Center for Cerebrovascular and Neuroendovascular Surgery
Lenox Hill Neurosurgery is the only department in New York City to receive the 2018 Healthgrades Stroke Care Excellence Award for superior outcomes in stroke management. Patients who suffer a stroke and receive their care at Lenox Hill Hospital have a lower risk of mortality. Additionally, Lenox Hill Hospital was one of only two hospitals in Manhattan to achieve an Excellent 30 Day survival and Above Average patient safety score in the 2018 U.S. News & World Report Rankings of the best hospitals for Neurology and Neurosurgery.
At Lenox Hill Neurosurgery, our experts specialize in the management of complex brain aneurysms, brain tumors, brain and spinal cord AVMs, tumors of the head and neck, stroke, and vascular malformations of the head and neck in adults and children. By implementing the latest technology to communicate with patients, their family members and other healthcare providers, our surgeons facilitate the understanding of complex problems and create an experience of comfort and outstanding results.
Our experts, together with the New York Head and Neck Institute, invented the nationally and internationally recognized Lenox Bypass™. Utilizing the most advanced techniques and expertise, our team offers options of cerebral bypass surgery for the treatment of large brain aneurysms, moyamoya disease and stroke prevention.
The collaborative enthusiasm of our surgeons enhances their individual skills and creates a safe environment. By utilizing less invasive techniques of endovascular neurosurgery, our experts perform coiling for brain aneurysms, embolization of AVMs and sclerotherapy of facial vascular malformations. A unique collaboration between the Brain Tumor Center and the endovascular neurosurgery teams at Lenox Hill Hospital offers the latest intra-arterial chemotherapy treatments for the care of patients with brain tumors.
Lenox Bypass™ at Northwell Health
The Lenox Bypass is a new type of intracranial (occurring within the skull) bypass developed and performed by our expert surgeons for the treatment of brain aneurysms that measure more than two centimeters.
The innovative procedure, developed by David J. Langer, MD, chairman of neurosurgery at Lenox Hill Hospital, and Peter D. Costantino, MD, executive director of the New York Head and Neck Institute, improves the safety of these types of bypass by avoiding neck incisions, drilling into the skull and use of long blood vessels required in traditional procedures.
Previous procedures required running a blood vessel from the neck into the brain. Use of a long vessel creates risk of crimping, by turning the head for example. Crimping these vessels can lead to stroke. With the Lenox Bypass, the surgeons run a blood vessel from the brain to behind the cheek. Patients benefit because this direct, safer approach not only eliminates the need for long neck incisions, but also the risk of crimping the vessel through everyday movements.
The creation of the Lenox Bypass was made possible due to the unique, team-based approach of the Northwell Health physicians. By working collaboratively across departments, Dr. Langer and Dr. Costantino were able to combine their skill sets to establish a new procedure that improves patient outcomes and gives renewed hope to those with large aneurysms.
An abstract about four Lenox Bypass cases has been published in the prestigious journal Neurosurgery. The abstract, Internal Maxillary Artery to Middle Cerebral Artery Bypass: Infratemporal Approach for Subcranial-Intracranial (SC-IC) Bypass, was co-authored by Northwell Health physicians Peter D. Costantino, MD; David J. Langer, MD; David Chalif, MD; Amir Dehdashti, MD; Mark Eisenberg, MD; Erez Nossek, MD; Rafael Ortiz, MD; and Avi Setton, MD.
Research & clinical trials
Research plays a major role in the growth and process of treatments we offer. The research and clinical trials David Langer, MD, and Rafael A Ortiz, MD, produce with brain aneurysms, stroke and interventional neuro-oncology have propelled the area of neurological medicine.
Working with investigators at the Feinstein Institutes for Medical Research, the research arm of Northwell Health, Dr. Langer and Dr. Ortiz have published and presented several studies on cerebral bypass surgery, carotid revascularization, mechanical thrombectomy, NOVA blood flow measurements, moyamoya disease, arteriovenous malformations in adult and children, medical technology and aneurysm treatment outcomes, among others.
For current clinical trials and to see our publications, click here.
Our treatments & services
Moyamoya disease treatment is directed to patients that are symptomatic with transient ischemic strokes (TIAs), strokes or bleeding. There is no medical therapy for the disease, although aspirin is often recommended because it is helpful for stroke prevention. Surgical treatment for symptomatic patients involves restoring blood flow to the deprived brain.
Two distinct types of brain bypass are utilized: 1) direct bypass or 2) indirect revascularization. A direct bypass is the moyamoya disease surgery treatment of choice for adults if the patient's particular anatomy allows it. During the direct bypass procedure, a blood vessel from the scalp (superficial temporal artery) is surgically attached to a brain blood vessel (middle cerebral artery) through a small skull defect. The bypass immediately provides additional blood to the starved brain.
The indirect technique is the moyamoya disease surgery treatment of choice for children and is also useful for adults with the disease. The indirect revascularization, or synangiosis, involves suturing a scalp blood vessel directly to the brain substance rather than to another blood vessel. The covering of the brain, called dura, may also be used during this operation to enhance the effectiveness of this technique. The restoration of blood flow following an indirect procedure may take weeks to months, but will typically provide sufficient blood flow as it matures to prevent future strokes.
Intracranial bypass is a surgical procedure used to reroute blood around a blocked blood vessel in the brain to restore blood flow. A small hole in the skull is made to expose the area of the brain that needs to be treated. The neurosurgeon then takes a healthy blood vessel from an area outside the brain and connects it to a blood vessel inside the brain. This reroutes blood around the aneurysm, restoring blood flow. In some cases, an intracranial bypass can involve taking a vein or artery from the arm or leg and use it to direct blood around a blockage. The first reported intracranial bypass surgery in the U.S. was performed at Lenox Hill Hospital.
This is a minimally invasive procedure that requires the insertion of a catheter into the femoral artery in the leg. Using real-time X-ray guidance, the catheter is then navigated through the blood vessel into the head and into the aneurysm. Soft platinum coils are then threaded through the catheter and deployed into the aneurysm. The coils conform to the shape of the aneurysm, fill the sac and block blood flow to prevent the aneurysm from rupturing. This procedure is performed under general anesthesia (light sedation). The hospital stay for uncomplicated aneurysm coil embolization is usually two to four days, and the full recovery time is five to seven days. For complicated endovascular coil embolizations, especially if the aneurysm has bled, the hospitalization period can range from one to two weeks, depending upon the patient's medical condition and the complications caused by the bleeding.
Aneurysm clipping is a surgical procedure performed on both ruptured and unruptured aneurysms. The aneurysm is surgically exposed through a small opening in the skull called a craniotomy. Once the aneurysm is located under microscopic guidance, the neurosurgeon places a surgical clip or clips around the base of the aneurysm. The clips cut off the blood flow to the aneurysm and allow flow through the normal vessels. Aneurysm clipping surgery is done under general anesthesia and also involves a neuro-monitoring team that observes the electrical functioning of the brain during the surgical procedure to ensure the best outcome.
Laser-assisted cerebral bypass surgery
This is a surgical procedure used to restore blood flow to the brain. A cerebral bypass is like a coronary bypass in the heart, but in the brain. Laser assisted cerebral bypass surgery is utilized when an aneurysm cannot be treated with clipping or coiling.
The conventional technique
A cerebral bypass is a surgical technique that involves connecting a blood vessel from outside the brain to a vessel within the brain in order to provide blood to an area that either needs more blood flow or is fed by a vessel that needs to be sacrificed to treat a specific pathology. Bypasses come in essentially two types. The first type is called a superficial temporal artery to middle cerebral artery bypass or STAMCA. The superficial temporal artery (STA) normally provides blood to the face and scalp and can safely be surgically disconnected from the scalp and attached to brain vessels. You can feel the pulse of the STA in front of your ear. This bypass is utilized to provide additional flow to the brain primarily after a loss of flow from a large vessel due to vascular disease. This operation is performed to decrease the risk of stroke in a small subset of patients.
The second type of bypass utilizes a transplanted vessel such as a saphenous vein or radial artery to connect an artery in the neck to a large brain vessel. These types of bypasses provide more flow than the lower flow STAMCA and are utilized primarily when a large vessel of the brain needs to be sacrificed in order to cure an untreatable aneurysm or skull base tumor that involves a major brain vessel.
Embolization and surgery of brain AVMs
A brain AVM can present in several different ways. Some brain AVMs present with bleeding in the head, others present with headaches, seizures, neurological signs (e.g., weakness), and others present incidentally (i.e., an MRI of the brain done for another reason showed a brain AVM).
The management and treatment of a brain AVM will depend on the patient's age, the symptoms and signs, and how easy or difficult it is to treat the AVM (i.e., size and location within the brain).
Some AVMs are managed conservatively, but others will need intervention to prevent bleeding in the head, seizures, and/or worsening of neurological symptoms. Interventions for AVMs include:
- Endovascular embolization—Injection of liquid adhesives (glue and/or Onyx) through catheters that are navigated from a small incision in the groin region (femoral artery) to the area of the AVM in the brain
- Surgery—Craniotomy (brain surgery) to remove the AVM
- Radiation—Less invasive modality, but it does not cure the AVM immediately as it takes some time to have its maximum final effect
Some AVMs may need treatment with several of the intervention modalities in order to achieve the final goal.
Sclerotherapy for venous malformations of the head and neck
A venous malformation is caused by weakness in the wall of a vein. It can present with swelling of the face or neck. The swelling fluctuates with positioning (it is more swollen when lying down than when standing up) and with circumstances with elevated pressure (crying, straining). There can be a bluish discoloration on the skin and there are no palpable pulsations. Urgency of treatment depends on the proximity of the malformation to the eye, airway, and/or tongue. Prevention of the normal development of the teeth and bones of the face also creates an urgent situation.
The diagnosis is made clinically and it can be supported by ultrasound, CT scan, and MRI without and with contrast.
Treatment is with sclerotherapy, surgery, laser, or a combination of these treatments. In sclerotherapy, a needle is introduced into the venous malformation under X-ray and ultrasound guidance. After verifying the correct position of the needle, sclerosing agents that injure the wall of the vein (e.g., Bleomycin, STS) are infused.
Sclerotherapy of lymphatic malformations of the head and neck
Lymphatic malformations of the facial region are divided into macrocystic (large cysts) or microcystic (small cysts). These are not malignant or cancerous lesions. Management of lymphatic malformations of the facial region should be tailored to the size of the malformation, the presenting symptoms, and the potential complications from the lesion.
Treatment of the malformation can be with surgical resection and/or endovascular microcatheter sclerotherapy. For the endovascular treatment, a needle is introduced into the malformation and the collection of lymphatic fluid is drained. This is followed by infusion of a sclerosing agent (medication that injures the lining of the malformation to prevent the fluid from accumulating again). Different agents can be infused for treatment of lymphatic malformations (e.g., Bleomycin, Doxycycline). Each of the drugs used for sclerotherapy can have potential complications, including injury to the facial nerve or damage to the skin, for example. The drug infused will depend on the size and location of the malformation.
Treatment of lymphatic malformations involving the airway (floor of the mouth, tongue) or intra-orbital region (compressing the eye) need to be addressed in a more emergent fashion than the lesions in other locations to prevent the potential complications of the malformation.
Carotid artery stenting and carotid endarterectomy
Carotid artery disease is a potential risk for ischemic stroke. Angioplasty and stenting of the carotid artery can decrease the risk of stroke.
The management options to decrease the chance of stroke in someone with carotid artery disease, includes:
- Medical management with antiplatelet agents (e.g., aspirin) and lipid lowering medications (statins)
- Balloon angioplasty and stenting
- Carotid endarterectomy (surgery)
The optimal treatment depends on the age of the patient, accompanying symptoms, comorbidities (medical history), and findings on imaging tests (carotid ultrasound, CTA, MRI/A, femoral cerebral angiogram).
Regardless of the treatment to fix the carotid artery, ischemic stroke preventive measures include treatment for hypertension, diabetes and high cholesterol, smoking cessation, and physical activity.
Mechanical thrombectomy for acute stroke
People with symptoms of acute ischemic stroke need to go to the hospital immediately for diagnosis and treatment. Some of the symptoms of acute ischemic stroke include:
- Sudden onset of weakness on one side of the body
- Inability to speak
- Sudden onset of numbness on one side of the body
- Double vision
- Slurred speech
At the time of arriving to the hospital, a head CT will be done to make sure that there is no bleeding in the head in order to start the appropriate ischemic stroke treatment. The only FDA approved therapy for acute ischemic stroke is intravenous infusion of tPA (clot busting drug). Those patients with stroke caused by occlusion of one of the large arteries of the brain that do not improve within one hour of starting the infusion of tPA, treatment with endovascular techniques is an option. Endovascular treatments are performed by introducing a catheter through the femoral artery (artery that takes blood to the leg) and navigating to the arteries of the brain where the occlusion is to infuse tPA directly, aspirate the clot, or mechanically pull the clot out.
Patients with acute ischemic stroke will need to be admitted to the hospital to find out the cause of the stroke and institute the appropriate treatment (medications and/or procedures) to prevent another stroke from happening.
Physical, occupational, and speech therapy are very important to improve the outcome and recovery after suffering an ischemic stroke.
The ELANA technique
ELANA, excimer laser-assisted nonocclusive anastomosis, is a technique using an excimer laser/catheter system for intracranial bypass surgery of the brain. The technique has been developed over the past 15 years by Tulleken and colleagues at UMC Utrecht in The Netherlands for treatment of primarily untreatable giant aneurysms. The emergence of transplanted conduit bypass is a valuable technique for managing these lesions and the subsequent development of ELANA bypass. The ELANA technique allows the operating surgeon to perform an extracranial-to-intracranial or intracranial-to-intracranial bypass using a transplanted large caliber conduit without occlusion of the recipient artery, thus eliminating intraoperative ischemic insult related to temporary occlusion time