“ University NeurosurgeryBrain & Spinal Column

Volume 8 Spring 2012

Dr. Anil Nanda, Professor and Chairman of the Department of Neurosurgery at LSU Health Sciences Center – Shreveport, in conjunction with Senator Sherri Cheek (R-Shreveport), the NFL, the New Orleans Saints, and the Concussion Coalition, helped to pass SB 189, known as the Louisiana Youth Concussion Act.

On June 28th, 2011, Governor Bobby Jindal signed the bill into law, making Louisiana’s youth safer in the sports arena. This law will require schools, clubs, and other organizations that sponsor youth athletics to provide the athletes and their parents with information about concussions and the potential long-term effects of playing after a head injury. Coaches and other officials are now required to undergo annual training in identifying concussion symp-toms. Coaches must remove any athlete from practice or a game if a concussion is suspected.

On September 6, 2011 Dr. Nanda and fourth year LSU medical student, Robert Smith, traveled to Baton Rouge for a ceremonial bill signing with Governor Jindal.Louisiana has now been added to the almost two dozen states that have passed a youth concussion act.

Dr. Brian Willis hosts Louisiana Neurosurgical Society MeetingThe Louisiana Neurosurgical Society hosted the 37th Annual Meeting in Shreveport, Louisiana at the Shreveport Convention Center. Dr. Brian Willis, Professor and Neurosurgeon at LSUHSC – Shreveport, serves as the President of the Louisiana Neurosurgical Society. The meeting participants included approxi-mately 40 neurosurgeons from Loui-siana. Dr. Brian Willis and Dr. Bharat Guthikonda, LANS Scientific Moderator, hosted a two-day conference in which several Neurosurgery faculty and resi-dents from LSUHSC - Shreveport, LSUH-

SC - New Orleans, and Tulane-Ochsner attended the Neuroen-doscopy Course and the Scientific Meeting.

Two sixth year residents of the Department of Neurosurgery received research awards. Benjamin Brown, MD, won the 2012 John Jackson Resident Award for his presentation, “CT Angi-ography: Reliable Tool for Predicting Anterior Communicating Artery Aneurysm Inflow Dominance.” This honor is awarded to the best clinical research article submitted for presentation at the conference. Rishi Wadhwa, MD, won the 2012 Dr. Dean Echols Award for best laboratory and research for his presentation, “Re-vision of Suboptimally Placed Lumbar Pedicle Screws Decreased Pullout Strength and Alters Biomedical Stability: A Pilot Cadav-eric Study.”

Featured Speakers included Dr. Alex Valadka and Dr. Douglas Brockmeyer. Dr. Valadka is a practicing Neurosurgeon, as well as CEO of the Seton Brain and Spine Institute in Austin, Texas. His presentations were titled, “Current Management of Trau-matic Brain Injury,” and “Washington Committee Update.” Dr. Brockmeyer is a Professor of Neurosurgery, Residency Program Director, and Marion L. Walker Endowed Chair of Neurosur-gery at the Primary Children’s Medical Center at the University of Utah Medical Center. His presentations were titled, “Current Concepts in Pediatric Neurosurgery,” and “Climbing Mount Everest.” Other presentations were made by faculty and staff of the Department of Neurosurgery from LSUHSC- Shreveport, including Dr. Anthony Sin, Dr. Prashant Chittiboina, Dr. David Connor, Dr. Cedric Shorter, and Dr. Osama Ahmed.

Dr. David Cavana-ugh of the Spine In-stitute of Louisiana honored members that have passed away in the last year. Dr. George Derry Beach and Dr. Fraser Edmund Landre-neau were among those mentioned. Dr. Brian Willis willhost the next Louisiana Neurosurgical Society Annual Meeting, held on January 11-12, 2013, in New Orleans.

Department Helps in Passing Louisiana Youth Concussion Law

Dr. Brian Willis, LANS President

Drs. Alex Valadka, Brian Willis, and Douglas Brockmeyer

After a blistering summer and what seems to be a mild winter, we are grate-ful for a wonderful 2011. As a depart-ment, we passed the 3,000 case mark, an accomplishment

for which we are very grateful to the entire department. Six years ago, the department passed 2,000 cases, and over that period of time, we have increased volume by over 50%. Over 3,000 cases makes us the busiest neurosurgical service in the state of Louisi-ana. We are profoundly grateful and moved by the trust of so many of our referring doctors, nurses, and patients.

As a department, we were saddened by the loss of Dr. John McDonald, emeritus chancellor and legendary surgeon, who initially helped the launching of the division and department of neurosurgery. He will be deeply missed.

We welcome two new residents, Chris Storey, M.D., PhD from LSU, and Richard Menger, M.D. from Georgetown, who both placed well in our competitive match. We look forward to Dr. Kim Burchiel coming as our graduation speaker as we get ready to say good-bye to our current chief residents.

Once again, if you have any questions, needs, comments or criticism, kindly feel free to call me and let me know if there are any problems in terms of patient care or sat-isfaction. Our goal now is to move toward outcome research and patient satisfaction so that we can put our complication rates and infection rates on the web to introduce a level of transparency that will hold us all more accountable. Here is wishing all of you a great 2012.

Sincerely,

Anil Nanda, MD, FACSProfessor and ChairmanDepartment of Neurosurgery

University NeurosurgeryBrain & Spinal Column

Medical Editor:Anil Nanda, MD, FACS

Designer/Writer:Lindsey M. HudsonLauren Sowell

Editors:Lindsey M. HudsonLauren SowellDiane MontgomeryBrain & Spinal Column is written for physicians and should be relied upon for medical education purposes only. It does not provide a complete overview of the topics covered, and should not replace the independent judgement of a physician about the appropriateness or risks of a procedure for a given patient.

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Message from the Chairman

For information regarding articlereferences please email the Editorial Office at lhuds1@lsuhsc.edu.

ANIL NANDA, MD, FACSProfessor Department Chairman

DONALD R. SMITH, MDClinical Professor

BRIAN K. WILLIS, MD, FACSProfessor BHARAT GUTHIKONDA, MDAssistant Professor

ANTHONY SIN, MDAssistant Professor

CHRISTINA NOTARIANNI, MDAssistant Professor

HUGO CUELLAR, MDAssistant Professor

GUOHONG LI, MD, PhDAssistant Professor of Research

GLORIA CALDITO, PhDAssociate Professor of BiometryBiostatistician

UNIVERSITY NEUROSURGERY FACULTY:

1. Khan IS, Javalkar V, Thakur JD, Nanda A. Intrasellar plasmacytoma: An illustrative case and literature review. J Clin Neurosci. 2012 Feb; 19(2):210-3. 2. Wadhwa R, Toms J, Nanda A, Abreo K, Cuellar H. Angioplasty and Stenting of a Jugular-Carotid Fistula Resulting from the Inadvertant Placement of a Hemodi-alysis Catheter: Case Report and Review of Literature. Semin Dial. 2011 Dec 9. doi: 10.1111/j.1525-139X.2011.01005.x. 3. Chittiboina P, Banerjee AD, Zhang S, Caldito G, Nanda A, Willis BK. How bullet trajectory affects outcomes of civilian gunshot injury to the spine. J Clin Neuro-sci. 2011 Dec;18(12):1630-3. 4. Wadhwa R, Khan IS, Thomas JO, Nanda A, Guthikonda B. Hemorrhagic subepen-dymal giant cell astrocytoma in a patient with tuberous sclerosis: Case report and review of the literature. Neurol India. 2011 Nov-Dec;59(6):933-5.5. Chittiboina P, Nixon M, Nanda A, Guthikonda B. Diagnosing paroxysmal autonomic instability with dystonia fol-lowing intracerebral hemorrhage. Neurol India. 2011 Nov-Dec;59(6):906-8.

6. Thakur JD, Chittiboina P, Khan IS, Nan-da A. Unique case of postpartum cerebral angiopathy requiring surgical interven-tion: Case report and review of literature. Neurol India. 2011 Nov\Dec;59(6):891-4.7. Nanda A. Curiosity, Compassion, and Composure. World Neurosurg. 2011 Nov 7. 8. Beckner ME, Sampath R, Flowers AB, Katira K, D’Souza D, Patil S, Patel RB, Nor-dberg ML, Nanda A. Low-Level Amplifica-tion of Oncogenes Correlates Inversely with Age for Patients with Nontypical Meningiomas. World Neurosurg. 2011 Nov 7. 9. Kumar PV, Vannemreddy P, Kumar D, Nanda A, Reddy P. Cardiac troponin I levels are a marker of myocardial dysfunc-tion in subarachnoid hemorrhage and predicts poor neurologic outcome. J La State Med Soc. 2011 Sep-Oct; 163(5):257-60.10. Banerjee AD, Ezer H, Nanda A. The artery of Bernasconi and Cassinari: a morphometric study for superselective catheterization. AJNR Am J Neuroradiol. 2011 Oct;32(9):1751-5. Epub 2011 Sep 22.

Department Recent Publications

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Message from the Chairman SUN President, Anil Nanda, MD, FACS, hosts meeting in Athens, Greece & Istanbul, Turkey

Dr. Anil Nanda, Professor and Chairman of the Depart-ment of Neurosurgery at LSU Health Sciences Center and 2011 President of SUN, organized the Society of University Neurosurgeons 45th Annual Meeting in Athens, Greece; Istanbul, and Izmir, Turkey, June 21-27, 2011. The theme of the meeting was Intercontinental Neurosurgery.

Dr. Anil Nanda presented on “Neurosurgical Aristeia and Peak Performance” in Athens. In Istanbul, he gave a presi-dential address titled “Gallipoli: Intercontinental Leader-ship through the Prism of Ataturk, Churchill, and Gandhi.” In the presidential address, Dr. Nanda discussed different facets of leadership as they apply to prominent figures in history. Important historical landmarks, such as World War I and the Turkish War of Independence, were brought together with a selection of neurosurgical cases to further illustrate this unique perspective. The talk was well received by the audience and covered by the Turkish Press and Cum-huriyet Newspaper.

Among other notable historic sites the group traveled to the Temple of Poseidon and the Acropolis in Athens, the Ciragan Palace, Topkapi Palace, Blue Mosque and Basilica Cistern in Turkey, as well as the Hagia Sophia, Archeologi-cal Museum, and Grand Covered Bazaar. Attendees were taken on a dinner cruise on the Bosphorus along the Istan-bul shoreline.

Those in attendance included Shreveport Neurosurgeons Dr. Donald Smith and Dr. Anthony Sin. Other notable guests included Simeon Gallagher, OFMCap who delivered

a presentation to SUN members in Athens, Istanbul, and Ephesus. There were over 120 internationally recognized neurosurgeons in attendance from multiple locations, in-cluding Sydney, Australia; Malaga, Spain; Recife, Brazil; and Matsumoto, Japan. They gathered to review clinical cases, describe trends in neurosurgery, and identify program in-novations from experts around the world.

The Hellenic Neurosurgical Society hosted SUN members for the one-day meeting in Athens. Yucel Kanpolat, MD, President of the Turkish Academy of Sciences, hosted the SUN guests in Istanbul, Izmir, and Ephesus.

Dr. Nanda’s Presidential Address was so well received that he was invited to return to Turkey in November of 2011 to speak on the anniversary of Atatürk’s death at Ankara University.

Dr. Peter Black, Dr. Yucel Kanpolat, and Dr. Anil Nanda at the SUN Annual Meeting in Istanbul, Turkey.

Chancellor John C. McDonald was instrumental in nurturing and de-veloping the department of neurosurgery from its inception, during his 32 year tenure at LSUHSC-S. The neurosurgery department was part of the department of surgery as a division and after 5 years became its own department.

Dr. McDonald had been a major force for the institution in the state, the community and our department. He passed away at 81 years of age. A memorial service was held at LSU Health Sciences Center - Shreveport on January 5, 2012.

Chancellor John C. McDonald Remembered

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Advancing Treatment of Atherosclerotic Disease at LSUHSC-SCerebrovascular disease takes an enormous medi-cal and financial toll on the United States each year. Every year, it is estimated that

795,000 people expe-rience a new or recurrent

stroke in the United States. Approximate-ly 610,000 of these are first attacks. The estimated direct medical cost of stroke for 2007 was $25.2 billion. While medical and open surgical therapies have been the mainstay of treatment for years, the use of endovascular techniques is growing. Endovascular therapies avoid the incision of traditional surgery, and instead treat a given disease through a catheter placed inside the diseased blood vessel.

Endovascular treatment of carotid stenosis in the neck has been the focus of many recent multicenter international studies. These studies have shown similar risk rates with open surgical endarterectomy and endovascular angioplasty and stent-ing. While there is debate on what should

be the “gold standard” for treating cervical atherosclerotic disease, angioplasty with stenting has clearly emerged as a safe and viable alternative to those patients not able to undergo traditional surgery.

While the focus historically has been treating atherosclerotic disease in the neck, advances in imaging techniques have allowed physicians to more frequent-ly identify atherosclerotic disease of the intracranial vessels. The mainstay of treat-ment for this disease is medical therapy with diet control and various medications. However, in cases refractory to our best medical care, the FDA has approved newly developed stents for use in the delicate vasculature of the brain.

Endovascular treatments for atheroscle-rotic disease are generally done in the outpatient setting. Patients arrive on the morning of the procedure and are moni-tored for one night in the Neuro Intensive Care Unit at LSU hospital. Patients are most often discharged the following day. Candidates for these procedures must be symptomatic from their lesion and meet predefined criteria as to the extent of their vessel narrowing. In both the cervical and intracranial varieties, patients must

have failed medical management or have disease so critical that it is not safe to continue without intervention. In the case of atherosclerotic disease in the neck, patients referred for stenting are usually not candidates for open surgery due to chronic medical illness, previous surgery to the neck, anatomical issues, or history of neck radiation. University Neurosurgery is pleased to announce a rapidly growing practice in delivering these treatments. Dr. Hugo Cuellar joined our staff in early 2010 as our Neurointerventionalist. Since that time, he has placed over thirty extra and intracranial stents over the last year and a half. This puts University Neurosur-gery at the forefront of our region for this growing field. Dr. Cuellar is also active in the research of cervical and intracranial atherosclerotic disease and has published several papers on the subject, adding to the growing evidence in support of these treatments.

Cerebrovascular disease is a leading cause of morbidity and death in the United States, and particularly in our region. We are happy to offer these cutting-edge services to North Louisiana and beyond to help combat this debilitating disease.

Hugo Cuellar, MDAssistant Professor

Department of Neurosurgery

Pre-Stent

Carotid Artery Stenosis

Post-Stent

Basilar Artery Occlusion

Pre-Stent Post-Stent

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A 76 year-old female, presented with complaints of visual loss in the left eye and decreased vision in the right eye, associated with headaches. On examination she was con-scious, alert, and oriented. A complete left eye visual loss and restricted peripheral vision on the right side was noted. No other deficits were found. She was a chronic smoker, had a history of migraines and multiple surgeries like tonsil-lectomy, adenoidectomy, D&C, hysterectomy, and cataract removal.

The ophthalmologist work up revealed a large parasellar mass, and she was then referred to us. A four vessel angio-gram revealed a giant ophthalmic artery aneurysm measur-ing approximately 26.9 x 21.1 x 20.3 mm, with a neck of 7.2 mm. (Fig 1 and 3) with atherosclerotic ICA.

Stenting/coiling was difficult. In view of age, bypass us-ing saphenous vein was considered. She underwent a left pterional craniotomy with zygomatic osteotomy and cervi-cal carotid exposure. An anterior clinoidectomy was done and a large paraophthalmic aneurysm was found. Proximal control was taken by clamping the cervical internal carotid artery, and a temporary clip was placed just proximal to the aneurysm. A combined technique of orthogonal dome first tandem clipping with straight clips and neck obliteration with curved clip was used. A total of five clips were used, four straight and one curved, thus a bypass was avoided (Fig 4). Intra-op angiogram and ICG showed patent ICA with filling of both the middle cerebral and the anterior cerebral artery. The post-op angiogram showed complete oblitera-tion of the aneurysm (Fig 2, 4) with a patent ophthalmic artery. Post-operatively, she had hemiparesis, a third nerve palsy, and altered sensorium, which later improved. At the last follow-up in April 2011 she was fully ambulatory, inde-pendent with resolved hemiparesis and third nerve palsy.

Anil Nanda, MD, FACSAshish Sonig, MD

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Case of the Month: Giant Aneurysms

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LSUHSC-Shreveport1501 Kings HighwayShreveport, LA 71103p: 318.813.1555, f: 318.813.1556

Willis Knighton NorthMedical Arts Building2551 Greenwood Rd., Ste. 320Shreveport, LA 71103p: 318.635.6363, f: 318.631.5392

Willis Knighton Bossier2300 Hospital Drive, Ste. 350Bossier City, LA 71111p: 318.742.8666, f: 318.742.8488

Willis Knighton Pierremont8001 Youree Drive, Ste. 830Shreveport, LA 71115p: 318.813.1555, f: 318.675.8958

Christus Schumpert Sutton Children’s HospitalOne St. Mary PlaceShreveport, LA, 71101p: 318.675.8913

Willis Knighton South2520 Bert Kouns, Ste. 105Shreveport, LA 71118p: 318.813.1555, f: 318.675.8958

Gamma Knife Radiosurgery1501 Kings HighwayShreveport, LA 71103p: 318.675.6195, f: 318.675.8944

NeuroInterventional Surgery1501 Kings HighwayShreveport, LA 71103p: 318.675.6195, f: 318.675.8944

Administrative Main Office

University NeurosurgeryLSUHSC - Shreveport, Dept. of Neurosurgery1501 Kings Highway, PO Box 33932Shreveport, LA 71130-3932p: 318.675.6404, f: 318.675.6867

Clinics

Billing Office: 318.813.1576Business Office: 318.675.8299Editorial Office: 318.675.5392Nursing Office: 318.813.1555, 888.740.7246

Department News:University Neurosurgery’smultidisciplinary team is pleased to serve youand your patients in the following locations. 2011 New Residents:

Christopher Storey, MD, PhD and Richard Menger, MD

Awards:

Dr. Anil Nanda receives the Junior Achievement Award, along with Dr. Phillip Rozeman and Mr. H.E. “Bud” Storer. Each year Junior Achievement of North Louisiana celebrates business role models in the community. A dinner in honor of this year’s Laureates was held Tuesday, October 11, 2011 at the Shreveport Country Club where Dr. Nanda recognized the whole department.

Dr. Anil Nanda and Mr. H.E. “Bud” Storer

2012 Upcoming Visiting Professors:

March 14 Richard Ellenbogen, MD April 4 Chris Shaffrey, MD

April 27 Levy Honored Speaker Kim Burchiel, MD, FACS

August 8 Gene Barnett, MD

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New Resident Receives Donald R. Smith Award

A concussion is a brief change in mental status lasting less than 30 minutes from a force-ful motion of the head. A con-cussion is often referred to as a mild traumatic brain injury. This can be a result of hitting another player, the ground, or being hit by sports equipment (ie: baseball or hockey puck.) Your child can get hit in the head or the body and sustain a concussion. The majority

of the time, they will not lose consciousness or “black out.” However, after the initial impact, your child may exhibit the following signs or symptoms of a concussion: head-ache, nausea or vomiting, confusion, difficulty remember-ing or paying attention, balance problems or dizziness, feeling sluggish, hazy, foggy, or groggy, bothered by light or noise, double or blurry vision, slowed reaction times, or sleep problems.

Concussions are common in young athletes and occur in almost 9% of all high school athletes. If you suspect your

child has a concussion, remove them immediately from the game or practice. Let them rest and recover from the brain injury. This includes physical rest and cognitive rest. Therefore, they may need to stay home from school. Do not let them play video or computer games that require exces-sive attention and concentration. They should rest until their symptoms have resolved for at least 24 hours. New legislation passed this year in Louisiana requires all athletes from 7-18 years of age who sustain a concussion in sports to be medically cleared by a physician or licensed trainer who specializes in concussions before being able to return to play. Most children will have resolution of their symp-toms within 24-48 hours of the injury. Tylenol or Advil can be used for headache or pain management.

Other ways to protect your children from concussion: Edu-cate your children on signs and symptoms of concussion. Let them know it is OK to report to their coach or parent if they think they have a concussion. It is better to sit out one game than an entire season. Make sure they have proper-fitting protective gear (helmets, pads) that is not worn or damaged. Coaches should teach children the techniques and rules of the game for safe play and hits. Encourage good sportsmanship and safe play.

Pediatric Corner: Sports Related Concussion in Young Athletes

Christina Notarianni, MDAssistant Professor

Department of Neurosurgery

The Donald R. Smith Award for excellence in neurosurgery is given in honor of Dr. Smith’s innumerable contributions to the practice of neurosurgery in Louisiana. The recipients are chosen from the graduating medical students at LSUHSC-Shreveport who have shown outstanding commitment and dedication to the field of neurosurgery.

This year’s recipient is Christopher Storey, MD, PhD, who was presented the award by Dr. Don Smith. Dr. Storey graduated from LSU and is a first year resident for University Neurosurgery. Past recipients of this award include Christina Notarianni, MD, Cedric Shorter, MD, Rishi Wadhwa, MD, Justin Haydel, MD, and Shihao Zhang, MD.The Department of Neurosurgery faculty and staff selected Christopher Storey, MD, PhD, and Richard Menger, MD, to be the newest residents in the residency program.

Our neurosurgical residency program provides an academic environment that fosters excellence in clinical neurosurgery and research. This seven year program trains residents to be outstand-ing clinicians, active investigators, and experienced educators in the neurosciences.

Christopher Storey, MD, PhD, receives Donald R. Smith Award.

Department of NeurosurgeryLouisiana State University Health Sciences CenterPO Box 33932, Shreveport, LA 71130-3932Academic Office 318.675.6404Clinic Office 318.813.1555www.universityneurosurgery.com

Nonprofit OrganizationU.S. Postage

PAIDShreveport, LAPERMIT NO. 4

Please visit universityneurosurgery.com for more information on upcoming events.

Mary Louise and Ben Levy, Jr. Conference Visiting Professorship in Neurosurgery Friday, April 27, 2012, 10 a.m. LSUHSC-S Main Auditorium Room 1-400 Kim J. Burchiel, MD, FACS Professor and Chairman of Neurological Surgery Oregon Health Sciences University in Portland, Oregon

University Neurosurgery Upcoming Event:

Department of Neurosurgery Faculty:

Anil Nanda, MD, FACSProfessor and Chairman

Donald R. Smith, MDClincal Professor

Brian K. Willis, MD, FACSProfessor

Bharat Guthikonda, MDAssistant Professor

Anthony Sin, MDAssistant Professor

Christina Notarianni, MDAssistant Professor

Hugo Cuellar, MDAssistant Professor