The Future of Neurosurgery at SBH

Dr. Ralph Rahme is Director of the Division of Neurosurgery at SBH. Most recently, before arriving at SBH in 2017, he completed a fellowship focusing on complex cranial and cerebral bypass surgery.

The following is an excerpt of a recent interview with Dr. Rahme.

Q. What are the capabilities of the Division of Neurosurgery? What kind of patients are you seeing? What kind of surgeries are you doing?
A. As a division, we have come a long way over the last year and a half. Thanks to the previous neurosurgeon, Dr. William Wirchansky, there had previously been significant growth in terms of the number of neurosurgical cases performed at SBH. Yet, up to that point, the majority of neurosurgical
focused on simple to medium complexity cases and primarily spine surgery. I personally come from an academic background and had undergone five extra years of subspecialized neurosurgical training on top of seven years of residency. Much of this subspecialized training involved complex cranial surgery, including skull base, vascular, and endovascular neurosurgery, dealing with some of the most complex disorders of the brain and spinal cord, such as aneurysms, vascular malformations, and tumors.

Q. What cases are you now seeing?
A. Before joining SBH, I spent a whole year training in highly complex
cranial surgery, including extracranial- intracranial bypass, a procedure that redirects blood flow from vessels outside the skull, such as head and neck vessels, to supplement or replace flow in the brain. This is often performed in patients with extreme narrowing of brain vessels that cannot be fixed surgically, like you would in a carotid endarterectomy for instance. In those patients, the blockage is either inside the skull or it is in the neck but extends all the way up to the skull. The only way to go around such blockages is to bring in vessels from outside the brain, through a small opening in the skull, and suture them directly to brain vessels. This is what
we call ischemic disease. The other type of disorders where a bypass can help includes complex aneurysms and skull base tumors involving large brain vessels. For instance, when a large tumor wraps around such vessels at the base of the skull, removing the tumor in its entirety may require sacrifice of the vessel. A bypass would allow us to bring in blood flow from elsewhere in the body, so that vessel sacrifice does not result in a stroke.
Another area of neurosurgery that we’ve been able to develop here is phase one of our neuroendovascular surgery program. We are hoping that, in the next few years, we will be able to develop the entire spectrum of neuroendovascular interventions.

Q. What types of patients does that include?
A. This could include patients with a multitude of disorders affecting brain vessels, such as strokes caused by blockages in vessels and hemorrhages caused by ruptured aneurysms or vascular malformations.

Q. What can you tell me about endovascular surgery?
A. Endovascular surgery, which is a minimally invasive approach, usually performed through a needle puncture in the groin, is a great complement to
traditional open surgery when managing vascular disorders in the brain. Evidently, open brain surgery is more invasive and involves larger incisions. Thus, with everything else being equal and both options being deemed equally feasible for a specific patient with a specific vascular lesion, endovascular surgery is generally preferred. However, the choice of technique may also depend on other factors, such as surgeon comfort with either procedure, patient preference, and so forth. Endovascular surgery definitely has a great future.

Q. Are you now doing a majority of scular cases?
A. It depends on the specific clinical context, patient, disease, etc. For aneurysms, I generally treat about 40 – 45 percent via open technique and 50-55 percent via endovascular technique. I happen to be one of a relatively small number of surgeons who would feel equally comfortable performing both techniques. I believe that, when you have a balanced approach, it really puts you in a good position where you can remove yourself and your own level of comfort from the equation. In fact, most surgeons nowadays tend to be biased towards endovascular treatment, which is often technically less demanding than open surgery, but may not necessarily be the best choice for that specific patient, that specific aneurysm, that specific shape, that specific size, or that specific location. Unfortunately, open surgery is gradually losing ground and becoming a lost art. One of the major factors that impacts a surgeon’s choice of technique is their own level of comfort with endovascular therapy versus open brain surgery. When you remove this factor from the equation, then the question becomes what is the best treatment for that specific patient. In fact, many aneurysms are best treated surgically, not endovascularly.

Q. Can you explain a little more about aneurysms and the benefits of vascular versus endovascular surgery?
A. An aneurysm is essentially a blister arising from a weak spot in the wall of a vessel. In the open technique or craniotomy, the surgeon makes an incision in the scalp, temporarily removes a piece of skull, and travels under the brain to find the aneurysm. A good amount of surgical dissection under the microscope is usually required to free the aneurysm and vessels from adjacent tissues and brain. Ultimately, a clip is placed on the aneurysm to pinch it shut. The clip stays there permanently. In the endovascular technique, the surgeon travels through the main artery of
the leg in the groin, as is done during an angiogram. We use a very flexible plastic tube, called a catheter, that is advanced inside the brain vessels and ultimately inside the aneurysm itself. Through the catheter, loops of metal or coils are gradually deployed inside the aneurysm, ultimately forming a tight basket. At times, a balloon or stent is deployed in the main vessel to help keep the coils inside the aneurysm. This balloon-assisted or stent-assisted coiling technique becomes necessary for aneurysms with wide necks, the neck being the base of the aneurysm where it comes off the vessel wall. Of course, the more devices we use, the more complex the procedure gets, and the higher the risk of complications. Another thing to remember is that once a stent is deployed inside a brain vessel, the combination of two blood thinners, typically aspirin and Plavix, becomes necessary to prevent blood from clotting on the stent, which can lead
to a stroke. For this reason, the wider the neck of the aneurysm, the more open surgery becomes the preferred modality. In contrast, a narrow neck makes the aneurysm more suitable for endovascular therapy. Virtually
any aneurysm can be treated surgically, if needed. However, not all aneurysms can be treated endovascularly. Also, aneurysms can sometimes recur after endovascular therapy. In contrast, the risk of an aneurysm coming back after clipping is close to zero. It might happen, but it is extremely rare. If you are a 30-year-old patient, you are likely to tolerate and recover well from open brain surgery under general anesthesia. Also, you would have a long remaining life expectancy. For this reason, you would be better off with a more durable treatment, such as clipping. In contrast, if you are 75-year-old with multiple medical problems, then endovascular therapy would likely be a better option for you, despite the small risk of recurrence.

Q. Do you use local anesthesia for the endovascular procedure?
A. Most endovascular neurosurgeons would typically treat patients under general anesthesia. I come from a different school of thought. The vast majority of endovascular cases I have performed in fellowship and subsequently in clinical practice were under local anesthesia. Patients are awake, but moderately sedated. It may seem like a big deal, a potentially “dangerous” procedure, but it really is not. On the contrary, I actually think it is safer this way, especially if the patient can cooperate. You get extremely important feedback from the patient. You talk to them during the procedure. If you put them to sleep, you lose that feedback. Yes, general anesthesia is probably more comfortable for the surgeon, since the patient is not moving, coughing, or breathing heavily, but you lose that clinical feedback. The last thing you would want is waking up a patient from anesthesia and realizing they can’t move their arm or leg, then having to retrospectively figure out what happened, what went wrong. You do not have this problem when the patient is awake. If something goes wrong, you will immediately know it and are able to react on the spot.

Q. What is that like?
A. Typically, if a patient is having a stroke during an awake procedure, you will automatically know that. They usually start getting agitated. Their vital signs change on the monitor. Their mental status changes: a second ago they were responding, now they are not. They become confused. They might develop slurred speech or difficulty finding words. You ask them “Hey, are you ok?” and realize they are obtunded, confused, or unable to speak. You ask them to lift their arm or leg, then realize they are weak. At this stage, if you react fast, you can often resolve the problem and reverse their symptoms.

Q. Is retreatment likely to happen years later?”
A. For aneurysms, it can happen any time, but generally tends to happen early on. If it hasn’t happened within the first couple of years, it likely won’t. Over time, after you deploy metal coils inside the aneurysm, the inner lining of the vessel typically forms a new layer of natural tissue that covers the coils. In some way, the vessel heals itself. The other thing I would like to emphasize here is that we always talk about brain surgery being a more morbid treatment compared with endovascular therapy. In reality, I always explain to patients that both treatments have roughly the same risks in terms of serious complications. For instance, if the aneurysm bursts during the procedure and starts bleeding in and around the brain, I would rather be doing open brain surgery and having direct access to the aneurysm, rather than being in an endovascular procedure, trying to control bleeding while operating at the groin, three feet away from the brain. Another complication that might equally occur with either technique is ischemic stroke secondary to blockages or clots in normal brain vessels. The real difference between the two techniques relates to patient convenience and hospital length of stay. Endovascular treatment is generally much more convenient because you come to the hospital, get treated via a needle stick in the groin, spend a night in the ICU, then go home the next morning. You return to work in a week or so. For a craniotomy, you come to the hospital, get the surgery, spend a night in the ICU, then spend a couple more days recovering in the hospital. You are going to have some pain and some swelling in the scalp or face for a few days. You will feel the effects of general anesthesia and might feel tired for a few weeks. Typically, you would spend up to four weeks out of work recovering. It is a definitely a lengthier recovery. However, the younger and healthier you are, the faster you are going to recover, as opposed to being older and less healthy.

Q. So it’s a decision determined by the patient and the condition?
A. As previously stated, when making this determination, I try to remove myself and my own level of comfort from the equation. What are the size and shape of the aneurysm? The bigger the aneurysm the better it would be for coiling. Why? Simply because it is like a big football field. You have so much wiggle room there when treating the aneurysm from the inside. If you are trying to treat a three millimeter aneurysm, you have very little room for error when you introduce a wire or try to deploy coils inside the aneurysm. Conversely, the smaller the aneurysm, the more suitable it would be for surgery. It is actually much easier to dissect and clip a small aneurysm than one that has grown large and has become stuck to adjacent tissues and brain.

Q. It also makes a difference if you are treating the aneurysm preventatively or whether it has already burst, right?
A. Right. When an aneurysm ruptures, this becomes an emergency and the aneurysm needs to be secured within 24 hours to prevent it from bursting again. Many people who survive the first aneurysm rupture won’t survive the second, hence the importance of timely treatment. In contrast, unruptured aneurysms are treated on an elective basis. I see those patients in clinic and spend a good amount of time counseling them. I usually go over the results of published studies on the natural history of brain aneurysms. This provides guidance as to which aneurysms have a higher risk of rupture, justifying preemptive treatment. I counsel each patient specifically about the risk of aneurysm rupture over their lifetime and help them reach an informed decision regarding treatment — whether it is simple observation, open surgery, or endovascular therapy. There are several factors that come into play here. The patient’s age is a very important one, specifically the remaining life expectancy. A 20-year-old is likely to survive another 50 – 60 years. An 80-year-old might live another 10 – 15 years. Each aneurysm has an estimated annual risk of rupture. This risk can add up significantly over a period of 60 years, but much less so over 15 years. This remaining life expectancy is very important to consider. Size and location of the aneurysm are also factors. Typically, aneurysms that grow on vessels in the front of the brain tend to behave less aggressively than those in the back of the brain. Yet another factor is whether the patient has had any previous aneurysm rupture.

Q. Do you see many young patients? How do you treat them?
A. A few. I remember, years ago, when I was in practice at the University
of Louisville, I treated lots of brain aneurysms, and a good number of those patients were in their 20s and 30s. That is not typical for aneurysms. Aneurysms usually develop with age. Patients are typically in their 50s or 60s. When young patients present with an aneurysm, I start thinking of the possibility of an underlying genetic problem. For instance, they might have been born with unusually weak soft tissues, making their vessel walls particularly vulnerable and prone to aneurysm formation. Unfortunately, given the general rarity of such patients, the risk of aneurysm rupture in this very young population has not been well studied. Nevertheless, I generally consider them at particularly high risk of rupture because of their weak vessel walls and tend to treat them aggressively. For instance, I would have a much lower threshold to treat a 20-year- old with a brain aneurysm compared with a 50-year-old with the same exact aneurysm. If studies suggest the risk of rupture for that particular aneurysm is low, I would probably recommend observation for the 50-year-old, but would still recommend treatment for the 20-year old. Also, as mentioned above, I would typically favor open surgery over endovascular treatment for most young patients. Another important element of patient counseling that I like to emphasize is lifestyle modification, especially smoking cessation. I always explain to patients that smoking is the number one reversible cause for aneurysm growth and rupture. Another important recommendation is blood pressure control. The number one cause that we cannot control, however, is genetics. Aneurysms are generally the result of a combination of genetic and environmental factors.

Q. Any other factors?
A. Much remains unknown about brain aneurysms. For the most part, they occur unpredictably. Studies have shown that people with a certain family history are at higher risk. Smoking degrades tissues in the body, especially the collagen and soft tissues in vessel walls. Hypertension hammers on the walls of the vessel. And, if the vessel wall is already weak and prone to aneurysm formation, then here you go: a blister will form on the wall and start growing.

Q. What other problems can be treated endovascularly?
A. Vascular malformations, which can be either congenital or acquired. These include arteriovenous malformations and fistulae, which are abnormal direct connections between high- pressure arteries and low-pressure veins that normally should not exist. Such abnormal connections can make those fine vessels prone to rupture and bleeding in the brain. To prevent this from happening, these lesions can be disconnected surgically, endovascularly, or even with radiation.

Q. I guess the diagnostic component is very important here, right?
A. Yes, absolutely. Currently, in phase one here at SBH, we have the full capability of doing diagnostic angiograms, both cerebral and spinal. This also includes three-dimensional angiography, which is state-of-the-art imaging. It gives a very nice three- dimensional reconstruction of the aneurysm or vascular malformation and clearly demonstrates its relationship to adjacent brain vessels.

Q. What about phase two?
A. We are hoping this will happen very soon. I am currently working with Dr. Ridwan Shabsigh [Chairman of the Department of Surgery], on a potential plan that would enhance our ability to care for patients with some of these more complex neurosurgical needs.

Q. What percentage of stroke patients have surgery shortly after their stroke? I thought it was very few, right?
A. It depends. The major challenge in treating stroke is being able to get to the patient on time. The traditional treatment window for intra-arterial
thrombectomy has been six hours. A few decades ago, nobody would even treat stroke. Stroke was a clinical diagnosis without real treatment. If you had a stroke, you would be disabled and remain so for the rest of your life,
hoping maybe to recover a little bit with physical therapy. During the 1990s, some of the earliest trials started yielding positive results, first with intravenous treatment, an injection of a clot buster in the vein. The problem, though, was that you couldn’t give this treatment beyond a narrow window of three hours, which was subsequently extended to four and a half hours. Unfortunately, very few stroke victims show up to the hospital that early. Then, intra-arterial therapy started gaining traction. You would travel inside the artery, get directly to the clot, and break it down or pull it out. Initially, we did not have those beautiful tools that allow us to suck the clot out or extract it. We had only the chemical treatment, the same clot buster we used in the veins. That treatment was okay, but not nearly as effective as mechanical devices. Those devices were a major technological breakthrough. They allowed us to go into the vessel and basically pull out or suck out the clot. We would not need to use blood thinners anymore. Blood thinners in patients with stroke can actually cause bleeding in the brain. Intra-arterial therapy not only increased treatment efficacy and reduced bleeding risk, but it also allowed us to extend the treatment window up to six hours. Plus, in a couple of the most recent trials, a significant number of patients with “wake-up strokes,” those that occur during sleep where we don’t really know how long the patient has had
the stroke for, were successfully treated with intra-arterial therapy. Many of those patients were treated well beyond the six- hour window. These patients underwent a special type of CT or MRI scan to check whether they still had salvageable brain tissue that lacked oxygen, but was still alive nonetheless. Patients whose brain is already dead do not really benefit from treatment and there is a higher risk of hemorrhage. In contrast, those with large amounts of salvageable tissue have a much more favorable benefit/ risk ratio and, thus, deserve aggressive treatment. Using this advanced imaging technology, we are now able to select patients for intervention on a case-by- case basis, well beyond the traditional six-hour window. This is reflected in the newest guidelines of the American Heart Association. Stroke is an evolving field, a moving target. More importantly, since stroke is a very common problem, advances in stroke treatment will likely have a huge positive impact on overall public health. Granted, only a fraction of strokes are currently eligible for this type of treatment. Many strokes you can’t do much about. You might end up treating about 5 – 10 percent of cases overall. Yet, this is still significant.

Q. Are you hopeful SBH will be doing this in the next few years?”
A. Yes. Right now, those patients come to our ER, get screened, and if they have a large vessel occlusion, they get transferred for intra-arterial therapy. We continue to provide the best care to our stroke patients and would be interested in potentially adding this to our currently available stroke therapies at SBH.

Q. What about phase three?
A. Phase three is a little down the road. We continue to explore what potential neurosurgical options we can offer to our local Bronx community. This may include some of the more advanced techniques we have discussed.