Neurovascular

The Neurovascular Division

The Neurovascular Division of the Department of Emergency Medicine performs both basic science and clinical research on neurovascular emergencies. The Division currently sponsors two separate fellowships: Neurovascular Emergencies and Neurocritical Care. We also offer rotations for emergency medicine residents to participate with the Greater Cincinnati/Northern Kentucky Stroke Team.

The Neurovascular Division currently has the following members:

The emergency medicine faculty and staff are integral members of the Greater Cincinnati/ Northern Kentucky Stroke Team. This is one of the most active stroke research teams in the world. Built on a long-standing multidisciplinary collaboration this team features immediate consultation for acute stroke patients for all 16 acute care hospitals in the Greater Cincinnati/Northern Kentucky region. With both vascular neurologists and emergency physicians sharing primary call this team treats almost 200 patients per year with reperfusion therapies. These therapies range from intravenous t-PA to intra-arterial approaches. The team also enrolls more than 50 patients per year in acute stroke treatment trials.

Ongoing Projects with Emergency Medicine Principal Investigators Include: CLEAR-ER, Ultrasound Enhanced Thrombolysis, and NETT (RAMPART, ALIAS and PROTECT)

The Combination Approach to Lysis Utilizing Eptifibatide And rt-PA in Acute Ischemic Stroke – Enhanced Regimen (CLEAR-ER) is an NIH funded, multicenter, randomized, double-blind trial to determine the safety of the combination of medium dose rt-PA (0.6 mg/kg total) plus eptifibatide (bolus 135 mcg/kg and 2 hour infusion at 0.75 mcg/kg/min) compared to standard dose rt-PA (0.9 mg/kg) in patients with acute ischemic stroke that can have the rt-PA initiated within 3 hours of symptom onset. Dr. Pancioli is the PI of this study which aims to obtain reliable estimates of the safety of the enhanced dosing regimen, building on the success of the original CLEAR trial. The study is nationally coordinated by Pam Schmit RN.

Dr. George (Chip) Shaw heads our basic science laboratory and has developed one of the premier models in the world to evaluate the effect of ultrasound on thrombolysis. It has been known for some time that ultrasound can enhance the action of thrombolytic medications including rtPA. However, the basic mechanism is not well understood. Dr. Shaw is currently performing research funded by a Whitaker Foundation Biomedical Engineering Research Grant ($227,000) to study this phenomenon at the microscopic level in the hopes of gaining insight into the mechanisms responsible for ultrasound enhanced thrombolysis (UET). In addition, Dr. Shaw was awarded a grant ($25,000) from the Neuroscience Institute (TNI) in 2002 to examine the effects of clot age on the thrombolytic efficacy of rt-PA and rt-PA with adjunctive ultrasound on human whole blood clots. This work is coming to fruition and insight into this problem will improve the understanding of UET Finally, the effects of rtPA concentration, temperature and other adjunctive therapies such as GP IIb/IIIa inhibitors are being studied in this highly reproducible model to provide the first ever series of quantitative data on rates of thrombolysis.

Neurological Emergencies Treatment Trials (NETT) Network. The NIH created this network to conduct large simple trials to reduce the burden of very acute injuries and illnesses affecting the brain, spinal cord and peripheral nervous system. Our group is fortunate to be one of 17 “hubs,” organized under the clinical coordinating center at the University of Michigan. We are currently enrolling patients in 2 trials from the NETT: RAMPART and ALIAS. Ms. Ewing is the clinical coordinator for the NETT Hub in Cincinnati.

Rapid Anticonvulsant Medication Prior to Arrival Trial (RAMPART) is an exception from informed consent (EFIC) trial investigating whether giving lorazepam intravenously or midazolam intramuscularly stops seizures in the pre-hospital arena. Patients are enrolled by EMS and consented upon arrival to the hospital. Dr. Pancioli serves as the PI for the UC hub. Dr. McMullan and Ms. Vonderschmidt are actively involved in site recruitment, and Ms. Ewing serves as the clinical coordinator for the hub.

Albumin in Acute Ischemic Stroke Trial (ALIAS) is a phase III randomized, double-blind, multicenter clinical trial of high dose human albumin therapy for neuroprotection in acute ischemic stroke. Patients whose NIHSS is 6 or greater are eligible for enrollment, and patients are able to receive IV or IA thrombolysis if appropriate. Dr. Pooja Khatri, a vascular neurologist is the UC site PI, and Ms. Ewing is the clinical coordinator for UC.

Progesterone for Traumatic Brain Injury (ProTECT III) will be a randomized, double blind, placebo control trial designed to investigate if IV progesterone is more effective than placebo for treating victims of moderate to severe acute traumatic brain injury. The study will examine patients’ six month outcomes. Drs. Lori Shutter (Neurocritical Care) and Jay Johannigman (Trauma Surgery) will be the co-PIs of the UC hub, while Dr. Jordan Bonomo will be the Emergency Medicine liaison to the study. Enrollment is anticipated to begin Spring 2010.

The Neurovascular Fellowship:

This fellowship provides the Emergency Medicine residency graduate with training in acute neurovascular emergencies in collaboration with the Greater Cincinnati/Northern Kentucky Stroke Team. This training is accomplished through clinical experience involving acute stroke intervention at The University of Cincinnati and other regional hospitals, as well as through didactic education in research methodologies, biomedical statistics, and principles of research design. Additional training is provided by the Departments of Neurology and Neurosurgery as well as the Division of Neuroradiology. Fellows are trained in the appropriate utilization of neuro-imaging, including CT, MRI, MRA and transcranial doppler. The fellow also directly participates in stroke call and ongoing acute interventional trials. Upon completion of the fellowship, the physician is proficient with diagnosis and treatment of acute stroke, including the use of IV and IA thrombolytic treatment options. The physician will be proficient in enrolling patients in acute clinical trials and understanding basic research methodologies. There are options for a 1 or 2 year fellowship, with varying emphasis on a clinical research focus. As of 2009, there have been 6 EM graduates of this fellowship, with 3 current EM fellows.

In July 2006 we partnered with the Department of Neurosurgery to develop a new curriculum to train Emergency Physicians in NeuroCritical Care. This aggressive 2-year program combines training in NeuroCritical Care with the 1 year Neurovascular Emergencies fellowship described above. This fellowship provides an avenue to certification (via the United Council on Neurologic Subspecialties) for the Emergency Physician interested in Critical Care. Upon completion of the fellowship, the physician will be proficient in critical care, including bronchoscopy, PA catheters, ventilator management and management of the critically ill, with a neurologic focus. They will also meet the goals of the original neurovascular emergencies fellowship. We currently have 2 positions per year, both offered through the Neurocritical Care national match. Our positions are filled through the entering class of 2010. Drs. Pancioli (Emergency Medicine), Dawn Kleindorfer (Neurology) and Lori Shutter (Neurosurgery – Neurocritical Care) are the joint fellowship directors.

Opportunities for Emergency Medicine Residents:

The Neurovascular Division has a long history of providing educational opportunities to emergency medicine residents who wish to acquire experiences in neurovascular research or the acute clinical management of neurological emergencies. Residents can join or initiate research projects or rotate with the stroke team treating acute stroke patients with reperfusion therapy (averaging greater than 100 calls per month and greater than 10 t-PA treats per month).