Clinical Programs
Cerebrovascular Center
Neurological surgery at University Hospitals of Cleveland (UHC) plays a leadership role in the treatment of cerebrovascular disease. An aggressive approach to cerebral ischemia utilizing a quick-response “brain attack” team of physicians, nurses and technicians from throughout the hospital provides prompt diagnosis and treatment of cerebrovascular neurologic disorders. The sense of urgency and need for rapid treatment of these problems has been successfully integrated with EMS personnel, primary and tertiary care providers and the general public. Multiple imaging modalities are utilized including noninvasive methods such as diffusion and perfusion weighted MRI, MRA/MRV, SPECT and PET scans. Cerebral angiography is used diagnostically and therapeutically for the delivery of thrombolytic agents to dissolve occlusive clots. Endovascular techniques are also used to place coils into inoperable cerebral aneurysms and to embolize arteriovenous malformations. Inoperable vascular malformations are also treated with stereotactic radiosurgery performed with the University Hospitals’ Gamma Knife Unit.
Despite many advances made in endovascular therapy, conventional surgery remains the treatment of choice for many types of aneurysms and vascular malformations. Advanced monitoring capability makes surgery safer and more predictable than ever and the experience and expertise of University Hospitals’ neurosurgeons attracts patients from across the country and around the world. Intra-operative angiography allows us to view the results of excluding an aneurysm or AVM from the rest of the circulation as it is being done. Postoperatively, dilatation or “ballooning” areas of vasospasm after subarachnoid hemorrhage has become routine. At University Hospitals of Cleveland, there is a highly collaborative and collegial relationship between neurosurgery and interventional neuroradiology and we believe this team approach improves patient outcomes.
Neurotrauma
Much of the resident’s neurotrauma experience is gathered at MetroHealth Medical Center (MHMC), which as a Level I Trauma Center sees hundreds of trauma patients yearly. The physicians at MHMC participate in a number of multi-center trials involving head injured or spinal cord injured patients. Ongoing studies involving advanced management protocols for the medical and surgical treatment of brain and spinal cord trauma patients are being conducted under the direction of Drs. Likavec, Lechner and Anderson, Geertman and Verrees. Clinical studies involve the application novel techniques of spinal instrumentation for stabilization.
Neuro-Oncology
We routinely utilize methods that allow us to maximize the safety and extent of surgical resection for patients with brain tumors. When appropriate, cortical stimulation is used to map the motor strip and speech centers. Our intra-operative MRI suite allows us to judge the extent of resection during surgery.
The Department of Neurological Surgery has been involved in many investigational clinical trials for malignant gliomas over the past several years. Our current malignant glioma trials include an IGF gene therapy protocol for newly diagnosed tumors and a Phase II study of radiolabeled monoclonal antibodies for unresectable primary and resected recurrent tumors. We also participate in multi-center trials which combine radiation, radiosurgery and chemotherapy. For newly diagnosed brain metastases, we are conducting a study of Gamma Knife radiosurgery alone (instead of following whole brain radiation) for patients who are elderly or have poor functional status.
Skull Base Surgery
The Department of Neurological Surgery carries out a large number of procedures involving both the anterior and posterior skull base. This includes a large number of patients with pituitary adenomas. Significant work examining the recovery of pituitary function after decompressive trans-sphenoidal surgery has been based at this center. We have also developed a unique technique of examining intra-sellar pressure and correlating recovery of visual and endocrine function based on this parameter.
There are a large number of other patients undergoing intracranial procedures for skull-base tumors including meningiomas as well as vestibular schwannomas. These are often operated upon in conjunction with the neuro-otologist. The local expertise in vestibular schwannomas and meningiomas make this an important resource for patients with neuro-fibromatosis. A number of other more unusual tumors such as clival chordomas, invasive nasopharyngeal tumors and craniopharyngiomas also contribute to the variety of skull-based tumors seen here.
Pediatric Neurosurgery
Rainbow Babies and Children’s Hospital (www.rainbowbabies.org) was the first pediatric hospital in Cleveland and is recognized as one of the finest children’s hospitals in the country. A new 244 bed patient tower with a unique emphasis on family-centered care opened in 1997 and a new operating suite opened in 1999. Rainbow has a Level I pediatric trauma center, a 20 bed pediatric intensive care unit, and the largest neonatal intensive care unit in the region. The Division of Pediatric Neurological Surgery performs several hundred operations yearly, and is an integral part of the residency training program. Residents are exposed to a broad range of pediatric neurosurgical problems, including hydrocephalus, trauma, cranial and spinal tumors, vascular disorders, epilepsy, spasticity, craniofacial malformations and other developmental disorders. Residents are trained in state-of-the-art techniques such as minimally invasive (endoscopic) neurosurgery, frameless navigation and intra-operative MRI. The pediatric neurosurgery service has a close working relationship with multiple surgical specialties for the treatment of trauma, complex spinal disorders, craniofacial and skull base abnormalities.
Disorders of the Spine
Training in spinal surgery is an integral part of the neurosurgical program. Cases range from simple lumbar and cervical discectomies to complex spinal reconstruction requiring spinal instrumentation. A full range of spinal instrumentation is performed here, including anterior cervical plating, posterior cervical lateral mass screws, thoracolumbar anterior plating, pedicle screws, lumbar interbody case fusion, and hook and rod constructs. The gamut of cases include degenerative spinal disease, spinal malignancies, infection, as well as trauma. We have expertise in dealing with conditions of the craniovertebral junction including rheumatoid basilar invagination and atlantoaxial subluxations. Operative capabilities are supplemented by a full-time technician for intra-operative SSEP’s, EMG and nerve stimulation.
Stereotactic Surgery
Development and application of advanced modern technology to neurosurgical procedures plays a prominent role in the neurosurgical department. Stereotactic techniques are routinely used for a wide variety of surgeries including frame-based biopsy and frameless guidance for craniotomy and biopsy. The department uses a wide variety of instruments including BRW, CRW and Leksell stereotactic frames. We were a beta test site for the Stealth frameless stereotactic system, which is in ongoing use now, with further frameless applications being developed in conjunction with our computer stereotaxy lab.
The department was also a beta test site for the Phillips “Linac” stereotactic device. With the arrival of our Gamma Knife, which has become the work horse for stereotactic radiosurgery, the Linac device will take on new tasks such as fractionated stereotactic radiotherapy with a reapplicable stereotactic frame. The state of the art Gamma Knife has up-to-date computerized conformational planning and offers the ability to utilize data directly transferred from both CT scanners and MRI scanners, as well as digital subtraction angiography (DSA) cameras.
Functional Neurosurgery
The area of functional neurosurgery is a rapidly growing subspecialty and includes a wide spectrum of procedures. Movement disorders such as Parkinson’s disease, dystonia and essential tremor are treated with stereotactically placed lesions or deep brain stimulators (DBS) in the subthalamic nucleus, globus pallidus interna and ventral thalamus. We are utilizing microelectrode recording and pioneering the use of intra-operative MRI to guide placement of the lesion or DBS.
In collaboration with the Department of Neurology, surgical treatment of epilepsy for both adult and pediatric patients has been expanded. Candidates for resection of an epileptogenic focus in the brain are evaluated with a variety of techniques including invasive monitoring utilizing stereotactically placed electrodes and craniotomy for subdural electrode grids. Appropriate candidates undergo surgical resection using electrocorticography, motor, and speech mapping to guide resection. Vagal nerve stimulators are also placed for medically refractory epilepsy patients who do not have a focal brain abnormality.
Other functional neurosurgery procedures performed in our department include microvascular decompression or radiofrequency or Gamma knife trigeminal rhizotomy for tic douloureux, sympathectomy for autonomic dystrophy or hyperhidrosis, selective dorsal rhizotomy and intrathecal pump implantation for spasticity and pain and epidural spinal cord stimulators for pain.
We participate in a NIH-supported study involving the restitution of bladder and bowel function by electrical stimulation in patients with spinal cord injury. Combined with posterior rhizotomy, this therapy has produced excellent results in the management of neurogenic bladder control.
