David Fiorella, MD, PhD: Advanced Stroke Treatment at Stony Brook University Hospital

By Katy Mena-Berkley
Thursday, November 14, 2019

David Fiorella, MD, PhD, Professor of Neurosurgery and Radiology, Director of the Stony Brook Cerebrovascular Center and Co-Director of the Stony Brook Cerebrovascular and Comprehensive Stroke Center, provides mechanical thrombectomy and other highly effective treatments to promote excellent outcomes among patients with stroke.

When individuals arrive at Stony Brook University Hospital with symptoms of stroke, they are in the care of expert clinicians at the first Joint Commission-certified Comprehensive Stroke Center in Suffolk County. For those diagnosed with acute ischemic stroke, the comprehensive treatment options may include lifesaving, function-preserving mechanical thrombectomy. Dr. Fiorella and his team perform well over 100 of these minimally invasive endovascular procedures each year to remove occlusive thromboemboli blocking critical blood flow to the brain.

“Multiple concordant randomized controlled trials have demonstrated that patients who undergo thrombectomy have substantially better outcomes than patients who are treated with medical management, including intravenous tPA,” says Dr. Fiorella, a board-certified, fellowship-trained neuroradiologist. “In fact, many patients who undergo mechanical thrombectomy shortly after the symptoms present can have normal or near-normal outcomes after what otherwise would have been devastating or deadly ischemic strokes.”

To determine whether a patient is a candidate for mechanical thrombectomy, Dr. Fiorella and his colleagues look for large vessel occlusion. This evaluation begins with a physical examination and history, followed by an immediate CT scan of the brain.

“The initial CT scan gives us important information. First is whether it is a hemorrhagic stroke, meaning a stroke secondary to bleeding in the brain, or an ischemic stroke, meaning a stroke secondary to a blocked blood vessel in the brain,” Dr. Fiorella explains. “The therapies for these two conditions are obviously divergent. So for a hemorrhage in the brain, the strategy is to control blood pressure and, in many cases, to reverse any anticoagulation that’s taking place. For ischemic stroke, the important thing is to remove the blockage.”

To determine if the blockage is due to a large vessel occlusion, clinicians conduct a computed tomography angiogram (CTA) after injecting intravenous dye to pacify the blood vessels in the brain and reveal any large vessel occlusion. A CT perfusion study may also be conducted to gather information about the volume of irreversibly injured brain and the ischemic penumbra that is endangered if the area of occlusion is not promptly addressed with mechanical thrombectomy.

To eliminate blockages, neurointerventionists may administer intra-arterial tPA in the case of minor strokes or intra-arterial tPA plus mechanical thrombectomy or mechanical thrombectomy alone for patients experiencing emergent large vessel occlusions.

To perform mechanical thrombectomy, a neurointerventionist relies on fluoroscopy to place a catheter in a blood vessel leading to the brain. The neurointerventionist then threads a smaller catheter through the larger one, guiding the smaller catheter into the actual circulation of the brain before inserting a stent retriever through the tiny tube. Using the stent retriever, the neurointerventionist mechanically captures and extracts the occlusive thromboemboli.

A 2019 meta-analysis in The Scientific World Journal found that mechanical thrombectomy “results in favorable outcomes at long-term follow-up for patients with acute ischemic stroke compared to standard medical treatment alone.” The study assessed measures of cognitive function, functional independence and quality of life.

“Mechanical thrombectomy maximizes preservation of viable brain,” Dr. Fiorella says. “The more viable brain that the patient has to enter rehabilitation with, the more successful rehabilitation will be and the more complete the patient’s recovery will be.”

Patients presenting with stroke at Stony Brook University Hospital’s Emergency Department benefit from rapid access to cerebrovascular suites for emergent revascularization. This reduces door-to-treatment time and improves outcomes. An experienced neuroanesthesia team fosters excellent outcomes as well.

“We have a dedicated cerebrovascular neuroanesthesia team,” Dr. Fiorella says. “That’s best practice, and it makes our Comprehensive Stroke Center stand out among other centers across the country.”

Mobile Solutions for Timely Treatment

To further expedite delivery of mechanical thrombectomy and other vital treatments for patients with stroke, Stony Brook Medicine has developed a mobile stroke unit program, the first of its kind on Long Island.

“This is a tremendous investment in improving stroke treatment,” Dr. Fiorella says of the units, which are ambulances equipped with leading-edge technologies to provide rapid, tailored care. “These units are strategically positioned along the Long Island Expressway and each covers a 10-mile radius, so people from the western end of Suffolk County all the way to Riverhead can access mobile stroke unit care.”

Each unit functions as a mobile stroke ER, enabling first responders to consult with Stony Brook ER physicians and stroke neurologists in real time through teleneurology. Often, those consultations and the mobile stroke units’ advanced technologies allow the crews to deliver initial treatment in the crucial minutes before the mobile stroke units reach a medical facility. They also help ensure patients who require mechanical thrombectomy are taken immediately to facilities with those capabilities, rather than having to be transported a second time. The units have CT scanners as well to perform on-site imaging and contrast injectors for CTAs.

“A person with suspected ischemic stroke and CT scans that show no hemorrhage can be administered intravenous tPA on-site, which markedly reduces the time to treatment. Intravenous tPA’s effectiveness is directly related to the time of administration,” Dr. Fiorella says. “We’re literally in some cases cutting hours off the time to administration of tPA. Moreover, because we can identify large vessel occlusions on-site, we can have an entire team waiting for patients at the Emergency Department to take them to our cerebrovascular suite to perform mechanical thrombectomy.”

Leaders in Research

In addition to leading the cerebrovascular team in delivering evidence-based stoke treatments, Dr. Fiorella and his colleagues conduct cutting-edge clinical trials building on the understanding of mechanical thrombectomy’s benefits after acute ischemic stroke. They are also active in trials to treat other types of stroke and cerebrovascular disease.

“Our involvement in these trials means that people we serve can gain early access to state-of-the-art devices and procedures that are unavailable at most other centers in the United States,” Dr. Fiorella says. “Medical care in the context of a clinical trial is often the most advanced care you can receive.”

Visit neuro.stonybrookmedicine.edu/centers/cvsc for more information.