Neurological Institute Annual Repor t

Transcription

1 Neurological Institute 2008 Annual Repor t

2 Contents 02 C H A I R M A N S W E L C O M E 04 C L E V E L A N D C L I N I C N E U R O L O G I C A L I N S T I T U T E O V E R V I E W 10 O U R C E N T E R S 22 PAT I E N T C A R E 24 C O M M U N I T Y C A R E O U T C O M E S 30 T E C H N O L O G Y A N D I N N O VAT I O N 38 R E S E A R C H 50 E D U C AT I O N 54 N E W S TA F F 56 N E U R O L O G I C A L I N S T I T U T E S TA F F 62 S E R V I C E S F O R P H Y S I C I A N S A N D PAT I E N T S On the cover: Neurosurgeon Jorge Gonzalez-Martinez, MD, PhD, joined the Neurological Institute s Epilepsy Center in Subsequently, he performed North America s first stereoelectroencephalography (SEEG) procedure, which opens the possibility of new treatment options for patients with intractable focal epilepsy.

3 Cleveland Clinic s Neurological Institute achieved significant growth in patient and surgical volumes in This annual report chronicles the progress that underlies the numbers: geographic expansion, new research insights, innovative treatment modalities, extended educational opportunities for healthcare professionals and the public, accelerated collection of clinical data, the addition of talented staff and promising affiliations with new partners. All these advances are driven by a fundamental goal: to provide exceptional patient care and improve outcomes.

4 Michael T. Modic, MD, FACR

5 Welcome 3 Dear Colleagues When we measure clinical outcomes, one variable we do not chart is geography. There are many reasons people do or do not survive acute events such as stroke, but there is no dispute that superior outcomes often correlate with immediate access to a medical center equipped with the resources to rapidly provide treatment according to updated, nationally recommended standards. In Cleveland Clinic s Neurological Institute, our patient-centered approach incorporates a strategic design for geographic diversity, predicated on the notion that the widely dispersed population we serve is entitled to a uniformly high level of care. Our goal is to distribute technology and expertise so that, whether an individual needs emergency or continuing care, location is never an issue. In fact, patient proximity is an integral component of our template for growth throughout Cleveland Clinic. We are resolved to function as an enterprise-wide entity, rather than as a chain of discrete facilities. Consequently, the health system is adopting a coordinated, continuous longitudinal care model, with variable resources at different regional sites. This configuration benefits our locally and nationally based patient populations alike. To the former group, broadened reach promises a consistent level of expertise close to home, no matter where home happens to be; for the latter, it augurs improved access and outcomes as well as unvarying standards of excellence. This thinking is reflected in the Neurological Institute s new Lou Ruvo Center for Brain Health, with addresses in Cleveland and Las Vegas; our new Center for Behavioral Health, which consolidates psychiatric resources at designated regional sites; our Sleep Disorders Center, which offers patients a common, high-quality experience at seven community-based overnight sleep laboratories; a new, hospital-based suburban Cleveland neurological site that addresses even the most complex disorders; and the Department of Physical Medicine and Rehabilitation, now part of our institute, with inpatient and outpatient locations throughout northeast Ohio. The principal enabler of this shift is technology. In the Neurological Institute, we are leveraging the technical infrastructure through our imaging capabilities, which are now distributed across the community, and the enhanced electronic medical record. The institute s Knowledge Program is focused on standardizing data collection within each patient s record to better track outcomes and analyze information. A complementary initiative, critical to regional growth, is the codification of standardized care pathways across the entire hospital system. I alluded to stroke care, possibly the best example in the Neurological Institute. With the population aging and stroke incidence rising, these patients are being diagnosed rapidly and treated appropriately, consistent with Get With The Guidelines SM protocols, at every Cleveland Clinic facility. Ultimately, the key to any successful undertaking is people. Here, the commingling of Cleveland Clinic and independent physicians, working together as one team, is an essential piece. Collaboration is a tenet of the multidisciplinary Neurological Institute and the foundation for a truly integrated system. In this annual report, we are pleased to demonstrate how this system is evolving and expanding to serve patients better and to prepare for the inevitable healthcare challenges to come. I look forward to continuing to document our progress. Sincerely, Michael T. Modic, MD, FACR Chairman, Cleveland Clinic Neurological Institute clevelandclinic.org/neuroscience

6 4 Overview Cleveland Clinic Neurological Institute Overview The multidisciplinary Cleveland Clinic Neurological Institute includes more than 250 medical, surgical and research specialists dedicated to the treatment of adult and pediatric patients with neurological and psychiatric disorders. The institute offers a disease-specific, patient-focused approach to care. Our unique, fully integrated model strengthens our current standard of care, allows us to measure quality and outcomes on a continual basis, and enhances our ability to conduct research. U.S.News & World Report s America s Best Hospitals survey ranked our neurology and neurosurgery programs sixth in the nation in 2008 and again in Our pediatric neurology and neurosurgery programs were ranked fourth in the nation in both years. Our neurology, neurosurgery, pediatric neurology/neurosurgery and psychiatry programs are also ranked best in Ohio. The institute model allows our patients to access the care they need through specialized, multidisciplinary, disease-specific centers that integrate the expertise of neurologists, neurosurgeons, orthopaedic surgeons, psychiatrists, psychologists, physiatrists, neuroradiologists and others into the comprehensive care of a single disease: Cleveland Clinic Lou Ruvo Center for Brain Health Brain Tumor and Neuro-Oncology Center Cerebrovascular Center Epilepsy Center Mellen Center for Multiple Sclerosis Treatment and Research Center for Neuroimaging Center for Neurological Restoration Center for Pediatric Neurology and Neurosurgery Neurological Center for Pain Neuromuscular Center Department of Physical Medicine and Rehabilitation Department of Psychiatry and Psychology Center for Regional Neurology Sleep Disorders Center Center for Spine Health In 2008, the Neurological Institute served 140,000 patients and performed 7,500 surgeries. We provide care across the spectrum of neurological disorders, including primary and metastatic tumors of the brain, spine and nerves; pediatric and adult epilepsy; headache, facial pain syndromes and associated disorders; movement disorders such as Parkinson s disease, essential tremor and dystonia; neurocognitive disorders such as dementia and Alzheimer s disease; cerebral palsy and spasticity; hydrocephalus; metabolic and mitochondrial disease; fetal and neonatal neurological problems; multiple sclerosis; stroke; cerebral aneurysms; brain and spinal vascular malformations; carotid stenosis; intracranial atherosclerosis; nerve and muscle diseases, including amyotrophic lateral sclerosis, peripheral neuropathy, myasthenia gravis and myopathies; sleep disorders; and mental/ behavioral health disorders and chemical dependencies. Right: A dedicated 16-bed Neurointensive Care Unit is staffed with neurologists, neurosurgeons, specially trained nurses, respiratory therapists, nutritionists and pharmacists, all under the direction of neurointensivists. The full-service unit, which treats more than 1,300 patients a year, is equipped to manage any neurological condition regardless of severity. Cleveland Clinic Neurological Institute 2008 Annual Report

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9 Overview 7 Expert, Specialized Diagnosis Neurological Institute physicians draw on advanced diagnostic capabilities and experience. Our imaging services include structural and functional magnetic resonance imaging (MRI), computed tomography (CT), positron emission tomography (PET), myelography, diagnostic cerebral/spinal angiography, interventional neuroradiology, and carotid and transcranial Doppler ultrasound. Our neuroimaging staff subspecializes in specific disease entities such as epilepsy and cerebrovascular disease, ensuring accurate, in-depth interpretations. Additional diagnostic tools are found in our epilepsy monitoring units, sleep laboratories, neuropsychological testing facilities, electromyography laboratory, autonomic laboratory and cutaneous nerve laboratory. The Latest Treatment Modalities Patients receive leading-edge treatment options at the Neurological Institute, where we continue to advance such innovations as deep brain stimulation (brain pacemakers), epilepsy surgery, stereotactic spine radiosurgery, endovascular treatment of cerebral aneurysms and vascular malformations, and neuroendoscopy. Distinctive services such as our three-week outpatient program for sufferers of chronic headaches and our Headache Infusion Suite provide intensive therapy when needed. The Brain Tumor and Neuro-Oncology Center s Translational Therapeutics Program is accelerating the process of bringing novel therapeutic agents from the laboratory to the patient. Joint Commission certification as a Primary Stroke Center and accreditation by the American Academy of Sleep Medicine are just two examples of our commitment to providing the most advanced and highest quality of care to our patients. Relevant Research We strive to conduct research directly related to conditions experienced by our patients, with programs in translational research, The Cerebrovascular Center s neurovascular intervention and operating suite is designed for traditional microsurgical procedures and for advanced, highly technical endovascular procedures. clinical trials of drug and device interventions, neuroimaging research, epidemiology and health outcomes, behavioral and psychiatric research, and research into better diagnostic methods. Typically, more than 100 clinical research trials are under way at any time in the Neurological Institute. In 2008, we were awarded more than $17.9 million in neurological-based grants and research contracts. Convenient Care in the Community We are committed to making access to world-class care convenient for all our patients, whether they come to us from down the street or half a world away. Our Neurological Institute regional centers represent a systemwide expansion of our services to Cleveland Clinic regional hospitals and family health centers throughout the community. In 2008, the Neurological Institute expanded to Lakewood Hospital, providing comprehensive services to Cleveland s West Side and western suburbs. The Cleveland Clinic Neurological Institute at Lakewood Hospital offers patients access to multiple specialists in a convenient location where they can receive evaluation, treatment, rehabilitation, preventive care and other services they require. In addition, Cleveland Clinic neurologists oversee inpatient care at a number of other Cleveland Clinic hospitals. Left: The first stereoelectroencephalographic (SEEG) procedure in North America is performed at Cleveland Clinic. SEEG targets specific brain areas to localize the epileptogenic zone more precisely and less invasively. clevelandclinic.org/neuroscience

10 8 Overview Our Sleep Disorders Center has also extended its regional presence with seven community-based overnight sleep laboratories, including five hotels where sleep studies are performed with patients convenience and comfort in mind. With the recent formation of our Center for Behavioral Health, we are building a regional network of mental health and psychiatric services to improve patient access to care and ensure quality and efficiency. structure lends itself to greater information sharing and process improvement opportunities. Through continuing education programs, learning opportunities range from basic nursing instruction to subspecialization in neurological nursing, enabling nurses, like their physician colleagues, to provide specialized care. Pioneering the Collection of Data and Outcomes The Knowledge Program, a joint initiative of the Neurological Institute, the Imaging Institute and the Information Technology Division, is designed to harness routinely collected electronic clinical and administrative data to allow us to optimize patient care and outcomes. Data from multiple electronic sources, including imaging results and clinical information collected during patient encounters, such as disease-specific measures of patients health status, are consolidated in a clinical data warehouse that can be accessed and queried by healthcare personnel. An integral part of this initiative is the standardization of clinical information documented within the electronic medical record. Information gained from the Knowledge Program informs and guides clinical care, quality improvement and research. Patients First For Neurological Institute nurses, opportunities abound on the job as well as through continuing education programs that enable subspecialization for those who are interested. Integrated Nursing Services The Neurological Institute integrates inpatient and ambulatory nursing, enhancing the continuum of patient care. This unique We recognize that a patient s healthcare experience is defined by both superior clinical outcomes and compassionate, personalized care: Did we respond when a patient needed us? Were that individual and his or her family treated with the dignity and respect that every person deserves? We have committed to measure this intensely human variable, patient satisfaction, and we have appointed a Patient Experience Officer to oversee this initiative. At Cleveland Clinic s Neurological Institute, we are dedicated to maximizing both patient care outcomes and the patient experience. In addition, advancing medical education and research in neurology, neurosurgery and psychiatry are institutional priorities. Right: A nurse in one of the Neurological Institute s inpatient units assesses a patient s functionality. Since 2003, Cleveland Clinic has held Magnet hospital status, the highest national designation of nursing excellence. Bestowed by the American Nurses Credentialing Center, Magnet status is the gold standard for patient care. Cleveland Clinic Neurological Institute 2008 Annual Report

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13 Our Centers 11 Our Centers With the formation of two new specialized, multidisciplinary centers for brain health and behavioral health, the Neurological Institute continued to grow in 2008, extending its model of integrated expertise for delivery of diseasespecific, patient-focused care. Cleveland Clinic Lou Ruvo Center for Brain Health A collaboration between the Neurological Institute and the Las Vegas-based Lou Ruvo Brain Institute has resulted in creation of this highly specialized clinical center for advancement of research, early detection and treatment of cognitive disorders such as Alzheimer s disease. The Cleveland Clinic Lou Ruvo Center for Brain Health brings together an interdisciplinary team of neuroscientists, physicians, therapists, surgeons, imaging specialists and other medical experts dedicated to preventing the disabling symptoms of chronic brain disease and prolonging healthy, vital aging in people at risk for dementia or cognitive disorders. New discoveries and emerging science tell us that cognitive disorders can be identified earlier than previously believed and potentially altered, says Michael T. Modic, MD, FACR, Chairman of the Neurological Institute. Our hope is to bring together world-class clinicians and researchers to advance our understanding of cognitive disorders and provide the best care possible for people who suffer from them, as well as their caregivers. The center will offer services in both Cleveland and Las Vegas, where a $100 million facility designed by renowned architect Frank Gehry recently welcomed its first patients. It houses clinical space, a diagnostic center, neuroimaging rooms, physician offices and laboratories devoted to clinical research. Randolph B. Schiffer, MD, a nationally known neurologist/ psychiatrist, serves as Director of the Cleveland Clinic Lou Ruvo Center for Brain Health. Dr. Schiffer spent 10 years as Chairman of the combined Department of Neuropsychiatry and Behavioral Science at Texas Tech University Health Sciences Center. The Neurological Institute was thinking about establishing a creative new medical program for cognition at precisely the same time the Lou Ruvo Brain Institute was being founded in Las Vegas to the same purpose, Dr. Schiffer says. The Neurological Institute brings with it almost 100 years of tradition and medical science in Cleveland. The Lou Ruvo Brain Institute brings with it a window to the great resources and populations of the Southwest. Together, we will create the pre-eminent program in the world for care of the cognitive impairment disorders. The center provides the most technologically advanced diagnostic services, including 3 Tesla MR and, in the future, PET/CT, performed by one of the world s leading neuroimaging academic medical centers. A multimodal treatment program for people with mild symptoms of impairment incorporates physical exercise, cognitive rehabilitation and cognitive-enhancing medications. The late Lou Ruvo, from whom the center takes its name, suffered from Alzheimer s disease. To his son, Larry Ruvo, Chairman of the Lou Ruvo Brain Institute, the center is the realization of a long-held dream: This is a perfect integration of Cleveland Clinic s mission and excellence in patient care, research and education and what we want to create here in Las Vegas With Cleveland Clinic as our operational partner, we will be able to hit the ground running. Left: Early peri-ventricular white matter signal changes in this 55-year-old woman with hypertension and glucose intolerance may be forward-looking warnings that she is at risk for one of the age-related cognitive loss syndromes during the decade ahead. clevelandclinic.org/neuroscience

14 12 Research Cleveland Clinic Neurological Institute 2008 Annual Report

15 Our Centers 13 The institute model allows patients to better access care through specialized, multidisciplinary, disease- specific centers that integrate the expertise of neurologists, neurosurgeons, orthopaedic surgeons, psychiatrists, psychologists, physiatrists, neuroradiologists and others into the comprehensive care of a single disease. Department of Psychiatry and Psychology The Department of Psychiatry and Psychology is restructuring under a new Center for Behavioral Health. The center includes an abundance of behavioral health resources widely dispersed across the Cleveland Clinic health system, which includes the main campus, 10 community hospitals and 17 family health centers throughout northeast Ohio. Consolidation of key services at designated regional locations will improve patient access to care as well as facilitate more effective patient management, ensure quality of care and drive operational improvements. In addition, this reorganization will encourage refinement of existing programs and development of innovative new behavioral healthcare models. Under the Center for Behavioral Health concept, selected Cleveland Clinic facilities will house specialized resources such as adult psychiatry, child and adolescent psychiatry, chemical dependency services and geropsychiatric programs. Geographically dispersed but closely integrated, this regional network will promote collaboration among behavioral health specialists and reinforce the team s ability to deliver comprehensive therapeutic services that return patients to full functionality. Patients will be triaged to the particular site where an appropriate concentration of skills and services can best meet their needs. This centralization of knowledge and expertise will, in turn, result in better clinical outcomes, more enlightened research and outcomes data based on a broad regional population, which will be especially relevant to referring physicians considering where to send their patients for specialized care. Brain Tumor and Neuro-Oncology Center The Brain Tumor and Neuro-Oncology Center (BTNC) is a national leader in the diagnosis, treatment and research of brain tumors. A multidisciplinary team of physicians and scientists focuses almost exclusively on brain tumors, facilitating opportunities to participate in international research protocols, share information on new developments and combine therapeutic approaches. As a result, the center brings the most promising new treatments to the clinical realm in an environment that emphasizes individualized patient care. The center is a pacesetter in the development, application and refinement of sophisticated therapies for life-threatening tumors. Each year, the team records approximately 8,000 outpatient visits and performs some 950 surgical procedures. The BTNC s Cleveland Clinic Gamma Knife Center, established in 1997, offers patients a nonsurgical option for treatment of brain and spinal metastases and other brain disorders. The Cleveland Clinic Gamma Knife Center is one of only a few such facilities worldwide certified by Elekta, sole manufacturer of the Gamma Knife, to train physicians in this precise form of stereotactic radiosurgery. In 2008, four hands-on courses drew more than 30 participants, bringing the total number trained to more than 400. Cleveland Clinic psychiatrists, psychologists, clinical nurse specialists, social workers, counselors and therapists provide a full spectrum of mental health and chemical dependence services. Left: Intraoperative image guidance allows neurosurgeons to remove brain tumors via minimal-access craniotomies. clevelandclinic.org/neuroscience

16 14 Our Centers The Cerebrovascular Center s state-of-the-art angiography room allows for endovascular and open craniotomy treatment of patients with cerebrovascular disease. Cerebrovascular Center The Cerebrovascular Center integrates neurologists, neurosurgeons, neuroradiologists and neurointensivists who offer expert diagnosis and medical, endovascular and surgical management of patients with all cerebrovascular conditions. With a unique mix of physician subspecialties, the center delivers endovascular therapy and care of the highest quality. Stroke care emphasizes aggressive acute intervention. The center is a Joint Commission-certified Primary Stroke Center and has one of the highest stroke-related volumes in North America, with more than 3,200 patient visits annually. Patients receive comprehensive care in the 16-bed Neurointensive Care Unit. Additionally, the center is home to a Neuroendovascular Research Laboratory, which focuses on cerebral aneurysm treatment, imaging research, blood-brain barrier function and cerebral hemorrhage management. The Epilepsy Center has one of the world s foremost epilepsy programs, with more than 4,000 adult and 2,000 pediatric patient visits annually. In 2008, epilepsy neurosurgeons performed more than 300 surgical procedures, including lobectomies, hemispherectomies, and implantation of vagal nerve and responsive neurostimulators. Patients have gained an improved quality of life due to the expertise of the clinical staff and the availability of leading-edge technologies such as stereoelectroencephalography (SEEG): chronic intracranial EEG monitoring with stereotactically implanted intracerebral electrodes. Cleveland Clinic introduced the first SEEG program in North America, thus offering patients with intractable focal epilepsy a more precise, less invasive approach to targeting the epileptogenic zone. Mellen Center for Multiple Sclerosis Treatment and Research The Mellen Center has the largest, most comprehensive program for MS care and research worldwide, managing more than 20,000 patient visits annually. The center offers the most advanced specialized treatments, supported by an extensive program of research and education. Patients are evaluated by a multidisciplinary team that makes individualized treatment recommendations. Epilepsy Center Superior diagnostic capabilities, extensive medical and surgical clinical treatment programs, and an active research focus have made Cleveland Clinic Epilepsy Center a site of national and international prominence for the management and investigation of epilepsy. The Mellen Center utilizes standardized tests, such as the 9-Hole Peg Test, to track disease progression and symptom management in multiple sclerosis patients. Right: The Epilepsy Center s adult and pediatric monitoring units use digital video EEG technology to locate seizure origin, a prelude to epilepsy surgery in appropriate candidates. Once considered a last resort, surgery in the hands of experts has become a safe, effective treatment for carefully selected patients who are refractory to medical therapy. Cleveland Clinic Neurological Institute 2008 Annual Report

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19 Our Centers 17 Basic and clinical research at Cleveland Clinic continues to shed light on MS. Mellen Center physicians fill leadership roles in multinational trials of promising new therapies, and they offer their patients opportunities to enroll in clinical research protocols. These physicians and their patients are true partners in the pursuit of new insights and treatments that can improve care. Patients in the Chronic Pain Rehabilitation Program are taught to reduce negative emotions that result from and worsen their pain. Center for Neuroimaging The Center for Neuroimaging houses specialists in structural and functional imaging of the central nervous system for a wide variety of neurological disorders. Subspecialization in disease entities (e.g., epilepsy, cerebrovascular disease, oncology) ensures accurate, in-depth, relevant interpretations. Across Cleveland Clinic, the Center for Neuroimaging supervises and interprets more than 60,000 CT scans and more than 50,000 MR scans each year. In cooperation with the Cerebrovascular Center, Neuroimaging provides cerebrovascular ultrasound, angiography and interventional neuroradiology services. The latter category includes more than 3,000 cerebral angiograms per year as well as management of acute stroke and internal/ external carotid artery embolizations, treatment of vasospasm and atherosclerotic occlusive disease, and carotid artery stenting. Neurological Center for Pain A leader in treatment of patients with pain disorders, this center integrates two pioneering Cleveland Clinic programs. The Headache Program brings an interdisciplinary approach to diagnosis and treatment of migraine, tension headache, daily headache and cluster headache, including intensive outpatient therapy known as IMATCH (Interdisciplinary Method for the Assessment and Treatment of Chronic Headache). The Section of Pain Medicine tailors comprehensive, innovative behavioral health and medical services to the needs of people in chronic pain. The section operates the Chronic Pain Rehabilitation Program, which combines physical rehabilitation, stress and pain control regimens, and medication management for patients who are functionally and psychosocially disabled by intractable pain. Center for Neurological Restoration This center is among the first in the world to bring together an interdisciplinary team of renowned neurologists, neurosurgeons, psychiatrists, neuropsychiatrists, researchers and other specialists who offer the latest medical and surgical treatments for patients with neurological and psychiatric disorders. Center physicians have earned wide recognition for expertise in medical management and innovation in the surgical treatment of movement disorders such as Parkinson s disease and dystonia, as well as behavioral disorders such as obsessive-compulsive disorder and depression. The surgical team is world renowned for performing hundreds of deep brain stimulation surgeries. Combined DTI and fmri mapping of the motor system. Expressive and receptive language regions are in orange. The multicolored lines connecting them are the fiber tracts that make up the language network. Left: Neurosurgeon Andre Machado, MD, PhD, performs deep brain stimulation (DBS) on a patient with Parkinson s disease. The Center for Neurological Restoration, which Dr. Machado directs, is an acknowledged world leader and innovator in DBS surgery, having implanted hundreds of brain pacemakers in patients with intractable neurological and psychiatric disorders. clevelandclinic.org/neuroscience

20 18 Our Centers The Neuromuscular Center uses electromyography (EMG) to detect abnormal electrical activity in muscles and nerves. With one of the largest EMG laboratories in Ohio, the center performs more than 3,000 such exams yearly. Neuromuscular Center The Neuromuscular Center treats patients with and conducts research on nerve and muscle disease, including amyotrophic lateral sclerosis and related disorders, peripheral neuropathy, myasthenia gravis and myopathies. The center s electromyography laboratory is among the largest in Ohio, with locations at Cleveland Clinic s main campus and six regional facilities, and a worldwide reputation for excellence and reliability. Additional resources include a highly specialized autonomic laboratory offering cardiovascular autonomic and tilt table tests, the quantitative sudomotor axon reflex test, quantitative sensory test, sympathetic skin response test, infrared dynamic pupillometry test and thermoregulatory sweat test. The center s cutaneous nerve laboratory provides muscle, nerve and skin biopsies; histopathological preparation of skin specimens; and pathological interpretation of skin biopsies for the diagnosis of small-fiber peripheral neuropathy. Center for Pediatric Neurology and Neurosurgery Cleveland Clinic pediatric neuroscience specialists see more than 10,000 children each year for an array of neurological disorders. The team offers state-of-the-art subspecialty care for children with brain malformations, neurofibromatosis, cerebral palsy and spasticity, headache, autonomic disorders, cyclic vomiting, hydrocephalus, myelomeningocele, metabolic and mitochondrial disorders, multiple sclerosis and other white matter disease, Tourette syndrome and other movement disorders, neuromuscular disease and muscular dystrophy, fetal and neonatal neurological problems, brain and spinal cord tumors, cerebrovascular disease, neurological complications of cardiac disease and epilepsy. Comprehensive advanced neurosurgical services, including neuroendoscopy, are available. Pediatric neurological and neurosurgical specialists collaborate with the Cleveland Clinic Pediatric Institute & Children s Hospital, providing comprehensive advanced care for all pediatric neurological disorders. Department of Physical Medicine and Rehabilitation Physical Medicine and Rehabilitation helps patients with impairments and disabilities in the areas of mobility, self-care, communication, swallowing and cognition. These conditions result from accident, illness or natural causes. A team approach to Vernon Lin, MD, PhD (right), Chairman of Cleveland Clinic s Department of Physical Medicine and Rehabilitation, and colleagues demonstrate how a noninvasive magnetic stimulator they developed can be applied over clothing to activate respiratory muscles in spinal cord injury patients. Right: U.S.News & World Report ranks Cleveland Clinic s pediatric neurology and neurosurgery services among the top four such programs in the nation. Specialists collaborate with the Cleveland Clinic Pediatric Institute & Children s Hospital, providing comprehensive advanced care for all pediatric neurological disorders. Cleveland Clinic Neurological Institute 2008 Annual Report

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23 Our Centers 21 Neurological Institute physicians draw on advanced diagnostic capabilities and experience. Patients receive leading-edge treatments and have opportunities to participate in clinical research trials. rehabilitation helps restore as much independence as possible so that patients can overcome physical, psychosocial, cognitive and vocational limitations. The Sleep Disorders Center performs more than 4,000 adult and pediatric sleep studies annually. A full range of services spans inpatient rehabilitation, skilled nursing care and outpatient care, enabling the staff to address individual needs during each phase of the rehabilitation process. This approach also allows effective coordination of care so that patients return to the community with the best chance to maintain the gains they have achieved. Center for Regional Neurology As part of Cleveland Clinic s nationally recognized Neurological Institute, the regional neurology program combines physicians and other healthcare providers in neurology, neurosurgery, neuroradiology and behavioral sciences, who treat adult and pediatric patients with neurological disorders. Regional facilities extend advanced treatments, technologies and the expertise of Cleveland Clinic into the surrounding communities and greater metropolitan areas, making it even easier for patients to access specialists who treat the most complex neurological conditions, including aneurysm and stroke, brain tumor, epilepsy, headache, multiple sclerosis, and sleep and spine disorders. Sleep Disorders Center Cleveland Clinic s Sleep Disorders Center is a multispecialty, comprehensive program dedicated to the diagnosis and treatment of sleep disorders in children and adults. Accredited by the American Academy of Sleep Medicine, the center comprises specialists in neurology, pediatrics, pulmonary medicine, internal medicine, psychiatry, psychology, otolaryngology and dentistry. More than 4,000 sleep studies are performed annually in seven laboratories throughout northeast Ohio. The Sleep Disorders Center is committed to advancing understanding of sleep disorders, their causes and treatment, and their relationship with other disorders. To this end, the center offers patients enrollment in investigational studies conducted in conjunction with national and international consortia or designed by Cleveland Clinic physicians. Center for Spine Health The Center for Spine Health brings together the expertise of specialists in neurosurgery, orthopaedic surgery and medical spine care to provide medical and surgical management of the full scope of back and spine problems, including scoliosis and kyphosis, spondylolisthesis, spinal stenosis, primary and metastatic spinal tumors, mature spine, cervical fractures and degenerative diseases of the spine. Physicians work closely with physical therapists and occupational therapists to develop a complete individualized treatment plan for each patient, integrating the functions of research, clinical practice and education with the goals of improving patient care, promoting collaboration among staff, and developing unique technologies and subspecializations. Left: A cervical spine X-ray shows posterior spinal instrumentation. Center for Spine Health surgeons have one of the country s highest success rates for even the most complex procedures, including lumbar surgeries, cervical and thoracic procedures, spinal deformity and spine tumor. clevelandclinic.org/neuroscience

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25 Patient Care 23 Patient Care At Cleveland Clinic, responsibility to patients extends beyond providing expert diagnosis and advanced treatment modalities. In the belief that patient satisfaction is a critical component of a successful clinical experience, the Neurological Institute is implementing new strategies to enhance communication and collaboration among staff and with patients. Daily Huddle Drawing on the Neurological Institute s multidisciplinary team structure, the daily huddle is a methodology to facilitate direct communication among professionals involved in the care of the neurological patient. Gathering at the same time each morning, this group of caregivers discusses the plan of care for the day for each patient. This coordinated effort allows direct input from all team members on medical, social and disposition issues related to the patient s medical condition. Nursing Leadership Group This weekly session joins Neurological Institute nurse managers from the ambulatory and inpatient settings with adult and pediatric operating room nurses, who treat many neurological patients. Assistant nurse managers, clinical nurse specialists and clinical instructors also attend. Group diversity is a strength as members present new initiatives and discuss issues such as stroke treatment and postoperative pain that cross all areas. Patient Advisory Council Established in May 2008, this collaborative group of patients, family members, staff and employees works on projects to improve patient care. Their input led to the remodeling of the Neurointensive Care Unit waiting area and the development of a new patient resource guide. Health Experience/Outcomes Team Neurological Institute researchers are working to quantify the impact of the patient experience on clinical outcomes. The focus is Cleveland Clinic s Healing Solutions Program, which offers meditation, Reiki, massage, spiritual care and individualized patient services. Patient Service Navigator A Patient Service Navigator visits hospitalized patients daily to address any needs or concerns. The navigator serves as a liaison for the patient and the care team, providing on-the-spot problem solving and regular feedback. Issues are tracked and reviewed by the inpatient arm of the institute s Patient Experience Team. Patient Support Groups Patients coping with serious or chronic illness are encouraged to share their experiences and socialize with others in similar situations through support groups such as the following: The Brain Tumor Support Group meets monthly at Cleveland Clinic Taussig Cancer Center. Open to patients, their family members and friends, this helpful forum invites participants to exchange information on practical concerns such as how a brain tumor affects job, family and ability to carry out daily activities. Nurse practitioners assist, providing information and answering questions about treatments, medications, available resources and other pertinent issues. The Pediatric Epilepsy Support Group addresses the needs of families caring for a child with refractory epilepsy, who often find their emotional resources depleted. Weekly group meetings become a source of strength and comfort for parents confronting difficult decisions about epilepsy surgery and guiding their child through difficult procedures such as invasive monitoring of seizures for accurate surgical planning. Left: The daily huddle is a forum for staff physicians, residents, fellows, rehabilitation specialists and other professionals to exchange information and develop a personalized care plan for each Neurological Institute inpatient. clevelandclinic.org/neuroscience

26 24 Community Care Community Care The Neurological Institute expanded geographically in 2008, reaching out to a broadly distributed patient population through the Center for Regional Neurology. This program combines physicians and other healthcare providers in neurology, neurosurgery, neuroradiology and behavioral sciences who care for adult and pediatric patients with neurological disorders. Regional facilities extend advanced treatments, technologies and the expertise of Cleveland Clinic into the surrounding communities and greater metropolitan areas, making it even easier for patients to access specialists who treat the most complex neurological disorders. Cleveland Clinic Neurological Institute at Lakewood Hospital This facility opened in this suburban Cleveland Clinic hospital in October 2008, offering a full spectrum of services for adult and pediatric patients with neurological disorders. These services, which ensure continued growth of the hospital s well-respected neuroscience program, include: general neurology neurosurgery cerebrovascular testing and treatment TCD/carotid ultrasound testing headache infusion clinic diagnostic evaluation and treatment for epilepsy evaluation, follow-up and infusion treatments for multiple sclerosis electromyogram testing neurorehabilitation and spasticity management The staff of the Lakewood institute comprises neurologists, neurosurgeons, neuroradiologists, neuroendovascular and cerebrovascular surgeons, therapists and specialized nurses. This team applies the most advanced treatments and technologies to the most complex conditions in a modern, comfortable setting close to patients homes. Center for Mood Disorders Treatment and Research at Lutheran Hospital In January 2008, an adult inpatient unit for diagnosis and treatment of mood disorders opened at Lutheran Hospital. The center ranks as the first in northeast Ohio offering both inpatient and outpatient programs dedicated to the treatment of mood disorders such as major depression and bipolar disorder. Depending on individual needs, these programs explore issues such as: assertiveness grief and loss healthy lifestyle development of new coping methods problem solving self-esteem comorbid anxiety and substance abuse stress and anger management The center s team includes physicians, nurses, social workers, therapists and programming staff committed to improving and maintaining patients mental health and well being. With a supportive, caring and structured approach, these professionals help patients reduce mood disorder symptoms, regain lost confidence and hope, and improve their functioning and quality of life. Cleveland Clinic Neurological Institute 2008 Annual Report

27 Community Care 25 Neurological Institute physicians provide services at Cleveland Clinic s main campus and at Cleveland Clinic community hospitals and family health centers throughout northeast Ohio, increasing patient access to specialized care. s Hospitals n Family Health Centers LAKE COUNTY Cleveland Clinic Lorain LORAIN COUNTY Cleveland Clinic Avon Cleveland Clinic Avon Lake Cleveland Clinic Elyria Chestnut Commons, Elyria Lake Erie Cleveland Clinic Westlake MEDINA COUNTY CUYAHOGA COUNTY Cleveland Clinic Lakewood Fairview Hospital Lakewood Hospital Cleveland Clinic Strongsville Cleveland Clinic Brunswick Medina Hospital Lutheran Hospital Huron Hospital Cleveland Clinic Children s Hospital, Shaker Marymount Hospital Cleveland Clinic Independence Cleveland Clinic Broadview Heights Cleveland Clinic Wooster (WAYNE COUNTY) Euclid Hospital Cleveland Clinic Willoughby Hills Cleveland Clinic Beachwood South Pointe Hospital Cleveland Clinic Solon SUMMIT COUNTY Hillcrest Hospital Cleveland Clinic Chagrin Falls PORTAGE COUNTY GEAUGA COUNTY Regional Sleep Centers Cleveland Clinic s Sleep Disorders Center joined with Cleveland Clinic health system s Marymount Hospital sleep program in 2008, resulting in expedited access for referring physicians and patients. The combined program has seven overnight sleep labs conveniently located throughout the region. Five of these labs are based in hotels, where adults and children 12 and older can undergo routine overnight sleep studies, including polysomnograms and positive airway pressure titrations. Geriatric Behavioral Health Services At selected community hospitals throughout the region, specialized multidisciplinary teams work with older adults, helping them adapt to age-related changes and improve their quality of life. Under the direction of board-certified psychiatrists, clinical professionals provide holistic assessment, diagnosis and treatment for conditions such as: significant changes in mental health confusion memory lapses and/or forgetfulness depression anxiety and/or nervous behaviors grief reaction difficulty adapting to change medication concerns suicide threats or attempts alcohol and/or substance abuse and misuse clevelandclinic.org/neuroscience

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29 Outcomes Outcomes The Neurological Institute strongly supports continuous measurement and transparent reporting of clinical outcomes, in the belief that making accurate information available to patients and their physicians will result in better healthcare decisions. Through the Knowledge Program, we are reinforcing our capability to collect and analyze clinical data, with the ultimate goal of improving the quality of our care and our outcomes. Brain Tumor Spine radiosurgery is a palliative treatment for pain, typically used in end-stage cancer patients whose disease has metastasized to the spine. Among 103 patients with painful spinal metastases who were treated with single-fraction Novalis spine radiosurgery in 2007 and 2008, pain scores showed a statistically significant improvement just one week after treatment, and these results remained stable over time. Clinical research trials are important discovery and therapeutic options for brain tumor patients. Almost 300 individuals were enrolled in these trials through Cleveland Clinic s Brain Tumor and Neuro-Oncology Center in Patients who underwent supratentorial craniotomy had 30- and 180-day survival rates of 99.1 percent and 93.5 percent, respectively. Among patients who underwent brain biopsies, 30- and 180- day survival rates reached 94.1 percent and 80.4 percent, respectively. Among pituitary surgery patients, 30- and 180-day survival rates exceeded 95 percent. Inpatient mortality following pituitary surgery was zero percent. Cerebrovascular Intravenous tissue plasminogen activator is indicated for treatment of acute ischemic stroke, if administered within 180 minutes of stroke onset symptoms. Cleveland Clinic s 2008 performance surpassed both the national average and the goal for the Get With The Guidelines SM Stroke Silver Performance Award. GWTG is a hospital-based quality improvement program for the American Stroke Association and the American Left: Before meeting with her clinician, a patient enters self-assessment data directly into the Knowledge Program electronic tablet. All Neurological Institute patients complete standardized health questionnaires prior to their appointments. clevelandclinic.org/neuroscience

30 28 Outcomes Patients Receiving Intravenous Tissue Plasminogen Activator in the Emergency Department within 180 Minutes of Onset of Stroke Symptoms Cleveland Clinic 2008 GWTG Silver Performance Award Goal National Average* Percent * Hospitals participating in GWTG for five or more years (N = 2,095) before surgery to 2.2 times per month after surgery, with 74 percent reporting no seizures postoperatively. Long-term seizure freedom was assessed in 550 Epilepsy Center patients who underwent temporal lobe surgery from 1997 through One year after surgery, 81 percent were seizure free; 70 percent maintained seizure freedom at five years. Among patients with persistent seizures following the surgery, seizure frequency declined an average 73 percent postoperatively. Heart Association. Cleveland Clinic was a 2008 recipient of the Stroke Silver Performance Award. While the Cerebrovascular Center saw an 11 percent increase in the number of procedures for ruptured cerebral aneurysm between 2007 and 2008, inpatient mortality remained below the expected rate (based on national normative data and APR- DRGs for the last three years). No inpatient deaths occurred in 2008 from nonruptured cerebral aneurysm. Mortality has remained below expected levels for three years. The Epilepsy Center s adult and pediatric monitoring units feature the latest technology, including all-digital video EEG equipment. Operating around the clock, these units are staffed by dedicated teams. Movement Disorders Among 27 Parkinson s disease patients implanted with deep brain stimulators in 2008, the average improvement in motor function was 57 percent after surgery (Unified Parkinson s Disease Rating Scale). Multiple Sclerosis Epilepsy In a random sample of patients who underwent epilepsy surgery between January 2007 and November 2008, average seizure frequency was reduced from 12.3 times per month The Mellen Center for Multiple Sclerosis Treatment and Research has treated more than 250 patients with intrathecal baclofen therapy (ITB) since In 2008, 17 patients underwent implantation of a baclofen pump. Mean spasticity scores showed a statistically relevant reduction following ITB therapy (Modified Ashworth Scale). Pain/Headache In 2008, 196 patients with status migrainosis, transformed migraine, cluster headache and chronic daily headache Cleveland Clinic Neurological Institute 2008 Annual Report

31 Outcomes 29 received intravenous infusion therapy lasting one to five days at the Neurological Center for Pain. Nearly 60 percent reported a 50 percent or greater reduction in pain immediately after treatment. Sixty-four individuals completed the center s Interdisciplinary Method for the Assessment and Treatment of Chronic Headache (IMATCH) outpatient program in Patients selfrated pain and disability scores decreased after the intensive treatment. The Chronic Pain Rehabilitation Program (CPRP) treats individuals who are emotionally and physically devastated by pain. Continuing a long-term trend in 2008, patients mean pain scores decreased and their functional status improved after enrollment in the CPRP (Pain Disability Index). Pediatric Neurology Among 46 pediatric patients treated for headache in 2008, both headache frequency and number of rescue medications needed in the previous three months showed improvement. Group means for headache frequency improved 46 percent in the mean seven-month interval between visits one and two (Pediatric Migraine Disability Assessment). In children with severe headaches, the average number of complete and partial school days missed in the preceding three months declined from 10.8 to 2.5. Among 202 inpatients treated in 2008 at the Center for Mood Disorders Treatment and Research at Lutheran Hospital, a Cleveland Clinic hospital, a statistically significant reduction in mean severity of depression occurred from admission to discharge (Hamilton Depression Scale, Montgomery-Asberg Depression Rating Scale). Sleep Disorders Sleepiness decreased among 217 sleep apnea patients who received positive airway pressure (PAP) treatment in 2008 (Epworth Sleepiness Scale). Functional status improved among 216 PAP-compliant sleep apnea patients who assessed their status before and after treatment (Functional Outcomes of Sleep Questionnaire). Spinal Cord Disease The Center for Spine Health uses a team approach to diagnosis, treatment, patient satisfaction and quality for individuals with spine tumors. This strategy is credited for annual increases in spine patients and cases studied at the weekly Spine Tumor Review Board, which engages surgeons, radiologists, pathologists and other specialists in a logic-based decision-making process. From 2006 through 2008, both the numbers of patients and cases studied more than doubled. Pediatric Neurosurgery Inpatient mortality remained below expected levels after surgery for Chiari malformation, with no deaths from 2006 through Psychiatric Disorders After one year of participation in the outpatient Women s Mental Health Management Group, 29 women diagnosed with major depression registered a group mean decrease of 2.2 points in depression severity score (PHQ-9). Group medication management had a positive effect on remission of depressive symptoms. Weekly Spine Tumor Review Board meetings involve multidisciplinary clinical teams that evaluate complex cases through a logic-based decision-making process. clevelandclinic.org/neuroscience

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33 Technology and Innovation 31 Technology and Innovation Patients benefit from the latest treatment modalities at the Neurological Institute, where scientists and clinicians working together continue to advance innovations and accelerate the process of bringing novel therapeutic agents from the laboratory to the bedside. Brain Tumor and Neuro-Oncology Center Prospective First-in-Man Safety Trial of Laser Treatment Cleveland Clinic s Brain Tumor and Neuro-Oncology Center (BTNC) was the first in the world to use a new, laser-based system in a human for minimally invasive treatment of a brain tumor. The AutoLITT (laser interstitial thermal therapy) system coagulates tumors through a special laser probe, precisely directed into the tumor, with the heating process monitored by specialized software and thermal MRI techniques. Gene Barnett, MD, FACS, leads this trial of a technology that could offer the benefits of conventional surgery for some inoperable tumors and spare patients more invasive interventions. Stereotactic Radiosurgery for Spinal Tumors Led by neurosurgeon Lilyana Angelov, MD, Cleveland Clinic s Spine Radiosurgery (SRS) program provides patients with specialized, integrated care for complex problems related to spine tumors. This program, the first of its kind in Ohio, is the state s largest and most established. To date, Dr. Angelov and her multidisciplinary spine care team have reviewed and approved management of more than 600 spine tumor cases and performed more than 250 spine radiosurgeries. Metastasis to the spinal column in cancer patients is often associated with disabling pain, and may result in neurological dysfunction and paralysis related to direct compression of the spinal cord or nerve roots by tumor or instability of the spinal column. Cleveland Clinic s SRS program uses a novel modality, the Novalis Shaped Beam Surgery system, to deliver a high dose of radiation to spinal metastases in a precise, conformal fashion, enveloping the tumor in three dimensions without significant scatter or spread beyond the target to sensitive adjacent organs such as the spinal cord. SRS can be used as a stand-alone treatment or as an adjunct to other modalities. It can even be used as salvage therapy after conventional radiation for spine metastases has failed. A noninvasive outpatient procedure with minimal recovery time, this highly selective, precise radiation therapy results in effective, rapid relief of pain and exceptional tumor control. Among patients treated at Cleveland Clinic, pain scores improved by nearly 80 percent as early as one week post-treatment compared with immediately before SRS. Moreover, this post-treatment pain relief was durable, with almost 90 percent of evaluable patients experiencing continued pain improvement at 12 months following SRS. Radiographic tumor control was obtained in approximately 90 percent of evaluated cases, including tumors traditionally perceived to be radioresistant, such as renal cell carcinoma and melanoma. Tailoring Treatment of Oligodendroglioma The discovery of a genetic alteration in oligodendrogliomas that was prognostic of improved response to treatment and survival was a landmark event in neuro-oncology. However, it was not entirely clear how best to use this information to tailor therapy for Left: Brain Tumor and Neuro-Oncology Center neurosurgeons perform more than 950 brain tumor surgeries each year, aided by the latest technological innovations. More than 25 percent of new brain tumor patients travel to Cleveland Clinic from outside Ohio. clevelandclinic.org/neuroscience

34 32 Technology and Innovation maximal benefit, without the harmful side effects associated with radiation and chemotherapies. Michael Vogelbaum, MD, PhD, has been a coleader of an international effort to define how best to use the information provided by analysis of this alteration, also referred to as 1p/19q codeletion. In 2008, he was the lead author of a paper published in the journal Neuro-Oncology, reporting the results of a study he led with the Radiation Therapy Oncology Group that examined a chemotherapy-only treatment for patients with malignant oligodendroglial tumors. He is now the U.S. Principal Investigator for a European-led Phase III trial of radiation and/or chemotherapy for 1p/19q non-codeleted anaplastic gliomas and the U.S. co-pi for another Phase III trial of radiation and/or chemotherapy for 1p/19q codeleted anaplastic gliomas. These studies will define the optimal treatment for patients with grade III gliomas. Epilepsy Center Enhanced Localization Ability with Magnetoencephalography (MEG) The MEG laboratory at Cleveland Clinic s Epilepsy Center has enhanced the center s diagnostic capabilities. Cleveland Clinic is among a select number of institutions in the world with this technology, which measures magnetic fields produced by electrical activity in the brain to localize the epileptic focus. MEG is used routinely to better identify epileptic sources in patients in whom the area of the brain causing the seizures would otherwise be difficult to identify. Since its inception, the MEG laboratory has tested more than 50 clinical patients. Results, taken with the rest of the clinical evaluations, have been used to refine the location of the epileptic focus, help guide the placement of intracranial recording electrodes or ascertain that the patient is not a surgical candidate. The neurocomputing and clinical neurophysiology teams have added capabilities to the basic MEG system, making it uniquely advanced. These new developments include: specialized software to post-process the recorded MEG waveforms continuous, synchronized digital video recording to enable direct correlation of the patient s physical actions with MEG waveforms online annotations that provide second-by-second testing and clinical information during a MEG recording an online database that keeps raw results as well as interpretations to facilitate ongoing quality assessment Mellen Center for Multiple Sclerosis Treatment and Research Optical Coherence Tomography to Monitor Axonal Injury Optical coherence tomography (OCT) is a rapid, noninvasive, painless test that generates high-resolution images of the retina. Cleveland Clinic researchers are exploring utilization of OCT to measure the thickness of the retinal nerve fiber layer and the volume of the macula. The optic nerve is an important site of injury in MS, and the ability to monitor the degree of injury would be an important advance in both clinical practice and experimental treatment trials. Center for Neuroimaging Correcting Motion-Corrupted Imaging Data High-Angular Resolution Diffusion-Weighted Imaging (HARDI) presents a challenge with regard to intrascan subject motion. Image volumes are acquired serially on subjects, varying the direction of diffusion sensitivity gradually throughout the scan. Robust calculation of the final diffusion tensor assumes no intrascan motion of the subject. HARDI acquisitions can take 10 minutes or more to acquire; thus, the assumption of no intrascan motion is problematic. Cleveland Clinic neuroradiologists demonstrated that a previously published tensor-fit method is sufficient in most cases when iterated up to 20 times on a single data set. Motion effects can be removed to the 0.2 mm level, thus reducing the error on the diffusion direction below 0.2 degree. Defining Anatomic-Based Seeds for Functional Connectivity Analysis Assessment of functional connectivity in the human brain, using low-frequency blood oxygen level-dependent (BOLD) Right: Magnetoencephalography (MEG) can evaluate the brain s spontaneous activity or its response to specific stimuli. With a very large number of sensors, as well as the absence of any effect from skull or scalp, MEG has an inherently high resolution and provides superior accuracy, especially when combined with MRI. Cleveland Clinic Neurological Institute 2008 Annual Report

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36 34 Technology and Innovation fluctuation present in dynamically sampled MRI data, has become a common technique. The most common method of assessing connectivity is to measure the temporal correlation between two functional brain regions. Due to individual variation in functional localization in the human brain, a standard technique for identifying regions of interest is to perform task-based functional MRI. This imposes a serious limitation on the ability to analyze functional connectivity in studies in which activation data also have been obtained. Cleveland Clinic researchers introduced a method for defining connectivity reference regions, based on combining anatomic landmarks with a regional measure of temporal coherence. This measure, derived from Kendall s coefficient of concordance, results in robust measures of functional connectivity. Monitoring System for Deep Brain Stimulators during MRI Performing functional MRI (fmri) studies of implanted deep brain stimulators (DBS) is important in understanding the mechanisms of this therapy. To date, all fmri has been done with externalized DBS leads connected directly to a pulse generator in the MRI console room immediately after surgical placement of the lead. In this configuration, it is straightforward to program the pulse generator such that the timing between acquired MRI data and the stimulation is known. When using implantable pulse generators (IPGs), it becomes problematic to determine the state of the IPG during the acquisition of MRI data. Cleveland Clinic developed a passive radiofrequency (RF) monitoring system, which, when placed over the implant on the patient s chest, determines the state of the pulse generator from characteristic low-frequency RF energy emissions. This enables researchers to correlate stimulation with regional changes in BOLD-weighted MRI signal. Working with Patients to Improve Functional MRI Quality Functional MRI studies are performed daily with standardized paradigms to provide consistent preoperative localization of motor, speech generation and receptive speech areas, with an 85 percent success rate. A program was developed in which a neuroradiologist interviews every patient to individualize the study when indicated, provide instructions for the paradigms, and emphasize the consequences of inattention and movement. A study that examined the effect of the prescan patient interview in improving scan quality showed that an intensive intervention can reduce unacceptable sequences from 15 percent to 5 percent. Previously, language fmri examinations were conducted only in English. The paradigms have been extended to include other languages, such as Spanish and French. Also, for language-challenged patients such as children and those with injuries such as strokes, simpler paradigms are available, incorporating pictures and simpler language. This change has resulted in a significant improvement in reliability of all clinical studies. Lateralization Score for fmri Studies to Judge Hemispheric Speech Dominance The major clinical utility for performing fmri studies is presurgical planning, particularly for epilepsy and brain tumor patients. The important issue is to identify the essential eloquent cortical areas governing language and motor activity so the surgeon can provide adequate margins to minimize post-surgical morbidity. Often, this issue is resolved by determining language lateralization, a process hitherto determined by the neuroradiologist based on a qualitative impression of the fmri images. Recent work has extended the qualitative impression of language lateralization with a quantitative lateralization index or score, which is computer-generated and based on an analysis of 42 patients who had both fmri and Wada lateralization. Wada is the gold standard; however, because it involves catheter angiography, it carries significant risk. Work at Cleveland Clinic shows how this computer-generated lateralization index more accurately identifies and quantifies the degree of qualitative language lateralization. For studies in which quality is not significantly degraded by motion or inattention, a qualitative lateralization Right: Postoperative X-ray shows placement of bilateral deep brain stimulation (DBS) leads and electrodes in a patient with obsessive-compulsive disorder (OCD). Cleveland Clinic is among four centers worldwide where psychiatric neurosurgery teams have collaborated to investigate the safety and efficacy of DBS for refractory OCD. Cleveland Clinic Neurological Institute 2008 Annual Report

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39 Technology and Innovation 37 correlation of R2=0.34 is increased to R2=0.60 when the neuroradiologist is assisted by the computer-generated index. Integration of Diffusion Tensor Imaging With diffusion tensor imaging (DTI), also known as tractography, neuroscientists are noninvasively probing the long-neglected white matter pathways in the brain. The significance of this technological leap forward was illustrated at the 2008 Cleveland Clinic Medical Innovations Summit, where DTI was among 10 breakthroughs that Cleveland Clinic physicians cited as most likely to impact medicine in the coming year. In clinical practice, Cleveland Clinic neuroscientists are utilizing DTI to create a detailed spatial wiring map of the brain, which can enhance surgical planning and prognosis accuracy. In the research laboratory, they are applying DTI to advance understanding of a wide range of brain disorders, including Parkinson s disease, epilepsy, multiple sclerosis and traumatic brain injury. Neurological Center for Pain/Center for Neurological Restoration Neurostimulation for Treatment of Cluster Headaches The Center for Neurological Restoration conducted an IRBapproved study in collaboration with the Neurological Center for Pain to assess the safety and efficacy of acute neurostimulation of the sphenopalatine ganglia (SPG) for treatment of severe cluster headaches. Five patients underwent SPG stimulation and three returned for a second trial, for eight total treatment sessions. Four treatment sessions (in three patients) produced complete resolution of at least one cluster attack within two minutes, suggesting that this technique may hold promise for treatment of these and other types of headache. Sleep Disorders Center Multidisciplinary CPAP Compliance Group Therapy Continuous Positive Airway Pressure (CPAP) therapy is the standard treatment for sleep apnea, but an estimated 30 percent to 50 percent of patients are noncompliant, for both mechanical and psychological reasons. Cleveland Clinic s Sleep Disorders Center started a group therapy initiative to target these patients. Led by a sleep specialist, a psychologist and a sleep technician, the groups of six to eight patients meet in sessions that last about 90 minutes. Patients discuss their problems with CPAP and receive tips from professionals, while learning from other patients. They have opportunities to try other CPAP masks and devices and, depending on the nature of the problem, they receive detailed individual treatment plans. Patient feedback has been highly positive. Biofeedback for Chronic Insomnia Chronic insomnia affects 10 percent to 15 percent of adults. Although hypnotic medicines are effective in some patients, they are not always safe for long-term use. Cleveland Clinic s Sleep Disorders Center is one of a very few centers in the country with a dedicated biofeedback program for chronic insomnia. The most commonly used forms of treatment are EMG biofeedback, respiratory biofeedback, thermal biofeedback and neurofeedback. Psychologists and sleep specialists offer the treatment in weekly sessions for five to six weeks. More than two-thirds of patients report significant improvement in chronic insomnia symptoms. Center for Spine Health Delaying Recurrences of Myxopapillary Ependymomas The Center for Spine Health is the largest center in the United States conducting adjuvant radiation therapy (ART) studies. A center study found the use of therapeutic radiation beneficial in delaying a second occurrence of myxopapillary ependymomas. Patients who did not receive ART had a median time to recurrence of 1.1 years, while those who received ART had a median time to recurrence of 9.6 years. Left: An MRI of a lumbar spine shows some involvement of Level 5 with an infectious or tumorous process. The Center for Spine Health utilizes advanced imaging technologies to diagnose a variety of spine-related conditions. clevelandclinic.org/neuroscience

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41 Research 39 Research The Neurological Institute conducts a robust research program that fosters a culture of innovation and collaboration. Physicians and scientists within the institute work closely with colleagues in the Lerner Research Institute, the basic science research arm of Cleveland Clinic, pursuing laboratory-based and clinical research as well as translational research that applies laboratory findings to improve patient care. In 2008, grant and contract research dollars funding neurological investigations in the Neurological Institute, Lerner Research Institute and Department of Neuroradiology totaled more than $17.9 million. Additional metrics from 2008 help quantify an expanding program: Number of new clinical research trials: 42 Number of active clinical research trials: 139 Staff leading clinical research trials: 50 New patients enrolled in clinical research trials: 772 Number of patients enrolled in clinical research trials: 1,690 Number of National Institutes of Health grants and contracts (includes Lerner Research Institute and Neuroradiology): 91 Number of non-nih neurological grants (includes Lerner Research Institute and Neuroradiology): 167 This support was instrumental to a number of noteworthy advances within the Neurological Institute. Cranial Radiosurgery for the Older Old Although the incidence of cancer increases with age, research studies have traditionally excluded older patients, especially those 75 and older. In cancer that spreads to the brain from another site, data from patients younger than 65 suggested that increasing age was associated with a poorer prognosis, irrespective of whether the patient received surgery, whole brain radiation or stereotactic radiosurgery (SRS). Despite the known efficacy of SRS in treating brain metastasis, little was known of its efficacy in older patients. Robert Weil, MD, and colleagues from the Brain Tumor and Neuro-Oncology Center performed the first large analysis of a consecutive series of patients 75 and older treated with SRS, which was generally the sole treatment for their brain metastases. In 44 patients treated over 13 years, SRS of one or more brain metastases produced results comparable to those found in younger patients: Average survival exceeded seven months, with more than one-third of patients surviving one year and longer. Patients tolerated the treatment well, with no loss of physical function. This study supports the idea that aggressive, multimodal treatment of cancer that spreads to the brain can be effective and safe in older patients, with results similar to those experienced by younger patients. Understanding Combat-Related Traumatic Brain Injury Traumatic brain injury (TBI) caused by improvised explosive devices is fast becoming the signature wound of the Iraq and Afghanistan wars. With a $1.4 million grant from the U.S. Left: Neural stem cells generate various types of cells. They can generate astrocytes, oligodendrocytes and neurons, according to the stimuli they are under. These cells are prime candidates for stem cell transplantation therapies. clevelandclinic.org/neuroscience

42 40 Research Stem cell biology and the resulting regenerative medicine hold the promise of moving medicine beyond simply dealing with symptoms. Department of Defense, Cleveland Clinic cognitive neuroscientist Stephen Rao, PhD, and collaborators are using advanced brain imaging techniques to better understand blast-related TBI. Dr. Rao, the Principal Investigator, is working with colleagues at Baylor College of Medicine. Their research will determine if blast-related TBI, thought to be produced by wave-induced changes in atmospheric pressure, can be differentiated from the better-studied civilian TBI, which is caused primarily by mechanical forces such as the sudden jolt from an auto accident or fall. Functional magnetic resonance imaging and diffusion tensor imaging will be used to identify differences and parallels between military and civilian TBI. As many as 20 percent of soldiers returning from Iraq and Afghanistan have TBI. Approximately 40 percent of these are mild cases that are often overlooked because they do not show up on traditional screening tests. Yet, if a solider returns to combat without treatment for a mild TBI, a second or third blast injury can be much more crippling, according to Dr. Rao. Each successive injury further depletes the neural reserve, hampering recovery. Furthermore, the effects of even one mild TBI can linger, manifested months or years later in memory problems, mood swings and constant frustration. Thus, research to identify damage caused by the first blast injury assumes even greater relevance. New Neuron Growth in Adult Brains Lerner Research Institute researchers discovered evidence of the generation of new neurons in adult brains. The findings, published in Brain, challenge views that the adult human brain lacks the ability to grow new neurons. This research, led by Bruce Trapp, PhD, Chairman of the Department of Neurosciences at Lerner Research Institute, involved examination of neurons in the brains of nine patients with multiple sclerosis (MS) and four healthy control group subjects. The study used advance staining techniques to detect and characterize neurons in normal subcortical white matter and acute and chronic demyelinated brain lesions. In MS, the immune system destroys the myelin sheaths that surround and protect nerves. The nerves then misfire, slowing or disrupting impulses. Dr. Trapp s team found that neurons occupying the white matter also are destroyed during demyelination. In a small percentage of old MS lesions, however, white matter neurons increased 72 percent compared with normal brain regions. The study suggests that demyelinated tissues produce signals that can enhance the generation of new neurons in damaged areas of the brain. Thus, there is evidence to support the thesis that new neurons can regrow in MS lesions. It is unclear how much function the new tissues have, but this basic science discovery may provide a basis for development of new therapies for MS and other neurodegenerative diseases. Grahame Kidd, PhD, left, and Bruce Trapp, PhD, analyze images of new neurons in multiple sclerosis brain sections. Collaborating with Dr. Trapp on the research were Susan Staugaitis, MD, PhD, and neurologists at the Mellen Center for Multiple Sclerosis Treatment and Research. Cleveland Clinic Neurological Institute 2008 Annual Report

43 Research 41 Unlocking Stem Cell Potential Jeremy Rich, MD, nationally known for his research on cancer stem cells and brain tumors, was recruited from Duke University Medical Center in 2008 to serve as Chairman of Lerner Research Institute s newly created Department of Stem Cell Biology and Regenerative Medicine. she would have pedaled alone. Dr. Alberts set out to investigate whether forced exercise, in which people are pushed beyond their normal limits, is therapeutic for Parkinson s patients. To test the theory, he designed a tandem bicycle that forces patients to pedal at accelerated rates. Among the early findings: Motor function improved significantly in patients arms, even though they were working only their legs, which suggests to Dr. Alberts that forced exercise impacts higher brain function and improves central motor function. Patients averaged a 30 percent improvement in their symptoms, and these gains were sustained for four weeks after they stopped forced exercising. Dr. Alberts posits that driving the central nervous system beyond its normal capacity can lead to biochemical changes necessary for these improvements. Brain precursor cells that give rise to myelin-forming cells are important for repairing damage from demyelinating diseases like multiple sclerosis. In this population, all precursor cells expressed a common marker molecule (red), but only a subset also expressed a marker associated with cell maturation (green). Stem cell biology and the resulting regenerative medicine hold the promise of moving medicine beyond simply dealing with symptoms. Dr. Rich s goal is to develop a comprehensive research group to study stem cells, from the basic science to implementation of new therapies to treat a variety of diseases. He plans to recruit about 10 faculty members in the next five years to build a department with approximately 100 employees. Forced Exercise Reduces Parkinson s Symptoms Sometimes, insight comes in an unlikely setting. Jay Alberts, PhD, Department of Biomedical Engineering, had just completed a 450-mile bicycle trip across Iowa to raise awareness of Parkinson s disease when a patient mentioned that she had no symptoms during the ride, and the tremor in her hand was gone afterward. The patient had been paired with a rider who set a faster pace than Further research is needed to understand the underlying mechanisms. Mark Lowe, PhD, of Cleveland Clinic s Imaging Institute, and Micheal Phillips, MD, Section Head of Imaging Sciences in the Department of Diagnostic Radiology, are collaborating on the project. Novel Oral Therapies for Multiple Sclerosis MS researchers are poised for a breakthrough in the form of the first-ever oral agents for treatment of the disease, which are now in Phase III testing. Neurologists at Cleveland Clinic s Mellen Center for Multiple Sclerosis Treatment and Research are closely involved in these promising investigations, as are the study participants among their patients. Mellen Center Medical Director Robert Fox, MD, is Principal Investigator on a Phase III study of the oral immunomodulator fumarate. Jeffrey Cohen, MD, Director of Experimental Therapeutics at the Mellen Center, was PI on a Phase III trial of the oral drug fingolimod. Dr. Cohen also serves on the adjudication board for an ongoing study of oral cladribine and the steering committee for trials of the immunomodulator laquinimod. clevelandclinic.org/neuroscience

44 42 Research The Spine Research Laboratory includes a state-of-the-art biomechanics laboratory. Biomechanical testing involves eccentric axial loading of a spinal motion segment to determine stress distribution within the intervertebral disc. Plasma Exchange as Treatment for Rare Complication The drug natalizumab helps treat multiple sclerosis by inhibiting white blood cells from entering the brain and attacking nerves, but this drug also lowers the patient s immunity. Some patients taking natalizumab have suffered an uncommon, but usually fatal, infection called progressive multifocal leukoencephalopathy (PML). In a study published in the journal Neurology, Robert Fox, MD, and colleagues examined the effect of plasma exchange in 12 MS patients taking natalizumab. This study showed that monoclonal antibodies can be removed from the body with plasma exchange, and this removal leads to improved immune function. Using population modeling, Dr. Fox and colleagues suggested that five plasma exchanges are needed to effectively remove natalizumab from the bodies of patients receiving this therapy. Plasma exchange may help convert PML into a manageable complication of treatment with natalizumab, which would improve the overall safety of this therapy. Tissue Collection Supports Multiple Sclerosis Research Many MS basic research studies require brain and spinal cord tissue from diseased patients. Because brain biopsies are rare, autopsy collection of tissues is vital in providing the required resources for these studies. Cleveland Clinic has developed an effective MS Tissue Donation Program. An advanced directive program includes educational materials, written informed consent, donor identification card, and a secure database with patient demographics and disease characteristics. A rapid autopsy protocol ensures 24/7 transportation, postmortem imaging and tissue procurement. At the time of death, calls from family and care providers are routed to the on-call MS tissue donation nurse coordinator, who activates the ambulance transport and notifies the imaging, autopsy and tissue-processing teams. The body undergoes Cleveland Clinic Neurological Institute 2008 Annual Report

45 Research 43 postmortem MRI, followed by brain and spinal cord removal and processing by a neuropathologist and the tissue-processing team. Local pathologists are utilized for distant patients. A total of 224 patients have enrolled in the advanced directive program. Since 1997, 64 patients have donated their tissues. Median postmortem interval (time from death to fixation) was 6.1 hours. This program has been successful in effectively procuring and rapidly processing MS tissues, and has supported high-impact publication in The New England Journal of Medicine, Annals of Neurology and Archives of Neurology. Spine Research Laboratory at Lutheran Hospital Eighty percent of American adults experience back problems at some point in their lives. Cleveland Clinic s Spine Research Lab (SRL), which relocated in 2008 to Lutheran Hospital, a Cleveland Clinic hospital, is dedicated to improving quality of life for people with spinal disorders through research, innovation and education. The SRL strengthens the comprehensive spine program developed in recent years at Lutheran. The program is noted for medical and surgical spine care and inpatient rehabilitation. The addition of the SRL, under the direction of Lars Gilbertson, PhD, intensifies a complementary focus on research and education. The SRL hosts medical students, bioengineering students, residents and fellows from the departments of Neurosurgery and Orthopaedic Surgery, along with research fellows from around the world. With the SRL, the spine program at Lutheran is fast becoming an integrated continuum with Cleveland Clinic s main campus and the Neurological Institute, as Dr. Gilbertson and staff work closely with Center for Spine Health Director Gordon Bell, MD, and his clinical staff. In recognition of its commitment to spinal care and research, the SRL received a five-year grant from Ohio s Third Frontier Commission. In its new home, the SRL seeks to establish itself as a national leader in spinal innovation and to educate the next generation of spine researchers and clinicians. Neurological Institute Chairs Holders of the following endowed chairs are entrusted with the stewardship of funds generated by the gifts of Cleveland Clinic s generous supporters. Gene Barnett, MD, FACS Director, Brain Tumor and Neuro-Oncology Center The Rose Ella Burkhardt Chair in Neurosurgery William Bingaman, MD Vice Chairman, Clinical Areas, Neurological Institute The Shusterman Endowed Chair Irene Katzan, MD, MS The Wamberg Family Endowed Chair in Stroke Research Michael T. Modic, MD, FACR Chairman, Neurological Institute The William P. and Amanda C. Madar Endowed Chair and Professorship Imad Najm, MD Director, Epilepsy Center The Joseph and Ellen Thomas Endowed Chair Stephen Rao, PhD Director, The Ralph and Luci Schey Foundation Center for Advanced Cognitive Function The Ralph and Luci Schey Endowed Chair in Cognitive Function Ali Rezai, MD * The Jane and Lee Seidman Chair in Functional Neurosurgery Richard A. Rudick, MD Vice Chairman, Research and Development, Neurological Institute Director, Mellen Center for Multiple Sclerosis Treatment and Research The Hazel Prior Hostetler Endowed Chair Tanya Tekautz, MD Brain Tumor and Neuro-Oncology Center The Karen Colina Wilson Endowed Chair in Pediatric Brain Tumor Research Jerrold Vitek, MD, PhD Center for Neurological Restoration The Edward F. and Barbara A. Bell Family Endowed Chair Michael Vogelbaum, MD, PhD Associate Director, Brain Tumor and Neuro-Oncology Center The Robert W. and Kathryn B. Lamborn Chair for Neuro-Oncology Robert J. Weil, MD Director of Laboratory Research, Brain Tumor and Neuro-Oncology Center The Melvin H. Burkhardt Chair in Neuro-Oncology Clinical Research Currently Unassigned Endowed Chairs The Andrea L. and Joseph F. Hahn, MD, Endowed Chair The Jane and Lee Seidman Chair in Functional Neurosurgery * Until July 2009 clevelandclinic.org/neuroscience

46 44 Research Selected Publications Neurological Institute staff authored more than 470 publications in 2008, including the following. For a complete list, go to clevelandclinic.org/nipublications. Brain Tumor and Neuro-Oncology Center Balmaceda C, Peereboom D, Pannullo S, Cheung YKK, Fisher PG, Alavi J, Sisti M, Chen J, Fine RL. Multi-institutional phase II study of temozolomide administered twice daily in the treatment of recurrent high-grade gliomas. Cancer Mar 1; 112(5): Chao ST, Barnett GH, Vogelbaum MA, Angelov L, Weil RJ, Neyman G, Reuther AM, Suh JH. Salvage stereotactic radiosurgery effectively treats recurrences from whole-brain radiation therapy. Cancer Oct 15;113(8): Georgitsi M, De Menis E, Cannavo S, Makinen MJ, Tuppurainen K, Pauletto P, Curto L, Weil RJ, Paschke R, Zielinski G, Wasik A, Lubinski J, Vahteristo P, Karhu A, Aaltonen LA. Aryl hydrocarbon receptor interacting protein (AIP) gene mutation analysis in children and adolescents with sporadic pituitary adenomas. Clin Endocrinol (Oxf ) Oct;69(4): Gibson SE, Zeng WF, Weil RJ, Prayson RA. Aurora B kinase expression in ependymal neoplasms. Appl Immunohistochem Mol Morphol May;16(3): Guo S, Chao ST, Reuther AM, Barnett GH, Suh JH. Review of the treatment of trigeminal neuralgia with gamma knife radiosurgery. Stereotact Funct Neurosurg. 2008;86(3): Kang TY, Jin T, Elinzano H, Peereboom D. Irinotecan and bevacizumab in progressive primary brain tumors, an evaluation of efficacy and safety. J Neurooncol Aug;89(1): Kim SH, Weil RJ, Chao ST, Toms SA, Angelov L, Vogelbaum MA, Suh JH, Barnett GH. Stereotactic radiosurgical treatment of brain metastases in older patients. Cancer Aug 15; 113(4): Marko NF, Toms SA, Barnett GH, Weil R. Genomic expression patterns distinguish long-term from short-term glioblastoma survivors: a preliminary feasibility study. Genomics May;91(5): Pineyro MM, Makdissi A, Faiman C, Prayson RA, Reddy SK, Mayberg MC, Weil RJ, Hamrahian AH. Poor correlation of serum alpha-subunit concentration and magnetic resonance imaging following pituitary surgery in patients with nonfunctional pituitary macroadenomas. Endocr Pract May;14(4): Sade B, Lee JH. High incidence of optic canal involvement in clinoidal meningiomas: rationale for aggressive skull base approach. Acta Neurochir (Wien) Nov;150(11): Cerebrovascular Center Albuquerque FC, Levy EI, Turk AS, Niemann DB, Aagaard- Kienitz B, Pride GL Jr, Purdy PD, Welch BG, Woo HH, Rasmussen PA, Hopkins LN, Masaryk TJ, McDougall CG, Fiorella DJ. Angiographic patterns of wingspan in-stent restenosis. Neurosurgery Jul;63(1):23-27;discussion Bhatt A, Vora NA, Thomas AJ, Majid A, Kassab M, Hammer MD, Uchino K, Wechsler L, Jovin TG, Gupta R. Lower pretreatment cerebral blood volume affects hemorrhagic risks after intraarterial revascularization in acute stroke. Neurosurgery Nov;63(5): Cucullo L, Couraud PO, Weksler B, Romero IA, Hossain M, Rapp E, Janigro D. Immortalized human brain endothelial cells and flow-based vascular modeling: a marriage of convenience for rational neurovascular studies. J Cereb Blood Flow Metab Feb;28(2): Fan QY, Ramakrishna S, Marchi N, Fazio V, Hallene K, Janigro D. Combined effects of prenatal inhibition of vasculogenesis and neurogenesis on rat brain development. Neurobiol Dis Dec;32(3): Kelly ME, Turner RD IV, Moskowitz SI, Gonugunta V, Hussain MS, Fiorella D. Delayed migration of a self-expanding intracranial microstent. AJNR Am J Neuroradiol Nov;29(10): Cleveland Clinic Neurological Institute 2008 Annual Report

47 Research 45 Masaryk T, Kolonick R, Painter T, Weinreb DB. The economic and clinical benefits of portable head/neck CT imaging in the intensive care unit. Radiol Manage Mar- Apr;30(2): Nagel MA, Cohrs RJ, Mahalingam R, Wellish MC, Forghani B, Schiller A, Safdieh JE, Kamenkovich E, Ostrow LW, Levy M, Greenberg B, Russman AN, Katzan I, Gardner CJ, Hausler M, Nau R, Saraya T, Wada H, Goto H, de Martino M, Ueno M, Brown WD, Terborg C, Gilden DH. The varicella zoster virus vasculopathies: clinical, CSF, imaging, and virologic features. Neurology Mar 11;70(11): Tayal AH, Tian M, Kelly KM, Jones SC, Wright DG, Singh D, Jarouse J, Brillman J, Murali S, Gupta R. Atrial fibrillation detected by mobile cardiac outpatient telemetry in cryptogenic TIA or stroke. Neurology Nov 18;71(21): Turk AS, Levy EI, Albuquerque FC, Pride GL Jr, Woo H, Welch BG, Niemann DB, Purdy PD, Aagaard-Kienitz B, Rasmussen PA, Hopkins LN, Masaryk TJ, McDougall CG, Fiorella D. Influence of patient age and stenosis location on wingspan in-stent restenosis. AJNR Am J Neuroradiol Jan;29(1): Turner RD, Byrne JV, Kelly ME, Mitsos AP, Gonugunta V, Lalloo S, Rasmussen PA, Fiorella D. Delayed visual deficits and monocular blindness after endovascular treatment of large and giant paraophthalmic aneurysms. Neurosurgery Sep;63(3): Epilepsy Center Bautista JF, Kelly JA, Harley JB, Gray-McGuire C. Addressing genetic heterogeneity in complex disease: finding seizure genes in systemic lupus erythematosus. Epilepsia Mar;49(3): Busch RM, Chapin JS, Umashankar G, Diehl B, Harvey D, Naugle RI, Nair D, Najm IM. Poor presurgical performance on both verbal and visual memory measures is associated with low risk for memory decline following left temporal lobectomy for intractable epilepsy. Epileptic Disord Sep;10(3): Chapin JS, Busch RM, Janigro D, Dougherty M, Tilelli CQ, Lineweaver TT, Naugle RI, Diaz-Arrastia R, Najm IM. APOE epsilon4 is associated with postictal confusion in patients with medically refractory temporal lobe epilepsy. Epilepsy Res Oct;81(2-3): Dutton C, Foldvary-Schaefer N. Contraception in women with epilepsy: pharmacokinetic interactions, contraceptive options, and management. Int Rev Neurobiol. 2008;83: Foldvary-Schaefer N, Stephenson L, Bingaman W. Resolution of obstructive sleep apnea with epilepsy surgery? Expanding the relationship between sleep and epilepsy. Epilepsia Aug;49(8): Jehi L, Najm IM. Sudden unexpected death in epilepsy: impact, mechanisms, and prevention. Cleve Clin J Med Mar;75 Suppl 2:S66-S70. Kim H, Piao Z, Liu P, Bingaman W, Diehl B. Secondary white matter degeneration of the corpus callosum in patients with intractable temporal lobe epilepsy: a diffusion tensor imaging study. Epilepsy Res Oct;81(2-3): Lachhwani DK, Loddenkemper T, Holland KD, Kotagal P, Mascha E, Bingaman W, Wyllie E. Discontinuation of medications after successful epilepsy surgery in children. Pediatr Neurol May;38(5): Mani J, Diehl B, Piao Z, Schuele SS, Lapresto E, Liu P, Nair DR, Dinner DS, Luders HO. Evidence for a basal temporal visual language center: cortical stimulation producing pure alexia. Neurology Nov 11;71(20): Zotev VS, Matlashov AN, Volegov PL, Savukov IM, Espy MA, Mosher JC, Gomez JJ, Kraus RH Jr. Microtesla MRI of the human brain combined with MEG. J Magn Reson Sep;194(1): Mellen Center for Multiple Sclerosis Treatment and Research Cardona AE, Sasse ME, Liu L, Cardona SM, Mizutani M, Savarin C, Hu T, Ransohoff RM. Scavenging roles of chemokine receptors: chemokine receptor deficiency is associated with increased levels of ligand in circulation and tissues. Blood Jul 15;112(2): Chang A, Smith MC, Yin X, Fox RJ, Staugaitis SM, Trapp BD. Neurogenesis in the chronic lesions of multiple sclerosis. Brain Sep;131(Pt 9): Cohen JA, Calabresi PA, Chakraborty S, Edwards KR, Eickenhorst T, Felton WL III, Fisher E, Fox RJ, Goodman AD, Hara-Cleaver C, Hutton GJ, Imrey PB, Ivancic DM, Mandell BF, Perryman JE, Scott TF, Skaramagas TT, Zhang H. Avonex combination trial in relapsing-remitting MS: rationale, design and baseline data. Mult Scler Apr;14(3): Fisher E, Lee JC, Nakamura K, Rudick RA. Gray matter atrophy in multiple sclerosis: a longitudinal study. Ann Neurol Sep;64(3): clevelandclinic.org/neuroscience

48 46 Research Fox RJ, McColl RW, Lee JC, Frohman T, Sakaie K, Frohman E. A preliminary validation study of diffusion tensor imaging as a measure of functional brain injury. Arch Neurol Sep;65(9): Lowe MJ, Beall EB, Sakaie KE, Koenig KA, Stone L, Marrie RA, Phillips MD. Resting state sensorimotor functional connectivity in multiple sclerosis inversely correlates with transcallosal motor pathway transverse diffusivity. Hum Brain Mapp Jul;29(7): Moll NM, Rietsch AM, Ransohoff AJ, Cossoy MB, Huang D, Eichler FS, Trapp BD, Ransohoff RM. Cortical demyelination in PML and MS: similarities and differences. Neurology Jan 29;70(5): Sutliff MH, Naft JM, Stough DK, Lee JC, Arrigain SS, Bethoux FA. Efficacy and safety of a hip flexion assist orthosis in ambulatory multiple sclerosis patients. Arch Phys Med Rehabil Aug;89(8): Trapp BD, Nave KA. Multiple sclerosis: an immune or neurodegenerative disorder? Annu Rev Neurosci. 2008;31: Young EA, Fowler CD, Kidd GJ, Chang A, Rudick R, Fisher E, Trapp BD. Imaging correlates of decreased axonal Na+/K+ ATPase in chronic multiple sclerosis lesions. Ann Neurol Apr;63(4): Center for Neuroimaging Ash LM, Modic MT, Obuchowski NA, Ross JS, Brant-Zawadzki MN, Grooff PN. Effects of diagnostic information, per se, on patient outcomes in acute radiculopathy and low back pain. AJNR Am J Neuroradiol Jun;29(6): Loddenkemper T, Friedman NR, Ruggieri PM, Marcotty A, Sears J, Traboulsi EI. Pituitary stalk duplication in association with moya moya disease and bilateral morning glory disc anomaly broadening the clinical spectrum of midline defects. J Neurol Jun;255(6): Lowe MJ, Beall EB, Sakaie KE, Koenig KA, Stone L, Marrie RA, Phillips MD. Resting state sensorimotor functional connectivity in multiple sclerosis inversely correlates with transcallosal motor pathway transverse diffusivity. Hum Brain Mapp Jul;29(7): Masaryk T, Kolonick R, Painter T, Weinreb DB. The economic and clinical benefits of portable head/neck CT imaging in the intensive care unit. Radiol Manage Mar- Apr;30(2): Phillips MD. Functional faults: fmri in MS. Neurology Jan 22;70(4): Center for Neurological Restoration Alberts JL, Voelcker-Rehage C, Hallahan K, Vitek M, Bamzai R, Vitek JL. Bilateral subthalamic stimulation impairs cognitivemotor performance in Parkinson s disease patients. Brain Dec;131(Pt 12): Cooper SE, Kuncel AM, Wolgamuth BR, Rezai AR, Grill WM. A model predicting optimal parameters for deep brain stimulation in essential tremor. J Clin Neurophysiol Oct;25(5): Floden D, Alexander MP, Kubu CS, Katz D, Stuss DT. Impulsivity and risk-taking behavior in focal frontal lobe lesions. Neuropsychologia. 2008;46(1): Guo Y, Rubin JE, McIntyre CC, Vitek JL, Terman D. Thalamocortical relay fidelity varies across subthalamic nucleus deep brain stimulation protocols in a data-driven computational model. J Neurophysiol Mar;99(3): Johnson MD, Miocinovic S, McIntyre CC, Vitek JL. Mechanisms and targets of deep brain stimulation in movement disorders. Neurotherapeutics Apr;5(2): Kaminsky Z, Petronis A, Wang SC, Levine B, Ghaffar O, Floden D, Feinstein A. Epigenetics of personality traits: an illustrative study of identical twins discordant for risk-taking behavior. Twin Res Hum Genet Feb;11(1):1-11. Khatib R, Ebrahim Z, Rezai A, Cata JP, Boulis NM, Doyle DJ, Schurigyn T, Farag E. Perioperative events during deep brain stimulation: the experience at Cleveland Clinic. J Neurosurg Anesthesiol Jan;20(1): Rezai AR, Machado AG, Deogaonkar M, Azmi H, Kubu C, Boulis NM. Surgery for movement disorders. Neurosurgery Feb;62(Suppl 2): Voon V, Krack P, Lang AE, Lozano AM, Dujardin K, Schupbach M, D Ambrosia J, Thobois S, Tamma F, Herzog J, Speelman JD, Samanta J, Kubu C, Rossignol H, Poon YY, Saint-Cyr JA, Ardouin C, Moro E. A multicentre study on suicide outcomes following subthalamic stimulation for Parkinson s disease. Brain Oct;131(Pt 10): Xu W, Russo GS, Hashimoto T, Zhang J, Vitek JL. Subthalamic nucleus stimulation modulates thalamic neuronal activity. J Neurosci Nov 12;28(46): Cleveland Clinic Neurological Institute 2008 Annual Report

49 Research 47 Neuromuscular Center Chahine LM, Patrick R, Tavee J. Complex regional pain syndrome after infliximab infusion. J Pain Symptom Manage Sep;36(3):e2-e4. Cheng G, Kaminski HJ, Gong B, Zhou L, Hatala D, Howell SJ, Zhou X, Mustari MJ. Monocular visual deprivation in macaque monkeys: a profile in the gene expression of lateral geniculate nucleus by laser capture microdissection. Mol Vis. 2008;14: Holmes RO Jr, Tavee J. Vasospasm and stroke attributable to ephedra-free xenadrine: case report. Mil Med Jul;173(7): McClelland S III, Bethoux FA, Boulis NM, Sutliff MH, Stough DK, Schwetz KM, Gogol DM, Harrison M, Pioro EP. Intrathecal baclofen for spasticity-related pain in amyotrophic lateral sclerosis: efficacy and factors associated with pain relief. Muscle Nerve Mar;37(3): Rini BI, Shook S. Is Guillain Barre syndrome likely in this patient? Oncology (Williston Park) Jan;22(1): Shook SJ, Mamsa H, Jen JC, Baloh RW, Zhou L. Novel mutation in KCNA1 causes episodic ataxia with paroxysmal dyspnea. Muscle Nerve Mar;37(3): Sorenson EJ, Windbank AJ, Mandrekar JN, Bamlet WR, Appel SH, Armon C, Barkhaus PE, Bosch P, Boylan K, David WS, Feldman E, Glass J, Gutmann L, Katz J, King W, Luciano CA, McCluskey LF, Nash S, Newman DS, Pascuzzi RM, Pioro E, Sams LJ, Scelsa S, Simpson EP, Subramony SH, Tiryaki E, Thornton CA. Subcutaneous IGF-1 is not beneficial in 2-year ALS trial. Neurology Nov 25;71(22): Tavee J, Morris H III. Severe postictal laryngospasm as a potential mechanism for sudden unexpected death in epilepsy: a near-miss in an EMU. Epilepsia.2008 Dec;49(12): Zhou L, Rafael-Fortney JA, Huang P, Zhao XS, Cheng G, Zhou X, Kaminski HJ, Liu L, Ransohoff RM. Haploinsufficiency of utrophin gene worsens skeletal muscle inflammation and fibrosis in mdx mice. J Neurol Sci Jan 15;264(1-2): Neurological Center for Pain Bigal M, Sheftell F, Tepper S, Tepper D, Ho TW, Rapoport A. A randomized double-blind study comparing rizatriptan, dexamethasone, and the combination of both in the acute treatment of menstrually related migraine. Headache Oct;48(9): Cleves C, Tepper SJ. Sumatriptan/naproxen sodium combination for the treatment of migraine. Expert Rev Neurother Sep;8(9): Sun-Edelstein C, Tepper SJ, Shapiro RE. Drug-induced serotonin syndrome: a review. Expert Opin Drug Saf Sep;7(5): Syrjala KL, Abrams JR, Polissar NL, Hansberry J, Robison J, DuPen S, Stillman M, Fredrickson M, Rivkin S, Feldman E, Gralow J, Rieke JW, Raish RJ, Lee DJ, Cleeland CS, DuPen A. Patient training in cancer pain management using integrated print and video materials: a multisite randomized controlled trial. Pain Mar;135(1-2): Tepper SJ, Stillman MJ. Clinical and preclinical rationale for CGRP-receptor antagonists in the treatment of migraine. Headache Sep;48(8): Tepper SJ, Zatochill M, Szeto M, Sheftell F, Tepper DE, Bigal M. Development of a simple menstrual migraine screening tool for obstetric and gynecology clinics: the menstrual migraine assessment tool. Headache Nov;48(10): Center for Pediatric Neurology and Neurosurgery Bedaiwy MA, Fathalla MM, Shaaban OM, Ragab MH, Elbaba S, Luciano M, El-Nashar SA, Falcone T. Reproductive implications of endoscopic third ventriculostomy for the treatment of hydrocephalus. Eur J Obstet Gynecol Reprod Biol Sep;140(1): Chappelow AV, Reid J, Parikh S, Traboulsi EI. Aicardi syndrome in a genotypic male. Ophthalmic Genet Dec;29(4): Factora R, Luciano M. When to consider normal pressure hydrocephalus in the patient with gait disturbance. Geriatrics Feb;63(2): Fong J, Wu G, Wyllie E, Gupta A. Interictal hypermetabolic subcortical band on brain FDG-PET in doublecortin mutation. Neurology Aug 12;71(7):535. Haas RH, Parikh S, Falk MJ, Saneto RP, Wolf NI, Darin N, Wong LJ, Cohen BH, Naviaux RK. The in-depth evaluation of suspected mitochondrial disease. Mol Genet Metab May;94(1): Loddenkemper T, Alexopoulos AV, Kotagal P, Moosa A, Lachhwani DK, Gupta A, Bingaman W, Wyllie E. Epilepsy clevelandclinic.org/neuroscience

50 48 Research surgery in epidermal nevus syndrome variant with hemimegalencephaly and intractable seizures. J Neurol Nov;255(11): Loddenkemper T, Friedman NR, Ruggieri PM, Marcotty A, Sears J, Traboulsi EI. Pituitary stalk duplication in association with moya moya disease and bilateral morning glory disc anomaly broadening the clinical spectrum of midline defects. J Neurol Jun;255(6): Parikh S, Cohen BH, Gupta A, Lachhwani DK, Wyllie E, Kotagal P. Metabolic testing in the pediatric epilepsy unit. Pediatr Neurol Mar;38(3): Weissman JR, Kelley RI, Bauman ML, Cohen BH, Murray KF, Mitchell RL, Kern RL, Natowicz MR. Mitochondrial disease in autism spectrum disorder patients: a cohort analysis. PLoS ONE. 2008;3(11):e3815. Department of Psychiatry and Psychology Busch RM, Chapin JS, Umashankar G, Diehl B, Harvey D, Naugle RI, Nair D, Najm IM. Poor presurgical performance on both verbal and visual memory measures is associated with low risk for memory decline following left temporal lobectomy for intractable epilepsy. Epileptic Disord Sep;10(3): Coffman KL. The debate about marijuana usage in transplant candidates: recent medical evidence on marijuana health effects. Curr Opin Organ Transplant Apr;13(2): Falcone T, Carlton E, Janigro D, Simon B, Franco K. Self-harm during first-episode psychosis. Br J Psychiatry Aug;193(2):167. Floden D, Alexander MP, Kubu CS, Katz D, Stuss DT. Impulsivity and risk-taking behavior in focal frontal lobe lesions. Neuropsychologia. 2008;46(1): Heinberg LJ, Coughlin JW, Pinto AM, Haug N, Brode C, Guarda AS. Validation and predictive utility of the Sociocultural Attitudes Toward Appearance Questionnaire for Eating Disorders (SATAQ- ED): internalization of sociocultural ideals predicts weight gain. Body Image Sep;5(3): Kaminsky Z, Petronis A, Wang SC, Levine B, Ghaffar O, Floden D, Feinstein A. Epigenetics of personality traits: an illustrative study of identical twins discordant for risk-taking behavior. Twin Res Hum Genet Feb;11(1):1-11. McKee MG. Biofeedback: an overview in the context of heartbrain medicine. Cleve Clin J Med Mar;75 Suppl 2:S31-S34. Muzina DJ. Depression and anxiety: distinguishing unipolar and bipolar disorders. Ann Clin Psychiatry Dec;20 Suppl 1:S19-S23. Pandya M, Kubu CS, Giroux ML. Parkinson disease: not just a movement disorder. Cleve Clin J Med Dec;75(12): Tesar GE. Whither hospital and academic psychiatry? Psychiatr Clin North Am Mar;31(1): Tetzlaff JE, Collins GB. Reentry of anesthesiology residents after treatment of chemical dependency is it rational? J Clin Anesth Aug;20(5): Sleep Disorders Center Aboussouan LS, Lattin CD, Kline JL. Determinants of long-term mortality after prolonged mechanical ventilation. Lung Sep;186(5): Foldvary-Schaefer N, Stephenson L, Bingaman W. Resolution of obstructive sleep apnea with epilepsy surgery? Expanding the relationship between sleep and epilepsy. Epilepsia Aug;49(8): Gugliotti D, Grant P, Jaber W, Aboussouan L, Bae C, Sessler D, Scahuer P, Kaw R. Challenges in cardiac risk assessment in bariatric surgery patients. Obes Surg Jan;18(1): Kaw R, Aboussouan L, Auckley D, Bae C, Gugliotti D, Grant P, Jaber W, Schauer P, Sessler D. Challenges in pulmonary risk assessment and perioperative management in bariatric surgery patients. Obes Surg Jan;18(1): Koo BB, Dostal J, Ioachimescu O, Budur K. The effects of gender and age on REM-related sleep-disordered breathing. Sleep Breath Aug;12(3): Malow BA, Foldvary-Schaefer N, Vaughn BV, Selwa LM, Chervin RD, Weatherwax KJ, Wang L, Song Y. Treating obstructive sleep apnea in adults with epilepsy: a randomized pilot trial. Neurology Aug 19;71(8): Minai OA, Malik N, Foldvary N, Bair N, Golish JA. Prevalence and characteristics of restless legs syndrome in patients with pulmonary hypertension. J Heart Lung Transplant Mar;27(3): Cleveland Clinic Neurological Institute 2008 Annual Report

51 Research 49 Selwa LM, Marzec ML, Chervin RD, Weatherwax KJ, Vaughn BV, Foldvary-Schaefer N, Wang L, Song Y, Malow BA. Sleep staging and respiratory events in refractory epilepsy patients: is there a first night effect? Epilepsia Dec;49(12): Center for Spine Health Foley KT, Mroz TE, Arnold PM, Chandler HC Jr, Dixon RA, Girasole GJ, Renkens KL Jr, Riew KD, Sasso RC, Smith RC, Tung H, Wecht DA, Whiting DM. Randomized, prospective, and controlled clinical trial of pulsed electromagnetic field stimulation for cervical fusion. Spine J May- Jun;8(3): Mroz TE, Joyce MJ, Steinmetz MP, Lieberman IH, Wang JC. Musculoskeletal allograft risks and recalls in the United States. J Am Acad Orthop Surg Oct;16(10): Mroz TE, Yamashita T, Davros WJ, Lieberman IH. Radiation exposure to the surgeon and the patient during kyphoplasty. J Spinal Disord Tech Apr;21(2): Schofferman J, Mazanec D. Evidence-informed management of chronic low back pain with opioid analgesics. Spine J Jan- Feb;8(1): Steinmetz MP, Patel R, Traynelis V, Resnick DK, Anderson PA. Cervical disc arthroplasty compared with fusion in a workers compensation population. Neurosurgery Oct;63(4): Steinmetz MP, Rajpal S, Trost G. Segmental spinal instrumentation in the management of scoliosis. Neurosurgery Sep;63(3 Suppl): Studer RK, Gilbertson LG, Georgescu H, Sowa G, Vo N, Kang JD. p38 MAPK inhibition modulates rabbit nucleus pulposus cell response to IL-1. J Orthop Res Jul;26(7): Vadala G, Studer RK, Sowa G, Spiezia F, Iucu C, Denaro V, Gilbertson LG, Kang JD. Coculture of bone marrow mesenchymal stem cells and nucleus pulposus cells modulate gene expression profile without cell fusion. Spine Apr 15;33(8): Vadala G, Sobajima S, Lee JY, Huard J, Denaro V, Kang JD, Gilbertson LG. In vitro interaction between muscle-derived stem cells and nucleus pulposus cells. Spine J Sep;8(5): Watters WC III, Baisden J, Gilbert TJ, Kreiner S, Resnick DK, Bono CM, Ghiselli G, Heggeness MH, Mazanec DJ, O Neill C, Reitman CA, Shaffer WO, Summers JT, Toton JF. Degenerative lumbar spinal stenosis: an evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis. Spine J Mar-Apr;8(2): Neurosurgical Anesthesiology Bala E, Sessler DI, Nair DR, McLain R, Dalton JE, Farag E. Motor and somatosensory evoked potentials are well maintained in patients given dexmedetomidine during spine surgery. Anesthesiology Sep;109(3): Cata JP, Noguera EM, Parke E, Ebrahim Z, Kurz A, Kalfas I, Mascha E, Farag E. Patient-controlled epidural analgesia (PCEA) for postoperative pain control after lumbar spine surgery. J Neurosurg Anesthesiol Oct;20(4): Elkassabany NM, Bhatia J, Deogaonkar A, Barnett GH, Lotto M, Maurtua M, Ebrahim Z, Schubert A, Ference S, Farag E. Perioperative complications of blood brain barrier disruption under general anesthesia: a retrospective review. J Neurosurg Anesthesiol Jan;20(1): Khatib R, Ebrahim Z, Rezai A, Cata JP, Boulis NM, Doyle DJ, Schurigyn T, Farag E. Perioperative events during deep brain stimulation: the experience at Cleveland Clinic. J Neurosurg Anesthesiol Jan;20(1): Maurtua MA, Deogaonkar A, Bakri MH, Mascha E, Na J, Foss J, Sessler DI, Lotto M, Ebrahim Z, Schubert A. Dosing of remifentanil to prevent movement during craniotomy in the absence of neuromuscular blockade. J Neurosurg Anesthesiol Oct;20(4): clevelandclinic.org/neuroscience

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53 Education 51 Education The Neurological Institute collaborates with Cleveland Clinic s Center for Continuing Education to offer a highly regarded series of continuing medical education (CME) programs to physicians and other healthcare professionals. In addition, the institute provides extensive graduate medical education opportunities, training some 170 clinical and research fellows and residents annually and hosting approximately 70 international and national physician-observers each year. Neurological Institute physicians direct the core neuroscience curriculum for approximately 120 medical students annually at Cleveland Clinic Lerner College of Medicine. They also share valuable information with the public on the latest neurological advances. This commitment to education was expressed in new forms in 2008, including presentation of the first Neurological Institute Research Day. Medical Professionals Continuing Medical Education The Center for Continuing Education is responsible for one of the world s largest, most diverse CME programs. In 2008, more than 15,000 professionals participated in more than 250 Neurological Institute-sponsored CME programs, ranging from weekly grand rounds in six departments to multi-day international symposia, regional programs, association meetings, guest lectures and training courses. The center s efforts to expand CME opportunities through nontraditional learning were highly successful in 2008, when 2,087 certificates were issued for completion of online neurological courses. The number represents a 60 percent increase over Graduate Medical Education The Neurological Institute offers approximately 30 accredited and non-accredited training programs providing physician education and research opportunities in neurology, neurosurgery, psychiatry and psychology. Residents and fellows work side by side with some of the world s most renowned experts in the neurosciences. Core residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) encompass adult neurology, child neurology, neurosurgery, adult psychiatry, and child and adolescent psychiatry. ACGME-accredited subspecialty fellowships and non-accredited fellowships are also available. Research fellowships are offered for MDs and PhDs interested in clinician/scientist careers. Neurological Institute Research Day In 2008, the Neurological Institute inaugurated Research Day, a forum showcasing the projects of medical students, residents, and clinical, research and post-doctoral fellows. Participants made 74 poster and platform presentations and competed for recognition awards at the event, which was judged by an interdisciplinary team of Neurological Institute staff members. Left: Residents review anatomy in the Spine Research Laboratory. The Neurological Institute offers almost 30 training programs in neurology, neurosurgery, psychiatry and psychology, enabling residents and fellows to learn from some of the world s most renowned experts in the neurosciences. clevelandclinic.org/neuroscience

54 52 Education Twelve presenters received awards for their work. Leopoldo Pozuelo, MD, was honored as the Neurological Institute Cleveland Clinic Lerner College of Medicine Teacher of the Year. Ultimately, the experience fostered a sense of community within the institute and exposed participants to methodologies that specialty areas outside their own apply to answer research questions. Attendees commented on the general enthusiasm and the opportunity to communicate across departments. The strongest testimonials came from presenters who said they looked forward to taking part in Research Day Patients and the Public Through a range of communication channels, Neurological Institute physicians and allied health professionals connect with the community, sharing information on specific neurological conditions, answering common questions, and helping patients and family members cope with challenging diagnoses and diseases. Among the most popular forums are: The first Neurological Institute Research Day, showcasing the work of medical students, residents and clinical fellows. For the presenters, Research Day was an opportunity to share their work and obtain helpful feedback, hone their writing and presentation skills, find new resources and collaborators, and earn recognition from mentors and peers. Participant Adrian Zachary, DO, MPH, alluded to a feeling of honor presenting research. For the physician-judges, Research Day reinforced an understanding of our excellence, in the words of Edward Benzel, MD. The event also inspired appreciation of and respect for the presenters and their work. Chief Resident Joyce Lee, MD, spoke for many when she remarked on the amount of research generated by the residents in the NI as busy as they are, they still manage to find the time to generate amazing research studies and papers. Health Talks, which are free educational seminars at Cleveland Clinic s main campus and Cleveland Clinic family health centers throughout northeast Ohio. Recent sessions have focused on management of pituitary disorders, Parkinson s disease and wellness, and treatment options for chronic back pain. Live web chats with physicians who discuss a variety of neurological disorders, diagnoses and therapeutic options. Topics have included medical management of back pain, pediatric brain tumor, neurofibromatosis, multiple sclerosis, sleep disorders, adult scoliosis and memory loss. Gatherings that forge lasting bonds, such as the Pediatric Epilepsy Support Group s second biennial reunion for children who underwent epilepsy surgery at Cleveland Clinic and their families. The two-day event in August 2008 drew 280 attendees from as far away as Ireland and South Africa. Educational as well as social, the reunion featured physician-led sessions for patients caregivers that focused on life after epilepsy surgery. Cleveland Clinic Neurological Institute 2008 Annual Report

55 Education 53 The Pediatric Epilepsy Support Group offers families of children with epilepsy a forum for education, discussion and camaraderie. Music and the Brain Can music speed the healing process? Should musicians and neuroscientists collaborate on healing techniques? Questions like these were addressed during Music and the Brain, three public programs presented jointly by the Neurological Institute and the Arts and Medicine Institute, in partnership with the U.S. Department of Health and Human Services and The Cleveland Orchestra. The innovative series began at Cleveland Clinic and unfolded on an international stage, drawing a total of more than 500 participants: Cleveland Clinic s Doctor-Patient Music Connection, which aims to improve medical care by raising the level of the physician-patient relationship through the performing arts, presented a piano and chamber music recital performed by physicians and patients. A reception followed the event, which was designed primarily for patients and their families. Two days later, a concert-symposium on neuromusic explored the relationship between music and the physiological and pathological processes in the nervous system. Co-directed by Kamal Chémali, MD, and Neil Cherian, MD, the daylong event featured lectures by nationally recognized experts, including Neurological Institute physicians. The session, offered for CME credit, attracted medical professionals as well as musicians. The day concluded with a panel discussion and piano recital at the Cleveland Institute of Music. Cleveland Clinic and The Cleveland Orchestra joined forces for a symposium at the Salzburg Festival in Austria, where a panel of international experts examined new understanding about the intersection of music and neuroscience, the effect of music on health and the brain s impact on musical ability. The program launched a collaboration between two world leaders in medicine and music. clevelandclinic.org/neuroscience

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57 New Staff 55 New Staff The lifeblood of any organization is its people. Cleveland Clinic Neurological Institute includes more than 250 medical, surgical and research specialists dedicated to the diagnosis, treatment and understanding of all neurological conditions affecting adult and pediatric patients. Due to its clinical expertise, academic achievement and research capabilities, the Neurological Institute has earned an international reputation, and continues to attract elite clinicians and scientists who aspire to be affiliated with one of the world s premier medical centers. In 2008, the following professionals joined the Neurological Institute staff: Lou Ruvo Center for Brain Health Randolph B. Schiffer, MD, neurologist/psychiatrist, Director Cerebrovascular Center Rishi Gupta, MD, vascular and interventional neurologist Ferdinand Hui, MD, interventional neuroradiologist Shaye Moskowitz, MD, PhD, endovascular neurosurgeon Epilepsy Center Juan Bulacio, MD, clinical neurophysiologist Jorge Gonzalez-Martinez, MD, PhD, neurosurgeon Stephen Hantus, MD, epileptologist John Mosher, PhD, neuroscientist, Section Head of the magnetoencephalography program Diosely Silveira, MD, PhD, epileptologist Lerner Research Institute James Kaltenbach, PhD, neuroscientist, Department of Neurosciences and Cleveland Clinic Head and Neck Institute Jeremy Rich, MD, neurologist, Chairman of the Department of Stem Cell Biology and Regenerative Medicine Neurological Center for Pain Deborah Tepper, MD, internist Stewart Tepper, MD, neurologist Center for Neurological Restoration Anwar Ahmed, MD, neurologist Center for Regional Neurology Sheila Rubin, MD, neurologist Jennifer Ui, MD, neurologist Joseph Zayat, MD, neurologist Sleep Disorders Center Sally Ibrahim, MD, sleep specialist Center for Spine Health Tagreed Khalaf, MD, medical spine specialist Department of Psychiatry and Psychology Joseph Austerman, DO, psychiatrist Left: Sally Ibrahim, MD, sees both adult and pediatric patients with sleep disorders. Reflecting the scope of the Sleep Disorders Center s capabilities, she treats a wide range of conditions, including sleep apnea, disorders of excessive daytime sleepiness, circadian rhythm disorders, restless legs syndrome and parasomnias. clevelandclinic.org/neuroscience

58 56 Neurological Institute Staff Neurological Institute Chairmen Michael T. Modic, MD, FACR Chairman, Neurological Institute William Bingaman, MD Vice Chairman, Clinical Areas, Neurological Institute Richard Rudick, MD Vice Chairman, Research and Development, Neurological Institute Edward Benzel, MD Chairman, Department of Neurological Surgery Kerry Levin, MD Chairman, Department of Neurology Vernon Lin, MD, PhD Chairman, Department of Physical Medicine and Rehabilitation Thomas Masaryk, MD Chairman, Department of Diagnostic Radiology George E. Tesar, MD Chairman, Department of Psychiatry and Psychology Bruce Trapp, PhD Chairman, Department of Neurosciences, Lerner Research Institute Lou Ruvo Center for Brain Health Randolph B. Schiffer, MD Director, Lou Ruvo Center for Brain Health Charles Bernick, MD Cynthia S. Kubu, PhD, ABPP-CN Richard Naugle, PhD Michael Parsons, PhD Alexander Rae-Grant, MD, FRCP (C) Stephen Rao, PhD Director, Schey Foundation Center for Advanced Cognitive Function Patrick Sweeney, MD Janice Zimbelman, PT, PhD Brain Tumor and Neuro-Oncology Center Gene Barnett, MD, FACS Director, Brain Tumor and Neuro-Oncology Center Manmeet Ahluwalia, MD Lilyana Angelov, MD, FRCS(C) Samuel Chao, MD Bruce H. Cohen, MD Joung Lee, MD David Peereboom, MD Jeremy Rich, MD Burak Sade, MD Glen Stevens, DO, PhD John Suh, MD Tanya Tekautz, MD Michael Vogelbaum, MD, PhD Robert Weil, MD Cerebrovascular Center Peter Rasmussen, MD Director, Cerebrovascular Center Neil Friedman, MBChB James Gebel, MD Rishi Gupta, MD Ferdinand Hui, MD Irene Katzan, MD, MS Gwendolyn Lynch, MD Edward Manno, MD Thomas Masaryk, MD Shaye Moskowitz, MD, PhD J. Javier Provencio, MD, FCCM Vivek Sabharwal, MD Ken Uchino, MD Epilepsy Center Imad Najm, MD Director, Epilepsy Center Andreas Alexopoulos, MD, MPH Jocelyn Bautista, MD William Bingaman, MD Juan Bulacio, MD Richard Burgess, MD, PhD Robyn Busch, PhD Jessica Chapin, PhD Tatiana Falcone, MD Nancy Foldvary-Schaefer, DO Paul Ford, PhD Jorge Gonzalez-Martinez, MD, PhD Ajay Gupta, MD Stephen Hantus, MD Jennifer Haut, PhD, ABPP-CN Lara Jehi, MD Cleveland Clinic Neurological Institute 2008 Annual Report

59 Neurological Institute 57 Patricia Klaas, PhD Prakash Kotagal, MD Deepak Lachhwani, MBBS, MD John Mosher, PhD Dileep Nair, MD Richard Naugle, PhD Paul Ruggieri, MD Diosely Silveira, MD, PhD Norman So, MD Andrey Stojic, MD, PhD George E. Tesar, MD Ingrid Tuxhorn, MD Elaine Wyllie, MD Mellen Center for Multiple Sclerosis Treatment and Research Richard Rudick, MD Director, Mellen Center for Multiple Sclerosis Treatment and Research Robert Bermel, MD Francois Bethoux, MD Adrienne Boissy, MD Jeffrey Cohen, MD Robert Fox, MD Keith McKee, MD Deborah Miller, PhD Alexander Rae-Grant, MD, FRCP (C) Richard M. Ransohoff, MD Mary Rensel, MD Lael Stone, MD Center for Neuroimaging Thomas Masaryk, MD Director, Center for Neuroimaging Manzoor Ahmed, MD Todd M. Emch, MD Stephen E. Jones, MD, PhD Mark Lowe, PhD Parvez Masood, MD Michael T. Modic, MD, FACR Doksu Moon, MD Micheal Phillips, MD Paul Ruggieri, MD Alison Smith, MD Todd Stultz, DDS, MD Andrew Tievsky, MD Center for Neurological Restoration Andre Machado, MD, PhD Director, Center for Neurological Restoration Anwar Ahmed, MD Jay Alberts, PhD Scott Cooper, MD, PhD Milind Deogaonkar, MD Darlene Floden, PhD Ilia Itin, MD Cynthia S. Kubu, PhD, ABPP-CN Richard Lederman, MD, PhD Donald A. Malone Jr., MD Cameron McIntyre, PhD Mayur Pandya, DO Patrick Sweeney, MD Jerrold Vitek, MD, PhD Center for Pediatric Neurology and Neurosurgery Elaine Wyllie, MD Director, Center for Pediatric Neurology Mark Luciano, MD, PhD Director, Center for Pediatric Neurosurgery Bruce H. Cohen, MD Xiao Di, MD, PhD Stephen Dombrowski, PhD Gerald Erenberg, MD Neil Friedman, MBChB Debabrata Ghosh, MD, DM Gary Hsich, MD Irwin Jacobs, MD Sudeshna Mitra, MD Manikum Moodley, MD Sumit Parikh, MD A. David Rothner, MD Tanya Tekautz, MD Neurological Center for Pain Edward Covington, MD Director, Neurological Center for Pain Cynthia Bamford, MD Neil Cherian, MD Steven Krause, PhD, MBA Jennifer Kriegler, MD Robert Kunkel, MD Jahangir Maleki, MD, PhD MaryAnn Mays, MD Judith Scheman, PhD Mark Stillman, MD Deborah Tepper, MD Stewart Tepper, MD Neuromuscular Center Kerry Levin, MD Director, Neuromuscular Center Mohammad Alsharabati, MD Kamal Chémali, MD Neil Friedman, MBChB Rebecca Kuenzler, MD Richard Lederman, MD, PhD Erik Pioro, MD, PhD David Polston, MD Robert Shields Jr., MD Steven Shook, MD Jinny Tavee, MD Lan Zhou, MD, PhD clevelandclinic.org/neuroscience

60 58 Neurological Institute General Adult Neurology Kerry Levin, MD Chairman, Department of Neurology Thomas E. Gretter, MD Richard Lederman, MD, PhD Patrick Sweeney, MD Department of Physical Medicine and Rehabilitation Vernon Lin, MD, PhD Chairman, Department of Physical Medicine and Rehabilitation Michael Felver, MD Medical Director, Center for Rehabilitation and Subacute Services Steven Landers, MD, MPH Medical Director, Home Care Services Raghavendra Allareddy, MD Frederick Frost, MD Sepideh Haghpanah, MD Juliet Hou, MD Lynn Jedlicka, MD Anantha Reddy, MD Kalyani Shah, MD Deborah Venesy, MD Department of Psychiatry and Psychology George E. Tesar, MD Chairman, Department of Psychiatry and Psychology Donald A. Malone Jr., MD Director, Center for Behavioral Health Susan Albers-Bowling, PsyD Kathleen Ashton, PhD Joseph M. Austerman, DO Scott Bea, PsyD Dana Brendza, PsyD Karen Broer, PhD Robyn Busch, PhD Jessica Chapin, PhD Kathy Coffman, MD Gregory Collins, MD Edward Covington, MD Roman Dale, MD Beth Dixon, PsyD Judy Dodds, PhD Tatiana Falcone, MD Darlene Floden, PhD Kathleen Franco, MD John P. Glazer, MD Lilian Gonsalves, MD J. Robert Gribble, PhD Jennifer Haut, PhD, ABPP-CN Leslie Heinberg, PhD Karen Jacobs, DO Joseph W. Janesz, PhD, LICDC Regina Josell, PsyD Elias Khawan, MD Patricia Klaas, PhD Steven Krause, PhD, MBA Cynthia S. Kubu, PhD, ABPP-CN Michael McKee, PhD Gene Morris, PhD David J. Muzina, MD Richard Naugle, PhD Mayur Pandya, DO Michael Parsons, PhD Leo Pozuelo, MD Kathleen Quinn, MD Ted Raddell, PhD Judith Scheman, PhD Isabel Schuermeyer, MD Jean Simmons, PhD Barry Simon, DO Catherine Stenroos, PhD David Streem, MD Adele Viguera, MD John Vitkus, PhD Cynthia White, PsyD Amy Windover, PhD Center for Regional Neurology Stephen Samples, MD Director, Center for Regional Neurology Mohammad Alsharabati, MD A. Romeo Craciun, MD Director, Stroke Center, Marymount Hospital James Gebel, MD Sheila Rubin, MD Roderick Spears, MD Andrey Stojic, MD, PhD Diana Tanase, MD Jennifer Ui, MD Joseph Zayat, MD Center for Regional Neurological Surgery Michael Mervart, MD Director, Center for Regional Neurological Surgery Samuel Borsellino, MD Roseanna Lechner, MD Samuel Tobias, MD Right: Epilepsy Center Director Imad Najm, MD, right, confers with William Bingaman, MD, Vice Chairman, Clinical Areas, Neurological Institute, at a patient management conference. These sessions bring center staff together to discuss patients suitable for epilepsy surgery. Cleveland Clinic Neurological Institute 2008 Annual Report

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