Perfexion Gamma Knife with its cover off before it left the factory in Sweden

Our multi-million dollar Gamma Knife up-grade is complete.  The new state-of-the-art  Gamma Knife Perfexion System is in place and our radio surgery program is back in full swing.

Dr. Michael Sisti from the Gamma Knife Center says, “We have had a great start for the week, with a total of eleven patients and the following conditions treated: three acoustic neuromas, four meningiomas, one Glomus Jugulare tumor, one brain metastasis, one lymphoma, and one case of trigeminal neuralgia.”

Our Centurion Perfexion Gamma Knife on Site

The Gamma Knife (not a literal knife) generates a highly concentrated beam of radiation that is used to specifically target these kinds of lesions in the brain as well as brain tumors, cerebral arteriovenous malformations (AVMs), and epilepsy.

The upgrade to the Perfexion system has expanded this capability to include more treatment areas within the brain, and an advanced planning system that enables even greater accuracy.

Reception

According to Elekta,the maker of the Perfexion System, there is also, “faster set-up and treatment delivery to one or more tumors in a single session[.]”

As the 100th unit produced by the company, Elekta gave the machine a unique gold finish and gold colored patient mattress.  Accordingly, Dr. Sisti and his group have coined it the Centurion Perfexion Gamma Knife!

Our Centurion Perfexion Gamma Knife on Site

Dr. Sisti says, “The unit is beautiful installed with its covering on too. We are happy to offer our patients the increased capability and accuracy of this new machine. Our treatments have been seamless.  We just treated our 2900th patient and we hope to treat our 3000th patient this year.”

Watch this video to learn more about the new Perfexion Gamma Knife.

Learn more from our page on Gamma Knife Radiosurgery and our previous blogs:Gamma Knife Upgrade Coming This Summer, One Picture Speaks a Thousand Words-These Neurosurgeons use Two and Radiosurgery Trials Looking Good for Epileptics.

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

Elekta, Inc. photo of new Perfexion® Gamma Knife.

Dr. Michael Sisti from the Gamma Knife Center tells us a multi-million dollar up-grade is coming to his Center this Summer.  They will be upgrading to a new state-of-the-art (5 million dollar plus) machine called the Gamma Knife Perfexion System.

The Gamma Knife isn’t really a knife, but a large machine that generates a highly concentrated beam of radiation that is used to specifically target a lesion in the brain.

The Gamma Knife is used to treat a multitude of problems including Brain Tumors, Cerebral Arteriovenous Malformations (AVMs), and Epilepsy.

The upgrade to the Perfexion system expands this capability to include more treatment areas.  Also, an advanced planning system means surgery will be performed with even greater accuracy.

According to Elekta, the maker of the Perfexion System, “System benefits include faster set-up and treatment delivery to one or more tumors in a single session[.]”

Watch this video to learn more about the new Perfexion Gamma Knife.

Dr. Sisti is excited about his Center‘s upgrade.  He says, “We will then have the two ultimate radiosurgery systems: Trilogy and Gamma Perfexion in one place.”

Also of note is that the whole Radiation Oncology Department at Columbia is undergoing a $50 million upgrade.  This is important to our cancer patients because many of them will receive their radiation therapy there.

Learn more from our page on Gamma Knife Radiosurgery and our previous blogs: One Picture Speaks a Thousand Words-These Neurosurgeons use Two and Radiosurgery Trials Looking Good for Epileptics.

Dr. Sean Lavine

Today we are seeing the integration of medicine and technology like never before and no where is this more true than in a subspecialty of medicine you may never have even heard of called Endovascular Surgical Neuroradiology (ESNR).  ESNR is formally defined by the Accreditation Council for Graduate Medical Education as “a clinical subspecialty for the diagnosis and treatment of neurovascular diseases using x-ray fluoroscopy and angiography.”

What this means is that surgeons can find and fix problems with our blood vessels from the inside out.  Using tiny instruments, powerful imaging technology, and sophisticated computer integration, surgeons can actually travel throughout the body and deep into the brain using our vessels themselves.

ESNR’s appeal is that it offers clinicians less invasive alternatives to traditional surgical procedures. They can more accurately target lesions with smaller incisions, cause less damage to surrounding tissue, and do it all with less blood loss.  What this means to their patients is less pain and a quicker recovery.

Here at the Department of Neurosurgery are three specialists in this area, Dr. Sean D. Lavine, Dr. Philip M. Meyers and Dr. Jobyna Whiting from the Endovascular Center, who are helping us to understand this innovative and emerging field of medicine.

According to the Center’s doctors, “ESNR is still in its formative years.”  Previously called Interventional Neuroradiology, just four years ago the name was changed to ESNR and the practice guidelines were broadened to accommodate more areas of medicine including neurology, neurosurgery, radiology, vascular surgery, and cardiology.

Probably the most commonly known use of ESNR is in the treatment of  atherosclerosis or narrowing of blood vessels from plaque buildup. Clogged arteries, either inside the brain or that feed the brain, are one of the leading causes of stroke.

The standard surgical treatment has been endarterectomy where surgeons actually open up the artery and remove the plaque. This can be very effective, especially with the carotid artery in the neck.  But, when the location of the artery is harder to get to, like when it is inside the brain, or if standard open surgery is too risky, an ESNR technique called angioplasty can be preferable.

The first balloon angioplasty was performed on the carotid artery in 1980.  Here, a tiny balloon is inserted in the narrowed vessel and inflated to widen the opening.  It is then deflated and removed.

Over time, this technique has been augmented with the use of stents and vascular filtration devices.  A stent can hold the walls of the narrowed blood vessel open with or without angioplasty. A vascular filtration device is used to keep pieces of plaque or blood clots from migrating away from the surgical field and preventing strokes when the stent angioplasty is taking place.

To actually extract clots from vessels, two other ESNR methods have also emerged, the Merci Device and the Penumbra Device.  According to Lavine, “The Merci Device was specially designed and tested for extracting clots from major cerebral arteries.  However, some stroke specialists have questioned the effect on patient outcome making this an area of continued clinical investigation.”

Dr. Lavine continues, “We also use the Penumbra Device to mechanically remove the stroke-causing clots with a microcatheter suction device delivered directly to the clot in the brain.”  Despite some controversy, there is tremendous interest in these techniques and the possibility of near-term medical advancement.

Dr. Philip Meyers

When talking about ESNR, Lavine and Meyers usually start by talking about the treatment of another condition, Cerebral Aneurysms.  They say, this is the new  “proving ground for ESNR.”

A cerebral aneurysm occurs when part of the wall of a blood vessel in the brain becomes thinned or damaged and bulges or balloons out. They are often only discovered once they have burst and caused a brain hemorrhage.

They can be surgically treated before or after they burst. The traditional treatment is called surgical clipping.  In this type of open brain surgery, surgeons place a clip at the base of the aneurysm to stop it from bleeding if it has ruptured, or to stop it from filling if it has not.

After 1990, with the introduction of the Guglielmi Detachable Coil, a new ESNR alternative became available called endovascular coiling. Through an artery in the groin, surgeons can reach the aneurysm and place a number of tiny flexible coils inside it.  This stimulates the formation of a clot that later heals and prevents the aneurysm from bursting.  This treatment  has become even more effective with the recent introduction of Bioactive coils.

The use of coils was until recently only possible in the type of aneurysm that has a narrow base or “neck.”  Surgeons were able to coil wide-necked aneurysms after 2002 when a stent, or mesh device, was designed for use at the base of the aneurysm to keep the coils from falling back into the main artery.

Shortly after the coil’s introduction, a large multi-year study, the International Subarachnoid Aneurysm Trial (ISAT), was implemented to compare clipping with coiling in unruptured aneurysms.  This study concluded in 2003 when it became clear that coiling had a better outcome. For unruptured aneurysms though, there is still some controversy as to which method is most effective. See our blog: Results From First IML: Aneurysm Coiling V. Clipping Still A Toss Up for more on this.

ESNR is also commonly used as an adjunct in the treatment of Arteriovenous Malformations (AVM).   Research has shown that preoperative endovascular embolization or “gluing” of the AVM to keep it from bleeding when operated on makes the surgery safer. To learn more about this technique see our blog: New Study Finds Little Risk And Much Benefit In “Gluing” Blood Vessels Before Surgery.

Similar ESNR techniques are being used to embolize the arteries that feed brain tumors before they are surgically removed.  This reduces the tumor’s blood supply and according to Lavine, “This benefits the patient in that it makes the surgical time shorter and there is less blood loss.”

ESNR techniques are also being used outside the fields of cardio and cerebrovascular medicine.   Spine surgeons are increasingly using ESNR techniques in the treatment of certain causes of back pain. In particular they are finding success with facet joint arthropathy, osteoporotic Vertebral Compression Fractures, and Spinal Tumors.  Using a minimally invasive, radiologically guided procedure they can treat the pain and disability by injecting cement to stabilize the area.

ESNR is an exciting new arena and more doctors are jumping on board.   A report authored by *members of the Department of Neurosurgery, including Lavine and Meyers, contained surveys they conducted that show more fellows and residents are venturing into this new field than ever before and that this trend is primed to continue.

They are also seeing a change in the faculty of ESNR programs.   The authors say, “While the majority of current faculty are still neuroradiologists, our study indicates that a shift is afoot and that neurosurgeons and neurologists will eventually outnumber their colleagues in radiology.”

The science is moving fast and with that comes some controversy, but without a doubt, this is a new frontier and the benefits to patients are only just beginning.

To learn more about this growing subspecialty see Dr. Sean Lavine and Dr. Philip Meyers’ chapter on the subject in the 12th edition of Merritt’s Neurology.

Also see our related Blogs: New Study Finds Little Risk And Much Benefit In “Gluing” Blood Vessels Before Surgery , Endovascular Surgery: To Clot Or Not To Clot, Results From First IML: Aneurysm Coiling V. Clipping Still A Toss Up

* Doctors who surveyed the ESNR Progams are: Dorothea Strozyk, MD; Simon Hanft, M.D; Christopher Kellner M.D.; Philip M. Meyers, M.D.; and Sean D. Lavine, M.D..