We recently spoke with Dr Fergus Robertson, Interventional Neuroradiology Consultant at the National Hospital for Neurology and Neurosurgery and Great Ormond Street Hospital for Children, to talk about the work of his neurovascular group. Together with his team, he has been developing new techniques and conducting pioneering research into the treatment a number of complicated conditions.
Q: Thank you for speaking with us Dr Robertson. Please could you tell us a little about about your areas of expertise?
Dr Fergus Robertson: I’m partly a diagnostic radiologist, reporting MRI and CT scans of the nervous system. The rest of my time is spent treating vascular problems of the brain and spine. Often, patients arrive as emergencies to the hospital with brain haemorrhages or strokes but I also treat many with longstanding problems in a more elective, planned way.
Q: How have the facilities at Queen Square Imaging Centre aided your research?
FR: My work is precise, challenging and demands the highest quality imaging when planning treatments. With its state-of-the-art MRI scanner and specialist neuroimaging radiographers, the centre offers a fantastic image quality across the board. From my perspective, the spine and blood vessel imaging really is some of the best I’ve seen anywhere.
Another area where the QSIC staff excel is in their innovation. If I need something new or different, they’ll happily invest time and effort to deliver an imaging solution.
An example of this is the recent introduction of a new MR imaging sequence which can now demonstrate flow through the tiny blood vessels around the spinal cord. These vessels are surrounded by bone and have, in the past, been very difficult to image without directly injecting them in the angiography suite. Now we are able to see them on a non-invasive MRI study, reducing risk to the patient.
Q: How has the work of your neurovascular group been helping patients?
FR: Traditionally, patients with neurovascular problems were treated by neurosurgeons via open surgical operations. But over the last decade we have seen increases in endovascular treatments by neuroradiologists in the angiography suite.
One particular area where there has been a dramatic shift is in the treatment of cerebral aneurysms. These small swellings on cerebral blood vessels may rupture, often causing life-threatening brain haemorrhage. In the past these were predominantly treated with an open operation to place a metal clip across the aneurysm neck. Although the procedure is usually successful, it is lengthy and dangerous particularly in unstable patients.
Now with modern technology a small tube can be passed via a small nick in the groin, through the blood vessels and into the brain under X ray guidance to pack the aneurysm with tiny platinum coils and prevent further bleeding. These endovascular procedures are generally less invasive, quicker and yield better outcomes than traditional surgery. Now 90 per cent of aneurysm patients at the National Hospital for Neurology and Neurosurgery are treated by the radiology team.
Q: What other areas of work does the group focus on?
FR: We have led the development of new stent treatments for more complicated aneurysms that were traditionally considered untreatable through endovascular techniques, either in view of their size or shape.
We treat a number of other vascular problems – arteriovenous malformations of the brain and spinal cord and also reduce the blood supply to tumours (embolisation) of the brain and spine, allowing surgeons to remove them more rapidly and with less blood loss.
Perhaps the largest growth area is the treatment of patients with stroke, one of the commonest problems in the UK. Many patients come to hospital with a blocked brain artery which leaves them with weakness, disrupted speech, loss of balance or other problems. Those who reach hospital in time are treated with clot-busting drugs. However, if these fail to open the blockage or if they cannot be administered, an increasing number of patients are being transferred to the angiography suite at Queen Square where we are now able to open the blockage mechanically by removing the clot through the blood vessels. There are real challenges in selecting which patients are likely to benefit from treatment and in getting the blood vessel open before the brain is permanently damaged.
In addition we’re also able to treat patients who experience symptoms from narrowed blood vessels in the head (intracranial stenosis) by opening up the vessel with balloons or stents, also delivered via tubes from the groin. This helps to restore arterial blood flow to areas of the brain and prevent strokes. We’re also helping people experiencing venous pressure problems in the head (idiopathic intracranial hypertension) by opening up narrowed veins improving drainage of the brain and preventing disabling headaches and blindness.
We also work closely with our spinal surgeons performing minimally invasive, image-guided surgical procedures, such as vertebroplasty and kyphoplasty, in which we inject cement to strengthen diseased areas of the spine.
Q: What is the neurovascular group doing to share its work with other medical professionals and improve best practice in the field?
We have an active research programme that has matured over the last ten years to match a workload which has grown from a handful of cases in the early 2000s to nearly 500 procedures now carried out at Queen Square and Great Ormond Street each year. We were finally able to expand our consultant numbers in 2011 to cope with the clinical workload, allowing a greater focus on research themes. We regularly present our experiences at local, national and international meetings.
We operate in a high risk field and work continuously to improve the quality and safety of our service. We have an active, rolling program of audit and neuroradiology leads the National Hospital in this field. With the ongoing restructuring of Neurosurgical services across north London we are working more closely than ever with our colleagues at linked trusts such as the Royal Free Hospital, and Bart’s and the London.
I work in an exciting and rapidly-evolving field with constant opportunities to develop and improve our service. The first class support provided by all the staff at Queen Square is integral to our ongoing success