Advancing Cerebrovascular Care: NSPC Specialists Elevate the Treatment of Rare Conditions

By Katy Mena-Berkley
Wednesday, November 17, 2021

Neuroendovascular specialists at NSPC Brain & Spine Surgery are dedicated to the delivery of tailored care for rare cerebrovascular conditions, including arteriovenous malformations in the brain, giant intracranial aneurysms and Moyamoya disease.

In the 1970s, a few forward-thinking physicians in the United States began to develop neuroendovascular, catheter-based treatment options to manage cerebrovascular conditions. In so doing, they engineered sophisticated new methods of disease management that NSPC Brain & Spine Surgery specialists embrace today.

John Pile-Spellman, MD, FACR, interventional neuroradiologist at NSPC Brain & Spine Surgery, is one of the innovative clinicians responsible for the development of the catheter-based treatments. His work continues to stand the test of time, offering hope and effective solutions to patients while also inspiring the next generation of clinicians to explore neuroendovascular, catheter-based treatment methods.

“Dr. Pile-Spellman was one of the pioneers of that whole endeavor, and then there were about three or four neurosurgeons in the country who went for the training. Then those three trained the next generation, and I was part of that next generation,” says Jonathan L. Brisman, MD, FACS, attending neurosurgeon, cerebrovascular and endovascular specialist at NSPC Brain & Spine Surgery. “Now there may be 200 neurosurgeons who have this training, which is invaluable to the patients we serve. Having the ability to manage a disease entity using all of the operations at your disposal — that is a privilege that benefits our patients who are living with rare cerebrovascular conditions.”

Sundeep Mangla, MD, interventional neuroradiologist at NSPC, exams a patient as part of an initial consult.

Addressing Brain AVMs

While they may go undetected for a significant period of time, arteriovenous malformations (AVMs) in the brain can cause catastrophic and even fatal consequences, underscoring the need for the advanced diagnostic methods offered at NSPC Brain & Spine Surgery.

“Patients with AVMs often present with seizures or headaches and, less often, with bleeds in the head,” Dr. Pile-Spellman says. “Neurologists, family practitioners and radiologists may be the first to detect changes and make referrals to our team at NSPC Brain & Spine Surgery. We work very closely with referring physicians to ensure that there is excellent continuity of care in all aspects for each patient.”

Jae Choi, MD, cerebrovascular neurologist at NSPC, and John Pile-Spellman, MD, FACR, interventional neuroradiologist at NSPC, discuss a plan of care for a patient with an unruptured brain aneurysm.

To investigate suspected brain AVMs, specialists at NSPC Brain & Spine Surgery can use an array of diagnostic tools, including CT scan, MRA and MRI.

“When we are able to determine the presence and architecture of the brain AVM, which includes the arteries that feed it, the arteries that are in passage, and the actual nidus and the draining veins, as well as issues regarding any associated aneurysms, we can make a treatment plan,” Dr. Pile-Spellman says. “This may include embolization as adjuvant or definitive therapy, as well as direct surgery with a craniotomy or stereotactic radiosurgery.”

Sundeep Mangla, MD, interventional neuroradiologist at NSPC, notes that many procedures the neurointerventionalists perform routinely at NSPC would be considered high-risk interventions at other facilities.

“We perform world-class, cutting-edge procedures for brain AVMs, including embolizing or blocking off abnormal blood vessels prior to surgery,” Dr. Mangla says. “We can also use radiosurgery in certain challenging cases to help treat patients with minimal risk of functional, neurologic problems or mortality. In situations where you don’t have a team with hundreds of years of combined experience or combined patient cases numbering into the thousands, the risks of treatment can be significantly higher.”

Patients with AVMs tend to be younger, Dr. Pile-Spellman notes, and they typically experience excellent outcomes. In many cases, the AVM does not usually occur directly within brain tissue, but immediately adjacent to it. The range of treatments available depends on the function of the nearby brain structures and how safely interventions can reasonably be performed without damaging the surrounding area.

Neurosurgeon John Grant, MD, and Dr. Choi are key members of the NSPC neurovascular team.

Options for Giant Intracranial Aneurysms

Developing personalized management plans is especially important in caring for patients with giant intracranial aneurysm (GA), a rare form of aneurysm greater than 25 millimeters in diameter. Specifically, determining the presence and size of the suspected aneurysm is a first step that the NSPC team takes before designing a treatment plan that addresses both the emergent situation and the patient’s long-term outcomes.

Once the diagnosis of GA has been established and delineated by means of MRA or CT angiography, physicians may attempt to preserve the parent vessel or to occlude it. Parent artery occlusion may be performed via balloon or coil embolization; other techniques are also available. Various stenting and balloon procedures may be utilized when parent vessel occlusion is not feasible.

In the minimally invasive coil embolization procedure, a neurointerventionalist inserts a catheter close to the aneurysm site, then threads a stent into the aneurysm, reinforcing the artery and alleviating pressure. Alternatively, surgically clipping the involved artery may be used to isolate the aneurysm from blood flow, alleviating the risk of a rupture.

All these procedures are technically quite demanding — which makes the expertise and experience of NSPC’s neurointerventionalists particularly essential.

While a ruptured GA needs immediate acute intervention, in other situations the clinician consults with colleagues and assesses the patient’s risk and preferences.

“There’s a spectrum to prognosis with rare cerebrovascular conditions,” Dr. Brisman says. “A GA could have a 5% to 10% chance of causing a fatal rupture on a yearly basis, while other disease may have only a 5% chance of stroke over 10 years. It depends on the extent of the disease.”

Patients also need to weigh in, he observes. Some patients will not pursue any procedure that carries a risk of disability, even if it means living with a heightened annual chance of death. Others want to prolong time with family and loved ones, even at the slight risk of disability that may accompany surgery.

“I usually take into account four factors,” Dr. Brisman says. “The most predictive factor in whether or not I’m going to offer an operation is the age and health of the patient.”

Next comes an assessment of the lesion itself. A GA of 4 centimeters, for instance, carries far greater risk than a 2.5-centimeter one.

“The third factor is my personal assessment of how easily I can repair the lesion,” Dr. Brisman continues. “Each lesion is distinct in terms of how easy or difficult it would be for me to repair it with a low complication rate.”

Finally, he returns to the patient’s willingness to take on certain kinds of risk.

“When you offer a patient an operation scheduled for next Tuesday that might have a 4% risk of a serious complication in exchange for elimination of a 15% to 20% risk of a vascular lesion causing a serious rupture over the next 22 years of their life, that’s a personal decision,” he says. “That’s not a decision a physician can make alone.”

“At NSPC, we treat all neurovascular diseases, rare and common. We aim to provide the least invasive solutions for these lesions when feasible; however, we also have a full spectrum of operative resources to offer. Our complication rate is very low. We also have a unique availability. We see patients much faster than they can typically make an appointment elsewhere — usually within 24 hours.”
Jonathan L. Brisman, MD, FACS, attending neurosurgeon, cerebrovascular and endovascular specialist, NSPC Brain & Spine Surgery

Jonathan L. Brisman, MD, FACS

Board-certified in neurosurgery, Jonathan L. Brisman, MD, FACS, attending neurosurgeon, cerebrovascular and endovascular specialist at NSPC, specializes in the treatment of cerebrovascular and endovascular conditions. He is one of about 200 neurosurgeons in the United States trained to perform endovascular and micro-neurosurgical techniques.

After earning his undergraduate degree, magna cum laude, from Harvard University, Dr. Brisman went on to receive his medical degree from Columbia College of Physicians and Surgeons. He completed his internship in general surgery and his residency in neurosurgery at Massachusetts General Hospital, where he also served as Chief Neurosurgical Resident. Dr. Brisman completed his interventional neuroradiology fellowship at Roosevelt Hospital in New York City, as well as a microvascular neurosurgical fellowship at Swedish Hospital in Seattle.

Board-certified in neurosurgery, Dr. Brisman specializes in the treatment of cerebrovascular and endovascular conditions and is one of roughly 200 neurosurgeons in the United States trained to perform endovascular and micro-neurosurgical techniques. Dr. Brisman has authored numerous articles published in peer-reviewed neurosurgery journals. He has also written extensively about arteriovenous malformation, carotid artery disease, intracranial aneurysms, subarachnoid hemorrhage and vasospasm.

Conservative Management in Appropriate Cases

After taking careful imaging of an AVM or GA, assessing it clinically and consulting with the patient, NSPC physicians may determine that the risks of a procedure outweigh the benefits, or that management of potential complications down the road should govern the approach to a particular case. In fact, as the field has advanced, NSPC physicians are now in a better place to assess each lesion with a keen eye to whether intervention will lead to better results than the natural outcomes of the defect, Dr. Brisman explains.

“Our understanding of how best to treat rare cerebrovascular conditions has evolved,” he says. “We’ve learned that some rare diseases are highly dangerous, while some are more benign than we thought. The question is whether we are performing better than the natural history. As a result, while some problems obviously mandate surgical procedures, we’ve often been treating certain lesions more conservatively.”

For this reason, NSPC specialists created the surveillance program known as CUBA — the Center for Unruptured Brain Aneurysms. By carefully selecting patients for this program, NSPC providers take advantage of the fact that only about 4% or fewer patients with an unruptured brain aneurysm experience a brain bleed annually and that many can be successfully managed with medication alone. Jae Choi, MD, a dual fellowship trained cerebrovascular neurologist, has acted as the Medical Director of CUBA since joining NSPC in 2016.

Dr. Choi notes that because he and the physicians of the NSPC neurovascular team have followed “nearly 1,000 patients with unruptured brain aneurysms for an average of five years,” they are uniquely equipped to collaborate and improve the lives of many people affected with this condition.

“Patients who are not being treated need to be followed closely to avoid any effects the brain aneurysm may have on their lives, such as ongoing seizures,” Dr. Pile-Spellman says. “Or an issue may come up regarding medication, or follow-up imaging may be needed.”

By keeping track of unruptured brain aneurysm patients after they’re discharged to their home providers, NSPC physicians can also quickly locate those patients and inform them as new technologies or medications emerge that might benefit their case.

“As physicians, we recognize that we see patients who are arriving with an unknown diagnosis. The process of diagnosing their condition and providing prognosis and options can be very daunting for them. Having empathy and compassion for what people are going through is really important.”
Sundeep Mangla, MD, interventional neuroradiologist, NSPC Brain & Spine Surgery

Sundeep Mangla, MD

Dr. Mangla has performed thousands of neurovascular interventions on Long Island and in both the Bronx and Brooklyn.

Dr. Mangla earned his bachelor’s degree and medical degree through an accelerated six-year program at Northeast Ohio Universities College of Medicine, where he also completed diagnostic radiology training. Dr. Mangla then completed a fellowship in diagnostic neuroradiology radiology at the University of Southern California and fellowships in interventional neuroradiology and endovascular neurosurgery at Yale University School of Medicine and University of Iowa Hospitals and Clinics.

Board-certified in radiology with a certificate of added qualification in neuroradiology, Dr. Mangla specializes in interventional neuroradiology. He is specifically focused on furthering the diagnosis and treatment of complex cerebrovascular diseases. During his 20-year career, Dr. Mangla has performed thousands of neurovascular interventions in the region and has established stroke intervention programs in Long Island, Brooklyn and the Bronx. In addition to his extensive clinical work, Dr. Mangla has also led and participated in a robust spectrum of clinical trials and research. He has also been instrumental in the development and testing of novel biomedical diagnostics and therapeutics for the treatment of cerebrovascular disease.

Treatments for Moyamoya Disease

Moyamoya disease — a chronic condition that involves the gradual blockage of the major arteries of the brain — may present through aphasia, cognitive impairment, and movement and vision problems, as well as through TIAs and seizures.

While the patient’s neurologist may manage a patient’s Moyamoya-associated complications medically, revascularization surgery is required to either restore blood flow through the narrowed vessels or to bypass them entirely. Another member of the NSPC team of neurointerventional specialists is John Grant, MD, FACS, a board-certified neurosurgeon who specializes in treating neurovascular conditions, including Moyamoya disease.

“Children do get Moyamoya disease,” Dr. Grant says, “but the adult variety is generally felt to be an acquired lesion.”

After taking detailed imaging via cerebral angiogram, CT angiogram or single photon emission CT, Dr. Grant may use a direct extracranial-intracranial bypass procedure to revascularize the afflicted area. In this surgery, he performs a small craniotomy and then detaches an end of the superficial temporal artery from the scalp and reattaches it to the middle cerebral artery, thus diverting blood flow from the scalp to the affected portion of the brain.

Alternatively, Dr. Grant may revascularize the area indirectly by attaching the superficial temporal artery to the surface of the brain or through placing of a graft — a portion of the temporalis muscle or a small section of the peritoneum — on the surface of the brain to increase blood flow to the area.

John Pile-Spellman, MD, FACR

Dr. Pile-Spellman is internationally known for his interventional neuroradiology expertise, which includes diagnosis, management and treatment of cerebral aneurysms, stokes, tumors and vascular malformations.

Dr. Pile-Spellman earned his undergraduate degree from the University of South Dakota and his medical degree from Tufts University School of Medicine. Following medical school, Dr. Pile-Spellman remained in Boston, where he completed his residency in diagnostic radiology and fellowship in neuroradiology at Massachusetts General Hospital. Dr. Pile-Spellman also completed a fellowship in interventional neuroradiology at New York University Medical Center and was a visiting fellow in endovascular radiology at Kiev Neurosurgical Institute in Kiev, Ukraine.

Board-certified in radiology, Dr. Pile-Spellman is internationally renowned for his interventional neuroradiology expertise, which includes diagnosis, management and treatment of cerebral aneurysms, strokes, tumors and vascular malformations. He also is closely involved in the development of image-based services and is dedicated to furthering the understanding and management of neurovascular diseases and has multiple patents for endovascular treatment devices and advanced diagnostic imagery. Dr. Pile-Spellman has published in more than 160 peer-reviewed journals and has served in a reviewer capacity for multiple academic publications, including The Lancet and The New England Journal of Medicine.

Uncommon Care for Common Conditions

Neurointerventionalists at NSPC care for a full range of more common cerebrovascular conditions, including arterial stenosis, hemorrhagic and ischemic stroke, and small brain aneurysms. Even for routine conditions, NSPC physicians create individualized treatment plans.

“We want everyone to feel like they’re being cared for with a personalized approach,” Dr. Mangla says. “We tailor the care to each patient. We offer an individualized approach to each patient’s condition.”

To deepen community knowledge of both common and rare cerebrovascular conditions, NSPC is hosting a CME program targeted to almost 3,000 physicians in the Long Island community.

“These physicians receive weekly emails and case studies that essentially share the case vignettes,” Dr. Mangla says. “They learn how patients with various conditions present to a primary care doctor and what the process of evaluating them involves, as well as the challenges that inherently affect patients and their teams.”

Seen here in Lake Success, outside of one their group’s seven Long Island offices, are the key members of the NSPC interventional neurovascular team: (L–R) Dr. Brisman, Dr. Mangla, Dr. Choi, Dr. Grant and Dr. Pile-Spellman.

Managing Rare Conditions in Real Life

Even patients with rare and serious cerebrovascular conditions have lives to get back to — as Dr. Pile-Spellman notes, these patients may be younger adults. As such, strategies for community management play a key role in NSPC’s approach. Particularly for patients under continued surveillance, NSPC providers make seamless care in the community setting a priority.

“We consider ourselves as members of that comprehensive medical team,” Dr. Mangla says. “We want our referring physicians to know we consider them critical to our patients’ care as well. We feel strongly that coordination with community providers ultimately leads to successful outcomes in our patients.”

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