At Neurological Surgery, P.C., neurosurgeon subspecialists treat adults and children with brain tumors by using a blend of clinical expertise, technological sophistication, personalization and compassion.
With roots on Long Island dating back more than 60 years, NSPC has grown into one of the country’s largest neurosurgery groups, featuring six locations and more than 20 neurosurgeons. The group’s substantial size allows for subspecialization in its ranks — a benefit for patients.
“We’re more than neurosurgeons. We’re also neurosurgeon subspecialists,” says Michael Brisman, MD, FACS, neurosurgeon at NSPC and Co-Medical Director of the Long Island Gamma Knife Center at Mount Sinai South Nassau. “That’s important because we have several neurosurgeons who focus on brain tumors, which are generally rare, but our team sees a lot of them. In adults, we frequently treat meningiomas, acoustic neuromas and pituitary tumors, most of which are benign, as well as malignancies, including gliomas and brain metastases.”
A hallmark of and point of pride for NSPC is the personal attention its neurosurgeons give to patients. NSPC neurosurgeons have privileges at several Long Island hospitals, and they, rather than residents or trainees, perform every procedure for the patients in their care. Patients have around-the-clock access to their neurosurgeons, and many interactions can take place remotely (see “Telehealth Takes Off”).
“We prize quality over volume,” says Ramin Rak, MD, FAANS, neurosurgeon at NSPC, and Director of the Brain and Spine Tumor Center and Director of Brain and Spine Trauma at Mount Sinai South Nassau. “We provide hands-on, one-on-one care to patients, and we treat them like our own family members. Our goal isn’t to operate on every patient, but to render individualized care that is most appropriate for each person. For me, that means treating patients based on not just their MRI scans, but also by factoring in their overall health, lifestyle and family situation.”
Michael Brisman, MD, FACS, regularly reviews the most recent medical literature to stay informed about new techniques to treat brain tumors. He frequently uses incision-free Gamma Knife radiosurgery for patients with acoustic neuromas, meningiomas or malignant tumors.
Brain tumors can be complex diagnoses, so NSPC neurosurgeons collaborate with a variety of specialists, beginning when adult patients present to an emergency department (ED) with acute symptoms, such as headache or seizure, or, more frequently, when neurologists, otolaryngologists or other clinicians refer individuals electively for evaluation.
“Diagnostically, neurosurgery is quite different than it was a generation ago, mostly due to the ready availability of MRI and CT,” Dr. Brisman says. “Patients typically enter our care with adequate imaging scans, and if not, we order new ones. In most cases, imaging can reveal what type of tumor a patient has.”
For small, benign tumors, treatment may entail no more than repeat imaging a year later to check for growth or other changes. If a tumor is large or symptomatic, a patient may be a candidate for a biopsy, outpatient radiation therapy, chemotherapy and/or surgical resection. Multidisciplinary care is paramount, regardless of treatment plan.
“Brain tumor patients need the expertise of many more specialists than just neurosurgeons,” Dr. Brisman says. “If, for example, an individual is a candidate for radiosurgery (a super-focused radiation technique), we collaborate with radiation oncologists. During surgeries, our neurosurgeons work with a team of up to 10 people in the operating room, including an anesthesiologist, a neuromonitoring physician to monitor the brain and spinal cord intraoperatively, a neurologist, physician assistants, nurses and more.”
A key member of the NSPC team is neurologist and neuro-oncologist Jai Grewal, MD, who works in conjunction with the neurosurgeons to manage malignant tumors with oral and intravenous chemotherapies.
“Dr. Grewal works exclusively with patients who have brain tumors,” Dr. Brisman says. “In addition to overseeing chemotherapy treatment, he helps patients access clinical trials. He has particular interest and expertise in high-grade gliomas for which existing treatments aren’t always satisfactory. He assists those patients with enrolling in suitable trials so they have access to the latest therapies.”
NSPC neurosurgeons partner with other specialists as needed, including endocrinologists, who manage hormone levels for patients with benign pituitary tumors, and otolaryngologists, who treat patients who experience hearing loss related to acoustic neuromas. Primary care physicians play an integral role by directing the management of chronic medical conditions and overseeing patients’ overall health.
Ramin Rak, MD, FAANS, discusses a planned brain tumor surgery with a patient in clinic. Communication between patients and their physician is essential to successful surgical outcomes.
Bloodless Brain Surgery
In recent years, numerous technological innovations have transformed the way neurosurgeons treat brain tumors, and the team at NSPC is versed in all of them. One of the most salient is radiosurgery, a super-focused form of radiation that Dr. Brisman refers to as “bloodless brain surgery.” Neurosurgeons can perform radiosurgery in conjunction with radiation oncologists using the Gamma Knife, CyberKnife and Novalis radiosurgery systems. Dr. Brisman performs most of his radiosurgery procedures using Gamma Knife at the Long Island Gamma Knife Center at Mount Sinai South Nassau, which was the first on Long Island to acquire the Gamma Knife system and has hosted thousands of the procedures over nearly two decades. The hospital is home to the Leksell Gamma Knife Perfexion, which is housed along with the Novalis radiosurgery system in a dedicated wing.
Candidates for Gamma Knife radiosurgery include most adults with acoustic neuromas and meningiomas, and this treatment is often the only one necessary for these patients, according to Dr. Brisman. For individuals with pituitary tumors, radiosurgery may be appropriate as an adjunct to endoscopic brain surgery to treat residual disease, which is frequently present following surgery.
“We also use Gamma Knife to treat malignant tumors, the most common of which are metastatic,” Dr. Brisman says. “In the past, we treated these tumors by irradiating the entire brain, which took a month and could cause hair loss and memory problems. Now, we can perform one-day, super-focused radiation.”
The process begins by placing a lightweight head frame on the patient, which prevents movement and permits precise targeting of the radiation beams. The patient undergoes an MRI or CT of the brain so the neurosurgeon and a radiation oncologist can plan how to irradiate the tumor. During treatment, the patient lies on a table that moves into the Gamma Knife Perfexion’s mouth, and several beams irradiate the tumor from a variety of angles with pinpoint accuracy while sparing healthy tissue.
“Treatment typically takes 30 to 60 minutes, and it’s usually curative for most patients,” Dr. Brisman says. “We conduct follow-up imaging at regular intervals, with the frequency depending on whether a tumor is benign or malignant.”
Neurosurgeon John Grant, MD, BCh, FRCS, FACS, MB, (left) and neuro-oncologist Jai Grewal, MD, confer remotely with a brain tumor patient. Drs. Grant and Grewal frequently use virtual consults to communicate with patients who live far away or want to avoid the rigors of an office visit.
Endoscopic Brain Surgery
Like incision-free radiotherapy, endoscopic brain surgery is part of a trend of increasingly less invasive treatments for brain tumors. Using long, thin neuroendoscopes and working in conjunction with an otolaryngologist, a neurosurgeon can access and remove certain brain tumors through the nostrils. The otolaryngologist inserts the scope and guides it to the front of the skull, and then the neurosurgeon uses specialized instruments to remove the tumor through the scope under real-time visualization. The surgery takes approximately one hour.
“We do a lot of endoscopic brain surgeries, mostly to remove pituitary tumors,” Dr. Brisman says. “Rather than making a large incision, we can put the scope deep into certain spaces, and it provides incredible illumination, magnification and visualization. Endoscopic surgery can also be used to remove colloid cysts and tumors in the ventricular system.”
(Fig. 1) Pre-Op and (Fig. 2) Post-Op images of a 46-year-old woman who presented with a 9 millimeter, right-sided pituitary adenoma with a recent diagnosis of Cushing’s disease. She underwent endoscopic transsphenoidal removal of the pituitary tumor, performed by Dr. Brisman. Post-operative imaging showed the tumor was completely removed.
Personalizing Brain Tumor Resection With Awake Craniotomy and Functional Mapping
Another of NSPC’s most advanced treatments for brain tumors, awake craniotomy with functional mapping, marries the high-tech and high-touch aspects of the practice’s approach to neurosurgery, producing excellent clinical outcomes while preserving function. With the patient awake during the procedure, Dr. Rak uses functional MRI (fMRI) and electrophysiology to map the brain as NSPC neuropsychologist Gad Klein, PhD, leads the patient through a series of cognitive and language tests. That allows Dr. Rak to identify the sources of various functions in the eloquent brain and avoid them as much as possible during tumor resection. Dr. Rak has been performing awake craniotomy with functional mapping for a decade and is a regional leader in this procedure.
“Awake craniotomy with functional mapping is individually designed care based on the patient’s needs, lifestyle and profession,” Dr. Rak says. “Rather than just using MRI enhancement or MRI and anatomical boundaries and navigation for resection, I operate based on functionality by mapping the areas of the brain responsible for speech, language, and motor and sensory functions. The entire procedure is custom designed for each patient.”
Dr. Rak uses awake craniotomy and functional mapping to remove a variety of brain tumors, including gliomas and metastatic brain tumors. This procedure relies on several technologies and surgical techniques, and recent advances in neuronavigation, microsurgery and fMRI, among others, allow Dr. Rak to resect tumors that were previously considered high-risk or inoperable due to their locations.
“We’re able to identify cortical and subcortical matter in regions of the brain that are functionally important,” Dr. Rak says. “The more we do these procedures, the more we find there’s a mismatch between the functionality of the brain and its anatomy. The locations of certain functions in the brain are different in each individual depending on several factors, including lifestyle and past insults or trauma. Every millimeter of location could affect the patient’s outcome and functionality, so it’s important to know exactly where each type of function arises.”
This pre-operative MRI study (Fig. 1) of a 62-year-old woman shows a 1.4 centimeter (cm)-by-1.4 cm metastatic adenocarcinoma mass of the right frontal lobe. Since the tumor was near critical speech areas of the brain, Dr. Rak performed an awake craniotomy so these critical areas could be located using special speech mapping techniques (Fig. 2) while the patient was awake in the operating room.
Before an awake craniotomy, Dr. Klein leads the patient through a series of tests to establish baseline levels of cognitive and language functioning. A preoperative fMRI scan helps determine how the tumor affects areas of the brain that are home to certain functions. Combining the fMRI with standard and neuronavigation MRIs allows Dr. Rak to feed comprehensive anatomical and functional information into a neuronavigation system.
The patient is sedated during the first stage of the procedure. Dr. Rak, with the aid of neuronavigation and other imaging, makes an incision in the skull and removes a small section of bone to expose the brain. An anesthesiologist brings the patient out of sedation, and Dr. Rak begins mapping the brain’s white and gray matter — an innovative approach that permits more extensive testing of the brain — using fMRI and electrophysiology. A neurophysiologist closely tracks the brain’s electrical activity throughout the procedure. While the brain receives electrical stimulation, Dr. Klein leads the patient through activities to stimulate cognitive and language function.
“We created an application for use on a tablet that shows pictures and sentences,” Dr. Rak says. “Dr. Klein asks patients to repeat sentences or perform tasks while I map the brain, and we can compare this intraoperative information to the patient’s baseline function. Based on what we learn, I’m able to approach the tumor from the part of the brain that will cause the fewest postoperative complications.”
The anesthesiologist places the patient back under sedation so Dr. Rak can remove the tumor. In some cases, the patient may be reawakened during resection for additional testing. Using microsurgical techniques, Dr. Rak precisely and delicately resects the tumor while minimizing disruption to healthy brain tissue. Patients typically spend two days in the hospital before returning home.
Dr. Rak’s patients have enjoyed outstanding outcomes and minimal postoperative deficits due to the elimination of uncertainty that awake craniotomy and functional mapping affords.
“With this procedure, we know exactly what’s important,” Dr. Rak says. “We don’t have to wait for the patient to wake up to see what he or she can do. The brain is a conscious organ. It’s not ideal to put it to sleep, work on it, wake it up and see what the patient’s functionality is. If you keep this organ as conscious as possible, you limit complications postoperatively and improve the patient’s quality of life.”
Dr. Brisman is a neurosurgeon at Neurological Surgery, P.C. (NSPC) and Co-Medical Director of the Long Island Gamma Knife Center at Mount Sinai South Nassau in Oceanside. He has performed over 1,000 “bloodless” radiosurgery procedures.
Dr. Rak, is a neurosurgeon at Neurological Surgery, P.C. (NSPC) and is Director of the Brain and Spine Tumor Center and Director of Brain and Spine Trauma at Mount Sinai South Nassau in Oceanside. Dr. Rak has been performing awake craniotomy with functional mapping during tumor resection for a decade and is a regional leader in this procedure.
Dr. Grant is a neurosurgeon at Neurological Surgery, P.C. (NSPC) and director of the practice’s Pediatric Brain Tumor Center.
Dr. Grewal is a key member of the brain tumor team at Neurological Surgery, P.C. (NSPC). Dr. Grewal works in conjunction with the practice’s neurosurgeons to manage malignant tumors with oral and intravenous chemotherapies. He also helps patients access clinical trials.
Skilled, Compassionate Pediatric Care
Treating brain tumors in children presents unique challenges.
“Children’s anatomy is smaller than adults’, which leaves less room for error during tumor resections,” says John Grant, MD, BCh, FRCS, FACS, MB, neurosurgeon and Director of Pediatric Brain Tumors at NSPC. “Importantly, children can have long lives following treatment, so it’s crucial to not do any harm during surgery that could cause problems later in life.”
The most common childhood brain tumors that Dr. Grant treats are astrocytomas, ependymomas and medulloblastomas. All three tend to respond well to chemotherapy and/or radiation following resection, according to Dr. Grant.
“Children with brain tumors typically enter our care when they present to an ED with hydrocephalus,” he says. “They usually receive a CT scan and an MRI of the entire neuroaxis with and without contrast. Then we take the tumor out and put in an external ventricular drain. Once we’ve done that, we review the pathology and determine whether chemotherapy and radiation are necessary. We can cure some, but by no means all, pediatric brain tumors with surgery alone.”
In Dr. Grant’s estimation, the most dramatic recent advancement in pediatric brain tumor care is the ability to diagnose these tumors using molecular arrays instead of light microscopes. That has enabled clinicians to refine and tailor treatments.
“Diagnoses are much more accurate with molecular array than light microscopy,” Dr. Grant says. “We can adjust chemotherapies and radiation treatment for certain tumors based on their molecular structure. That’s been a big change recently. There are a number of different chemotherapy agents we can use now, depending on each tumor’s molecular signature. I think that’s going to transform the field even more in the future because the more we know about the molecular structure of tumors, the more we’ll be able to use very specific chemotherapy agents.”
Dr. Grant estimates that surgery is curative for 25% or less of his young patients. Most require additional treatment, which is why Dr. Grant attends a weekly tumor board meeting via videoconference with pediatric neuro-oncologists and other specialists at NYU Langone Health and its Hassenfeld Children’s Hospital. A multidisciplinary team discusses the case of each of Dr. Grant’s patients. The team reviews patients’ pathology and imaging studies, and determines whether chemotherapy and/or radiation therapy is warranted.
“We try to get every patient into a clinical trial,” Dr. Grant says. “Many different chemotherapy agents are available only on a research basis, so we want to enroll every patient in a study. That improves outcomes and our ability to treat children in the future. Children are always better off in a clinical trial, no matter what kind of treatment they receive.”
For Dr. Grant, what truly differentiates NSPC is the attentiveness of its experts.
“When children and their families come to NSPC, they get me, all the time,” he says. “Every family gets my cell phone number. I’m always available to them, and their child is assured of receiving individualized care. I’m personally responsible for how my patients do.”
That is true for every neurosurgeon at NSPC.
For more information, visit nspc.com.