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Neurological
Institute
Outcomes | 2007
Patients First
Outcomes 2007
Quality counts when referring patients to hospitals and physicians, so Cleveland Clinic has created a series of Outcomes
books similar to this one for many of its institutes. Designed for a healthcare provider audience, the Outcomes books
contain a summary of our surgical and medical trends and approaches, data on patient volume and outcomes, and a
review of new technologies and innovations.
Although we are unable to report all outcomes for all treatments provided at Cleveland Clinic — omission of outcomes
for a particular treatment does not mean we necessarily do not offer that treatment — our goal is to increase outcomes
reporting each year. When outcomes for a specific treatment are unavailable, we often report process measures that
have documented relationships with improved outcomes. When process measures are unavailable, we report volume
measures; a volume/outcome relationship has been demonstrated for many treatments, particularly those involving surgical
technique.
Cleveland Clinic also supports transparent public reporting of healthcare quality data and participates in the following
public reporting initiatives:
• Joint Commission Performance Measurement Initiative (www.qualitycheck.org)
• Centers for Medicare and Medicaid (CMS) Hospital Compare (www.hospitalcompare.hhs.gov)
• Leapfrog Group (www.leapfroggroup.org)
• Ohio Department of Health Service Reporting (www.odh.state.oh.us)
Our commitment to providing accurate, timely information about patient care is designed to help patients and referring
physicians make informed healthcare decisions. We hope you find these data valuable. To view all our Outcomes books,
visit Cleveland Clinic’s Quality and Patient Safety website at clevelandclinic.org/quality/outcomes.
1
Neurological Institute
Dear Colleague:
I am proud to present the 2007 Cleveland Clinic Outcomes books. These books provide information on results, volumes and innovations
related to Cleveland Clinic care. The books are designed to help you and your patients make informed decisions about treatments and
referrals.
Over the past year, we enhanced our ability to measure outcomes by reorganizing our clinical services into patient-centered institutes. Each
institute combines all the specialties and support services associated with a specific disease or organ system under a single leadership at a
single site. Institutes promote collaboration, encourage innovation and improve patient experience. They make it easier to benchmark and
collect outcomes, as well as implement data-driven changes.
Measuring and reporting outcomes reinforces our commitment to enhancing care and achieving excellence for our patients and referring
physicians. With the institutes model in place, we anticipate greater transparency and more comprehensive outcomes reporting.
Thank you for your interest in Cleveland Clinic’s Outcomes books. I hope you will continue to find them useful.
Sincerely,
Delos M. Cosgrove, MD
CEO and President
2
what’s inside
Chairman’s Letter
04
Institute Overview
05
Quality and Outcomes Measures
Brain Tumor
08
Cerebrovascular Disease
21
Epilepsy
25
Headache
30
Movement Disorders
34
Multiple Sclerosis
36
Neuromuscular Disease
41
Pediatric Neurology and Neurosurgery
43
Psychiatric Disorders
48
Sleep Disorders
52
Spinal Disorders
56
Neurological Surgery Anesthesiology
60
Surgical Quality Improvement
62
Patient Experience
66
Innovations
70
New Knowledge
78
Staff Listing
86
Contact Information
90
Institute Locations
90
Cleveland Clinic Overview
92
Online Services
eCleveland Clinic
DrConnect
MyConsult
93
Chairman’s Letter
Dear Colleagues,
I am pleased to present to you this extensive collection of outcomes from
Cleveland Clinic’s Neurological Institute. Transparency, quality and outcomes
measurement have always been a priority for us. We have enhanced these efforts
with major programs to identify, develop, and capture specific quality measures
and outcomes in each patient’s electronic medical record. This novel endeavor,
led by Irene Katzan, MD, and Jocelyn Bautista, MD, allows us to capture
both general and disease-specific outcomes and quality measures with each
patient encounter. In this way, our performance and impact can be continuously
monitored and refined over time as part of our routine clinical practice.
In this book, we provide you with outcomes for specific conditions and treatments
because we understand these play a pivotal role in determining where to turn for
specialized care. I invite you to review our outcomes statistics and to compare us
with other healthcare providers. I think you will find that our outcomes, as well as
our patient satisfaction, are among the best in the nation.
Initiatives in recent years have included upgrading the technology in our Gamma
Knife Center, introducing an intensive treatment program for patients with chronic
headache, performing the first deep-brain stimulation on a minimally conscious
patient, designing and leading clinical trials of the first disease-modifying
agent approved for treatment of multiple sclerosis in a decade, expanding our
Pediatric Epilepsy Monitoring Unit, adding a thermoregulatory sweat test in our
Neuromuscular Center, and expanding our overnight sleep monitoring facilities
to hotel-based community locations. We expect these and other advances
will further our goal of continual improvement in our outcomes and patient
satisfaction.
As always, we look forward to working with you to provide the utmost in
neurological care for all patients.
Michael T. Modic, MD, FACR
Chairman, Neurological Institute
Outcomes 2007
4
Institute Overview
The multidisciplinary Cleveland Clinic Neurological Institute includes
more than 200 medical, surgical and research specialists dedicated to the
treatment of adult and pediatric patients with neurological and psychiatric
disorders. The institute offers a disease-specific, patient-focused approach
to care. Our unique, fully integrated model strengthens our current standard
of care, allows us to measure quality and outcomes on a continual basis,
and enhances our ability to conduct research.
and adult epilepsy; headache, facial pain syndromes and associated
disorders; movement disorders such as Parkinson’s disease, essential
tremor and dystonia; cerebral palsy and spasticity; hydrocephalus;
metabolic and mitochondrial disease; fetal and neonatal neurological
problems; multiple sclerosis; stroke; cerebral aneurysms; brain and spinal
vascular malformations; carotid stenosis; intracranial atherosclerosis; nerve
and muscle diseases, including amyotrophic lateral sclerosis, peripheral
neuropathy, myasthenia gravis and myopathies; sleep disorders; and
mental/behavioral health disorders and chemical dependencies.
U.S.News & World Report’s “America’s Best Hospitals” survey consistently
has ranked our neurology and neurosurgery programs among the top 10 in
the nation. Our neurology, neurosurgery and psychiatry programs are also
ranked best in Ohio.
Expert, Specialized Diagnosis
The institute model allows our patients to better access the care they
need through specialized, multidisciplinary, disease-specific centers that
integrate the expertise of neurologists, neurosurgeons, psychiatrists,
psychologists, neuroradiologists and others into the comprehensive care of
a single disease:
• Brain Tumor and Neuro-Oncology Center
Our Neurological Institute physicians draw on advanced diagnostic
capabilities and experience.
Our imaging services include structural and functional magnetic resonance
imaging (MRI), computed tomography (CT), positron emission tomography
(PET), myelography, diagnostic cerebral/spinal angiography, interventional
neuroradiology, and carotid and transcranial Doppler ultrasound. Our
neuroimaging staff subspecialize in specific disease entities, such as
epilepsy and cerebrovascular disease, ensuring accurate, in-depth
interpretations.
• Center for Headache and Pain
• Center for Neurological Restoration
• Center for Pediatric Neurology and Neurosurgery
• Center for Spine Health
Additional diagnostic tools are found in our Epilepsy Monitoring Units,
Sleep Laboratories, Neuropsychological Testing Facilities, Electromyography
Laboratory, Autonomic Laboratory and Cutaneous Nerve Laboratory.
• Cerebrovascular Center
• Epilepsy Center
• Mellen Center for Multiple Sclerosis Treatment and Research
• Neuromuscular Center
• Sleep Disorders Center
We provide care across the spectrum of neurological disorders, including
primary and metastatic tumors of the brain, spine and nerves; pediatric
5
The Latest Treatment Modalities
Patients can receive leading-edge treatment options at the Neurological
Institute, where we continue to advance such innovations as deep brain
stimulation (brain pacemakers), epilepsy surgery, stereotactic spine
radiosurgery, blood-brain barrier disruption, endovascular treatment of
cerebral aneurysms and vascular malformations, and neuroendoscopy.
Distinctive services such as our three-week outpatient program for
sufferers of chronic headaches and our Headache Infusion Suite provide
intensive therapy when it is needed. The Brain Tumor and Neuro-Oncology
Center’s Translational Therapeutics Program is accelerating the process of
bringing novel therapeutic agents from the laboratory to the patient, while
maintaining the highest standards of efficacy and safety. Joint Commission
certification as a Primary Stroke Center and accreditation by the American
Academy of Sleep Medicine are just two examples of our commitment to
providing the most advanced and highest quality of care to our patients.
Neurological Institute
Relevant Research
6
National ranking U.S.News
& World Report gave to
We strive to conduct research directly related to conditions experienced by our patients, including programs in
translational research, clinical trials of drug and device interventions, neuroimaging research, epidemiology and
health outcomes, behavioral and psychiatric research, and research into better diagnostic methods. Typically,
more than 100 clinical research trials are underway at the Neurological Institute. In the area of basic science,
a core of internationally recognized scientists with external funding totally $10 million annually conduct
investigations at the Cleveland Clinic Lerner Research Institute Department of Neurosciences.
Cleveland Clinic’s neurology
and neurosurgery programs
in 2007
Convenient Care in the Community
We are committed to making access to world-class care convenient for all patients — whether coming to us
from near or far. Our Neurological Institute Regional Centers are a system-wide effort to extend our services
to regional hospitals and at Cleveland Clinic family health centers throughout the community. In addition,
Cleveland Clinic neurologists oversee inpatient care at a number of Cleveland Clinic hospitals. Our Sleep
Disorders Center is pioneering the idea of hotel-based sleep studies, offering overnight studies at five locations
throughout the community for patients’ convenience and comfort.
Integrated Nursing Services
15
Number of locations
throughout the region
where Neurological
Institute staff treat patients,
bringing neurological care
to convenient community
locations
Nursing in the institute integrates inpatient and ambulatory nursing, enhancing the continuum of patient care.
This unique structure also lends itself to greater information sharing and process improvement opportunities.
Through continuing education programs, we are able to broaden nursing educational opportunities from basic
nursing instruction to subspecialization in neurological nursing, much like our physician colleagues.
Pioneering the Collection of Data and Outcomes
The Knowledge Program is a joint initiative of the Neurological Institute, the Imaging Institute and the Division
of Information Technology, and is designed to harness routinely collected electronic clinical and administrative
data to allow us to optimize patient care and outcomes. Data from multiple electronic sources, including
imaging results and clinical information collected during patient encounters such as disease-specific measures
of patients’ health status, will be consolidated into a clinical data warehouse that can be accessed and
queried by healthcare personnel. An integral part of this initiative is the standardization of clinical information
documented within the electronic medical record. Information gained from the Knowledge Project will inform
and guide clinical care, quality improvement and research.
At the Cleveland Clinic Neurological Institute, we are dedicated to maximizing patient care outcomes and the
patient experience, and to advancing medical education and research in all areas of neurology, neurosurgery
and psychiatry.
Outcomes 2007
6
2007 Statistical Highlights
Staff Physicians
Clinical Residents and Fellows
220
Admissions
134
Brain Tumor and Neuro-Oncology
6,932
906
17
Center for Neurological Restoration
Advanced Practice Nurses
27
Cerebrovascular
1,138
Physician Assistants
15
Epilepsy
1,175
Research Fellows
Initial Outpatient Visits
10,783
333
Neurocognitive
411
Neurology
406
Brain Tumor and Neuro-Oncology
465
Pediatric Neurology
220
Center for Neurological Restoration
326
Psychiatry and Psychology
759
Cerebrovascular
515
Regional Neurological Institute
809
Spine
Epilepsy
27
1,557
Headache and Pain
862
Mellen Center
749
Inpatient Days
Neurocognitive
304
Brain Tumor and Neuro-Oncology
Neurology
803
Center for Neurological Restoration
1,475
Neuromuscular
771
Cerebrovascular
6,568
Pediatric Neurology
1,109
6,015
1,818
2,242
Psychiatry and Psychology
916
Regional Neurological Institute
360
Neurology
Sleep
156
Pediatric Neurology
Spine
2,638
Psychiatry and Psychology
Regional Neurological Institute
184,854*
3,843
120
8,409
7,142
8,354
Center for Neurological Restoration
6,499
Surgical Cases
4,135
Brain Tumor and Neuro-Oncology
9,536
Center for Neurological Restoration
Epilepsy
736
Spine
Brain Tumor and Neuro-Oncology
Cerebrovascular
4,075
Epilepsy
Neurocognitive
Total Outpatient Visits
35,897
Headache and Pain
13,315
Cerebrovascular
Mellen Center
20,301
935
489
1,057
Epilepsy
370
4,105
Neurocognitive
450
Neurology
4,995
Regional Neurological Institute
Neuromuscular
8,121
Spine
Pediatric Neurology
7,623
Neurocognitive
Psychiatry and Psychology
Regional Neurological Institute
47,497
7,706
162
3,679
Neuroimaging Studies**
Total CT Brain Scans
60,000
50,000
Sleep
11,690
Total MR Brain Procedures
Spine
30,977
Total Cerebral Angio Procedures
3,000
*includes outpatient procedures and diagnostic studies
** studies performed on main campus, Cleveland Clinic satellites and
family health centers, estimated
7
Neurological Institute
Brain Tumor
Overview
Tumor Diagnosis Distribution
151 Schwannoma
894 Glioma
185 Pituitary
434 Metastases
381 Meningioma
Gliomas remain the most common tumor type.
Procedure Distribution
81 Pituitary Surgery
289 Gamma Knife®
53 Infratentorial Craniotomy
79 Novalis®
272 Supratentorial Craniotomy
64 Brain Biopsy
The majority of patients undergo supratentorial craniotomy or Gamma Knife® radiosurgery.
Outcomes 2007
8
Surgical Site Infection Rates
Rate per 100 Clean Cases (Percent)
5
4
3
2
1
0
2005
2006
2007
Surgical site infections remain stable at three percent. Per CDC guidelines, “Clean Cases” are defined as uninfected operative wounds in which no
inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tract is not entered.
Patient Enrollment
500
Therapeutic Trials
Genetic Trials
400
300
200
100
0
2003
2004
2005
2006
2007
Therapeutic trial enrollment has remained consistent over the past few years, with enrollment in genetic trials over 250 yearly.
9
Neurological Institute
Outcomes per Procedure
Brain Biopsy: Inpatient Mortality
Number
6
Actual Deaths
Expected Deaths
5
4
3
2
1
0
2003
2004
2005
2006
2007
Expected deaths are based on APR-DRGs which adjust for the severity of the patient population.
Brain Biopsy: Length of Stay
Days
6
Number of Cases
120
5
100
4
80
3
60
2
40
1
20
0
2003
2004
2005
2006
2007
Mean LOS
Target LOS
Cases
0
Mean length of stay (LOS) for brain biopsy admissions was the lowest in five years. Target LOS is calculated based on APR-DRGs which adjust
for the severity of the patient population.
Outcomes 2007
10
KPS Status following Brain Biopsy (N=61)
Percent of Patients
100
Immediately Post-Op
60-Days Post-Op
80
60
40
20
0
Improved
Declined
No Change
Change in KPS (Karnovsky Performance Scale) was defined as a change of 20 points or more. Ninety-five percent of patients either improved or remained
stable immediately following stereotactic brain biopsy.
Supratentorial Craniotomy: Survival
Percent Survival
100
Number of Surgeries
500
80
400
60
300
40
200
20
100
0
30-Day Survival
180-Day Survival
# of Surgeries
0
2003
2004
2005
2006
2007
Supratentorial craniotomy procedural volumes were 16 percent above 2003 values at 272 cases. 180-day survival was a record 92.3 percent.
11
Neurological Institute
Supratentorial Craniotomy: Inpatient Mortality and Length of Stay
Days
6
Number of Deaths
12
5
10
4
8
3
6
2
4
1
2
0
2003
2004
2005
2006
2007
Target LOS
Mean LOS
Actual Mortality
Expected Mortality
0
Expected deaths are based on APR-DRGs which adjust for the severity of the patient population.
KPS Status following Supratentorial Craniotomy (N=248)
Percent of Patients
100
Immediately Post-Op
60-Days Post-Op
80
60
40
20
0
Improved
Declined
No Change
Change in KPS (Karnovsky Performance Scale) was defined as a change of 20 points or more. Performance status was stable or improved in
over 90 percent of patients immediately after supratentorial craniotomy.
Outcomes 2007
12
Supratentorial Craniotomy: Survival by Tumor Type
Glioma
Number of Surgeries
150
Percent Survival
100
80
120
60
90
40
60
20
30
0
2003
2004
2005
2006
2007
30-Day Survival
180-Day Survival
# of Surgeries
0
Meningioma
Percent Survival
100
Number of Surgeries
100
80
80
60
60
40
40
20
20
0
2003
2004
2005
2006
2007
30-Day Survival
180-Day Survival
# of Surgeries
0
Metastases
Percent Survival
100
Number of Surgeries
50
80
40
60
30
40
20
20
10
0
2003
2004
2005
2006
2007
30-Day Survival
180-Day Survival
# of Surgeries
0
Thirty and 180-day survival remained robust in 2007 for supratentorial craniotomy independent of tumor type.
13
Neurological Institute
Infratentorial Craniotomy: Survival
Percent Survival
100
Number of Surgeries
100
80
80
60
60
40
40
20
20
0
2003
2004
2005
2006
2007
30-Day Survival
180-Day Survival
# of Surgeries
0
Thirty and 180-day survival remained robust in 2007 for infratentorial
craniotomies at 100 and 96.2 percent.
Outcomes 2007
14
Infratentorial Craniotomy: Survival by Tumor Type (2003-2007)
Percent Survival
100
Number of Surgeries
50
30-Day Survival
80
40
60
30
40
20
20
10
180-Day Survival
# of Surgeries
0
Glioma
Meningioma
Brain
Metastases
Schwannoma
0
KPS Status following Infratentorial Craniotomy (N=53)
Percent Survival
100
Immediately Post-Op
60-Day Post-Op
80
60
40
20
0
Improved
Declined
No Change
Change in KPS (Karnovsky Performance Scale) was defined as a change of 20 points or more. Performance status was stable or improved in
over 90 percent of patients undergoing infratentorial craniotomy.
15
Neurological Institute
Pituitary Surgery: Survival
Percent Survival
100
Number of Surgeries
100
80
80
60
60
40
40
20
20
0
2003
2004
2005
2006
2007
30-Day Survival
180-Day Survival
# of Surgeries
0
Thirty and 180-day survival remained at 100 and 98.8 percent respectively for pituitary tumors in 2007.
KPS Status following Pituitary Surgery (N=90)
Percent of Patients
100
Immediately Post-Op
60-Day Post-Op
80
60
40
20
0
Improved
Declined
No Change
Change in KPS (Karnovsky Performance Scale) was defined as a change of 20 points or more. Performance status remained stable or
improved in 100 percent of patients immediately after pituitary surgery.
Outcomes 2007
16
Pituitary Surgery: Inpatient Mortality
Days
5
Number of Deaths
1.0
4
0.8
3
0.6
2
0.4
1
0.2
0
2003
2004
2005
2006
2007
Mean LOS
Target LOS
Actual Mortality
Expected Mortality
0
There have been no inpatient deaths following pituitary surgery in the past five years. Target
Length of Stay (LOS) is calculated based on APR-DRGs which adjust for the severity of the
patient population.
17
Neurological Institute
Stereotactic Radiosurgery: Survival
Gamma Knife® and Novalis® radiosurgery deliver high intensity, focused radiation directly to multiple sites within a tumor. Gamma Knife® is used for
single treatments of small tumors. Novalis® is used for larger tumors.
Gamma Knife®
Percent Survival
100
Number of Deaths
300
80
240
60
180
40
120
20
60
0
2003
2004
2005
2006
2007
30-Day Survival
180-Day Survival
# of Procedures
0
The number of Gamma Knife® cases peaked in 2007 despite a six-week hiatus for upgrading to the Gamma Knife® PerfexionTM. Thirty and
180-day survival for Gamma Knife® were 97.6 and 91.3 percent respectively with the highest 180-day survival in the last five years.
Novalis®
Percent Survival
100
Number of Procedures
100
80
80
60
60
40
40
20
20
0
2003
2004
2005
2006
2007
30-Day Survival
180-Day Survival
# of Procedures
0
A record of 79 patients were treated with Novalis® stereotactic radiosurgery in 2007 representing a 22 percent increase from 2006.
Outcomes 2007
18
Gamma Knife® Stereotactic Radiosurgery: Survival by Tumor Type
Meningioma
Percent Survival
100
Number of Procedures
50
80
40
60
30
40
20
20
10
0
2003
2004
2005
2006
2007
30-Day Survival
180-Day Survival
# of Procedures
0
Metastases
Percent Survival
100
Number of Procedures
160
80
150
60
140
40
130
20
120
0
2003
2004
2005
2006
2007
30-Day Survival
180-Day Survival
# of Procedures
110
Pituitary
Percent Survival
100
80
20
60
15
40
10
20
5
0
19
Number of Procedures
25
2003
2004
2005
2006
2007
30-Day Survival
180-Day Survival
# of Procedures
0
Neurological Institute
Gamma Knife® Stereotactic Radiosurgery: Survival by Tumor Type
Acoustic/Schwannoma
Percent Survival
100
Number of Procedures
50
80
40
60
30
40
20
20
10
0
2003
2004
2005
2006
2007
30-Day Survival
180-Day Survival
# of Procedures
0
Spine Radiosurgery for Painful Spinal Metastases (N=54)
BPI Score
10
8
6
4
2
0
Baseline
W1
W2
W3
M1
M3
Brief Pain Inventory (BPI) scores following spine radiosurgery in patients presenting with painful spinal metastases. Individual and mean patient scores
+ 1 s.e. on the BPI, a brief 10-item self-rating pain scale, are plotted for each time period: baseline, weeks 1-3 (WI-W3), months 1 and 3 (M1, M3)
after spine radiosurgery. Spine radiosurgery is a palliative treatment for pain, typically in end-stage cancer patients. A total of 54 patients with painful
spinal metastases were treated with single fraction Novalis® spine radiosurgery from 2006 to 2007. As early as week one post treatment there was a
statistically significant improvement in patient pain scores. At one month the response rate (the number of patients with improvement in pain) was
85 percent. These results remained stable over time.
Outcomes 2007
20
Cerebrovascular Disease
Stroke Treatment Quality
Clinical Measure
Measure Description
National Average
Jan-March 2004*
GWTG
Performance
Award Goal**
2006
Cleveland
Clinic
2007
Cleveland
Clinic
DVT Prophylaxis
The percentage of patients at risk for Deep Venous
Thrombosis (DVT) who received DVT Prophylaxis
by the second hospital day
77.5%
(1513/1953)
85%
91.3%
93.6%
(220/235)
Antithrombotics
within 48 hrs
Percent of ischemic stroke or TIA patients who
receive antithrombotic medication within 48 hours
of hospitalization
95.2%
(2592/2724)
85%
96.7%
96.1%
(199/207)
Antithrombotics at
Discharge
Percent of ischemic stroke or TIA patients
discharged on antithrombotics (e.g., warfarin,
aspirin, other antiplatelet drug)
96.9%
(2685/2771)
85%
96.2%
98.6%
(350/355)
Anticoagulation for
Atrial Fibrillation
Percent of ischemic stroke or TIA patients
with atrial fibrillation who are discharged on
anticoagulation therapy (warfarin/Coumadin or
heparin/heparinoids) unless an absolute or relative
contraindication exists
96.5%
(167/173)
85%
97.0%
94.6% (35/37)
IV tPA use (Eligible
<2hr arrival)
Percent of acute ischemic stroke patients who
arrive at the ED within 120 minutes (two hours)
of onset of stroke symptoms who receive IV t-PA
within 180 minutes (three hours) of onset of stroke
symptoms
40.8%
(69/169)
85%
85%
60.0% (3/5)
Statin at Discharge
Percent of ischemic stroke or TIA patients with
LDL > 100 mg/dL OR on cholesterol reducer prior
to admission who are discharged on cholesterol
reducing drugs
57.1%
(1255/2199)
85%
85.2%
90.9%
(229/252)
Smoking
Counselling
documented
Percent of smokers who are documented of
receiving smoking cessation advice or medication
(e.g., Nicoderm® or Zyban®) at discharge
85%
85.0%
100.0%
(101/101)
54.5%
(274/503)
Quality Measure indicators are based upon Get With The GuidelinesSM (GWTG) definitions. GWTG is the premier hospital-based quality improvement
program for the American Heart Association and the American Stroke Association. It empowers healthcare provider teams to consistently treat heart and
stroke patients according to the most up-to-date guidelines and is consistent with quality measures used as part of The Joint Commission’s Primary Stroke
Center Certification process.
**Cleveland Clinic exceeds the “Get with the Guidelines” targets of 85 percent compliance in six of the seven core GWTG-Stroke measures
21
Neurological Institute
Cerebrovascular Procedural Volume
Number of Procedures
4,000
Diagnostic Procedures
Endovascular Procedures
3,000
2,000
1,000
0
2003
2004
2005
2006
2007
Distribution of Major Case Type
Number of Procedures
350
AVM
Unruptured Cerebral Aneurysm
Ruptured Cerebral Aneurysm
300
250
200
150
100
50
0
2003
Outcomes 2007
2004
2005
2006
2007
22
Treatment of Unruptured Aneurysms
Number of Procedures
200
Endovascular
Microsurgery
100
0
2003
2004
2005
2006
2007
Treatment of Ruptured Aneurysms
Number of Procedures
150
Endovascular
Microsurgery
100
50
0
2003
2004
2005
2006
2007
Changes in Treatment Options for Patients with Cerebrovascular Disease
Percent of Procedures
100
Endovascular Treatment
Surgical Treatment
50
0
23
2003
2004
2005
2006
2007
Neurological Institute
Ruptured Aneurysms: Length of Stay
Number of Cases
160
Days
20
Total Inpatient Cases
Mean LOS
120
15
80
10
40
5
0
2003
2004
2005
2006
2007
0
Unruptured Aneurysms: Length of Stay
Number of Cases
200
Days
8
150
6
100
4
50
2
0
Total Inpatient Cases
Mean LOS
0
2003
2004
2005
2006
2007
Discharge Status
2007 Discharge Status
Home
Non-ruptured Aneurysms
Ruptured Aneurysms
80%
37%
Home Health
5%
5%
Acute Rehab
3%
14%
Skilled Nursing Facility
6%
7%
Expired
1%
19%
Other
5%
18%
Outcomes 2007
24
Epilepsy
Long-term seizure-freedom following frontal lobe surgery for epilepsy: (N=119 surgeries from 1997-2007).
Probability of seizure-freedom
1.0
0.8
0.6
0.4
0.2
0.0
0
1
2
3
4
Time since surgery (years)
Time Since Surgery
6 months
1 year
2 years
4 years
% Seizure-Free
60%
59%
56%
44%
In patients with persistent seizures after surgery, there was a significant drop in seizure frequency down from a mean of 120 seizures/month
preoperatively to 20 seizures/month postoperatively.
There are no long-term outcome results published for other centers. Short term rates of seizure freedom in this patient population varied from
13 to 80 percent.
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Neurological Institute
Seizure-freedom following hemispherectomy for epilepsy (N=65 surgeries from 2004-2006)
Probability of seizure-freedom
1.0
0.8
0.6
0.4
0.2
0.0
0
1
2
3
Time since surgery (years)
Time Since Surgery
6 months
1 year
2 years
3 years
% Seizure-Free
79%
75%
67%
53%
Outcomes 2007
26
Seizure-freedom following temporal lobectomy for epilepsy (N=474 surgeries from 1997-2007)
Probability of seizure-freedom
1.0
0.8
0.6
0.4
0.2
0.0
0
1
2
3
4
5
6
7
8
9
10
11
Time since surgery (years)
Time since surgery
1 year
2 years
5 years
10 years
% seizure-free (Cleveland Clinic)
81%
75%
71%
68%
% seizure-free (national)
72%
54%
59%
51%
In patients with persistent seizures after surgery, there was a significant improvement in seizure frequency: down from an average of 52 seizures/month
preoperatively to 14 seizures/month postoperatively (73 percent reduction in seizure frequency). National seizure-free rates represent a weighted average
of recent studies conducted in the United States1-7.
1. Erickson JC, Ellenbogen RG, Khajevi K, Mulligan L, Ford GC, Jabbari B. Temporal lobectomy for refractory epilepsy in the U.S. military. Mil Med. 2005;170:201-205;
2. Spencer SS, Berg AT, Vickrey BG, et al. Predicting long-term seizure outcome after resective epilepsy surgery: The multicenter study. Neurology. 2005;65:912-918;
3. Kelley K, Theodore WH. Prognosis 30 years after temporal lobectomy. Neurology. 2005;64:1974-1976; 4. Yoon HH, Kwon HL, Mattson RH, Spencer DD, Spencer
SS. Long-term seizure outcome in patients initially seizure-free after resective epilepsy surgery. Neurology. 2003;61:445-450; 5. Foldvary N, Nashold B, Mascha E, et al.
Seizure outcome after temporal lobectomy for temporal lobe epilepsy: A Kaplan-Meier survival analysis. Neurology. 2000;54:630-634; 6. Salanova V, Markand O, Worth R.
Longitudinal follow-up in 145 patients with medically refractory temporal lobe epilepsy treated surgically between 1984 and 1995. Epilepsia. 1999;40:1417-1423;
7. Sperling MR, O’Connor MJ, Saykin AJ, Plummer C. Temporal lobectomy for refractory epilepsy. JAMA. 1996;276:470-475.
27
Neurological Institute
Seizure-freedom following posterior quadrant resections for epilepsy (N=60 surgeries from 1997-2007)
Probability of seizure-freedom
1.0
0.8
0.6
0.4
0.2
0.0
0
1
2
3
4
5
6
7
8
9
10
11
Time since surgery (years)
Time Since Surgery
1 year
2 year
5 years
10 years
% Seizure-Free
69%
66%
66%
55%
Outcomes 2007
28
Depression Scores after Temporal Lobectomy (N=250)
Mean BDI-II Score
15
Pre-Surgery
Post-Surgery
10
5
0
Left Temporal
Right Temporal
Mean depression scores, as measured by the Beck Depression Inventory-II (BDI-II), were decreased six months following temporal lobectomy,
indicating an improvement in depressive symptoms.
Change in Mood Severity after Temporal Lobectomy (N=250)
11% Worsened Mood
67% No Mood Change
22% Improved Mood
Individual changes in mood, as measured by the BDI-II, following temporal lobectomy for intractable epilepsy. Change in mood was defined as moving
from one severity category to another. Severity categories are BDI-II scores 0-13 for minimal, 14-19 for mild, 20-29 for moderate, and 29-63 for severe
depression.
29
Neurological Institute
Headache
Pain Outcome Following IMATCH (N=36)
Pain Ratings (0=No Pain; 10=Worst Possible Pain)
10
Admission
Discharge
8
6
4
2
0
Current
Average
Least
Worst
Pain
Pain scores (mean + s.d.) decrease following the IMATCH (Interdisciplinary Method for the Assessment and Treatment of Chronic Headache) Program.
N=36 patients completing the three-week program in 2007.
Stress, Anxiety and Depression Following IMATCH (N=36)
Emotional Functioning Scores
Scale Score
35
Admission
Discharge
30
25
20
15
10
5
0
DASS Stress Scale
DASS Anxiety Scale
DASS Depression
Measures of stress, anxiety, and depression all decrease following IMATCH, indicating improvement. Mean DASS-42 (Depression, Stress, and Anxiety
Scale) subscale scores are plotted with their standard deviations.
Outcomes 2007
30
Functional Status Following IMATCH (N=36)
Disability Scores
Scale Score
100
Admission
Discharge
80
60
40
20
0
Pain Disability
Index (0-70)
Headache
Disability
Index (0-100)
Dizziness
Neck Disability
Handicap Index
Index
(0-100)
(0-100)
Disability scores improve (higher scores indicate greater levels of disability) following completion of the IMATCH program.
Patient Satisfaction Following IMATCH (N=36)
Treatment Helpfulness Ratings (-5 to 5)
Average Satisfaction
5
4
3
2
1
0
Whole
Program
Medical
Treatment
Psychological
Treatment
Physical
Therapy
Program Components
Scores on the Treatment Helpfulness Questionnaire indicate high rates of patient satisfaction.
31
Neurological Institute
Infusion Therapy for Headache
The Headache Center Infusion Suite provides intravenous treatments specifically for headaches under the guidance of a headache staff physician.
Same-day care is also available for patients in the Headache Program.
Headache Infusion Suite
2,000
1,000
0
Number of
Infusions
Number of
Patients
The number of yearly infusions continues to increase, with headache patients averaging two to three infusions each in 2007.
Pain Reduction with Infusion Therapy (N=198)
Percent of Patients
100
80
60
40
20
0
0-24
25-49
50-74
75-100
Percent Pain Reduction
Percent of patients reporting various levels of pain reduction following infusion therapy. Over 60 percent of patients reported a 50 percent or greater
reduction in pain immediately after treatment.
Outcomes 2007
32
Botox Therapy for Headache
1,000
500
0
Number of Injections
Number of Patients
Botox continues to be a popular treatment for headache, with patients
averaging two treatments per year.
33
Neurological Institute
Movement Disorders
Deep Brain Stimulation (DBS) Procedures
80
2006
2007
60
40
20
0
Parkinson’s
Disease
Tremor
Dystonia
Other
Improvement in Motor Scores with DBS
UPDRS Motor Scores
80
Stimulation on
Stimulation off
60
40
20
0
Bilateral DBS, N=28
Unilateral DBS, N=27
Type of Surgery
Improvement in motor functioning in Parkinson’s disease with deep brain stimulation. Motor functioning is measured with the Unified Parkinson’s Disease
Rating Scale, Part III (Motor Subscale). Motor scores are shown with the stimulator in the on and off states.
Outcomes 2007
34
Percent Improvement in Motor Function following DBS for Parkinson’s Disease
100
80
60
40
20
0
Bilateral DBS, N=28
Unilateral DBS, N=27
Type of Surgery
Percent improvement on Unified Parkinson’s Disease Rating Scale (UPDRS), Part III (Motor Subscale) following deep brain stimulation treatment for
Parkinson’s Disease.
35
Neurological Institute
Multiple Sclerosis
Intrathecal Baclofen Therapy
Intrathecal baclofen (ITB) therapy is approved by the FDA for the treatment of severe spasticity of spinal or cerebral origin refractory to other treatment
modalities. The Mellen Center has been using this therapeutic modality since its approval, with over 250 patients treated since 1990. The intrathecal
infusion device (baclofen pump) is implanted by neurosurgeons at the Center for Neurological Restoration at Cleveland Clinic. Patient selection, testing,
and postoperative management are performed in the Mellen Center Spasticity Clinic.
From January to December 2007, 19 patients underwent the implantation of a baclofen pump.
Diagnosis/Indication for ITB
Multiple Sclerosis
Number of Patients
10
ALS (Amyotrophic Lateral Sclerosis)
2
Cerebral Palsy
2
Stroke
1
Spinal Cord Injury
1
Myelopathy
2
Adrenomyeloneuropathy
1
Total
19
Three patients had complications leading to treatment discontinuation in two patients.
Postoperative Outcome
Infection leading to removal of the device and treatment discontinuation
Number of Patients
2
Device malfunction requiring surgical revision; patient continued treatment
1
No complications
16
Total
19
Outcomes 2007
36
Modified Ashworth Scale following ITB (N=17)
Spasticity Score
4
3
2
1
0
Before
After
Treatment
Spasticity scores on the Modified Ashworth Scale (0=no increase in tone, 4=severe increase in tone) at baseline and after ITB therapy. There was a
statistically significant (p<0.001, paired t-test) reduction in spasticity after treatment. Average follow-up for the 17 patients was 167 days.
Spasm Frequency following ITB (N=17)
Spasm Frequency Score
4
3
2
1
0
Before
After
Treatment
Spasm Frequency Scale scores (0=no spasms, 4=more than 10 spasms/hour) at baseline and at most recent follow-up visit. There was a statistically
significant (p<0.001, paired t-test) reduction in spasm frequency after treatment. Average follow-up for the 17 patients was 167 days.
37
Neurological Institute
Ambulating Following ITB
The Mellen Center has developed expertise in the use of ITB therapy in ambulatory patients. ITB therapy in this population has the same potential
benefits in terms of reduction of bothersome spasticity which may interfere with activities of daily living, sleep, and quality of life in general. However,
a common concern about ITB is that it may cause increased weakness with loss of function. Ten of our ITB patients (59 percent) were ambulatory
at baseline. Only one patient became nonambulatory at follow-up. This patient had a diagnosis of amyotrophic lateral sclerosis (ALS) and the loss of
ambulation was attributed to rapid disease progression.
Gait Speed (Timed 25-Foot Walk)
Gait Speed (seconds)
20
15
10
5
0
Before
After
There was no significant change in gait speed, as measured with the Timed 25-Foot Walk Test, following ITB, supporting the conclusion that ITB can be
used in carefully selected ambulatory patients without loss of function.
Outcomes 2007
38
Natalizumab (Tysabri®) Therapy
Natalizumab (Tysabri®) is the newest approved disease-modifying therapy for multiple sclerosis. Because of safety concerns (two cases of PML:
Progressive Multifocal Leukoencephalopathy), there are restrictions imposed by the FDA on the administration of the medication. The Mellen Center
is one of the centers approved to administer natalizumab. Between Aug. 29, 2006, and Jan. 2, 2008, 108 patients were started on natalizumab at
the Mellen Center. The average treatment duration to date is 242 days, for an average number of seven infusions. Eighteen patients (16.7 percent)
discontinued therapy. The reasons for treatment discontinuation are presented below. There were no cases of PML. The treatment was judged to be
effective in 83.3 percent of patients, defined as clinical and/or MRI stability at follow-up visits. Significant improvement of neurologic status was noted
in 11 percent of the total number of patients treated. The usual goal of disease-modifying therapies in MS is to achieve relative stability; an actual
improvement in neurological function is unusual.
Time to Tysabri® Treatment Discontinuation
Percent Patients Continuing Treatment
100
80
60
40
20
0
0
5
10
15
Months
Kaplan-Meier curve of time to treatment discontinuation. Approximately 80 percent of patients continue on treatment at 15 months.
Reasons for Discontinuation
Allergy
39
Number of Patients
4
Details
One of the four patients developed neutralizing antibodies against natalizumab.
Lack of efficacy
7
Unknown
3
Three patients transferred care closer to home; it is not known if they continued
treatment with natalizumab.
Complications
1
One patient developed multiple infections.
Side effects
1
One patient developed headache, nausea.
Other
2
One patient became pregnant and one patient decided to discontinue treatment
due to potential adverse effects.
Neurological Institute
Botulinum Toxin Therapy
Botulinum toxin (BT) is used off-label in the United States for the treatment of focal spasticity.
Diagnoses of patients treated with BT in 2007
Diagnosis/Indication for BT
Number of Patients
Multiple Sclerosis
25
Traumatic Brain Injury
2
Cerebral Palsy
5
Stroke
9
Myelopathy
4
Other
4
Total
49
Between January and December 2007, 49 patients initiated BT
therapy at the Mellen Center. A majority of these patients have
multiple sclerosis (MS). No patients developed complications.
Two patients (4 percent) reported transient side effects after the
injections. Two patients (4 percent) decided to discontinue BT
therapy (not related to side effects).
Botox Treatment Effectiveness (N=47)
Percent Patients Reporting Treatment Effectiveness
100
80
First follow-up visit
Last follow-up visit
60
40
20
0
Effect on symptoms
Effect on function
Percent of patients reporting treatment effectiveness following botox therapy for focal spasticity. Patients were assessed at first follow-up visit (three
months after initial treatment) and subsequently every three months. Average last follow-up was six months, with a range up to 12 months. The average
follow-up period for the 47 patients who continued treatment is 170 days. The average dose injected at the most recent session was 360 units of
botulinum toxin A. Most patients reported benefit with treatment both on symptoms and function, and the results were stable over time.
Outcomes 2007
40
Neuromuscular Disease
Skin Biopsy for Small Fiber Sensory Neuropathy
Number of Procedures
250
200
150
100
50
0
Total
SFSN
SFSN exclusively
by skin bx
Cleveland Clinic is one of a few medical centers with a cutaneous nerve laboratory to facilitate evaluation of small fiber sensory neuropathy (SFSN).
In 2007, we performed skin biopsies with intraepidermal nerve fiber density evaluation for 233 patients. One hundred and seventy eight patients
(76 percent) were diagnosed with SFSN based on the biopsy results. In 79 patients (44 percent) the diagnosis was made exclusively by skin biopsy.
Our data are consistent with reports by other medical centers that skin biopsy is a valuable diagnostic tool and is more sensitive than electrophysiological studies for diagnosing SFSN1-3.
1. McArthur JC et al. Epidermal nerve fiber density: normative reference range and diagnostic efficiency. Arch Neurol. 1998 Dec;55(12):1513-1520; 2. Periquet MI
et al. Painful sensory neuropathy: prospective evaluation using skin biopsy. Neurology. 1999 Nov;53(8):1641-1647; 3. Herrmann DN et al. Plantar nerve AP and skin
biopsy in sensory neuropathies with normal routine conduction studies. Neurology. 2004 Sep;63(5):879-85.
41
Neurological Institute
Treatment of Painful Peripheral Neuropathy (N=42)
Pain Scores in Peripheral Neuropathy
50
40
30
20
10
0
-10
Mean VAS at
Baseline
Mean VAS at
Last Follow-up
Mean Change
in VAS
Of 42 patients with painful peripheral polyneuropathy followed for up to one year, 60 percent showed improvement in visual-analog pain scores (VAS)
with various treatment modalities.
Patients showed an average improvement (reduction in pain scores) of 25 percent. This compares to an average improvement of 12 to 42 percent in
published studies of treatment of neuropathic pain4-5.
4. Hampf G, Bowsher D, Nurmikko T. Distigmine and amitriptyline in the treatment of chronic pain. Anesth Prog. 1989 Mar-Apr;36(2):58-62; 5. McCleane G. Topical
application of doxepin hydrochloride, capsaicin and a combination of both produces analgesia in chronic human neuropathic pain: A randomized, double-blind,
placebo-controlled study. Br J Clin Pharmacol. 2000 June;49(6):574-579.
Outcomes 2007
42
Pediatric Neurology and Neurosurgery
Pediatric Neurosurgery (< 18 years)
Procedures
300
Days
6
200
4
100
2
0
Pediatric Neurosurgery
Procedures
Mean LOS
0
2003
2004
2005
2006
2007
Congenital Malformation
Procedures
100
Pediatric Congenital
Malformation
Adult Congenital
Malformation
75
50
25
0
2003
2004
2005
2006
2007
Chiari Malformation
Procedures
Days
8
100
Chiari Malformation
Mean LOS
75
6
50
4
25
2
0
0
2003
43
2004
2005
2006
2007
Neurological Institute
Spasticity
Procedures
Days
25
10
20
8
15
6
10
4
5
2
Adult
Peds
Mean LOS
0
0
2003
2004
2005
2006
2007
Tumors
Procedures
30
Days
12
Tumors
Mean LOS
20
9
10
3
0
0
2003
2004
2005
2006
2007
Hydrocephalus
Procedures
300
Days
6
Adult Normal
Pressure
Hydrocephalus
200
4
100
2
Pediatric
Hydrocephalus
Mean LOS
0
0
2003
Outcomes 2007
2004
2005
2006
2007
44
Endoscopic Third Ventriculostomy (ETV)
Number of Cases
30
Days
6
ETV Cases
Mean LOS
20
4
10
2
0
2004
2005
2006
0
2007
Time to Treatment Failure Following Endoscopic Third Ventriculostomy
Percent
100
80
60
40
20
0
0
10
20
30
40
Months
Time to treatment failure following endoscopic third ventriculostomy (ETV). Treatment failure is defined as recurrence of symptoms and/or need for
repeat surgery. Approximately 85 percent of patients continue to be symptom-free after one year, 76 percent after two years, and 70 percent after
three years.
45
Neurological Institute
Pediatric Headache (N=18)
50
Visit 1
Visit 2
40
30
20
10
0
Peds MIDAS
Headache
Frequency
Rescue
Doses
School
Days Missed
Pediatric patients treated for headache showed an improvement in PedsMIDAS (Migraine Disability Assessment Score), headache frequency, and
number of rescue medications needed. The number of school days missed is one of the questions included in the PedsMIDAS interview. N=18
pediatric patients with two PedsMIDAS scores an average of three months apart.
Pediatric EMG
Number of Studies
60
Total EMGs
EMGs with OR/Sedation
40
20
0
2003
2004
2005
2006
2007
There are very few medical centers in the country that provide high-quality electromyography (EMG) for the pediatric population with the option of
EMG under sedation, resulting in a more comprehensive examination and less discomfort for the patient.
Outcomes 2007
46
Pediatric Neurometabolic Clinic
The term idiopathic developmental delay is used to define some 3 percent of the population that has unexplained neurologic and developmental
symptoms including autism and epilepsy. Until very recently, this population of children and adults, some with progression of their symptoms
for unexplained reasons, remained largely without a diagnosis. With advances in technology and improving diagnostic skills the ability to reach
a conclusive diagnosis in this population has steadily improved. While there is no national standard, tertiary care centers such as ours have the
potential to reach a diagnosis 30 to 50 percent of the time1.
Neurometabolic Clinic Diagnostic Yield
Number of Patients
350
300
250
200
150
100
50
0
New patient
consults
Diagnosis established via
muscle, genetic, or CSF
In 2007 our Neurometabolic Clinic evaluated over 300 patients presenting with unexplained neurologic and/or developmental symptoms, and we
were able to establish a diagnosis in 125 patients, or 40 percent.
1. van Karnebeek CD, Scheper FY, Abeling NG, Alders M, Barth PG, Hoovers JM, Koevoets C, Wanders RJ, Hennekam RC. Etiology of mental retardation in children
referred to a tertiary care center: a prospective study. Am J Ment Retard. 2005 Jul;110(4):253-67.
47
Neurological Institute
Psychiatric Disorders
Psychiatric Admissions
Number of Patients/Patient-Days
10,000
Days
10
Admissions
8,000
8
6,000
6
4,000
4
2,000
2
Patient Days
Mean LOS
0
0
2003
2004
2005
2006
2007
Chronic Pain Rehabilitation Program
The Chronic Pain Rehabilitation Program is a comprehensive, interdisciplinary team approach to the treatment of patients with chronic pain. These
patients typically have pain that is not amenable to usual medical, surgical or interventional approaches. Most have substantial pain-related
functional impairment and many have substantial psychological distress as well.
Pain Intensity following Treatment
(0=No Pain, 10=Worst Possible Pain)
Pain Score
10
2006
2007
8
6
4
2
0
Admission
Discharge
6 months
12 months
Mean pain scores decrease following enrollment in the Chronic Pain Rehabilitation Program. Two hundred fifty-nine patients were admitted to the
program in 2006 and 233 in 2007. Approxmately 80 percent of patients completed the program. Typical treatment duration is 3.5 weeks.
Outcomes 2007
48
Depression Scores following Treatment
DASS Depression Score
40
2006
2007
30
20
10
0
Admission
Discharge
6 months
12 months
Depression scores, as measured with the DASS (Depression, Anxiety and Stress Scale) depression subscale, show improvement following treatment.
Anxiety Scores following Treatment
DASS Anxiety Score
40
2006
2007
30
20
10
0
Admission
Discharge
6 months
12 months
Anxiety scores, as measured with the DASS, show improvement with treatment.
Pain Disability following Treatment
(0=No Disability, 70=Total Disability)
Average Pain Disability Index (PDI)
70
2006
2007
60
50
40
30
20
10
0
Admission
Discharge
6 months
12 months
Functional status, as measured with the Pain Disability Index (PDI), shows improvement following treatment.
49
Neurological Institute
Patient Satisfaction with Chronic Pain Rehab Program
Percent of Patients
100
Excellent Rating
(Top Box)
80
Would Recommend
60
40
20
0
2006
2007
Fifty-three percent of patients rated the Chronic Pain Rehabilitation Program as Excellent at 6-month follow-up. Ninety percent of patients would
recommend the program to a friend. N=47 in 2006 and N=43 in 2007 (number of patients completing the survey).
Depressive symptom improvement with deep brain stimulation (DBS) in highly refractory depression
Percent Change in Score
0
HDRS
MADRS
-10
-20
-30
-40
-50
-60
-70
Baseline
(N=15)
1
(N=15)
3
(N=15)
6
(N=15)
12
(N=11)
Time Since Surgery (Months)
Change in Montgomery-Asberg Depression Rating Scale (MADRS) and Hamilton-24 Depression Rating Scale (HDRS) over time for the
subject population.
Outcomes 2007
50
Binge Eating Group
The Binge Eating Group is a cognitive behavioral group therapy conducted by the Section of General and Health Psychology and Bariatric and
Metabolic Institute, designed for bariatric surgery patients who reported behaviors consistent with Binge Eating Disorder (BED). BED has been
associated with poorer surgery outcomes including weight regain, and is thus an important factor to assess and treat for bariatric surgery patients.1,2
Patients are routinely given the Binge Eating Scale (BES) at their initial assessment by Psychology.3 Patients with elevated scores, those who meet
criteria for BED, or those who demonstrate other binge eating behaviors as determined by the interview are referred to the Binge Eating Group. The
BES and number of binges per week are then routinely assessed at the end of the four-week group to determine treatment progress along with a
satisfaction questionnaire.
The Binge Eating Group is a cognitive behavioral treatment including elements of self-monitoring, stimulus control, cognitive restructuring, body
image processing, stress management and relaxation training, and group support. The sample consisted of 81 patients who completed all four
sessions of the group, 86 percent of whom were female.
Outcomes following Binge Eating Therapy (N=81)
25
Before Treatment
20
After Treatment
15
10
5
0
Average BES
Average Number of
Binge Eating Episodes
The patient average on the BES showed a significant reduction following group treatment (p<.001). The average number of binge eating episodes
also showed a significant reduction following group treatment (p < .001). Average patient satisfaction was 4.52 (Very Satisfied to Extremely
Satisfied) on a scale of 1 (Extremely Dissatisfied) to 5 (Extremely Satisfied).
1. Guisado Macias JA, Vaz Leal FJ. Psychopathological differences between morbidly obese binge eaters and none-binge eaters after bariatric surgery. Eat Weight
Disord. 2003 Dec;8(4):315-318; 2. Hsu LK, Benotti PN, Dwyer L, Roberts SB, Saltzman E, Shikora S, Rolls BJ, Rand W. Nonsurgical factors that influence the
outcome of bariatric surgery: A review. Psychosomatic Medicine. 1998 May-Jun,60(3):338-346; 3. Gormally J, Black S, Daston S, Rardin D. The assessment of binge
eating severity among obese persons. Addictive Behaviors. 1982 Jan;7(1):47-55.
51
Neurological Institute
Sleep Disorders
Volume of Sleep Studies
Number
5,000
4,000
3,000
2,000
1,000
0
2004
2005
2006
2007
Distribution of Sleep Studies in 2007
234 Multiple Sleep
Latency Test
1870 Polysomography
2386 Polysomography
w/PAP
The Sleep Disorders Center performed 4490 total sleep studies in 2007. Several quality indicators are tracked each quarter for each of its
accredited sleep laboratories. Out of 4256 overnight studies performed in 2007, only three sentinel events occurred related to comorbid
cardiovascular disease. PAP=positive airway pressure.
Outcomes 2007
52
Types of Sleep Studies Performed in 2007
Number of Studies
2,500
Adult
2,000
Pediatric
1,500
1,000
500
0
PSG
Split study PAP titration
PSG-EEG
MSLT/MWT
PSG=polysomnography, Split study=combination PSG and PAP (positive airway pressure) titration, PSG-EEG=combination PSG and standard
electroencephalography, MSLT=multiple sleep latency test, MWT=multiple wake test.
Interscorer Reliability
Percent Reliability
100
80
60
40
20
0
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
Sleep study quality rests largely on the expertise of the recording technologists and interpreting physicians. Interscorer reliability is tracked each
quarter for all technologists. The American Academy of Sleep Medicine requires technologists to achieve a score of at least 85 percent compared
to the sleep staging and event scoring of a board-certified sleep medicine physician. For 2007, interscorer reliability for all Cleveland Clinic Sleep
Disorders Center locations surpassed the national standard.
53
Neurological Institute
Sleep Apnea
Improvement in Sleepiness (N=60)
ESS Score
20
15
10
5
0
Before PAP
After PAP
Sleepiness as measured with the Epworth Sleepiness Scale (ESS) in sleep apnea patients seen from June to December 2007, before and after PAP
(positive airway pressure) treatment. Higher scores indicate more severe daytime sleepiness; PAP treatment reduced sleepiness into the normal
range (<10). Average duration of treatment was 86 days.
Improvement in Fatigue (N=60)
FSS Score
60
40
20
0
Before PAP
After PAP
Fatigue as measured with the Fatigue Severity Scale (FSS) in sleep apnea patients seen from June to December 2007, before and after PAP
treatment. Higher scores indicate more severe fatigue. Patients showed a 9 percent improvement in fatigue after PAP treatment.
Outcomes 2007
54
Improvement in Depressive Symptoms (N=60)
PHQ-9 Score
15
10
5
0
Before PAP
After PAP
Depressive symptoms as measured with the Patient Health Questionnaire (PHQ-9), in sleep apnea patients seen from June to December 2007, also
improved after PAP treatment. PHQ-9 scores of 5-9 suggest mild depression, <5 suggests minimal depression.
Insomnia
Sleep Skills Group
Number of Patients
14
Before
12
After
10
8
6
4
2
0
No Insomnia
Mild
Moderate
Severe
Insomnia Category
The Sleep Skills Group is a novel treatment for insomnia started in 2007, one of the first of its kind in Northeast Ohio. After a five-week session, 69
percent of participants had a significant improvement in insomnia, and 22 percent of participants no longer had insomnia, as measured with the
Insomnia Severity Index.
55
Neurological Institute
Spinal Disorders
Selected Spinal Procedures
Type of Procedure
Tumor
Correction
Deformity
Decomcompressive
Biopsy
Arthrodesis
0
200
400
600
800
1,000
Number of Procedures
Spinal decompression remains the most frequently performed procedure for spine disease.
Mean Length of Stay (LOS) in Spinal Disorders
Days
10
Mean LOS
Target LOS
8
6
4
2
0
Sp
ina
De
ld
efo
rm
ge
ity
Sp
ne
ra
tiv
ina
es
No
lf
pin
ra
ed
ctu
ise
n-
re/
as
de
tra
e
Ne
ge
ne
um
a
ra
rvo
tiv
Sp
us
em
sy
us
ina
ste
cu
m
los
Sp
lt
um
dis
ke
lv
or
ord
let
ina
as
cu
lar
er
al-
pr
im
ar
ma
lfo
rm
ati
on
y
Target LOS is calculated based on APR-DRGs which adjust for the severity of the patient population.
Outcomes 2007
56
Surgical Site Infections following Spinal Surgery
Number of Cases
2,100
Total Clean Cases
1,800
Infections
1,500
1,200
900
600
300
0
Instrumented
Non-instrumented
Total
Infections by Procedure Type (N=2026)
Number of Infections
30
20
10
0
57
Ar
thr
od
De
es
is
co
mp
De
res
siv
for
Co
mi
ty
rre
Tu
cti
on
mo
r
e
Neurological Institute
Complications following Spinal Surgery (N=2026)
Number
50
40
30
20
10
0
Dural
Mechanical
Systemic
Unspecified
Type of Complication
Complications were defined as follows: Dural = related to hemorrhage, hematoma, postoperative fistula, or wound disruptions; Mechanical =
related to device, implant, or graft; Systemic = related to organ system involvement, central nervous system or otherwise.
Complications by Procedure Type (N=2026)
Number
50
40
30
20
10
0
Ar
thr
od
De
es
is
co
mp
De
res
siv
for
Co
mi
ty
rre
Tu
cti
on
mo
r
e
Procedure Type
Outcomes 2007
58
Spinal Surgery Complications and Mortality
Percent
50
40
30
20
10
0
Overall Complication Rate
59
30-Day Mortality Rate
Neurological Institute
Neurological Surgery Anesthesiology
Perioperative Normothermia in Neurological Surgery Cases (N=1,607)
Percent
100
80
60
40
20
0
1st
N=426
2nd
N=381
3rd
N=383
4th
N=417
Quarter
Source: Anesthesia Record Keeping System (ARKS)
The Section of Anesthesia for Neurological Surgery continues its emphasis on the management of perioperative normothermia (≥36.0˚C). Achieving
perioperative normothermia has been shown to reduce surgical wound infection rates. Performance increased substantially in 2007. The addition of
this measure in early 2008 to the Anesthesiologist Dashboard clinical practice reporting tool for staff anesthesiologists will provide data for continuous
improvement.
Patient Satisfaction with Management of Postoperative Nausea & Vomiting
Percent Favorable Responses
100
80
60
40
20
0
2006
n=253
2007
n=517
Source: Perioperative Health Documentation System (PHDS)
The department of General Anesthesiology visits spine, craniotomy and other neurological surgery inpatients on their second postoperative day in
the hospital to evaluate the early postoperative period and to obtain patients’ responses to a standardized anesthesia experience survey. Favorable
responses to the question “I threw up or felt like throwing up” are “Disagree very much” or “Disagree moderately”. Results for 2006 and 2007 for
neurological surgery inpatients are shown.
Outcomes 2007
60
Patient Satisfaction with Anesthesia Services
Percent Favorable Responses
100
80
60
40
20
0
2006
n=253
2007
n=514
Source: Perioperative Health Documentation System (PHDS)
A question in the postoperative patient satisfaction survey obtained during postoperative rounds asks for the response to the statement “I was satisfied
with my anesthesia care”. Favorable responses include “Agree very much” or “Agree moderately”. Results for 2006 and 2007 for spine, craniotomy
and other neurological surgery patients are shown.
61
Neurological Institute
Surgical Quality Improvement
Surgical Care Improvement Program (SCIP)
SCIP is a national campaign aimed at reducing surgical complications by 25 percent by the year 2010. SCIP is sponsored by the Centers for Medicare
and Medicaid Services (CMS) in collaboration with a number of other national partners serving on the steering committee, including the American Hospital
Association (AHA), Centers for Disease Control and Prevention (CDC), Institute for Healthcare Improvement (IHI), The Joint Commission and others.
Cleveland Clinic is committed to improving the care of surgical patients and participates in SCIP. A multidisciplinary team including the Surgery Institute,
Anesthesiology Institute, Infectious Disease Department, Nursing Institute, and Quality and Patient Safety Institute works together to ensure that our
surgical patients receive appropriate care.
Appropriate Preoperative Prophylactic Antibiotic Timing 2007
Percent
100
80
60
Cleveland Clinic
National Average*
Top Hospitals*
40
20
0
Jan Feb Mar Apr May Jun
Jul
Aug Sep Oct Nov Dec
* Source:United States Department of Health and Human Services, Hospital Compare
Most current reported discharges July 2006 to June 2007.
“Top Hospitals” represent the top 10 percent of reporting hospitals nationwide.
National average of all reporting hospitals in the United States.
Outcomes 2007
62
Appropriate Prophylactic Antibiotic Selection 2007
Percent
100
80
60
Cleveland Clinic
National Average*
Top Hospitals*
40
20
0
Jan Feb Mar Apr May Jun
Jul
Aug Sep Oct Nov Dec
* Source:United States Department of Health and Human Services, Hospital Compare
Most current reported discharges July 2006 to June 2007.
“Top Hospitals” represent the top 10 percent of reporting hospitals nationwide.
National average of all reporting hospitals in the United States.
Prophylactic Antibiotics Discontinued within 24 Hours After Surgery 2007
Percent
100
80
60
Cleveland Clinic
National Average*
Top Hospitals*
40
20
0
Jan Feb Mar Apr May Jun
Jul
Aug Sep Oct Nov Dec
* Source:United States Department of Health and Human Services, Hospital Compare
Most current reported discharges July 2006 to June 2007.
“Top Hospitals” represent the top 10 percent of reporting hospitals nationwide.
National average of all reporting hospitals in the United States.
63
Neurological Institute
Recommended Venous Thromboembolism Prophylaxis Received by Patient 2007
Percent
100
80
60
Cleveland Clinic
National Average*
Top Hospitals*
40
20
0
Jan Feb Mar Apr May Jun
Jul
Aug Sep Oct Nov Dec
* Source:United States Department of Health and Human Services, Hospital Compare
Most current reported discharges January 2007 to June 2007.
“Top Hospitals” represent the top 10 percent of reporting hospitals nationwide.
National average of all reporting hospitals in the United States.
Recommended Venous Thromboembolism Prophylaxis Ordered 2007
Percent
100
80
60
Cleveland Clinic
National Average*
Top Hospitals*
40
20
0
Jan Feb Mar Apr May Jun
Jul
Aug Sep Oct Nov Dec
* Source:United States Department of Health and Human Services, Hospital Compare
Most current reported discharges January 2007 to June 2007.
“Top Hospitals” represent the top 10 percent of reporting hospitals nationwide.
National average of all reporting hospitals in the United States.
Outcomes 2007
64
Surgery Patients Who Received their Beta Blocker Perioperatively 2007
Percent
100
80
60
Cleveland Clinic*
40
20
0
Jan Feb Mar Apr May Jun
Jul
Aug Sep Oct Nov Dec
* No national benchmark data available at this time
65
Neurological Institute
Patient Experience
Outpatient - Neurological Institute
We ask our patients about their experiences and satisfaction with the services provided by our staff. Although our patients are already indicating we
provide excellent care, we are committed to continuous improvement.
Overall Rating of Care 2007
Percent
100
N=5,565
80
60
40
20
0
Excellent
Very Good
Good
Fair
Poor
Overall Rating of Provider Care 2007
Percent
100
N=5,595
80
60
40
20
0
Outcomes 2007
Excellent
Very Good
Good
Fair
Poor
66
Would Recommend Provider 2007
Percent
100
N=5,431
80
60
40
20
0
67
Extremely
Likely
Very
Likely
Somewhat
Likely
Somewhat
Unlikely
Very
Unlikely
Neurological Institute
Inpatient - Cleveland Clinic
With the support of the Center for Medicare and Medicaid Services (CMS) and its partner organizations, the first national standard patient experience
survey was implemented in late 2006. Adult medical, surgical, and obstetrics and gynecology patients treated at acute care hospitals across the country
are included in the survey. Results collected for initial public reporting, published on www.hospitalcompare.gov in March 2008, are shown here.
Overall Rating of Care (0 worst - 10 best scale)
October 2006 - June 2007
Percent “9” or “10”
100
80
60
40
20
0
Cleveland Clinic
HCAHPS National Average
Total Cleveland Clinic Survey Respondents = 4,725
Would Recommend Facility
October 2006 - June 2007
Percent “Yes, definitely”
100
80
60
40
20
0
Cleveland Clinic
HCAHPS National Average
Total Cleveland Clinic Survey Respondents = 4,725
Outcomes 2007
68
Going Mobile and Pain-Free
David Marshall Jr., OD, PhD, is no stranger to Cleveland Clinic. With a range of health problems, including reflex sympathetic
dystrophy (RSD), Dr. Marshall had become very familiar with 9500 Euclid Ave. over the course of four years.
He had previously undergone surgery to receive a spinal cord stimulator to ward off the pain from RSD. But when a new pain
from spinal stenosis left him immobile, he turned to Cleveland Clinic’s Center for Spine Health.
The pain, he says, radiated from his sternum to his shoulder and prevented him from doing so much as lifting his chin from
his chest. “There wasn’t much I could do,” he says. “I could lift my head for a second,
but the pain would drop it back down again.”
Dr. Marshall underwent a C3-4 discectomy and revision spine surgery, and the results
were noticeable immediately.
“The next day I felt the best I had in four years,” he says, noting that the surgery
relieved him of much of the pain associated with RSD as well.
Leading up to the procedure, Dr. Marshall says his spinal cord stimulator had been
on “24 hours a day, seven days a week.” Since that day, however, he says the device
is only on about 50 percent of the time, and, with his physician’s blessing, he is
currently working to wean himself off the device completely.
69
Neurological Institute
Innovations
Brain Tumor and Neuro-oncology Center
2
• Installed the Gamma Knife® PerfexionTM Radiosurgery Unit, the
second unit of this type in the United States. The Gamma Knife® PerfexionTM
Unit allows for treatment in a wider range of anatomical structures, offers
enhanced planning, uses all imaging modalities, increases patient
comfort and reduces treatment time.
Ranking that Discover
magazine gave Cleveland
Clinic’s work with deep
brain stimulation for
minimally conscious
patients in its list of top
scientific discoveries in
2007.
Gamma Knife® PerfexionTM
• Further refined the first program in Ohio for the treatment of spinal
tumors using high precision, noninvasive stereotactic radiosurgery (with
Novalis® shaped-beam surgery) to encompass the Novalis® use for
spine pain.
Image shows a metastasis to the spine with the target area defined
(red outline). A very conformal desired dose is delivered with stereotactic radiosurgery (blue). The spine cord (green) does not receive
significant radiation, as can be clearly seen.
• Demonstrated impact of STAT3 inactivation on GBM tumor formation.
Percent Survival
100
Vector
80
Parental
N709
60
N714
40
Tumors N709 and N714 contain
inactivated STAT3 and show improved
survival in animal studies.
20
0
0
20
40
60
80
100
120
Time (days)
Outcomes 2007
70
• Initiated a collaboration with industry to develop laser interstitial thermal therapy for brain tumors – moving initial research from the preclinical
phase to a first-in-man trial.
• Showed IL-8 to be a key mediator of NF-kB induced glioma cell invasion.
• Demonstrated that methoxyamine can sensitize established GBM tumors to the effects of chemotherapy.
Center for Headache and Pain
• Established IMATCH (Interdisciplinary Method for the Assessment
and Treatment of Chronic Headache) program for adults with chronic
headaches. One of only a few in the country, IMATCH is an intensive,
multidisciplinary outpatient program for patients who have exhausted
other treatment options.
Center for Neurological Restoration
• Implanted the first Deep Brain Stimulator (DBS) in a patient with severe traumatic brain injury, demonstrating behavioral improvement from
a minimally conscious state.
• Investigated stimulation of spheno-palatine ganglia for treatment of severe cluster and migraine headaches.
• Performed ongoing investigations exploring the utilization of DBS for treating Obsessive Compulsive Disorder and Depression.
71
Neurological Institute
Center for Pediatric Neurology and Neurosurgery
• Established a dedicated Pediatric Syncope and Autonomic Clinic in collaboration with the Neuromuscular Center and Pediatric Cardiology.
• Recognized by the Children’s Tumor Foundation as one of 29 multidisciplinary NF (neurofibromatosis) clinics in the country. Awarded funding by the
American Tumor Foundation.
• Developed the first Pediatric Multiple Sclerosis (MS) and White Matter Disorders Clinic in Ohio in collaboration with the Mellen Center.
Center for Spine Health
• Established The Neurological Institute Collaborative Community of Innovation (NICCI). NICCI is a new initiative designed to create, promote and
nurture a culture of creativity, innovation and teamwork in the Neurological Institute.
• OrthoMEMS (microelectromechanical system), a Cleveland Clinic spin-off company, is moving rapidly toward clinical trials with its micro-pressure
sensor, the OrthoChip. The first clinical application of this battery-less, telemetric micro-sensor will be for the assessment of intervertebral disc
function and the more accurate determination of the indications for and contraindications to spine fusion surgery.
Outcomes 2007
72
Cerebrovascular Center
• Opened a state-of-the-art angiography room that allows for endovascular and open craniotomy treatment of a patient with cerebrovascular disease.
• Developed Temporary Endovascular Bypass technology for stroke treatment.
• Successfully formed Cleveland Clinic spin-off company, ReVasc Inc, which focuses on the development of a new technology for the treatment of
ischemic stroke.
• Completed 160-patient, five-center U.S. Multicenter Wingspan Registry.
• First in Ohio to use Enterprise stent to treat wide-necked aneurysms.
• First in Ohio to use Enzo deflectable tip micro catheter to treat aneurysms.
73
Neurological Institute
Department of Psychiatry and Psychology
• Developed and implemented an Outcome Scale which measures target symptoms, housing and social support
needs on admission and at discharge. This will allow quantitative measurement of improvement during a
patient’s inpatient stay.
• Developed and implemented an SBAR modified for psychiatry. The SBAR (Situation, Background, Assessment
and Recommendation) is a tool that is used to report to the next shift, improving communication between
providers.
• Implemented a suicide-assessment protocol for the medical floors.
• Established routine screening for metabolic syndrome in all psychiatric patients on the Cleveland Clinic unit.
Developed programs to promote healthy lifestyles.
1
• Implemented programs to train trainers in a new crisis intervention model, Non Abusive Psychological and
Physical Intervention. This is the first step in a move toward a trauma-informed model of care in our hospital.
Age, in months, of the
youngest epilepsy surgery
patient at Cleveland Clinic
Epilepsy Center
73
Age, in years, of the oldest
epilepsy surgery patient at
Cleveland Clinic
Acquisition of MEG Signals
MEG gantry with
patient seat.
Subject seated in chair
during MEG recording.
306 magnetic sensors
record from all brain areas.
• Launched installation of the first clinical MEG
(magnetoencephalogram) system in Ohio. The MEG will improve
non-invasive localization of the seizure focus in patients who
suffer from intractable epilepsies.
• Opened an expanded eight-bed Pediatric Epilepsy Monitoring Unit which has been renovated with state-of-the-art
video-EEG monitoring equipment.
• Participated in a multi-center clinical trial to test the efficacy of NeuroPace in the treatment of non-surgical
pharmacoresistant epilepsy. NeuroPace is an implantable neurostimulator designed to deliver electrical
stimulation in response to detected EEG seizure activity, to suppress clinical seizures.
Outcomes 2007
74
Mellen Center for Multiple Sclerosis
• Utilized Diffusion Tensor Imaging as a non-invasive MRI-based technique to measure remyelination.
Diffusion tensor images from a patient with MS. Left: mean diffusivity (MD), indicating the overall amount of water diffusion; Middle: fractional anisotropy (FA), indicating the amount of anisotropy (or “elongatedness”) of diffusion; Right: colorized
primary eigenvector maps, illustrating different directions of the primary fiber tract. Red is left-right; green is up-down; blue
is in-out of the page. The arrows indicate the effect of an MS lesion disrupting water diffusion: overall diffusion is increased
(bright on MD map), anisotropy is decreased (dark on FA map), and the primary fiber direction is disrupted (loss of color on the
eigenvector map).
• Developed a protocol that improved the safety of Tysabri®, an FDA-approved disease-modifying therapy for MS.
• Developed a transmigration assay laboratory test to monitor brain inflammation.
• Developed the first Pediatric MS and White Matter Disorders Clinic in Ohio in collaboration with the Center for Pediatric Neurology.
• Assisted in the development and evaluation of a new Hip Flexion Assist Orthosis (HFAO) in ambulatory MS patients with hip flexor weakness. The
HFAO is safe, cost-effective and had a high level of patient satisfaction with use as well as facilitating significant improvement in walking speed and
endurance.
75
Neurological Institute
Neuroanesthesiology
• Developed a central line catheter prototype incorporating jugular bulb sampling which allows placement of a single catheter for assessing global
oxygen delivery/oxygen use ratios in the brain during cranial surgery, as well as central venous pressure monitoring and fluid delivery. The
catheter prototype is being developed for market by the Interplex company.
Neuromuscular Center
• Implemented thermoregulatory sweat testing as an added tool in our battery of autonomic and quantitative sensory testing, allowing more
sophisticated diagnosis of autonomic and small fiber neuropathic disorders.
• Provided skin biopsy histopathology and interpretation for the diagnosis of small fiber neuropathy as a national referral service.
• Established a neuromuscular ultrasound service for the diagnosis of focal peripheral neuropathies, such as entrapment neuropathies.
Ultrasound of the superficial peroneal nerve revealing a cystic mass.
Outcomes 2007
76
Sleep Disorders Center
• Expanded our pediatric sleep program.
• Established a comprehensive Cognitive Behavioral Program incorporating
individual and group therapy for the treatment of insomnia.
• Collaborated with University Hospitals Case Medical Center
to explore ambulatory polysomnography.
• Collaborated with Cleveland Clinic Cardiovascular Surgery to study the
perioperative morbidity of sleep apnea.
Cleveland Clinic Neurological Institute Regional Centers
• Established a community neurosurgery team approach.
• Established a strategic plan to place neurologists in Cleveland Clinic family health centers and surrounding hospitals.
Cleveland Clinic Knowledge Program
• Developed methods of integrating data from Epic and multiple electronic sources into a discrete clinical data repository for Neurological and
Imaging Institute patients.
• Established the routine collection of patient health status measures as discrete data fields within the outpatient encounter.
• Implemented the use of kiosks and tablets for the electronic collection of patient-reported health status measures.
77
Neurological Institute
New Knowledge
The Neurological
Institute staff authored
more than 400
publications in 2007.
For a complete list go to
www.clevelandclinic.org/
quality/outcomes.
Beall EB, Lowe MJ. Isolating physiologic noise sources with independently determined spatial measures.
Neuroimage. 2007 Oct 1;37(4):1286-1300.
Bello-Haas VD, Florence JM, Kloos AD, Scheirbecker J, Lopate G, Hayes SM, Pioro EP, Mitsumoto
H. A randomized controlled trial of resistance exercise in individuals with ALS. Neurology. 2007 Jun
5;68(23):2003-2007.
Bhattacharyya PK, Lowe MJ, Phillips MD. Spectral quality control in motion-corrupted single-voxel J-difference
editing scans: An interleaved navigator approach. Magn Reson Med. 2007 Oct;58(4):808-812.
Birdno MJ, Cooper SE, Rezai AR, Grill WM. Pulse-to-pulse changes in the frequency of deep brain stimulation
affect tremor and modeled neuronal activity. J Neurophysiol. 2007 Sep;98(3):1675-1684.
Busch RM, Lineweaver TT, Naugle RI, Kim KH, Gong Y, Tilelli CQ, Prayson RA, Bingaman W, Najm IM,
Diaz-Arrastia R. ApoE-epsilon4 is associated with reduced memory in long-standing intractable temporal lobe
epilepsy. Neurology. 2007 Feb 6;68(6):409-414.
Butson CR, Cooper SE, Henderson JM, McIntyre CC. Patient-specific analysis of the volume of tissue activated
during deep brain stimulation. Neuroimage. 2007 Jan 15;34(2):661-670.
Caron TH, Bell GR. Combined (tandem) lumbar and cervical stenosis. Semin Spine Surg. 2007
Mar;19(1):44-46.
Chemali KR, Zhou L. Small fiber degeneration in post-stroke complex regional pain syndrome I. Neurology.
2007 Jul 17;69(3):316-317.
Claybrooks R, Kayanja M, Milks R, Benzel E. Atlantoaxial fusion: a biomechanical analysis of two C1-C2 fusion
techniques. Spine J. 2007 Nov;7(6):682-688.
Cohen JA, Rovaris M, Goodman AD, Ladkani D, Wynn D, Filippi M. Randomized, double-blind, dosecomparison study of glatiramer acetate in relapsing-remitting MS. Neurology. 2007 Mar 20;68(12):939-944.
Covington E. Chronic pain management in spine disorders. Neurol Clin. 2007 May;25(2):539-566.
Deogaonkar M, Walter BL, Boulis N, Starr P. Clinical problem solving: finding the target. Neurosurgery. 2007
Oct;61(4):815-824; discussion 824-825.
Di X. Multiple brain tumor nodule resections under direct visualization of a neuronavigated endoscope. Minim
Invasive Neurosurg. 2007 Aug;50(4):227-232.
Dutta R, McDonough J, Chang A, Swamy L, Siu A, Kidd GJ, Rudick R, Mirnics K, Trapp BD. Activation of the
ciliary neurotrophic factor (CNTF) signalling pathway in cortical neurons of multiple sclerosis patients. Brain.
2007 Oct;130(Pt 10):2566-2576.
Fattal O, Link J, Quinn K, Cohen BH, Franco K. Psychiatric comorbidity in 36 adults with mitochondrial
cytopathies. CNS Spectr. 2007 Jun;12(6):429-438.
Ferrara LA, Gordon I, Coquillette M, Milks R, Fleischman AJ, Roy S, Goel VK, Benzel EC. A preliminary
biomechanical evaluation in a simulated spinal fusion model. Laboratory investigation. J Neurosurg Spine.
2007 Nov;7(5):542-548.
Fiorella D, Levy EI, Turk AS, Albuquerque FC, Niemann DB, Aagaard-Kienitz B, Hanel RA, Woo H, Rasmussen
PA, Hopkins LN, Masaryk TJ, McDougall CG. US multicenter experience with the wingspan stent system for
the treatment of intracranial atheromatous disease: periprocedural results. Stroke. 2007 Mar;38(3):881-887.
Outcomes 2007
78
Fiorella D, Woo HH. Emerging endovascular therapies for symptomatic
intracranial atherosclerotic disease. Stroke. 2007 Aug;38(8):2391-2396.
Hwang SH, Kayanja M, Milks RA, Benzel EC. Biomechanical comparison
of adjacent segmental motion after ventral cervical fixation with varying
angles of lordosis. Spine J. 2007 Mar;7(2):216-221.
Fiorella D, Chow MM, Anderson M, Woo H, Rasmussen PA, Masaryk TJ. A
7-year experience with balloon-mounted coronary stents for the treatment
of symptomatic vertebrobasilar intracranial atheromatous disease.
Neurosurgery. 2007 Aug;61(2):236-242; discussion 242-243.
Janigro D, Awasthi S, Awasthi YC, Sharma R, Yadav S, Singhal
SS, Hallene K. RLIP76 in AED drug resistance. Epilepsia. 2007
Jun;48(6):1218-1219.
Fisher E, Chang A, Fox RJ, Tkach JA, Svarovsky T, Nakamura K, Rudick
RA, Trapp BD. Imaging correlates of axonal swelling in chronic multiple
sclerosis brains. Ann Neurol. 2007 Sep;62(3):219-228.
Jeha LE, Najm I, Bingaman W, Dinner D, Widdess-Walsh P, Luders H.
Surgical outcome and prognostic factors of frontal lobe epilepsy surgery.
Brain. 2007 Feb;130(Pt 2):574-584.
Ford PJ, Kubu CS. Ameliorating and exacerbating: surgical ”prosthesis” in
addiction. Am J Bioeth. 2007 Jan;7(1):32-34.
Kapural L, Mekhail N, Bena J, McLain R, Tetzlaff J, Kapural M, Mekhail M,
Polk S. Value of the magnetic resonance imaging in patients with painful
lumbar spinal stenosis (LSS) undergoing lumbar epidural steroid injections.
Clin J Pain. 2007 Sep;23(7):571-575.
Ford PJ, Boulis NM, Montgomery EB Jr, Rezai AR. A patient revoking
consent during awake craniotomy: An ethical challenge. Neuromodulation.
2007 Oct;10(4):329-332.
Fox RJ, Lee JC, Rudick RA. Optimal reference population for the multiple
sclerosis functional composite. Mult Scler. 2007 Aug;13(7):909-914.
Gandour J, Tong Y, Talavage T, Wong D, Dzemidzic M, Xu Y, Li X, Lowe
M. Neural basis of first and second language processing of sentence-level
linguistic prosody. Hum Brain Mapp. 2007 Feb;28(2):94-108.
Gonzalez-Martinez JA, Bingaman WE, Toms SA, Najm IM. Neurogenesis
in the postnatal human epileptic brain. J Neurosurg. 2007
Sep;107(3):628-635.
Gonzalez-Martinez JA, Srikijvilaikul T, Nair D, Bingaman WE. Longterm seizure outcome in reoperation after failure of epilepsy surgery.
Neurosurgery. 2007 May;60(5):873-880.
Gupta A, Chirla A, Wyllie E, Lachhwani DK, Kotagal P, Bingaman
WE. Pediatric epilepsy surgery in focal lesions and generalized
electroencephalogram abnormalities. Pediatr Neurol. 2007
Jul;37(1):8-15.
Kapural L, Stillman M, Kapural M, McIntyre P, Guirgius M, Mekhail N.
Botulinum toxin occipital nerve block for the treatment of severe occipital
neuralgia: a case series. Pain Pract. 2007 Dec;7(4):337-340.
Katzan IL, Dawson NV, Thomas CL, Votruba ME, Cebul RD. The
cost of pneumonia after acute stroke. Neurology. 2007 May
29;68(22):1938-1943.
Keary TA, Frazier TW, Busch RM, Kubu CS, Iampietro M. Multivariate
neuropsychological prediction of seizure lateralization in temporal epilepsy
surgical cases. Epilepsia. 2007 Aug;48(8):1438-1446.
Kerber CW, Wanke I, Bernard J Jr, Woo HH, Liu MW, Nelson PK. Rapid
intracranial clot removal with a new device: the alligator retriever. AJNR
Am J Neuroradiol. 2007 May;28(5):860-863.
Kilincer C, Inceoglu S, Sohn MJ, Ferrara LA, Benzel EC. Effects of angle
and laminectomy on triangulated pedicle screws. J Clin Neurosci. 2007
Dec;14(12):1186-1191.
Hahn JS, Pohl D, Rensel M, Rao S. Differential diagnosis and evaluation
in pediatric multiple sclerosis. Neurology. 2007 Apr 17;68(16 Suppl
2):S13-S22.
Hinson JT, Fantin VR, Schonberger J, Breivik N, Siem G, McDonough B,
Sharma P, Keogh I, Godinho R, Santos F, Esparza A, Nicolau Y, Selvaag E,
Cohen BH, Hoppel CL, Tranebjaerg L, Eavey RD, Seidman JG, Seidman
CE. Missense mutations in the BCS1L gene as a cause of the Bjornstad
syndrome. N Engl J Med. 2007 Feb 22;356(8):809-819.
Huang D, Cossoy M, Li M, Choi D, Taege A, Staugaitis SM, Rehm S,
Ransohoff RM. Inflammatory progressive multifocal leukoencephalopathy
in human immunodeficiency virus-negative patients. Ann Neurol. 2007
Jul;62(1):34-39.
79
Neurological Institute
Kirsch J, Rasmussen PA, Masaryk TJ, Perl J, II, Fiorella D. Adjunctive
rheolytic thrombectomy for central venous sinus thrombosis: technical case
report. Neurosurgery. 2007 Mar;60(3):E577-E578.
Loddenkemper T, Holland KD, Stanford LD, Kotagal P, Bingaman W, Wyllie
E. Developmental outcome after epilepsy surgery in infancy. Pediatrics.
2007 May;119(5):930-935.
Krishnaney AA, Park J, Benzel EC. Surgical management of neck and low
back pain. Neurol Clin. 2007 May;25(2):507-522.
Machado A, Azmi H, Deogaonkar M, Rezai A. MRI-guided procedures for
the management of chronic pain. Tech Reg Anesth Pain Manag. 2007
Apr;11(2):113-119.
Kuncel AM, Cooper SE, Wolgamuth BR, Grill WM. Amplitude- and
frequency-dependent changes in neuronal regularity parallel changes in
tremor With thalamic deep brain stimulation. IEEE Trans Neural Syst
Rehabil Eng. 2007 Jun;15(2):190-197.
Lederman RJ. Tremor in instrumentalists: Influence of tremor type on
performance. Med Probl Perform Art. 2007 Jun;22(2):70-73.
Lee JYK, Deogaonkar M, Rezai A. Deep brain stimulation of globus
pallidus internus for dystonia. Parkinsonism Relat Disord. 2007
Jul;13(5):261-265.
Levin KH. Nonsurgical interventions for spine pain. Neurol Clin. 2007
May;25(2):495-505.
Levy EI, Turk AS, Albuquerque FC, Niemann DB, Aagaard-Kienitz B, Pride
L, Purdy P, Welch B, Woo H, Rasmussen PA, Hopkins LN, Masaryk TJ,
McDougall CG, Fiorella DJ. Wingspan in-stent restenosis and thrombosis:
incidence, clinical presentation, and management. Neurosurgery. 2007
Sep;61(3):644-650.
Levy EI, Mehta R, Gupta R, Hanel RA, Chamczuk AJ, Fiorella D, Woo HH,
Albuquerque FC, Jovin TG, Horowitz MB, Hopkins LN. Self-expanding
stents for recanalization of acute cerebrovascular occlusions. AJNR Am J
Neuroradiol. 2007 May;28(5):816-822.
Lin R, Svensson L, Gupta R, Lytle B, Krieger D. Chronic ischemic cerebral
white matter disease is a risk factor for nonfocal neurologic injury
after total aortic arch replacement. J Thorac Cardiovasc Surg. 2007
Apr;133(4):1059-1065.
Loddenkemper T, Moddel G, Schuele SU, Wyllie E, Morris HH III. Seizures
during intracarotid methohexital and amobarbital testing. Epilepsy Behav.
2007 Feb;10(1):49-54.
Outcomes 2007
Machado A, Ogrin M, Rosenow JM, Henderson JM. A 12-month
prospective study of gasserian ganglion stimulation for trigeminal
neuropathic pain. Stereotact Funct Neurosurg. 2007;85(5):216-224.
Marchi N, Angelov L, Masaryk T, Fazio V, Granata T, Hernandez N, Hallene
K, Diglaw T, Franic L, Najm I, Janigro D. Seizure-promoting effect of
blood-brain barrier disruption. Epilepsia. 2007 Apr;48(4):732-742.
Marko NF, Weil RJ, Toms SA. Nanotechnology in proteomics. Expert Rev
Proteomics. 2007 Oct;4(5):617-626.
Marrie RA, Cutter G, Tyry T, Vollmer T, Campagnolo D. Disparities in the
management of multiple sclerosis-related bladder symptoms. Neurology.
2007 Jun 5;68(23):1971-1978.
Mathews CA, Jang KL, Herrera LD, Lowe TL, Budman CL, Erenberg G,
Naarden A, Bruun RD, Schork NJ, Freimer NB, Reus VI. Tic symptom
profiles in subjects with Tourette syndrome from two genetically isolated
populations. Biol Psychiatry. 2007 Feb 1;61(3):292-300.
Matsumoto R, Nair DR, LaPresto E, Bingaman W, Shibasaki H, Luders
HO. Functional connectivity in human cortical motor system: a corticocortical evoked potential study. Brain. 2007 Jan;130(Pt 1):181-197.
Mazanec D, Reddy A. Medical management of cervical spondylosis.
Neurosurgery. 2007 Jan;60(1 Suppl 1):S43-S50.
Mermigkis C, Chapman J, Golish J, Mermigkis D, Budur K, Kopanakis
A, Polychronopoulos V, Burgess R, Foldvary-Schaefer N. Sleep-related
breathing disorders in patients with idiopathic pulmonary fibrosis. Lung.
2007 May;185(3):173-178.
80
Mermigkis C, Kopanakis A, Foldvary-Schaefer N, Golish J,
Polychronopoulos V, Schiza S, Amfilochiou A, Siafakas N, Bouros D.
Health-related quality of life in patients with obstructive sleep apnoea
and chronic obstructive pulmonary disease (overlap syndrome). Int J Clin
Pract. 2007 Feb;61(2):207-211.
Modic MT, Ross JS. Lumbar degenerative disk disease. Radiology. 2007
Oct;245(1):43-61.
Modic MT. Degenerative disc disease: genotyping, MR imaging and
phenotyping. Skeletal Radiol. 2007 Feb;36(2):91-93.
Mohit AA, Orr RD. Percutaneous vertebral augmentation in osteoporotic
fractures. Curr Opin Orthop. 2007 May;18(3):221-225.
Mohyuddin T, Jacobs IB, Bahler RC. B-type natriuretic peptide and cardiac
dysfunction in Duchenne muscular dystrophy. Int J Cardiol. 2007 Jul
31;119(3):389-391.
Nathoo N, Ugokwe K, Chang AS, Li L, Ross J, Suh JH, Vogelbaum MA,
Barnett GH. The role of (111)indium-octreotide brain scintigraphy in
the diagnosis of cranial, dural-based meningiomas. J Neurooncol. 2007
Jan;81(2):167-174.
Newport DJ, Calamaras MR, DeVane CL, Donovan J, Beach AJ, Winn
S, Knight BT, Gibson BB, Viguera AC, Owens MJ, Nemeroff CB, Stowe
ZN. Atypical antipsychotic administration during late pregnancy:
placental passage and obstetrical outcomes. Am J Psychiatry. 2007
Aug;164(8):1214-1220.
Obuchowski NA, Schoenhagen P, Modic MT, Meziane M, Budd GT.
Incidence of advanced symptomatic disease as primary endpoint
in screening and prevention trials. AJR Am J Roentgenol. 2007
Jul;189(1):19-23.
81
Orr RD, Postak PD, Rosca M, Greenwald AS. The current state of cervical
and lumbar spinal disc arthroplasty. J Bone Joint Surg Am. 2007 Oct;89
Suppl 3:70-75.
Pearson KH, Nonacs RM, Viguera AC, Heller VL, Petrillo LF, Brandes
M, Hennen J, Cohen LS. Birth outcomes following prenatal exposure to
antidepressants. J Clin Psychiatry. 2007 Aug;68(8):1284-1289.
Polston DW. Cervical radiculopathy. Neurol Clin. 2007
May;25(2):373-385.
Ransohoff RM, Zamvil SS. Neuroimmunotherapeutics comes of age.
Neurotherapeutics. 2007 Oct;4(4):569-570.
Ransohoff RM. Natalizumab for multiple sclerosis. N Engl J Med. 2007
Jun 21;356(25):2622-2629.
Robertson J, Sanelli T, Xiao S, Yang W, Horne P, Hammond R, Pioro EP,
Strong MJ. Lack of TDP-43 abnormalities in mutant SOD1 transgenic mice
shows disparity with ALS. Neurosci Lett. 2007 Jun 13;420(2):128-132.
Rudick RA, Miller D, Hass S, Hutchinson M, Calabresi PA, Confavreux C,
Galetta SL, Giovannoni G, Havrdova E, Kappos L, Lublin FD, Miller DH,
O’Connor PW, Phillips JT, Polman CH, Radue EW, Stuart WH, Wajgt A,
Weinstock-Guttman B, Wynn DR, Lynn F, Panzara MA. Health-related
quality of life in multiple sclerosis: effects of natalizumab. Ann Neurol.
2007 Oct;62(4):335-346.
Sakaie KE, Lowe MJ. An objective method for regularization of fiber
orientation distributions derived from diffusion-weighted MRI. Neuroimage.
2007 Jan 1;34(1):169-176.
Schiff ND, Giacino JT, Kalmar K, Victor JD, Baker K, Gerber M, Fritz B,
Eisenberg B, O’Connor J, Kobylarz EJ, Farris S, Machado A, McCagg C,
Plum F, Fins JJ, Rezai AR. Behavioural improvements with thalamic
stimulation after severe traumatic brain injury. Nature. 2007 Aug
2;448(7153):600-603.
Neurological Institute
Schuele SU, Bermeo AC, Alexopoulos AV, Locatelli ER, Burgess RC,
Dinner DS, Foldvary-Schaefer N. Video-electrographic and clinical features
in patients with ictal asystole. Neurology. 2007 Jul 31;69(5):434-441.
Singh M, Jacobs IB, Spirnak JP. Nephrolithiasis in patients with Duchenne
muscular dystrophy. Urology. 2007 Oct;70(4):643-645.
Spears RC, Ifthikharuddin S. New-onset headache from cerebral venous
thrombosis. Headache. 2007 Feb;47(2):275-276.
Steinmetz MP, Stewart TJ, Kager CD, Benzel EC, Vaccaro AR. Cervical
deformity correction. Neurosurgery. 2007 Jan;60(1 Suppl 1):S90-S97.
Stewart TJ, Schlenk RP, Benzel EC. Multiple level discectomy and fusion.
Neurosurgery. 2007 Jan;60(1 Suppl 1):S143-S148.
Videtic GMM, Adelstein DJ, Mekhail TM, Rice TW, Stevens GHJ, Lee
SY, Suh JH. Validation of the RTOG recursive partitioning analysis (RPA)
classification for small-cell lung cancer-only brain metastases. Int J Radiat
Oncol Biol Phys. 2007 Jan 1;67(1):240-243.
Viguera AC, Koukopoulos A, Muzina DJ, Baldessarini RJ. Teratogenicity
and anticonvulsants: lessons from neurology to psychiatry. J Clin
Psychiatry. 2007;68 Suppl 9:29-33.
Viguera AC, Whitfield T, Baldessarini RJ, Newport DJ, Stowe Z, Reminick
A, Zurick A, Cohen LS. Risk of recurrence in women with bipolar disorder
during pregnancy: prospective study of mood stabilizer discontinuation. Am
J Psychiatry. 2007 Dec;164(12):1817-1824.
Tavee J, Mays M, Wilbourn AJ. Pitfalls in the electrodiagnostic studies of
sacral plexopathies. Muscle Nerve. 2007 Jun;35(6):725-729.
Viguera AC, Newport DJ, Ritchie J, Stowe Z, Whitfield T, Mogielnicki J,
Baldessarini RJ, Zurick A, Cohen LS. Lithium in breast milk and nursing
infants: clinical implications. Am J Psychiatry. 2007 Feb;164(2):342-345.
Trapp BD, Wujek JR, Criste GA, Jalabi W, Yin X, Kidd GJ, Stohlman S,
Ransohoff R. Evidence for synaptic stripping by cortical microglia. Glia.
2007 Mar;55(4):360-368.
Vogelbaum MA. Convection enhanced delivery for treating brain tumors
and selected neurological disorders: symposium review. J Neurooncol.
2007 May;83(1):97-109.
Turk AS, Rowley HA, Niemann DB, Fiorella D, Aagaard-Kienitz B, Pulfer
K, Strother CM. CT angiographic appearance of in-stent restenosis
of intracranial arteries treated with the Wingspan stent. AJNR Am J
Neuroradiol. 2007 Oct;28(9):1752-1754.
Wallace RC, Karis JP, Partovi S, Fiorella D. Noninvasive imaging of
treated cerebral aneurysms, part I: MR angiographic follow-up of coiled
aneurysms. AJNR Am J Neuroradiol. 2007 Jun;28(6):1001-1008.
Turner RD, Gonugunta V, Kelly ME, Masaryk TJ, Fiorella DJ. Marginal
sinus arteriovenous fistulas mimicking carotid cavernous fistulas:
diagnostic and therapeutic considerations. AJNR Am J Neuroradiol. 2007
Nov;28(10):1915-1918.
Turner RD, Rosenblatt SM, Chand B, Luciano MG. Laparoscopic
peritoneal catheter placement: results of a new method in 111 patients.
Neurosurgery. 2007 Sep;61(3 Suppl):167-172; discussion 172-174.
Vadala G, Sowa GA, Smith L, Hubert MG, Levicoff EA, Denaro V,
Gilbertson LG, Kang JD. Regulation of transgene expression using an
inducible system for improved safety of intervertebral disc gene therapy.
Spine. 2007 Jun 1;32(13):1381-1387.
Outcomes 2007
Warnke JP, Di X, Mourgela S, Nourusi A, Tschabitscher M. Percutaneous
approach for thecaloscopy of the lumbar subarachnoidal space. Minim
Invasive Neurosurg. 2007 Jun;50(3):129-131.
Wehner T, LaPresto E, Tkach J, Liu P, Bingaman W, Prayson RA, Ruggieri
P, Diehl B. The value of interictal diffusion-weighted imaging in lateralizing
temporal lobe epilepsy. Neurology. 2007 Jan 9;68(2):122-127.
Widdess-Walsh P, Jeha L, Nair D, Kotagal P, Bingaman W, Najm I.
Subdural electrode analysis in focal cortical dysplasia: predictors of surgical
outcome. Neurology. 2007 Aug 14;69(7):660-667.
82
Widdess-Walsh P, Kotagal P, Jeha L, Wu G, Burgess R. Multiple auras:
clinical significance and pathophysiology. Neurology. 2007 Aug
21;69(8):755-761.
Williams MA, McAllister JP, Walker ML, Kranz DA, Bergsneider M, Del
Bigio MR, Fleming L, Frim DM, Gwinn K, Kestle JRW, Luciano MG,
Madsen JR, Oster-Granite ML, Spinella G. Priorities for hydrocephalus
research: report from a National Institutes of Health-sponsored workshop. J
Neurosurg. 2007 Nov;107(5 Suppl Pediatrics):345-357.
Wyllie E, Lachhwani DK, Gupta A, Chirla A, Cosmo G, Worley S, Kotagal
P, Ruggieri P, Bingaman WE. Successful surgery for epilepsy due to early
brain lesions despite generalized EEG findings. Neurology. 2007 Jul
24;69(4):389-397.
13,835,686
External funding in
dollars for Cleveland
Clinic neuroscience-based
research in 2007
Zhou L, Kitch DW, Evans SR, Hauer P, Raman S, Ebenezer GJ,
Gerschenson M, Marra CM, Valcour V, Diaz-Arrastia R, Goodkin K, Millar L,
Shriver S, Asmuth DM, Clifford DB, Simpson DM, McArthur JC. Correlates
of epidermal nerve fiber densities in HIV-associated distal sensory
polyneuropathy. Neurology. 2007 Jun 12;68(24):2113-2119.
83
Neurological Institute
NEUROLOGICAL INSTITUTE TEAM INVESTIGATES BRAIN PATHOLOGY IN MULTIPLE SCLEROSIS
177
Number of active CCNI
clinical research trials
A team of investigators in the Neurological Institute and Lerner Research Institute is studying changes in the brains
and spinal cords of patients with multiple sclerosis (MS). One goal of the study is to develop more informative
imaging tools that can be used to monitor and treat MS patients. In this study, regions of the brain were selected
from postmortem magnetic resonance images (MRI) of 10 MS patients, and classified into MRI-defined categories.
One of the categories identified swollen axons and axonal loss, pathologies that are associated with neurological
disability in MS. Studies to characterize cellular and molecular changes in brain tissue are continuing. We expect
to gain improved understanding of mechanisms leading to brain damage in MS patients, and improve methods to
monitor treatments for individual patients using noninvasive MRI methods. Studies supported by the NIH (NINDS
PO1 NS38667).
Axonal Measurements By MRI Region Type
Fraction of NAWM (+s.d.)
1.0
NAWM
T2-only
T2T1MTR
0.8
0.6
1660
Total number of patients
enrolled in CCNI clinical
research trials
0.4
0.2
0.0
area
count
diameter
Plot of percentage axonal area, axonal count, and swelling index in each MRI group (gray bars denote T2weighted imaging only; black bars denote T2-weighted, T1-weighted, and magnetization transfer ratio abnormal
[T2T1MTR]) relative to the means for normal-appearing white matter (NAWM; hatched bars) regions.
Fisher E, et al. Ann Neurol. 2007;62:219–228.
Outcomes 2007
84
NEUROLOGICAL INSTITUTE TEAM DETECTS CHANGES IN BRAIN ACTIVATION PATTERNS IN EARLY ALZHEIMER’S DISEASE
A team of investigators in the Neurological Institute is studying changes in brain activation of healthy older individuals (ages 65-85) who are genetically at
risk for developing Alzheimer’s disease (AD) and individuals who have Mild Cognitive Impairment (MCI), a condition that typically precedes the diagnosis
of AD. One goal of the study is to develop an imaging biomarker that can detect the earliest brain changes associated with AD. Nineteen MCI patients,
19 genetically at-risk but healthy older adults and 19 healthy older adults not at-risk for AD (control) were administered a memory task while undergoing
functional magnetic resonance imaging (fMRI). Results indicate that fMRI is sensitive to detecting the earliest changes in AD, even before patients become
symptomatic. The goal is to use this imaging technology to assess the efficacy of drugs designed to delay the onset of AD. Studies supported by the NIH
(NIA R01 AG022304).
Three groups of older participants, MCI patients, individuals at-risk for developing AD and healthy
not-at-risk control subjects, were asked to discriminate names of famous individuals from those
of unfamiliar persons. The difference in brain activation (Famous > Unfamiliar) is shown in blue.
MCI and at-risk participants exhibited greater brain activity than Controls. Results suggest that
early AD-related changes require the brain to “work harder” to achieve similar levels of task
performance. Rao SM, et al. Submitted.
NEUROLOGICAL INSTITUTE AND IMAGING INSTITUTE EVALUATE DEEP BRAIN STIMULATION WITH FMRI
Investigators from the Neurological Institute and the Imaging Institute have collaborated to study the effect of deep brain stimulation (DBS) in patients
with Parkinson’s disease using functional MRI. The investigators are determining how the brain is activated during DBS for Parkinson’s disease. Early
results demonstrated a consistent pattern of brain activation produced by stimulation within the ipsilateral thalamus and globus pallidus. These studies
will lead to better understanding of the relationship between brain activation and DBS in Parkinson’s disease, and will provide the necessary information to
maximize therapeutic benefits of this treatment. Studies supported by the NIH (NINDS R01 NS052566-01A1).
Brain Activation Patterns with DBS
Functional MRI obtained during active deep brain stimulation. Images A and
B demonstrate the activation pattern during unilateral right-sided activation.
Image C demonstrates activation during unilateral left-sided stimulation. Images are projected using radiological convention. Phillips, et al. Radiology.
2006;239:209–216.
85
Neurological Institute
Staff Listing
Chairman
Michael T. Modic, MD, FACR
Vice Chairman, Clinical Areas
William Bingaman, MD
Kristen Eastman, PsyD
Darlene Floden, PhD
Catherine Gaw, PhD
John Glazer, MD
Lilian Gonsalves, MD
Shannon Griffith, PhD
Jennifer Haut, PhD
Vice Chairman, Research and Development
Richard Rudick, MD
Quality Review Officer
Jocelyn Bautista, MD
Leslie Heinberg, PhD, MA
Karen Jacobs, DO
Joseph Janesz, PhD, LICDC
Regina Josell, PsyD
Eileen Kennedy, PhD
Patricia Klaas, PhD
Steven Krause, PhD, MBA
Department of Neurological Surgery
Edward Benzel, MD
Chairman, Department of Neurological Surgery
Department of Neurology
Kerry Levin, MD
Chairman, Department of Neurology
Cynthia Kubu, PhD
Kathleen Laing, PhD
Amy Lee, PhD
Donald Malone, Jr., MD
Beth Ann Martin, PhD
Michael McKee, PhD
Scott Meit, PsyD, MBA
Gene Morris, PhD
David Muzina, MD
Department of Psychiatry and Psychology
Richard Naugle, PhD
George Tesar, MD
Chairman, Department of Psychiatry and Psychology
Shannon Perkins, PhD
Susan Albers-Bowling, PsyD
Kathleen Ashton, PhD
Scott Bea, PsyD
Dana Brendza, PsyD
Karen Broer, PhD
Kumar Budur, MD
Kathy Coffman, MD
Gregory Collins, MD
Edward Covington, MD
Roman Dale, MD
Beth Dixon, PsyD
Judy Dodds, PhD
Outcomes 2007
Leopoldo Pozuelo, MD
Kathleen Quinn, MD
Ted Raddell, PhD
Judith Scheman, PhD
Isabel Schuermeyer, MD
Jean Simmons, PhD
Barry Simon, DO
Catherine Stenroos, PhD
David Streem, MD
Adele Viguera, MD
John Vitkus, PhD
Cynthia White, PsyD
Amy Windover, PhD
86
Center for Regional Neurology
Stephen Samples, MD
Director, Center for Regional Neurology
Cynthia Kubu, PhD
Richard Lederman, MD, PhD
A. Romeo Craciun, MD
Andre Machado, MD, PhD
Sheila Rubin, MD
Donald Malone, Jr., MD
Joseph Zayat, MD
Mayur Pandya, DO
Patrick Sweeney, MD
Center for Regional Neurological Surgery
Michael Mervart, MD
Director, Center for Regional Neurological Surgery
Samuel Borselino, MD
Samuel Tobias, MD
Brain Tumor and Neuro-Oncology Center
Gene Barnett, MD, FACS
Director, Brain Tumor and Neuro-Oncology Center
Lilyana Angelov, MD
Samuel Chao, MD
Bruce Cohen, MD
Heinrich Elinzano, MD
Joung Lee, MD
David Peereboom, MD
Burak Sade, MD
Center for Neuroimaging
Thomas Masaryk, MD
Director, Center for Neuroimaging
Stephen E. Jones, MD, PhD
Mark Lowe, PhD
Doksu Moon, MD
Micheal Phillips, MD
Paul Ruggieri, MD
Alison Smith, MD
Todd Stultz, DDS, MD
Andrew Tievsky, MD
Center for Pediatric Neurology and Neurosurgery
Elaine Wyllie, MD
Director, Center for Pediatric Neurology
John Suh, MD
Mark Luciano, MD, PhD
Director, Center for Pediatric Neurosurgery
Glen Stevens, DO, PhD
Bruce Cohen, MD
Tanya Tekautz, MD
Xiao Di, MD, PhD
Michael Vogelbaum, MD, PhD
Stephen Dombrowski, PhD
Robert Weil, MD
Gerald Erenberg, MD
Neil Friedman, MBChB
Center for Neurological Restoration
Ali Rezai, MD
Director, Center for Neurological Restoration
Debabrata Ghosh, MD, DM
Gary Hsich, MD
Irwin Jacobs, MD
Anwar Ahmed, MD
Manikum Moodley, MD
Scott Cooper, MD, PhD
Sumit Parikh, MD
Milind Deogaonkar, MD
A. David Rothner, MD
Darlene Floden, PhD
Ilia Itin, MD
87
Neurological Institute
Center for Spine Health
Robyn Busch, PhD
Edward Benzel, MD
Director, Center for Spine Health
Jessica Chapin, PhD
Gordon Bell, MD
Nancy Foldvary-Schaefer, DO
William Bingaman, MD
Ajay Gupta, MD
Edwin Capulong, MD
Lara Jehi, MD
Russell DeMicco, DO
Prakash Kotagal, MD
Lars Gilbertson, PhD
Deepak Lachhwani, MD
Augusto Hsia Jr., MD
Dileep Nair, MD
Serkan Inceoglu, PhD
Ingrid Tuxhorn, MD
Iain Kalfas, MD
Tim Wehner, MD
Gaurav Kapur, MD
Elaine Wyllie, MD
Tatiana Falcone, MD
Tagreed Khalaf, MD
Ajit Krishnaney, MD
Paula Lidestri, MD
Center for Headache and Pain
Daniel Mazanec, MD
Mark Stillman, MD
Director, Center for Headache and Pain
Robert McLain, MD
Cynthia Bamford, MD
Thomas Mroz, MD
Neil Cherian, MD
R. Douglas Orr, MD
Thomas Gretter, MD
Richard Schlenk, MD
Steven Krause, PhD, MBA
Michael Steinmetz, MD
Jennifer Kriegler, MD
Santhosh Thomas, DO
Robert Kunkel, MD
Fredrick Wilson, DO
MaryAnn Mays, MD
Adrian Zachary, DO, MPH
Roderick Spears, MD
Deborah Tepper, MD
Cerebrovascular Center
Peter Rasmussen, MD
Director, Cerebrovascular Center
David Fiorella, MD, PhD
Rishi Gupta, MD
Stewart Tepper, MD
Mellen Center for Multiple Sclerosis Treatment
and Research
Irene Katzan, MD
Richard Rudick, MD
Director, Mellen Center for Multiple Sclerosis Treatment and Research
Gwendolyn Lynch, MD
Francois Bethoux, MD
J. Javier Provencio, MD, FCCM
Jeffrey Cohen, MD
Vivek Sabharwal, MD
Robert Fox, MD
Keith McKee, MD
Epilepsy Center
Imad Najm, MD
Director, Epilepsy Center
Andreas Alexopoulos, MD
Deborah Miller, PhD
Alexander Rae-Grant, MD
Mary Rensel, MD
Lael Stone, MD
Jocelyn Bautista, MD
William Bingaman, MD
Richard Burgess, MD, PhD
Outcomes 2007
88
Neurocognitive Center
Richard Ransohoff, MD
Richard Rudick, MD
Interim Director, Neurocognitive Center
Susan Staugaitis, MD, PhD
Michael Parsons, PhD
Jerrold Vitek, MD, PhD
Stephen Rao, PhD
Riqiang Yan, PhD
Stephen Stohlman, PhD
Janice Zimbelman, PhD
Neuromuscular Center
Kerry Levin, MD
Director, Neuromuscular Center
Kamal Chemali, MD
Rebecca Kuenzler, MD
Erik Pioro, MD, PhD
David Polston, MD
Robert Shields Jr., MD
Steven Shook, MD
Jinny Tavee, MD
Deborah Venesy, MD
Lan Zhou, MD, PhD
Sleep Disorders Center
Nancy Foldvary-Schaefer, DO
Director, Sleep Disorders Center
Charles Bae, MD
Kumar Budur, MD
Michelle Drerup, PsyD
Prakash Kotagal, MD
Jyoti Krishna, MD
William Novak, MD
Carlos Rodriguez, MD
Department of Neurosciences, Lerner Research Institute
Bruce Trapp, PhD
Chairman, Department of Neurosciences, Lerner Research Institute
Cornelio Bergmann, PhD
Biomedical Engineering, Lerner Research Institute
Jay Alberts, PhD
Elizabeth Fisher, PhD
Aaron Fleischman, PhD
Cameron McIntyre, PhD
Shuvo Roy, PhD
Cell Biology, Lerner Research Institute
Luca Cucullo, PhD
Damir Janigro, PhD
Nicola Marchi, PhD
Anatomic Pathology, Lerner Research Institute
Richard Prayson, MD
Neuroanesthesiology
Michelle Lotto, MD
Head, Section of Neurosurgical Anesthesia
Zeyd Ebrahim, MD
Interim Chair, Institute of Anesthesiology and Critical Care
Armin Schubert, MD
Chairman, Department of General Anesthesiology
Rafi Avitsian, MD
Ehab Farag, MD
Mariel Manlapaz, MD
Marco Maurtua, MD
Vivek Sabharwal, MD
Gloria Walters, MD
Hitoshi Komuro, PhD
Bruce Lamb, PhD
Wendy Macklin, PhD
Sanjay Pimplikar, PhD
89
Some physicians may practice in multiple locations. For a detailed list
including staff photos, please visit clevelandclinic.org/staff.
Neurological Institute
Contact Information
Institute Locations
General Patient Referral
Cleveland Clinic Neurological Institute physicians see patients at the locations below. Please inquire about availability of specific services at each
location when calling.
24/7 hospital transfers or physician consults
800.553.5056
Main Campus
Neurological Institute Appointments/Referrals
9500 Euclid Ave.
Toll-free 866.588.2264
Cleveland, OH 44195
On the Web at clevelandclinic.org/neuroscience
866.588.2264
Additional Contact Information
General Information
216.444.2200
Hospital Patient Information
Neurological Institute Regional Centers
Euclid Hospital
18901 Lake Shore Blvd.
Euclid, OH 44119
216.531.9000
216.444.2000
Fairview Hospital
Patient Appointments
18101 Lorain Ave.
216.444.2273 or 800.223.2273
Cleveland, OH 44111
216.476.7000
Special Assistance for Out-of-State Patients
Complimentary assistance for out-of-state patients and families
800.223.2273, ext. 55580, or email [email protected]
Hillcrest Hospital
6780 Mayfield Road
Mayfield Heights, OH 44124
International Center
Complimentary assistance for international patients and families
800.884.9551 or 001.631.439.1578 or visit clevelandclinic.org/ic
440.312.4500
Huron Hospital
13951 Terrace Road
Cleveland Clinic in Florida
866.293.7866
For address corrections or changes, please call 800.890.2467
clevelandclinic.org
East Cleveland, OH 44112
216.761.3300
Lakewood Hospital
14519 Detroit Ave.
Lakewood, OH 44107
216.521.4200
Outcomes 2007
90
Lutheran Hospital
Lorain Family Health and Surgery Center
1730 West 25th St.
5700 Cooper Foster Park Road
Cleveland, OH 44113
Lorain, OH 44053
216.696.4300
440.204.7400
Marymount Hospital
Strongsville Family Health and Surgery Center
12300 McCracken Road
16761 SouthPark Center
Garfield Heights, OH 44125
Strongsville, OH 44136
216.581.0500
440.878.2500
Cleveland Clinic Children’s Hospital Shaker Campus
Solon Family Health Center
2801 Martin Luther King Jr. Drive
29800 Bainbridge Road
Cleveland, OH 44104
Solon, OH 44139
216.721.5400
440.519.6800
Cleveland Clinic Family Health Centers
Westlake Family Health Center
30033 Clemens Road
Westlake, OH 44145
Beachwood Family Health and Surgery Center
440.899.5555
26900 Cedar Road
Beachwood, OH 44122
Willoughby Hills Family Health Center
216.839.3000
2570 SOM Center Road
Willoughby Hills, OH 44094
Chagrin Falls Family Health Center
440.943.2500
551 E. Washington St.
Chagrin Falls, OH 44022
Cleveland Clinic Wooster
440.893.9393
1739 Cleveland Road
Wooster, OH 44691
Independence Family Health Center
330.287.4500
5001 Rockside Road
Crown Center II
Independence, OH 44131
216.986.4000
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Neurological Institute
Cleveland Clinic Overview
Cleveland Clinic, founded in 1921, is a nonprofit multispecialty academic
medical center that integrates clinical and hospital care with research and
education. Today, 1,800 Cleveland Clinic physicians and scientists practice
in 120 medical specialties and subspecialties, annually recording more
than 3 million patient visits and more than 70,000 surgeries.
In 2007, Cleveland Clinic restructured its practice, bundling all clinical
specialties into integrated practice units called institutes. An institute
combines all the specialties surrounding a specific organ or disease
system under a single roof. Each institute has a single leader and focuses
the energies of multiple professionals onto the patient. From access and
communication to point-of-care service, institutes will improve the patient
experience at Cleveland Clinic.
Cleveland Clinic’s main campus, with 37 buildings on 140 acres in
Cleveland, Ohio, includes a 1,000-bed hospital, outpatient clinic, specialty
institutes and supporting labs and facilities. Cleveland Clinic also operates
14 family health centers; eight community hospitals; two affiliate hospitals;
a 150-bed hospital and clinic in Weston, Fla.; and health and wellness
centers in Palm Beach, Fla., and Toronto, Canada. Cleveland Clinic Abu
Dhabi (United Arab Emirates), a multispecialty care hospital and clinic, is
scheduled to open in 2011.
At the Cleveland Clinic Lerner Research Institute, hundreds of principal
investigators, project scientists, research associates and postdoctoral
fellows are involved in laboratory-based research. Total annual research
expenditures exceed $150 million from federal agencies, non-federal
societies and associations, and endowment funds. In an effort to bring
research from bench to bedside, Cleveland Clinic physicians are involved in
more than 2,400 clinical studies at any given time.
In September 2004, Cleveland Clinic Lerner College of Medicine of Case
Western Reserve University opened and will graduate its first 32 students
as physician-scientists in 2009.
Cleveland Clinic is consistently ranked among the top hospitals in America
by U.S.News & World Report, and our heart and heart surgery program
has been ranked No. 1 since 1995.
For more information about Cleveland Clinic, visit clevelandclinic.org.
Outcomes 2007
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Online Services
eCleveland Clinic
eCleveland Clinic uses state-of-the-art digital information systems to offer
several services, including remote second medical opinions to patients
around the world; personalized medical record access for patients;
patient treatment progress for referring physicians (see below); and
imaging interpretations by our subspecialty trained radiologists. For more
information, please visit eclevelandclinic.org.
DrConnect
Online Access to Your Patient’s Treatment Progress
Whether you are referring from near or far, DrConnect can streamline
communication from Cleveland Clinic physicians to your office. This
online tool offers you secure access to your patient’s treatment progress at
Cleveland Clinic. With one-click convenience, you can track your patient’s
care using the secure DrConnect website. To establish a DrConnect
account, visit eclevelandclinic.org or email [email protected].
MyConsult
MyConsult Remote Second Medical Opinion is a secure online service
providing specialist consultations and remote second opinions for more
than 600 life-threatening and life-altering diagnoses. The MyConsult
service is particularly valuable for people who wish to avoid the time
and expense of travel. For more information, visit eclevelandclinic.org/
myconsult, email [email protected] or call 800.223.2273,
ext 43223.
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Neurological Institute
Please visit us on the Web at clevelandclinic.org.
9500 Euclid Avenue, Cleveland, OH, 44195
Cleveland Clinic is a nonprofit multispecialty academic medical
center. Founded in 1921, it is dedicated to providing quality
specialized care and includes an outpatient clinic, a hospital
with more than 1,000 staffed beds, an education institute and
a research institute.
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© The Cleveland Clinic Foundation 2008