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Making the mind run smoothly

A neurosurgeon introduces new treatments for cerebrovascular disorders.

Charles Matouk.
Photo by Kristin Hynes
Charles Matouk

Charles Matouk, MD, associate professor of neurosurgery and of radiology & biomedical imaging, and chief of neurovascular surgery at Yale Medicine, still marvels at an advance in stroke treatment that he now employs numerous times a month. The procedure—mechanical thrombectomy—became a standard part of clinical practice about five years ago. It uses a device called a stent retriever to remove a blood clot from the brain.

Matouk remembers one of the early patients on whom he performed a mechanical thrombectomy—a man in his mid-70s who had been rushed to a hospital after showing classic symptoms of ischemic stroke, including loss of speech. After receiving intravenous tissue plasminogen activator (tPA) to help dissolve the clot, the patient was flown to Yale New Haven Hospital, where Matouk and his team went to work. A catheter was threaded into a groin artery up through the neck to the clot site. Using X-ray-guided imaging, Matouk inserted the stent retriever—a piece of wire with a wire cylinder at the end—into the catheter. The stent expanded into the clot, gripping it and allowing it to be pulled from the body.

The procedure is done with the patient under sedation but awake; in this case, the effect was immediate. “Within minutes,” Matouk said, “he was able to move his arm and speak in complete sentences.” Matouk noted that while tPA is effective on smaller clots, it often fails to break up larger ones. “Now,” he said, “we have a relatively simple surgical intervention that is up to 90% effective at clot retrieval and that can completely change the course of someone’s disease.”

Practicing surgery was not always Matouk’s plan. Although he grew up in a medical family in Montreal with an internist mother, a pulmonologist father, and a gastroenterologist sister, he entertained the idea of being a lawyer, even taking an LSAT preparatory course after graduating from McGill University. “But because it’s what my family does, I figured I would try medical school,” he said. “Once there, I knew I was where I belonged.”

As a medical student at the University of Calgary, Matouk was initially drawn to internal medicine but decided that a surgical specialty would enable him to make a greater difference in his patients’ lives. He was inspired to choose neurovascular surgery after witnessing the result of an endovascular procedure on a patient with symptoms that included rapidly progressing dementia. “Disconnecting an abnormal blood vessel that had caused the problem cured the patient,” he said. “Seeing the symptoms fully reversed astonished me.”

After medical school, Matouk did sub-internships in neurosurgery at Montreal General and Boston Children’s Hospitals. He then trained in the University of Toronto’s neurosurgery program for 10 years, during which time he did research in vascular biology. For the next two years, he was a clinical fellow in interventional neuroradiology at the University of Toronto and a clinical associate in neurosurgery at St. Michael’s Hospital. He came to Yale in 2011 as an assistant professor, becoming chief of neurovascular surgery within the Department of Neurosurgery in 2016.

“My mission when I arrived was to be a clinician,” Matouk said, “and to help build a clinical program worthy of the Yale name.” Along with his medical counterparts in vascular neurology and the neuro-ICU, Matouk and his neurovascular surgery team have both expanded clinical capacity—the Yale Stroke Center is now one of the largest in the country—and integrated research with clinical service. “Clinical volume, which translates to experience, is the most important predictor of patient outcomes,” Matouk said. “And I am proud of how we have leveraged our research expertise to foster strong clinical programs.”

Matouk’s own current research examines how to determine which aneurysms and vascular malformations need immediate treatment, and which can be safely monitored. “Brain aneurysms are actually pretty common,” he explained. Large ones are usually treated to prevent rupture. The recommendation for smaller aneurysms is generally more conservative—lowering blood pressure, avoiding alcohol, and smoking cessation—because surgical treatment carries some risk. But some small aneurysms also rupture, and there had been no way to predict which ones. “We have been working with an imaging paradigm that had not been used before for brain aneurysms, and that we have found can help us with these predictions,” Matouk said. “Now we are focusing on strengthening the evidence so that this technique can become the standard of care for aneurysm patients.”

In addition to clinical practice and research, Matouk also directs the neurovascular/endovascular clinical and research fellowships. “What I want to impart to the clinical fellows,” said Matouk—who has won several teaching awards—“is the importance of understanding disease pathophysiology.” Some conditions, such as hypertension and diabetes, he noted, are so common that many thousands of patients can be enrolled in clinical trials to get the right answer to a clinical question. But diseases affecting the blood vessels of the brain and spinal cord are much less common; clinical trials, which rely on large numbers of patients, can’t provide the answers for an individual patient. “You have to understand the pathophysiological basis of a disease and how it interacts with each person’s particularities—their unique ‘plumbing’—to guide therapeutic decisions,” he said. “There is no substitute for the intimate experience gained on the wards and operating rooms in service of our patients.”