.

“We go through every case and make sure we completed procedures according to best practices. It’s our deep dive into quality care,” Levitt says. “We’re always asking ourselves, ‘Were we fast enough?’ or ‘Are we missing anything we need to deliver better care?’”

Ultimately, he says, this level of neurological surgery and neurology coordination ensures UW Medicine patients receive the highest level of care available.