University of Pittsburgh NEUROSURGERY NEWS Winter 2016, Volume 17, Number 1 Accreditation Statement The University of Pittsburgh School of Medicine is accredited by the The Evolution of the Gamma Knife at UPMC Accreditation Council for Continuing Medical Education (ACCME) to In the late 20th century, Lars Leksell conceived of the provide continuing medical Gamma Knife® in Sweden. The device non-invasively education for physicians. treats brain tumors, vascular malformations, and other The University of Pittsburgh School of Medicine neurological conditions by cross-firing approximately designates this enduring 200 gamma rays to a specific target, sparing the material for a maximum of 0.5 AMA PRA Category 1 surrounding tissue. Below is a timeline of UPMC’s CreditsTM. Each physician history with this groundbreaking technology. should only claim credit commensurate with the extent of their participation in 1987 — Presbyterian University Hospital installed the activity. Other health care the Gamma Knife model U, the first ever 201 Cobalt professionals are awarded 0.05 continuing education Source Gamma Knife in North America. units (CEU) which are equivalent to 0.5 contact Figure 2. Leksell Gamma Knife Icon hours. 1990 — The spectrum of indications increased, and Disclosures long-term Gamma Knife radiosurgery results showed Greg Bowden, MD, Edward high brain tumor control rates and successful closure A. Monaco III, MD, PhD, 1996 — A third version of the Gamma Knife was Ajay Niranjan, MD, MBA, of arteriovenous malformations (AVMs). and Svetlana Trofimova, installed at UPMC, which used robotics to successfully MS, PA-C, have reported no pinpoint the target. relationships with proprietary 1992 — UPMC installed a newer version of the device, entities producing health care known as Gamma Knife model B. This model solved a goods or services. previous issue of recharging the device’s energy sources. 2006 — UPMC installed the Gamma Knife Perfexion, L. Dade Lunsford, MD, is a a larger, fully robotic unit with more efficient dose delivery. consultant for AB Elekta and Insightec DSMB. Dr. Lunsford Indications increased to include brain metastases, deep is a stockholder in AB Elekta. skull base tumors, and malignant brain tumors. Hideyuki Kano, MD, PhD, receives grant research support from Elekta. 2015 — Since installing its first Gamma Knife unit Instructions 28 years earlier, the team at UPMC treated more than To take the CME evaluation 13,500 patients (see Figure 1), published more than 400 and receive credit, please visit peer-reviewed outcomes studies, and trained more than UPMCPhysicianResources. com/Neurosurgery and click 1,700 professionals in methods and long-term outcomes on the course Neurosurgery of Gamma Knife radiosurgery. News Winter 2016. 2016 — UPMC welcomes the state-of-the-art Leksell Gamma Knife Icon (see Figure 2). This model is equipped with an on-board CT scanner and microradiosurgery capabilities, further advancing the successful treatment of Figure 1. Breakdown of indications treated by Gamma Knife brain tumors, AVMs, and various neurological conditions. radiosurgery from 1987 through 2015 at UPMC. Free Online CME To take the CME evaluation for this issue, visit our education website: UPMCPhysicianResources.com/Neurosurgery. Affiliated with the University of Pittsburgh School of Medicine, UPMC is ranked among the nation’s best hospitals by U.S. News & World Report. 2 neurosurgery ne wS Chairman’s Message One Size Does Not Fit All One feature of UPMC’s Department of radiosurgery treatment and innovation. This leadership in Neurological Surgery that I am most proud innovation is replicated in our programs for cranial nerve of is that physicians in our department microvascular decompression (MVD) and expanded endoscopic are able to provide precise, tailored care endonasal approaches (EEA) for skull base lesions. Adding to each patient. Our patients have access high-definition fiber tractography (HDFT) to our diagnostic to an arsenal of experts from a broad armamentarium has further improved our ability to perform spectrum of subspecialties. This deep safer and more effective surgical procedures. and varied expertise provided by our physicians — in a highly collaborative At UPMC’s Department of Neurological Surgery, we have the environment — allows us to confidently diagnose both common surgical expertise and advanced technology to provide precise, and rare conditions. By identifying critically important nuances patient-specific care. Our experienced surgeons — working as and details of each patient’s condition, we are able to map part of an innovative, multidisciplinary team — can confidently out optimal treatment strategies. diagnose even the most difficult conditions and map out an effective treatment strategy that is highly personalized to the A key factor in helping us reach this unparalleled level of needs of the patient. performance is our long-standing tradition of innovation and leadership. By developing novel approaches for the management Expertise has long been the intellectual cornerstone of our of complex and previously untreatable conditions, we are reducing department. Innovation has been the preeminent driving force. the morbidity and mortality associated with both the natural history as well as the treatment for many conditions. Robert M. Friedlander, MD, MA Our innovation and leadership can clearly be seen in this issue Chairman and Walter E. Dandy Professor of Neurological Surgery of our newsletter as we spotlight UPMC’s remarkable Gamma Co-Director, UPMC Neurological Institute Knife® program, which was established more than 29 years ago and has since remained at the forefront of stereotactic Faculty Contact Us Chairman Assistant Professors Clinical Assistant Brain Function & Behavior Neurosurgical Oncology Robert M. Friedlander, MD, MA Nduka Amankulor, MD Professors 412-647-7744 412-647-8312 David J. Bissonette, PA-C, MBA J. Brad Bellotte, MD Brain Tumors Pediatric Neurosurgery Professors (Executive Administrator) Daniel M. Bursick, MD 412-647-2827 412-692-5090 C. Edward Dixon, PhD Diane L. Carlisle, PhD David L. Kaufmann, MD Peter C. Gerszten, MD, MPH Carotid Disease Referrals Donald J. Crammond, PhD Vincent J. Miele, MD 412-647-2827 412-647-3685 L. Dade Lunsford, MD Andrew F. Ducruet, MD Monte B. Weinberger, MD John J. Moossy, MD Avniel Ghuman, PhD Cerebrovascular Residency Program David O. Okonkwo, MD, PhD Paola Grandi, PhD Research Associate 412-647-2827 412-647-6777 Ian F. Pollack, MD Stephanie Greene, MD Professor Clinical Neurophysiology Spine Mingui Sun, PhD Miguel Habeych, MD, MPH Hideyuki Kano, MD, PhD 412-647-3450 412-802-8199 Associate Professors Brian Jankowitz, MD Research Assistant Cranial Nerve Disorders Spine Radiosurgery Edward A. Monaco III, MD, PhD Jeffrey Balzer, PhD Professors 412-647-3920 412-647-9786 Ava Puccio, PhD, RN Johnathan Engh, MD Yue-Fang Chang, PhD Donations UPMC Mercy Neurosurgery R. Mark Richardson, MD, PhD Juan C. Fernandez-Miranda, MD Wendy Fellows-Mayle, PhD 412-647-7781 412-471-4772 Mandeep Tamber, MD, PhD Paul A. Gardner, MD Esther Jane, PhD Endonasal Surgery D. Kojo Hamilton, MD Clinical Professors Wenyan Jia, PhD 412-647-6778 Department of Adam S. Kanter, MD, FAANS Adnan A. Abla, MD Daniel Premkumar, PhD Neurological Surgery Ajay Niranjan, MD, MBA Hong Qu Yan, MD, PhD Endovascular Matt El-Kadi, MD, PhD 412-647-7768 UPMC Presbyterian Raymond F. Sekula Jr., MD, MBA Joseph C. Maroon, MD Suite B-400 Clinical Instructors Gamma Knife® Parthasarathy D. Thirumala, MD Daniel A. Wecht, MD, MSc 200 Lothrop St. Elizabeth C. Tyler-Kabara, MD, PhD Jeffrey W. Bost, PA-C 412-647-7744 Erin E. Paschel, PA-C Pittsburgh, PA 15213 Clinical Associate MEG Brain Mapping Center Editor: Peter C. Gerszten, Professors Chief Residents 412-648-6425 Michael J. Rutigliano, MD, MBA MD, MPH Gurpreet S. Gandhoke, MD Movement Disorders David S. Zorub, MD Website: neurosurgery.pitt.edu Ali Kooshkabadi, MD 412-647-7744 Robert Miller, MD Email: [email protected] Affiliated with the University of Pittsburgh School of Medicine, UPMC is ranked among the nation’s best hospitals by U.S. News & World Report. WINTER 2016, Volume 17, Number 1 3 Trigeminal Neuralgia Radiosurgery by Ajay Niranjan, MD, MBA, Edward A. Monaco III, MD, PhD, as well as patients with a symptomatic duration of three years or Svetlana Trofimova, MS, PA-C, L. Dade Lunsford, MD fewer, experienced faster initial pain response, including complete or some pain relief. One hundred ninety-three (43 percent) of 450 Gamma Knife® stereotactic radiosurgery (SRS) is a minimally patients who achieved initial pain relief reported some recurrence invasive surgical approach for managing medically refractory at a median of 50 months after initial relief. Fifty-three patients trigeminal neuralgia (TN). The goal of Gamma Knife SRS for TN (12 percent) developed new facial numbness. These symptoms is to eliminate or reduce face pain in order to improve patients’ resolved in 17 patients. Patients who developed sensory loss had quality of life, and numerous reports have documented its better long-term pain control (78 percent at five years). efficacy and safety. Because SRS is the Repeat radiosurgery least invasive procedure was performed for 193 for TN, it is a good patients (43 percent). treatment option for After one year, 26 patients with other percent of these patients high-risk medical were completely pain conditions and those free and 78 percent were who do not want to pain free with or without accept the greater risk medications. The prob- associated with other ability of maintaining surgical procedures. adequate pain relief was 80 percent after one Over the past 28 years, year and 74 percent 1,218 patients have after two years. undergone Gamma Knife SRS for TN at UPMC. The role of Gamma Knife In our retrospective SRS in the management review of 503 patients of medically refractory who underwent SRS Figure 1. Contrast enhanced axial MRI with coronal and sagittal reconstruction TN has evolved signi- for management of showing Gamma Knife radiosurgery dose plan for left-sided trigeminal neuralgia. ficantly over the past refrac tory TN (see A 4 mm collimator is used to deliver 80 Gy central dose.