Leading Neurosciences 2013 Year in Review
A proud tradition of excellence, with a new name. The Methodist Hospital is now Houston Methodist Hospital. This new name reflects the pride in who we are and where we are from. Our commitment to advancing medicine with global impact begins in Houston, Texas, where we pioneer a better tomorrow through research, cutting-edge innovation and breakthroughs to rewrite the future of health.
That’s the difference between practicing medicine and leading it.
Contents
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Leading Medicine: An Overview
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Pursuing Medical Discoveries
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Breaking new ground
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Advancing Technology
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Educating for Tomorrow
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Leading Medicine: An Overview
Pursuing Medical Discoveries
Breaking New Ground
Advancing Technology
Educating For Tomorrow
message from the Department of Neurology Chair Dear Colleagues, The Houston Methodist Neurological Institute was established to provide a continuum of care from the point of diagnosis through reintegration with family and the community. In 2013, we have continued to distinguish ourselves globally as a center of excellence that is enhanced by our affiliation with Weill Cornell Medical College and provides the maximum level of diagnostic and clinical care. This year we provided meaningful translational research that broadens our understanding of the major neurological challenges of neuromuscular diseases, dementing illness and stroke. In patients with amyotrophic lateral sclerosis (ALS), we documented for the first time that the loss of protective T-regulatory lymphocytes accelerates disease, and that T-regulatory lymphocytes also appear to influence disease progression in patients with chronic inflammatory demyelinating polyneuropathy (CIDP). Our Myasthenia Gravis Clinic participated in a trial to assess the therapeutic value of methotrexate in treatment-refractory myasthenia gravis patients and also began a trial using antibodies that target pro-inflammatory white blood cells. The Nantz National Alzheimer Center (NNAC) continued its studies of the complexities of Alzheimer’s disease, where evidence of certain preclinical biomarkers provides encouraging potential for the early detection and prevention of disease. In addition, the NNAC is partnering with our Concussion Center to achieve a better understanding of the relationships of traumatic brain injury, concussion and dementia. Our Eddy Scurlock Stroke Center has continued its legacy of leading clinical research with the first multicenter trial of stem cell therapy in acute ischemic stroke. We also noted that intensive medical therapy, rather than intracranial stenting, was superior at our center as well as at other leading centers. Our national and international status is only made possible by our extraordinary physicians and medical team members and the superlative care they render our patients, as well as our outstanding residents that perpetuate our educational mission to train the nation’s most promising leaders of neurology and translational neuroscience. Sincerely,
Stanley H. Appel, MD Director, Houston Methodist Neurological Institute Chair, Department of Neurology Peggy and Gary Edwards Distinguished Endowed Chair in ALS Research Professor of Neurology, Weill Cornell Medical College
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message from the Department of Neurosurgery Chair Dear Colleagues, As the chair of the Department of Neurosurgery, it is my pleasure and privilege to work with this outstanding group of surgeons and describe our activities and accomplishments for 2013. We are one of the busiest neurosurgical programs in the nation. I’m pleased to report that we performed over 4,000 open operative cases, including treatments for cerebrovascular disorders, brain tumors, spinal disorders and functional neurosurgery. Our new Cerebrovascular Center offers patients access to a multidisciplinary team of specialists, subspecialists and health professionals who are trained in the provision of care for all diseases of the cerebrovascular system, including brain aneurysms, brain arteriovenous malformations, spinal vascular malformations, moyamoya disease, cavernous malformations, carotid disease and stroke. Our team members have a track record of excellence in novel research and multicenter trials of cerebrovascular disease as well as many ongoing protocols. This year, we were first in the region to perform subcortical surgery and remove a deep brain lesion through an opening that was smaller than a dime. This center has also seen expansion in research with the opening of the Cerebrovascular Research Laboratory, which will evaluate the basic underlying mechanisms of these diseases. Our new Spine Center also offers patients access to a multidisciplinary team of specialists, subspecialists and health professionals who are trained in the provision of all key spinal care services. Our surgeons are experts in using new, advanced image-guided, minimally-invasive spine procedures, which allows them to do intricate, complicated surgeries with better reliability and outcomes. In 2013, the Kenneth R. Peak Center for Brain and Pituitary Tumor Treatment and Research continued to grow and expand. Researchers at the Peak Center have developed a way to deliver chemotherapy directly and selectively into the mitochondria — the energy source for all cells — of glioblastoma cells. In collaboration with Rice University’s Center for Nanoscale Science, researchers have invented a novel nanosyringe made from single wall carbon nanotubes that selectively kills these brain cancer cells by the delivery of chemotherapy directly into the mitochondrial DNA of these individual tumor cells. We continue to operate one of the busiest, functional neurosurgery programs in the world, providing surgical options for Parkinson’s disease, movement disorders and chronic pain. This year, as in years previous, we maintained our commitment to training the next generation of neurosurgeons. Our outstanding neurosurgery residency program is accomplished by instruction in the highest standards of care, which is integrated throughout with our top-level research and leading-edge technology. The Department of Neurosurgery is truly leading medicine in regards to clinical care, research and education. Yours Sincerely,
Gavin Britz, MBBCh, MPH, FAANS Chair, Department of Neurosurgery Co-Director, Houston Methodist Neurological Institute Professor of Neurosurgery, Weill Cornell Medical College
Leading Medicine: An Overview
Pursuing Medical Discoveries
Breaking New Ground
Advancing Technology
Educating For Tomorrow
PIONEERING THE PATH: THE HOUSTON METHODIST NEUROLOGICAL INSTITUTE The Houston Methodist Neurological Institute continues to be regarded as one of the leading neuroscience centers in the nation. In 2013, the institute was ranked No. 11 by U.S. News & World Report out of 1,370 hospitals and maintained its position as the top-ranked program in Texas for neurology and neurosurgery. The staff at the Neurological Institute offers unparalleled inpatient and outpatient care for neurological disorders. Our physicians are among the finest specialists in the nation in multiple aspects of neurological care. Both general and subspecialty expertise is provided in state-of-the-art facilities. The Neurological Institute is recognized as a research leader. Our teams are dedicated to the development of new treatments and therapies for such neurological challenges as stroke, Parkinson’s disease, Alzheimer’s disease, amyotrophic lateral sclerosis (ALS), myasthenia gravis, brain tumors, concussion, spinal disorders, brain aneurysms, brain arteriovenous malformations, moyamoya disease, stuttering, Tourette’s syndrome and chronic inflammatory demyelinating polyneuropathy (CIDP).
Houston Methodist NEURLOGICAL INSTITUTE 2013 At a Glance
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Clinical Programs
Through collaboration with Weill Cornell Medical College, the Neurological Institute operates fully accredited neurology and neurosurgery residency programs to train our future brightest and best neuroscientists, neurologists and neurosurgeons. We are committed to our patients and to treat their neurological disorders with highly skilled, compassionate care. Through the integration of neurological specialties, we are able to provide the utmost in personalized care for complex neurological disorders, from diagnosis to treatment to rehabilitation. This type of excellence in patient care is at the forefront of all we do and all we strive to achieve.
27 4,000
Countries Represented in Patients treated at Houston Methodist Neurological Institute
over
open operative cases
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Subspecialities are represented within the Institute
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over 75 physicians and neuroscientists
Houston Methodist NEURLOGICAL INSTITUTE Medical Staff Neurology Stanley H. Appel, MD Chair, Dept. of Neurology Mohammad Al Baeer, MD David R. Beers, PhD Igor Cherches, MD David Chiu, MD Howard S. Derman, MD Everton Edmondson, MD Randolph Evans, MD Stanley P. Fisher, MD Santosh A. Helekar, MD, PhD Julia Jones, MD Eugene C. Lai, MD, PhD Brian Loftus, MD Steven Lovitt, MD Joseph C. Masdeu, MD, PhD Greg McLauchlin, MD Belen Pascual, PhD Milvia Y. Pleitez, MD Kenneth Podell, PhD Gustavo C. Romรกn, MD David B. Rosenfield, MD Pankja Satija, MD Ericka P. Simpson, MD Bryan M. Spann, DO, PhD Abraham P. Thomas, MD Ron Tintner, MD Amit Verma, MD Aparajitha Verma, MD John Volpi, MD Olga Waln, MD Weihua Zhao, MD, PhD Neuroradiology David Carrier, MD Steve Fung, MD Hani Haykal, MD David King, MD Jonathan Levine, MD Marlin Sandlin, MD Sanjay Singh, MD John Surratt, MD Neuropathology Suzanne Powell, MD Andreana Rivera, MD Hidehiro Takei, MD
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Neurosurgery Gavin W. Britz, MBBCh, MPH, FAANS Chair, Dept. of Neurosurgery Alfonso Aldama-Luebbert MD David S. Baskin, MD J. Bob Blacklock, MD David Cech, MD Mario Dulay, PhD Richard G. Federley, PhD Eugene V. Golanov, MD, PhD Robert G. Grossman, MD Richard Harper, MD Paul Holman, MD Christof Karmonik, PhD Tanvi Kumar, MS Edward Murphy, MD Pamela New, MD Warren Parker, MD Rob G. Parrish, MD, PhD Andrew C. Roeser, MD Martyn Sharpe, PhD Richard Simpson Jr., MD, PhD Hanna Tang, MD Todd Trask, MD Jonathan Zhang, MD G. Alexander West, MD, PhD Interventional Neuroradiology Orlando Diaz, MD Richard Klucznik, MD Neuropsychiatry Ranjit Chacko, MD Alric D. Hawkins, MD Neurorehabilitation Monika S. Ayyar, MD Purvi Desai, MD Teresa D. Kaldis, MD Jenny M. Lai, MD Lawrence H. Nguyen, MD Neurological Intensive Care Richard Day, MD Drew Ludwig, DO Anakara Sukumaran, MD Michael Zwillman, MD Neuro-ophthalmology Andrew G. Lee, MD Sushma Yalamanchili, MD
Leading Medicine: An Overview
Pursuing Medical Discoveries
Breaking New Ground
Advancing Technology
Educating For Tomorrow
new hires
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Gavin W. Britz, MBBCh, MPH, FAANS,
Joseph C. Masdeu, MD, PhD,
Eugene V. Golanov, MD, PhD,
Richard G. Federley, PhD,
was named chair of the Department of Neurosurgery at Houston Methodist Hospital and co-director of the Houston Methodist Neurological Institute. Dr. Britz is one of the most experienced cerebrovascular surgeons in the United States in the treatment of aneurysms using microsurgical and endovascular techniques. His clinical practice largely focuses on the treatment of disorders of the cerebrovascular system and brain tumors including the skull base. Dr. Britz’s research focuses on understanding the cerebral microcirculation and in the evaluation of novel tools to treat a wide variety of problems such as brain aneurysm and skull base tumors. Prior to joining Houston Methodist, Dr. Britz served as director of the Cerebrovascular Center and associate professor of neurosurgery at Duke University Medical Center in Durham, North Carolina.
the first physician-scientist to detect an early imaging feature of Alzheimer’s disease, joined as director of the Nantz National Alzheimer Center. Dr. Masdeu brings more than 30 years of experience as a clinician, researcher and leader in Alzheimer’s and neuroimaging, having led neurology departments in New York and his native Spain. He comes from the National Institutes of Health, where he served the past six years as a senior staff physician and scientist in the Section of Integrative Neuroimaging of the Clinical Brain Disorders Branch. Dr. Masdeu’s vision for the Nantz National Alzheimer Center is its elevation in status to become the preeminent center in the United States in the prevention of Alzheimer’s disease, while also conducting research to bring better therapeutic approaches to patients who already experience symptoms from this disease.
was named director of Cerebrovascular Research Laboratory. Dr. Golanov is a neuroscientist and physiologist experienced in in vivo and in vitro experimental and clinical research. He has extensive firsthand experience and expertise in multidisciplinary and integrative research in various areas of neurophysiology in animals and humans: He previously served as program manager of neuroscience and subject matter expert in neuroscience/neurotrauma at the Telemedicine and Advanced Technology Research Center, U.S. Army Medical Research and Material Command/Tunnell Governmental Services, Bethesda, MD. Included among the nationwide initiatives he has launched are the biology of vascular malformations of the brain and multidisciplinary translational research in critical care.
joined the Department of Neurosurgery as research scientist. Dr. Federley has served as a chemistry instructor and invited lecturer. As a research investigator, he has special interests in DNA replication, enzyme kinetics, site specific DNA modification and purification, mass spectrometry, methods development, surface plasmon resonance and in vitro microscopy and will be evaluating cerebral microcirculation.
Leading Neurosciences
accolades Andrew Lee, MD, chair of the Department of Ophthalmology and David Baskin, MD, director of the Department of Neurosurgery Residency Training Program and director of the Kenneth R. Peak Center for Brain and Pituitary Tumor Treatment and Research, were invited by NASA to review scientific proposals for possible application in future space flights. The group studied the phenomenon of elevated intracranial pressure in space and possible countermeasures to treat it. This will become an important problem with longer space missions that include extended periods on the international space station and a flight to Mars, which would be a 30-month mission. Both were selected for expertise in their respective fields and experience with some of the unique neuro-ophthalmologic problems seen in NASA astronauts after long-duration space flight. The Cullen Foundation and Mission Connect, a project of the TIRR Foundation, awarded nearly $700,000 to a brain-machine interface project that University of Houston (UH) and Houston Methodist Hospital Research Institute scientists hope will someday help paraplegics walk. The funds will be used to purchase Rehab Rex, the latest version of a robotic exoskeleton that helps legs move. UH Professor of Electrical and Computer Engineering, Jose Luis Contreras-Vidal, PhD, and Houston Methodist Neurological Institute neurosurgeon, Robert G. Grossman, MD, are working on perfecting a non-invasive brain-machine interface technology that patients can use to operate an advanced robotics system such as the exoskeleton. The Eddy Scurlock Stroke Center, led by David Chiu, MD, was awarded the Get With the Guidelines – Stroke Gold Plus Achievement Award by the American Heart Association.
Abraham Thomas, MD,
Olga Waln, MD, joined the Movement
vascular neurologist, joined the Eddy Scurlock Stroke Center after completing his neurovascular clinical fellowship at University of California San Francisco. Dr. Thomas’ clinical interests include the evaluation of both critically and acutely hospitalized patients with cerebrovascular disease and outpatients with cerebrovascular disease, including the clinical sequelae of ischemic and hemorrhagic stroke. His primary research interests include: pathophysiological mechanisms of stroke, epidemiological analysis of risk factors of stroke, preventive measures of stroke and the acute treatment of stroke.
Disorders & Neuro-rehabilitation Center. Dr. Waln is a fellowship-trained movement disorders neurologist. Her primary clinical and research interests are the evaluation and management of patients with Parkinson’s disease, tremors, dystonia, chorea, tics and gait disorders, including botulinim toxin treatment, deep brain stimulation and intrathecal baclofen pump treatment.
Richard Klucznik, MD, was the recipient of the Joe Niekro Foundation’s Joe Niekro Medical Humanitarian of the Year. The award was in recognition of his research advancements and treatments of cerebral aneurysms.
Robert G. Grossman, MD, professor of neurosurgery at the Houston Methodist Hospital, received the 2013 Distinguished Service Award of The Society of University Neurosurgeons for his decades of service as a clinician, teacher and researcher.
Houston Methodist Neuro Intensive Care Unit was recognized by the American Association of Critical-Care Nurses (AACN) with a Gold Beacon Award for Excellence. Recipients of AACN’s Gold Beacon Award demonstrate excellence in sustained unit performance and patient outcomes. The Houston Methodist Neuro ICU was the only unit in Texas and one of only four in the nation to achieve this standard. The United States Department of Defense awarded a two-year $2 million peer-reviewed grant to support the research programs of the North American Clinical Trials Network (NACTN) for Treatment of Spinal Cord Injury. NACTN is a consortium of university hospital neurosurgery departments, sponsored by the Christopher & Dana Reeve Foundation, with the goal of bringing promising therapies for spinal cord injury into clinical trials. Robert G. Grossman, MD, professor of neurosurgery, is the principal investigator.
Christof Karmonik, PhD, was awarded a grant from Siemens for his research project, Evaluation of Computational Fluid Dynamics Research Platform for Analyzing Blood Flow in Aneurysms. Gavin W. Britz, MBBCh, MPH, FAANS, was the recipient of the Joe Niekro Foundation’s research grant. Jenny Henkel, PhD and Dave Beers, PhD, were awarded the 2013 Moran Foundation
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Publication Award by the Research Institute for their outstanding translational research paper, Regulatory T-lymphocytes mediate amyotrophic lateral sclerosis progression and survival, which was published in EMBO Molecular Medicine.
Leading Medicine: An Overview
Pursuing Medical Discoveries
Breaking New Ground
Advancing Technology
Educating For Tomorrow
The Many Facets of Alzheimer’s Disease The Nantz National Alzheimer Center (NNAC) continues to be in the vanguard of identification and interpretation of Alzheimer’s disease from the anatomical, biological and molecular levels. Sophisticated neuroimaging technology and unique applications of that technology provide researchers and physicians with a preclinical window into the brain. Studies at NNAC include identification of the neurobiological precursors of Alzheimer’s disease and ongoing attempts to understand the molecular etiology of the neuropathology in early-stage, largely asymptomatic disease. Positron emission tomography (PET) has shown through the use of biomarkers that abnormal amounts of beta amyloid are evident in the brain as many as 20 years before initial symptoms develop. NNAC researchers are now studying a new biomarker that will bind with abnormal tau protein in the brain. “When abnormal tau begins to increase in the brain, neurons tend to die, so we know that the two are linked,” says Joseph Masdeu, MD, PhD. Masdeu was recruited from the Intramural Research Program of the National Institutes of Health as director of the Nantz National Alzheimer Center. He will lead research on Alzheimer’s disease and neuroimaging at the NNAC. Masdeu and others hypothesize that removal of harmful proteins before irreversible damage occurs may affect the progression of the disease. However, Alzheimer’s is not caused by an overabundance of amyloid or tau alone.
PET scans administered with a radioactive tracer known as fludeoxyglucose (PET-FDG) allows NNAC researchers and physicians to study metabolic activity of the brain.
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“We know these are two of many potential causative factors. Inflammation may also play a significant role. We are developing biomarkers for the inflammatory response in Alzheimer’s pathology, investigating potential dysfunction within the blood-brain barrier and T cell infiltration of the brain. Alzheimer’s disease is complex, and we do not yet have a complete understanding of its neurobiology,” says Masdeu. PET scans administered with a radioactive tracer known as fludeoxyglucose (PET-FDG) provide NNAC researchers with a live picture of metabolic brain activity. “These technologies allow us to study the neurobiology of the brain and gain insight into the presymptomatic stages of the disease. Ultimately, these technologies may have an impact on our current therapeutic approach, changing it from a symptomatic track to a preclinical one,” says Masdeu. Researchers at NNAC are also looking at the role of the temporal pole in Alzheimer’s disease and related frontal temporal dementias. The temporal pole is a large area of the brain that has historically been regarded as “enigmatic” due to its unknown function. Belen Pascual, PhD, a research scientist at NNAC, recently published a landmark study in Cerebral Cortex that used resting-state functional connectivity (RSFC) analysis to map the topography of functional networks anchored in the temporal pole. Her study shows that the temporal pole acts as a cortical convergence zone. This region of the brain is specifically affected by the frontotemporal dementias, another set of diseases which, like Alzheimer’s, causes cognitive impairment in older adults. Gustavo Roman, MD, and Brian Spann, DO, PhD, are expanding their clinical efforts at the NNAC to help define epidemiological factors initiating and amplifying disease progression.
“When abnormal tau begins to increase in the brain, neurons tend to die. So we know that the two are linked.� Joseph Masdeu, MD, PhD Director, Nantz National Alzheimer Center Director, Department of Neuroimaging Graham Family Distinguished Endowed Chair in Neurological Sciences
Leading Medicine: An Overview
Pursuing Medical Discoveries
Breaking New Ground
REX: The Robotic Exoskeleton Through a research grant from the Cullen Foundation and Mission Connect, a project of the TIRR Foundation, University of Houston (UH) Professor of Electrical and Computer Engineering, Jose Luis Contreras-Vidal, PhD, and Houston Methodist Neurological Institute neurosurgeon, Robert G. Grossman, MD, are studying the use of a robotic exoskeleton, Rex, that may someday help paraplegics walk after spinal cord injuries. One focus is augmenting the individual’s manual control of the exoskeleton through a non-invasive EEG-based brain-machine interface (BMI). The BMI is equipped with algorithms used to extract information from the EEG that signals motor intent, such as “start”, “stop”, “turn right”, and “turn left.” “Our research is focused on understanding the organization of motor circuits for walking in humans. We know that central pattern generators in the lumbosacral spinal cord are important, but equally vital are the brainstem, cerebellum and motor cortex,” says Robert Grossman, MD, professor of neurosurgery and co-founder of the Houston Methodist Neurological Institute.
“Neuroimaging studies indicate that cortical areas play an important role in the generation of bipedal gait, although, it is still not understood how the brain initiates walking and anticipates foot placement,” says Grossman. The feasibility of BMI technology has been demonstrated in primates and humans. BMI decoding of human gait has been demonstrated in studies by the UH co-investigators in this trial. “The hope is that this study can pave the way for Rex to safely bring mobility and independence to paraparetic and paraplegic individuals and thereby improve quality of life,” says Grossman.
The BMI is equipped with algorithms that are used to extract information from the individuals’ EEG that signal motor intent such as “start”, “stop”, “turn right”, and “turn left.”
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Advancing Technology
Educating For Tomorrow
“The hope is that this study can pave the way for Rex to safely bring mobility and independence to paraparetic and paraplegic individuals and thereby improve quality of life.� Robert Grossman, MD Co-Founder, Houston Methodist Neurological Institute Professor of Neurosurgery, Weill Cornell Medical College
Leading Neurosciences
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Leading Medicine: An Overview
Pursuing Medical Discoveries
Breaking New Ground
Advancing Technology
Educating For Tomorrow
amyotrophic Lateral Sclerosis: Forging a Path to Treatment The Houston Methodist MDA/ALS Center is the first multidisciplinary care center in the U.S. for individuals afflicted with amyotrophic lateral sclerosis (ALS). Here, patients with ALS benefit from the most progressive diagnostic approaches, innovative treatments and compassionate support for themselves and their family.
Researchers at the Peggy and Gary Edwards ALS Laboratory in memory of Jeannette M. (Sonja) Edwards 13
Leading Neurosciences
“Our ALS studies documented for the first time that patients with decreased numbers of T-regulatory cells had faster disease progression and decreased survival. Thus the loss of protective T-regulatory lymphocytes shortens survival; the therapeutic goal is to enhance these neuroprotective cells.” Stanley Appel, MD Director, Houston Methodist Neurological Institute Chair, Department of Neurology Peggy and Gary Edwards Distinguished Endowed Chair in ALS Research Professor of Neurology, Weill Cornell Medical College
The MDA/ALS team of researchers and physicians aggressively search for clues to this enigmatic disease through their participation in several promising research trials. One recent study investigated translating data gained from the immune system of ALS mice and replicating it in individuals with sporadic ALS. “What the study showed was that during the slow phase of the disease, mice had a number of protective immune parameters,” says Stanley Appel, MD, director of the Houston Methodist Neurological Institute and chair of the Department of Neurology. Neuroprotection in the slow phase of disease in ALS mice is mediated by anti-inflammatory innate immune M2 microglia and both Th2 lymphocytes and regulatory T-lymphocytes with high FoxP3, a transcription factor required for T-regulatory function. “Studies led by Dr.David Beers have shown that as the disease becomes more aggressive, the microglia shift to a proinflammatory M1 phenotype and the T cells shift to a Th1 phenotype with the release of toxic free radicals, cytokines, and chemokines. When T-regulatory cells are injected into affected mice, the mice live 88 percent longer,” says Appel. Human replication of this immunological response in the ALS mice was confirmed in our laboratory with a study led by Jenny Henkel, PhD, and published in EMBO Molecular Medicine. “Our ALS studies documented for the first time that patients with decreased numbers of T-regulatory cells had faster disease progression and decreased survival. Thus the loss of protective T-regulatory lymphocytes shortens survival; the therapeutic goal is to enhance these neuroprotective cells” says Appel.
Houston Methodist is a participating site in a multicenter trial that is testing for benefit of fingolimod in the promotion of T cells in ALS. Fingolimod (Gilenya®) is an immuno-modulating agent that is FDA-approved for use in multiple sclerosis. “Fingolimod is helpful in MS; we are also looking at this as a phase I trial – a very short study – to look for safety with the hope of initiating our own multicenter, placebo-controlled trial,” says Ericka Simpson, MD, director of the ALS Clinical Research Division and co-director of the MDA/ Neuromuscular Clinic. “Dr. Weihua Zhao has been investigating the protective effects of regulatory T-lymphocytes on proinflammatory microglia. Her work has demonstrated that during the early injury stage of the disease, neurons signal the microglia to be neuroprotective and T-regulatory cells help promote the neuroprotective functions of microglia,” says Appel. With further neuronal injury, microglia shift to a proinflammatory toxic phenotype; T-regulatory cells are no longer available to modulate the microglia, and toxic signals are released that kill the damaged neurons. “As we put all of this together, we can now say that a prominent role for T-regulatory cells in ALS models and possibly in human ALS itself, is to modulate microglial functions and thereby promote neuronal protection and repair. This important discovery will contribute to our overall understanding of this devastating disease,” says Appel. Leading Neurosciences
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Leading Medicine: An Overview
Pursuing Medical Discoveries
Breaking New Ground
Advancing Technology
Educating For Tomorrow
Stabilizing the Instability of Myasthenia Gravis The Houston Methodist MDA/Neuromuscular Clinic is home to the Myasthenia Gravis Clinic - a state-of-theart care and research center for myasthenia gravis, an autoimmune disease that causes weakness and fatigue of muscles under voluntary control. Myasthenia gravis currently has no cure, however, immune-modulating treatment has proven to stabilize the disease. Recently, the clinic participated in a trial to assess the viability of methotrexate, a well-established immunosuppressive agent, as a therapeutic option for treatment-refractory myasthenia gravis patients. Results of the phase II tests were positive. Currently, the clinic is participating in two studies investigating the use of bleimumab (Benlysta®) and eculizumab (Soliris®) as treatment options for myasthenia gravis. “These monoclonal antibodies that target white cells have also been used as treatment for patients who have not responded well to standard therapies, such as steroids, intravenous immunoglobulin (IVIG) and plasmapheresis. We are looking to expand our research in this area,” says Ericka Simpson, MD, director of the ALS Clinical Research Division and co-director of the MDA/Neuromuscular Clinic. In addition to these research efforts, Houston Methodist launched a patient-supported education conference to assist patients and their families in coping with the chronicity of living with myasthenia gravis. In its fourth year, the conference hosts guest speakers who are leaders in the field of myasthenia gravis care and research. “We provide education about the disease to patients and health care professionals, including how to avoid exacerbating factors,” says Simpson.
Demyelinating Polyneuropathy The Houston Methodist MDA/Neuromuscular Clinic continues to lead in the research of chronic inflammatory demyelinating polyneuropathy, or CIDP. CIDP is an immune-mediated neuropathy that causes weakness, falls, numbness, and lack of balance. Similar to myasthenia gravis, CIDP is routinely treated with intravenous immunoglobulin (IVIG) and steroids. A trial initiated at the Neuromuscular Clinic attempts to look at biomarkers, specifically T-regulatory cells. “There is evidence that T-regulatory cells decrease when disease activity is high and increase with the administration of IVIG, showing correlation with improvement,” says Simpson. Although IVIG is already FDA-approved for the treatment of CIDP, another study at the clinic is evaluating subcutaneous administration. “There is an impetus to find a way to administer immunoglobulin subcutaneously since it is currently given intravenously, which requires a nurse, often an infusion center and the drug itself is quite expensive,” says Simpson.
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Leading Neurosciences
“There is evidence that T-regulatory cells decrease when disease activity is high and increase with the administration of IVIG, showing correlation with improvement.” Ericka Simpson, MD Director, Neurology Residency Program Director, Neuromuscular Medicine Fellowship Program Co-Director, MDA/Neuromuscular Clinic Director, ALS Clinical Research Division Professor of Neurology, Weill Cornell Medical College
targeting the Sleeping Brain The Houston Methodist Neurological Institute is one of the few neurological centers that offers asleep deep brain stimulation (DBS) for patients with movement disorders such as Parkinson’s disease and dystonia. With the use of a real-time MRI scanner, neurosurgeons are able to locate the target area within the brain, see the electrodes as they enter the brain and guide the electrodes to the exact target area while the patient is asleep. Once patients are asleep, burr holes are drilled for placement of the electrodes and small towers are mounted that will display markers on the MRI scanner. “Towers indicate how to create a safe trajectory to our target. Once the scans indicate that we’re on target, we make the final placement with the electrode and scan to see if the electrode is properly set,” says Richard Simpson, Jr, MD, PhD, neurosurgeon and renowned DBS expert. Deep brain stimulation is achieved through an implanted pacemaker that sends electrical impulses to targeted areas in the brain via the implanted electrodes. Although the mechanism of action is not fully understood with DBS,
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it is hypothesized that in Parkinson’s disease, for example, the stimulation may induce chemical changes in the brain. Long-term stimulation may actually induce DNA changes in cellular activity. DBS has been shown to reduce stiffness, tremors and dyskinesia in Parkinson’s disease and other forms of dystonia. Parkinson’s disease and dystonia are the only two movement disorders that have received FDA approval for DBS treatment. “The potential for asleep DBS, especially deep-seated brain procedures, is substantial. This would include tumor biopsies, epilepsy surgery, lesionectomies and the removal of deep hematomas,” says Simpson.
“The potential for asleep DBS, especially deep-seated brain procedures, is substantial. This would include tumor biopsies, epilepsy surgery, lesionectomies and the removal of deep hematomas.” Richard Simpson, Jr, MD, PhD Professor of Neurosurgery, Weill Cornell Medical College
Leading Medicine: An Overview
Pursuing Medical Discoveries
Breaking New Ground
Advancing Technology
Educating For Tomorrow
Discovering Innovations in Stroke Therapy The Eddy Scurlock Stroke Center continues its legacy of leading clinical research with the first multicenter, double-blind, randomized, placebocontrolled trial that tests the efficacy of stem cell therapy and stroke. stem cells and stroke therapy Using a biologic product that is manufactured from human stem cells, scientists and physicians are conducting a Phase II study on the safety and efficacy of stem cells and stroke. The success of any stroke therapy is predicated on the time lapse between the occurrence of stroke and start of medical care. Tissue plasminogen activator (TPA) therapy must be administered within the first 4.5 hours after stroke onset. Outcomes are better the earlier TPA is given. Statistics show that only approximately 15 percent of patients arrive in time for treatment within 4.5 hours of their stroke. “This trial is enrolling patients up to 48 hours post ischemic stroke, regardless of TPA administration. The aim of our study, the first multicenter stem cell trial for stroke, is to find a signal that stem cell therapy improves long-term neurological outcomes for the patient with acute ischemic stroke,” says David Chiu, MD, professor of neurology and medical director of the Eddy Scurlock Stroke Center. “The stem cells seem to work at blocking an inflammatory response that worsens ischemic injury to the brain,” says John Volpi, MD, director of the Cerebral Blood Flow Lab and co-director of the Eddy Scurlock Stroke Center. “Stem cells may work through a combination of cellular mechanisms: production of growth factors, reduction of inflammation, improvement of local circulation through angiogenesis, protection of neurons that are at risk in stroke, and enhancing recovery of damaged cells. This is how we think stem cell treatments will potentially benefit the patient with stroke,” says Chiu.
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Intracranial Stenting “Over the last decade, Houston Methodist has been defining the role of carotid and intracranial stenting,” says Chiu. Physicians at Houston Methodist helped lead the Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) trial, which evaluated stenting treatments versus aggressive medical therapy for stroke prevention in patients with symptomatic intracranial arterial stenosis. “We were surprised to discover that it was the outcomes of the intensive medical therapy arm rather than the outcomes of intracranial stenting that were superior at the more experienced centers. The novel finding in SAMMPRIS turns out to be the medical protocol for treating this population of patients. This protocol is now referred to as the SAMMPRIS medical management regimen for stroke prevention,” says Chiu. “It’s interesting that experienced comprehensive stroke centers such as our Eddy Scurlock Stroke Center can offer value beyond cutting-edge surgical and endovascular interventions.”
“We were surprised to discover that it was the outcomes of the intensive medical therapy arm rather than the outcomes of intracranial stenting that were superior at the more experienced centers.� David Chiu, MD Medical Director, Eddy Scurlock Stroke Center Professor of Neurology, Weill Cornell Medical College
Leading Medicine: An Overview
Pursuing Medical Discoveries
Breaking New Ground
Advancing Technology
Educating For Tomorrow
Advancing Cerebrovascular Care 2013 marked the creation of the Houston Methodist Cerebrovascular Center. Led by Dr. Gavin Britz, MBBCh, MPH, FAANS, chair of the Department of Neurosurgery and co-director of the Houston Methodist Neurological Institute, the strength of the center lies in the years of experience and unique skills of its physicians, including Richard Klucznik, MD, Jonathan Zhang, MD, and Orlando Diaz, MD. “The combined experience of our team is unsurpassed. Beyond brain aneurysms, we offer expertise in arteriovenous malformations, dural and spinal fistulas, and many additional areas of neurosurgical services and research efforts. I feel we are virtually untouchable in what we can offer patients.” says Britz. Neuronavigation: Minimizing Brain Injury Within the Cerebrovascular Center, specialists are advancing surgical techniques during operative procedures in order to reduce the potential of brain injury that can result in speech, visual or motor dysfunction. When tumors lie close to what neurologists refer to as the “eloquent cortex,” conscious patient response is vital. “I believe that the best way to minimize brain injury is to, first, use neuronavigation to delineate the tumor, then use cortical and subcortical mapping and sometimes, when indicated, perform the operation while the patient is awake, which allows us to stimulate and observe the patient neurologically,” says Britz. Awake craniotomies are not standard neurosurgical procedures. “We use an electrophysiological probe to stimulate different areas of the brain to determine exactly where speech or motor movement activity is located. Then we resect the tumor. With this technique, we are able to give our patients the best technology and skills available and achieve optimal results,” says Britz.
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STATE-OF-THE–ART ENDOVASCULAR THERAPY FOR INTRACRANIAL ANEURYSMS Intracranial aneurysm patients at the Cerebrovascular Center receive the most sophisticated endovascular and microvascular therapy available. “In endovascular therapy, we offer patients simple coiling, balloon-assisted coiling, stent-assisted coiling and flow diversion,” says Britz. Microsurgical options for treatment of brain aneurysms include simple clipping, clip reconstruction, adenosine-induced transient asystole and cerebral bypasses. “We are creating a state-of-the-art cerebrovascular laboratory now to investigate causes of poor outcomes post aneurysm rupture. We will be exploring not only the clinical side of treatment, but also the basic science of stroke and post subarachnoid hemorrhage,” says Britz.
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THE MINIMALLY-INVASIVE PATH OF THE FUTURE Pioneering the use of new techniques and state-of-the-art, sophisticated technology, the Cerebrovascular Center is furthering the evolution of surgery within the brain toward more minimally-invasive procedures. With leading-edge applications, neurosurgeons are now able to practice what is termed a “six-pillared approach” for the minimally-invasive removal of deep subcortical tumors and lesions. “The six-pillared approach encompasses mapping of the brain, often with three-dimensional replication, to plan the trajectory of entry. We make a small opening no larger than a dime into the sulcus, which is a natural cleft in the brain. We maneuver safely through the folds and delicate fibers of the brain using GPS navigation and high-end optics. We can then successfully remove the tumor or resect the lesion with a tool that is about the size of a pencil without harm to the tissues around the abnormal area. Targeted therapy can also be delivered in this fashion,” says Gavin Britz, MBBCh, MPH, FAANS, chair of the Department of Neurosurgery and co-director of the Houston Methodist Neurological Institute.
“This is going to be a game-changer for brain surgery that involves subcortical structures. Abnormalities below the surface of the brain are going to be very easily accessible using this technology to remove the lesions without damaging the normal brain structures,” says Britz. Patients who undergo this type of surgery can anticipate going home the next day with a mild headache. “This is a much safer procedure that can be done more elegantly than we’ve done before. The length of stay will be shorter, the patient will do better and there should be fewer complications,” says Britz.
“The six-pillared approach encompasses mapping of the brain, often with threedimensional replication, to plan the trajectory of entry. We make a small opening – no larger than a dime – into the sulcus and maneuver safely through the folds and delicate fibers of the brain using GPS navigation and high-end optics. We can then successfully remove the tumor or resect the lesion without harm to the tissues around the abnormal area.” Gavin Britz, MMBCh, MPH, FAANS Chair, Department of Neurosurgery Co-Director, Houston Methodist Neurological Institute Professor of Neurosurgery, Weill Cornell Medical College
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Cerebral Blood Flow Lab Innovative use of ultrasound techniques sets the Cerebral Blood Flow Lab apart from other vascular flow labs in the country. Neuroimaging the brain under stress, similar to a stress test for the heart, allows physicians to assess for stroke risk. “We instruct patients to hold their breath. Carbon dioxide builds up and allows their brain to react. If their brain reacts normally, then we know patients have a good reserve and are not at high stroke risk; a low reserve indicates blockage or chronic small vessel disease,” says John Volpi, MD, director of the Cerebral Blood Flow Lab and co-director of the Eddy Scurlock Stroke Center. Vascular dementia is also tested in the lab. “We can use advanced ultrasound techniques to measure overall blood flow in the brain, which we believe may be useful in determining if memory loss is due to chronic ischemia,” says Volpi. Physicians can then tailor therapy toward further prevention if the memory loss is vascular in origin. The Cerebral Blood Flow Lab works in concert with neurologists who focus on concussions and brain trauma. “We’ve hypothesized that blood flow in the brain changes after concussion and that the reactivity of the brain changes after a concussion as well. Using our ultrasound reactivity tests, we can measure how well an athlete’s brain is responding to stimuli and how well blood is flowing. This is an objective way to discern whether or not an athlete is ready to go back to play,” says Volpi.
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“We can use advanced ultrasound techniques to measure overall blood flow in the brain, which we believe may be useful in determining if memory loss is due to chronic ischemia.” John J. Volpi, MD Co-Director, Eddy Scurlock Stroke Center Director, Cerebral Blood Flow Lab
“We do know that there is a direct link between a history of multiple concussions and an increased risk of developing dementing illnesses, but we know there is more to uncover,” says Podell.
taking Concussion Care to the Community The Houston Methodist Concussion Center, directed by Howard Derman, MD, is a unique, state-of-the-art facility that specializes in all aspects of brain trauma with an emphasis on sports-related concussion. “Using a multidisciplinary approach, we treat all aspects involved in head injury, including brain, cognition, vestibular, balance-related issues, and cervical strain and whiplash, “says Kenneth Podell, PhD, co-director of the Houston Methodist Concussion Center. The center is one of only a few programs nationally that works closely with the NFL, the NCAA, and area Division I universities. Additionally, the center works with more than 300 high schools in the Houston area. “We believe that involving neurologists, neuropsychologists, neurosurgeons, otolaryngologists and sports medicine physicians is key to treating patients as quickly as possible,” says Podell. The center is designed to be an open access clinic. “We will see most patients 24 to 48 hours from the time of referral.
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Our goal is to work with the referral source to help optimize recovery from concussion by addressing physical symptoms, cognitive problems, vestibular problems and any signs of whiplash that may occur. We coordinate the patient’s care though the referral source, which allows them to be integral in the care of their patient,” says Podell. Another distinguishing attribute of the center is its large community outreach program. “We have more than 30 full-time and part-time athletic trainers who go into the community and assist other athletic trainers, coaches, parents, and athletes in getting assessments or care and education about concussions,” says Podell. In 2013, the center reached more than 5000 people through lectures and education programs. Baseline testing, an integral part of community outreach, is a vital measurement tool for the diagnosis of head injury. The center performed more than 4,000 baseline tests in area schools in 2013.
The Nantz National Alzheimer Center (NNAC) and the Houston Methodist Concussion Center have partnered together in order to better understand the relationship between traumatic brain injuries, concussions and dementias. Through ongoing research, the NNAC and the Houston Methodist Concussion Center will specifically address the relationship of head injuries to the development of dementia.
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Advanced mapping of the brain helps preserve human functions In an effort to make medicine more personalized and improve outcomes, physicians at Houston Methodist Hospital are using all the imaging data that the patient has received to make surgical and radiation therapy decisions that could lead to better outcomes and provide fewer side effects for patents.
Surgical deficits in the brain, head and neck can lead to long-term side effects that dramatically diminish the quality of life of the patient. It is important for physicians to be able to visually understand where critical or eloquent pathways exist in the brain or in the head and neck area, and to have a predetermined idea of where blood vessels and cranial nerves lie. Eloquent areas in the brain include speech, visual and motor fiber tracts. The brain and the head and neck area are the most complex in having a three-dimensional and stereoscopic understanding of individual patients. Using technologies integrated in a Computer Augmented Virtual Environment (CAVE) called Plato’s CAVE, surgeons and radiation oncologists are able to plan surgery and radiation therapy by understanding the precise location of the safest corridors of approach for their radiation beam or surgical scalpel. Gavin Britz, MBBCh, MPH, FAANS, chair of the Department of Neurosurgery and co-director of the Houston Methodist Neurological Institute, David Baskin, MD, vice chair of the Department of Neurosurgery and director of the Kenneth R. Peak Center for Brain and Pituitary Tumor Treatment and Research, Donald Donovan, MD, chair of the Department of Otolaryngology, Mas Takashima, MD, member of the Department of Otolaryngology, and Brian Butler, MD, chair of the Department of Radiation Oncology, use this visual decision-making platform to design the best and safest strategy for the patient and to plan therapies well in advance of delivering them. “For those of us in the neurosurgical spectrum, Plato’s Cave provides a preoperative way to delineate the
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important fiber tracts in the brain and determine the best surgical corridor to access lesions,” says Britz. “It is absolutely one-of-a-kind.” Houston Methodist physicians are developing techniques that better preserve the most important human functions – the very things that make us who we are and enable us to communicate with our world. By advancing the art of functional avoidance, we can better treat patients with brain, ear, nose and throat tumors which lie close to the eloquent pathways that create or store memories, fetch words, make our fingers feel and our ears hear. Anatomic avoidance techniques are well defined, using images of structures such as the brain stem or the spinal cord. Functional avoidance goes several steps further, identifying and avoiding the electronic and chemical circuitry in the brain that brings to life essential activities such as speech, thought process, word recall, or meaningful gestures of a hand or an eye. Drs. Butler, Britz, Baskin, Donovan and Takashima have integrated a functional map of the brain that identifies “safe” corridors through which surgeons and radiation oncologists can navigate for the best outcome. On a case-by-case basis, physicians use the functional map, reference markers and a triangulating GPS-like system to safely work within millimeters of a critical functional pathway. The map also identifies which pathways are serial or parallel. Serial pathways have no redundancy, so there is no recovery if they are disrupted. This vital information further helps determine the safest approach to a tumor.
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S afely nav igating a b rain map to deli v er innovati v e , pinpoint treatments
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With the pinpoint accuracy provided by mapping functional pathways in the brain comes the need for microsurgical technology to help surgeons maneuver along those tiny corridors to the tumors. Surgical microscopes magnify a ¼-inch section into a huge visual world for a surgeon, and there has been an explosion of surgical instrumentation such as micro-scalpels and other micro tools. Still, many tumors can be challenging to access. David Baskin, MD, director of the Kenneth R. Peak Center for Brain and Pituitary Tumor Treatment and Research, has collaborated with Rice University’s Nanoscience Department to invent several of these tools including a nano-syringe, which selectively kills brain cancer cells by delivering chemotherapy drugs directly into the cells, and a mitochondrial “smart bomb” that targets mitochondria in glioblastoma cells and destroys mitochondrial activity.
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To safely reach dangerous tumors, Dr. Baskin uses a map for neural navigation, and manipulates a tiny 2.8 millimeter endoscope that provides a high-definition, real-time view into the front base of the patient’s skull, the brain stem and the spinal cord, all through the patient’s nostril, with no incisions. He also uses a technology called BrainPath to safely pass microscopic tools and treatments into deep, hard-to-reach places in the patient’s brain. The combination of neural imaging, functional avoidance, microsurgical tools and pinpoint radiation technology continues to propel advancements in treatment for tumors of the brain, ear, nose and throat. Physicians and researchers at Houston Methodist are in the driver’s seat on pushing these advancements forward.
“Using fusion technology that can accurately combine multiple high-res images, we can visualize fiber tracks, arteries, veins and tiny corridors in the brain that allow us to navigate without damaging functional capacity of the patient”. We can see where we are in the brain with one millimeter accuracy.” David S. Baskin, MD Professor, Vice Chair and Residency Director, Department of Neurosurgery Director, Kenneth R. Peak Center for Brain and Pituitary Tumor Treatment and Research Learn more at houstonmethodist.org/peakcenter
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The Amazing Cap: Portable Transcranial Magnetic Stimulation Under the direction of David Rosenfield, MD, researchers at the Speech and Language Center have developed a revolutionary new device that provides portable transcranial magnetic stimulation (TMS). “We have been able to create a TMS device in the form of a cap that the patient wears. This flexible, portable, and variable device delivers magnetic stimuli to multiple sites on the brain, allowing the patient to use it for in-home treatment,” says Santosh Helekar, MD, PhD, associate research professor of neuroscience and director of the Songbird Neurophysiology Laboratory. The cap can also be used as a diagnostic tool for certain motor-related diseases such as ALS. Stimuli from TMS measure the function of the motor pathway from the primary motor cortex and brainstem out through the spinal cord and peripheral nerves. “Using TMS methods, we can actually measure the integrity of that pathway. In ALS, the pathway doesn’t function because the motor neurons in the brain degenerate. We can establish how badly these neurons are damaged in this condition,” says Helekar. The Speech and Language Center is involved in a small clinical trial to determine efficacy of the TMS cap in Tourette’s syndrome. The trial is being done in collaboration with neurologists at Children’s Mercy Hospital in Kansas City. “There is a substantial reduction in tics from standard TMS. The conventional TMS treatment for that patient requires him or her to come every day of the week for about two to three weeks. But in our case, we can actually give the cap to patients and let them receive their stimuli at home. Instead of drug therapy, this is a way to calm down the areas of the brain that produce these tics,” says Helekar. Other potential applications of the portable TMS include depression, stroke rehabilitation and Parkinson’s disease. “Brain stimulation is an important research tool, just as brain imaging is. Right now, any scientist or physician who conducts neuroscience research can use this tool to stimulate a particular part of the brain and study the effects of that stimulation. As it exists now it is a research tool, but has great potential for use in diagnosis and therapy,” says Helekar.
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A Multidisciplinary Approach to Spine Care Houston Methodist Neurological Institute continued its innovative approach to therapy with the establishment of the new Houston Methodist Spine Center. Here, a multidisciplinary culture offers patients the latest innovations in the treatment for spinal disorders. The center is comprised of leading neurosurgeons, including J. Bob Blacklock, MD, Paul Holman, MD, Rob Parrish, MD, Todd Trask, MD, Alfonso AldamaLuebbert, MD, David Cech, MD, Richard Harper, MD, Warren Parker, MD and Andrew C. Roeser, MD, as well as neurologists, physical therapists, physiologists and rehabilitation specialists. The center’s philosophy of total care, coupled with state-of-the-art technology, provides patients with the maximum in medical treatment, resulting in better outcomes and shorter recovery times.
A New Way of Looking at the Spine The Houston Methodist Neurological Institute is one of only a handful of medical institutions worldwide that has fully incorporated the use of new, image-guided technology to navigate the spine in the perioperative setting. The O-arm is a sophisticated imaging apparatus that provides real time scans in 2-D or 3-D. Used in combination with computer software, the O-arm vastly improves the precision of spinal surgical techniques and the correct placement of reparative hardware, such as pedicle screws.
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“The O-arm rotates around the spine and captures multiple fluoroscopic images. We consistently obtain quality intraoperative images even in challenging cases when patients are obese, have osteoporosis, or have previously placed spinal hardware,” says Holman, primary user and instructor of the O-arm technology. There is ongoing concern about the amount of radiation used in the OR, which typically requires the donning of lead aprons by the surgical staff. This is not a factor with the O-arm. “Because we are using image guidance, while the O-arm is actually taking the images the surgeon and the operating staff actually leave the room or stand behind a lead shield. It completely eliminates the radiation exposure for the surgical team,” says Holman. Although the patient is still exposed to a similar amount of radiation that is associated with fluoroscopy, repeat CAT scans or imaging are no longer required.
The O-arm is a sophisticated imaging apparatus that provides real time scans in 2-D or 3-D. Used in combination with computer software, the O-arm vastly improves the precision of spinal surgical techniques and the correct placement of reparative hardware, such as pedicle screws.
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The eye as a window to the brain: Using advanced imaging to diagnose neurological disease Through collaboration with the Houston Methodist Department of Ophthalmology, the Houston Methodist Neurological Institute has unique access to top neuro-ophthalmologists. Under the direction of Andy Lee, MD, these specialists play a key role in providing integrated care for patients with visual disturbances. At Houston Methodist Hospital, advanced applications using magnetic resonance imaging (MRI) help ophthalmologists, neurologists and neurosurgeons understand pathologies of the visual system in unique ways. Magnetic resonance imaging (MRI) is a versatile tool in the diagnosis of diseases of the eyes and central nervous system. For example, dynamic MRI of the orbits can be used to record movies of the eyes in motion. As the patients are instructed to move their eyes in certain directions, ophthalmologists are able to visualize pathologies in extraocular muscle structure and function to aid the diagnosis and treatment of strabismus. Diffusion tensor imaging (DTI) provides information on the directional motion of water, which is useful for evaluating the integrity of structured tissues such as white matter tracts along the visual pathway. “Pathologies such as ischemia, demyelination and traumatic injury can be determined along the course of the optic nerve, optic tract and optic radiation by DTI. Tractography can also be performed to determine if a tumor, for example, is directly involving or displacing a white matter tract,” says Steve Fung, MD, assistant professor and medical director of the MRI Core at Houston Methodist Research Institute.
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Functional MRI (fMRI) can be used to localize eloquent cortex in neurosurgical cases. fMRI is frequently performed to identify areas of the brain that are important for motor, language, memory and vision and their proximity to the tumor or lesion that requires resection. “We had a case in which a patient with vision change was found to have an arteriovenous malformation, or AVM, close to the anterior occipital lobe. fMRI was performed to test the visual system which demonstrated the AVM nidus was close to the anterior tip but not involving the primary visual cortex. Endovascular embolization of the AVM resulted in correction of the visual symptoms,” says Dr. Fung. Frequently, neurological disease first presents as a visual disorder. Ophthalmologists, neurologists, neurosurgeons and radiologists at Houston Methodist are dedicated to the sophisticated application of technology to ensure accurate diagnosis for planning the most efficacious treatment. “Most people see an ophthalmologist for problems of their eyes which are really part of the central nervous system,” says Fung. “The eye is a window to the brain.”
“We had a case in which a patient with vision change was found to have an arteriovenous malformation, or AVM, close to the anterior occipital lobe. fMRI was performed to test the visual system which demonstrated the AVM nidus was close to the anterior tip but not involving the primary visual cortex. Endovascular embolization of the AVM resulted in correction of the visual symptoms.�
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A Holistic Approach to Neurorehabilitation At the Houston Methodist Neurological Institute, we have paired exemplary collaboration with the best in progressive technology for the care of patients with impaired neurological function. This combination of medical teamwork and the newest advances in medical science culminates in one of the top neurorehabilitation programs in the nation. A variety of neurological impairments can result through events such as stroke, traumatic brain injury, or development of a brain tumor and from progressive neurodegenerative disorders such as multiple sclerosis or Parkinson’s disease. Our neurorehabilitation program takes a comprehensive approach to individuals who have sustained a neurological deficit. “One of our newest advancements is the ability to address vision and motor deficits with the Dynavision D2. It is a visuomotor and cognitive training system that is designed to benefit such problems as visual field loss, inefficient scanning, motor processing and reaction times,” says Jenny M. Lai, MD, physiatrist and section chief of Physical Medicine and Rehabilitation. “We’re also able to help patients who suffer from spasticity with the most current applications of the intrathecal baclofen pump, which places the catheter tip at top of the cervical vertebrae,” says Lai. This year saw the institution of transitional living center rooms to help patients integrate back into daily routines. “It is like apartment-style living, although physicians and nursing staff are there for hands-on assistance. We provide a simulated trial of how patients would do if they were in their own environment,” says Lai. “As a physician, you look at a person holistically. With our neurorehabilitation program we are able to do this. We can direct a tier of medical professionals to specific areas of patient need and help these individuals return to functionality,” says Lai.
“One of our newest advancements is the ability to address vision and motor deficits with the Dynavision D2, a visuomotor and cognitive training system that is designed to benefit such problems as visual field loss, inefficient scanning, motor processing and reaction times.” Jenny M. Lai, MD Section Chief, Physical Medicine and Rehabilitation
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Houston Methodist Institute for Technology, Innovation & Education (MITIE ) SM
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HOUSTON MITIE AT A GLANCE More than
6,300
learners in 2013
One of the largest and most comprehensive education and research facilities in the world, MITIE is leading the practice of medicine for physicians and health care providers. MITIE offers multidisciplinary, hands-on learning opportunities using advanced imaging systems and robotics. Surgeons and other health professionals are able to continually refine and acquire new skills that allow them to perform at optimal levels throughout their careers. Using procedural laboratories and sophisticated simulation tools, our research programs are focused on the development and assessment of emerging technologies and technical skills to improve the care of patients through less invasive therapies. At MITIE, the finest researchers and clinicians are building on our legacy of ingenuity and accelerating the discovery and delivery of better care and better cures.
40,000 square feet of education and research space
26 More than
Surgical specialties from across the world
20,000
learners since inception
For more information, visit mitietexas.com
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PREPARING THE NEXT GENERATION The most talented future neurologists and neurosurgeons receive exceptional training and preparation at the Houston Methodist Neurological Institute. Through our primary academic affiliation with Weill Cornell Medical College and NewYork-Presbyterian Hospital, physicians serve as faculty members in the provision of fully accredited neurology and neurosurgery residency programs. Residents are exposed to unique and complex cases, state-of-the-art technology, and high patient volumes, all of which are designed to prepare exceptional training for prospective neurologists and neurosurgeons. ACADEMIC PROGRAMS A seven-year residency program in neurosurgery, with extensive exposure to advanced operative techniques, neurology, neuropathology and neuroradiology. The program includes a full year of protected research time and eight months of focused subspecialty exposure in preparation for academic and practice careers. A four-year accredited adult neurology residency program offers comprehensive training in clinical neurology and mentorship in the clinical and basic sciences that provides a strong foundation for the practicing neurologist and physician-scientist. A one-year accredited post-graduate clinical neurophysiology fellowship program is comprised of all aspects of clinical neurophysiology and encompasses electromyography (EMG), electroencephalography (EEG), nerve conduction, sleep, evoked potentials, intra-operative monitoring and additional clinical testing modalities.
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A one-year accredited neuromuscular medicine fellowship focuses training on clinical neuromuscular medicine and includes electro diagnostic medicine, neuropathology, clinical/ translational experience and rehabilitation. The neuromuscular fellowship provides a large and varied clinical experience with greater than 75 neuromuscular patients evaluated each week from both the outpatient and inpatient services. Neurology and neurosurgery grand rounds present the latest information about the nervous system and neurological disorders. Grand rounds also provide an excellent venue for presentations by visiting professors. World-class scientists, researchers and neurologists and neurosurgeons present their work to the group in an environment of collaboration and scientific inquiry. Annual skull base, cerebrovascular and spine courses for residents and fellows provide a hands-on cadaveric course designed to educate senior neurosurgery residents and fellows in the latest techniques in neurosurgery. In addition to anatomy, the course presents common microsurgical, endoscopic and endovascular approaches to the brain and spine, indications for their use and complication avoidance.
Neurosurgery Clinical Faculty and Residents
Neurology Residents, Program Directors and Visiting Professor
HOUSTON METHODIST hospital Leading Medicine yesterday, today and tomorrow At Houston Methodist, we’ve built a legacy of ingenuity that spans multiple decades and disciplines. In the last 95 years, we’ve transformed from a humble 19-bed community hospital to a global leader in health care, treating patients from 90 countries in more than 8,150 visits last year. In 2004, Houston Methodist established a long-term affiliation with Weill Cornell Medical College and New York-Presbyterian Hospital in New York City. Through this affiliation, three internationally renowned institutions collaborate to bring tomorrow’s advances to our patients today. Together, we provide cutting-edge clinical and biomedical research, and education and training for future physicians and scientists. One of the nation’s top research medical schools, Weill Cornell Medical College ranked No. 15 in the 2015 U.S. News & World Report Best Medical Schools list. For Houston Methodist clinicians and researchers, “leading medicine” is a holistic call for excellence in every aspect of patient care. We consistently rank among the best hospitals in the country. In 2013, U.S. News & World Report named Houston Methodist the “Best Hospital in Texas” for the second consecutive year, with 12 specialties recognized in the Best Hospitals list. Houston Methodist is consistently recertified to Magnet status for exceptional nursing. Because of our reputation, the finest researchers and clinicians from around the world are joining us to build on our legacy of ingenuity and accelerate the discovery and delivery of better care and better cures. That’s the difference between practicing medicine and leading it.
FAST FACTS 73 Operating Rooms
1,119
Licensed Beds (824 operating beds)
1,862
Affiliated Physicians
6,101 Employees
8,150
International Patient Encounters (from 90 foreign countries)
36,310 Inpatients in 2013
61,043
Emergency Room Visits in 2013
301,478
Outpatient Visits in 2013
FORTUNE is a registered trademark of Time Inc. and is used under license. From FORTUNE Magazine, February 3, 2014 ©2014 Time Inc. FORTUNE and Time Inc. are not affiliated with, and do not endorse products or services of, Licensee.
Leaders in Research Accelerating discovery and delivery to patients
At Houston Methodist, we are dedicated to defining the future of medicine. We engineer discoveries in the lab to become clinically useful products, channel the best innovations through early stage clinical trials and actively transition those innovations to our industry partners. Our commitment to the full cycle of discovery and delivery sets us apart as leaders who provide patients from around the world access to the latest health care advances.
More than 840 active clinical protocols $55m TOTAL RESEARCH FUNDING IN 2013 See all the ways we’re leading medicine at hmleadingmedicine.com
Photo courtesy of WHR Architects, Inc. Š Aker/Zvonkovic Photography, Houston, Texas
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Houston Methodist Hospital 6565 Fannin Street Houston Texas 77030
LEADING MEDICINE YESTERDAY, TODAY AND TOMORROW. At Houston Methodist we have a proud tradition of revolutionizing medicine. Our past achievements have built a legacy that spans multiple decades and disciplines, and that same culture of excellence inspires us to be the pioneers of tomorrow.
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