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L. Nelson "Nick" Hopkins III, MD -- Part One

Angioplasty.Org recently talked with Dr. L. Nelson "Nick" Hopkins, Chairman of Neurosurgery, Professor of Radiology, and Director of the Toshiba Stroke Research Center at the University at Buffalo, State University of New York. Truly one of the pioneers in the treatment of stroke, as well as the non-surgical therapies developed to treat both stroke and carotid disease, Dr. Hopkins provides a unique perspective into the growing area of cross-specialty and multidisciplinary collaboration between and among medical specialities.

This three-part interview covers a range of topics:

  • Part One discusses the diagnosis and treatment of stroke;
  • Part Two deals with carotid artery disease;
  • Part Three discusses how imaging may impact future treatment, and how reimbursement questions must be resolved for this field to move forward.
L. Nelson "Nick" Hopkins III, MD
L. Nelson Hopkins, MD
University of Buffalo

Q: How does this relate to the treatment and diagnosis of carotid disease?
Dr. Hopkins: There are two issues with carotid disease. One is -- in patients who have severe carotid stenosis who have not yet had a major stroke, our job is to try to identify which patients are at risk for a stroke, identify the area of stenosis, how bad the stenosis is, some of the characteristics of that stenosis, and, if it fits the bill for a dangerous stenosis, then we need to fix that before the patient has a stroke.

On the other hand, there are patients who have carotid stenosis who progress to carotid occlusion and have a stroke because of the carotid occlusion. In that case, we have to identify whether or not it’s feasible for us to reopen that occluded artery to reverse the stroke. And there again we rely on CT perfusion and CT angiography to help us determine whether or not it’s reasonable to try to reopen an acutely occluded carotid artery, thus enabling us to revascularize an ischemic brain and prevent or reverse a major stroke.

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Q: One of the issues that patients write in about, is that they’re very confused about carotid artery stenosis, whether they’re at risk, how to get it diagnosed, which type of doctor should they go? Can you address that a bit?
Dr. Hopkins: First, it’s important for patients to know what constitutes a degree of stenosis that warrants treatment. If the patients are having neurologic symptoms, like mini-strokes, as a result of the narrowing in their carotid artery, then any stenosis greater than 50% should be fixed. If the patient is not having any neurologic symptoms then, if the degree of stenosis is over 60% and if the patient is an otherwise relatively healthy individual with a reasonable life expectancy, then that’s a patient where revascularizing or repairing that carotid artery makes sense, according to major studies that have been carried out.

There are now, at this point in time, two FDA-approved treatments for the treatment of carotid stenosis. One is surgery, or endarterectomy, where an incision is made in the neck, the artery is opened up and the plaque is peeled out, and then the artery is re-closed, circulation is reestablished. That’s a good operation, it’s been around for 55, 60 years, and the results are very good. It is a more invasive procedure, it leaves a scar on your neck, and there are other downsides of open surgery. Like, for example, if you’re not in the best medical shape, if you have heart disease, then the open surgery is considerably more of a stress on your system and on your heart than is the alternative, which is carotid angioplasty and stenting - where again the endovascular approach is used, employing the vascular highway. A small stent is navigated up into the carotid artery and then that stent is opened up and used to force the artery open. We normally place some kind of protection device either above or below when we’re putting in a stent, because when you do put in a stent and then dilate it up afterwards with a balloon, you can release debris. And so we try to put some kind of embolic protection device up to capture any debris that might be released during the procedure, as a way to reduce the risk of that procedure.

But in general, we just need to understand there are these two options. One is less invasive approach, using carotid angioplasty and stenting and one is a more invasive approach using surgery. I personally have been doing surgery now for well over 30 years, and I know it’s a good operation, and I’ve learned over the years which patients are generally better candidates for surgery. In our center, we’ve done over 2,000 carotid stents as well. So we’re really beginning to get a good feel for who is a better candidate for surgery, and who’s a better candidate for stenting. And fortunately for our patients, we’re finding that these two procedures are quite complimentary -- that is to say the patients who are bad candidates for surgery are usually good candidates for stents, and vice versa.

I think it’s critically important that you get an unbiased opinion from somebody who either does both, or somebody who has a team where you have surgeons and interventionalists on the same team or at least in the same institution who can get together and give you an unbiased approach as to which is the best way to treat your particular carotid artery narrowing.

Q: How does a patient determine whether they’ll be evaluated well? This goes back to the turf wars…what’s the model that you’re using in Buffalo to overcome these turf issues?
Dr. Hopkins: In our shop we’re very fortunate in that we don’t have any turf issues, because our endovascular team is our neurosurgical team. We are all trained in both disciplines, and so we’re very lucky. If you’re in a situation where you have one group doing one procedure and another group doing the other -- the most common scenario is cardiologists doing the carotid stent and vascular surgeons doing the surgery -- then you want to find a place where the team is working together, and where you can get a unified approach from the two disciplines. Hopefully the two disciplines get together and look at your case and decide which is the best way to do it.

Short of that, you should make sure that you get another opinion. If you get an opinion, say from a surgeon, and he says “this case has to be done with surgery”, you go get another opinion from a cardiologist or somebody who does carotid stenting, like a neurosurgeon, and you then can at least get an opinion from both disciplines to help you decide which one makes more sense. If you’re finding that one’s telling you one thing, and one’s telling the other, you need to get another opinion until you find somebody that breaks the tie for you.

Q: Or you should get on a plane to Millard Fillmore Hospital in Buffalo!
Dr. Hopkins: Obviously, I think we are able to do a great job because we do both, but there are lots of places in the country where you can get very, very good treatment by a good integrated team, and I think that’s what you really want to do. Get to a place where the team is reasonably well integrated and where you’re going to get a good *unbiased* opinion as to what’s the best way to treat your problem.

Q: Some patients write in that they’ve had an ultrasound exam on their carotids and then have gotten a CT or invasive angiogram and the results are very different, either much worse or not as bad.
Dr. Hopkins: You’re bringing up a very, very important point. You should never, ever allow yourself to have major surgery on the basis of one non-invasive test. I think that is just critical. If you have an ultrasound that says you have an 80% stenosis, and you have a surgeon who’s telling you that you need to have it fixed, tell him you want another study and another opinion -- because you will find a significant discrepancy between CT angiograms and MR angiograms and real angiograms versus the ultrasound.

The carotid ultrasound is a great screening tool and it is extremely operator-dependant. If you have a very experienced operator who has a really good track record, you can get very accurate results. But there are many, many centers where, although it’s a great screening tool, the accuracy is not comparable to that of a CT angiogram. We find in our shop that CT angiogram is far more accurate than Doppler, or ultrasound. MR angiogram is somewhere in-between, and diagnostic angiogram with contrast and a catheter-based procedure is still probably the gold standard.

So we tend to, in elderly patients who come to us with carotid stenosis and an ultrasound, we’ll always order another less-invasive procedure like a CTA or an MRA and, if there’s a discrepancy between the two, then we’ll go to diagnostic angiogram, catheter-based angiogram. In patients where we see a lot of disease and where we think we need as much information as possible, we’re liable to go to a diagnostic angiogram to better assess the patient’s collateral circulation. So it just depends on the patient and the patient’s own situation. But certainly never rely on ultrasound alone to allow somebody to operate on your neck. That’s just not a good thing to do.

(continue to Part Three)

This interview was conducted by Burt Cohen of Angioplasty.Org.