The Vascular Neurosurgery Program at UCSF

where experience meets innovation
The Vascular Neurosurgery Program at UCSF
University of California
San Francisco
Neurological Surgery
Our Team
Neurological Surgery
Neurology
Neurointerventional Radiology
Nursing
Michael Lawton, MD
Wade Smith, MD, PhD
Claiborne Johnston, MD
Nerissa Ko, MD
Andrew Josephson, MD
Heather Fullerton, MD
Mai Nguyen-Huynh, MD
Vineeta Singh, MD
Anthony Kim, MD
Sharon Poisson, MD
Randall Higashida, MD
Van Halbach, MD
Christopher Dowd, MD
Lisa Hannegan, MS, CNS, ACNP
Nancy Quinine, RN
Neuroanesthesia
Roger Noss, PhD
Russell Lyon, PhD
Paul Jasiukaitis, PhD
David Perry, PhD
Hanmin Lee, PhD
Gamma Knife Radiosurgery
Michael McDermott, MD
Nalin Gupta, MD
Penny Sneed, MD
William Young, MD
Pekka Talke, MD
Neurophysiology
vascular neurosurgery at ucsf
The Vascular Neurosurgery Program at the University of California, San Francisco is a comprehensive, multidisciplinary program
dedicated to treating brain aneurysms, subarachnoid hemorrhage, arteriovenous malformations, cavernous malformations,
stroke, and intracranial hemorrhage.
Program Highlights
• The UCSF Vascular Neurosurgery
Program is the busiest in California
and the 6th busiest in the nation*
• High surgical volume equates to
better patient outcomes; more than
450 aneurysms were treated last
year (2009) at UCSF, including 260
aneurysms treated microsurgically
• The UCSF Center for Stroke and
Cerebrovascular Disease is accredited
by the Joint Commission as a primary
stroke center
• UCSF has 29 state-of-the-art
operating rooms, 28 neurological
ICU beds, and 4 neurointerventional
angiography suites
* University Hospital Consortium database
Contact Us
• The UCSF Vascular Neurosurgery
Program is part of a multidisciplinary
team of more than 30 specialists
that works together daily and meets
weekly to coordinate and individualize
patient care
• The UCSF Center for
Cerebrovascular Research has 11
dedicated investigators, a Program
Project Grant from the National
Institutes of Health, an active AVM
Study Project, and is a Center of
Excellence in Patient Research
• The UCSF Vascular Neurosurgery
Program helped form the Aneurysm
and AVM Foundation
(www.aneurysmfoundation.org)
Aneurysm/Brain Attack Hot Line
877-BRAIN-1-1
Neurosurgical Clinic Referrals
415-353-7500
Neurosurgery On Call
415-443-HEAD
Vascular Neurosurgery On Call
415-443-STROKE
Dr. Lawton’s Office
415-353-2529
Vascular Neurosurgery is at your
service. Our physician-to-physician
Brain Attack Hotline is available 24
hours a day, seven days a week
for emergency consultations and
referrals to UCSF Medical Center.
We maintain a Subarachnoid
Hemorrhage Bed that is ready
to receive patients with ruptured
aneurysms immediately.
Physicians are invited to send
cases for film review. Films or
CDs should be mailed with a
brief clinical summary to:
Vascular Neurosurgery Program
c/o Michael Lawton
505 Parnassus Avenue, M-780
San Francisco, CA 94143-0112
Vascular Neurosurgery Online:
neurosurgery.ucsf.edu
avm.ucsf.edu
Surgical case volumes for aneurysms and vascular
malformations have been steadily increasing over
the past decade at UCSF.
400
350
300
aneurysms
250
200
150
Giant anterior communicating artery aneurysm, projecting
forward on top of the optic nerves and chiasm, as seen
through a left pterional craniotomy.
100
50
0
1998
1999
2000
2001
2002
Aneurysms
2003
2004
2005
2006
2007
2008 2009
Vascular Cases
The Vascular Neurosurgery Program
at UCSF takes a multidisciplinary
approach to treating aneurysms, with
a team of neurosurgeons, interventional
neuroradiologists, and neurologists
that collaborates to choose the best
treatment for each patient. We offer
both surgical and endovascular
approaches, such as coiling, to
treat aneurysms. Some small
aneurysms (< 7 mm in diameter)
can be observed without treatment.
Microsurgical clipping requires refined
technique and skill. Aneurysms referred
for surgery are often complex, with
broad necks or unusual anatomy
that makes them unfavorable for
coiling, or have recurred after previous
coiling. In these cases, an advanced
surgical technique such as bypass
may be needed. Care after aneurysm
treatment, particularly for patients with
ruptured aneurysms, requires intensive
care, monitoring for vasospasm
with transcranial Doppler velocity
measurements, and endovascular
therapies like intra-arterial vasodilators
and angioplasty. At UCSF the
complete team and range of services
is available 24 hours to ensure
the highest quality of care.
Studies demonstrate a direct
relationship between clinical volume
and patient outcome; there are
significantly fewer adverse outcomes
and deaths in high-volume hospitals.
For this reason, it is risky to treat
aneurysm patients outside of regional
centers of excellence. There is also a
significant cost justification to transfer
patients from low-volume hospitals
that treat less than 45 aneurysm
patients per year. At UCSF, steadily
climbing aneurysm volume and
excellent patient outcomes reflect these
results and our regional strength. We
maintain a Subarachnoid Hermorrhage
Bed, ready to receive patients with
ruptured aneurysms immediately.
The aneurysm was clipped with stacked fenestrated clips,
with complete occlusion of the aneurysm. Note the distal
anterior cerebral arteries seen in the interhemispheric fissure.
An arteriovenous malformation (AVM)
is an abnormal tangle of arteries
connected directly to veins, without
intervening capillaries, resulting in a
high-flow, low-resistance pathway for
blood. This abnormal circulation makes
AVMs susceptible to rupture, causing
bleeding in the brain. AVM hemorrhage
is fatal in 10% of patients and causes
neurological deficits in 25%.
Brain AVMs are curable. Many AVMs
can be embolized by injecting agents
that clog feeding arteries and reduce
blood flow through the tangle. Other
AVMs can be removed surgically
by disconnecting the abnormal vessels
and separating the tangle from the
brain. Smaller AVMs can be treated
with stereotactic radiation, using the
Gamma Knife® to precisely target the
tangle and induce occlusive scarring
over a 2-year period.
The optimal combination of treatment
modalities and their sequence depends
on the anatomy of the AVM and
the patient’s clinical presentation.
Sometimes optimal therapy is
observation. Therefore, treatment
planning requires an experienced
and selective team.
At UCSF, AVMs are one of our specialties
and our surgical experience includes
nearly 500 AVMs over the last decade.
Our surgical results are measured and
analyzed as part of the UCSF AVM
Study Project, which has been used
to develop new methods, such as the
Lawton-Young Grading Scale, to select
patients for surgical therapy. Our surgical
specimens are studied in the laboratories
of the Center for Cerebrovascular
Research to discover mechanisms for
AVM development and hemorrhage.
Our studies are identifying genetic
predictors of hemorrhage risk that may
lead to individualized risk assessment
and improve treatment decisions.
arteriovenous malformations
This AVM was located adjacent to language cortex, and speech mapping
during an awake craniotomy identified Wernicke’s area (#40).
This AVM had clean margins, was dissected away from eloquent areas,
and was removed completely.
cavernous malformations
Cavernous malformations, also called
cavernous angiomas or cavernomas,
are abnormal clusters of dilated
capillaries and veins that form caverns.
Their endothelial lining is weak, which
can cause bleeding in the brain and
seizures or focal neurological deficits.
Surgical removal is the only treatment,
as cavernous malformations are not fed
by arteries and cannot be embolized.
These lesions are not radiosensitive
and stereotactic radiosurgery is not
recommended. Surgical removal is
often curative and management
depends on careful patient selection
for surgery, based on the lesion’s
anatomy and the patient’s symptoms.
Accessible cavernous malformations,
especially those that come to a brain
surface, can be removed safely with
surgery. These lesions can be separated
from the brain and removed without
violating normal brain tissue. Even
cavernous malformations that surface
on the brainstem can be removed
safely, and one third of the cavernous
malformations in our surgical experience
have been located in the brainstem.
Surgical results depend on selecting
the best approach. Over 25
different approaches are used to
optimize exposure and minimize
brain disruption. New approaches
to access difficult lesions, like the
supracarotid-infrafrontal approach to
the anterior-inferior basal ganglia and
the supracerebellar-supratrochlear
approach to the posterior-inferior
thalamus were developed by the UCSF
Vascular Neurosurgery team. We have
also developed schemes to standardize
selection of surgical approach.
Our surgical experience with cavernous
malformations includes over 350
patients. Intraoperative navigation,
neurophysiological mapping, and
sophisticated microsurgical techniques
are used to provide superior outcomes.
After surgery, 73% of our patients were
completely seizure-free and 16% of
patients had improvement in seizures.
Top: Axial T2-weighted MRI
demonstrates a medullary
cavernous malformation with
surrounding hemosiderin ring.
Middle: The cavernous
malformation was exposed
with a left far-lateral craniotomy
and was seen coming to the
lateral surface of the medulla,
between the vagus, accessory,
and hypoglossal nerve rootlets
and next to the vertebral artery.
Bottom: The cavernous
malformation was
removed completely.
A stroke occurs every minute, and death
from stroke occurs every three minutes.
Most strokes are caused by blood clots
that block the flow of blood to the brain,
resulting in the death of brain cells.
Carotid artery atherosclerosis is one
of the most common causes of stroke.
Carotid bruits and transient ischemic
attacks often lead to the diagnosis
of carotid stenosis and impending
stroke. Symptomatic carotid stenosis
greater than 50% is an indication for
carotid endarterectomy.
During carotid endarterectomy, the
exposed artery is temporarily clamped
and atherosclerotic plaque is removed.
The carotid artery is sutured closed
using microsurgical technique, which
makes patch grafts unnecessary. The
brain is protected using the same
techniques as with brain aneurysms,
with general anesthesia and
neurophysiological monitoring for
ischemia during cross-clamping. Bypass surgery is another treatment for
ischemia offered by the UCSF Vascular
Neurosurgery Program. Extracranial-tointracranial (EC-IC) bypasses augment
ischemic disorders
Michael Lawton MD, chief of the Vascular Neurosurgery Program at UCSF, uses advanced microsurgical techniques to perform a bypass.
blood flow to the brain by connecting
scalp arteries or high-flow grafts to
the brain’s arteries. Bypasses are
indicated for patients with intracranial
atherosclerosis and moyamoya
disease. Bypasses are also indicated
for patients with cervical carotid artery
occlusion and inadequate blood flow
from other arteries, namely the opposite
carotid artery and the vertebrobasilar
circulation. We are currently enrolling
patients in the Carotid Occlusion
Surgery Study (COSS), which is
comparing results with bypass surgery
versus those with medical management.
research
Cerebral aneurysm wall including vasa vasorum
Clinical Research
• In the UCSF Brain Arteriovenous
Malformation Study, researchers are
building a prospective registry of AVMs
and other vascular malformations of the
brain, and are tracking treatment results
and patient outcomes.
• UCSF is a member of the multicenter Brain Vascular Malformation
Consortium, which studies the
clinical behavior and genetics of three
cerebrovascular disorders: cavernous
malformations, Sturge-Weber
Syndrome, and Hereditary Hemorrhagic
Telangiectasia. The consortium is part
of the Rare Disease Clinical Research
Network program administered
by the NIH Office of Rare Disease
Research and the National Institute of
Neurological Disorders and Stroke.
• UCSF is currently participating in an
NIH-funded, randomized clinical trial
to determine if extracranial-intracranial
(EC/IC) bypass surgery combined
with best medical therapy can reduce
subsequent ipsilateral ischemic stroke
(the Carotid Occlusion Surgery Study).
• Epidemiology and clinical course
studies of brain arteriovenous
malformations are underway to identify
risk factors for disease susceptibility or
spontaneous intracranial hemorrhage.
• Genomic studies, including genomewide SNP and expression, are being
conducted to help identify genes
involved in brain arteriovenous
malformation or hemorrhage.
• Risk-stratification algorithms are being
developed to predict surgical outcomes.
Map of wall shear stress inside an
anterior communicating artery aneurysm
Pathlines of blood flow and mixing
inside an anterior communicating
artery aneurysm
Vectors depicting magnitude of
flow velocity inside an anterior
communicating artery aneurysm
Laboratory Research
Basic science research at UCSF
focuses on:
• Determining the role of inflammatory
oxidative stress in cerebral aneurysms.
• Comparing anatomical and
clinical exposure in cerebrovascular
surgical approaches to optimize
surgical outcomes.
• Examining the effects of radiation
on transgenic arteriovenous fistula.
• Developing gene and cellbased therapy for the treatment
of ischemic stroke.
• Developing clinically relevant animal
models of cerebrovascular disorders:
- Animal models combining
manipulation of genetic
background and growth factor stimulation to induce
brain arteriovenous malformations.
- Animal models of intracranial
aneurysm used to study the
influence of hemodynamics
and inflammatory pathways
on lesion progression.
UCSF Department of Neurological Surgery
505 Parnassus Avenue, M779
San Francisco, CA 94143-0112
Nonprofit Org
U.S. Postage
PAID
University of
California
San Francisco
Contact Us
Aneurysm/Brain Attack Hot Line
877-BRAIN-1-1
Neurosurgical Clinic Referrals
415-353-7500
University of California
San Francisco
Neurological Surgery
vascular
neurosurgery
at ucsf
Neurosurgery On Call
415-443-HEAD
Vascular Neurosurgery On Call
415-443-STROKE
Dr. Lawton’s Office
415-353-2529
Vascular Neurosurgery is at your
service. Our physician-to-physician
Brain Attack Hotline is available 24
hours a day, seven days a week
for emergency consultations and
referrals to UCSF Medical Center.
We maintain a Subarachnoid
Hemorrhage Bed that is ready
to receive patients with ruptured
aneurysms immediately.
Physicians are invited to send
cases for film review. Films or
CDs should be mailed with a
brief clinical summary to:
Vascular Neurosurgery Program
c/o Michael Lawton
505 Parnassus Avenue, M-780
San Francisco, CA 94143-0112
Vascular Neurosurgery Online:
neurosurgery.ucsf.edu
avm.ucsf.edu