Randy S. Bell MD, FAANS
CDR, MC, USN
Associate Professor and Chief, Neurological Surgery Walter Reed National Military Medical Center
Uniformed Services University of Health Sciences
As we continue to highlight the incredible advancements within cerebrovascular neurosurgery this month, it is important to remember the paradoxically positive contributions to medicine that originate from the experience treating wartime injuries. This has never been truer than during the care of members of the armed forces from America’s conflicts since 2001.
The late 1990s and early 2000s saw debate raging in cerebrovascular neurosurgery over the best method (traditional open surgery versus new endovascular techniques) to treat many conditions. Within this context, a young West Point graduate and neurosurgery resident at Walter Reed Medical Center, COL (ret) Rocco A. Armonda, MD, FAANS, saw tremendous opportunity. Inspired by his chairman, LTC (sep) Richard G. Ellenbogen, MD, FAANS, he set out to bring a new skill set to the care of America’s active duty military population. Following the completion of his neurosurgical residency, Dr. Armonda started his cerebrovascular and endovascular fellowship with Robert H. Rosenwasser, MD, FAANS, at Thomas Jefferson University in Philadelphia. During this time he learned techniques that he would bring to bear to advance the care of the most severe battlefield head injuries.
Dr. Armonda deployed to Iraq near the start of Operation Iraqi Freedom (2003-4) as the commander of the 207th Head and Neck Team, 44th Medical Command, 18th Airborne Corps, 82nd Airborne Division. Over the next 14 months, he, and his deployed neurosurgery partner LTC Richard J. Teff, MD, FAANS, would care for some of the worst brain injury casualties seen since the Vietnam Conflict. Many of the lessons gleaned from the Vietnam conflict, especially the treatment of penetrating head injuries, had been lost due to technological advancement as well as attrition and inexperience. Moreover, the prevalence of improvised explosive devices (IEDs) used in these conflicts resulted in the proliferation of high-energy blast injuries. Rocco recently reflected on his time on deployment, recalling a particularly challenging patient who presented early in his experience with bifrontal penetrating head and facial injury. This patient was rapidly decompressed surgically but later died due to a delayed rupture of an undiagnosed traumatic aneurysm. With this patient in mind, Dr. Armonda realized a more aggressive approach was necessary for the treatment of these new types of injuries.
As survival from battlefield head and neck injuries improved with more aggressive surgical treatment, the increased prevalence of traumatic cerebrovascular injuries became more apparent. Dr. Armonda was the first United States neurosurgeon to perform cerebral angiography in the battlefield setting, augmenting the ability to diagnose early traumatic intracranial arterial injuries. Upon his return from Iraq in 2004, he incorporated routine cerebral angiography into the downstream diagnostic algorithm for all patients who returned with penetrating head injury from blast. He was the first to note a connection between the blast overpressure wave and the onset of severe traumatic vasospasm and helped pioneer and validate the use of endovascular techniques (coils, glue) in the treatment of traumatic intracranial aneurysms. He has since authored or co-authored numerous papers describing this experience. As a result, the military approach to the treatment of severe penetrating and closed brain injury, and associated cerebrovascular compromise is now the standard of care in civilian neurosurgery as well. In addition, cerebral angiography and neurointerventional surgery (mechanical thrombectomy, etc.) is now performed as needed both on the battlefield as well as downrange at domestic military medical centers.
Dr. Armonda is now retired from active duty service but continues to use the approaches he innovated on the battlefield in his current practice at Georgetown University Medical Center and the MedStar Washington Hospital Center where he now focuses on bringing superb stroke care to his patients. He remains actively involved in the training and mentorship of the next generation of military cerebrovascular neurosurgeons. He consistently notes a passion for the advancement of the management of many cerebrovascular pathologies and remains an inspiration for the ongoing work carried on today by the neurosurgeons he trained.
On this Memorial Day, we salute the service and ingenuity of Dr. Armonda in advancing the care of America’s soldiers as well as the treatment of cerebrovascular disorders.
Editor’s Note: We encourage everyone to join the conversation online by using the hashtag #VascularNeurosurgery.