Fellowship-trained surgeons in White Plains Hospital’s recently enhanced cranial neurosurgery program deliver multidisciplinary evaluation and leading-edge treatments rarely found outside metropolitan academic medical centers.
With significant additions to the hospital’s team of specialists and an arsenal of cutting-edge technologies, even the most advanced procedures — many of them minimally invasive — are now locally available.
An Uncommon Level of Care
Lack of specialized expertise or equipment at smaller hospitals is why patients with brain tumors or chronic neurologic conditions are typically referred to major academic institutions for advanced surgical treatment. However, over the past year, under the leadership of Kaushik Das, MD, White Plains Hospital’s Chief of Neurosurgery, and Emad N. Eskandar, MD, Montefiore Medical Center’s Chair of Neurosurgery and the Jeffrey P. Bergstein Professor at Albert Einstein College of Medicine, the cranial neurosurgery program has risen to the level of those at the best teaching hospitals.
Dr. Eskandar, previously at Massachusetts General Hospital and Harvard Medical School, was recruited to the position of Professor and Chair of the Department of Neurosurgery at Montefiore – Einstein in 2018, after a competitive nationwide search. Dr. Das was named Chief of Neurosurgery at White Plains Hospital three years ago and as a long-standing member of the White Plains community has also played a significant role in the program’s evolution.
A major step toward achieving the objective of providing the highest levels of surgical care locally has been the partnership with Montefiore Medical Center, which brought Dr. Eskandar and his colleague Vijay Agarwal, MD, Assistant Professor of Neurosurgery and of Otorhinolaryngology at Albert Einstein College of Medicine and Director of the Skull-Base Tumor Center at Montefiore, to White Plains Hospital in 2018. White Plains Hospital made additional investments in equipment and personnel to fully utilize the neurosurgeons’ subspecialty training during their regular visits from Montefiore, of which White Plains Hospital is a member.
Today, White Plains Hospital offers a full spectrum of sophisticated procedures to effectively address complex brain tumors and debilitating neurological conditions, such as epilepsy, Parkinson’s disease and trigeminal neuralgia.
Kaushik Das, MD, Chief of Neurosurgery at White Plains Hospital, and Emad N. Eskandar, MD, Montefiore Medical Center’s Chair of Neurosurgery and the Jeffrey P. Bergstein Professor at Albert Einstein College of Medicine, envision White Plains Hospital as a regional hub for neurosurgery for complex brain tumors and debilitating neurological conditions, such as epilepsy, Parkinson’s disease and trigeminal neuralgia.
Specialized Skill and Technology
Dr. Das, Vice President of Brain and Spine Surgeons of New York, highlights the benefits of obtaining advanced care locally.
“I’ve been living in this community since high school, and I get it,” he says. “When someone in your family is ill, you want the best for them, but all else being equal, it’s much easier for them to be close to home. Most patients want to stay in Westchester. They don’t want to go to the city to get the care they need.”
The investment in building a premier cranial neurosurgery program to meet that local need has taken many forms, he points out. In addition to the newly incorporated Varian Edge radiosurgery system, which delivers precisely targeted, high-dose radiation to brain tumors with minimal damage to surrounding tissue, the hospital has acquired more operating room microscopes, an updated stealth image guidance system for biopsies and navigated brain surgery, and increased EEG monitoring for epilepsy patients. Dr. Das, a general neurosurgeon and spine specialist who also treats primary and metastatic brain tumors, has developed a monthly neuro-oncology conference in coordination with the hospital’s cancer center as well.
“The administration is definitely committed,” he says. “Since I’ve been here and we’ve handled increasingly complex cases, we’ve had numerous discussions about what we need to take the service to the next level, whether it’s equipment or support. As one example, we now have seven-day-a-week coverage from physician assistants to help attending physicians focus on the most complicated cases.”
The physician staff has grown to include 17 neurosurgeons, with eight providing on-call services around the clock. The ICU facilities have been upgraded, and clinicians there have undergone specialized training to handle complex cases.
These investments helped lay the foundation for a world-class cranial neurosurgery program at White Plains Hospital, reflecting a commitment to patients and the distinguished neurosurgeons who treat them.
Vijay Agarwal, MD, Assistant Professor of Neurosurgery and of Otorhinolaryngology at Albert Einstein College of Medicine and Director of the Skull-Base Tumor Center at Montefiore, consults with a patient at White Plains Hospital Center for Cancer Care.
Advanced Tumor Treatments
In the course of his three fellowships — at Mayo Clinic, Emory University and the University of New South Wales — Dr. Agarwal has helped pioneer several advances in open skull base surgery. He later built Montefiore’s skull base program and has now expanded the range of tumors surgically treated at White Plains Hospital to include acoustic schwannomas, pituitary adenomas and skull base tumors. Dr. Agarwal uses minimally invasive approaches, working through the nose and sinuses, whenever possible. For the treatment of cerebrospinal fluid (CSF) leaks and encephaloceles, as well as pituitary tumors, he works together with an ear, nose and throat (ENT) surgeon. Like his colleagues, Dr. Agarwal uses minimally invasive techniques to reduce morbidity and speed recovery. Some of his techniques are rare at even the most elite medical facilities.
“There are some things we’ve done that nobody else in the state and few neurosurgeons in the country are doing,” he says. “For instance, we perform eyebrow craniotomies, using a small, nearly invisible incision along the eyebrow to reach deep-seated brain tumors. Our patients have had excellent outcomes and rapid recovery with this technique.”
While treatment for brain tumors is determined on a case-by-case basis, Dr. Agarwal says symptomatic tumors causing seizures, visual impairment or other neurological symptoms require treatment. Surgical treatment for large tumors or tumors that are close to a critical part of the brain comes with greater risk to memory, speech or other neurological function, making the surgeon’s experience level critical.
Patients treated at White Plains Hospital for exceptionally complex conditions experience lifesaving results. Dr. Agarwal recalls the recent case of a man with a massive pituitary macroadenoma that was stealing his vision and had triggered a series of strokes.
“When he was transferred over to us, he was completely confused, unaware of his surroundings and slowly dying,” Dr. Agarwal says. “We presented his case to several large academic centers around the country and were repeatedly told it was too dangerous to operate because the tumor completely encased the internal carotid artery and the optic chiasm. We performed an endoscopic surgery, through the nose and without an external incision. Two weeks later, the patient was recovering his vision, back at work and fully functional, with minimal neurologic deficit.”
Once he fully recovers, the resection will be completed through a minimally invasive transcranial approach.
Dr. Eskandar recruited his esteemed colleague, Dr. Agarwal, to join him at White Plains Hospital to further develop the neurosurgical program.
Dr. Eskandar also uses advanced techniques to treat cranial tumors, particularly meningiomas and primary tumors in eloquent parts of the brain. This requires special expertise, such as performing speech or motor mapping. In addition, he is an expert in the surgical treatment of epilepsy, trigeminal neuralgia and Parkinson’s disease, for all of which he has helped develop some of the most promising treatments.
The CDC estimates that 3.4 million Americans have active epilepsy. As few community hospitals offer surgical treatment of the condition, White Plains Hospital is notable for the range of evaluation and treatment options it provides, Dr. Eskandar says. White Plains Hospital has a prestigious designation as a Level 4 Epilepsy Center. This is the highest level and is reserved almost exclusively for large academic medical centers with expertise in the surgical treatment of epilepsy.
The key to effective surgical treatment of epilepsy is identifying the site in the brain giving rise to the seizures — also called the seizure focus — in order to maximize the potential for seizure freedom and to reduce any potential risks. The first step is a Phase I investigation, which relies on MRI, EEG and other noninvasive modalities to ascertain the location of the seizure focus. Often, however, it is not possible to unequivocally locate the seizure focus through these approaches. In these cases, it is necessary to perform a Phase II investigation, which entails placing electrodes directly on the brain to more precisely locate the seizure focus. A Phase II investigation traditionally requires open craniotomy, which is a large surgery. Dr. Eskandar uses robotic surgery to place multiple, very thin electrodes through tiny openings in the skull.
“This technique — stereotactic EEG — is much better tolerated by patients, and it’s where the field is moving,” he says.
Drs. Das, Agarwal and Eskandar have advanced the neurosurgery program at White Plains Hospital by offering cutting-edge treatments — many of which are performed with minimally invasive techniques.
For patients whose seizure focus is limited to the right (nondominant) temporal lobe, a traditional lobectomy can offer a 70 to 80 percent chance of being virtually seizure-free, with very low risk of cognitive or other side effects. However, certain patients whose seizures are bilateral or arising from the left temporal lobe may have an increased risk of speech or memory problems following traditional surgery. For these patients, Dr. Eskandar offers less invasive options.
For example, he can ablate the area of seizure focus using a stereotactically introduced fiber-optic probe. Alternatively, he can insert electrodes through a small, dime-size cranial opening and connect them to a small defibrillator-like device implanted under the scalp that detects and averts seizure activity in the area. Similarly, with deep brain stimulation, he can make two small openings in the skull, introduce 1-millimeter-thick electrodes into the thalamus, and attach them to wires that run underneath the scalp and neck to a pulse generator that sits along the chest wall.
“These are all relatively new therapies that are finding a bigger role in treating cases where, in the past, there would not have been a surgical option, and hence no definitive treatment,” Dr. Eskandar says.
The outcomes of these minimally invasive approaches are similar to those of conventional epilepsy surgeries and far superior from a morbidity perspective, he says. “There’s less time in the operating room, minimal blood loss, less discomfort — they’re just much better tolerated by patients.”
Parkinson’s and Trigeminal Neuralgia
Parkinson’s disease affects more than 10 million people worldwide, according to the Parkinson’s Foundation. The first line of treatment — medical therapy — often loses effectiveness in five to 10 years and can have serious side effects, including hypotension and hallucination. Advanced surgical treatments can offer superior outcomes, Dr. Eskandar says.
“Deep brain stimulation for Parkinson’s is an amazing, potent surgery that’s been found to be better than the best medical therapy,” he says. “It started in France, and the FDA approved it for advanced Parkinson’s in 2002, but it took awhile to gain acceptance. Today, this is a procedure that’s almost always performed at a big academic hospital.”
Between 75 and 80 percent of patients with Parkinson’s disease gain significant benefit from deep brain stimulation, particularly amelioration of tremor and rigidity and an average 50 percent reduction in medication, Dr. Eskandar says.
He also sees excellent outcomes with minimally invasive surgery for trigeminal neuralgia, an excruciating condition.
“Before there were treatments, there was a significant risk of suicide for patients with trigeminal neuralgia because the condition is so painful and because it’s triggered by very basic activities of living — things like eating, drinking and kissing,” he says.
Trigeminal neuralgia is usually caused by an aberrant artery compressing the trigeminal nerve. Patients who do not respond to medical treatment have a full range of surgical options at White Plains Hospital. The most durable and successful is microvascular decompression, which carries very low risk with an experienced surgeon, Dr. Eskandar notes.
“It’s a small, beautiful, elegant surgery that takes two or three hours and is performed under a microscope,” he says. “We make a quarter-size opening in the skull, identify the artery that’s compressing the trigeminal nerve, gently move it aside and then put in small, pea-sized cushions made of Teflon to separate the artery from the nerve. It is effective over 90 percent of the time, and it works long term because it addresses the root cause of the problem.”
Other effective options include rhizotomy, which is minimally invasive, and radiosurgery, which is noninvasive. While their benefits are less durable than those of microvascular decompression, the fact that they are less invasive may make them better options in certain cases, depending on patients’ needs and preferences, according to Dr. Eskandar.
The complex cranial neurosurgeries now available at White Plains Hospital are attracting patients from well beyond its catchment area. Recently a woman came to Dr. Eskandar from New Hampshire for surgical treatment of trigeminal neuralgia. She ended up having lifesaving surgery at White Plains Hospital to remove a large brain tumor — a meningioma — that was undetected until the patient had an MRI to evaluate her trigeminal neuralgia.
Dr. Eskandar performed a keyhole craniotomy to microscopically resect the tumor, which was pressing on the optic nerve and carotid artery. White Plains Hospital will later perform radiosurgery for the tumor, followed by surgical treatment for trigeminal neuralgia.
A Team Effort
White Plains Hospital also stands out from other community hospitals for its multidisciplinary approach to every cranial neurosurgery case. Ear, nose and throat surgeons participate in the planning and surgery for removal of skull base tumors, while radiosurgeries are performed in collaboration with radiation oncologists.
Physician assistants provide specialized post-operative care, and, while the hospital’s newly enlarged contingent of PAs translates to excellent floor support, cranial neurosurgeries — particularly the more complex procedures — receive a high level of post-operative care from attending surgeons.
“We are very hands-on,” Dr. Das says. “Two board-certified neurosurgeons handle most neurosurgery cases.”
Patients meet with all the specialists involved in their case, and the specialists coordinate their schedules so patients can make as few visits to the hospital as possible, Dr. Eskandar says.
“It’s more of a community hospital feel, where you get to see your physicians and talk to them, and they’re accessible and available,” Dr. Das adds. “It’s less intimidating, and you don’t have to drive all the way to the city and pay for parking.”
Plans to Grow
Drs. Eskandar and Das envision White Plains Hospital becoming a regional hub for neurosurgery, especially with the planned addition of an endovascular suite where subspecialists can offer advanced treatment of aneurysms, arterial malformations and stroke.
“These endovascular procedures are usually performed without opening the head; they’re done through the vessel now, so you need those technological capabilities,” he says. “In addition, you need the post-op ICU to help take care of those patients.”
Dr. Eskandar hopes to see more neurosurgical subspecialties, such as pediatrics, at White Plains Hospital to further leverage the expertise available there and through Montefiore.
“We have a very experienced team,” he says. “For the conditions we’re treating, it’s the highest level of care — the same care you could get at the most prominent academic institution — which is remarkable.”
For additional information, visit wphospital.org and click on “Services & Specialties” and then “Neurosurgery.”