The Center for Image-Guided Neurosurgery (CIGNS) directed by Constantinos Hadjipanayis, MD, PhD, incorporates the expertise of individuals in neurosurgical oncology, Gamma Knife stereotactic radiosurgery, stereotactic and functional neurosurgery, neuro-oncology, radiation oncology, and neuroradiology. Ajay Niranjan, MD, MBA, is associate director of the center and L. Dade Lunsford, MD, is director emeritus. The goal of the center is to provide quality patient care using minimal access or minimally invasive stereotactic and radiosurgical technology, MRI-guided focused ultrasound, and image-guided brain tumor surgery that includes fluorescence-guided surgery, use of a robotic-assisted exoscope, and endoscopic colloid cyst removal.
The CIGNS is a leader in advanced imaging of the brain that incorporates magnetoencephalography (MEG). In 1981, the center was the first U.S. center to install a dedicated computed tomography (CT) scanner in a unique stereotactic operating room suite. The CIGNS was also the first North American center to initiate a clinical program for Gamma Knife stereotactic radiosurgery in 1987 and continues to be an international leader in this field. Currently, two Gamma Knife units are located at UPMC Presbyterian, one of the few clinical sites in the world with two clinical units. In 2024, the center upgraded one of its units to the latest generation Gamma Knife, Esprit, which incorporates advanced robotics, expands the role of radiosurgery to include cranial vertebral junction targets, provides greater patient access, and enhances patient safety. Both the existing ICON® Gamma Knife and the new Esprit system incorporate a cone beam CT imaging system to facilitate a mask stereotactic fixation system for selected patients.
Gamma Knife technology represents one of the most advanced and minimally invasive methods to treat patients with brain tumors, skull-based tumors, arteriovenous malformations (AVMs), and pain or movement disorders. Over 18,000 patients have undergone Gamma Knife stereotactic radiosurgery at UPMC Presbyterian since 1987. In addition, spinal radiosurgery using several radiosurgical systems is offered under the direction of neurosurgeon Peter Gerszten, MD, who serves as the Peter E. Sheptak Endowed Professor at the University of Pittsburgh.
In 2024, the CIGNS will incorporate a new therapeutic device to its armamentarium for disorders of the brain that incorporates focused ultrasound and use of a sophisticated new MRI. The minimally invasive and incisionless technology termed, ExAblate Neuro, will be the first focused ultrasound system in western Pennsylvania. This device represents the next generation of image-guided neurosurgery and is FDA-approved for lesional thalamotomy for essential tremor. The new focused ultrasound technology will also be used in research studies for patients with brain tumors in combination with novel therapeutic agents. The ExAblate Neuro system will be used in research studies with Alzheimer’s and epilepsy patients as well. Jorge González-Martínez, MD, PhD, will be actively treating patients with the ExAblate Neuro system for essential tremor in addition to Drs. Hadjipanayis and Niranjan who will be engaged in research studies on brain tumors.
A major focus of the CIGNS is sophisticated imaging of the brain to localize important functions of the brain (speech, motor, vision, and sensory functions). In 2021, UPMC installed the new MEGIN TRIUX® Neo magnetoencephalography (MEG) unit to perform functional brain mapping in patients with brain tumors, epilepsy, trauma, and degenerative brain disorders. The MEG is routinely used in the CIGNS for presurgical planning and determination of important regions of the brain to avoid for safer surgery by our neurosurgical oncologists and epilepsy surgeons. Dr. Niranjan is the operations director of MEG and Andre Pereira is the lead technologist. He continues to pursue cutting edge MEG research that seeks to develop more specific paradigms to pinpoint the anatomic areas of speech, visual, motor, and sensory function.
The Center for Image-Guided Neurosurgery is an international training site for radiosurgery and minimally invasive neurosurgery, holding six week-long training courses per year. Over the last 20 years, more than 2,500 neurosurgeons, neuro-otologists, radiation oncologists, medical physicists, and nurses have trained at this center. These courses are among the highest rated post-graduate courses offered at the University of Pittsburgh. In 2015, the center opened a new state-of-the-art education and training facility equipped with the latest generation high-definition display systems. In July of 2020—during the early COVID pandemic—the center offered online Gamma Knife training courses. Course participants from around the world become “temporary” students at the University of Pittsburgh for one week. Instruction is possible using more than 35 lectures, videos, and course materials. Hands on training in collaboration with Elekta, Inc. allows students to turn their personal computers temporarily and remotely into radiosurgery planning workstations. Students can now study radiosurgery effectively, avoiding the transportation and housing costs involved with national or international travel.
CIGNS also participates in the training of selected fellows who compete for the Leksell Gamma Knife Society three-month fellowship in Pittsburgh. Finally, neurosurgery residents at UPMC spend a three-month dedicated block for study during their third year of training to complete certification in brain radiosurgery, typically participating in more than 150 cases during the rotation.
In addition, the center conducts numerous clinical, long-term outcome research projects (typically producing 20+ peer reviewed publications each year). CIGNS is the coordinating center for the International Radiosurgery Research Foundation (IRRF), a multi-institutional international clinical consortium of centers of excellence performing stereotactic radiosurgery. The IRRF currently has members from the United States, Asia, Africa, Europe, and Asia. Multiple retrospective clinical trials have been published or are underway. More than 10,000 articles have now been published worldwide in the field of stereotactic radiosurgery. The University of Pittsburgh has the highest number of studies, having been cited more than 100 times.
Each year, more than 600 patients undergo Gamma Knife radiosurgery at the CIGNS, making it one of the busiest centers in the world. Each year, center faculty publish approximately 20 clinical research studies, now exceeding more than 700 combined peer reviewed publications and over 1,400 publications when book chapters and presentations are included.
In 2022, the third edition of Intracranial Stereotactic Radiosurgery was released by CRC Press, with Dr. Lunsford, and Jason Sheehan, MD, co-director of the Gamma Knife Center at the University of Virginia—and former fellow at the University of Pittsburgh—serving as editors.
More than 100 U.S. or international fellows have received training at this center since 1987. The center provides an opportunity for advanced training in image-guided stereotactic and functional surgery at the fellowship level. The CAST-approved fellowship has two tracks, one for candidates interested in a functional focus (movement disorders, pain, and epilepsy with study supervised by Dr. González-Martínez) and one for candidates focusing on neurosurgical oncology and radiosurgery (supervised by Drs. Hadjipanayis, Lunsford and Niranjan). The functional track includes epilepsy and movement disorder experience plus three months on the radiosurgery service. The radiosurgery track includes nine months on the radiosurgery service and three months on the functional service. Currently, all PGY-3 residents spend three months each on the Gamma Knife service each year. In addition, there is now a CAST-accredited neurosurgical oncology fellowship incorporates GK radiosurgery into the curriculum in addition to surgical resection of primary brain, skull-based, and spinal tumors at UPMC Presbyterian Shadyside.
The multidisciplinary Center for Image-Guided Neurosurgery includes the clinical and research efforts of radiation oncologists John Flickinger, MD; Serah Choi MD, PhD; Christopher Wilke, MD; Andrew Zureich, Yoshio Arai, MD; and Susan Rakfal, MD. The participating medical physics group consists of Greg Bednarz, PhD, and Kelin Wang, PhD. The APPs include Lana Trofimova, PAC, and Louisa Urgo Shin, PAC, who provide patient care assistance for the CIGNS program. Five full-time dedicated, and very talented, nurses headed by Miranda Crum, BSN, and assisted by RNs Mark Geminetti, Zarina Corwin, Kristen Jeannette, and Brenda Unghajer who provide pre, intra, and post radiosurgery care to more than 600 patients every year. They are all especially trained in conscious sedation techniques to provide comfort and attentive care to our patients.
Kelly Powell, Dana Adams, and Julie Martin are an extremely capable administrative team that ensures prompt patient approvals and care.