Options widening for wide-necked aneurysms

16 Pages·2011·8.31 MB·English

Cerebrovascular Issue
Newsletter of the Swedish Neuroscience Institute Winter 2010
Options widening for wide-necked aneurysms
Yince Loh, M.D., Interventional Neuroradiology
Swedish Neuroscience Institute
Intracranial aneurysms are present in up to Those aneurysms that have a balloon-like
4 percent of the population. These potentially opening, or neck, from the parent vessel are typi-
dangerous vascular lesions are being detected cally good candidates for coiling. Not infrequent-
with increasing frequency in asymptomatic pa- ly, however, the aneurysm’s shape does not permit
tients by advances in noninvasive imaging tech- safe coiling. When the aneurysm’s neck is wide, it
niques, such as magnetic resonance angiography appears more like a molehill than a balloon (see
(MRA). Appearing like blisters on the wall of the Figure 1). A molehill configuration is often re-
brain’s blood vessels, aneurysms develop when the ferred to as a “wide-necked aneurysm.” The wide
In This Issue blood vessel’s native repair ability is exceeded by neck allows an unwanted protrusion of coils back
the mild, but constant, injury created by flowing
Wide-necked aneurysm
blood under high pressure. The five most com-
options
mon risk factors for developing an aneurysm are:
Detecting cerebral
smoking, female gender, high blood pressure,
microemboli
middle age and family history.
Advances in thrombolysis
Intracranial aneurysms are complex lesions
MR perfusion imaging in that require a highly specialized, multidisciplinary
A brain aneurysm
cerebrovascular disease approach that is individualized for each patient.
Key members of the care team for these patients
Emerging concepts:
TIA clinics include endovascular neuroradiologists, neuro-
surgeons with special expertise in aneurysm sur-
PFO closure for migraine
gery and neuroanesthesiologists. Availability of
Approaches to AVM/AVF dedicated neurocritical care units is an essential
care component. A consensus recommendation
SNI clinical trials
by these specialists may include close observation,
Around SNI obliteration of the aneurysm with a surgical clip, A wide-necked
brain aneurysm
or filling the vascular outpouching with filamen-
Transcranial
tous coils that are introduced by endovascular Figure 1. Brain aneurysm vs. wide-necked brain aneurysm
magnetic stimulation
microcatheters via an artery in the leg. This latter (Illustration courtesy of Boston Scientific Corporation)
Bike MS Ride process is called “coiling.” (Continued on page 3)
Brain Cancer Walk
Detecting cerebral microemboli with transcranial doppler
Summer student
research program Colleen Douville, RVT, Director, Cerebrovascular Ultrasound, and
David W. Newell, M.D., Cerebrovascular Neurosurgery
WebEx® remote
Since its introduction in 1982, transcranial for detection of a variety of substrates, including
conferencing
doppler ultrasound (TCD) has evolved into a por- thrombotic, platelet and atheromatous emboli.
SNI lab accreditation table, multimodality, noninvasive method for real-
Microembolic signals (MES) within the in-
time imaging of intracranial vasculature.
SNI updates tracranial vasculature are most frequently identi-
The detection of cerebral microemboli is fied in patients with large-vessel atherosclerotic
SNI Directory
among the more remarkable capabilities of TCD. disease, such as carotid stenosis. They have also
Introducing: Pediatric Emboli create countable signals in the ultrasound been reported in intracranial arterial stenosis, ar-
Neuroscience Center
display due to the higher reflection of sound waves terial dissection, cardiac disease and atheroaortic
compared to the blood cells. Experimental mod- plaque. Additionally, they have been seen in arter-
els have shown a high sensitivity and specificity ies distal to coiled aneurysms.
www.swedish.org/neurosicence (Continued on page 6)
wwwww.swn.isbnloibglo.cgo.mcom Winter 2010 1
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Editorial
Swedish Neuroscience Institute
550 17th Ave., Suite 500
Launching SNIblog.com
Seattle, WA 98122
206-320-2800 John W. Henson, M.D., FAAN, Editor, and Susan Allen, Executive Editor, BrainWaves
www.swedish.org/neuroscience SNI is leveraging communication tools Other SNI communication tools
www.sniblog.com that deliver information to patients, referring At SNI we provide print and electronic
physicians and the public as a crucial part of options to meet the needs of various audi-
providing care at the advancing edge of neu- ences.
Media Inquiries
rological knowledge. The goals of these tools
206-386-2748 BrainWaves. This
are two-fold. One goal is to update established
206-405-6482 (pager) patients and their doctors regarding the latest print news letter is de-
signed to be an educa-
developments in our programs and centers.
tional resource about
Editor The other is to lower the barrier for patients
neurological topics
John W. Henson, M.D., FAAN and physicians who are facing a new neuro-
for physicians in the
logical problem to discover tertiary subspe-
Executive Editor
Pacific Northwest.
Susan Allen cialty care.
Each issue focuses on
Designer A new SNI communication tool conditions treated at SNI. Staff members au-
Rhea Bishop
Dan Rizzuto, Ph.D., thor the articles.
Production Assistant director of SNI research,
Physicians Practice.
Karen Pabillon
and John Henson,
Swedish has the exclu-
M.D., recently launched
sive contract with this
SNI Administration SNIblog.com to comp-
practice management
lement other commu-
Marcel C. Loh journal to customize
Chief Administrative Officer nication efforts and to content in six issues
Swedish Cherry Hill provide a communication
annually. Although the
outlet for the staff of SNI. SNIblog.com offers
Marc R. Mayberg, M.D. journal is not exclu-
brief notes about advances in neurological
Co-Executive Director sively used for SNI in-
care provided in SNI’s centers, as well as news
Swedish Neuroscience Institute formation, many neu-
items about the institute that are of interest to
rological topics have been covered in recent
David W. Newell, M.D.
our patients and referring physicians.
issues. Swedish maintains an online library of
Co-Executive Director
Swedish Neuroscience Institute Blog content is more dynamic than Web past content in the Health Professionals sec-
content. Search engines are able to detect tion of its website at www.swedish.org.
John W. Henson, M.D., FAAN
targeted key words within each entry, which
Director, Neurology Division Swedish Neuroscience Institute website
Swedish Neuroscience Institute helps direct highly relevant Web traffic to the (www.swedish.org/neuroscience). Earlier
blog. This aids in the dissemination of infor-
Charlotte A. Foster, R.N. this year the SNI website took on a new look as
mation to patients and physicians. Viewers
Clinical Director part of a project to redesign the entire Swedish
also can subscribe to an e-mail notification
Swedish Neuroscience Medical Center website. SNI members are now
system that will alert them to newly posted
Specialists able to directly update information about their
material.
programs, and are actively developing online
As is the case with any communication patient resources for each of SNI’s programs.
tool, however, blogs also have limitations. The SNI website is a repository of information
For example, blogs are not able to incorpo- about our neurological services, research, clin-
rate the interactive features of social media ical trials and professional expertise.
that exponentiate information transfer to a
Our goal is to continuously improve ac-
selected audience. Therefore, SNI will build
cess to neurological information and the de-
upon its existing menu of communication
livery of that information to interested groups
tools by launching social media outlets in v
of patients and referring physicians.
the near future.
2 Winter 2010 www.swedish.org/neurosicence
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Advances in thrombolysis
Bill Likosky, M.D., FAAN, FAHA, Medical Director for Stroke and Telestroke, Swedish Neuroscience Institute
Washington State has one of the high-
est stroke mortality rates in the nation. To
improve this situation, acute intervention-
al therapies for stroke are being employed
to restore circulation to ischemic brain
tissue that surrounds areas of completed
infarction, while avoiding risk of hemor-
rhage due to reperfusion of large areas of
infarcted brain tissue.
Urgent thrombolysis with intrave-
nous alteplase is the only therapy known
to improve clinical outcomes following
acute stroke. Unfortunately, alteplase has
had limited usage because many patients
arrive in an emergency department after
Stenosis of the vertebral artery origin on conventional angiogram and attendant perfusion defect in the right
the three-hour treatment window. The cerebellar hemisphere as seen on dynamic contrast enhanced (perfusion) MRI.
FDA has also approved two clot removal
and research identifying brain at risk of in- profile during this longer window for these
devices based on the ability to restore
farction following a stroke. patients appears similar to that at three
circulation. These devices are used up to
hours.
eight hours after symptom onset. Several A recent European study demonstrat-
approaches to improved acute stroke care ed the efficacy of alteplase up to 4.5 hours Another promising advance employs
are now under way, including extension after ischemic stroke in patients younger a new thrombolytic agent called des-
of the thrombolysis window to 4.5 hours, than age 80 years who have neither dia- moteplase. Derived from the saliva of the
identification of safer thrombolytic agents betes mellitus or prior stroke. The safety (Continued on page 13)
Wide-necked aneurysms
(Continued from page 1)
into the artery. This can lead to a number of an intracranial stent to be used for such
problems, including failure to obliterate the situations.
aneurysm and stroke. Thus, in situations
Once a stent is deployed across the
where an aneurysm is not surgically acces-
sible or the patient cannot undergo surgery, neck of the aneurysm, coils are placed into
no therapeutic options can be offered. the aneurysm through the stent wall. The
stent struts prevent the coils from falling
back into the artery by essentially creating
A stent is a tube made of tiny, cross-
a “chain link fence” across the neck of the
linked nickel and titanium struts
which allows the stent it to pop back aneurysm (see Figure 2). Figure 2. Stent and coil placement.
into shape after being compressed. Image courtesy of Boston Scientific. Neuroform®
Stenting, however, produces another
The stent is compressed into a Microdelivery Stent System. The Neuroform® Microdelivery
set of problems. A stent is a foreign body Stent System is approved under a Humanitarian Device
catheter with an inner diameter of
Exemption (HDE). © 2009 Boston Scientific Corporation or
that can promote formation of a blood clot
less than 1/100th of an inch. The its affiliates. All rights reserved.
inside the vessel, which is why patients
combination of the stent’s compress-
are placed on two antiplatelet medica-
ibility, flexibility and low catheter
For more information
profile makes it navigable into the tions to thin the blood, usually aspirin and
blood vessels of the brain clopidogrel (Plavix®), after placement of a The combination of stents and coiling
stent. The length of time required to thin provides a new treatment approach
Until recently, wide-neck aneurysms the blood after stent placement is unclear, for many patients with wide-necked
could not be treated by coiling. The U.S. although stents may become incorporated aneurysm. To discuss this treatment
Food and Drug Administration, howev- into the vessel wall and covered with endo- in more detail, contact Yince Loh,
v M.D., or Joseph Eskridge, M.D., at
er, has approved a tubular device called thelium within weeks.
206-320-2800.
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MR perfusion imaging in cerebrovascular disease
Todd Czartoski, M.D., Medical Director, Inpatient Neurology; and
Bart Keogh, M.D., Ph.D., Director of Diagnostic Neuroradiology, Swedish Neuroscience Institute
Recent advances in neuroimaging pro- administered during the
vide clinicians with multiple modalities for serial acquisition of MRI
assessing cerebral vasculature in patients images at 1500 ms inter-
with transient ischemic attack (TIA) and vals. MRI signal loss due
stroke. Among these, magnetic resonance to the first passage of Gd
(MR) perfusion imaging interrogates the through the cerebral vas-
physiological properties of cerebral blood culature is used to com-
flow and perfusion, thus providing ad- pare the timing of blood
ditional information to stroke specialists passing through all seg-
above and beyond the standard anatomic ments of the brain paren-
information derived from routine MRI se- chyma. (Gillard, et al.) (see
quences. Figure 1) Although there Figure 2a. MR Diffusion (left) and perfusion- weighted imaging (right)
are a number of param-
Importantly, this physiological infor- Diffusion-weighted imaging revealed
eters that can be used to detect changes in
mation is provided in the same axial two- an area of restricted diffusion in the right
blood flow, “time to peak” (TTP) is both
dimensional format as routine anatomic hemisphere consistent with a watershed
a robust and rapid method that provides
images and diffusion-weighted images type acute infarct (see Figures 2a and 2b),
clinically relevant images that emphasize
(DWI), thus allowing excellent anatomic whereas MR perfusion imaging showed
perfusion within larger brain vessels. The
correlation and detection of areas of ab- a much larger area of impaired perfusion
two cases below illustrate the clinical utility
normal perfusion that correspond to arte- affecting the right middle cerebral artery
of MR perfusion imaging using TTP maps.
rial territories and with areas of infarction. (MCA) territory. A severe, 95-percent
MR perfusion has quickly become a readily proximal right MCA stenosis was seen
Case 1
available alternative to traditional methods on cerebral angiogram. A self-expanding
A 75-year-old, right-handed patient
of perfusion measurement such as PET, stent was placed at the site of stenosis.
with hypertension and type 2 diabetes mel-
SPECT and Xenon CT perfusion. Clopidogrel was added and transcranial
litus was transferred to Swedish Medical
Doppler confirmed improved flow in the
Center with new onset of left-sided weak-
In perfusion MRI, an intravenous bo-
right MCA territory. The patient showed
ness. The patient had experienced a prior
lus of rapidly-infused gadolinium (Gd) is
slight improvement and was discharged
right pontine stroke, and stroke risk fac-
to the acute rehabilitation unit on hospital
tors had been ad-
day eight.
dressed at that time
with warfarin for
Case 2
atrial fibrillation,
A 62-year-old patient with hyper-
aggressive blood
tension, type 2 diabetes mellitus, hyper-
sugar control and
lipidemia and a history of a prior stroke
high-dose statin
presented with increased left-side weak-
therapy. On the
ness and numbness. The diabetes was
day of admission
diet controlled and the patient was taking
the patient’s exist-
a daily aspirin and a statin. Examination
ing left hemiparesis
confirmed weakness of grip and wrist ex-
worsened abrupt-
tension in the left hand, impaired sensation
ly. Examination
and pronation of the left hand. An initial
also revealed left
head CT showed no acute change.
hemineglect. The
National Institute Diffusion-weighted images (see
of Health Stroke Figures 3a and 3b) showed a small area of
Scale (NIHSS) was restricted diffusion involving the right mid-
15 (the NIHSS dle cerebral artery/anterior cerebral artery
ranges from 0 in- (MCA/ACA) watershed region. MR perfu-
dicating no signs sion imaging revealed a much larger area
or symptoms to 42 of diminished perfusion involving most of
Figure 1. Curve showing the time course of signal loss in a region of interest over for the most severe the right hemisphere. Magnetic resonance
the anterior cerebral artery as a bolus of gadolinium traverses the vasculature.
category.) angiography (MRA) of the neck revealed a
Signal changes in voxels (volume elements) throughout the brain are then
compared to this curve.
4 Winter 2010 www.swedish.org/neurosicence
BW_Nwsltr_WINTER_final.indd 4 1/5/11 4:55 PM
Figure 2b.
Right MCA stenosis (left).
Right MCA, post stent (right).
Figure 3a. DWI (top left), MR perfusion Figure 3b. DWI (top left), MR
(top right), Right ICA angiogram (right). perfusion (top right), Right ICA
angiogram post stent (left).
Arrows designate the proximal
dissection with high grade steno-
and distal ends of the stent.
sis in the mid-cervical internal ca-
rotid artery. Heparin was started.
A stent was placed on hospital day
two. MRI showed complete reso- For more
lution of the perfusion defect. The
information about
patient’s neurological status re-
the DEFUSE-2 trial,
turned to baseline and the patient
see Dr. Likosky’s
was discharged home on hospital
day 10. article on page 3
of this issue and
Conclusion
contact the Swedish
MR perfusion is a powerful
Stroke Program at
tool that can be performed rapidly
to assess relative blood flow in the 206-320-3484.
brain. Areas of the brain with de-
creased perfusion surrounding a
focus of acute infarction represent the “ischemic penumbra,” or sur- tion with Stanford Hospital & Clinics in the DEFUSE-2 trial to
rounding area at risk for conversion to infarction. This data can be better understand this technique and optimize its use. v
used to guide medical and endovascular or surgical management.
(Moftakhar, et al.) The perfusion technique used in our practice References
emphasizes perfusion abnormalities in larger vessels because larger Gillard, J; Valdman A, etal. Clinical MR Neuroimaging. Chapter 7: Cerebral Perfusion
imaging by exogenous contrast agents. Cambridge 2005. Pg 109-118.
vessels are more amenable to intervention than smaller vessels, as
Moftakhar R, et al. Effects of carotid or vertebrobasilar stent placement on cerebral perfu-
detailed in the two cases above. We are engaged in active collabora-
sion and cognition. AJNR Am J Neuroradiol. 2005 26:1772-80.
www.sniblog.com Winter 2010 5
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Emerging concepts in vascular neurology:
TIA clinics help prevent strokes and unnecessary hospital admissions
Michael Fruin, ARNP Swedish Neuroscience Institute
Tom Jaspee placed an anxious call to admitted as an inpatient for a 24-hour ob- The effectiveness of the TIA clinic is
Dr. Lewis’s office at 9 a.m. sharp. He didn’t servation and evaluation. supported by findings from the EXPRESS
give many details, other than to say his wife Trial (Luengo-Fernandez R, et al.). In this
This mock case study highlights the
was worried about problems he was having trial, there was an 80 percent reduction of
role a TIA clinic might have played in
with his speech the previous night. Later 90-day stroke risk when TIA and minor
avoiding an emergency room visit and hos-
that morning in Dr. Lewis’s office, Tom said stroke patients received urgent evaluation
pitalization, while still providing the TIA
he had had trouble getting his thoughts out and treatment in a standardized urgent-
patient the necessary urgent care.
for a few minutes. He said he felt fine im- care clinic setting. Patients at high risk of
mediately afterwards and didn’t want to While hospital admission is appropri- stroke, such as those with high-grade ste-
raise a ruckus. Tom’s wife added that his ate for the subset of patients at high risk for nosis of the internal carotid artery or with
right face drooped and the episode took al- having a stroke after TIA, significant num- atrial fibrillation, are admitted to the neur-
most 30 minutes to clear up. She was wor- bers of emergency room visits and admis- ology service as indicted. Patients at low
ried that Tom had suffered a stroke. sions could be avoided by a recent advance risk of stroke receive patient education and
v
in evaluating patients in a TIA clinic. TIA a stroke prevention plan is implemented.
Dr. Lewis was well aware of Tom’s high
clinics are being pioneered in the United
risk of stroke following his transient isch-
Reference
Kingdom, where patients with TIA can be
emic attack (TIA). Realizing that he could Luengo-Fernandez R, Gray AM, Rothwell PM. “Effect of
seen by a stroke specialist in an urgent-care
not manage this urgent issue in his office, urgent treatment for transient ischaemic attack and minor
clinic setting in which a standardized pro- stroke on disability and hospital costs (EXPRESS study): a
Dr. Lewis sent the patient to the emergency prospective population-based sequential comparison.” Lancet
tocol of neurologic evaluation and diagnos- Neurology 8:235-243. 2009.
room and after a six-hour stay, Tom was
tic testing is administered.
Cerebral microemboli
(Continued from page 1)
There is strong evidence that MES detection predicts future Future advances in TCD technology will permit full automa-
ipsilateral stroke risk in patients with symptomatic carotid stenosis tion and better identification of the composition and size of circu-
(Markus HS, et al.; King A, et al.). A recent study of patients with lating embolic materials, thus improving its value for patients with
asymptomatic carotid stenosis demonstrated that MES predicted cerebrovascular disease.
subsequent ipsilateral stroke and TIA, and also ipsilateral stroke
Contact Colleen Douville, RVT, at colleen.douville@swedish.
alone, and that it is helpful in selecting patients who will benefit
org or 206-320-4080, for more information about TCD for detec-
from carotid endarterectomy (Markus, HS et al.).
v
tion of cerebral microemboli.
Identification of active embolization provides crucial patho-
physiological information to the neurologist and can also aid in the References
Markus HS, MacKinnon A. Asymptomatic embolisation, detected by doppler ultrasound, pre-
selection of tailored therapy aimed at reducing the risk of stroke. dicts stroke risk in symptomatic carotid artery stenosis. Stroke 2005; 36: 971–75.
Emboli from different sources have unique compositions and re- King A, Markus HS. Doppler embolic signals in cerebrovascular disease and prediction of
stroke risk: a systematic review and meta-analysis. Stroke 2009; 40: 3711–17.
quire specific therapy, such as antiplatelet agents for emboli from
Markus HS, King A, Shipley M, Topakian R, Cullinane M, Reihill S, Bornstein NM, Schaafsma
large artery atherosclerotic plaque and anticoagulants for cardiac A. Lancet Neurol. 2010 9:663-71. Epub 2010 9:663-71.
emboli.
TCD for Emboli Monitoring
Patient location: Inpatient ward, neurointensive care unit,
or outpatient clinic
Set up time: 10 minutes
Typical duration of monitoring: 20 minutes to one hour
Tech supervision during monitoring: Yes
Patient discomfort: Minimal, but must remain still for
monitoring period
Special ultrasound equipment required: Yes
Specialized technologist skill required: Yes
Microembolic signals in the middle cerebral artery are indicated by a green arrow.
6 Winter 2010 www.swedish.org/neurosicence
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PFO closure for migraine
Mark Reisman, M.D., Chief Scientific Officer and Director, Cardiovascular Research & Education; Cindy J. Fuller, Ph.D., Research Scientist;
and Jill T. Jesurum, Ph.D., Scientific Director, Swedish Heart & Vascular Institute
Migraine is a primary headache dis- The mechanism for this potential re- primary endpoint (cessation of headache)
order that causes significant suffering in lationship is not understood, but investi- and secondary endpoint (>50-percent re-
approximately 13 percent of the popula- gators have focused on possible interatrial duction in headache frequency and days)
tion of the United States. It accounts for transit of vasoactive chemicals that bypass was surprising. Eligibility criteria for the
an estimated $23 billion in annual cost to the pulmonary capillary bed, or on micro- trial may have excluded those patients who
the economy through health-care expenses emboli from the venous circulation which were most likely to benefit from PFO clo-
and lost productivity. might trigger cortical spreading depres- sure. For instance, patients were excluded
sion and transient regional hypoperfu- from MIST if they had a history of stroke
Two major features of migraine are
sion. Migraineurs may have higher plate- or hypercoagulability, and subjects had to
migraine aura (MA) and headache. MA
let reactivity (Jesurum JT et al., 2010) or fit within a narrow range of headache fre-
occurs in nearly one-third of migraine pa-
pro-coagulant state (e.g., protein C or S quency. If patients with a greater migraine
tients and consists of one or more
burden or hypercoagulability were
focal neurological symptoms that
Presence more likely to achieve meaningful
develop gradually over 5-20 minutes of PFO
reductions in headache frequency
and persist for less than 60 minutes.
and severity, these exclusion cri-
MA typically precedes development
teria could have altered the study
of migraine headache.
Vasoactive outcome.
Microemboli Atrial anatomy
substances
Several years ago single-center from venous favoring platelet
bypass Other trials are in progress or
retrospective analyses first reported circulation activation
pulmonary in the pipeline that may better elu-
an apparent association between circulation
cidate the effect of PFO closure on
partial or complete relief of migraine
migraine. The migraine-PFO asso-
symptoms and transcatheter clo-
ciation offers opportunities for col-
sure of patent foramen ovale (PFO)
laboration between scientists and
for secondary stroke prevention
Susceptible clinicians in both neurology and
(Reisman M, et al., 2005). The fora- neuronal
cardiology. The long-term goals of
men ovale normally serves as a one- substrate
collaborative trials are improved
way valve in the interatrial septum
quality of life and reduced cerebro-
for physiologic right-to-left shunt in
vascular sequelae for individuals
utero. Complete fusion of interatrial Clinical Outcomes: Neuropathology: who suffer from migraine. v
septae normally occurs by two years
• Functional disability • White and gray
of age. When septae fail to fuse, how- • Cognitive dysfunction matter abnormalities
References
ever, the PFO is a potential tunnel •• AMuigraraine •• MCoicrtriocianlf asrpcrteioandsing Dowson A et al., Circulation 2008 117:1397-404.
that can be opened by reversal of the depression Jesurum JT et al., J Headache Pain 2007 8:209-16.
• Stroke
Jesurum JT et al., Am J Cardiol 2008 102:916-920.
interatrial pressure gradient. PFO is • Vascular dementia
Jesurum JT et al., Neurology 2010; 74 [suppl. 2].
the most common form of right-to-
Reisman M et al., J Am College Cardiol 2005
left circulatory shunt (RLS). 45:493-495.
Studies have shown that as many as 50 deficiency) than non-migraineurs,
percent of individuals with MA will have a possibly resulting in greater load of
PFO, whereas PFO is present in about 25 microemboli in the arterial circula-
percent of the general population and in tion. The brains of migraineurs may
migraineurs without aura (MO). In analy- be more sensitive to circulatory
ses performed by Swedish researchers, changes than are the brains of those
MA patients had a larger RLS than patients without migraine. The combination
with MO, despite similar interatrial anat- of potential triggers and susceptible
omy (Jesurum JT, et al., 2007), and were neuronal substrate may result in an
about 4.5 times more likely to have greater enhanced risk of MA among pa-
tients with PFO.
than 50 percent reduction in migraine fre-
quency following PFO closure (Jesurum JT,
The Migraine Intervention with
et al., 2008). These observations indicated
STARFlex Technology (MIST) trial
a potential pathophysiological relationship
was a randomized trial of PFO clo-
between migraine and PFO.
sure in migraine (Dowson A et al.).
Transesophageal echocardiogram demonstrating a patent
The failure of the trial to meet its foramen ovale (arrow).
www.sniblog.com Winter 2010 7
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AROUND SNI
Swedish Neuroscience Institute Staff Photo – 2010
8 Winter 2010 www.swedish.org/neurosicence
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BW_Nwsltr_WINTER_final.indd 9 1/5/11 4:55 PM
AROUND SNI
TMS: A new way to lift depression
Transcranial magnetic stimulation
(TMS) is a Federal Drug Administration-
approved therapy for treatment-resistant
depression, and may also be effective for
depression associated with Parkinson’s
disease, tinnitus, chronic pain and other
conditions. It uses repetitive pulses from
a 1.5-Tesla electromagnet to activate neu-
ronal circuits in targeted cortical regions,
such as the left dorsolateral prefrontal
cortex, for depression. TMS is part of the
services (in addition to electroconvulsive
therapy, deep brain stimulation and va-
gus nerve stimulation) that are offered
by Seattle Neuropsychiatric Treatment
Center (SeattleNTC) in conjunction
with SNI’s Center for Neurological
Restoration. For more information, see
v
www.seattlentc.com.
Kenneth Melman, M.D., medical director of SeattleNTC, in a mock demonstration of TMS with SNI
administrative assistant Karen Pabillon.
Biking to create a world free from MS
For two days and 150 miles, a team The team, which raised $76,938.21, Team captain Lily Jung Henson,
of 102 registered riders – the Swedish was one of the few groups to raise more M.D., MMM, FAAN, reminds Swedish
Smyelin Babes – took a stand against mul- than 100 percent of its goal. Bike MS helps employees, and their friends and families,
tiple sclerosis. This year’s Bike MS Ride fund research, education, and support that it’s not too soon to think about being
through Skagit County was a testament to programs and services for individuals di- part of this great effort next year. For more
the dedication these riders share as they agnosed, their families and friends, and information about the MS Society, or to join
rode through all kinds of weather – sun, health-care professionals who had dedi- next year’s Swedish Smyelin Babes team, go
v
rain and even a bit of hail – to raise money cated their careers to treating and finding to http://bikewas.nationalmssociety.org/.
for the National Multiple Sclerosis Society. a cure for MS.
10 Winter 2010 www.swedish.org/neurosicence
BW_Nwsltr_WINTER_final.indd 10 1/5/11 4:55 PM