Q & A with Dr. Al-Ali

Q: What is neurointerventional surgery?

A: Neurointerventional surgery is a relatively recent specialty, as opposed to neurosurgery (where physicians perform open surgeries on the brain and spine, dealing mainly with hemorrhagic stroke and its causes such as brain aneurysm or malformation of the blood vessels), or neurology (which deals predominantly with ischemic stroke prevention and treatment through the veins, among other diseases such as seizures, multiple sclerosis, etc.) Neurointerventional surgery (NIS) is a newly recognized medical specialty, which deals with hemorrhagic and ischemic stroke prevention and treatment, using a catheter advanced through the blood vessels, without open surgery (minimally invasive technique). So a neurointerventionalist is a “stroke doctor”.

Q: What exactly is a stroke?

A: The description of a stroke is sudden change in neurological status. The words “sudden” and “neurological” are very important here.

Q: Are all strokes the same?

A: No, there are two kinds of stroke:

1- Ischemic: happens when a blood vessel which feeds the brain, in the head or neck, is abruptly blocked

2- Hemorrhagic: occurs when a blood vessel inside the brain starts leaking blood, either from an aneurysm or other abnormal vessel

Q: Which kind of stroke do you specialize in?

A: In my specialty, Neurointerventional Surgery (NIS), we are concerned with both kinds of stroke, hemorrhagic and ischemic. Remember we are the stroke doctors.

Q: What is a brain aneurysm, and how do you treat it?

A: An aneurysm is a “blister” or small balloon formed on the weakened side of a blood vessel. If the aneurysm grows in size, it can rupture like an overinflated balloon. Neurointerventionalists can treat aneurysms either by filling them from the inside using coils (we call the procedure coiling), or by placing a tight strut stent in the blood vessel where the aneurysm originated (we call this procedure flow diverter aneurysm embolization). When we find the aneurysm before it ruptures we treat to prevent it from rupturing, and when we encounter it after it has ruptured we treat it to stop it from rupturing again.

Q: How do you prevent and treat ischemic stroke?

A: Ischemia refers to tissue that is lacking nutrition due to a blocked blood vessel. The best thing to do is of course prevent ischemic stroke, which is why it is so important to follow the primary care doctor’s recommendation for blood pressure, weight, and diabetes control (we call these measures primary prevention). Sometimes, despite all of these measures, blood vessels become so narrow that they decrease the blood flow to the brain. A neurointerventionalist can open these vessels by use of a balloon or stent, in order to prevent a stroke (we call this secondary prevention). However, when the patient presents with a completely blocked blood vessel the aim is to open this blood vessel as fast as possible to prevent the tissue from dying. Usually, upon arrival in the emergency room, the patient is given a blood clot dissolving medication (easily administered through a small vein in the arm). This is a fast way of opening some, but not all, blocked vessels. Then the patient is taken to the Neurointerventional Suite, where the blood clot is removed.

Q: How do you remove the clot?

A: Blood vessels are divided into two categories: arteries and veins. Arteries take fresh blood from the heart to the organs. Veins return the used blood back to the heart. These vessels are like a faucet and drain. Ischemic stroke happens when the artery (faucet) is blocked by a blood clot. Just like the highway system, blood vessels in the human body are connected. Therefore we can insert a catheter in a blood vessel in the leg and navigate it all the way to the clot in the brain. We then either capture the clot by a stent, or we apply suction to it through a large catheter, before dragging it out of the body.

Q: What is stenting?

A: Stenting means placing a stent in a narrow blood vessel in order to make it wider. A stent is a metallic hollow tube, which holds the walls of the vessel open.

Q: How would you summarize what a Neurointerventional surgeon deals with?

A: We perform cerebral angiography (picture of the blood vessels in the brain) in order to identify the causes of patients’ new neurological symptoms. We then either prescribe medications or perform procedures aiming at stroke prevention or treatment (such as carotid artery stenting, opening of a blocked vessel causing cerebral ischemia, or closing of the source of bleeding inside the brain). In short, a neurointerventionalist specializes in treating, through a catheter, cerebrovascular diseases (abnormalities of the blood vessels in the head and neck).

Q: Do you mean a neurointerventionalist is like an interventional cardiologist?

A: Yes, very much so. However, although we use the same approach (deliver treatment through a catheter advanced through the arteries and veins) there are two main differences:

1. Interventional cardiologists treat blood vessels in the heart, while we deal with blood vessels in head and neck. We treat ischemic stroke (blocked vessel in the brain) as well as hemorrhagic stroke (bleeding in brain), as opposed to interventional cardiologists who deal with ischemic causes mainly.

2. Neurointerventional surgery deals also with fractured vertebrae of the spine (compression fracture) through noninvasive approach, such as vertebroplasty and kyphoplasty.

Q: A neurointerventionalist also treats fractured vertebrae?

A: Absolutely, but only in the case of specific fractures: compression fractures, induced by osteoporosis (thinning of the bone), or metastatic disease. But not all neurointerventionalists perform these procedures, and not all physicians who perform these procedures are Neurointerventional surgeons.

Q: Do you personally perform these procedures?

A: Yes. It is one of the procedures which gives me most satisfaction, since I feel I am helping relieve significant back pain while taking minimal risk.

Q: Certain publications and some physicians do not believe in these vertebral augmentation procedures, and some publications have contested their usefulness.

A: I am aware of these claims, however, in my community we believe these trials had significant shortcomings, and new trials are needed. From my experience of more than 20 years, I believe that, with careful patient selection, these are very potent and useful procedures.

Q: Where do you practice?

A: The bulk of my practice is at Cleveland Clinic-Akron General Hospital, and I also hold privileges and see patients at Summa Akron City Hospital, as well as Mercy Medical Center and Aultman Hospital in Canton.