Upload
others
View
1
Download
0
Embed Size (px)
Citation preview
Neurological Institute2013 YEAR IN REVIEW
CONTENTS1 Neurological Institute Overview
4 Welcome from the Chairman
HIGHLIGHTS FROM OUR CENTERS
6 Advent of 7T MRI Scanner Elevates Neuroimaging Research Abilities, Aspirations
10 Novel Approaches to Refractory Epilepsy: Bringing New Hope to Diverse Patients in Need
14 Virtual Reality System Ushers in New Era of Immersive, Multisensory Rehab in a Controlled Environment
18 Deploying Personalized Medicine for Smarter Therapeutic Targeting of Brain Tumors
20 Teaming with the NFL Players Association to Promote Brain Health of Retired Athletes
INNOVATIONS IN BRIEF
24 Proliferation of Care Paths Transforms Care Culture and Promotes Consistent, Evidence-Based Treatment Decisions
26 Brain-Computer Interface Technology: Helping Restore Function After Neurologic Injury
27 Alzheimer Disease Trials Program Takes a ‘Multiple Shots on Goal’ Approach
28 ‘Hyperacute’ MRI Protocol Results in Fewer — but More Effective — Endovascular Stroke Interventions
29 NIH Grant Helps Chart Synaptic Wiring in the Autism Brain
30 Neurological Institute Staff
34 Resources for Physicians
On the cover: High-resolution T2-weighted image from Cleveland Clinic’s new 7T MRI scanner. See story on page 6.
CLEVELAND CLINIC NEUROLOGICAL INSTITUTE | 1
Cleveland Clinic Neurological InstituteWHO WE ARE, HOW WE WORK TOGETHER
Cleveland Clinic’s multidisciplinary Neurological Institute includes more than 300
medical, surgical and research specialists dedicated to the diagnosis, treatment and
rehabilitation of adults and children with brain and CNS disorders.
The institute is structured into
four departments — Neurology,
Neurological Surgery, Physical
Medicine and Rehabilitation,
and Psychiatry and Psychology
— that oversee education
and training, and coordinate
activities across our condition-
based centers.
DEPARTMENTS
CENTERS
PHYSICIANS
OUR INSTITUTE MODEL allows patients to access
care through 15 specialized, condition-specific centers.
Each center incorporates a multidisciplinary approach to the
diagnosis and management of a particular condition or group
of conditions.
NEUROLOGICAL INSTITUTE DEPARTMENTS AND CENTERS
Department of Neurology
Department of Neurological Surgery
Department of Physical Medicine and Rehabilitation
Department of Psychiatry and Psychology
Center for Behavioral Health
Lou Ruvo Center for Brain Health
Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center
Cerebrovascular Center
Concussion Center
Epilepsy Center
Mellen Center for Multiple Sclerosis Treatment and Research
Center for Neuroimaging
Neurological Center for Pain
Center for Neurological Restoration
Neuromuscular Center
Center for Pediatric Neurology and Neurosurgery
Center for Regional Neurosciences
Sleep Disorders Center
Center for Spine Health
2 | YEAR IN REVIEW 2013
$13M IN RESEARCH GRANTS, 7,500+ TRIAL ENROLLEES
Our clinical services are complemented by a robust research program that fosters innovation and
collaboration. Neurological Institute physicians and scientists work closely with colleagues in the Lerner
Research Institute, Cleveland Clinic’s basic science research arm, to pursue laboratory-based and
translational research in addition to our hundreds of ongoing clinical trials. We recently enhanced our
neuroimaging research capabilities across multiple conditions with acquisition of a 7T MRI scanner.
200,000+ PATIENT VISITS,
17,700+ ADMISSIONSAcross our more than 200,000 annual
patient visits and more than 17,700 annual
admissions, the Neurological Institute
manages the most common to the most
complex disorders of the brain and CNS. For
patients with challenging conditions in need
of leading-edge treatments, our physicians
and surgeons are regularly advancing
innovations in specialty areas including:
› Epilepsy surgery and SEEG
› Stereotactic radiosurgery
› Deep brain stimulation
› Laser interstitial thermal therapy for
brain tumors
› Endovascular treatment of cerebral
aneurysms and vascular malformations
› Neuroendoscopy
› Concussion assessment and management
1 MILLION VISITS’ WORTH OF HEALTH STATUS MEASURESThe Neurological Institute is dedicated to data-
informed clinical care. Our Knowledge Program
interactive data collection platform, now in
its seventh year, has captured health status
measure (HSM) data from more than 1 million
patient visits. At every outpatient visit, HSMs
are administered to patients electronically, while
providers report outcomes during the usual
medical documentation process.
We aggregate these patient- and provider-
generated data with information from other
sources — such as imaging results and
data from the growing number of care paths
embedded in our electronic medical record
system — to optimize clinical decision-making,
quality improvement and research. The result
is better care for communities and individuals
alike. Better and broader data means more
effective and efficient care at the population
level. For individual patients, our data-
informed approach to caregiving means we can
choose our tools wisely and wield them more
confidently to deliver the best outcome possible.
CLEVELAND CLINIC NEUROLOGICAL INSTITUTE | 3
3-STATE PRESENCE = ACCESS, REACHWe are committed to making access to the most advanced neurological care convenient for all patients.
Neurological Institute services are available at Cleveland Clinic community hospitals and family health
centers throughout Northeast Ohio, as well as in Las Vegas and in Weston, Fla. As a result, patients can
access our specialists within a couple hours’ flight time from almost any spot in the continental U.S.
Key components of our broad regional network include 120 acute inpatient rehabilitation beds at
Cleveland Clinic facilities across Northeast Ohio and a team of more than 750 specialty-trained therapists
at more than 45 locations offering physical medicine and rehabilitation services.
LAS VEGAS LOU RUVO CENTER FOR BRAIN HEALTH MAIN CAMPUS
CLEVELANDCLINIC
WESTONCLEVELAND CLINICFLORIDA
NEUROLOGICAL INSTITUTE VITAL STATISTICS (2012)
206,760 Annual outpatient visits
17,731 Annual admissions
114,297 Annual inpatient days
9,769 Annual surgical/interventional procedures
77,218 Annual neuroimaging studies
266 Staff physicians
149 Clinical residents and fellows
20 Research fellows
NEUROLOGICAL INSTITUTE RESEARCH FUNDING (2012)
$12.96M Total grant and contract research funding
63 Federal grants and contracts
181 Nonfederal grants and contracts
237 Active clinical research projects
77 New clinical research projects (initiated 2012)
58 Staff leading clinical research projects
7,580 Patients enrolled in clinical research projects
4 | YEAR IN REVIEW 2013
MICHAEL T. MODIC, MD, FACRCHAIRMAN, CLEVELAND CLINIC NEUROLOGICAL INSTITUTE
CLEVELAND CLINIC NEUROLOGICAL INSTITUTE | 5
Dear Colleagues,
The age of high-definition healthcare is here.
Breakthroughs in visualization and big data are
enabling us to see more and do more than ever
before, with payoffs in research and the clinical
care of our patients.
This edition of the Neurological Institute’s Year in
Review is rich with examples:
7-tesla MRI. The Neurological Institute is
proud to have completed installation of a 7T
MRI scanner in 2013, enabling us to conduct
neuroimaging research at spatial resolutions up
to five times greater than those possible at regular
field strengths. The story on page 6 outlines our
planned uses of the scanner and the daunting
engineering efforts behind its installation.
Immersive virtual environments for rehab and
research. 2013 also saw the continent’s first
nonmilitary installation of the CAREN 6-degrees-
of-freedom treadmill here at the Neurological
Institute. As detailed on page 14, this platform
allows us to safely challenge patients through
immersive ambulatory courses simulating nearly
any scenario from real life. We’ve been busy
deploying the treadmill for rehabilitation, research
and clinical analysis purposes in Parkinson disease,
multiple sclerosis and a growing list of other
clinical applications.
Expanded genomic profiling of brain tumors. In
2013 the Neurological Institute made personalized
medicine much more of a reality for patients with
select brain tumors by offering expanded genomic
profiling. By testing tumors for thousands of
genetic abnormalities that could impact therapy,
the expanded profiling empowers our specialists to
advise patients in a more personalized way on the
treatment course that’s best for them. Details are
on page 18.
Additional examples profile the Neurological
Institute’s expanding collection of EMR-embedded
care paths designed to generate data for ongoing
quality improvement (page 24) and our burgeoning
research efforts in brain-computer interface
technology and their potential rehabilitative payoffs
(page 26).
As advances in technology and computing allow
us to see more and do more, opportunities for
cooperation, collaboration and data sharing will
only increase. I invite you to review the past year
with us in these pages and contact me if our
initiatives may intersect with yours in ways that
might benefit all our patients.
Respectfully,
MICHAEL T. MODIC, MD, FACR
Chairman, Cleveland Clinic Neurological Institute [email protected]
WELCOME FROM THE CHAIRMAN
6 | YEAR IN REVIEW 2013
Cleveland Clinic installed a 7-tesla
MRI scanner on its main campus in
2013, making it one of only 13 medical
centers in the U.S. with 7T MRI
scanning abilities.
The new scanner’s more than doubling
in field strength (relative to the previous
3T standard) permits researchers to
produce in vivo body images at spatial
resolutions up to five times greater
than those possible at clinical field
strengths. Its images can approach the
spatial resolution of CT scans while
maintaining the superior soft-tissue
contrast of MRI. Because of FDA
restrictions on the clinical use of MRI
scanners with field strengths above
4T, the new scanner will be used for
biomedical research purposes.
NEW WINDOWS INTO BRAIN RESEARCH
“With this 7T imaging facility, we can
begin to explore brain function and
structure at an unprecedented level,”
HIGHLIGHTS FROM OUR CENTERS
Advent of 7T MRI Scanner Elevates Neuroimaging Research Abilities, Aspirations
says Mark Lowe, PhD, Cleveland
Clinic’s Director of High-Field MRI,
whose team finalized installation
of the scanner in December. “The
advantage of MRI has always been its
ability to study the brain as a system.
This greatly enhances that ability by
allowing us to simultaneously study the
brain both as a system and at nearly
microscopic scales.”
The new scanner’s enhanced imaging
research capabilities are still being
explored and prioritized. For one,
functional MRI is likely to be improved,
as the higher field strength will allow
for its performance at very high spatial
and temporal resolution, which will
open up new areas of investigation in
neuropsychiatry and other research
areas.
“We will be working to develop magnetic
resonance spectroscopic imaging
(MRSI) sequences suited for ultra-high
CLEVELAND CLINIC NEUROLOGICAL INSTITUTE | 7
High-resolution T2-weighted image
from the 7T MRI scanner showing detail
in the hippocampus and other structures.
Spatial resolution: 400 microns in-plane.
Acquisition time: 4 minutes.
8 | YEAR IN REVIEW 2013
fields to take advantage of the increased
spatial and spectral resolution they
provide,” notes Amit Anand, MD, Vice
Chairman for Research in Cleveland
Clinic’s Center for Behavioral Health.
Extremely high-resolution diffusion
tensor imaging of the hippocampus with
the 7T scanner may permit discovery of
novel biomarkers in Alzheimer disease
and other cognitive disorders.
Areas of epileptogenic focus are
normally too small to identify with
standard MRI, but one hope is that
these foci will be able to be localized
with 7T imaging, enabling more precise
surgical removal of seizure-producing
brain areas.
When it comes to brain tumors, the
high spatial resolution and contrast-
to-noise ratio of 7T imaging will
allow for superior definition of tumor
boundaries within the brain. In
musculoskeletal imaging, it has already
been demonstrated that the higher
field strength permits better imaging of
cartilage.
MOVING INTO MULTINUCLEAR MRI
Previously, all whole-body MRI scanners
at Cleveland Clinic produced images
based on proton excitation. Protons are
the most abundant nuclei in the human
body and by far the most common ones
used in MRI imaging. However, other
nuclei in the body occur naturally in a
form that can be studied with MRI.
Beyond its high field strength, the
new 7T system is the first whole-body
MRI scanner at Cleveland Clinic with
multinuclear imaging capability. In
addition to producing images that
provide anatomic or functional detail
from protons, the scanner can yield
information on metabolic processes
using other nuclei, such as sodium,
phosphorus and carbon. This capability
permits the study of more-complex
processes, such as cell metabolism.
“This facility puts Cleveland Clinic at the
forefront of biomedical research with
MRI,” says Dr. Lowe. “It will keep us
very competitive for research dollars
for years to come while also creating
good opportunities across our regional
biomedical research community.”
“The advantage of MRI has always been its ability to study the brain as a system. This greatly enhances that ability by allowing us to simultaneously study the brain both as a system and at nearly microscopic scales.”
— MARK LOWE, PhD
CLEVELAND CLINIC NEUROLOGICAL INSTITUTE | 9
The Scanner’s Journey and Installation: No Small Engineering Feat
Installation of the 7T MRI scanner began in July, and image
production started by September. Installation, including the opening
of a 7T MRI facility adjacent to the Mellen Center for Multiple
Sclerosis Treatment and Research, was complete before year’s end.
The magnet at the heart of the 7T system was constructed to
order by its manufacturer, Siemens Healthcare, over 18 months.
Behind this long production window is the enormous amount of
superconducting wire (see “By the Numbers” sidebar) needed to
produce the magnet.
To maintain field strength, the wire must be kept very cold,
requiring large amounts of liquid helium for cooling. At 80,000
pounds, the magnet had to be shipped by boat from its production
site in Oxford, England, taking three weeks to cross the Atlantic
Ocean. Because the helium would boil away during a journey of
that length, the magnet was shipped warm and then cooled at
Cleveland Clinic over several weeks. Another several weeks were
needed to pump current through the magnet to get it up to field
strength. The overall process was slowed by the worldwide helium
shortage of the past two years.
Once the magnet was up to field strength, Siemens engineers
needed 90 days to finish installation of the electronics necessary
to produce high-quality images. Physicists from Cleveland Clinic’s
Imaging Institute then performed final tuning to customize the
scanner facility for the specific research needs desired.
7T SCANNER BY THE NUMBERS
5-FOLD Potential increase in
spatial resolution (vs.
clinical field strengths)
$10.5 MILLIONCleveland Clinic’s
investment in the
scanner
80,000 Weight (in pounds) of the
scanner’s magnet
350 Length (in miles) of tin-
niobium wire needed to
construct the magnet
20,000 Amount of liquid helium
(in liters) necessary to cool
the magnet
10 | YEAR IN REVIEW 2013
Jorge Gonzalez-Martinez, MD, PhD, one of the Neurological Institute neurosurgeons who implants
the RNS neurostimulator and performs laser ablation for patients with refractory epilepsy.
CLEVELAND CLINIC NEUROLOGICAL INSTITUTE | 11
Two of the newest treatment options
for patients with refractory epilepsy
— the NeuroPace® RNS® System
neurostimulator and laser ablation —
differ in important ways. The RNS
neurostimulator, a promising option for
patients who are not good candidates
for surgery, could potentially be offered
to hundreds of thousands of epilepsy
patients. Laser ablation, in contrast, is
a potent intervention but is appropriate
for a more modest subset of patients —
those with small, localized lesions deep
in the brain.
One thing the two novel modalities have
in common is that Cleveland Clinic’s
Epilepsy Center was at the forefront of
their testing and/or adoption — and has
insights to share from early experience
in their use.
NEUROSTIMULATOR STOPS SEIZURES BEFORE THEY START
The RNS neurostimulator received
FDA clearance in November 2013 for
treatment of medically refractory partial
seizures in adults with no more than
two epileptogenic foci. Clinical trials
demonstrated a 50 percent or greater
reduction in seizure frequency in more
HIGHLIGHTS FROM OUR CENTERS
Novel Approaches to Refractory Epilepsy: Bringing New Hope to Diverse Patients in Need
than half of patients two years after
device implantation.
Cleveland Clinic was one of the centers
participating in the pivotal trials,
implanting the device in seven patients.
Some have had the device in place
for six to seven years. As of its FDA
approval date, the neurostimulator had
been placed in 256 patients, with some
being treated for more than eight years.
The battery-powered RNS
neurostimulator is implanted in the
cranium anywhere on the cortex where
seizures are originating. It works by
monitoring electrical activity in the
brain. If abnormal activity is detected,
the device sends electrical impulses
to the seizure focus via leads, helping
prevent seizure onset. The impulses are
imperceptible to the patient.
Cranially implanted
RNS neurostimulator
connected to one or two
leads placed at seizure
foci. Illustration courtesy
of NeuroPace Inc.
12 | YEAR IN REVIEW 2013
Unlike open-loop devices (e.g., those
used in vagal nerve stimulation) that
provide constant electrical stimulation,
the RNS neurostimulator’s novel
closed-loop design allows it to deliver
stimulation only when needed.
WHAT IT MEANS FOR PATIENTS
The device provides hope for patients
with disabling and medically refractory
epilepsy who cannot undergo surgery
because the focal areas cannot be
resected or are too far apart. “These
are patients who have no other resort,
and this device offers them new hope
for seizure reduction,” says Dileep Nair,
MD, an epileptologist in Cleveland
Clinic’s Epilepsy Center.
Dr. Nair believes about 20 to 30
percent of patients with medically
refractory epilepsy may benefit from
the RNS neurostimulator. He notes that
those with bitemporal lobe epilepsy
benefit most.
Interest in the therapy is high, as
more than 50 patients were on a
waiting list for device implantation at
Cleveland Clinic when it was approved
in November. Their ability to benefit
depends on “ensuring that we know
exactly where their seizures are coming
from,” says Dr. Nair, which puts a
premium on experience in device
implantation and seizure localization.
MORE APPLICATIONS AHEAD
The device comes with a programmer
that enables the treating physician to
noninvasively program the detection
and stimulation parameters. The
programmer also can display the
patient’s brain electrical activity
(electrocorticogram) in real time.
“The RNS neurostimulator is always
monitoring brain activity, so having it
implanted is like constantly being in
the epilepsy monitoring unit,” explains
Dr. Nair. “It has a range of diagnostic
abilities.”
Beyond diagnostic applications, he
envisions eventual use of the device
(and similar neurostimulators in
development) for delivering anti-
epileptic medications directly to a
specific portion of the brain to reduce
the agents’ side effects.
“A device like this represents a kind
of brain-machine interface that may
benefit patients with other forms of
neurological disease,” says Dr. Nair.
“This technology is going to lead into
several new avenues of therapy.”
LASERS FOR MINIMALLY INVASIVE ABLATION OF SMALL, FOCAL LESIONS
Throughout 2013, while the RNS
neurostimulator was nearing regulatory
approval, Cleveland Clinic neurosurgeon
Jorge Gonzalez-Martinez, MD, PhD, was
steadily building his experience base
in the use of another therapy recently
cleared by the FDA — laser ablation.
Cleveland Clinic is one of a handful of
epilepsy centers nationwide employing
the procedure.
Laser ablation represents a less
invasive, less costly and potentially
safer alternative to more traditional
forms of surgery for refractory epilepsy
arising from small, localized brain
regions. “Laser therapy is a good first-
step surgery to try if the lesions are
small and deep in the brain,” says Dr.
Gonzalez-Martinez.
The advantages of laser ablation relative
to resective surgery include:
CLEVELAND CLINIC NEUROLOGICAL INSTITUTE | 13
• Minimal invasiveness. No craniotomy is
required, and the incision is typically
just 3 mm in diameter.
• Less tissue damage. Ablation of the
target tissue is precise and localized,
avoiding removal of nonepileptogenic
brain tissue and theoretically reducing
complications and adverse effects. No
radiation is involved.
• Shorter hospital stays. Patients are
typically discharged the day after
laser ablation. Compared with the
five- or six-day stay often required
with craniotomy, this should translate
to lower overall treatment costs.
The primary disadvantage is that laser
therapy is restricted to patients with
small lesions.
The utility of laser ablation is enhanced
when the seizure foci are located with
stereoelectroencephalography (SEEG)
and when intraoperative MRI is used
for real-time monitoring of intracranial
pathology. These measures, which can
reduce the need for reoperation, are
THE NEW TREATMENT OPTIONS AT A GLANCE
Advantages Drawbacks Most likely to benefit/ ideal candidates
RNS neuro-stimulator
• Can be placed anywhere on cortex where seizures originate
• Stimulation is imperceptible to patient
• Can be implanted for months, years or lifetime
• No brain tissue removed, so no associated decrease in brain function
• Provides ongoing monitoring of brain activity, with potential diagnostic utility
• Not approved for use in patients under age 18
• Reduces, but does not eliminate, seizures
• Nearly half of patients do not achieve significant improvement
• Patients with implant cannot undergo MRI, electroconvulsive therapy or transcranial magnetic stimulation
• Patients who cannot/will not undergo surgery
• Patients with bitemporal lobe epilepsy
• Patients in whom vagal nerve stimulation has failed
Laser ablation
• Less invasive than resective surgery (no craniotomy)
• Less tissue damage than with resective surgery, with potential for reduction in adverse effects
• Shorter hospital stay (typically 1 day vs. 5-6 days), with resulting cost savings
• Appropriate only for patients with small lesions deep in brain
• Pediatric patients with hypothalamic hamartoma
• Patients with tuberous sclerosis or mesial temporal sclerosis
• Patients with unsuccessful prior resective surgery
• Patients hesitant about resective surgery
typically used during laser ablation at
Cleveland Clinic, says Dr. Gonzalez-
Martinez. Robotic assistance is
considered as well to optimize the
precision of laser placement.
“We typically follow patients for six
months after laser surgery to determine
treatment success,” Dr. Gonzalez-
Martinez notes. While volumes at
Cleveland Clinic are currently too small
for robust outcomes analysis, only one
patient to date has required reoperation
with craniotomy and resection.
Cleveland Clinic has begun enrolling
patients in a multicenter trial evaluating
the efficacy of laser ablation for
temporal lobe epilepsy marked by
mesial temporal sclerosis.
Intraoperative MRI showing
laser ablation in progress
in a patient with epilepsy,
with isothermal areas
located in the right frontal
periventricular region.
14 | YEAR IN REVIEW 2013
Imagine a patient with Parkinson
disease undergoing physical therapy for
neuromuscular re-education. Instead of
walking in a straight line on a treadmill
surrounded by the sights and sounds
of a therapy suite or biomechanics lab,
she has the experience of walking along
a gravel path. The path feels rocky
and uneven beneath her feet, twisting,
turning and meandering uphill and
down. Surrounded on all sides by trees,
a blue sky and chirping birds, with
the gravel making a crunching sound
underfoot, the patient’s senses are
immersed in navigating this challenging
walk.
Despite all the sights and sounds,
the patient’s experience is a virtual
one, taking place in a controlled, safe
environment on Cleveland Clinic’s main
campus. This scenario is repeated
regularly since the installation of the
new CAREN (Computer Assisted
Rehabilitation Environment) system
at Cleveland Clinic in mid-2013. The
system, manufactured by Amsterdam-
based Motek Medical, is a high-tech
medical and research platform that
HIGHLIGHTS FROM OUR CENTERS
Virtual Reality System Ushers in New Era of Immersive, Multisensory Rehab in a Controlled Environment
allows clinicians to view and analyze
patients’ balance, locomotion and
coordination. It serves as a valuable tool
for rehabilitation, clinical analysis and
research.
“We want physical therapy to challenge
patients, but it’s always a question of
how to do so in a safe environment,”
says Jay Alberts, PhD, who is leading
Cleveland Clinic’s CAREN system
initiative. “The CAREN system puts
us on the leading edge by enabling us
to safely challenge patients through
different courses in an immersive virtual
environment.”
Cleveland Clinic’s acquisition of the
CAREN system, which was funded by
a grant from the state of Ohio, marks
the first nonmilitary installation of the
platform in North or South America.
HOW IT WORKS
The foundation of the CAREN platform
is a “6 degrees of freedom” motion base
that turns and moves up and down
or left and right. The base is topped
with force plates or an instrumented
CLEVELAND CLINIC NEUROLOGICAL INSTITUTE | 15
16 | YEAR IN REVIEW 2013
treadmill, and the system has real-
time motion capture capabilities that
integrate visual projection and surround
sound. Not only can patients experience
walking on a path, they can navigate a
boat deck, stroll through an airport or
simulate just about any scenario from
real life — all under close monitoring
(and while harnessed for safety).
“Challenges can be customized, with
levels of difficulty automatically based
on patient performance,” explains Dr.
Alberts, who is Director of Cleveland
Clinic’s Concussion Center and a
researcher in the Department of
Biomedical Engineering. “The system
registers and reacts more quickly
than human perception, making
microadjustments and even going into a
soft shutdown as needed.”
The system allows for the registration,
evaluation, clinical analysis and
rehabilitation of balance, including
the body’s visual, auditory, vestibular,
tactile and proprioceptive systems. Its
software merges data from all hardware
components, enabling measurable and
quantifiable evaluation, rehabilitation
and research, leading to constantly
monitored progression.
“Beyond the virtual immersion features,
the system is a complete biomechanics
laboratory — in a quarter of the size
of a traditional lab,” Dr. Alberts says.
“It measures EMG muscle activation
patterns in real time, helping identify
where a patient may have a deficiency
and what can be done to improve it.”
COLLABORATIVE BY DESIGN
With the CAREN system, neurologists,
rehabilitation specialists, orthopaedists,
occupational therapists and
physiotherapists can collaborate with
one another — and with researchers in
biomechanical engineering, pediatrics,
mental health and other disciplines —
to both evaluate patients’ functional
behavior and help restore or improve
that function. A computer scientist
rounds out the interdisciplinary mix,
Challenges can be customized, with levels of difficulty automatically based on patient performance.
CLEVELAND CLINIC NEUROLOGICAL INSTITUTE | 17
writing code to customize virtual scenes
and experiences beyond those provided
with the system.
“Protocols and programs currently being
developed using CAREN are leading the
creation of groundbreaking rehabilitation
techniques,” Dr. Alberts notes.
ENGAGING FOR PATIENTS, EMPOWERING FOR CLINICIANS AND RESEARCHERS
Since patients began using the CAREN
system in September, their reaction
has been enthusiastic. “Patients like
the system’s gamelike and interactive
features,” says Dr. Alberts. “From our
standpoint, it offers the best of both
worlds — it’s engaging for patients
while measuring outcomes in a highly
systematic, objective way.”
So far the system has been used
primarily for patients with Parkinson
disease and multiple sclerosis, but
it has many more potential clinical
applications, including the diagnosis
and treatment of various neuromuscular
and other neurological conditions. Plans
are underway to use the system in
the Concussion Center, including for
facilitation of return-to-play decisions
for concussed athletes.
The system is also at the heart of
translational research efforts. “Using
the CAREN system for research will
help us clinically, and clinical utilization
certainly complements our research
efforts,” Dr. Alberts says.
The system also will facilitate
development of mobile applications
by validating measurements taken
using mobile devices. “We can use
information learned from the system
and transfer a pared-down version to
a mobile app,” Dr. Alberts explains.
“We’re working on customized multiple
sclerosis and Parkinson disease apps,
and data from the CAREN system
should allow us to develop them much
more quickly.”
Personalized medicine services
have been part of the toolbox of the
Neurological Institute’s Rose Ella
Burkhardt Brain Tumor and Neuro-
Oncology Center since 1999, when 1p
chromosome deletion testing was first
offered. After adding more and more
such services in the ensuing years, the
center decided in 2013 to begin offering
patients with select brain tumors the
option of having their tumor tissue
undergo genomic profiling to test for
thousands of genetic abnormalities that
could potentially impact their treatment.
“As we’ve offered more personalized
medicine over the years, we’ve reached
the point where it clearly makes sense
to perform personalized tumor testing
for genetic abnormalities in some
cases rather than offer just a few
specific tests,” says Gene Barnett, MD,
MBA, Director of the Burkhardt Brain
Tumor Center, which works closely
with Cleveland Clinic’s Taussig Cancer
Institute.
KNOWLEDGE IS POWER
The Burkhardt Brain Tumor Center
offers genomic profiling primarily
HIGHLIGHTS FROM OUR CENTERS
Deploying Personalized Medicine for Smarter Therapeutic Targeting of Brain Tumors
for patients with new or recurrent
glioblastoma, or atypical or malignant
meningioma. It can provide a more
rational basis on which to choose drug
therapies, be they conventional or
investigational, by offering data about
particular characteristics that a patient’s
tumor may have.
“The genomic profiling is looking for
specific pathways within the tumor
that we might target,” Dr. Barnett
explains. “The results can help us
avoid treatments that are not predicted
to be helpful while suggesting other
treatments that are more likely to be in
the patient’s best interest.” Historically,
he says, patients have been treated
with a standard drug paradigm or
an investigational therapy without
knowledge of whether their specific
tumor would or would not benefit from
that approach.
The tissue analysis uses next-generation
sequencing to assess for hundreds of
known cancer genes, and results are
available in two to three weeks. The
process requires an adequate amount
of tumor tissue, so testing cannot
be performed for all eligible patients,
18 | YEAR IN REVIEW 2013
particularly if they have had a needle
biopsy. However, in some cases
more invasive or larger biopsies can
be performed so that tissue can be
submitted for comprehensive testing.
The testing is very sensitive in finding
many types of gene abnormalities,
Dr. Barnett says. In some cancers,
nearly two-thirds of all tissue samples
assessed are found to have at least one
actionable gene alteration.
Because the profile is of the tumor, not
the patient’s own genome (genetic
makeup), it does not necessarily provide
any information about heritability of the
patient’s condition.
THE FUTURE IS COMING FAST
The Burkhardt Brain Tumor Center is
one of a select number of prominent
centers across the country performing
genomic profiling of brain tumors to
guide treatment. “We are recognizing
that an important part of the future lies
in molecular testing of these tumors,”
Dr. Barnett says.
That future will likely include changes
to clinical guidelines to incorporate
genomic testing guidance, he adds, but
more experience and information are
needed first. “This type of testing may
very well become part of the standard of
care for management of certain tumors,
but we’re not there yet.”
Cleveland Clinic is contributing to the
insights needed in the interim through
participation in a clinical trial of genomic
testing across a number of tumor types,
including malignant meningiomas and
other brain tumors.
Meanwhile, Dr. Barnett and his Burkhardt
Brain Tumor Center colleagues are
focused on refining this personalized
medicine service to their patients and
assessing its benefits, as there is of
course no guarantee that it will generate
results useful for guiding therapy for any
given patient.
“In some patients, the results have
suggested new routes of treatment we
would not have considered on our own,”
Dr. Barnett says. “But it’s too early to say
how effective it is.”
CLEVELAND CLINIC NEUROLOGICAL INSTITUTE | 19
20 | YEAR IN REVIEW 2013
CLEVELAND CLINIC NEUROLOGICAL INSTITUTE | 21
Nearly every month brings new
reports raising concern over the
potential long-term consequences of
repeated head impacts in football. In
response, Cleveland Clinic has teamed
with the National Football League
Players Association (NFLPA) in an
unprecedented program to assess and
improve the brain health and overall
well-being of retired NFL players.
The program, called The Trust,
offers former players physical and
neurological evaluations followed by a
comprehensive ongoing plan to relieve
symptoms, restore function and improve
cognitive skills.
Cleveland Clinic will host players at
three sites — in Cleveland, at Cleveland
Clinic Florida in Weston, Fla., and at
Cleveland Clinic Lou Ruvo Center for
Brain Health in Las Vegas. Players
can also choose to visit the two other
medical centers participating in The
Trust: the University of North Carolina in
Chapel Hill, N.C., or Tulane University
in New Orleans.
HIGHLIGHTS FROM OUR CENTERS
Teaming with the NFL Players Association to Promote Brain Health of Retired Athletes
“Former NFL players are at increased
risk for neurological disease,” says Jay
Alberts, PhD, Director of Cleveland
Clinic’s Concussion Center. “The
program’s goal is to identify potential
problems — physical, neurological or
cognitive — sooner, which may lead
to earlier interventions and treatments.
In response, we’re developing a sort of
brain health and restoration center.”
IN-DEPTH INITIAL ASSESSMENT
Players who choose to take part in the
program visit one of the participating
sites for two days of assessment starting
with a comprehensive medical exam
that includes determining the player’s
injury history, functional symptoms and
personal concerns. That’s followed by
a battery of tests, an MRI of the brain,
cognitive evaluations, psychological
interviews and balance assessments.
Non-neurological tests and interventions
(internal medicine exam, wellness
screening, nutrition counseling and
life skills consultation) round out the
initial visit.
22 | YEAR IN REVIEW 2013
The tests draw on Cleveland Clinic
innovations in concussion assessment,
including the Cleveland Clinic
Concussion App for the iPad®, which
evaluates postural stability and motor
and cognitive function.
FOLLOW-UP BASED ON THE ‘NEUROLOGICAL PASSPORT’
After their initial visit, players are
given a personalized treatment plan
customized to their individual needs.
The plan includes communication
between the player and his local
healthcare team via phone, computer,
videoconferencing or other methods.
“This population needs a comprehensive
evaluation and treatment approach,”
says Dr. Alberts. “Each player will
leave with his own ‘neurological
passport’ that outlines exactly where
he is cognitively and neurologically. If
changes occur after he goes home,
we can intervene in a systematic and
strategic way.”
The aim is to practice some degree of
anticipatory medicine, he adds, with
the assistance of emerging distance
health offerings (see sidebar, next page).
“The cumulative effect of repeated
collisions and resultant brain trauma
can manifest as cognitive impairment,
decreased motor functioning, incessant
pain and psychological/behavioral
issues including irritability, impaired
insight and impulse control, paranoia,
violent outbursts, and even suicide,”
notes Charles Bernick, MD, Associate
Medical Director of the Lou Ruvo Center
for Brain Health. “By taking a proactive
approach, this program is helping
retired players be assessed, diagnosed
and treated before symptoms arise or
grow too serious.”
YIELDING INSIGHTS BEYOND RESEARCH
While the program is clinical in
nature and not a research project,
opportunities to do research may be
considered by the NFLPA in the future.
“Even as the program now stands, we
will learn a lot about caring for these
players,” Dr. Alberts notes, “and some
of that may translate to caring for other
patients with similar histories.”
Each player leaves with his own ‘neurological passport’ that outlines exactly where he is cognitively and neurologically.
CLEVELAND CLINIC NEUROLOGICAL INSTITUTE | 23
NE X T STEPS:
Diving into Distance Health
As Cleveland Clinic’s participation in The Trust evolves, it will provide increasing
opportunities to assess new distance health offerings.
“We will be developing and refining additional mobile apps for program participants to use
after they return home to keep us connected with their progress,” says Dr. Alberts. He cites
Cleveland Clinic’s existing “MyHealth: Spine” app (in beta testing) and additional apps for
motor and cognitive training as examples.
“The aim is to begin to practice anticipatory or predictive medicine,” he says. For example,
if a retired NFL player began showing signs of depression or motor function changes via a
mobile app he was regularly using, the healthcare team at his Cleveland Clinic site could
catch those changes via serial monitoring before the condition became more serious.
Additionally, the app could be programmed with a predictive algorithm to recommend
interventions to the player once the depressive or functional changes began occurring at a
potentially concerning rate.
“The result will be more personalized medicine that doesn’t require one-on-one visits with a
provider,” notes Dr. Alberts.
Ultimate goals include translating these distance health offerings to other, larger patient
groups and potentially making the Cleveland Clinic distance health apps available to non-
Cleveland Clinic sites participating in The Trust.
24 | YEAR IN REVIEW 2013
INNOVATIONSIN BRIEF
Proliferation of Care Paths Transforms Care Culture and Promotes Consistent, Evidence-Based Treatment Decisions
The journey from volume-based to value-based care requires clear
pathways. That was the idea behind the Neurological Institute’s
recent efforts to produce a collection of disease-specific Cleveland
Clinic Care Paths.
Now, two years and a couple dozen care paths into the initiative, the
institute has found that care paths provide more than just a road map
to evidence-based and efficient care. The process of developing them
is a cultural transformation in itself. “Our caregivers are being engaged
across the care continuum to solve problems in multidisciplinary,
patient-centered ways that promote value over the volume-based
tradition,” says Neurological Institute Chairman Michael T. Modic, MD.
Much More than Guidelines
Cleveland Clinic Care Paths are more than just practice guidelines.
They are instead process-based tools designed for translation into the
electronic medical record (EMR) to guide clinical work flow and assist
providers in making guidelines operational.
Care paths start as evidence- or consensus-based guides developed
by multidisciplinary teams of clinical experts for the management of
a specific condition (see sample work flow excerpt). The aim is to
standardize care around the best evidence, clearly identify meaningful
outcomes of care and identify relevant process metrics.
The care paths are then analyzed for opportunities for practice
transformation and efficiencies. “We are using care paths as the
organizing principle to align our services to reduce unnecessary
variation from the most evidence-based, patient-focused and efficient
standard of care,” explains Dr. Modic. One focus is to match patients
to the most appropriate level of clinician for their needs at various
stages of care. For instance, initial management of acute back pain
without red flags may be best provided by a specialized physical
therapist or nurse practitioner rather than a medical spine specialist,
who is engaged for more persistent or complicated cases.
› NEUROLOGICAL INSTITUTE CARE PATHS TO DATE
Completed
› Low back pain
› Radiculopathy
› Neck pain
› Obstructive sleep apnea
› Concussion
In review and/or piloting
› Headache
› Epilepsy
› Multiple sclerosis
› Delirium
› Glioblastoma multiforme
› Alzheimer disease
› Hemorrhagic stroke
› Transient ischemic attack
› Ischemic stroke
› Post-acute stroke management
› Physical therapy for low back pain
In development
› Brain metastases
› Depression
› Vertebral fracture
› Fibromyalgia
› Autonomic disorders
› Pediatric headache
› Insomnia
› Spine metastases
› Multiple sclerosis comprehensive care
› Spine surgery
› Chronic pain
› Normal pressure hydrocephalus
CLEVELAND CLINIC NEUROLOGICAL INSTITUTE | 25
Providervisit
Symptoms/complaints
Screening questions • STOP-BANG • ESS • Wellness widget • ISI
Testing?
Significantcomorbidities or
other sleepcomplaints?
PolysomnographyHome sleep
testing
PAP treatmentindicated
High clinicalsuspicion
High clinicalsuspicion
PositiveNegative NegativePositive
Future re-evaluation vs. need for sleep
medicine consultation
Future re-evaluation vs. need for sleep
medicine consultation
Yes
Yes
No No
Positive Negative
Excerpt of a work flow from the Obstructive Sleep Apnea Care Path. This portion focuses on deciding when to use home sleep testing vs. polysomnography.
Following care process analysis, care paths are
piloted for work flow studies and improvements
at select Cleveland Clinic health system facilities.
Then they are translated into the EMR to guide
— and ideally improve — clinical work flow. This
is achieved through standardized documentation
templates, order sets, and clinical decision-support
and predictive analytical tools.
Embedding care paths in the EMR enables
outcomes and process monitoring, such as the
ability to generate condition-specific metrics for
individual physicians, departments and facilities to
drive continuous quality improvement.
“The aim is to standardize and measure care across
time, venues and provider types,” says Dr. Modic.
“But we are finding that participation in care path
development is transforming our teams to work
together in new ways that optimize outcomes over
cost — in other words, to deliver value-based care.”
28 Care Paths and Counting
As of late 2013, the Neurological Institute had
28 disease-specific care paths completed or
under development (see list on page 24). The
initiative has since spread to the overall Cleveland
Clinic enterprise, with 67 care paths currently in
development or completed organizationwide.
Next steps include exploring opportunities to make
Cleveland Clinic Care Paths available to outside
providers and health systems.
26 | YEAR IN REVIEW 2013
Brain-Computer Interface Technology: Helping Restore Function After Neurologic InjuryBrain-computer interface (BCI) systems allow a person to communicate — through analysis and
modulation of brain signals — with a device such as a computer, robotic arm or a variety of other
machines. When used by patients with spinal cord injury, stroke or other neurological diseases, these
systems (also known as brain-machine interface technology) allow individuals to perform activities that
have become difficult or impossible to do because of their injury or disease.
BCI systems function by analyzing signals in the brain that are produced during an intention to perform a
function, such as grasping an object. The electrical signals generated during this “motor imagery” are then
processed using a computer-based algorithm and delivered as a command to a device that performs the
function originally intended by the patient. Thus, using a BCI system, a patient with arm paralysis is able
to grasp an object, using a prosthetic arm, simply by thinking about doing so.
Cleveland Clinic’s Center for Neurological Restoration, in collaboration with researchers from Case Western
Reserve University, has begun an initiative to research ways to enhance the brain signals generated during
motor imagery. By improving the specificity of cortical signals generated during various motor imagery
tasks, they hope to improve the efficiency and safety of using BCI devices, allowing the devices to move
out of the laboratory setting and be considered for day-to-day use.
Darlene Lobel, MD, who is leading the initiative for Cleveland Clinic, says her team expects preliminary
research results beginning in 2014.
The sequence of steps involved in using BCI technology to stand to walk from a sitting position.
›
CLEVELAND CLINIC NEUROLOGICAL INSTITUTE | 27
Alzheimer Disease Trials Program Takes a ‘Multiple Shots on Goal’ ApproachCurrent therapies for Alzheimer disease (AD) produce modest improvement in symptoms and a temporary
delay in cognitive decline. They do not affect the underlying biological processes leading to cell death.
To address the urgent need for new therapies, especially disease-modifying therapies, Cleveland Clinic
Lou Ruvo Center for Brain Health has developed one of the largest U.S. clinical trials programs for AD
therapeutics. We are taking a “balanced matrix” approach, investigating agents that target diverse
mechanisms of action, address multiple stages of AD, and come in a variety of formulations. Specifically,
we have underway:
• Three trials assessing various approaches to AD prevention
• Four trials of interventions in patients with very early AD
• Thirteen trials of interventions for more severe dementia in patients with AD
Similarly, we are pursuing studies of interventions that take on AD in three different ways, as detailed in
the figure below:
• Disease-modifying therapies that target amyloid plaques
• Disease-modifying therapies that address nonamyloid targets, such as neurofibrillary tangles
• Therapies that treat or improve AD’s symptomatic manifestations
We are carrying out this broad program through a network of four trial sites with extensive national reach.
The Lou Ruvo Center for Brain Health has locations in Las Vegas; at Cleveland Clinic’s main campus in
Cleveland; in Lakewood, Ohio, outside of Cleveland; and in Weston, Fla. These sites form a unique AD
clinical trials consortium that matches patient location with available studies, extending the ability to
enroll patients and accelerate therapeutic testing.
“We have adopted a ‘multiple shots on goal’ strategy for AD therapeutics, since only about 5 percent
of investigational drugs for CNS diseases ultimately succeed in clinical testing and come to market,”
explains Jeffrey Cummings, MD, ScD, Director of the Lou Ruvo Center for Brain Health. “As we diversify
the therapies tested and enhance our trials network, we are raising the likelihood of the breakthrough
treatment successes so urgently needed in AD.”
Targeting Alzheimer Disease on Three Fronts
›
The three broad focus
areas of the Lou Ruvo
Center for Brain Health
clinical trials program
for AD, with examples of
therapies being assessed
in each.
Amyloid disease-modifying therapies
• Bexarotene • Immunotherapy • BACE inhibitor
Nonamyloid disease-modifying therapies
• Resveratrol • Pioglitazone
Symptomatic therapies
• Dextromethorphan/quinidine • Transcranial magnetic stimulation • Axona®
28 | YEAR IN REVIEW 2013
‘Hyperacute’ MRI Protocol Results in Fewer — but More Effective — Endovascular Stroke Interventions
It’s a clinical curiosity: Endovascular stroke therapy (EST) has demonstrated effective recanalization rates
and a good safety profile for patients with acute ischemic stroke caused by large vessel occlusion, but
most clinical trials have failed to show that EST improves clinical outcomes.
Specialists in Cleveland Clinic’s Cerebrovascular Center suspected that suboptimal patient selection is to
blame for the disconnect. Specifically, they speculated that the traditional tools for patient selection, CT
and CT angiography (CTA), do not sufficiently reveal brain tissue viability in this population that does not
achieve recanalization with or is ineligible for IV tPA.
That suspicion prompted these clinicians to implement a “hyperacute” MRI protocol to perform pretreatment
MRI on EST-eligible acute stroke patients with large vessel occlusion to assist in patient selection.
“We hypothesized that adding pretreatment MRI to determine the core infarct volume before interventions
could improve patient selection and, in turn, improve outcomes,” explains M. Shazam Hussain, MD,
FRCP(C), Head of Cleveland Clinic’s Stroke Program in the Cerebrovascular Center.
He and colleagues conducted a retrospective analysis of outcomes before and after implementation of the
protocol at Cleveland Clinic in April 2010. Acute stroke patients with large vessel occlusion who were
considered for EST — including mechanical thrombectomy and/or intra-arterial thrombolysis — were
identified over 28-month periods before and after protocol implementation. Those before the protocol (n
= 88) were selected based on CT/CTA; those after the protocol (hyperacute MRI group; n = 179) were
selected based on CT/CTA and MRI.
Dr. Hussain’s team found that nearly 50 percent fewer evaluated patients ended up receiving EST in
the hyperacute MRI group compared with the pre-protocol group. The hyperacute MRI group also had
statistically significantly better modified Rankin Scale scores at 30 days, both overall and among those
who underwent EST, compared with the pre-protocol group. On adjusted multivariate analysis, EST was
associated with significantly better outcomes and lower mortality in the hyperacute MRI period than
during the pre-protocol period.
The analysis, which has been accepted for publication in Stroke, was in press at the time of this writing.
“Our use of hyperacute MRI in patients with acute large vessel occlusion appears to have reduced utilization
of EST and was accomplished without significant delay in the start of intervention,” says Dr. Hussain. “This
approach may aid in patient selection for EST, although further confirmatory study is needed.”
›
Left: Noncontrast head CT
without evidence of an acute
infarct despite left middle
cerebral artery (MCA) syndrome
on examination. Right: Axial
diffusion trace MRI in the same
patient within 20 minutes,
showing infarction of the entire
left MCA territory.
CLEVELAND CLINIC NEUROLOGICAL INSTITUTE | 29
NIH Grant Helps Chart Synaptic Wiring in the Autism Brain
Bruce Trapp, PhD, is shining light on the autism brain — literally.
Years ago, Dr. Trapp, Chairman of the Department of Neurosciences in Cleveland Clinic’s Lerner Research
Institute, found a way to make astrocyte cells glow fluorescently. This allowed him to study how astrocytes
are generated in the developing brain and how they associate with synapses in the adult brain. It is well
established that astrocyte processes surround and modulate the function of synapses. Now, with help from
a $1.97 million grant from the National Institute of Mental Health, the Trapp lab will study how astrocytes
respond to altered synapses in the autism brain.
Previous studies have shown that both synapses and astrocytes are altered in brains with autism. To date,
however, the two structures have not been investigated in a single study. “With this grant, we will be able
to chart the wiring of the synapses and determine if the associations of astrocyte processes with synapses
are altered in the autism brain,” explains Dr. Trapp.
By lighting up astrocytes, as they plan to do in their study, researchers in the Trapp lab will be able to
map the cells’ appearance and determine, for example, whether they are malformed. In brain areas with
altered astrocytes, the researchers will establish the relationship between astrocytes and synapses using
three-dimensional electron microscopy. “We are fortunate to have one of the world’s few 3-D electron
microscopes,” says Dr. Trapp. “We will be performing a detailed connectome study on small regions of the
autism brain.”
While he doesn’t suspect that mapping astrocytes will be a silver bullet for curing autism, Dr. Trapp
believes this research will help pave the way to a treatment. “We hope to identify therapeutic targets and
share the data to generate future research.”
›
30 | YEAR IN REVIEW 2013
STAFFCLEVELAND CLINIC NEUROLOGICAL INSTITUTE
NEUROLOGICAL INSTITUTE LEADERSHIP
Michael T. Modic, MD, FACR Chairman, Neurological Institute
William Bingaman, MD Institute Vice Chairman, Clinical Areas
Richard Rudick, MD Institute Vice Chairman, Research and Development
Stephen Samples, MD Institute Vice Chairman, Regional Neurosciences
Edward C. Benzel, MD Chairman, Department of Neurological Surgery
Kerry Levin, MD Chairman, Department of Neurology
Donald A. Malone Jr., MD Chairman, Department of Psychiatry and Psychology
Frederick Frost, MD Chairman, Department of Physical Medicine and Rehabilitation
Thomas Masaryk, MD Chairman, Department of Diagnostic Radiology
Bruce Trapp, PhD Chairman, Department of Neurosciences
Jocelyn Bautista, MD Institute Quality Improvement Officer
Adrienne Boissy, MD Institute Patient Experience Officer
CENTERS AND DEPARTMENTS
Center for Behavioral Health
Donald A. Malone Jr., MD Director
Manish Aggarwal, MD
Veena Ahuja, MD
Amit Anand, MD
Kathleen Ashton, PhD
Joseph M. Austerman, DO
Florian Bahr, MD
Sarah Banks, PhD, ABPP-CN
Joseph Baskin, MD
Scott Bea, PsyD
Aaron Bonner-Jackson, PhD
Adam Borland, PsyD
Minnie Bowers-Smith, MD
Susan Albers Bowling, PsyD
Robert Brauer, DO
Dana Brendza, PsyD
Karen Broer, PhD
Robyn Busch, PhD
Kathy Coffman, MD
Gregory Collins, MD
Edward Covington, MD
Horia Craciun, MD
Roman Dale, MD
Syma Dar, MD
Sara Davin, PsyD, MPH
Ketan Deoras, MD
Beth Dixon, PsyD
Judy Dodds, PhD
Michelle Drerup, PsyD
Jung El-Mallawany, MD
Emad Estemalik, MD
Tatiana Falcone, MD
Lara Feldman, DO
Darlene Floden, PhD
Kathleen Franco, MD
Margo Funk, MD
Harold Goforth, MD
Lilian Gonsalves, MD
Jennifer Haut, PhD, ABPP-CN
Justin Havemann, MD
Leslie Heinberg, PhD
Kelly Huffman, PhD
Karen Jacobs, DO
Joseph W. Janesz, PhD, LICDC
Amir Jassani, PhD
Jason Jerry, MD
Xavier Jimenez, MD
Daniel Jones, PhD
Regina Josell, PsyD
Elias Khawam, MD
Patricia Klaas, PhD
Steven Krause, PhD, MBA
Cynthia S. Kubu, PhD, ABPP-CN
Richard Lightbody, MD
Jane Manno, PsyD
Manu Mathews, MD
Michael McKee, PhD
Douglas McLaughlin, DO
Julie Merrell, PhD
Amit Mohan, MD
Gene Morris, PhD
Douglas Moul, MD
Donna Munic-Miller, PhD
Kathryn Muzina, MD
Richard Naugle, PhD
Mayur Pandya, DO
Michael Parsons, PhD
Leopoldo Pozuelo, MD
Kathleen Quinn, MD
Ted Raddell, PhD
Laurel Ralston, DO
Stephen Rao, PhD
Joseph Rock, PsyD
Michael Rosas, MD
Robert Rowney, DO
Judith Scheman, PhD
Isabel Schuermeyer, MD
Cynthia Seng, MD
Jean Simmons, PhD
Barry Simon, DO
Catherine Stenroos, PhD
David Streem, MD
Amy Sullivan, PsyD
Giries Sweis, PsyD
George E. Tesar, MD
Mackenzie Varkula, DO
Adele Viguera, MD, MPH
John Vitkus, PhD
Kelly Wadeson, PhD
Cynthia White, PsyD
Molly Wimbiscus, MD
Amy Windover, PhD
Lou Ruvo Center for Brain Health
Jeffrey Cummings, MD, ScD Director
Sarah Banks, PhD, ABPP-CN
Charles Bernick, MD
Aaron Bonner-Jackson, PhD
Le Hua, MD
Gabriel Léger, MD
Justin Miller, PhD
Donna Munic-Miller, PhD
Jagan Pillai, MD, PhD
Alexander Rae-Grant, MD
Stephen Rao, PhD Director, Schey Foundation Center for Advanced Cognitive Function
Babak Tousi, MD
Po-Heng Tsai, MD
Ryan Walsh, MD, PhD
Timothy West, MD
Dylan Wint, MD
Xue (Kate) Zhong, MD, MSc
Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center
Gene Barnett, MD, MBA Director
Manmeet Ahluwalia, MD
Lilyana Angelov, MD
CLEVELAND CLINIC NEUROLOGICAL INSTITUTE | 31
Toomas Anton, MD
Samuel Chao, MD
Kambiz Kamian, MD
John Lee, MD
Joung Lee, MD
Alireza Mohammadi, MD
Erin Murphy, MD
Michael Parsons, PhD
David Peereboom, MD
Pablo Recinos, MD
Violette Recinos, MD
Jeremy Rich, MD
Steven Rosenfeld, MD, PhD
Isabel Schuermeyer, MD
Glen Stevens, DO, PhD
John Suh, MD
Tanya Tekautz, MD
Jose Valerio-Pascua, MD
Michael Vogelbaum, MD, PhD
Jennifer Yu, MD, PhD
Cerebrovascular Center
Peter Rasmussen, MD Director
Mark Bain, MD
Dhimant Dani, MD
Megan Donohue, MD
Erin Dyer, MD
Abeer Farrag, MD
Darlene Floden, PhD
Neil Friedman, MBChB
Jennifer Frontera, MD
Joao Gomes, MD
Stephen Hantus, MD
Ferdinand Hui, MD
M. Shazam Hussain, MD
Damir Janigro, PhD
Irene Katzan, MD, MS
Zeshaun Khawaja, MD
Ajit Krishnaney, MD
John Lee, MD
Mei Lu, MD, PhD
Gwendolyn Lynch, MD
Edward Manno, MD
Thomas Masaryk, MD
Laurie McWilliams, MD
J. Javier Provencio, MD
Violette Recinos, MD
Andrew Russman, MD
Susan Samuel, MD
Gabor Toth, MD
Ken Uchino, MD
Dolora Wisco, MD
Epilepsy Center
Imad Najm, MD Director
Badih Adada, MD
Andreas Alexopoulos, MD, MPH
Jocelyn Bautista, MD
William Bingaman, MD
Juan Bulacio, MD
Richard Burgess, MD, PhD
Robyn Busch, PhD
Tatiana Falcone, MD
Nancy Foldvary-Schaefer, DO, MS
Paul Ford, PhD
Nestor Galvez-Jimenez, MD
Jorge Gonzalez-Martinez, MD, PhD
Ajay Gupta, MD
Stephen Hantus, MD
Jennifer Haut, PhD
Lara Jehi, MD
Stephen E. Jones, MD, PhD
Patricia Klaas, PhD
Prakash Kotagal, MD
Deepak Lachhwani, MBBS, MD
Chetan Malpe, MD
John Mosher, PhD
Ahsan Moosa Naduvil Valappil, MD
Dileep Nair, MD
Richard Naugle, PhD
Silvia Neme-Mercante, MD
Elia Pestana Knight, MD
Adriana Rodriguez, MD
Paul Ruggieri, MD
Norman So, MD
Andrey Stojic, MD, PhD
George E. Tesar, MD
Guiyun Wu, MD
Elaine Wyllie, MD
Zhong Ying, MD, PhD
General Adult Neurology
Stephen Samples, MD Institute Vice Chairman, Regional Neurosciences
C. Daniel Ansevin, MD
Kristin Appleby, MD
Dina Boutros, MD
Thomas E. Gretter, MD
Zulfiqar Hussain, MD
Kuruvilla John, MD
Richard Lederman, MD, PhD
Nimish Thakore, MD
Roya Vakili, MD
Robert Wilson, DO
Mellen Center for Multiple Sclerosis Treatment and Research
Richard Rudick, MD Director
Robert Bermel, MD
Francois Bethoux, MD
Adrienne Boissy, MD
Jeffrey Cohen, MD
Devon Conway, MD
Robert Fox, MD
Juliet Hou, MD
Le Hua, MD
Keith McKee, MD
Deborah Miller, PhD
Manikum Moodley, MD, FCP, FRCP
Daniel Ontaneda, MD
Alexander Rae-Grant, MD
Megan Rahmlow, MD
Richard M. Ransohoff, MD
Mary Rensel, MD
Lael Stone, MD
Amy Sullivan, PsyD
Timothy West, MD
Mary Willis, MD
Center for Neuroimaging
Paul Ruggieri, MD Director
Aliye Bricker, MD
Todd M. Emch, MD
Ramin Hamidi, DO
Virginia Hill, MD
Rebecca Johnson, MD
Stephen E. Jones, MD, PhD
Brooke Lampl, DO
Daniel Lockwood, MD
Mark Lowe, PhD
Michael Martinez, MD
Thomas Masaryk, MD
Parvez Masood, MD
Manoj Massand, MD
Michael T. Modic, MD
Doksu Moon, MD
Stuart Morrison, MD, MBChB, FRCP
Ellen Park, MD
Michael Phillips, MD
Alison Smith, MD
Todd Stultz, DDS, MD
Andrew Tievsky, MD
Jawad Tsay, MD
Unni Udayasankar, MD
Neil Vachhani, MD
Esben Vogelius, MD
Neurological Center for Pain
Edward Covington, MD Director
Cynthia Bamford, MD
Eric Baron, DO
Neil Cherian, MD
Sarah Davin, PsyD
Emad Estemalik, MD
Kelly Huffman, PhD
Steven Krause, PhD, MBA
Jennifer Kriegler, MD
Jahangir Maleki, MD, PhD
Manu Mathews, MD
MaryAnn Mays, MD
Judith Scheman, PhD
Mark Stillman, MD
Giries W. Sweis, PsyD
Deborah Tepper, MD
Stewart Tepper, MD
Brinder Vij, MD
32 | YEAR IN REVIEW 2013
Center for Neurological Restoration
Andre Machado, MD, PhD Director
Anwar Ahmed, MD
Jay Alberts, PhD
Kristin Appleby, MD
Scott Cooper, MD, PhD
Hubert Fernandez, MD
Darlene Floden, PhD, ABPP-CN
John Gale, PhD
Michal Gostkowski, DO
Ilia Itin, MD
Cynthia S. Kubu, PhD, ABPP-CN
Richard Lederman, MD, PhD
Darlene A. Lobel, MD, FAANS
Donald A. Malone Jr., MD
Sean Nagel, MD
Mayur Pandya, DO
Ela B. Plow, PhD, PT
Joseph Rudolph, MD
Stewart Tepper, MD
Ryan Walsh, MD, PhD
Neuromuscular Center
Kerry Levin, MD Director
Kara Browning, MD
Neil Friedman, MBChB
Joshua Gordon, MD
Zulfiqar Hussain, MD
Rebecca Kuenzler, MD
Yuebing Li, MD, PhD
Mei Lu, MD, PhD
Manikum Moodley, MD, FCP, FRCP
John Morren, MD
Erik Pioro, MD, PhD
David Polston, MD
Robert Shields Jr., MD
Steven Shook, MD
Jinny Tavee, MD
Nimish Thakore, MD
Jennifer Ui, MD
Pediatric and Congenital Neurosurgery
Stephen Dombrowski, PhD
Mark Luciano, MD, PhD
Violette Recinos, MD
Center for Pediatric Neurology
Kerry Levin, MD Interim Director
Neil Friedman, MBChB
Gary Hsich, MD
Irwin Jacobs, MD
Kambiz Kamian, MD
Sudeshna Mitra, MD
Manikum Moodley, MD, FCP, FRCP
Sumit Parikh, MD
A. David Rothner, MD
Tanya Tekautz, MD
Department of Physical Medicine and Rehabilitation
Frederick Frost, MD Chairman and Executive Director, Cleveland Clinic Rehabilitation and Sports Therapy
Richard Aguilera, MD
Jay Alberts, PhD
Melissa Alvarez-Perez, MD
Keerthi Atluri, MD
Sree Battu, MD
Kim Gladden, MD
Juliet Hou, MD
Lynn Jedlicka, MD
John Lee, MD
Yu-Shang Lee, PhD
Zong-Ming Li, PhD
Ching-Yi Lin, PhD
Vernon W.H. Lin, MD, PhD
Jane Manno, PsyD
Carey Miklavcic, DO
Ela B. Plow, PhD, PT
Matthew Plow, PhD
Anantha Reddy, MD
Michael Schaefer, MD
Patrick Schmitt, DO
Dan Shamir, MD
Patrick Shaughnessy, MD
Yana Shumyatcher, MD
Kelly Wadeson, PhD
Center for Regional Neurosciences
Stephen Samples, MD Institute Vice Chairman, Regional Neurosciences
Jeremy Amps, MD
C. Daniel Ansevin, MD
Toomas Anton, MD
Kristin Appleby, MD
Eric Baron, DO
Samuel Borsellino, MD
Dina Boutros, MD
Luzma Cardoma, MD
A. Romeo Craciun, MD
Carrie Diulus, MD
Megan Donohue, MD
Atef Eltomey, MD
Todd Francis, MD, PhD
Naila Goenka, MD
Joshua Gordon, MD
Raqeeb Haque, MD
Dulara Hussain, MD
Zulfiqar Hussain, MD
Kambiz Kamian, MD
Robert Kosmides, MD
Don K. Moore, MD
Tiffany Perry, MD
Sheila Rubin, MD
Teresa Ruch, MD
Joseph Rudolph, MD
Andrey Stojic, MD, PhD
Nimish Thakore, MD
Jennifer Ui, MD
Roya Vakili, MD
Simona Velicu, MD
Robert Wilson, DO
Joseph Zayat, MD
Sleep Disorders Center
Nancy Foldvary-Schaefer, DO, MS Director
Loutfi Aboussouan, MD
Charles Bae, MD
A. Romeo Craciun, MD
Ketan Deoras, MD
Michelle Drerup, PsyD
Sally Ibrahim, MD
Krystyna Kolaczynski, MD
Alan Kominsky, MD
Jyoti Krishna, MD
Megan Lavery, PsyD
Reena Mehra, MD, MS
Omar Minai, MD
Douglas Moul, MD, MPH, FAASM
Silvia Neme-Mercante, MD
Carlos Rodriguez, MD
Frederick Royce Jr., MD
Jessica Vensel-Rundo, MD, MS
Harneet Walia, MD
Tina Waters, MD
Center for Spine Health
Gordon Bell, MD Director
Daniel Mazanec, MD Associate Director
Jeremy Amps, MD
Lilyana Angelov, MD
Toomas Anton, MD
Adam Bartsch, PhD
Edward Benzel, MD
William Bingaman, MD
Samuel Borsellino, MD
Edwin Capulong, MD
Edward Covington, MD
Russell DeMicco, DO
Carrie Diulus, MD
Alef Eltomy, MD
Michael Eppig, MD
Todd Francis, MD, PhD
Frederick Frost, MD
CLEVELAND CLINIC NEUROLOGICAL INSTITUTE | 33
Kush Goyal, MD
Raqeeb Haque, MD
Garett Helber, DO
Augusto Hsia Jr., MD
Iain Kalfas, MD
Kambiz Kamian, MD
Tagreed Khalaf, MD
Ajit Krishnaney, MD
Andre Machado, MD, PhD
Jahangir Maleki, MD, PhD
Manu Mathews, MD
E. Kano Mayer, MD
Robert McLain, MD
Don Moore, MD
Thomas Mroz, MD
R. Douglas Orr, MD
Tiffany Perry, MD
Anantha Reddy, MD
Teresa Ruch, MD
Judith Scheman, PhD
Richard Schlenk, MD
Santhosh Thomas, DO, MBA
Deborah Venesy, MD
Fredrick Wilson, DO
Adrian Zachary, DO, MPH
COLLABORATIVE DEPARTMENTS
Section for Neurosurgical Anesthesia, Department of General Anesthesiology, Anesthesiology Institute
Rafi Avitsian, MD Section Head
Sekar Bhavani, MD
Matvey Bobylev, MD
Zeyd Ebrahim, MD
Hesham Elsharkawy, MD
Ehab Farag, MD
Samuel Irefin, MD
Paul Kempen, MD, PhD
Reem Khatib, MD
Mariel Manlapaz, MD
Marco Maurtua, MD
Antonio Ramirez, MD
Stacy Ritzman, MD
Leif Saager, MD
David Traul, MD, PhD
Guangxiang Yu, MD
Department of Neurosciences, Lerner Research Institute
Bruce Trapp, PhD Chairman
Cornelia Bergmann, PhD
Jianguo Cheng, MD, PhD
John Gale, PhD
James Kaltenbach, PhD
Hitoshi Komuro, PhD
Bruce Lamb, PhD
Yu-Shang Lee, PhD
Ching-Yi Lin, PhD
Yoav Littner, MD
Sanjay W. Pimplikar, PhD
Erik Pioro, MD, PhD
J. Javier Provencio, MD, FCCM
Richard M. Ransohoff, MD
Susan Staugaitis, MD, PhD
Stephen Stohlman, PhD
Dawn Taylor, PhD
Riqiang Yan, PhD
Department of Biomedical Engineering, Lerner Research Institute
Jay Alberts, PhD
Yin Fang, PhD
Elizabeth Fisher, PhD
Aaron Fleischman, PhD
Zong-Ming Li, PhD
Cameron McIntyre, PhD
Ela B. Plow, PhD, PT
Matthew Plow, PhD
Vlodek Siemionow, PhD
Weidong Xu, MD
Department of Cell Biology, Lerner Research Institute
Damir Janigro, PhD
Nicola Marchi, PhD
Department of Anatomic Pathology, Pathology & Laboratory Medicine Institute
Richard Prayson, MD
Susan Staugaitis, MD, PhD
CLEVELAND CLINIC FLORIDA
Badih Adada, MD
Michelle Dompenciel, MD
Néstor Gálvez-Jiménez, MD, MSc, MS (HSA), FACP
Danita Jones, DO
Tarannum Khan, MD
Ramon Lugo-Sanchez, MD
Chetan Malpe, MD
Ryan McTaggart, MD
Graham Mouw, MD, FAANS, FACS
Linda Pao, MD
Megan Rahmlow, MD
Adriana Rodriguez, MD
Richard Roski, MD
Virgilio D. Salanga, MD
Efrain Salgado, MD
Alexandra Soriano Caminero, MD
Po-Heng Tsai, MD
CLEVELAND CLINIC NEVADA
Jeffrey Cummings, MD, ScD Director, Lou Ruvo Center for Brain Health
Sarah Banks, PhD, ABPP-CN
Charles Bernick, MD
Le Hua, MD
Gabriel Leger, MD
Justin Miller, MD
Donna Munic-Miller, PhD
Ryan Walsh, MD, PhD
Timothy West, MD
Dylan Wint, MD
Xue (Kate) Zhong, MD, MSc
YEAR IN REVIEW STAFF
Managing Editor, Glenn Campbell
Art Director, Chip Valleriano
Principal Photography, Russell Lee Yu Kwan Lee Steve Travarca
Principal Illustration, Amanda Mendelsohn Mark Sabo
For address changes
or more information
about Cleveland Clinic’s
Neurological Institute,
please contact:
Cleveland Clinic
9500 Euclid Ave./AC311
Cleveland, OH 44195
216.448.1022
clevelandclinic.org/
neuroscience
Cleveland Clinic is a
nonprofit academic medical
center ranked among the
nation’s top hospitals
(U.S. News & World
Report), where more than
3,000 physicians in 120
specialties collaborate to
give every patient the best
outcome and experience.
clevelandclinic.org
Year in Review is written for
physicians and should be
relied on for medical
education purposes only. It
does not provide a complete
overview of the topics
covered and should
not replace the independent
judgment of a physician
about the appropriateness
or risks of a procedure for a
given patient.
©The Cleveland Clinic
Foundation 2013
34 | YEAR IN REVIEW 2013
24/7 ReferralsReferring Physician Hotline 855.REFER.123 (855.733.3712) clevelandclinic.org/refer123
Live help connecting with our specialists, scheduling and confirming appointments, and resolving service-related issues.
Hospital Transfers 800.553.5056
Stay Connected to Cleveland Clinic on …
Physician Directory. View our staff at clevelandclinic.org/staff.
Same-Day Appointments. Cleveland Clinic offers same-day appointments to help your patients get the care they need, right away. Have your patients call our same-day appointment line, 216.444.CARE (2273) or 800.223.CARE (2273).
Track Your Patients’ Care Online. Establish a secure online DrConnect account for real-time information about your patients’ treatment at Cleveland Clinic at clevelandclinic.org/drconnect.
Critical Care Transport Worldwide. To arrange for a critical care transfer, call 216.448.7000 or 866.547.1467. For STEMI (ST elevated myocardial infarction), acute stroke, ICH (intracerebral hemorrhage) or aortic syndrome transfers, call 877.379.CODE (2633). Learn more at clevelandclinic.org/criticalcaretransport.
CME Opportunities: Live and Online. Visit ccfcme.org to learn about the Cleveland Clinic Center for Continuing Education’s convenient, complimentary learning opportunities.
Outcomes Data. View Outcomes books at clevelandclinic.org/outcomes.
Clinical Trials. We offer thousands of clinical trials for qualifying patients. Visit clevelandclinic.org/clinicaltrials.
Executive Education. Learn about our Executive Visitors’ Program and two-week Samson Global Leadership Academy immersion program at clevelandclinic.org/executiveeducation.
ABOUT CLEVELAND CLINIC
Cleveland Clinic is an integrated healthcare delivery system with local, national and international reach. At Cleveland Clinic, more than 3,000 physicians and researchers represent 120 medical specialties and subspecialties. We are a nonprofit academic medical center with a main campus, eight community hospitals, more than 75 northern Ohio outpatient locations (including 16 full-service family health centers), Cleveland Clinic Florida, Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas, Cleveland Clinic Canada, Sheikh Khalifa Medical City and Cleveland Clinic Abu Dhabi.
In 2013, Cleveland Clinic was ranked one of America’s top 4 hospitals in U.S. News & World Report’s annual “America’s Best Hospitals” survey. The survey ranks Cleveland Clinic among the nation’s top 10 hospitals in 14 specialty areas, and the top in heart care for the 19th consecutive year.
DOWNLOAD OUR NEW PHYSICIAN REFERRAL APP!
With our free Physician Referral App, you can view all our specialists and get in touch immediately with one click of your iPhone®, iPad®, or Android™ phone or tablet.
Download today at the App Store or Google Play.
RESOURCES FOR PHYSICIANS
Contacting us is now easier than ever.
Great things happen when a medical center puts patients first.
Visit clevelandclinic.org/ClevelandClinicWay for details or to order a copy.
The Cleveland Clinic WayBy Toby Cosgrove, MD, CEO and President of Cleveland Clinic
The Cleveland Clinic Foundation 9500 Euclid Avenue / AC311Cleveland, OH 44195
13-NEU-591