Columbia Neurosurgery » Cerebrovascular

How Does a Neurosurgeon Know What to Say When an AVM Patient Asks, “What Are My Chances Doc?”

Department Author — Thu, 07 Jan 2010 13:55:09 +0000

Doctors often use grading scales that measure the most salient features of an illness to predict the outcome of a given treatment. These scales have been developed over the years and take in the experiences of many doctors and their patients with varying degrees of a problem. Things like how large is the injury, how old is the patient, and how have other patients in the past done with this particular treatment are taken into account.

Dr. Steven R. Isaacson from the Gamma Knife Center and Dr. E. Sander Connolly from the Cerebrovascular Center and their colleagues have given a comprehensive review of one problem in particular, Cerebral Arteriovenous Malformations (AVM). AVM is a condition in the brain where tiny blood vessels in one area become tangled. It is commonly treated with radiosurgery, but if left untreated the AVM can cause damage to brain cells, cause a hemorrhage, or trigger seizures. Dr. Isaacson says that the aim of their paper was to give neurosurgeons the best tools out there to help them answer their patients questions about outcome.

The Gamma Knife is one of the devices used to perform radiosurgery on an AVM. This is not the kind of surgery we are used to thinking of, it doesn’t even use a knife, rather it focuses a highly concentrated beam of radiation into the brain. The results of radiosurgery can take between one and three years to fully realize but is still preferred when open brain surgery would be too risky for the patient. The aim of the surgery is complete obliteration of the AVM. That means, within the three year window, the AVM disappears and normal blood flow returns to the area.

In their paper, Drs. Isaacson and Connolly and their colleagues reviewed a number of different grading scales that have been developed to predict the outcome of radiosurgery for patients with an AVM and have come up with two in particular that are the most useful.

The first is the Spetzler-Martin (SM) grading system, proposed in 1983 to predict the success of AVM microsurgery. This system devides AVMs into six basic types using size, where in the brain it is located, and what its venous drainage is like, to predict surgical outcome. Since then a modified version of this scale (mSM) was developed to account for more complicated types of AVM. The authors say, both grading systems “are easy to use and have been shown to be relatively predictive of radiosurgcial outcome.”

The second scale they recommend is the Radiosurgery-based grading system (RBGS). The RBGS was proposed in 2002 and uses values for the volume of the AVM and it’s location in the brain, but also includes the patient’s age.

Dr. Isaacson has stressed that outcome is an important subject to discuss with patients even when they haven’t brought up the question themselves. These grading systems give doctors the tools to do just that.

To learn more see Drs. Isaacson and Connolly’s paper A Comprehensive Review of Radiosurgery for Cerebral Arteriovenous Malformations: Outcomes, Predictive Factors, and Grading Scales in Vol. 86, No. 3, 2008 of the Journal of Stereotactic and Functional Neurosurgery.

A Place for Brain Surgeons to Debrief

Department Author — Tue, 29 Dec 2009 09:44:34 +0000

Science and technology have advanced by leaps and bounds in the last ten years and no where is this more true than in the field of cerebrovascular surgery. This branch of neurosurgery deals with problems with the blood vessels that supply the brain. New microsurgical and endovascular techniques have enabled these surgeons to help more people and to deal with increasingly complicated problems. New technologies, techniques, and tricks of the trade are fast evolving as each new complication is tackled.

Several years ago physicians, scientists and engineers at the top of this field had the brilliant idea to get together and talk about what they are learning from these complications. They called this meeting the Cerebrovascular Complications Conference (3C Meeting). Part of their mission statement was, “Through open dialogue, 3C hopes to enhance physician education, stimulate progress in the field of cerebrovascular surgery, and improve patient care.”

For this year’s annual 3C meeting in Jackson Hole, Wyoming, our own Dr. Sean Lavine from the Endovascular Center was part of the planning team. About this year’s conference he said, “The conference provided a unique opportunity for both traditional open vascular neurosurgeons and endovascular neurosurgeons to learn from the candid discussion of complications experienced by an international group of neuro-endovascular specialists of all levels of experience.” The conference lasted 3 full days and featured a multitude of case presentations as well as state of the art medical education methods like 3-D anatomy and surgical simulation.

Results from first IML: Aneurysm Coiling v. Clipping Still a Toss up

Department Author — Wed, 23 Dec 2009 13:51:13 +0000

Two years ago at their annual meeting the Congress of Neurological Surgeons (CNS) introduced Integrated Medical Learning (IML), a great new way to make the most of having so many neurosurgeons in the same place at the same time. According to the CNS website, “Integrated Medical Learning® allows participants to define the content and direction of sessions targeted at the most practical and important clinical and scientific questions of the day. Learners evaluate key evidence, interact with faculty, and define current and future practice.” They do this using online surveys before and after the meeting and handheld interactive devices during the meeting.

Dr. E. Sander Connolly from the Cerebrovascular Center and colleagues were involved in this program and were particularly interested in how this large group of neurosurgeons would divide in terms of treatment for brain aneurysms. Their results were presented as one of the top ten abstracts at this year’s CNS meeting.

An aneurysm occurs when part of a blood vessel weakens and bulges or b alloons out. Most of the time this causes what is called a berry aneurysm that is at risk for bursting. When this happens in the brain, surgeons usually treat it one of two ways: Clipping, where, in an open brain procedure, they place a small clip at the base of the aneurysm, or coiling, where they go into the brain using tiny instruments via blood vessels and fill the aneurysm with a flexible coil to keep it from rupturing.

Before the 2007 meeting, attendees were given access to review articles highlighting the latest research on this topic. Then, at the meeting surgeons were presented with 8 patient-cases that could be treated either by coiling or clipping. The surgeons used handheld interactive devices to answer questions about these cases. Specifically they were asked which procedure they would choose to perform in each case. At this year’s meeting Dr. Connolly and his colleagues presented the results: 328 surgeons responded and though individually they tended to have strong opinions one way or the other, the group was for the most part evenly split. A condition known as clinical equipoise.

With the use of IML these researchers took advantage of the coming together of neurosurgeons from around the world to find out the current state of treatment for a very particular problem. This is useful information, especially for those trying to decipher whether one treatment is better than another. IML was an enriching experience for those involved and is a great tool to help further the science of neurosurgery. We look forward to the results from this year’s IML.

To learn more see the article: Community and Individual Equipoise for Ruptured Intracranial Aneurysm Clipping versus Coiling: Results form Integrated Medical Learning. The full article can be found in Neurosurgery volume 65(2), August 2009, p 407

Dr. Robert Solomon, chairman of the Department of Neurosurgery, in a video series on Cerebral Aneurysms.

Galbraith Award Given to New York Aneurysm Study

Department Author — Tue, 15 Dec 2009 18:31:37 +0000

Lead author Dr. Brad Zacharia with Dr. E. Sander Connolly from the Cerebrovascular Center and colleagues received the Galbraith Award at this year’s annual meeting of the Congress of Neurological Surgeons (CNS) for their study of the treatment of brain aneurysms in the State of New York.

An aneurysm is a bulge in a blood vessel that is caused by weakening of the vessel wall. Aneurysms can be life threatening if they burst and often require surgical treatment. There are two types of surgery that are performed and it remains controversial which is best. Clipping has been the treatment of choice for the last 40 years. This involves a craniotomy and placement of a tiny clip at the base of the aneurysm. With the advent of endovascular surgery coiling has become another option. A small flexible coil is passed through blood vessels into the brain where it is placed in the aneurysm to keep it from bursting. Recent studies have suggested that endovascular coiling has a better outcome.

The authors used the New York Statewide Planning and Research Cooperative System (SPARCS) to look at all the patients that were discharged from a hospital in New York State that had a primary diagnosis of brain aneurysm between the years 2005 and 2007. They found about 3,000 patients with that diagnosis, discharged from over a hundred hospitals. They divided the hospitals into high and low volume based on the number of these kinds of patients treated. Then they looked at the general outcome for these patients and correlated it to whether the hospital was high volume or low and to the type of surgery the patient had.

The authors found that between surgical treatments, the best outcome was found in the group that had undergone endovascular coiling. Between high and low volume hospitals they found that more low volume medical centers were performing this procedure but, independent of surgical treatment a better outcome was found in the large volume medical centers.

When they compared the data during this three year period (2005-2007) to a previous five year period(1995-2000) they actually found no overall improvement in outcome despite the fact that the use of endovascular coiling (the procedure with a better outcome) had increased since 1995. The authors surmised that this is likely because more low volume centers (which overall had poorer outcomes regardless of procedure) are performing this kind of surgery. This result is of concern and the authors recommended that more research be done to look into this further.

A poster presentation of this research: Trends in Outcome for the Treatment of Intracranial Aneurysms in New York State: A 3-year Population Based Study

This study can be found in the August 2009, Vol. 65, issue 2 of Neurosurgery

More about Brain Aneurysms and their treatment.

What are They, a Bunch of Neurosurgeons? Yes, and They’ve Got the Papers to Prove it

Department Author — Mon, 14 Dec 2009 16:38:42 +0000

Like a lot of smart people, neurosurgeons know that it is important to keep learning. The Congress of Neurological Surgeons (CNS) Meeting is a week-long event where neurosurgeons from around the world get together to teach and learn from each other. Many of the doctors from the different Centers at the Department of Neurosurgery attended and spoke at this year’s meeting in New Orleans. They talked about the work they are doing and presented a number of recently published papers.
Their papers are published in journals like Neurosurgery and the Journal of Neurosurgery and serve as an important form of communication between those in the field when not attending conferences like the CNS meeting. The conferences provide a good forum for researches to get feedback from their peers and it is also a good place to talk about what is coming down the pike. A lot of which is still under investigation, and for which papers have not yet been written.
At the CNS meeting this year, members on the editorial board of the above mentioned journals conducted a special seminar on what makes for good research. Dr. Paul McCormick, Director of the Spine Center co-directed this course. Dr. Peter Angevine also from the Spine Center, and Dr. E. Sander Connolly from the Cerebrovascular Center were among the faculty.
They, along with their colleagues at the Neurological Institute have a long track record of publishing papers and they know that if the research method is bad then even the best idea will be discredited. In this course, the faculty critically reviewed recently published papers to better inform neurosurgeons on how to get the most out of their research and how to best communicate their results. They each highlighted different aspects of study design and presentation to consider.
For example, Dr. Angevine talked about how the outcome of any new treatment has to be thoroughly investigated in terms of cost versus benefit to the patient. One way to do this is to use graded questionnaires about daily living before and after a procedure. Costs to the patient must include, not only direct costs like hospital and doctor fees but also indirect costs like how much is lost in wages from time off work or what is the impact on a family when a primary care-giver is out of commission.
Developments in neurosurgery are moving fast, those in the field need to attend conferences like the CNS meeting and when they can’t, they need to read their colleagues’ papers to keep up. The research presented in these papers needs to be done well for their benefit to be realized. When research is thorough, and the method is sound, then the cream rises to the top, what is truly bad gets thrown out, the field moves forward, and ultimately it is the patient that benefits.

Marc Otten, M.D.

Neurosurgery Webmaster — Sat, 24 Oct 2009 16:00:48 +0000

Education
Weill Medical College of Cornell University, M.D. 2006
Philosophy, Princeton University, B.A. 1999

Honors/Awards
George G. Reader Prize in Public Health, Weill Medical College of Cornell University, 2006
Alpha Omega Alpha, Weill Medical College of Cornell University, 2006
Russek Fellow, American College of Cardiology NY Cardiovascular Symposium, 2004

Professional Memberships
American Association of Neurological Surgeons, Resident Member
Congress of Neurological Surgeons, Resident Member

Andrew F. Ducruet, M.D.

Neurosurgery Webmaster — Sat, 24 Oct 2009 14:33:24 +0000

Education
Medical School:Columbia University College of Physicians & Surgeons, M.D. 2004

College: Princeton University, Chemistry, B.A. 1999

Honors/Awards:
Alpha Omega Alpha, Columbia College of Physicians & Surgeons, 2004
Magna cum laude, Princeton University, 1999

Professional Memberships:
American Association of Neurological Surgeons, Young Neurosurgeons Committee Member
American Association of Neurological Surgeons, Resident Member
Congress of Neurological Surgeons, Resident Member

Current Position:
Fellowship: Endovascular Neurosurgery at the Barrow Neurological Institute, in Phoenix, AZ.

Cerebrovascular Research Laboratory

Brigitte Matsuoka — Thu, 22 Oct 2009 19:08:56 +0000

Dr. E. Sander Connolly’s Cerebrovascular Laboratory employs experimental models to study the mechanisms of cerebral ischemia/reperfusion injury, with a focus on clinical translation. The NIH is funding the effort to analyze a recently identified a component of the complement cascade that mediates post-ischemic cerebral injury, and we are currently to delineate the mechanisms of this injury, and to develop specific techniques of targeting complement and translating these findings to human neuroprotective trials.

Related basic science projects include an active collaboration with Dr. Carol Troy seeks to understand novel mechanisms of caspase-mediated post-ischemic neuronal cell death/survival. In addition, recent laboratory studies are underway to study the role of the complement cascade, programmed cell death, and neurogenesis in spontaneous intracerebral hemorrhage, as well.

We have recently begun recruiting patients for an FDA-funded multicenter, phase II clinical trial aimed at assessing the safety of tiopronin in patients with aneurysmal subarachnoid hemorrhage(aSAH) and also to obtain preliminary data on the efficacy of tiopronin versus placebo in reducing serum and CSF 3AP levels in this stroke patient population. Collaborating principle investigators participating in this trial include Dr. Brian L. Hoh and Dr. J. Mocco from the Neurosurgery Department at the University of Florida, and also Dr. Louis J. Kim from the Neurosurgery Department at the University of Washington.

Other clinical research efforts include those concerning vascular re-activation of large and small cerebral vessels through the effects of subarachnoid hemorrhage and other trauma, and the auto-regulation of vessels in relation to arteriovenous malformations and other pathological vascular conditions. In collaboration with Dr. Eric Heyer (Anesthesiology), the lab has also shown that possession of the ε4 allele of the ApoE gene (originally characterized in Alzheimer’s Diseases) is a risk factor for neurocognitive decline following carotid endarterectomy. Researchers in the laboratory also play a pivotal role in the international effort to identify genes responsible for the formation of cerebral aneurysms.

Anthony L. D’Ambrosio, M.D.

Brigitte Matsuoka — Tue, 04 Aug 2009 16:41:02 +0000

Dr. D’Ambrosio earned his medical doctorate from the Vanderbilt University School of Medicine where he graduated Alpha Omega Alpha. He completed his Neurological Surgery Internship, Residency and Chief Residency at the Neurological Institute of New York, Columbia University. In addition, he completed a Skull Base and Cerebrovascular Surgery Fellowship in the Department of Neurological Surgery at the University of South Florida in Tampa.

Dr. D’Ambrosio’s practice is devoted to brain tumors, skull base tumors, meningiomas, acoustic neuromas, pituitary tumors, microvascular decompression for trigeminal neuralgia and hemifacial spasm, cerebral aneurysm treatment, degenerative spine disease, and intervertebral disc disease.

He uses state-of-the-art technology such as frameless image guidance systems, awake craniotomy, and stereotactic radiosurgery (i.e. GammaKnife, BrainLab, Tomotherapy) for the treatment of primary and metastatic brain tumors. He has particular expertise in the use of endoscopic techniques to remove complex intracranial tumors at the base of the brain.

Dr. D’Ambrosio directs our Northern New Jersey practice based in Ridgewood, NJ. He is the Director of Neuro-Oncology – Disease Management Team at the Luckow Cancer Center of The Valley Hospital in Ridgewood, NJ. Dr. D’Ambrosio is also the Director of Neurosciences for the St. Joseph’s Healthcare System in Paterson and Wayne, NJ. He sees patients at The Valley Hospital, St. Joseph’s Regional Medical Center, St. Joseph’s Wayne Hospital, Chilton Memorial Hospital, and Mountainside Hospital. With his main office in Ridgewood, New Jersey, Dr. D’Ambrosio has helped to establish a center of excellence for Columbia Neurosurgery in the communities of Bergen, Passiac and Essex counties.

Board Certified:	American Board of Neurological Surgery
Medical School:	Vanderbilt University School of Medicine, Nashville, T.N, M.D. 1999
Residency Training:	Columbia University Neurological Institute of New York
Fellowship Training:	Cerebrovascular and Skull Base Surgery, The University of South Florida, Tampa General Hospital

Sean D. Lavine, M.D.

Brigitte Matsuoka — Tue, 04 Aug 2009 16:34:34 +0000

Dr. Lavine dedicates his practice exclusively to diseases associated with the cerebrovascular system and to those diseases treated with Endovascular Neurosurgical and Interventional Neuroradiological Procedures. He was among the first surgeons in the country to complete training in these procedures after completing neurosurgical training. He serves as a Clinical Co-Director of Neuroendovascular Services at the Columbia University Medical Center, New York Presbyterian Hospital. Together with Drs. Robert Solomon, E. Sander Connolly, Philip Meyers & Jobyna Whiting, Dr. Lavine & the Department offer comprehensive care of cerebrovascular and related diseases. Additionally, Dr. Lavine collaborates with all other members of the Department of Neurosurgery and many other specialties that recommend the use of minimally invasive endovascular and percutaneous procedures to the benefit of patients with a wide variety of conditions.

Board Certified:	American Board of Neurological Surgery
Medical School:	Cornell University Medical College 1991
Residency Training:	University of Southern California
Fellowship Training:	Neuroendovascular Surgery and Neuro-interventional Radiology, University of Southern California.

Learn more here: The Making Of A Neurosurgeon: Dr. Sean Lavine

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