UF Health Synergy In Neuromedicine

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2 | Progress Report 2014 | 352.273.9000 | UF Health Neuromedicine

Letter from the Chairman

For the past few years at UF Health, our strategic plan has centered on the theme, “Forward Together.” The Neuromedicine Interdisciplinary Clinical and Academic Program, or NICAP, is a vibrant group that includes neurosurgery, neurology and all hospital components that support neuromedicine. Our goal is to create the ultimate patient experience. This goal requires a very high level of collaboration.

This report highlights the synergy between neurosurgeons, neurologists and the hospital at UF Health. Through each featured case, we hope to demonstrate the interaction and cooperation evident in all we are doing to move neuromedicine forward.

We hope you will appreciate our move to a concise, digital format this year, complete with multimedia components like website links, videos and photo slideshows. I am honored to share our efforts with you.

Sincerely,

William A. Friedman, M.D. Director Neuromedicine Interdisciplinary Clinical and Academic Program Professor and Chairman Department of Neurological Surgery University of Florida College of Medicine

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YEAR IN REVIEW World Leader in Brain Tumor Research: Duane Mitchell, M.D., Ph.D., and his team of 10 researchers celebrated their first year at the Preston A. Wells Jr. Center for Brain Tumor Therapy at UF. Mitchell’s addition to the program was made possible by a Lillian S. Wells Foundation gift and matching funds totaling $20 million. Mitchell, the principal investigator on seven first-in-human protocols, brings expertise in the use of immunotherapy to treat malignant brain tumors.

Affiliation with Orlando Health: UF Health Neurosurgery at Orlando Health brings UF’s commitment to patient care, research and education to Central Florida while making advanced neuromedicine accessible to millions of patients throughout the state and expanding training opportunities for physicians. UF Health Neurosurgery at Orlando Health features five faculty physicians and five mid-level practitioners.

4 | Progress Report 2014 | 352.273.9000 | UF Health Neuromedicine

National Conferences: At the Congress of Neurological Surgeons annual meeting in Boston, seven UF Department of Neurosurgery faculty members and two residents gave 16 presentations on various topics, including clinical quality improvement, social media’s role in the clinical practice, controversies in neuromodulation and cerebrovascular neurosurgery and performance measures in traumatic brain injury.

Major Grants: UF has secured approximately $8 million for neuromedicine and neuroscientific research during the last fiscal year, including studies using the immune system to fight pediatric brain tumors through the use of nanotechnology, establishing a human grade IV glioma stem cell line bank and proving that cerebral aneurysm formation is an inflammatory process. UF has one of the highest research-funded departments of neurosurgery in the United States.

1000 Deep Brain Stimulation Lead Implantations: Kelly D. Foote, M.D., UF Health neurosurgeon, implanted his 1,000th lead in a patient with dystonia. He and his partner, UF Health neurologist Michael S. Okun, M.D., serve as codirectors of the UF Health Center for Movement Disorders and Neurorestoration. They perform approximately 150 lead implantations a year.

In 2014, their work was featured on CNN and in The Wall Street Journal, The New York Times and Smithsonian magazine.

Residency Programs: In a Doximity and U.S. News & World Report survey, UF’s Department of Neurosurgery Residency Program was recognized as sixteenth in the country. It is one of only three programs in the nation certified to train U.S. Department of Defense-sponsored military residents.

Joint Commission Comprehensive Certification: The UF Health Shands Comprehensive Stroke Center team, including two cerebrovascular neurosurgeons, four vascular neurologists and two stroke program coordinators, received national certification from The Joint Commission. They are available 24/7 to treat patients with transient ischemic attacks, acute ischemic stroke, aneurysms and subarachnoid, cerebral and intracerebral hemorrhages.

Florida Center for Brain Tumor Research: The FCBTR was developed to coordinate the efforts of Florida’s public and private universities and hospitals to discover cures and develop treatment modalities. The FCBTR has collected thousands of brain tumor specimens, DNA, blood and clinical data and has provided those resources to researchers all over the U.S. The Center hosted its annual summit in the spring, which is open to physicians, researchers, scientists, nurses and students.

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View gallery NEUROLOGY

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ery g r u os r u e n + y g olo r u e n Robert’s Story: On an ordinary spring day while spending time with his family, Robert Passmore felt a strange sensation as he was sitting on the couch.

He tried to get up, but couldn’t. He thought he was having a muscle spasm or a severe cramp of some sort. But after a few minutes, he realized the entire left side of his body had gone limp.

“I didn’t know what was going on, but I knew something was wrong,” Robert said. “I thought I might be having a small heart attack.”

Robert wasn’t having a heart attack. He was having a brain attack. His cousin drove him to the local emergency room where doctors told him he had a stroke.

Robert remembers thinking, “This can’t be happening. I’m 38 years old.”

Doctors at the community hospital gave him tissue plasminogen activator, also known as ‘the clot-buster,’ and he was flown, via the UF Health ShandsCair helicopter, to the UF Health Shands Comprehensive Stroke Center.

Anna Khanna, M.D., a UF Health vascular neurologist, issued a stroke alert after receiving the phone call for a consult from Robert’s emergency doctors.

“Once a stroke alert is initiated, our process flows very smoothly,” Khanna said. “We have excellent communication with the ShandsCair team, and collaboration with the emergency and transfer teams, neurologists and neurosurgeons is key.”

Robert, who had a complete occlusion in the right middle cerebral artery, was rushed to the endovascular angiography suite, where Brian Hoh, M.D., a UF Health cerebrovascular/endovascular neurosurgeon, completely removed the clot in 22 minutes using a stentreiver device and a suction aspiration device.

“I didn’t realize how serious all this was,” Robert said. “The doctors fixed me up so fast.”

He didn’t know it, but he was suffering from cardiomyopathy, which caused a clot to travel from his heart into his brain.

Five days later, Robert walked out of the hospital with no residual effects from the stroke.

“I still can’t believe what happened to me,” Robert said. “I had a stroke just six months ago, but I am fine now, watching my kids play football and helping with the family barbecue business.”

To request a new neurosurgery patient appointment, call 352.273.6990.

To request a new neurology patient appointment, call 352.265.8408.

To transfer a patient, call 1.800.987.2673.

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Watch video NEUROLOGY

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6 22 Top 2% 330 By the numbers:

Surrounding community hospitals refer an average of 330 stroke patients annually to the UF Health Shands Comprehensive Stroke Center.

The Joint Commission has awarded the UF Health Shands Comprehensive Stroke Center national certification as a comprehensive stroke center.

UF Health joins the elite 2 percent of hospitals in the U.S. that have acquired this designation.

UF Health cerebrovascular/ endovascular neurosurgeon Brian Hoh, M.D., completely removed Robert Passmore’s blood clot in just 22 minutes after discovering complete occlusion in the right middle cerebral artery following an acute ischemic, cardioembolic stroke.

The UF Health Shands Comprehensive Stroke Center is home to four highly trained and subspecialty board-certified vascular neurologists and two expert cerebrovascular/ endovascular neurosurgeons who are on call 24 hours a day, seven days a week, to provide direct, state-of-the-art care.

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View gallery EXPERIENCE

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e u q i n ch e t + ce n e i r expe Jackie’s Story: Seven years ago, Jackie Tonguis of Manderville, Louisiana, was at a restaurant with her husband when she felt an electric pain shoot down the left side of her face.

“It almost knocked me out of the chair,” she said.

A few weeks later, Jackie, 77, was at a dental appointment and the pain happened again. One of the office employees knew a neurologist, and Jackie immediately went in for an evaluation. She was diagnosed with trigeminal neuralgia.

In trigeminal neuralgia, the trigeminal nerve, which carries sensations from the face to the brain, is compromised. The disorder has several possible causes, said William A. Friedman, M.D., professor and chairman of the University of Florida Department of Neurological Surgeons. Vascular compression is the most common cause. Pressure from the superior cerebellar artery can pulsate against the nerve, wearing through a sheath surrounding it, called the myelin, and sending pain through the patient’s face. Tumors can also be the cause of pain, or, sometimes, multiple sclerosis can affect the nerve.

Jackie was prescribed a medication called Tegretol. However, Tegretol can cause a slew of side effects — something she knows all too well. On Christmas Eve 2013, Jackie, on her way to church, fell off her back porch and was hospitalized overnight. In the weeks following, a home nursing service visited her and found her sodium levels to be dangerously low. She was hospitalized again for five days and taken off Tegretol. But her pain was excruciating, and she resumed the medication.

Jackie’s children started researching other treatments for trigeminal neuralgia and found UF Health Neurosurgery online. Friedman, a UF Health neurosurgeon, specializes in trigeminal neuralgia and treats between 150 and 175 patients a year.

“It’s one of the largest numbers of anybody in the country,” Friedman said. “We do get patients from all over the eastern half of the United States.”

On a Thursday in February 2014, Jackie was in Friedman’s waiting room for her appointment. While she was waiting, four other patients approached her, unbidden, to tell her of their successful surgeries. Then, she met with Friedman.

“He said, ‘You’re down here from Louisiana?’” Jackie said. “I told him I was, and he said, ‘All right. We’d better do this tomorrow.’”

The next day, Jackie was in Friedman’s operating room. There, Friedman saw that Jackie’s neuralgia was triggered by her superior cerebellar artery. He lifted the artery away from her nerve and placed a pad between the artery and the nerve.

Jackie left Gainesville for home, just north of New Orleans, that Monday. Since her surgery, she’s been pain-free.

To request a new neurosurgery patient appointment, call 352.273.6990.

To transfer a neurosurgical patient, call 1.800.987.2673.

8 | Progress Report 2014 | 352.273.9000 | UF Health Neuromedicine

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175 4,000 1,000 3 By the numbers:

Professor and Chairman of the UF Department of Neurological Surgery, William A. Friedman, M.D., is well-known for the three major treatment options for people with trigeminal neuralgia: microvascular decompression, radio frequency lesion and radiosurgery.

Patients with trigeminal neuralgia come from all over the United States to receive treatment from Dr. Friedman because of his experience treating the disease.

Within the last year, he helped patients from more than 1,000 miles away.

Since he began treating this debilitating condition 30 years ago, Dr. Friedman and others at UF Health have treated more than 4,000 patients successfully.

In the last year, Dr. Friedman has performed 175 procedures to alleviate pain caused by trigeminal neuralgia.

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View gallery PATIENT

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am e t n ia c i s y ph + t n patie Corey’s Story: The seizures came in little 30-second flashes, sending a rushing feeling through his brain as if his blood were pounding in his veins.

Corey Hammond, then a University of Florida student, didn’t realize the feelings he was experiencing were seizures until one afternoon on a surfing trip with friends when he suffered the worst form of seizure, a grand mal.

Corey’s seizures were the result of a scooter accident he’d suffered a few years earlier, in 1997, when he was just a junior in high school.

Once the seizures started, they never went away, worsening over time, despite the medications prescribed by doctors in his hometown, Melbourne, Florida.

“The medication wasn’t working,” said Raina Hammond, Corey’s wife. “I was having to call 9-1-1 a lot.

We felt like we were at a crossroads. We had to do something different.”

Corey, now 35 and a stay-at-home dad to 4-year-old daughter Aila, opted to seek treatment at UF Health. Our team of epilepsy experts recommended surgery as a way to not only control the seizures but also hopefully reduce the amount of medications Corey would need over time.

“Typically after a patient has taken two to three medications and nothing is working, we start thinking about surgery for control,” said Jean Cibula, M.D., one of the UF Health neurologists who treated Corey.

“We want to help patients get control of their seizures so they can live their lives.”

Prior to surgery, the team maps out the part of the brain responsible for the seizures. In Corey’s case, initial tests weren’t clear, so physicians took the extra step of implanting electrodes deeper into the brain to make sure they obtained a precise picture of the problem area.

The testing revealed that Corey’s seizures stemmed from the temporal lobe, so UF Health neurosurgeon Steven N. Roper, M.D., carefully removed a problematic segment in May 2013.

More than a year has passed since Corey’s surgery — and since his last seizure. The recovery process is slow, but Corey is now able to drive and is back to doing things he loves, like caring for his little girl and cooking his family dinner. He has trouble multitasking and finding words sometimes, but if the trade-off is being seizure-free, the side effects are well worth it, he said.

“It’s like a marathon, a long journey,” he said “I am glad to be on the other side.”

To request a new neurosurgery patient appointment, call 352.273.6990.

To request a new neurology patient appointment, call 352. 265.8408.

10 | Progress Report 2014 | 352.273.9000 | UF Health Neuromedicine

Watch video PATIENT

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Level 4

7,500 1,525 550 By the numbers:

More than 550 people with intractable epilepsy have participated in UF Health’s experimental drug and device studies since 1992.

Since the program’s inception in 1992, the team has performed more than 1,525 epilepsy surgeries.

UF Health epilepsy experts treat patients with seizure disorders, syncope, migraine, stroke and sleep disorders during approximately 7,500 visits a year.

Less than 1 percent of hospitals nationwide have Level 3 or Level 4 designation. UF Health Shands Hospital is one of them. UF Health Comprehensive Epilepsy Program is a Level 4 program.

According to the National Association of Epilepsy Centers, a fourth - level center provides the more complex forms of intensive neurodiagnostic monitoring, as well as more extensive medical, neuropsychological and psychosocial treatments. Fourthlevel centers offer a complete evaluation for epilepsy surgery, including intracranial electrodes, and provide a broad range of surgical procedures for epilepsy.

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View gallery SPECIALIST

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am e t + ist l a i c spe Frida’s Story: For more than a decade, Marcos Falcon had to share his wife with a relentless companion whose hold on her became more distracting and debilitating as the years passed.

She was deeply involved, against her will, in a relationship with Parkinson’s disease.

“We often referred to her disease as ‘Mr. Parkinson’s,’ “ Marcos Falcon said. “He was an uninvited guest in our house, and we wanted him gone.”

In 2005, Frida Falcon, a native Peruvian, was diagnosed with the disease. At first, she was able to find ways around the symptoms. As an artist, she was always working with her hands, and when she sculpted, the effects of the disease were mild. Drug therapy worked for a long time.

But eventually, the dyskinesia resulting from the various medications and muscular pains and tremors worsened, and she and her husband had to seek a more serious level of care.

Together, they investigated five centers around the world, and eventually focused in on the UF Health Center for Movement Disorders and Neurorestoration, 2,900 miles away from home.

“After visiting two other centers, we chose UF Health because we found the doctors to be kind and genuine. All of the people were so warm and inviting,” Marcos Falcon said. “The entire team seemed to really care about Frida, and they knew how important this medical journey was for us.”

In February, Kelly D. Foote, M.D., and Michael S. Okun, M.D., co-directors of the UF Health Center for Movement Disorders and Neurorestoration, performed bilateral deep brain stimulation on Frida. Less than a month later, the stimulators were implanted, and by the beginning of April, she was almost 100 percent symptom-free.

“When my symptoms were at their worst, I required a caretaker. I couldn’t drive. I was in pain,” Frida Falcon said.

Okun said after surgery, the results were better than expected.

“Frida is doing great,” Okun said. “She posed some complexities in that she had numerous, advanced symptoms of the disease. We were aiming to relieve several medical issues for her, and we were able to succeed.”

“I have officially divorced Mr. Parkinson,” Frida Falcon said. “There was no more room for him in my life.

We’re done.”

To request a new movement disorders patient appointment, call 352.294.5400.

12 | Progress Report 2014 | 352.273.9000 | UF Health Neuromedicine

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4 88 1,110 8,294 By the numbers:

Data experts at the UF Health Center for Movement Disorders and Neurorestoration maintain a research database with 8,294 patient records, which is used for several research purposes, all aimed at discovering better treatments for movement disorders.

UF Health neurosurgeon Kelly D. Foote, M.D., and UF Health neurologist Michael S. Okun, M.D., co-directors of the UF Health Center for Movement Disorders and Neurorestoration, have implanted implanted more than 1,100 deep brain stimulation leads in 682 patients since the Center’s inception in 2002. The duo completes approximately 15 DBS surgeries each month.

Currently, the University of Florida is home to more than 85 research studies involving movement disorders.

The UF Health Center for Movement Disorders and Neurorestoration is home to four nationally recognized centers of excellence, including the National Parkinson Foundation Center of Excellence, Tyler’s Hope Center for a Dystonia Cure, BachmannStrauss Dystonia and Parkinson’s Disease Center of Excellence, and the National Tourette Syndrome Association Center of Excellence. The NIH-designated headquarters of the nationwide Clinical Research Consortium for Spinocerebellar Ataxias is also based at the Center.

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At UF Health Neuromedicine, we are dedicated to providing technically superb, compassionate and timely medical care for our patients. We are committed to the education of resident physicians and continuing medical education for practicing physicians in the art and science of neuromedicine. We are always exploring and developing — through clinical and basic research at the Evelyn F. and William L. McKnight Brain Institute at the University of Florida — new and better treatments for neurological and neurosurgical disorders.

McKnight Brain Institute Fact Sheet College of Medicine Fact Sheet UF Health Shands Fact Sheet

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One of the nation’s top centers for the treatment of cerebrovascular disease, including cerebral aneurysms and arteriovenous malformations.

World-renowned center for the treatment of movement disorders and neurorestoration.

One of the largest neuromedicine inpatient Medicare providers in the country.

One of the highest-funded academic neurosurgery departments in the country.

Comprehensive scope of services unparalleled in the southeastern United States.

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neurosurgery.ufl.edu / 352.273.9000 neurology.ufl.edu / 352.273.5550 1149 Newell Drive, Gainesville, Florida 32610