Dr. Neil Feldstein

The annual Pool Symposium was held once again here at Columbia and the theme this year was pediatric neurosurgery.

Dr. Neil A. Feldstein, Dr. Richard Anderson, and Dr. Saadi Ghatan from the Pediatric Neurosurgery Center were all there and each presented in their areas of expertise.

Dr. Feldstein spoke about chiari malformations* and craniosynostosis** surgery. He can be seen in the top left photo discussing normal skull anatomy.

Dr. Richard Anderson

Dr Anderson presented Spinal Dysraphism and Neurosurgical Management of Childhood Spasticity. He can be seen at right elucidating spasticity treatment options.

Dr. Ghatan discussed hydrocephalus*** and epilepsy**** management. He can be seen in the bottom left photo relaying the history of epilepsy surgery.

Dr. Saadi Ghatan

Dr. Feldstein tells us, “We also had guest speakers who discussed pain management and Emergency Room management of our patients.”

Once again, the event was a great success!

*Read more stories about Chiari Malformation:
More Evidence That Riskiest Part Of Chiari Surgery May Not Be Necessary
Should We Let Our Chiari Kids Play?
Last Year…Brain Surgery, This Year…Freethrow Championship
Medical First: Boy’s Brainstem Saved By A Nose    

**You can learn more about craniosynostosis from our blog, The Importance Of Baby’s ‘Soft Spot’. 

***Read the story about Sherman Alexie: Born With Hydrocephalus, Now A Well Known Author. 

****Read this story, All He Wanted Was To Drive: An Epilepsy Success Story

Forty years later, that boy has become Dr. Sean Lavine, a neurosurgeon and specialist in endovascular and cerebrovascular surgery.   The field of medicine he has chosen is a tough one too.

In this innovative and intense area of medicine, Lavine thrives.  One of his mentors, Dr. Martin Weiss from the University of Southern California’s Department of Neurosurgery (USC) says, “He has a rare combination of intellect, delightful personality and very high technical capacity – that is a perfect combination for being an outstanding neurosurgeon – which is what he is. That is just how I feel about him. I am very proud of him.  I’m proud to have been associated with him and look forward to following his distinguished career. He was the kind of person that you wanted to like. You had to like him because he was just someone who made you proud to be a neurosurgeon.”

When Lavine entered his undergraduate studies at the University of California Los Angeles (UCLA ) he says, “I had the idea that I would do medicine – That, I knew from the start. I had no idea at that time that I would be interested in the neurosciences.”

While a sophomore at UCLA, Lavine met Charles Olmstead,Ph.D, professor in the Department of Psychiatry and Biobehavioral Sciences.   Olmstead was recruiting students to intern in his Developmental Disabilities Immersion Program (DDIP).  According to Olmstead, “We took between thirty and thirty five undergraduates from UCLA and moved them into a communal living type situation.”

Lavine says, “When I met Olmstead, I was looking for something a little more intense. UCLA is a huge school with 450 people in a science class. I was intrigued by the small classrooms and the intense experience [that the program offered].” Lavine was accepted into the program and spent one whole quarter, living and studying at a state Hospital for the developmentally disabled.

Olmstead says, “They [the undergraduates] had to do community service, work a certain number of hours and then go into one of the laboratories and work up a research project.  There were eight full UCLA professors running labs there at that time. Sean completed his research and was able to present it at the Society for Neuroscience‘s meeting that year (1985) in Dallas. He was very young to present.  Sean was spontaneous – when he saw something he was interested in, he jumped on it.”

Lavine says, “I studied Krabbe’s Disease.  I did surgery on mice, isolating the sciatic nerve then taking electrical recordings.  That is when I got into the surgery side of things.”

Also, Lavine says, “At DDIP, I got to see the incredible consequences of neurological diseases in people.  There were kids there, for example, who never had their hydrocephalus treated. They were never shunted so their heads just grew and grew until they were basically the size of a table top. There were also people there who were self-mutilators and ultra violent because of neurological disease. This all had a huge impact on me.”

When the program ended and he graduated from UCLA, Lavine took a year off to work as DDIP’s coordinator.

By the end of that year, Lavine had been accepted into several medical schools. Lavine says, “I am always looking for a new challenge and a new experience. I could have stayed in California but when I got into Cornell, in New York City, I jumped at the chance.”

It was at Cornell that he solidified his interest in neurosurgery and after four years, Dr. Sean Lavine returned to his home state of California and began the first of a seven-year residency in Neurosurgery at USC.

Head of USC’s Department of Neurosurgery at the time was Dr. Martin Weiss who says, “We only accept two residents per year into the program- so, it’s competitive.  I was chairman of the department for 26 years. I trained roughly 50 residents during my career. He [Lavine] is certainly one of the top residents that have come through our program. He was someone who took his work seriously. Wonderful sense of humor but serious about what he does and Neurosurgery requires someone who is serious about his work.”

Lavine’s residency at USC coincided with an exciting time in neurosurgery, with the emergence of a new area of specialization called Interventional Neuroradiology, now renamed Endovascular Surgical Neuroradiology.  For the first time, neurosurgeons were officially being trained in the endovascular techniques formerly reserved for interventional cardiologists and neuroradiologists.  Applying these techniques in the arena of brain surgery was revolutionary and allowed for faster, less invasive treatment for a greater number of conditions.

Lavine says, “There was this group of about five guys right before us that really were pioneers. They went up against a lot, they had to get into angio rooms in the middle of the night and on weekends. The radiologists were very resistant to letting us in their area and they owned all the equipment to do this work. Those guys really had some struggles. One of them was actually trained by a cardiologist because radiologist refused to train him in those techniques.”

At that time, USC in particular was a hot bed of activity with a number of faculty who were pioneering this new arena.  In addition to Dr. Martin Weiss there were two others in particular:  Dr. Steven Giannotta, a specialist in Vascular Neurosurgery and current Chair of Neurological Surgery and; Dr. Michael Apuzzo, Edwin Todd/Trent H. Wells, Jr. Professor, specialist in Neurosurgery and Radiation Oncology, and a man who has been called, “the Godfather of Neurosurgery.”

Dr. Apuzzo says, “I felt that it was an important specialty that would be part of the future of neurosurgery. I felt that- as early as in the 80’s when it first began.  I went to Europe to see how they were doing it.  I went to Moscow and the Ukraine.  I came back and began to publish things about it.  We were the earliest to encourage neurosurgeons to do it.   When Sean trained it was a high point in the whole field of neurosurgery. [At USC ] it was a peak in terms of the people, level of the residents, and procedures done- and Sean was a part of that.”

Weiss, Apuzzo, and Giannotta all took a special interest in Lavine and encouraged him to pursue this new training.  According to Apuzzo, “We all felt he was an exceptionally talented person from many sides- in many areas.  He was part of the cream of the crop- and these are very good people.  He is a very unusual person with strength, dignity and the kind of intelligence you like all neurosurgeons to have.”

Dr. Giannotta says, “We thought he would be a pioneer.”

According to Dr. Lavine, “Gionnotta was really one of the guys that talked me into it. He insisted that the ‘pure open vascular surgeon’ was a thing of the past.  I was fortunate enough to be around him.  He saw the future very early on, as did Weiss and Apuzzo.   They all pushed me to apply for this fellowship.  It was a bit painful at the time because our training is so long to begin with.”

He was finally convinced and in 1998, after completing seven years of neurosurgery residency he entered into USC’s two year fellowship in Neuroendovascular Surgery and Neuro-interventional Radiology.

Lavine says, “The timing was really good for me.  I think I was number seven, possibly, of all the endovascularly trained neurosurgeons in the United States.  Now there are over a hundred of us.”

His mentors had been right too;  He was very well suited to this new specialty and he thrived.   Dr. Apuzzo says, “He was one of the very first people to be trained in both microsurgery and endovascular.  He was not only trained but talented.”

According to Dr. Giannotta, “Sean was technically, in surgery, sort of precocious.  It came very easy to him.   In that way, he stood out.   He is a good role model as a double threat vascular neurosurgeon who can do both open and endo-vascular surgery.”

“He was very much in demand when he finished his training,” Says Dr. Weiss. “He had his pick of numerous places that wanted him because he was so talented.  He could have had a job here if he wanted it.   I think he knew that but, he was enchanted by the opportunities at Columbia- which has provided a wonderful fertile environment for him.  Being a good farmer, he found a fertile field and grew the crops appropriately.”

Dr. Lavine has been at the Department of Neurosurgery for nine years now and he says, “ I still find the field very exciting. We are ultra sub-specialized at Columbia, unlike any other group.  Most places, they do a lot of general neurosurgery.  Here, we just really focus on one area.   In doing that, I have realized, you become an expert in the area and much more comfortable doing that kind of work.”

His field is also driven by technology that is constantly improving, with new methods and tools coming out all the time. “That, to me, is very exciting.  I love working with the new products and learning how to do the new techniques,” says Lavine.

Dr. Lavine’s enthusiasm is contagious and has made him a prolific teacher.   In addition to his role as Assistant Professor of Neurological Surgery and Radiology he is regularly invited to train residents and fellows across the country.   He says, “That gives me a tremendous amount of enjoyment.   I go to these fellows’ courses and lecture and do the hands-on training with people and try to inspire them to come into this field. There is still such a void.”

The making of any Neurosurgeon is long and arduous. It takes intelligence, skill, tenacity and sometimes it is just a matter of being at the right place at the right time.  The making of a great neurosurgeon, however takes much more. It takes bravery, heart, and most of all passion.  It is that fire in the belly that drives success.  It is what turned that little boy with the blue tackle box into the Neurosurgeon he is today.

Last year Tom and Terri Hughes sat in a tidy hospital waiting room while their 13 year old son Troy underwent brain surgery.  Hours later, when Troy’s surgeon, Dr. Neil A. Feldstein from the Pediatric Neurosurgery Center emerged from the operating room and asked Tom and Terri into a small side room, Tom remembers, ”that was the longest ten feet I ever walked.”

Troy’s parents were still reeling from the sudden diagnosis of Hydrocephalus and Chiari Malformation given to their son just a few weeks earlier. Conditions that were only discovered after he and another kid butted heads in a football game, he got a headache that would not go away, and he finally had an MRI.

With a Chiari Malformation, part of the brain, the cerebellum, actually protrudes down into the spinal canal.   Hydrocephalus, also called water on the brain, is a condition where there is a buildup of cerebrospinal fluid and pressure in the brain, one sign of which may be a larger than average-sized head.

Tom says, “Before surgery we didn’t know anything was wrong with Troy.  He always had a kind of big head.  We had a hard time finding hats and helmets that fit him, but I have a big head too and so does my dad, so we didn’t worry about it.  He did occasionally get headaches, but lots of people do.   His grades were dipping lately, also, but we thought it was because he was getting more interested in sports.”

Dr. Feldstein said that the Chiari Troy was diagnosed with was mild enough that surgery wasn’t necessary.  He said, though, that he did need to surgically address the hydrocephalus because of the pressure it put on Troy’s brain.  He also wanted to make sure that his football injury hadn’t caused any bleeding.

Dr. Feldstein was able to perform a newer procedure called an endoscopic third ventriculostomy for Troy.  In this minimally invasive surgery, surgeons work with tiny instruments, endoscopes, and a sophisticated computer and CT scanner to precisely map the patient’s brain.  They are able to locate the third ventricle and insert a small narrow scope directly there with minimal disruption to surrounding brain tissue.

The ventricles (there are four of them) are cavities deep in the brain where the cerebrospinal fluid is produced.  Once Dr. Feldstein reached the third ventricle, he made a small hole in its floor, essentially creating a drain for the cerebrospinal fluid to keep it from building up in his head.

After surgery, in that small side room at Columbia Presbyterian Hospital, Dr. Feldstein told Tom and Terri, “Troy did great. He’s a strong boy.  Just remember, no more contact sports.”

Fortunately, Troy loves all sports, not just football.  He was, in fact, a pretty good basketball player and just one week after his surgery, with a still-bald head and stitches, Troy entered a local free-throw contest.

“It was amazing.  There he was at the free throw line,” his dad said, “showing incredible focus and agility when a week before he was having brain surgery.”   Troy went all the way to the New Jersey State Free Throw Championships and took second place.

That wasn’t good enough for Troy, though, so he kept practicing.  Over the next year, not only did his free-throw get better, his headaches went away, and his grades started to come up.   His dad said, “Where he was getting C’s and D’s before surgery, he started getting A’s and B’s.”

Troy started high school in the fall of last year, with a renewed sense of purpose. He joined the cross country and basketball teams and according to his dad, he started doing something uncharacteristic of the average teenager, he started to give back.

A little background: Troy had a personal hero, a minor league baseball player named Joel Stevens. Joel had been a local high-school athlete like Troy who did so well that after high school he was recruited by the Baltimore Orioles. His career was cut short though, when, at the age of 22, Joel died of colon cancer.   After he died, his teammates set up a charity for sick kids called Joel’s Kids.

When Troy’s illness was discovered, his dad called Joel Stevens’ old high-school coach who was also a personal friend of the family.   Coach Mike sent Troy a commemorative wrist band with Joel’s old number 24 on it and said the whole school was rooting for him.

Troy continues to wear that wristband and this year he decided that for every point he scored in basketball, he’d give one dollar of his own chore money to Joel’s Kids.

By mid March, Troy had earned a ton of points, his parents matched the money, and at the end-of-season banquet, the basketball booster club presented Troy with a check that matched the money once more.

That banquet, coincidentally, was held the night before this year’s New Jersey State Free Throw Championships.  Once again, Troy had won his way to a place at States and this time he was determined to come in first.

In the end, Troy and another kid were tied, both with 23 out of 25 shots. They called a “shoot out” and Troy won it (3/5 to his opponent’s 1/5).  Keep up the great shots, Troy!  We’re rooting for you!

Troy Hughes wins NJ State Free Throw Championship

Learn more about Pediatric Hydrocephalus and Chiari Malformation.

Sherman Alexie, winner of a National Book Award, has just come out with a new book of short stories called “War Dances” as reported by the New York Times, LA Times, and the Colbert Report.  NY Times called his last book, The Absolutely True Diary of a Part-Time Indian, a “commercial breakthrough.”  In this book, Alexie created a character who like himself was born with a condition called Hydrocephalus.

Video

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.

Hydrocephalus is that state in which something has occurred to prevent this orderly procession of events. If this occurs, there is a relative build up of spinal fluid in the brain which can lead to injury or even death if not treated. It is very important to realize that hydrocephalus is the result of some event on the nervous system and that a child’s prognosis is not so much based on the hydrocephalus as the cause of the hydrocephalus. While many cases have no clear cause, the following have been associated with the development of hydrocephalus; bleeding, infection, trauma, tumors, vascular problems, and structural problems. Some occur during pregnancy and others after birth. In addition, a small number can be transmitted genetically.

In early infancy hydrocephalus is usually detected by the family or pediatrician as a rapidly enlarging head. This may or may not be associated with symptoms such as vomiting, failure to thrive, irritability, delay or loss of developmental milestones. Later in infancy and into childhood, there are rarely rapid changes in head size, but rather symptoms as already described. Depending on the child’s age at the time of discovery various radiographic techniques are available to confirm the diagnosis. In the first six to twelve months of life, the diagnosis can often be made with an ultrasound of the brain. After the skull fuses the diagnosis is best made with MRI or CT. Each of these tests have their plusses and minuses, but overall most neurosurgeons would favor an MRI scan. While this test takes longer than a CT scan and usually requires sedation, it gives a much better picture of the brain and the possible cause of the hydrocephalus. This information may effect the treatment options for the child.

It is important to realize that while hydrocephalus is very treatable, the underlying cause may not be or may have caused irreversible damage to the brain. It is important for the doctors taking care of a child with hydrocephalus to determine if the problem is ongoing or if it has resolved but left enlarged but stable ventricles. This can sometimes be difficult to tell and often the decision will be based on many factors including symptoms, eye exams, changes in level of activity or school performance. In addition to this often the child will have repeated (serial) radiographic exams to look for changes in the ventricles.

If the diagnosis of hydrocephalus has been made there are rarely options other than surgery for treatment. If a definable mass is causing the obstruction of flow it may be possible if not essential to remove the mass and allow for normal flow and resolution of the hydrocephalus. More often then not  the blockage cannot be removed and the fluid needs to bypass the normal circulation. Most surgeons use various types of systems called shunts to channel the fluid from the ventricles to other sites in the body such as the abdominal cavity, chest cavity or the heart. Each of these sites have various pros and cons, but by far and away the most popular for pediatrics is the abdominal cavity. Here the spinal fluid is absorbed onto the surface of the bowels to be returned to the blood stream along with the vital salts and other products it contains.

There are many different shunt systems on the market and there is no such thing as a luxury model versus an economy model. Most neurosurgeons are comfortable with one or more systems and utilize these almost exclusively. What is most important is that your surgeon be well trained in all shunt systems, and shunting methods. In its most simplistic form, a shunt is an inert plastic tube less than an eighth of an inch thick that allows for fluid to flow through it in one direction. There is usually a valve system that regulates the flow as well as a reservoir or “bubble” which can be felt through the skin. This reservoir allows for sampling of the spinal fluid with the use of a tiny needle if indicated to test for function or infection. Like all foreign bodies, the shunts can malfunction or become infected which will lead to the replacement of the shunt system.

In addition to these operations, certain types of hydrocephalus can be treated by making a tiny hole internally in the ventricle to reestablish normal flow. This procedure called a ventriculostomy is becoming very popular due to better surgical instruments and imaging techniques. As with shunts, the third ventriculostomy can fail over time, requiring further surgery. The risk of infection with a ventriculostomy is certainly lower than in shunting and this is one of the main reasons it has become an attractive alternative to shunting in the appropriate patient.

As mentioned earlier, the prognosis for successful management of hydrocephalus is excellent. It is however the underlying cause that will ultimately determine a child’s outcome.

The adult brain usually produces about one half liter (500cc) of CSF daily in spaces within the brain called ventricles. The CSF circulates out of the ventricles, bathes the brain and spinal cord, and is reabsorbed into the bloodstream. Hydrocephalus is derived from the Greek: “hydro”-water and “cephalus” – head. Hydrocephalus usually results either from: 1) an imbalance between CSF production and absorption (communicating hydrocephalus); or 2) when there is a blockage within the ventricular system such as a tumor that prevents CSF circulation (obstructive hydrocephalus).

Adult communicating hydrocephalus is most commonly referred to as normal pressure hydrocephalus (NPH). However this is a misnomer, as the pressure may or may not be normal in a given patient. NPH usually occurs in older adults, with the majority of affected patients over 60 years of age. Most cases of adult communicating hydrocephalus/NPH are primary/idiopathic and of unknown cause. Some patients develop secondary NPH in association with or following subarachnoid hemorrhage, head injury, brain tumor, or meningitis.

Depending on the cause and type of hydrocephalus, a variety of neurosurgical interventions may be used for treatment.

Adult Communicating Hydrocephalus/Normal Pressure Hydrocephalus (NPH)

Symptoms
NPH has three primary symptoms:

• gait disturbance/imbalance
• urinary frequency/incontinence
• cognitive slowing/short term memory difficulty/dementia

Epidemiology
NPH is estimated to impact 0.5% of the population over 65 years old. However, this is likely an underestimate due to lack of recognition by patients and physicians unfamiliar with this condition.

Why is this a hard diagnosis?
Each of the primary symptoms has many other causes in the elderly population, and no combination of the cardinal symptoms is absolutely diagnostic.
The symptoms often develop slowly over a long period of time, and are mistaken for “normal aging”.
The ventricles enlarge with normal aging and with degenerative diseases such as Alzheimer’s disease.
All described diagnostic tests have false positives and negatives. No test is perfect in its ability to diagnose this condition.

Figure 1: Typical axial T2 weighted MRI scan from an NPH patient, showing ventricular enlargement, out of proportion to that anticipated due to normal aging.

Patient evaluation
1) Patients are evaluated by our multidisciplinary, experienced team composed of Movement Disorder Neurology, Cognitive/Aging Neurology, Neuroradiology, and Neurosurgery.

2) Patients who possibly have NPH based on their history and physical examination undergo brain imaging using MRI (CT scanning if pacemaker present). (See figure 1). Various sophisticating MR analyses help solidify the diagnosis of NPH.

3) All patients with possible of probable NPH are then evaluated with spinal fluid drainage to determine to what degree they improve with a test removal of spinal fluid. This testing is done in coordinated fashion between the Movement Disorder Neurology and Neurosurgery teams, using videotape analysis of gait function and cognitive testing before, during, and after spinal fluid drainage. Videotape analysis results in an unbiased Movement Disorder specialist determining to what degree function is improved by spinal fluid removal. This testing allows us to much better prognosticate whether a cerebrospinal fluid shunt implantation surgery will result in patient benefit.

While spinal fluid drainage is done as an outpatient is some certain circumstances via lumbar puncture (spinal tap), the majority of patients are admitted to the hospital of a spinal fluid lumbar drainage trial. A small catheter is placed into the lumbar (lower back) spinal fluid space, allowing spinal fluid removal over 2-3 days. In comparison with an outpatient spinal tap, inpatient lumbar spinal fluid drainage is more accurate and predictive of whether a shunt surgery will subsequently be of benefit.

Treatment
Ventricular shunt surgery: If a patient’s symptoms improve with spinal fluid drainage, a shunt surgery is offered to the patient (and family). The goal of a shunt is to divert CSF into another region of the body where it can be absorbed, such as the peritoneal (abdominal) cavity or int o a vein just above the heart. The shunt is a soft tube that is just over 2mm (less than 1/8 inch) in diameter. The synthetic shunt material is generally very well tolerated by the human body. The entire shunt is implanted either within the skull or under the skin. No components of the shunt are visible outside of the body. Between the shunt catheter in the brain and the catheter that goes to the abdomen or bloodstream, there is a one way valve that regulates CSF flow through the shunt. If there is too much flow, the ventricles will collapse and bleeding can occur. If there is too little flow, the patient’s symptoms will not improve.

All NPH shunts that we implant contain a magnetically programmable valve. This allows us to fine tune the shunt function over time to maximize patient safety and minimize complications. Shunt surgery is usually brief and safe. The shunt is implanted under general anesthesia in a procedure that takes about an hour. A small hole is made in the skull, and the membranes between the skull and brain are opened. The brain end of the shunt is gently passed through the brain into the lateral ventricle. The valve and abdominal (peritoneal) end is passed under the skin and then implanted into the abdominal cavity through a small abdominal incision. For venous shunts that are placed just above the heart, a percutaneous, minimally invasive technique is used.

Endoscopic third ventriculostomy: In some cases of adult hydrocephalus we are able to determine that there is a CSF blockage that can be potentially bypassed using an endoscopic surgery. In this type of shunt surgery, an endoscopic camera and microinstruments are manipulated through a minimally invasive, computer guided approach into the ventricle. A small hole is made in the floor of the third ventricle, allowing CSF to flow out of the brain. When successful, this type of surgery corrects the hydrocephalus without requiring a shunt implantation.

Results
Patients whose symptoms improve with spinal fluid drainage have a better than 80% chance of sustained improvement in gait function following implantation of a CSF ventricular shunt system. Improvement in cognition and urinary function is more variable, but occurs >50% of the time. A shunt is an implantable tube that allows the excess fluid to drain from the ventricles to other parts of the body for reabsorption. The exact type and location in the body of the ventricular shunt system is determined by the treating surgeon. Most NPH shunts are placed from the brain ventricle into the abdominal peritoneal cavity, although sometimes shunts are implanted into a large vein just above the heart using minimally invasive technology.

Complications
Due our surgical experience, careful patient evaluation, multidisciplinary approach, and expert Neuroanesthesia, our center has an overall complication rate in NPH shunt surgery of <5%. This is far better than the 10-25% rates reported in large series in the medical literature. Complications can include infection (1-2%), the need to revise or reposition a shunt (1-2%), seizures (<1%), anesthestic/medical complications (1-2%), brain hemorrhage (<1%) or abdominal injury (<1%). Major complications are exceedingly rare.

Longitudinal Follow-up
NPH requires long term follow up of shunt function to minimize complications and maximize benefits. Shunt valves often need to be reprogrammed over time to get the best clinical benefit in a given patient.

For more information on Adult Hydrocephalus, contact Dr. Gaetan Moise.