NEUR SURGERYupdateVolume 1 - January 2012Issue 1 - Spring 2012

Spine Caseof the

MonthA 57-year-old man with a remote history ofquiescent thyroid cancer was experiencingprogressive, severe back pain and profoundleg weakness. Imaging disclosed pathologic fracture of L2, abnormal angulationof the thoracolumbar spine, and severe spinal cord compression. Radiation ther-apy, chemotherapy, and/or kyphoplasty would not be sufficient in treating thispatient because of the acute and progressive collapse of his spinal column. Sev-eral 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 spinaldeformity was corrected, the construct was locked in place with pedicle screwsand titanium rods (see intraoperative image). The patient experienced a gratify-ing response with improved lower extremity function and almost total elimina-tion of his pain. He is home and is currently undergoing adjuvant therapy.

INSIDE THIS ISSUE:Page 2: Diagnosis and Treat-

ment of CerebralAneurysms

Page 2: Pineal Tumor Surgery

Page 3: Neurosurgery Teamwelcomes NicholasQandah, D.O.

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.

Carilion ClinicP.O. Box 13727Roanoke, VA 24036

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

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

Neuroscience TalksCarilion Clinic’s neurosurgery team offers awide selection of neuroscience talks that weare happy to bring to your practice, group,hospital, service club, community gathering,or medical society. We are delighted to givethese sessions to an audience of one or several hundred. Talks can be tailored inlength and can even be paired with a lunchor dinner. Some common topics are listed tothe right, but we are happy to cover virtuallyany neuroscience-related subject. To arrangea talk, please call us at 540-526-1200.

Low back painNeck painPinched nerve syndromesConcussionReturn to play after neurological injurySevere head injuriesHematomasIntracranial hemorrhagesAneurysmal ruptureSpina bifidaChiari malformationTethered spinal cordSpinal deformityScoliosisCommon brain tumorsSeizuresStroke managementCarpal tunnel syndrome/ulnar neuropathyBrachial plexus injuries

HydrocephalusVentricular-peritoneal shuntsNormal pressure hydrocephalusDementiasSports injuriesEthics in the neurosciencesCyberKnife stereotactic radiationPituitary tumorsNeuro critical careParkinson’s diseaseEpilepsy care and surgeryBrain deathSpinal fractures Breaking bad newsImplantable pain devicesInteresting casesCare of neurolgic patients in the primary

care officeAnd many more...

Topics include:

NEURSURGERY updateVolume 1 - January 2012

A male patient (see adjacent image)presented with progressiveheadaches and cognitive difficulties.MRI disclosed a very large pinealgland mass with associated hydro-cephalus. Pineal tumors are rare andare notoriously dangerous to remove,and often are very malignant. Thetumor was too large to removethrough a more standard infratentor-ial, supracerebellar approach, or viaan endoscope. Rather, after place-ment of a ventricular drainagecatheter for control of hydro-

cephalus, the tumor was approachedby working under the occipital lobeand via opening of the tentoriumcerebelli. State-of-the-art stereotacticguidance and microscopic tech-niques were employed to attack thetumor. A gross total resection was af-fected. Final pathology was consis-tent with a “pineocytoma,” which is arelatively benign tumor. The patientis making a very good neurologic recovery with mild eye movementdifficulties (residual Parinaud’s phenomenon). He requires no adjuc-

tive therapy. This is the second ofthese extremely rare tumors to besuccessfully removed at CarilionClinic in February.

Rupture of a cerebral aneurysm is adevastating and often lethal event.Recognition of signs and symptoms,and early transfer to a neuro-vascularcenter, is critical in the management ofthe disease. Fifty percent of those whosustain a rupture will die. Twenty per-cent of survivors will sustain

another hemorrhage within twoweeks of the original one.

Generally, the presentation of ananeurysmal rupture is apoplectic. Patients experience the sudden onsetof the most severe headache imagina-ble, often referred to as a “thunderclap” headache. Many people pass outor rapidly drop into coma. Others maybe confused or agitated. Patients whoremain awake often complain of se-vere 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 ofthe brain or between the hemispheres,or in the sylvian fissure, there has beenan aneurysmal rupture until provenotherwise. Sometimes hemorrhageswill blow out into the low frontal lobesor temporal lobes.

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

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

For all patients with confirmed orsuspected aneurysmal rupture, immediate transfer to a neuro-vascularcenter is imperative. While awaitingtransfer, the patients should be givenonly light analgesics (no over-seda-tion). Those who are obtunded shouldbe intubated. Blood pressure shouldbe lowered to systolics of less than160. Anticonvulsants, such as Dilantinor Keppra, can be initiated.

At Carilion Clinic, the stroke teaminvolves the close integration of neurosurgeons, interventional neuro-radiologists, critical care specialists, rehabilitation specialists, and neurolo-gists in the care of these very sick patients.

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

The Carilion Clinic Neurosurgeryresidency program is now in itsfifth year and just underwent a re-certification site visit. This six-yearprogram has met with outstandingsuccess. Top medical students fromacross the country compete for thesingle yearly spot. The residentteam has developed into a force to be reckoned with, within the hospitaland nationally. They have boasted top scores in the yearly national inserviceexam and have populated national meetings with dozens of presentations.They are actively integrating with instructors at the Virginia Tech CarilionSchool of Medicine and are engaging with researchers at The Edward Via College of Osteopathic Medicine. We truly hope and encourage you to meetour residents and assist in their education.

Neurosurgery was delighted to wel-come back graduate Nick Qandah, D.O., in fall 2011. Dr. Qandah trainedin the Carilion Clinic NeurosurgeryResidency Program and then wentoff to fellowship training in minimallyinvasive and complex deformityspine surgery at the University ofWashington-Harbor View program inSeattle. Dr. Qandah was an outstand-ing resident, perennially the nationaltop scorer in the neurosurgery in-ser-vice examinations. He is board certi-fied and is armed with a wealth oftop-end skills in the management of

the most complex spinal disorders,from degenerative changes totrauma and infection to neoplasticdisease. He is skilled with all facets ofspinal column surgery, as well as sur-gery on the spinal nerves and spinalcord themselves. Dr. Qandah is also aproficient and highly skilled brainsurgeon with special interests inbrain tumors and aneurysm surgery.Patients find Dr. Qandah to be ex-tremely empathetic, caring, and veryeasy to talk to. Dr. Qandah can bereached directly at 540-526-1200.

Diagnosis and Treatment of Ruptured Cerebral Aneurysms

Brain Surgery Case of the Month

The Neurosurgery Team Welcomes Nicholas Qandah, D.O.

Nicholas Qandah, D.O.working with neuro-surgery residents in simulation

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

Sagittal MRI with contrast demonstrating alarge pineal region mass.

Neurosurgery Residency Going Strong

ComeJoin UsWe encourage any and allmembers of the medical com-munity to come to our campusand spend time with the neu-rosurgery team. On any givenday, several operations can beobserved. On Tuesday after-noons, you can participate inacademic sessions with ourresidents, attending neurosur-geons, neuroradiologists,pathologists, traumatologists,critical care specialists,anatomists, and otherproviders. The experience includes traditional “walkrounds” filled with fascinatingcases, exceptional neurologicexams, stunning radiographicfindings, and a lot of open dis-course and hearty discussions.You are always welcome! Furthermore, if you know of interested medical students,college students, or highschool students, we routinelysupport their involvement inour surgeries, clinics, androunds. If this sort of activityinterests you, please call us at540-526-1200.