Expert consultation for complex cerebrovascular neurosurgery

Almost all patients with cerebrovascular disease should be referred to a subspecialist for assessment. This is particularly true in cases that may be deemed inoperable, because new technology and advanced surgical approaches—hybrid open/endovascular approaches, new aneurysm clipping devices, and novel stent constructs—have changed what is possible.

“Referral is essential in complex cases when there are concerns about the size or location of a lesion, or when a condition has recurred or failed previous treatment,” says Visish Mani Srinivasan, MD, a Penn Medicine cerebrovascular neurosurgeon. “A subspecialist can promptly and accurately diagnose the condition and develop a treatment plan that ensures the best possible outcomes.”

Penn Neurosurgery offers access to one of the region’s finest multidisciplinary programs in cerebrovascular surgery. The team has made it simple to expedite referrals for cerebrovascular disease, the second leading cause of death worldwide.

“A subspecialist team has rather unique expertise and experience taking care of each of those conditions at the highest level; there is nothing that’s beyond the level of expertise of our physicians and our team at large,” Dr. Srinivasan adds.

When to consult a cerebrovascular neurosurgeon

Dr. Srinivasan stresses that the Penn cerebrovascular neurosurgery team is ready and willing to talk with other physicians about all cerebrovascular conditions at any stage. He emphasizes that it is never too early to consult with a cerebrovascular surgical subspecialist, even in cases that seem simple or appropriate for conservative management.

However, there are specific aspects of disease that should definitely prompt a consultation, second opinion, or referral. For example, as aneurysms and other cerebrovascular abnormalities grow, they become more likely to cause complications, such as impinging on nearby structures, rupture, and stroke.

Location is another important consideration. Conditions affecting eloquent locations such as the vertebral or basilar arteries or brainstem should be assessed by a specialist. “Those are sensitive areas of the brain, fraught with potential problems, and those cases require more expertise because they are difficult to take out while preserving surrounding brain tissue and normal function,” Dr. Srinivasan notes.

Failure of previous treatment is also a key indicator that subspecialty care may be appropriate. In these cases, such as previously treated basilar aneurysms, typical tools may not work well.

“Not only do you have to treat a condition that has proven itself to fight back, but you’re working around the previous treatment, which sometimes increases the challenge,” Dr. Srinivasan says. “For example, if someone had a prior surgery, you must do a second open surgery working around scar tissue or clips. This requires a certain familiarity with the treatment changes that happen with that prior approach.”

Finally, any patient who has multiple lesions should be referred to a specialist who has a deeper understanding of the manifestations of genetic cerebrovascular disease. Cases related to newly discovered genetic mutations may be managed differently, and these patients often require genetic testing and counseling.

Advanced diagnosis techniques in cerebrovascular disease

Advanced imaging technology is critical in diagnosing and fully understanding cerebrovascular conditions. The Penn Medicine Cavernous Malformation Center uses high-resolution MRI with cavernoma-specific MR sequences to identify small or multiple cavernomas, and high-resolution, high-definition angiography to produce extremely detailed images of brain vasculature.

Penn specialists also use angiograms to diagnose cerebrovascular conditions, a superior method to CT with contrast. We enhance angiograms with artificial intelligence algorithms to support the detection and visualization of stroke and aneurysm. These tools are also helpful through the monitoring and postoperative management phases.

Advanced surgical approaches for cerebrovascular conditions

When surgery is the best path forward for patients with a cerebrovascular condition, they are best served by a team with expertise in the latest approaches to maximize outcomes, minimize complications, and shorten recovery.

MMA embolization for subdural hematoma

Middle meningeal artery (MMA) embolization for subdural hematoma is expected to become a more common neurosurgery due to the aging population. In this minimally invasive procedure, the surgeon uses a catheter to block the middle meningeal artery, stopping blood flow and allowing the hematoma to resolve.

Penn Medicine was involved in the clinical trials of this procedure, which is the new standard of care. “We perform a large number of these procedures and continue to make innovations in patient selection and improvement of the procedure,” Dr. Srinivasan says.

Cerebral stent placement/angioplasty

Performing angioplasty and placing stents often presents specific challenges.

“Generally, in patients requiring angioplasty, vasculopathy is present in all their arteries. You’re going to cross some atherosclerotic plaques along the way. And as we age, arteries lose elasticity and get twisty. Those factors make it difficult to get where the surgeon needs to go,” Dr. Srinivasan explains.

Subspecialists see these cases much more frequently and have increased knowledge of the anatomy and how to navigate around these challenges. In addition, experts have extensive experience creating novel extended stent constructs, such as using two stents to create an H-shaped device.

Treatment options for cavernomas

Neurovascular surgeons are well positioned to recommend the best treatment for cavernomas. We may recommend medical management or resection.

“Even a surgeon capable of taking out a cavernoma may not understand the surrounding anatomy that may cause issues and what taking it out will affect,” Dr. Srinivasan says. “In addition, cavernoma resection is best performed by a specialist because it can happen in conjunction with a genetic element.”

Centers with a large volume of these cases are better positioned to have the best outcomes.

Resection of brain stem lesions

Subspecialist surgeons are very effective at removing entire lesions in eloquent, sensitive areas of the brain, such as the brainstem. The focus is resecting the entire lesion, rather than subtotal resection, without causing stroke or damage.

“All the core functions of the brain are connected to the brain stem. This area controls wakefulness and consciousness, motor control, sensory control, breathing, and circulation,” Dr. Srinivasan says. “This is the technical pinnacle of cranial neurosurgery.”

The Penn team uses a variety of tools to operate here, including advanced mapping, image-based surgical guidance, and very small, specialized tools.

Connecting your patients to the latest options in cerebrovascular conditions

Because Penn Medicine is involved in basic research and clinical trials of novel treatment options for cerebrovascular conditions, our patients have access to options that may not be available elsewhere.

Advantages of collaborative care

At Penn Medicine, care of a patient with a neurovascular condition extends far beyond the surgeon. For the best possible outcomes, patients need a team with experience in their specific condition to help them through the entire treatment trajectory.

“The expertise that comes from a large volume of cases—that expands beyond just the surgeon’s personal expertise, but the whole team. This includes neuroanesthesiologists, neurointensivists, and neurorehabilitation specialists. That’s where subspecialists stand out,” Dr. Srinivasan says. “We are all very familiar with everything from preoperative planning to surgical techniques to the postoperative recovery course. We are equipped to get the most out of the potential for function and recovery.”

Referrals and consultations

To get a second opinion or consultation from a Penn Medicine cerebrovascular surgeon, or to make an emergency transfer, please call 877-937-7366 or refer a patient online.