PHYSICIAN SPOTLIGHT: Lucas Elijovich, MD on Memphis Medical News

PHYSICIAN SPOTLIGHT: Lucas Elijovich, MD

By: CONSTANCE ADCOCK

Interventional Neurologist

Lucas Elijovich likes being part of a specialized team. An assistant professor of neurology and neurosurgery, he is a fresh presence at Semmes-Murphey Clinic and Methodist University Hospital/ UTHSC, having received his training in the young discipline of interventional neurology. Born in Argentina, his parents said their farewells to their extended families and moved to the U.S. when Lucas was just a toddler… he grew up in New Jersey.

Tufts University educated, he received his medical doctorate at the University of Texas Medical Branch at Galveston. Following a residency in neurology at New York University, he completed a fellowship in vascular and critical care neurology at University of California, San Francisco, followed by a fellowship in interventional neuroradiology at Hymann-Newman Institute of Neurology and Neurosurgery at St. Luke’s and Roosevelt Hospital Center, N.Y. where his wife gave birth to their first son, now 2 ½.

Stroke Update

Three Types of Strokes

· Ischemic stroke accounts for 87 percent

· Hemorrhagic stroke accounts for 13 percent

· Trans-ischemic attacks (TIAs)

Stroke Stats

· A leading cause of long-term disability in the US

· 3rd leading cause of death

· 795,000 new or recurrent stroke events a year

· A death from stroke occurs every 4 minutes

· A stroke occurs every 40 seconds, on average

· 4.7 estimated stroke survivors alive today

· $73.7 in 2010 for stroke related med costs/disability

Source: American Stroke Association

His fascination with the anatomy of the brain and spinal cord began with a senior year college course in central nervous system anatomy. “I never thought I’d become a physician,” said Elijovich, despite coming from a family “full of physicians,” including both parents and his paternal grandfather. “I was interested in science and lots of different things…” But it was an unlikely trip to the morgue with a medical school professor that steered him toward neurology.

“The class was taught by Stanley Jacobson, PhD, someone who loved what he was teaching and his enthusiasm was contagious. I was fascinated by what I saw.” Later on, in medical school, “neuroscience piqued my interest…I came back to my initial fascination – trying to decide between neurosurgery and neurology. The timing for me was right. I came along at a good time – neurologists were beginning to do interventional neurology.” In his clinical care, Elijovich focuses on stroke and critical neurological care, both in adults and children and also practices as an interventional neurologist, having trained in endovascular surgery.

Elijovich recounted that it was a Portuguese neurologist who performed the first cerebral angiography on humans in 1927 - Egas Moniz, MD. Historically, neurologists performed angiographies until radiologists took over and though today different disciplines perform cerebral angiographies including radiologists, neurosurgeons, and neurologists, Elijovich said “… the field (neurology) has come full circle.”

When asked about his attraction to critical care neurology, he stated, “Taking care of patients who are so sick when they come to the hospital and then seeing them walk out is extremely satisfying. Ten to twenty years ago, there was much less we could do. Now, with interventional treatment we have more options. It’s a technical challenge too…each patient’s clinical characteristics and anatomy are different and that technical and intellectual challenge are things I enjoy.”

And the interdisciplinary teamwork approach? “I could have gone into solo practice but working with established partners is an elevated learning experience.” Elijovich’s fellowship and training at Hymann-Newman Institute at St. Luke’s and Roosevelt Hospital in New York – with one of the highest volume of pediatric interventional cases in the world – enables him to consult at Le Bonheur. “The training I received in New York was unique – many (interventional neurologists) have never treated children. And the parents of the children are dealing with such angst…” As the father of a 2 ½ year old, he well understands what parents go through.

Elijovich is part of the UTHSC Brain Attack Team (BAT) comprised of emergency physicians, neurologists, radiologists, nurses and other health professionals who rapidly evaluate patients presenting in the ER, treating stroke events and determining who qualifies for receiving IV tPA, the time sensitive care for occlusive/ischemic stroke. Approved in 1996, tPA is still the standard of care; other drugs have been tested but not approved.

Although studies have proven tPA’s effectiveness, “… it is not as effective as we’d like it to be in certain situations, for example when one of the large intracranial vessels is blocked off, such as the carotid, the middle cerebral or the basilar artery. Studies have shown that tPA will open that vessel about 25 percent of the time – not good odds. And that is where combining endovascular treatment comes in. It’s much more effective than IV tPA in opening the large blood vessels at the base of the brain, usually more than 2 mm in diameter. For someone who has a large vessel occlusion, within the window of zero to eight hours, we may offer endovascular therapy.”

“Treating an occlusive stroke usually entails the delivery of more tPA directly into the clot – intrarterial thrombolysis – or mechanical embolectomy. The two FDA devices approved to accomplish the latter are the Merci Retrieval System® device - essentially a corkscrew that allows you to pull the clot out - and the Penumbra System– an aspiration device that performs like a ‘vacuum’ for the brain. Both are much more effective in terms of opening up blood vessels than tPA and they work anywhere from 50-80 percent of the time. Unfortunately, not everyone who has a vessel opened up will be okay because stroke is such a time sensitive emergency.”

Before treatment, Elijovich emphasized that, “…we are careful to inform the patients/families that these procedures are not without risk, however, given the general outcome of large vessel occlusions without treatment, we tend to be aggressive in our approach.” Mortality rates begin at 40 percent and can exceed 80 percent for an occlusion in one of the major intracranial arteries. “Although the Merci and Penumbra devices are FDA approved, they have not yet been proven to improve outcome and clinical trials are ongoing to evaluate efficacy. One trial is the Interventional Management of Stroke 3 (IMS 3) study comparing the use of IV tPA versus IV tPA plus these interventional tools that we now have.”

Endovascular techniques also offer an option for hemorrhagic strokes, caused by aneurysms or arteriovenous malformations (AVMs). Aneurysms are commonly treated with surgical clipping which requires a craniotomy. But in the 1990’s, a newer procedure was developed called endovascular coiling. The procedure involves threading a microcatheter into the aneurysm and placing detachable platinum coils inside the lumen of the aneurysm, stopping blood flow and preventing re-rupture. Surgical clipping and coiling were evaluated in the International Subarachnoid Aneurysm Trial (ISAT: Lancet Neurology, May 2009), causing controversy in the field when results determined that coiling was favored over surgical clipping among patients (who qualified for both procedures) over the long term due to mortality rates.

An ominous diagnosis of AVM occurs in less than one percent of the general population; it is found in children at birth or as young as 1 or 2 years old and its presentation can be a catastrophic event with seizures, intracranial bleeding or heart failure, according to Elijovich. Treating the tangled cluster of malformed blood vessels also requires a multidisciplinary team and usually a combination of treatment modalities: embolization, surgery and radiation/radiosurgery. “One endovascular technique developed is to inject a substance like medical grade ‘Krazy Glue’ or ‘Onyx’, another liquid embolic agent, into these areas and slow down the blood flow through the lesion,” he said. “Embolization may facilitate surgery and/or radiosurgery, allowing the lesion to be obliterated. The course of treatment and modalities employed is dependent upon multiple factors, including the location and size of the AVM and specific patient characteristics.”

Elijovich was invited to present a medical talk at the SILAN conference this fall in his native country, Argentina – he is fluent in Spanish but admits that speaking medical terminology in Spanish was a challenge. For his sport and leisure pursuits, Elijovich indulges in tennis with colleagues, occasionally soccer and snowboarding though there’s little chance for that in the South. “I spend a lot of time with my wife and my son. Soccer is in your blood if you are from Argentina so my son has a lot of soccer balls.”