Vol. 1, No. 2 n Spring 2010

Focus on Brain AneurysmsNew endovascular treatments make complete occlusion a reality

By Christopher W. Nichols, M.D.Endovascular Surgical Neuroradiology and Vascular Neurology South Denver Neurosurgery

In the general population, about 2 percent of people have a brain aneurysm. Of those, 20 percent will have multiple aneurysms.1 While the majority—2.7 million per year—are unruptured, approximately 27,000 people in the United States each year will have a ruptured aneurysm. Although the risk of rupture is low, the risk of death can be up to 50 percent.2,3

Despite the high risk of morbidity or mortality associated with aneurysm rupture, 85 percent of aneurysms are not detected until rupture. For primary-care physicians, neurologists, neurosurgeons, and other health-care professionals, it’s important to understand

INSIDE

2 Research Briefs

:: Decreasing the Risks of Deep Brain Stimulation

:: Treating Trigeminal Neuralgia

:: Vertebral Compression Fracture Study

3 Brain AneurysmSupport Group

7 InterventionalNeuroradiology Services at Littleton Adventist Hospital

8Meet Our Physicians

Intracranial Atherosclerotic Disease Rates IncreasingTreatment options now include angioplasty and stenting

By Christopher W. Nichols, M.D.Endovascular Surgical Neuroradiology and Vascular Neurology South Denver Neurosurgery

In Colorado, stroke is the third leading cause of death and theleading cause of long-term disability. While extracranial carotid disease and cardioembolic disease are the most common causes of stroke, experts suspect that approximately 10 percent of strokes are the result of intracranial atherosclerotic disease, a process that causes the pathological narrowing of arteries in the head.1

Unfortunately, with rates of high cholesterol, hypertension, obesity and diabetes continuing to rise, researchers speculate that intracranial atherosclerotic disease will be encountered more often. In one study

�� continued on page 6

�� continued on page 3

A: A 44-year-old man with a ruptured middle cerebral artery aneurysm and four additional aneurysms.

C: A 61-year-old woman with a ruptured middle cerebral artery aneurysm and additional aneurysms on the left SCA and basilar tip.

DSA image with selective injection into the right internal carotid artery reveals a high-

grade stenosis of the right middle cerebral artery (MCA)

with reduced distal blood flow. See page 6 for image after

stent placement.

With kind permission from Springer Science+Business Media: Neuroradiology (2008) 50:349–354, Buhk,

Jan-Hendrik et al. © The Authors (2007).

With kind permission from Springer Science+Business Media: Neuroradiology (2007) 49:747–751, Peluso, J. et al.

research briefs

Deep Brain Stimulation Shows PromiseSouth Denver neurosurgeon improves risk/benefit ratio

David VanSickle, M.D., Ph.D., is currently working on improving the risk/benefit ratio for deep brain stimulation surgery. Deep brain stimulation is performed for both Parkinson’s disease as well as essential tremor and soon will be performed for obsessive-compulsive disorder and epilepsy. The efficacy of this procedure has been well proven with numerous, randomized controlled studies published in journals such as the Journal of the American Medical Society and the New England Journal of Medicine. While the efficacy is not in question, the risks of this surgery have held back widespread adoption. Dr. VanSickle

has tailored his practice and techniques to reduce these risks. Currently, the infection risk has been reduced to approximately one-third of the national published baseline by making operative changes to the procedure. The risks of troublesome side effects from the stimulation have been reduced by doing the initial programming in a rehabilitation setting over a period of approximately one week. It is hoped that by improving the risk/benefit ratio of DBS surgery, significantly more widespread adoption can occur, which would allow the known and well-documented benefits of this surgery to be experienced by more individuals.

2 Neuroscience News | Spring 2010

Treatment Options for Trigeminal Neuralgia (TN)   Although it strikes just 1 percent of the population, trigeminal neuralgia (TN) is a devastating condition that is often misdiagnosed or sub-optimally treated with antiseizure medications. TN is caused by a blood vessel pressing on the trigeminal nerve as it exits the brain stem. This pressure sends abnormal signals to the brain, shooting sudden, severe shocklike pains through the side of the eye, jaw or cheek. This pain often leads incorrectly to a periodontal diagnosis resulting in tooth extraction. The condition most often occurs in patients over the age of 50; and it is more common in women than men.

Diagnosis is generally made through a thorough neurological exam to rule out other conditions that create similar pain, such as cluster headaches or traumatic injury to the trigeminal nerve. Patients most likely will be referred for an MRI to rule out a tumor or multiple sclerosis. Magnetic resonance angiography also may be used as it can more clearly show blood vessel problems and any compression of the trigeminal nerve close to the brain stem.

J. Adair Prall, M.D., a neurosurgeon with South Denver Neurosurgery in Littleton, specializes in this condition and offers three treatments for TN patients:

:: Microvasular decompression (MVD): Surgery to implant a small felt pad between the blood vessels and the trigeminal nerve to alleviate the pressure; 90–95 percent success rate with relatively no complications. Drawbacks: Invasive surgery requiring general anesthesia and two-day hospital stay with a two-week recovery.

:: Radiosurgery (Gamma Knife): One-hour outpatient treatment involving focused radiation to damage the pain fibers; 80 percent success rate with no recovery time. Drawbacks: 2 percent chance of facial numbness, a potential delay in improvement of days to weeks.

:: Percutaneous radiofrequency rhizotomy (PRR): Outpatient surgery that uses an electrode to damage the trigeminal nerve; 90-95 percent success rate with immediate relief. Drawbacks: guaranteed facial numbness.

Vertebral Compression Fracture StudyBen Guiot, M.D., a neurosurgeon with South Denver Neurosurgery, is the principle investigator in a Vertebral Compression Fracture Study. Vertebral compression fractures (VCF) are bone fractures of the spine, often caused by osteoporosis. VCF is commonly treated with kyphoplasty or vertebroplasty.

Kyphoplasty involves inserting a balloon into the vertebral body and inflating it to restore height to the fractured segment; bone cement is then injected to stabilize the fracture. Vertebroplasty involves injecting bone cement directly into the vertebral body to stabilize the fracture.

Guiot’s VCF study assesses the effectiveness of a new device, called OsseoFix™, a small implant that is inserted into the vertebral body. Cement is then injected directly into the implant itself. The manufacturer, Alphatec Spine®, says OsseoFix™ is designed to reduce fractures and to use less cement.

“This study is a continuation of clinical research I’ve been doing since my residency and fellowship in 1998,” says Guiot, who is currently in the process of establishing an industry-sponsored research center in Littleton.

For more information, call South Denver Neurosurgery at 303.734.8650 or go online to

southdenverneurosurgery.org

Local Support for Brain AneurysmsBrain aneurysm patients and their families can find support, resource referrals and education through the Colorado Brain Aneurysm Foundation. Carol Gill, who suffered a ruptured brain aneurysm in 2001, and her husband started the group. It is an offshoot of the Boston-based Brain Aneurysm Foundation.

The foundation sponsors a Brain Aneurysm Support Group, which meets on the first Wednesday of each month at Littleton Adventist Hospital. The meetings are facilitated by a physical therapist specially trained in brain aneurysm rehabilitation. Each meeting features a topic related to the recovery process, such as memory, concentration, depression, loneliness and wellness. In addition to education and companionship, the group shares resources and personal experiences that can help other survivors.

Gill began the group after struggling through her own recovery with little education or resources. “My husband remembers frantically trying to find information when it happened,” Gill says.

For more information, including a meeting schedule and online resources, go to www.bafound.org/support/supgrp_colorado.php or call Carol Gillat 303-779-1821.

the risk factors associated with aneurysm formation and when screening is warranted.

Risk FactorsRecent studies prove an increased risk of aneurysm formation in patients with a family history of brain aneurysms. About 20 percent of cerebral aneurysms have a genetic component. Familial intracranial aneurysms are those that have been identified in two or more first-degree relatives. The relative risk for intracranial aneurysms in such families is about four times that of the general population.4,5,6 The most important inherited conditions associated with aneurysms include Ehlers-Danlos IV, Marfan’s syndrome, neurofibromatosis FR1, and polycystic kidney disease.

Other risk factors that can weaken the walls of arteries that may lead to aneurysm formation include::: Smoking :: High blood pressure:: Atherosclerosis :: Trauma:: Systemic infection, such as

endocarditis

Age and gender also contribute to risk. For men, cerebral aneurysms are most common after age 65. Brain an-eurysms appear more often in women between 30 and 60 years of age.

TestingScreening all asymptomatic individuals is cost prohibitive due to the expense of screening examinations, the low incidence of

brain aneurysms, and the low rate of annual rupture. Consequently, neurology and neurosurgery experts recommend screening only those patients at high risk.

Those with increased risk for developing brain aneurysms include people who::: Have two first-degree family

members who have suffered a ruptured brain aneurysm.

:: Suffer from disorders of the arteries, including polycystic kidney disease and fibromuscular dysplasia.

If a patient is at risk for an aneurysm or an aneurysm is suspected due to symptoms, primary-care physicians should refer the patient for screening with MR angiography or CT angiography. These examinations are 90 percent sensitive for the detection of aneurysms of 2 millimeters or greater and nearly 100 percent sensitive for aneurysms larger than 5 millimeters, with the risk of false positives being extremely low.7

If an aneurysm is observed or suspected on MRA or CTA, the patient should be referred to a neurosurgeon or neurologist specializing in cerebrovascular disorders. Confirmatory testing

Brain Aneurysms from page 1

Neuroscience News | Spring 2010 3

Ruptured Aneurysm Surgical Clip

Artery

Endovascular coiling (top) is less invasive than clipping (bottom) but requires follow-up angiograms to confirm that the aneurysm remains occluded.

Balloon angioplasty with stenting compares favorably to surgical bypass.

Illustration courtesy of Boston Scientific Corporation, © 2008.

4 Neuroscience News | Spring 2010

is often obtained through cerebral angiography.

TreatmentAny patient with an aneurysm should be referred to a neurosurgeon or neurologist for further evaluation. Regardless of treatment, all patients need to work with their primary-care physician to modify their vascular risk factors, especially smoking and high blood pressure.

For unruptured aneurysms, the decision to pursue treatment is based on the size, morphology and location of the aneurysm, overall health and medical history of the patient, the presence of additional symptoms (such as cranial nerve compression or mass-effect related symptoms) and the presence of smoking or a family history of rupture. Generally, aneurysms larger than 7 millimeters have the highest risk of rupture, and aneurysms in the posterior circulation (arising off the vertebral or basilar arteries) are more likely to rupture. In many cases, observation with annual imaging scans will be recommended.

Treatment options for patients requiring therapy include:1. Surgical clipping: Of the

patients who receive surgical intervention, clip occlusion remains the most common treatment. In this procedure, performed by a neurosurgeon, a small clip is placed across the neck of the aneurysm to block the normal blood flow from entering the aneurysm.

2. Artery occlusion and bypass: If clipping is not possible or the artery is too damaged, a neurovascular surgeon may perform a bypass. In a bypass procedure, a vessel is grafted around the region of the aneurysm, and the vessel harboring the aneurysm occluded. Generally, bypass procedures are more complex than either surgical clipping alone or endovascular coiling.

3. Endovascular coiling: Performed by a physician specializing in neuro-endovascular procedures (either a neurosurgeon, neurologist, or neuroradiologist) in an angiography suite, this procedure uses a catheter to insert coils or glue into the aneurysm, thereby preventing blood flow from entering. This procedure is generally less invasive than clipping or bypass, but it does require follow-up angiograms to confirm that the aneurysm remains occluded.

Endovascular AdvancementsEndovascular treatment for aneurysms is relatively new compared with surgical interventions. While endovascular treatment is

less invasive, thereby offering more rapid recovery times, significant rates of recurrence exist in aneurysms treated by endovascular methods, and long-term follow-up is required. Rates of recurrence and retreatment are highest in younger patients, those with larger aneurysms or wider necks and those for which initial treatment results in incomplete occlusion.9

While treating recurrences is generally safe and bears a low risk of complication, advances in coil technology and development of neurovascular-specific stents have made the likelihood of completely occluding an aneurysm at initial treatment much higher in recent years. This is particularly due to the advances in coils, which allows them to be packed more densely within

Illustrations courtesy of eV3.

Onyx 500 liquid embolic agent hardens as it is diffused into the blood, then serves as a “glue” to obtain complete occlusion.

Christopher W. Nichols, M.D.Stroke & Vascular Neurology

Endovascular Neurosurgery/Interventional NeuroradiologySouth Denver Neurosurgery

Christopher Nichols, M.D., is a board certified neurologist by the American Board of Psychiatry and Neurology. He is the only neurologist specializing in interventional neuroradiology in Colorado.

Dr. Nichols specializes in the treatment of::: �Acute stroke:: �Brain aneurysms:: �Brain arteriovenous malformations (AVMs):: �Dural arteriovenous fistulas (dAVFs):: �Spinal vascular malformations:: �Cervical and intracranial arterial disease:: �Cerebral venous thrombosis:: �Diagnostic cervical and cerebral angiography:: �Provocative testing (Wada and balloon test

occlusion tests)

Dr. Nichols’ current research and clinical interests include::: � Long-term follow-up of patients undergoing

angioplasty for symptomatic vasospasm:: � Advances in angioplasty treatments for intracranial

disease: vasospasm, intracranial artherosclerosis and stroke

Dr. Nichols completed his undergraduate degree at Yale University, and obtained his medical degree from Drexel University College of Medicine. He completed his medical internship and neurology residency at the University of Colorado. Dr. Nichols completed two fellowships at the University of Cincinnati, one in stroke and vascular neurology and a second in endovascular surgical neuroradiology (interventional neuroradiology).

Dr. Nichols is an active member in several professional societies, including the American Stroke Association, the American Academy of Neurology, and the Society of Vascular and Interventional Neurology.

Dr. Nichols lives with his wife and daughter in the Denver area.

the aneurysm and completely cover the aneurysm neck.8,9

Neuro-endovascular specialists, including Christopher Nichols, M.D., of South Denver Neurosurgery in Littleton, Colo., are currently employing new technologies in coiling aimed at decreasing rates of aneurysm recurrence. Those technologies include::: Onyx HD 500 liquid embolic agent:

This agent (ethylene vinyl-alcohol copolymer dissolved in dimethyl sulfoxide of DMSO) precipitates and hardens as it is diffused into the blood. It functions as “glue” and shows promise for obtaining complete occlusion initially, with low rates of aneurysm recurrence. Early trials of Onyx HD 500 show safe use in giant aneurysms or those with large necks that may not be treatable by coil occlusion or surgical clipping.9

:: Pipeline covered stents: These stents are a braided mesh cylinder composed of 48 individual platinum and cobalt chromium microfilaments, providing 35 percent of the metal coverage (compared to 10 percent or less with standard neurovascular stents). These are designed to cover the neck of the aneurysm and redirect blood flow without occluding parent vessels with flow demand. The pipeline stent has not yet been approved by the FDA.

Sources:1. Rinkel, J.E., et al. Prevalence and risk of rupture of intracranial

aneurysms: a systematic review. Stroke. 1998; 29:251-256.

2. Wiebers, D.O. Unruptured intracranial aneurysms—risk of rupture and risks of surgical intervention. New England Journal of Medicine. 1998; 339:1725-33.

3. National Institutes of Health website (www.nih.gov).

4. Broderick, et al. Greater Rupture Risk for Familial as Compared to Sporadic Unruptured Intracranial Aneurysms. Stroke online.(http://stroke.ahajournals.org) 2009.

5. Ronkainen, A., Hernesniemi J., Puranen M., Niemitukia L., Vanninen R.L., Kuivaniemi H., et al. Familial intracranial aneurysms. Lancet. 1997;349: 380-384.

6. Schievink, W.I. Genetics of intracranial aneurysms. Neurosurgery. 1997; 40:651-662.

7. Zuccarello, M. Who should be screened for brain aneurysms? University of Cincinnati Neuroscience Institute, 2010.

8. Campi, A. Retreatment of Ruptured Cerebral Aneurysms in Patients Randomized by Coiling or Clipping in the International Subarachnoid Aneurysm Trial (ISAT). Stroke. 2007; 38:1538.

9. Molyneux, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2,143 patients with ruptured intracranial aneurysms: a randomized comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet. 2005; 366: 809-17.

10. Molyneux A: Cerebral Aneurysm Multicenter European Onyx (CAMEO) Trial: Results of a Prospective Observational Study in 20 European Centers. American Journal of Neuroradiology. January 2004; 25:39-51.

Neuroscience News | Spring 2010 5

of 510 patients with asymptomatic extracranial carotid stenosis, 12.9 percent had significant intracranial stenosis.2 It is important to recognize patients who may be at high risk for developing disease and understand the options for patients with documented disease.

Risk FactorsIntracranial stenosis rates are highest in patients of black, Japanese, Chinese and Hispanic origin. Other risk factors for intracranial stenosis risk are similar to those of cardiovascular disease, including:

:: Hypertension:: Diabetes:: High cholesterol:: Smoking :: Being male:: Other vascular disease

Patients who fit these criteria—particularly those with vascular disease—are at highest risk for developing intracranial atherosclerotic stenosis, with the highest rates of disease seen in patients with carotid stenosis. Similarly, any patient who presents to an emergency department with stroke symptoms is at high risk of intracranial stenosis, and should undergo further

evaluation. Patients who have had a stroke or transient ischemic attack (TIA) attributed to stenosis of a major intracranial artery face a 12–14 percent risk of subsequent stroke during the two-year period after the initial ischemic event,

despite treatment with antithrombotic medications.3,4

Patients suspected of having intracranial stenosis, either due to risk factors or stroke, should be referred for assessment by a neurovascular specialist. Treatment may include medical therapy and risk-factor management by the primary-care physician, but also may include surgical or endovascular treatment.

Diagnostic TestingFour types of diagnostic tests are commonly available for patients at risk of intracranial stenosis:

Transcranial Doppler Ultrasound (TCD):Noninvasive and can be performed in physician offices, but low sensitivity and specificity.

MR Angiography (MRA):Noninvasive, contrast administration NOT required; disadvantages are that it may require gadolinium, lower spatial resolution and a long study that requires a great deal of patient compliance.

CT Angiography (CTA):Well-tolerated, rapid scan; higher spatial resolution than MRA, but less than DSA; disadvantages include radiation exposure and venous artifact.

Digital Subtraction Angiography (DSA)::: Still the gold standard for

determination of degree of stenosis, dynamic flow information is obtained, high spatial resolution with small pixel size, measurement criteria have been established in the WASID trial.

:: A disadvantage is limited availability of this test because of the high level of skill and training required. In addition, it is an invasive test that presents a 0.7 percent minor or major stroke risk with each procedure.

Many studies have attempted to define the best diagnostic test, but results vary between studies. At this time, noninvasive tests remain best to exclude disease, but catheter-based angiography remains the gold standard for quantification.

TreatmentDue to the high mortality risk of patients with intracranial stenosis, maximizing medical intervention is recommended for nearly all patients. Current treatments include:

:: Maximizing medical therapy is the first-line treatment with potentially the greatest benefit in prevention of stroke. This includes treating risk factors for stroke including hypertension, elevated LDL, smoking and diabetes.5

:: Treatment with aspirin or other antiplatelet therapy.

:: Surgical bypass.:: Endovascular treatment,

including balloon angioplasty with or without stenting.

6 Neuroscience News | Spring 2010

Atherosclerotic Stenosis from page 1

South Denver Neurosurgery is one of four practices in Colorado able to provide endovascular treatment

options, including angioplasty and stenting for severe narrowing or

patients at high risk for stroke.

Carotid artery with normalized blood flow after stent placement.

With kind permission from Springer Science+Business Media: Neuroradiology (2008) 50:349–354, Buhk, Jan-Hendrik et al. © The Authors (2007).

Aspirin vs. WarfarinAs mentioned earlier, many patients with symptomatic intracranial stenosis are at very high risk for recurrent stroke. A recently completed medical treatment trial, Warfarin versus Aspirin for Symptomatic Intracranial Stenosis (WASID), showed that aspirin was

as effective and safer than warfarin for preventing stroke or vascular death in patients with IS. The trial also showed that patients with 70–99 percent intracranial stenosis are at particularly high risk of stroke

despite antithrombotic therapy and usual management of vascular risk factors.4,6 Subgroup analysis showed no benefit by treatment with warfarin in any of the suspected high-risk groups, including posterior circulation stenosis and those who recently had a stroke (the so-called use of short-term anticoagulation).7

Angioplasty and Stent TreatmentDue to the high risk of stroke for patients with severe stenosis, newer treatment strategies have focused on mechanical dilation with balloon angioplasty with or without stent placement. Both techniques can be performed with a high degree of technical success and a low risk of complications.8,9 Long-term clinical follow-up of intracranial angioplasty patients demonstrates a risk of future strokes that compares favorably to patients receiving medical therapy.8 A randomized trial of medical management versus treatment with angioplasty or stenting is still awaited.

Littleton Stroke Center Offers Interventional Neuroradiology ServicesThe Stroke Center at Littleton Adventist Hospital is one of just four centers in Colorado—and the furthest center south—to offer interventional neuroradiology. This service provides life-saving, nonsurgical options for patients with ruptured aneurysms and also for stroke patients who need immediate intervention for hemorrhaging, clots or blockages in the brain. The hospital offers 24/7 coverage by neurosurgeons and neuro-interventionalists.

Interventional neuroradiology procedures available through South Denver Neurosurgery physicians at Littleton Hospital include:

Littleton Hospital is a Primary Stroke Center certified by the Joint Commission, which means the hospital adheres to nationally accepted standards and recommendations for stroke care. The hospital is also a recipient of the American Stroke Association’s “Get With The Guidelines” Stroke Gold Performance Achievement Award. The stroke program is a coordinated effort consisting of approximately 20 medical experts across a number of departments, including emergency medical services, the emergency department, radiology, neurology, nursing, ICU, physical therapy, speech therapy, the lab, administration and others.

For more information, contact Littleton Hospital’s stroke coordinator at 303.734.8694.

Neuroscience News | Spring 2010 7

Sources1. Derdeyn C., Chimowitz, M. Angioplasty and Stenting

for Atherosclerotic Intracranial Stenosis: Rational for a Randomized Clinical Trial. Neuroimaging Clin N Am. 2007; 71(3): 355-ix.

2. Elmore, et al. The prevalence of asymptomatic intracranial large-vessel occlusive disease: the role of diabetes. J Neuroimaging. 2003; 13(3): 224-227.

3. Qureshi A., et al. Consensus Conference on intracranial atherosclerotic disease: rationale, methodology, and results. J Neuroimaging. 2009; 19(S1): 1S-10S.

4. Kasner, et al. Predictors of ischemic stroke in the territory of symptomatic intracranial arterial stenosis. Circulation. 2006; 113: 555-63.

5. National Institutes of Health clinicaltrials.gov website, February 2010.

6. Chimowitz, et al. Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis. New England Journal of Medicine. 2005; 352(13): 1305-16.

7. Kasner, et al. Warfarin vs. aspirin for symptomatic intracranial stenosis: subgroup analysis from WASID. Neurology. 2006; 67(7): 1275-8.

8. Marks M., et al. Angioplasty for Symptomatic Intracranial Stenosis. Clinical Outcome. Stroke. 2006; 37: 1016.

9. Fiorella D., et al. U.S. Multicenter Experience with the Wingspan Stent System for the Treatment of Intracranial Atheromatous Disease: Periprocedural Results. Stroke. 2007; 38(3): 881-887.

Patients presenting with stroke or TIA symptoms should have testing for both intracranial and

extracranial atherosclerotic disease. If intracranial

atherosclerotic disease is detected, the gold standard

for quantifying stenosis remains catheter based

angiography.

:: Intra-arterial TPA (Tissue Plasminogen Activator): An injection of clot-busting drugs into the clot in the blood vessel to break-up the clot interfering with blood flow. In some cases, this can be effective up to six hours after onset of stroke symptoms.

:: Clot Extraction Technology: Devices that can be threaded through blood vessels to the brain to extract clots. In some cases, this can be effective up to eight hours after onset of stroke symptoms. Physicians currently utilize the Penumbra System™ and Merci Retrieval System™.

:: Angiography: Diagnostic testing that can quickly identify the cause of bleeding in the brain.

:: Stent and Coil insertion or surgery to address brain aneurysms.

New research is being conducted into balloon angioplasty with stenting for use in patients with cerebral stenosis.

PRSRT STDU.S. Postage

PAIDDenver, CO

Permit No. 1818

7780 S. Broadway, Suite 260

Littleton, CO 80122

About UsSouth Denver Neurosurgery provides state-of-the-art diagnostic and treatment programs for a wide range of brain and spinal disorders. We partner with our patients and their physician team to make individualized decisions and treatment plans. Our physicians are some of the most experienced in the Rocky Mountain region, offering the latest, most up-to-date procedures and treatment options to patients.

Physicians desiring a consult, please call: 303.734.8650

Locations:Littleton Adventist Hospital CampusArapahoe Medical Plaza III7780 S. Broadway, Suite 260Littleton, CO 80122Porter Adventist Hospital CampusHarvard Park Medical Plaza 950 E. Harvard Ave., Suite 620Denver, CO 80210South Denver Neurosurgery303.734.8650 (phone)303.734.8653 (fax)www.SouthDenverNeurosurgery.org

Ben Guiot, M.D. Neurosurgeon, board-certified by the American Board of Neurological Surgeons and the Royal College of Physicians and Surgeons of Canada. Specializing in all aspects of spine care including::: Minimally invasive

spine surgery:: Spinal deformity correction:: Reconstruction of complex

spinal disorders

Christopher Nichols, M.D.Neurologist, specializingin stroke and vascular neurology and endovascular neurosurgery, including evaluation and treatment of:

:: Brain aneurysms:: Arteriovenous

malformations:: Dural arteriovenous

fistulas:: Acute stroke and

intracerebral hemorrhage:: Cervical and intracranial

arterial disease:: Cerebral vasculopathy:: Cerebral venous

thrombosis

J. Adair Prall, M.D.Neurosurgeon,specializing in::: Trigeminal neuralgia:: Spinal disorders:: Neuro-oncology:: Minimally invasive

and motion preserving spine surgery

:: Stereotactic radiosurgery (Gamma Knife and CyberKnife)

David VanSickle, M.D., Ph.D.Neurosurgeon, Ph.D.in bioengineering, specializing in::: Deep brain stimulation

(DBS) for Parkinson’s and essential tremor

:: Epilepsy surgery:: Neuro-oncology:: Spinal cord stimulator

implantation for pain:: Transphenoidal surgery

(pituitary surgery):: Minimally invasive and

motion preserving spine surgery

:: Stereotactic radiosurgery (Gamma Knife and CyberKnife)

Meet Our Physicians

CenturaHealthcomplieswiththeCivilRightsActof1964andSection504oftheRehabilitationActof1973,andnopersonshallbeexcludedfromparticipationin,bedeniedbenefitsof,orotherwisebesubjectedtodiscriminationintheprovisionofanycareorserviceonthegroundsofrace,religion,color,sex,nationalorigin,sexualpreference,ancestry,age,familialstatus,disabilityorhandicap.