A Triannual Publication of Augusta University
NEUROSCIENCE OUTLOOK News and Research from the Departments of Neurology and Neurosurgery
VOL. 14 | ISSUE 2
VOL. 14 | ISSUE 2 NEUROSCIENCE OUTLOOK
FROM THE CHAIRMEN We’ve experienced quite a bit of administrative change since the last issue of our newsletter. Our very own former Chair of Neurology, Dr. David Hess, was appointed the 27th Dean of the Medical College of Georgia at Augusta University. Dr. Hess has shown tremendous commitment to our institution and we wish him much success in his new role. Dr. Jerry Ned Pruitt, longtime faculty member in the Neurology department, has been appointed Interim Chairman.
DEAR READERS,
We are pleased to report that our Comprehensive Stroke Center has won yet another award from the American Heart Association and American Stroke Association (News from the Departments). The School of Medicine recently celebrated the AOA inductees at the annual banquet and Dr. Robert Bakos, a retired neurosurgeon from Rochester, NY, delivered the keynote lecture. Our research spotlight in this issue describes promising results of a study of multipotent adult progenitor cells (MAPC) for acute stroke therapy. MultiStem in Acute Stroke to Enhance Recovery Study (MASTERS) is a phase 2, multicenter, double-blind, randomized, placebo-controlled trial that took place at 33 sites in the US and the UK. The main results were published in this year’s March online issue of Lancet Neurology. Our educational spotlight outlines the history of Medical Illustration at our institution (one of only four such programs in the world) and the unique relationship between this field and neurosurgery.
From left: Cargill H. Alleyne Jr., MD Professor and Marshall Allen Distinguished Chair of Neurosurgery
IN THIS ISSUE VOL. 14 | ISSUE 2
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
J. Ned Pruitt, MD Professor and Interim Chair of Neurology
We’ve also inserted a short essay from one of our Neurosurgery alumni, Dr. Ernest Fokes, who graduated from the neurosurgery program in 1969. Dr. Fokes provides an amusing anecdote about one of his more memorable patients. As usual, we provide an update of the accomplishments, and academic output of our respective departments. Enjoy! Cargill H. Alleyne Jr., MD Professor and Marshall Allen Distinguished Chair of
marketing@augusta.edu.
CLINICAL SPOTLIGHT: CELL THERAPY IN STROKE_______________________ 8
Editor-in-chief: Cargill H. Alleyne, Jr., MD
EDUCATIONAL SPOTLIGHT: MEDICAL ILLUSTRATION IN THE NEUROSCIENCES AT MCG AND AU _____________________________ 10
Assistant Editor: Julie Kurek, MD Illustrations: Colby Polonsky, MS, CMI
ESSAY: JEZEBEL______________________________________ 12
Contributors: David C. Hess, MD, Michael Jensen, MS, CMI, Colby Polonsky, MS, CMI, Cargill H. Alleyne, Jr., MD, Ernest Fokes, MD
Neurosurgery
PUBLICATIONS & PRESENTATIONS_____________ 14 J. Ned Pruitt, MD
THE CLINICAL TEAM__________________________ 15
Professor and Interim Chair of Neurology
2
3
augustahealth.org/neuro VOL. 14 | ISSUE 2 NEUROSCIENCE OUTLOOK
VOL. 14 | ISSUE 2 NEUROSCIENCE OUTLOOK
NEWS from the DEPARTMENTS (January-April 2017) Dr. Hess named Dean David C. Hess MD, former Chairman of Neurology and Presidential Distinguished Chair, was named Dean and Executive Vice President for Medical Affairs and Integration on April 28, 2017. Hess has been Chairman of Neurology since 2001. Jerry Ned Pruitt, MD was named Interim Chair and John Morgan, MD, PhD was named Interim Executive Vice-Chair of the Department of Neurology.
Retired neurosurgeon delivers AOA lecture Dr. Robert Bakos, Professor Emeritus of Neurosurgery, University of Rochester, delivered the Alpha Omega Alpha Visiting Professorship lecture “The strange case of Dr. Billroth and Mr. Brahms” on April 19, 2017. He was introduced by Dr. Cargill H. Alleyne, Jr., Vice-Councilor and Treasurer of the Augusta chapter of AOA. Bakos also delivered the lecture to the Music History II class. In addition, he delivered talks to the Department of Neurosurgery, the Neurology and Neurosurgery Interest group and at the AOA induction ceremony. Bakos has had over a decade of musical training at the Cleveland Music School (a teaching institution for the Cleveland Orchestra). He trained in violin and clarinet and studied music theory, composition, counterpoint, and harmony. He has traveled to Vienna over 40 times and has an interest in both the musical and medical history of the region. His love for medical history and music spawned several lectures including the popular series “Dead Germanic Composers & How They Got That Way.” Drs. Alleyne and Bakos worked closely together in the early 2000’s in their respective roles of Associate Program Director and Program Director at University of Rochester, NY.
FACULTY & STAFF UPDATE Cargill H. Alleyne Jr., MD (Department of Neurosurgery) was named a Castle Connolly Top Doctor for 2017. He moderated the Spetzler Symposium, Session VI: Skull base III in Los Angeles, CA, in April. He was also interviewed for the Channel 6 (ABC) Means Report (“From the race to the operating room: One woman’s survival from a brain aneurysm”) in February, and featured (with Dr. Heger) in a WJBF-TV Channel 6 News segment (“Child undergoes brain surgery for rare condition”) in March. Ian Heger, MD (Department of Neurosurgery) was featured (with Dr. Alleyne) in a WJBF-TV Channel 6 News segment (“Child undergoes brain surgery for rare condition”) in March. He was also featured in an article in Augusta Chronicle about the Chiari malformation (“Once rare ailment seen more often”).
David C. Hess, MD (Department of Neurology) was named Dean and Executive Vice President for Medical Affairs and Integration. He was also named a Castle Connolly Top Doctor for 2017.
Sergei A. Kirov, PhD (Department of Neurosurgery) served on the National Institutes of Health study section: NIH ZRG1 F03A (20), Fellowships: Neurodevelopment, Synaptic Plasticity, Neurodegeneration Study Section in February 2017.
John Morgan, MD, PhD (Department of Neurology) was named Interim Executive Vice-Chair of the Department of Neurology.
Stroke Team wins another award The Stroke Service at Augusta University Medical Center was awarded with the 2017 Silver Plus and Target: Stroke Elite Plus Honor Roll from the American Heart Association/ American Stroke Association. The Silver Plus Quality Award is Augusta University Medical Center an advanced level of recognition acknowledging hospitals for Augusta, GA consistent compliance (12 consecutive months) with Quality Measures embedded within the Patient Management Tool. The Quality Measures include percent of acute ischemic stroke patients who arrive at the hospital within 120 minutes of time last known well and for whom IV t-PA was initiated at the hospital within 180 minutes of time last known well; early antithrombotics; VTE prophylaxis; antithrombotic therapy at discharge; anticoagulation for AFib/Aflutter at discharge; smoking cessation advice or counseling during hospital stay; and statin prescribed at discharge. The Stroke Honor Roll-Elite Plus threshold is time to thrombolytic therapy within 60 minutes in 75 percent or more of acute ischemic stroke patients treated with IV tPA AND time to thrombolytic therapy within 45 minutes in 50 percent of acute ischemic stroke patients treated with IV tPA. Congratulations to the entire Stroke Team!
4
J. Ned Pruitt, MD (Department of Neurology) was named Interim Chair of the Department of Neurology.
Kapil D. Sethi, MD (Department of Neurology) was named a Castle Connolly Top Doctor for 2017.
RESIDENT UPDATE Nathan Todnem, MD (PGY-5) passed the written neurosurgery Board examinations for credit. Congratulations!
5
augustahealth.org/neuro VOL. 14 | ISSUE 2 NEUROSCIENCE OUTLOOK
VOL. 14 | ISSUE 2 NEUROSCIENCE OUTLOOK
THANK YOU, NEUROSCIENCE DONORS!
NEUROSURGERY CONFERENCE SCHEDULE (May - August 2017) May 3 10 a.m. Anatomy 11 a.m. Business 12 p.m. Case Conference
June 16 10 a.m. Radiology 11 a.m. Functional - Dr. Giller 12 p.m. Case Conference
May 12 10 a.m. Radiology 11 a.m. Gamma Knife 12 p.m. Case Conference
June 23 9 a.m. Pathology - Dr. Sharma 10 a.m. Resident Meeting 11 a.m. Journal Club 12 p.m. M&M
May 17 9 a.m. 10 a.m. 11 a.m. 12 p.m.
Pathology Resident Meeting GNS Presentations M&M
May 23 GNS June 2 11 a.m. Business 12 p.m. Case Conference June 9 10 a.m. Oral Board Review 11 a.m. Neuro 101: Chris Bannerjee 12 p.m. Case Conference
July 28 9 a.m. Pathology: Dr. Sjharma 10 a.m. Resident Meeting 11 a.m. Journal Club 12 p.m. M&M
July 7 10 a.m. Anatomy 11 a.m. Business 12 p.m. Case Conference: Joe Kilianski July 14 10 a.m. 11 a.m. 12 p.m.
Cargill H. Alleyne
Madison Heights LLC
ALS Association of Georgia, Inc.
M. Sue Martin
Alzheimer's Association
Medtronic
Augusta SLP, LLC d/b/a Benton House of Augusta
Sara M. Melton
Mary Barnette
Lynda B. McGahee
Family Care
Dean E. Nusbaum
Marian C. Clark
Pamela T. Parker
August 18 10 a.m. Radiology 11 a.m. Functional: Dr. Giller 12 p.m. Case Conference
Kathryn C. Claxton
Petsch Respiratory Services
John T. Collins
Pickens Pulley
Cooper & Company
Revenue Revenue
August 25 9 a.m. Pathology 10 a.m. Resident Meeting 11 a.m. Journal Club 12 p.m. M&M
CSRA Parkinson Walk
Michael H. Rivner
Claude G. Dorn
Barbara Slack
Amber A. Dowdy
Allen S. Snell
Evans Care Group, LLC d/b/a Marshall Pines Alzheimer
Teva Pharmaceuticals
Ernest C. Fokes
TIGA Inc. d/b/a Comfort Keepers
Barbara D. Frazier
Thom E. Tuckey
Billy L. Godowns
US Battery
August 4 10 a.m. Anatomy 11 a.m. Business 12 p.m. Case Conference: Khoi Nguyen
June 30 No Conference
Oral Board Review Neuro 101: Angela Viers Case Conference
July 21 10 a.m. Radiology 11 a.m. Functional: Dr. Giller 12 p.m. Case Conference
January 1, 2017 - April 30, 2017
August 11 10 a.m. Oral Board Review 11 a.m. Neuro 101: Dr. Alleyne 12 p.m. Case Conference
NEUROLOGY GRAND ROUNDS SCHEDULE (May - August 2017) May 4
Dr. Debra Moore-Hill: Epilepsy
Richard Jakobczyk
John R. Vender
May 11
Dr. Julie Kurek: Movement Disorders
Lundbeck LLC
ViaCord
May 18
Dr. Elizabeth Sekul: Child Neurology
Samuel D. Macomson
May 25
Dr. Sam Tsappidi: Neuro ICU
June 1
Senior Resident Presentation
June 8
Senior Resident Presentation
June 15
Senior Resident Presentation
June 22
Senior Resident Presentation
June 29
Senior Resident Presentation
July 6
No Grand Rounds
July 13
No Grand Rounds: Kiawah Conference
July 20
Dr. Ned Pruitt: Education Update
July 27
Fellow: Dusit Adstamongkonkul
August 3
Dr. Leslie Rudzinski: Epilepsy
August 10
Dr. John Morgan: Movement Disorders
August 17
UPCOMING MEETINGS (May - August 2017) May 8-10:
American Board of Neurological Surgery (Orals) Houston, TX
May 26-28:
Georgia Neurosurgical Society Sea Island, GA
Dr. Fenwick Nichols: Vascular
May 20-23:
Society of Neurological Surgeons Houston, TX
August 24
Dr. Michael Rivner: Neuromuscular
August 31
Dr. Tom Swift: Case Presentation
July 24-28:
Society of Neuro-Interventional Surgery Colorado Springs, CO
6
7
augustahealth.org/neuro VOL. 14 | ISSUE 2 NEUROSCIENCE OUTLOOK
VOL. 14 | ISSUE 2 NEUROSCIENCE OUTLOOK
CLINICAL SPOTLIGHT
CELL THERAPY IN STROKE
David C. Hess, MD
Stem cell therapy has generated a great deal of excitement in the field of neurology, especially as applied to stroke; cell therapy is the preferred term as the cells used do not meet the strict definition of stem cells. Since 2003, investigators in the Department of Neurology at Augusta University, have been developing multipotent adult progenitor cells (MAPC) for acute stroke therapy. In 2004, we started collaborating with Athersys Inc., a biotechnology company based in Cleveland, Ohio, on MAPC. Athersys had licensed MAPC from Catherine Verfaillie, a Belgian research hemaotologist, who was working at the University of Minnesota at the time; their proprietary product was called MultiStemR.
Drs. Hess, Borlongon and Carroll share a patent with Athersys on the use of MultiStem in neurological disease. Athersys, with our support, obtained Investigational New Drug status from the FDA for MulitStem. We assembled a Clinical Advisory Group to design a clinical trial and began the MultiStem in Acute Stroke to Enhance Recovery Study (MASTERS) clinical trial in 2013. This was a phase 2, multicenter, double-blind, randomized, placebo-controlled trial with a dose escalation phase that took place at 33 sites in the US and the UK with David C. Hess serving as the clinical Principal Investigator. The main results were published in this year’s March online issue of Lancet Neurology. 1
A team comprised of three members: two at Augusta University – James Carroll, Chief of Pediatric Neurology and David C. Hess, former Chair of Neurology, current Dean of the Medical School, as well as Cesar Borlongon Ph.D., now at the University of South Florida- received coveted U grant funding from the NIH/NINDS to develop and apply MultiStem as a therapy for acute ischemic stroke. They found that delivering these cells intravenously 24 hours post stroke provided ideal efficacy. Interestingly, the team learned that the major mechanism of action was immunomodulatory and that entry to the brain was not critical, with the spleen and lymph system being the targeted organs. Increasingly, the immune system is shown to play a major role in the sequelae of stroke with reactivity resulting in tissue injury after a stroke and the following immunodepression predisposing to bacterial infections. Targeting of immunomodulatory organs is a shared mechanism of action among stem cell populations, be they bone marrow, hematopoietic or umbilical cord stem cells. Underscoring this, animals without spleens have not shown benefit from MultiStem after ischemic stroke.
Overall, MultiStem was found to be both safe and well tolerated. While the primary outcome of Global Stroke Recovery at 90 days did not show a significant difference between the MultiStem and placebo groups, “excellent outcome” as defined by a modified Rankin score of 0 or 1 was significantly improved with MultiStem at one year and there was a strong trend at three months. In post hoc analyses, subjects treated within the 24 to 36 hour time window showed strong or significant trends in a number of secondary outcomes suggesting that this time window was optimal. The MultiStem group also had fewer infections and shorter hospitalizations. It should be noted that 24-36 hours was the original time target and that expansion of the window occurred in order to increase recruitment at certain sites where cell processing facilities had limited hours of operation.
UGA-MCG team has developed a porcine stroke model and has NIH funding to investigate the use of induced pluripotent stem cells (iPS) and neural progenitor cells (iPS-NP) implanted into an area of stroke. We feel this may be an optimal approach to “chronic stroke” and opens up the potential to use autologous transplantation in stroke patients, i.e. iPS-NP derived from a patient’s own skin cells. This will be the subject of a future newsletter.
2. Kalladka D, Sinden J, Pollock K, Haig C, McLean J, Smith W, et al. Human neural stem cells in patients with chronic ischaemic stroke (pisces): A phase 1, first-in-man study. Lancet. 2016;388:787-796 3. Steinberg GK, Kondziolka D, Wechsler LR, Lunsford LD, Coburn ML, Billigen JB, et al. Clinical outcomes of transplanted modified bone marrow-derived mesenchymal stem cells in stroke: A phase 1/2a study. Stroke. 2016;47:1817-1824
1. Hess DC, Wechsler LR, Clark WM, Savitz SI, Ford GA, Chiu D, et al. Safety and efficacy of multipotent adult progenitor cells in acute ischaemic stroke (masters): A randomised, double-blind, placebo-controlled, phase 2 trial. The Lancet. Neurology. 2017;16:360-368
These promising results have prompted an ongoing as well as a planned multicenter, randomized, double-blind trial of MultiStem in stroke. Both trials have a time window for infusion of 18 to 36 hours after ischemic stroke. One trial is ongoing in Japan and the other trial, which will begin in the fall of 2017, will include 300 subjects from North America and Europe and Dr. Hess will once more serve as one of the lead clinical investigators. This trial underwent a Special Protocol Assessment with the U.S. FDA. It is an exciting time for Cell Therapy in stroke. On May 6-7, 2017 the Stem Cell as an Emerging Paradigm for Stroke (STEPS 4) meeting was held in Washington, D.C. Attendees included representatives from the FDA, NIH, academia, and industry. The MultiStem trial was reviewed as well as two, small open-label, non-randomized, single arm trials of neural stem cells using the CTX line of ReNeuron as well as neutralized mesenchymal stem cells as part of the SB623 trial held by SanBio. 2, 3 Both these trials demonstrate the safety and feasibility of stereotactic implantation of neural stem cells or neutralized bone marrow cell into an area of “chronic stroke,” chronic being defined as more than six months after initial stroke. Dr. Hess summarized what was learned from the three trials and the group worked to develop guidelines to move the field forward. Also in attendance was our collaborator from the University of Georgia, Franklin West Ph.D. A
8
9
augustahealth.org/neuro VOL. 14 | ISSUE 2 NEUROSCIENCE OUTLOOK
MEDICAL ILLUSTRATION IN THE NEUROSCIENCES AT MCG AND AU Michael A. Jensen, MS,MI, CMI, MS, CMI, Cargill H. Alleyne, Jr., MD
NEUROSCIENCE OUTLOOK
VOL. 14 | ISSUE 2
EDUCATIONAL SPOTLIGHT
Representative art by illustrators Figure 6: Osler's likeness, (Cushing; colorized by Jensen) Figure 7: Brain and heart (Harrison) Figure 8: Cavernous malformation resection (Rekito) Figure 9: Ned's Head (Jensen) Figure 10: Myelin sheath destruction (Polonsky)
Medical illustration is a fascinating but often misunderstood branch of art, and has remained that way through much of its history. And yet, medical illustration continues to be an essential and integral part of both medical education and of medical practice. Medical Illustrators are highly trained visual artists who communicate complex scientific ideas in a meaningful, aesthetic and understandable manner. They train, teach and educate all the various branches of medical professionals through their art. Arguably, the first medical illustrators were among the Renaissance artists of the 15th and 16th centuries, such as Leonardo da Vinci and Stefan van Calcar, who illustrated the first anatomy textbook, “de Humani Corporis Fabrica” by anatomist Andreas Vesalius (figure 1).
Figure 1
As anatomical understanding and medical education in the late 19th century accelerated, schools for the training of medical illustrators began to appear, with the first school being established at Johns Hopkins School of Medicine in 1911 by Max Brödel (figure 2). Neurosurgeons such as Harvey Cushing (figure 3) were particularly interested in the contribution of medical art in their practice, and so many of the first modern illustrations created were related to neurosurgery. The friendship between Cushing, the father of American neurosurgery, and Brödel, the father of medical illustration, began at Johns Hopkins where Cushing would fastidiously illustrate each of his surgical cases once completed. The two remained lifelong friends and exchanged letters well into advanced age. Figure 4 shows a playful rendering of Brödel by Cushing.
Figure 7
Brödel (1870-1941) directed the medical illustration program at Johns Hopkins until his retirement in 1940. One of his protégés, Jack Wilson, was brought to the Medical College of Georgia (MCG) in April 1948 by President, Dr. G. Lombard Kelly, to illustrate for the faculty. More importantly, Mr. Wilson was also charged with developing an academic medical art program, similar to that at Johns Hopkins. Working with a second former Brödel student, Orville Parkes (Figure 5), Wilson developed a graduate curriculum which was approved in 1949. Parkes became the first director of the MCG Medical Illustration Graduate Program, and served from 1949 until his retirement in 1974. The first graduate of the program in 1951 was Robert C. Benassi, who for many years was the head of the Section of Medical Illustration at the Mayo Clinic. Figure 2
Figure 3
Figure 4
Figure 6
The Medical Illustration Graduate Program at MCG (now Augusta University) was the first accredited graduate program of its kind in the world. It has enjoyed uninterrupted accreditation since 1967, and this month, the program graduated its 373rd medical illustrator. In keeping with the relationship established by Dr. Cushing, many of these individuals have specialized in neurosurgical, neurological, and neuroanatomical illustration. In 1959, Dr. George C. Smith (the first Chief of the Division of Neurosurgery) hired program graduate Frances DeRoller as the first medical illustrator in the Division Neurosurgery, a position she held until her death in 1973. In the years following, an impressive list of some of the most successful medical illustrators in the business have worked at MCG Neurosurgery, including Octavia Garlington, David Mascaro, Milton Burroughs, Steve Harrison, Andrew E.B. Swift, Andrew J. Rekito and Michael A. Jensen. Currently, MCG/AU alumna Colby Polonsky adds her talents to this legacy, serving as medical illustrator for the Department of Neurosurgery. Examples of the art of some of these illustrators are seen in Figures 6-10.
Figure 8
As medical knowledge and surgical innovations improve the quality of life, medical illustrators will continue to play their part behind the scenes, documenting and elucidating that information through fascinating and authoritative imagery.
Figure 5
10
Figure 9
11
Figure 10
augustahealth.org/neuro VOL. 14 | ISSUE 2 NEUROSCIENCE OUTLOOK
NEUROSCIENCE OUTLOOK
VOL. 14 | ISSUE 2
ESSAY
JEZEBEL
Ernest C. Fokes, MD, (NS ’69) "Ernie, we've got a guy here in the emergency room who was shot in the neck. He's moving all four extremities but I'll swear, the x-rays look like the bullet is inside his spinal canal. He's drunk and thrashing about and I'm afraid he's going to do himself some damage." Your basic middle of the night call from the ER. "OK, try and hold him still and I'll be right there.” So with that I get dressed and drive to the hospital and go to the ER. Here was a middle aged, unkempt, moderately large white male, truly moving all four extremities, lying on the x-ray table with two orderlies trying to hold him down. The x-rays were somewhat indistinct owing to the fellow's lack of cooperation but, sure enough, there appeared to be a bullet inside the spinal canal in his neck at about the C-5 C-6 level. My examination, such as could be done with no cooperation on the part of the victim confirmed, so far as could be told, that he was neurologically intact. Again, lack of cooperation more or less ruled against a detailed sensory examination but he was certainly intact from a motor standpoint. With a foreign body in the spinal canal there was a clear indication for surgical intervention so I called the OR, explained the problem and asked for the Anesthesiologist to come over and give me a hand. I needed to have better x-rays and to do so the patient needed to be sedated. Furthermore, I couldn't tell whether his neck was stable, which is to say whether or not the missile had done enough bony damage so that he was in danger of having excessive movement of the bones in his neck and doing damage to his spinal cord. From a practical standpoint with all of the thrashing about he was doing, he had probably already answered that question. Nonetheless, I thought it was appropriate to place him in "tongs.” "Tongs" are a device somewhat similar to the old fashioned ice tongs that were once used to lift large blocks of ice. From a Neurosurgical standpoint they are affixed to the sides of the skull after first shaving and prepping the area and then a cord is attached to which a certain amount of weight is then affixed. The idea is to hold the neck in a relatively straight and stable position. My friend Tom Robinson, the Anesthesiologist arrived and I explained the situation to him and he gave the man some IV sedation which had a nice effect on his energetic attempts to get up and leave! This having been done I asked the nurses if the patient had any family present and was told that he did and that they were in the x-ray department waiting room. Here I found the three men and a woman. The woman was noticeably very sheepishly sitting away from the others. The oldest of the three stepped up and introduced himself as the patient's 12
father. I suppose he was in his late 60s, large, full beard, wearing a heavy wool plaid coat. The other two, the father told me were the patient's brothers, also very large men, heavy set and at least one of them had a suspicious looking bulge beneath his coat over the left side of his chest. There was a distinct odor of alcohol about the two brothers. I couldn't say about the father. The father, aided by the two brothers and with no encouragement from me quickly related that his son had been shot in the parking lot of the VFW in Dahlonega, Georgia. Dahlonega is a small town north of Atlanta and aside from there being a small college there, its main claim to fame was that it was the site of the "gold rush" in Georgia and the gold leaf that adorns the capitol dome came from that area. It is the site of the line "there's gold in them thar hills" from Edgar Allan Poe's story "The Gold Bug". I explained to the father and the two brothers the need for the patient's being placed in tongs, obtained the father's permission and told them he would also need to go to surgery and I would explain that once I had stabilized the man's neck. So, I went back into the x-ray room where the patient was still on the x-ray table and with Tom's assistance providing a little more sedation and the orderlies standing by shaved an area on either side of my patient's head, applied a local anesthetic and positioned the tongs. This having been done we placed him on a Stryker frame, a special bed used for patients in tongs. A cord was attached to the tongs, passed over a pulley and a weight attached. Now we obtained better x-rays. Sure enough the bullet appeared to be dead center in the spinal canal. Now I have to say, if the person who did the shooting had shot this man repeatedly for the rest of his life I don't believe he could have accomplished what he had accomplished in this instance. The spinal cord is rather large in the mid cervical area due to the abundance of motor neurons present and also due to the fact that all of the nerve fibers from below and going to below lie there. What I was seeing looked impossible, yet there it was. The main problem seemed to be to keep the man still enough to not do damage to himself before I could get him to the OR and remove the bullet. This episode was beginning to take on some of the features of the Old West with Doc Adams of Gun Smoke removing a bullet. Our patient was beginning to stir about so Tom and I and the two orderlies rolled him out into the corridor of the x-ray department to talk to him, assuming in his condition he could understand, and to his family about the proposed surgery. I noticed the woman, whose relationship to the others hadn't been explained to me (and I hadn't asked) was still sitting in a corner, arms
folded over her chest, head bowed and trembling. I walked over to the father and the two brothers came to his side, the woman kept her distance. "I need to take your son to the operating room. He has a bullet in the spinal canal pressing against his spinal cord, but so far as I can tell at this moment it hasn't done any damage to his spinal cord. If it remains in place it is a potential site of infection and could yet damage his spinal cord and paralyze him. Also, if it should move or displace, it could damage his spinal cord. Possibly due to my explanation and from the diminishing effects of the sedation Tom had given, our patient was beginning to wake up and let it be known in no uncertain terms, "Let me up and I'll kill that son of a bitch!!" I assumed he was referring to his assailant. I asked Tom if he would give him a little more sedation as it seemed that he probably had a high tolerance to the medication…I reckoned his tolerance was derived from a not inconsiderable routine alcohol intake.
I went back and in my most diplomatic fashion said, "You know, I can't answer that right now as it depends on what all we have to do. The most important thing now is to get that bullet out and we'll worry about the rest of it later." That seemed to satisfy him. At least for the moment. So, we took the victim to the operating room, where Tom gave him a general anesthetic and we carefully rolled him onto the operating table with the tongs and traction intact. I prepped his neck, made my incision and carried the dissection down to the spinous processes of C5-C6. I was pleased to see that the bony structure seemed stable and that basically the bullet, which turned out to be of .32 caliber had passed between the laminae of those two vertebrae on the left side. I removed a bit more of the laminae and there was the missile lying comfortably outside the dura mater, indenting it slightly but leaving it intact. I lifted it out, asked for a basin, asked for silence in the room and then in my best Doc Adams fashion dropped it with a resounding "clang" into the metal basin; irrigated and closed the wound. As I said before this man could have been shot on an hourly basis for the rest of his life and not experienced such a wound as this. I went to the waiting room where father, brothers and Jezebel were waiting. Jezebel off to one side. I told them we had accomplished what we set out to do and their son (brother) was waking up and moving well. Barring any additional problems such as infection I thought we could rest easy. They all shook my hand, expressed their thanks and Jezebel looked visibly relieved. My patient had an uneventful post-operative course and was discharged from the hospital four days later. When he returned for his follow up visit and suture removal he was alone, sober and expressed his gratitude for my care of him.
The father waited patiently as I explained the problem and the necessary surgery. He then offered, "Doctor, the whole problem started with that Jezebel sitting over there in the corner." With that all three turned and glared at the poor wretch trembling in the corner of the waiting room. It occurred to me to wonder how all four had come to the hospital from Dahlonega and if they had been present at the shoot-out? The father then went on to say that he was a minister and before I took his son to the operating room he wanted us all to kneel and pray. I have to say, this was a new experience for me and I was at a loss for words. Tom, however, leaned over and whispered very, very softly, "Ernie, I think we better do as he says. I think the other two may be packing!" Judging by the obvious bulge on the left side of the chest of one of the brothers and the loose fitting coat of the other which I believed could conceal almost anything, I thought the odds were that Tom was right. "Let's all kneel," said the preacher with the two brothers looking menacingly at us, and Tom and I and the two brothers, two orderlies and the Jezebel all complied. Said the preacher, "Lord we're calling on you to guide this fine doctor's hand. Let it be steady. Let it not slip. (Oh, Lord, I thought. What would be the consequences of that?) Let not one single thought of this foul Jezebel who has brought this misfortune down on my boy's head come into this man's mind. She will be dealt with, Lord. For now let this man's hand be rock steady as he goes about the task of saving my boy's life. Amen!" "Amens" came from both brothers and we stood. My prayer had been that no one would walk into the x-ray department and see this scene. At least that prayer was answered although with the two orderlies present I was sure this adventure would soon be spread throughout the hospital. One of the brothers stepped over to me and asked, "Doc, how much does an operation like this cost?" Before I could answer Tom said, "Just a minute," and pulled me aside. "Ernie, for God sake, don't tell him. I think they are on the way to knock over a 7/11 store!"
13
augustahealth.org/neuro VOL. 14 | ISSUE 2 NEUROSCIENCE OUTLOOK
VOL. 14 | ISSUE 2 NEUROSCIENCE OUTLOOK
PUBLICATIONS & PRESENTATIONS (January-April 2017) PRESENTATIONS: Alleyne CH: A career in Neurosurgery. Neurosurgery Interest Group, Augusta University, January 2017. Kislin M, Sword J, Fomitcheva IV, Croom D, Pryazhnikov E, Lihavainen E, Toptunov D, Rauvala H, Ribeiro AS, Khiroug L, Kirov SA: Reversible disruption of neuronal mitochondria by ischemic and traumatic injury revealed by 2-photon imaging in the murine neocortex. Keystone Symposia on Mitochondria Communication, Taos, NM, January 2017.
Nguyen KD, Choudhri HF, Macomson SD: The intercostal nerve as a target for diagnostic biopsy. American Association of Neurological Surgeons Meeting, Los Angeles, CA, April 2017 (poster).
THE CLINICAL TEAM
PUBLICATIONS: Alleyne CH: Joan’s Bones. North Charleston, SC, CreateSpace Independent Publishing Platform, 2017.
ALS CLINIC Michael H. Rivner, MD
Vaibhav K, Baban B, Dhandapani KM, Hoda MN: MicroRNA therapy in murine thromboembolic stroke. International Stroke Conference, Houston, TX, February 2017.
Giller CA: Deep brain stimulation for Psychiatric Disease: A neurosurgeon’s perspective. American Neuropsychiatry Association, Atlanta, GA, February 2017.
Kirov SA: Live imaging of brain injury depolarizations and their impact on neuroglia. American Society for Neurochemistry, Little Rock, AR, March, 2017. Kirov SA: Live imaging of brain injury depolarizations and their impact on neuroglia. American Society for Neurochemistry, Little Rock, AR, March 2017.
Bruno A, Zahranb A, Palettac N, Maalia L, Nichols FT, Figueroa RA: Standardized method to measure brain shifts with decompressive hemicraniectomy. Journal of Neuroscience Methods 280:11–15, 2017. Ma MW, Wang J, Zhang Q, Wang R, Dhandapani KM, Vadlamudi RK, Brann DW: NADPH oxidase in brain injury and neurodegenerative disorders. Mol Neurodegeneration 12(1): 7, 2017. Fouda AY, Pillai B, Dhandapani KM, Ergul A, Fagan SC: The angiotensin type II receptor agonist, compound 21, provides neuroprotection through interleukin-10 upregulation. Eur J Pharmacol 799: 128-134, 2017.
Alleyne CH: Update on subarachnoid hemorrhage and intracranial aneurysms. Comprehensive Stroke Management Update. Hilton Head, SC, April 2017.
Braun M, Vaibhav K, Saad NM, Fatima S, Brann DW, Vender JR, Wang LP, Hoda MN, Baban B, Dhandapani KM: Activation of myeloid toll-like receptor 4 mediates T-lymphocyte polarization after traumatic brain injury. J Immunol 198(9): 3615-3626, 2017.
Alleyne CH: Complication management and avoidance: Vascular malformations. American Association of Neurological Surgeons Meeting, Los Angeles, CA, April 2017.
Giller CA, Mornet P, Moreau JF: The first formulation of image-based stereotactic principles: the forgotten work of Gaston Contremoulins. Journal of Neurosurgery 2017 Feb 17:1-10 (Epub ahead of print).
Fomitcheva IV, Sword J, Croom D, Kirov SA: Spreading depolarization-induced disruption of dendritic ultrastructure in the murine neocortex revealed by quantitative serial section electron microscopy. International Conference on Spreading Depolarizations: 19th meeting of the Co-Operative Studies on Brain Injury Depolarizations (COSBID), Berlin, Germany, April 2017.
Yowtak J, Jenkins P, Giller C: Transection of omohyoid muscle as an aid during vagus nerve stimulator implantation. World Neurosurgery 99: March, 2017 118-121.
Johnson TS, Aguilera D, Al-Basheer A, …Giller CA, Grosshans D, Heger IM, …Munn DH: Safety and tolerability of combining the IDO-inhibitor indoximod with re-irradiation for pediatric patients with progressive brain tumors treated on the NLG-2105 phase 1 trial (NCT02502708). American Society of Pediatric Hematology/Oncology, 30th Annual Meeting. Concurrent Paper Sessions with Luminary Investigators (top 10 abstract from over 400 submitted). Montreal, Quebec, Canada, April 2017.
Rahimi SY, Todnem ND: Evolution of ischemic stroke therapy. Journal of Neurology, Neurosurgery, and Spine 1(5): December 2016
Rahimi SY, Vender JR, Todnem ND, Alleyne CH Jr: Endovascular embolization with adjuvant stereotactic radiosurgery for ruptured brain arteriovenous malformations in high surgical risk patients. American Association of Neurological Surgeons Meeting, Los Angeles, CA, April 2017 (poster). Nguyen KD, Alleyne CH Jr: Successful treatment of a severe case of Vein of Galen aneurysmal malformation. American Association of Neurological Surgeons Meeting, Los Angeles, CA, April 2017 (poster).
14
NEURO CRITICAL CARE K. Alfredo Garcia, MD Sam Tsapiddi, MD
MEMORY DISORDERS John C. Morgan, MD, PhD 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
Pandya C, Fatima S, Vaibhav K, Dhandapani KM, Baban B, Hoda MN: Improving rheo-erythrocrine functions: a novel therapeutic approach for efficient cerebral blood flow after acute ischemic stroke. International Stroke Conference, Houston, TX, February 2017.
Kirov SA: Spreading depolarization and hypoosmotic challenge trigger distinct mechanisms of cellular swelling in the brain. CaribeGLIA-7 Symposium on Molecular Mechanisms of Neuron-Glia Interactions In Vivo and In Vitro, Universidad Central del Caribe, San Juan-Bayamon, Puerto Rico, February 2017.
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 Tsappidi, MD
GAMMA KNIFE CENTER Cargill H. Alleyne Jr., MD Cole A. Giller, MD, PhD John R. Vender, MD
Woodall NM, Rahimi SY: Arteriovenous fistula mimicking vestibular schwannoma. Neurology 87(11):1184, September 2016
Rivner MH, Liu S, Quarles B, Fleenor B, Shen C, Pan J, Mei L: Agrin and LRP4 antibodies in Amyotrophic Lateral Sclerosis Patients. Muscle Nerve 55(3):430-432, 2017 (PMID: 27756107) Li D, Usuki S, Quarles B, Rivner MH, and Yu RK: Anti-sulfoglucuronosyl paragloboside antibody: A potential serologic marker of amyotrophic lateral sclerosis. ASN Neuro Sep 28;8(5), 2016. pii: 1759091416669619. Print 2016 Oct. (PMID: 27683876) Wolfe GI, Kaminski HJ, Aban IB, …Rivner MH…et al: A randomized trial of thymectomy in myasthenia gravis. NEJM 375(6):511-522, 2016 (PMID: 27509100)
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 Sam Tsappidi, MD
To make an appointment for your patient, please call 706-721-4581.
augustahealth.org/neuro 15
augustahealth.org/neuro VOL. 14 | ISSUE 2 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.