Insights & Innovations

A partnership between ChristianaCare cardiologists and oncologists is enhancing heart care for breast cancer patients receiving high-risk chemotherapy.

The Cardio-Oncology Program was established five years ago by physician leaders from the health system’s Women’s Cardiology Clinic and the Helen F. Graham Cancer Center & Research Institute to prevent and effectively treat cardiotoxicity in breast cancer patients on chemotherapy. The program also sees women with lymphoma and ovarian and uterine cancers who receive high-risk chemotherapy and need to be monitored for cardiotoxicity.

There is a growing need for ongoing patient surveillance because of the emergence of new chemotherapy drugs that can cause cardiotoxicity, and because breast cancer survivors are living longer and dealing with the lasting effects of treatment, according to Dr. Horn.

“Fortunately, there are a number of actions cardiologists can take to address the complication, including prescribing medications, recommending adjustments to care plans and suggesting lifestyle modifications,” Dr. Sernyak noted. “Sometimes, chemotherapy can even be paused to give the heart time to recover from cardiotoxicity, and then resumed so treatment can be completed.”

At ChristianaCare, the Cardio-Oncology Program is structured with patient convenience and efficiency in mind. When women receive a referral, clinic staff schedule appointments for them to have an echocardiogram and see a cardiologist within one week to avoid any delay in the start of their chemotherapy.

“The appointments happen on the same day,” Dr. Sernyak explained. “First, they have their echo and immediately afterward they meet with a doctor to review their results and discuss appropriate next steps based on the findings.”

Patients then return for follow-up testing every three months and appointments with a cardiologist every six months throughout their chemotherapy regimen and beyond to evaluate their heart function and identify and treat any cardiotoxicity that may develop, Dr. Horn added.

Program cardiologists keep referring physicians closely up to date on patients’ status through the ChristianaCare electronic medical record system and personal consultations.

“We emphasize building strong, collaborative working relationships,” Dr. Sernyak said. “The oncologists appreciate the expertise our cardiologists bring to the care team, which enables them to focus on treating breast cancer. It’s a partnership designed to deliver an exceptional patient experience and achieve the best possible medical outcomes.”

To refer a patient to the Cardio-Oncology program at ChristianaCare, please call (302) 623-1929 or fill in the form on this page.

At least 6.5 million people aged 40 years and older in the United States have peripheral artery disease (PAD). Like many chronic cardiovascular conditions, the prevalence of PAD increases with age: By age 70, more than 10% of men and nearly 10% of women will be diagnosed with the disorder. By age 80, those figures increase to more than 25% and 20%, respectively.¹

PAD’s most severe manifestation is critical limb ischemia (CLI). Recent research indicates that as many as 1 in 4 people who develop CLI will have an amputation within one year of their diagnosis.² A 2021 study found that the rate of hospital admissions for CLI increased from 0.9% to 1.4% between 2011 and 2017, while PAD admissions nearly doubled, going from 4.5% to 8.9%, over the same period.³

Both the equipment and surgical techniques used to manage PAD and CLI are rapidly evolving. One of the most novel therapies now available at ChristianaCare is transcatheter arterialization of deep veins (TADV), which is used to treat patients with the most severe CLI who have run out of revascularization options. TADV is designed to reestablish blood flow by diverting arterial flow from the tibial artery to deep veins in the foot.

“We connect the vein to the artery and backfill the tissues of the wound to get oxygen to that area,” Dr. Leung explained. “With advances like these, as well as increased awareness among referring physicians to send their patients to specialists like our team if they have PAD, I believe we are making progress in reducing the number of amputations that are done.”

He continued: “This is a rapidly evolving field with lots of innovations and novel devices and, at ChristianaCare, our patients have access to those options, including investigational procedures in clinical trials. We are involved in the development of complex revascularization techniques, such as pedal access and pedal loop revascularization to treat the very small arteries in the foot. Even though this is not generally done that frequently, it is something we do here on a routine basis.”

ChristianaCare was also involved in the trials introducing drug-eluting balloons and drug-eluting stents, which had become common in the treatment of cardiovascular disease, to treat peripheral vascular disease.

“This is now standard of care, but our patients had access to these technologies in trials before they were commercially available,” said Dr. Leung, who also stressed the importance of podiatry and wound care in the management of these patients. “Our team of vascular interventionalists regularly visits our affiliated off-site wound care center to evaluate patients for surgery, as it is more convenient for patients to be seen there.”

The interventional vascular team works closely with ChristianaCare’s team of vascular surgeons and a multidisciplinary group of experts including infectious disease physicians, endocrinologists and nephrologists, as well as the many podiatrists who work in the area. In addition, cardiologist Vikash Rambhujun, MD, has returned to ChristianaCare after a one-year fellowship at Yale University Hospital, where he studied vascular medicine and procedural care of PAD. His work is expected to complement that of the others on the multidisciplinary team.

“We also partner with primary care physicians to raise awareness,” Dr. Leung said. “Many of the patients we see have come into the emergency department with disease that is already quite advanced. By working with primary care and family practice and encouraging them to send patients to us early on, we can improve their outcomes.”

To refer a patient with Peripheral Artery Disease to ChristianaCare, please call (302) 733-5625 or fill in the form on this page.

References

1.     CDC. Peripheral arterial disease (PAD). Accessed May 13, 2024. https://www.cdc.gov/heartdisease/PAD.htm#

2.     Mustapha JA, Saab FA, Ranger WR, et al. Treatment of peripheral artery disease and critical limb ischemia: an observational Michigan Medicare analysis. J Crit Limb Ischem. 2023;3(2):E56-E63.

3.     Anantha-Narayanan M, Doshi RP, Patel K, et al. Contemporary trends in hospital admissions and outcomes in patients with critical limb ischemia: an analysis from the National Inpatient Sample Database. Circ Cardiovasc Qual Outcomes. 2021;14(2):e007539.

“The preservation of sexual function is a major factor for men in choosing PAE,” Dr. Grilli said. “Many also prefer the procedure over surgery because it doesn’t involve the insertion of a scope into the urethra and is substantially more comfortable for the patient.”

ChristianaCare closely monitors the effectiveness of PAE by surveying patients before and multiple times after the procedure. The results show 95% of patients report significant improvement in their BPH symptoms.

Dr. Grilli is part of a highly skilled team of four vascular interventional radiologists at ChristianaCare who specialize in performing PAE with the latest equipment and technology. Together, they perform a high volume of the procedures, which translates to greater clinical expertise and better patient outcomes.

“As a doctor, it’s very gratifying to be able to help men regain normal urinary function and experience improved quality of life,” he said.

To refer a patient for Prostate Artery Embolization at ChristianaCare, please call (302) 733-5625 or fill in the form on this page.

Atrial fibrillation, or Afib, is a heart arrhythmia associated with an increased risk for stroke, heart failure and other cardiovascular comorbidities. It is more commonly diagnosed in men and those of advancing age; roughly three-fourths of those with the condition are 65 years or older. Up to 6.1 million people in the United States have Afib, a figure that is projected to reach nearly 12 million by 2030.¹

Because of patients’ increased risk, it is imperative to mitigate any structural issues with the heart that can lead to stroke, according to Kevin Tsai, MD, a clinical cardiac electrophysiologist at ChristianaCare.   

“The irregular heart rhythm in Afib can cause blood to pool in the left atrial appendage (LAA), a small pouch in the upper left chamber of the heart, which increases the risk of clot formation,” Dr. Tsai said. “If a clot dislodges and travels through the bloodstream to the brain, it can cause a stroke.”

When patients with Afib arrive at ChristianaCare, clinicians assess for symptoms and treat risk factors associated with the condition, including hypertension, heart disease, diabetes, obesity, alcohol/tobacco use and sleep apnea. Patients’ stroke risk is assessed by a score calculated using multiple risk factors, including presence of congestive heart failure, hypertension and diabetes as well as history of stroke and vascular disease, among other factors, according to Dr. Tsai.  

Anticoagulants (blood thinners) are traditionally prescribed to reduce patients’ stroke risk. However, in patients unable to tolerate long-term anticoagulants, perhaps due to fall or bleeding risks, ChristianaCare offers occlusion of the LAA, which has been shown to be effective in reducing Afib-related stroke.²

In addition, treatment of Afib focuses on controlling heart rate or rhythm. The aim is generally to control heart rate without converting Afib to a normal rhythm. This treatment is commonly used for patients who tolerate Afib well without symptoms. Rhythm control aims to restore and maintain normal rhythm and is commonly used for patients who have limiting symptoms from Afib.

“Roughly 20% of patients with Afib have no symptoms and, for them, we typically employ the rate control strategy,” Dr. Tsai said. “However, the remaining 80% have symptoms that can greatly diminish quality of life, such as palpitations, shortness of breath and fatigue. Rhythm control strategy is used in these patients to reduce the overall Afib burden by modifying electrical properties of the heart with antiarrhythmic medications and/or catheter-based ablations.”

Although catheter ablation has been shown to be more effective in maintaining normal rhythm, antiarrhythmic medication is currently first-line therapy, according to Dr. Tsai. In patients with Afib that is refractory to antiarrhythmic therapy, catheter ablation can be considered. (Future guidelines may change with recent large clinical trials showing favorable results with the approach; it currently has a class Ia indication with reduction in mortality in patients with heart dysfunction and heart failure due to Afib.)

Generally, the goal of ablation is to disable the cells in the heart that are responsible for triggering and propagating Afib. Two common ablation methods are cryoablation (freezing these cells) or radiofrequency ablation (heating the cells). Both approaches are offered at ChristianaCare, and they can be performed safely and effectively as outpatient procedures.

In cryoablation, electrophysiologists use a balloon catheter to freeze the targeted heart cells, disabling their ability to transmit electrical currents. This procedure can be tricky, however, because if the seal between the balloon, which contains nitrogen refrigerants, and the cardiac tissue isn’t closed, the flow of warm blood can make the procedure less effective, according to Dr. Tsai. The freezing strategy, although mostly safe, can damage nearby structures.

In radiofrequency ablation, electrophysiologists use a catheter to deliver heat to the targeted cardiac cells, rendering them unable to transmit electrical signals. This heating strategy, in rare cases, can also cause collateral damage to nearby structures, Dr. Tsai said.

The most recent advancement in Afib is pulsed-field ablation (PFA), which was approved by the FDA in December 2023 and involves a large electrical current (1 microsecond in duration) that causes cardiac cells to undergo apoptosis. ChristianaCare is expected to begin offering PFA within the next year, and Dr. Tsai believes it will change the treatment landscape of rhythm control for Afib.

“The benefit of PFA is that different tissues in your body absorb the electrical field at different amplitudes,” Dr. Tsai explained. “You can deliver PFA and it will only affect the cardiac cells without adverse effects to nearby structures, including the esophagus, arteries/veins and the phrenic nerve.”

To refer a patient with Atrial Fibrillation to ChristianaCare, please call (302) 623-1929 or fill in the form on this page.

References

1.     Colilla S, Crow A, Petkun W, et al. Estimates of current and future incidence and prevalence of atrial fibrillation in the U.S. adult population. Am J Cardiol. 2013;112(8):1142-1147.

2.     Moras E, Gandhi K, Yakkali S, et al. Left atrial appendage occlusion as a strategy for reducing stroke risk in nonvalvular atrial fibrillation. Cardiol Rev. 2024 Jul 30. doi:10.1097/CRD.0000000000000757

ChristianaCare’s new multidisciplinary Center for Aortic Health brings together some of the region’s leading subspecialty experts in cardiovascular care, including vascular surgeons, cardiologists, cardiothoracic surgeons, interventional radiologists and others, to centralize the care of patients with aortic disease and improve their outcomes.

“Aortic pathology requires specialized management, and we provide the most optimal care for these patients when we work together seamlessly,” said one of the Center’s co-directors, vascular surgeon Kathryn E. Bowser, MD. “There are cutting-edge developments constantly going on in this field, and a center like this one is needed to give patients the best options.”

Led by Dr. Bowser, preventive cardiologist Stephen Meng, MD, and cardiothoracic surgeon J. Daniel Robb, MBBS FRCS, the Center proactively identifies patients with aortic pathology such as aortic aneurysms and aortic dissection before these conditions become emergent; provides them with the latest in medical, surgical and endovascular management; and maintains ongoing coordinated longitudinal care for months and years afterward. Other patients presenting with life-threatening acute aortic dissection receive emergency lifesaving complex surgery and are similarly followed longitudinally.

“The team at the Center for Aortic Health utilizes a multidisciplinary approach that emphasizes patients’ long-term heart health,” said Dr. Robb, who serves as a co-director of the Center along with Drs. Bowser and Meng. “We also pride ourselves in having expertise and experience with multiple surgical and treatment approaches so that we can truly offer patients the best options for their specific needs. We strongly believe that these various approaches are best used in a multidisciplinary team setting to provide patients with inclusive and optimal care.”

For surgical procedures, the Center offers a state-of-the-art hybrid OR, located in the Gerret and Tatiana Copeland Heart & Vascular Interventional Suites, where both open surgery and endovascular procedures can be performed in the same space, with access to advanced imaging technologies including angiography, ultrasound and CT. It’s the only OR of its kind in Delaware. Within the next year, a second hybrid OR will be constructed, increasing the Center’s capacity to manage complex cases.

Thoracic endovascular aortic repair (TEVAR) and endovascular aortic repair (EVAR) have become the first choice of treatment in many patients with thoracic and abdominal aortic aneurysms, respectively. However, many patients have anatomy that is not suitable for standard TEVAR/EVAR procedures, according to Dr. Robb. Novel endograft devices have made TEVAR/EVAR possible for more patients, and ChristianaCare is recognized by device manufacturers as a high-volume institution with the expertise needed to implant these newer models.

“For example, in 2023, we became the first center in Delaware to implant the Gore^Ò TAG^Ò Thoracic Branch Endoprosthesis, a novel endograft designed to repair the descending thoracic aorta in cases of aneurysm, transection or dissection,” Dr. Bowser said. “Within the next few months, we will also be offering Gore’s Thoracoabdominal Branch Endoprosthesis, another endograft option that allows us to tailor treatment to a patient’s specific anatomy. These are just two examples of the ongoing developments in the field to which patients in the Center for Aortic Health will have access.”

“Patient selection is clearly key to achieving the best possible outcomes in these procedures,” Dr. Robb added.

Another aspect of this customized care for aortic disease is seen in women.

“We are learning more about aortic pathology in women,” Dr. Bowser noted. “Most existing research had primarily been done in men, but more recent studies demonstrate that we must account for differences not only in vasculature size but other factors that may affect care decisions.”

For example, studies have shown that women have a threefold increase in the risk for aortic dissection or rupture, and acute aortic syndromes, such as aortic dissection, occur at smaller aneurysm sizes in women than men.²

“A 5-cm aneurysm in a woman is much more likely to rupture than a similarly sized aneurysm in a man,” Dr. Bowser said. “Our center incorporates all of the latest research into our decision making to create a personalized treatment plan for each patient.”

It was a very specific decision to name the program the “Center for Aortic Health,” according to Dr. Meng.

“We are not just focused on pathology and surgery,” he said. “Our program is distinguished by a patient-centered focus that aims to prevent catastrophes with education and screening. For example, we have been in discussion with the program at Nemours Children’s Health about transitioning some of their pediatric aortic patients into our care as they reach adulthood. There are familial conditions such as Marfan syndrome, Loeys-Dietz syndrome and vascular Ehlers-Danlos syndrome that can raise the risk of aortic pathology conditions. We believe it is important to have a lifelong care plan, not only for the patient but for their family members who may be affected. The Center for Aortic Health offers our community convenient access to world-class expertise right here in their local area.”

To refer a patient to the Center of Aortic Health at ChristianaCare, please call (302) 733-5700 or fill in the form on this page.

References

1.     Czerny M, Grabenwöger M, Berger T, et al. EACTS/STS guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ. Eur J Cardiothorac Surg. 2024;65(2):ezad426.

2.     Boczar KE, Cheung K, Boodhwani M, et al. Sex differences in thoracic aortic aneurysm growth. Hypertension. 2019;73(1):190-196.

Transcatheter aortic valve replacement (TAVR) at ChristianaCare is revolutionizing the treatment of severe aortic stenosis in older adults.

“TAVR has almost completely replaced open-heart surgery for these patients over the past decade,” said interventional cardiologist and fellowship program director Erin Fender, MD. Dr. Fender is part of a multidisciplinary team that specializes in performing the minimally invasive procedure for the health system’s Structural Heart Disease Program.

“These benefits make the TAVR procedure a safe and effective option for the majority of older adults with serious cases of aortic stenosis, including patients in their 80s and 90s,” Dr. Fender noted. “Our interventional cardiologists do hundreds of procedures a year, supported by cardiac surgeons, cardiac nurses and other professionals with extensive experience in TAVR. This multidisciplinary approach and large number of cases translates to advanced expertise that ensures patients receive high quality care.”

ChristianaCare’s TAVR success rate is 99%, and many large clinical trials have repeatedly demonstrated that the long-term survival rates for TAVR equals that of surgery.

“We’re proud to be Delaware’s leader in performing the procedure,” Dr. Fender said.

At ChristianaCare, patients benefit from a timely and efficient TAVR process. When a patient is referred, a cardiac nurse immediately contacts them to arrange every aspect of their care and address any questions or concerns they may have. The nurse assists the patient in scheduling necessary testing and appointments with an interventional cardiologist and cardiac surgeon—often all on the same day to maximize convenience.

After the TAVR, patients return to ChristianaCare for postoperative checkups and then are seamlessly transitioned back to the care of their local doctor. Through the process, the TAVR team keeps the referring physician informed about their patient, the outcome of the procedure and instructions for follow-up care.

“We strive to develop collaborative relationships with doctors by providing thorough communication and being available for consults when needed,” Dr. Fender explained. “By the time the patient meets with me or one of my colleagues, we’ve already reviewed their testing results and are prepared to recommend a course of action, including scheduling their procedure, if appropriate. All of this typically happens within just a few weeks. It’s a well-coordinated pathway focused on delivering an excellent patient experience.”

To refer a patient for TAVR at ChristianaCare, please call (302) 733-1507 or fill in the form on this page.

Ineffective and inefficient prehospital communication between emergency medical staff and hospitals is a significant challenge in stroke and ST-elevation myocardial infarction management, leading to delays in treatment and resulting in sentinel events.

“When neurologists can have that information available, prior to the patient’s arrival at the hospital, it can make all the difference in the world because seconds truly matter in stroke care,” said Dr. Gannon. ChristianaCare’s stroke program is one of the largest nationally and one of only 300 comprehensive centers across the country. “With this system, paramedics can communicate with our stroke teams while they’re on their way to the hospital, which gives our staff time to access and review the patient’s chart. This is particularly important if the patient is unable to speak for themselves or doesn’t have a family member present.”

Research suggests that stroke patients lose approximately 1.9 million brain cells per minute during care delays, making rapid initiation of antithrombotic therapy crucial, added Doug Huisenga, the senior program manager for ChristianaCare’s systemwide stroke program. However, although these drugs are widely used and effective, there are contraindications in many patients, including a history of cerebral hemorrhage and/or ischemic stroke (within the past three months).

“That’s why having access to a patient’s personal health information is so important,” he said.

Of note, hypertension and hyperlipidemia as well as tobacco use are very common in Delaware. ChristianaCare is the only comprehensive stroke center on the I-95 corridor between Baltimore and Philadelphia.

The initiative with New Castle County EMS and ChristianaCare means Delaware is now one of 12 states nationally in which the Twiage system is in use. By providing patient data and GPS-tracked ETA for all incoming ambulances in real time, Twiage helps reduce hospital efficiency and enables earlier initiation of treatment, meaning lives are saved.

“ChristianaCare is already likely in the top 1% of hospitals nationally in door to needle time,” said Huisenga, referring to the initiation of antithrombotic treatment. “However, one of the ways we can make that even better is to improve prehospital communications — and that’s what we’ve done with Twiage thanks to this collaboration with New Castle County EMS.”

Cutting-edge magnetic resonance (MR)-guided focused ultrasound technology is allowing neurologists at ChristianaCare to provide outpatient procedures for patients struggling with essential tremor (ET) and Parkinson’s disease.

Developed in the early 2000s, and approved by the FDA in 2016, the technique allows for tremor control without surgical incisions, meaning that patients can recover quickly, are not at risk of destabilizing infections and are able to experience immediate reduction of their tremors. This summer, Justin Martello, M.D., the Parkinson’s and movement disorders director at ChristianaCare Neurology Specialists, will use the technology for ET and Parkinson’s patients as the first in the state of Delaware to offer this treatment.

In focused ultrasound, MRI is used to develop a detailed picture of a patient’s brain. Ultrasound wavelengths are then used to heat and kill the specific cells responsible for causing the individual’s tremors, essentially creating a lesion in the region of the brain.

“We can pretreat the region at low levels of heat energy without causing any damage,” Dr. Martello said. “This stuns the cells. We can then review the MRI and ask the patient how they are feeling.”

Adding to the procedure’s safety is the fact that it can be nondestructively tested and guided by immediate patient feedback, according to Dr. Martello. In ET patients, the procedure can be done on both sides of the brain — albeit in separate treatments about nine months apart — to achieve full relief from tremors affecting both sides of the body.

“If the tremor is still there or the patient has side effects, we know we are not in the right spot, but we haven’t done any permanent damage so we can move on to a different area,” Dr. Martello noted. “By doing that, we can make sure we are treating the correct area and avoiding side effects.”

Essential tremor is the most common movement disorder in the United States, affecting an estimated 6.4 million people.¹ The disorder typically occurs later in life and is an inherited condition in up to 70% of patients.²

“Everyone has a tremor center of their brain,” Dr. Martello explained. “For patients with tremors it is not functioning correctly.”

Focused ultrasound has been found to be very effective for tremor. A study published in The New England Journal of Medicine in 2016 determined that patients’ mean scores for hand tremor improved by 47% at three months in the cohort receiving the treatment, compared with 0.1% in study participants who underwent a sham procedure.³ And the noninvasive nature of the technique makes it particularly appealing for older patients who may be poorly suited for an invasive approach.

“The results can be dramatic,” Dr. Martello said. “Patients who have been living with this for decades are able to come out of the procedure and drink from a glass.”

Dr. Martello and team will select a very specific area of the brain to create a small lesion to decrease or eliminate the tremor. They have to weigh treating a larger area of the brain for more tremor reduction against possible increased risk of side effects.

Recent five-year data have been promising, showing that Clinical Rating Scale for Tremor scores significantly improved by 73.3% and 73.1% from baseline at both 48 and 60 months post-treatment, respectively.⁴

“Back in the day, we wanted to treat the whole tremor so we did big lesions, but we saw side effects such as balance issues,” Dr. Martello said, adding that correcting this behavior has caused some surgeons to create too small of a lesion, which may allow for the tremors to return. “Trying to find a middle ground of treating enough of the involved cells, but not so much that you are getting side effects.”

References

1. Crawford S, Lally C, Petrillo J, et al. How many adults in the US have essential tremor? Using data from epidemiological studies to derive age-specific estimates of prevalence. Neurology. 2020;94(15 suppl):4458.
2. Lorenz D, Frederiksen H, Moises H, et al. High concordance for essential tremor in monozygotic twins of old age. Neurology. 2004;62(2):208-211.
3. Elias WJ, Lipsman N, Ondo WG, et al. A randomized trial of focused ultrasound thalamotomy for essential tremor. N Engl J Med. 2016;375(8):730-739.
4. Cosgrove GR, Lipsman N, Lozano AM, et al. Magnetic resonance imaging-guided focused ultrasound thalamotomy for essential tremor: 5-year follow-up results. J Neurosurg. 2022;138(4):1028-1033.

A patient diagnosed with multiple sclerosis (MS) 20 years ago would have faced significant disability, pain, and perhaps a shortened life span.

Although there’s currently no cure for the neurologic disorder, which typically occurs in young adults aged 20 to 40 years, neurologists at ChristianaCare are embracing new treatments designed to help manage the course of the disease and limit its disabling effects. Treatments include disease-modifying therapies (DMT), which can slow disease progression and relieve some symptoms. 

“The best practice in managing a patient’s MS is through a multidisciplinary team approach that meets both the medical and nonmedical needs of patients, during any stage of the disease,” said Xiaoyang Li, M.D., a neuroimmunologist at ChristianaCare. “Our patients are guided through different treatment options during all stages of their lives, including instruction for patients and families about medicines and how to best manage symptoms.”

With immunotherapies such as DMTs, patients who start treatment early in the disease course can lead relatively normal lives. In MS, the immune system attacks healthy tissue and nerve cells in error, causing muscle weakness and movement problems. DMTs work by lowering the activity of the immune system, limiting its ability to attack healthy cells. In many patients, these drugs alter the course of MS, reducing their risk for disease relapse, decreasing disease activity and slowing symptom progression.

The FDA has approved more than a dozen DMTs for different types of MS, including clinically isolated syndrome, relapsing-remitting, secondary progressive and primary progressive. However, the drugs have proved most effective in treating the first three types.

Most of the DMTs recommended by neurologists within ChristianaCare’s MS Comprehensive Center of Excellence are infusion-based and can be administered in six-month dosing schedules. Because of a range of choices depending on the patient’s type of MS, treatments can be tailored for a specific patient, allowing for better disease management.

Still, although DMTs offer increased efficacy, often with fewer side effects than more traditional treatments, they do not reverse any nerve damage caused by MS that occurred prior to diagnosis. 

Even with these advances, “the most important consideration in the overall management of MS is an early diagnosis and early treatment intervention with the most advanced therapies available,” Dr. Li said.

Using a suite of innovative, minimally invasive techniques, the neurointerventional surgery team at ChristianaCare is transforming the treatment of aneurysms, offering care tailored specifically to patients’ individual needs.

Of these techniques, endovascular coiling is the oldest, dating back to the 1990s. The procedure involves the use of small, flexible catheters that are typically inserted via a patient’s femoral artery. Once the catheter has reached the brain, the surgeon is able to place coils in the aneurysm.

Platelets adhere to the coils and heal in a way that restricts blood from reaching the out-pouching of the aneurysm.¹

“This is a very sophisticated way to treat an aneurysm without having to open up the patient’s head and displace their brain,” Dr. Albani said. “Everything is done from within the artery without causing any disruption to the brain tissue.”

Although the technique works on saccular aneurysms — those with a lollipop or mushroom-like shape — others, which are fusiform or wide-necked in shape, require alternative approaches. For these, an open celled stent can be used which has gaps that can be crossed by a wire or a microcatheter, but will hold coils into an aneurysm. The stents are placed in the parent artery near the aneurysm, and a guidewire is passed through the stent in order to place coils within the aneurysm.

“Once placed, the stents help buttress the coils in order to keep them from falling out,” she said.

For certain patients, a finer mesh stent may be used, according to Dr. Albani. These permeable, flow-diverting stents are made of a very fine-gauge mesh that looks similar to a woman’s stocking.

They act to divert blood away from the aneurysm.

“Blood can still seep in, but it is not driving into the aneurysm,” Dr. Albani said. “The analogy I use for patients is it’s kind of like a coffee filter — the water will pass through but not flow with abundance. And the more filters you put in, the less flow you get through it. Over time, the body will endothelialize; the lining of the vessels will grow over the flow-diverting stent, remodeling the blood vessel and effectively sealing it from the inside.”

More recent technologies include the Woven EndoBridge WEB Embolization System (MicroVention) and the Contour Neurovascular System (Stryker).

“The WEB system looks almost like a square ball of yarn and keeps blood from getting into the aneurysm,” Dr. Albani said.

The Contour system, which Dr. Albani noted is shaped like an umbrella that has been inverted by the wind, can be inserted into an aneurysm and cinched down in order to serve as a wall that coils can be inserted behind. Indicated for wide-necked aneurysms, neither system uses a stent, meaning nothing needs to be placed in the parent artery, negating the need for antiplatelet medications that may not work for all patients.

“Whenever we put a stent into somebody’s artery, we have to put them on antiplatelet medications, and this usually involves keeping them on aspirin for life,” Dr. Albani said. “These devices can be a godsend for patients who can’t take aspirin, or who for other reasons we don’t want to put on blood thinners.”

Key to the ChristianaCare team’s approach is a deep understanding of, and experience with, each of the techniques, allowing them to customize each patient’s care.

“We have been early adopters of all of these things, have lots of experience using them and can tailor a patient’s treatment to what they need,” Dr. Albani said. “We have everything we need to make sure the patients are covered, and are here 24/7/365 to help with questions or concerns.”

References

1. Ogilvy CS. Neurosurgical clipping versus endovascular coiling of patients with ruptured intracranial aneurysms. Stroke. 2003;34(10):2540-2542.

Patients receiving care in the Neurocritical Care Unit at ChristianaCare with concern for seizure may benefit from a new electroencephalographic (EEG) technology on-boarded by health-system neurologists.

The platform, called Ceribell^® EEG (by the manufacturer of the same name), enables rapid evaluation of possible seizure activity when a standard EEG is not immediately. The technology enables ChristianaCare neurologists to quickly evaluate for seizure activity even when EEG technicians are not immediately available.

For patients with suspected seizure, time to diagnosis is a key determinant of outcomes, similar to the door-to-needle times in the management of ischemic stroke, as indicated by research. The sooner neurologists can start antiseizure treatment in patients, the more likely they can keep the brain disorder under control.

The primary benefit of Ceribell’s Food and Drug Administration-approved EEG device is that it is completely automated and can be operated by doctors and nurses at the bedside, without a specialized EEG technician, after minimal training. The device is a reduced-montage (8-channel) circumferential EEG that produces tracings covering the frontal, temporal and occipital areas. During evaluation, electrodes are implanted in a soft, adjustable headband attached around the head and secured for electrode grip, and amplified brain signals are transmitted to a pocket-sized device that allows patient data to be entered and viewed in real time.¹

Currently, the technology is being used by neurologists as well as nurses and advanced care practitioners in the neuro-ICU at ChristianaCare’s ewark facility. Pending results, it may be expanded to other facilities later this year.

In studies, Ceribell^® EEG has been shown to significantly reduce time to diagnosis. A recent analysis published in the journal Epilepsia Open found that mean time to epilepsy diagnosis with the device was 23.8 minutes.² In her experience with the technology, though, Dr. Wang said it can essentially provide diagnostic information in “real time.”

With that said, Ceribell^® EEG doesn’t — and won’t — replace conventional, state-of-the-art EEG platforms, which are more accurate and provide a more complete reading of electrical activity in the brain, according to Richard K. Choi, D.O.. Many patients initially evaluated with the novel device will undergo conventional EEG later to confirm early findings, he said.

“Ceribell^® EEG is really like the farmer’s dog barking in the middle of the night — it can warn us that something is or is not happening in a patient’s brain; but the farmer, or in this case the neurologist, will still need to confirm whether it’s something serious,” explained Dr. Choi, a neurologist and neurocritical care specialist at ChristianaCare. “Our use of this technology really highlights ChristianaCare’s ability to see a challenge and find an effective way to address it. It really reflects our values and behaviors, one of which is making sure we’re using all resources available to ensure the best care for our patients.”

References

1. Parvizi J, Gururangan K, Razavi B, et al. Detecting silent seizures by their sound. Epilepsia. 2018;59(4):877-884.
2. LaMonte MP. Ceribell EEG shortens seizure diagnosis and workforce time and is useful for COVID isolation. Epilepsia Open. 2021;6(2):331-338.

Botox (onabotulinumtoxinA, Allergan) injections have emerged as the most effective option for the treatment of chronic migraine, and specialists at ChristianaCare were early adopters of the innovative approach.

Botox is a neurotoxin that, when injected into muscle tissue, can prevent movement of the treated muscle for a limited time. Best known as a treatment for smoothing wrinkles in the skin on the face, these injections have traditionally been used to treat neuromuscular issues, including spasms and other muscle-contracting conditions.

“In addition to being the most effective treatment we have for refractory chronic migraine, Botox doesn’t have any systemic effects,” said Mitra Assidi-Khansari, M.D., a headache medicine specialist and the director of education in the Division of Neurology. “So, when we inject it into those tiny muscles on the cranial facial area, the medication basically remains in those muscles. It doesn’t float in your system, doesn’t affect the kidney or liver, and doesn’t penetrate your brain and cause cognitive side effects or changes in appetite or mood.” 

As a result, the former “is, unfortunately, a very undertreated disorder,” noted Jessica Bradley, M.D., a headache medicine specialist ChristianaCare. “Many patients don’t seek care until the migraines have gotten bad enough that they are forced to seek treatment options.” 

Botox was approved by the FDA in 2010 for use in the treatment of chronic migraine in adults with symptoms that have not responded to three other “standard treatments” (eg, calcitonin gene–related peptide antagonists and receptors). Based on the FDA guidelines, Botox can be administered every three months, for a total of four full treatments annually.

A standard protocol has been established for administering a total of 155 units of Botox. A recommended paradigm calls for injections on the frontal area, the temple, the occipital region over the cervical spinal area and on the top of the shoulders for a total of about 31 shots. 

Botox exerts its effect mainly by decreasing signaling on the motor fibers and reducing muscle tension in the cranial facial areas. There are some theories indicating that it can also disrupt the signaling on the sensory fibers.

In a study involving 245 patients with migraine, 82.9% reported that Botox helped control their symptoms.²

Despite its effectiveness, patients need to set expectations on what to anticipate from Botox treatments.

“The first thing I tell patients is that the treatments often don’t work in the first session,” Dr. Bradley said. “Botox treatments often have a cumulative build up in effect, and it can take up to three rounds of treatment to reach maximum migraine control. I explain this to my patients before starting so they know what to expect and won’t feel discouraged if the first treatment does not work well. I encourage patients to try at least three rounds of Botox before determining its effectiveness.” 

References

1. Stewart WF, Shechter A, Rasmussen BK. Migraine prevalence. A review of population-based studies. Neurology. 1994;44(6 suppl 4):S17-S23.
2. Yalinay Dikmen P, Kosak S, Ilgaz Aydinlar E, et al. A single-center retrospective study of onabotulinumtoxinA for treatment of 245 chronic migraine patients: survey results of a real-world experience. Acta Neurol Belg. 2018;118(3):475-484.