Neuroscience Update - Summer 2010

Could your patient’s back pain be a serious issue?

IN THIS ISSUE

Sleep disorders

Beaumont, Royal Oak offers multidisciplinary

stroke program

Minimally-invasive surgery for acoustic

neuromas

Auditory neuropathy spectrum disorder

Gamma Knife® center

Neuroscience Program Overview

By Mick Perez-Cruet, M.D., M.S, vice-chief, Neurological Surgery, Beaumont Hospital, Royal Oak

Low back pain will affect almost 80 percent of Americans at some point during life. Many of these patients can treat their pain without seeking medical attention through over-the-counter therapies like anti-inflammatory medications, heating pads and rest. However, there are low back pain sufferers that have a condition known as lumbar herniated nucleus pulposus, more commonly known as herniated disc.

What is a herniated disc?A herniated nucleus pulposus, or HNP, occurs when the disc material breaks the disc annulus and impedes on a nerve root, essentially pinching the nerve. This can be a very symptomatic injury and patients with HNP usually present with leg and back pain often accompanied with numbness and/or weakness in the area. Another common symptom is parasthesia or tingling down the legs, usually concentrated to one side.

When should patients seek treatment?Not all back pain requires medical attention. In fact, a pulled muscle in the low back area can mimic many neurological defects. If a patient’s symptoms do not subside within two to three weeks and/or

are not improved with anti-inflammatory medications, it could be time to seek a specialist as a more complex problem might exist. Furthermore, if a patient presents with bowel/bladder changes and/or foot drop, immediate attention should be sought as the nerve impingement from the herniated disc is severe.

How is an HNP diagnosed?The most commonly used form of diagnostic testing to identify a herniated disc is magnetic resonance imaging, or MRI. The sagittal and axial images provide a concise picture of the nucleus pulposus and its placement in relation

updateNEWS FROM THE NEUROSCIENCE PROGRAM

Neuroscience

(continued on page 4)Dr. Perez-Cruet performing minimally-invasive spine surgery.

2 • NeuroscieNce update • spriNg 2010

Note from the ChiefThe Neuroscience program at Beaumont Hospital, Royal Oak proudly presents the first of many newsletters to provide information on topics of interest to physicians and patients who we are pleased to serve.

Beaumont invests in the growth of neuroscience care in recognition of the increasing demands from the public for services, including the care of our aging population. A majority of Americans are commonly seen in emergency centers and primary care physicians’ offices with back and neck pain, headaches and dizziness. Diagnostic evaluations frequently identify these common symptoms to be caused by:

• degenerative conditions of the spine or disc problems• carotid artery disease leading to strokes• hemorrhages into the brain or on its surface• brain tumors• subdural hematomas• birth defects

Many of these conditions can be easily identified with modern diagnostic evaluations and can be solved with interventional procedures that often are minimally invasive.

The care of patients of all ages is a priority at Beaumont and one taken especially seriously in neurosciences, as we provide care for neurological patients from newborns to the elderly. The technical and intellectual resources available at Beaumont also allow us to care for patients with very complex problems, and we are glad to bring these services to the community we serve.

This newsletter provides an overview of the services available in our facilities, the physicians and medical personnel who work and support our departments. It also highlights topics of interest for physicians and patients we serve and is an ongoing resource for the community to which we provide we care.

Fernando G. Diaz, M.D., Ph.D.Chief, Neurological Surgery, Beaumont Hospital, Royal Oak

Fernando G. Diaz, M.D., Ph.D.

Neurological SurgeryFernando Diaz, M.D., Ph.D.Chief, Neurosurgery

Mick Perez-Cruet, M.D., M.S.Vice-Chief, Neurosurgery

Holly Gilmer, M.D.Chief, Pediatric Neurosurgery

Daniel Michael, M.D., Ph.D.Chief, Neurotrauma

Attending PhysiciansStephen Boodin, M.D.Phillip Friedman, M.D.Rick Olson, M.D.Daniel Pieper, M.D.Karol Zakalik, M.D.

Associate PhysiciansRyan Barrett, D.O.Bradley Hall, D.O.Girish Hiremath, M.D.Robert Johnson, M.D.Todd Nida, M.D.Omar Qahwash, D.O.

Adjunct PhysiciansKonstantin Elisevich, M.D., Ph.D.Murali Guthikonda, M.D.Steven Ham, D.O.Fredrick Junn, M.D.Steven Kalkanis, M.D.Ghaus Malik, M.D.Jack Rock, M.D.Mark Rosenblum, M.D.Teck Soo, M.D.Sandeep Sood, M.D.

Stroke ProgramSusan Catto, M.D.Medical Stroke Director

Physician ExtendersHolly Weissman, N.P.Chief Physician ExtenderKim Cameron, P.A.Megan Clippard, N.P.Becky Doherty, N.P.Lauren Gurski, P.A.Justin Hugelier, P.A.Jennifer Jehle, N.P.Megan Keiser, N.P.Rosie Mannina, N.P.Kristen McGrath, N.P.Jamie Peysakhov, P.A.

AdministrationCharles Shanley, M.D.Senior Vice President and Associate Chief Medical OfficerVictoria Hollingsworth-SchulerAdministrative Director, NeuroscienceLori SheridanAdministrative Manager, NeuroscienceRachael WadeAdministrative Assistant, NeuroscienceAdministrative Office248-551-2300

spriNg 2010 • NeuroscieNce update • 3

Sleep disorders are common, have significant impact on quality of life, health

By Gary Trock, M.D., co-director, Beaumont Sleep Evaluation Services

Most Americans spend a third of their lives sleeping. However, sleep disorders may significantly impact health

and quality of life but are often ignored.

InsomniaThe most common sleep disorder is insomnia, which is defined as difficulty initiating sleep, trouble maintaining sleep, non-refreshing sleep or early arousals. Insomnia can contribute to hypertension, heart disease, depression and may worsen pre-existing medical conditions. Individuals can try a variety of strategies to improve insomnia on their own.

• Atmosphere – The sleep room should be for sleeping only. Homework, television, cell phones and other distractions should not be done in the sleep room. The room should also be comfortable, cool and dark.

• Caffeine – Caffeine can stay in the blood for over 12 hours, so those with insomnia should not consume caffeine after noon. Heavy meals or exercise should be avoided within two hours of bedtime.

should get out of bed, engage in a quiet activity for a short time in another room and then return to the sleep room.

• Schedule – It is important to maintain adequate sleep hygiene by maintaining a similar sleep schedule weekdays and weekends and avoid sleeping in on weekends or holidays.

• Sleep aids – Over-the-counter sleep aids are usually counterproductive, but prescription sleep medication may be prescribed for a short period of time with persistent insomnia. However, the conservative measures discussed should be tried before seeking medication therapy.

accidents. Sleep apnea may also contribute to high blood pressure, heart disease, stroke, diabetes and dementia.

Symptoms of sleep apnea include:

• loud snoring at night• arousals with choking• arousals with rapid heart rate• daytime sleepiness, despite adequate sleep• respiratory pauses as observed by bed

partner

If sleep apnea is suspected, the individual should consult either their primary care physician or a sleep specialist.

There are a variety of other sleep disorders with the recent diagnostic manual listing 82 separate sleep disorders. Most individuals with sleep disorders experience either excessive sleepiness or the inability to sleep. If conservative measures do not resolve the symptoms, consulting a primary care physician and sleep specialist may be needed.

Beaumont Hospital’s Sleep Evaluation Services accepts direct or physician referrals. For more information, go to www.beaumonthospitals.com/sleep.

For a referral, call Beaumont Physician Referral at 800-633-7377.

Most people experience short-term insomnia from time to time. However, if it persists longer than one month, it could have a negative effect on a person and a doctor should be consulted.

• Napping – Napping during daytime may be refreshing; however, people who experience difficulty initiating sleep at night should avoid daytime napping.

• Tossing and turning – Individuals should not remain in bed awake. If sleep does not come within 30 minutes, the person

Obstructive sleep apneaObstructive sleep apnea syndrome is another common disorder and is on the rise. Sleep apnea is the reduction or stoppage of breathing during sleep; it can result in significant daytime sleepiness, which may impair work performance and result in


Golfer finds relief for debilitating back pain

to the annulus of the disc to determine whether or not herniation has occurred.

Can an HNP be treated non-surgically?There are many successful conservative management options for an HNP, the most common two being physical therapy and epidural steroid injections. Although both are simply potential pain relievers and do not repair the disc, they can improve and possibly resolve the patient’s symptoms. Other non-surgical methods include muscle relaxants, oral steroids, traction, chiropractic manipulation and acupuncture. The method of treatment for a herniated disc is due in large part to the severity of a patient’s symptoms, the outcome the patient expects and the avenues they are willing to explore.

What are the surgical options?If and when a patient chooses surgical treatment, the most common procedure for HNP repair is a microdiscectomy, which can be performed either traditionally open or minimally invasively. Although the recovery from the surgery is comparable in both approaches, the minimally invasive method tends to have more cosmetic scarring and preserves the paraspinous muscle. Regardless of approach, the microdiscectomy is done on an outpatient basis, usually under general anesthesia; it is approximately a one-hour surgery to remove the portion of disc that is herniated and release the impinged nerve.

Recovery is minimal and most patients are back to work within two weeks, although all patients should adhere to strict weight restrictions following the procedure to allow the area to heal properly. Most often, patients report immediate relief although some residual parasthesia may present as the nerve regains its posture and function following surgery.

A herniated disc can be a painful intrusion to the daily routine for many people, and although many conservative treatments are available, surgical intervention is sometimes the most effective approach to relieve a patient’s symptoms and return the patient to a higher quality of life.

Dr. Perez-Cruet specializes in minimally invasive spine surgery.

patient’s back pain (continued from front page)

Dave Richards was an avid golfer and enjoyed sports until the physical activity caused a painful degeneration in his spine. He underwent a four-level fusion in 2007, had a successful recovery and was back to spending four days a week in the gym.

Then, during a workout about 18 months later, Dave felt a painful twinge. “I just knew something was wrong,” he says.

Over the course of the next few months, Dave visited every specialist who would see him, underwent every possible diagnostic test and exhausted every treatment option. “I lost more than 20 pounds, was spending 22 hours a day on my back and needed morphine to manage the pain,” recalls Dave.

After several opinions and even more theories about potential causes of his agonizing pain, Dave was all but sent on his way with no solution in sight.

Then Dave met Bradley Hall, D.O., who spent an hour and a half during their first consultation asking question after question hoping to understand everything Dave had been through and then explaining potential surgical scenarios. “Dr. Hall seemed to be the guy who solves the problems that no one else can solve,” says Dave. “He told me that he thought he could fix me, but he wouldn’t know until he got in there. I liked that he showed me every picture I had and explained everything; he really built up my confidence in him.”

Dave consented to surgery in April 2009 in an attempt to relieve his pain and regain his life. During surgery, Dr. Hall diagnosed nerve damage that previously had been undetected, removed a portion of the previous bone graft that had overgrown the area and replaced three-quarters of the prior fusion. Within 48 hours of his surgery, Dave was sitting up for 45 minutes at a time, something he hadn’t done in months. “I got better really fast,” says Dave. “Although I am still in rehab, I am living a normal life again.”

Dave Richards, almost one year after surgery


Beaumont Hospital, Royal Oak offers nationally certified, multidisciplinary stroke programBy Chris Kazmierczak, M.D., neuro and interventional radiologist

Since the Joint Commission awarded Beaumont primary stroke center certi- fication in 2006, physicians have treated more than 800 acute stroke patients per year as they arrive through one of the busiest Emergency centers in the state.

As a primary stroke center, Beaumont provides around-the-clock availability of acute medical, neurosurgical and endovascular stroke care by highly specialized physicians. Additionally, multiple clinical trials take place through the cooperation of Radiology, Neurology and Emergency Medicine departments as they relate to patients with acute stroke.

Beaumont’s stroke program begins with rapid triage and assessment by our emergency center physicians along with a dedicated in-house stroke team and neurologist consultation. Patients are imaged with state of the art CT scanners, which provide the information to best determine what treatment options may be available. In addition to standard intravenous tPA therapy, interventional neuroradiologists are on hand to offer the full complement of endovascular treatment options including intra-arterial tPA and mechanical thrombectomy (Merci retriever and Penumbra), all performed in a neuro biplane angiography suite.

A dedicated neuro intensive care unit and neuro progressive care beds allow patient care to be delivered by nursing staff specifically trained in the care of patients with neurologic disease. Treatment pathways for acute stroke care and post-discharge risk factor modification are in place and allow for consistent high quality care. Highly trained professionals from Speech Pathology, Physical and Occupational Therapy see all patients early during their admission and are proactive in planning their needs, including inpatient or outpatient therapy.

The multidisciplinary approach to the care of stroke patients at Beaumont brings together many different departments and medical subspecialties with the goal of seamless integration to provide the best possible care of your patients.

Beaumont’s multi-disciplinary stroke team.

Physician spotlight: Bradley Hall, D.O., Neurosurgeon

Bradley Hall, D.O., is a neurosurgeon who specializes in both general neurological surgery as well as complex spine surgery; he also applies his surgical skill in neurotrauma patients at Beaumont, Royal Oak.

Dr. Hall completed his residency program at Providence Hospital in conjunction with the Michigan State University School of Osteopathic Medicine. He then completed a Complex Spine Surgery Fellowship at the Miami School of Medicine Project to Cure Paralysis Program. Dr. Hall is also an active member of many state and national neurosurgical societies including the Congress of Neurological Surgeons.

Dr. Hall treats and manages disorders of the brain, including brain tumors, neurotrauma, cerebrovascular anomalies, intracerebral hemorrhage, hydrocephalus and stereotaxy.

His subspecialty, though, is complex spine as he has extensive experience with degenerative spine disease, spinal tumors, spine deformity, spine trauma, vascular malformations and syringomyelia.

Dr. Hall has treated challenging cases that some consider hopeless. His research interests include medically induced hypothermia for spinal cord injuries. Dr. Hall is a staff physician with the Michigan Head and Spine Institute, PC, and has an outpatient clinical office at Royal Oak.

Dr. Hall and Justin Hugelier, P.A., reviewing 3-D spine images for back pain diagnosis.


Narayan Verma, M.D., is a clinical neurologist who is a board-certified specialist in epilepsy and sleep medicine. He completed his residency as well as a fellowship in clinical neurophysiology at Wayne State University. He is a well-published author, an examiner for the board of clinical neurophysiology and a clinical associate professor of neurology at the Oakland University William Beaumont School of Medicine.

In 1991, Dr. Verma started the first epilepsy monitoring program with Fernando Diaz, M.D. For the last 14 years, he has shared his expertise and knowledge with the physicians and patients of Beaumont Hospital and was instrumental in opening the EMU in July 2008.

Currently, Dr. Verma is the director of the Epilepsy Monitoring Unit on 8 South at Beaumont Hospital, Royal Oak. This three-

Physician spotlight: Narayan Verma, M.D., Clinical Neurophysiology

Dr. Verma and Dr. Zakalik evaluating a patient in the EMU.

NeurologyAttending PhysiciansMazen Al-Hakim, M.D.Kheir Al-Zouhayli, M.D.Martin Belkin, D.O.Lawrence Eilender, M.D.Anthony Emmer, D.O.Raina Ernstoff, M.D.Jonathan Fellows, D.O.Sonia Fernando, M.D.Michelle Furmaga, M.D.Jodi Ganley, D.O.Neil Gilbert, M.D.Rashmi Gupta, M.D.Mark Kachadurian, D.O.Brian Kirschner, M.D.William Leuchter, M.D.Sami Mounayer, M.D.Saraswati Muttal, M.D.Steven Newman, M.D.Steven Schecter, M.D.Lalitha Sivaswamy, M.D.Alexander Spitzer, M.D.Alex Steinbock, D.O.Gary Trock, M.D.Richard Trosch, M.D.Narayan Verma, M.D.

Associate PhysiciansWilliam Boudouris, D.O.Norman Burns, M.D.Nancy Jingyang Cao, M.D., Ph.D.Mitchell Elkiss, D.O.Heather Lee, D.O.Elizabeth Leleszi, M.D.Zef Lucaj, M.D., Ph.D.Eileen McCormick, D.O.Andrea Rossi, D.O.Howard Rossman, D.O.Vijay Samuel, M.D.Alka Shah, M.D.Mark Silverman, D.O.Bruce Silverman, D.O.Susan Smietana, D.O.Elizabeth Smith, M.D.Nader Warra, D.O.Danny Watson, M.D.Esther Young, D.O.

Adjunct PhysiciansAaron Ellenbogen, D.O.Shelley Knowles, M.D.Danette Taylor, D.O.

NeuroradiologyAttending PhysiciansChris Kazmierczak, M.D.Anant Krishnan, M.D.Samir Noujaim, M.D.Sneha Patel, M.D.Richard Silbergleit, M.D.Kurt Tech, M.D.Ay-Ming Wang, M.D.Jeffrey Wilseck, D.O.

room unit equipped with 24-hour video surveillance and EEG monitoring allows Dr. Verma and other neurophysiology professionals to diagnose seizure origin in a variety of patients who also receive around-the-clock supervision from technologists and nursing staff. If needed, special sphenoidal electrodes can also be place by a radiologist for further study.

Pediatric and adult patients referred to the EMU typically suffer from:

• intractable seizures, fully or partially unresponsive to treatments

• seizures or pseudoseizures of unknown origin resulting in transient ischemic attacks or syncopy

Patients stay in a private room for two to five days, depending on their individual seizure activity. Patients can expect:

• a medical history will be taken and physical exam will be performed

• medication orders• daily rounds• EEG results• treatment plan formulation• discharge follow-up

The EMU is a leading edge facility, allowing physicians like Dr. Verma an advanced approach to treating seizures, an often serious condition.

To refer a patient to the EMU or for more information about these services, please contact Dr. Verma, Clinical Neurophysiology, at 248-551-1281.


Beaumont offers endoscopic minimally invasive surgery for patients with acoustic neuromas By Dennis Bojrab, M.D., Otolaryngology, and Daniel Pieper, M.D., Neurological Surgery

Acoustic neuromas are the most common benign brain tumor of the posterior fossa originating on the eighth cranial nerve, which controls hearing and balance. These

tumors account for six percent of all brain tumors and are generally slow growing.

Early symptoms include hearing loss, tinnitus (ringing of the ear) and possibly vertigo or balance problems. Later symptoms associated with tumor growth include facial weakness, numbness or tingling of the face, headache and even coma. Early detection and treatment allow for the best outcomes for patient safety and preservation of hearing and facial nerve function. Treatment options

include traditional surgical approaches, radiosurgery (Gamma Knife®) or careful patient observation with follow-up MRI scans to determine growth.

Combined efforts of otologic and neurologic surgeons have been in place since the 1960s for improved care of the patients with posterior fossa tumors. With this working relationship, we have developed one of the largest programs in the nation with minimally invasive skull base surgery by the use of the endoscope. Endoscopic surgery with the minimally invasive approach has been performed in our center safely for more than five years in a select number of patients without the need for traditional open surgical approaches with brain retraction. Patient selection is key to this approach and depends on tumor size, hearing and other cranial nerve preoperative evaluations.

With our fully endoscopic approach, we avoid drilling through the mastoid bone or cutting a large opening in the skull. Instead, a small dime-sized opening is made behind the mastoid, and intraoperative cranial nerve monitoring of the facial and hearing nerves begins. An endoscope and precise endoscopic instruments are used to safely remove the tumor.

Endoscopic approach allows for no brain retraction or manipulation, resulting in far fewer complications such as ataxia, discoordination and hearing loss. Rates of facial nerve paralysis, CSF leaks, neurologic injuries such as stroke and cerebellar contusions have also declined as a direct result of utilizing an endoscopic approach. Patients are usually able to be discharged home within 24 to 48 hours after surgery.

Overall, the endoscopic approach for the resection of acoustic neuromas is not only cost effective but affords the patient improved quality of life with less surgical recovery.

Superior nuchal line posterior mastoid groove

Incision location for endoscopic approach

Patient story: Surgery helps patient overcome seizure disorderIn 2008, Laura Ingram was referred to the Epilepsy Monitoring Unit as a result of having 12 to 15 seizures per day since the age of two with a very limited quality of life. “I never thought my life would be complete,” Laura says. “I could not work or go out somewhere without a friend or family member present to make sure I did not have a seizure.”

After three days in the EMU, Narayan Verma, M.D., a neurologist and director of the unit, determined that Laura had a left temporal lobe that was surrounded with atrophied tissue causing her to seize. She was then sent to Karol Zakalik, M.D., a neurosurgeon for a left temporal lobectomy.

Since the surgery, Laura has been seizure free. She is now able to work, drive and do things for herself as well as for her son, Billy, most of which was unable to do prior because of the frequency and severity of her seizures. “I no longer have to take any of my medications so I am pill free!” says Laura. “Since I have overcome my seizure disorder, my life has changed for the better.”

Laura credits her success to the dedication and attention she received from Drs. Zakalik and Verma and the help of the EMU. “I want to thank Dr. Verma and Dr. Zakalik for all of their hard work and knowledge,” says Laura. “You are the best and you will always be my lifesaver.”

Laura and her son, Billy


Beaumont experts provide early detection and accurate diagnosis for children with auditory neuropathy spectrum disorderBy Shelly Schindler, Au.D.

• Congratulations to Daniel Michael, M.D., Ph.D., Neurological Surgery, who will be installed May 1 as the 145th President of the Michigan State Medical Society.

• Congratulations to 5 East, which was just designated as the site for all neurological intensive care unit patients.

• Mick Perez-Cruet, M.D., M.S., will release a new textbook this summer, entitled Minimally Invasive Spinal Fusion: Techniques and Operative Nuances.

Neuro news

For some children, objective audiological testing suggests normal hearing thresholds, yet they behave as if they are hearing impaired and their speech and language milestones may also be significantly delayed. For these children, careful and thorough testing may diagnose auditory neuropathy spectrum disorder, or ANSD, a diagnosis that can have a profound impact on a child and his or her family.

ANSD is only recently being fully understood. With this disorder, the ear/cochlea is able to hear sounds, but the message is not being properly sent to the brain via the nerve. As understanding of this disorder increases, we know that the breakdown may occur at any number of different points along the pathway, from the inner hair cells of the cochlea along the auditory nerve to the brainstem.

How Is ANSD diagnosed?Newborn hearing screenings allow the identification of ANSD in infancy. In order to do this, the screening hospital must use diagnostic testing that assesses the entire auditory pathway through the brainstem by using automated auditory brainstem response screeners.

For formal assessment of an infant or young child’s hearing, a test battery approach is necessary. With ANSD, behavioral assessment may yield inconsistent responses to sounds. Otoacoustic emissions testing is often used to determine normal outer hair cell function of the cochlea. Many hospitals use a screener version of this test to screen their babies. However, in ANSD, the cochlear function is believed to be normal; therefore, babies with the disorder will pass this assessment. It is necessary to perform brainstem-evoked auditory responses (also known as auditory brainstem response, in order to evaluate the neural synchronization of the entire auditory system. Children with ANSD often exhibit clear cochlear responses; however, neural synchronization

is not evident and classic waveforms are not present. An additional assessment to confirm the disorder is middle ear muscle reflexes. This assessment looks at the auditory reflex pathway; these reflexes are typically absent with ANSD.

Infants who experience perinatal diseases including hyperbilirubinemia, hypoxic insults, ischemic insults, prematurity and neurological disorders are at greater risk of ANSD. Additionally, the disorder may be evident in babies with demyelinating diseases, hydrocephalus, immune disorders, inflammatory neuropathies and severe developmental delay. For this reason, the Joint Committee on Infant Hearing has recommended that all babies who have spent time in the neonatal intensive care unit receive newborn hearing screenings using automated auditory brainstem response testing.

How is ANSD treated?Treatment of ANSD is complex and differs for each child. Many of these children will derive little benefit from traditional hearing aid amplification. Traditional amplification is often attempted to see if there is any noticeable improvement in the child’s responses to sound.

Many facilities are reporting success when fitting these children with cochlear implants. Current FDA regulations require that a child be at least one year of age before implantation and not receiving measurable benefit from hearing aids. Other children are successful using a manual form of communication such as sign language.

Regardless of the treatment, it is essential that we identify this disorder early and begin to provide the necessary support to the child and family.

For more information or to refer a patient, please contact Clinical Neurophysiology Audiology at 248-551-2119.

• Jeffrey Wilseck, D.O., Neuroradiology, was recently installed as a Fellow in the American Osteopathic College of Radiology.

• As the president of the Michigan Association of Neurological Surgeons, Holly Gilmer, M.D., will host the 28th Annual MANS Meeting June 11 – 13 at Grand Traverse Resort. For more information, go to www.mansorg.com

• The department of Neuroscience would like to welcome Robert Johnson, M.D., to the Neurological Surgery staff. Dr. Johnson specializes in epilepsy management and has offices located in Southfield, Novi and Detroit.


Beaumont Gamma Knife® center provides alternative treatment for some brain tumors, some neurological syndromes

Gamma Knife Model 4 C Unit in the Beaumont Gamma Knife Center

Gamma Knife® indications• acoustic neuroma• astrocytomas• arteriovenous malformation• cavernous angioma• choroid plexus papilloma• craniopharyngioma• epilepsy• functional disorders• glomus tumor• gliomas • lymphoma• meningioma• metastases• movement disorders• pinealoma• pineoblastoma• pineocytoma• pituitary tumor• trigeminal neuralgia• venous angioma

Trigeminal neuralgia 16%

Brain metastases 52%

Pituitary 3%

Acoustic neuroma 11%

Arteriovenous malformations 3%Glioblastoma multiforme 1%

meningioma 12%

Glomus 2%

By Peter Chen, M.D., Radiation Oncology

Gamma Knife®, or GK, is a dedicated non-invasive stereotactic radiotherapy (radiosurgical) machine that replaces traditional

surgery with a focused array of 201 intersecting beams of high intensity gamma, or X-ray, radiation.

The gamma radiation is delivered from 201 Cobalt-60 sources that provide the ability to precisely conform the radiation beams to the shape of an intracranial lesion in an intensely focused manner such that surrounding normal brain tissue is optimally spared. The delivery of the dose by the Gamma Knife to a brain tumor is very precise, with submillimeter accuracy.

As a result, GK has become the primary non-invasive alternative to neurosurgery for various brain tumors and other neurological syndromes. Approved by the FDA in 1988, GK has successfully treated more than 300,000 patients worldwide at state-of-art cancer centers such as the Mayo Clinic, Johns Hopkins, University of California– San Francisco and Beaumont Hospital, Royal Oak.

GK treatment avoids the risks of open neurosurgical procedures such as hemorrhage, infection and spinal fluid leakage as well as risks from general anesthesia.

Since the opening of the Beaumont Gamma Knife Center in December 2006, a total of 919 patients have been treated. Of these, the most frequent diagnoses are depicted as percentages on the pie graph below.

The Beaumont Gamma Center has been actively involved with maintenance of all GK-treated patient data from time of diagnosis to treatment with subsequent reporting of results. To date, 30 scientific abstracts and publications have been submitted, presented at national and international meetings and published in proceedings and medical journals. Additionally, an annual symposium, New Frontiers in Neuroscience, is held each April to present the latest leading edge technologies and treatments along with long-term results of such GK stereotactic radiosurgical treatment.


Medical mission: A multidisciplinary approach to meningoencephalocele repair in the PhilippinesBy Daniel R. Pieper, M.D., and Judith Hack, R.N.

In January 2007, a team consisting of a neurosurgeon, craniofacial surgeon, anesthesiologist and surgical nurses traveled to the

Philippines to provide hope and help to individuals with congenital malformations.

The team traveled to Davao in the province of Mindanao, located in the southeastern portion of Philippines to operate on native patients with meningoencephaloceles, a malformation in which the intracranial contents herniate through a cranial bone defect causing a variety of facial disfigurements.

Some surgical procedures require more than one surgeon and/or specialty to ensure the best patient outcome. This team approach is an established one in many fields, and neurological surgery is no exception. Neurosurgeons are now requiring the expertise of a craniofacial surgeon in the treatment of anterior skull base tumors for greater visualization of the affected area as well as their site reconstruction techniques.

One of the more common disorders treated with this multidisciplinary approach is the meningoencephalocele. Typically, this is not a common abnormality seen in North America or Europe, but is often found in Southeast Asian countries, like the Philippines. The lack of adequately trained neuro/craniofacial surgeons, equipment and funding in these countries has subsequently limited the population from receiving the treatment they need. Thus, the medical mission is born.

The initial planning for the trip and subsequent surgeries was difficult as there was no knowledge regarding the conditions of the hospital, operating room or available equipment. In addition to the standard surgical requirements, consideration was also given to every possible complication that could arise due to the suboptimal conditions of the location.

Prior to the team’s arrival, all patients were screened with imaging as well as for medical health evaluations and severity of their deformities. Patients with complicated or multiple defects were declined treatment on-site and recommended travel to the United States for more extensive surgery. The patients cleared for surgery based on the on-site specifications underwent a preoperative consultation with the team. Despite the presence of interpreters, an extensive language barrier remained. However, the team never underestimated the risk these patients and families were taking by entrusting their lives to total strangers in hopes of living a normal life after treatment.

Surgical supplies were limited and their use was planned by the local hospital; this was based on pre-selected patients so efficiency was essential. If a necessary supply was low or no longer available, the team made quick adjustments and proceeded with the procedure. Many amendments had to be made to the process to which the surgeons were typically accustomed; for example, blood was in shortage as were regulatory anesthesia protocols. In addition to

performing the complex encephalocele repairs and bone flap reconstructions, the team had to be constantly aware of supply shortage, unforeseen complications and anesthetic concerns. Post-operatively, the local hospital employees had to be educated on patient care, complication foresight and suture removal to ensure that the patients were followed accurately as the team would be returning home.

During the inaugural trip in 2007, four encephalocele patients were operated on and treated. Since then, the trip has continued annually; the most recent trip in January 2010 saw the treatment of 10 patients in a week. This is due, in large part, to the increased efficiency and technique of the multidisciplinary team. The team strives to replicate the most advanced and surgically sound operating room possible in order to offer the affected people of Davao an improved quality of life, something they might have otherwise gone without.

Davao Hospital

OR supplies

Operating room in Davao


Traumatic Brain and Spinal Cord Injuries – When an accident results in brain or spinal cord injury, treatment often begins at one of Beaumont’s Emergency Centers. Our EC’s offer leading edge imaging and advanced telemetry for fast, accurate diagnosis of injuries.

Our multidisciplinary team of ER staff, trauma surgeons, neurosurgeons and rehab specialists work together to begin immediate treatment, which is essential for best outcomes.

Gamma Knife ® – Beaumont’s Gamma

Knife® treats brain tumors and neurological conditions with pinpoint accuracy.

Gamma Knife® delivers a highly therapeutic dose of radiation to the brain accurately and without the risks of open surgery like general anesthesia, infection and bleeding. Only the target tissue receives a significant radiation dose and no incision is required. Recovery is quick and treatment is generally done on an outpatient basis.

In addition to tumors, Gamma Knife® can be used for arteriovenous malformations, trigeminal neuralgia, Parkinson’s disease, essential tremors, epilepsy and obsessive-compulsive disorder.

Neuro Oncology – Our specialists diagnose and treat malignant brain and spine tumors in children and adults using neuroimaging techniques like positron emission tomography, magnetic resonance spectroscopy imaging, Gamma Knife® and spinal radiosurgery. The team includes neuro oncologists, neurosurgeons, radiation therapists and neuroradiologists.

Cranio-Facial and Skull Base – Beaumont’s Cranio-Facial program brings together specialists to provide integrated care for children with a range of craniofacial disorders, such as cleft lip or palate. The multidisciplinary team includes plastic

surgeons, otolaryngologists, maxillo facial surgeons and neurosurgeons.

Pediatric Neurosurgery – At Beaumont Children’s Hospital, pediatric neurologists, neurosurgeons and interventional neuroradiologists are available to treat a variety of neurological conditions in infants and children. Our experts are skilled and equipped to handle the most severe head and spine trauma issues in children.

As the only hospital in SE Michigan provid- ing pediatric interventional treatment of brain aneurysms, arteriovenous malformations and vascular tumors, we reduce or eliminate the need for traditional surgery methods.

Epilepsy and Movement Disorders – Our team treats a broad grouping of neurological conditions like epilepsy, Parkinson’s disease, dystonia, spasticity, Huntington’s disease and movement disorders caused by brain injury.

An Epilepsy Monitoring Unit opened at Beaumont Royal Oak as a specialized inpatient unit designed to evaluate, diagnose and treat children and adults with seizures. The EMU offers leading diagnostic capabilities and physician consultation.

Beaumont is also a leader in using deep brain stimulation (DBS) to treat various neurological and movement disorders like Parkinson’s disease, essential tremor, dystonia, tremor due to multiple sclerosis and chronic pain.

Pain Management – Safe and effective pain management is an integral part of treatment. Beaumont’s neuroscience team works in conjunction with anesthesiologists on a variety of treatments and procedures.

Physicians have innovative options for treating pain including dorsal column stimulators that can be adjusted for varying levels of pain as well as an implantable intrathecal drug pump. Beaumont’s advanced radiosurgery equipment

Neuroscience program overviewis helpful in treating focal pain conditions because it’s less invasive than surgery and can be repeated if symptoms recur.

Spine – Our team performs minimally invasive surgeries on complex spinal conditions including spinal trauma, spinal deformities, and spinal oncology. This approach significantly improves patient outcomes with less blood loss, less pain, lower infection rates and shorter hospital stays.

Interventional Neuroradiology and Stroke – Beaumont Royal Oak is designated a Primary Stroke Center by the Joint Commission affirming the success of our comprehensive stroke care. Our team includes specially trained and certified nursing staff, more interventional stroke specialists than any other hospital in Michigan, dedicated ICU beds for stroke patients, interventional neurosurgeons and neuroradiologists who can administer intra-arterial TPA and remove blood clots from the brain, and a dedicated neuroscience unit with 66 beds and 9 monitored critical care beds.

A minimally-invasive approach is provided by our team to treat vascular diseases of the central nervous system and spine including aneurysms, vascular malformations, arterial/venous stenosis, and tumors of the brain, head and neck requiring surgical intervention.

Intraoperative Monitoring – Intraoperative monitoring allows surgeons to check the functionality and integrity of the nervous system during surgery. The use of electro- physiological methods measures brain, nerve and spinal cord activity and has shown to improve patient safety and surgical outcomes.

Beaumont’s IOM team has training and experience exceeding many programs in the nation in the surgical areas of neurosurgery, orthopedics, otolaryngology/head and neck and urology.

3711 Thirteen Mile RoadRoyal Oak, Michigan 48073

Neuroscience update is published quarterly in support of the Neuroscience Program at Beaumont Hospitals.

For comments or suggestions, please call Rachael Wade at 248-551-2300

Neurosurgery physician extender team makes the difference in coordinated patient careWith a team of 11 nurse practitioners and physician assistants, the neurological surgery physician extenders at Beaumont Hospital, Royal Oak provide a wide range of specialized care around the clock for all neurosurgical patients throughout the hospital.

Whether the surgeon is off-site, in surgery or with another patient, any member of the physician extender team is always available to perform STAT consultations and to respond to urgent or emergent matters regarding neurosurgical patients on the floors, in the intensive care units or in the Emergency Center.

These highly trained individuals also develop close relationships with the nurses on the medical and surgical floors as well as the intensive care units, which facilitates easier and faster communication. Additionally, since the extender team rounds daily with the neurosurgeons on every patient on the service, they are very helpful in communicating with patients and families. These nurse practitioners and physician assistants provide a number of patient and family educational tools and services, ensuring that patients and family members have a complete understanding of their diagnoses, prognoses and surgical procedures.

As they often are a consult service, the physician extenders work well in conjunction with internists, oncologists, pediatricians and other primary service providers to provide coordinated patient care. Moreover, they work collaboratively with the hospital discharge planners to coordinate disposition issues specific to the neurosurgical patients, including placement in extended care facilities, discharge medications, rehabilitation and palliative care, when needed.

For more information, call a physician extender through the on-call pager at 248-992-3295.

Neuroscience Update - Summer 2010

Documents

Transcript of Neuroscience Update - Summer 2010