1541 Gull Rd Suite 200
Kalamazoo MI 49048
Medical School: Other - 1985
Accepts Medicare: Yes
Participates In eRX: No
Participates In PQRS: No
Participates In EHR: No
License #: 4301078901
Request Appointment Information
Awards & Recognitions
Dr. Firas Al Ali is associated with these group practices
|HCPCS Code||Description||Average Price||Average Price
Allowed By Medicare
|HCPCS Code:61624||Description:Transcath occlusion cns||Average Price:$2,675.15||Average Price Allowed
|HCPCS Code:75894||Description:X-rays transcath therapy||Average Price:$782.43||Average Price Allowed
|HCPCS Code:36217||Description:Place catheter in artery||Average Price:$773.74||Average Price Allowed
|HCPCS Code:36215||Description:Place catheter in artery||Average Price:$597.47||Average Price Allowed
|HCPCS Code:36216||Description:Place catheter in artery||Average Price:$626.98||Average Price Allowed
|HCPCS Code:75716||Description:Artery x-rays arms/legs||Average Price:$389.74||Average Price Allowed
|HCPCS Code:75685||Description:Artery x-rays spine||Average Price:$306.64||Average Price Allowed
|HCPCS Code:75665||Description:Artery x-rays head & neck||Average Price:$284.56||Average Price Allowed
|HCPCS Code:75676||Description:Artery x-rays neck||Average Price:$283.00||Average Price Allowed
|HCPCS Code:75680||Description:Artery x-rays neck||Average Price:$238.86||Average Price Allowed
|HCPCS Code:99144||Description:Mod cs by same phys 5 yrs +||Average Price:$175.95||Average Price Allowed
|HCPCS Code:75710||Description:Artery x-rays arm/leg||Average Price:$190.77||Average Price Allowed
|HCPCS Code:75898||Description:Follow-up angiography||Average Price:$195.29||Average Price Allowed
|HCPCS Code:75671||Description:Artery x-rays head & neck||Average Price:$182.89||Average Price Allowed
|HCPCS Code:99145||Description:Mod cs by same phys add-on||Average Price:$92.93||Average Price Allowed
|HCPCS Code:36218||Description:Place catheter in artery||Average Price:$121.64||Average Price Allowed
|HCPCS Code:99213||Description:Office/outpatient visit est||Average Price:$72.55||Average Price Allowed
|HCPCS Code:99202||Description:Office/outpatient visit new||Average Price:$71.00||Average Price Allowed
HCPCS Code Definitions
- Selective catheter placement, arterial system; initial third order or more selective thoracic or brachiocephalic branch, within a vascular family
- Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family
- Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family
- Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.
- Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method; central nervous system (intracranial, spinal cord)
- Selective catheter placement, arterial system; additional second order, third order, and beyond, thoracic or brachiocephalic branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate)
- Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family.
- Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion, other than for thrombolysis
- Angiography, extremity, unilateral, radiological supervision and interpretation
- Transcatheter therapy, embolization, any method, radiological supervision and interpretation
- Angiography, extremity, bilateral, radiological supervision and interpretation
Medical Malpractice Cases
Medical Board Sanctions
Critical Care (Intensivists)
*These referrals represent the top 10 that Dr. Al Ali has made to other doctors
Acute Ischemic Stroke Treatment, Part 2: Treatment "Roles of Capillary Index Score, Revascularization and Time". - Frontiers in neurology
Due to recent results from clinical intra-arterial treatment for acute ischemic stroke (IAT-AIS) trials such as the interventional management of stroke III, IAT-AIS and the merit of revascularization have been contested. Even though intra-arterial treatment (IAT) has been shown to improve revascularization rates, a corresponding increase in good outcomes has only recently been noted. Even though a significant percentage of patients achieve good revascularization in a timely manner, results do not translate into good clinical outcomes (GCOs). Based on a review of the literature, the authors suspect limited GCOs following timely and successful revascularization are due to poor patient selection that led to futile and possibly even harmful revascularization. The capillary index score (CIS) is a simple angiography-based scale that can potentially be used to improve patient selection to prevent revascularization being performed on patients who are unlikely to benefit from treatment. The CIS characterizes presence of capillary blush related to collateral flow as a marker of residual viable tissue, with absence of blush indicating the tissue is no longer viable due to ischemia. By only selecting patients with a favorable CIS for IAT, the rate of GCOs should consistently approach 80-90%. Current methods of patient selection are primarily dependent on time from ischemia. Time from cerebral ischemia to irreversible tissue damage seems to vary from patient to patient; so focusing on viable tissue based on the CIS rather than relying on an artificial time window seems to be a more appropriate approach to patient selection.
Acute ischemic stroke treatment, part 1: patient selection "the 50% barrier and the capillary index score". - Frontiers in neurology
The current strategy for intra-arterial treatment (IAT) of acute ischemic stroke focuses on minimizing time from ictus to revascularization and maximizing revascularization. Employing this strategy has yet to lead to improved rates of successful outcomes. However, the collateral blood supply likely plays a significant role in maintaining viable brain tissue during ischemia. Based on our prior work, we believe that only approximately 50% of patients are genetically predisposed to have sufficient collaterals for a good outcome following treatment, a concept we call the 50% barrier. The Capillary Index Score (CIS) has been developed as a tool to identify patients with a sufficient collateral blood supply to maintain tissue viability prior to treatment. Patients with a favorable CIS (f CIS) may be able to achieve a good outcome with IAT beyond an arbitrary time window. The CIS is incorporated into a proposed patient treatment algorithm. For patients suffering from a large stroke without aphasia, a non-enhanced head CT should be followed by CT angiography (CTA). For patients without signs of stroke mimics or visible signs of structural changes due to large irreversible ischemia, CTA can help confirm the vascular occlusion and location. The CIS can be obtained from a diagnostic cerebral angiogram, with IAT offered to patients categorized as f CIS.
Relative Influence of Capillary Index Score, Revascularization, and Time on Stroke Outcomes From the Interventional Management of Stroke III Trial. - Stroke; a journal of cerebral circulation
Until recently, acute ischemic stroke (AIS) trials have failed to show a benefit of endovascular therapy compared with standard therapy, leading some authors to recommend decreasing the time from ictus to revascularization to improve outcomes. We hypothesize that improving patient selection using the capillary index score (CIS) may also be a useful strategy.CIS was calculated, blinded to outcome, from pretreatment diagnostic cerebral angiograms for 78 subjects in the Interventional Management of Stroke III database with internal carotid artery and middle cerebral artery trunk occlusion. The CIS was dichotomized into favorable (fCIS=2 or 3) and poor (pCIS=0 or 1). Outcomes were categorized based on the modified Rankin Scale score at 90 days (0-2 considered a good outcome). Modified thrombolysis in cerebral infarction score 2b or 3 was considered good revascularization. Multivariable logistic regression was performed to relate CIS, time from ictus to revascularization, modified thrombolysis in cerebral infarction score, and National Institue of Health Stroke Scale score to good outcomes.Only CIS and modified thrombolysis in cerebral infarction scores were correlated with good outcomes (P<0.01). Patients with fCIS and good revascularization achieved 71% modified Rankin Scaleâ‰¤2, compared with 13% for patients with pCIS and good revascularization.In this subset of patients from the Interventional Management of Stroke III Trial, CIS and modified thrombolysis in cerebral infarction were strong predictors of outcome after endovascular reperfusion. Using the CIS to improve patient selection could be a powerful strategy to improve rate of good outcomes in endovascular therapy. A randomized trial is needed.URL: http://www.clinicaltrials.gov. Unique identifier: NCT00359424.Â© 2015 American Heart Association, Inc.
Reviving Intracranial Angioplasty and Stenting "SAMMPRIS and beyond". - Frontiers in neurology
We review the methods and results of Stenting and Aggressive Medical Management for Preventing Recurrent Stroke (SAMMPRIS) and provide a critical review of its strengths and limitations. In SAMMPRIS, the aggressive medical treatment arm (AMT arm) did substantially better than the Wingspan Stenting plus aggressive medical management arm (WS+ arm). Complications in the first 30â€‰days post intervention led to the disparity between treatment arms. A major contribution of SAMMPRIS was the added value that AMT and lifestyle change may provide, when compared to a precursor trial, Warfarin-Aspirin Symptomatic Intracranial Disease (WASID), designed to prevent stroke in persons with high-grade symptomatic intracranial occlusive disease, however, the results of neither of these two trials have ever been reproduced. On the other hand, we argue that technical limitations of the Wingspan stent system (WS System) and lack of an angioplasty only intervention arm may have led to a premature launch of the trial and early termination of the study. Future randomized trials with different devices and modified patient selection criteria are warranted.
Capillary Index Score in the Interventional Management of Stroke trials I and II. - Stroke; a journal of cerebral circulation
The Capillary Index Score (CIS) is a simple angiography-based scale for assessing viable tissue in the ischemic territory. We retrospectively applied it to Interventional Management of Stroke (IMS) trials I and II to evaluate the predictive value for good outcomes.CIS was calculated from pretreatment diagnostic cerebral angiograms blinded to outcome. IMS I and II diagnostic cerebral angiogram images of sufficient quality were reviewed and CIS calculated for treated subjects with internal carotid artery or M1 occlusion. CIS scoring (0-3) was dichotomized into favorable (f CIS; 2 or 3) and poor (p CIS; 0 or 1). Modified thrombolysis in cerebral infarction score 2b or 3 was considered good revascularization. CIS and modified thrombolysis in cerebral infarction scores were compared with good outcome, defined as modified Rankin Scale scoreâ‰¤2 at 90 days.Twenty-eight of 161 subjects met the inclusion criteria. Thirteen (46%) had f CIS. Good clinical outcome was significantly different between the 2 CIS groups (62% for f CIS versus 7% for p CIS; P=0.004). Good reperfusion correlated to good outcome (P=0.04). No significant differences in time to intravenous or intra-arterial treatment were identified between f CIS and p CIS groups (P>0.25).A f CIS was found in â‰ˆ50% of subjects and was a virtual prerequisite for good outcome in this study subgroup of IMS I and II. We call this the 50% barrier.Â© 2014 American Heart Association, Inc.
Collaterals at angiography and outcomes in the Interventional Management of Stroke (IMS) III trial. - Stroke; a journal of cerebral circulation
Endovascular strategies provide unique opportunity to correlate angiographic measures of collateral circulation at the time of endovascular therapy. We conducted systematic analyses of collaterals at conventional angiography on recanalization, reperfusion, and clinical outcomes in the endovascular treatment arm of the Interventional Management of Stroke (IMS) III trial.Prospective evaluation of angiographic collaterals was conducted via central review of subjects treated with endovascular therapy in IMS III (n=331). Collateral grade before endovascular therapy was assessed with the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology scale, blinded to all other data. Statistical analyses investigated the association between collaterals with baseline clinical variables, angiographic measures of recanalization, reperfusion and clinical outcomes.Adequate views of collateral circulation to the ischemic territory were available in 276 of 331 (83%) subjects. Collateral grade was strongly related to both recanalization of the occluded arterial segment (P=0.0016) and downstream reperfusion (P<0.0001). Multivariable analyses confirmed that robust angiographic collateral grade was a significant predictor of good clinical outcome (modified Rankin Scale scoreâ‰¤2) at 90 days (P=0.0353), adjusted for age, history of diabetes mellitus, National Institutes of Health Stroke Scale strata, and Alberta Stroke Program Early CT Score. The relationship between collateral flow and clinical outcome may depend on the degree of reperfusion.More robust collateral grade was associated with better recanalization, reperfusion, and subsequent better clinical outcomes. These data, from the largest endovascular trial to date, suggest that collaterals are an important consideration in future trial design.http://www.clinicaltrials.gov. Unique identifier: NCT00359424.
Spontaneous cervical artery dissection: the borgess classification. - Frontiers in neurology
The pathogenesis of spontaneous cervical artery dissections (sCAD) and its best medical treatment are debated. This may be due to a lack of clear classification of sCAD. We propose the new Borgess classification of sCAD, based on the presence or absence of intimal tear as depicted on imaging studies and effect on blood flow.This is a single-center investigator-initiated registry on consecutive patients treated for sCAD. In the Borgess classification, type I dissections have intact intima and type II dissections have an intimal tear.Forty-four patients and 52 dissected arteries were found. Forty-nine of 52 dissections (93%) were treated with dual anti-platelet therapy. Twenty-one of 52 dissections were type I; 31 were type II. Type I dissections were more likely to present with ischemic symptoms [stroke, transient ischemic attack (TIA)] (pâ€‰=â€‰0.001). More type I dissections occurred in the vertebral artery, while more type II dissections occurred in the internal carotid artery (pâ€‰<â€‰0.001). Follow-up averaged 18.1â€‰months (range: 3-108â€‰months) with no recurrent ischemic events (stroke, TIA), deaths, or hemorrhage. Forty-six vessels had 6â€‰month follow-up on medical treatment; 19/46 (41%) healed. Type I dissections were more likely to heal than type II (pâ€‰<â€‰0.001).The two dissection types in the Borgess classification appear to relate to clinical presentation and rate of healing, making the classification useful in clinical management. Dual anti-platelet therapy for sCAD seems to have a very low risk of subsequent stroke; however, a large prospective study is needed to investigate the best treatment.
The capillary index score: rethinking the acute ischemic stroke treatment algorithm. Results from the Borgess Medical Center Acute Ischemic Stroke Registry. - Journal of neurointerventional surgery
Despite increased recanalization rates in the treatment of acute ischemic stroke, the percentage of patients with a good clinical outcome of all those treated has not risen above 50%. This 50% barrier may be broken by improving the criteria for treatment selection. This study investigated the addition of the capillary index score (CIS), a new index for assessing remaining viable tissue in the ischemic area, to the existing criteria.The Borgess Medical Center Ischemic Stroke Registry is a non-randomized single-center single-operator registry of consecutive subjects admitted for intra-arterial treatment of acute ischemic stroke. The CIS was calculated from a pre-intervention catheter cerebral angiogram in subjects with internal carotid artery (ICA) or middle cerebral artery (MCA) (M1) occlusion. Thrombolysis In Myocardial Infarction (TIMI) 2 or 3 was considered successful recanalization. A modified Rankin Scale (mRS) of 0-2 at 3 months was considered a good outcome.ICA or MCA (M1) occlusion was found in 46 of 58 consecutive patients treated by the same operator. Recanalization was successful in 72% of patients and 27% had a good outcome. CIS was available for 26 patients; 42% were favorable (2 or 3) and 58% were poor (0 or 1). A good outcome was found only in the favorable CIS group (p=0.0148). Successful recanalization (p=0.0029) and time from ictus to revascularization (p=0.0039) predicted a good outcome. Of patients with favorable CIS and TIMI 3, 83% had a good outcome.Favorable CIS and recanalization were strong predictors of a good outcome. By using this new index as an adjunct to other criteria, the CIS may improve patient selection and help break the 50% barrier.
Vertebral artery ostium atherosclerotic plaque as a potential source of posterior circulation ischemic stroke: result from borgess medical center vertebral artery ostium stenting registry. - Stroke; a journal of cerebral circulation
Although atherosclerotic plaque in the carotid and coronary arteries is accepted as a cause of ischemia, vertebral artery ostium (VAO) atherosclerotic plaque is not widely recognized as a source of ischemic stroke. We seek to demonstrate its implication in some posterior circulation ischemia.This is a nonrandomized, prospective, single-center registry on consecutive patients presenting with posterior circulation ischemia who underwent VAO stenting for significant atherosclerotic stenosis. Diagnostic evaluation and imaging studies determined the likelihood of this lesion as the symptom source (highly likely, probable, or highly unlikely). Patients were divided into 4 groups in decreasing order of severity of clinical presentation (ischemic stroke, TIA then stroke, TIA, asymptomatic), which were compared with the morphological and hemodynamic characteristics of the VAO plaque. Clinical follow-up 1 year after stenting assessed symptom recurrence.One hundred fourteen patients underwent stenting of 127 lesions; 35% of the lesions were highly likely the source of symptoms, 53% were probable, and 12% were highly unlikely. Clinical presentation correlated directly with plaque irregularity and presence of clot at the VAO, as did bilateral lesions and presence of tandem lesions. Symptom recurrence at 1 year was 2%.Thirty-five percent of the lesions were highly likely the source of the symptoms. A direct relationship between some morphological/hemodynamic characteristics and the severity of clinical presentation was also found. Finally, patients had a very low rate of symptom recurrence after treatment. These 3 observations point strongly to VAO plaque as a potential source of some posterior circulation stroke.
Safety, feasibility, and short-term follow-up of drug-eluting stent placement in the intracranial and extracranial circulation. - Stroke; a journal of cerebral circulation
The use of bare metal stents to treat symptomatic intracranial stenosis may be associated with significant restenosis rates. The advent of drug-eluting stents (DESs) in the coronary circulation has resulted in a reduction of restenosis rates. We report our technical success rate and short-term restenosis rates after stenting with DESs in the intracranial and extracranial circulation.This study was a retrospective review of the period between April 1, 2004, and April 15, 2006, of 59 patients with 62 symptomatic intracranial or extracranial atherosclerotic lesions at 2 medical centers (University of Pittsburgh and Borgess Medical Center).The mean age of our cohort was 61+/-12 years. The location of the 62 lesions was as follows: extracranial vertebral artery 31 (50%), intracranial vertebral artery or basilar artery 18 (29%), extracranial internal carotid artery (ICA) near the petrous bone 5 (8%), and intracranial ICA 8 (13%). There were 2 (3%) periprocedural complications: 1 non-flow-limiting dissection and 1 disabling stroke. Fifty vessels were available for follow-up angiography or computed tomography angiography at a median time of 4.0+/-2 months. A total of 2 of 36 extracranial stents (7%) and 1 of 26 intracranial stents (5%) were found to have restenosis > or = 50% at follow-up.This report demonstrates that DES delivery in the intracranial and extracranial circulation is technically feasible. A small percentage of patients developed short-term in-stent restenosis. Longer-term follow-up is required in the setting of a prospective study to determine the late restenosis rates for DESs in comparison with bare metal stents.
Map & Directions
1541 Gull Rd Suite 200 Kalamazoo, MI 49048
1521 Gull Rd
1717 Shaffer Road North Professional #229
1541 Gull Rd Ste 200