Cerebrovascular Fellowship at Toronto Western Hospital, University of Toronto

Fellow: Krunal Patel

Toronto Western Hospital & Krembil Brain Sciences Institute
University of Toronto
Toronto, Canada

Supervisors: Professor Michael Tymianski & Dr Ivan Radovanovic

The Toronto Western Hospital (TWH) Cerebrovascular Unit provides a supra-regional and national service for complex cerebrovascular cases. This includes the City of Toronto, Greater Toronto Area (GTA), Ontario and beyond. The team of clinicians includes representatives from neurosurgery, interventional neuroradiology, radiotherapy, neurology, stroke and an active clinical and lab based research team. The neurovascular and interventional neuroradiology departments have a highly experienced, well-published and innovative team who work closely in the management of complex cerebrovascular and spinal vascular conditions. They have one of the largest volume practices in Canada and one of the most experienced surgical and interventional neuroradiology teams in the Western world.

This Cerebrovascular fellowship with Dr Tymianski and Dr Radovanovic, both world renowned, well respected and widely published Cerebrovascular experts, was well placed to equip me with advanced skills, knowledge and experience to enable me to deal with complex neurovascular cases, including previously endovascularly treated, recurrent aneurysms and complex arteriovenous malformations. I also gained significant experience minimally invasive techniques in aneurysm clipping and day case aneurysm surgery which was not offered anywhere in the UK.

Elective work was channeled through a monthly multi-disciplinary meeting. Here, patients are discussed, imaging is reviewed and treatment options considered and planned. A weekly Cerebrovascular clinic attended by representatives of the multi-disciplinary team allows for new and follow up patients to be reviewed pre or post treatment. I was responsible for triaging new referrals made to the Cerebrovascular services, contributing to the monthly MDT and reviewing new and follow up patients at the Cerebrovascular clinic. In addition to the elective workload TWH has a high volume cerebrovascular emergency case load for subarachnoid haemorrhage, carotid stenosis and intracranial haemorrhage. I was often responsible for taking Cerebrovascular call and coordinating acute admissions, planning appropriate investigations and management plans in conjunction with the on call neurosurgical and interventional neuroradiology teams.

I was exposed to the whole range of Neurovascular brain and spinal pathology including aneurysms, arteriovenous malformations, carotid stenosis, moya-moya disease, neurovascular compression syndromes, cranial and spinal dural arteriovenous fistulae, cavernous malformations and arteriovenous malformations of the brain and spine. I operated on a number of Cerebrovascular cases, many independelty (16 EC-IC bypass, 9 Carotid endarterectomy, 35 Aneurysms, 14 arteriovenous malformations, 3 Cavernoma, 3 Cranial dural arteriovenous fistulae, 5 spinal arteriovenous fistulae and 65 microvascular decompressions for trigeminal neuralgia/hemifasical spasm).

The aspects of this fellowship which allowed me to develop my skills further were my exposure to retractorless aneurysm surgery for ruptured and unruptured aneurysms, keyhole transcranial (mini-pterional and lateral supraorbital) approaches for aneurysms, endoscopic transpterional approaches to the anterio-lateral skull base, hybrid suite surgery for micro and high grade AVMs and low-flow bypass for moya-moya disease and intracranial atherosclerotic disease. I was also able to learn the planning of gamma knife surgery for arteriovenous malformations, which most UK Cerebrovascular surgeons do not get exposure to. This has allowed me to develop a better understanding of the strengths and limitations of gamma knife for the treatment of brain AVMs and will prove useful in my future practice. I also had extensive exposure to a cadaveric and animal lab where I was able to practice my micro-anastomosis techniques to develop the skills required for bypass surgery.

My extensive operative UK neurosurgical training (approximately 1900 cases) prior to the start of my fellowship and experience as a Locum Consultant in Neurovascular enabled me to be in a good position to benefit from the complex case load during my fellowship. Having been a Chief Resident and Locum Consultant prior to my fellowship made me a natural teacher and leader for junior and senior residents and Cerebrovascular fellows more junior to me. I contributed to service, teaching, research, audit and management as an integral and valued member of the University of Toronto Postgraduate Department and have made collaborative research links and friends from all over the world including with other fellows, residents and staff.

I believe this fellowship training has put me in a good position to be able to deliver world-class cerebrovascular care to my patients and train the next generation of Cerebrovascular surgeons. This experience has been vital in allowing me to develop my own technique, aimed, where possible, at reducing soft tissue and bony disruption to allow faster recovery with improved cosmetic results following surgery.