Into the Brain and Beyond by UCLA Neurosurgery

DEPARTMENT OF NEUROSURGERY

INTO THE BRAIN AND BEYOND PERFECTING THE NEUROSURGICAL HEALING OF TODAY INVENTING THE NEUROSURGERY OF TOMORROW UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

UCLA NEUROSURGERY

RECOGNITIONS

AWARDS AND

Top 10 Neurosurgery Department according to U.S. News and World Report

TABLE OF 4

The New Gold Standard UCLA HEALTH: AN OVERVIEW

Message from the Chairman NEIL A. MARTIN, MD, FAANS

Awards & Recognitions UCLA NEUROSURGERY DEPARTMENT

No. 2 in National Institutes of Health (NIH) Research Grants at $5,943,956

A Truly Multidisciplinary Team UCLA NEUROSURGERY FACULTY OVERVIEW

Mapping the Future of Neurosurgical Healing A YEAR IN REVIEW

Pioneers in Minimally-Invasive Surgery CUTTING EDGE TECHNIQUES & PROCEDURES

The Perfect Patient Experience UCLA NEUROSURGERY CLINICAL QUALITY PROGRAM

No. 5 in the world for most research papers published in medical journals

Joint Commission National Quality Approval awarded to UCLA Stroke Center

The UCLA Stroke Center is a designated center of the NIH-funded Specialized Programs of Translational Research in Acute Stroke (SPOTRIAS)

Cover image: White Matter Fibers, HCP Dataset Red Corpus Callosum courtesy of Scientific Visualization Team, Laboratory of Neuro Imaging. www.humanconnectomeproject.org

World-Class, Patient-Centered Care BRAIN TUMOR PROGRAM

UCLA NEUROSURGERY

FACULTY AWARDS

GRANTS AND

CONTENTS 24

Leaders In Next-Generation, Hi-Definition Neurosurgery PITUITARY TUMOR PROGRAM

Revolutionizing Skull Base Surgery UCLA SKULL BASE TUMOR PROGRAM

World-Renowned Pioneers & Experts STEREOTACTIC RADIOSURGERY PROGRAM

Worldâ&#x20AC;&#x2122;s Most Comprehensive Stroke Center UCLA STROKE CENTER

The Discovery of Stimulating Memory in the Human Brain ITZHAK FRIED, MD, PHD

More Than 50 Years of Excellence ADULT EPILEPSY SURGERY PROGRAM

Saving Lives on the Battlefields, Sports Fields and Playgrounds UCLA BRAIN INJURY RESEARCH CENTER

Inventing the Future of Neurocritical Care

Linda M. Liau, MD, PhD, marked the milestones for two patients living 10 years beyond glioblastoma multiforme, who were enrolled in the first personalized brain cancer vaccine developed at UCLA and now in Phase III clinical trials in America and Europe. Dr. Liau recently received the prestigious Athena Award. Itzhak Fried, MD, PhD, was among the top 10 finalists for the Global B.R.A.I.N Prize competition (Breakthrough Research and Innovation for Neurotechnology) inspired by Israeli President Shimon Peres and Israel Brain Technologies. He is recognized among the top neuroscientists in the world for his recent discovery of boosting memory in the gateway of the hippocampus, the mainframe of human memory. Nestor Gonzalez, MD, received the Innovative Science Award from the American Heart Association for his pioneering research in the prevention and treatment of stroke.

NEUROCRITICAL ICU

The Movement Disorder Experts NEUROMODULATION & NEUROBIONICS PROGRAM

A World-Class Team of Integrated Specialists UCLA SPINE CENTER

World-Class Pediatric Epilepsy Experts PEDIATRIC EPILEPSY SURGERY PROGRAM

Global Neurosurgery Institute

Isaac Yang, MD, is honored to receive the Award for Excellence in Education for his continued brilliance and innovation to teaching in clinics and the classroom. Gary W. Mathern, MD, was appointed Co-Editor-in-Chief of Epilepsia, the official medical journal of the International League Against Epilepsy (ILAE).

THE EDIE & LEW WASSERMAN BUILDING

Global Leaders UCLA NEUROSURGERY: OUR DEPARTMENT IN SUMMARY

Dan Lu, MD, PhD, & V. Reggie Edgerton, PhD, received a $6 million grant from the NIH to study groundbreaking stimulation for recovering function in patients with spinal cord injury. Nancy McLaughlin, MD, PhD, received a grant from the University of California to improve and perfect neurosurgical care.

UCLA HEALTH

THE NEW GOLD STANDARD

t UCLA Health, our mission is to deliver leading-edge patient care, research and education. Our vision is to heal humankind, one patient at a time, by improving health, alleviating suffering and delivering acts of kindness. With a culture of caring, compassion, dignity and privacy, our integrated approach is focused on bringing world-class experts together to care for the patient and family as one.

“OUR PRESCRIPTION OF EXCELLENCE IS TO PROVIDE THE BEST PATIENT EXPERIENCE WITH EVERY PATIENT, EVERY ENCOUNTER, EVERY TIME.”

4 | UCLA HEALTH: THE NEW GOLD STANDARD

Best in the West, U.S. News & World Report Ranked #1 hospital in the West for 23 consecutive years, top 5 in the nation, and Best Hospital Honor Roll for 24 consecutive years, Ronald Reagan UCLA Medical Center is the #1 hospital in California and the West Coast, receiving the Best in the West honor from US News & World Report.

Joint Commission Gold Award Certified as a Comprehensive Stroke Center by the Joint Commission, receiving their Gold Award for quality.

Comprehensive Stroke Center Certified as a Comprehensive Stroke Center by the American Heart Association/American Stroke Association.

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

24 YR. RONALD REAGAN MEDICAL CENTER RANKED #1 HOSPITAL IN THE WEST FOR 24 CONSECUTIVE YEARS

1.5 MIL. 1.5 MILLION PATIENTS ARE SEEN IN MORE THAN 80 COMMUNITY-BASED CLINICS OF THE UCLA FACULTY PRACTICE

96-99% 96 TO 99 PERCENTILE IN PATIENT SATISFACTION ACCORDING TO INDEPENDENT NATIONAL SURVEYS

80,000 80,000 PATIENTS ARE TREATED ANNUALLY AT UCLA HOSPITALS

BUILT FOR MIRACLES RONALD REAGAN UCLA MEDICAL CENTER Level 1 Trauma Center: Our trauma center represents the highest level of emergency care to tackle any traumatic injury, 24 hours a day, 7 days a week, 365 days a year. Neurosurgical Operating Rooms: We can accommodate more than 2,000 cases a year. • High-definition, magnification video systems for microsurgery • Electrophysiologic equipment for brain monitoring • Intraoperative angiography • Frameless stereotactic imaging workstation (BrainLAB) for neuro-navigation

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

Stereotactic Radiosurgery: Gold-standard noninvasive, bloodless surgery instrumentation, Novalis TX equipped with GPS-like image guidance system, 3D-multiplanar computerized models for high-resolution brain mapping. Interventional Imaging Suite: Interventional angiography suites equipped with 3D rotational angiography for endovascular procedures. Comprehensive Stroke Center: Our Brain Attack Team specializes in rapid stroke care response using the latest in neurosurgical interventions and neuro-intensive care at UCLA and around Southern California.

Edie Baskin Bronson & Richard “Skip” Bronson Cerebral Blood Flow Laboratory: Clinical transcranial Doppler evaluations and cerebral blood flow testing on patients. Singleton Neuro-ICU 24-7 • Continuous EEG monitoring • 3 Tesla MRI scanners and PET-CT Scan for acute crises • Cerebral microdialysis • Brain oximetry • Transcranial Doppler • World’s first ICU Robot • Comprehensive ICU supercomputing system for predictive medicine

UCLA HEALTH: THE NEW GOLD STANDARD | 5

MESSAGE FROM

THE CHAIRMAN

ear colleagues and friends, As neurosurgeons and neuroscientists, we marvel daily at the capacity of the human brain to repair and heal itself. Yet it is our patients’ courage to triumph over the most devastating conditions that inspires us to continue our exploration into the inner space of the brain and spine, as we unearth solutions to the most critical neurological problems that face millions of Americans today. The recentlylaunched national initiative to map the human brain feels similar to the country’s ambition to land a man on the moon. In my opinion, our team of biomedical scientists and surgeons are closer than ever to unraveling the mysteries of some of the most puzzling diseases such as cancer, stroke, traumatic injury,

6 | MESSAGE FROM THE CHAIRMAN

epilepsy, Parkinson’s disease, Alzheimer’s disease and autism. In reporting on our innovative technology and latest research endeavors, we share the stories of how we have profoundly improved the quality of life and, in many cases, saved the lives of our patients and their families. We use a 360-degree integrative and multidisciplinary team approach to patient care that translates into superior clinical outcomes. Ronald Reagan UCLA Medical Center consistently ranks number one on the West Coast and in the top five in the nation, according to U.S. News and World Report. The UCLA Department of Neurosurgery also ranks year after year in the top 10 in the world according to U.S. News and World Report. Our high annual rankings are the result of our patients’

successes combined with our innovation to translate science and technology into medical breakthroughs at the bedside. Our UCLA Brain Injury Research Center translates the biology of traumatic brain injury into real-world treatments to raise the standard of care and protect our soldiers on the battlefield, athletes on the sports field and children on the playground. Their expertise has led to advising the U.S. Military, the NFL and the recent release of the first evidencebased guidelines for sports concussions. The UCLA Stroke Center continues to be a world leader in research and treatment of cerebrovascular disease. Certified by the Joint Commission as a Comprehensive Stroke Center and funded by a prestigious National Institutes of Health SPOTRIAS

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

(Specialized Programs of Translational Research in Acute Stroke) grant, it is one of just eight such centers in the country. We reach beyond our community to serve the entire Southern California region with the Telestroke unit, and hospitals across the country through our Tele-ICU network, which beams in a neurointensivist via telemedicine to treat critical patients in community hospitals lacking this expertise. Our endovascular devices invented at UCLA circle the globe treating patients with stroke. The UCLA Brian Tumor Program continues to shine as a beacon of hope, carrying a record of patients with brain tumors living longer than patients treated at any other hospital. Our personalized brain cancer vaccine, DCVax, is the first of its kind and is currently in

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

Phase III clinical trials in 46 centers throughout America. It is on the road to FDA approval as well as clinical trials throughout Europe. Using this vaccine, we are harnessing the patientâ&#x20AC;&#x2122;s immune system, genetics, pathology, brain mapping and a wide database of bioinformatics to optimize outcomes. Through a recently-awarded NIH grant in the UCLA Spine Center, we are innovating next-generation neurobionics and neuromodulation with interventions that may enable patients with severe paralysis to stand, step, and regain voluntary muscle control once lost to injury. Additionally, our neuroscientists recently discovered that stimulating the entorhinal cortex in the brain could lead to boosting memory in patients with Alzheimerâ&#x20AC;&#x2122;s disease.

Looking ahead, we are on the threshold of opening the Global Neurosurgery Institute in the Edie and Lew Wasserman Building at UCLA to deploy the latest advancements in telemedicine that will surround our patients with world-class expertise. Today, we will share how we make beating impossible odds possible, by staying focused on our mission of working together as a team to provide exceptional patient care and invent the future of neurosurgery.

Neil A. Martin, MD, FAANS PROFESSOR & W. EUGENE STERN CHAIR IN NEUROSURGERY

MESSAGE FROM THE CHAIRMAN | 7

UCLA NEUROSURGERY DEPARTMENT

AWARDS & RECOGNITIONS TOP 10 NEUROSURGERY DEPARTMENT ACCORDING TO U.S. NEWS AND WORLD REPORT

NO. 2 IN NATIONAL INSTITUTES OF HEALTH (NIH) RESEARCH GRANTS AT $5,943,956

10 TOP SURGEONS VOTED BY THE CONSUMERS’ RESEARCH COUNCIL OF AMERICA

NO. 5 IN THE WORLD FOR MOST RESEARCH PAPERS PUBLISHED IN MEDICAL JOURNALS

THE UCLA STROKE CENTER IS A DESIGNATED CENTER OF THE NIH-FUNDED SPECIALIZED PROGRAMS OF TRANSLATIONAL RESEARCH IN ACUTE STROKE (SPOTRIAS)

JOINT COMMISSION NATIONAL QUALITY APPROVAL AWARDED TO UCLA STROKE CENTER

7 CLINICIANS IN THE UCLA NEUROSURGERY DEPARTMENT VOTED BEST DOCTORS IN AMERICA

WRITING THE GUIDELINES FOR THE MEDICAL COMMUNITY:

EDITORS OF LEADING NEUROSURGICAL JOURNALS Linda M. Liau, MD, PhD Editor-in-Chief, Journal of Neuro-Oncology Gary W. Mathern, MD Co-Editor-in-Chief, Epilepsia

James I. Ausman, MD Surgical Neurology International Langston T. Holly, MD Serves on the Editorial Board of the Journal of Neurosurgery – Spine

David A. Hovda, PhD Serves on Editorial Boards of Journal of Neurotrauma and the Journal of Cerebral Blood Flow & Metabolism

UCLA NEUROSURGERY SERVES We are honored to serve our country’s veterans through our collaboration with the West Los Angeles Veterans Administration Hospital. We provide a full-time staff of world-class neurosurgical experts dedicated to the men and women of the US Armed Forces. Our team is privileged to manage an average of nearly 100 cases a week referred from around Southern California and across the United States.

8 | AWARDS & RECOGNITIONS

Our team is dedicated to excellence in patient care and advancing research throughout the Greater Los Angeles community. We provide neurosurgical expertise in the Ronald Reagan UCLA Medical Center, Mattel Children’s Hospital UCLA, UCLA Medical Center (Santa Monica), UCLA Spine Center (Santa Monica), and Harbor-UCLA Medical Center.

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

FACULTY OVERVIEW he faculty members of the UCLA Department of Neurosurgery are experts in the diagnosis, treatment and management of diseases in the brain and spine. We consistently rank in the top 10 programs in the nation according to U.S. News and World Report. The strength of the UCLA Department of Neurosurgery is the collaboration between its multidisciplinary teams of experts in every relevant field focused on a specific disease or

funding. We deliver the latest translations of basic science into cutting-edge treatments at the bedside for our patients. As leaders in neurosurgery, we continue to attract and train the next generation of neuroscientists and neurosurgical pioneers, mapping new frontiers of the human brain and discovering cures for the most complex neurological diseases facing our families today, and our childrenâ&#x20AC;&#x2122;s families tomorrow.

disorder of the brain or spine. Our patients are the beneficiaries of centralized, world-class expert care provided by specialists who have spent a lifetime dedicated to discovering the best treatments to target a disease at every level. Our clinicians, scientists and researchers rank 5th in world for published medical journal studies that have unearthed the evidence to write the guidelines and standards of care for the medical community. Our team ranks 2nd in National Institutes of Health

OUR MISSION The mission of the Department of Neurosurgery is to invent the future of neurosurgery by improving neurosurgical treatment of brain and spinal disease through innovative research and development, by providing and advancing the highest level of surgical and medical care for our patients and by training the next generation of neurosurgical pioneers.

EXECUTIVE LEADERSHIP

Neil A. Martin, MD, FAANS

Linda M. Liau, MD, PhD

PROFESSOR & W. EUGENE STERN CHAIR IN NEUROSURGERY & CO-DIRECTOR OF THE UCLA STROKE CENTER

PROFESSOR & VICE CHAIR OF ACADEMIC AFFAIRS & DIRECTOR OF THE UCLA BRAIN TUMOR PROGRAM

Marvin Bergsneider, MD

Langston T. Holly, MD

David A. Hovda, PhD

PROFESSOR & CO-VICE CHAIR OF CLINICAL AFFAIRS, RESIDENCY PROGRAM DIRECTOR

ASSOCIATE PROFESSOR & CO-VICE CHAIR OF CLINICAL AFFAIRS FOR THE DEPARTMENT OF NEUROSURGERY & DIRECTOR OF THE UCLA SPINE CENTER

PROFESSOR & VICE CHAIRMAN OF RESEARCH AFFAIRS & DIRECTOR OF THE BRAIN INJURY RESEARCH CENTER

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

FACULTY OVERVIEW | 9

CLINICIANS James I. Ausman, MD, PhD

John G. Frazee, MD

Gary W. Mathern, MD

CLINICAL PROFESSOR & DIRECTOR OF THE NEUROENDOSCOPY PROGRAM & CHIEF OF NEUROSURGERY AT WEST LOS ANGELES VA MEDICAL CENTER

PROFESSOR IN RESIDENCE & DIRECTOR OF THE PEDIATRIC EPILEPSY SURGERY PROGRAM & PEDIATRIC NEUROSURGERY PROGRAM

Ulrich Batzdorf, MD

Itzhak Fried, MD, PhD

Duncan Q. McBride, MD

PROFESSOR & EXECUTIVE DIRECTOR OF SPINAL NEUROSURGERY

PROFESSOR & DIRECTOR OF THE EPILEPSY SURGERY PROGRAM.

ASSOCIATE CLINICAL PROFESSOR & CHIEF OF NEUROSURGERY AT HARBORUCLA MEDICAL CENTER

Donald P. Becker, MD

Nestor Gonzalez, MD, FAHA

Nancy McLaughlin, MD, PhD

ASSISTANT PROFESSOR OF NEUROSURGERY & RADIOLOGICAL SCIENCES & RUTH AND RAYMOND STOTTER ENDOWED CHAIR IN NEUROSURGERY

ASSISTANT CLINICAL PROFESSOR OF NEUROSURGERY

Alessandra Gorgulho, MD

Nader Pouratian, MD, PhD

CLINICAL PROFESSOR

DISTINGUISHED PROFESSOR & CHAIRMAN EMERITUS OF NEUROSURGERY

Manuel M. Buitrago Blanco, MD, PhD ASSISTANT PROFESSOR OF NEUROSURGERY, NEUROLOGY & NEUROCRITICAL CARE

Melvin Cheatham, MD CLINICAL PROFESSOR & UCLA DEPARTMENT OF NEUROSURGERY ADVISORY BOARD

Antonio De Salles, MD, PhD PROFESSOR & CO-DIRECTOR OF THE STEREOTACTIC SURGERY PROGRAM, & CO-DIRECTOR OF THE RADIOSURGERY PROGRAM

CLINICAL INSTRUCTOR IN STEREOTACTIC SURGERY

Jean-Philippe Langevin, MD

ASSISTANT PROFESSOR & DIRECTOR OF THE NEUROSURGICAL MOVEMENT DISORDERS PROGRAM

Bob Shafa, MD ASSISTANT PROFESSOR

ASSISTANT PROFESSOR OF NEUROSURGERY

Jorge Lazareff, MD PROFESSOR OF NEUROSURGERY

Paul M. Vespa, MD, FCCM, FAAN PROFESSOR IN RESIDENCE OF NEUROSURGERY & NEUROLOGY & DIRECTOR OF THE NEUROCRITICAL CARE PROGRAM

Duc H. Duong, MD

Daniel Lu, MD, PhD

Isaac Yang, MD

CLINICAL PROFESSOR

ASSISTANT PROFESSOR OF NEUROSURGERY

ASSISTANT PROFESSOR & NEUROSURGEON

Fredric L. Edelman, MD

Dennis R. Malkasian, MD, PhD

CLINICAL PROFESSOR

ASSOCIATE CLINICAL PROFESSOR OF NEUROSURGERY

10 | FACULTY OVERVIEW

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

RESEARCH SCIENTISTS Christopher C. Giza, MD

Neil G. Harris, PhD

Mayumi Prins, PhD

ASSOCIATE PROFESSOR IN RESIDENCE WITH SECONDARY APPOINTMENT IN PEDIATRIC NEUROLOGY

ASSOCIATE PROFESSOR IN RESIDENCE

ASSOCIATE PROFESSOR IN RESIDENCE & DIRECTOR OF THE UCLA TRAUMATIC BRAIN INJURY PREVENTION & EDUCATION PROGRAM

Thomas C. Glenn, PhD

Xiao Hu, PhD

Robert M. Prins, PhD

ADJUNCT ASSISTANT PROFESSOR & CO-DIRECTOR OF THE CEREBRAL BLOOD FLOW LABORATORY

ASSOCIATE PROFESSOR IN RESIDENCE

Fernando Gómez-Pinilla, PhD

Carol A. Kruse, PhD

Richard L. Sutton, PhD

PROFESSOR

ADJUNCT ASSOCIATE PROFESSOR

PROFESSOR & DIRECTOR OF THE NEUROTROPHIC RESEARCH LABORATORY

Grace Griesbach, PhD

Valeriy I. Nenov, PhD

ASSISTANT PROFESSOR

ADJUNCT PROFESSOR & DIRECTOR OF THE BRAIN INTENSIVE MONITORING & MODELING LABORATORY

JOINT APPOINTMENTS Nasim Afsar-manesh, MD ASSISTANT CLINICAL PROFESSOR, INTERNAL MEDICINE & NEUROSURGERY

Anthony P. Heaney, MD, PhD ASSOCIATE PROFESSOR, ENDOCRINOLOGY & NEUROSURGERY

Tom Belle Davidson, MD

Reza Jahan, MD

DIRECTOR OF NEUROONCOLOGY, MATTEL CHILDREN’S HOSPITAL UCLA WITH JOINT APPOINTMENT IN NEUROSURGERY

ASSISTANT PROFESSOR, INTERVENTIONAL NEURORADIOLOGY & NEUROSURGERY

Gary Duckwiler, MD

Scott Krahl, PhD

PROFESSOR, INTERVENTIONAL NEURORADIOLOGY & NEUROSURGERY

ASSOCIATE PROFESSOR & NEUROPHYSIOLOGIST

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

A. Nick Shamie, MD ASSISTANT PROFESSOR OF ORTHOPAEDIC SURGERY & NEUROSURGERY

FACULTY OVERVIEW | 11

MAPPING THE FUTURE OF NEUROSURGICAL HEALING

A YEAR IN REVIEW 1.

Brain Cancer Vaccine Team Celebrates Patient Living 10 Years and Phase III Clinical Trial Read More – Pg. 22

2. 3.

Congress of Neurological Surgeons Grants Synthes Skull Base Surgery Award for SRT Study

UCLA Stroke Center Awarded ‘Comprehensive Stroke Center’ Certification Read More – Pg. 39

American Heart Association Innovative Science Award for Stroke Prevention Research Read More – Pg. 37

Intraoperative CT Guided Endoscopic Surgery, Breakthrough for Brain Hemorrhage Patients Read More – Pg. 36

6. 7.

New Method for Memory Strengthening Could Lead to Treatment of Alzheimer’s Disease Read More – Pg. 42

David A. Hovda Appointed to the Defense Health Board, Advising Secretary of Defense Read More – Pg. 50

12 | A YEAR IN REVIEW

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

s mankind advances its technologies in communication, medicine and other vital sciences, the world is fast decreasing in scale. Today, the lifesaving breakthroughs that take place in our laboratories and operating rooms can be and are exported around the world with lightening speed. This fact sheds new light on the value of the work our doctors and research scientists do every day. Our work, once limited to those in our own backyard, now affects and improves the lives of millions around the globe.

Driven by a common spirit of exploration, the members of the UCLA Department of Neurosurgery are pushing and creating new boundaries in the field of neuroscience and truly mapping the future of neurosurgical healing. Pioneering and innovation have long been ingrained into the tradition of our department and its many comprehensive programs. Thus today we are proud to celebrate yet another year of invaluable accomplishment and contribution to the world of neuroscience and neurosurgery.

UCLA Announces First EvidenceBased Guidelines for Sports Concussions Read More – Pg. 50

9. EVA the Robo-Doc Joins the Neuro-ICU Team at UCLA Read More – Pg. 52

10. 500th Deep Brain Stimulation Treatment Performed at UCLA

11.

UCLA Spine Center Opens in Santa Monica, CA

Read More – Pg. 56

12. NIH Grant for $6 Million to Restore Spinal Cord Function Read More – Pg. 62

13.

Mystery of Rare Pediatric Epilepsy Unlocked – Possible Key to Understanding Autism Read More – Pg. 68

14.

NIH Grant to Develop Predictive Monitoring System, Using IBM Big Data Software Read More – Pg. 53

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

A YEAR IN REVIEW | 13

PIONEERS IN

MINIMALLY– INVASIVE SURGERY EXPANDED ENDOSCOPIC ENDONASAL APPROACH The UCLA team is one of a few in the country utilizing the Expanded Endoscopic Endonasal Approach. The team of neurosurgeons and sinus, head and neck surgeons routinely use an endoscope, 4mm in diameter, with a high definition video camera on the tip and microsurgical instruments to enter the nasal passage. This eliminates the need for a facial incision or craniotomy to remove tumors. • Craniopharyngiomas • Chrodomas • Meningiomas

• Pituitary tumors • Cerebrospinal fluid leaks • Colloid cyst

• Neurocysticercosis

ENDOSCOPIC-ASSISTED MICROSURGERY Endoscopic-assisted brain surgery treats trigeminal neuralgia and its accompanying severe facial pain with remarkable precision and positive outcomes. Microvascular decompression of the facial nerve draws on microsurgery to separate the blood vessel causing compression on the facial nerve. The surgery entails making a small incision about the size of a nickel behind the ear and uses neuro-navigation to enter the brain stem and move the trigeminal nerve away from the blood vessel. The pain is instantaneously stopped and cured in up to 90 percent of patients. • Trigeminal neuralgia

• Hemifacial spasm

• Vestibular nerve section

NON-INVASIVE STEREOTACTIC RADIOSURGERY Our specially trained neurosurgeons invented the gold-standard for non-invasive brain surgery using stereotactic radiosurgery. The Novalis Tx delivers shaped beams of radiation, using the BrainLab imageguidance system to maximize precision in treatment while protecting vital brain tissue. • Skull base tumors › Meningiomas › Chordomas › Craniopharyngiomas

• Arteriovenous malformations • Metastatic brain tumors • Pituitary tumors • Primary tumors

• Primary malignant tumors • Spinal tumors • Trigeminal neuralgia

Inventing the Future of Neurosurgery UCLA neurosurgeons pioneer the field of minimally-invasive brain and spine surgeries.

Microcraniotomy experts in dime-size incisions beneath the eyebrow or under the hairline.

Microsurgical operations using tiny or no incisions lead to enhanced outcomes and shorter hospital stays.

No incision, bloodless brain and spine surgery, with no anesthesia.

Invented the gold-standard of noninvasive brain and spine surgery.

UCLA operating suites are among the most advanced in the world.

14 | PIONEERS IN MINIMALLY-INVASIVE SURGERY

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

ombining our spirit of innovation and mission for excellent patient care, we bring the future forward as we invent the next generation of neurosurgery today. UCLA neurosurgeons have pioneered minimally-invasive, endoscopic brain and spine surgery to improve outcomes and lessen recovery times. Our highly-experienced neurosurgeons lead the field, having performed thousands of minimally-invasive, non-invasive and endovascular surgeries to repair the brain and spine.

Ronald Reagan UCLA Medical Center operating suites are among the most advanced in the world. Using image guidance systems combined with endoscopic instruments and highdefinition video cameras, we can perform brain surgery using natural nasal passageways to the brain or through dime-size incisions. These techniques replace the need for an open craniotomy and long scalp incisions. Our specially trained neurosurgeons are at the forefront of neuronavigation and neuroendoscopy innovations. Their breakthrough

techniques and technology have led to accessing tumors and vascular malformations in areas of the brain and spine, which were once thought inoperable 15 years ago. Though these tumors and malformations often lie deep within the brain, angled-lens endoscopes give the neurosurgeons visual access to operate around corners, thus improving their ability to completely magnify and remove the tumor while simultaneously reducing complications.

MINIMALLY-INVASIVE SPINE SURGERY Neurosurgeons specially trained in spine surgery utilize minimally-invasive keyhole incisions, ½ inch in diameter, to repair the spine and thus eliminate discomfort, lessen recovery times, reduce trauma and shorten hospital stays. UCLA is a pioneer in stereotactic radiosurgery, which uses an invisible blade of shaped beam radiation and an image-guidance system to remove spinal tumors and other abnormalities. • Artificial disc • Kyphoplasty • Laminectomy

• Lumbar fusion • Microdisectomy • Pedicle screw placement

• Posterior cervical disectomy • Spinal mass & tumor resection • Thoracic discectomy

MINIMALLY-INVASIVE ENDOVASCULAR EXPERTS Combining our expertise in keyhole-sized incisions with CT-Scan image guidance, we use blood vessels as routes to vascular malformations, minimizing the need for a craniotomy. Guglielmi detachable coils (GDCs) invented at UCLA have transformed the treatment of intracranial aneurysms around the world. Similarly, our MERCI clot retrieval device made it possible to stop a stroke in progress. It was recently modified to become the SOLITAIRE Flow Restoration Device, for restoring blood flow after a stroke. • Arteriovenous malformations (AVM) • Cerebral aneurysms

• Meningioma (preoperative embolization) • Stroke

EXPERTS IN MICROCRANIOTOMY EYEBROW INCISIONS UCLA neurosurgeons draw on minimally-invasive microcraniotomy surgical techniques to remove brain tumors or vascular malformations that would normally require a long scalp incision and a larger bony opening. This eyebrow incision technique conceals a facial scar and minimizes damage to healthy brain tissue. Using CT-Scan image guidance and endoscopic assistance, minimally-invasive brain surgery, called Intraoperative CT guided Endoscopic Surgery (ICES), is in clinical trials to remove blood in the event of a hemorrhagic stroke. These techniques are revolutionizing neurosurgery.

Neuronavigation using GPS-like precision in navigating through vital control centers of the brain.

Experts in the expanded endoscopic endonasal approach, utilizing the natural nasal passage to the brain, thus eliminating the craniotomy.

Pioneers in endovascular treatments employ coils and blood vessel routes into the brain, while avoiding surgery to repair vascular malformations.

Neuroendoscopy, high-definition video cameras for optimizing visibility.

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

PIONEERS IN MINIMALLY-INVASIVE SURGERY | 15

UCLA NEUROSURGERY

CLINICAL QUALITY PROGRAM THE PERFECT PATIENT EXPERIENCE, EVERY TIME, ANY TIME, 24-7 s clinicians and leaders on the frontlines of medicine at UCLA, we have the experience, ingenuity and most importantly, the responsibility to reform healthcare from the inside. UCLA is one of the premier academic medical centers that set the standards for medical care in the country and the world. In the Neurosurgery Department’s three-part mission dedicated to patient care, teaching, and research, we endeavor to develop a system to standardize quality that can be implemented throughout the Ronald Reagan UCLA Medical Center, UCLA Health, UC campuses and beyond. We believe that by diagnosing the deficits in healthcare through our experience in the trenches, we can contribute to repairing the U.S. healthcare system with a strategic approach to quality care. For over a decade, we have ranked in the top five hospitals in the country and “Best in the West” according to U.S. News and World Report. We are in a unique

position to be an example for the rest of the medical community, while understanding that upholding the highest standards also means refining our internal systems and innovating new systems. Neil A. Martin, MD, Professor & W. Eugene Stern Chair in Neurosurgery, formed the UCLA Neurosurgery Clinical Quality Program to improve our patient care, enhance patient safety, increase efficiency and reduce costs for our patients. Our program involves the specialties and combined disciplines of faculty members, nurses, care partners, therapists, pharmacists, infection control specialists, patient affairs liaisons and medical center finance department representatives. By working together as a team to evaluate overall performance, we have created more efficient systems in our daily operations.

THE NEUROSURGERY CLINICAL QUALITY PROGRAM IS FOCUSED ON THE FOLLOWING INITIATIVES: 1: INFECTION PREVENTION

2: BLOOD PRESSURE CONTROL PROJECT The Blood Pressure Control Project was designed to determine the safest and most effective oral blood pressure medications for Neurosurgery patients and to reduce the time required to get blood pressure to target levels.

The Infection Prevention Program works with UCLA Health’s Antimicrobial Stewardship Program to identify and correct improper antibiotic use. Surgical site infections for spinal fusions and laminectomies have been reduced to just 8 in the last 30 months. Blood stream infections have been virtually eliminated, with only 1 in the last 66 months.

3: THE READMISSION REDUCTION INITIATIVE 1 1 5 4 3 2 4 8 3 4 0 0 6 3 6 3 2009

2010

2011

30-Day Readmissions

2012

The team has conducted an extensive three-year chart review of readmissions, categorizing preventability and common causes of re-hospitalizations. Interventions have been designed and are being implemented to address the most common causes of readmissions.

4: NEUROSURGERY QUALITY IMPROVEMENT DASHBOARD The Neurosurgery Dashboard collects metrics for overall care, quality, safety, patient satisfaction and efficiency, allowing the team to continue providing the highest quality health care.

16 | CLINICAL QUALITY PROGRAM

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

NEUROSURGERY ENHANCED RECOVERY, VALUE & SAFETY (NERVS) he UCLA Department of Neurosurgery has deployed evidencebased and best-practice clinical protocol to aim for the ideal surgical experience. An emerging concept in health care is the value of disease-specific, patient-oriented outcomes encompassing the total episode of care divided by the sum of total costs. The ideal surgical care episode is defined by: relief of signs and symptoms, accelerated recovery, minimal discomfort and absence of complications. The Neurosurgery Enhanced Recovery after surgery, Value & Safety project (NERVS) led by Nancy Mclaughlin, MD, PhD, and Neil A. Martin, MD, is focused on comprehensive redesign of neurosurgical care. In two baseline case studies, we documented improved clinical outcomes and reduced total costs for the entire episode of surgical care. Cost assessment emerged as critical to contain or reduce cost of delivery of care and further improve and maximize value of care. This redesign strategy requires a total system approach focused on three phases: pre-operative assessment and preparation, anesthetic and conduct of surgery, and postoperative management and recovery stages

of care. Only by addressing all three phases of care and by encompassing all medical specialties and related services, can we effectively achieve ideal surgical care. The objectives are to improve patient outcome and patient satisfaction while decreasing the cost of care delivery. We are assessing our processes throughout each phase of care and establishing benchmark outcome and cost data of four common surgical procedures encompassing 65% of elective cases. After completion of the redesign and measurement of its

impact, the program will be implemented throughout the UCLA Department of Neurosurgery and other departments across UC campuses. The NERVS project was one of 11 recipients, across the entire UC System, selected for a new grant award of $250,000 to improve the safety and quality of surgical care, jointly sponsored by the UC Center for Health Quality & Innovation and the Office of Risk Services. We believe this is the future of optimal care delivery in all specialties, offering patients optimal value and best outcomes delivered at the lowest cost.

IMPROVE DELIVERY OF PATIENT CARE DECREASE OVERALL COST

CLINICAL OUTCOMES

RISK MGMT.

IMPROVE PATIENT SATISFACTION

NERVS

PATIENT SAFETY

5: PATIENT/FAMILY ADVISORY COUNCIL The Neurosurgery PFAC is co-led by family members of patients and representatives from the department with the objective of creating a partnership between physicians, nurses, staff, patients and families. Members of the council provide input and feedback on patient care, services provided, new policies, and also recommend new programs and strategies. WENDY TUCKER, CO-CHAIR OF THE PFAC WITH HUSBAND, MARCO FERREIRA

7: IMPROVING THROUGHPUT: AVERAGE LENGTH OF STAY Eliminating inefficiencies that lead to late discharge will help ensure that patients can pick up their medications, settle at home in a timely manner and get answers to any questions that may arise while their primary providers are available to help answer questions.

4.5 4 4.5 4 4.3 4.5 4.5 4

2009

2010

4 3.5 3.7 4

2011

4 3.5

2012

Average Length of Stay

6: TRANSITIONS OF CARE PROJECT The Transitions of Care project was designed to evaluate the discharge process and improve care during this vulnerable time. This has involved a formal process to ensure appropriate follow-up for patients and clarification of discharge paperwork.

8: HEALTH CARE SUSTAINABILITY & WASTE REDUCTION The team is reducing waste by implementing the following programs: green IT, green office, green labs, water waste reduction, recycling of plastic and cardboard containers on the unit, discarding linens, re-stocking unused supplies, repackaging intubation trays, and evaluation of lab utilization. BENNY CHAN / FOTOWORKS

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

CLINICAL QUALITY PROGRAM | 17

Linda M. Liau, MD, PhD

18 | BRAIN TUMOR PROGRAM

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

“

My hope is to ultimately find a cure for brain cancer. I have several patients out 5 to 10 years after their original diagnosis of glioblastoma, which is a disease with a prognosis of usually less than two years. Each year we celebrate our patient survivors and that is what makes working here at UCLA so worthwhile. —Linda M. Liau, MD, PhD, Director of the Brain Tumor Program at UCLA

inda M. Liau, MD, PhD, Vice Chair of the Department of Neurosurgery and Director of the Brain Tumor Program at UCLA, leads a multidisciplinary team of world-class neurosurgeons, neuroscientists, neuropathologists, neuro-oncologists, neuroradiologists, interventional radiologists, radiation oncologists, geneticists, basic scientists and clinical scientists. The team is dedicated to the diagnosis, management and treatment of all types of brain tumors. They meet regularly to develop coordinated care that translates to optimal clinical outcomes and patients living longer than those treated at other centers. As world leaders in the treatment of brain tumors, our neurosurgeons utilize the most advanced technology in intra-operative imaging, awake craniotomy, minimally-invasive endoscopic surgery and non-invasive stereotactic radiosurgery.

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

”

The UCLA Brain Tumor Program is a model for other health care institutions nationwide. Dr. Liau’s record of achievement is impeccable as a principal recipient of four prestigious National Institutes of Health (NIH) grants and the Editor-in-Chief of the Journal of Neuro-Oncology. She has personally performed more than 1,000 brain tumor surgeries, and she and her colleagues at UCLA treat over 500 brain tumor patients each year. Dr. Liau collaborates with several other neurosurgeons who operate on brain tumors (Dr. Neil A. Martin, Dr. Marvin Bergsneider and Dr. Isaac Yang), as well as UCLA neuro-oncologists (Dr. Timothy Cloughesy, Dr. Albert Lai and Dr. Leia Nghiemphu), neuropathologists (Dr. William Yong and Dr. Harry Vinters), radiation oncologists (Dr. Tania Kaprealian), and neuroradiologists (Dr. Whitney Pope), in the hunt to better understand and treat these brain tumors.

BRAIN TUMOR PROGRAM | 19

A PERSONAL QUEST TO CURE BRAIN CANCER True Bench to Bedside: UCLA Innovation Now in Phase III Clinical Trials hile completing her residency at UCLA, Dr. Linda M. Liau lost her mother to metastatic cancer. That pivotal moment changed the course of her life and many others. As a physician-scientist, she is in a unique position to translate her pre-clinical findings in the laboratory to the clinic. She received early recognition and seed funding from most notably the Kimmel Translational Science Award, given by the Sidney Kimmel Foundation dedicated to cancer research. This led to the development of the first personalized brain cancer vaccine in the UCLA laboratory. This novel immunotherapy involves surgically removing a patient’s tumor and then drawing blood to extract immune cells from the

patient’s body. In the lab, Dr. Liau isolated a specific type of immune cell, called a dendritic cell, and activated it to train the patient’s immune cells to recognize, hunt down, and eliminate the tumor cells. The custom-made vaccine is developed from the patient’s activated dendritic cells (DCs), which when injected back into the body, jumpstart the patient’s immune system to train “killer T cells” to seek out the tumor and strike it dead on the spot in the brain. Today, the DCVax-L® vaccine is in Phase III, randomized, multi-center clinical trials for glioblastoma in 46 hospitals in the United States, and has entered multiple centers internationally in Europe. The UK Health System has just adopted DCVax as a national priority trial.

Dr. Liau’s dream is to secure FDA approval for this immunotherapy as a standard treatment—in conjunction with surgery, radiation, and chemotherapy—for patients with glioblastoma multiforme. The hope is to work toward curing brain cancer once and for all.

DENDRITIC CELL (RED) ENGULFING A BRAIN TUMOR CELL (BLUE)

GENETIC PROFILING & PREDICTIVE MEDICINE UCLA brain cancer researchers have banked more than 5,000 brain tumor specimens. With molecular diagnostics, gene expression analysis, next generation genetic sequencing, and advanced medical bioinformatics, we have a robust database of patient profiles to help develop predictive, individualized treatment plans for new patients that increase survival.

UCLA BRAIN TUMOR BOARD MEETING

TIM CLOUGHESY, DIR. UCLA NEURO-ONCOLOGY PROG.

BRAIN TUMOR BOARD MEETING Multidisciplinary Collaboration

ROBERT M. PRINS, PHD, ASSOCIATE PROF. IN RESIDENCE

20 | BRAIN TUMOR PROGRAM

UCLA Brain Tumor experts meet once a week at the UCLA Brain Tumor Board meeting to discuss patient cases and devise the optimal treatment plan for each individual patient, based on weighing all medical and surgical options. This relieves the patient from the need to visit multiple offices. The UCLA Brain Tumor Board is a resource for other clinics and doctors. Local, national and international physicians send in brain tumor cases to receive expert consultation on how to treat the challenging ones.

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

BRAIN TUMOR PROGRAM PRECISION PRE-OPERATIVE & INTRA-OPERATIVE

BRAIN MAPPING rior to the brain surgery, our patients undergo a 3D MRI in order to allow for pre-operative and intra-operative brain mapping. For tumors near language areas, patients also undergo functional MRI (fMRI) scans, where they perform tasks such as reading, thinking, spelling and talking, which enables us to image these functional control centers of the brain. Those fMRI scans and the 3D MR images with white matter tractography are

carefully processed to be used in surgery to physically map the control centers on the brain as the neurosurgeon removes the brain tumor. For tumors very close to functional language areas, the “asleep, awake, asleep” technique was perfected by anesthesiologists at UCLA, to allow neurosurgeons to wake patients during surgery and test vital functions such as talking or moving, while they remove the tumor. Patients are then put back to sleep for the nonmapping portion of the surgery.

History of Firsts First in-human use of a dendritic cell (DC)-based cancer vaccine for brain tumor patients [now known as DCVax]. First in-human use of a replicating retroviral vector (RRV) for gene therapy for malignant gliomas [now known as Toca-511TM]. First in-human use of combination therapy of DC vaccine with novel toll-like receptor (TLR-7) agonist, resiquimod. First to develop cDNA microarray gene expression-based classification of glial tumors. First to identify molecular genetic subgroup of glioblastoma that may be predictive of response to immunotherapy.

1ST

5,000

3,000

TO DEVELOP PERSONALIZED BRAIN CANCER VACCINE

BANKED SAMPLES OF HUMAN TUMORS, BLOOD, AND CSF

BRAIN TUMOR SURGERIES PERFORMED

DIFFERENT TYPES OF BRAIN TUMORS TREATED

First intra-operative awake mapping of music comprehension/ production areas in the brain. First to use high-field intraoperative iMRI in the West Coast.

INTERDISCIPLINARY TEAM Linda M. Liau, MD, PhD PROGRAM DIRECTOR Neil A. Martin, MD, Marvin Bergsneider, MD, Bob Shafa, MD, Isaac Yang, MD, Robert M. Prins, PhD, Carol A. Kruse, PhD, Emma Billingslea-Yoon, NP

Michael Selch, MD, Tania Kaprealian, MD

NEUROSURGERY

STEREOTACTIC RADIOSURGERY

Whitney Pope, MD

Timothy F. Cloughesy, MD, Albert Lai, MD, Leia Nghiemphu, MD

NEURORADIOLOGY

Clinical Success

RADIATION ONCOLOGY

Nader Pouratian, MD, PhD

Jennifer Sugioka was the fifth glioblastoma patient to receive the DCVax vaccine and this year celebrates 13 years cancer free.

NEURO-ONCOLOGY

TUMORS TREATED Gliomas Astrocytomas Brainstem gliomas Ependymomas Gangliogliomas Glioblastomas Medulloblastomas Mixed gliomas Oligodendrogliomas Optic nerve gliomas

Metastatic Cancer Brain cysts Brain metastasis Choroid plexus papillomas CNS lymphoma Cystic tumors Dermoid tumors Germinomas Lymphoma Pineal tumors

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

Skull Base Tumors Acoustic neuroma Adenomas Chordomas Craniopharyngiomas Epidermoid tumors Meningiomas Pituitary tumors Rathke’s cleft cyst

Spinal Cord Tumors Astrocytomas Ependymomas Meningiomas Schwannomas

(L TO R): DCVAX PATIENT, JENNIFER SUGIOKA & BRAIN TUMOR PROGRAM DIRECTOR, DR. LINDA M. LIAU AT THE 2011 UCLA VISIONARY BALL.

BRAIN TUMOR PROGRAM | 21

BRAIN TUMOR PROGRAM

PATIENT HIGHLIGHT

BRAD SILVER

LIVING PROOF t 33, Brad Silver, a swimming and water polo coach, suffered from blinding headaches that he tried to ignore. It was meant to be a happy time. His wife was seven months pregnant and he couldn’t wait to meet his son. As an all-American athlete, growing up surfing and lifeguarding in Huntington Beach, he knew that something was awry with his body. A visit to the hospital turned into a battery of tests that ended in devastating news. “You have two months to live,” Brad recalled the doctor’s prognosis. He was diagnosed with late stage brain cancer, a glioblastoma. Surgery was not an option. “I needed to find something, or someone, to at the minimum keep me alive so I could be there for the birth of my son,” he said. Brad went for a second and third opinion. Then he found Dr. Liau at UCLA. “I chose Dr. Linda M. Liau and Dr. Tim Cloughesy because they got to know me as a father

22 | BRAIN TUMOR PROGRAM

and an athlete,” he said. “At other hospitals the doctors were divided. At UCLA, they were not just a surgeon and oncologist, they worked together as my team and I trusted them to do everything they could to keep me alive.” Dr. Liau performed his surgery on April 10, 2003. She removed a golf ball-sized tumor from his left lateral lobe. Nine days later, he witnessed the miracle of his son’s birth. He called him Brad Silver Jr. in memory of himself. Not knowing how many days, weeks or months he would have left with his family, he entered a phase I clinical trial. Dr. Liau used a section of his tumor to create a personalized vaccine. From his drawn blood, she extracted his immune cells and trained them to recognize his brain tumor cells as an invader. These immune cells, called dendritic cells, would train killer T-cells to hunt down, attack and eliminate the brain cancer cells. She then injected this host of dendritic cells back into his body as a vaccine. With the help

of Dr. Liau, Brad experienced his son’s first breath of life, his first smile, his first laugh, his first words and his first steps. Year after year, on April 10th, Brad sent flowers to Dr. Liau on his anniversary of life after brain cancer. Simultaneously, he celebrated the birthday of his son, Brad Silver Jr. “Initially, I thought I would only see his birth, then I no longer had to change his diapers. He was wearing undies,” Brad said with a chuckle. “He starts to walk and run, now he swims, he plays tennis, he surfs and stand-up paddles with me.” Today, Brad and his family celebrate 10years cancer-free and Brad Silver Jr.’s 10th birthday in Abu Dhabi, where he now lives with his family. He no longer needs to be close to UCLA. He simply sends his MRI scans into Dr. Liau via email.

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

BRAIN TUMOR PROGRAM

BRAD’S TIMELINE MAY Dr. Liau creates and administers the personalized brain cancer vaccine.

2003 FEBRUARY Brad’s headaches lead to an MRI that reveals brain cancer.

NIH Grants National Cancer Institute

MARCH 17 Biopsy reveals stage IV glioblastoma. He is told by outside doctors that surgery is not an option.

2004

APRIL 10 Dr. Liau removes the golf ball sized tumor from Brad’s brain. Brad begins radiation and chemotherapy.

Phase I study of dendritic cell immunotherapy for malignant gliomas.

APRIL 19 Nine days later Brad witnesses the birth of his son.

Gene expression-based classification of glial tumors.

APRIL Brad celebrates his son’s first birthday, sends Dr. Liau flowers to mark one year living cancer-free.

2005

APRIL Brad celebrates his son’s second birthday. He marks two years cancer-free. Brad completes two years of chemotherapy.

2006

APRIL Brad celebrates his son’s third birthday and he realizes, “I don’t have to be a cancer patient anymore, now I get to just be me.”

2013

APRIL Brad cuts the cake for his son’s 10th birthday. He celebrates the 10-year milestone of living beyond cancer. “My life is back to what it was 11 years ago.”

“

90 percent of patients with GBM die in the first year, the other five percent within two years, and hardly anyone is around after five. I’m not a statistic. They don’t have statistics for survivors. I have lived 10 years and I continue to soak in life as a father, a husband, a teacher, a surfer. I’m 100 percent back to being me because of Dr. Liau and the vaccine. —Brad Silver

BRAD’S TEAM

”

Linda M. Liau, MD, PhD Dr. Liau’s clinical expertise is in intra-operative functional brain mapping and use of intra-operative imaging for resection of brain tumors. Her research efforts are focused on the molecular biology of brain tumors, gene therapy, immunotherapy, and brain cancer vaccines.

Linda M. Liau, MD, PhD, Robert M. Prins, PhD, Emma Billingslea-Yoon, NP

Timothy Cloughesy, MD, Whitney Pope, MD, John Bentson, MD

NEUROSURGERY

NEURO-ONCOLOGY & NEURORADIOLOGY

Judith Ford, MD

Harry Vinters, MD, William Yong, MD

RADIATION ONCOLOGY

NEUROPATHOLOGY

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

Dendritic cell-based vaccine targeting MAA in malignant gliomas. PACAP modulation of SHH signaling in human medulloblastoma. Adoptive transfer of alloCTL for immunotherapy of recurrent gliomas. CNS anti-tumor immunity induced by dendritic cell vaccination and TLR agonists. Cell invasion, motility, and proliferation level estimate maps in glioma imaging. Office of the NIH Director Cellular quiescence and brain tumor stem cells. National Institute of Neurological Disorders and Stroke Translational development of replication-competent retrovirus vectors. UCLA Neurosurgery Research Training & Education Program.

Total NIH Funding

$4,141,837 TOTAL NIH/NON-NIH GRANTS, INCLUDING DIRECT & INDIRECT COSTS, FOR THE DURATION OF THE RESEARCH PERIOD

BRAIN TUMOR PROGRAM | 23

Marvin Bergsneider, MD

24 | PITUITARY TUMOR PROGRAM

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

“

An intriguing movie when I was growing up was the Fantastic Voyage—watching a surgeon become miniaturized to go inside the body to operate on a patient. Today, we have transformed that fantasy into reality at UCLA by using video to give us ultra-high magnification and resolution from an endoscope projected on high-definition screens in our operating theater.

”

—Marvin Bergsneider, MD, Co-Director of the Pituitary Tumor Program at UCLA

he UCLA Pituitary Tumor Program brings together an experienced interdisciplinary team of world-class specialists in the diagnosis, treatment and management of pituitary tumors. Our team has performed more than 500 endoscopic surgeries with techniques pioneered and perfected at UCLA. We treat a high volume of cases every year, making our team one of the most experienced in the nation. We work together to provide patients with the most optimal plan of care that optimizes quality of life and meets their individual needs.

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

The combined neurosurgery-endocrine clinic is one of a few in the country that provides patients with a joint-consult to weigh the options of surgery and medications with Marvin Bergsnieder, MD, Co-Director of the UCLA Pituitary Tumor Program specializing in minimally invasive and endoscopic surgery, and Anthony P. Heaney, MD, PhD, Co-Director of UCLA Pituitary Tumor Program specializing in endocrinology. As leaders in the management of pituitary tumors, we bring together the experts once a month for the UCLA Pituitary Tumor Board to discuss the pathology, diagnosis and treatment of a patient.

PITUITARY TUMOR PROGRAM | 25

PITUITARY PROGRAM

PATIENT HIGHLIGHT

JENGI MARTINEZ

SAVING HER WINGS fter returning from a mission in 2006, Jengi Martinez, a pilot in the Air Force, visited a military doctor at Camp Pendleton in San Diego. Something was not right. Jengi had been flying since high school. She pilots a C-17, one of the largest aircrafts in the military, flying in and out of war zones to transport troops—wounded soldiers in medical evacuations from the battlefields and fallen comrades home to their families. “It’s a very humbling experience to bring them home so they can be with their families,” Jengi said. “I’m proud every day.” The magnitude of her missions easily outweighed the unusual symptoms that Jengi was experiencing. It wasn’t difficult to ignore the irregular periods and unusual weight gain, until the doctor announced that Jengi had a brain tumor. At 31, the diagnosis came on the tails of a neardecade-long investigation that led her to multiple specialists and many misdiagnoses. More tests revealed the tumor was just outside her brain in the pituitary gland, which is about the size of

26 | PITUITARY TUMOR PROGRAM

a pea, yet it controls hormones and a multitude of functions in the body. The military is very strict about pilots using any medications. “I knew this tumor wouldn’t kill me, but it could kill my career and that is so much a part of who I am,” Jengi said. In despair, she sought a second opinion outside the military. She visited the Pituitary Tumor Program clinic at UCLA to meet with Dr. Marvin Bergsneider, renowned neurosurgeon and Dr. Anthony P. Heaney, expert endocrinologist. In her first consult with the doctors, she was impressed that they had already read her pathology, medical records, examined her images and presented her with realistic options. She explained meds were not an option for her. Together, they discussed the minimally-invasive, endoscopic endonasal surgery that would not require a craniotomy or incisions to remove the tumor. “After meeting my doctors, I felt confident I could beat this tumor,” Jengi said. The doctors then graciously consulted with the military doctors so that Jengi had a chance to return to the cockpit.

Dr. Bergsneider and Dr. Heaney suggested she attend their patient support group. The patients and their families really helped her, and her mother understand what to expect for the surgery and recovery. For the first time since her diagnosis, she sat in a room full of people on the same journey. Each person was at a different stage of treatment and recovery, but each gave her great comfort and confidence in Dr. Bergsneider and Dr. Heaney. In 2012, she underwent the endoscopic endonasal procedure to remove the pituitary tumor. The recovery was quick, and within four weeks, she was back in the cockpit, executing her duties and serving her country. To celebrate her restored health and weight loss, Jengi competed in her first triathlon. “I’m so thankful to Dr. Bergsneider, Dr. Heaney and Dr. Wang for being an advocate for me,” Jengi said from the cockpit of her airplane at March Air Force Base, just weeks after the surgery. “I feel like I’m starting fresh. Not only do I get to serve my country, but I get to do a job that I love.”

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

HIGH-DEFINITION

ADVANCED ENDOSCOPIC SURGERY OPERATING THEATER r. Bergsneider operates side by side with the top UCLA head and neck surgeons specializing in skull base surgery and rhinology. He harnesses endoscopic instruments with high-definition magnification, resolution and

video to project on plasma screens in one of the most advanced endoscopic operating theaters in the country. He specializes in the following treatments: endoscopic endonasal surgery, microscopic endonasal surgery and minimallyinvasive keyhole craniotomy.

PITUITARY PROGRAM

Highlights Experience with more than 500 endoscopic surgeries to remove pituitary tumors. Joint neurosurgery-neuroendocrine clinic is one of just a few in the nation. Minimally-invasive surgical options for the removal of pituitary tumors using endoscopic techniques pioneered and perfected at UCLA. Non-invasive treatments: Stereotactic radiosurgery utilizes the Gold Standard NovalisTx shapedbeam radiation to eliminate the tumor with GPS-like precision without surgery.

Comprehensive Care Clinic

DR. MARVIN BERGSNEIDER COLLABORATES WITH UCLA HEAD AND NECK SURGEON DR. MARLIENE WANG

Joint Neurosurgery-Endocrine Clinic

500

100

2.3

2,171

MORE THAN 500 CASES TREATED BY THE PITUITARY PROGRAM AT UCLA

AVERAGE NUMBER OF PITUITARY TUMORS TREATED EACH YEAR

REDUCED LENGTH OF HOSPITAL STAY TO 2.3 DAYS FROM 4.1 IN 2010

REDUCED AVERAGE COST PER PITUITARY CASE BY $2,171

INTERDISCIPLINARY TEAM PROGRAM CO-DIRECTORS

Marvin Bergsneider, MD & Anthony P. Heaney, MD, PhD Neil A. Martin, MD, Nancy McLaughlin, MD, PhD

Noriko Salamon, MD NEURORADIOLOGY

NEUROSURGERY

As leaders in the management of pituitary tumors, we bring together the experts once a month for the UCLA Pituitary Tumor Board Meeting to discuss the pathology, diagnosis and treatment of a patient.

Marilene Wang, MD, Jeffrey Suh, MD ENDOSCOPIC SINUS SURGERY

Nader Pouratian, MD, PhD

Michael Selch, MD, Tania Kaprealian, MD

STEREOTACTIC RADIOSURGERY

RADIATION ONCOLOGY

CONDITIONS TREATED Acromegaly Craniopharyngioma Cushing’s disease

The combined neurosurgeryendocrine clinic is one of a few in the country that provides patients with a joint-consult to weigh the options of surgery and medications with an interdisciplinary team, led by neurosurgeon Dr. Marvin Bergsnieder and endocrinologist Dr. Anthony P. Heaney.

Nelson’s syndrome Parasellar meningioma Pituitary insufficiency

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

(L TO R): DR. MARVIN BERGSNIEDER AND DR. ANTHONY P. HEANEY Pituitary tumors Prolactinomas Rathke’s cleft cyst

Thyrotropinomas

www.pituitary.ucla.edu

PITUITARY TUMOR PROGRAM | 27

UCLA SKULL BASE

TUMOR PROGRAM he UCLA Skull Base Tumor and Acoustic Neuroma Program unite 10 different specialties in a multidisciplinary team to provide exceptional treatments and optimize quality of life for patients battling skull base tumors such as meningiomas, epidermoids and acoustic neuromas. There are multiple approaches for treating these tumors that are classified as benign. However, when tumors of this type develop near vital control centers of the brain, they can be life

threatening or debilitating, often causing a loss of neurological function such as hearing and balance for patients. Our neurosurgeons, Isaac Yang, MD, Marvin Bergsneider, MD, and Neil A. Martin, MD, specialize in skull base tumors, minimally-invasive surgical techniques and non-invasive stereotactic radiosurgery. Dr. Yang works side by side with ENT otolaryngologists, to deliver a comprehensive approach to these complex disorders. They collaborate with interventional radiologists,

stereotactic radiosurgery specialists, radiologists, head and neck surgeons, facial plastic surgeons, pathologists and basic scientists for evaluation and diagnostic testing that ultimately results in a personalized approach to treatment. A variety of factors including patient age, health, tumor location/size and tumor growth rate are weighed in evaluating the best treatment options. At UCLA, the specialists join together to determine the most effective personalized treatment strategy for each individual patient.

ENDOSCOPIC, MINIMALLY-INVASIVE TECHNIQUES REVOLUTIONIZE SKULL BASE SURGERY Advanced endoscopic endonasal surgery and keyhole craniotomy use the endoscope, which has revolutionized the removal of these skull base tumors. UCLA neurosurgeons are specially trained in team-approach operating room techniques and minimially-invasive endoscopic surgery. Microsurgical instruments used with the endoscope increase the surgeon’s ability to remove the complete tumor in most cases, therefore decreasing the chance for reoccurrence while setting the stage for optimum recovery.

ISAAC YANG, MD, ASSISTANT PROF. & NEUROSURGEON

28 | UCLA SKULL BASE TUMOR PROGRAM

MINIMALLY-INVASIVE ENDOSCOPIC SURGERY

• Use of the natural passageway or the keyhole ½ inch-diameter incision to enter the brain • The endoscope tube, 4mm in diameter and equipped with a video camera, projects high-visibility deep in the brain • Keyhole incision procedures or a micro-craniotomy begins with an incision hidden in the eyebrow or beneath the hairline • High-definition video cameras project unsurpassed illumination, magnification and optical resolution of the surgical field • High visibility equals complete tumor removal • Fewer side effects than craniofacial surgery • Eliminates a long scalp incision craniotomy and skull bone removal • No visible scars • Reduces recovery times and shortens hospital stays

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

SKULL BASE PROGRAM

COMPREHENSIVE TREATMENT:

ACOUSTIC NEUROMAS coustic neuroma, also known as neurinoma or vestibular schwannoma, is a benign (non-cancerous) fibrous tissue growth arising from the vestibulocochlear nerve. Located in the inner ear, the vestibulocochlear nerve (eighth cranial nerve) controls hearing and balance. Acoustic neuromas slowly grow over many years,

but do not metastasize to other areas. However, these tumors are located deep within the skull near centers of the brain that control vital functions. Pressure resulting from tumor growth can press against these sensitive structures. Symptoms can range from mild to severe and can include loss of hearing in one ear, ringing of the ear (tinnitus), loss of balance, and dizziness.

DIAGNOSIS & SURVEILLANCE

INTRAOPERATIVE BRAIN MAPPING

In the diagnostic or surveillance phase, patients with small, asymptomatic acoustic neuromas are evaluated through regular intervals of MRI scans, audiograms and radiographic tests combined with CT scans. This provides the team with a more in-depth understanding of the tumor’s effects on the patient’s brain and hearing nerves.

With our highest priority to preserve neurological function while ensuring we remove as much of the tumor as possible, we conduct intraoperative brain and nerve monitoring to assess motor functions and neurophysiological functions during the surgery. This allows us the ability to go as deep and far as possible without disrupting facial nerves, balance and cognitive functions.

UCLA neurosurgeons routinely use minimally-invasive techniques: In non-invasive radiosurgery, the Novalis Tx is used with the BrainLab neuronavigation system, in which focused beams of radiation strike the tumor with GPS-like precision while preserving vital control centers. In the translabyrinthine approach, the surgeon makes a “C” shaped incision behind the ear and enters through the ear’s mastoid and semicircular canals to reveal the most lateral aspect of the tumor. In the retro-sigmoid approach, also known as keyhole craniotomy, the surgeon makes a small incision behind the ear, which provides the neurosurgeon access to the cerebellum and brainstem. In the middle fossa approach, an incision is made in front of the ear. Bone covering the top of the internal auditory canal is removed to expose the tumor. In the Endoscopic Endonasal Approach (EEA), an endoscope is used to enter the brain via the nasal passage and remove the tumor, eliminating the need for incision and shortening recovery time.

PRECISION TREATMENT In the case of a tumor requiring surgery, the goal is to completely remove the tumor while preserving hearing and balance. At UCLA, the neurosurgeon works in tandem with the headand-neck surgeon to perform these delicate surgeries. With larger tumors, surgeons may operate for up to 20 hours as they work tirelessly to ensure preservation of neurological function while accessing and removing the tumors.

Highlights

UCLA EEA Cases NEURO-NAVIGATION IMAGING

WHO WE ARE

February 2008–June 2013 Pituitary tumors: 328 Rathke’s cleft cyst: 39

Isaac Yang, MD, Marvin Bergsneider, MD, Neil A. Martin MD, Nancy McLaughlin, MD, PhD

Akira Ishiyama, MD, Quinton Gopen, MD, Vishad Nabili, MD

NEUROSURGERY

HEAD AND NECK SURGERY

Nader Pouratian, MD, PhD

Michael Selch, MD, Tania Kaprealian, MD

STEREOTACTIC RADIOSURGERY

RADIATION ONCOLOGY

Craniopharyngioma: 12 Meningioma: 13 Chordoma: 10 Spontaneous CSF leak: 16 Misc: 75

TUMORS WE TREAT Acoustic neuromas (vestibular schwannomas) Chordomas

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

Petroclival and cavernous sinus meningioma Skull base tumors (meningiomas and epidermoids)

TOTAL: 493 UCLA SKULL BASE TUMOR PROGRAM | 29

A COMPREHENSIVE APPROACH TO DELIVER THE HIGHEST QUALITY OF CARE ur doctors and research scientists here at UCLA have pioneered stereotactic radiosurgery and the led the nation in developing next generation technologies that have made this procedure a noninvasive, safe and targeted treatment for malignant and benign tumors, arteriovenous malformations and intractable pain of the brain and spine. The UCLA team of radiosurgery specialists has treated more than 10,000 patients and is among the most experienced in the world. Radiosurgery is surgery without the incision or anesthesia. The outpatient procedure is under an hour. The focused beams of radiation have GPS-like precision

in targeting and eliminating the tumor or malformation while leaving vital brain tissue unharmed. This requires advanced 3D imaging that allows for the neurosurgeon and physicist to plan in virtual reality a 360degree, revolving focused beam strike to all sides. Patients receive a comprehensive approach to treatment planned by our team of neurosurgeons, radiation oncologists, radiologists, dosimetrists and medical physicists who meet weekly to deliver the highest quality of care and optimal outcomes. The team has consistently reported safe and effective outcomes for patients at UCLA, and has set the gold standard for radiosurgery to benefit patients across the nation and around the globe.

WHO WE ARE Nader Pouratian, MD, PhD, Antonio De Salles, MD, PhD, Daniel Lu, MD, PhD, Nancy McLaughlin, MD, PhD, Bob Shafa, MD, Isaac Yang, MD, Nestor Gonzalez, MD

Tania Kaprealian, MD, Pat Kupelian, MD, Phil Beron, MD, Michael Selch, MD RADIATION ONCOLOGY

NEUROSURGERY

30 | STEREOTACTIC RADIOSURGERY PROGRAM

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

NON-INVASIVE STEREOTACTIC RADIOSURGERY

SRS PROGRAM

Facts & Figures

10,000 MORE THAN 10,000 PATIENTS TREATED SINCE THE PROGRAM DEBUTED

1st FIRST TO INTRODUCE RADIOSURGERY IN THE UNITED STATES

1980 YEAR OUR PROGRAM WAS FOUNDED, PIONEERING RADIOSURGERY FOR 33 YEARS

Gold Standard UCLA’s Novalis ShapedBeam Surgery system now considered the Gold Standard for image-guided, shaped-beam radiosurgery—uses stereotactic technology as well as highly specialized computer software for radiation therapy planning. Enables treatment of intracranial lesions once considered inoperable due to proximity to eloquent or critical structures. Avoids many of the co-morbidities common to invasive surgery, such as infections, hemorrhage and other complications.

CONDITIONS TREATED or tumors that do not respond to either medical or surgical treatment, UCLA offers state-ofthe-art, focused-beam radiation therapy. The Novalis Shaped-Beam Stereotactic Radiotherapy system was developed at UCLA, and is the most technologically advanced system of its kind. This non-invasive treatment is safe and very effective. In a bloodless, bladeless elimination of the tumor, the neurosurgeon collaborates with a physicist and radiation oncologist to map the brain and target the tumor with GPS-like precision using focused beams of radiation, while protecting vital brain tissue. This

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

outpatient procedure takes up to 40 minutes and can be an alternative to open brain surgery for some types of tumors.

Malignant & Benign Brain Lesions Primary Brain Tumors Brain Metastasis Arteriovascular Malformations Trigeminal Neuralgia Spine & Organ Disorders Parkinson’s Disease Essential Tremor Dystona Spine Tumors

STEREOTACTIC RADIOSURGERY, FOCUSED-BEAM RADIATION, USING A FRAMELESS IMAGE-GUIDANCE SYSTEM ON THE SPINE

STEREOTACTIC RADIOSURGERY PROGRAM | 31

SRS PROGRAM

PATIENT HIGHLIGHT

AUSTIN WELCH

OVERCOMING ADVERSITY t the Chadwick High School junior class retreat, Austin Welch stands up with a bald head among a crowd of peers to make a bold case for becoming junior class president. He resembles a young Bill Clinton when talking about the importance of helping people and perseverance. Shortly after his 15th birthday while surfing in Hawaii, Austin felt pins and needles in his left hand. He paddled in. A headache followed. His speech slurred. He struggled to tell his parents what was happening to him. They rushed him to the emergency room. The scans revealed an arteriovenous malformation (AVM), a tangled web of abnormal veins and arteries in his brain, which arrests blood flow and can produce devastating bleeding. “It came out of the blue. It didn’t seem that bad at first, then I started to see doctors and receive really bad news. That was tough. It’s not easy to face your own mortality at 15,” Austin said.

32 | STEREOTACTIC RADIOSURGERY PROGRAM

When he returned home to Palos Verdes, he visited specialist after specialist who offered little hope. The location of the AVM presented serious risks. The physicians suggested that he would be paralyzed and have speech deficits even with a surgery. Austin was the star of the basketball team and president of his sophomore class. He was not about to give that up, so he continued the search. His parents eventually received a referral through a friend to see Dr. Nestor Gonzalez, renowned neurosurgeon and neurointerventionalist at UCLA. Austin connected with Dr. Gonzalez instantly because he spoke to him like an adult, while other physicians addressed his parents, not him. Since the risks of surgery were high, Dr. Gonzalez recommended that Austin have endovascular embolization to treat some dangerous portions of the AVM, followed by stereotactic radiosurgery that would target the AVM with focused beams of radiation. The Novalis Tx protects

the healthy brain tissue while zeroing in to remove the AVM without open brain surgery. Austin had an angiogram that revealed three aneurysms on the walls of the blood vessels that fill up like a balloon with blood and carry a high risk of bleeding. Dr. Gonzalez sealed off the aneurysms with ONYX, a liquid agent that solidifies the aneurysm, therefore restoring blood flow in the brain. Austin then had a 30-minute stereotactic radiosurgery treatment planned and executed by Dr. Gonzalez and his team at UCLA. Austin became president of his junior class at Chadwick High School. He recently received his acceptance to go to Dartmouth College. Today, as he nears graduation, Austin is proud to serve as president of Chadwick High School and his dream is to one day say, “Vote for me for President of the United States of America.”

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

UCLA SRS CLINICAL OUTCOMES

SRS PROGRAM

In recent years, neurosurgeons have turned to stereotactic radiosurgery to treat inoperable brain tumors, arteriovenous malformations (AVM) and other abnormalities that can cause debilitating pain such as trigeminal neuralgia. The clinical outcomes have been promising and continue to improve with our innovations to BrainLab, our neuro-imaging guidance system, and the Novalis Tx. As a result, our patients are experiencing less invasive and more effective radiosurgery that ultimately improves their quality of life.

29+71+X STEREOTACTIC RADIOSURGERY USING FOCUSED-BEAM RADIATION & IMAGE GUIDANCE TO TREAT AN AVM

71.5%

VOL. REDUCTION AFTER SRT

“

BRAINSTEM METASTASIS

151151111110= 5210= 90% 1 YR. CONTROL GIANT AVM

15115111110 5210 = = 71.5% VOL. REDUCTION

TRIGEMINAL NEURALGIA

1511511500 5210 = = 79.3% PAIN RELIEF MENINGIOMA

151151111110= 5210= 90-97% CONTROL RATE PITUITARY TUMOR APPROACHING 100% 151151111110 5210= RADIOGRAPHIC CONTROL AT 32 MONTHS

When I thanked Dr. Gonzalez for saving my life, he said to me, ‘the world needs better politicians— intelligent, generous, strong, good people just like you.’ He cares about me, not just as a patient, but as a person. It’s incredible to be where I am. —Austin Welch

AUSTIN’S TEAM

”

Nestor Gonzalez, MD Dr. Nestor Gonzalez is a Ruth & Raymond Stotter Professor in neurosurgery and interventional neuroradiology who has unique training, having completed two separate and distinct residency training programs in both radiology and neurosurgery as well as a fellowship in interventional neuroradiology. Nestor Gonzalez, MD

Antonio De Salles, MD, PhD

NEUROSURGERY

RADIOSURGERY

Antoinette Anderson

Viktor Szeder, MD, Radoslav Raychiev, MD, Amit Balgude, MD, Angelos Konstas, MD

CLINICAL & RESEARCH COORDINATOR

History of Firsts The UCLA Stereotactic Radiosurgery Program was formed in 1980 when the Karolinska Institute of Stockholm, Sweden donated one of two “Gamma Knife” units in existence at the time for the purpose of collaborative research. Since that time, the UCLA radiosurgery team has innovated treatments with the Gamma Knife, LINAC Scalpel, XKnife and, more recently, with Novalis Tx, to now deliver the most advanced, safest and effective radiosurgery in the world. Frameless Novalis Tx is the most advanced radiosurgery developed with the expertise of UCLA radiosurgeons. The system does not require a halo treatment frame to be fastened to the patient’s head, making the outpatient procedure comfortable, painless, safer and more effective. First radiosurgery for trigeminal neuralgia with linear accelerators in the world. First Gamma Knife radiosurgery in America. First Novalis radiosurgery in America. First endoscopic clipage of aneurysm.

Highlights We advanced stereotactic radiosurgery from a minimallyinvasive procedure to completely non-invasive. Highly-effective way of treating the most difficult tumors in the brain, spine and in other areas of the body.

INTERVENTIONAL NEURORADIOLOGY

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

STEREOTACTIC RADIOSURGERY PROGRAM | 33

Neil A. Martin, MD

34 | UCLA STROKE CENTER

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

“

Every day, we touch and save the lives of patients struck by stroke, not just here at UCLA, but also in hospitals across California through our Telestroke Network, and around the world through our endovascular treatments invented by our clinicians. We are mapping the next frontier of stroke care. In the past, when a patient suffered a stroke, the goal was to stabilize the brain for rehabilitation. Today at UCLA, we snare the clot, reverse the stroke and restore the brain. As a result, we witness medical miracles and resilience in our patients.

”

—Neil A. Martin, MD, Professor & W. Eugene Stern Chair in Neurosurgery & Co-Director, UCLA Stroke Center

he UCLA Stroke Center is a national and international leader in the diagnosis, treatment and management of cerebrovascular diseases. More than 15,000 patients have been cared for at the UCLA Stroke Center that has been certified as a Comprehensive Stroke Center by the Joint Commission and the American Heart Association. We are one of only five centers nationwide with a specialized translational research grant from the National Institutes of Health to study promising new surgical interventions and therapies for stroke. Our clinicians and scientists are among the world’s

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

foremost leaders and pioneers in the treatment of ischemic and hemorrhagic stroke, having developed the first FDA-approved MERCI device—a mechanical device that uses a micro-wire to remove the blood clot and stop a stroke in progress. This year, the team supplanted the MERCI device with the FDA-approved SOLITAIRE Flow Restoration Device. The Guglielmi detachable coils (GDCs) invented at UCLA have transformed the treatment of intracranial aneurysms and are now used around the world. Endovascular therapies innovated and pioneered by interventional radiologists and neurosurgeons at UCLA have now been adopted in medical centers across the globe.

UCLA STROKE CENTER | 35

Nestor Gonzalez, MD

UCLA STUDY SHOWS PROMISE & HOPE FOR HEMORRHAGIC STROKE PATIENTS Minimally-Invasive Intraoperative CT Guided Endoscopic Surgery (ICES) t the 2013 International Stroke Conference, UCLA neurosurgeons announced the potentially groundbreaking results of the randomized, controlled phase II clinical trial, which determined that minimally-invasive endoscopic surgery appears to have safer and more effective outcomes as compared with the standard medical treatment for brain hemorrhage. In the past, open surgery that involved a large incision further traumatized the brain in an effort to remove the blood. The procedure failed to improve the outcome of the patient’s quality of life in the aftermath of a hemorrhagic stroke. This devastating, critical condition has a mortality rate of more than 75 percent. If the patient manages to survive, he or she faces a life of long-term severe disability. The UCLA-originated clinical trial led by Dr. Paul M. Vespa and Dr. Neil A. Martin, in conjunction with Johns Hopkins University, set out to determine the safety and effectiveness of removing blood using a “keyhole” incision—smaller than the size of a dime—with Intraoperative CT guided Endoscopic Surgery (ICES). The endoscope, a tiny probe with a camera on the tip, was used to navigate with GPS-like precision. This

image-guided system displays CT scans of the brain on monitors that allows surgeons to pinpoint the bleeding. A catheter was then placed in the tiny bur hole, and the blood was immediately removed. As a result, the procedure was safe with no further bleeding or harm to the patient. On average, 71 percent of the blood was immediately removed. This procedure was performed at seven major medical centers with 24 enrolled patients. Eighteen of the patients had the endoscopic surgery and six had standard medical treatment. After six months, post-op, the neurological outcomes for patients were better and mortality was lower with the endoscopic surgery patients as compared to standard medical treatment patients. Endoscopic surgery has the key advantage to get the blood out all at once, immediately alleviating the pressure on the brain and setting the stage for ultimate recovery.

NIH-FUNDED SPOTRIAS NETWORK The UCLA Stroke Center is in the National Institutes of Health (NIH)-funded Specialized Programs of Translational Research in Acute Stroke (SPOTRIAS) network conducting early phase clinical trials, sharing data and driving new therapies for acute stroke patients.

36 | UCLA STROKE CENTER

BEFORE AND AFTER IMAGES OF HEMORRHAGIC STROKE PATIENT TREATED WITH ICES

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

INTRODUCING A NEW PARADIGM

UCLA STROKE CENTER

History of Firsts

RESEARCH TRANSLATES TO MEDICAL BREAKTHROUGHS estor Gonzalez, MD, an internationally-recognized neurosurgeon and interventional neuroradiologist at UCLA, received the prestigious American Heart Association (AHA) Science Innovation Award in recognition of “introducing a new paradigm into medicine.” He is studying the mechanisms that lead to the formation of new conduits to supply blood to the brain in patients with narrowing cerebral arteries (the structures that bring blood to the brain). By targeting these natural mechanisms to improve blood flow to the brain through medical and surgical treatments, new paths can be created to treat patients with symptoms of TIA or stroke.

Dr. Gonzalez is leading the application of Encephalo-duro-arterio-synangiosis (EDAS) surgery, an indirect bypass for the treatment of narrowing arteries in the brain. In the surgery, he opens a window into the surface of brain and “borrows” an artery from the scalp, placing it in contact with the brain at which point new blood vessels begin to grow in response to natural molecules produced by the body when the brain is deprived of oxygen. EDAS is deemed safe and effective because the procedure does not disrupt the native brain arteries. The National Institutes of Health (NIH) and the National Institute of Neurological Disorders (NINDS) sponsor this research conducted by Dr. Gonzalez.

First mechanical device therapy for acute ischemic stroke: • MERCI Retriever • Invented at UCLA Leading device therapies for cerebral aneurysms: • Guglielmi detachable coil, Matrix coil. • Invented at UCLA Leading catheter therapy for intracranial arteriovenous malformations and fistulae: • ONYX as liquid embolic agent for intracranial arteriovenous malformations and fistulae • Invented at UCLA First clinical cellphone PACS system for remote review of CT and MRI scans in acute stroke developed at UCLA.

15,000 1,200 1 of 5 PATIENTS TREATED SINCE THE PROGRAM BEGAN IN 2001

US HOSPITALS CONDUCTING GOVERNMENT-FUNDED STROKE RESEARCH

SURGERIES PERFORMED EACH YEAR

1st MOST COMPREHENSIVE STROKE CENTER IN THE WORLD

WHO WE ARE CO-DIRECTORS

First cerebral blood flow laboratory to use bedside xenon CBF studies and TCD for stroke critical care and research.

Lucas Restrepo, MD

VASCULAR NEUROSURGERY

NEUROHOSPITALIST NEUROLOGY

Latisha Ali, MD, Doojin Kim, MD, David S. Liebeskind, MD

Nestor Gonzalez, MD, Gary Duckwiler, MD, Reza Jahan, MD, Sachin Rastogi, MD, Satoshi Tateshima, MD, Viktor Szeder, MD

STROKE NEUROLOGY

Paul M. Vespa, MD, Manuel M. Buitrago Blanco, MD

INTERVENTIONAL NEURORADIOLOGY

NEUROCRITICAL CARE

CONDITIONS TREATED Aneurysms Arterial dissection Arteriovenous malformations Carotid and intracerebral arterial stenosis

Cavernous angiomas Hematomas Hemifacial spasm Intracranial and spinal AVMs

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

First routine use of intraoperative digital subtraction angiography for evaluation after surgical aneurysm and AVM treatment. First Neuro ICU-adjacent comprehensive stroke imaging center with CT, PET, 3T MRI.

Neil A. Martin, MD, Bruce Dobkin, MD, Jeffrey L. Saver, MD, Sidney Starkman, MD John G. Frazee, MD

First US multicenter trial of endoscopic treatment for acute intracerebral hemorrhage.

Moyamoya disease Stroke Trigeminal neuralgia

Doctor Highlight JEFFREY L. SAVER MD, IS PROFESSOR OF NEUROLOGY, CODIRECTOR OF THE UCLA STROKE CENTER, AND MEDICAL DIRECTOR OF THE STROKE UNIT.

UCLA STROKE CENTER | 37

UCLA STROKE CENTER

PATIENT HIGHLIGHT

JON GALVAN

BEATING THE IMPOSSIBLE earing a deadline, Jon Galvan, a senior producer for a video game company, arrived at the studio early to finalize a project for shipment. Jon plays and makes video games for a living. Yet that July morning in 2008, the rising pressure felt more palpable than the play. While testing the game, he chewed on sunflower seeds. The crackling ceased when he heard a loud jarring pop in his brain that felt like an explosion striking him down. “I did a header into the drywall,” Jon recalled barreling toward the wall as he lost consciousness that morning in the production studio. He shouted out for help but his words sounded jumbled and slurred. “Before, I went down, I thought to myself, I’m not going out like this.” At 38 years old, Jon and his wife, Nicole, had just celebrated their son’s second birthday. His career was on the rise after producing the video game Medal of Honor at Electronic Arts, among others. In the virtual reality gaming world, Jon

38 | UCLA STROKE CENTER

could calculate the odds to continue to play or yield to game over. In reality, he faced tough odds for survival. The pop was a severe hemorrhagic stroke in the basal ganglia brought on by undiagnosed hypertension. He had less than 25 percent chance of survival. If he survived, the deficits could be immeasurable. A friend arranged for Jon to be transferred to the UCLA Stroke Center. That move increased his odds. The ambulance arrived at UCLA. Dr. Neil A. Martin, Professor & W. Eugene Stern Chair in Neurosurgery and renowned stroke expert, met Nicole, Jon’s wife, to explain his condition. The standard treatment of open brain surgery often resulted in poor outcomes. Dr. Martin introduced the possibility of performing an experimental procedure called ICES, Intraoperative CT guided Endoscopic Surgery, which could potentially remove all of the blood and alleviate deadly intracranial pressure. Both could set the stage for an ultimate recovery. Nicole agreed. Jon was wheeled into the endoscopic operating theater at UCLA. Dr. Martin made a tiny

incision about the size of a dime above Jon’s eyebrow and then a bur hole to insert an endoscope that navigated his brain. The CT scans pointed him to the area that was bleeding. He gently inserted a catheter and removed all the blood. After the surgery, Jon spent weeks in the neuro-ICU. At first he could not walk or talk. Eventually, he emerged from the ICU and entered extensive rehabilitation that entailed training his brain to rewire itself. He gradually regained function— walking, talking and even telling jokes again. He returned to playing video games, and began volunteering at the studio. Today, he is working part-time and is set to begin on a UCLA clinical trial to stimulate his spinal cord and further rehabilitate his motor function. “At one point, I realized that I wasn’t suppose to be here and I said thank you to Dr. Martin,” Jon said. “Whatever he did to me was unique, special, a one-shot deal that saved my life. I not only recovered, I’m thriving.”

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

TELEMEDICINE CONNECTING TO OUR COMMUNITY & SHARING OUR EXPERTISE The UCLA Stroke Center innovated the Telestroke Network Partner Program (red lines), which gives community hospitals across California direct, immediate, around-the-clock video consultations with UCLA stroke experts. Through two-way video conferencing, our neurologists can beam into a local hospital to give a stroke-specific neurologic exam while reviewing local diagnostic images for rapid response to stroke, when minutes can mean the difference between brain damage and full recovery. The UCLA Tele-ICU Network (blue lines) provides around-the-clock neurocritical care specialists to assist patients with brain and spine trauma emergencies in hospitals without this expertise throughout California and across the country in Atlantic City, New Jersey.

LOS ANGELES COUNTY

AWARD-WINNING CARE

JON’S TEAM Neil A. Martin, MD Professor & W. Eugene Stern Chair in Neurosurgery, Dr. Neil A. Martin is Co-Director of the UCLA Stroke Center and Director of the Aneurysm and AVM Program. Dr. Martin specializes in the research and treatment of neurovascular disorders, including arteriovenous malformation, aneurysm and stroke. Neil A. Martin, MD NEUROSURGERY

Patrick Pezeshkian, MD, Justin Dye, MD Colin Buchanan, MD NEUROSURGERY RESIDENTS

Paul M. Vespa, MD, Alex Nee, MD, Benjamin Emanuel, MD

Jonathan Cotliar, MD

NEUROCRITICAL CARE TEAM

DERMATOLOGY

Areti Tillou, MD

Saleh Salehmoghaddam, MD

GENERAL SURGERY

NEPHROLOGY

The UCLA Stroke Center has been certified as a comprehensive stroke center by the Joint Commission and the American Heart Association/ American Stroke Association. It is one of the first 10 stroke centers in the nation to receive the prestigious designation. The UCLA Stroke Center has also received the two highest American Heart Association awards recognizing excellence in stroke treatment: Gold Plus Stroke Award and Target: Stroke Honor Roll hospital. American Heart Association American Stroke Association CERTIFICATION Meets Standards for

Comprehensive Stroke Center

Joint Commission National Quality Approval (Awarded to UCLA Stroke Center)

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

UCLA STROKE CENTER | 39

UCLA STROKE CENTER

PATIENT HIGHLIGHT

JAMIE MORISHITA

HOLDING OUT HOPE t first her right hand tingled. The numbness crawled onto her face and crept down her leg, paralyzing her. Frightened, Jaime Morishita visited doctor after doctor. At 30 years old, she appeared healthy, with her only problem being high blood pressure. The medications failed to stop these bouts of paralysis. As a mother of three, she grew more fearful. She and her husband had planned to have another baby, but her health would not permit it. The episodes and headaches increased. “As long as I don’t breathe too hard,” Jaime would say to herself, “I can control it.” What Jaime didn’t realize was these episodes were strokes, transient ischemic attacks on her brain. The blood flow would just stop, causing the brain to lose oxygen. “Even just blowing bubbles for my children at the park would trigger the numbness to strike me and disconnect my entire right side from my body,” Jaime said. She stopped exercising

40 | UCLA STROKE CENTER

and going places where she may exert too much energy, for fear of the episodes. By her 32nd birthday, a neurologist diagnosed her with Moyamoya, a cerebrovascular disorder that causes narrowing of the carotid arteries and, as a result, tiny blood vessels that form to compensate for the lack of blood flow in the brain. The tangle of tiny blood vessels on the MRI scans looks like a “puff of smoke,” translated to Moyamoya in Japanese. These tiny blood vessels could break at any time causing hemorrhage— essentially a major stroke. Her neurologist referred her to Dr. Nestor Gonzalez, a pioneer and expert in the treatment of cerebrovascular disorders. Dr. Gonzalez specializes in the most minimally-invasive approach to treat Moyamoya. On May 7, 2012, Jaime underwent EDAS (Encephalo-Duro-Arterio-Synangiosis), an indirect bypass that involves Dr. Gonzalez carefully removing a native artery from her scalp and implanting it in her

brain. As a result, the brain gives off a chemical to grow blood vessels from the artery, thus revascularizing the brain. Within weeks, on June 27, 2012, she went in for her first angiogram and the blood vessels were sturdily growing, already increasing blood flow in her brain. The mini-strokes stopped. Jaime began to feel normal again. At six months, she received her second angiogram post-op and the vessels continue to grow and flow. Shortly after, Jaime discovered her womb was also growing. An ultrasound confirmed a healthy baby on the way. “I can’t believe that I’m pregnant. I actually didn’t think we would be able to have another child. I was so scared that I was going to have to live with those episodes. Dr. Gonzalez was right to do EDAS. He is amazing. Now I have my miracle baby,” Jaime says, rubbing her six-month bump.

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

UCLA EDAS REVASCULARIZATIONS (ENCEPHALO-DURO-ARTERIO-SYNANGIOSIS)

29+71+X

TOTAL NUMBER OF EDAS PROCEDURES: 102

70 32

Endovascular and surgical treatments developed at UCLA are now circling the globe.

EDAS REVASCULARZATION

Average age: 30 (Range 4-57)

The donor artery is placed in close proximity to the superficial brain arteries. A network of collaterals forms between the donor artery and the adjacent brain vessels without a surgical anastomosis.

“

I can’t believe that I’m pregnant. I actually didn’t think we would be able to have another child. I was so scared that I was going to have to live with those episodes. Dr. Gonzalez was right to do EDAS. He is amazing. Now I have my miracle baby. —Jamie Morishita

JAMIE’S TEAM

More than 15,000 patients treated at the UCLA Stroke Center.

Certified Comprehensive Stroke Center by the Joint Commission.

MOYAMOYA DISEASE

Angiographic follow up average: 13 months

World’s Leading Stroke Center.

Telestroke Network services the entire Southern California region.

SYMPTOMATIC INTRACRANIAL ARTERIAL STENOSIS

Clinical follow-up average: 14 months

Highlights

NIH-funded center among five in the nation conducting translational research for stroke.

MOYAMOYA DISEASE

Female/male: 47/23

UCLA STROKE CENTER

”

NIH Grants National Institute of Neurological Disorders & Stroke Cerebral lactate metabolism following human traumatic brain injury. Surgical indirect revascularization for symptomatic intracranial arterial stenosis.

Total NIH Funding

$1,557,164 TOTAL NIH/NON-NIH GRANTS, INCLUDING DIRECT & INDIRECT COSTS, FOR THE DURATION OF THE RESEARCH PERIOD

Nestor Gonzalez, MD Dr. Nestor Gonzalez is an Assistant Professor in Neurosurgery and Interventional Neuroradiology who has unique training, having completed two separate and distinct residency training programs in both radiology and neurosurgery, as well as a fellowship in interventional neuroradiology.

Nestor Gonzalez, MD, Brandon Evans, MD, Justin Dye, MD, Collin Buchanan, MD,

Viktor Szeder, MD, Radoslav Raychiev, MD, Amit Balgude, MD, Angelos Konstas, MD

NEUROSURGERY

INTERVENTIONAL NEURORADIOLOGY

EDAS Outcomes Functional outcome: 95% (mRs≤2) Post-operative stroke rate: 0 Long-term stroke rate: 3% Cerebral hemorrhage: 0 Reoperations: 3%

Jeffrey L. Saver, MD, David Liebeskind, MD STROKE NEUROLOGISTS

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

UCLA STROKE CENTER | 41

42 | ITZHAK FRIED: THE DISCOVERY OF STIMULATING MEMORY IN THE HUMAN BRAIN

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

ITZHAK FRIED

THE DISCOVERY OF STIMULATING MEMORY IN THE HUMAN BRAIN t the intersection of the brain and the mind exists the lifework of Itzhak Fried, MD, PhD, Professor of Neurosurgery, Psychiatry and Bio-Behavioral Sciences at UCLA. His operations have led to hundreds of patients living seizure-free lives, while his explorations have unearthed a groundbreaking discovery of stimulating memory in a critical junction of the brain. This finding, reported in the New England Journal of Medicine by Dr. Fried and his UCLA colleagues, could lead to treatments for boosting memory in patients with early dementia and Alzheimer’s disease. Reaching this point is just one milestone in a series of marathons probing the inner space of the human brain for more than 25 years. Dr. Fried is one of the top 10 finalists for the Global B.R.A.I.N (Breakthrough Research and Innovation for Neurotechnology) Prize competition inspired by Israeli President Shimon Peres and Israel Brain Technologies. Each neuroscientist in the finalists has demonstrated “breakthrough achievements that have significant impact on humanity.” Since his early days as a neuroscientist, he aspired to unlock the fundamentals of brain functions that are uniquely human. Yet, he realized that only one kind of doctor could truly interact with the living human brain. Dr. Fried set out to become a neurosurgeon. He completed medical school at Stanford University and moved on to Yale University for his neurosurgical residency training with a focus on treating patients with epilepsy. After a year on the faculty at Yale, UCLA recruited Dr. Fried to take over the Adult Epilepsy Surgery Program. “There was a fantastic team at UCLA and an infrastructure with a great tradition for epilepsy surgery set by Paul Crandall,” Dr. Fried said. “He developed the technology to go precisely into the brain to gain the location of the group of cells responsible for the seizures and later remove them with surgery. We furthered the clinical research when we listened in to individual cells. We could cure our patients, while at the same time we were able to bring these recordings to the level of a single neuron, which provided insight into how human memory works and how other functions of the brain are carried out at the neuronal level.”

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

Early on at UCLA, he implanted intracranial subdural electrodes to localize the area of the brain producing the seizures for his patients. While monitoring the chronic seizures of a 16-year-old girl, he and his team conducted cognitive tasks. As they applied electrical stimulation at a particular site in the left frontal lobe, she laughed when shown a picture of a horse. “That horse is funny,” she said. The laughter escalated on the next task when she read a sentence about a rainbow. This time the rainbow was funny. “Then this charming girl looked at all of us and upon electrical stimulation of the area, she laughed hysterically and said, ‘you guys are so funny,’” Dr. Fried said, recalling the moment of discovering this phenomenon in the supplementary motor area of the brain where laughter occurred. The finding was later published in Nature in February of 1998. In recording single brain cells, or neurons, to determine and group the brain networks causing the seizures, he listened in on cells and/or groups of cells that responded to specific individuals such as a particular celebrity. The first single cell recording of this type was of a cell, which responded uniquely to Bill Clinton. In another patient a neuron responded to Jennifer Aniston, firing each time any photo of her was shown to the patient, whether it was in color, in black and white, or the actress in profile. It was as if the neuron knew the identity or the concept of Jennifer Aniston and did not really care about the particular way the actress was displayed. In fact such a neuron would respond even to the written name of the person or to the sound of her name. “The Jennifer Aniston cell gave us profound insight on how the brain codes concepts and shapes our memories,” he said. It showed an uncanny code of explicit representation of concepts in individual neurons. Dr. Fried published these insights with his colleagues in the 2013 February issue of Scientific American. Dr. Fried’s laboratory has contributed significantly towards understanding cognition through direct recordings from brain cells in humans. His team was the first to record individual brain cells in the act of summoning a spontaneous memory. This study published in Science magazine revealed not only where a

remembered experience is registered but also, in part, how the brain is able to recreate it. Furthermore, in a different set of studies he has shown that cells in another area of the brain, the supplementary motor area, signal the formation of human will, even before it is recognized by self. For these achievements he has been named Fellow of The American Association for the Advancement of Science. “I’m always learning,” Dr. Fried said. “The consummate physician is always learning.” Recently, his sons challenged him to run a marathon not realizing that he had spent his life running marathon after marathon. They bet him that he could not cross the finish line. He quietly trained for a few months and then invited his family to Paris in spring 2009 to watch him cross the marathon finish line. Yes, his sons lost the bet. Today, he has completed marathons in other parts of the globe. Likewise, he has forged collaborations with physicians and scientists around the globe. Dr. Fried brought the field of epilepsy surgery to Israel. He modeled the country’s first program after UCLA. His most recent discovery of a critical area in the brain, where stimulation enhances memory, gained recognition around the world. Being in the top 10 finalists for the Global B.R.A.I.N. prize really translates to being one of the top neuroscientists in the world. He has spent many years studying the hippocampus, the memory’s mainframe. The stimulation, electrical currents, applied through the electrodes implanted in the brain, turned out to be most effective in the entorhinal cortex, the golden gateway of the hippocampus. The next challenge is to determine if a brain pacemaker, electrodes implanted in the brain, which are currently used to treat movement disorders such as Parkinson’s disease and essential tremor, could be used for patients with memory disorders such as dementia, stroke, epilepsy or brain injury. “This kind of clinical research and patient care is a lifelong marathon, not for sprinters,” Dr. Fried said. “There is still much work to be done. Looking back does capture some amazing moments. It is a great source of satisfaction to change a person’s life for the better through brain surgery, and at the same time learn the fundamentals of the human condition.”

ITZHAK FRIED: THE DISCOVERY OF STIMULATING MEMORY IN THE HUMAN BRAIN | 43

44 | ADULT EPILEPSY SURGERY PROGRAM

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

“

Every patient is unique and special. We direct our efforts to remove brain networks responsible for seizures while preserving those networks responsible for the function and well-being of the individual. —Itzhak Fried, MD, PhD, Director of the Adult Epilepsy Surgery Program

or more than 50 years, UCLA has led the world in the diagnosis, management and surgical treatment of intractable epilepsy for children and adults. Our Seizure Disorder Center performs between 40 and 50 surgeries annually. UCLA’s neurosurgeons pioneered many of the innovations in the evaluation and surgical treatment of seizure disorders since its inception. The UCLA team has performed more than 1,000 surgeries to stop seizures in children and adults suffering from epilepsy. UCLA has a long history of treating epilepsy, having pioneered surgical

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

”

procedures for the treatment of epilepsy since 1961. Itzhak Fried, MD, PhD, Director of the Adult Epilepsy Surgery Program in the Department of Neurosurgery at UCLA and Co-Director of the UCLA Seizure Disorder Center, and his team, are world-class experts, specializing in the advanced diagnosis, treatment and management of epilepsy. We intersect a wide range of specialties including: neurosurgery, neurology, clinical neurophysiology, electrophysiology, neuropsychology, occupational therapy, psychiatry, neuroradiology, specialized nurses in epilepsy, EEG technologists skilled in epilepsy, epileptology and physiology.

ADULT EPILEPSY SURGERY PROGRAM | 45

SETTING THE GOLD STANDARD Neurosurgical Protocol for Epilepsy Developed at UCLA ur outcomes for epilepsy surgery lead the world because we use an advanced, three-pronged protocol developed at UCLA, which is the standard for neurosurgeons worldwide. In the first phase, we evaluate patients in our telemetry unit, which is equipped with video and non-invasive scalp electroencephalograph electrodes, to document and characterize seizures. As part of the evaluation, patients undergo extensive brain imaging, including advanced MRI protocols such as T1- and T2- weighted inversion

recovery, FLAIR, 3D reconstruction, diffusion tensor imaging (DTI) and positron emission tomography (PET) scans. In some cases a special technique probing magnetic dipoles in the brain (magnetic source imaging) is used. The findings are then presented to the epilepsy surgery team, a panel consisting of neurologists, neurosurgeons, electrophysiologists, radiologists, psychologists and our coordinating clinical nurse specialist. If the source of the seizures cannot be localized or if it is near a language or movement center of the brain, we will perform

stimulation mapping using subdural (over the surface of the brain) or depth electrodes implanted in the brain. The patient will then undergo another round of observation and recording of the seizures in the telemetry unit. In the final phase, our team uses imaging technology, including electrocorticography (ECoG), functional brain mapping and intra-operative image guidance to map the route to the region of the brain, while protecting vital control centers. Finally, the neurosurgeon removes the abnormality in the brain and as result eliminates the seizures.

UCLA STUDY SHOWS THAT SURGERY CAN LEAD TO A SEIZURE-FREE LIFE Research Shows Surgery Should Not Be Delayed Surgery for epilepsy was once seen as a last resort for patients and was only performed when anti-seizure medications failed to stop the seizures. A recent, evidence-based, multi-center study led by UCLA set the guidelines that if a patient continues to experience seizures after two anti-seizure medications have failed, then an evaluation for surgery from a comprehensive epilepsy center should not be delayed. The recent controlled, randomized UCLA study published in the Journal of the American Medical Association in March 2012, examined 38 patients who failed to have seizures controlled after trying two anti-seizure drugs. The team randomly assigned 15 to brain surgery and 23 to continued medical treatment, all patients were similar in age and diagnosis. During the second year follow ups, the 23 patients on anti-seizure medications still suffered from seizures. Eleven of the brain surgery patients were seizure free. Evidence-based research now shows that surgery should be considered as soon as possible. Epilepsy will strike one in a hundred Americans at some point in their life. Seizure disorders are rising in people after the age of 60 and will continue to increase as the baby boomers age. Research has shown patients

46 | ADULT EPILEPSY SURGERY PROGRAM

live an average of 22 years with uncontrolled seizures before considering surgery. On average, patients living with uncontrolled seizures are at increased risk for drowning and other fatal accidents. Depression, progressive memory loss and other cognitive disorders debilitate these patientsâ&#x20AC;&#x2122; quality of life. Children are at risk for slow-to-no development of vocational and social skills. Our evidence now shows patients should consider evaluation for surgery early, before the harmful consequences become irreversible. With 50 years dedicated to the surgical treatment of epilepsy, we are world leaders in helping hundreds of patients go on to live productive, seizure-free lives.

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

A RECORD OF

DISCOVERY & INNOVATION tzhak Fried, MD, PhD, Director of the Adult Epilepsy Surgery Program at UCLA, uses depth electrodes implanted in patients with epilepsy to localize seizures in the brain for diagnosis and surgery. Simultaneously, he studies the fundamental functions of the neurons in an effort to develop applications to restore lost neurological function due to epilepsy, memory disorders such as Alzheimerâ&#x20AC;&#x2122;s disease or stroke. Recently published in the 2013 February issue of the Scientific American, he and his UCLA team reported on recording a single brain cell, the Jennifer Aniston neuron, which revealed how neurons code and shape human memories. In his latest research published in the September 2013 issue of Nature Neuroscience, he and a team of neuroscientists discovered the grid cells, like GPS in the brain, which help people keep track of their location while moving in an unfamiliar environment.

ADULT EPILEPSY PROGRAM

History of Firsts First chronic depth electrode recordings for epilepsy. First EEG telemetry for epilepsy. First chronic microelectrode recordings from patients with epilepsy. First correlation of electrophysiological characteristics of epileptic hippocampus with tissue pathology obtained from en bloc anterior temporal resections. First laboratory to establish parallel human/animal research protocols for epilepsy First PET scans for epilepsy diagnosis. First long-term EEG monitoring with sphenoidal and scalp electrodes

1,000

1960

1ST

MORE THAN 1,000 SURGERIES PERFORMED TO TREAT SEIZURES

YEAR THE EPILEPSY SURGERY PROGRAM WAS ESTABLISHED AT UCLA

CHRONIC MICROELECTRODE RECORDINGS FROM PATIENTS WITH EPILEPSY

SURGICAL TREATMENT OF 18 DIFFERENT TYPES OF EPILEPSY

WHO WE ARE Gary W. Mathern, MD, PhD

Sandra Dewar, RN, MS

DIRECTOR, PEDIATRIC EPILEPSY SURGERY PROGRAM

CLINICAL DIRECTOR, SIEZURE DISORDER CENTER

Jerome Engel, Jr., MD, PhD DIRECTOR, SEIZURE DISORDER CENTER

CONDITIONS TREATED Epilepsy where seizure focus is near functional area of brain Extratemporal lobe epilepsy hemimegalencephaly Hippocampal sclerosis Lennox-Gestaut syndrome

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

and other epilepsies with drop attacks Mesial frontal lobe epilepsy Mesial temporal lobe epilepsy Perinatal strokes Rasmussen encephalitis

First to hold a comprehensive international conference on epilepsy surgery (First Palm Desert Conference, 1986). First to establish an internationallyaccepted classification of surgical outcome (the Engel Classification).

Itzhak Fried, MD, PhD PROGRAM DIRECTOR

Aicardi syndrome Cortical dysplasia Epilepsy caused by small tumors of blood vessel malformations Epilepsy where resection is not an option

First to established multidisciplinary Phase I and Phase II protocols for surgery.

Sturge-Weber syndrome Trauma Tuberous sclerosis complex Tumors, especially DNET and low grade gliomas Unilateral polymicrogyria

First to identify pathological high frequency oscillations (pHFOs) as biomarkers of the epileptogenic region. Among the first to demonstrate widespread neocortical thinning as characteristic of classical mesial temporal lobe epilepsy with hippocampal sclerosis. First to establish an epilepsy surgery program in Israel.

ADULT EPILEPSY SURGERY PROGRAM | 47

ADULT EPILEPSY SURGERY PROGRAM

PATIENT HIGHLIGHT

RICK SMITH

ROCKET SURGERY e felt a bolt of lightening strike his head and body. A blackout followed. Rick Smith, an aerospace engineer, slipped out of his office chair and onto the floor at Wyle Laboratories. He had just celebrated his big 4-0. Until that first grand mal seizure, he was healthy. Another engineer entered his office to see Rick convulsing on the floor. He dialed 9-1-1. When Rick came to, an ambulance crew was surrounding him. After that initial seizure, his driving privileges were restricted. Fortunately, his wife, Karen, worked at the laboratory, so he was able to continue working. Even with antiseizure medications, Rick endured unexpected seizures, most commonly complex partial seizures, or “stare-offs”, for more than nine years. Everywhere he went, he had to think about the impact a seizure would have on him and those around him. In search of a life beyond his seizures, he met with Sandra Dewar, RN, MS, Jerome Engel, Jr.,

48 | ADULT EPILEPSY SURGERY PROGRAM

MD, PhD, Itzhak Fried, MD, PhD, and a large team of doctors at the UCLA Seizure Disorder Center to determine if he was a surgical candidate. He discovered all of the potential catalysts to his adult onset epilepsy. They asked him a series of questions. He answered yes to each one, from having experienced blows to the head and exposure to chemicals, to experiencing high levels of stress. The team of clinicians explained that Rick would need to check into the hospital for a set of studies, which included 24-hour supervised video EEG monitoring so the medical team could pinpoint the start of the seizures. The clinicians found the scar tissue in his brain where the overactive cells misfired during an epileptic seizure. They were confident they had isolated the problem area. Next, the Wada test was done. This required a portion of his brain to be anesthetized while they tested his neurological, motor, and verbal functions. He passed with flying colors. He recalls one of the

happiest days of his life was when Dr. Fried emerged from a huddle with his research team and said to Rick, “We believe you’re a candidate for surgery.” Rick underwent brain surgery by Dr. Fried to have the scar tissue removed and, in return, got his old life back. Today, at age 60, 12 years after surgery, Rick is seizure-free. He is a grandfather with two grandsons. His son now works at the laboratory with him. Rick continues to pursue his work at NTS Technical Systems in Santa Clarita, CA, with a passion. He is so grateful to enter his golden years without having to rely on medications to control his seizures. “I cannot believe they cured my epilepsy. It’s a medical miracle. My only regret is not undergoing surgery sooner. I could have saved myself from suffering from nine years of seizures. I want to blast it out to anyone suffering from epilepsy to go to UCLA. You can live seizure-free.”

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

A TRIBUTE TO

PAUL H. CRANDALL

A PIONEER IN THE SURGICAL TREATMENT OF EPILEPSY n remembrance, we honor Paul H. Crandall, the father of the Epilepsy Surgery Program at UCLA and pioneer in the surgical treatment of epilepsy. He was one of the founding members of the neurosurgery division, which became a department in 2008. Dr. Crandall cared for patients, conducted clinical research and taught for 32 years. He retired in 1988 as a professor emeritus and passed away in 2012. Dr. Crandall started UCLA’s first research

program in the surgical treatment of epilepsy in 1960. He also led one of UCLA’s longest running NIH grants and was responsible for developing the first seizure-monitoring unit. During NASA’s early Gemini orbital mission, Dr. Crandall heard mission control reporting an astronaut’s heart rate. Intrigued, he contacted NASA to find out how they were able to remotely monitor heart rate and transmit multiple channels of data back to earth. He obtained the FM telemetry device from NASA and connected it to electrodes implanted in the brain

to record signals on a reel-to-reel recorder. This led to 24-hour monitoring of the patient and the recording of the first seizure at UCLA in 1968. Soon after, he simultaneously video recorded the patient to compare external behavior with brain activity. Using these recordings, Dr. Crandall honed in on the brain cells causing the seizures. He would then remove those cells in surgery and thus put an end to the seizures. Today, EEG telemetry protocols that Dr. Crandall developed are the standard used in hospitals worldwide.

DR. ALFONSINA Q. DAVIES ENDOWED CHAIR IN HONOR OF PAUL CRANDALL, MD Thomas and Nadia Davies invested more than a decade in search of a solution for the epileptic seizures that debilitated their daughter, Alfonsina, “Nina”, since her birth. In 1977, Dr. Crandall performed an experimental brain surgery on their 17-year-old daughter to end her seizures. She went on to earn her doctoral degree in education and become the Assistant Superintendent of the Santa Ana School District. Nina helped many children with disabilities get a second chance at life, just as she had received. Decades later, in 2011, Nina passed away

“

I cannot believe they cured my epilepsy. It’s a medical miracle. My only regret is not undergoing surgery sooner. I could have saved myself from suffering from nine years of seizures. I want to blast it out to anyone suffering from epilepsy to go to UCLA. You can live seizure-free. —Rick Smith

”

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

(TOP L-R) NADIA & THOMAS DAVIES (BOTTOM L-R) DR. PAUL CRANDALL & ALFONSINA DAVIES

due to SUDEP (Sudden Unexpected Death in Epilepsy). In memory of their daughter and in honor of Dr. Crandall, the Davies established an endowed chair in their names to continue to support UCLA as a world-leader in the surgical treatment of epilepsy for generations to come. Dr. Crandall’s spirit will live on in the Chair awarded to a preeminent physician-scientist with a history of creativity, innovation and willingness to view old problems in new ways with new technology. With the support this endowment provides, thousands more patients suffering from epilepsy will live in a future without seizures.

RICK’S TEAM Itzhak Fried, MD, PhD Professor in Residence and Director of the Epilepsy Surgery Program, Dr. Fried’s research and clinical work is dedicated to the treatment of intractable seizure disorders and epilepsy.

Itzhak Fried, MD, PhD

Susan Bookheimer, PhD

NEUROSURGERY

NEUROPSYCHOLOGY

Jerome Engel, Jr., MD, PhD

Sandra Dewar, RN, MS

NEUROLOGY

CLINICAL NURSE SPECIALIST

ADULT EPILEPSY SURGERY PROGRAM | 49

BRAIN INJURY

RESEARCH CENTER avid A. Hovda, PhD, is the founding and current Director of the Brain Injury Research Center and the Vice Chair for Research for the Department of Neurosurgery at UCLA. His early discoveries of the detrimental effects concussions have on the brain led to the military and the National Football League recognizing traumatic brain injury (TBI). In 2011, the White House appointed Dr. Hovda to the Defense Health Board, a team of 14 experts from across the country to advise the Secretary of Defense on matters dealing with the health and care of

service members. The appointment came as a result of Dr. Hovda receiving the highest civilian honor in 2011, the Strength of the Nation award, for his efforts to save troops suffering from multiple concussions on the battlefield, as well as his research that led to a standardized recovery protocol for warriors wounded from brain trauma. He was a key expert in establishing the National Intrepid Center of Excellence in Bethesda, Maryland which focuses on diagnosing, treating, managing and studying service members with TBI, and educating families on the long-term effects of concussions.

DR. HOVDA RECEIVING THE STRENGTH OF THE NATION AWARD

THE UCLA SPORTS CONCUSSION CLINIC & BRAIN SPORT PROGRAM Christopher C. Giza, MD, opened the UCLA Sports Concussions Clinic to diagnose, treat and manage concussions for both young and professional athletes. Dr. Gizaâ&#x20AC;&#x2122;s team also educates parents, coaches and leagues about preventing multiple concussions. His Brain Sport Program works with high schools and colleges to obtain baseline neurological exams pre-season so that, if a head injury is sustained during the season, physicians can properly diagnose the concussion. This year, Dr. Giza announced the first evidence-based guidelines for the management of sports-related concussions at the American Academy of Neurology meeting in San Diego. If a concussion is suspected, players must be immediately removed from the game followed by an evaluation by a licensed health care professional.

50 | UCLA BRAIN INJURY RESEARCH CENTER

RAISING AWARENESS ON SPORTS CONCUSSIONS IN THE NATIONAL FOOTBALL LEAGUE Dr. Hovda has been an internationally-recognized expert on concussion awareness for over two decades. He helped the National Football League in the 1990s recognize the potentially detrimental side effects of multiple concussions on the football field. His research and education have helped the NFL set practices to diagnose the symptoms of an initial concussion and remove players from action while the brain shuts down to repair itself.

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

BIRC PROGRAM

PROTECTING OUR TROOPS

FROM TRAUMATIC BRAIN INJURY he UCLA Brain Injury Research Center (BIRC) experts have extended their expertise to protect our soldiers from traumatic brain injuries (TBI) and multiple concussions—the signature wounds of the Afghanistan and Iraq wars. At the request of the Joint Chiefs of Staff U.S. Army, David A. Hovda, PhD, formed a team to visit Afghanistan to set up concussion care centers, concussion units and the installation of three MRI scanners. His research inspired the military’s protocols for the diagnosis, treatment and management of TBI as well as increased awareness of

concussions among the troops. IED blasts have made TBI, which gradually erodes the nervous system, the silent killer of these wars. Christopher C. Giza, MD, an associate professor of neurosurgery at UCLA, travelled to the frontlines of Afghanistan to oversee the establishment of these programs. Concussion units were built to provide protective environments for soldiers in the vulnerable recovery stage. In addition, concussion care centers were put in place, complete with MRI scanners and experts trained in protocols that will decrease the vast numbers of soldiers carrying these invisible wounds home from war.

History of Firsts First to describe a metabolic cascade following TBI. First to describe the cost of mild TBI in the capacity for plasticity during development. First to redefine the role of the fuel glucose after TBI. First to use quantitative positron emission tomography after TBI. First to combine cerebral microdialysis, positron emission tomography along with monitoring in ICU. First to be recognized by the US Army and Marine Corps for help in mild TBI. First to establish a University of California annual meeting on TBI. First to describe the neuroscience between TBI, PTSD and Parkinson’s Disease.

DR. GIZA (2ND FROM LEFT) WITH TROOPS AT THE KANDAHAR AIRFIELD

First to map the regional brain volumetric changes and connections across time after TBI. First to describe the neuroscience of diet and exercise on recovery after TBI.

BIRC UCLA IS AN OFFICIAL ADVISOR TO:

NIH Grants

California Athletic Commission US Department of Defense National Football League

Total NIH Funding

World Boxing Council

$15,597,410

Major League Baseball Medical Research Council NATO

TOTAL NIH/NON-NIH GRANTS, INCLUDING DIRECT & INDIRECT COSTS, FOR THE DURATION OF THE RESEARCH PERIOD

NCAA

WHO WE ARE David A. Hovda, PhD DIRECTOR Christopher C. Giza, MD, Paul M. Vespa, MD, Neil A. Martin, MD, Tom C. Glenn, PhD, Fernando Gomez-Pinilla, PhD,

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

Neil G. Harris, PhD, Grace Griesbach, PhD, David McArthur, PhD, Mayumi Prins, PhD, Richard L. Sutton, PhD

UCLA BRAIN INJURY RESEARCH CENTER | 51

Neuro ICU

Paul M. Vespa, MD

52 | NEUROCRITICAL CARE PROGRAM

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

ur neurosurgical/neurological ICU is a world-leader in providing patients with minute-to-minute, 24-7 critical care. In the 24-bed, state-of-the-art ICU, Paul M. Vespa, MD, a renowned neurocritical care specialist, leads an elite team of neurosurgical and neurological residents, respiratory technologists, electroencephalography (EEG) technologists and specialized neuroscience nurses. Each patient is continuously monitored with EEG, cerebral

“

microdialysis, brain oximetry, the world’s first ICU Robot—built by InTouch Health—and a comprehensive ICU Supercomputing System. Additionally, the Edie Baskin Bronson and Richard “Skip” Bronson Cerebral Blood Flow laboratory provides advanced diagnostics of cerebral circulation using transcranial Doppler and XENON-133 CBF measurement. Adjacent to the ICU are CT, MRI and PET scanners to ensure rapid response to any critical event.

We invent the future of critical care to enable the future for our patients.

”

—Paul M. Vespa, MD, Director of the Neurocritical Care Program

INVENTING A NEW PREDICTIVE MODEL Changing outcomes requires changing our treatments. At UCLA, we pioneered continuous EEG in the NeuroICU to detect silent seizures that occur in 24 percent of brain trauma patients and can result in elevated intracranial pressure. This innovation is becoming a new standard of care internationally. Dr. Vespa and UCLA bioengineers have received an NIH grant to develop

and test a bedside monitor/alarm system to detect rising intracranial pressure. The team is using big data software by IBM to analyze in real-time streams of physiological signals coming from the bedside monitor to predict the elevation of intracranial pressure. This takes our care in the ICU from responsive to a predictive and preventative approach.

INVENTING THE FUTURE: 24/7 ROBOTICS & TELEMEDICINE

IROBOT-DOC: REVOLUTIONIZING ACCESS

RONI (Robot of the Neuro-ICU) was the world’s first ICU robot and was pioneered right here at UCLA in 2005. In the case of a stroke, when minutes mean the difference between preserving or losing brain function, RONI enables the neurocritical care specialist to beam into the neuro-ICU and be virtually bedside with the patient in minutes. Under the control of the physician at a computer away from the ICU, the 5’6 robot has a head that is a flat screen projecting the physician’s face allowing for real-time, two-way, face-to-face communication with the nursing staff, patients and families in the ICU. The telepresence is remarkably human in nature enabling the physician to conduct a neurological exam on a patient. Studies have demonstrated that RONI can decrease morbidity, mortality and length of patient’s stay. The concept of a robot-doctor is now becoming a new standard of care across the United States.

Based on our experience with RONI, we have just launched the next generation of telerobotics, the iRobot-Doc EVA, Executive Virtual Attending physician. EVA represents a big step forward since it can drive itself around the ICU using autonavigation and can be operated via iPad by the push of a button. EVA saves time by moving to the bed of a patient in distress while the doctor checks the electronic medical record for critical information. EVA’s high-resolution optics and real-time data displays enable a full evaluation of the patient by the remote doctor. UCLA is using this technology to bring our expertise to our community hospitals so that neurocritical specialists can save lives through remote consultations. In this way, we hope to deliver the best care anywhere, anytime.

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

NEUROCRITICAL CARE PROGRAM | 53

Nader Pouratian, MD, PhD

54 | UCLA CENTER FOR NEUROMODULATION & NEUROBIONICS

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

“

The brain is a complex electrical circuit. Neurobionics is the electronic interface with the human brain. We implant electrodes to stimulate or, in essence, reset the electrical activity for people debilitated by their disease. —Nader Pouratian, MD, PhD, Director of the Neuromodulation & Neurobionics Program

he UCLA Neuromodulation and Neurobionics Program brings together a world-class team of neurosurgeons, neurologists, psychiatrics, pediatric neurologists and psychiatrists, electrophysiologists, bioengineers, computer scientists and neuroscientists specialized in deep brain stimulation for movement disorders such as Parkinson’s disease, essential tremor and dystonia and other neurologic and psychiatric diseases. Our team is a national leader, having treated more than 500 patients with brain pacemakers since the program’s inception. Each week, we treat one to two

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

”

patients. We are pioneers in the use of stereotaxis in deep brain stimulation with a vast experience in computer-assisted image guidance that allows us to implant the brain pacemakers with precision. Our team of experts in brain pacemaker implants are improving and extending quality of life for patients who have reached a stage where medications are no longer reliable. In advancing deep brain stimulation, the team is launching early clinical trials, implanting electrodes deep in the brain to stimulate neuronal activity in patients suffering from severe depression and obsessive compulsive disorder.

UCLA CENTER FOR NEUROMODULATION & NEUROBIONICS | 55

NEXT GENERATION Translating Brain Signals into Language and Movement r. Nader Pouratian, MD, PhD, has been conducting research using imaging techniques to map the human brain and electrical recording techniques to decode the signals that neurons use to communicate with each other. Essentially, he is translating

neuronal language. The first generation of this brain-computer interface uses an electrode cap on the patient’s head that translates thoughts or brain signals into letters that can be spelled out on a computer screen. The goal is also to reconstruct sounds into language using the brain-computer interface known as

the translator—using electrodes connected to the brain and a computer that interprets what you are trying to say. Next-generation nanoelectrodes implanted in the brain will translate thoughts or intended activities connected to a brain-computer interface embedded in a prosthetic arm or leg.

500TH PATIENT IMPLANTED WITH A BRAIN PACEMAKER AT UCLA Celebrating the 500th patient implanted with a brain pacemaker at UCLA, Dr. Nader Pouratian performed the surgery and shared the experience with 40 million viewers from around the world on Twitter. It was the first awake brain surgery to be publicly shared using Twitter and video-based social media platform Vine. The patient, Brad Carter, a 39-year-old actor and musician from Los Angeles, played a guitar in the operating room while Dr. Pouratian tested the electrical impulses to stimulate his brain and slow his benign essential tremor. In the summer of 2006, the tremors began First Live-Tweeted Brain Surgery in the World in his hands and eyes. Medications failed to stop the tremors that gradually deteriorated his career as musician and song writer. “Little by little, it steals you,” Brad said about the uncontrollable Dexter and the Mentalist. tremors. “I felt my creative life vanishing. I wanted to prolong my Brad brought his guitar into the operating room with hopes of creative life, my life.” fine-tuning the stimulation, so he could return to his passion and In a medical miracle moment caught on Vine and posted on perform live again. After his second surgery to have the battery Twitter, Brad’s tremors slowed and he played the guitar live in the placed and his pacemaker programmed, Brad appeared on stage OR. “And he was really good,” Dr. Pouratian said. at UCLA to play guitar live, captivating the world once again. Once the videos posted, they rapidly circled the globe like a “There’s nothing like losing a skill that you were really good at to grapevine. Millions of folks watched in awe, including William make you want to have that skill back,” Brad said. “I can’t wait to be Shatner who shared the Vines with fans, friends and followers. Brad creative again and I can’t wait to play guitar again. I’m very excited is no stranger to cameras. He has acted on shows such as CSI, to record an album as this gets better.”

56 | UCLA CENTER FOR NEUROMODULATION & NEUROBIONICS

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

NEUROMODULATORS RAISING THE BAR FOR DEEP BRAIN STIMULATION ader Pouratian, MD, PhD, Director of the UCLA Center for Neuromodulation and Neurobionics, and his team is currently developing and testing a sensing generator that will continuously record signals in the brain and automatically program the frequency of the stimulation to deliver the therapy in real time without the physician and patient needing to fine-tune. This will improve the current method to implant electrodes and later fine-tune the stimulation. The sensing generator will automate and personalize deep brain stimulation. BRAIN PACEMAKER IMPLANTED TO TREAT PARKINSON’S

NEUROMODULATION & NEUROBIONICS

Conditions Treated A wide range of neurological diseases cause tremors, spasticity, muscle rigidity, pain and other movement disorders. These symptoms are produced by irregular activity in the brain. Neuromodulation can be effective for patients who have not responded sufficiently to other less-invasive treatment options for conditions such as the following: Movement Disorders: Parkinson’s disease, essential tremor, dystonia (including cervical dystonia). Spasticity: Multiple Sclerosis, cerebral palsy, stroke, spinal cord injury, head injury. Pain: Trigeminal neuralgia, occipital neuralgia, cluster headaches, migraines.

500

1ST

MORE THAN 500 DEEP BRAIN STIMULATIONS PERFORMED

OUR WORLD-CLASS EXPERTS INTERSECT 10 MEDICAL SPECIALTIES

INVESTIGATING USE OF DBS IN 7 NEW APPLICATIONS

TO UTILIZE STEREOTAXIS IN DEEP BRAIN STIMULATION

Nader Pouratian, MD, PhD PROGRAM DIRECTOR Susan Y. Bookheimier, PhD, Alexander Bystritsky, MD, PhD Patricia Walshaw, PhD

NEUROLOGY

DEPARTMENT OF PSYCHIATRY AND BIOBEHAVIORAL SCIENCES

Antonio De Salles, MD, PhD DIRECTOR OF FUNCTIONAL NEUROSURGERY

NEUROLOGY, DIRECTOR OF UCLA MOVEMENT DISORDER PROGRAM

RADIATION ONCOLOGY

YVETTE BORDELON, MD, PHD, IS ASSISTANT PROFESSOR OF NEUROLOGY SPECIALIZING IN MOVEMENT DISORDERS.

OUR THERAPIES Deep brain stimulation (DBS) Intrathecal infusion pumps Microvascular decompression

Tourette’s syndrome Post-traumatic Stress Syndrome Dementia Depression Addiction Morbid obesity Tinnitus

Doctor Highlight

Jeff Bronstein, MD, PhD

Tania Kaprealian, MD

Future Therapy We are investigating deep brain stimulation for:

INTERDISCIPLINARY TEAM Yvette Bordelon, MD, PhD, Allan Wu, MD

Psychiatric Disease: Obsessive Compulsive Disorder.

Motor cortex stimulation Radiofrequency ablation Spinal & peripheral nerve stimulation

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

Stereotactic radiosurgery

UCLA CENTER FOR NEUROMODULATION & NEUROBIONICS | 57

NEUROMODULATION & NEUROBIONICS

PATIENT HIGHLIGHT

RICHARD ROTHENBERG

THE BIONIC MAN ichard Rothenberg walked on Main Street with his family at Disneyland. It was turning out to be a memorable day, though not exactly the kind of memory for the family photo album. Pain racing like wildfire through his knees, elbows and hips became devastatingly clear to him. He recalls the moment as the line of demarcation splitting his life into two distinct halves. While threading through the crowd, his cousins, both doctors, listened to Richard describe the radiating pain that his orthopedist and acupuncturist failed to control. His cousins detected a neurological problem, the type they see in the elderly, not a 37-year-old man in the prime of his life. Richard went to UCLA to see Jeff Bronstein, MD, PhD, a renowned neurologist. The neurological test and MRI scans confirmed his cousins’ suspicions of Parkinson’s disease. “I started to deteriorate,” Richard said.

58 | UCLA CENTER FOR NEUROMODULATION & NEUROBIONICS

“It came in peaks and valleys. At my worst I would become completely paralyzed unable to move for 45 minutes to an hour, for 4 to 5 times a day. All I could do was lie down and hope being frozen would pass. It was a terrifying experience. Even though I knew it would pass, I felt like I was never going to move again.” The medications worked initially, but then ceased. In denial, he refused to consider Dr. Bronstein’s recommendation for surgery. Gradually, his work and family slipped away. He moved in with his parents because he could no longer take care of himself. His ex-wife took care of his children. The days turned into years. Then a wake-up call came in the form of a lung infection that exacerbated the Parkinson’s symptoms. He visited Dr. Nader Pouratian to explore a brain pacemaker. “On my first visit with Dr. Pouratian, I immediately had a good feeling about him,” Richard said. “He had very steady hands and a firm

handshake. He also made me feel confident and was very tolerant of all my family asking him a million questions. With this procedure, bedside manner is important, as you’re awake for part of the surgery.” Six years after his initial diagnosis, Richard began an awake craniotomy for deep brain stimulation. “The effect of the procedure was instantaneous. When they switched me on, my nerves felt smooth—for the first time in a long time. It was truly magical. I’m the envy of all my non-bionic friends. The affect this has had on my life with my kids—I can now be a physically active father.” Richard returned to work as a banker and enjoys being able to participate in physical activities with his kids. “My daughter really only knew me with Parkinson’s disease,” Richard said. “It’s a new life for us now. Miracles can happen.” This year, Richard fell in love, married, and is now the father of twins.

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

NEUROMODULATION & NEUROBIONICS

RICHARD’S TIMELINE

2005

Richard is diagnosed with Parkinson’s at UCLA.

History of Firsts First to provide image guidance of deep brain stimulation surgery.

2006

Medications temporarily control the disease.

2007-09

First to provide comprehensive surgical management of peripheral nerve disease.

Medications cease to be effective and the disease gradually takes over his body.

Highlights

His life deteriorates. Richard can no longer work, take care of himself or be a father to his children.

2010

2011

We have performed more than 500 deep brain stimulation surgeries, more than any other center in Southern California.

Brain pacemaker is implanted, giving Richard a new lease on life. He returns to work and finds joy in once again becoming an active father.

Our extensive experience in computer-assisted image guidance allows us to implant brain pacemakers with precision.

2012 Richard gets married and fathers twins.

“

The effect of the procedure was instantaneous. When they switched me on, my nerves felt smooth—for the first time in a long time. It was truly magical. I’m the envy of all my non-bionic friends. The affect this has had on my life with my kids—I can now be a physically active father. —Richard Rothenberg

RICHARD’S TEAM

We have pioneered the use of stereotaxis in deep brain stimulation.

”

We perform the DBS procedure using an “asleep-awake-asleep” craniotomy ensuring patient comfort and in-depth testing to optimize outcomes. Besides deep brain stimulation, we perform spinal cord stimulation, peripheral nerve stimulation, and other innovative procedures almost daily.

NIH Grants

Nader Pouratian, MD, PhD Dr. Pouratian’s primary neurosurgical interest is in surgeries that preserve and restore function to patients, including movement disorder surgeries, surgeries for psychiatric conditions and surgeries for peripheral nerve injuries and tumors.

Total NIH Funding

$968,996 TOTAL NIH/NON-NIH GRANTS, INCLUDING DIRECT & INDIRECT COSTS, FOR THE DURATION OF THE RESEARCH PERIOD

Nader Pouratian, MD, PhD

Eric Behnke

NEUROSURGERY

CLINICAL SPECIALIST IN OR

Arik Johnson, MD

Susan Bookheimer, MD

NEUROLOGY/PSYCHOLOGY

NEUROPSYCHOLOGIST

Yvette Bordelon, MD, Jeff Bronstein, MD NEUROLOGY

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

UCLA CENTER FOR NEUROMODULATION & NEUROBIONICS | 59

Langston T. Holly, MD

60 | UCLA SPINE CENTER

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

“

Our Spine Center gives patients access to a team of experts working together to evolve the optimal treatment plan. We weigh the options of non-invasive and minimally-invasive approaches to eliminate chronic pain and get them back to normal daily living. We take the journey with our patients from surgery through rehabilitation. —Langston T. Holly, MD, Director of the UCLA Spine Center

he UCLA Spine Center is one of the only academic spine programs in the country with a completely integrated practice that incorporates neurosurgeons, orthopaedic surgeons, physiatrists and clinical scientists in one seamless unit. Langston T. Holly, MD, Director of the UCLA Spine Center, specializes in neurosurgery and collaborates with specialists in orthopedic care to lead a world-class spine team in the diagnosis, management and treatment of spinal disorders, spinal injuries, chronic spinal pain and degenerative spinal diseases. Our experienced surgeons performed more than 900 surgeries last year. The UCLA Spine Center leads the nation in National Institute of Health (NIH) spine research funding. Active research programs include basic and clinical science for spinal cord injury research as well as advanced imaging techniques for the evaluation of degenerative spine disease. It is also one of the very few centers in the world with the ability to readily translate basic science breakthroughs discovered in the laboratory

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

”

to the treatment of spinal disorders in patients. We are leaders in the bench-to-bedside approach, which translates to our patients receiving unique cutting-edge treatments and innovative surgical techniques that optimize outcomes and improve recovery and function. Additionally, UCLA has a tradition of treating patients with Chiari malformation and with syringomyelia, going back over 30 years. We have treated more than 350 patients with Chiari malformation and more than 150 patients with syringomyelia. Chiari malformation and syrinomyelia are complex entities, which are frequently missed in diagnosis. Our panel of specialists who constitute a center for the treatment of these disorders is also involved in disseminating information among the medical community, patients and their families. The human spine is the strength and nerve center of the human body, for this reason, our neurosurgeons are committed to the full recovery of our patients every step of the way from the evaluation through surgery and rehabilitation.

UCLA SPINE CENTER | 61

RE-ENABLING MOTOR FUNCTION Restoring Spinal Cord Function by Modulating Spinal Cord Circuitry aniel Lu, MD, PhD, Assistant Professor of Neurosurgery and Director of the Neuromotor Recovery and Rehabilitation Center, and Reggie Edgerton, PhD, Distinguished Professor of Integrative Biology, are conducting groundbreaking translational bench-to-bedside research to stimulate lost motor function in six patients inflicted with a spinal cord injury that has resulted in paralysis of the extremities. The clinical trials are modulating the excitability of the neural circuits that control the spinal cord. We stimulate these circuits with epidural electrodes placed over the lumbosacral spinal cord. When this stimulation is combined with motor training, the neural circuits become remarkably effective at basic movements, such as standing and stepping and even maintaining balance. The research team is demonstrating that the spinal cord neurons are intelligent and have a memory of these movements to stand

and step with minimal input from the brain. The National Institutes of Health awarded a significant grant of $6 million to Dr. Lu and Dr. Edgerton to conduct these clinical trials that could have applications for patients with paralysis. More than 5 million Americans live with paralysis that results in an inability to move the upper and lower extremities. An estimated 1.3 million suffer from spinal cord injury. Christopher Reeve was afflicted with this injury that paralyzed him from the neck down. New hope for patients with spinal cord injury came when Rob Sommers, 25, paralyzed for four years as the result of a car accident, stood for 30 minutes and took steps on a treadmill with assistance. This breakthrough study was published in the prestigious medical journal, The Lancet in 2011, by Dr. Edgerton and a team of scientists from University of Louisville, the California Institute of Technology and the Pavlov Institute

of Physiology in St. Petersburg, Russia. The stimulation transmited signals that mimiced the brain to initiate motor function. The rehabilitation retrained the spinal cord network to produce movements to stand and take steps. In addition, after weeks and months of daily stimulation, significant improvement occurred in bladder function, blood pressure control, temperature control and sexual function. Dr. Lu and Dr. Edgerton are focused on further improving patientsâ&#x20AC;&#x2122; ability to recover greater levels of motor and autonomic function through the synergistic effects of pharmacological neuromodulation combined with epidural stimulation and locomotor training. The time has finally come when we can tell patients that through novel therapies, they may return to a normal life after their injury, and that here at UCLA, we will be with them every step of the way.

INNOVATION, DISCOVERY & ADVANCING OF TRANSLATIONAL SCIENCE At the UCLA Spine Center, we are at the forefront of innovation and technology to improve the treatment of spinal disorders and develop new strategies to increase functional recovery after spinal cord injury. The Neuromotor Recovery and Rehabilitation Center (NRRC) directed by Dr. Daniel Lu, utilizes cutting-edge tools, such as the upper extremity robot, to assess function and test regimens that can improve spinal cord function. Our researchers utilize advanced molecular techniques and multiple approaches to increase the capacity of nerve cells to establish circuits and process information. The research is also focused on the application of the intrinsic power of nutrients serving as food for the central nervous system, which can help damaged spinal cord circuits improve function and foster rehabilitative strategies.

62 | UCLA SPINE CENTER

THE UPPER EXTREMITY ROBOT IS USED TO ASSESS MOTOR FUNCTION

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

SPINE CENTER

TOP 5 IN THE NATION

UHC RANKS UCLA AMONG TOP SPINE CENTERS he University Healthsystem Consortium (UHC) reviews national academic medical centers to determine excellence in clinical outcomes, reviewing quality, safety and cost effectiveness. Based on studies concluded in March of 2013, the UHC ranked the UCLA Spine Center at Ronald Reagan UCLA

Medical Center #4 in the nation for spine surgery. The UHC quality and accountability study takes into account and evaluates all 62 academic spine centers in the nation.

Cases

LOS

Readmit Rate

PENN HOSP

1,170

1.04

4.44%

DUHS DUKERALEIGH

874

0.71

4.46%

URMC HIGHLAND

649

0.75

3.24%

UCLA SANTA MONICA

592

1.07

3.38%

NEWTOWN

406

0.81

5.28%

TOTAL NUMBER OF SPINE SURGERY CASES SINCE 2005

Coordinated care—neurosurgery and orthopaedic specialists collaborate to evolve the best plan of care to meet the individual needs and lifestyle of our patients. NIH-funded translational research for spinal cord injury, one of an elite few in the country. Pioneers in minimally-invasive spine surgery.

Spine Center

5,955

Highlights

Non-invasive spine surgery—the Novalis Tx stereotactic radiosurgery is a focused beam of radiation to treat tumors and abnormalities without spine surgery. Non-surgical solutions for degenerative spinal conditions include radiofrequency ablation, spinal cord stimulation, spinal injections, trigger point injections, physical therapy, rehabilitation and pain management.

0% RATE OF CEREBROSPINAL FLUID LEAK ON 101 MINIMALLY-INVASIVE LUMBAR MICRODISCECTOMIES

RATE OF REOPERATION FOR RECURRENT DISC HERNIATION ON 101 MINIMALLY INVASIVE LUMBAR MICRODISCECTOMIES

RANKED #4 IN THE NATION FOR SPINE SURGERY BY THE UHC

The Spine Center’s educational program is one of the first to integrate orthopaedic and neurosurgical fellows, residents and other international trainees in an active, collegial spine center. National leader among Spine Centers in NIH funded research.

INTERDISCIPLINARY TEAM Langston T. Holly, MD DIRECTOR Ulrich Batzdorf, MD, Daniel Lu, MD, PhD, Duncan Q. McBride, MD

David Fish, MD, Jae Jung, MD PHYSICAL MEDICINE & REHABILITATION

NEUROLOGICAL SURGERY

A. Nick Shamie, MD

V. Reggie Edgerton, PhD, Fernando Gomez-Pinilla, PhD

ORTHOPAEDIC SURGERY

RESEARCH SCIENTISTS

CONDITIONS TREATED Chiari malformation Congenital abnormalities Degenerative disc disease

Disc herniation Osteomyelitis Rheumatoid arthritis

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

Scoliosis Spinal cord tumors Spinal injury

Stenosis Syringomyelia

UCLA SPINE CENTER | 63

SPINE CENTER

PATIENT HIGHLIGHT

CODY WILLIAMS

YOUTHFUL DETERMINATION n a Friday night in 2009, the first football game of the season at Santa Monica High School, Cody Williams, a junior playing varsity, tackled the quarterback as he entered the end zone. Cody’s facemask caught on the quarterback’s knee. Snap. Cody’s head jerked back at a velocity that injured his neck and spine. Cody blacked out. He crashed onto the field. His mother, Stacy, dressed in his jersey emblazoned with “14” waited for him to get up. “Get up,” she silently repeated over and over as he lay motionless on the field. The ambulance rushed him to Santa Monica UCLA Hospital. Dr. Langston T. Holly had just emerged from a surgery when he received word of the football player with a spinal cord injury. He was paralyzed from the neck down, essentially a quadriplegic. Dr. Holly saw Cody’s mom wearing his football jersey and he remembered his own mom wearing his jersey to his football games. He then flashed forward to his own sons playing football. “I performed the surgery in the same way I

64 | UCLA SPINE CENTER

would do it if it was my own son laying there on the operating table,” Dr. Holly said, reflecting on the more than nine hour surgery that it took to stabilize Cody’s neck and spine. When Cody awoke from surgery, he could move his left arm, which filled his mother with hope. Cody was still quadriplegic, but Dr. Holly set the stage for rehabilitation of his spine to begin. “To me, I feel like Dr. Holly is an angel sent to the hospital because he did a perfect surgery on me,” Cody said. “If I didn’t have him, I don’t know where I would be today.” Dr. Holly referred Cody to his colleague Daniel Lu, MD, PhD, the principal investigator on a NIH-funded clinical trial to restore function to spinal cord injury patients. With novel rehabilitation and spinal cord stimulation that harnesses the circuitry of the spinal cord, Cody is seeing meaningful gains in his hands and even his legs. “Right after the surgery, I couldn’t even sit up,” Cody said. “But now I can sit up, I can swim. I can stand and take steps in physical

therapy. I will walk again.” In June 2011, Cody graduated from Santa Monica High School and received a standing ovation from the crowd as he accepted his diploma. For him and his Mom, this was a glorious, crowning moment in their journey from that night on the football field. Three months later, Cody was invited to speak on stage at the famous TedX Youth Conference in Santa Monica. He took the stage, holding a microphone (a miraculous feat for someone with his injury). “I came here to talk about staying positive through bad times,” Cody said into the microphone with a bold confidence. “I got hurt a couple years ago, and people always ask me, ‘Why are you so happy?’ I tell them there is really no point in getting down and upset. Getting down will just make you feel worse about it. Staying positive will help you get through it... Today, I can walk 40 steps with a walker.” The audience burst into applause and cheers. Today, Cody feels stronger than ever.

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

SPINE CENTER

CODY’S TIMELINE

National Leaders

2009 SEPTEMBER 11TH Cody is paralyzed from the neck down. Dr. Holly performs an emergency nine-hour surgery.

DECEMBER Physical therapy begins.

SEPTEMBER 12TH Following an all-night surgery Cody is placed in an induced coma in the ICU for healing.

2010

SEPTEMBER 15TH He wakes from coma and can move both hands.

AUGUST Cody stands with assistance on a walker, walks in the pool with assistance and swims using his arms. JUNE Cody graduates from Santa Monica High School.

2011 JANUARY Cody enrolls in spinal cord injury trial with Dr. Lu.

FEBRUARY Cody takes 40 steps on a walker and 55 the following week.

2012

MAY Cody uses a fork, writes with a pencil and walks with assistance on a treadmill.

APRIL Cody begins a clinical trial. Dr. Lu uses novel spinal cord stimulation to enable standing and stepping function.

2013

APRIL 12TH “I feel stronger than I ever have, I know I’m going to walk again, Mom,” says Cody, after stimulation therapy at Dr. Lu’s lab.

“

To me, I feel like Dr. Holly is an angel sent to the hospital because he did a perfect surgery on me. If I didn’t have him, I don’t know where I would be today. —Cody Williams

CODY’S TEAM

”

Langston T. Holly, MD Associate Professor and Co-Vice Chair of Clinical Affairs for the Department of Neurosurgery. Dr. Holly is a member of the UCLA Spine Center located in Santa Monica. Dr. Holly’s focus is on minimallyinvasive and image-guided techniques in the surgical management of degenerative, traumatic and neoplastic spinal disorders. Langston T. Holly, MD, Aaron Cutler, MD, Daniel Lu, MD, PhD, Paul M. Vespa, MD

Melinda Guttry, Jacquelyn Glenn PHYSICAL & OCCUPATIONAL THERAPY

NEUROSURGERY

Edgar Anaya, Piia Haakana, Naomi Gonzalez

The UCLA Spine Center is one of the leading centers conducting NIH studies on spinal cord injury and imaging for evaluation of spinal disorders. Using Diffusion Tensor Imaging (DTI), we are able to generate a 3D image of the spinal cord nerves called the “fiber tractography” (above middle/right). DTI can identify separate nerve fibers running rostral-caudal, antero-posterior, and left to right. It is more detailed than standard MRI (above left).

NIH Grants National Institute of Neurological Disorders & Stroke MRS and DTI as biomarkers of spinal cord viability in chronic spinal cord injury. MRS to explore spinal cord viability in chronic spinal cord injury. Enabling forelimb function with agonist drug and epidural stimulation in SCI. Neurotrophins Support Spinal Cord Learning and Rehabilitation.

Total NIH Funding

$8,199,155 TOTAL NIH/NON-NIH GRANTS, INCLUDING DIRECT & INDIRECT COSTS, FOR THE DURATION OF THE RESEARCH PERIOD

RESEARCH

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

UCLA SPINE CENTER | 65

Gary W. Mathern, MD, with patient Dylan Catania

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UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

“

This is about changing kids’ lives for the better. Even with half of your brain removed, you can do a lot. Our patients go on to thrive, walk, talk, play, read, drive and graduate from high school and college.

”

—Gary W. Mathern, MD, Director of the Pediatric Epilepsy Surgery Program

he UCLA Pediatric Epilepsy Surgery Program is a world leader in the diagnosis, treatment and management of rare childhood diseases that cause intractable epilepsy. Our interdisciplinary team has performed more than 750 surgeries on infants and children with intractable epilepsy. More than 225 of those patients received hemispherectomies since the center’s inception in 1986. We were the first to operate on infantile spasms and are one of the few centers in the world that offers surgery to children with intractable epilepsy. Our team consults with pediatricians around the world, and children come to UCLA from across the country. The majority of children who receive surgery go on to live seizure-free lives.

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

One reason children have such good outcomes is that we conduct highly detailed and accurate evaluations prior to surgery. Our team is sensitive to the emotional, developmental, psychological, educational, social, economic and familial challenges facing the families of children undergoing surgery. We collaborate seamlessly with the child’s physician before and after to ensure the best outcomes. Our team includes talented and compassionate specialists in pediatric neurosurgery, pediatric neurology, child psychiatry, pediatric neuroradiology, pediatric neuropsychology, developmental linguistics and neuropathology, clinical nurse specialist and social workers.

PEDIATRIC EPILEPSY SURGERY PROGRAM | 67

BANKING ON THE FUTURE OF DNA TECHNOLOGY A Decade of Brain Tissue Sampling Helps Unlock Mystery of Rare Pediatric Epilepsy or more than a decade, Gary W. Mathern, MD, Director of the Pediatric Epilepsy Surgery Program at UCLA, has slowly and methodically collected brain tissue and DNA from children with a very rare disease called hemimegalencephaly. This debilitating disease causes severe epilepsy. Currently, Dr. Mathern performs hemispherectomy procedures to remove the dysfunctional hemisphere of the brain and eliminate the occurrence of seizures, which damage the entire brain. Dr. Mathern knew the answer to what was going on with these children lay in their tissue and

DNA. He was the only one in the world who stored these vital tissue samples, waiting until technology caught up. Today, the answer can be found in a recent edition of Nature Genetics. Dr. Mathern’s study has uncovered a trio of genes, called de novo somatic mutations, which control cell size and proliferation and are the catalyst of hemimegalencephaly. The study suggests that drugs already in existence to stop or lower the signals from these mutated genes could be designed to reduce or eliminate the need for radical surgery that entails removing half of the child’s brain. This could be the tip of the iceberg and lead to the

genetic mutations that may cause other childhood diseases like autism. Dr. Mathern is the Co-Editor in Chief of Epilepsia, a renowned medical journal supported by the International League Against Epilepsy. He received the Ambassador for Epilepsy Award of the International Bureau for Epilepsy and the International League Against Epilepsy to recognize his outstanding international contributions to advancing the cause of epilepsy. Recently, he awed a wide audience at TEDxConejo with his presentation What Can You Do With Half a Brain?

PIONEER IN GIVING SEIZURE-FREE LIFE TO CHILDREN Gary W. Mathern, MD, is a Professor and Director of the Pediatric Epilepsy Surgery Program and Pediatric Neurosurgery Program in the Department of Neurosurgery at UCLA. He is a pioneer in the surgical treatment of children with epilepsy. He is highly pursued for his expertise in treating pediatric epilepsy with the cerebral hemispherectomy that entails removing half of the dysfunctional brain causing seizures in infants and children. He modified an intricate surgical technique, a lateral hemispherecotomy, to perform this procedure on infants that was published in the Journal of Neurosurgery in 2004 and is now used worldwide. After the hemispherectomy, the brain miraculously rewires functions using only one side of the brain. For this reason, he advocates this procedure to be performed as early as

68 | PEDIATRIC EPILEPSY SURGERY PROGRAM

possible because the brain is more plastic in early development. The later the surgery, the longer the infant or child suffers multiple seizures that can cause debilitating and irreparable brain damage. He recommends that a child be evaluated for surgery if two anti-seizure medications have failed to stop the seizures. Families have described their children pre-surgery as trapped inside their bodies and post-surgery as alive, thriving, walking and talking. This is a true marvel of neurosurgery and a gift of life Dr. Mathern has given to families stuck in an endless cycle of thirty to fifty seizures a day that rob their children of life and normal development. Without the surgery, these children would have been headed to an IQ of 50, not being able to recognize mom or dad by age one, not likely to talk or engage in social

activity. The radical neurosurgical intervention frees the child’s brain to develop. Dr. Mathern has performed hundreds of these surgeries and his patients go on to miraculous recoveries, learning how to talk, read and go to school, obtain their driver’s licenses and graduate from high school and college.

DR. GARY W. MATHERN WITH DYLAN CATANIA IN 2010

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

QUEST FOR A CURE hortly after his daughter Grace’s 10th birthday, Seth Wohlberg witnessed the tragic attack of Rasmussen’s Encephalitis (RE) on her brain. In an instant, uncontrollable seizures ensued. This rare disease began to paralyze one side of her body. The only treatment was to remove half of her brain and rely on plasticity —the brain’s ability to rewire itself—to return many of her neurological functions. In 2010, Dr. Gary W. Mathern performed a hemispherectomy freeing Grace of the seizures. Mr. Wohlberg started the RE Children’s Project, a non-profit organization, to support scientific

research toward a cure for RE. Mr. Wohlberg has become the leading voice, steward, and advocate for this rare disease in America and across the globe. The RE Children’s Project supports UCLA research in collecting the brain tissue of patients with RE and studying the brain and immunologic cells along with genetics to unlock the cause in order to develop novel treatments and ultimately a cure.

PEDIATRIC EPILEPSY PROGRAM

History of Firsts One of the first extensive pediatric epilepsy surgery centers in the world. First to apply FDG-PET in clinical decision-making for pediatric epilepsy. First to apply FDG-PET/ MRI coregistration for pediatric patients, and magnetoencephalography MEG in tuberous sclerosis complex. First to invent and perform lateral hemispherectomy procedure for young children. First comprehensive tuberous sclerosis complex clinic in North America for children with epilepsy.

SETH WOHLBERG WITH DAUGHTER GRACE

First to operate on infantile spasms.

NIH Grants Cortical plasticity after hemispherectomy.

750

225

SURGERIES ON INFANTS AND CHILDREN WITH INTRACTABLE EPILEPSY

HEMISPHERECTOMIES PERFORMED ON INFANTS & CHILDREN

80% OF HEMISPHERECTOMY PATIENTS ARE NOW LIVING SEIZURE-FREE

1st HOSPITAL TO OPERATE ON INFANTILE SPASMS

Total NIH Funding

Gary W. Mathern, MD PROGRAM DIRECTOR Joyce Wu, MD, Joyce Matsumoto, MD, Lakha Rao, MD, Shaun Hussain, MD, Noriko Salamon, MD

PEDIATRIC NEUROLOGY

Jason Lerner, MD

PEDIATRIC NEURORADIOLOGY

PEDIATRIC EEG LABORATORY

$4,002,612 TOTAL NIH/NON-NIH GRANTS, INCLUDING DIRECT & INDIRECT COSTS, FOR THE DURATION OF THE RESEARCH PERIOD

Doctor Highlight

Harry V. Vinters, MD NEUROPATHOLOGY

CONDITIONS TREATED Brain trauma Cavernomas Cortical dysplasia hemimegalencephaly

Pathophysiology of developing dysplastic human cortex. Molecular characterization of hemimegalencephaly.

WHO WE ARE Raman Sankar, MD, PhD

Mechanisms altering electrical conductivity & DTI in epilepsy patients.

Hippocampal sclerosis Hypothalamic hamartoma Hypothalamic hamartomas infarctions

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

Infections Rasmussen encephalitis Sturge-Weber syndrome Tuberous sclerosis complex

tumors Other rare conditions associated with intractable epilepsy

RAMAN SANKAR, MD, PHD, IS PROFESSOR OF NEUROLOGY & PEDIATRICS AND CHIEF OF PEDIATRIC NEUROLOGY.

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PEDIATRIC EPILEPSY SURGERY PROGRAM

PATIENT HIGHLIGHT

DYLAN CATANIA

SMALL WONDER he Catanias rang in the 2010 New Year with the birth of their healthy baby boy, Dylan. He was born 6 pounds, 5 ounces and measured 19 inches. Ellen was swaddling her newborn to go home from the hospital when the first seizure struck. His eyes rolled and rhythmically twitched. His body shuddered. Ellen pressed the nurse button and then ran into the hall, yelling for help as her baby looked vacant. Dylan was rushed into neonatal intensive care. Tests revealed that Dylan had hemimegalencephaly, a rare congenital disease that causes one side of the brain to grow larger than the other. Dylan’s parents and their 9-year-old daughter, Bella, waited for answers that finally came that afternoon, when Dr. Gary W. Mathern, an expert in hemimegalencephaly and the Director of the Pediatric Epilepsy Program at UCLA, entered their lives. The only treatment to stop the seizures was to surgically remove the enlarged half of his brain.

70 | PEDIATRIC EPILEPSY SURGERY PROGRAM

“‘I’m going to take care of this, don’t you worry,’ Dr. Mathern said to us on our first meeting, and we hung on to his words through every seizure that followed,” Ellen said. The hemispherectomy would give the left side of his brain a chance at neuroplasticity, the brain’s natural ability to rewire itself, to enable development. Without the treatment, the seizures on the right side would eventually move to the left and hijack his brain in such a way that by his second birthday he would be mentally retarded, unable to talk or recognize his parents, and never reach an IQ of more than 50. With the surgery, he had a chance to develop, walk and talk. The physical set back would affect the left side of his body, Dylan would be weak, his left hand would be paralyzed and he would have a blind spot in his left eye. He would need to be at least three months to undergo this radical procedure. Until then, he suffered fifty to sixty seizures a day. More than one thousand seizures later, Dylan entered operating room number 7 at Mattel

Children’s Hospital at UCLA. Within minutes, the anesthesiologist relaxed him to sleep. Dr. Mathern slipped on his magnified glasses. He raised his scalpel and said to the nurse, “Call Mom and Dad. Tell them we’re beginning.” The clock read 9:15 a.m. The surgery meant navigating through the tiny folds of the brain to arrive at the corpus callosum at the base that connected the two hemispheres. He delicately disconnected the right hemisphere of the brain, being careful not to leave any tissue connected that would lead to seizures. By 3:55 p.m., he and his team stitched up Dylan. At 4:20 p.m., Dr. Mathern went down to see Ellen and Jeff to report a successful surgery. Today, Dylan is three years old. He has remained seizure-free since the surgery, in April 2010. Each developmental milestone is a victory for the family and they have celebrated many. Dylan knows his parents and big sister, Bella. The toddler talks, walks, laughs, dances, claps and brings his family utter joy each and every day.

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

ACCESSING DYLAN’S BRAIN

BRAIN FUNCTION & THE PROBLEM Right hemisphere

Inter-hemispheric fissure Left hemisphere

Right hemisphere

Inter-hemispheric fissure Left hemisphere

Corpus callosum

Thalamus

Lateral ventricles

Cross-section (shown at right) Brainstem

Frontal lobe

Cross-section

Temporal Sylvian lobe fissure

The brain is divided into two hemispheres by a fissure and is connected to the rest of the body through the brainstem.

Cuts in scalp

Internal capsule

Brainstem

The major connection through which the two hemispheres communicate is the corpus callosum.

The hemispheres also communicate with the brainstem and spinal cord through the thalamus and internal capsule.

A t-shaped cut in the scalp was peeled back into two flaps.

DYLAN’S SURGERY 2.

The affected hemisphere of Dylan’s brain was disconnected from the other hemisphere and brainstem. Most of the disconnected hemisphere was allowed to remain in place, where it will continue to receive blood and help with normal growth and skull formation.

Cuts in skull

Holes

Corpus callosum Lateral ventricles Thalamus Thalamus

Cortex

Temporal horn

Brainstem

The hemispheres of the brain contain fluid-filled, irregularshaped cavities called ventricles.

“

A section of the cortex was removed, creating a “doughnut hole” through which internal brain structures could be accessed.

Once the skull was penetrated and the brain exposed, an incision was made that followed the shape of the ventricle.

There are no words to describe him. Dr. Mathern is outstanding. He saved our son’s life. He saved our lives. Dylan is now the baby boy we had been waiting for. —Jeff Catania (Dylan’s Father)

DYLAN’S TEAM

”

Gary W. Mathern, MD Professor in Residence and Director of the Pediatric Epilepsy Surgery Program and Pediatric Neurosurgery Program. Dr. Mathern works in conjunction with the Epilepsy Surgery Program to provide surgical treatment for children with epilepsy.

Gary W. Mathern, MD,

Noriko Salamon, MD

Barbara Van De Wiele, MD

PEDIATRIC NEUROSURGERY

PEDIATRIC NEURORADIOLOGY

ANESTHESIA

Raman Sankar, MD, PhD

Conrad Szeliga, Andrea Duran, Jimmy Nguyen

Judith Brill, MD

PEDIATRIC NEUROLOGY

Holes were drilled in the exposed skull and cuts joined the holes.

EEF SPECIALISTS

Exposed brain

Bone flap

The flap of Dylan’s skull was opened, using his temporalis jaw muscle as a hinge. The bone section continued to receive blood supply.

Staples in Scalp

The disconnected part of Dylan’s brain is still alive and seizing but is harmless. His skull was closed using titanium screws and his scalp stapled shut.

PEDIATRIC ICU

Illustrations by Paul Duginski Los Angeles Times

Harry Vinters, MD NEUROPATHOLOGY

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

PEDIATRIC EPILEPSY SURGERY PROGRAM | 71

GLOBAL NEUROSURGERY

INSTITUTE COLLABORATION. DISCOVERY. EXCELLENCE. The Edie & Lew Wasserman Building

e are on the verge of opening the first-of-its-kind Global Neurosurgery Institute in the Edie and Lew Wasserman Building at UCLA in 2014. The top two floors of this stateof-the art facility will become the headquarters for the UCLA Department of Neurosurgery, uniting our world-class expert neurosurgeons and neuroscientists in one place, to ignite a truly unique atmosphere of collaboration that will transform the way we practice medicine and perform our translational bench-to-bedside research at UCLA.

As one of the world’s top 10 neurosurgery departments, we are leading the world in research, patient care and training of the next generation of neurosurgical pioneers. The Global Neurosurgery Institute will house the most advanced patient clinic, faculty center, training pavilion and comprehensive neurosurgery campus, poised to invent the future of neurosurgery. This institute, and all that it stands to accomplish for the global future of neurosurgery, was realized and made possible by the vision and support of private donors.

INVENTING THE FUTURE OF HEALTH CARE

EXPERT KNOWLEDGE, GLOBAL EXCHANGE

Global Neurosurgery Institute

Clinical Pavilion, One Place, Team Care

Advancing our spirit of collaboration across disciplines to provide our patients with the most cutting-edge treatments and care is expanding beyond our walls to network with experts across the nation and around the world in the Global Neurosurgery Institute at UCLA. Accumulated global knowledge on confronting neurological diseases and disorders of the brain and spine such as stroke, cancer, Parkinson’s, Alzheimer’s and autism, will be in our hands. The latest in treatments and fundamental understanding of these diseases from the physical, to the mental, to the genetic level will provide us with boundless opportunities to solve neurological problems and fully restore the brain so our patients will no longer by paralyzed by disease, but instead move beyond to live healthy, productive and worthwhile lives.

We are building a patient care center where world-class experts who are dedicated to solving the mysteries of your disease collaborate to optimize the most advanced treatment plan available, all accessible in one place. Video conferencing will provide truly global patient-doctor interactions. With the goal to improve survival and quality of life, we will devise a personalized plan of care for our patients. Experts in neurosurgery, neurology, psychology, brain mapping, cardiology, diet, nutrition and physical therapy from UCLA, and around the world, will interact in a dynamic atmosphere to weigh the risks and benefits of treatments, to enhance optimal outcomes for our patients. This coordinated team will reform health care from the inside to set a new gold standard focused on collaboration, the secret weapon to beating these diseases of the brain and spine.

72 | GLOBAL NEUROSURGERY INSTITUTE

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

OUR VISION FOR THE FUTURE OF NEUROSURGICAL CARE Neurosurgery Scholars Pavilion: Global Possibilities On the top floor of our headquarters will be the Neurosurgery Scholars Pavilion, home to our international network connecting our doctors and scientists to medical centers and research facilities across the United States, Latin America, Israel, Asia, Europe, Africa and the Middle East. By fostering global possibilities for advancing research, neurosurgical techniques, collaborations and clinical trials, this pavilion will ultimately lead to medical breakthroughs and cures for neurological disease and disorders.

A GLOBAL CENTER OF RESOURCES & EXPERTISE Global Conference Pavilion: Convergence of Technology & Unparalleled Reach We envision the Global Neurosurgery Institute to be a global brain, or mission control center, for neurosurgery and neuroscience that will centralize medical knowledge using supercomputers, telemedicine and global conferencing, transforming the way we practice medicine. We are moving from responsive toward predictive medicine for our patients at UCLA and beyond. Our development of the 70-seat Global Conference Pavilion will be wired with the most advanced technology, internationally connected for collaborative opportunities across international time zones and geographical borders. We will be setting the international stage for physicians and scientists to work together to provide next-generation medicine and direct access to experts for the betterment of patient care. The possibilities are endless. Our patients will be the legacy of combined global experience and lifetimes dedicated to unearthing the solutions and treatments for tomorrow. Our power to conquer neurological disorders and disease is within reach as we connect our global knowledge, expertise and resources. United, we care for our patients, across America, and every continent and population around the world.

THE 70-SEAT GLOBAL CONFERENCE PAVILION WILL ACT AS A HUB FOR CONNECTING PHYSICIANS AND SCIENTISTS FROM AROUND THE GLOBE

TRAINING THE NEUROSURGICAL PIONEERS OF TOMORROW Neurosurgery Training Pavilion: Advancing Lifesaving Care Our mission at UCLA is laser-focused on innovation, from the latest technologies to cutting edge patient treatments. Our vision is to help hundreds, thousands and even millions of patients through innovation. With the same dedication, we train our neurosurgical residents with the latest techniques and treatments, as they take our methods of lifesaving care beyond our walls. The Neurosurgery Training Pavilion will have the latest technology for mock surgery practice using image-guidance systems to perfect neurosurgical skills in the most lifelike simulated experiences. Using our high-definition video and telemedicine, our neurosurgical residents can virtually beam into operating rooms in leading medical facilities across the country, while residents around the world can observe our world-class neurosurgeons perform surgeries.

THE NEUROSURGERY TRAINING PAVILION WILL BE EQUIPPED WITH THE LATEST TECHNOLOGY FOR MOCK SURGERY TO PERFECT THE SKILLS OF TOMORROWâ&#x20AC;&#x2122;S NEUROSURGEONS

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

GLOBAL NEUROSURGERY INSTITUTE | 73

GLOBAL LEADERS O

ur mission to heal humankind one patient at a time is the tie that binds our cross-collaborations with a variety of other specialties at UCLA Health. Together we deliver unrivaled, centralized, world-class care and the latest translations of basic research into

medical breakthroughs at the bedside for our patients. We continue to attract and train the next generation of neuroscientists and neurosurgical pioneers mapping new frontiers of the human brain and discovering cures for the most complex neurological diseases facing our families today, and our children’s families tomorrow.

UCLA NEUROSURGERY: OUR DEPARTMENT IN SUMMARY Advisors to the NFL, MLB, U.S. Military and White House Appointee on the Defense Health Board, for traumatic brain injury and concussion treatment.

World’s leading stroke center—NIHSPOTRIAS network designation and certified by the Joint Commission as a Comprehensive Stroke Center.

UCLA Brain Injury Research Center leads the nation and the world.

UCLA Brain Tumor Program leading the world in next-generation medicine.

Voted “Best Doctors in America” by medical professionals across the nation.

Developed the first personalized brain cancer vaccine, DCVax.

No. 2 in National Institutes of Health (NIH) Research Grants at $5,943,956 for 2012.

Voted “Top Surgeons” by Consumers’ Research Council of America.

Global B.R.A.I.N. Prize top 10 finalist for discovering memory boosting.

No. 5 in the world for most published research papers in medical journals.

Voted “Super Doctors” by physicians and peers across the nation.

Pioneers in minimally-invasive, endoscopic and non-invasive brain surgery.

Authors of evidence-based guidelines for brain and spinal disorders.

Pioneers in minimally-invasive endovascular therapies for stroke.

First Neuro-ICU in the world to use robotics and telemedicine.

Top 10 Neurosurgery Department in the nation according to U.S. News and World Report for more than 20 years. No. 1 Best Hospital in Southern California, Los Angeles, and Top 5 Hospitals in America according to U.S. News and World Report for more than 20 years.

CONTACT THE UCLA DEPARTMENT OF NEUROSURGERY James I. Ausman, MD, PhD Tel: 310-825-5482 Fax: 310-206-6242

Fredric L. Edelman, MD Tel: 818-781-3350 Fax: 818-781-7237

Ulrich Batzdorf, MD UCLA Spine Center Tel: 310-825-5079 Fax: 310-825-7245

Itzhak Fried, MD, PhD Adult Epilepsy Surgery Tel: 310-825-8409 Fax: 310-794-2147

Donald P. Becker, MD Professor Emeritus Tel: 310-794-1222 Fax: 310-825-7245

Nestor Gonzalez, MD UCLA Stroke Center Tel: 310-825-5154 Fax: 310-206-6242

Marvin Bergsneider, MD Pituitary Tumor Program Tel: 310-206-4100 Fax: 310-825-9385

Langston T. Holly, MD UCLA Spine Center Tel: 310-267-5580  Fax: 310-206-1857

Linda M. Liau, MD, PhD Brain Tumor Program Tel: 310-267-2621  Fax: 310-825-9385

Gary W. Mathern, MD  Pediatric Epilepsy Surgery Tel: 310-825-7961 Fax: 310-825-0922

Bob Shafa, MD Brain Tumor Program Tel: 310-825-1988 Fax: 310-825-9385

Daniel Lu, MD, PhD UCLA Spine Center Tel: 310-267-2975 Fax: 310-825-7245

Duncan Q. McBride, MD  Harbor-UCLA Medical Center Tel: 310-319-3475 Fax: 310-319-4575

Paul M. Vespa, MD, FAANS Neurocritical Care Tel: 310-267-9448 Fax: 310-267-3841

Neil A. Martin, MD, FAANS UCLA Stroke Center Tel: 310-825-5482  Fax: 310-206-6242

Nader Pouratian, MD, PhD Neuromodulation & Neurobionics Program Tel: 310-206-2189 Fax: 310-794-1848

Isaac Yang, MD Skull Base Tumor Program Tel: 310-267-2621 Fax: 310-825-9385

UCLA NEUROSURGERY: INTO THE BRAIN AND BEYOND

REFERRING PHYSICIANS Nancy McLaughlin, MD, PhD Tel: 310-825-5482 Fax: 310-206-6242

Jean-Philippe Langevin, MD Tel: 310-825-5482 Fax: 310-206-6242

310-825-5111

www.uclahealth.org/refer

UCLA DEPARTMENT OF NEUROSURGERY 757 Westwood Plaza, Suite 6236 Los Angeles, CA 90095-7436 www.neurosurgery.ucla.edu

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