Interventional Neurology and NeuroEndovascular surgery in two corners of Asia: The United Arab Emirates and Japan.
Daniel Vela-Duarte, MD, MSCR
Vascular Neurologist
NeuroEndovascular surgery / Interventional Neurology fellow.
Miami Cardiac and Vascular Institute, Baptist Neuroscience Center, Miami, USA
Twitter: @DanielVelaMD
For the second edition of “The Core”, our quarterly newsletter, I wanted to explore systems of care, neuroendovascular practices, and stroke treatment in two different corners of Asia, The United Arab Emirates (UAE) and Japan; fascinating and interesting countries from many points of view.
My first guest is someone I learned a lot from while in my vascular neurology fellowship at the Cleveland Clinic, Ohio. His dedication to teaching was phenomenal. Dr. Seby John did his neurology residency at the Cleveland Clinic, followed by fellowships in vascular neurology and Endovascular surgical neuroradiology, both at the same institution. Here is our conversation.
Vela: Our audience has probably read seminal papers on reversible cerebral vasoconstriction syndrome, which you authored while being in fellowship, and after establishing collaborations with Dr. Hajj-Ali and Dr. Calabrese. What would you advise to the fellows reading us on how to conduct clinical research during training?
Seby John, MD
Staff Physician, Neurology and Neurointerventional Surgery, Cleveland Clinic Abu Dhabi
Al Maryah Island, Abu Dhabi, United Arab Emirates
Clinical Associate Professor of Neurology
Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
John: Residency and fellowship are ideal times to foster an interest or hone your skills in research. Fortunately, the specialty of cerebrovascular diseases, particularly neurointervention, is constantly evolving, and the field itself lends to innovation. So, there is much research that can be pursued. As you have alluded to, a key component to developing your research during training is identifying a mentor early on. You can have more than a single mentor. It will also be beneficial to align with a group with similar interests. It goes without saying that research often demands a lot of time and dedication. Sharing responsibilities, challenges, and successes with your core group makes research fun and keeps you engaged. Networking! Use early career platforms offered by scientific societies. Once you are comfortable, do not hesitate to pursue local, national, and international collaborations.
Vela: After learning and practicing neurology and interventional neurology in the American health care system, tell us a bit about your experiences once you moved to Bangalore (India).
John: Although I stayed in Bangalore only for a short 18 months, I learned a lot from my experience there. Despite Bangalore being a leading metropolitan city in India, delivering optimal stroke care faces numerous obstacles.
Stroke awareness among the public is woefully lacking. Even among the medical community, many are not aware of powerful treatment options such as mechanical thrombectomy. While strong concerted efforts are ongoing, there is a lack of organized systems of care to ensure the right patient reaches the right hospital. Stroke treatments, including intravenous thrombolysis, are prohibitively expensive, which plays a considerable role in availing treatment since a large proportion of patients do not have medical insurance. For the interventionalist, the majority of the hospitals have single-plane angiography systems. You have to be extremely judicious, efficient, and frugal with the use of equipment while balancing patient outcome/safety with cost.
Vela: You are currently established at the Cleveland Clinic Abu Dhabi. Tell us about the health-care system there. How is your practice, and what are the challenges that both physicians and patients face to deliver and receive stroke care?
John: Cleveland Clinic Abu Dhabi (CCAD) works very much like the model of care delivered in Cleveland Clinic, Ohio. CCAD is Joint Commission International-accredited and is the designated stroke center for the emirate of Abu Dhabi. We have a full complement of cerebrovascular staff and services and are fortunate to offer comprehensive stroke care to a large patient population. My practice is predominantly vascular neurology and neurointerventional surgery, but I also do some general neurology work. Because of the center of excellence status, we are able to take care of all emergencies such as stroke requiring mechanical thrombectomy, SAH, or any complex cerebrovascular issue. This is extremely gratifying for our team and me. The challenge, however, is to get the patient here in a timely fashion. Since its inception in 2015, we have worked closely with our regional partners to improve triaging and transfers (akin to a hub and spoke model). As you know, this is especially critical with LVO requiring mechanical thrombectomy, and we are making steady progress. Telestroke options are on the horizon.
Vela: After navigating through different health systems in the US, India, and currently in the middle east; What could you point out as the main barriers each country has to overcome in stroke care in the next years?
John: For developing countries, improving public awareness, developing a centrally organized emergency response (ambulance system) with defined triage/transfer protocols, and making treatment accessible and affordable are fundamental challenges to overcome. As I said earlier, stroke treatments remain extremely expensive. Steps such as inclusion of alteplase under the essential medication list by the World Health Organization is a major step towards ensuring better stroke treatment utilization.
For developed countries, issues related to access to thrombectomy needs sorting. This includes ongoing discussions regarding the optimal triage protocols (bypassing directly to thrombectomy center) and coordinating emergency response systems. For both settings, requirements for the neurointerventionalist will have to be carefully assessed to guide future training of the specialist. Efforts such as MT2020 are key to improving access to thrombectomy, and I am very optimistic about its global role in the coming years.
Vela: Tell us a bit about your current research efforts, projects, and collaborations.
John: We have a unique stroke population here in UAE. For instance, the mean age of ischemic stroke is almost a decade earlier than that seen in the USA. Also, we have a much higher proportion of hemorrhagic stroke, and arteriovenous malformations are more frequently encountered than my experience in Cleveland. Our current research efforts include establishing epidemiological stroke data for this region. I am also working on thrombectomy in intracranial atherosclerotic occlusions, clot analysis and stroke systems of care. We have multiple ongoing industry-sponsored international registries in ischemic and hemorrhagic stroke. We frequently collaborate with regional partners, especially the MENA-SINO group, and have been fortunate to collaborate with SVIN on multiple COVID projects.
Vela: How is the current situation of COVID-19 at your hospital, and how did it impact your service? Tell us about your cases, if you don’t mind describing a remarkable case you treated with COVID, and lastly, how the hospital adapted units, protocols, and such.
John: Our hospital treated a large number of patients with COVID-19 during the first wave of the pandemic here in UAE. Organizational changes, especially with regards to expanding critical care services, were rapidly instituted. Being the dedicated stroke center, we also received patients with stroke and COVID-19. In contrast to the experience of multiple international centers, we recorded an increase in the presentation of ischemic and hemorrhagic strokes. Acute cerebrovascular disease was seen in 5.2% of COVID-19 patients (3.2% ischemic, 2% hemorrhagic) [1]. In our series, patients with COVID-19 and ischemic stroke were significantly younger, predominantly male, had lesser rate of cardiovascular risk factors, and more severe clinical presentation compared to those ischemic stroke patients without COVID-19. There was also a remarkably high rate (75%) of large vessel occlusion (LVO) in COVID-19 patients with ischemic stroke [2], and 73% of these patients were below the age of 50 years. LVOs were observed in multiple vessels, uncommonly affected vessels, in atypical locations, and had a large thrombus burden. With the second wave, despite the number of COVID-19 cases being much higher than the first wave, we thankfully have not seen cases of COVID-19 and concurrent stroke.
Vela: Thank you, Seby, for taking the time to share with the audience of “The Core”
- John S et al. Characteristics and admission patterns of stroke patients during the COVID 19 pandemic: A single center retrospective, observational study from the Abu Dhabi, United Arab Emirates. Clin Neurol Neurosurg. 2020.
- John S et al. Characteristics of Large-Vessel Occlusion Associated with COVID-19 and Ischemic Stroke. Am J Neuroradiol. 2020.
Vela: My second guess for the first quarterly edition of 2021 and our audience of “The Core” is someone who I recently met through what it became our -new normal-, our meetings on video-platforms. I’d like to introduce Dr. Kittipong Srivatanakul; He is a Junior Associate Professor at Tokai University School of Medicine in Kanagawa, Japan. He did his residency in neurosurgery at Tokyo Medical and Dental University in Tokyo, Japan, and also had the opportunity to pursue further training at the Bicetre Hospital in France. Tell us a bit about yourself, your interests, your hobbies, and what drew you to the field of neuroendovascular surgery.
Kittipong Srivatanakul, MD, MSc.
Junior Associate Professor, Department of Neurosurgery
Tokai University School of Medicine, Kanagawa, Japan.
Head Physician of Neurosurgery and Endovascular Surgery Department Asahi General Hospital, Chiba, Japan.
Twitter: @Kittijack1
Srivatanakul: I started out my training as a pure neurosurgeon in the first 6-7 years of my career. At first, I was a great believer in clipping of aneurysms, and I was quite skeptical about endovascular treatment. It was at the end of the year 2002 that we had a case of a ruptured paraclinoid aneurysm. Clipping would require exposure of the proximal carotid artery in the neck, so we called an endovascular surgeon (later on, my first mentor in this field) for help. There were two aneurysms, and the procedure was completed in less than two hours with an excellent result. This brief experience totally changed my way of thinking. The more I get involved in this field, the more I find it very challenging for me and beneficial for the patient. The best way to save the brain is not to touch the brain!
I play golf once in a while and love to cook during the weekends. Golf demands a good strategy as it is with neuroendovascular surgery. Cooking also requires good planning and precise execution. With these similarities to neuroendovascular surgery, I think these hobbies help me when I need to manage difficult cases.
Vela: Many of us, particularly fellows, have learned and enjoyed your lectures on advanced neuroanatomy and angiography. How did you become part of “Neuroangio”? How was the collaboration with Dr. Maksim Shapiro and Dr. Eytan Raz established?
Srivatanakul: It is always great to have feedback! Some of the presentations require tremendous time and effort to prepare, and it is rewarding to hear that someone has enjoyed and benefited from them. My first encounter with Maksim and Eytan was during a meeting in France (ABCwin meeting). I had an opportunity to lecture on anatomy there, and later on, I had the honor to be recommended as a faculty for the BANANA (Basic and Advanced Neurovascular ANAtomy) course in 2019. As we have similar interests but work in different environments, we found it useful and exciting to have a regular exchange of information.
Vela: Also, what has caught my attention during your lectures is the detailed and impressive quality of the images that you use. I recently learned that you started drawing them some time ago. Tell us about your experience/education/training in medical illustration. Where did you learn? How did it all start? What software do you use?
Srivatanakul: I have to admit that I did not do well in my art classes at school, but in trying to find an efficient way to teach, I think a good illustration is really worth a thousand words. My great mentor, Prof. Pierre Lasjaunias was a man with great drawing skills, and I learned a lot from his works. After a long period of many trial-and-errors using various tools, I now use mainly an iPad to draw. I bought different books on drawing, but none of them teach you how to draw blood vessels! As I am not a professional medical artist, my illustrations might lack some artistic points, but I always want my drawings to have the three following qualities: not too complex to deliver the intended message(s), precise, and beautiful.
Illustrations can help with learning, but if not done correctly, it can be misleading. I really believe that drawing is not only a great way to teach but also to learn. I hold anatomy courses in Japan twice a year and we give blank diagrams to the participants to draw and “fill in the blanks” to complete a skull base arterial network, etc. I think this is a very effective way to teach anatomy. Anatomy is not easy to learn, but with technology and good illustrations, I believe it should be a more friendly subject to everyone. If some of you here reading this are interested in drawing, please contact me through Facebook or Twitter.
Vela: Japan is a unique country with particular epidemiology of cerebrovascular disorders. How could you describe the uniqueness of your practice for our audience to learn about? What conditions do you feel are more prevalent and/or different from the reported in the US and European literature.
Srivatanakul: As described in the literature, we have more ruptured aneurysms than most parts of the world. The Japanese health-care system practically provides medical care equally to everyone independent of their income. However, approval of new tools is extremely slow here, and we are about 5 years behind when it comes to tools.
Vela: What are the challenges that the Japanese health system, physicians, and patients face in stroke care?
Srivatanakul: I think we are in a very good situation from the patient’s point of view. Anyone can have the same care, and with a dense population, accessibility to a stroke center is not that difficult. However, in many centers, they have a small number of stroke cases with only a few interventionists, and that puts a lot of burden on their personal life as being on-call for strokes once every other day is not easy.
Vela: Tell us a bit about your current research efforts, projects, and collaborations.
Srivatanakul: Our team is a part of the national survey project for rare diseases and recently participated in the analysis of pial supply in dural arteriovenous fistula study. We have also been working on some projects with the team at NYU on dural fistulas. I invite regularly international speakers to participate in our anatomy course, to give the opportunity for the younger generation in Japan to see the real giants in the field.
Vela: How is the current situation of COVID-19 at your hospital, and how did it impact your service? Tell us about your cases, if you don’t mind describing a remarkable case you treated with COVID, and lastly, how the hospital adapted units, protocols, and such.
Srivatanakul: At this present time, we have about ~3000 new cases per day in Japan, getting worse and worse but not anywhere close to the situation in the US. We started our original protected code stroke protocol as early as at the beginning of March, one of the earliest centers to respond to this pandemic concerning acute stroke care. So far, fortunately, I have only had 2 cases with COVID-19 and stroke.
Vela: Dear Kittipong, thank you very much for taking the time to share with the audience of “The Core.” We look forward to learning from your lectures and participating in your anatomy course.
