INTERVENTIONAL NEURORADIOLOGY AT OHSU History Organization Activity Commitment

• • INTERVENTIONAL NEURORADIOLOGY AT OHSU History Organization Activity Commitment to research

HISTORY OF INR AT OHSU • • Charles Dotter- January 16, 1064 Josef Rosch Chuck Kerber Stan Barnwell- July 1, 1991

RECEPTION OF A NEUROSURGEON BY DX NEURORADIOLOGIST-1991 • “I DON’T WANT YOU HERE” • “I AM NOT GOING TO HELP YOU DO ANYTHING HERE” • “I AM GOING TO DO EVERYTHING I CAN TO GET YOU THROWN OUT OF HERE”

PROGRESSION OF STAFFING-5 CURRENT • Stan Barnwell- Neurosurgeon, 1991 • Gary Nesbit- Neuroradiologist, 1993 • Bryan Petersen-Peripheral Interventional Radiologist, 1996 • Aclan Dogan- Neurosurgeon, 2005 • David Lee-Cardiologist, 2008 • Jeremy Fields-Neurologist, 2011 • MY BASIC CONCEPT: – “if you can compete with me and are a nice person, it will be easier if I just hire you”

ACTIVITY • Progressive increase in case numbers: • 1990 - 50 diagnostic angiograms, <8 INR cases • 1320 for 2009 -10

SCOPE OF PRACTICE AKA “THE WORKS” • • • Aneurysms Carotid PTA and stent AVM Intracranial stenosis Stroke interventions Tumors Vertebroplasty/Kyphoplasty Epistaxis Carotid blow-out syndrome

COMMITMENT TO RESEARCH • 70% of Neurointerventional patients are enrolled in some clinical trial or registry • Reflected in scope of practice- if we do it, we usually do it as part of a trial

SCOPE OF PRACTICE = RESEARCH • Aneurysms: GDC, HELPS, MAPS, CERECYTE, PRET, HCAT • Carotid PTA and stent: CREST, CHOICE, SAPPHIRE • AVM: CORDIS NBCA • Intracranial stenosis: SSYLVIA, SAMMPRIS • Stroke interventions: MERCI, SWIFT, TREVO, PENUMBRA • Tumors: EV 3 ONYX • Vertebroplasty/Kyphoplasty: MAYO TRIAL, KAVIAR

HOW THIS RESEARCH AFFECTS OUR PRACTICE CREST TRIAL • 2502 patients • OHSU largest enroller- 120 pts • CEA=CAS for low risk patient population

HOW THIS RESEARCH AFFECTS OUR PRACTICE: PGLA COATED COIL TRIALS • MAPS (630 pts- OHSU largest enroller) and CERECYTE Trial (500 pts) • PGLA coated coils, although more expensive, are no more effective than bare platinum for treatment of cerebral aneurysms • Both trials show significant reduction in M&M compared to earlier ISAT trial, noting technique of coiling of aneurysms has improved.

HOW THIS RESEARCH AFFECTS OUR PRACTICE: HELPS TRIAL • HELPS Trial (499 pts, OHSU largest US enrolling site) • HYDROGEL coils statistically reduce aneurysm recurrence compared to uncoated platinum coils • 5/6/2008 5/4/2011

HOW THIS RESEARCH AFFECTS OUR PRACTICE: SSYLVIA TRIAL • • Vertebral origin and intracranial stenting trial ONLY 61 pts (OHSU largest enroller) Clinical Outcomes 30 -Day Periprocedural Stroke 4/61 (6. 6%) & Death Rate (EC+IC, N = 61) • Led to HDE approval • Prescient for small, non-randomized trials • “PRE 9 -11 Trial”

HOW THIS RESEARCH AFFECTS OUR PRACTICES: SAMMPRIS • SAMMPRIS Trial (451/764, OHSU largest enroller) • Trial stopped intracranial stenting for atheroma • Stroke/death: Medical arm 5. 8%, PTA/stent 14%

HOW THIS RESEARCH AFFECTS OUR PRACTICE: STROKE RETRIEVERS • MERCI (151 pts) and PENUMBRA (125 pts) (OHSU largest enroller) • Using corkscrews and vacuum cleaners you can clear clot from brain arteries

HOW THIS RESEARCH AFFECTS OUR PRACTICE: “STENT-TRIEVERS” • SWIFT (200 pts) AND TREVO TRIAL (200 pts) (OHSU largest enroller) • Stent retrievers are much safer and more effective than MERCI corkscrew • OHSU SWIFT trial results: Solitaire Merci Number 18 17 Intubation 94% (17/18) 100% (17/17) NS Recanalization TIMI 2/3 94% (17/18) 47% (8/17) . 002 Good outcome MR 0 -2 90 d 44% (8/18) 29% (5/17) NS Death 11% (2/18) 53% (9/17) . 007

AREAS OF GROWTH • • • Carotid stenting Revascularization for acute stroke Cerebral aneurysms Vertebroplasty/kyphoplasty Preoperative embolization AVM-Onyx

CHALLENGES FOR NEUROSURGERY IN THIS FIELD: TIME AND FUNDING • No dedicate large scale funding • Training beyond residency: too long and too poor • Originally had neurosurgery residents training for two years, mostly in folded into the residency (Kenny Liu, Ray Tien, Todd Kuether, Jordi Kellogg) • Absent infolded Fellowship and no funding, training neurologists, body IR • Jeremy Fields, Erek Helseth • I predict with no enfolded Fellowship or funding, neurology will inundate this field.

THANKS!!!!!!!!!