Stroke specialist on endovascular neurosurgery and why it's better for some patients

What excites Thana Theofanis, MD, a neurosurgeon and stroke specialist on the team at Main Line Health-Jefferson Neurosurgery, about what's happening in her field, is the way endovascular treatments are being applied to different vascular diseases of the brain.

A person could come to the hospital having a stroke with a major blocked artery in the brain, says Dr. Theofanis. "We can go in through the patient's wrist, reaching all the way up to the brain to get access to the blockage and surgically remove the blood clot."

Compared to traditional vascular neurosurgery, where open brain surgeries used to be the only role of the neurosurgeon, the era of endovascular neurosurgery is one of constant change and innovation. While the only option for endovascular procedures used to be accessing the femoral artery through the groin-a more sensitive and often more painful area-endovascular treatments today, including diagnostic angiograms, can be done through the radial artery in the wrist.

Postoperatively, for a radial access procedure, a band just needs to go on the wrist for one hour with no activity restrictions; this limits the amount of time the patient has to spend in the hospital if they're getting a same-day procedure. Endovascular surgery is minimally invasive and speeds up diagnosis, treatment and recovery for patients.

Stroke treatments keep getting better

Twenty-five years ago, says Theofanis, stroke wasn't even considered a surgical disease.

"When someone came into the ER having a stroke, you basically just watched it happen. Then came tPA, the clot-busting medication, and then if you got to the hospital within six hours of having a stroke, you could go for an interventional procedure."

Under the new stroke guidelines and with the assistance of sophisticated imaging and procedures, stroke specialists like Theofanis have up to 24 hours to perform an interventional procedure, such as thrombectomy, involving removing blood clots from the veins or arteries.

"The different ways of treating brain aneurysms are also much more sophisticated," says Theofanis.

"Before, the only endovascular option was coiling. Now we have flow diverters, which are special types of stents to remodel the blood vessel to eliminate the aneurysm. We also have the web device that almost fills the aneurysm like a balloon, shutting it down."

What all this means for patients is that neurointerventionalists have more efficient and effective ways of saving and improving lives while also minimizing patient down time and recovery.

App streamlines stroke care and coordination

Theofanis and her colleagues now use Viz.ai, an FDA-cleared stroke triage application that physicians download to their phones. If a stroke patient comes to Bryn Mawr Hospital, for example, as soon as the stroke CT scan is done, the image is sent directly to the app and the physician gets an alert that the patient just got a CT scan.

The physician is able to open the app and look at the image right away. This is particularly helpful when there's a large vessel occlusion (blockage). The neurointerventionalist has the technology at their fingertips to quickly detect the vessel occlusion and make a decision whether to proceed with thrombectomy.

Theofanis calls it game-changing, given the limited number of neurointerventionalists at any hospital, and the fact she can have her phone handy to pull an image up, make a decision quickly, and communicate with others who are using the app, such as radiologists or people in the emergency department vs. receiving a communication and having to bring up her laptop and go through security and communication checks.

"In terms of patient outcomes, the only consistent thing is that the faster you get a patient to mechanical thrombectomy, the faster you get the vessel open. The biggest stride we're having with this application is that it eliminates steps that are unnecessarily time-consuming."

Since everyone has sophisticated cell phones these days, Theofanis continues, "The app is in some ways as good or better than desktop. The images are very good, it's pretty remarkable, and the information you're able to get is very useful and meaningful for patient care."

Neurointervention and patient care

Getting through the toughest parts of the journey together with her patients is one of the aspects of her work Theofanis appreciates the most.

"I'm often with patients at a very critical time-especially if they're having a stroke or ruptured brain aneurysm-and develop a special bond with the patient and the family. We get through a difficult time together in the hospital as the family places trust in our neurosurgical team, knowing we're providing the patient with top neurological care. And then during recovery, to be able to look back and say, 'We all got through that together.'"

Some of the patients Theofanis sees come to her when something has been discovered incidentally. A patient with headaches and dizziness may get a brain MRI, for example, which should be followed up with a visit to the neurosurgeon. "It's still important to see a neurosurgeon even if it's not emergent," says Theofanis.

On the other hand, if a scan incidentally discovers a brain aneurysm, a neurosurgeon can take a look and determine whether there are high-risk features that warrant elective treatment or to just keep an eye on the aneurysm. A neurosurgeon who subspecializes in brain aneurysms can also point out the nuances, as well as risks and benefits of various courses of action.

Did you know?
A new neurointervention lab is opening at Paoli Hospital in Spring 2022-delivering world-class care not usually found in the community.

As for being a female neurosurgeon in a male-dominated field, says Theofanis, she's grateful to have a female partner, neurosurgeon Michelle J. Smith, MD, at Main Line Health-Jefferson Neurosurgery. During her training, Theofanis was also fortunate to be mentored by a female faculty member, Dr. Stavropoula Tjoumakaris.

"A lot remains to be done as women are still in the minority in surgical subspecialties-especially neurosurgery/neurointervention-but it's been gratifying for me as I've climbed the ranks to be an example. Students, even nurses and residents, seem to appreciate seeing a more gender-diverse leadership. I think it's good for overall morale of the team."

Main Line Health serves patients at hospitals and health centers throughout the western suburbs of Philadelphia. In addition to stroke and aneurysm, Dr. Theofanis also treats patients with brain tumors.

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