Physicians Update

continued on p. 4

BRAIN TUMORS

Multipronged Approach Takes Aim at Malignant Brain Tumors

Researchers and clinicians at UCLA are making progress in their efforts to find e�ective treatments for malignant brain tumors — in part through a strategy that recognizes multiple options are needed coupled with the ability to predict which therapies will most bene�t each speci�c patient.

“Thanks to our work in molecularly and genetically classifying these tumors, we have

a better appreciation that there are di�erent subtypes of the disease, and not all types can be treated equally,” explains Linda Liau, MD, PhD, director of the UCLA Brain Tumor Center.

Malignant gliomas, the most common of which is glioblastoma, are among the most lethal cancers and the second-leading cause of cancer death among young adults.

FALL 2015Brain Tumor & Stroke Issue

Brain Tumor p. 1

Rehabilitation p. 3

Neuro ICU p. 6

Stroke Treatment p. 8

Neuroradiology p. 10

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News from UCLA Health

How obstructive sleep apnea damages the brain

UCLA researchers have reported the first evidence that obstructive sleep apnea contributes to a breakdown of the blood-brain barrier that plays an important role in protecting brain tissue. The damage to the brain that can result from obstructive sleep apnea can lead to high blood pressure, depression, memory loss and anxiety, as well as contribute to stroke, diabetes, loss of testosterone and endocrine-related problems.

uclahealth.org/apneabraindamage

Department of Neurosurgery ranked No. 2

The UCLA Department of Neurosurgery ranks No. 2 in the nation in scholarly research, according to a paper published in the Journal of Neurosurgery that rated the academic publishing output of faculty at 103 American neurosurgical residency programs from 2009 to 2013.

uclahealth.org/neurosurgeryranking

Why children’s recovery times vary after traumatic brain injury

New research by UCLA scientists and colleagues suggests that damage to the fatty sheaths around the brain’s nerve fibers — and not the severity of the injury itself — explains why some youngsters bounce back quickly from traumatic brain injuries while others suffer devastating side effects for years.

uclahealth.org/pediatricbraininjury

Treatment of aortic disorders has changed dramatically in the past decade, with the introduction of more minimally invasive, endovascular surgical techniques — many originated at UCLA. �e UCLA Aortic Center o�ers a comprehensive slate of options for patients with all stages of aortic disease, from traditional open surgery to the latest minimally invasive repairs.

�e aorta — the body’s primary and largest artery — carries oxygenated blood from the heart to vessels that feed the rest of the body. It is susceptible to a variety of disorders, including aneurysms, valvular disease, atherosclerotic occlusive disease, traumatic aortic injury and aortic dissections.

Complex aneurysms & aortic dissectionsAortic aneurysms can occur anywhere along the aorta — from the heart to the abdomen — when a weak part of the aorta expands like a balloon, forming a blood-�lled sac. Such bulges can be life-threatening if they grow too large and rupture. For small aortic aneurysms, a “watch-and-wait” approach may be taken. However, medium and large aneurysms o�en call for immediate treatment. While physicians still don’t know what causes aortic aneurysms, risk factors can include genetic predisposition, along with cigarette smoking, high blood pressure and chronic pulmonary disease.

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Four decades of pioneering new approaches �e UCLA Aortic Center continues to advance the understanding and treatment of aortic disease, building on a four-decade history of leadership that embraces minimally invasive solutions.

In the 1970s, UCLA surgeons expanded knowledge of the physiological processes behind aortic aneurysms. In the following decade, they developed an aortic prosthesis to prevent blood leakage from the repair site of aneurysms, dissections and blockages — a game-changing device still in use. In the 1990s, UCLA surgeons were the �rst to combine open surgery and endovascular repair for thoraco-abdominal aortic aneurysms. �roughout the early 2000s, UCLA continued to innovate, including developing custom endogra�s to repair di�cult abdominal aneurysms in 2012.

Such commitment is essential in aortic disease. “Today, with advanced surgical and minimally invasive technologies, we can help address the needs of patients with the most complicated aortic conditions,” says William Quinones-Baldrich, MD, director, UCLA Aortic Center, and professor of vascular surgery. “We can o�er more de�nitive alternatives, even if patients are considered high risk for traditional repair.”

UCLA Aortic Center brings innovation and comprehensive care to complex aortic disease

The Cystic Fibrosis Program at Mattel Children’s Hospital UCLA o�ers comprehensive clinical care, research and educational support for infants, children, adolescents and adults with cystic �brosis. �e program was recently accredited by the Cystic Fibrosis Foundation. �is designation recognizes high-quality, specialized care that leads to improved survival and quality of life.

Approximately 30,000 children and adults in the United States have cystic �brosis (CF), an autosomal recessive disorder that a�ects one in about 3,000 Caucasian births. �e discovery of the CF gene in 1989, isolation of the CFTR protein (cystic �brosis transmembrane conductance regulator) and improved understanding of the molecular mechanisms of the disease are being translated into new therapies. Life expectancy for patients with CF has improved dramatically.

New therapies to maintain lung functionPatient care has changed signi�cantly in recent years largely due to two major avenues of progress:

• The publication of standardized care guidelines by the Cystic Fibrosis Foundation

• The emergence of oral medications that target the underlying cause of the disease and slow the decline of lung function

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Access to state-of-the-art treatments“We know there are many di�erent elements to excellent care for children with cystic �brosis,” says Marlyn S. Woo, MD, professor of pediatrics and Cystic Fibrosis Program pediatric director. “�is is why accreditation will bene�t our patients. All accredited CF centers get information on the latest developments and treatments �rst from the Cystic Fibrosis Foundation. We have access to newer treatments, research medications and new �ndings.”

Having a nurse specialist, respiratory therapist, dietitian and social worker on the team is also bene�cial for patients. “CF patients have specialized needs, they need a lot of treatments and have a lot of equipment they need to learn to use. We provide that support” Dr. Woo says.

Following a visit, notes and records are sent within 24 hours to the patient’s primary care physician. Dr. Woo says. “Primary care physicians are vital partners in caring for these children.”

UCLA’s Cystic Fibrosis Program receives accreditation for pediatric and adult care

UCLA Clinical Updates Learn about the Latest Advances from UCLA

Adult Epilepsy Program The recent introduction of two innovative surgical procedures at UCLA’s Adult Epilepsy Program offers adults with debilitating seizures greater access to safe and effective treatments.

Improving Heart-Failure Management The CardioMEMS HF System is the first implantable hemodynamic monitoring device for heart failure approved by the Food and Drug Administration.

UCLA Aortic CenterThe UCLA Aortic Center offers a comprehensive slate of options for patients with all stages of aortic disease, from traditional open surgery to the latest minimally invasive repairs.

Catheterization Advances for Congenital Heart DiseaseMinimally invasive catheter-based interventions are associated with less risk and easier recovery and now are considered the standard of care in treating all patients with congenital heart disease.

Targeting COPDUCLA’s Division of Pulmonary and Critical Care Medicine offers the latest treatments for COPD, including therapies available through clinical studies not offered at most centers.

UCLA Cystic Fibrosis ProgramThe Cystic Fibrosis Program at Mattel Children’s Hospital UCLA offers comprehensive clinical care, research and educational support for infants, children, adolescents and adults with cystic fibrosis.

Early Kidney Disease DetectionA unique program in UCLA’s Division of Pediatric Nephrology offers specialized care for children with renal and/or urinary-tract abnormalities beginning when an abnormality is detected in utero.

Full-Service HIV/AIDS Care, Education and ResearchThe Care-4-Families program at Mattel Children’s Hospital UCLA provides a single point of contact and a broad spectrum of comprehensive, family-focused services for HIV-infected newborns, children, adolescents, pregnant women and mothers and HIV-exposed infants.

To download these and other clinical advances at UCLA Health, go to: uclahealth.org/clinicalupdates

Continuing Medical Education: Save the DateUCLA Brain Attack! ’16 Stroke Symposium When: Saturday, May 7, 2016

Where: UCLA Carnesale Commons

What: The UCLA Comprehensive Stroke Center presents the 21st annual UCLA Brain Attack! symposium, covering the practical, clinical aspects of stroke prevention, diagnosis and treatment. The course will include stroke risk factors, diagnostic testing and medical and interventional therapy.

This course is approved for AMA PRA Category 1 Credit.™

Cost: $200 – Early Registration $225 – Registration after Friday April 15, 2016 $150 – UC Faculty and Staff

Register: Go to cme.ucla.edu/courses and select “UCLA Brain Attack! ’16 Symposium”

3 UCLA Physicians Update

UCLA Partnership Will Expand Rehab Services for Los AngelesUCLA Health is partnering with Cedars-Sinai Medical Center to dramatically expand the availability of acute rehabilitation services in Los Angeles. The California Rehabilitation Institute, scheduled to open early next year, will be a freestanding, 138-bed acute rehab hospital in Century City that will more than triple the number of beds currently available for rehabilitation at the two facilities. In addition to the combined expertise of the two prominent healthcare organizations, the e�ort includes a managing partner, Select Medical, which treats more than 60,000 patients a day at its rehabilitation facilities around the country.

“�is joint venture between UCLA Health and Cedars-Sinai will not only signi�cantly expand the availability of rehabilitation services in the community, but through a consolidated, coordinated and experienced group working under the same roof, we will be able to achieve a level of quality and specialization of services that neither organization could have provided alone,” says David N. Alexander, MD, medical director of the California Rehabilitation Institute and UCLA’s Neurological Rehabilitation and Research Unit.

Featuring the latest treatment protocols and equipment, along with 24-hour availability of medical care, the specialized rehabilitation hospital will have all private rooms, with a therapy gym on each �oor. �e institute will admit patients from both UCLA and Cedars-Sinai, as well as other hospitals and skilled-nursing facilities and, occasionally, directly from patients’ homes. About half of the patients will be recovering from neurological diagnoses, including stroke, traumatic brain injury, and spinal cord injury, Dr. Alexander says.

Patients at the facility will follow an intensive regimen, including treatment by various rehabilitation specialists each day. On-site sta� and physical, occupational, speech and recreation therapists, as well as social workers,

psychologists and neuropsychologists, will work with physicians to develop an individualized program designed to meet each patient’s rehabilitation goals while ensuring that any comorbid or concurrent medical problems are addressed.

“It is extremely important to have acute rehabilitation available to patients, and there has been a major unmet need,” Dr. Alexander says. “Hospital stays are shorter than in the past, and as improved therapies have become available, we are now seeing more people recover who would have otherwise remained more signi�cantly impaired. �ese patients o�en need assistance to improve their mobility and their ability to perform basic daily activities. Acute rehabilitation improves recovery, reduces morbidity and mortality, increases the likelihood of home discharge and allows patients to become more independent.”

“ �is joint venture between UCLA Health and Cedars-Sinai … will be able to achieve a level of quality and specialization of services that neither organization could have provided alone.”

Rehabilitation

Progress is being made to treat

malignant brain tumors using a strategy

that combines multiple options with the

ability to predict which therapies will

most benefit specific patients.

Next-generation sequencing techniques

make it easier to identify molecular

targets and direct patients to

appropriate clinical trials.

STORY HIGHLIGHTS

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Malignant gliomas are among the

most lethal cancers and the second-

leading cause of cancer death among

young adults.

Brain Tumors

COVER STORY

Multipronged Approach Takes Aim at Treating Malignant Brain Tumors

“�e ability of glioblastoma to in�ltrate and damage the surrounding brain makes it a particularly devastating tumor, in which complete surgical removal is impossible,” says Timothy Cloughesy, MD, director of the UCLA Neuro-Oncology Program at Ronald Reagan UCLA Medical Center. “It also is one of the most resistant tumors to radiation and chemotherapy. And because we don’t know how or what causes this tumor to develop, and it is detectable only when fully formed, we can’t prevent it or catch it early.”

Given the absence of a single e�ective therapy, UCLA’s e�orts to change the outcomes of glioblastoma focus around evaluating and o�ering many promising therapies in clinical trials that approach killing or controlling the tumor from a variety of fundamental mechanisms. �ese include molecularly guided therapies — drugs that exploit information obtained by genetically pro�ling tumors then targeting speci�c molecular abnormalities found in a subgroup of patients; therapy that uses genes to deliver viruses to the tumor; and immune-based therapies, including tumor vaccines, to activate the patient’s native system against the cancer.

With next-generation sequencing techniques, it is now much easier to identify molecular targets than even a few years ago, Dr. Cloughesy notes. Nearly every patient’s tumor can be sent for sequencing, and then the patient can be assigned to a clinical trial based on the abnormalities found. “�e drug companies are working with us to develop very focused agents,” Dr. Cloughesy says. “A drug might focus on a mutation found in only about 3 percent of glioblastomas, but if you can �nd something of great bene�t for that small group of patients, that is signi�cant. It’s a step toward personalized medicine.”

�e UCLA Neuro-Oncology Program o�ers trials of drugs that target various mutations of the epidermal growth factor receptor (EGFR), the most common glioblastoma abnormality. The program also has trials of compounds targeting IDH-mutated tumors, as well as drugs taking aim at tumors with molecular pathways that, when activated, are known to contribute to tumor growth and progression.

When brain-tumor researchers are asked about the most promising areas for future study, both genetic profiling and immunotherapy consistently top the list, Dr. Liau says. UCLA is at the forefront of both �elds. UCLA’s immune-based therapies currently in clinical trials use treatments that enable the immune system to kill tumor cells by targeting factors, known as immune checkpoint inhibitors, which impede the immune system from successful tumor control. In addition, Dr. Liau and her colleagues developed the first dendritic cell (DC)-based vaccine, known as DCVax, for brain-tumor patients to be used in humans. “The problem with brain tumors is that, despite treatment, they tend to come back,” Dr. Liau says. “�e promise of immunotherapy and vaccines is that they can hopefully prevent the cancer from returning.”

(continued from cover)

“ �anks to our work in molecularly and genetically classifying these tumors, we have a better appreciation that there are di�erent subtypes of the disease, and not all types can be treated equally.”

5 UCLA Physicians Update

Colored coronal magnetic resonance

imaging (MRI) scan through the head

of a 48-year-old male patient with a

glioblastoma (red), with surrounding

oedema (fluid) that is compressing the

left ventricle (at right). A glioblastoma

is a particularly malignant brain cancer

that arises from the supporting glial

cells in the brain. Treatment is with a

combination of surgery and radiotherapy,

but the prognosis is poor.

Multipronged Approach Takes Aim at Treating Malignant Brain Tumors

Fi�een years ago, most experts believed it was not possible, because of the blood-brain barrier, for patients to mount an immune response to brain cancers. “We’ve found that these tumor vaccines can not only mount an immune response, but that a signi�cant percentage of patients have had no recurrence for more than 10 years now, which for glioblastoma is very rare,” Dr. Liau says.

Currently, Dr. Liau and her colleagues at the UCLA Brain Tumor Center have begun to publish on genetic pro�ling and biomarkers to determine which patients are likely to fare well on immunotherapy. “Right now, we’re treating everyone the same way,” she says. “I am hopeful that in the next few years, we will have biomarkers that we can test either in the patient’s blood or via imaging. With these biomarkers, we will know in advance which patients will respond, and for those who won’t, we will work on other ways to treat the tumor.”

Many of the ongoing clinical trials for brain tumors grew out of studies that began at UCLA,

which has a strong research base in each of the four major treatment targets: immunotherapy and tumor vaccines; alterations in cancer-cell metabolism; going a�er cancer stem cells to make them more sensitive to treatment; and taking aim at the IDH1 mutation, which is found in a subtype of glioblastomas and associated with significantly different tumor behavior.

“At UCLA, we are part of both a leading academic institution and a leading treatment center, and we have taken advantage of that by developing close working relationships along the continuum from the bench to the bedside,” Dr. Liau says. “Our basic scientists meet regularly to discuss what’s going on in the laboratories, and we share that information with the clinicians. �is is particularly important in the brain tumor �eld, and it has been a key to our success in bringing new therapies to fruition.”

“ At UCLA, we are part of both a leading academic institution and a leading treatment center, and we have taken advantage of that by developing close working relationships along the continuum from the bench to the bedside.”

UCLAHEALTH.ORG 1-844-4UCLADR (1-844-482-5237)

How has neurocritical care evolved in recent years?

Neurocritical care has grown significantly as a subspecialty in the 21st century, with the development of professional certification, accreditation for neurocritical-care fellowship programs, and the recent recognition by the nonprofit medical quality watchdog Leapfrog Group that neurocritical-care specialists are essential for critically ill brain patients. We used to consider neurocritical care to be a postoperative ward where patients would go just to recover from surgery. They were treated like other critical-care patients with

heart monitoring, and if they didn’t wake up it was just assumed the prognosis was poor and they were going to die. What has emerged is a brain-speci�c treatment for these patients. At programs such as ours, it has become critical care for the brain rather than critical care for the heart.

What do you mean by that?

While traditional critical care monitors the heart with an EKG, neurocritical care uses an EEG to monitor the brain. If we have a patient who is in a coma, for example, rather than focusing only on monitoring blood pressure, heart rate and cardiac arrhythmias, we will administer

Paul Vespa, MD

With professional certification, fellowship

accreditation and increasing national

recognition, neurocritical care has grown

significantly as a subspecialty.

As understanding has grown that silent,

nonconvulsive seizure activity leads

to poor outcomes, continuous EEG

monitoring has become the standard

of care in neuro ICUs.

STORY HIGHLIGHTS

ICU of the Future Improves Care for Neurocritical PatientsThe emergence of neurocritical care as a recognized subspecialty over the last

two decades has led to the development of comprehensive centers for neurological

emergencies where significantly better outcomes can be achieved than from

general intensive care units. Paul Vespa, MD, professor of neurosurgery

and neurology at the David Geffen School of Medicine at UCLA and director of

UCLA Health’s Neurocritical Care Program — which has received the center of

excellence designation — discusses the state of the field.

Neurocritical Care

“ We have established what we call the ICU of the Future, which includes not only the service lines, but new technological and therapeutic approaches for monitoring the brain and delivering more personalized treatments for neurological emergencies.”

treatments to restore and enhance brain function, as well as controlling pressure inside of the brain and detecting and stopping seizures in the brain. Prior to this, critical care was more about monitoring blood pressure, heart rate and cardiac arrhythmias with these patients.

You and your colleagues helped to pioneer continuous EEG brain monitoring of patients in the neurointensive care unit.

That’s right. Starting in the late 1990s, we were the first to show that the brain can have silent, nonconvulsive seizure activity, and that these seizures lead to poor outcomes. �at has created a whole field of monitoring the brain. Continuous EEG monitoring has become the standard of care in neuro ICUs. Now, when we treat patients, we adjust medications and surgical interventions based on what the brain needs rather than what the heart rhythm is, and we use continuous monitoring for that feedback.

In what other ways is the care at a center such as UCLA’s different for neurocritical patients?

Beyond the state-of-the-art technology, we provide around-the-clock monitoring and coverage by a neuro-intensivist. Too o�en, in facilities that don’t have neurocritical-care expertise, the approach is therapeutic nihilism — the feeling that “nothing is going to work and we should just stop.” In those circumstances, the treatment o�en is about preparing the family for death. We are optimistic that the brain can recover, we know how to enhance that recovery, and we are not looking to withdraw care when recovery is possible.

What types of patients should be referred to UCLA?

We are a center of excellence for neurological emergencies — especially for complicated cases — and we definitely want to encourage transfer of these patients. For any patients with brain trauma, brain hemorrhage, subarachnoid hemorrhage and other complex and serious brain injuries, the outcomes are going to be better at a comprehensive neurocritical-care center.

What is the future of neurocritical care?

That is something we are helping to define by creating technology and therapeutic approaches that are at the cutting edge and not generally available in hospitals. We have established what we call the ICU of the Future, which includes not only the service lines, but new technological and therapeutic approaches for monitoring the brain and delivering more personalized treatments for neurological emergencies. For example, we are using micro-dialysis, PET, MRI and other advanced imaging approaches in the ICU for improved continuous monitoring of patients. Our ICU of the Future is also employing telemedicine approaches, building on work that UCLA pioneered a decade ago to treat patients remotely with an ICU robot. Today, more than 1,500 robots are in U.S. hospitals, a significant number of them in ICUs. Our program uses the technology to deliver care for neurological emergencies at community hospitals via telemedicine, as well as employing a robot at UCLA’s neuro ICU to treat patients and supervise care overnight. We have basically created a human laboratory for studying every aspect of the comatose brain to determine how it can be fixed. We are using the latest and best technologies to treat patients today, as well as generating tomorrow’s therapies.

7 UCLA Physicians Update

Removing clots with the Solitaire device,

developed at UCLA, has been shown to

reduce poststroke disability and increase

independence after three months.

Because tPA provides only a modest

benefit, researchers at UCLA have spent

two decades developing alternative

treatments to open blocked arteries in

stroke patients.

While tPA reopens vessels 25-to-30

percent of the time, Solitaire has

been shown to open a blocked artery

88 percent of the time.

STORY HIGHLIGHTS

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New Retrieval Device Shown to Be Major Benefit for Stroke PatientsA new device to remove obstructing blood clots represents a breakthrough in the treatment of acute ischemic stroke, according to Je�rey Saver, MD, director of the UCLA Comprehensive Stroke Center. A multicenter clinical trial, headed by Dr. Saver, found that in patients with acute ischemic stroke — in which a clot blocks the blood supply to part of the brain — removing the clot with the stent retriever device, which was developed at UCLA, signi�cantly reduced poststroke disability and increased the percentage of patients who were independent in their daily function a�er three months.

�e device, called Solitaire, represents the �rst major advance in the treatment of acute ischemic stroke in 20 years — since the development of the clot-busting drug tPA, Dr. Saver says. He notes that approximately �ve-out-of-six strokes are ischemic; acute ischemic stroke is the second leading cause of death worldwide and the leading

cause of adult disability. For years, the only proven treatment was tPA, but it provides only a modest bene�t — when used up to four-and-a-half hours a�er the stroke’s onset, it dissolves the targeted clot between one-third and one-half of the time.

As a result, Dr. Saver explains, UCLA has spent the past two decades developing an alternative approach — mechanically attacking clots to pull them from occluded vessels. �e �rst such device, the MERCI Coil Retriever, was invented at UCLA and cleared for use by the U.S. Food and Drug Administration in 2004. �e MERCI device was shown to reopen arteries 60-to-65 percent of the time, but only fully reopening them one-fourth of the time, with modest impact on patient outcomes. “We needed newer-generation devices that would do a better job of opening arteries,” Dr. Saver says.

Stroke

“ �is is an ideal use of telemedicine because the exam needed to make decisions on the treatment of these patients is largely visual, the medical decision-making is complex, and there aren’t enough neurologists to go around.”

9 UCLA Physicians Update

New Retrieval Device Shown to Be Major Benefit for Stroke Patients

�e Solitaire stent retriever, which entered clinical trials on the basis of preclinical research conducted by Reza Jahan, MD, a UCLA professor of radiology and a member of the UCLA Comprehensive Stroke Center, is such a device. Unlike the MERCI retriever — a helical-shaped coil designed to grab and pull the clots out of the blocked artery — Solitaire is a mesh-columned cage, with crossing struts that can expand and engage the clot at multiple points. “A neurointerventionalist physician goes up with a wire catheter inserted in the groin, deploys the columnar mesh stent into the clot, the mesh embeds in the clot, the neurointerventionalist pulls the retrievable stent out, and the clot comes with it, restoring blood �ow,” Dr. Saver says. “It’s like pulling the cork out of a wine bottle.”

�is has proved much more e�ective in pulling out clots, Dr. Saver notes, and it is also a signi�cant advance over tPA alone. For patients with a large clot, tPA reopens vessels 25-to-30 percent of the time. In the multicenter study, the stent retriever device opened the artery 88 percent of the time, even when there was a large clot. Four other clinical trials published within the last year have shown similar results.

�e advance has implications on regional systems of stroke care. “In the past, we have set these up so that patients were preferentially brought to primary stroke centers capable of giving intravenous tPA to chemically dissolve the clot,” Dr. Saver says. “We need to evolve ambulance routing protocols to make sure that patients who will bene�t from thrombectomy are brought to comprehensive stroke centers where there is the capability to perform this intervention, which requires a neurocatheter lab, neurointerventionalist physicians, and advanced postprocedural neurocritical care.”

Telestroke Program Expands UCLA’s Expertise to Other Centers“Time is brain” is a common mantra in the stroke-treatment field, referring to the urgency of treating patients suffering from acute stroke — initially, in most cases, with the clot-busting drug tPA — before irreversible damage occurs. But in rural areas, and even many urban communities, hospitals that are otherwise capable of treating such patients may not have a neurologist — much less a neurologist with vascular training — available around the clock to go to the hospital and conduct the evaluation necessary before the drug can be administered.

The UCLA Telestroke Program addresses that concern by providing participating hospitals with 24/7 access to the expertise of the UCLA Comprehensive Stroke Center. “Many emergency room physicians are uncomfortable making a decision about thrombolytic therapy. They would much rather have a vascular neurologist helping them in making that determination,” says Latisha Katie Ali, MD, a vascular neurologist and director of UCLA’s Telestroke Program. “Through our televideo systems, we are able to conduct a visual examination, take a clinical history, review the neuroimaging and rapidly assess patients in a way that potentially changes their management.”

Hundreds of patients are seen remotely each year by UCLA Stroke Center experts through the program, which began in 2009 and currently has participation agreements with 23 hospitals throughout California. When emergency department physicians at these hospitals recognize a patient who may qualify, they contact the UCLA Telestroke Program and an expert reviews the case on a high-definition screen. “The technology is at the point where we can even zoom in enough to see changes in the pupil of the patients,” Dr. Ali says. “And to be able to interact with patients and their family members and see them for ourselves is much more effective than relying on a conversation with an ER physician.”

“This is an ideal use of telemedicine because the exam needed to make decisions on the treatment of these patients is largely visual, the medical decision-making is complex, and there aren’t enough neurologists to go around,” says Jeffrey Saver, MD, director of the UCLA Comprehensive Stroke Center. “This program provides much better access for patients in these emergency situations by enabling UCLA neurologists to make those judgments on demand.”

Solitaire is a mesh columned cage, with

crossing struts that can expand and

engage the clot at multiple points.

“Stent-Retriever Thrombectomy after Intravenous t-PA vs. t-PA Alone in Stroke,” New England Journal of Medicine, June 11, 2015

One-Call Stroke Acceptance LineFor immediate acceptance of acute stroke transfers to UCLA, call (310) 825-0909 Press 1 For patients whose symptoms began in the past 12 hours with:Brain hemorrhage • Subarachnoid hemorrhage • Brain trauma

Ischemic stroke

Courtesy of Medtronic. © Corvidien. Used with permission.

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The UCLA Comprehensive Stroke Center

is a first point of contact to quickly

assess and intervene with patients

thought to have had a stroke.

A large team that can respond

quickly is essential to the successful

treatment of a stroke.

STORY HIGHLIGHTS

When ‘Time is Brain,’ Prompt Response Essential to Successful Stroke TreatmentAs the �rst point of contact in quickly assessing and intervening with patients brought to the UCLA Comprehensive Stroke Center, the interventional neuroradiology team plays a key role in the success of UCLA’s stroke program.

When patients in Los Angeles appear to be suffering from acute stroke, emergency responders use the Los Angeles Prehospital Stroke Screen, a tool validated at UCLA, to identify those who should be transferred to the UCLA Comprehensive Stroke Center for potential interventional treatment. For patients who are routed to UCLA, the “brain

attack” team is activated. A�er an initial rapid evaluation to determine whether the patient is su�ering from an acute stroke as opposed to a stroke mimic, the team ensures that the patient is stable before further assessment using advanced imaging — either CT or MRI. If stroke intervention is indicated, the front-line treatment is medical, in the form of intravenous tissue plasminogen activator (tPA), a clot-busting drug that can be administered e�ectively up to four-and-a-half hours a�er an acute stroke.

If a patient shows blockage of a large vessel of the brain — most commonly the internal carotid

11 UCLA Physicians Update

artery, the middle cerebral artery or the basilar artery — he or she is taken to the angiography suite. �ere, assuming intravenous tPA hasn’t resolved the problem, the interventional neuroradiology team seeks to remove the clot. “�is requires a large team that can respond quickly,” says Gary R. Duckwiler, MD, chief of the Division of Interventional Neuroradiology at UCLA. At all times, he notes, UCLA has a neurologist and interventional neuroradiologist on call, along with MR/CT techs, nurses and angiographic techs. “It is essential to have a system in place that will attend to the patient immediately and e�ciently, because ‘time is brain,’” Dr. Duckwiler says. “We know that opening up blocked arteries as quickly as possible provides the best chance of recovery.”

�e mainstay for removing clots and reopening vessels in patients with large occlusions that can’t be unblocked by tPA are devices that Dr. Duckwiler and his colleagues navigate, under X-ray guidance, through the artery of the groin, a�er an angiogram has identi�ed the site of the blockage and the �ow of blood to the brain. �ese stent-retriever devices are attached to a small wire and deployed through a catheter toward the brain vessels. “The devices are self-expanding,” Dr. Duckwiler says. “We place the device at the level of the clot, the stent retriever expands in the clot, the device captures it and then we pull it out in an e�ort to restore f low in the blood vessel.”

UCLA has been involved in developing the clot-removing technique from the beginning — the UCLA Division of Interventional Neuroradiology invented the first device approved by the U.S. Food and Drug Administration for use in opening up brain vessels in acute stroke, the MERCI retriever, and conducted the clinical trials that showed it improved outcomes for patients with large-vessel occlusions who fail to respond to medical therapy. “Our team has been involved in the advances in acute stroke care from the outset, both with medical and interventional therapies,” Dr. Duckwiler notes. �e devices have improved signi�cantly over the years, to the extent that Dr. Duckwiler and his colleagues are now able to successfully retrieve the blood clot in 80-to-90 percent of cases.

Patients who are successfully treated also bene�t from the full continuum of care o�ered by the UCLA Comprehensive Stroke Center, including the dedicated neurointensive team attending to patients in the neuro ICU, along with the specialists who work with patients during rehabilitation.

“Honing our practice over many years has made our team adept at getting patients assessed and treated quickly and successfully, in an environment where every aspect of care across the continuum is critical for overall patient recovery,” says Dr. Duckwiler. “�is has contributed to signi�cantly better overall outcomes, as demonstrated in multiple studies.”

“ It is essential to have a system in place that will attend to the patient immediately and e�ciently, because ‘time is brain.’ We know that opening up blocked arteries as quickly as possible provides the best chance of recovery.”

One-Call Stroke Acceptance LineFor immediate acceptance of acute stroke transfers to UCLA, call (310) 825-0909 Press 1 For patients whose symptoms began in the past 12 hours with:Brain hemorrhage • Subarachnoid hemorrhage • Brain trauma • Ischemic stroke

Interventional Neuroradiology

If a patient shows blockage of a large

vessel of the brain, he or she is taken

to the angiography suite of the UCLA

Comprehensive Stroke Center, where

a neurologist and interventional

neuroradiologist are always on call,

along with MR/CT techs, nurses and

angiographic techs.

Blockage removed, full flow restored

to the middle cerebral artery.

Blockage of a large brain vessel

(middle cerebral artery).

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PAIDU C L A

Physicians UpdateFALL 2015

CHIEF COMMUNICATIONS

OFFICER Nancy Jensen

CHIEF MARKETING OFFICER Pattie Cuen

DIRECTOR, MARKETING

COMMUNICATIONS Judi Goodfriend

EDITOR

David Greenwald

CONTRIBUTOR

Dan Gordon

MEDICAL EDITORS James Atkinson, md Brandon Koretz, md

DESIGN

Donenfeld & Associates

Copyright © 2015 by UCLA Health. All rights reserved.

For inquiries about UCLA Physicians Update, contact UCLA Health Marketing Communications, Box 956923, Los Angeles, CA 90095-6923 uclahealth.org

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CALIFORNIA DEPARTMENT of MANAGED HEALTH CARE

UCLA Physician Access Line

1-844-4UCLADR (1–844–482–5237)

Be connected 24/7 with an appropriate UCLA physician to assist with questions about your patient’s care and referrals.

Please have the following information available: • Phone number where you can be reached in 20 minutes (cell phone is recommended)

• Patient name

• Patient contact number (for possible follow-up appointments)

If the call is regarding an inpatient transfer, the following information also will be needed:

• Patient date of birth• Current patient location (hospital and specific unit)• Face sheet faxed to UCLA Health at 310-825-2700

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