Progressive Neuroscience...Marketing & Advertising 2 Chiari 1 Malformation: Accurate Diagnosis &...

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Volume 3 No. 1 l Fall 2010

Progressive NeuroscienceA publication for physicians produced by the Institute for Neurosciencesat Winthrop-University Hospital

• CCSVI & Multiple Sclerosis

• Chiari 1 Malformation

• Lateral Extracavity Corpectomy for Spine Tumors

Message from the Chiefs

Advancements in the diagnosis and treatment of patients with life-altering diseases of the brain and

spine continue to astound.

At Winthrop-University Hospital’s Institute for Neurosciences, we strive to integrate many of these

developments into patient care as rapidly as possible.

However, despite amazing technology, exceptionally trained and experienced physicians and

surgeons, and innovative programs and services, we remain mindful that we do not treat disembodied

symptoms. We treat people who are frightened, vulnerable and facing life-threatening situations.

In this issue of Progressive Neuroscience — which marks the beginning of our third volume — we,

once again, highlight some of our most recent approaches to diagnosis and treatment, covering:

• The latest approach to Chiari 1 Malformation

• The relationship of multiple sclerosis and CCSVI

• Using LICOX® for patients with serious brain injuries

• Spine tumor surgery

• Carotid angioplasty and stenting for carotid stenosis

• fMRI to reduce the risk of functional impairment during brain surgery

We are proud to be able to bring you these clinically relevant articles, and continue to focus on our

ongoing partnership in the care of your patients.

Michael H. Brisman, MD Malcolm H. Gottesman, MD

Chief, Division of Neurosurgery Chief, Division of Neurology

Co-Director, Institute for Neurosciences Co-Director, Institute for Neurosciences

Michael H. Brisman, MD Malcolm H. Gottesman, MD

Chiari 1 Malformation: Accurate Diagnosis & Appropriate Management are Vital to Proper Treatment l 2

CCSVI & Multiple Sclerosis:The Controversy Continues l 4

Monitoring of Cerebral Oxygenation in Patients with Serious Brain Injuries l 6

Lateral Extracavity Corpectomy for Spine Tumors is Effective & Safe l 7

Carotid Stenting Gains Momentum for Patients With Carotid Stenosis l 9

fMRI Illuminates Blood Flow, Reducing Risk of Functional Impairment during Brain Surgery l 11

Contributing Physicians & Surgeons

Table of Contents

Progressive Neuroscience l Fall 2010 l 1

Winthrop-UniversityHospital’s Institute forNeurosciences specializes in the latest and most effective neurological procedures for:

• Acoustic Neuroma• Astrocytoma• Arteriovenous Malformation

of Brain & Spine • Back Pain• Brain Aneurysms• Brain & Spinal Traumas • Brain Tumors• Carotid Stenosis• Cerebral Aneurysms • Cerebrovascular &

Endovascular Diseases• Chiari Malformation • Chronic Pain • Degenerative Scoliosis • Epilepsy• Facial Pain • Glioblastoma• Herniated Discs• Hydrocephalus• Intracranial Atherosclerotic

Disease • Intracranial Hemorrhage• Memory Disorders• Meningiomas• Metastatic Tumors• Movement Disorders• Moyamoya Disease• Multiple Sclerosis• Neck Pain• Neurological Cancers• Neuromuscular Diseases• Normal Pressure

Hydrocephalus• Ossification of Posterior

Longitudinal Ligament• Parkinson’s Disease • Pediatric Neurological

Conditions • Peripheral Nerve Disorders• Phantom Limb Pain• Pinched Nerve• Pituitary Adenoma• Post Herpetic Neuralgia • Sciatica• Seizure Disorder • Spasticity• Spina Bifida• Spinal Cord Injury • Spinal Stenosis • Spine Fractures • Spine Tumors • Stroke• Subarachnoid Hemorrhage• Subdural Hematoma • Syringomyelia• Trigeminal Neuralgia

Progressive Neuroscience is produced by the Institute for Neurosciences at Winthrop-University Hospital, 259 First St., Mineola, NY 11501, 516-663-0333, www.winthrop.org.

Michael H. Brisman, MDChief, Neurosurgery

Co-Director, Institute for Neurosciences

Malcolm H. Gottesman, MDChief, Neurology

Co-Director, Institute for Neurosciences

Charles M. StrainChairman of the Board

John F. CollinsPresident & CEO

Phyllis AbramsWriter/Editor

Charles WalshGraphic Designer

Garry J. SchwallChief Operating Officer

Solomon A. Torres Vice President Administration

John P. BroderVice President

External Affairs & Development

J. Edmund KeatingVice President

Marketing & Advertising

2

Chiari 1 Malformation:Accurate Diagnosis & AppropriateManagement are Vital to Proper Treatment

Chiari 1 Malformation (CM1) — a congenital anomaly characterized by a misshapen orundersized posterior cranial fossa — causes herniation of the cerebellar tonsils throughthe foramen magnum into the spinal canal.

Once considered rare, the numberof reported CM1 cases is increas-ing significantly, as access toadvanced diagnostic imagingexpands, and the ability to recog-nize brain stem and spinal cordcompression improves. Currently,an estimated 200,000 to 2 millionAmericans have the condition.

Generally asymptomatic throughchildhood, CM1 usually presents inadolescence or early adulthood. The complex symptomatology — caused by the herniated tissuepressing against the brainstem and disrupting the normal flow of cerebrospinal fluid (CSF) —includes severe headaches and painful tension at the base of the skull that may worsen withcoughing or other types of exertion.

“Symptoms vary significantly in severity andtype, reflecting the extent of herniation. Theyusually progress over time and, because of theircomplexity, can often be misdiagnosed.”

Michael Brisman, MDChief, Division of Neurosurgery

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Additionally, sensory and motordeficits, vision problems, tinnitus, dizzi-ness and vertigo, impaired musclecoordination and fine motor skills canoccur. Other symptoms may includechronic fatigue, sleep apnea, syncope,balance problems and, in severe cases,paralysis. What’s more, with blockedCSF, hydrocephalus, syringomyelia andother complications can arise.

“Symptoms vary significantly in severity and type, reflecting the extent ofherniation,” said Winthrop-UniversityHospital’s Chief of Neurosurgery,Michael Brisman, MD. “They usuallyprogress over time and, because of theircomplexity, can often be misdiagnosed.Many people with CM1 can suffer foryears because of that. Accurate diagno-sis and a comprehensive treatment planare vital before the patient’s nervoussystem suffers permanent damage.”

Since many CM1 symptoms can mimicthose of other disorders, a completemedical history, as well as physical

and neurological examinations, are fundamental to the workup, with thediagnosis confirmed by an MRI.

Treatment is based on the patient’s age,overall health and medical history, aswell as the extent and type of the condi-tion. Asymptomatic patients, or thosewith mild symptoms, are usually moni-tored carefully and managed medicallyto control pain and other symptoms.

“Surgery is advisable for patients insevere pain,” explained Dr. Brisman.“And, when a symptomatic syrinx exists,surgery is usually advised, since thepockets of fluid formed by the syrinxcan lead to spinal cord damage and per-manent neurological deficits. Surgery isthe only treatment that can correct func-tional disturbances or halt the progres-sion of damage to the nervous system.”

At Winthrop, Dr. Brisman and pediatricneurosurgeon Elizabeth Trinidad, MD,are known for their skill and experiencein performing posterior fossa decom-

pression. The procedure involves a smallcraniectomy at the base of the skull towiden the foramen magnum. This isusually followed by a laminectomy ofthe C1 or C2 — depending on the extentof the herniation — to expose the duraand effectively decompress the area. Toenlarge the dura, traditionally, aduraplasty is performed, as well. Whena syrinx is present, surgeons may alsoinsert a shunt in to the syrinx cavity torestore normal CSF flow.

According to Dr. Brisman, “The goal isto keep the abnormality from gettingworse. About 80 percent of patients whoundergo the procedure improve.”

For more information, call the Institutefor Neurosciences at 1-866-NEURO-RXor visit www.winthrop.org.


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CCSVI & Multiple Sclerosis:The Controversy Continues

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The cause of multiple sclerosis (MS), aneurological disorder identified nearly150 years ago, remains a mystery —

and a cure continues to be elusive.

Ranked among the most challenging chron-ic diseases, the inflammatory condition —which affects an estimated 2.5 million individuals worldwide — involves lesionsthat damage the myelin surrounding neurons in the central nervous system andcause irreversible damage to the signal-transmitting axons.

Traditionally, the condition has been linkedto immune system malfunction and inflam-mation. However, a radical new theory pro-posed by vascular surgeon Paolo Zamboni,MD, in Italy, postulates that MS is a vasculardisease caused or exacerbated by “chroniccerebrospinal venous insufficiency (CCSVI),[which is] characterized by combinedstenoses of the principal pathways ofextracranial venous drainage, including theinternal jugular veins (IJVs) and the azygous(AZY) vein, with development of collateralcircles and insufficient drainage.”1

According to Dr. Zamboni, the stenosis andconsequent abnormal blood flow, as well asvenous pressure, cause reflux that results incerebral edema and leakage of red bloodcells and fluids into the brain. Although hesays that this can lead to an immune reactionand inflammation that damages myelin andnerves, he concedes that it is still not provenwhether CCSVI is a cause of MS or possiblya product of the illness.2 Iron deposits havebeen documented in MS lesions, which formsymmetrically around a vein, and it is knownthat CCVSI in the lower body can result inthe deposit of iron and cause inflammation,which can lead to sclerosis and degenerativelesions.

Taking his work beyond imaging IJVs andAZYs with ultrasound and magnetic reso-nance to uncover CCSVI in MS patients, Dr. Zamboni has employed percutaneoustransluminal angioplasty (PTA) to open thenarrowed vessels and maintain patency. Hehas concluded that “PTA of venous stricturesin patients with CCSVI is safe…[and] inpatients with relapsing-remitting MS, theclinical course is positively influenced.”3

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Unprecedented Controversy

In record time, Dr. Zamboni’s effortshave created unprecedented controver-sy among scientists and MS specialists.Some have conducted limited investiga-tions with mixed results. Most notably,two separate and highly publicizedinvestigations in Germany and Sweden4,5

have failed to reproduce his findings.

The controversy has also revealed MSpatients’ deep frustration. While med-ications used to minimize their symp-toms and disabilities have multipliedover the last decade, their options con-tinue to be restricted to lifetime use ofpowerful drugs — some with severe sideeffects. Emphasizing the urgent need forlarge, well-controlled studies that canprovide answers quickly, patients haveunited, using the Internet to mount anextraordinary campaign that has movedthe National Multiple Sclerosis Societyand the MS Society of Canada to com-mit nearly $2.5 million in support ofstudies focusing on the role of CCSVI inthe MS disease process.

“Dr. Zamboni’s work is to be commend-ed for originality and determination,”said Malcolm Gottesman, MD,

Winthrop-University Hospital’s Chief ofNeurology and Director of its highlyregarded MS Treatment Center, which isstaffed by a team of clinicians recog-nized for their expertise in managingcomplex cases, as well as their commit-ment to participating in clinical trialsand conducting original research.

“The fluctuating course of MS makes itdifficult to be certain if a given treat-ment is effective. Correlation andcausality are readily confused, and Dr.Zamboni’s theory is not free of this type

of bias. While his concept is new andhighly unconventional, it is, neverthe-less, worthy of further research.”

At Winthrop, while patients are nottreated for CCSVI, Dr. Gottesman andJohn Pile-Spellman, MD, a leadingendovascular neuroradiologist, areworking together to screen MS patientswho request that their IJVs and AXY be evaluated.

Winthrop’s state-of-the-art MRI technol-ogy can image cerebral and neck veinsnon-invasively in order to assess for thevenous stenosis associated with CCSVI.Additionally, the availability of perfusiontesting, with both MRI and CT, revealschanges in blood volume and blood flowthought to be associated with CCSVI.“In spite of being able to see these asso-ciated changes on imaging, our knowl-edge of this is evolving, and much workneeds to be done,” said Dr. Pile-Spellman.

“Currently, we regard this as a researcharea,” Dr. Gottesman added. “So far thedata have not been consistent or repro-duced. MS does not seem to be causedby impaired cerebral drainage.”


REFERENCES

1. Zamboni P, Galeotti R, Menegatti E, et. al. Aprospective open-label study of endovascular treat-ment of chronic cerebrospinal venous insufficiency.Journal of Vascular Surgery. December 2009;50:6;1348-1358.2. Seminar at New York University Medical Center,Feb. 2010.3. Zamboni P, Galeotti R, Menegatti E, et. al. Aprospective open-label study of endovascular treat-ment of chronic cerebrospinal venous insufficiency.Journal of Vascular Surgery. December 2009;50:6;1348-1358.4. Doepp F. No cerebrocervical venous congestionin patients with multiple sclerosis. Annals ofNeurology. August 2010; (68) 2:173-183.5. Sundstrom P. Venous and cerebrospinal fluidflow in multiple sclerosis: A case-control study.Annals of Neurology. August 2010; (68) 2:255-259.

The controversy has also revealedMS patients’ deep frustration.While medications used to minimize their symptoms and disabilities have multiplied overthe last decade, their options continue to be restricted to lifetime use of powerful drugs —some with severe side effects.

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As fragile as it is crucial, the brainis totally dependent on theblood’s constant supply of oxy-

gen and glucose to maintain normal cellintegrity. Because the organ cannotstore oxygen, traumatic brain injury(TBI) and acute neurological disorders,such as stroke — which generally interrupt or obstruct blood flow andsimultaneously increase the metabolicrate — are often catastrophic.

If not detected rapidly and treated early,a primary injury to the brain can triggera cascade of destruction that reacheswell beyond the initial insult and leadsto significant secondary damage thatmay develop over time due to systemicevents, such as hypoxia, hypotensionand ischemia.

Therefore, in addition to immediateintervention, brain-injured patientsrequire close monitoring to prevent andalleviate secondary injury, which canresult in poor, long-term functional outcomes or death.

Well Beyond the Penlight

Although the use of a penlight for pupilassessment remains fundamental to aneurological examination, neurologistshave gone well beyond relying on it forevaluation of brain-injured patients.“Advances in brain-monitoring technol-ogy are enabling us to perform excep-tionally precise and quantifiable neuro-logical assessments,” said neurocriticalcare expert Elzbieta Wirkowski, MD,Director of Winthrop-UniversityHospital’s Cerebrovascular DisordersProgram and Co-Director of theHospital’s Neuroscience Intensive CareUnit (NeuroICU).

“We now have improved tools thatdetect, track and help us respond morerapidly to critical changes in intracranialpressure (ICP), cerebral perfusion pres-sure (CPP) and brain tissue oxygenation(PbtO2), which is vital to tissue survival.”

One of those tools, the LICOX® BrainTissue Oxygenation Monitoring System,assesses PbtO2 levels associated with

secondary injury and treatment inter-ventions. Dr. Wirkowski and a staffwith advanced training in neurocriticalcare use the technology to monitorbrain parenchymal oxygenation whenmanaging patients with severe cerebral injuries.

Safe, Reliable, Accurate

“The depth and duration of tissuehypoxia are outcome indicators inpatients with serious brain injuries,”

explained Dr. Wirkowski. “LICOX® is asafe, reliable and accurate oxygen-levelmonitor that allows for continuous,qualitative monitoring of O2, as well astemperature, in cerebral tissues.

“It enables us to measure the differencebetween delivery and consumption ofoxygen; increase the O2 level, as neces-sary; and fine-tune the supply to main-tain brain-tissue oxygen tension abovethreshold levels, while simultaneouslyevaluating the patient’s response totreatment.”

How LICOX® Works

To measure oxygenation, the LICOX®

system uses an oxygen-sensitive probethat is placed into brain tissue. Theprocess involves drilling a burr hole andplacing an intracranial bolt, with theprobe inserted via the dedicated portand tunneled under the scalp. Guided bythe patient’s condition and CT scans, theprobe is either positioned near thelesion to obtain local PbtO2 levels, or inhealthy tissue to evaluate global oxy-genation. Once in place, the probe isconnected via a cable to a monitor thatdisplays oxygen and temperature valuescontinuously.

“The equipment detects brain hypoxiaas it occurs so we can intervene immediately,” Dr. Wirkowski explained.“Although there are risks, the benefitsclearly outweigh the risks.”

PbtO2 monitoring adds a significantdimension to the care of patients withsevere brain injuries. By coupling theuse of LICOX® with the NeuroICU’sother state-of-the-art equipment —which includes the latest technology tomeasure ICP and CPP — Winthrop isespecially well equipped to reduce thepossibility of secondary brain injury,and maintains its position at the fore-front of neurocritical care.


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Monitoring of Cerebral Oxygenation in Patients with Serious Brain Injuries

Assessment Values that HelpMonitor Patients with Serious Brain Injuries

• PbtO2 normal range: 25-50 mm Hg • ICP normal range: under 10 mm Hg• MAP normal range: 70-110 mm Hg• CPP normal range: 70-100 mm Hg• PaCO2 normal range: 35-45 mm Hg• PaO2 normal range: 80-100 mm Hg• SjvO2 normal range: 60-70%


Lateral Extracavity Corpectomy forSpine Tumors is Effective & Safe

At 70, ST, began to have difficulty walking. He presented with persistent, progressive backpain unrelated to level of activity and refractory to medication. After an X-ray and MRIrevealed the presence of a tumor on his spine at T6, a percutaneous needle biopsy identified

the lesion as a solitary plasmacytoma.

To stabilize the spine and resect the tumor, a lateral extracavitary corpectomy — which allows forthe simultaneous exposure of the posterior bony elements and anterior vertebral column throughthe same, small incision — was performed at Winthrop-University Hospital by neurosurgeonBenjamin Cohen, MD, who specializes in spine surgery, and Marc Agulnick, MD, the Hospital’sChief of Orthopaedic Spine Surgery.

After stabilizing the spine posteriorly with pedicle screws and hooks linked together withrods on either side of the spinal column, theyaccessed the front of the spine by resecting asection of the posterior rib on one side. Throughthat one small portal, the diseased vertebra wasremoved, the stabilizing instrumentation wasaffixed, and an expandable, titanium mesh cagefilled with the resected rib was placed to produce a bone graft, facilitate spinal fusion and create a new, cancer-free “vertebra.”

This technically challenging surgery requires extraordinary skill, experience and thorough knowl-edge of the thoracic and retroperitoneal anatomy. “A lateral extracavitary corpectomy affords usmore than enough exposure for decompression, grafting and restoration of normal column heightand alignment,” explained Dr. Cohen, who teams with Dr. Agulnick frequently on such cases.

Dr. Agulnick added: “This less invasive approach is especially attractive when anterior decompres-sion must be combined with posterior fusion. With one operation, instead of a much more lengthyand involved two-stage procedure, we can access the anterior lateral aspects of the spine and durawithout exposing the anterior thoracic or abdominal cavity.”

“A lateral extracavitary corpectomyaffords us more than enough exposurefor decompression, grafting and restoration of normal column height and alignment.”Benjamin Cohen, MD

Continued on pg. 8

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Spine Tumor Surgery... Continued

Spinal masses, which vary greatly, arecharacterized by type and location:extradural tumors, which affect the ver-tebrae, are mostly metastatic; intradural-extramedullary tumors — generallybenign — develop in the meninges,nerve roots or at the base of the spinalcord; and intramedullary lesions, whichcan be benign or malignant, begin in thesupporting cells within the spinal cord.

Given the wide range of spinal lesions,Drs. Cohen and Agulnick routinelymake treatment decisions together witha multidisciplinary team of otherWinthrop specialists, including neurora-diologists; general, vascular and tho-racic surgeons; radiation, medical andneuro-oncologists; and interventional

radiologists. To design the safest andmost effective treatment plans, they takeinto account the type and location of thetumor, progression of neurologicalsymptoms and degree of spinal stability,as well as the patient’s age and overallhealth.

ST’s case was typical of many theyencounter. “Most of the neoplasms wesee are metastatic,” said Dr. Cohen. “Thechallenge is to use the least invasivemethod to remove as much of the dis-eased tissue as possible, decompress theneural elements, maintain mechanicalstability, preserve or improve neurologi-cal function, alleviate pain and enhancequality of life — always focusing on lim-iting patient risk and morbidity.”

They met the challenge with ST, who isnow cancer-free, walks normally andhas no back pain. In fact, over the pastyear, he recovered well enough to land a100-lb. fish on a recent outing.


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Pre-operative saggitalMRI of thoracic spine with contrastshowing tumor

Post-operative anterior/posterior and lateral X-rays of the thoracic spine showing spinal stabilization reconstruction

Pre-operative saggital and coronal CTreconstructions of the thoracic spine

Carotid Stenting Gains Momentum forPatients With Carotid Stenosis


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At first, 66-year-old SL brushed off the weakness in her left arm and numbness on the leftside of her face. But the next day — with the symptoms persisting and unable to swallowher morning coffee — she suspected she was having a stroke, called 911 and was transport-

ed to her local hospital.

Since the window of opportunity for emergencystroke treatment had closed, SL needed focusedand comprehensive intensive care so she wastransferred to Winthrop-University Hospital’sNew York State-designated Stroke Center.There, she was evaluated by the Hospital’smulti-disciplinary Stroke Team and admitted tothe specialized Neuroscience Intensive CareUnit (NeuroICU) for close, continuous monitor-ing and treatment.

SL’s symptoms were found to be due to carotid stenosis. “In such cases, in addition to the administration of anti-coagulants, anti-hypertensives, statins and anti-platelet agents, carotidendarterectomy is the surgical treatment of choice for standard-risk patients,” said JonathanBrisman, MD, Winthrop’s Director of Cerebrovascular and Endovascular Neurosurgery. “Itshaves the accumulated plaque from the vessel’s walls, widens the lumen and restores normalblood flow to the brain.”

“While endarterectomy is still consideredthe gold standard for acceptable surgicalcandidates, stenting is advised forpatients unable to undergo the moreinvasive surgical procedure.”

Jonathan Brisman, MD

Continued on pg. 10

Right internal carotid artery angiogram, lateral viewbefore stenting

After stenting

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Carotid Stenting... Continued

Endarterectomy has been a safe andeffective treatment for carotid revascu-larization over the past 70 years. But itis a conventional surgical procedurewith all the traditional risks. Approxi-mately 15 years ago, carotid arterystenting — a catheter-based, percutaneous intervention — was introduced as an alternative procedurefor treating carotid stenosis, whenappropriate.

Less-invasive than endarterectomy,stenting involves fitting a tiny metalmesh tube against the vessel walls afterangioplasty to serve as a scaffold that

maintains vessel patency once thelumen has been expanded. “Whileendarterectomy is still considered thegold standard for acceptable surgicalcandidates,” explained Dr. Brisman,“stenting is advised for patients unableto undergo the more invasive surgicalprocedure. I perform endarterectomyfor standard-risk patients and prefer tostent high-risk patients.”

“High risk” in such cases, is based onthe findings of the landmark 2004Stenting and Angioplasty withProtection in Patients at High Risk forEndarterectomy (SAPPHIRE) Trial, arandomized comparison of endarterec-tomy with stenting, which defined“high risk” as including age >80, thepresence of severe cardiac or pul-monary disease, contralateral carotid

occlusion, hard-to-access occlusion,previous radiation therapy, radical necksurgery or endarterectomy withrestenosis.

The findings of the SAPPHIRE Trial —which concluded that endarterectomyand stenting are equally safe and effective — were underscored by theconclusions of the recently published(2010) Carotid RevascularizationEndarterectomy versus Stenting Trial(CREST), which showed similar netoutcomes between the two approaches.“Now we have two reliable and durableways to treat carotid artery disease,”

commented Dr. Brisman, who is one offewer than 100 American neurosur-geons with advanced training in bothendarterectomy and carotid stenting,and has clinical experience to provideexpert perioperative care for suchpatients.

According to Dr. Brisman, SL wasclearly a high-risk patient. An MRI andangiogram revealed a severely occlud-ed carotid artery with the area ofstenosis located too high to permit theuse of endarterectomy. What’s more,she had serious co-morbidities, includ-ing coronary and peripheral artery dis-ease. “All we could do after she wasadmitted to the NeuroICU was wait tosee if the occlusion would reopen on itsown sufficiently to allow us to inter-vene,” he said.

After a week of medical therapy andclose monitoring, a second angiogramwas performed, revealing that whileSL’s carotid artery remained severelystenotic, it was no longer completelyoccluded. In order to prevent furtherischemic damage, Dr. Brisman recom-mended stenting.

Working with a team of special-proce-dure technologists and nurses withadvanced training in endovascularcarotid procedures, he inserted acatheter into the femoral artery througha small puncture in the groin. Using X-ray guidance, he threaded the catheterthrough the aorta into the carotid artery,and after performing a balloon angio-plasty at the site of stenosis, implanted astent, widening the opening and sup-porting the arterial wall.

According to Dr. Brisman’s partner,John Pile-Spellman, MD, a leadingendovascular neuroradiologistrenowned for his skill in carotid stent-ing, “Balloon angioplasty with stentinghas gained wider acceptance in themedical community over the last severalyears, becoming a more appealingoption for many patients.”

For SL, it was a valuable option. Severaldays after her stent was implanted, shewas discharged from the Hospital forrehabilitation, eventually returninghome with manageable neurologicaldeficits affecting her left arm. Herspeech was markedly improved, and herability to swallow was completelyrestored.

“At Winthrop, we have the skill andexperience to perform both endarterec-tomy and carotid stenting,” said Dr.Brisman. “It affords us great flexibility,and provides stroke patients with themost appropriate, timely, safe and effec-tive treatment.”


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The diagnostic capability of magnetic resonance imaging (MRI) — which employs a strongmagnetic field and radio waves to create detailed anatomic images of internal body struc-tures, organs and soft tissues — has evolved to elucidate the location of functional brain

regions that are responsible for specific cognitive functions. This process — functional MRI (fMRI)— highlights and produces exquisite, high-resolution images of cortical areas as they change withthe patient’s performance of specific tasks.

At Winthrop-University Hospital,fMRI technology, which measuresand maps metabolic and hemody-namic changes that occur in thebrain at rest and during activity, isfostering insights into the brain’sinner workings, demonstrating that basic and complex mental actsand processes have specific neuralcorrelates.

With the growing clinical andinvestigative use of this technology,clinicians and scientists are uncovering an ever-growing inventory of neurological secrets thatreveal how a normal, diseased or injured brain performs. fMRI can show the visual and motor cor-tices’ processing areas and the sections of the brain responsible for expressive and receptive lan-guage. Especially significant is the technology’s ability to examine how brain function is altered bycertain neurological conditions — such as tumors, epilepsy, vascular abnormalities, trauma ordegenerative diseases — and in some cases how it responds to specific treatments.


“Functional MRI presents us with a widening rangeof opportunities to improve our understanding ofbrain organization. We can assess neurosurgicalrisk, and neurosurgical procedures can be plannedwith an eye towards increased patient safety.” Gad Klein, PhD

fMRI Illuminates Blood Flow, Reducing Risk of Functional Impairment during Brain Surgery

Continued on pg. 12

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fMRI Illuminates Blood Flow... Continued

The fMRI Process

During the fMRI imaging process, thepatient is asked to perform a particularcognitive or motor task. Each taskprompts neural activity leading toincreased cerebral perfusion — andthus oxygen consumption — in the area of the brain responsible for theundertaking.

The increased neural activity and hemo-dynamic responses lead to local changesin the relative concentration of oxyhe-moglobin and deoxyhemoglobin, which— due to their different magnetic prop-erties — can be detected by the MRIscanner. This change in the ratio of oxyhemoglobin to deoxyhemoglobin isknown as the blood-oxygen-level-dependent (BOLD) response. The acti-vated areas, which are highlighted onlow-resolution images, are overlayedonto higher-resolution traditional MRIimages, and with specially designed sta-tistical analyses, specific cortical areasare linked to specific tasks.

“Functional MRI presents us with awidening range of opportunities toimprove our understanding of brainorganization,” said neuropsychologistGad Klein, PhD. “In addition to beingable to measure neural activity, we can also assess neurosurgical risk, andneurosurgical procedures can beplanned with an eye towards increasedpatient safety.”

The assessment of risk — whichdepends to a great extent upon theaccurate delineation between the struc-tural and functional aspects of the brain— is critical to planning successful neu-rosurgery. “Before a brain tumor,epilepsy focus or vascular abnormalityin proximity to eloquent cortex can betreated, we must differentiate abnormaltissue from the critical functional areasresponsible for cognitive functions suchas language and movement,” explainedDr. Klein.

“For example, when preparing for braintumor surgery, fMRI brain mapping isparticularly important. Since tumors caninfiltrate functional brain tissue and canalso shift the tissue away from its usualanatomic location, it’s crucial to identifythe area responsible for language ormotor function pre-operatively.

“Additionally, for drug-refractoryepilepsy patients, who may benefit fromresective surgery, fMRI can sometimesreveal atypical language representationin the brain. This can help us predictwhether the patient will be at risk for alanguage deficit post-operatively.”

Potential roles for fMRI include:• Pain management by identifying cor-

tical areas that are modified by painreduction following therapy

• Increasing understanding of thephysiological bases for neurologicaldysfunction

• Broadening insight into the physio-logical basis for cognition and per-ception

In addition to clinical applications, Dr.Klein and neurologist Alan Ettinger,MD, who specializes in epilepsy, areconsidering utilizing fMRI as part of a

research study of depression in epilepsypatients — a condition affecting morethan 33 percent of adults and over 25percent of children with epilepsy.

“Functional brain imagery with fMRI isallowing us to delve into ever-deeperneurological areas that have, in the past,been beyond the reach of neuroscience,”said Dr. Klein.


Case Study

A 49-year-old, right-handed male, who had a previously resected left parasagittal/falcine lesion, subsequently developed persistent seizures that were failing best medical management. Imaging revealed new tumor growth in the left frontal lobe that extended posteriorly to the motor strip and was in proximity to language areas,including Broca’s area. It was determined that intracranial electrodes should beplaced to better determine the focus of his seizure onsets and to map out language,as well as motor function prior to any future procedure. Pre-surgical fMRI was per-formed for both language and motor tasks to help delineate these functional regionsbefore electrode placement. The fMRI process clearly revealed activation of primarymotor cortex, as well as expressive language sites in the frontal lobe. Relayed to theneurosurgeon, this information was used to help guide intracranial electrode place-ments and resulted in the need for fewer electrodes, reducing patient morbidity.Additionally, it allowed for tailored, and therefore time-shortened, electrocorticalstimulation mapping, which reduced the patient’s discomfort and stress.

3-D reconstruction of the brain withgreen area representing expressive language function and red outline representing approximate area of tumor.Language function mapped inferior totumor margin.

3-D reconstruction of the brain withgreen area representing motor cortex andred outline representing approximatearea of tumor. Motor function mappedposterior to tumor margin.

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Michael H. Brisman, MDChief, Division of NeurosurgeryCo-Director, Institute forNeurosciences516.255.9031

Dr. MichaelBrisman special-izes in stereotac-tic surgery andradiosurgery forbrain tumorsand trigeminalneuralgia. He isBoard Certified

by the American Board of Neuro-logical Surgeons and is a Fellow ofthe American College of Surgeons.His post-graduate trainingincludes a neurosurgical residencyand surgical internship at TheMount Sinai Medical Center inNew York, where he was ChiefResident. He received his medicaldegree from Columbia University’sCollege of Physicians and Surg-eons. Dr. Brisman has publishednumerous articles in professionaljournals. He is also on the Boardof Directors of the New York StateNeurosurgical Society and theNassau County Medical Society.

Malcolm H. Gottesman, MDChief, Division of NeurologyCo-Director, Institute forNeurosciencesDirector, MS Treatment Program516.663.4525

Dr. MalcolmGottesman spe-cializes in thetreatment ofmultiple sclero-sis (MS), and isthe founder ofWinthrop’s MSTreatment

Program. The program conductsoriginal clinical research and participates in state-of-the-artclinical trials. Dr. Gottesman wasinstrumental in the establishmentof the Stroke Program andNeuroscience Intensive Care Unitat Winthrop. He is Board Certifiedin Psychiatry and Neurology. Hispost-graduate training includes aresidency in neurology at LongIsland Jewish Medical Center,where he was Chief Resident. Healso completed an internship andresidency in psychiatry at BostonUniversity Medical Center. Dr.Gottesman received his medicaldegree in an accelerated BS-MRprogram jointly sponsored byRensselaer Polytechnic Instituteand Albany Medical College. Hehas published numerous articles in professional journals and presentsat national and international con-ferences. Dr. Gottesman receivedan MS Leadership award from theLong Island MS Society.

Marc Agulnick, MDChief, Division of Orthopaedic Spine Surgery516.739.9270

Dr. MarcAgulnick specializes in thetreatment ofspinal deformi-ties using the lat-est spine surgerytechniques andtechnology. He is

Board Certified in OrthopaedicSurgery. His post-graduate train-ing includes a Fellowship in Adultand Pediatric Spine Surgery atBeth Israel Spine Institute in NewYork. He completed a residency inorthopaedic surgery and aninternship in general surgery atSUNY Stony Brook. Dr. Agulnickreceived his medical degree fromthe University of Medicine andDentistry of New Jersey, where hewas elected to the Alpha OmegaAlpha Honor Medical Society. Hehas published numerous articles inprofessional journals, and writtenbook chapters on spinal injuriesand spine surgery.

Jonathan L. Brisman, MD Director, Cerebrovascular &Endovascular Neurosurgery516.255.9031

Dr. JonathanBrisman special-izes in cebro-vascular andendovascular surgery. As one of fewer than 100 neurosurgeons

nationwide with dual training inmicroneurosurgery and endovas-cular techniques (and the first onLong Island), he is skilled inaneurysm clipping and endovascu-lar coiling for brain aneurysms, aswell as in advanced procedures totreat brain arteriovenous malfor-mations (AVM), carotid stenosisand acute stroke. His post-gradu-ate training includes anInterventional NeuroradiologyFellowship at Roosevelt Hospital inNew York and a MicrovascularNeurosurgical Fellowship atSwedish Hospital in Seattle. Hecompleted a neurosurgical resi-dency and surgical internship atMassachusetts General Hospital,where he was Chief NeurosurgeryResident. Dr. Brisman received hismedical degree from ColumbiaUniversity’s College of Physiciansand Surgeons, and has publishednumerous articles in peer-reviewed journals, including New England Journal of Medicineand Lancet.

Benjamin R. Cohen, MDNeurosurgeon516.255.9031

Dr. BenjaminCohen is a Board CertifiedNeurosurgeonspecializing inspinal surgery.His practiceincludes revisionspine surgery,

adult scoliosis and the treatmentof spinal infection and metastasis.Dr. Cohen has a special interest inminimally invasive procedures,including kyphoplasty, X-STOP™and microdiscectomy, as well as surgery for spinal tumors. Hispost-graduate training includes aFellowship in Complex SpinalSurgery at the University ofAlabama, as well as a neuro-surgical residency and generalsurgery internship at the AlbanyMedical Center. Dr. Cohen earnedhis medical degree from TheChicago Medical School, where hewas elected to the Alpha OmegaAlpha Honor Medical Society. Hehas authored and co-authorednumerous articles in professionaljournals.

Gad E. Klein, PhDNeuropsychologist516.255.9031

Dr. Gad Kleinspecializes in thecognitive aspectsof neurologicaldisorders, in-cluding epilepsyand movementdisorders, suchas Parkinson’s

disease, as well as brain tumorsand dementia. Dr. Klein is also anexpert in advanced neuroimagingtechniques such as functional MRI(fMRI), as well as the Wada testand electrocortical stimulationmapping. His post-graduate train-ing includes a postdoctoralFellowship at the LIJ EpilepsyCenter, focusing on the neuropsy-chological aspects of epilepsy andfunctional neurosurgery. He alsoreceived advanced training infunctional neuroimaging at theMartinos Center for BiomedicalImaging at Massachusetts GeneralHospital in Boston. Dr. Klein com-pleted an internship in clinicalneuropsychology at the NorthShore-LIJ Health System andreceived his doctorate in neu-ropsychology from the CUNYGraduate Center. He has pub-lished numerous articles in peer-reviewed journals.

John Pile-Spellman, MDEndovascular Neuroradiologist516.255.9031

Dr. John Pile-Spellman is aninternationallyknown endo-vascular neuro-radiologist, specializing in the diagnosis,management and

treatment of cerebral aneurysms,strokes, tumors and vascular mal-formations. Dr. Pile-Spellman hasmany years of experience in devel-oping high impact, clinically rele-vant imaging and treatment para-digms. His post-graduate trainingincludes Fellowships in Neuroradi-ology at Massachusetts GeneralHospital and in InterventionalNeuroradiology at New YorkUniversity Medical Center; he wasalso a visiting Fellow in Endovas-cular Neurosurgery at the KievNeurosurgical Institute, Kiev,Ukraine. Dr. Pile-Spellman complet-ed a residency in diagnostic radiol-ogy at Massachusetts GeneralHospital in Boston, and earned hismedical degree from TuftsUniversity School of Medicine inBoston. Prior to joining Winthrop,he was an attending radiologist andDirector of Academic Intervention-al Neuroradiology at New YorkPresbyterian Hospital. He was alsoVice Chair of Research and Directorof Interventional MRI at ColumbiaUniversity Medical Center. He haspublished more than 150 articles inpeer-reviewed journals.

Elzbieta Wirkowski, MD Director, Cerebrovascular Disorders& Stroke ProgramCo-Director, Neuroscience Intensive Care Unit516.663.4525

Dr. ElzbietaWirkowski spe-cializes in cerebrovascularneurology andneurocriticalcare. She isBoard Certifiedin Neurology,

Vascular Neurology and Neuro-critical Care. Her post-graduatetraining includes a Cerebrovas-cular Fellowship at Long IslandJewish Medical Center, where sheparticipated in multiple researchtrials dealing with neurocriticaland cerebrovascular problems. Shealso completed a residency andinternship in neurology at LIJ. Dr.Wirkowski earned her medicaldegree with honors from WarsawUniversity in Poland, where shealso studied molecular biology. Sheis the author of many articles pub-lished in professional journals.

Contributing Surgeons & Physicians

Care without compromise.

SM

Non-Profit Org.US PostageP A I D

Permit #13Mineola, NY

Institute for Neurosciences259 First Street, Mineola, NY 115011-866-NEURO-RX

www.winthrop.org

Winthrop-University Hospital is a 591-bed teaching hospital located on LongIsland in Mineola, NY. A major regionalhealthcare resource, the Hospital has been a leading healthcare provider formore than a century, dedicated to theintegrity, dignity and well-being of every individual. Winthrop offers a fullcomplement of advanced inpatient andoutpatient services with a deep commit-ment to medical education and research.

Physicians and surgeons in Winthrop’sInstitute for Neurosciences are pioneer-ing the use of technologically advancedapproaches for the diagnosis and treatment of diseases of the brain andspine, including computerized imagingsystems, state-of-the-art surgical inter-ventions and the latest generation of medication therapies.

The Institute’s interdisciplinary teamincludes neurologists; neurosurgeons; neurointensivists; pediatric neurologistsand neurosurgeons; neuroradiologists;vascular surgeons; orthopaedic spine surgeons; neuro-oncologists; neuro-pathologists; neurophysiologists; and specially trained nurse practitioners,physician assistants and nurses. Special-ized physical and occupational therapy,social work and other supportive servicesare also key components of the Institute.The Institute’s experts are up to date onthe latest developments in neuroscienceand help pave the way for new discoveriesthrough participation in clinical researchtrials, which enable them to providepatients with access to tomorrow’s mostpromising therapies.

Winthrop-University Hospital’s Institute for Neurosciences

Programs & Services Offered by the Institute for NeurosciencesNeuroscience Intensive Care UnitThe 14-bed acute care NeuroICU is reserved for patients with serious, complex neurological issues.The focus is on providing continuous monitoring and instantaneous results of critical values, allowing the expert staff, experienced in using advanced technology and providing neurocritical care,to employ aggressive interventions that treat neurological deterioration.

Neurology

Neurosurgery

Neuroradiology

Pediatric Neurology

For more information, call the Institute for Neurosciences at 1-866-NEURO-RX.

Epilepsy ProgramMovement Disorders ProgramMultiple Sclerosis Treatment Center

Neuromuscular/Peripheral Neuropathy ProgramNYS Designated Stroke Center with AHA and ASA “Gold” Level Status

Aneurysm TreatmentCT Perfusion ScanningInterventional NeuroradiologyNeuroangiography

Neuro Diagnostic LabPositron Emission Tomography (PET) ScanningUltrafast Computed Tomography (CT) & Magnetic Resonance Imaging (MRI)

Attention Disorders & Learning Disabilities Treatment

Craniosynostosis SurgeryBrain Tumor TreatmentEvaluation & Treatment of Children with Headaches

Evaluation & Treatment of Neurological Disorders

Myelomeningocele SurgeryNeuro Developmental Screening & Early Intervention

Pediatric Intensive Care UnitSeizure Disorders ManagementTreatment for Hydrocephalus & Other CNS Anomalies

3D Spinal Navigation Aneurysm Coiling & ClippingDisc ReplacementBrain Aneurysm ProgramBrain Tumor ProgramBrain & Skull Base SurgeryCarotid Stenting & EndarterectomyCerebrovascular & Endovascular SurgeryChiari Decompression SurgeryComplex & Minimally Invasive Spinal Surgeries Complex Cranial Surgery Computer-Assisted Resection of Brain TumorsCyberKnife® RadiosurgeryEndoscopic Pituitary SurgeryEpilepsy Surgery ProgramFacial Pain/Trigeminal Neuralgia ProgramImage-Guided Spine SurgeryKyphoplasty

Merci®/Penumbra Clot Retrieval Microdiscectomy Microneurosurgical Techniques Microvascular Decompression for Trigeminal Neuralgia

Neuro-oncologyNeuropathologyParkinson’s Disease Surgery ProgramPosterior Lumbar Interbody Fusion Prestige® Cervical Disc Programmable Shunt PlacementSpinal StimulationSpine Revision SurgeryStereotactic Radiosurgery Traumatic Brain & Spine Injury Diagnosis & Treatment

X-Stop® for Spinal Stenosis

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