endovascular procedures. Whatever approach is employed, says Dr. Riina, “we’re now able to successfully treat most—if not all— aneurysms, unruptured and ruptured, with a very, very high success rate and excellent outcome.” This expertise, also made possible by the division’s two other leading cerebrovascular surgeons, Jafar J. Jafar, MD, professor of neurosurgery, neurosurgeon-in-chief, and director of cerebrovascular surgery, and Paul P. Huang, MD, assistant professor of neurosurgery and head of cerebrovascular surgery at Bellevue Hospital Center, has made NYU Langone the go-to center on the East Coast for complex aneurysms, arterial malformations, and other cerebrovascular disorders, with patients routinely flying in from the West Coast and elsewhere. “We’re not seeing run-of-the-mill cases anymore; we are seeing cases requiring that added expertise, or those that have been attempted at other institutions without success,” Dr. Riina notes. DIVISION OF CEREBROVASCULAR SURGERY Managing the Most Complex Cerebrovascular Conditions with a Range of Approaches 2014 Highlights — • Performed over 1,000 neurointerventional/ endovascular radiology procedures, with the treatment of over 250 brain aneurysm repairs (both endovascular and open) and 75 brain AVMs • Novel minicraniotomy approaches to brain aneurysms using an eyebrow or blepharoplasty incision largest referral center for brain aneurysms and arterial-venous malformation (AVM) of the brain and spinal cord advanced imaging including dedicated neuro-digital biplane angiography equipment and hybrid operating room NYU LANGONE MEDICAL CENTER / NEUROLOGY AND NEUROSURGERY / 2014 PAGE 9 CLINICAL CARE Dr. Riina is currently working on several new devices of his own design, including a bifurcation flow-diverter that he recently patented, which steers blood flow away from aneurysms located in branching vessels. He is also collaborating with one of the Medical Center’s pediatric ENT specialists on a tracheal stent that could avoid the need for tracheotomies in conditions such as tracheomalacia or in patients whose airway has been damaged by trauma or radiation therapy. The division utilizes advanced imaging equipment in their procedures, including digital biplane angiography, which marries three-dimensional angiography to a neuro-navigational guidance system. They are now working with a leading technology company on an even more advanced concept, in which three-dimensional translucent images of the brain’s blood vessels would be superimposed over the surgeon’s field of vision during surgery, giving the surgeon “X-ray vision.” “Our field is all about advanced imaging and intervention,” says Dr. Riina. “We’re always looking for the next technological step that will make our treatments even more effective. The definition of the neurosurgeon is evolving—now an image-based, minimally invasive interventionalist who brings the latest technology to bear on the treatment of complex neurological problems.” In NYU Langone’s “hybrid” operating room, cerebrovascular neurosurgeons perform both open and minimally invasive, imageguided procedures, often within the same operation if necessary. The hybrid OR combines the features of a standard operating room with the technology of a neuroradiology interventional suite, including built-in digital X-ray fluoroscopy mounted on a robotic arm, computer guidance systems, and three-dimensional video-integrated technology that projects threedimensional images of the surgical field onto high-definition plasma monitors. Two additional neurosurgical hybrid ORs are slated for installation in a new clinical pavilion, scheduled to open in 2017. “The hybrid room provides the ultimate flexibility,” says Dr. Riina. “When the patient is on the table, I can come in, get the additional diagnostic information I need, and do whatever intervention is necessary. Whether that involves a minimally invasive incision through a 1-cm craniotomy over an eyebrow or through the eyelid, a needlestick in the groin to deliver a flow-diverter, or a skull-base approach for an unusual vascular lesion—it can all be done right then and there.” “HYBRID” OR COMBINES OPEN AND IMAGE-GUIDED SURGICAL FACILITIES PAGE 10 NYU LANGONE MEDICAL CENTER / NEUROLOGY AND NEUROSURGERY / 2014 NYU LANGONE MEDICAL CENTER / NEUROLOGY AND NEUROSURGERY / 2014 PAGE 11 CLINICAL CARE With every minute’s delay in administering the clotbusting drug tPA to an ischemic stroke patient, another two million brain cells die, explains Koto Ishida, MD, assistant professor of neurology and director of NYU Langone’s Comprehensive Stroke Care Center. That is why, although their average “door-to-needle” time (elapsed time from ambulance arrival to tPA injection) was under 60 minutes, the center’s team spent considerable time this year planning for implementation of the Helsinki Model. This protocol shaves off additional minutes through steps that include the ambulance team pre-notifying the hospital when a stroke patient is en route; a triage process that sends the patient directly from the ambulance to a CT-scanner; and administration of tPA right in the CT-scan suite. The new model, which was developed in close collaboration with NYU Langone’s Ronald O. Perelman Department of