Neurosurgery Update - Spring 2012

Low back pain Neck pain Pinched nerve syndromes Concussion Return to play after neurological injury Severe head injuries Hematomas Intracranial hemorrhages Aneurysmal rupture Spina bifida Chiari malformation Tethered spinal cord Spinal deformity Scoliosis Common brain tumors Seizures Stroke management Carpal tunnel syndrome/ulnar neuropathy Brachial plexus injuries

Hydrocephalus Ventricular-peritoneal shunts Normal pressure hydrocephalus Dementias Sports injuries Ethics in the neurosciences CyberKnife stereotactic radiation Pituitary tumors Neuro critical care Parkinson’s disease Epilepsy care and surgery Brain death Spinal fractures Breaking bad news Implantable pain devices Interesting cases Care of neurologic patients in the primary care office And many more...

Volume1- January2012

update

NEUR SURGERY Carilion Clinic P.O. Box 13727 Roanoke, VA 24036

Carilion Clinic’s neurosurgery team offers a wide selection of neuroscience talks that we are happy to bring to your practice, group, hospital, service club, community gathering, or medical society. We are delighted to give these sessions to an audience of one or several hundred. Talks can be tailored in length and can even be paired with a lunch or dinner. Some common topics are listed to the right, but we are happy to cover virtually any neuroscience-related subject. To arrange a talk, please call us at 540-526-1200.

Topics include:

©2012 Carilion Clinic Strategic Development J706 2/12/GG

Neuroscience Talks

NEUR SURGERY update

Issue 1 - Spring 2012 Volume 1- January 2012

Carilion Clinic’s Neurosurgery Team

Back row: Resident Chine Logan, D.O.; Resident Eric Marvin, D.O.; Lauren Goater, PA-C; Resident Michael Sawvel, D.O.; Portia Tomlinson, PA-C; Resident Jordan Synkowski, D.O.; Amy Osterman, PA-C; Resident Jonathon McNeal, D.O.; Resident Aaron Danison, D.O. Front row: Rod Dunker, M.D.; Nicholas Qandah, D.O.; Lisa Apfel, M.D.; John Fraser, M.D.; Gary Simonds, M.D.; Zev Elias, M.D.

Spine Case of the

Month A 57-year-old man with a remote history of quiescent thyroid cancer was experiencing progressive, severe back pain and profound leg weakness. Imaging disclosed pathologic fracture of L2, abnormal angulation of the thoracolumbar spine, and severe spinal cord compression. Radiation therapy, chemotherapy, and/or kyphoplasty would not be sufficient in treating this patient because of the acute and progressive collapse of his spinal column. Several other medical centers told the patient that nothing could be done surgically.

With intraoperative monitoring of sensory and motor evoked potentials, Carilion Clinic’s neurosurgery team removed the L2 vertebra and tumor, and replaced the vertebral body with an expandable titanium cage. Once the spinal deformity was corrected, the construct was locked in place with pedicle screws and titanium rods (see intraoperative image). The patient experienced a gratifying response with improved lower extremity function and almost total elimination of his pain. He is home and is currently undergoing adjuvant therapy.

Visit us on the web: Carilionclinic.org/neurosurgery • 800-422-8482

INSIDE THIS ISSUE: Page 2: Diagnosis and Treatment of Cerebral Aneurysms Page 2: Pineal Tumor Surgery Page 3: Neurosurgery Team welcomes Nicholas Qandah, D.O.

1

Diagnosis and Treatment of Ruptured Cerebral Aneurysms

Three-dimensional arteriogram of a large complicated carotid aneurysm flanked by two smaller ones, recently obliterated surgically by Carilion Clinic’s neurosurgery team.

Rupture of a cerebral aneurysm is a devastating and often lethal event.

Recognition of signs and symptoms, and early transfer to a neuro-vascular center, is critical in the management of the disease. Fifty percent of those who sustain a rupture will die. Twenty percent of survivors will sustain

another hemorrhage within two weeks of the original one.

Generally, the presentation of an aneurysmal rupture is apoplectic.

Patients experience the sudden onset of the most severe headache imaginable, often referred to as a “thunder clap” headache. Many people pass out or rapidly drop into coma. Others may be confused or agitated. Patients who remain awake often complain of severe headache and neck ache, nausea, near-syncope, and photophobia.

Seldom are the symptoms subtle.

A computed tomography (CT) scan, not a magnetic resonance imaging (MRI), should be obtained immediately. If subarachnoid blood is detected, particularly at the base of the brain or between the hemispheres, or in the sylvian fissure, there has been an aneurysmal rupture until proven otherwise. Sometimes hemorrhages will blow out into the low frontal lobes or temporal lobes.

If a CT scan is not positive, strong consideration should be given to an LP. The red cell count in an LP is less

reliable, due to traumatic taps, than is the presence of xanthochromia (yellow tint to the fluid), which must be tested for.

For all patients with confirmed or suspected aneurysmal rupture, immediate transfer to a neuro-vascular center is imperative. While awaiting transfer, the patients should be given only light analgesics (no over-sedation). Those who are obtunded should be intubated. Blood pressure should be lowered to systolics of less than 160. Anticonvulsants, such as Dilantin or Keppra, can be initiated.

At Carilion Clinic, the stroke team involves the close integration of neurosurgeons, interventional neuroradiologists, critical care specialists, rehabilitation specialists, and neurologists in the care of these very sick patients.

If you suspect a patient has a ruptured aneurysm, please get them to the closest emergency department as quickly as possible. A team of experts will take over the care from there.

Brain Surgery Case of the Month A male patient (see adjacent image) presented with progressive headaches and cognitive difficulties.

MRI disclosed a very large pineal gland mass with associated hydrocephalus. Pineal tumors are rare and are notoriously dangerous to remove, and often are very malignant. The tumor was too large to remove through a more standard infratentorial, supracerebellar approach, or via an endoscope. Rather, after placement of a ventricular drainage catheter for control of hydro2

cephalus, the tumor was approached by working under the occipital lobe and via opening of the tentorium cerebelli. State-of-the-art stereotactic guidance and microscopic techniques were employed to attack the tumor. A gross total resection was affected. Final pathology was consistent with a “pineocytoma,” which is a relatively benign tumor. The patient is making a very good neurologic recovery with mild eye movement difficulties (residual Parinaud’s phenomenon). He requires no adjuc-

tive therapy. This is the second of these extremely rare tumors to be successfully removed at Carilion Clinic in February.

Sagittal MRI with contrast demonstrating a large pineal region mass.

The Neurosurgery Team Welcomes Nicholas Qandah, D.O.

Come Join Us We encourage any and all

Nicholas Qandah, D.O. working with neurosurgery residents in simulation Neurosurgery was delighted to welcome back graduate Nick Qandah, D.O., in fall 2011. Dr. Qandah trained in the Carilion Clinic Neurosurgery Residency Program and then went off to fellowship training in minimally invasive and complex deformity spine surgery at the University of Washington-Harbor View program in Seattle. Dr. Qandah was an outstanding resident, perennially the national top scorer in the neurosurgery in-service examinations. He is board certified and is armed with a wealth of top-end skills in the management of

the most complex spinal disorders, from degenerative changes to trauma and infection to neoplastic disease. He is skilled with all facets of spinal column surgery, as well as surgery on the spinal nerves and spinal cord themselves. Dr. Qandah is also a proficient and highly skilled brain surgeon with special interests in brain tumors and aneurysm surgery.

Patients find Dr. Qandah to be extremely empathetic, caring, and very easy to talk to. Dr. Qandah can be reached directly at 540-526-1200.

Neurosurgery Residency Going Strong The Carilion Clinic Neurosurgery residency program is now in its fifth year and just underwent a recertification site visit. This six-year program has met with outstanding success. Top medical students from across the country compete for the single yearly spot. The resident team has developed into a force to be reckoned with, within the hospital and nationally. They have boasted top scores in the yearly national inservice exam and have populated national meetings with dozens of presentations.

They are actively integrating with instructors at the Virginia Tech Carilion School of Medicine and are engaging with researchers at The Edward Via College of Osteopathic Medicine. We truly hope and encourage you to meet our residents and assist in their education.

members of the medical community to come to our campus and spend time with the neurosurgery team. On any given day, several operations can be observed. On Tuesday afternoons, you can participate in academic sessions with our residents, attending neurosurgeons, neuroradiologists, pathologists, traumatologists, critical care specialists, anatomists, and other providers. The experience includes traditional “walk rounds” filled with fascinating cases, exceptional neurologic exams, stunning radiographic findings, and a lot of open discourse and hearty discussions.

You are always welcome!

Furthermore, if you know of interested medical students, college students, or high school students, we routinely support their involvement in our surgeries, clinics, and rounds. If this sort of activity interests you, please call us at 540-526-1200.

3