Neuroscience Outlook Vol 14 Issue 1

A Triannual Publication of Augusta University

NEUROSCIENCE OUTLOOK News and Research from the Departments of Neurology and Neurosurgery

VOL. 14 | ISSUE 1

VOL. 14 | ISSUE 1 NEUROSCIENCE OUTLOOK

FROM THE CHAIRMEN

DEAR READERS,

We present you with another issue of Neuroscience Outlook in which we chronicle newsworthy items from the departments of Neurology and Neurosurgery. Our cover article features a new tool in the treatment of deepseated neurosurgical lesions by way of stereotactic laser ablation. While the technology and the indications for its use remain in evolution, it is proving to be a useful adjunct in the treatment of a variety of difficult lesions. Also, the treatment of migraine headaches with Botox is featured in the Clinical Spotlight. The duties of Dr. Hess, Chairman of

IN THIS ISSUE

Neurology, were recently expanded when he was named Interim Dean of the School of Medicine (News from the

VOL. 14 | ISSUE 1

Departments). We also describe some administrative changes in the Neurology department and provide an update and on the Neurosurgery match.

From left: Cargill H. Alleyne Jr., MD Professor and Marshall Allen Distinguished Chair of Neurosurgery

We are very fortunate to have several well-wishers who are willing to demonstrate their support to our departments by donating funds. Regardless of the amount, each and every donation helps to facilitate our tripartite mission

David C. Hess, MD Professor and Presidential Distinguished Chair of Neurology

of research, education, and clinical care. We are deeply indebted to these individuals and groups who are part of the lifeblood of our mission. We take our research and educational responsibility seriously and to that end we are happy to list the accolades and the publications and presentations of our collective group. Enjoy!

Cargill H. Alleyne Jr., MD Professor and Marshall Allen Distinguished Chair of

Neuroscience Outlook is produced triannually

DEPARTMENT NEWS___________________________ 4

by the Medical College of Georgia Departments

FACULTY & STAFF UPDATE______________________ 5

of Neurology and Neurosurgery and the Augusta University Division of Communications and Marketing.

SCHEDULES AND UPCOMING MEETINGS________ 6

Please direct comments or questions to marketing@augusta.edu.

CLINICAL SPOTLIGHT: LASER ABLATION_______________________________ 8

Editor-in-Chief: Cargill H. Alleyne Jr., MD Assistant Editor: Julie Kurek, MD

CLINICAL SPOTLIGHT: BOTOX FOR HEADACHES _____________________ 12

Medical Illustrations: Colby Polonsky, MS, CMI

PUBLICATIONS & PRESENTATIONS_____________ 14

Design and Layout: Sergio Gallardo

THE CLINICAL TEAM__________________________ 15

Contributors: Cole A. Giller, MD, PhD, MBA, Yong D. Park, MD, and J. Ned Pruitt, MD

Neurosurgery David Hess, MD Professor and Presidential Distinguished Chair of Neurology

2

3

augustahealth.org/neuro VOL. 14 | ISSUE 1 NEUROSCIENCE OUTLOOK

VOL. 14 | ISSUE 1 NEUROSCIENCE OUTLOOK

NEWS from the DEPARTMENTS (September-December 2016) Neurology Department announces administrative changes Several new administrative changes were made in the department of Neurology. Debra Moore-Hill, MD, Yong Park, MD, Ned Pruitt, MD, John Morgan, MD, PhD and Chris Bonham were named to the Department of Neurology Executive Committee. Anthony Murro, MD was appointed Director of the Neurophysiology Fellowship to succeed Michael River, MD, who although retired, continues to work part time in the Department of Neurology. Debra Moore-Hill, MD is Neurology Residency Program Director. Ned Pruitt, MD is Neurology Clerkship Director and Askiel Bruno, MD is Associate Clerkship Director. Fenwick Nichols, MD is the Vascular Neurology Fellowship Director. Heather Snipes was appointed the Coordinator for the Neurophysiology and Vascular Neurology Fellowships. Debbie Langston remains the Neurology Residency Coordinator.

Neurosurgery Match remains highly competitive Neurological Surgery remains one of the most competitive specialties. In the 2015-2016 match season the percentage of U.S. seniors left unmatched who ranked the specialty as their only choice was 19.7%. If only U.S. seniors are considered, this makes Neurosurgery the second most competitive specialty behind Orthopedic Surgery (20.8% unmatched). Dermatology was third (18.6% unmatched).1

FACULTY & STAFF UPDATE Cargill H. Alleyne Jr., MD (Department of Neurosurgery) was selected Vice-Councilor/Treasurer, Alpha Omega Alpha Honor Society, Medical College of Georgia, in September. He also served as instructor of the High-yield Primary Board Review course at the Congress of Neurological Surgeons meeting in San Diego, CA in September. In addition, one of his patients was featured in MCG Medicine “The Monster Inside Her Head.” Brain edition, Fall 2016/Winter 2017

Krishnan C. Dhandapani, PhD (Department of Neurosurgery) served on the Neurobiology C study section for the VA in December.

Ian Heger, MD (Department of Neurosurgery) was re-certified by the American Board of Pediatric Neurosurgery (ABPN).

Our program also remains very competitive. For the current (2016-17) interview season, 168 applicants applied for one position in our program. We interviewed 27 applicants (including three MCG students). We are in the process of compiling our rank list for the current season but will likely rank 20-25 applicants. For the prior interview season (2015-16) we received 185 applications for one position. Forty-one interviews were offered and 37 applicants accepted. Thirty were ranked (including two MCG students).

Historically our MCG students have done quite well in the match. Since 2005 we have a 95.4% match rate (1 student unmatched) with former students matching at programs such as Duke, University of Miami, UC Davis, Stanford University, Loma Linda University, Wake Forest University, the Brigham, Emory University, University of Alabama, LSU New Orleans, Tulane University, University of Oklahoma, Medical College of Virginia, University of New Mexico, Tufts Medical Center, University of Buffalo, and University of Michigan.

National Residency Matching Program, Results and Data: Main Residency Match. National Resident Matching Program, Washington, D.C. 2016

David C. Hess, MD (Department of Neurology) was on the organizing committee for the 4th International Symposium on Tolerance and Conditioning: 30 Years of Science and Hope in Suzhou, China, in November. He was also an invited speaker and participant in the NIH-sponsored Collaterals Conference 2016 at UCLA, Los Angeles, CA in November. In addition, he served as Consultant to P.I. Franklin West on a University of Georgia NIH/NINDS 1R01NS093314-01A1 grant (Combined Nanoparticle and Neural Stem Cell Therapies in a Pig Model of Stroke, 2016 to 2020)

1

Neurology Chair named Interim Dean David Hess, MD, Chairman of Neurology since 2001, was named Interim Dean of the Medical College of Georgia at Augusta University and Executive Vice-President of Medical Affairs and Integration in December. The appointments were effective January 17th when former Dean, Peter Buckley, MD, left our institution to become the Dean at Virginia Commonwealth University School of Medicine. Dr. Hess received a BA from Johns Hopkins University in 1979 and an MD from the University of Maryland School of Medicine in 1983. He then completed a neurology residency and cerebrovascular fellowship at the Medical College of Georgia before joining the faculty. He is boardcertified in internal medicine, neurology and vascular neurology.

The Medical College of Georgia, founded in 1828, is the 13th oldest medical school in the nation. It is also one of the largest medical schools in the nation with 223 in the class of 2016. As the state’s only medical school it offers clinical training at more than 200 sites across Georgia. MCG and its teaching hospitals provide postgraduate education to nearly 500 residents in 44 different programs.

4

Sergei A. Kirov, PhD (Department of Neurosurgery) participated in NIH ZRG1 F03A (20), Fellowships: Neurodevelopment, Synaptic Plasticity, Neurodegeneration Study Section in June 2016.

Yong Park, MD (Department of Neurology) served as chair of the Korean Epilepsy Preceptorship Program.

Jeffrey Switzer, DO (Department of Neurology) was elected as Fellow of the American Heart Association – Stroke Council.

5

augustahealth.org/neuro VOL. 14 | ISSUE 1 NEUROSCIENCE OUTLOOK

VOL. 14 | ISSUE 1 NEUROSCIENCE OUTLOOK

THANK YOU, NEUROSCIENCE DONORS!

NEUROSURGERY CONFERENCE SCHEDULE (January - April 2017) January 6 12 p.m.

January 13 11:30 a.m.

January 20 January 27 10 a.m.

11 a.m.

12 p.m.

February 3 10 a.m.

11 a.m.

12 p.m.

February 10 10 a.m.

11 a.m.

12 p.m.

February 17 10 a.m.

11 a.m.

12 p.m.

Case Conference

Dr. Fallaw Interviews

Resident Meeting Journal Club M&M

Anatomy Business-Dr. Giller Case Conference

Oral Board Review Neuro 101 - Khoi Nguyen Case Conference

Radiology Functional - Dr. Giller Case Conference

February 24 9 a.m.

10 a.m.

11 a.m.

12 p.m.

Pathology Resident Meeting Journal Club M&M

March 3 10 a.m.

11 a.m.

12 p.m.

Anatomy Business-Dr. Giller Case Conference

March 10 10 a.m.

11 a.m.

12 p.m.

Oral Board Review Neuro 101 - Dr. Macomson Case Conference

March 17

Written Exam

September - December 2016

April 14 10 a.m.

11 a.m.

12 p.m.

Radiology Functional - Dr. Giller Case Conference

April 21 10 a.m.

11 a.m.

12 p.m.

Oral Board Review Neuro 101 - Dr. Macomson Case Conference

April 28 9 a.m.

10 a.m.

11 a.m.

12 p.m.

Pathology Resident Meeting Journal Club M&M

Gail S. Adams

Salvatore Collura

Edwina F. Heath

Nancy L. McNair

Barbara Salisbury

Al Arnold Properties LLC

Lynne Czutrin

Robert E. Heisler

Medtronic

Susan Schoedel

Cathy Davies

Steven Heser

MetroPower

Kim Schuenemann

Mark D. Davis

James F. Hilliard

Tiernan Meyer

Roger P. Schurig

Michelle D. De Jesus

Kirby Holley

Lisa Miner

Martha M. Scott

Depuy Orthopaedics Inc.

Home Sales

Stephen Miner

Christine Seaver

Gail Hooper

Sue Mitchell

Elizabeth A. Sekul

Badr A. Ibrahim

Daniel A. Morris

Kapil D. Sethi

Asher S. Imam

Eric T. Moser

Hemang H. Shah

Integrity Medical

Merlin Nelson

Charles Shealey

Sharon K. Jackson

Jon Notestein

Kathryn K. Jarvis

Nufactor

Georgia L. Shenburger

Maurice Johnson

Kevin K. Nusbaum

William C. Johnston

Whitney C. O’Keeffe

Abdelazim Sirelkhatim

Walter R. Jones

Ann O’Shea

Megan Spindler

Jacque Jureqicz

PAR Fore Parkinson’s Inc.

Eric Steckler

Cargill H. Alleyne The ALS Association American Board of Professional Neuropsy Richard J. Anderson

Rose Derango

Beth Antonakos

Debbie Doerr

Avanir Pharmaceuticals

Forest Doolen

Mary Avgoulas

March 24 9 a.m.

10 a.m.

11 a.m.

12 p.m.

Pathology Resident Meeting Journal Club M&M

April 7

Sankar Bandyopadhyay Battle Lumbar Co., Inc.

No Conference

Rebecca Battle Edward Bender

NEUROLOGY GRAND ROUNDS SCHEDULE (January - April 2017)

James Bender Jody Bender Daniel R. Bergtholdt

January 5

Dr. Jeremiah Yim

January 12

Dr. Yong Park: Epilepsy

January 19

Dr. Debra Moore-hill: Rank Meeting

January 26

Dr. Kapil Sethi: Movement Disorders

February 2

Dr. Tom Swift: Case Presentation

February 9

Dr. Shachie Aranke

February 22:

March 2

Dr. Anthony Murro: Epilepsy

March 9

Dr. Ned Pruitt: Headaches

March 16

Dr. Tom Swift: Case Presentation

March 23

Dr. Askiel Bruno: Stroke Update

March 30

Dr. Ed Hartmann: Neuromuscular

April 6

No Grand Rounds: Masters Week

April 13

Dr. Jeff Switzer: Stroke

April 20

Dr. Alfredo Garcia: Neuro ICU

April 27

No Grand Rounds: AAN Meeting

March 8-11:

North American Spine Society Boston, MA

March 25-28:

American Academy of Neurology Fall Session Las Vegas, NV

April 22-28:

Research Update in Neuroscience for Neuro surgeons, Woods Hole, MA

April 22-26:

6

American Neurological Association Baltimore, MD

American Board of Neurological Surgery (Orals) Houston, TX

Toomas Eisler Thomas W. Ellers Joe Entrekin David Eubank Express Scripts Inc.

Pamela T. Parker

Reed Kaiser

Margaret G. Patrick

Ronald Kaiser

Frances L. Street Laura B. Swan Al Swenton Kenneth A. Vatz

Virginia Kirkwood

Nancy Pierce

Charles Vella

Meledy Kise

Kent A. Posey

ViaCord

Ruben Kloda

Thomas B. Potter

Susan Vines

Caroline Lamb

Karen Powell

Dorothy Warren

Ki H. Lee

Edward Przbyl

Kathleen M. Ley

Joel Redfield

Jeanne A. Warrington

Alton L. Lightsey

Revenue Revenue

Brad Lindsey

Felix G. Rivera

Sara Lippa

Asher L. Rivner

Caryn Lobdell

Harold P. Rivner

Mark G. Loomus

Joshua Rivner

Abdul Hafiz

Louisville & Wadley Railway Company

Michael H. Rivner

Michael Hall

Frank J. Lozito

Waren F. Chumley

Mary E. Harmon

Cynthia Claybon

Susan Harrington

Marks Capital NY Corp

Tyler Cockle

Harris Foundation

Sandra H. Collins

Mary Ruth Haworth

Kristy A. Bouchard Donad C. Bray Kathy Brite Mariah L. Burch Debra Bushweiler Mary A. Calhoun Lisa C. Campbell Mary Jo Carlton Linda D. Carroll Mary Chase Chem Nuclear Systems LLC

Peggy Francis

Dennis Kaiser

Melissa Pfeiffer

Eileen V. Brandon

February 23 Dr. Mary Gregory: Child Neurology

Karen Eggenberger

Paul Singer

Ashley Keown

Michael A. Bone

February 16 Dr. John Morgan: Movement Disorders

Shawn Dunn

Julie S. Kelley

Joanne M. Blount

February 20-21: AANS/CNS Section on Cerebrovascular Surgery

Houston, TX

Lisa Drozdick

PCS Administration, Inc.

Gary Bewer

UPCOMING MEETINGS (January - April 2017)

Sue Downing

Rachel Franklin Nancy S. Gall Elizabeth A. Gamble Elizabeth Garcia Gayle G. Garry Billy Gibson Glenn R. Goldfarb Martha Goldhorn Thomas Goyt Stan Greenberg Caitlin Groeber Elliott G. Gross Melvyn Haas

Peter Rivner Teresa F. Rollins Jorge Romero

Virginia T. Matthews

Dan Rosa

Pamela C. McGraw

James W. Ryan

Jeanne Urban

David Weaver John W. Weaver Marsha Weaver Paul Weaver Daniel Wendorff Barbara Wetherell Daniel Whitebook Ronni Whitebook Melody Wilbanks Mitzi J. Williams James Wilson Dichen Zhao

augustahealth.org/neuro VOL. 14 | ISSUE 1 NEUROSCIENCE OUTLOOK

VOL. 14 | ISSUE 1

CLINICAL SPOTLIGHT

LASER ABLATION:

A NEW TOOL FOR DIFFICULT NEUROSURGICAL PROBLEMS

NEUROSCIENCE OUTLOOK

Cole A. Giller, MD, PhD, MBA, Yong D. Park, MD

Although stereotactic thermocoagulation of small intracranial lesions in humans has been used for 70 years1, a new twist in technology has resurrected a keen interest in ablation for a variety of neurosurgical disorders. By using MRI sequences capable of displaying tissue temperature, real-time observation of the growing heat map is possible as a laser-tipped probe delivers focal heat to create an ablative lesion.

This allows the surgeon to either discontinue the treatment in order to limit high temperatures near critical structures, or to repeat the treatment as needed to encompass the desired region.

also effective for lesions that are often not easily treated with radiosurgery, such as benign tumors, hypothalamic hamartomas, the tubers of tuberous sclerosis, and epileptic foci3. Furthermore, unlike radiosurgical treatment, laser ablation carries no risk of radionecrosis or the occurrence of radiation induced tumors. In fact, laser ablation has been used to eliminate necrotic tissue following complications of radiosurgery.

Laser ablation in its present form is new, and indications are still being refined and discovered.

Although this technology will not replace craniotomy or radiosurgery, its ability to ablate lesions that are either difficult to resect or unresponsive to radiation is proving to be a welcome addition to the neurosurgical armamentarium.

The laser ablation procedure is invasive because it entails stereotactic insertion of the fiberoptic probe.

But because all that is required is a 3 mm twist drill hole made through a 3 mm scalp incision, the routine surgical risks are low and hospital stays are only one to two days. More importantly, laser ablation allows treatment of small, troublesome lesions not easily resected through a craniotomy either because their location is unfavorable or because they cannot be distinguished from normal tissue with the naked eye.

The Laser Ablation Procedure Laser ablation depends heavily on stereotactic technique and precision. Although our preference is for framed stereotaxis, some centers use frameless methods. Ablation usually proceeds under general anesthesia because the patient must be absolutely still during the MRI sequences. In the operating room, the stereotactic apparatus is used to guide placement of the fiberoptic laser through a small skin incision and a twist drill hole in the skull (Fig 1). The patient is then brought to the MRI suite, where images are obtained to display the entire length of the laser probe. The laser is then activated while sequential MRI scans are obtained that show a color map in real-time of the rising tissue temperatures (Fig 7), as well as an estimate of the tissue that has been destroyed (Fig 8).

Laser probes are available with differently shaped tips, allowing the surgeon to create elliptical or spherical lesions depending on the choice of probe, and some laser probes can direct the laser light perpendicular to the axis of the probe for greater flexibility. While watching the expanding color map of temperatures superimposed on the MRI images, the neurosurgeon can decide when to end the ablation based on the size of the lesion and on adjacency to critical structures.

The lesion can be repeated, and the probe can be inserted or withdrawn to create lesions of various shapes most suited to the target. MRI sequences can then be obtained immediately to document the size and shape of the lesion. The patient is then brought

Potential targets for laser ablation include metastatic and primary tumors as well as those not amenable to treatment by other methods such as radiosurgery. For example, cavernous angiomas do not respond to radiation, and yet they can be safely eliminated with laser ablation2. Laser ablation is

8

back to the operating room, the fiberoptic probe removed, and the wound closed with a single stitch.

medial parietal lobe, (Fig 10) consistent with cortical dysplasia. Spike and wave patterns with focal slowing were detected over these regions with interictal EEG monitoring, although ictal recordings showed only a right posterior onset and were poorly localizing.

Magnetoencephalography (MEG) showed multiple sites of dipoles throughout the region of the MRI lesions.

Because of the size of the MRI lesion and the diffuse ictal EEG findings, it was not feasible to resect the entire region of interest. To better localize seizure onset, ten SEEG depth electrodes were inserted for Phase II monitoring of the right posterior quadrant, guided by the MEG studies, the MRI findings, and the preoperative EEG. The pattern of rhythmic discharges revealed three areas of onset within the medial and lateral right parietal lobe, each approximately correlated with areas of cortical dysplasia identified by MRI.

Surgical options included resection of the region thought most likely to be epileptogenic, with the potential of further resection in a staged fashion if the seizures continued. Rather than accept the possibility of a series of craniotomies, the family chose laser ablation as the means of removing the epileptogenic zones. Review of the EEG data suggested that the most active region was the component in the right posterior medial parietal lobe (Fig 10).

The steps of the operation were as in Case 1. A probe trajectory was planned so that the ablated area would include the most active contacts of the SEEG electrodes and maximize the amount of included abnormal tissue (Fig 11). After visualizing the laser probe on an MRI image (Fig 12), a lesion was created and then repeated to increase its diameter. The probe was then withdrawn 7 mm and a lesion created, resulting in cylinder-shaped ablation (Fig 13). As before, the probe was removed, the wound closed with a single stitch, and the patient discharged without neurological changes on the second postoperative day.

Case One: Cavernous Angioma and Epilepsy A 15 year-old girl presented with a 10 year history of complex partial seizures occurring two to three times per week. The seizures were recalcitrant to medical therapy and characterized by unresponsiveness, head turning to the right, and automatisms. An MRI scan showed a one cm lesion consistent with a cavernous malformation surrounded by hemosiderin, located in the right temporal stem adjacent to the inferior insula (Fig 2). An associated developmental venous anomaly (DVA) was noted in close proximity to the lesion. Interictal EEG showed right-sided temporal spikes. A Wada test showed left language dominance and suggested that either a right or left temporal lobectomy would confer a high risk of verbal memory loss. She was doing well in school and hoped to attend college.

Phase II implantation of five SEEG depth electrodes was performed to sample the region adjacent to the lesion, the hippocampal area, the temporal and frontal opercula, and the insula. The ictal data was consistent with seizure spread from the region of the lesion to the temporal opercula and insula. Because of her high functional status, the family chose laser ablation rather than a lesionectomy through a craniotomy.

Her operation began with general anesthesia, attachment of a stereotactic frame and acquisition of a planning MRI with contrast. Several trajectories were considered, and the approach felt best to target the lesion while avoiding the DVA and other cerebral vessels entered through the inferior frontal lobe and traversed the insula (Fig 3 to 6). The fiberoptic laser was placed through the lesion using this trajectory, and the patient was brought back to the MRI suite for the ablation. A lesion was made using a laser tip with a length of 10 mm while monitoring the heat map and ablation zone (Fig 7 and 8), then repeating the process twice so that the final lesion encompassed the hemosiderin boundary and the inferior portion of the insula (Fig 9). Moving the tip for an additional lesion was not necessary. The patient returned to the operating room, the probe was removed and the wound closed with a single stitch. The patient awoke without neurological changes and was discharged on the second postoperative day.

Conclusion Laser ablation is a new method by which small, difficult lesions can be ablated under real-time monitoring without the need for a craniotomy. Cases have been reported for its use to treat metastatic and primary brain tumors, hypothalamic hamartomas, cortical dysplasia and other epileptic foci, temporal lobe seizures (by ablation of the hippocampus and amygdala), cavernous malformations, progressive radionecrosis and strokeinduced edema. Advantages of the technique include the ability to ablate tumors not easily treated with craniotomy or radiosurgery, applicability to patients

Case Two: Cortical Dysplasia A nine year-old boy presented with a three year history of complex partial seizures occurring three to four times each week despite maximal medical therapy. Generalized seizures were infrequent but required stabilization in the ICU. An MRI showed regions of abnormally thickened gray matter along the surfaces of the right lateral and

(continued on page 10) 9

augustahealth.org/neuro VOL. 14 | ISSUE 1 NEUROSCIENCE OUTLOOK

VOL. 14 | ISSUE 1 NEUROSCIENCE OUTLOOK

(Continued from page 9.) too ill for open surgery, the possibility of staged and repeated treatment, the lack of risk of oncogenesis, an immediate therapeutic effect and a shorter hospital stay and a shorter time to adjuvant therapy. However, experience is early, and most of these promising initial results have not yet been followed by randomized, controlled studies. It is likely that laser ablation will nevertheless prove to be a useful neurosurgical tool, and that its appropriate place in treatment strategies will be determined by the data accruing from this very active field.

Spiegel EA, Wycis HT, Marks M, Lee A. Stereotaxic apparatus for operations on the human brain. Science 1947;106:349-350.

2 McCracken DJ, Willie JT, Fernald B, Saindane AM, Drane DL, Barrow DL, Gross RE. Magnetic resonance thermography-guided stereotactic laser ablation of cavernous malformations in drug-resistant epilepsy: imaging and clinical results. Operative Neurosurgery 2016;12:39-48.

3 Medvid R, Ruiz A, Komotar JR, Jagid JR, Ivan ME, Quencer RM, Desai MB. Current applications of MRI-guided laser interstitial thermal therapy in the treatment of brain neoplasms and epilepsy: a radiologic and neurosurgical review. AJNR 2015;36:1998-2006.

1

Figure 7

Oblique MRI showing real-time color map obtained during lesioning in Case 1.

Figure 8

Figure 9

Oblique MRI showing area of ablation in Case 1.

Coronal FLAIR MRI showing lesion of Case 1 encompassing cavernous angioma and a portion of the inferior insula

Figure Legends

Figure 1

Laser probe has been placed stereotactically, held in place by an anchoring bolt (blue cap).

Figure 4

Coronal MRI of Case 1 showing probe passing through lesion (arrow). Insula is marked by I.

Figure 2

Coronal MRI showing cavernous angioma in temporal stem and inferior insula (Case 1).

Figure 5

Merged datasets of MRI and CT scans of Case 1 showing probe passing through middle cerebral artery candelabra without intersecting vessels.

10

Figure 3

Planned stereotactic trajectory for Case 1.

Figure 6

Merged datasets of MRI and CT scans of Case 1 showing probe passing though lesion while avoiding the associated DVA.

Figure 10

Sagittal MRI of Case 2 showing most active region (arrows) of presumed cortical dysplasia.

Figure 11

Figure 12

Sagittal MRI of Case 2 showing planned trajectory.

Sagittal MRI of Case 2 showing probe placement.

Figure 13

Merged MRI and CT datasets of Case 2 showing laser lesion (purple) and sites of most active SEEG contacts (red).

11

augustahealth.org/neuro VOL. 14 | ISSUE 1 NEUROSCIENCE OUTLOOK

NEUROSCIENCE OUTLOOK

VOL. 14 | ISSUE 1

CLINICAL SPOTLIGHT

BOTOX FOR HEADACHES: WHO? WHEN? WHERE? J. Ned Pruitt, MD

It is estimated that approximately 45 million Americans suffer from migraines. For many of these patients the migraines are managed with both preventative medications as well as acute medications when the migraines occur. Even then, many times a month a migraine causes one to two days or more of disability with each migraine event. For some patients migraines are so frequent that 15 to 25 days of each month are spent battling a migraine. Certainly, this disability is no less severe than other forms of disability and may last as long as 25 to 30 years. Most people with chronic migraines begin with episodic migraines.

These patients may start out with just a few headaches and migraines each month. For some individuals the frequency and severity of their headaches and migraines gets worse over time. Many factors may influence this change in frequency including pregnancy, birth control, weight gain, stress and other health conditions such as hypertension. As the migraines become more frequent and there is less and less recovery time in between migraine attacks, an individual may go from a few headache days a month to one every few days.

Eventually, he or she gets to the point where he or she has15 or more headache days a month. With each headache lasting 4 hours or more and 8 of those days associated with migraine, this, by definition, is a Chronic Migraine. Botox should be considered as a potential additional preventative medication for these patients with chronic migraine and experiencing more than 15 headache days per month. Chronic migraine sufferers have often been to many physicians and been on many different daily medications in an effort to decrease the number of migraines. In these cases, Botox can be a very helpful addition to management.

A headache specialist should be able to sort through past and current medications for migraine management and determine the best preventative as well as acute migraine therapies.

Botulinum toxin or Botox was given FDA approval in 2010 for patients suffering from chronic migraine when these migraines are occurring more than 15 days per month. Botox can be used with other forms of preventative medications such as propranolol, amitriptyline, and topiramate. Botox can also be used in addition to standard medications for the acute treatment of a migraine attack such as sumatriptan (Imitrex), riztriptan (Maxalt) and zolmatriptan (Zomig) to name just a few. Botox was approved by the FDA because of its ability to lower the number of migraine days per month by approximately one third in patients who suffered from chronic migraine. Therefore, a patient suffering from 21 to 25 migraine headache days per month might expect a decrease in the number of migraine days to 14 to 18 days per month. Botox will not treat acute migraines and Botox will not stop migraines from occurring. Botox does not seem to be helpful in patients suffering from migraines less than 14 days per month.

in headache days. However, patients may not see a full effect on migraines until after their third series of Botox injections.

vision. The most common adverse reactions reported by patients being treated for chronic migraine have been neck pain and headache. Although Botox therapy for chronic migraines involves specific injections in the forehead, temples, and upper neck, the effects of the botulinum toxin may spread from the area of injection to other areas of the body, causing symptoms similar to those of botulism poisoning. These symptoms can include swallowing and breathing problems. The FDA says it knows of no confirmed cases of the spread of the toxin when Botox has been used at the recommended dose to treat a variety of symptoms. These include chronic migraines, severe underarm sweating, or conditions such as blepharospasm, an involuntary muscle spasm in the muscles surrounding the eyes.

Botox injections are done using a standard FDA approved protocol, which includes small doses of the medication into superficial muscles of the forehead, bilateral temporal areas, upper cervical paraspinal and trapezius muscles (Figures 1-4). These injections are done with a fine needle and the procedure itself can take less than 15 minutes to accomplish. Because the injections are quite superficial, systemic side effects of the medication are extremely rare. However, occasionally after the forehead injections, patients may experience a temporary drooping of the eyelid and in very rare cases a temporary period of double

Botox treatments occur every 12 weeks. During this time frame, patients keep close records of their migraine frequency with a headache calendar. This allows not only tracking of the number of migraines but will often help reveal patterns and triggers that aid in management.

Patients often see a significant reduction in headache days after the first treatment. Some patients start to feel results as early as four weeks. Over the course of two treatment sessions, patients should notice a reduction

FIGURE 5

FIGURE 4

Mechanism of action of Botulinum toxin: Botox interferes with SNARE proteins. This blocks the vesicle where Acetylcholine (ACh) is stored from binding to the membrane; inhibiting the release of the neurotransmitter from the neuron.

Figure 1

Figure 2

Figure 3

12

Figure 4

13

augustahealth.org/neuro VOL. 14 | ISSUE 1 NEUROSCIENCE OUTLOOK

VOL. 14 | ISSUE 1 NEUROSCIENCE OUTLOOK

PUBLICATIONS & PRESENTATIONS (September-December 2016) PRESENTATIONS: Alleyne CH: Neurologic injury and neuroprotection after subarachnoid hemorrhage. American Academy of Neurological Surgery Meeting, Jackson Hole, WY, September 2016.

Alleyne CH: Neurovascular interventions for ischemic and hemorrhagic stroke. Alpha Phi Psi meeting. Augusta, GA, October 2016.

Kislin M, Sword J, Fomitcheva I, Croom D, Pryazhnikov E, Lihavainen E, Toptunov D, Rauvala H, Ribeiro A, Khiroug L, Kirov S: Reversible disruption of neuronal mitochondria by ischemic and traumatic injury revealed by quantitative two-photon imaging in the neocortex of anesthetized mice. The 46th Society for Neuroscience Annual Meeting, San Diego, CA, November 2016.

Hess DC: The TEMPO EMS -a planned prehospital trial of RIC in acute stroke. Fourth International Symposium on Tolerance and Conditioning: 30 Years of Science and Hope in Suzhou, China, November 2016.

Hess DC: Remote ischemic conditioning: An exercise mimetic? Fourth International Symposium on Tolerance and Conditioning: 30 Years of Science and Hope in Suzhou, China, November 2016.

Hess DC, Ji X: Chronic RIC as a treatment for Vascular Cognitive Impairment and Dementia (VCID). Fourth International Symposium on Tolerance and Conditioning: 30 Years of Science and Hope in Suzhou, China, November 2016.

Hess DC: Telestroke in Rural Georgia. 30th Biennial Institute for Georgia Legislators (hosted by the Carl Vinson Institute at the University of Georgia), Athens, GA, December 2016.

Nguyen K, Alleyne CH: Treatment of severe case of Vein of Galen malformation in a neonate. Georgia Neurosurgical Society Meeting, Greenboro, GA, December 2016.

PUBLICATIONS: Kislin M, Sword J, Fomitcheva I, Croom D, Pryazhnikov E, Lihavainen E, Toptunov D, Rauvala H, Ribeiro A, Khiroug L, Kirov S: Reversible disruption of neuronal mitochondria by ischemic and traumatic injury revealed by quantitative two-photon imaging in the neocortex of anesthetized mice. J Neurosci [Epub ahead of print; Dec 1], 2016.

Wechsler LR, Demaerschalk BM, Schwamm LH, Adeoye OM, Audebert HJ, Fanale CV, Hess DC, Majersik JJ, Nystrom KV, Reeves MJ, Rosamond WD, Switzer JA; on behalf of the American Heart Association Stroke Council; Council on Epidemiology and Prevention; and Council on Quality of Care and Outcomes Research: Telemedicine quality and outcomes in stroke: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 48(1):e3-e25, Jan 2017.

Al Kasab S, Hess DC, Chimowitz, MI: Rationale for ischemic conditioning to prevent stroke in patients with intracranial arterial stenosis. Brain Circ 2:67-71, 2016.

Jovin TG, Albers GW, Liebeskind DS; STAIR IX Consortium (Hess DC). Stroke Treatment Academic Industry Roundtable: The Next Generation of Endovascular Trials. Stroke 47(10):2656-65, Oct 2016.

Yowtak J, Sharma S, Forseen SE, Alleyne CH: Anterior gray matter pituicytic heterotopia with monomorphic anterior pituitary cells: A variant of nonsecretory pituitary adenoma neuronal choristoma? Report of a rare case and review of the literature. World Neurosurg S1878-8750 (16) 30983-4, 2016.

Yowtak J, Jenkins P, Giller C: Transection of the omohyoid as an aid during vagal nerve stimulator implantation. World Neurosurg S1878-8750(16) 31305-5, 2016.

THE CLINICAL TEAM ALS CLINIC Michael H. Rivner, MD

NEURO CRITICAL CARE K. Alfredo Garcia, MD Sam Tsapiddi, MD

MEMORY DISORDERS John C. Morgan, MD, PhD

NEUROLOGISTS Askiel Bruno, MD James Carroll, MD K. Alfredo Garcia, MD J. Edward Hartmann, MD David C. Hess, MD Julie A. Kurek, MD Gregory Lee, PhD Debra Moore-Hill, MD John C. Morgan, MD, PhD Anthony M. Murro, MD Fenwick T. Nichols III, MD Yong Park, MD J. Ned Pruitt II, MD Michael H. Rivner, MD Elizabeth Sekul, MD Kapil D. Sethi, MD Suzanne H. Smith, MD Thomas Swift, MD Jeffrey A. Switzer, DO Sam Tsapiddi, MD

MOVEMENT DISORDERS Cole A. Giller, MD, PhD Julie A. Kurek, MD John C. Morgan, MD, PhD Kapil D. Sethi, MD

NEUROMUSCULAR DISEASES J. Edward Hartmann, MD J. Ned Pruitt II, MD Michael H. Rivner, MD

SPINE CENTER Cargill H. Alleyne Jr., MD Ian Heger, MD S. Dion Macomson, MD Scott Rahimi, MD John R. Vender, MD

MULTIPLE SCLEROSIS CENTER Suzanne H. Smith, MD

NEUROSURGEONS Cargill H. Alleyne Jr., MD J. Dan Dillon, MD Cole A. Giller, MD, PhD Ian Heger, MD S. Dion Macomson, MD Scott Rahimi, MD John R. Vender, MD

EPILEPSY CENTER Cole A. Giller, MD, PhD Mary Gregory, MD, PhD Debra Moore-Hill, MD Anthony M. Murro, MD Yong Park, MD Gregory Lee, PhD GAMMA KNIFE CENTER Cargill H. Alleyne Jr., MD Cole A. Giller, MD, PhD John R. Vender, MD

Hewett SJ, Shi J, Gong Y, Dhandapani K, Pilbeam C, Hewett JA: Spontaneous glutamatergic synaptic activity regulates constitutive COX-2 expression in neurons: opposing roles for the transcription factors CREB and Sp1. J Biol Chem 291(53): 27279-27288, 2016.

Todnem N, Yowtak J, Alleyne CH: Case report of a rare case of Pituitary Adenoma Neuronal Choristoma (PANCH) and review of the literature. Georgia Neurosurgical Society Meeting, Greensboro, GA, December 2016.

Yowtak J, Giller C: Implantation of combined subdural grids and depth electrodes for invasive seizure monitoring. Georgia Neurosurgical Society Meeting, Greensboro, GA, December 2016.

14

Members of the Augusta University Neurology and Neurosurgery departments are shown in bold

PEDIATRIC NEUROSCIENCES James Carroll, MD Morris Cohen, EdD Mary Gregory, MD, PhD Ian Heger, MD Yong Park, MD Elizabeth Sekul, MD SKULL BASE TUMOR CENTER Cargill H. Alleyne Jr., MD John R. Vender, MD SLEEP MEDICINE Anthony M. Murro, MD Yong Park, MD

STROKE AND CEREBROVASCULAR CENTER Cargill H. Alleyne Jr., MD Askiel Bruno, MD David C. Hess, MD Fenwick T. Nichols III, MD Scott Rahimi, MD Jeffrey A. Switzer, DO

To make an appointment for your patient, please call 706-721-4581.

augustahealth.org/neuro 15

augustahealth.org/neuro VOL. 14 | ISSUE 1 NEUROSCIENCE OUTLOOK

Communications and Marketing 1120 15th Street, AD 1121 Augusta, Georgia 30912

Non-Profit Organization U.S. Postage

PAID

Augusta, GA Permit No. 210 CHANGE SERVICE REQUESTED

Wrong address?

Need to update your information?

Tell us by email at marketing@augusta.edu Or call us at 706-721-7406.