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"This technique — stereotactic EEG — is much better tolerated by patients, and it's where the field is moving," he says. For patients whose seizure focus is limited to the right (nondominant) tem- poral lobe, a traditional lobectomy can offer a 70 to 80 percent chance of being virtually seizure-free, with very low risk of cognitive or other side effects. However, certain patients whose seizures are bilat- eral or arising from the left temporal lobe may have an increased risk of speech or memory problems following traditional surgery. For these patients, Dr. Eskandar offers less invasive options. For example, he can ablate the area of seizure focus using a stereotacti- ca l ly i nt roduced f iber- opt ic probe. Alternatively, he can insert electrodes through a small, dime-size cranial opening and connect them to a small defibrillator- like device implanted under the scalp that detects and averts seizure activity in the area. Similarly, with deep brain stimula- tion, he can make two small openings in the skull, introduce 1-millimeter-thick electrodes into the thalamus, and attach them to wires that run underneath the scalp and neck to a pulse generator that sits along the chest wall. "These are all relatively new therapies that are finding a bigger role in treating cases where, in the past, there would not have been a surgical option, and hence no definitive treatment," Dr. Eskandar says. The outcomes of these minima l ly invasive approaches are similar to those of conventional epilepsy surgeries and far superior from a morbidity perspec- tive, he says. "There's less time in the operating room, minimal blood loss, less discomfort — they're just much better tolerated by patients." PARKINSON'S AND TRIGEMINAL NEURALGIA P a r k i n s on 's d i s e a s e a f fe c t s m or e t h a n 10 m i l l ion pe ople worldw ide, according to the Parkinson's Foundation. The first line of treatment — medica l therapy — often loses effectiveness in f ive to 10 yea rs a nd ca n have serious side ef fect s, i nclud i n g hy potension and ha llucination. Advanced surgica l treatments can offer superior outcomes, Dr. Eskandar says. "Deep brain stimulation for Parkinson's is an amazing, potent surgery that's been found to be better than the best medical therapy," he says. "It started in France, and the FDA approved it for advanced Parkinson's in 2002, but it took awhile to gain acceptance. Today, this is a pro- cedure that's almost always performed at a big academic hospital." Between 75 and 80 percent of patients with Parkinson's disease gain significant benef it from deep bra in stimulation, particularly amelioration of tremor and rigidity and an average 50 percent reduc- tion in medication, Dr. Eskandar says. He also sees excellent outcomes with minimally invasive surgery for trigeminal neuralgia, an excruciating condition. "Before there were treatments, there was a significant risk of suicide for patients with trigeminal neuralgia because the condition is so painful and because it's triggered by very basic activities of living — things like eating, drinking and kissing," he says. Trigeminal neuralgia is usually caused by an aberrant artery compressing the trigeminal nerve. Patients who do not respond to medical treatment have a full range of surgical options at White Plains Hospital. The most durable and successful is microvascular decompression, which carries very low risk with an experienced surgeon, Dr. Eskandar notes. "It's a small, beautiful, elegant surgery that takes two or three hours and is per- formed under a microscope," he says. "We make a quarter-size opening in the skull, identify the artery that's compressing the trigeminal nerve, gently move it aside and then put in small, pea-sized cushions made of Teflon to separate the artery from the nerve. It is effective over 90 percent of the time, and it works long term because it addresses the root cause of the problem." Other effective options include rhi- zotomy, which is minimally invasive, and radiosurgery, which is noninvasive. While their benefits are less durable than those of microvascular decompression, the fact that they are less invasive may make them better options in certain cases, depending on patients' needs and preferences, according to Dr. Eskandar. The complex cranial neurosurgeries now available at White Plains Hospital are Meet Vijay Agarwal, MD DR. AGA RWA L is Director of the Skull-Base Tumor Center at Montefiore Medical Center in the Bronx and Assistant Professor of Neurosurgery and of Otorhinolaryngology at Albert Einstein College of Medicine. He attended Chicago Medical School and was a neurosurgery resident at Duke University Medical Center. He completed fellowships in mini- mally invasive and endoscopic skull base neurosurgery at the Center for MIS Neurosurgery in Sydney, Australia; open skull base neurosurgery at Mayo Clinic; and open cerebro- vascular surgery at Emory University Hospital. Dr. Agarwal specializes in neurological surgery, acoustic schwannomas, meningiomas, pituitary adenomas, and primary and skull base tumors. He sees patients at both Montefiore Medical Center and White Plains Hospital. At White Plains Hospital, Dr. Agarwal performs traditional and minimally invasive surgery for brain tumors such as gliomas, meningiomas and pituitary tumors, working closely with radiation oncologists in the provision of stereotactic radiosurgery, particularly for brain metastases. M D N E W S . C O M /// M D N E W S L O N G I S L A N D ■ 2 019 0 9

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