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Advances in Surgery for Stroke Prevention

An African American family of four.
Michael Alexander, MD, director of the Neurovascular Center and Endovascular Neurosurgery.

Michael Alexander, MD 

Physicians understand what puts someone at risk for ischemic stroke, the most common type of stroke, which is caused by blood clots and blockages in arteries. Now, pioneering Cedars-Sinai research is advancing a surgical technique that helps doctors intervene in certain high-risk patients prone to ischemic stroke.

Two recent studies led by Dr. Michael Alexander, director of the Neurovascular Center and Endovascular Neurosurgery, show that stents implanted in arteries in the brain can reduce stroke risk in patients with severe intracranial atherosclerosis.

The condition is managed with blood thinners, cholesterol-lowering drugs and blood pressure medications—but some patients don't respond to such treatment and can be at greater risk for stroke.

Atherosclerosis is a disease that causes arteries to narrow because of a buildup of cholesterol plaque, which reduces blood flow. It develops either for genetic reasons or as a result of high blood pressure, high cholesterol or lifestyle risks, such as smoking.

Enter the brain stent: For such patients, whose blocked artery is large enough to fit a tiny stent, physicians may consider the procedure. A surgeon inserts a tube about as thick as a spaghetti noodle through an artery near the groin, guided up to the blocked brain artery by X-ray. The stent is placed to expand the artery and allow more blood to reach the brain.

"Since these studies, the pendulum is swinging back, and people are getting more confident in this stenting option."

"Over a period of a couple months, layers of cells form in the area, and the stent heals into the wall of the artery," Dr. Alexander says.

In 2019, Dr. Alexander's WEAVE trial found that patients who underwent the procedure had a significantly lower incidence of stroke and death. A follow-up study in 2020, WOVEN, found patients with brain stents had a 30% lower risk for stroke over a year compared to patients treated with medications only.

Though the brain stent technology is over a decade old, the procedure stalled in the U.S. because of poor results in a previous study. Dr. Alexander's studies, as well as a greater understanding of which patients are likely to benefit and increased training for surgeons, mean the brain stent is on its way to becoming the standard of care.

"Since these studies, the pendulum is swinging back, and people are getting more confident in this stenting option," says Dr. Alexander, who has overseen training of more than 30 physicians in the procedure.  

Cedars-Sinai patients treated for ischemic stroke have among the lowest 30-day mortality in the country—a credit to new interventions, an excellent nursing staff and a multidisciplinary approach to helping patients recover, Dr. Alexander says.