tomorrow's neurological care. today

NEUROLOGICAL INSTITUTE | 2007 ANNUAL REPORT

Tomorrow’s Neurological Care.

Today.

Cleveland Clinic’s Neurological Institute is a multidisciplinary institute that

combines all physicians and other healthcare providers in neurology, neurosurgery,

neuroradiology, the behavioral sciences and nursing who treat adult and

pediatric patients with neurological disorders. This structure allows for a disease-

specifi c, patient-focused approach to care. Our unique, fully integrated model

is benefi cial to our current standard of care, allows us to measure quality

and outcomes on a continual basis, and enhances our ability to conduct research.

CONTENTS 2 Chairman’s Welcome

4 Neurological Institute Overview

6 Education

10 Research

18 The Knowledge Program

OUR CENTERS OF CARE

20 Brain Tumor and Neuro-Oncology Center

28 Cerebrovascular Center

36 Epilepsy Center

44 Center for Headache and Pain

50 Mellen Center for Multiple Sclerosis Treatment and Research

58 Center for Neuroimaging

62 Center for Neurological Restoration

68 Neuromuscular Center

74 Center for Pediatric Neurology and Neurosurgery

84 Department of Psychiatry and Psychology

92 Sleep Disorders Center

98 Center for Spine Health

ADDITIONAL INFORMATION

108 Neurological Institute Staff

112 Upcoming Symposia

113 How to Refer Patients

113 Locations

CLEVEL ANDCLINIC.ORG /NEUROSCIENCE | 866.588.2264

2 | WELCOME

NEUROLOGICAL INSTITUTE 2007 ANNUAL REPORT

WELCOME | 3


DEAR COLLEAGUES

A newly arriving staff member mentioned to me that he thought cognition should be the fi fth vital sign. Medical

school has taught us to check for temperature, pulse, blood pressure and respiratory rate. But a key sign of a healthy

brain is its ability to do its job: to think.

Today, cognitive disorders and their prevalence are a greater

problem than anyone ever anticipated they could be. As we

all live longer lives, we also encounter a greater magnitude of

cognitive problems, on a personal, professional and societal

level. At the same time, we also are at a unique age of discovery

regarding these disorders. We’re learning that cognitive disorders

can be identifi ed at a stage earlier than previously believed and

potentially be altered. We’re also learning that more precise

identifi cation of the problem and understanding of the mecha-

nisms behind the damage can help us combat this high price

of aging. We’re realizing that memory programs, physical and

occupational therapy, even more precise identifi cation of brain

anomalies causing cognitive disorders can help us to better keep

our mental capacities intact. We’ve also identifi ed that the risk

factors for dementia overlap with those relative to cardiovascular

disease.

At a place like Cleveland Clinic, where we routinely incorporate

multidisciplinary, disease-based care, within our Neurological

Institute, we feel we have the perfect breeding ground for a cog-

nitive disorders program. In 2007, we announced the creation

of our new Center for Brain Health, which will bring together

researchers, clinicians, therapists, surgeons, imaging special-

ists and a variety of other experts to continue to advance our

understanding of cognitive disorders and to provide the optimum

in care to patients who suffer from them.

The Center for Brain Health will share the unique attributes of

our other centers and departments, promoting collaboration

across all care providers, offering patients a complete continuum

of care and infusing education and research into all that we do.

In 2007, these centers and departments of the Neurological

Institute continued to enhance their facilities, technologies and

processes, which I am pleased to share with you here in our

2007 annual report.

Of particular note is our undertaking of the Knowledge Program,

which is an institute-wide effort to standardize our data collec-

tion within each patient’s electronic medical record to better

track outcomes and analyze data.

As we continue to evolve and enhance our institute, I look

forward to sharing with you updates regarding our new Center

for Brain Health, our Knowledge Program and other efforts to

improve patient care.

Sincerely,

Michael T. Modic, MD, FACR

Chairman, Neurological Institute

4 | OVERVIEW


CLEVELAND CLINIC NEUROLOGICAL INSTITUTE

OVERV IEW

The multidisciplinary Cleveland Clinic Neurological Insti-

tute (NI) includes more than 220 medical, surgical and

research specialists dedicated to the treatment of adult

and pediatric patients with neurological and psychiatric

disorders. The institute offers a disease-specifi c, 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 consistently has ranked our neurology and neu-

rosurgery programs among the top 10 in the nation. Our

neurology, neurosurgery and psychiatry programs are also

ranked best in Ohio.

The institute model allows our patients to better access

the care they need through specialized, multidisciplinary,

disease-specifi c centers that integrate the expertise of

neurologists, neurosurgeons, psychiatrists, psychologists,

neuroradiologists, and others, into the comprehensive

care of a single disease:

° Center for Brain Health

° Brain Tumor and Neuro-Oncology Center

° Cerebrovascular Center

° Epilepsy Center

° Center for Headache and Pain

° Mellen Center for Multiple Sclerosis Treatment

and Research

° Center for Neurological Restoration

° Neuromuscular Center

° Center for Pediatric Neurology and Neurosurgery

° Sleep Disorders Center

° Center for Spine Health

Additionally, our Center for Neuroimaging and Depart-

ment of Psychiatry and Psychology provide care across

all our disease-based centers.

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 disor-

ders; movement disorders such as Parkinson’s disease,

essential tremor and dystonia; cerebral palsy and spastic-

ity; hydrocephalus; metabolic and mitochondrial disease;

fetal and neonatal neurological problems; multiple sclero-

sis; stroke; cerebral aneurysms; brain and spinal vascular

malformations; carotid stenosis; intracranial atherosclero-

sis; nerve and muscle diseases, including amyotrophic

lateral sclerosis, peripheral neuropathy, myasthenia gravis

and myopathies; sleep disorders; and mental/behavioral

health disorders and chemical dependencies.

EXPERT, SPECIALIZED DIAGNOSIS

Our Neurological Institute physicians draw on advanced

diagnostic capabilities and experience.

Our imaging services include structural and functional

magnetic resonance imaging (MRI), computed tomogra-

phy (CT), positron emission tomography (PET), myelogra-

phy, diagnostic cerebral/spinal angiography, interventional

neuroradiology, and carotid and transcranial Doppler ultra-

sound. Our neuroimaging staff subspecializes in specifi c

220 Staff Physicians

134 Clinical Residentsand Fellows

17Research Fellows

27Advanced Practice Nurses

15 Physician Assistants

NI STAFF BY

THE NUMBERS

OVERVIEW | 5


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 can receive leading-edge treatment options at

the Neurological Institute, where we continue to advance

such innovations as deep brain stimulation (brain pace-

makers), epilepsy surgery, stereotactic spine radiosurgery,

blood-brain barrier disruption, endovascular treatment of

cerebral aneurysms and vascular malformations, and neu-

roendoscopy. Distinctive services such as our three-week

outpatient program for sufferers of chronic headaches

(IMATCH) and our Headache Infusion Suite provide

intensive therapy when it is 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,

while maintaining the highest standards of effi cacy and

safety. Joint Commission certifi cation 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 condi-

tions experienced by our patients, including programs in

translational research, clinical trials of drug and device

interventions, neuroimaging research, epidemiology and

health outcomes, behavioral and psychiatric research,

and research into better diagnostic methods. More than

175 clinical research trials are under way at the Neuro-

logical Institute. In the area of basic science, a core of

internationally recognized neuroscientists with external

funding totaling $10 million annually conduct investiga-

tions at the Cleveland Clinic Lerner Research Institute.

CONVENIENT CARE IN THE COMMUNITY

We are committed to making access to world-class

care convenient for all patients — whether coming

to us from near or far. Our Neurological Institute Regional

Centers are a system-wide effort to extend our services

to regional hospitals and at Cleveland Clinic family health

centers throughout the community. In addition, Cleveland

Clinic neurologists oversee inpatient care at a number

of Cleveland Clinic hospitals. Our Sleep Disorders Center

has pioneered the idea of hotel-based sleep studies,

offering overnight studies at multiple locations throughout

the community for patients’ convenience and comfort.

INTEGRATED NURSING SERVICES

Nursing in the institute integrates inpatient and ambul-

atory nursing, enhancing the continuum of patient care.

This unique structure also lends itself to greater informa-

tion sharing and process improvement opportunities.

Through continuing education programs, we are able to

broaden nursing educational opportunities from basic

nursing instruction to subspecialization in neurological

nursing, much like our physician colleagues.

At Cleveland Clinic’s Neurological Institute, we are

dedicated to maximizing patient care outcomes and the

patient experience, and to advancing medical education

and research in all areas of neurology, neurosurgery and

psychiatry.

6 | EDUCATION


EDUCAT ION

CONTINUING MEDICAL EDUCATION

The Neurological Institute collaborates with Cleveland Clinic’s Center

for Continuing Education to offer a variety of programs to physicians.

The center is responsible for one of the largest and most diverse CME

programs in the world. In 2007, there were more than 8,500 partici-

pants in 195 Neurological Institute-sponsored CME programs. The

programs ranged from weekly grand rounds in neurosurgery, neurology,

epilepsy and psychiatry to week-long symposia that provided in-depth

updates about the latest treatment options or research results on a

variety of neurological-based topics.

In its mission to provide a wide array of fi rst-rate continuing medical

education opportunities to medical professionals throughout the world,

the center also offers neurology-based online CME credit. In 2007,

1,303 CME certifi cates were awarded for the completion of online neuro-

logical courses covering topics such as migraine headaches, depression

and multiple sclerosis.

RESIDENCIES AND FELLOWSHIPS

The Neurological Institute offers extensive opportunities in physi-

cian education and research. We take special pride in training future

practitioners. The institute offers more than 30 training programs in

neurology, neurosurgery, psychiatry and psychology. This includes core

residency ACGME-accredited programs in adult neurology, child neurol-

ogy, neurosurgery, adult psychiatry and child and adolescent psychiatry,

as well as ACGME-accredited subspecialty fellowships and non-accredit-

ed fellowships. In 2007, 170 clinical and research fellows and residents

were trained through our programs.

NI RESIDENCIES

Adult Neurology

Child and Adolescent Psychiatry

Child Neurology

Psychiatry

Neurosurgery

NI FELLOWSHIPS

Chronic Pain Rehabilitation

Clinical Neuroimmunology

Clinical Neurophysiology/EEG

Clinical Neurophysiology/EMG

Endovascular Neuroradiology

Epilepsy

Epilepsy Surgery

Functional and Restorative Neurosurgery

Headache

Health Psychology

Movement Disorders

Neurocritical Care

Neuromuscular Medicine

Neuropsychology

Neurosurgical Oncology

Pediatric Neurosurgery

Psychosomatic Medicine

Skull Base Surgery

Sleep Medicine

Spine Medicine

Spine Surgery

Vascular Neurology

The Neurological Institute is committed to providing quality medical education to physicians, nurses

and other medical professionals within the institute, as well as regionally, across the country and

all over the world. From continuing medical education to residencies and fellowships to our observer

program, education is incorporated into all aspects of our institute.

170 clinical and

research fellows

and residents

were trained

120 medical students

matriculated in

NI’s core and

elective programs

EDUCATION | 7


8 | EDUCATION


Our training programs offer research opportunities for trainees who plan to pursue careers in

academic neurology, neurosurgery, and psychiatry and psychology. We offer fl exible programs

that foster individual interests. Trainees are expected to participate in basic and clinical re-

search projects and are encouraged to present their fi ndings at national meetings.

CLEVELAND CLINIC LERNER COLLEGE OF MEDICINE

The Cleveland Clinic Lerner College of Medicine of Case Western Reserve University is a

unique medical school established in 2002 that sets new standards for the training of physi-

cian investigators through innovative approaches to the integration of basic science, research

and clinical medicine. Physicians within the Neurological Institute direct the basic neurosci-

ence curriculum in years one and two of the school. This includes organization of the content

and teaching of the topics in a problem-based learning format. In 2007, 76 Neurological

Institute staff members taught courses at the medical school.

Additionally, physicians within the Neurological Institute direct the neurology, neurosurgery

and psychiatry clinical curriculum, including basic rotations, acting internships and advanced

electives. Cleveland Clinic’s basic rotations in neurosciences have been rated by the medical

school students as the best in the city.

70

international observers

visited our centers

of excellence

8,588 participants in CME-accredited,

NI-sponsored programs

490

CME hours offered in

NI-sponsored programs

195 CME-accredited programs

offered by the NI

2007 NI

PUBLICATIONS

352 journal articles

64

book chapters

7

books

EDUCATION | 9


Research is a thread that runs throughout the entire fi ve-year medical

school curriculum. Neurological Institute physicians and scientists

mentor a number of medical students with projects in the clinical and

basic neurosciences. Medical students are invited to present their

projects at the annual Neurological Institute Research Day, when

poster and platform presentations are given, and medical students,

residents and fellows compete for recognition awards.

INTERNATIONAL PHYSICIAN OBSERVER PROGRAM

International Physician Observers are foreign physicians selected

to visit a designated medical department at Cleveland Clinic. The

program exposes participants to the latest practices within a specialty

area through clinical interactions, operating room observations and

teaching conferences. In 2007, the Neurological Institute hosted 70

international observers to our centers of excellence.

2007 EDUCATIONAL

H IGHL IGHTS

° The Brain Tumor and Neuro-Oncology Center held

the fi rst international symposium on Stereotactic Body

Radiation Therapy and Stereotactic Radiosurgery

in Orlando, Fla.

° The Center for Spine Health held its week-long spine

review course in Cleveland and in Cairo, Egypt

° The Epilepsy Center attracted nearly 650 attendees

to its Epileptology Review course and the 17th Interna-

tional Epilepsy Symposium

° Our Department of Neurosurgery held a neuro-endo-

scopic surgery course in Beijing, China, for more than

200 participants

° The Department of Psychiatry and Psychology hosted

the second annual Post Traumatic Stress Disorder

Symposium for more than 230 mental healthcare

professionals

10 | RESEARCH


Conducting exceptional research has been an important part of

the mission of Cleveland Clinic since its inception in 1921. At

Cleveland Clinic, neurological research is conducted on three

levels:

° Fundamental, laboratory-based biomedical research, conducted

in the research institute

° Translational research that applies fi ndings from the laboratories

to our patients and clinical populations

° Patient-based clinical research aimed at developing new tests

or treatments, or aimed at understanding disease and its impact

INNOVATIONS

In 2007, the NI founded the Neurological Institute Community

of Collaborative Innovation (NICCI), a multidisciplinary group

of physicians, scientists and bioethicists from the Neurological

Institute, the Lerner Research Institute and the Department of

Bioethics. The group’s mission is to create and maintain a culture

of innovation within the institute, and to manage any associated

confl icts of interest. NI staff were active innovators in 2007, reg-

istering 21 inventions with the Cleveland Clinic Innovations offi ce

and receiving three patents and four licenses for their discoveries.

Three new spin-off companies were created in 2007 based on NI

technology: Autonomic Technologies, CardioNomic and ReVasc

Technologies.

GRANTS AND CONTRACTS

Neurological research conducted within the Neurological Insti-

tute, Lerner Research Institute and the Department of Neuroradi-

ology received strong support in 2007. Grant and research dollars

funding neurologic investigations totaled almost $14 million in

2007, including more than $9 million for laboratory-based re-

search and nearly $5 million for patient-based research. Funding

came from federal, state, local, corporate and private sources,

including more than 50 grants from the National Institutes of

Health.

RESEARCH

NOT-FOR-PROFIT SPONSORS

OF NI RESEARCH

ALS Association

American Cancer Society

American Epilepsy Society

American Parkinson Association

American Sleep Medicine Foundation

Centers for Disease Control

Consortium of Multiple Sclerosis Centers

Epilepsy Foundation

Metanexus Institute

Nancy Davis Foundation

National Brain Tumor Foundation

National Epifellows Foundation

National Library of Medicine

National Parkinson Foundation

NIH — Eunice Kennedy Shriver National Institute

of Child Health and Human Development

NIH — National Cancer Institute

NIH — National Institute of Allergy and

Infectious Diseases

NIH — National Institute of Mental Health

NIH — National Institute of Neurological Disor-

ders and Stroke

NIH — National Institute on Aging

National Multiple Sclerosis Society

Ohio Department of Development

Research Triangle Institute (RTI International)

Tuberous Sclerosis Alliance

U.S. Army Research Offi ce

U.S. Department of Energy

Wallace Clinical Trials Center

RESEARCH | 11


PUBLICATIONS

Many notable discoveries were made, as evidenced by

the many manuscripts accepted by high-impact journals

in 2007. Institute researchers’ manuscripts appeared in

infl uential publications such as EMBO Journal, Journal

of the American Medical Association, Lancet, Nature,

Nature Neurosciences, New England Journal of Medi-

cine, Proceedings of the National Academy of Sciences

USA, and Science. In 2007, NI staff authored more

than 400 journal articles, book chapters and books.

LERNER RESEARCH INSTITUTE

The Lerner Research Institute is the basic science

research arm of Cleveland Clinic, housing all of our

laboratory-based and translational biomedical research.

A hallmark of the institute is its focus on disease-

oriented research, working to create new diagnostic

tools, treatments and therapies, in collaboration with

partners in the clinical institutes.

Thirty-six Lerner Research Institute scientists pursued

neurologically based research projects in 2007, including

10 Neurological Institute clinicians who also conducted

basic research in the Lerner Research Institute. This

structure of bringing laboratory-based and clinical

researchers together encourages translational research

— taking the discoveries made in the laboratory to the

patient’s bedside as quickly and safely as possible. The

environment of collaboration between basic and clinical

researchers has the more immediate effect of improving

patient care today.

Neurological investigations within Lerner Research In-

stitute are carried out in the departments of Biomedical

Engineering, Cell Biology and Neurosciences.

This fl uorescence microscopy depicts cells being generated from neural

stem cells, which can generate in vitro astrocytes, oligodendrocytes and

neurons according to the stimuli they are under. These cells are prime

candidates for stem cell transplantation therapies. Here, the green staining

is for the astrocyte marker glial fi brilary acidic protein and the red is the

oligodendrocyte precursor marker platelet-derived growth factor receptor-

alpha. Oligodendrocyte precursors (red) migrate away from the core while

astrocytes (green) proliferate without apparent migration.

Department of Neurosciences

The Department of Neurosciences, founded in 1994, is

chaired by Bruce Trapp, PhD, and comprises a core of

internationally recognized scientists. The department is

divided into several core groups that focus on funda-

mental aspects of brain function and the pathogenesis

of human disease. Strong basic science programs have

resulted in the development of animal models of human

diseases, which include rodents, zebrafi sh and primates.

Departmental researchers directly investigate the patho-

genesis of human central nervous system (CNS) diseases

and have developed a unique rapid autopsy program for

these studies. The overall goal of the department is to

elucidate the cause of nervous system diseases and to

develop therapeutics that stop or delay their progression.

The interactions between faculty in the departments of

neurosciences, neurology, neurological surgery, radiology

and behavioral medicine provide a unique environment

for reaching these goals.


12 | RESEARCH

A major strength of the department is developmental

neurobiology. Most faculty members have a research

program in brain development. These interests range

from stem/progenitor cells to the function of disease-

related genes including the amyloid precursor protein,

chemokines, myelin proteins, neurotransmitter receptors,

BACE1 and the reticulins.

The department is noted internationally for its program in

glial development, recently discovering a primitive neural

cell with stem-cell-like characteristics. These cells show

a remarkable capacity to generate new myelin in a rodent

model of human myelin disease. Other developments

include mouse and zebrafi sh lines in which cells of the

oligodendrocyte lineage express green fl uorescence

protein. The mice have become a common and valuable

resource in the glial research community. A major project

focuses on Akt signaling in oligodendrocytes, which in-

duces hypermyelination. Another recent discovery is the

identifi cation of a role for chemokines in oligodendrocyte

colonization of the developing rodent brain. Additional

current research includes cerebellar development,

especially migration of granule cells, and the use of both

rodent and zebrafi sh models to study the function of the

amyloid precursor protein during development.

The glial research program has close ties with physicians

in the Neurological Institute’s Mellen Center for Multiple

Sclerosis Treatment and Research. Studies conducted

here on the function of myelin proteins in mice have

demonstrated that long-term axonal survival depends

upon trophic support from myelin. As an extension of

these basic science studies, Cleveland Clinic research-

ers described axonal degeneration as a major cause of

neurological disability in MS patients. A rapid autopsy

program was developed for individuals with MS. A

unique aspect of these autopsies is a post mortem MRI

that has been instrumental in defi ning pathological cor-

relates of MRI abnormalities.

Current research in the neurodegenerative disease

program includes a strong focus on Alzheimer’s disease.

This includes investigations of molecular mechanisms

of neurodegeneration in Alzheimer’s disease, focusing

on the role of β-secretase, its interacting proteins and

modifi cation of its activity in disease pathogenesis; the

genetic, therapeutic and environmental factors modify-

ing Alzheimer’s disease pathogenesis using transgenic

mouse models of the disease; and the normal biologi-

cal functions of the amyloid precursor protein in both

zebrafi sh and mice and the implications these may have

for neurodegenerative disease mechanisms underly-

ing Alzheimer’s disease. Additional neurodegenerative

research includes the mechanisms of neuronal degen-

eration in amyotrophic lateral sclerosis (ALS) and the

pathogenesis of neurodegeneration in an animal model of


RESEARCH | 13

ALS. Neuroimaging research within the section examines

the functional neuroimaging correlates of neurodegenera-

tive disease pathogenesis, including Alzheimer’s disease,

Parkinson’s disease and MS.

The Neuromodulation Research Center (NMRC) focuses

on the functional and physical changes in patients with

movement disorders, the mechanisms of deep brain

stimulation (DBS), and the development of new applica-

tions for DBS. The center incorporates investigators

from the institute’s departments of Neurosciences and

Biomedical Engineering as well as faculty from the Neu-

rological Institute and the Imaging Institute. The NMRC

is unique in that it uses a multidisciplinary approach to

understand how neurological diseases arise and progress

within the CNS. The NMRC then works to translate these

understandings into clinical therapeutic applications.

NMRC researchers were the fi rst to describe the effect

of stimulation in the subthalamic nucleus on the basal

ganglia thalamic circuit. The NMRC also has modeled

the effect of stimulation on neuronal tissue using fi nite

element models of neural tissue based on anatomi-

cal and electrophysiological data from primates with

Parkinsonism. Current research includes using quantita-

tive kinematic measures to assess the effects of DBS on

motor control and daily living experiences of Parkinson’s

disease (PD) patients, including the interaction between

cognitive and motor function and the effect of exercise

on PD motor symptoms; studying the mechanisms

of DBS using functional MRI to evaluate the network

changes that take place during DBS in PD patients;

studying mechanisms of DBS through imaging, modeling

and quantitative kinematic studies in dystonia and PD;

developing closed-loop systems for DBS programming;

and using chronic recording from cortical neurons to

develop prosthetic devices.

The Neuroinfl ammation Research Center (NIRC) con-

ducts multidisciplinary translational research to address

neuroinfl ammation in human disorders including MS,

Alzheimer’s disease, Parkinson’s disease, amyotrophic

lateral sclerosis (ALS) and stroke. The center includes an

internationally recognized initiative in MS that provides

DETECTING CHANGES IN BRAIN ACTIVATION

PATTERNS IN EARLY ALZHEIMER’S DISEASE

A team of investigators in the Neurological Institute

is studying changes in brain activation of healthy

older individuals (ages 65-85) who are genetically

at risk for developing Alzheimer’s disease (AD)

and individuals who have Mild Cognitive Impair-

ment (MCI), a condition that typically precedes the

diagnosis of AD. One goal of the study is to develop

an imaging biomarker that can detect the earliest

brain changes associated with AD. Nineteen MCI

patients, 19 genetically at-risk but healthy older

adults, and 19 healthy older adults not at-risk for

AD (Control) were administered a memory task

while undergoing functional magnetic resonance

imaging (fMRI). Results indicate that fMRI is sensi-

tive to detecting the earliest changes in AD, even

before patients become symptomatic. The goal is to

use this imaging technology to assess the effi cacy

of drugs designed to delay the onset of AD.

Studies supported by the NIH (NIA R01 AG022304).

Three groups of older participants, MCI patients, individuals at-

risk for developing AD, and healthy not-at-risk control subjects

were asked to discriminate names of famous individuals from

those of unfamiliar persons. The difference in brain activation

(Famous > Unfamiliar) is shown in blue. MCI and at-risk par-

ticipants exhibited greater brain activity than controls. Results

suggest that early AD-related changes require the brain to “work

harder” to achieve similar levels of task performance. (Rao SM,

et al. Submitted.)


14 | RESEARCH

a template for program development and exemplifi es

bench-to-bedside evolution. Our current focus includes

neuroimmunology, leukocyte traffi cking, blood-brain

barrier function, cytokine action and signaling, and

innate immune mechanisms (including Toll-like recep-

tors) in furtherance of the mission to understand how

the CNS interacts with the hematogenous compartment

and the peripheral nervous system. The center recently

established a program of study in a viral model of MS

and received grant support from the National Institute

of Allergy and Infectious Diseases/NIH for this research.

In 2007, the center developed a new mouse model of ce-

rebral vasospasm to study how infl ammatory cells in the

cerebrospinal fl uid precipitate ischemic stroke in patients

who have suffered subarachnoid bleeding. Other current

projects include the study of a novel mouse model of

microglial activation in Alzheimer’s disease, and a new

and more clinically relevant model of Duchenne muscular

dystrophy, which will be used to defi ne how infl amed

and dystrophic muscle becomes fi brotic.

Biomedical Engineering

Lerner Research Institute’s Biomedical Engineering

Department provides a forum in which engineers, basic

scientists and physicians can interact, seeking together

to apply engineering principles to solve biomedical

problems. Active research programs include biological

microelectromechanical systems (BioMEMS) and the

design and utilization of micro-computed tomography

(micro-CT), quantifying images of the brain in multiple

sclerosis, and recording and modeling the brain’s electri-

cal activity.

Biomedical imaging staff researchers work on a variety

of research projects that include clinical, microscopic

and small animal imaging applications. The primary goal

of these investigators is to develop novel imaging and

image post-processing techniques to detect, diagnose

and monitor the progression of disease and to evaluate

different treatment therapies. Research and development

within this group includes tissue characterization using

high-frequency intravascular ultrasound, 3D real-time

ultrasound and multimodality imaging, quantitative

analysis of tissue damage due to multiple sclerosis in MR

images of the brain, and 3D quantitative phenotyping in

micro-CT images of mice.

EVALUATING DEEP BRAIN STIMULATION WITH fMRI

Investigators from the Neurological Institute

and the Imaging Institute have collaborated

to study the effect of deep brain stimulation

(DBS) in patients with Parkinson’s disease

using functional MRI. The investigators are

determining how the brain is activated during

DBS for Parkinson’s disease. Early results

demonstrated a consistent pattern of brain

activation produced by stimulation within

the ipsilateral thalamus and globus pallidus.

These studies will lead to a better under-

standing of the relationship between brain

activation and DBS in Parkinson’s disease,

and will provide the necessary information

to maximize therapeutic benefi ts of this

treatment.

Studies Supported by the NIH (NINDS R01

NS052566-01A1).

Functional MRI obtained during active deep brain stimulation. Images A and B

demonstrate the activation pattern during unilateral right-sided activation. Image C

demonstrates activation during unilateral left-sided stimulation. Images are projected

using radiological convention. Phillips, et al. Radiology. 2006;239:209–216.

The overall goal of the department is to elucidate

the cause of nervous system diseases and to develop

therapeutics that stop or delay their progression.

The interactions between faculty in the departments

of neurosciences, neurology, neurological surgery,

radiology and behavioral medicine provide a unique

environment for reaching these goals.

A

B

C

CEREBROVASCUL AR CENTER | 15



16 | RESEARCH

Nanotechnologists use microelectronics, microfabrication

and micromachining technologies to improve medical di-

agnostics and therapies by reducing device size and cost.

Their collaborative studies involve engineering micro-/

nanometer-sized features for tissue engineering, protein

analyses, assays and cell interrogation. Among the ap-

plications being developed are miniaturized versions of

drug delivery systems, transducers for ultrasound images

and in situ telemetrically monitored pressure/temperature

sensors for minimally invasive surgery/follow-up.

The neural control group performs basic science and

clinical research related to neural control of movement.

The program focuses mainly at system level of the

central nervous system (CNS) as well as the muscular

system. Research interests include understanding CNS

plasticity/reorganization as a result of disease and medi-

cal intervention, and its relation with functional recovery.

Current projects include evaluating effects of deep

brain stimulation on lessening symptoms in Parkinson’s

disease and the underlying mechanisms using neural-

network simulation, and understanding CNS reorganiza-

tion in stroke and other neurological disorders using

neuroimaging and electrophysiological techniques.

Cell Biology

The Department of Cell Biology investigates the roles of

specifi c cell types in health and disease, researching cell

and molecular biology and infl ammation. Neurological-

INVESTIGATING BRAIN PATHOLOGY IN MULTIPLE SCLEROSIS

A team of investigators in the Neurological Institute and Lerner

Research Institute is studying changes in the brains and spinal cords of

patients with multiple sclerosis. One goal of the study is to develop more

informative imaging tools that can be used to monitor and treat MS

patients. In this study, regions of brain were selected from postmortem

MRIs of 10 multiple sclerosis patients, and classifi ed into MRI-defi ned

categories. One of the categories identifi ed swollen axons and axonal

loss, pathologies that are associated with neurological disability in MS.

Studies to characterize cellular and molecular changes in brain tissue are

continuing. We expect to gain improved understanding of mechanisms

leading to brain damage in MS patients, and improve methods to moni-

tor treatments for individual patients using noninvasive MRI methods.

Studies Supported by the NIH (NINDS PO1 NS38667).

Plot of percentage axonal area, axonal count and swelling index in each magnetic reso-

nance imaging group (gray bars denote T2-weighted imaging only; black bars denote

T2-weighted, T1-weighted and magnetization transfer ratio abnormal [T2T1MTR]) rela-

tive to the means for normal-appearing white matter (NAWM; hatched bars) regions.

Sd - standard deviation. Fisher E, et al. Ann Neurol. 2007;62:219–228.

countarea diameter

1.0

0.8

0.6

0.4

0.2

0.0

1.0

0.8

0.6

0.4

0.2

0.0

Fraction of NAWM (+s.d.)Fraction of NAWM (+s.d.)

NAWMT2-onlyT2T1MTR

Axonal Measurements By MRI Region Type

This histological image of a goat lumbar spine segment (stained with H&E

for an in vivo biocompatibility assessment of microelectromechanical

systems, or MEMS, materials) shows a cross-section of vertebral endplates

and disc, with the location of the MEMS chip in the void in the disc (arrow).

There is no evidence of infl ammatory or infectious cellular response, con-

fi rming the biocompatibility of the MEMS materials with living tissue.


RESEARCH | 17

based research currently being conducted includes

investigations of the blood-brain barrier, multiple drug re-

sistance, stroke and cerebrovascular damage, peripheral

markers of CNS damage, and molecular and proteomic

analysis of neurological disorders.

PATIENT-BASED RESEARCH

The Neurological Institute conducts research on condi-

tions experienced by our patients. Clinical research

protocols include programs in bench-to-bedside transla-

tional research, trials of drugs and devices, neuroimaging

research, epidemiology and health outcomes, behavioral

and psychiatric research, and investigations into better

diagnostic methods. More than 175 clinical research

protocols were active within the Neurological Institute

in 2007, including 44 newly opened studies. Patient-

based clinical research within the institute is conducted

by multidisciplinary research teams combining expertise

and clinical knowledge of investigators focusing on re-

search computing and informatics, clinical trial methods,

outcomes assessment and neuroimaging. Multidisci-

plinary teams that comprise of staff physicians, clinical

investigators of various professional disciplines, clinical

fellows, full-time research fellows, residents, nurses and

certifi ed research coordinators are supported by shared

enabling resources to coordinate study startup and

conduct, and to assist with study design, data capture

and analysis. Through a multidisciplinary, team approach

that uses central resources, we are able to generate new

knowledge that will create better treatment options for

our patients.

More than 1,600 patients were enrolled in clinical trials

at the Neurological Institute in 2007, including almost

700 newly enrolled patients, with more than 60 of our

staff members leading these trials. Research studies

covered the range of neurological conditions we treat, in-

cluding Alzheimer’s disease and dementia, spine disease,

brain tumors, epilepsy, headache and pain, multiple scle-

rosis, Parkinson’s disease and other movement disorders,

depression and affective disorders, nerve and muscle

disease, neuropediatrics and congenital disorders, sleep

disorders, stroke and neurocritical care.

2007 NI CLINICAL TRIAL HIGHLIGHTS

° Assessing the entry of chemotherapeutic agents into

brain metastases in women with breast cancer

° Evaluating selective, 5-lipoxygenase inhibition by Bo-

swellia serrata herbal medicine approach as an adjuvant

therapy in newly diagnosed and recurrent high grade

gliomas

° CONFIRM: comparing fumarate with Copaxone® in

patients with relapsing-remitting multiple sclerosis

° CARE-MS II: comparing two doses of alemtuzimab

(CAMPATH-1h) with Rebif® in patients with relapsing-

remitting multiple sclerosis

° Deep brain stimulation for obsessive-compulsive disorder

° Deep brain stimulation for the minimally conscious state

° Predictors of bipolar disorder recurrence in pregnancy

and the postpartum period

° Sensitivity of fMRI in identifying cognitive and functional

brain changes in preclinical Huntington’s disease

° Evaluating Duragen® plus adhesion barrier matrix to

minimize adhesions following lumbar discectomy

° Assessing changes in quality of life following surgery

versus medical management in persons with medically

intractable epilepsy

° IRIS: determining if pioglitazone is effective in lowering

the risk of stroke or myocardial infarction among non-

diabetic men and women with a recent ischemic stroke

and insulin resistance

Active trials 177

New trials 44

NI staff leading trials 64

2007 NI CLINICAL RESEARCH TRIALS AT A GLANCE

18 | THE KNOWLEDGE PROGRAM


At the core of the Knowledge Program is a redesign of

the way the Neurological Institute organizes the immense

amount of clinical information it has. “The project is an

institute-wide effort to change the way we collect data so

that it can be harvested and used,” explains neurologist

Irene Katzan, MD, who is directing the Knowledge Pro-

gram. “Our goal is to be able to look at data on both an

individual and group level to evaluate clinical treatment

over time and provide better care.”

One of the fi rst obstacles to be overcome was how to

make patient information that traditionally is gathered by

the nurse or physician during the clinical encounters more

readily available for future use. The Knowledge Program

is tackling this by utilizing a standardized format for enter-

ing information during patient visits. During the patient’s

appointment, all clinical information will be collected

and entered into the patient’s electronic medical record

in a standardized way, beginning with the evaluation of

incoming patients’ current health status. Obtaining infor-

mation on patients’ health using validated scales provides

means to determine how patients are doing and to better

judge responses to treatment.

“This is an electronic system in which patients complete

a self-administered questionnaire when they come in

for their appointment, prior to seeing the physician,”

Dr. Katzan explains. The health status measures will

include generic measures, such as the European Quality

of Life scale, as well as well-established disease-specifi c

scales such as the Headache Impact Test 6. “Establish-

ing a quantitative baseline will allow us to then look at

trends over time,” Dr. Katzan notes. Part of the process,

too, is ensuring that all physicians know how to access

the information to use it during each patient encounter.

The electronic patient questionnaires, which interface

with EPIC, Cleveland Clinic’s electronic medical record

software, are being rolled out center by center within the

Neurological Institute. By the end of 2008, they will be in

use institute-wide.

In addition, the Knowledge Program is in the process

of implementing a computer-adaptive testing system to

assess patients’ health status, in collaboration with a

National Institutes of Health initiative called the Patient-

Reported Outcomes Measurement Information System

(PROMIS). With this method, a computerized algorithm

determines the next best question in the series, based

upon prior responses from the patient. Dr. Katzan

describes this tool as “the future of patient-reported

outcomes assessment,” adding that it “creates a more

precise picture of what’s going on with the patient, using

fewer questions.”

At the other end of the patient care process, the

Neurological Institute needed a method to consistently

track outcomes of interventions, an essential element

in creating a meaningful database. Unfortunately, some

Neurological Institute patients are lost to follow-up due to

geographic distance or other reasons, Dr. Katzan says. To

THE KNOWLEDGE PROGRAM

Cleveland Clinic’s Neurological Institute treats more than 140,000 patients every year, making it one

of the busiest centers for neurological diagnosis and treatment in the United States. The Knowledge

Program is a visionary venture designed to leverage this patient volume to systematically analyze patient

care and improve outcomes for Neurological Institute patients.

THE KNOWLEDGE PROGRAM | 19


capture data on these patients, the Neurological Institute

plans to implement a simple but consistent and organized

telephone follow-up system. “This will make our patient

follow-up more systematic and ensure that the outcomes

information we capture is as accurate as possible.”

Dr. Katzan says.

By virtue of its complexity and scope, the Knowledge Pro-

gram is undoubtedly a bold concept, but Dr. Katzan notes

that the Neurological Institute is uniquely positioned to

make it a success due to its large patient population,

technological capabilities and organizational structure.

“We are one of the few institutions with all of the neces-

sary elements to implement such an ambitious database,

and we are leading the way,” she says. “Once we have all

of the pieces in place and operational, it is a matter of us-

ing the database for improving the quality and outcomes

of care.”

The Knowledge Program is a visionary venture

designed to leverage this patient volume to

systematically analyze patient care and improve

outcomes for Neurological Institute patients.

As part of the Knowledge Program, all Neurological Institute patients input their answers to standardized health questions prior to their appointments.

BRAIN TUMOR AND

NEURO-ONCOLOGYCENTER

22 | BRAIN TUMOR AND NEURO-ONCOLOGY CENTER

CLINICAL PROGRAMS

Neuro-oncologists, medical oncologists, neurosurgical oncologists, radiation oncologists,

neuropathologists, neuroradiologists and nurses in the Brain Tumor and Neuro-Oncology Cen-

ter (BTNC) collaborated in the treatment of more than 4,600 children and adults with brain

tumors and other related conditions in 2007.

Innovative and experimental nonsurgical treatments for life-threatening tumors, state-of-the-art

surgical techniques and targeted radiation neuro-oncology technologies applied in combi-

nation with molecular and chromosomal testing have positioned the Brain Tumor and Neuro-

Oncology Center at the forefront of individualized care for patients with brain tumors.

Clinical programs in the center include medical therapeutics, radiation therapy and neuro-

surgical treatment, as well as alternative methods for patients with a variety of benign and

malignant CNS conditions. The team at the BTNC cares for patients with gliomas, metastases,

pituitary and neuro-endocrine tumors, skull base tumors (meningiomas and schwannomas),

neurofi bromatosis and other phakomatoses, and primary central nervous system lymphoma.

NEURO-ONCOLOGY

BTNC neuro-oncology team members are experts in the use of medical therapeutics for the

treatment of brain tumors, including:

° Chemotherapy/growth modifi ers — traditional anti-tumor drugs as well as new agents

targeted at specifi c tumor modalities

° Immunotherapy — stimulating the patient’s immune system against tumor cells

° Intra-arterial chemotherapy with or without blood-brain barrier disruption — a procedure

in which chemotherapeutic agents are delivered to the brain through the bloodstream

with or without opening the normal barriers that may prevent those drugs from entering

the brain

° Alternative and complementary treatments — including dietary interventions and yoga

NEUROSURGICAL ONCOLOGY AND RADIATION NEURO-ONCOLOGY

BTNC surgeons, who pioneered computer-assisted stereotactic techniques for brain surgery in

the 1980s, have extended the scope of operable brain tumors through the use of leading-edge

technology, including:

° Stereotactic neurosurgery — computer-guided surgery that serves as a GPS system for

the brain, often using ‘fi ber tracking’ and functional MRI that allows the surgeon to see

the function and ‘wiring’ of the brain

° Minimally invasive as well as endoscopic and endoscopic-assisted surgical procedures

° Intraoperative magnetic resonance imaging (iMRI) — navigational guidance and monitor-

ing during tumor resection

° Convection-enhanced delivery — the slow, continuous infusion of drugs through the brain

to enhance drug delivery to brain tumors

° Intraoperative radiation therapy — uses the INTRABEAM®, a 50 kVp device placed in

the resection cavity of metastatic brain tumors to deliver a high local dose of radiation at

the time of surgery to prevent or delay the need for whole brain irradiation

° Fractionated radiotherapy — widespread exposure of the brain and tumor to repeated

low doses of radiation

Initial outpatient visits 465

Total outpatient visits 8,354

Admissions 906

Inpatient Days 4,075

Surgical Cases 935

2007 STATS


BRAIN TUMOR AND NEURO-ONCOLOGY CENTER | 23

° Brachytherapy — direct implantation of a radiation source within a tumor site

° Cranial radiosurgery — the delivery of high-intensity, focused radiation directly to mul-

tiple sites within the tumor using the Gamma Knife® or Novalis®. Gamma Knife® is used

for single treatments of small tumors; Novalis® is used for larger tumors.

° Spinal radiosurgery — the delivery of high-intensity, focused radiation directly to spinal

metastases employing the Novalis® shaped-beam platform.

FELLOWSHIPS

The BTNC offers several non-ACGME-accredited fellowships. These include two two-year fel-

lowships in neurosurgical oncology and a one-year fellowship in skull base surgery.

A fundamental goal of this combined clinical and research fellowship program is exposure to

the design and operation of clinical trials, as well as contribution to the neuro-oncology litera-

ture. Fellows are expected to participate in the design, IRB application process and manage-

ment of new clinical trials and to produce clinical trials and reports.

CLINICAL RESEARCH

In 2007, 374 patients were enrolled in clinical trials related to their diagnosis. In addition to its

own phase I-II trials, the BTNC participates in several national and international consortia, in-

cluding New Approaches to Brain Tumor Therapy (NABTT) sponsored by the National Cancer

Institute, Radiation Therapy Oncology Group (RTOG), American College of Surgeons Oncology

Group (ACoSOG) and Children’s Oncology Group (COG).

BTNC physicians have developed a reputation for national and international leadership in

neuro-oncology clinical trials. BTNC physicians serve as national and international principal

investigators on multiple RTOG and pharmaceutical industry trials.

Open adult clinical trials include studies of medications, radiation therapies, stereotactic radio-

surgery, chemotherapies, gene therapies, hormone therapies, blood-brain barrier disruption,

devices, intraoperative optical spectroscopy, dietary and herbal complementary and alternative

medicine and stress reduction for astrocytomas, glial tumors, lymphomas, metastases and

oligodendrogliomas.

Open child and adolescent protocols include studies of medications, chemotherapies, chemo-

radiation therapies, radiotherapies and second-look surgeries for malignant brain tumors, CNS

AT/RT, CNS embryonal tumors, ependymoma, NGGCT, gliomas, CNS germinomas, medullo-

blastomas, neurofi bromatosis type 1, astrocytomas and solid tumors.

The Brain Tumor and Neuro-Oncology Center’s new

Gamma Knife® Perfexion equipment is the most

technologically advanced model available, allowing for

treatment in a wider range of anatomical structures,

enhanced planning, use of all imaging modalities and

reduced treatment time.

The Brain Tumor and Neuro-Oncology

Center initiated a collaboration with

industry to develop laser interstitial

thermal therapy for brain tumors —

moving initial research from the pre-

clinical phase to a fi rst-in-man trial.

INNOVATION


24 | BRAIN TUMOR AND NEURO-ONCOLOGY CENTER

LABORATORY RESEARCH

The BTNC has two primary laboratories under the direction of Drs. Michael Vogelbaum and

Robert Weil. Current research focuses on molecular genetics, apoptosis, engineering, immu-

nology, progenitor cells and genomics/proteomics. In addition to basic research in these areas,

BTNC researchers in the Translational Therapeutics Program, directed by Michael Vogelbaum,

MD, PhD, perform preclinical testing of novel agents for treating brain tumors with the aim

of bringing these agents to clinical trials. The BTNC laboratories collaborate closely on basic

research projects with the Cancer Biology and Immunology departments in the Lerner

Research Institute.

Basic research projects in progress include:

° Mechanisms for sensitizing glioma cells to chemotherapy

° The role of STAT3 in the biology of gliomas

° Genetic alterations and biological characterization of primary cell cultures derived from

malignant gliomas

° Genetic alterations in GBMs (loss or gain of 19q, 1p and other novel alterations) and their

correlations with patient survival

° Development of a clinical assay for detection of deletions in CDKN2A, ARF, PTEN and

p53 genes in gliomas

° 7,5-lipoxygenase inhibition as an adjuvant glioma therapy

° Molecular biology of brain tumors

° Blood-brain barrier, tumor markers and human gliomas project

° Molecular pathology of gliomas: “glioma genotyping”

° Transcription factors and brain tumors

° Molecular genetic investigation of pituitary tumors

° Genetic polymorphism analyses of brain tumors

The Brain Tumor and Neuro-Oncology

Center had 56 active clinical trials in

2007.

RESE ARCH

The Brain Tumor and Neuro-Oncology Center surgical services include sophisticated intraoperative techniques such as

awake craniotomy, physiologic mapping, radiotherapy, navigation, ultrasound and MRI.



2003 20052004 2006 2007

6

5

4

3

2

1

0

6

5

4

3

2

1

0

12

10

8

6

4

2

0

12

10

8

6

4

2

0

DaysDays Number of DeathsNumber of Deaths

Target LOSMean LOSActual MortalityExpected Mortality

Supratentorial Craniotomy: Inpatient Mortality and Length of Stay

2003 2004 2005 2006 2007

100

80

60

40

20

0

100

80

60

40

20

0

100

80

60

40

20

0

100

80

60

40

20

0

Percent SurvivalPercent Survival Number of SurgeriesNumber of Surgeries

30-Day Survival180-Day Survival# of Surgeries

Infratentorial Craniotomy: Survival

2003 2004 2005 2006 2007

5

4

3

2

1

0

5

4

3

2

1

0

1.0

0.8

0.6

0.4

0.2

0

1.0

0.8

0.6

0.4

0.2

0

DaysDays Number of DeathsNumber of Deaths

Mean LOSTarget LOSActual MortalityExpected Mortality

Pituitary Surgery: Inpatient Mortality

Expected deaths are based on

APR-DRGs, which adjust for the

severity of the patient population.

Thirty and 180-day survival remained

robust in 2007 for infratentorial cran-

iotomies at 100 and 96.2 percent.

There have been no inpatient deaths

following pituitary surgery in the past

fi ve years. Target length of stay (LOS)

is calculated based on APR-DRGs,

which adjust for the severity of the

patient population.


OUTCOMES HIGHLIGHTS

JOE CASE

Age: 33

Hometown: Uniontown, Ohio

Diagnosis: Glioblastoma

Treatment: Initial surgery and radiation therapy

with concurrent temozolomide, additional

temozolomide for fi ve days out of every

28 days for 12 cycles, and daily dosing of

erlotinib (Tarceva®) for three years.

Dizziness wasn’t enough to slow down Joe Case, a busy business owner who had not seen

a doctor in years. As hearing and visual disturbances set in, however, Mr. Case knew it was

time to seek help. CT and MR imaging confi rmed a tumor, but surgery at a local hospital

failed to remove it entirely. He made the commitment to get the best care he possibly could,

and found people to drive him more than an hour to Cleveland Clinic every day for six weeks

for radiation therapy. Afterward, he joined a trial of Tarceva®, a lung cancer chemotherapy

drug being studied in glioblastoma. Three years later, the tumor hasn’t grown. Case, who is

married and has a 1½-year-old son, stays more active than ever, and just participated in the

American Brain Tumor Association’s annual 5K race.

“Next to my wife and family, Cleveland Clinic has been my godsend. I tell anyone who has

any cancer problems not to waste their time anywhere else. I don’t have the words to praise

Cleveland Clinic enough for the fact that I am still here. My doctors and nurses are like

family to me now.”



PUBLICATION HIGHLIGHTS

Marko NF, Weil RJ, Toms SA. Nanotechnology in proteomics. Expert Rev Proteomics. 2007

Oct;4(5):617-626.

Nathoo N, Ugokwe K, Chang AS, Li L, Ross J, Suh JH, Vogelbaum MA, Barnett GH. The role

of (111)indium-octreotide brain scintigraphy in the diagnosis of cranial, dural-based menin-

giomas. J Neurooncol. 2007 Jan;81(2):167-174.

Videtic GMM, Adelstein DJ, Mekhail TM, Rice TW, Stevens GHJ, Lee SY, Suh JH. Validation

of the RTOG recursive partitioning analysis (RPA) classifi cation for small-cell lung cancer-only

brain metastases. Int J Radiat Oncol Biol Phys. 2007 Jan 1;67(1):240-243.

Vogelbaum MA. Convection enhanced delivery for treating brain tumors and selected neuro-

logical disorders: symposium review. J Neurooncol. 2007 May;83(1):97-109.

More than 300 physicians and physi-

cists have been trained on Gamma

Knife® technology through the Brain

Tumor and Neuro-Oncology Center.

EDUCATION

2003 2004 2005 2006 2007

100

80

60

40

20

0

100

80

60

40

20

0

300

240

180

120

60

0

300

240

180

120

60

0

Percent SurvivalPercent Survival Number of DeathsNumber of Deaths

30-Day Survival180-Day Survival# of Procedures

Stereotactic Radiosurgery: Survival

The number of Gamma Knife® cases

peaked in 2007 despite a six-week

hiatus for upgrading to the Gamma

Knife® PerfexionTM. Thirty and 180-

day survival for Gamma Knife® were

97.6 and 91.3 percent respectively

with the highest 180-day survival in

the last fi ve years.


OUTCOMES HIGHLIGHTS

28 | CEREBROVASCUL AR CENTER


CEREBROVASCULARCENTER



CLINICAL PROGRAMS

Cleveland Clinic’s Cerebrovascular Center offers a unique mix of physician subspecialties deliv-

ering endovascular therapy and cutting-edge care of the highest quality with proven successful

outcomes. The quality stroke care that we deliver places an emphasis on aggressive acute

stroke intervention and multi-modality therapy of brain aneurysms and AVMs. In addition,

there is strength in stroke prevention through our vascular neurology team, with leverage on

outcomes research.

Endovascular approaches are standard of care, and our advanced imaging capabilities will

guide treatment decisions. Patients also receive comprehensive care in our 16-bed neurointen-

sive care unit staffed by neurointensivists, inpatient nursing and dedicated mid-level praction-

ers. Our Cerebrovascular Center received re-certifi cation as a Primary Stroke Center in 2007.

We provide patients effi cient, high-quality care for acute stroke, coupled with excellent patient

outcomes and shorter lengths of stay. With a case severity index in the top 2.2 percent in the

United States, the Cerebrovascular Center performed better than national comparisons for

inpatient mortality, length of stay and hospital costs in 2007.

Long-term, risk-factor modifi cation programs are available through the Cerebrovascular Center

in conjunction with physical medicine and rehabilitation services.

Cerebrovascular disease states we treat include:

Carotid Occlusive Disease (Stenosis)

Cleveland Clinic specialists are leaders in carotid endarterectomy and carotid angioplasty for

this disease with outcomes that surpass national averages.

Cerebral Aneurysms

Treatment of ruptured and unruptured brain aneurysms and arteriovenous malformations

(AVMs) continues to outnumber all other cerebrovascular surgical procedures. In addition to

microsurgical clipping, endovascular neurosurgeons also use detachable coils, intracranial self-

expanding stents and new embolic agents to treat aneurysms and AVMs.



Admissions 1,138


Surgical Cases 1,057

2007 STATS

The Neurological Institute’s dedicated, 16-bed neurointensive care unit is staffed by a team of neurologists, neurosurgeons,

specially trained nurses, respiratory therapists, nutritionists and pharmacists, all under the direction of neurointensivists.

The unit is equipped for intracranial pressure monitoring, continuous EEG/Evoked Potential monitoring, transcranial Doppler

ultrasound monitoring, and brain tissue oxygenation and metabolism monitoring.



Arteriovenous Malformations (AVMs)

The center provides multidisciplinary consultation and treatment for these disorders, including

microsurgical resection, embolization and Gamma Knife® stereotactic radiosurgery.

2007 Cerebrovascular Center highlights:

° In collaboration with hospitals across the Cleveland area, we are working to increase the

number of Joint Commission-certifi ed stroke sites and provide coverage where needed

° We developed the Temporary Endovascular Bypass technology for stroke treatment

° We completed the world’s largest-ever study of intracranial atherosclerotic disease

FELLOWSHIPS

Neurointensive Care

Four two-year fellowships are available in neurointensive care. The fellowship provides com-

prehensive training in neurointensive care, medical and surgical intensive care and vascular

neurology. There is an active clinical research program including therapeutic hypothermia and

neuromonitoring. This fellowship is the only UCNS-approved Neurological Intensive Care Unit

fellowship in the region, and is one of the fi rst nine programs in the country to receive this

certifi cation.

Vascular Neurology

Two ACGME-accredited one-year fellowships in vascular neurology are offered for those who

desire further subspecialty training in this area.

Endovascular Neuroradiology

The Cerebrovascular Center offers two ACGME-accredited two-year fellowships in endovascu-

lar neuroradiology. The fellowships provide trainees an organized, comprehensive, supervised,

full-time educational experience in neuro-endovascular surgery/interventional neuroradiology

(NES/INR). This experience includes the management of patients with neurological disease,

In 2007, the Cerebrovascular Center

opened a state-of-the-art angiography

room that allows for endovascular and

open craniotomy treatment of patients

with cerebrovascular disease.

INNOVATION

The Cerebrovascular Center’s new neurovascular intervention and operating suite is designed for traditional microsurgical

procedures as well as for advanced, highly technical endovascular procedures.


the performance of NES/INR procedures, and the integration of NES/INR therapy into the

clinical management of patients.

CLINICAL RESEARCH

Current clinical trials offered through Cleveland Clinic’s Cerebrovascular Center include:

° Phase III, randomized, multicenter, open label clinical trial to examine whether a com-

bined intravenous (IV) and intra-arterial (IA) approach to recanalization is superior to

standard IV rt-PA (Activase®) alone when initiated within three hours of acute ischemic

stroke onset

° NeuroThera® Effectiveness and Safety Trial (NEST-2), a phase III, randomized, multi-

center, double-blind, controlled study to assess safety and effectiveness of the treatment

of ischemic stroke with the NeuroThera® Laser system within 24 hours from stroke onset

° Carotid occlusion surgery study (COSS) for symptomatic carotid occlusion

° IRIS trial to determine if pioglitazone, compared with placebo, is effective in lowering the

risk for stroke or myocardial infarction among non-diabetic men and women with a recent

ischemic stroke and insulin resistance

° Long-term cardiac complications of subarachnoid hemorrhage

° Percutaneous mechanical hematoma evacuation of spontaneous intracranial hemorrhage

° Matrix and Platinum Science (MAPS) trial for cerebral aneurysm embolization comparing

two FDA-approved embolic coil types for safety and effi cacy

° Trial for patients who have had a stroke or TIA possibly related to a patent foramen ovale

(CLOSURE-I)

° Warfarin vs. Aspirin (WARCEF) in reduced cardiac ejection fraction

° Use of rimonabant vs. placebo in patients with multiple cardiovascular risk factors and

abdominal obesity to show reduction of cerebrovascular events (CRESCENDO)

In 2007, the Cerebrovascular Center

completed the 160-patient, fi ve-center

U.S. Multicenter Wingspan Registry.

RESE ARCH

The Cerebrovascular Center has one of the highest stroke-related patient volumes in North America, seeing more than 3,200

stroke patients annually.



2003 2004 2005 2006 2007

200

100

0

200

100

0

EndovascularMicrosurgery

Number of ProceduresNumber of Procedures

Treatment of Unruptured Aneurysms

2003 2004 2005 2006 2007

150

100

50

0

150

100

50

0

EndovascularMicrosurgery


Treatment of Ruptured Aneurysms

Discharge Status

2007 DISCHARGE STATUS UNRUPTURED ANEURYSMS RUPTURED ANEURYSMS

Home 80% 37%

Home Health 5% 5%

Acute Rehab 3% 14%

Skilled Nursing Facility 1% 19%

Expired 1% 19%

Other 5% 18%


OUTCOMES HIGHLIGHTS

The Cerebrovascular Center offers

four different fellowships for training in

advanced cerebrovascular care.

EDUCATION

TERESA MARTENS

Age: 23

Hometown: Higginsville, Missouri

Diagnosis: Symptomatic moyamoya disease

Treatment: Bypass surgery and encephalo-

duroarteriomyosynangiosis (EDAMS)

Teresa Martens was having a series of mini-strokes, but she was busy with school and plan-

ning her wedding, so she ignored them. When she fi nally went to see a local neurologist, he

wanted to do a brain biopsy, which would have required her to shave her head. As a bride

to be, she was quite hesitant. Meanwhile, her insurance company noticed all the tests she

was having and called to suggest she travel to Cleveland Clinic to see Peter Rasmussen, MD.

She agreed, and was diagnosed, treated and ready to go home within 10 days of arriving in

Cleveland. Today, she feels great and is back to her busy life.

“This was such a scary thing to go through. I really needed answers and hope. Since my

treatment, I have talked with a few people who know someone who is suffering from similar

mini-stroke-like episodes, and I always refer them to Cleveland Clinic. I even carry the

phone number to Cleveland Clinic in my cell phone to have ready to hand out! Without

Cleveland Clinic, I really could have suffered irreversible brain damage.”




Fiorella D, Levy EI, Turk AS, Albuquerque FC, Niemann DB, Aagaard-Kienitz B, Hanel RA,

Woo H, Rasmussen PA, Hopkins LN, Masaryk TJ, McDougall CG. US multicenter experi-

ence with the wingspan stent system for the treatment of intracranial atheromatous disease:

periprocedural results. Stroke. 2007 Mar;38(3):881-887.

Fiorella D, Woo HH. Emerging endovascular therapies for symptomatic intracranial atheroscler-

otic disease. Stroke. 2007 Aug;38(8):2391-2396.

Fiorella D, Chow MM, Anderson M, Woo H, Rasmussen PA, Masaryk TJ. A 7-year experience

with balloon-mounted coronary stents for the treatment of symptomatic vertebrobasilar intrac-

ranial atheromatous disease. Neurosurgery. 2007 Aug;61(2):236-242; discussion 242-243.

Katzan IL, Dawson NV, Thomas CL, Votruba ME, Cebul RD. The cost of pneumonia after

acute stroke. Neurology. 2007 May 29;68(22):1938-1943.

Kerber CW, Wanke I, Bernard J Jr, Woo HH, Liu MW, Nelson PK. Rapid intracranial

clot removal with a new device: the alligator retriever. AJNR Am J Neuroradiol. 2007

May;28(5):860-863.

Kirsch J, Rasmussen PA, Masaryk TJ, Perl J, II, Fiorella D. Adjunctive rheolytic thrombectomy

for central venous sinus thrombosis: technical case report. Neurosurgery. 2007 Mar;60(3):E-

77-E578.

Levy EI, Turk AS, Albuquerque FC, Niemann DB, Aagaard-Kienitz B, Pride L, Purdy P, Welch

B, Woo H, Rasmussen PA, Hopkins LN, Masaryk TJ, McDougall CG, Fiorella DJ. Wingspan

in-stent restenosis and thrombosis: incidence, clinical presentation, and management. Neuro-

surgery. 2007 Sep;61(3):644-650.

Levy EI, Mehta R, Gupta R, Hanel RA, Chamczuk AJ, Fiorella D, Woo HH, Albuquerque FC,

Jovin TG, Horowitz MB, Hopkins LN. Self-expanding stents for recanalization of acute cerebro-

vascular occlusions. AJNR Am J Neuroradiol. 2007 May;28(5):816-822.

Lin R, Svensson L, Gupta R, Lytle B, Krieger D. Chronic ischemic cerebral white matter dis-

ease is a risk factor for nonfocal neurologic injury after total aortic arch replacement. J Thorac

Cardiovasc Surg. 2007 Apr;133(4):1059-1065.

Turk AS, Rowley HA, Niemann DB, Fiorella D, Aagaard-Kienitz B, Pulfer K, Strother CM. CT

angiographic appearance of in-stent restenosis of intracranial arteries treated with the Wing-

span stent. AJNR Am J Neuroradiol. 2007 Oct;28(9):1752-1754.

Turner RD, Gonugunta V, Kelly ME, Masaryk TJ, Fiorella DJ. Marginal sinus arteriovenous

fi stulas mimicking carotid cavernous fi stulas: diagnostic and therapeutic considerations. AJNR

Am J Neuroradiol. 2007 Nov;28(10):1915-1918.

Wallace RC, Karis JP, Partovi S, Fiorella D. Noninvasive imaging of treated cerebral aneu-

rysms, part I: MR angiographic follow-up of coiled aneurysms. AJNR Am J Neuroradiol. 2007

Jun;28(6):1001-1008.


EPILEPSY CENTER

38 | EPILEPSY CENTER

CLINICAL PROGRAMS

Adult and Pediatric Epilepsy

Cleveland Clinic’s Epilepsy Center is one of the leading epilepsy programs in the world. In

2007 our team again saw one of the largest patient volumes in the world in outpatient clinics

and evaluated nearly 1,000 adult and pediatric patients in two dedicated, state-of-the-art

epilepsy monitoring units equipped with digital video-EEG technology.

Specialized neuroimaging services include advanced high-resolution magnetic resonance imag-

ing (MRI using specialized imaging techniques), functional magnetic resonance imaging (fMRI),

magnetic resonance spectroscopy (MRS), ictal single-photon-emission computed tomography

(SPECT) and positron emission tomography (PET). Cleveland Clinic’s Epilepsy Center recently

opened the fi rst clinical magnetoencephalography (MEG) program in northeastern Ohio to

further assist in the diagnosis and workup of patients with epilepsy. With advanced MEG

equipment and world-renowned research scientists in the fi eld of clinical and applied neuro-

physiology, we are introducing state-of-the-art noninvasive diagnostic abilities that will enable

our physicians and staff to manage the most complex and challenging epilepsy cases.

Our Pediatric Epilepsy Program is one of the world’s premier programs for children and

adolescents who are affected with epilepsy. Combining a multidisciplinary approach towards

the most advanced monitoring and treatment with compassion and caring, Cleveland Clinic’s

program achieves excellent patient outcomes. Pediatric patients are evaluated in the newly

expanded Pediatric Epilepsy Monitoring Unit and in the Pediatric and Neonatal ICUs.



Admissions 1,175


Surgical Cases 227

2007 STATS

The Epilepsy Center’s pediatric services include a child-friendly, self-contained, eight-bed pediatric epilepsy monitoring unit,

a dedicated pediatric epilepsy staff and one of the most experienced epilepsy surgery programs in the country.


EPILEPSY CENTER | 39

Epilepsy Surgery

Our Epilepsy Surgery Program for adults and children with medication-resistant epilepsy is

one of the foremost programs of its kind in the world. Cleveland Clinic was one of the fi rst

institutions in the world to perform brain mapping for pre-surgical evaluation in epilepsy.

Performing more than 200 surgeries annually, including nearly 90 pediatric epilepsy proce-

dures, our surgeons have expertise in the leading treatments for surgical epilepsy, including

extra-temporal surgery, hemispherectomy, lesionectomy, temporal lobectomy and vagal nerve

stimulation. In addition, Cleveland Clinic Epilepsy Center is the only program in the state of

Ohio to offer a new investigational technique of computer-assisted responsive neurostimula-

tion (RNS, NeuroPace®) for select patients with focal epilepsy who failed various antiepileptic

medications and are not resective surgery candidates.

Cognitive Behavioral Program

This multidisciplinary, comprehensive cognitive and behavioral program provides psychosocial

assistance to patients with seizures at various stages of the patient’s evaluation and treatment.

By bringing together epileptologists, psychiatrists, neuropsychologists, social workers and

rehabilitation specialists, the program seeks to care for the full spectrum of physical, mental,

emotional, social and practical needs and issues that affect the lives of our epilepsy patients.

FELLOWSHIPS

The Epilepsy Center’s education programs offer in-depth exposure to our comprehensive ap-

proach to the diagnosis and management of adults and children with epilepsy, including surgi-

cal and investigational treatments. The aim of our program is the most comprehensive training

of future academic epileptologists and epilepsy surgeons. Our graduates have played and will

continue to play an integral role in treatment and innovation in epilepsy.

Currently, our approved educational/training programs consist of the following:

° Five one-year fellowships in clinical neurophysiology/EEG, which provide an intensive

experience in EEG and evoked potentials in the diagnosis and management of epilepsy

° Five one-year non-ACGME epilepsy fellowships

° A one-year surgical epilepsy fellowship

The Epilepsy Center installed the fi rst

clinical MEG (magnetoencephalogram)

system in Ohio. The MEG will improve

noninvasive localization of the seizure

focus in patients who suffer from

intractable epilepsies.

INNOVATION

The Pediatric Epilepsy Support Group is led by a pediatric epileptologist and provides families of children with epilepsy a

venue for education, discussion and camaraderie.


40 | EPILEPSY CENTER

CLINICAL RESEARCH

The many facets of epilepsy are refl ected in the scope of the Epilepsy Center’s clinical

research. Some of the areas currently being studied through clinical trials include:

° The genetics of epilepsy

° Hormone therapy for women with seizures

° Development of novel treatment techniques

° Responsive neurostimulation (RNS) with the NeuroPace® trial

° Clinical drug trials

° Physiologic markers and characterization of depressive subtypes in treatment-

refractory epilepsy

LABORATORY RESEARCH

Cleveland Clinic Lerner Research Institute and Epilepsy Center scientists are pursuing basic

and translational research that aids in the understanding of the neurological basis for epilepsy

and potential molecular-level interventions for the disease. Some of our current areas of

research include:

° Molecular genetics and cellular mechanisms of epilepsy

° Molecular and cellular mechanisms of resistance to antiepileptic medications

° Application of deep brain stimulation in epilepsy

In 2007, 411 patients were enrolled

in clinical trials through the Epilepsy

Center.

RESE ARCH

The Epilepsy Center’s monitoring units use digital video-EEG technology to accurately locate seizure origin.



0 21 3Time since surgery (years)

4

1.0

0.8

0.6

0.4

0.2

0.0

1.0

0.8

0.6

0.4

0.2

0.0

Probability of seizure freedomProbability of seizure freedom

0 21 3Time since surgery (years)

1.0

0.8

0.6

0.4

0.2

0.0

1.0

0.8

0.6

0.4

0.2

0.0


0 21 3 4 5 6 7 8 9 1110Time since surgery (years)

1.0

0.8

0.6

0.4

0.2

0.0

1.0

0.8

0.6

0.4

0.2

0.0


0 654321 9 10 117 8Time since surgery (years)

1.0

0.8

0.6

0.4

0.2

0.0

1.0

0.8

0.6

0.4

0.2

0.0


Long-Term Seizure Freedom Following Frontal Lobe Surgery for Epilepsy (n=119 surgeries from 1997-2007)

Seizure Freedom Following Hemispherectomy for Epilepsy (n=65 surgeries from 2004-2006)

Seizure Freedom Following Temporal Lobectomy for Epilepsy (n=474 surgeries from 1997-2007)

Seizure Freedom Following Posterior Quadrant Resections for Epilepsy (n=60 surgeries from 1997-2007)


OUTCOMES HIGHLIGHTS

RUSSELL BROOKER

Age: 2

Hometown: Lowell, Ohio

Diagnosis: Epilepsy

Treatment: Hemisphrectomy

Russell began having seizures at 2 weeks old. A trip to the local emergency room and a stay

in a Columbus hospital didn’t yield any answers. The seizures returned about six months

later, along with pneumonia. A doctor in Columbus advised Russell’s parents to take their

worsening child to Cleveland Clinic, where he was taken to the ICU immediately due to

complications with his breathing. William Bingaman, MD, and colleagues removed Russell’s

right hemisphere over the course of two surgeries. Russell has been completely seizure-free

ever since and undergoes therapy to improve his left-side motor skills.

“If we hadn’t gone to Cleveland Clinic, Russell wouldn’t be here today,” says Russell’s mother.

“They saved my son’s life. It was so scary, but they explained everything so well and made us

feel like they were going to fi x it. And they did.”




Busch RM, Lineweaver TT, Naugle RI, Kim KH, Gong Y, Tilelli CQ, Prayson RA, Bingaman W,

Najm IM, Diaz-Arrastia R. ApoE-epsilon4 is associated with reduced memory in long-standing

intractable temporal lobe epilepsy. Neurology. 2007 Feb 6;68(6):409-414.

Gonzalez-Martinez JA, Bingaman WE, Toms SA, Najm IM. Neurogenesis in the postnatal

human epileptic brain. J Neurosurg. 2007 Sep;107(3):628-635.

Gonzalez-Martinez JA, Srikijvilaikul T, Nair D, Bingaman WE. Longterm seizure outcome in

reoperation after failure of epilepsy surgery. Neurosurgery. 2007 May;60(5):873-880.

Gupta A, Chirla A, Wyllie E, Lachhwani DK, Kotagal P, Bingaman WE. Pediatric epilepsy

surgery in focal lesions and generalized electroencephalogram abnormalities. Pediatr Neurol.

2007 Jul;37(1):8-15.

Janigro D, Awasthi S, Awasthi YC, Sharma R, Yadav S, Singhal SS, Hallene K. RLIP76 in AED

drug resistance. Epilepsia. 2007 Jun;48(6):1218-1219.

Jehi LE, Najm I, Bingaman W, Dinner D, Widdess-Walsh P, Luders H. Surgical outcome and

prognostic factors of frontal lobe epilepsy surgery. Brain. 2007 Feb;130(Pt 2):574-584.

Loddenkemper T, Moddel G, Schuele SU, Wyllie E, Morris HH III. Seizures during intracarotid

methohexital and amobarbital testing. Epilepsy Behav. 2007 Feb;10(1):49-54.

Loddenkemper T, Holland KD, Stanford LD, Kotagal P, Bingaman W, Wyllie E. Developmental

outcome after epilepsy surgery in infancy. Pediatrics. 2007 May;119(5):930-935.

Marchi N, Angelov L, Masaryk T, Fazio V, Granata T, Hernandez N, Hallene K, Diglaw T, Franic

L, Najm I, Janigro D. Seizure-promoting effect of blood-brain barrier disruption. Epilepsia.

2007 Apr;48(4):732-742.

Matsumoto R, Nair DR, LaPresto E, Bingaman W, Shibasaki H, Luders HO. Functional

connectivity in human cortical motor system: a corticocortical evoked potential study. Brain.

2007 Jan;130(Pt 1):181-197.

Schuele SU, Bermeo AC, Alexopoulos AV, Locatelli ER, Burgess RC, Dinner DS, Foldvary-

Schaefer N. Video-electrographic and clinical features in patients with ictal asystole.

Neurology. 2007 Jul 31;69(5):434-441.

Wehner T, LaPresto E, Tkach J, Liu P, Bingaman W, Prayson RA, Ruggieri P, Diehl B. The value

of interictal diffusion-weighted imaging in lateralizing temporal lobe epilepsy. Neurology. 2007

Jan 9;68(2):122-127.

Widdess-Walsh P, Jehi L, Nair D, Kotagal P, Bingaman W, Najm I. Subdural electrode analysis

in focal cortical dysplasia: predictors of surgical outcome. Neurology. 2007 Aug 14;69(7):660-

667.

Widdess-Walsh P, Kotagal P, Jehi L, Wu G, Burgess R. Multiple auras: clinical signifi cance and

pathophysiology. Neurology. 2007 Aug 21;69(8):755-761.

Wyllie E, Lachhwani DK, Gupta A, Chirla A, Cosmo G, Worley S, Kotagal P, Ruggieri P, Binga-

man WE. Successful surgery for epilepsy due to early brain lesions despite generalized EEG

fi ndings. Neurology. 2007 Jul 24;69(4):389-397.

The Epilepsy Center hosted its

17th International Epilepsy Symposium

in June 2007.

EDUCATION




CENTER FOR

HEADACHE AND PAIN

46 | CENTER FOR HEADACHE AND PAIN

CLINICAL PROGRAMS

The Center for Headache and Pain offers a unique, interdisciplinary approach to headache

management involving specialists in adult neurology, pediatric neurology, internal medicine,

psychology, nursing, physical therapy and nutrition. Effective preventive and abortive treat-

ment for migraine, tension headache and cluster headache frequently involves a combination

of pharmacologic agents, behavioral therapy, psychotherapy, nutrition, physical therapy and

other modalities.

The infusion program is devoted to intravenous infusions specifi c for headaches and provides

urgent, inpatient-type care to patients who would otherwise have visited an emergency room.

In 2007, infusion patient volume continued to increase. This allowed for the successful out-

patient treatment of many otherwise stable headache patients who suffered episodes of acute

exacerbations of pain as well as the initiation of treatment for the many patients with chronic

headache disorders. The infusion program also provided an accessible site for initiation of

analgesic research studies and analgesic treatment, including detoxifi cation from medications

that perpetuate headaches.

The Cleveland Clinic Center for Headache and Pain also has pioneered home care infusion

nursing, which has allowed patients to remain in the comfort of familiar surroundings while

receiving aggressive medical therapy.

Additionally, Cleveland Clinic has been one of the early adopters of botulinum type A therapy

for headache, and this service has attained steady growth since the headache program was

created in 2004. Patient referrals for this treatment continued to expand in 2007.

In 2007, the Center for Headache and Pain initiated the IMATCH Program (Interdisciplinary

Method for the Assessment and Treatment of Chronic Headache). This three-week program

was designed to provide a multidisciplinary approach to the diagnosis and intensive treat-

ment of longstanding, functionally disabling headache disorders. It incorporates the fusion and

coordination of a number of invaluable services for this impaired patient population, including

behavioral management, intensive physical therapy, medical management (including the infu-

sion room) and education, and has treated nearly 100 patients to date. Treatment focuses on

enabling patients to regain normal functioning that has been lost due to pain. While pain may

not be eliminated completely, patients are taught how to manage the pain so that it does not

consume their lives.



2007 STATS

The Center for Headache and Pain

established the IMATCH (Interdisci-

plinary Method for the Assessment

and Treatment of Chronic Headache)

program for adults with chronic

headaches. One of only a few in

the country, IMATCH is an intensive,

multidisciplinary outpatient program

for patients who have exhausted other

treatment options.

INNOVATION

The Center for Headache and Pain utilizes biofeedback to teach patients how to control symptoms of chronic headache.


CENTER FOR HEADACHE AND PAIN | 47

Current Average Least Worst

Pain Ratings (0=no pain; 10=worst possible pain)

10

8

6

4

2

0

10

8

6

4

2

0

AdmissionDischarge

DASS Stress Scale DASS Anxiety Scale DASS Depression

35

30

25

20

15

10

5

0

35

30

25

20

15

10

5

0

Emotional functioning scoresEmotional functioning scores

AdmissionDischarge

Pain Disability Headache Dizziness Neck Disability

100

80

60

40

20

0

100

80

60

40

20

0

Disability scoresDisability scores

AdmissionDischarge

Pain Outcome Following IMATCH (n=36)

Stress, Anxiety and Depression Following IMATCH (n=36)

Functional Status Following IMATCH (n=36)

Pain scores (mean + s.d.) decrease following

the IMATCH (Interdisciplinary Method for the

Assessment and Treatment of Chronic Headache)

Program. N=36 patients completing the three-

week program in 2007.

Measures of stress, anxiety, and depression all

decrease following IMATCH, indicating improve-

ment. Mean DASS-42 (Depression, Stress and

Anxiety Scale) subscale scores are plotted with

their standard deviations.

Disability scores improve (higher scores indicate

greater levels of disability) following completion

of the IMATCH program.


OUTCOMES HIGHLIGHTS

HALLIE NEWHOUSE

Age: 23

Hometown: New Alexandria, Penn.

Diagnosis: Migraines with and without aura,

restless legs syndrome and iron defi ciency

Treatment: The IMATCH program

(Interdisciplinary Method for the Assessment

and Treatment of Chronic Headache), a

three-week intensive multidisciplinary

outpatient program that includes neurology,

psychology, nutrition and physical therapy

Ms. Newhouse started having chronic migraines when she was 13 years old. They contin-

ued as she went to college, and she even had to take one semester off when her headaches

caused her to miss classes too frequently. She saw 15 neurologists in Pennsylvania over

the years searching for relief. When she read about Cleveland Clinic’s IMATCH program on

the Internet, she went to Cleveland right away. She experienced signifi cant relief within one

week of beginning the program and, importantly, is now able to function through the rare

headaches that she does get. She recently graduated from college after making the Dean’s

List two semesters in a row and is going to graduate school soon.

“This program absolutely put my life back on track. I am a functioning adult now. I was

taking 29 pills a day; now I take only six. I recently went eight months without a headache.

I had one this winter but I didn’t end up in the hospital, which is a big improvement for me.

Cleveland Clinic changed my life.”


CENTER FOR HEADACHE AND PAIN | 49

FELLOWSHIPS

Two one-year clinical/research fellowships in headache are available, one in adult headache

and another in pediatric headache medicine. This training program provides signifi cant experi-

ence in the diagnosis and management of adult and pediatric headache disorders, inpatient

headache management, ancillary treatment techniques such as biofeedback and stress

management, and the design and execution of headache research protocols. This is a non-

ACGME position, but has been accredited by the UCNS and AAN and AHS. After one year the

applicant may sit for the UCNS-accredited board examination.

CLINICAL RESEARCH

For headache sufferers, access to clinical trials of the newest, potentially effective pharmaco-

logic agents is an important attribute of the Cleveland Clinic Center for Headache and Pain.

Some of the current trials include:

° Comparison of an investigational oral drug with placebo for the treatment of moderate or

severe headache

° Neurogenetic studies of migraine headache

° Comparison of an investigational oral drug with placebo for the treatment of early mi-

graine headache

° Comparison of an investigational oral drug with placebo for the treatment of an acute

menstrual migraine

° Measurement of psychophysical markers in patients with a variety of headaches


Kapural L, Stillman M, Kapural M, McIntyre P, Guirgius M, Mekhail N. Botulinum toxin occipi-

tal nerve block for the treatment of severe occipital neuralgia: a case series. Pain Pract. 2007

Dec;7(4):337-340.

Spears RC, Ifthikharuddin S. New-onset headache from cerebral venous thrombosis.

Headache. 2007 Feb;47(2):275-276.

The Center for Headache and Pain

had 37 patients enrolled in clinical

trials in 2007.

RESE ARCH

More than 600 participants received

CME credit for Cleveland Clinic’s

online “Update on Migraine Headache”

course.

EDUCATION


0-24 50-74 75-10025-49

Percent Pain Reduction

100

80

60

40

20

0

100

80

60

40

20

0

Percent of PatientsPercent of Patients

Pain Reduction with Infusion Therapy (n=198)

Percent of patients reporting various levels of pain reduction following

infusion therapy. More than 60 percent of patients reported a 50 percent

or greater reduction in pain immediately after treatment.

MELLEN CENTER FOR

MULTIPLE SCLEROSISTREATMENT AND RESEARCH

52 | MELLEN CENTER FOR MULTIPLE SCLEROSIS TREATMENT AND RESEARCH

CLINICAL PROGRAMS

As one of the leading centers in the world for the diagnosis and management of multiple

sclerosis (MS), the Mellen Center includes a comprehensive array of clinical programs related

to its core mission.

Medical Programs

The core team includes neurologists, advanced practice nurses and physician assistants. The

Infusion Center, in its recently expanded 15-chair setting, has seen a 30 percent increase

in volume with the reintroduction of natalizumab (Tysabri®), a monthly infusion therapy for

relapsing forms of MS. The medical program also has been enhanced by the addition of Dr.

Alexander Rae-Grant to the staff.

Imaging Program

Two large grants were awarded by the National Multiple Sclerosis Society: one is to study

the clinical and imaging characteristics of damage to the hippocampus, which is a commonly

injured brain region supporting memory; the other is to further study functional connectiv-

ity in white matter, which is known to be impaired in MS patients and may lead to reduced

cognitive and memory function. Methodological development work was published observing

a correlation between white matter disease burden and functional connectivity, as well as a

novel method to determine fi ber direction within diseased white matter.

Comprehensive Care Program

We are refocusing our comprehensive care program using the Chronic Care Model developed

by Edward Wagner at the MacColl Institute. To that end we are enhancing the educational

opportunities on our website, offering programs for patients who are newly diagnosed and

conducting the “Mellen Center Learning Series” that is intended to help participants improve

their overall wellness and self-management strategies for living with MS.



2007 STATS

The Mellen Center utilizes tests like timed gait trials and visual acuity testing to track patients’ disease progress and symp-

tom management.


Rehabilitation Program

The clinical activity of the rehabilitation and spasticity clinic continues to expand. Additional

equipment has been added to the therapy program to assess patient balance and the effec-

tiveness of wheelchair seating and selection. We continue to improve and validate the Mellen

Center Gait Test to improve sensitivity to change and safety of the patient.

FELLOWSHIPS

The Mellen Center offers four non-ACGME-approved fellowships in clinical neuroimmunology.

Fellows have the option of focusing clinical work/rehabilitation in a one-year program or on

clinical trials, MRI or clinical research in a two-to-three year program.

As one of the premier centers in the world for treatment and research related to multiple

sclerosis, the Mellen Center provides fellows with an unparalleled opportunity to experience

a comprehensive clinical multiple sclerosis program and participate in a world-class research

program.

CLINICAL RESEARCH

The Mellen Center staff and the individuals who come here for care maintain a strong partner-

ship in MS research. Research is aimed at unraveling the complexities of MS. The staff is

dedicated to understanding the effects and causes of the disease, improving its management

and working toward a cure. Researchers investigate more effective supportive care, better

rehabilitation techniques and more effective medical therapies.

Current studies of new MS therapies include: fi ngolimod (FTY-720) in both relapsing-remitting

and primary progressive MS, fumarate (BG-12), fampridine (4-aminopyridine), double-dose

glatiramer acetate (Copaxone), alemtuzimab (CAMPATH-1h), ocrelizumab, glatiramer acetate

(Copaxone) combined with interferon beta-1a (Avonex), laquinimod, atacicept and atorvastatin

(Lipitor), each of which may provide new treatment options for MS patients. Mellen Center

physicians occupy leadership positions in all of these multinational trials.

MELLEN CENTER FOR MULTIPLE SCLEROSIS TREATMENT AND RESEARCH | 53

The Mellen Center utilized Diffusion

Tensor Imaging as a noninvasive

MRI-based technique to measure

remyelination.

INNOVATION

Physical therapists at the Mellen Center develop personalized treatments to help MS patients improve their strength, gait

and overall function.


54 | MELLEN CENTER FOR MULTIPLE SCLEROSIS TREATMENT AND RESEARCH

Some of our ongoing non-treatment studies include:

° A clinical trial of a web-based self-monitoring program, which aims to develop the Inter-

net for use in patient self-management

° Diffusion tensor MR imaging studies of natalizumab (Tysabri®) and corticosteroids (Solu-

Medrol®), which will develop new imaging markers of degeneration

° A biomarker study of interferon beta-1a (Avonex) therapy, which hopes to predict who

will respond to therapy

° A functional MRI study of hand movements in MS, which aims to understand how the

brain re-organizes after injury from MS

° Studies of optical coherence tomography, which seek to develop a new approach to

monitor neural degeneration

° A 15-year follow-up of patients in the pivotal trial of interferon beta-1a (Avonex®) in

relapsing-remitting MS

LABORATORY RESEARCH

Neurologists at the Mellen Center collaborate with researchers at major medical centers, uni-

versities and the NIH in sophisticated laboratory research. The dual focus of this research is

to contribute to the understanding of the underlying disease process in MS and to advance our

knowledge of currently available treatments. Signifi cant grants to the Mellen Center from agen-

cies such as the NIH and the National Multiple Sclerosis Society refl ect the Mellen Center’s

exemplary standing as a nationally recognized center for laboratory research.

Current areas under study include:

° mechanisms responsible for myelin and nerve cell destruction in MS patients

° cellular and molecular biology of infl ammation, myelin formation and regeneration

° investigation of laboratory models of MS

In 2007, the Mellen Center received

$1,296,884 for research through

grants and contracts.

RESE ARCH

The Mellen Center offers a monthly

lunch-and-learn series for newly

diagnosed patients and their families

that reviews the disease, its symptoms

and treatment options.

EDUCATION

The center’s 1.5 Tesla MR scanner provides images of MS lesions in the brain and spinal cord to track disease state and

responsiveness to treatment.



Before After

Treatment

4

3

2

1

0

4

3

2

1

0

Spasticity ScoreSpasticity Score

Modifi ed Ashworth Scale Following Intrathecal Baclofen Therapy (n=17)

Before After

Treatment

4

3

2

1

0

4

3

2

1

0

Spasm Frequency ScoreSpasm Frequency Score

Spasm Frequency Following Intrathecal Baclofen Therapy (n=17)

Effect on symptoms Effect on function

100

80

60

40

20

0

100

80

60

40

20

0

Percent Patients Reporting Treatment EffectivenessPercent Patients Reporting Treatment Effectiveness

First follow-up visitLast follow-up visit

Botox® Treatment Effectiveness (n=47)

Spasticity scores on the Modifi ed Ashworth

Scale (0=no increase in tone, 4=severe

increase in tone) at baseline and after ITB

therapy. There was a statistically signifi cant

(p<0.001, paired t-test) reduction in spastic-

ity after treatment. Average follow-up for the

17 patients was 167 days.

Spasm Frequency Scale scores (0=no

spasms, 4=more than 10 spasms/hour)

at baseline and at most recent follow-up

visit. There was a statistically signifi cant

(p<0.001, paired t-test) reduction in spasm

frequency after treatment. Average follow-up

for the 17 patients was 167 days.

Percent of patients reporting treatment

effectiveness following Botox® therapy for

focal spasticity. Patients were assessed

at fi rst follow-up visit (three months after

initial treatment) and subsequently every

three months. Average last follow-up was six

months, with a range up to 12 months. The

average follow-up period for the 47 patients

who continued treatment is 170 days. The

average dose injected at the most recent

session was 360 units of botulinum toxin A.

Most patients reported benefi t with treat-

ment both on symptoms and function, and

the results were stable over time.


OUTCOMES HIGHLIGHTS

PATRICIA SUBSTELNY

Age: 39

Hometown: Cleveland Heights, Ohio

Diagnosis: Multiple Sclerosis

Treatment: Monthly natalizumab (Tysabri®)

infusions for MS and botulinum toxin

injections for leg spasticity and tightness

every three months.

Patricia Substelny was a busy Human Resources professional by day and an aerobics

instructor by night 11 years ago when she started to have problems with her eyes and

weakness in her legs. The diagnosis of MS came one month before her wedding in the fall of

1997. Although today she is no longer able to be employed, she is active as a volunteer with

the MS Society and other local charities, which she actually fi nds to be more fulfi lling.

“It is a true partnership at the Mellen Center. I am the patient and I am responsible for

taking my medication and doing my exercises, but I really feel like I am on a team with the

doctors and nurses. We are all working toward the same goal. They are just as happy as I

am when I am doing well and just as concerned when I am not.”




Cohen JA, Rovaris M, Goodman AD, Ladkani D, Wynn D, Filippi M. Randomized, double-

blind, dose comparison study of glatiramer acetate in relapsing-remitting MS. Neurology. 2007

Mar 20;68(12):939-944.

Dutta R, McDonough J, Chang A, Swamy L, Siu A, Kidd GJ, Rudick R, Mirnics K, Trapp BD.

Activation of the ciliary neurotrophic factor (CNTF) signalling pathway in cortical neurons of

multiple sclerosis patients. Brain. 2007 Oct;130(Pt 10):2566-2576.

Fisher E, Chang A, Fox RJ, Tkach JA, Svarovsky T, Nakamura K, Rudick RA, Trapp BD.

Imaging correlates of axonal swelling in chronic multiple sclerosis brains. Ann Neurol. 2007

Sep;62(3):219-228.

Fox RJ, Lee JC, Rudick RA. Optimal reference population for the multiple sclerosis functional

composite. Mult Scler. 2007 Aug;13(7):909-914.

Hahn JS, Pohl D, Rensel M, Rao S. Differential diagnosis and evaluation in pediatric multiple

sclerosis. Neurology. 2007 Apr 17;68(16 Suppl 2):S13-S22.

Marrie RA, Cutter G, Tyry T, Vollmer T, Campagnolo D. Disparities in the management of mul-

tiple sclerosis-related bladder symptoms. Neurology. 2007 Jun 5;68(23):1971-1978.

Rudick RA, Miller D, Hass S, Hutchinson M, Calabresi PA, Confavreux C, Galetta SL, Giovan-

noni G, Havrdova E, Kappos L, Lublin FD, Miller DH, O’Connor PW, Phillips JT, Polman CH,

Radue EW, Stuart WH, Wajgt A, Weinstock-Guttman B, Wynn DR, Lynn F, Panzara MA.

Health-related quality of life in multiple sclerosis: effects of natalizumab. Ann Neurol. 2007

Oct;62(4):335-346.

Ransohoff RM. Natalizumab for multiple sclerosis. N Engl J Med. 2007 Jun 21;

356(25):2622-2629.




CENTER FOR

NEUROIMAGING

60 | CENTER FOR NEUROIMAGING

CLINICAL PROGRAM

The Center for Neuroimaging includes specialists in structural and functional imaging of the

central nervous system for the diagnosis of neurological lesions, injury or metabolic disease.

Subspecialization in specifi c disease entities (e.g., epilepsy and cerebrovascular disease) ensures

accurate, in-depth, relevant interpretations. Across the Cleveland Clinic health system, the

Center for Neuroimaging supervises and interprets more than 60,000 CT scans and more than

50,000 MR scans each year. The normal turn-around time for reports is two to three hours,

with daily quality checks performed according to American College of Radiology guidelines.

Neuroimaging also functions in cooperation with the Cerebrovascular Center to provide

cerebrovascular ultrasound, angiography and interventional neuroradiology services. The latter

includes more than 3,000 cerebral angiograms per year, as well as state-of-the-art manage-

ment of acute stroke, internal/external carotid artery embolizations, Guglielmi detachable coil

occlusion of intracranial aneurysms, treatment of vasospasm and atherosclerotic occlusive

disease, and carotid artery stenting.

FELLOWSHIPS

Two ACGME-accredited fellowships are available: endovascular surgical neuroradiology and

diagnostic neuroradiology. The endovascular fellowship provides trainees an organized, com-

prehensive, supervised, full-time educational experience and is available to candidates with

appropriate prior training in neurosurgery, neuroradiology and stroke neurology. The diagnostic

neuroradiology program is open to suitable radiology candidates and provides a broad experi-

ence with state-of-the-art imaging equipment across all modalities for the evaluation of adult

and pediatric disorders of the brain and spine.


Beall EB, Lowe MJ. Isolating physiologic noise sources with independently determined spatial

measures. Neuroimage. 2007 Oct 1;37(4):1286-1300.

Bhattacharyya PK, Lowe MJ, Phillips MD. Spectral quality control in motion-corrupted single-

voxel J-difference editing scans: An interleaved navigator approach. Magn Reson Med. 2007

Oct;58(4):808-812.

Gandour J, Tong Y, Talavage T, Wong D, Dzemidzic M, Xu Y, Li X, Lowe M. Neural basis of fi rst

and second language processing of sentence-level linguistic prosody. Hum Brain Mapp. 2007

Feb;28(2):94-108.

Kapural L, Mekhail N, Bena J, McLain R, Tetzlaff J, Kapural M, Mekhail M, Polk S. Value of

the magnetic resonance imaging in patients with painful lumbar spinal stenosis (LSS) undergo-

ing lumbar epidural steroid injections. Clin J Pain. 2007 Sep;23(7):571-575.

Modic MT, Ross JS. Lumbar degenerative disk disease. Radiology. 2007 Oct;245(1):43-61.

Modic MT. Degenerative disc disease: genotyping, MR imaging and phenotyping. Skeletal

Radiol. 2007 Feb;36(2):91-93.

Obuchowski NA, Schoenhagen P, Modic MT, Meziane M, Budd GT. Incidence of advanced

symptomatic disease as primary endpoint in screening and prevention trials. AJR Am J Roent-

genol. 2007 Jul;189(1):19-23.

Sakaie KE, Lowe MJ. An objective method for regularization of fi ber orientation distributions

derived from diffusion-weighted MRI. Neuroimage. 2007 Jan 1;34(1):169-176.

Total CT brain scans 60,000

Total MR brain procedures 50,000

Total cerebralangio procedures 3,000

Studies performed on main campus, Cleveland Clinic family health centers and affi liated hospitals, estimated

2007 STATS

In 2007, the Center for Neuroimaging

obtained the fi rst mobile CT head scan-

ner in the state of Ohio.

INNOVATION

The Center for Neuroimaging received

a three-year, $768,000 grant from the

National Multiple Sclerosis Society in

2007 to study diffusion tensor imaging

changes within the hippocampus and

fornix and their relationship to memory

in patients with MS.

RESE ARCH




DALE WESSELL

Age: 67

Hometown: Fort Walton Beach, Fla.

Diagnosis: Stroke due to carotid

dissection

Treatment: Emergency carotid artery

stenting

Dale Wessell and his wife were up from Florida visiting family for the holidays. On Christ-

mas Eve, while driving from Oberlin to Elyria to go shopping, his vision suddenly became

blurred. He pulled over to let his wife, Debbie, drive, and was near crawling just to get to the

passenger seat. A former nurse, Debbie recognized the symptoms of stroke and rushed to a

nearby Oberlin hospital. Doctors there confi rmed an evolving stroke, initiated treatment and,

recognizing an impending catastrophe, summoned an emergency helicopter. Upon arrival

at Cleveland Clinic, Mr. Wessell was unable to speak and paralyzed on the right side; his

family was told he might not survive. He was rushed to the operating room for emergency

treatment, where he was found to have a carotid dissection, a spontaneous injury to the in-

ner wall of the artery to the left side of the brain. With the consent of his wife and emergent

approval from the institutional review board, an experimental fl exible stent was used to

re-open the artery before signifi cant permanent damage to the brain. Several hours later, he

was able to speak and move his entire body again. Today, he is completely recovered.

“Thank the Lord I was near Cleveland when this happened. They did an awesome job and

saved my life. Afterward, the doctors answered all my questions and never made me feel

like they had another patient in the world. They gave me as much time as I needed. I can’t

say enough about my care. It was miraculous.”



CENTER FOR

NEUROLOGICALRESTORATION

64 | CENTER FOR NEUROLOGICAL RESTORATION

CLINICAL PROGRAMS

Movement Disorders

A team of experts including renowned neurologists, neurosurgeons, researchers and a host

of support personnel offers the latest proven treatments for people with movement disorders,

including Parkinson’s disease, essential tremor and dystonia. Our surgical team is world-

renowned for performing deep brain stimulation (DBS) surgeries and has experience with

more than 1,200 DBS implants. This group also has expertise in the surgical management of

spasticity. Various medication clinical trials as well as gene therapy surgical trial programs are

under way.

Psychiatric Disorders

The Center for Neurological Restoration (CNR) team of neurosurgeons, psychiatrists and

psychologists has been involved in studies using DBS for treating obsessive-compulsive dis-

order and major depression for the past seven years with promising outcomes. Patients with

disabling OCD and depression are being actively enrolled in these studies. The center also

performs vagal nerve stimulation for medically refractory depression.

Chronic Pain

For more than a decade, our neurosurgical surgeons have provided surgical management of

chronic pain conditions including failed back surgery syndrome, RSD, CRPS, facial pain, stroke

pain and other chronic pain disorders. Various surgical procedures including lesioning and the

implantation of intrathecal infusion pumps, spinal cord stimulators, peripheral nerve stimula-

tors, cranial nerve stimulators and brain stimulators are performed for patients.

FELLOWSHIPS

Surgical Fellowship: Deep brain stimulation surgery is an area of specialty training available

with a one-year and two-year fellowship in functional and restorative neurosurgery. One fellow

is accepted for intensive training in surgery for the management of movement disorders such

as Parkinson’s disease, dystonia and spasticity; chronic pain; psychiatric disorders; and other

central nervous system disease states. In addition, fellows gain experience in peripheral and

central neurostimulation, intra-axial medication delivery and ablative procedures for pain and

movement disorders.

Medical Fellowship: For those interested in the medical management of movement disorders,

a one-year and two-year fellowship in movement disorders is offered. Two fellows are ac-

cepted for this intensive program, which includes exposure to all of the movement disorders

seen in our clinics. The depth and breadth of our program provides fellows with an unparal-

leled experience in the diagnosis and management of all aspects of these complex disorders.

CLINICAL RESEARCH

Clinical research interests in the center are focused on refi ning the use of DBS in movement

disorders and expanding its application to other problems. Current clinical trials available

relate to:

° Application of deep brain stimulation to psychiatric disorders, including depression and

obsessive-compulsive disorder



Admissions 333


Surgical Cases 489

2007 STATS

The Center for Neurological

Restoration implanted the fi rst deep

brain stimulator in a patient

with severe traumatic brain injury,

demonstrating behavioral improvement

from a minimally conscious state.

INNOVATION


° Evaluation of functional MRI in patients with implanted neurostimulators

° Development of frameless techniques for deep brain stimulator placement

° Development of cortical interfaces for neural prostheses

° Multidisciplinary assessment of severe brain injury and application of deep brain stimula-

tion to treat cognitive disorders following severe brain injury

° Deep brain stimulation for pain

LABORATORY RESEARCH

Scientists at Cleveland Clinic’s Lerner Research Institute are involved in several major projects

related to deep brain stimulation and neurological restoration:

° Cerebellar stimulation for recovery of motor function following cortical strokes

° Corpus callosum stimulation for recovery of functions following subcortical strokes

° Effects of chronic electrical stimulation of the subthalamic nucleus on tissue integrity

° The effectiveness of deep brain stimulation of intralaminar nuclei of thalamus in a model

of focal cortical seizures induced by intracortical penicillin and generalized seizures

induced by intraperitoneal PTZ (pentylenetetrazole) in adult rats

° Effi cacy of subthalamic nucleus stimulation using variable wave-form external pulse gen-

erator (VWEPG) in ameliorating Parkinsonism in 6-hydroxydopamine-lesioned hemipar-

kinsonian rats


Birdno MJ, Cooper SE, Rezai AR, Grill WM. Pulse-to-pulse changes in the frequency of

deep brain stimulation affect tremor and modeled neuronal activity. J Neurophysiol. 2007

Sep;98(3):1675-1684.

Butson CR, Cooper SE, Henderson JM, McIntyre CC. Patient-specifi c analysis of the volume of

tissue activated during deep brain stimulation. Neuroimage. 2007 Jan 15;34(2):661-670.

Deogaonkar M, Walter BL, Boulis N, Starr P. Clinical problem solving: fi nding the target.

Neurosurgery. 2007 Oct;61(4):815-824; discussion 824-825.

Kuncel AM, Cooper SE, Wolgamuth BR, Grill WM. Amplitude- and frequency-dependent

changes in neuronal regularity parallel changes in tremor with thalamic deep brain stimulation.

IEEE Trans Neural Syst Rehabil Eng. 2007 Jun;15(2):190-197.

Lee JYK, Deogaonkar M, Rezai A. Deep brain stimulation of globus pallidus internus for dysto-

nia. Parkinsonism Relat Disord. 2007 Jul;13(5):261-265.

Machado A, Azmi H, Deogaonkar M, Rezai A. MRI-guided procedures for the management of

chronic pain. Tech Reg Anesth Pain Manag. 2007 Apr;11(2):113-119.

Machado A, Ogrin M, Rosenow JM, Henderson JM. A 12-month prospective study of gas-

serian ganglion stimulation for trigeminal neuropathic pain. Stereotact Funct Neurosurg.

2007;85(5):216-224.

Schiff ND, Giacino JT, Kalmar K, Victor JD, Baker K, Gerber M, Fritz B, Eisenberg B, O’Connor

J, Kobylarz EJ, Farris S, Machado A, McCagg C, Plum F, Fins JJ, Rezai AR. Behavioural

improvements with thalamic stimulation after severe traumatic brain injury. Nature. 2007 Aug

2;448(7153):600-603.

CENTER FOR NEUROLOGICAL RESTORATION | 65

The Center for Neurological Restora-

tion, in collaboration with the Center

for Headache and Pain, investigated

stimulation of the spheno-palatine

ganglia for treatment of severe cluster

and migraine headaches.

RESE ARCH

The Center for Neurological Restoration

held a one-day symposium on move-

ment disorders in 2007 for physicians

and nurse practitioners, addressing

restless legs syndrome, pharmacologi-

cal management of Parkinson’s disease,

and surgical therapies for advanced

Parkinson’s disease, dystonia and es-

sential tremor.

EDUCATION


DIANE HIRE

Age: 54

Hometown: Norwalk, Ohio

Diagnosis: Severe intractable depression

Treatment: Deep brain stimulation surgery

Diane Hire struggled with unrelenting depression for 20 years. Every morning, her fi rst

thought was that she would be able to go back to bed in 16 hours. She tried a variety of

treatments, but none provided sustained relief. One day, a therapist she was seeing heard

a lecture by Donald Malone, MD, about deep brain stimulation at Cleveland Clinic and sent

Ms. Hire’s records to him. She had surgery with Ali Rezai, MD, in November 2006; the de-

vice was activated in January 2007. Today, Ms. Hire is excited to wake up and enjoys talk-

ing to people, reading, working around the yard and house, and just being active — things

she hadn’t done in decades.

“Before, I was just a walking dead person. Only my body was alive. I didn’t know if I even

knew how to be well anymore. But I couldn’t ask for kinder, gentler people than Dr. Malone

and Dr. Rezai. They were so responsive and always had my best interest at heart. Because

of them, I am now 180 degrees away from where I was. My life is changed completely.”


CENTER FOR NEUROLOGICAL RESTORATION | 67

Parkinson’sDisease

Tremor Dystonia Other

80

60

40

20

0

80

60

40

20

0

20062007

Deep Brain Stimulation (DBS) procedures

Bilateral DBS, N=28 Unilateral DBS, N=27

Type of Surgery

80

60

40

20

0

80

60

40

20

0

UPDRS Motor ScoresUPDRS Motor Scores

Stimulation onStimulation off

Improvement in Motor Scores with DBS

Bilateral DBS, N=28 Unilateral DBS, N=27

Type of Surgery

100

80

60

40

20

0

100

80

60

40

20

0

Percent Improvement in Motor Function Following DBS for Parkinson’s Disease

Improvement in motor functioning in

Parkinson’s disease with deep brain

stimulation. Motor functioning is

measured with the Unifi ed Parkin-

son’s Disease Rating Scale, Part III

(Motor Subscale). Motor scores are

shown with the stimulator in the on

and off states.

Percent improvement on Unifi ed

Parkinson’s Disease Rating Scale

(UPDRS), Part III (Motor Subscale)

following deep brain stimulation

treatment for Parkinson’s Disease.


OUTCOMES HIGHLIGHTS

NEUROMUSCULARCENTER

70 | NEUROMUSCUL AR CENTER

CLINICAL PROGRAM

Treating neuromuscular diseases such as amyotrophic lateral sclerosis (ALS), peripheral nerve

injury, myasthenia gravis and myopathies requires a unique combination of medical expertise

and compassion. Specialists in the Neuromuscular Center successfully achieve this blend and

strive to apply the latest technology to help patients optimize their quality of life and minimize

their disability. To assist in the accurate diagnosis of these disorders, our specialists rely on

diagnostic modalities such as electrodiagnosis (e.g., EMG); autonomic testing; and muscle,

nerve and skin biopsies to supplement the history and physical examination.

FELLOWSHIPS

A one-year, ACGME-accredited fellowship is available in neuromuscular medicine, and a one-

year ACGME-approved fellowship is offered in clinical neurophysiology/EMG. Fellows have the

opportunity to gain experience in the range of neuromuscular diseases, as well as training in

the EMG laboratory, the autonomic disorders laboratory (tilt table, valsalva and pupillometry

testing), the quantitative sensory testing laboratory (QST, QSART and thermoregulatory sweat

testing), the quantitative muscle testing laboratory, and the histopathology laboratory for

epidermal nerve fi ber analysis in skin.

CLINICAL RESEARCH

Physicians in the Neuromuscular Center are engaged in a number of clinical and translational

research projects focused on improving the treatment of this cluster of diseases. Our patients

have the opportunity to participate in new drug trials sponsored by pharmaceutical companies

and the National Institutes of Health (NIH). Some of the current protocols include:

° Recombinant methionyl human brain-derived neurotrophic factor (r-metHuBDNF) in

patients with ALS

° SR 57746A in patients with ALS

° Topiramate in ALS

° Celebrex® in patients with ALS

° The ALS Care Program: a database resource for measuring and improving ALS outcomes

° AVP-923 (dextromethorphan/quinidine) in the treatment of patients with pseudobulbar affect

° High-dose CoQ10 in ALS

° Arimoclomol in a single patient with ALS

° IGIV chromatography (IGIV-C) 10 percent treatment in subjects with chronic infl amma-

tory demyelinating polyneuropathy

LABORATORY RESEARCH

Researchers in the Department of Neurosciences in Cleveland Clinic’s Lerner Research

Institute are dedicated to advancing the understanding of the genetic basis of neuromuscular

diseases. Examples of basic research related to neuromuscular diseases include:

° Genetic therapy utilizing genes for neural growth factors and anti-apoptotic intracellular

proteins for treatment of neuromuscular disorders

° Identifi cation of molecular pathways leading to degeneration of motor neurons in ALS

° Incorporation of the WLDS mutation to delay axonal degeneration

° Exploration of mechanisms and potential therapies for treating muscle infl ammation and

fi brosis associated with Duchenne muscular dystrophy



2007 STATS

The Neuromuscular Center added

thermoregulatory sweat testing to

our battery of autonomic and quantita-

tive sensory testing, allowing more

sophisticated diagnosis of autonomic

and small fi ber neuropathic disorders.

INNOVATION


NEUROMUSCUL AR CENTER | 71

Total SFSN SFSN exclusivelyby skin bx

250

200

150

100

50

0

250

200

150

100

50

0


Skin Biopsy for Small Fiber Sensory Neuropathy

Mean VAS atBaseline

Mean VAS atLast Follow-up

Mean Changein VAS

50

40

30

20

10

0

-10

50

40

30

20

10

0

-10

Pain ScoresPain Scores

Treatment of Painful Peripheral Neuropathy (N=42)

Cleveland Clinic is one of a few medical centers with a cutane-

ous nerve laboratory to facilitate evaluation of small fi ber sensory

neuropathy (SFSN). In 2007, we performed skin biopsies with

intraepidermal nerve fi ber density evaluation for 233 patients. One

hundred and seventy eight patients (76 percent) were diagnosed

with SFSN based on the biopsy results. In 79 patients (44 percent)

the diagnosis was made exclusively by skin biopsy. Our data are

consistent with reports by other medical centers that skin biopsy is

a valuable diagnostic tool and is more sensitive than electrophysi-

ological studies for diagnosing SFSN.

Of 42 patients with painful peripheral polyneuropathy followed for

up to one year, 60 percent showed improvement in visual-analog

pain scores (VAS) with various treatment modalities.

Patients showed an average improvement (reduction in pain scores)

of 25 percent. This compares to an average improvement of 12 to

42 percent in published studies of treatment of neuropathic pain.


OUTCOMES HIGHLIGHTS

CATHLEEN WAGNER

Age: 53

Hometown: Columbiana, Ohio

Diagnosis: Myasthenia gravis

Treatment: Thymectomy and

immunosuppressant therapy

Cathleen Wagner began having weakness in her neck and arms, drooping eyelids and dif-

fi culty speaking. Her primary care doctor accurately diagnosed myasthenia gravis and sent

her to a local neurologist, who ordered a CT scan. This revealed a coexisting thymoma, and

Ms. Wagner’s neurologist then referred her to Cleveland Clinic neurologist Kerry Levin, MD.

Because Ms. Wagner had a history of cardiac arrhythmia, surgery was riskier. Cleveland

Clinic thoracic surgeons, however, were able to successfully remove the thymoma and

Dr. Levin began a treatment regime to treat her myasthenia gravis. Today her condition is

managed with immunosuppression — and she is back at her rigorous job as a kindergarten

teacher.

“Dr. Levin takes such a personal interest. He really listens and wants to know what is going

on. He always takes in account the fact that I spend all day with little kids when we are

making decisions about my care and is never willing to settle for ‘good enough.’ When I

told him I was having trouble smiling, he didn’t dismiss that as something I would just have

to live with. He insisted we could get me back to 100 percent. He has never given up.”


NEUROMUSCUL AR CENTER | 73

Neuromuscular Center research is

exploring mechanisms and potential

therapies for treating muscle infl am-

mation and fi brosis associated with

Duchenne muscular dystrophy.

RESE ARCH

The Neuromuscular Center has trained

three fellows per year in EMG and

neuromuscular disease for the last 20

years, and has continuously trained

residents, fellows and observers in our

EMG lab since 1975.

EDUCATION


Bello-Haas VD, Florence JM, Kloos AD, Scheirbecker J, Lopate G, Hayes SM, Pioro EP,

Mitsumoto H. A randomized controlled trial of resistance exercise in individuals with ALS.

Neurology. 2007 Jun 5;68(23):2003-2007.

Chemali KR, Zhou L. Small fi ber degeneration in post-stroke complex regional pain syndrome I.

Neurology. 2007 Jul 17;69(3):316-317.

Lederman RJ. Tremor in instrumentalists: Infl uence of tremor type on performance. Med Probl

Perform Art. 2007 Jun;22(2):70-73.

Levin KH. Nonsurgical interventions for spine pain. Neurol Clin. 2007 May;25(2):495-505.

Polston DW. Cervical radiculopathy. Neurol Clin. 2007 May;25(2):373-385.

Robertson J, Sanelli T, Xiao S, Yang W, Horne P, Hammond R, Pioro EP, Strong MJ. Lack of

TDP-43 abnormalities in mutant SOD1 transgenic mice shows disparity with ALS. Neurosci

Lett. 2007 Jun 13;420(2):128-132.

Tavee J, Mays M, Wilbourn AJ. Pitfalls in the electrodiagnostic studies of sacral plexopathies.

Muscle Nerve. 2007 Jun;35(6):725-729.

Zhou L, Kitch DW, Evans SR, Hauer P, Raman S, Ebenezer GJ, Gerschenson M, Marra CM,

Valcour V, Diaz-Arrastia R, Goodkin K, Millar L, Shriver S, Asmuth DM, Clifford DB, Simpson

DM, McArthur JC. Correlates of epidermal nerve fi ber densities in HIV-associated distal sen-

sory polyneuropathy. Neurology. 2007 Jun 12;68(24):2113-2119.




CENTER FOR

PEDIATRIC NEUROLOGYAND NEUROSURGERY

76 | CENTER FOR PEDIATRIC NEUROLOGY AND NEUROSURGERY

CLINICAL PROGRAMS

Child neurologists and neurosurgeons at Cleveland Clinic provide family-integrated, com-

prehensive, advanced care in the diagnosis and treatment of children with a wide array of

neurological disorders. U.S.News & World Report recently ranked Cleveland Clinic’s pediatric

neurology and neurosurgery services among the top four programs in the country.

PEDIATRIC NEUROLOGY

Our staff members — all board-certifi ed in both pediatrics and neurology — are committed

to providing the highest quality clinical care, research, teaching and training in the pediatric

neurosciences. This is achieved through collaboration with Cleveland Clinic pediatric subspe-

cialists in every medical and surgical fi eld to offer the most advanced care and individualized

treatment for a wide range of pediatric neurological conditions. The center includes dedicated

disease-based clinical programs:

The Pediatric Neuromuscular Disease Program diagnoses and treats such conditions as

muscular dystrophy, spinal muscular atrophy, congenital myopathies and myasthenia gravis,

hereditary neuropathies and other polyneuropathies using advanced techniques including

specialized DNA tests, pediatric EMG and neuropathological examination of nerve and muscle

biopsies. Affected children have access to the latest therapies, including drug trials, plasma-

pheresis and immunoglobulin infusion when indicated.

The Pediatric Movement Disorders and Spasticity Program offers traditional medical and inno-

vative therapies, including botulinum toxin injections guided by electromyography, deep brain

stimulation, physical therapy, orthopaedic interventions, intrathecal baclofen infusion and

selective dorsal rhizotomy. Conditions treated include Tourette syndrome, ataxia, spasticity,

cerebral palsy and myelomeningocele.

The Pediatric/Adolescent Headache Program offers state-of-the-art patient care, education

and innovative research. The program provides expert evaluation and treatment of those af-

fected by both acute and chronic headaches, especially those with refractory headaches who

have failed previous attempts at therapy. In addition, a three-week inpatient rehabilitation

program is offered to those whose headaches have resulted in excessive school absences and

overuse of medication. Collaboration with other specialties including psychology and rehabili-

tation ensures positive outcomes. An infusion suite is available on an urgent/emergency basis

for those experiencing headache crises.

The Pediatric Neurometabolic and Genetic Disorders Program provides diagnosis and treat-

ment for the complex genetic and metabolic disorders that are the underlying basis of many

pediatric neurological and developmental issues. Areas of particular focus include central

nervous system white matter disorders, underlying genetic and metabolic disorders in the set-

ting of mental retardation and epilepsy, disturbances of mitochondrial oxidative phosphoryla-

tion and fatty acid oxidation, disorders of amino and organic acid metabolism, and lysosomal

storage diseases.

The Pediatric Cerebrovascular Disorders Program offers advanced imaging, including brain

MRI, MRA, cerebral angiogram and CT angiogram, as well as other comprehensive diagnostic

and therapeutic interventions for all forms of neonatal and childhood stroke. Children with

acute stroke are cared for in a pediatric intensive care unit staffed full-time by experienced

Initial outpatient visits 1,109


Admissions 220

Inpatient Days 736

2007 STATS


pediatric intensivists in conjunction with our pediatric neurologists. Special areas of stroke

interest include children with central nervous system vasculitis, stroke associated with cardiac

disease or interventions, neonatal stroke and the vasculopathy of neurofi bromatosis.

The Pediatric Neurocardiology Program offers care for children with a wide variety of con-

genital and acquired heart diseases, including the management of associated neurological con-

ditions and complications of these disorders, as well as a comprehensive neuromuscular and

neurometabolic evaluation for children with unexplained cardiomyopathy or children undergo-

ing heart transplantation.

The Neonatal and Fetal Neurology Program offers prenatal consultation for a wide range of

neurological disorders detected in utero by fetal ultrasound, magnetic resonance imaging or

amniocentesis. Consultation and treatment also is provided for a variety of newborn conditions

including hypoxic-ischemic encephalopathy, neonatal seizures, stroke, CNS malformations,

brachial plexopathies and other newborn problems.

The Pediatric Neuro-Oncology Program specializes in the treatment of brain and spinal cord

cancer and offers sophisticated radiotherapies, including Gamma Knife® for brain tumors;

computer-assisted imaging for precise surgical planning, navigation and tumor resection; and

the most advanced chemotherapy as part of national study protocols.

The Neurocutaneous Disorders Program provides multidisciplinary care for a large popula-

tion of children with neurocutaneous disorders such as neurofi bromatosis, tuberous sclerosis

and Sturge-Weber syndrome. Cleveland Clinic received designation from the Children’s Tumor

Foundation as one of only 33 affi liate neurofi bromatosis clinics nationally.

CENTER FOR PEDIATRIC NEUROLOGY AND NEUROSURGERY | 77

The Center for Pediatric Neurology

and Neurosurgery developed the fi rst

Pediatric Multiple Sclerosis and White

Matter Disorders Clinic in Ohio in

collaboration with the Mellen Center.

INNOVATION

U.S.News & World Report recently ranked

Cleveland Clinic’s pediatric neurology and

neurosurgery services among the top four

programs in the country.



The Pediatric White Matter Disorders and Multiple Sclerosis Program offers advanced

diagnosis and treatment of multiple sclerosis and white matter disease in children. Distinction

between the many genetic, metabolic and acquired forms of pediatric white matter disease is

facilitated by collaboration with Pediatric Neurology team members who are world-renowned

specialists in the clinical and laboratory diagnosis of this group of disorders.

The Cyclic Vomiting Program provides expert evaluation and treatment for those individuals

with episodic unexplained vomiting. This program is one of only three in the country and the

only one in Northeast Ohio. The consultation includes evaluation by a neurometabolic special-

ist and metabolic gastroenterologist. Experts in pediatric headache, psychology and psychiatry

are an integral part of the team.

The Pediatric Epilepsy and Sleep Disorders Program provides comprehensive care for children

with epilepsy, often in the setting of complex neurological diseases. Sophisticated diagnosis of

pediatric seizure disorders and their underlying causes is available. Children with sleep disor-

ders receive state-of-the-art consultation and testing by pediatric sleep specialists.

Through the Community Pediatric Neurology Program, Cleveland Clinic pediatric neurologists

deliver clinical services in community settings including Hillcrest Hospital, Fairview Hospital

and Cleveland Clinic Wooster. These practices provide convenient access for patients and their

families in a community setting.

Pediatric neurologists at Cleveland Clinic are all board-certifi ed in both pediatrics and neurology.



PEDIATRIC AND CONGENITAL NEUROSURGERY

Cleveland Clinic’s pediatric and congenital neurosurgery services were one of the fi rst in the

country to emphasize the continuity of treatment of pediatric problems into adulthood, treating

congenital problems regardless of age. A variety of subspecialty programs are offered.

The center has broad experience in the treatment of brain and spinal cord malformations,

including Chiari malformation in children and adults. Surgical intervention for these congenital

abnormalities uses an innovative minimally invasive approach. Brain and spinal cord tumors are

biopsied and surgically resected in coordination with Pediatric Oncology and the Brain Tumor

and Neuro-Oncology Center using the latest localizing and minimally invasive techniques.

The latest technology, such as an adjustable antibiotic system, is offered for the treatment of

hydrocephalus in children and adults, resulting in an infection rate lower than national norms.

A $1 million study of outcomes for shunting in hydrocephalus is ongoing.

Our neuroendoscopy program has extensive experience in ventricular and extra ventricular

minimally invasive procedures. Advances include a combination of endoscopy with navigation

systems for complex procedures and resection of tumor masses. In 2007, the neuroendoscopic

program directed a neurosurgical course in Beijing, China, in a unique collaboration with

Peking Union Medical Center.

Cerebral palsy patients are seen in a unique multidisciplinary clinic for assessment, surgical

evaluation, follow- up and ongoing care. Combined neurosurgical and orthopaedic procedures

are performed to treat spasticity quickly and effectively. The section directs a course in the

treatment of spasticity and its regional therapies in children.

Center neurosurgeons and plastic surgeons collaborate in the treatment of craniofacial disor-

ders. Cleveland Clinic designed a pneumatic molding helmet that is utilized for more control

and fl exible head reshaping.

In our Aging Brain Clinic, specialists from multiple disciplines evaluate patients from around

the country with regard to dementia and normal pressure hydrocephalus.

FELLOWSHIPS

Pediatric neurosurgery offers a one-year, non-ACGME accredited fellowship in pediatric neuro-

surgery under the auspices of the Department of Neurosurgery. In the pediatric neurosurgery

fellowship, the focus is on learning the most advanced surgical treatments for hydrocephalus

and congenital abnormalities in children and adults. Minimally invasive techniques using

endoscopy are emphasized.

In addition to its certifi ed residency training program in Pediatric Neurology, Cleveland Clinic also

offers certifi ed subspecialty pediatric fellowships in Headache, Neuromuscular Disease, Sleep

Medicine and Epilepsy. These fellowships benefi t from collaboration with specialists in other cen-

ters throughout Cleveland Clinic, and are among only a few in the country that offer in-depth sub-

specialty training in the diagnosis and treatment of children and adolescents with these disorders.

CLINICAL RESEARCH

The Center for Pediatric Neurology and Neurosurgery participates in a range of clinical trials aimed

at improving management of a number of specifi c pediatric neurologic and neurosurgical disorders.

Pediatric neurology researchers are

exploring new ways to use MRI

and EEG to expand the potential pool

of pediatric candidates for epilepsy

surgery.

RESE ARCH


The pediatric neurology residency pro-

gram celebrated its 30th anniversary

in 2007, with more than 45 physicians

having graduated from the program.

We are one of only a few programs in

the country to offer a combined fi ve-

year training program that includes two

years of pediatrics training followed

by three years of pediatric neurology

training.

EDUCATION


Current clinical research includes:

Pediatric Neurology

° Ongoing coordination of the Ohio Pediatric Stroke Registry, the only pediatric state-based

registry in the country

° Ongoing participation in the International Pediatric Stroke Study (IPSS) collaborative

° Drug treatments in Duchenne muscular dystrophy and spinal muscular atrophy

Pediatric and Congenital Neurosurgery

° Treatment of children with spasticity: differences in intrathecal baclofen delivery

° Evaluation of new molding helmet in cranial abnormality

° Third ventriculostomy: outcome-related to CSF fl ow

° Neuroendsocopic-assisted chiari surgery compared with conventional standard surgical

approach

° Evaluating cognitive and neuropsychological effects of a study drug in children with par-

tial seizures

° Accelerator quantitation of imbalance in normal pressure hydrocephalus

° Treatment of children with chronic hydrocephalus

° Gait and balance in normal pressure hydrocephalus using the Medtronic Strata® Adjust-

able Valve and the Codman® Hakim™ Programmable Valve CSF content in normal pres-

sure hydrocephalus

° Developmental venous anomaly indices for patients undergoing lumbar drainage of CSF

for normal pressure hydrocephalus

LABORATORY RESEARCH

Basic research at Cleveland Clinic’s Lerner Research Institute that investigates the cellular and

molecular biology of brain development and neuronal and glial function contributes signifi -

cantly to advances in clinical care in pediatric neurology and neurosurgery.

Current basic research projects include:

° Oxygen delivery in hydrocephalus after surgical treatment

° Cerebrovascular and blood fl ow changes in chronic hydrocephalus

° CSF metabolite/cytokine expression in hydrocephalic CSF


Pediatric neurosurgeons at Cleveland Clinic

are some of the most experienced in the nation

for shunting pediatric hydrocephalus and adult

cases of normal pressure hydrocephalus.


2003 2004 2005 2006 2007

300

200

100

0

300

200

100

0

6

4

2

0

6

4

2

0

ProceduresProcedures DaysDays

Pediatric NeurosurgeryProceduresMean LOS

Pediatric Neurosurgery (<18 years)

Peds MIDAS HeadacheFrequency

RescueDoses

SchoolDays Missed

50

40

30

20

10

0

50

40

30

20

10

0

Visit 1Visit 2

Pediatric Headache (n=18)

New patientconsults

Diagnosis established viamuscle, genetic or CSF

350

300

250

200

150

100

50

0

350

300

250

200

150

100

50

0

Number of PatientsNumber of Patients

Neurometabolic Clinic Diagnostic Yield

Pediatric patients treated for headache showed an improve-

ment in PedsMIDAS (Migraine Disability Assessment Score),

headache frequency, and number of rescue medications

needed. The number of school days missed is one of the

questions included in the PedsMIDAS interview. N=18

pediatric patients with two PedsMIDAS scores an average of

three months apart.

In 2007 our Neurometabolic Clinic evaluated more than

300 patients presenting with unexplained neurologic and/or

developmental symptoms, and we were able to establish

a diagnosis in 125 patients, or 40 percent.


OUTCOMES HIGHLIGHTS

AIDAN VON GUNTEN

Age: 4

Hometown: Amherst, Ohio

Diagnosis: Left-side hemiparesis, due to

presumed perinatal ischemic stroke

Treatment: Physical and occupational

therapy and adaptive aquatics

When Aidan was about 3 months old, his mother, who works in early childhood intervention,

noticed that he was only reaching with his right hand. She watched him for about a month

before taking him to his Cleveland Clinic pediatrician. Aidan was referred to Cleveland Clinic

pediatric neurologist Neil Friedman, MB, ChB, who quickly began a comprehensive series of

diagnostic tests. An MRI demonstrated that a stroke had occurred, most likely before birth.

Aidan has been going for therapy to improve his balance and left-side strength for about

three years and today is a very social and active little boy. He plays soccer and many people

who interact with him are surprised to learn he has any limitations at all.

“The systematic approach of helping us right away gave us such a positive impression of

Cleveland Clinic,” says Aidan’s mom. “If our pediatrician hadn’t been so open to referring us

to Dr. Friedman right away and if we hadn’t gotten in to see such an excellent neurologist

so quickly, Aidan might not have gotten the help he needed so fast. Dr. Friedman is very

thorough and very comforting. He takes my concerns seriously and has always treated me

like a partner in Aidan’s care.”



° Dural substitutes

° Telemetric intracranial pressure measurement

° CSF circulation and solute clearance

° Intracranial pulse pressure changes in chronic hydrocephalus

° Study of the brain’s adaptation to chronic hypoxia hydrocephalus through stimulation of

VEGF and angiogenesis

° Study of cerebral hydro- and hemodynamic interaction to increase cerebral blood fl ow at

time of ischemic risks


Di X. Multiple brain tumor nodule resections under direct visualization of a neuronavigated

endoscope. Minim Invasive Neurosurg. 2007 Aug;50(4):227-232.

Di X, Luciano M. A novel endoscopic technique to suboccipital ecompression and atlas lamine-

ctomy for chiari malformation type I: technical note. WSJ. 2007;2(1):27-31.

Hinson JT, Fantin VR, Schonberger J, Breivik N, Siem G, McDonough B, Sharma P, Keogh I,

Godinho R, Santos F, Esparza A, Nicolau Y, Selvaag E, Cohen BH, Hoppel CL, Tranebjaerg L,

Eavey RD, Seidman JG, Seidman CE. Missense mutations in the BCS1L gene as a cause of the

Bjornstad syndrome. N Engl J Med. 2007 Feb 22;356(8):809-819.

Mathews CA, Jang KL, Herrera LD, Lowe TL, Budman CL, Erenberg G, Naarden A, Bruun RD,

Schork NJ, Freimer NB, Reus VI. Tic symptom profi les in subjects with Tourette syndrome

from two genetically isolated populations. Biol Psychiatry. 2007 Feb 1;61(3):292-300.

Mohyuddin T, Jacobs IB, Bahler RC. B-type natriuretic peptide and cardiac dysfunction in

Duchenne muscular dystrophy. Int J Cardiol. 2007 Jul 31;119(3):389-391.

Singh M, Jacobs IB, Spirnak JP. Nephrolithiasis in patients with Duchenne muscular dystro-

phy. Urology. 2007 Oct;70(4):643-645.

Turner RD, Rosenblatt SM, Chand B, Luciano MG. Laparoscopic peritoneal catheter place-

ment: results of a new method in 111 patients. Neurosurgery. 2007 Sep;61(3 Suppl):

167-172; discussion 172-174.

Warnke JP, Di X, Mourgela S, Nourusi A, Tschabitscher M. Percutaneous approach for

thecaloscopy of the lumbar subarachnoidal space. Minim Invasive Neurosurg. 2007

Jun;50(3):129-131.

Williams MA, McAllister JP, Walker ML, Kranz DA, Bergsneider M, Del Bigio MR, Fleming

L, Frim DM, Gwinn K, Kestle JRW, Luciano MG, Madsen JR, Oster-Granite ML, Spinella G.

Priorities for hydrocephalus research: report from a National Institutes of Health-sponsored

workshop. J Neurosurg. 2007 Nov;107(5 Suppl Pediatrics):345-357.

Wyllie E, Lachhwani DK, Gupta A, Chirla A, Cosmo G, Worley S, Kotagal P, Ruggieri P,

Bingaman WE. Successful surgery for epilepsy due to early brain lesions despite generalized

EEG fi ndings. Neurology. 2007 Jul 24;69(4):389-397.




DEPARTMENT OF

PSYCHIATRY AND PSYCHOLOGY

86 | DEPARTMENT OF PSYCHIATRY AND PSYCHOLOGY

CLINICAL PROGRAMS

The Department of Psychiatry and Psychology provides comprehensive adult, child and ado-

lescent mental health and chemical dependency services.

Adult Psychiatry

Inpatient and outpatient services are provided for the full range of adult psychiatric disorders.

The chief inpatient diagnoses are psychoses, alcohol and/or drug abuse, personality disorders

and mood disorders. The most common outpatient diagnoses treated are mood, anxiety and

somatoform disorders. Adult psychiatry also includes the Center for Psychiatric Neuromodula-

tion and the growing Mood Disorders Research Program.

Child and Adolescent Psychiatry

The department’s very active program in child and adolescent psychiatry offers outpatient and

crisis-oriented inpatient treatment. In the under 18 population, the leading inpatient diagnoses

in 2007 were psychoses, personality disorders, depression, anxiety disorders and DSM-IV

“childhood mental disorders,” including disruptive behavior disorders, pervasive developmen-

tal disorders, eating disorders and tic disorders. The top three diagnoses in 2007 among the

pediatric outpatient population were Attention Defi cit-Hyperactivity Disorder, mood disorders

and anxiety, and dissociative or somatoform disorders.

Section of Pain Medicine

The Section of Pain Medicine provides diagnosis and treatment of chronic pain and related

problems. It operates the Chronic Pain Rehabilitation Program, which is an interdisciplinary,

biopsychosocial rehabilitation program for patients with serious pain-related functional impair-



Admissions 759


2007 STATS

Cleveland Clinic psychiatrists and psychologists participate in the team-based care of patients across the various Neurologi-

cal Institute centers and Cleveland Clinic institutes, incorporating mental and behavioral health services into the continuum

of patient care.


DEPARTMENT OF PSYCHIATRY AND PSYCHOLOGY | 87

ment or psychological distress. This all-day program provides inpatient care as well when

needed.

Psychosomatic Medicine

This section is staffed by psychiatrists, residents, a fellow in psychosomatic medicine and a

team of psychiatric occupational therapists who provide psychiatric consultation to hospital-

ized patients and their caregivers on medical and surgical units for psychiatric and neuro-

psychiatric disorders that occur during hospital admission. It is among the most active and

highly valued teaching services. The most common problems encountered include post-

operative delirium, mood disorders, adjustment disorders and assessment for either safety or

capacity, or both. Section staff also participate in the Epilepsy, Preventive Cardiology, Trans-

plant and Women’s Health centers and the Taussig Cancer Institute, as well as the Bakken

Heart-Brain Institute.

General and Health Psychology

Health psychologists provide behavioral assessment and treatment including biofeedback and

cognitive-behavioral, supportive and other types of psychotherapy on an outpatient basis.

Section members also serve important roles in Executive Health, the Center for Headache and

Pain, Bariatric Surgery and Women’s Health.

Neuropsychology

Specialists in this area work closely with physicians in other disciplines to provide neuropsy-

chological testing for patients with cognitive disturbance related to epilepsy, multiple sclerosis,

movement disorders, dementia, hydrocephalus, head injury and cardiothoracic surgery.

Alcohol and Drug Recovery Center

Our specialists in this area provide high-quality, multidisciplinary care and treatment for all

age groups with alcohol and drug abuse or addiction. Treatment is individualized to include

inpatient care, partial hospitalization and intensive or routine outpatient care or a combination

of these as needed to evaluate, detoxify and treat patients.

Psychiatric Neuromodulation Center

The Psychiatric Neuromodulation Center is a unique and distinctive feature of the depart-

ment’s collaboration with the Center for Neurological Restoration. It provides conventional and

innovative treatments to patients with psychiatric disorders refractory to common treatment

modalities. Patients with treatment-resistant depression or obsessive compulsive disorder in

particular can benefi t from evaluation and consultation with center physicians.

FELLOWSHIPS

Two comprehensive chronic pain rehabilitation fellowships are available through the Section

of Pain Medicine. Each fellow participates in the Chronic Pain Rehabilitation Program doing

biofeedback-assisted psychotherapy. Research primarily involves using our IRB-approved data

registry. Fellows also participate in couples and groups sessions, including a psychodynamic

group and CBT-based groups, as well as monthly aftercare.

The psychosomatic fellowship is a one-year training program, and involves rotations in

cardiology, oncology, transplantation and Women’s Health. In addition, the fellow may

The Department of Psychiatry and

Psychology developed and implement-

ed an SBAR modifi ed for psychiatry.

The SBAR (Situation, Background,

Assessment and Recommendation)

is a tool that is used to report to the

next shift, improving communication

between providers.

INNOVATION


88 | DEPARTMENT OF PSYCHIATRY AND PSYCHOLOGY

participate in research related to a topic of interest in consultation-liaison psychiatry.

The fellow also teaches residents and medical students, and provides supervision in the

Emergency Department. The fellow may also see patients for longitudinal follow-up in the

Psychosomatic Clinic with supervision from faculty.

The neuropsychology fellowship through the Association of Postdoctoral Programs in Clinical

Neuropsychology is a two-year program and is designed to provide specialty training in pediat-

ric or adult neuropsychology at the post-doctoral level.

CLINICAL RESEARCH

The department participates in multicenter clinical trials supported by the National Institutes

of Health (NIH), corporations and private foundations, as well as in-house trials conducted

exclusively at Cleveland Clinic. The primary focus of clinical trials is the development and

investigation of new pharmacological and other treatments for psychiatric disorders.

The Cleveland Clinic Mood Disorders Research Center is nearing the completion of the largest

double-blind, placebo-controlled trial of divalproex sodium to date in the acute treatment of

bipolar depression. The trial is being completed in collaboration with partners at Case Western

Reserve University.

Current child and adolescent psychiatry clinical trials include:

° First psychotic episode in children and adolescents, a four-year retrospective review

° S-100 B as a serum marker for early detection of infl ammation in psychotic children

° Cytokines in psychotic children

° Depression and epilepsy in childhood

° Infl ammatory markers in depression and epilepsy

° MRI fi ndings in temporal lobe epilepsy and depression

° A retrospective review of cognitive impact on epileptic children post-frontal lobectomy

Current psychology research includes:

° Cancer fatigue

° Facial allograft research and clinical protocol

° Palliative care and quality of life for those in long-term care

° Evaluation and treatment of tinnitus

° Strategies for managing patients with tinnitus

° Psychophysiologic remodeling of the failing human heart

° Heart-rate variability biofeedback in the treatment of early heart failure

° The health effects of spiritually focused meditation for people with acute leukemia

Current neuropsychology research includes:

° The role of cortisol dysregulation in depression and hippocampal dysfunction associated

with temporal lobe epilepsy

° An fMRI study of attention networks in multiple sclerosis

° Evaluating the risks and benefi ts associated with the application of deep brain stimulation

in the treatment of a variety of disorders such as Parkinson disease, tremor, dystonia,

pain, obsessive compulsive disorder, depression and neurocognitive disorders as a result

of brain injury

The new Cleveland Clinic Mood

Disorders Inpatient Unit includes an

IRB-approved research database as

part of the admissions process, which

helped to identify incorrect primary

diagnoses in 26 of the fi rst 100 admit-

ted adult patients in 2007.

RESE ARCH

More than 230 mental healthcare

professionals attended the Department

of Psychiatry and Psychology’s second

annual Post Traumatic Stress Disorder

symposium in 2007.

EDUCATION



Admission Discharge 6 months 12 months

10

8

6

4

2

0

10

8

6

4

2

0

Pain Score (0=No Pain, 10=Worst possible pain)Pain Score (0=No Pain, 10=Worst possible pain)

20062007

Pain Intensity Following Chronic Pain Rehabilitation Program Treatment

12(N=11)

6(N=15)

3(N=15)

Time Since Surgery (Months)

1(N=15)

Baseline(N=15)

0

-10

-20

-30

-40

-50

-60

-70

0

-10

-20

-30

-40

-50

-60

-70

Percent Change in ScorePercent Change in Score

HDRSMADRS

Depressive Symptom Improvement with Deep Brain Stimulation in Highly Refractory Depression

Average BES Average Number ofBinge Eating Episodes

25

20

15

10

5

0

25

20

15

10

5

0

Before Treatment

After Treatment

Outcomes Following Binge Eating Therapy (n=81)

Mean pain scores decrease following en-

rollment in the Chronic Pain Rehabilitation

Program. Two hundred fi fty-nine patients

were admitted to the program in 2006 and

233 in 2007. Approximately 80 percent of

patients completed the program. Typical

treatment duration is 3.5 weeks.

Change in Montgomery-Asberg Depression

Rating Scale (MADRS) and Hamilton-24

Depression Rating Scale (HDRS) over time

for the subject population.

The patient average on the BES showed

a signifi cant reduction following group

treatment (p<.001). The average number

of binge eating episodes also showed a

signifi cant reduction following group treat-

ment (p < .001). Average patient satisfac-

tion was 4.52 (Very Satisfi ed to Extremely

Satisfi ed) on a scale of 1 (Extremely Dis-

satisfi ed) to 5 (Extremely Satisfi ed).


OUTCOMES HIGHLIGHTS

DAVID A ND DIANE RAGOZINE

Age: 57 and 55 years old

Hometown: Bristolville, Ohio

Diagnosis: Decades of chronic drug

and alcohol addiction

Treatment: Buprenorphine (Suboxone®)

maintenance therapy

This husband and wife spent years addicted to prescription drugs and alcohol. They tried

many times to stop, but nothing lasted. Mr. Ragozine fi nally went to see Gregory Collins, MD,

who put him on Suboxone®, which often is used as initial therapy, but less often offered

as long-term maintenance. Several months later, Mrs. Ragozine also sought help from

Dr. Collins. Today they are both clean and attend 12-step meetings with sponsors several

times a week. They continue to take Suboxone® daily.

“I was a slave to my addiction,” says Mr. Ragozine. “It took our money and our pride. Dr. Col-

lins really understands how hopeless narcotic addiction is and he’s been a miracle man for

us. His approach of combining the medication with intensive therapy is what saved us.”

“I was slowly dying and would be dead today if it weren’t for Dr. Collins’ help. My heart is not

heavy anymore. I don’t know what I would do without this treatment,” says Mrs. Ragozine.




Fattal O, Link J, Quinn K, Cohen BH, Franco K. Psychiatric comorbidity in 36 adults with

mitochondrial cytopathies. CNS Spectr. 2007 Jun;12(6):429-438.

Ford PJ, Kubu CS. Ameliorating and exacerbating: surgical “prosthesis” in addiction. Am J

Bioeth. 2007 Jan;7(1):32-34.

Ford PJ, Boulis NM, Montgomery EB Jr, Rezai AR. A patient revoking consent during awake

craniotomy: an ethical challenge. Neuromodulation. 2007 Oct;10(4):329-332.

Keary TA, Frazier TW, Busch RM, Kubu CS, Lampietro M. Multivariate neuropsychologi-

cal prediction of seizure lateralization in temporal epilepsy surgical cases. Epilepsia. 2007

Aug;48(8):1438-1446.

Newport DJ, Calamaras MR, DeVane CL, Donovan J, Beach AJ, Winn S, Knight BT, Gibson

BB, Viguera AC, Owens MJ, Nemeroff CB, Stowe ZN. Atypical antipsychotic administration

during late pregnancy: placental passage and obstetrical outcomes. Am J Psychiatry. 2007

Aug;164(8):1214-1220.

Pearson KH, Nonacs RM, Viguera AC, Heller VL, Petrillo LF, Brandes M, Hennen J, Cohen

LS. Birth outcomes following prenatal exposure to antidepressants. J Clin Psychiatry. 2007

Aug;68(8):1284-1289.

Viguera AC, Koukopoulos A, Muzina DJ, Baldessarini RJ. Teratogenicity and anticonvulsants:

lessons from neurology to psychiatry. J Clin Psychiatry. 2007;68(Suppl)9:29-33.

Viguera AC, Whitfi eld T, Baldessarini RJ, Newport DJ, Stowe Z, Reminick A, Zurick A, Cohen

LS. Risk of recurrence in women with bipolar disorder during pregnancy: prospective study of

mood stabilizer discontinuation. Am J Psychiatry. 2007 Dec;164(12):1817-1824.

Viguera AC, Newport DJ, Ritchie J, Stowe Z, Whitfi eld T, Mogielnicki J, Baldessarini RJ, Zurick

A, Cohen LS. Lithium in breast milk and nursing infants: clinical implications. Am J Psychiatry.

2007 Feb;164(2):342-345.




SLEEP DISORDERSCENTER

94 | SLEEP DISORDERS CENTER

CLINICAL PROGRAM

The Sleep Disorders Center is accredited by the American Academy of Sleep Medicine. Our

clinical program continues to expand, refl ecting the widespread incidence of these disorders

in the population. To date, the center has performed more than 47,000 sleep studies. The

introduction of hotel-based sleep laboratories in 2005 strategically situated in the Greater

Cleveland region contributed signifi cantly to the center’s expansion throughout 2006 and

2007. Jyoti Krishna, MD, joined the center in 2007 as head of the pediatric sleep program.

Construction is under way for a new pediatric sleep clinic at our Fairhill location.

FELLOWSHIPS

Five one-year, ACGME-accredited fellowships are available with the center. Designed to

develop a range of competencies in sleep medicine, the fellowship provides trainees with

eligibility for the American Board of Sleep Medicine. Trainees are provided with a broad expo-

sure to sleep medicine including polysomnographic technology and the treatment of adult and

pediatric patients with sleep disorders, with a strong emphasis on clinical neurophysiology.



2007 STATS

The Sleep Disorders Center established

a comprehensive Cognitive Behav-

ioral Program in 2007, incorporating

individual and group therapy for the

treatment of insomnia.

INNOVATION

Annually, more than 4,000 sleep studies are performed at our main center’s nine-bed lab and at hotel-based sleep labs

throughout the community.


SLEEP DISORDERS CENTER | 95

Before PAP After PAP

ESS ScoreESS Score

20

15

10

5

0

Sleep Apnea: Improvement in Sleepiness (n=60)

Before PAP After PAP

PHQ-9 ScorePHQ-9 Score

15

10

5

0

Sleep Apnea: Improvement in Depressive Symptoms (n=60)

No Insomnia Mild Moderate

Insomnia Category

Severe

Number of PatientsNumber of Patients

14

12

10

8

6

4

2

0

Before

After

Insomnia Sleep Skills Group

Sleepiness as measured with the Epworth Sleepiness

Scale (ESS) in sleep apnea patients seen from June to

December 2007, before and after PAP (positive airway

pressure) treatment. Higher scores indicate more

severe daytime sleepiness; PAP treatment reduced

sleepiness into the normal range (<10). Average dura-

tion of treatment was 86 days.

Depressive symptoms as measured with the Patient

Health Questionnaire (PHQ-9), in sleep apnea patients

seen from June to December 2007 also improved after

PAP treatment. PHQ-9 scores of 5-9 suggest mild

depression, <5 suggests minimal depression.

The Sleep Skills Group is a novel treatment for

insomnia started in 2007, one of the fi rst of its

kind in Northeast Ohio. After a fi ve-week session, 69

percent of participants had a signifi cant improvement

in insomnia, and 22 percent of participants no

longer had insomnia, as measured with the Insomnia

Severity Index.


OUTCOMES HIGHLIGHTS

EDWINA POLK

Age: 39

Hometown: Cleveland, Ohio

Diagnosis: Obstructive sleep apnea

Treatment: Continuous positive airway

pressure (CPAP)

Edwina Polk was helping countless people to fi nd the source of their sleeping problems

working as a polysomnography technologist at Cleveland Clinic’s Sleep Disorders Center. Yet

it took her a while to consider that her excessive tiredness could be due to a sleep disorder

of her own. She considered the diffi culty concentrating and remembering information to be

a way of life. Finally, when even adding extra sleep to her routine didn’t help, she decided to

undergo some of the tests she had administered so frequently to others. After going through

basic sleep tests and positional sleep therapy, her doctor found that a CPAP was just what

she needed. Now Ms. Polk enjoys having much more energy during the day and getting

things done.

“Cleveland Clinic solved my problems — I’m not tired during the daytime and I’m able to

concentrate. Now I’m able to get up and do all the things I need to do.”


SLEEP DISORDERS CENTER | 97

CLINICAL RESEARCH

Clinical studies in the Sleep Disorders Center include research into the causes of sleep

disorders, evaluation of innovative treatments and understanding co-morbidities and sleep

disorders. Current areas of research include:

° Major depressive disorder in sleep disorder patients

° Effects and prevalence of sleep apnea in bariatric surgery patients

° Finding the gene for restless legs syndrome

° Sleep disorders complicating epilepsy

° Use of wireless polysomnography in hospitalized patients

° Comparison of ambulatory and laboratory polysomnography for the diagnosis of obstruc-

tive sleep apnea


Mermigkis C, Chapman J, Golish J, Mermigkis D, Budur K, Kopanakis A, Polychronopoulos V,

Burgess R, Foldvary-Schaefer N. Sleep-related breathing disorders in patients with idiopathic

pulmonary fi brosis. Lung. 2007 May;185(3):173-178.

Mermigkis C, Kopanakis A, Foldvary-Schaefer N, Golish J, Polychronopoulos V, Schiza S,

Amfi lochiou A, Siafakas N, Bouros D. Health-related quality of life in patients with obstructive

sleep apnea and chronic obstructive pulmonary disease (overlap syndrome). Int J Clin Pract.

2007 Feb;61(2):207-211.

The Sleep Disorders Center collabo-

rated with Cleveland Clinic’s Cardiovas-

cular Surgery Department to study the

perioperative morbidity of sleep apnea.

RESE ARCH

Since 1995, when the accredited

clinical sleep medicine fellowship

began, the Sleep Disorders Center has

trained 54 clinical fellows who cur-

rently practice sleep medicine around

the world, including Korea, Singapore,

Saudi Arabia, Greece, Thailand and

Lebanon.

EDUCATION




CENTER FOR

SPINE HEALTH

100 | CENTER FOR SPINE HEALTH

CLINICAL PROGRAMS

Specialists in neurosurgery, orthopaedic surgery and medical spine provide state-of-the-art

medical and surgical management for the full scope of back and spine problems.

The following highlights some of the subspecialty programs in the Center for Spine Health that

have achieved a national reputation:

Scoliosis and Kyphosis: Non-operative treatment typically involves bracing to temporarily

halt the worsening of the curve during a growth spurt. For spinal deformities approaching or

greater than 45 degrees associated with pain, functional impairment or severe cosmetic defor-

mity, spine stabilization surgery is performed. Surgeons employ spinal fusion in combination

with bone grafts and pedicle screws to stabilize the spine and correct the deformity. Whenever

possible, the procedure is performed in part or completely minimally invasively.

Spondylolisthesis: Nonsurgical treatment includes muscle relaxants, acetaminophen or anti-

infl ammatory agents in combination with physical therapy, non-aerobic exercise and stretching

to improve fl exibility of the trunk muscles. Spinal fusion and spinal instrumentation are recom-

mended in cases in which the spondylolisthesis causes neuropathy or incontinence.

Spinal Stenosis: Medical treatment options for spinal stenosis include nonsteroidal anti-infl am-

matory drugs (NSAIDs), intrathecal cortisone injections, exercise and physical therapy. We

also offer gabapentin and related drugs, the fi rst group of medications to provide an effective

nonsurgical treatment option for symptomatic lumbar stenosis with neurogenic claudication.

Surgical intervention is recommended when these measures are ineffective and pain interferes

with quality of life. Surgical treatment to permanently decompress the spinal canal includes

laminectomy with or without fusion, foraminotomy and spinal fusion with or without instru-

mentation.

Primary and Metastatic Spinal Tumors: Depending on the pathology and location of the tumor,

treatment options include analgesics and steroids to manage pain and infl ammation, brac-

ing to increase spinal stability, chemotherapy, radiation therapy, and/or surgical resection in

Initial outpatient visits 2,638


Admissions 1,557


Surgical Cases 3,679

2007 STATS

Center for Spine Health surgeons offer spine stabilization surgery for both adult and pediatric cases of scoliosis, performing

the procedure using minimally invasive techniques whenever possible.


CENTER FOR SPINE HEALTH | 101

combination with spinal fusion. Embolization is performed as an adjunct to surgery for very

vascular tumors.

Mature Spine: The focus of the program is on conservative treatment for patients over age 60

experiencing chronic back pain. Options include pharmacologic and non-pharmacologic treat-

ments such as medications and supplements, physical, occupational and aquatic therapy, and

bracing.

Degenerative Spine: Conservative treatment is emphasized, including bed rest for acute pain,

stretching, low-impact exercise, pharmacologic therapy, spinal manipulation, heat and acu-

puncture. When pain is refractory to conservative treatments, surgical options may be used

and include laminectomy, spinal fusion or discectomy.

Cervical Fractures: Minor fractures frequently are treated with a cervical collar. Surgery is rec-

ommended for cases that involve neurological injury and the removal of a portion of bone to

relieve pressure on the spinal cord. More severe fractures may require manipulation or surgery

to restore the normal skeletal conformation. This may involve traction or surgery with bone

grafting and instrumentation.

Minimally Invasive Spinal Surgery: In certain cases of degenerative disease of the spine,

scoliosis, kyphosis, spinal column tumors, infection, fractures and herniated discs, minimally

invasive techniques may be used to speed recovery from surgery, minimize postoperative pain

and improve the fi nal outcome. The spine surgeons at Cleveland Clinic are leaders in the fi eld

and have been instrumental in advancing these techniques, including: spinal fusion, deformity

corrections (such as for scoliosis), repair of herniated discs, decompression of spinal tumors

and repair and stabilization of vertebral compression fractures.

Degenerative Diseases of the Spine: Degenerative diseases of the spine affect all regions of

the spine. Physicians at Cleveland Clinic provide state-of-the-art care that ranges from the

least invasive to complex surgical procedures to decompress neurological compression and/or

The Center for Spine Health offers medical

acupuncture to treat musculoskeletal and

spinal pain, as well as fatigue, stress and

muscle tension.

Stereotactic spine radiosurgery can deliver a very precisely targeted, high dose of radiation that can effectively control pain

or tumors in as little as a single session.



spinal instability or deformity. All treatments are individualized and may be multi-staged. The

most effective and least risky approaches are chosen on a case-specifi c basis.

FELLOWSHIPS

The Center for Spine Health offers a one-year fellowship in spine surgery that provides exper-

tise in diagnosing and treating all aspects of spinal disease, with emphasis on degenerative

disorders, adult deformity, complex reconstruction and revision techniques, and emerging

technologies. Surgical decision-making is emphasized as the fellow rotates through both ortho-

paedic and neurosurgical spine services. Laparoscopic and thoracoscopic minimally invasive

techniques, kyphoplasty and artifi cial disc techniques are taught. The fellow develops exper-

tise in applying both anterior and posterior spinal instrumentation systems. Fellows participate

in basic science and/or clinical research, and are expected to complete two research projects

over the course of the year.

The Center for Spine Health also offers a fellowship in spine medicine, training broadly compe-

tent specialists in this emerging specialty, focused on the evaluation and management of the full

spectrum of spine disorders. Fellows have the opportunity to develop outstanding clinical skills

grounded in an evidence-based framework. Fellows are exposed to a wide range of diagnostic

and therapeutic modalities including electrodiagnostics, acupuncture, manipulation, physical

The Center for Spine Health spine medicine fellowship focuses not only on procedural techniques, but also on spine well-

ness, surgical evaluations, imagery interpretation and pharmacologic therapies.

Center for Spine Health physicians

perform 1,600 interventional spine

procedures with center fellows as part

of the spine medicine fellowship.

EDUCATION



therapy, pain management and lumbar interventional spine procedures. Scholarly activity is

encouraged and expected. Fellows are active participants in clinical research and writing.

CLINICAL RESEARCH

Physicians in the Center for Spine Health participate in numerous clinical trials related to pain

management, advanced surgical techniques and new technology.

Current protocols include:

° Prospective outcomes evaluation of decompression with or without instrumented fusion

for lumbar stenosis with degenerative grade I spondylolisthesis (SLIP)

° Lumbar spine instability study: the role of fl exion/extension radiographs

° A prospective, randomized clinical investigation of the Cervitech, Inc. porous-coated mo-

tion artifi cial disc for stabilization of the cervical spine

° A chart review comparing surgical to conservative management in the treatment of type II

odontoid fractures among the elderly

° A retrospective, randomized controlled trial of duragen plus adhesion barrier matrix to

minimize adhesions following lumbar discectomy

° Cost savings in the operative room, standard radiographs vs. fl uoroscopy for localization

° A prospective, multicenter, randomized controlled study to compare the spinal sealant system

as an adjunct to sutured dural repair with standard of care methods during spinal surgery

° A multicenter, prospective, randomized, controlled clinical trial comparing the safety and

effectiveness of the Mobi-C prosthesis with conventional anterior cervical discectomy and

fusion in the treatment of symptomatic degenerative disc disease in the cervical spine

° The effectiveness of physical therapy for patients with lumbar spinal stenosis

° An assessment of P-15 bone putty in anterior cervical fusion with instrumentation inves-

tigational plan

° Determining the optimal surgical approach (ventral versus dorsal) for patients with multi-

level cervical spondylotic myelopathy

The Spine Research Laboratory actively develops investigations to address the problems Center for Spine Health physicians

encounter in the clinical setting.

The Center for Spine Health established

the Neurological Institute Collabora-

tive Community of Innovation (NICCI),

a new initiative designed to create,

promote and nurture a culture of cre-

ativity, innovation and teamwork in the

Neurological Institute.

INNOVATION



LABORATORY RESEARCH

The research focus of the Spine Research Laboratory (SRL) is largely “translational” in its

emphasis on moving discoveries in basic science research to applications at the clinical level.

The close involvement of clinicians from Cleveland Clinic’s Center for Spine Health is a key

ingredient in maintaining this translational focus. The current “research portfolio” of the SRL

mirrors the interests of Center for Spine Health clinicians, and therefore incorporates the views

of surgical spine specialists (neurosurgical and orthopaedic) and medical spine specialists

(trained in physical medicine and rehabilitation, and osteopathic medicine).

The SRL has a number of ongoing, long-term research endeavors conducted under the aus-

pices of fi ve unique research pillars:

SpinalMEMS. Development of wireless, miniature pressure sensors that can be implanted

within an intervertebral disc and transmit real-time data for extended periods of time — pro-

viding clinicians with information as to the load-bearing, hydration and overall health of the

disc in response to different treatments and rehabilitation strategies.

Spine Biomechanics. Use of robotics technology to simulate changes in spinal neuromuscular

control strategies in response to pain.

Bone Bioengineering. Computational simulation of spinal bone remodeling and adaptive pro-

cesses in response to aging, trauma and disease.

Tissue Engineering. Development of animal models of intervertebral disc degeneration for

establishing causal links between disc degeneration, neoinnervation and pain.

Spinal Cord Injury. Development of biologic approaches to spinal cord regeneration following

traumatic injury.

Additionally, customized research projects are developed by medical students, residents and

fellows involved with the SRL.

A focus of the Spine Research Laboratory is bringing basic science investigations to clinical practice.

The Cleveland Clinic Center for Spine

Health spin-off company OrthoMEMS,

a microelectromechanical system, is

moving rapidly toward clinical trials

with its micro-pressure sensor, the

OrthoChip. The fi rst clinical application

of this battery-less, telemetric micro-

sensor will be for the assessment of

intervertebral disc function and the

more accurate determination of the

indications for and contraindications to

spine fusion surgery.

RESE ARCH



TumorTumor

CorrectionCorrection

DeformityDeformity

DecompressiveDecompressive

BiopsyBiopsy

ArthrodesisArthrodesis

0 400 600200 800

Number of Procedures

1,000

Type of ProcedureType of Procedure

Selected Spinal Procedures

Spinal deformity

Degenerative spine disease

Spinal fracture/trauma

Non-degenerative musculoskeletal-primary

Spinal tumor

Nervous system disorder

Spinal vascular malformation

10

8

6

4

2

0

10

8

6

4

2

0

DaysDays

Mean LOSTarget LOS

Mean Length of Stay (LOS) in Spinal Disorders

Spinal decompression remains the most

frequently performed procedure for spine

disease.

Target LOS is calculated based on APR-

DRGs, which adjust for the severity of the

patient population.


OUTCOMES HIGHLIGHTS

JO STEINHURST

Age: 84

Hometown: Cleveland, Ohio

Diagnosis: Spinal pain

Treatment: Medical acupuncture

Mrs. Steinhurst had injured her spine about 50 years ago when she was chasing her four-

year-old son and fell down the stairs. Years of physical therapy weren’t enough to ward off

the pain and she was forced to wear a leather and metal brace frequently to ease the pain.

Recently, she discovered medical acupuncture with Daniel Mazanec, MD, at Cleveland

Clinic’s Center for Spine Health and had immediate results. She now takes only over-the-

counter arthritis pills for her spinal injury because of the success of acupuncture.

“Nothing did for me what the fi rst go at acupuncture did. My back has not been as comfort-

able for most of my adult life as it is now. And, I have a physician doing it, which adds a

feeling of security. I go back every six to eight weeks for a ‘tune-up.’ The only regret I have

is that I waited until I was 84 to do this.”




Caron TH, Bell GR. Combined (tandem) lumbar and cervical stenosis. Semin Spine Surg.

2007 Mar;19(1):44-46.

Claybrooks R, Kayanja M, Milks R, Benzel E. Atlantoaxial fusion: a biomechanical analysis of

two C1-C2 fusion techniques. Spine J. 2007 Nov;7(6):682-688.

Covington E. Chronic pain management in spine disorders. Neurol Clin. 2007 May;25(2):539-

566.

Ferrara LA, Gordon I, Coquillette M, Milks R, Fleischman AJ, Roy S, Goel VK, Benzel EC. A

preliminary biomechanical evaluation in a simulated spinal fusion model. Laboratory investiga-

tion. J Neurosurg Spine. 2007 Nov;7(5):542-548.

Hwang SH, Kayanja M, Milks RA, Benzel EC. Biomechanical comparison of adjacent seg-

mental motion after ventral cervical fi xation with varying angles of lordosis. Spine J. 2007

Mar;7(2):216-221.

Kilincer C, Inceoglu S, Sohn MJ, Ferrara LA, Benzel EC. Effects of angle and laminectomy on

triangulated pedicle screws. J Clin Neurosci. 2007 Dec;14(12):1186-1191.

Krishnaney AA, Park J, Benzel EC. Surgical management of neck and low back pain. Neurol

Clin. 2007 May;25(2):507-522.

Mazanec D, Reddy A. Medical management of cervical spondylosis. Neurosurgery. 2007

Jan;60(1 Suppl 1):S43-S50.

Mohit AA, Orr RD. Percutaneous vertebral augmentation in osteoporotic fractures. Curr Opin

Orthop. 2007 May;18(3):221-225.

Orr RD, Postak PD, Rosca M, Greenwald AS. The current state of cervical and lumbar spinal

disc arthroplasty. J Bone Joint Surg Am. 2007 Oct;89 Suppl 3:70-75.

Steinmetz MP, Stewart TJ, Kager CD, Benzel EC, Vaccaro AR. Cervical deformity correction.

Neurosurgery. 2007 Jan;60(Suppl 1):S90-S97.

Stewart TJ, Schlenk RP, Benzel EC. Multiple level discectomy and fusion. Neurosurgery. 2007

Jan;60(1 Suppl 1):S143-S148.

Vadala G, Sowa GA, Smith L, Hubert MG, Levicoff EA, Denaro V, Gilbertson LG, Kang JD.

Regulation of transgene expression using an inducible system for improved safety of interverte-

bral disc gene therapy. Spine. 2007 Jun 1;32(13):1381-1387.


108 | NEUROLOGICAL INSTITUTE

Cleveland Clinic’s Neurological Institute is a multidisciplinary team of specialists offering innovative technology for diagnosis and treatment of all

neurological conditions affecting adult and pediatric patients. Because of our clinical expertise, academic achievement and innovative research,

the Neurological Institute has earned an international reputation for excellence.


NEUROLOGICAL INSTITUTE STAFF

NEUROLOGICAL INSTITUTE CHAIRMEN

Michael T. Modic, MD, FACRChairman, Neurological Institute

William Bingaman, MDVice Chairman, Clinical Areas, Neurological Institute

Richard Rudick, MD Vice Chairman, Research and Development, Neurological Institute

Edward Benzel, MDChairman, Department of Neurological Surgery

Kerry Levin, MDChairman, Department of Neurology

Thomas Masaryk, MDChairman, Department of Diagnostic Radiology

George Tesar, MDChairman, Department of Psychiatry and Psychology

Bruce Trapp, PhDChairman, Department of Neurosciences, Lerner Research Institute

CENTER FOR BRAIN HEALTH

Richard Rudick, MDInterim Director, Center for Brain Health

Richard Lederman, MD, PhD

Michael Parsons, PhD

Stephen Rao, PhDDirector, Schey Center for Cognitive Neuroimaging

Patrick Sweeney, MD

Janice Zimbelman, PT, PhD

BRAIN TUMOR AND NEURO-ONCOLOGY CENTER

Gene Barnett, MD, FACSDirector, Brain Tumor and Neuro-Oncology Center

Lilyana Angelov, MD, FRCS(C)

Samuel Chao, MD

Bruce H. Cohen, MD

Joung Lee, MD

David Peereboom, MD

Burak Sade, MD

John Suh, MD

Glen Stevens, DO, PhD

Tanya Tekautz, MD

Michael Vogelbaum, MD, PhD

Robert Weil, MD

CEREBROVASCULAR CENTER

Peter Rasmussen, MDDirector, Cerebrovascular Center

Rishi Gupta, MD

Irene Katzan, MD, MS

Gwendolyn Lynch, MD

Thomas Masaryk, MD

Shaye Moskowitz, MD, PhD

J. Javier Provencio, MD, FCCM

Vivek Sabharwal, MD

EPILEPSY CENTER

Imad Najm, MDDirector, 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

Jorge Gonzalez-Martinez, MD, PhD

Ajay Gupta, MD

Stephen Hantus, MD

Jennifer Haut, PhD, ABPP-CN

Lara Jehi, MD

Patricia Klaas, PhD

Prakash Kotagal, MD

Deepak Lachhwani, MB.BS, MD

John Mosher, MD, PhD

Dileep Nair, MD

NEUROLOGICAL INSTITUTE | 109


Richard Naugle, PhD

Diosely Silveira, MD, PhD

George Tesar, MD

Ingrid Tuxhorn, MD

Elaine Wyllie, MD

CENTER FOR HEADACHE AND PAIN

Mark Stillman, MDDirector, Center for Headache and Pain

Cynthia Bamford, MD

Neil Cherian, MD

Steven Krause, PhD, MBA

Jennifer Kriegler, MD

Robert Kunkel, MD

MaryAnn Mays, MD

Roderick Spears, MD

Deborah Tepper, MD

Stewart Tepper, MD

MELLEN CENTER FOR MULTIPLE SCLEROSIS

TREATMENT AND RESEARCH

Richard Rudick, MDDirector, 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, MDDirector, Center for Neuroimaging

Manzoor Ahmed, MD

Todd M. Emch, MD

Stephen E. Jones, MD, PhD

Mark Lowe, PhD

Parvez Masood, MD

Doksu Moon, MD

Micheal Phillips, MD

Paul Ruggieri, MD

Alison Smith, MD

Todd Stultz, DDS, MD

Andrew Tievsky, MD

CENTER FOR NEUROLOGICAL RESTORATION

Ali Rezai, MDDirector, Center for Neurological Restoration

Anwar Ahmed, MD

Scott Cooper, MD, PhD

Milind Deogaonkar, MD

Darlene Floden, PhD

Ilia Itin, MD

Cynthia S. Kubu, PhD, ABPP-CN


Andre Machado, MD, PhD

Donald Malone Jr., MD

Mayur Pandya, DO

Patrick Sweeney, MD

Jerrold Vitek, MD, PhD

NEUROMUSCULAR CENTER

Kerry Levin, MDDirector, Neuromuscular Center

Kamal Chémali, MD

Thomas E. Gretter, MD

Rebecca Kuenzler, MD


Erik Pioro, MD, PhD

David Polston, MD

Robert Shields Jr., MD

Steven Shook, MD

Patrick Sweeney, MD

Jinny Tavee, MD

Lan Zhou, MD, PhD

CENTER FOR PEDIATRIC NEUROLOGY

AND NEUROSURGERY

Elaine Wyllie, MDDirector, Center for Pediatric Neurology

Mark Luciano, MD, PhDDirector, Center for Pediatric Neurosurgery

Bruce H. Cohen, MD

Xiao Di, MD, PhD

Stephen Dombrowski, PhD

Gerald Erenberg, MD

Neil Friedman, MB, ChB

Debabrata Ghosh, MD, DM

Gary Hsich, MD

Irwin Jacobs, MD

Manikum Moodley, MD

Sumit Parikh, MD

A. David Rothner, MD

Tanya Tekautz, MD


110 | NEUROLOGICAL INSTITUTE


DEPARTMENT OF PSYCHIATRY AND PSYCHOLOGY

George Tesar, MDChairman, Department of Psychiatryand Psychology

Susan Albers-Bowling, PsyD

Kathleen Ashton, PhD

Joseph M. Austerman, DO

Scott Bea, PsyD

Dana Brendza, PsyD

Karen Broer, PhD

Kumar Budur, MD

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

Jennifer Haut, PhD, ABPP-CN

Leslie Heinberg, PhD

Karen Jacobs, DO

Joseph Janesz, PhD, LICDC

Regina Josell, PsyD

Elias Khawan, MD

Patricia Klaas, PhD

Steven Krause, PhD, MBA

Cynthia S. Kubu, PhD, ABPP-CN

Donald Malone Jr., MD

Michael McKee, PhD

Scott Meit, PsyD, MBA

Gene Morris, PhD

David Muzina, MD

Richard Naugle, PhD

Mayur Pandya, DO

Michael Parsons, PhD

Shannon Perkins, 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, MDDirector, Center for Regional Neurology

A. Romeo Craciun, MDDirector, Stroke Center, Marymount Hospital

Sheila Rubin, MD

Jennifer Ui, MD

Joseph Zayat, MD

CENTER FOR REGIONAL NEUROLOGICAL SURGERY

Michael Mervart, MDDirector, Center for Regional Neurological Surgery

Samuel Borsellino, MD

Samuel Tobias, MD

SLEEP DISORDERS CENTER

Nancy Foldvary-Schaefer, DODirector, Sleep Disorders Center

Loutfi Aboussouan, MD

Kathleen Ashton, PhD

Charles Bae, MD

Kumar Budur, MD

Michelle Drerup, PsyD

Sally Ibrahim, MD

Alan Kominsky, MD

Prakash Kotagal, MD

Jyoti Krishna, MD

William Novak, MD

Carlos Rodriguez, MD

CENTER FOR SPINE HEALTH

Edward Benzel, MDDirector, Center for Spine Health

Gordon Bell, MD

Edwin Capulong, MD

Russell DeMicco, DO

Lars Gilbertson, PhD

Augusto Hsia Jr., MD

Serkan Inceoglu, PhD

Iain Kalfas, MD

Tagreed Khalaf, MD

Ajit Krishnaney, MD


NEUROLOGICAL INSTITUTE | 111


Paula Lidestri, MD

Daniel Mazanec, MD

Robert McLain, MD

Thomas Mroz, MD

R. Douglas Orr, MD

Judith Scheman, PhD

Richard Schlenk, MD

Michael Steinmetz, MD

Santhosh Thomas, DO, MBA

Fredrick Wilson, DO

Adrian Zachary, DO, MPH

NEUROANESTHESIOLOGY

Michelle Lotto, MDHead, Section of Neurosurgical Anesthesia

Zeyd Ebrahim, MDO.R. Clinical Director

Armin Schubert, MDChairman, Department of General Anesthesiology

Rafi Avitsian, MD

Ehab Farag, MD, FRCA

Mariel Manlapaz, MD

Marco Maurtua, MD

Vivek Sabharwal, MD

Gloria Walters, MD


DEPARTMENT OF NEUROSCIENCES

Bruce Trapp, PhDChairman, Department of Neurosciences, Lerner Research Institute

Cornelia Bergmann, PhD

Hitoshi Komuro, PhD

Bruce Lamb, PhD

Wendy Macklin, PhD

Sanjay W. Pimplikar, PhD

Richard M. Ransohoff, MDDirector, Neuroinfl ammation Research Center, Lerner Research Institute

Susan Staugaitis, MD, PhD

Stephen Stohlman, PhD

Jerrold Vitek, MD, PhD

Riqiang Yan, PhD


BIOMEDICAL ENGINEERING

Jay Alberts, PhD

Elizabeth Fisher, PhD

Aaron Fleischman, PhD

Cameron McIntyre, PhD

Shuvo Roy, PhD


CELL BIOLOGY

Damir Janigro, PhD

PATHOLOGY AND LABORATORY MEDICINE INSTITUTE

ANATOMIC PATHOLOGY

Richard Prayson, MD

NEWLY ARRIVING STAFF

Ferdinand Hui, MD

Bushra Malik, MD


2008 -2009 CONT INU ING MED ICAL EDUCAT ION

September 26-27, 2008Optimizing Function through Spasticity Management: Midwest Spasticity Conference 2008

COURSE DIRECTORS: Francois Bethoux, MD, and Mark Luciano, MD, PhD

Bertram Inn and Conference CenterAurora, Ohio

October 20-22, 2008Gamma Knife Perfexion — Update Training

COURSE DIRECTOR: Gene Barnett, MD

Cleveland Clinic Gamma Knife CenterCleveland, Ohio

October 30-31, 2008Neuroimaging in Traumatic Brain Injury

COURSE DIRECTORS: Stephen Rao, MD, and Harvey Lenin, PhD

InterContinental Hotel and Bank of America Conference CenterCleveland, Ohio

November 5-7, 200811th Annual Neuroscience Nursing Symposium

COURSE DIRECTOR: Kimberly Hunter

Hilton Garden Inn Hotel, Downtown ClevelandCleveland, Ohio

November 6-8, 2008Neuro-Oncology: Current Conceptsin conjunction with Mexican Neurosurgery, Neuro-Oncology, and Radiosurgery Societies


Fiesta Americana Grand Los CabosLos Cabos, Mexico

November 21, 20083rd Annual Post Traumatic Stress Disorder Symposium

COURSE DIRECTORS: Joseph Janesz, PhD, and Bridget Dwyer, MA, PC


December 1-5, 2008Gamma Knife Perfexion Training


Cleveland Clinic Gamma Knife CenterCleveland, Ohio

December 4-7, 2008North American Neuromodulation Society 12th Annual Meeting

SCIENTIFIC PROGRAM DIRECTOR: Ali R. Rezai, MD

Mandalay Bay Resort and CasinoLas Vegas, Nev.

February 9-11, 2009Case Studies in Epilepsy Surgery

COURSE DIRECTORS: William Bingaman, MD, and Imad Najm, MD

The Silvertree HotelSnowmass Village, Colo.

February 20-22, 20093rd Annual International Symposium on Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery

COURSE DIRECTORS: Lilyana Angelov, MD, Gene Barnett, MD, Edward Benzel, MD, Sam Chao, MD, and John Suh, MD

The Grand Floridian Resort and SpaLake Buenavista, Fla.

June 19-21, 2009Epileptology: Comprehensive Review and Practical Exercises

COURSE DIRECTORS: Andreas Alexopoulos, MD, Deepak Lachhwani, MD, and Imad Najm, MD


June 22-24, 200918th International Cleveland Clinic Epilepsy Symposium: Epilepsy Surgery — Improving OutcomesCOURSE DIRECTORS: Imad Najm, MD and William Bingaman, MD


112 | CONTINUING MEDICAL EDUCATION


All physicians are cordially invited to attend the following Cleveland Clinic Neurological Institute CME symposia and

ongoing programs:

Cleveland ClinicCelebrating 75 Years of Excellence in

CONTINUING MEDICAL EDUCATION

For more information, please visit clevelandclinic.org/neuroscience/CME.

CONTACT INFORMATION AND LOCATIONS | 113


CONTACT INFORMAT ION AND LOCAT IONS

General Patient Referral

24/7 hospital transfers or physician consults 800.553.5056

Neurological Institute Appointments/Referrals Toll-free 866.588.2264

On the Web at clevelandclinic.org/neuroscience

The Neurological Institute is a Cleveland Clinic-wide endeavor to provide world-class diagnosis and treatment to all patients — whether coming to us from near or far. Institute physicians see patients at Cleveland Clinic’s main campus, six Neurological Institute Regional Centers and nine Cleveland Clinic family health centers.

Please inquire about availability of specifi c services at each location when calling.

Main Campus

9500 Euclid Ave.Cleveland, Ohio 44195 866.588.2264

Neurological Institute Regional Centers

Euclid Hospital18901 Lake Shore Blvd.Euclid, Ohio 44119216.531.9000

Fairview Hospital18101 Lorain Ave.Cleveland, Ohio 44111216.476.7000

Hillcrest Hospital6780 Mayfi eld RoadMayfi eld Heights, Ohio 44124440.312.4500

Huron Hospital13951 Terrace RoadEast Cleveland, Ohio 44112216.761.3300

Lakewood Hospital14519 Detroit Ave.Lakewood, Ohio 44107216.521.4200

Lutheran Hospital1730 West 25th St.Cleveland, Ohio 44113216.696.4300

Cleveland Clinic Family Health Centers

Beachwood Family Health and Surgery Center26900 Cedar RoadBeachwood, Ohio 44122216.839.3000

Chagrin Falls Family Health Center551 E. Washington St.Chagrin Falls, Ohio 44022440.893.9393

Independence Family Health Center5001 Rockside RoadCrown Center IIIndependence, Ohio 44131216.986.4000

Lorain Family Health and Surgery Center 5700 Cooper Foster Park RoadLorain, Ohio 44053440.204.7400

Solon Family Health Center 29800 Bainbridge RoadSolon, Ohio 44139440.519.6800

Strongsville Family Health and Surgery Center 16761 SouthPark CenterStrongsville, Ohio 44136440.878.2500

Westlake Family Health Center 30033 Clemens RoadWestlake, Ohio 44145440.899.5555

Willoughby Hills Family Health Center 2570 SOM Center Rd.Willoughby Hills, Ohio 44094440.943.2500

Cleveland Clinic Wooster1739 Cleveland RoadWooster, Ohio 44691330.287.4500

This fall, Cleveland Clinic is introducing the future of healthcare with the opening of the Sydell and Arnold Miller Family Pavilion and the Glickman Tower.

These buildings, which represent the largest construction and philanthropy project in Cleveland Clinic history, embody the pioneering spirit and commitment to quality that defi ne Cleveland Clinic. These structures are a tangible expression of institutes, our new model of care that organizes patient services by organ and disease.

At 1 million square feet, the Miller Family Pavilion is the country’s largest single-use facility for heart and vascular care. The 12-story Glickman Tower, new home to the Glickman Urological & Kidney Institute, is the tallest building on Cleveland Clinic’s main campus. Both will help us improve patient experience by increasing our capacity and by consolidating services, so patients can stay in one location for their care.

With 278 private patient rooms, more than 90 ICU beds and a combined total of nearly 200 exam rooms and more than 90 procedure rooms, patients will have faster access to Cleveland Clinic cardiac and urological services.

For details, including a virtual tour, please visit meetthebuildings.com.

I N T R O D U C I N G

THE FUTURE OF HEALTHCARE

114 | OTHER NEWS


OUTCOMES DATA AVA IL ABLEThe latest outcomes data from Cleveland Clinic’s Neurological Institute are now available. Charts, graphs and tables illustrate the scope and volume of procedures performed in our institute each year. To view the outcomes books for the Neurological Institute and many other Cleveland Clinic institutes, visit clevelandclinic.org/quality/outcomes.

Cleveland Clinic’s neurology and neurosurgery programs are ranked sixth

in the nation and our pediatric neurology and neurosurgery services are ranked

fourth by U.S.News & World Report.

Innovative new

buildings improve patient

access, experience.

11

Outcomes | 2007

NeurologicalInstitute

The Neurological Institute is one of 26 institutes at Cleveland Clinic that group multiple specialties

together to provide collaborative, patient-centered care. The institute is a leader in treating the

most complex neurological disorders, advancing innovations such as deep brain stimulation, epilepsy

surgery, stereotactic spine radiosurgery and blood-brain barrier disruption. Annually, our staff of

more than 200 specialists serves 140,000 patients and performs 6,000 surgeries. Cleveland Clinic

is a nonprofi t multispecialty academic medical center, consistently ranked among the top hospitals

in America by U.S.News & World Report. Founded in 1921, it is dedicated to providing quality

specialized care and includes an outpatient clinic, a hospital with more than 1,000 staffed beds,

an education institute and a research institute.

Cleveland Clinic ©2008 | Design: Chip Valleriano | Editor: Christine Coolick | Principal Photography: Al Fuchs, Don Gerda, Neil Lantzy, Russell Lee, Yu Kwan Lee, Tom Merce, Steve Travarca

The Cleveland Clinic Foundation9500 Euclid Avenue / AC311Cleveland, OH 44195

Our neurology and neurosurgery services are ranked sixth in the nation and our pediatric neurology and

neurosurgery services are ranked fourth by U.S.News & World Report.

tomorrow's neurological care. today

Documents

neurological disorders

multidisciplinary institute

institute model

welcomeneurological

patient care

new center

institutewide effort

diseasebased care