One was authored by Dr. Paul Gigante, Dr. Neil Feldstein, and Dr. Richard Anderson and was in the format of a poster presentation.  The paper was entitled, C1-2 Instability from Os Odontoideum Mimicking Intramedullary Spinal Cord Tumor: Report of Two Cases.

The other was a presentation given by Dr. Christopher Kellner entitled, The Role of Aneurysms in Children with Arteriovenous Malformations. This was based on a paper authored by Kellner, Dr. Michael McDowell, Dr. Geoffrey Appelboom, Ivan Kotchetkov, Dr. Raqeeb Haque, Dr. Neil Feldstein, Dr. E. Sander Connolly, Dr. Robert Solomon, Dr. Philip Meyers, Dr. Sean Lavine, and Dr. Richard C.E. Anderson.

He says, ”Something was really wrong. The side of my face started to droop. I was getting weaker and paralysis was starting.  I was having a hard time walking. I was slurring my speech, my face was starting to not-work.”

Steve couldn’t believe what was happening to him. Though the economy was taking its toll on him, the one thing he had always counted on was his health. “I’m in good shape.” He says, “I had never been in the hospital.”

He was taken to Monmouth Hospital in New Jersey where doctors immediately got to work. He was admitted and three hours later he was diagnosed with a burst arteriovenous malformation (AVM) in the back of his brain.

An AVM is an abnormal tangle of blood vessels that form a kind of nodule in the brain. Commonly, AVMs go undetected unless they burst.  In Steve’s case, his AVM was behind his left ear in an area of the brain called the cerebellum. The cerebellum largely controls balance and coordination which is why Steve was having such a hard time walking.

Steve says, “Dr. Estin comes in and says, ‘I got good news and bad news: the good news is, it is operable; the bad news is that we can’t do the surgery here.’” But good news again, Estin told him he knew just the right place to send him; Columbia Presbyterian Medical Center in New York City to see Dr. Sean Lavine,  Dr. Dorothea Altshul and Dr. E. Sander Connolly.

Steve was stabilized at Columbia. His symptoms abated and he felt better, but he was told that they would have to remove the AVM because there was a good chance it would start bleeding again, and next time he might not be so lucky. He had arrived at the hospital on a Saturday and the surgery was scheduled for Monday.

Then, on Sunday, Steve did a very unusual thing; he walked out of the hospital. Well enough to walk now, he said, “I had to get fresh air.” He had come so close to death and his ordeal wasn’t over yet. He needed some time outside. “I had to really pull teeth and beg but they said yes. I went out of the hospital and walked the streets of New York City,” Steve says. “They even gave me a note to carry with me. I had my hospital bracelet and my cell phone.”

After a few hours, Steve checked himself back into the hospital, ready to face whatever came next. What came next were two operations spread over two days. The first was a minimally invasive procedure performed by Dr. Sean Lavine and Dr. Dorothea Altshul , called endovascular embolization to block off blood flow to the AVM. The second was the complicated brain surgery to actually remove the AVM.

Steve says, “I was surrounded by the most talented people.  Dr. Connolly is just incredible. I went in smiling and I came out smiling.  They really had my best interests in mind. They saved my life – period.“

In the early days of recovery, Steve had the support of his friends. His first walk around the neighborhood was a little shaky.   Steve says, “Well, we did a few houses down the block, and when we got back he [his friends’ ten year old son] looked at me and said with a smile, ‘you did not do too well, but will try again tomorrow.’” That was a lightning moment for Steve; after everything he’d been through, he got back the most important thing of all – the possibility of tomorrow.   And that, he says, changed him. “I have a lot to be grateful for. I don’t get bothered by things anymore. I enjoy every day.”

“I would like to thank Monmouth Hospital and their staff; David Estin, M.D for the good-news/bad-news approach, it worked!; Columbia University Medical Center and their staff;  Sean Lavine M.D.; Dorothea Altshul M.D.; E. Sander Connolly Jr, M.D.;and all the people that were behind the scenes. I truly believe their talents are second to none. THANK YOU.” – Steve Hartler

Related: Arteriovenous Malformations (AVM), Cerebral Arteriovenous Malformation, Best Doctors In NY Now Available To More In NJ, How Does A Neurosurgeon Know What To Say When An AVM Patient Asks, “What Are My Chances Doc?”, New Study Finds Little Risk And Much Benefit In “Gluing” Blood Vessels Before Surgery, Eight Years Ago I Got The Worst Headache Of My Life

The program, entitled Current Management of Ischemic and Hemorrhagic Stroke, provided an “up-to-date appraisal of the evaluation and treatment of acute stroke, carotid disease, intracranial vascular disease, arteriovenous malformations (AVMs), and aneurysms.”

The one-day course was co-directed by Dr. E. Sander Connolly Jr. from the Cerebrovascular Center, and Dr. Joshua Z. Willey from the Department of Neurology.

According to Dr. Solomon, “The conference was a service for the medical community by the Neurological Institute to optimize patient care in the community; to update their knowledge base on the latest information about diagnosis and treatment of cerebrovascular diseases.”

The department of Neurological Surgery at Columbia puts on some form of continuing medical education at least once a year on various topics of interest to outside practitioners.

In addition to Dr. Solomon and Dr. Connolly from the Cerebrovascular Center, several other members of our department spoke at this event: from the Endovascular and Cerebrovascular Centers - Dr. Sean Lavine, Dr. Philip Meyers, and Dr. Dorothea Strozyk; and from the Gamma Knife Center - Dr. Steven Isaacson.  A list of our doctors and their presentation topics is below:

Robert Solomon, M.D.- Microsurgery for AVMs
E. Sander Connolly Jr., M.D. – Microsurgery for Aneurysms
Sean Lavine, M.D. – Endovascular Treatment of Aneurysms
Philip Meyers, M.D. – Endovascular Treatment of AVMs
Dorothea Strozyk, M.D. - Endovascular Treatment of Acute Ischemic Stroke
Steven Isaacson, M.D. - Radiosurgery for AVMs in eloquent areas

According to Dr. Solomon, “The conference was a great success.  About 150 local neurologists, nurses, and neurosurgeons got together to discuss management of ischemic and hemorrhagic stroke.  As well, all forms of surgical treatment of cerebrovascular diseases were covered.”

He also said, “There was a lively group discussion during the lunch hour with many members of the audience given a chance to voice their opinions and ask for advise from the faculty panel.”

At the two day course, Dr. Lavine presented and provided hands-on training during their Cerebral bAVM‘s Session (bAVM stands for brain Arteriovenous Malformations).  His subjects were,  Anatomy and Architecture Review of bAVM’s and Strategy and Complication Avoidance when Treating bAVM’s.

Dr. Lavine regularly participates in these kinds of fellows courses and says, “They give me a tremendous amount of enjoyment.”

Nicole Ricci, her husband Dan & their daughter Victoria

One evening, eight years ago, Dan Ricci came home to find ice cream melting on the counter and his wife passed out on the floor of their bathroom.  His wife Nicole says, that afternoon, ”out of the clear blue sky, I got the worst headache of my life.” What she didn’t know then was that she was very close to losing her life.

At just twenty five years old, Nicole Ricci had a rupture in her brain and her head was quickly filling with blood. This had caused her to black out.  When she came-to she started vomiting and losing her vision.

Local doctors sent her to Columbia Presbyterian where she was taken into the care of Dr. E. Sander Connolly and Dr. Sean Lavine.  She says, once she got there, “I  knew I was going to be OK.  They were just take-charge doctors.  Very compassionate and down-to-earth. They made me very comfortable.”

They immediately set about finding what was causing the bleed in Nicole’s head.  Dr. Lavine performed an angiogram. During an angiogram, a catheter is threaded through blood vessels in the groin all the way up  to the brain.  There, dye is injected that is picked up by X-Ray to create a map of the current state of the vessels in the area.

In Nicole’s case, the map revealed a 3 cm tangled mass of blood vessels called an arteriovenous malformation (AVM) on the right side of her brain.  An AVM is a rare abnormality that Nicole had probably had since she was born.  Normally asymptomatic, AVM’s often go undetected until they burst, like Nicole’s had, and can be fatal.

Once they are discovered, they can be surgically removed or treated with Gamma Knife Radiosurgery. Nicole was a good candidate for surgical removal of the AVM, but before they could do that she had to be stabilized medically.  The bleeding was causing a dangerous build up of pressure in her skull, so a shunt was placed in her spine to drain off the fluid.

When she was stable enough, Dr. Lavine repeated the angiogram and this time, like a spelunker in a maze of caves, he mapped out the vessels that fed the AVM and walled them off by a process called endovascular embolization.  This reduced the risk that she would start hemorrhaging again when the AVM was removed.

Finally, Dr. Connolly performed the surgery to remove the AVM. “I was told it was the size of a ping-pong ball,” says Nicole.  Three days later, Nicole went home.   Her vision back and her headache gone.

About four months after surgery, Nicole went back to work. She says, “I wanted to get back to life.” A life, she says, she doesn’t for a minute take for granted. “I should have died and I didn’t. I got a second chance at life – I got to have my daughter.” Five years ago, Nicole gave birth to a baby girl, Victoria. ”She’s like a gift,” says Nicole.

“I owe it to Dr. Lavine and Dr. Connolly, ” she says, ” They saved my life. That place [Columbia] is such an important part of my life.  They saved my life there.  From the nurses to the people at the front desk; everyone was just very accommodating.  Dr. Lavine and Dr. Connolly – they’re the best. I couldn’t have asked for better doctors.”

While she was recovering, Nicole says she came across an on-line AVM and aneurysm support group.   She says it really helped to read the stories and talk with people who went through the same thing. She posted her own story on the site and says she still updates her profile.

She hopes telling her story will help others; that they’ll see how great she is doing and think, “maybe I’ll be all right too.”

Related Blogs: New Study Finds Little Risk And Much Benefit In “Gluing” Blood Vessels Before Surgery, A Protein In The Blood May Be A Clue To Arteriovenous Malformations In The Brain, Endovascular Neuroradiology; The New Frontier, How Does A Neurosurgeon Know What To Say When An AVM Patient Asks, “What Are My Chances Doc?”, One Picture Speaks A Thousand Words, These Radiosurgeons Use Two

This Congress is highly regarded and hosts participants and speakers from around the world. This year, the meeting will also hold the 4th International Symposium on Microneurosurgical Anatomy and the Annual Meeting of the World Academy of Neurological Surgery (WANS).

On the first day of the Conference Dr. Solomon, who also heads the Cerebrovascular Center, will be involved in a pre-congress course and panel discussion on Vascular Neurosurgery during which, he will present a lecture on Deep Hypothermic Circulatory Arrest for Complex Intracranial Aneurysms.

Dr. Solomon will  start the next day by speaking about Multimodal Treatment of Intracranial Arteriovenous Malformations (AVM). Then, for the rest of the morning he’ll be taking part and lecturing in a Vascular Symposium on the Neurosurgical Management of Paraclinoidal Aneurysms. He’ll end the day at a Controversies Session with his talk entitled, The Natural History of Unruptured Intracranial Aneurysms.

Dr. McCormick will also take part in a Controversies Session that day.  His will focus on degenerative disease of the Cervical Spine and his talk will provide a Critical Analysis of the Cervical Disc Replacement.

The next day, Dr. Solomon will be taking part in another Vascular Symposium where he will speak about how he manages Basilar Artery Aneurysms.

Dr. McCormick will speak that day too about How to Gain Access to the Anterior Portion of Thoracic Spine from the Back. Then in the afternoon he will take part in a seminar in which he will present the topic, Relationship Between Sagittal Balance and Clinical Outcome. Lastly, in the evening he will host a conference on his specialty, Intradural and Intramedullary Spinal Tumors.

Finally, on the last day of the conference, Dr. Solomon will participate in another Controversies Session in which he will speak about the Microsurgical Treatment of Spetzler-Martin Grade IV-V AVMs.

As you can see, they have a lot to prepare for.  We wish them happy trails and look forward to hearing all about this monumental event.

The Washington Post said Sunday that he was still in critical condition and that doctors were still trying to determine the cause of the bleed. This comes just weeks after the diabetic rocker reportedly suffered an emergency appendectomy in Texas.

We asked Dr. Robert Solomon, head of the Department of Neurosurgery at Columbia University Medical Center, several questions and though he is not involved in the care of Mr. Michaels, he was able to illuminate us generally on the condition and it’s treatments.

What kinds of things can cause a sudden brain bleed?

Sometimes, a sudden hemorrhage around the brainstem can be benign and not related to any identifiable vascular anomaly.  In those cases patients make an excellent recovery.   However, the bigger concern is the presence of an aneurysm or possibly an Arteriovenous Malformation(AVM).  Both of these conditions are potentially life threatening, but can be diagnosed with an arteriogram.  The fact that the diagnosis in Mr. Michaels’ case remains unknown, suggests that the initial arteriogram was normal, thereby essentially ruling out these two types of dangerous lesions.

Can a brain bleed be related to diabetes or a recent appendectomy?

Diabetes and the prior appendectomy probably do not have any role in this type of brain bleed.

Why does a brain bleed cause a headache?

Anytime there is bleeding into or around the brain, headache is the most reliable symptom. The headache relates to sudden increase in the intracranial pressure and irritation and inflammation of the membranes that surround the brain.

What can happen to a person when there is a hemorrhage at the base of the brain stem?

Usually the hemorrhage itself is not dangerous, and will reabsorb spontaneously.  Although the patient may feel bad for a while, recovery over 1 to 2 months can be expected.  The real problem is concern over what caused the hemorrhage.   If there is an aneurysm, an arteriovenous malformation, or even a brain tumor, the hemorrhage may be a warning sign of more serious problems ahead.

What kinds of surgery can be done to treat a brain hemorrhage?

If a lesion is identified that caused the bleeding, treatment will be indicated. Treatment options depend on the exact diagnosis and location, and whether or not critical structures are involved.  Some aneurysms and arteriovenous malformations can be treated with endovascular techniques via a catheter inserted in the leg artery.  Sometimes open surgery is effective and safe in curing the problem.   Rarely stereotactic radiosurgery can be used for arteriovenous malformations and tumors that cannot be easily removed with conventional surgery.

All of us in the Department of Neurological Surgery wish Mr. Michaels a speedy and complete recovery.

A Cerebral Arteriovenous Malformation (AVM) is a rare tangle of blood vessels in the brain that carries a high risk of hemorrhaging.  Brain surgeons have found that “gluing” or blocking off the blood supply to these malformations before surgery cuts down on blood loss and patients do better.  Dr. Robert Solomon along with several other neurosurgeons from the Department of Neurosurgery recently took a close look at the risks associated with this procedure, and the results were encouraging.

This process of  ”gluing” is actually called embolization, a procedure that starts by inserting a tube into an artery in the patient’s groin.  Through this tube surgeons use tiny instruments to snake their way through arteries to the problem area in the brain.  Once there, they inject a glue like substance that blocks off the blood supply to the AVM.

Embolization was first developed in 1968 and for a long time it was used as a primary treatment for AVM.  Used alone however, it wasn’t as successful as surgeons wanted.  Over the next couple of decades, advances in microsurgery (that is surgery with tiny instruments and the use of a microscope) enabled surgeons to completely remove the AVM.

By 1997, with the opening of the Gamma Knife Center, surgeons were using a multi step, multi-technique approach that was resulting in better outcomes and saving more lives.  It became standard practice at Columbia Medical Center to perform an AVM embolization before either microsurgery or Radiosurgery with the Gamma Knife.

Of course, the story does not stop there.  Medicine is ever evolving and surgeons are always looking for better ways to help their patients.  One of the ways they do this is by performing retrospective studies.  They look at surgical cases over a period of several years and correlate the procedures done with the outcomes.  By doing this, they come up with ways to further refine and improve their methods.

Dr. Solomon and his team did just that when they looked at the outcomes of over 200 AVM patients since 1997 who underwent embolization.  They knew that embolization before surgery was beneficial but they wanted to quantify any downside.

They looked to see if the procedure itself was the cause of any neurological problems.  Using this data they also hoped to find any patterns that could predict the occurrence of deficits in patients to better control for them.

What they found overall was that the risk of performing the embolization itself was low.  Of the 202 patients only five had any lasting deficits, that is only about 2%.

Furthermore, they were able to come up with a number of predictors for these problems.  One was the size of the AVM.  When the AVM was larger than 6 cm in diameter the risk increased.  There was also a slightly increased risk when the AVM was smaller than 3 cm.

Another risk factor they found was the number of procedures needed to complete the job.  In some cases, it was necessary to perform more than one embolization in which case the risk of poor side effect went up.  But only minimally.

The last two factors that they discovered were the location of the AVM and whether or not it had a large venous drainage.

Having predictive factors like these will help surgeons choose more carefully who receives exactly what kind of treatment and improve the patients chances of a good outcome.  In the end, the risk proved to be quite small and, by a long shot, didn’t outweigh the benefits of this procedure.

To learn more see their paper, Adjuvant Embolization With N-Butyl Cyanoacrylate in theTreatment of Cerebral Arteriovenous Malformations in the on-line journal Stroke (2009;40:2783)

This study was multi-institutional and included the following co-authors from the Department of Neurosuregy: Michael Sisti, MD from the Gamma Knife Center; and Robert Solomon, MD ; Sean Lavine, MD; E. Sander Connolly, MD; and Philip Meyers, MD from the Cerebrovascular Center.

Other blogs about AVM: A Protein In The Blood May Be A Clue To Arteriovenous Malformations In The Brain, How Does A Neurosurgeon Know What To Say When An AVM Patient Asks, “What Are My Chances Doc?”, One Picture Speaks A Thousand Words, These Radiosurgeons Use Two