Strong Neurosurgeons Give Albany-Area Woman Second Chance at Life

December 08, 1999

Even though a potential time bomb lurks within the folds of their brains, most patients with arteriovenous malformations (AVM) experience healthy, carefree lives, unaware of any physical problem hidden within their bodies. But when this tangled web of arteries and veins begins hemorrhaging, induces seizures, or causes sudden death, this congenital defect usually comes to light.

Deborah Hart of Surprise, New York is one of the fortunate ones. Her AVM was discovered before it resulted in catastrophe. Like most patients with AVMs, Hart lived a normal life - she graduated from high school, married, held a full-time job, and enjoyed time with her friends. Except for an occasional migraine headache, life was fine. But, when Hart, 35, suffered a serious grand mal seizure two years ago while riding in an automobile, her potentially fatal disorder was discovered.

Arteriovenous malformations are a fairly common disorder, accounting for one percent of all strokes. By today's projections, a young adult with an AVM has a 40 to 50 percent risk of major or fatal bleeding in his or her projected life span. Three percent of individuals who have AVMs will experience cerebral hemorrhage and one percent die per year.

Extensive testing found Hart's AVM buried deep within the dominant hemisphere of her brain - the control center for her language and motor function. Because her AVM was so large and located so deep inside the left temporal lobe, she was a high-risk candidate for traditional surgery. Until now, treatment options for high-risk patients like Hart were virtually non-existent. Thanks to cutting-edge technology and a newly recruited team of specialized neurosurgeons at Rochester's Strong Memorial Hospital, Hart underwent treatment that has given her a second chance at a normal life.

Hart's surgical team included neurosurgeons Cargill Alleyne, M.D., and Robert Maciunas, M.D., and neuroradiologist Yuji Numaguchi, M.D., of the new Center for Image-Guided Surgery at Strong Memorial Hospital. Dr. Alleyne, who has expertise in both cerebrovascular and endovascular surgery, received specialized training at Barrow Neurological Institute, under the direction of world-renowned vascular neurosurgeon Robert Spetzler, M.D.

Hart's case is unique for many reasons - among them, she is the first patient in Rochester to undergo surgical removal of an AVM using new high-tech, image-guided equipment; and she remained conscious for a portion of the procedure while the surgical team used functional mapping to pinpoint the exact location of her language and motor centers which were near the AVM. Hart also underwent three prior glue embolizations on her AVM, performed by the same surgical team of Drs. Alleyne, Maciunas, and Numaguchi.

New Generation of Technology Lowers Risk

Using a new technique known as "interactive image-guided surgery," Hart's surgical team was able to navigate deep into her brain -- to the precise location of her AVM -- steered by three-dimensional MRI images of Hart's brain, which were displayed on an overhead computer monitor. Using this interactive, computer-driven system, surgeons were able to place a probe in Hart's brain and "see" on the monitor, exactly where they were in her brain. This helped them to plan a safe approach. For patients with brain tumors, this technique can also help surgeons determine the dimensions of a tumor by differentiating between tumor, scar tissue, and/or brain matter. As a result, surgeons are able to more fully remove lesions in difficult-to-reach locations with much lower risk to the patient.

Because Hart's AVM was located in a sensitive part of the brain, the surgical team also used a new technique known as "functional mapping" in which they stimulated various portions of her brain during the surgery to ensure that Hart's normal language and motor functions remained intact. Hart was intermittently awakened during her surgery to test her motor and language functions. She responded to specific commands, which enabled the surgical team to prevent inadvertent damage to healthy areas of her brain.

Once the surgeons located and removed Hart's AVM, an intraoperative angiography was performed while she was still in the operating room. This angiography is a type of x-ray that images blood flow. This allowed the surgical team to review their work, ensuring that the AVM was completely removed and that restructured blood vessels were functioning as planned, before closing the surgical wound. Traditionally, this would have been performed hours after the patient left the operating suite.

Hart's surgery represented the first time in Rochester that a patient has undergone complex brain surgery for an AVM using image-guided techniques, functional mapping, and intraoperative angiography.

"For decades, brain surgery has been hampered by the same challenge that faced the ancient mariners," Maciunas said. "Because these early seamen lacked good navigational tools, they sailed near the shore, afraid to venture too deep into the ocean out of fear of what they might encounter and whether or not they could find their way back. Likewise, neurosurgeons have tended to stay near the skull and shied away from tackling anomalies that were buried deep into the brain tissue."

Maciunas, who was recently recruited to Strong from Vanderbilt University, where image-guided brain surgery is routine, said that these navigational tools are now revolutionizing neurosurgery. "Deborah's surgery represented the first time that we've brought our full arsenal of new high-tech surgical tools to the aid of a single patient with an AVM here in Rochester. It's exciting because it puts Strong in a league with the world's leading neurosurgical centers as being able to offer state-of-the-art surgical solutions for patients with lesions in delicate, once-inaccessible areas of the brain."

Strong Memorial Hospital's team of nine adult and pediatric neurosurgeons are specialists in treating patients with blood vessel disorders such as aneurysms and AVMs, complex brain tumors, as well as those who've suffered strokes, epilepsy, movement disorders such as Parkinson's Disease, chronic pain, and complex disorders of the spine. Strong Memorial Hospital had the only Neurology and Neurosurgery programs in Upstate New York to be ranked in U.S. News & World Report's 1999 America's Best Hospitals edition.

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