VOL. 11 | ISSUE 3
NEUROSCIENCE OUTLOOK
NEWS AND RESEARCH FROM THE DEPARTMENTS OF NEUROLOGY AND NEUROSURGERY AT GEORGIA REGENTS NEUROSCIENCE CENTER
COMPREHENSIVE TREATMENT OF EPILEPSY An extensive history of offering superlative care for all types of seizure disorders
FROM THE CHAIRMEN
DEPARTMENT NEWS
Cargill H. Alleyne Jr., M.D., and David C. Hess, M.D.
We present another issue of Neuroscience Outlook. In the clinical spotlight we review the current status of the epilepsy program, one of the oldest in the nation, and review two unique pediatric instrumentation cases. We also highlight a recent article chronicling the rich history of the Neurosurgery department and describe a collaborative cannabinoid clinical trial. We thank the unusually large number of donors, helped by the success of the ALS ice-bucket challenge. Faculty and resident updates and academic productivity are also documented. Enjoy! Cargill H. Alleyne Jr., M.D. Professor and Marshall Allen Distinguished Chair of Neurosurgery calleyne@gru.edu
David C. Hess, M.D. Professor and Presidential Distinguished Chair of Neurology dhess@gru.edu
Cover Legend 1. Operative view of hippocampal multiple subpial transections. 2. Epilepsy surgery. 3. SISCOM study showing frontal activity. 4. Intraoperative navigation for depth electrode placement. 5. Skull film of responsive neurostimulation system. 6. 3-D view of depth electrodes adjacent to hippocampus. 7. Ictal EEG from SEEG. 8. 5-year-old child monitored with subdural grids unit. 9. Neuropsychological testing. 10. PET scan showing temporal hypometabolism. 11. Worksheet for intracranial grids. 12. DTI images showing white matter pathways. 13. Neocortical brain mapping prior to resection. 14. Wada test. 15. EEG data rendered audible. 16. Intracranial subdural grids and depth electrodes. 17. SISCOM. 18. 3-D reconstruction of intracranial electrodes in dysplastic mass. 19. Hippocampal resection. 20. Data obtained during EEG monitoring in ICU.
NEUROSCIENCE OUTLOOK A publication of the Georgia Regents University Departments of Neurology and Neurosurgery Editor-in-chief: Cargill H. Alleyne, Jr., M.D. Editor: Phil Malkinson Illustrations: Colby Polonsky, M.S. Contributors: Ian Heger, M.D., Jonathan Tuttle, M.D., Cole Giller, M.D., Ph.D., M.B.A., Gregory Lee, Ph.D., Debra Moore-Hill, M.D., Anthony Murro, M.D., Yong Park, M.D., Suzanne Strickland, M.D.
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Epilepsy Trial Cannabinoid clinical trial is on its way A Georgia initiative to help children with epilepsy is coming to fruition. Yong Park, M.D., (department of Neurology), and Michael Diamond, M.D., (Chairman of Obstetrics and Gynecology and Associate Dean for Research) are working in collaboration with Governor Nathan Deal to open a clinical trial to determine the efficacy of CBD (cannabidiol) in epileptic children. Governor Deal’s commitment to the project has helped foster an agreement with leading prescription cannabinoid company GW Pharmaceuticals, a UK-based pharmaceutical company that currently conducts clinical research at 12 sites across the United States and has enrolled over 300 children in its cannabinoid studies. Together, Governor Deal, Dr. Park, and Dr. Diamond will open two studies to treat children with severe epilepsy in the Children’s Hospital of Georgia.
CBD is a non-psychoactive component of the cannabis plant that may help reduce the severity and frequency of epileptic episodes. GRU investigators hope to strengthen the body of knowledge surrounding medicinal use of the cannabis plant and unlock remedies and treatments for the families of children who have developed this debilitating disease. The study will be open to children with medication-resistant epilepsy. In the near future, Drs. Park and Diamond hope to expand the trial to sites in Atlanta and Savannah so that children in those areas may also experience the trial’s benefits. The study team believes that its efforts can change the way people perceive cannabinoid research and clinical use, and introduce a new treatment program for those epileptic children who are most in need.
Departmental history article published
The department of Neurosurgery recently published an article chronicling the history of our program from its inception almost six decades ago (Neurosurgery 75:295-305, 2014; DOI 10:.1227/ NEU.0000000000000421). We also describe the early neurosurgeons and the state of neurosurgery in Augusta dating back to 1937. The article focuses on our contributions to the fields of stereotactic and functional neurosurgery, spine, and medical illustration, and lists our major accomplishments in our first decade as a full department.
FACULTY & STAFF UPDATES
New Faculty
Greg Sengstock, M.D., Ph.D., joined the Neurology faculty in June 2014 as Assistant Professor of Neurology at Aiken Regional Medical Center (ARMC). Dr. Sengstock obtained his M.D. and Ph.D. from the University of South Florida. J. Daniel Dillon, M.D., a neurosurgeon at ARMC, was given a faculty appointment in the department of Neurosurgery. Brian Raj, M.D., Jonas Vanags, M.D., and Jeff Borkoski, M.D., joined our faculty at St. Joseph’s Candler in Savannah to bring us to six fulltime faculty there. Brian Raj, M.D., finished his residency in Neurology at Duke University and is a Neurohospitalist at Candler Hospital. Jonas Vanags, M.D., is a graduate of the Medical College of Georgia and completed his neurology residency and neuromuscular fellowship at Duke University. Dr. Vanags will direct the neuromuscular program at our SJC campus. Jeff Borkoski, M.D., has been in practice in Florida and joins us as a Neurohospitalist at Candler Hospital.
CME course organized
The department of Neurology organized “Neurology for the Non-Neurologist,” a GRU CME course held at Kiawah Island July 10–12, 2014.
Cargill H. Alleyne Jr., M.D., (department of Neurosurgery) fulfilled duties as the Chair of the Nominating Committee of the Georgia Neurosurgical Society. He is also past Chair of the Neurology/ Neurosurgery section of the National Medical Association, which held its annual meeting in Honolulu, Hawaii, Aug. 2-6, 2014. In addition, he was named one of Castle Connolly’s Top Regional Doctors in 2014. Krishnan M. Dhandapani, Ph.D., (department of Neurosurgery) has mentored several Ph.D. students. His most recent, David Fessler, graduated with his Ph.D. in July 2014. David is currently a second-year medical student at the University of Cincinnati School of Medicine. David C. Hess, M.D., (department of Neurology) participated in the NSD-K (NIH) Study Section and the American Board of Psychiatry and Neurology Vascular Neurology Test Question Assembly in June 2014. He was also one of Castle Connolly’s Top Doctors in 2014.
Sergei A. Kirov, Ph.D., (department of Neurosurgery) participated in the NIH ZRG1 F03A (20) Fellowships: Neurodevelopment, Synaptic Plasticity, Neurodegeneration Study Section in June 2014. Gregory P. Lee, Ph.D., (department of Neurology) has received the Distinguished Service Award to the field of neuropsychology from the National Academy of Neuropsychology. Scott Y. Rahimi, M.D., (department of Neurosurgery) was the Academic House Advisor for House 3 at MCG, GRU. He is the advisor/mentor for a group of 25 MCG first-, second-, and third-year medical students. This new program administered by the Student Affairs office, pairs 20 houses with 40 basic science and clinical faculty advisors. There are 25 students and two faculty members/house.
RESIDENT UPDATES Farewell:
David Wang, M.D., was honored at the annual neurosurgery graduation ceremony in June. Dr. Wang is currently fulfilling a military obligation in Tripler Army Medical Center in Honolulu, Hawaii.
Dr. Wang is seen with members of the Neurosurgery faculty.
Michelle DeJesus, M.D., completed her neurology residency in June. She is currently a Neuro-hospitalist in Grand Rapids, Michigan. Thomas Kurian, M.D., completed his neurology residency in June. He is currently practicing in California.
Welcome:
This July we welcomed our new PGY-1 neurosurgery resident Joseph Kilianski, M.D. Dr. Kilianski graduated from University of Texas Southwestern Medical School.
Five new PGY-2 neurology residents were also welcomed. They were Dusit Adstamongkonkul (Chulalongkorn University Faculty of Medicine, Thailand); Chizoba Ezepue (Nnamdi Azikiwe University, Nigeria); Biren Patel (St. George’s University School of Medicine, Grenada); Amrinder Singh (Dayanand Medical College, India); and Nabil Wees (University of Damascus, Syria). James Shou, a PGY-3 from Virginia Commonwealth University School of Medicine, also joined the neurology residency.
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CLINICAL SPOTLIGHT
Spinal instrumentation in the pediatric patient Advances in instrumentation and screw placement enhance surgical results
The pediatric spine requires special consideration when instrumentation and fusion are required. Factors such as future growth and congenitally abnormal anatomy are elements that need to be considered when planning surgical intervention. Recent advances in instrumentation technology as well as novel screw placement techniques have made spinal instrumentation in children and adolescents safer and more successful. CASE 1 (TRAUMATIC L1-2 FRACTURE): The patient is a 5-year-old healthy boy who was involved in a motor vehicle collision as a restrained passenger. On presentation, his neurologic examination was intact and he complained of back pain and abdominal pain. He underwent an emergency exploratory laparotomy to treat a transverse colon injury, which was treated by resection and diverting colostomy. His spine CT revealed a severe 2 distraction injury at Figure 2. Pre-operative L1-L2 with splaying of T2-weighted sagittal MRI the facet joints bilaterally showing distraction across (figures 1 and 2). An the L1-L2 disc space as well MRI revealed the spinal as posterior ligamentous disruption and subcutaneous cord was without injury hematoma. Note the increased and there was evidence signal in the L2 vertebral of a compression fracture body, which is consistent with at L1. Pedicle screw a compression fracture.
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1c Figure 1. Pre-operative CT scan showing Chance-like injury across the L1-L2 disc space and distraction at (a) spinous processes, (b) left facet, and (c) right facet.
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Ian Heger, M.D., and Jonathan Tuttle, M.D. fixation was felt to be contraindicated due to the small diameter of the pedicles. Therefore, sublaminar hooks were used to instrument at T12 and L2. It was decided to bring our construct to T12 due to the compression fracture at L1. Postoperative X-rays reveal restoration of the anatomical alignment, which was re-demonstrated in X-rays at three months (figure 3). He is now fully ambulatory and pain-free. His abdominal injury healed and his colostomy was reversed. CASE 2 (CHIARI DECOMPRESSION RESULTING IN OCCIPITAL-CERVICAL FUSION): A 10-year-old girl presented with a headache for two months and sleep apnea requiring bi-pap. She had previously been seen by a pediatric pulmonologist who felt she had central sleep apnea. A brain MRI was ordered and a pediatric neurosurgery consult was placed. Upon presentation, she had a normal neurologic exam; however, her MRI revealed a 27 mm cerebellar tonsillar herniation and a cervical and thoracic syrinx (figure 4). She underwent a Chiari decompression and C1 laminectomy at an outside facility. She had transient improvement in her headaches, but persistent numbness and tingling in her left hand and foot. A repeat MRI during the fifth postoperative month revealed foramen magnum decompression, but a tight-appearing foramen magnum, persistent cervical and thoracic syrinx, and retroversion of the odontoid process with cervicomedullary impression (figure 5). The patient underwent a revision Chiari decompression at our institution with duraplasty. The postoperative MRI done eight months later revealed a welldecompressed dorsal
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Figure 3. Post-operative X-rays taken immediately post-operatively (a, b) and at three months (c) showing restoration and maintenance of good alignment.
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Figure 4. T1-weighted MRI (sagittal view) showing cerebellar tonsillar herniation.
Figure 5. T2-weighted MRI (sagittal view) showing a crowded foramen magnum, persistent cervicothoracic syrinx, and retroversion of the odontoid.
foramen magnum with ventral cervicomedullary impression from a retroflexed odontoid (figure 6). Unfortunately, the patient’s symptoms of sleep apnea progressed despite decompression. The decision was made for the patient to undergo an occiput-to-axis posterior spinal fusion using occipital condylar fixation. The patient was taken to the operating room and under fluoroscopic guidance, occipital condylar screws as well as C1 and C2 screws were placed (figures 7a-d). The surgery and postoperative care were uneventful. At the most recent follow-up, the patient was still having some headaches and sleep apnea. ENT is planning a tonsillectomy in the near future.
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Figure 7. Axial (7a), sagittal (7b and c), and coronal (7d) CT scan reveals excellent placement of the condylar, C1, and C2 screws.
BRIEF REVIEW OF OCCIPITAL CONDYLE LITERATURE: Dr. Juan Uribe and colleagues have published several papers, first depicting the feasibility and then proving the biomechanical strength of occipital condylar screws 1-3. In discussing the need for occipital fixation points to treat trauma, rheumatoid arthritis, infection, tumor, and congenital malformations, they first showed 3.5 mm condylar screws could safely be placed within cadaver condyles. No cadaver age was mentioned 1. The next step was proving biomechanical equivalence to 6 midline occipital plates with screws placed within Figure 6. T2-weighted MRI the keel, C1 and C2. The study was performed in (sagittal view) reveals a wellcadavers with an age range of 54–76 years 2. decompressed dorsal foramen More recently, Dr. Uribe and colleagues studied magnum with resolution of the the anatomy of the occipital condyle. The occipital syrinx, but with ventral cervicomedullary impression from a condyle was measured in 340 patients with an retroflexed odontoid. average age of 28.4 years and range of 20–38 years 3. The average height, AP length, and width were 9.9 mm, 22.4 mm, and 11.2 mm, respectively. They noted the occipital condyle is bounded by the hypoglossal canal, superiorly; the V3 segment of the vertebral artery and C1 nerve root, inferiorly; the internal jugular vein and the ICA, laterally; and the spinal cord, medially. Case 2 is unique since the patient was under the age of 18 years, but it required complex instrumentation. We appreciate the occipital condylar studies that preceded our case, as they provided excellent guidance. We applied a similar approach of thorough imaging preoperatively, including a CT cervical spine with sagittal and coronal reformats, as well as a cervical MRI. We did not obtain a vascular study, such as a cervical CTA. We identified a starting point that was 5 mm lateral to the medial border of the occipital condyle. Our trajectory was roughly 17 degrees from lateral to medial with a 5-degree cranial angulation. With careful preoperative planning, and review of the imaging and (Top) Drilling a pilot hole for occipital condyle screw anatomy, excellent surgical results can be obtained when instrumenting while protecting the vertebral artery. (Bottom) Occiput to C2 posterior spinal instrumentation. the pediatric patient.
1. Uribe JS, Ramos E, Vale F. Feasibility of occipital condyle screw placement for occipitocervical fixation: a cadaveric study and description of a novel technique. J Spinal Disord Tech 2008; 21:540 – 6. 2. Uribe JS, Ramos E, Youssef AS, et al. Craniocervical fixation with occipital condyle screws. Biomechanical analysis of a novel technique. Spine 2010; 35(9): 931-938. 3. Le TV, Dakwar E, Hann S et al. Computed tomography-based morphometric analysis of the human occipital condyle for occipital condyle-cervical fusion. JNS Spine 2011; 15:328-331.
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CLINICAL SPOTLIGHT
Epilepsy
at the Medical College of Georgia, GRU An extensive history of offering superlative care for all types of seizure disorders Cole Giller, M.D., Ph.D., M.B.A., Gregory Lee, Ph.D., Debra Moore-Hill, M.D., Anthony Murro, M.D., Yong Park, M.D., Suzanne Strickland, M.D.
Figure 1. Epilepsy Monitoring Unit at GRU.
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A growing awareness of the problems faced by the estimated 3 million Americans afflicted with epilepsy has spawned the development of comprehensive epilepsy centers that offer the latest advances in drug therapy, neuroimaging techniques, and neurosurgery. At GRU, we have worked for more than 50 years to become one of the
most experienced epilepsy centers in the country, creating a critical mass of expertise, resources, and experience that work together seamlessly to treat the most complex epileptic conditions. The goal of this article is to highlight some of our capabilities and resources that enable us to provide superlative care to patients with epilepsy.
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CLINICAL EXPERIENCE The treatment of patients with epilepsy began at GRU almost a half century ago, gaining momentum when Dr. Hermann Flanigin, a colleague of the famed neurosurgeon Wilder Penfield, joined the faculty 30 years ago to launch a sophisticated surgical arm to the program. The result has been a thriving epilepsy center that has provided complete epilepsy care for decades. The GRU Center for Epilepsy has treated more than 2,300 patients over the past five years, and has performed more than 1,800 surgeries for epilepsy since its inception. Our epilepsy program is supported by the major adult and pediatric hospitals of the GRU system, and includes a wide array of personnel: adult and pediatric epileptologists, epilepsy neurosurgeons, adult and pediatric neuropsychologists, dedicated epilepsy nurses, and a full complement of specialized epilepsy nurse clinicians, nurse practitioners, physician assistants, social workers, and coordinators. Our ancillary services such as radiology and pathology have accrued a tremendous expertise in the specific needs of patients with epilepsy, and our multidisciplinary epilepsy surgery team meets weekly to discuss the complex surgical decisions and interventions that are often required to treat difficult cases. These diverse but coordinated efforts are the basis for our designation as a Level IV epilepsy center—the highest possible level awarded by the National Association of Epilepsy Centers—and allow us to offer unique and superlative care to both adults and children with any type of seizure disorder. CLINICAL FACILITIES The wide scope of our epilepsy resources is founded on many years of epilepsy practice and expertise at GRU. Our teams address both adult and pediatric epilepsy, with core facilities based at the adult hospital on the GRU campus and at the adjacent Children’s Hospital of Georgia. A key component of the GRU Epilepsy Program is the Epilepsy Monitoring Unit. This six-bed inpatient facility provides continuous EEG-video monitoring under direct continuous supervision of nursing staff. Medication discontinuation, prolonged recording, and repeated trials of sleep deprivation allow direct recording of seizures. Because the monitoring is continuous, the SPECT isotope can be injected as soon as the seizure starts regardless of the time of day, ultimately allowing brain perfusion imaging of a typical seizure. The
minimum 50 percent seizure reduction within two years following implantation. The RNS system is a novel implanted brain stimulator that continuously records EEG from implanted intracranial electrodes, detects seizure activity, and responds with a programmed sequence of electrical responses delivered to the seizure focus. Recently approved by the FDA, the RNS system is now a part of the armamentarium at GRU. monitoring unit also provides inpatient intracranial EEG recordings for epilepsy surgery evaluation. Our adult neurology/ neurosurgery ICU is staffed by board-certified neuro-intensivists and dedicated neurological ICU nurses, and our pediatric ICU housed at the Children’s Hospital of Georgia has extensive experience with the treatment of children with seizures. These facilities enhance the delivery of specialized treatment of patients after epilepsy surgery and of those with critical neurological illnesses, including subarachnoid hemorrhages, traumatic brain-injured patients, status epilepticus, and intracranial hemorrhage. Figure 2. Left: Exploded diagram of operative plan for modified hemispherotomy. Right: operative photograph of modified hemispherotomy at GRU.
SURGICAL TREATMENT OF EPILEPSY AT GRU The GRU Epilepsy Program offers a full range of surgical options, including implantation of depth electrodes (stereoencephalography or SEEG) and subdural grids for long-term Phase II monitoring; awake intraoperative mapping of speech, motor, and visual areas to guide resection; resective procedures such as temporal lobectomy and extratemporal topectomy; disconnection procedures such as multiple subpial transection, corpus callosotomy, and modified hemispherotomy; and neuromodulation procedures such as implantation of vagus nerve stimulators and closed-loop, deepbrain stimulators. Eighty-nine percent of temporal lobectomies and 71 percent of our extratemporal resections resulted in Engel Class I or II outcomes after one year. Our epilepsy center is one of the original sites chosen to evaluate the Neuropace responsive neurostimulator (RNS). This multicenter, doubleblinded, randomized controlled trial demonstrated that almost 50 percent of patients developed a
ADVANCED EVALUATION OPTIONS: NEUROPSYCHOLOGY AND NEUROIMAGING Our epilepsy program includes adult and pediatric neuropsychologists with decades of experience with the assessment of patients with epilepsy. Neuropsychological evaluations are used to establish a baseline using broad-based cognitive and personality/emotional tests along with quality of life measures, assist in the lateralization and localization of brain dysfunction, help predict if there is risk for postoperative cognitive impairment, identify any psychiatric issues requiring attention, and aid in determining the likelihood of postoperative seizure control. Neuroimaging capabilities include ordinary MRI as well as more complex methods of f MRI and tractography, which allow localization of language and motor centers. This information is crucial for surgical planning and is supplemented by Wada testing to provide lateralization of language and memory function. Other commonly used studies include SPECT, SISCOM studies, PET, and magnetoencephalography (MEG) to identify the location of seizure onset and spread patterns.
Figure 3. Left: EEG data from implanted depth electrodes showing seizure onset from the left hippocampus (above, black) with rapid spread to the right hippocampus (below, blue). Right: Merged images showing depth electrodes (red) in contact with the inferior surfaces of the left and right hippocampi (blue).
UNIQUE RESOURCES: CONTINUOUS ICU MONITORING AND WOMEN WITH EPILEPSY CLINIC In response to recent observations that subclinical seizures are surprisingly common in the ICU population, GRU established a Continuous ICU EEG monitoring program to detect harmful seizure activity that may worsen a patient’s neurological status if unrecognized. The monitoring program has played a crucial role in ICU care, allowing our
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neuro-intensivists to aggressively treat subclinical seizures as they occur. Furthermore, the use of continuous EEG allows us to safely guide treatment in patients with traumatic brain injury and other conditions that result in refractory elevated intracranial pressure for which induced coma, hypothermia, or burst suppression are required. The treatment of women with epilepsy poses particular challenges and problems that require highly specialized care. For example, close monitoring after conception is essential to avoid seizures, loss of fetal life, and complications to the pregnancy as a result of fluctuating antiepileptic medication levels. Our adult epileptologists have a strong interest in treating women with epilepsy and have created a Women with Epilepsy clinic to address these important needs.
Case Study
A 45-year-old woman presented with a history of seizures intractable to medical management that began when she was 6 years old. They often began at the onset of sleep, and were accompanied by an aura of a “butterfly feeling.” During the seizures, she became unresponsive, had movements of her left arm and leg, and twitching of her left face. The seizures occurred six to eight times daily and impaired her ability to work. No interictal discharges were detected during continuous EEG-video monitoring, and ictal recordings of her multiple complex partial seizures with generalization failed to provide localizing information. An MRI showed a non-enhancing lesion in the posterior frontal lobe just beneath the central sulcus that appeared bright on FLAIR and T2 images, and an ictal SPECT exam showed activity in the same region. An fMRI study and magnetoencephalography studies were consistent with one another, showing that the lesion was slightly anterior to the hand and face motor cortex. Neurocognitive testing
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Figure 1. Lateral skull radiograph showing placement of subdural grid of contacts and several depth electrodes placed through the grid (red arrow). Inset shows an MRI FLAIR sequence demonstrating the lesion (red arrow in inset). Figure 2. Reconstructions based on CT and MRI data showing the central sulcus (orange), the lesion (yellow), the motor cortex identified by the MEG studies (red), and the depth electrodes (green). These objects are magnified in the inset.
showed signs of right frontal lobe dysfunction, including motor slowing and perseverations. A Wada study confirmed left language dominance and revealed no left-right asymmetry in memory. Because the EEG failed to localize the site of
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onset, and because the lesion was potentially within the motor cortex, a Phase II evaluation with implantation of subdural grids and intracranial depth electrodes was recommended. At craniotomy, a large grid was placed on the surface of the frontal lobe and several depth electrodes were inserted into the vicinity of the region with the aid of an intraoperative navigation device (figures 1 and 2). Over the next few days, data from these electrodes identified specific areas of high ictal EEG activity during her seizures. In addition, bedside stimulation of the grid contacts allowed identification of her motor cortex. The data showed that the sites of seizure onset were restricted to the region surrounding the lesion, and that it would be feasible to resect the majority of tissue while sparing the motor cortex. However, because of the close association of the epileptic zone to the motor and pre-motor cortex, the patient was counseled that the risk of a temporary motor deficit was high and that
EPILEPSY RESEARCH AT GRU Epileptologists at GRU are leading research efforts in three directions. In the first, Dr. Yong Park is directing an investigational study of cannabidiol (CBD) for the treatment of childhood refractory epilepsy. (See Department News, page 2.) Dr. Debra Moore-Hill will direct an investigational study of brivaracetam, which is a drug with a mechanism similar to levetiracetam (Keppra), but with far greater potency. The focus of Dr. Moore-Hill’s study will be the intravenous use of brivaracetam therapy for nonconvulsive seizures. Dr. Anthony Murro will lead a study directed at the use of pregablin for treatment of primary generalized seizures. If effective, this drug will broaden the current limited range of treatment options for primary generalized epilepsy.
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Figure 3. Frontal lobe surface exposed prior to resection. Paper tags mark the sites of motor stimulation. Depth electrodes (arrow) were left in place for guidance to active tissue.
a mild permanent deficit was likely. At a second craniotomy, the grid was removed and cortical stimulation under propofol anesthesia was used to map the motor cortex in greater detail (figure 3). These data confirmed that the handmotor cortex was located just posterosuperiorly to the planned resection and identified areas of access to the lesion outside of the primary motor cortex. The lesion was approached through a small sulcus, allowing resection of parts of the anterior and inferior pre-central gyrus as well as the posterior portion of the gyrus immediately anterior to this area in a subpial fashion. Intraoperative real-time
navigation was used for anatomic guidance, and the underlying white matter was noted to be abnormally firm. The depth electrodes that had shown high ictal activity during monitoring were then followed along their deep course and the resulting gray matter also was resected (figure 4). At all times, care was taken to avoid undercutting the primary motor cortex. Pathological examination of the resected tissue confirmed cortical dysplasia. Immediately after the resection she developed a left-upper-extremity monoplegia, but this deficit rapidly improved. She now has only a subtle and clinically insignificant hemiparesis and has been seizurefree for 2.5 years.
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Figure 4. Operative view of resection cavity.
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William C. Mobley Mobley Mechanical Inc. Darlene Moore Jessica Moore Travis Moore Lee Morris Martin Morris Cynthia Morton Mount Paran Homes Deborah Mulford Annie Murrah-Hanson Anne Murray Elizabeth Murray Cosmo Muti Cindy Nelson Joe Newell JT Newell Mary Newell Stefanie Newhall Amy Nikolaou Kelly Nobbs Tobin North North American Steve Saunders International Rally (NASSIR 7) April Nunnallee Allison O’Dea Jon Olson Suzanne Osborn Laura Osborne Katherine Pace Barbara Page Cynthia Partridge Teresa Pate Pooja Patel Paths Center, LLC Eloisae Patterson Justin Pauley Karen Pemberton Abby Peoples Kasey Petersen Yng Phan Phoenix Printing Company Inc. Jody Pickle Christine Playforth Michael Polak Sandra Porter Kent Posey Wendy Posey Melinda Prescott Rhonda Prescott Katherine Pryor Rebecca Pryor T.C. Pryor Daniela Pusl Chanda Pye Michael Quick Stephen Quillen Melissa Quinlan Sarah Rabin Mark Rader Frieda Ramsey Richard Rasmussen Steven Ratley Eileen Ray continued on page 11
Volume 11 | Issue 3 gru.edu/neuro
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PUBLICATIONS & PRESENTATIONS
May–August 2014 PUBLICATIONS Alleyne CH Comment on: Multimodal treatment of complex unruptured cavernous and paraclinoid aneurysms. Neurosurgery 74:61, 2014 Alleyne CH Comment on Middle cerebral artery bifurcation aneurysms: An anatomical classification scheme for planning optimal surgical strategies. Operative Neurosurgery 10:154, 2014
Alleyne CH Comment on: Treatment of blister-like aneurysms with the pipeline embolization device. Neurosurgery 74:532, 2014 Farook JM, Shields J, Tawfik A, Markand S, Sen T, Smith SB, Brann DW, Dhandapani KM, Sen N Induction of GADD34 attenuates Akt activation and induces cell death following traumatic brain injury. Cell Death and Disease 4:e75, 2013 Meador KJ, Baker GA, Browning N, Cohen MJ, et al Breastfeeding in children of women on
antiepileptic drugs: cognitive outcomes at age 6 years. JAMA Pediatrics doi:10.1001/ jamapediatrics.2014.118. Villarreal N, Riccio CA, Cohen MJ, Park Y Adaptive skills and somatization in children with epilepsy. Epilepsy Research and Treatment Vol. 2014, Article ID 856735, 7 pages, 2014. doi:10.1155/2014/856735 Ignatowski TA, Spengler RN, Dhandapani KM, Folkersma H, Butterworth R, Tobinick E Perispinal etanercept for post-stroke neurological and
cognitive dysfunction— scientific rationale and current evidence. CNS Drugs 28: 679-697, 2014 Eroglu B, Kimbler DJ, Moskophidis D, Yanasak N, Dhandapani KM, Mivechi NF. Therapeutic inducers of HSP70/HSP110 protect mice against traumatic brain injury. J Neurochem 130: 626641, 2014 Platt SR, Holmes SP, Howerth EW, Duberstein KJ, Dove CR, Kinder HA, Wyatt EL, Linville AV, Lau VW, Stice SL, Hill WD, Hess DC, West FD Development and characterization of
a Yucatan miniature biomedical pig permanent middle cerebral artery occlusion stroke model. Exp Transl Stroke Med 6(1):5, 2014 Buckley KM, Hess DL, Sazonova IY, Periyasamy-Thandavan S, Barrett JR, Kirks R, Grace H, Kondrikova G, Johnson MH, Hess DC, Schoenlein PV, Hoda MN, Hill WD Rapamycin up-regulation of autophagy reduces infarct size and improves outcomes in both permanent MCAL, and embolic MCAO, murine models of stroke. Exp Transl Stroke Med 6:8, 2014
PRESENTATIONS Alleyne CH Dr. Richard Franklin Slaughter—The first neurosurgeon in Augusta. Georgia Neurosurgical Society Spring Meeting, Sea Island, Ga., May 2014
Woodall MN Microsurgical anatomy: Anatomical triangles and their clinical significance. Georgia Regents University Department of Neurosurgery Grand Rounds, Augusta, Ga., May 2014
Nguyen KD, Woodall MN, Macomson SD, Rahimi SY Standardizing external ventricular drain management. Georgia Neurosurgical Society Spring Meeting, Sea Island, Ga., May 2014
Zakharia Y, Johnson T, Colman H, Vahanian N, Link C, Kennedy E, Sadek R, Kong F, Vender J, Munn D, Rixe O A Phase I-II study of the combination of indoximod and temozolomide for adult patients with temozolomide-refractory primary malignant brain tumors.
American Society of Clinical Oncology 50th Annual Meeting, Chicago, Ill., May 2014 Hess DC Treatment of migraine. Internal Medicine Update, Kiawah Island, S.C., June 2014 Hess DC The Alzheimerization of dementia: Vascular cognitive impairment. Internal Medicine Update. Kiawah Island, S.C., June 2014 Hess DC Stem cell therapy of disease.
Internal Medicine Update, Kiawah Island, S.C., June 2014 Alleyne CH Neurosurgery and tips for medical school. Pre-matriculation Grand Rounds, Georgia Regents University, Augusta, Ga., July 2014 Alleyne CH Subarachnoid hemorrhage and unruptured intracranial aneurysms: Diagnosis and management. Neurology Residents Noon Conference, Georgia Regents University, July 2014
Names in blue indicate faculty members or residents in the Georgia Regents University Neurosurgery or Neurology departments.
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NEUROSCIENCE OUTLOOK Volume 11 | Issue 3
Hess DC Dizziness: Evaluation and management. Neurology for the Non Neurologist. Kiawah Island, S.C., July 2014 Hess DC Hype or hope: Stem cell treatment of neurological diseases. Neurology for the NonNeurologist, Kiawah Island, S.C., July 2014 Hess DC Neurocritical care cases. Critical Care Medicine Update, Kiawah Island, S.C., July 2014
THANKS TO OUR DONORS
Kirov SA Astroglial and neuronal integrity during cortical spreading depolarization. In: Pathological potential of neuroglia: Possible new targets for medical intervention (Parpura V, Verkhratsky A, eds). Springer, August 31, 2014 Switzer JA, Sikora AN, Hess DC, Fagan SC Minocycline repurposing for acute cerebral hemorrhage. In: Amantea D, ed. Rational Basis for Clinical Translation in Stroke Therapy. CRC Press, 2014
Hess DC Treatment of acute ischemic stroke in 2014. Critical Care Medicine Update, Kiawah Island, S.C., July 2014 Switzer JA Effective utilization of telestroke in a comprehensive stroke care setting University of Texas Southwestern, Dallas, Texas, July 2014 Alleyne CH Update on management of cerebral aneurysms. National Medical Association Meeting, Honolulu, Hawaii, August 2014
Ghuman MS, Woodall MN, Alleyne CH Teaching neuroimages: microvascular decompression of the optic nerve. Neurology 82:1847, 2014
Woodall MN, Tuttle JA Cervical myelopathy with severe lumbar degenerative disease. SpineMonitor 2014 August
Woodall MN, Alleyne CH Author response. Comment on: Teaching neuroimages: microvascular decompression of the optic nerve. Neurology 2014 May; 82(20): 1847. doi: 10.1212/01.wnl. 0000450225.45489.9b
Steffensen AB, Sword J, Croom D, Kirov SA, MacAulay N Role of neuronal cotransporters in spreading depolarizationinduced dendritic beading. 46th Sandbjerg Meeting on Membrane Transport, Sønderborg, Denmark, May 2014 Vaibhav K, Baban B, Khan MB, Liu JY, Hess DC, Dhandapani KM, Hoda MN Remote ischemic preconditioning (RIPreC) protects from traumatic brain injury. National Neurotrauma Society Annual Meeting,
San Francisco, Calif., June–July 2014 Shields JS, Dhandapani KM Toll-like receptor 4 mediates posttraumatic changes to the circadian clock. National Neurotrauma Society Annual Meeting, San Francisco, Calif., June–July 2014
Jeremy Ray Tracy Ray David Rector Santosh Reddy Melissa Reed Tab Reed Jill Reesor Lisa Regan David Reid Andrew Reinstatler Christa Resavy ResMed Jennifer Richards Keri Rikard Ted Rikard Ring Photography Inc Asher Rivner Harold Rivner Joshua Rivner Michael Rivner Peter Rivner Robert Rivner Roberta Rivner Donald Roach Nona Roach Lisa Roberts Robin’s Treasures Abbie Robinson Carla Robinson Jennifer Robinson Michael Roche Leah Ronen David Roop Elaine Ross Jennifer Rothhardt Joanne Ruda Genave Ruiz Jennifer Rushing Firman Sakir Annie Sallee Clare Sallee D. Sallee Kaili Sasiene Mr. and Mrs. Jake Sasser Jeannia Satcher Jack Saunders Abhinav Saxena Robyn Schuller Lauren Schumann Roger Schurig Noel Schweers Amy Scoggins Kapil Sethi Gary Shafer Michaela Shafer Rajesh Shah Shaun Shaker Michael Shapiro Emily Sheppard Ginny Short Paige Short SHS Reunion ‘98 Mark Silver Patricia Simmons Katherine Simms Paul Singer Michele Singletary
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September–December 2014
CONFERENCE SCHEDULES
Neurosurgery Sept. 5
Sept. 12
11 a.m. noon
Sept. 26
Oct. 3
Oct. 10
Oct. 24
Anatomy
11 a.m.
Oral board review
9 a.m.
Pathology— Dr. Suash Sharma
10 a.m.
Resident Meeting
11 a.m.
Journal Club
noon
Case Conference
10 a.m.
Radiology
11 a.m.
Functional—Dr. Cole Giller
noon
Case Conference
9 a.m.
Pathology—Dr. Suash Sharma
10 a.m.
Resident Meeting
11 a.m.
Journal Club
Nov. 7
M&M
10 a.m.
Anatomy
11 a.m.
Business—Dr. Cole Giller
noon
Case Conference
Nov. 17
Nov. 21
Interviews 9 a.m.
Pathology
10 a.m.
Resident Meeting
11 a.m.
Journal Club
noon
M&M
8 a.m.
Endoscopic Skull Base Approaches— Dr. Danny Prevedello
9 a.m.
Neuro/ENT Skull Base Lab
10 a.m.
Oral Board Review
noon
11 a.m.
Neuro 101— Dr. Nathan Todnem
10 a.m.
Oral Board Review
11 a.m.
Neuro 101—Basheer Shakir
noon Oct. 17
Faculty Meeting
10 a.m. noon Sept. 19
Case
Dec. 5
Dec. 12
Case Conference
M&M No conference
10 a.m.
Anatomy
11 a.m.
Business—Dr. Cole Giller
noon
10 a.m.
Radiology
11 a.m.
Functional—Dr. Cole Giller
noon
noon Nov. 26
Case Conference
Case Conference
Case Conference
Dec. 19
Interviews
Dec. 26
No conference
Neurology Sept. 4 Dr. Tom Swift
Case Presentation
Sept. 11 Dr. Elizabeth Sekul
Child Neurology
Sept. 18 Dr. Suzanne Smith
Multiple Sclerosis
Sept. 25 Dr. Jeff Switzer
Stroke
Oct. 2 Dr. Michael Rivner
Neuromuscular
Oct. 9 Dr. Tom Swift
Case Presentation
Oct. 16
Bill Draper, DVM, DACVIM
Common Problems in Veterinary Neurology
Oct. 23 Dr. Debra Moore-Hill
Epilepsy
Oct. 30 Dr. Subhashini Ramesh
Neuro Critical Care
Nov. 6 Dr. Kapil Sethi
Movement Disorders
Nov. 13 Dr. Tom Swift
Case Presentation
Nov. 20 Dr. Ed Hartmann
Neuromuscular
Nov. 27 No Grand Rounds
Holiday
Dec. 4 Dr. David Hess
Stroke
Dec. 11 Dr. Tom Swift
Case Presentation
Dec. 18 Dr. Fenwick Nichols
Stroke
Dec. 25 No Grand Rounds
Holiday
All neurology conferences are held from 8-9 a.m.
Meeting Schedule
American Neurological Association Oct. 10–14 Baltimore, Md. Congress of Neurological Surgeons Oct. 18–22 Boston, Mass. American Academy of Neurology Fall Session Oct. 31–Nov. 2 Las Vegas, Nev. Research Update in Neuroscience for Neurosurgeons Oct. 25–Nov. 1 Woods Hole, Mass. American Board of Neurological Surgery (Orals) Nov. 12–14 Houston, Texas North American Spine Society Nov. 12–15 San Francisco, Calif. AANS/CNS Section on Pediatric Neurological Surgery Dec. 2–5 Amelia Island, Fla. Georgia Neurosurgical Society Dec. 6–7 Greensboro, Ga.