Updates in Neurology and Neurosurgery Orlando, FL 32804 Orlando FL Adventhealth Neuroscience Institute • Winter 2020 • Volume II, Issue I

Non-Profit Org. U.S. Postage 2520 N. Orange Ave, Suite 200 PAID Permit 3635 Updates in Neurology and Neurosurgery Orlando, FL 32804 Orlando FL AdventHealth Neuroscience Institute • Winter 2020 • Volume II, Issue I

AdventHealth Neuroscience Institute is Committed to Expanding to Meet Our Customers’ Need for Access to Comprehensive Surgical and Subspecialty Care

The Neuroscience Institute (NSI) at AdventHealth continues to develop care models for patients with a diverse range of neurologic conditions in an innovative, accessible, holistic and patient-centered manner. We are committed to “making it easy” for referring physicians and patients, both regionally and internationally, to obtain timely access to highly specialized neurologists and surgeons. Our quaternary hospital in Orlando continues to lead with investigator-initiated research, exploring Craig Brubaker, PhD new treatments such as Gamma Tile for brain tumors, and beginning a neurocritical care fellowship Vice President, AdventHealth program. However, over the last year, we have also been expanding access points for surgical Neuroscience Institute and medical programs. At our Celebration campus, new offerings include 24/7 neurosurgical and neurovascular stroke programs, a multidisciplinary neuro-oncology/ neurosurgery clinic, and a functional In This Issue neurosurgery program. Our North AdventHealth Neuroscience Institute 2020 Highlights 2 Star is ensuring we are providing customer-focused, value-based care throughout our Central Florida Division. Virtual Inpatient Psychiatric Unit — The Future 2 of Telemedicine in Behavioral Health Our journey to providing top subspecialty neurological Is Augmenting Reality the Next Frontier in 3 care also continues. We now have programs for Spine Surgery? movement disorders, neuromuscular conditions, AdventHealth Opens Multidisciplinary Brain Tumor 4 headache and migraine care, neuroimmunology, Program at Celebration behavioral neurology, epilepsy, and memory care. These New Treatment Options Available for Neurological 4 programs are led by accomplished physicians in each Patients: Deep Brain Stimulation, Normal Pressure AdventHealth Neuroscience Institute Welcomes New Physicians of their areas. They will collaboratively focus on scaling Hydrocephalus Program, Botulinum Toxin Program each subspecialty, conducting research to further the for Movement Disorders, MR-guided Focused Ultrasound for Essential Tremor body of evidence in their fields, and developing a Anwar Ahmed, MD Ryan Mizell, MD national destination center for subspecialty neurology Minimally Invasive Brain Surgery Program Studies 5 care in the Health Village on the Orlando campus. the Long-term Recurrence Rates After Undergoing Executive Medical Director of Board-Certified Neurologist, Endoscopic Endonasal Pituitary Tumor Surgery Neurology Neuroimmunology AdventHealth is leaning into our national mental health AdventHealth’s Neuromuscular Clinic Grows and 6 Board-certified neurologist Anwar Ryan Mizell, MD, is a board- crisis as well. We will offer a Spravato clinic for treatment- Achieves National Recognition Ahmed, MD, FAAN, has joined certified neurologist whose resistant depression as well as a second Mental Health the AdventHealth Neuroscience primary focus is on treating Taking a Proactive Lifestyle Approach to Promoting 6 Institute (NSI) as Executive Medical patients with complex Outlook Clinic for the uninsured population. Our Brain Health: The Quest for Achieving Director of Neurology. His special multiple sclerosis (MS) and divisional focus on substance abuse and identification Neurogenesis and Synaptogenesis interests include movement neuroimmunology issues. After of suicide risk will also continue to mature. This year, Coagulopathy and Bleeding Progression After 7 disorders and tremor analysis in earning bachelor’s degrees our Hope and Healing Center, in partnership with the Isolated Blunt Head Injury Parkinson’s disease and related in exercise and sport science Seminole County Sheriff’s Office, will also open in Migraine Treatment Update: Four New Medications 8 neurodegenerative disorders, and biomedical sciences at Approved by FDA as well as dystonia. Dr. Ahmed is also a fellow of the American the University of Florida (UF) and the University of South Seminole County. Academy of Neurology. He came to the NSI from the Cleveland Florida, respectively, he completed a master’s degree in Over the next ten years, the AdventHealth Neuroscience Endovascular Neurosurgery Update: Management of 9 Clinic in Ohio, where he served in multiple leadership roles in biobehavioral science with a specialization in biomechanics at Chronic Subdermal Hematoma Through Institute will continue to focus on innovation while the movement disorders and neurological restoration programs UF and earned his medical degree at the University of Central Endovascular Therapy advancing neurology and neurosurgery care to meet the and the Huntington Disease Center of Excellence. A graduate of Florida. He then completed his internship and residency in George Simon, MD, Named Executive Director 9 the esteemed Dow Medical College in Pakistan, he completed adult neurology at the University of Louisville, followed by a evolving needs of the local and national community with of Moffitt Cancer Center-AdventHealth his neurology residency at Wayne State University’s hospitals fellowship in multiple sclerosis/neuroimmunology at the MS patient-centered strategies. Joint Clinical Research Unit in Michigan followed by a fellowship in surgical approaches Center of Excellence at the Baltimore VA and University of to movement disorders and motor physiology at Columbia- Maryland Medical Center. Dr. Mizelll’s research has involved Preoperative Optimization for Patients Undergoing 10 Presbyterian University Medical Center in New York and a clinical investigating the associations between the thinning of retinal Elective Lumbar Spinal Fusion research fellowship in movement disorders at the Cleveland layers, cortical lesions, and leptomeningeal enhancement in Inter-professional Education for Collaborative Practice 10 Clinic. His research and published works have focused on such people with MS using 7 Tesla MRI. Secondary Stroke Prevention in the Community 11 topics as unusual movement disorders, treatment of tremor caused by multiple sclerosis, brain stimulation for movement Cervical Artificial Discs Provide Alternative to 11 disorders, and Parkinson’s disease. Cervical Spinal Fusion for Some Patients AdventHealthNeuroInstitute.com AdventHealth Neuroscience Institute Welcomes 12 New Physicians 12 AdventHealth Neuroscience Institute 2020 Highlights Is Augmenting Reality the Next Frontier in Spine Surgery?

These are exciting times at the AdventHealth Neuroscience Institute. We continue to expand our neuroscience Each year, surgeons perform more Opportunities — most bulky and heavy, high cost, learning services to the Central Florida community and beyond. Here are a few highlights: than one million instrumented spinal curve, some systems with poor localization of local anatomical • This summer we established a full-service neurosurgery program at AdventHealth Celebration, including a procedures in the United States. While structures, poor battery life, not compatible with other systems, multi-disciplinary neuro-oncology clinic. Full-service interventional neuroradiology and stroke care began the rise in computer-assisted surgical adds the step of wearing a headset during surgery (except there at the end of October. navigation and robotics technology Hybrid OR) has improved outcomes, significant • Our early adoption of robotic-assisted spine surgery has been well received by patients. We just completed challenges remain. Attention shift — TM our 350th robotic spine case in the system. 3. iSight the need for surgeons to look away • The neurocritical care department’s fellowship program welcomed our first two fellows this year, generating Strengths — lightweight with excellent ergonomics, excellent Christopher J. Baker, MD Chetan K. Patel, MD from the patient during the surgical a new wave of educational conferences. display, binocular/3D display, mitigates attention shift, Chief of Neurosurgery, Executive Medical Director, procedure to access information AdventHealth • Increasing numbers of patients have been enrolled in the surgical epilepsy and minimally invasive brain Spine, AdventHealth on a screen — remains the greatest imperceptible lag, good battery life, low cost, minimal learning Neuroscience Institute Neuroscience Institute surgery programs. challenge and can decrease both the curve, can use with or without surgical loupes, can be used with Section Chair, Robotics & almost all existing imaging, navigation and robotics systems • We have expanded the number of offices where patients can go for neurosurgical spine and brain care in Navigation, North American surgeon’s cognitive and motor task Central Florida. Spine Society performance. Augmented Reality Opportunities — adds the step of wearing a headset during • We have a revitalized movement disorder program under the care of Drs. Reddy and Ahmed to serve our (AR) could provide a solution that will surgery community’s deep brain stimulation needs. improve both surgical efficiency and • Our AdventHealth spine care navigation program continues to expand into more local ERs and care centers patient outcomes by super-imposing Evolving the AR Approach to Benefit to connect back pain sufferers to the appropriate clinician. contextually relevant patient information Patients and Surgeons so that it is easily and readily available Whether you are a prospective patient or clinician, give us a call if you think we can help. to the surgeon without ever looking The iSightTM AR system has been in use since May of 2020. As away from the patient to a screen. expected, it has mitigated attention shift away from the patient with the potential of improved safety and efficiency. In my Exploring the Application of AR in Spine current cases to date, it has resulted in a 25-55% improvement Surgery — Opportunity and Challenges in the time required to place pedicle screws. This reduction in Virtual Inpatient Psychiatric Unit — The Future of time certainly means less anesthetic time but may also result Telemedicine in Behavioral Health Many industries, including medicine, are looking to AR as the in less blood loss and improved clinical outcomes. Once this next big opportunity. As with any new technology, the goals study is complete, I am looking forward to publishing my results are to make something easier, improve efficiency or achieve that evaluate the clinical outcomes. An estimated 20 percent of the U.S. as needed. In fact, some patients are now psychiatrically a better outcome. In the case of spine surgery, this means population suffers from a mental stabilized before they are medically stabilized, removing the improving patient safety and clinical outcomes while also Using a lightweight headset has been comfortable and has health or substance abuse condition. Baker Act and eliminating the need and cost of a sitter. reducing overall procedure time. Furthermore, by avoiding reduced neck discomfort in complex multilevel surgeries. The This challenge is exacerbated by a repetitive neck twisting and improving ergonomics, this most surprising part of this journey however has been to learn significant shortage of psychiatrists and technology has the potential to decrease neck discomfort. that the system has a minimal learning curve. The ability to inpatient behavioral healthcare beds utilize current navigation and robotics technology that already both nationally and locally, resulting in For the last seven years, I have extensively explored the exists in my operating room was the key to reducing cost and Luis Allen, MD long care delays. Unfortunately, the gap various options for incorporating AR into spine surgery, intuitively using the AR system without the need to acquire Medical Director, continues to grow and by 2025, demand evaluating different approaches as the technology has evolved. new skills. Psychiatrist may outstrip supply by 6,090 to 15,600 I have found benefits and opportunities in what is currently AdventHealth Center for psychiatrists according to a report from on the market. As a result of this experience, I have focused The Future of AR in Spine Surgery Behavioral Health the National Council for Behavioral my work on developing a different approach that focuses Health. To address these challenges exclusively on a spine surgeon’s needs that can be met with As the simultaneous localization and mapping (SLAM) and improve patient care, outcomes existing technology in a cost-efficient package called iSightTM. technology improves, registration of local patient anatomy and and value, the AdventHealth Center for accurate display of holographic visualizations will dramatically Behavioral Health has created a Virtual The evolution of these efforts is listed below along with the Inpatient Psychiatric (VIP) Unit through strengths and primary challenges encountered with each: improve. As mobile computing power and efficiency improves, the use of telemedicine. the headsets will continue to become lighter and less bulky. 1. Google Glass This should enable us to use holographic projections that One of the first programs of its type in Improved Outcomes facilitate planning and execution of every step of surgery, the country, the primary goals of this Strengths — lightweight with excellent ergonomics, low cost, making AR an indispensable tool for all spine surgeons. The new model of care include the following: Implementation of the VIP Unit has increased the standard of minimal learning curve goal for incorporating AR into spine surgery should be to • care, patient satisfaction and staff satisfaction while decreasing Improve initial response time enhance the accuracy, safety, and efficiency that ultimately • Provide patients with quicker access to comprehensive overall LOS, sitter utilization, readmission rates, wait time for Opportunities — resolution insufficient, display too peripheral, culminate in improved clinical outcomes. I believe that it is behavioral health services psychiatric services and cost. A virtual psychiatric bed is a monocular display, suboptimal lag and poor battery life, adds • Reduce inpatient length of stay (LOS) fraction of the cost of a traditional inpatient psychiatric bed. In the step of wearing a headset during surgery our obligation not just to deliver the best possible care today, • Serve as an immediate resource for ED physicians fact, every Baker Act released saves $1,741.84 based on a two- but to create innovative solutions that exceed what we can do • Serve as good stewards of limited inpatient beds day inpatient psychiatric unit LOS and a four-day average LOS 2. Entirely Custom AR System (Hybrid OR, today. If we can envision a better future, it is our responsibility on a medical floor with sitter utilization. In addition, this new Hololens, Magic Leap, Xvision) to help create it. Providing Integrated Psychiatric Care virtual model of care ensured that AdventHealth was already prepared with a critical telemedicine infrastructure when Strengths — excellent displays, binocular/3D display, mitigates To learn more about this technology, or to participate in Traditionally, when a patient with a medical condition is Baker COVID-19 hit. attention shift, imperceptible lag, high level of processing the live surgery visitation program, please email Sheri Acted in the state of Florida, they must be medically stabilized power, some can project 3D holographic objects Peterson, Director AdventHealth Medical Group Spine before transferring to the psychiatric inpatient unit to receive Future Plans Health at Altamonte at [email protected]. behavioral healthcare. This typically involves an average four- day LOS on the medical unit before inpatient psychiatric care One VIP Unit currently serves 10 Orlando area AdventHealth can even begin. In addition, by law, a Baker Acted patient on the campuses, including Orlando, Winter Garden, Winter Park, East medical unit must have a “sitter” stay with the them 24/7 until Orlando, Apopka, Altamonte, Celebration, Kissimmee and the Lake they are officially under psychiatric care, an additional expense. Mary ER. Future plans include expanding the unit to additional AdventHealth locations in Florida. By contrast, through the VIP Unit, behavioral healthcare is AdventHealth NSI’s Chetan Patel, MD, Presented “Pushing the Frontiers of Spine provided in a parallel manner from the time the patient arrives In addition, knowing that there is a shortage of providers and Surgery Through Advanced Technologies and Robotics” at International Meetings at the hospital. Using telemedicine, our multidisciplinary it can take over 30 days to receive psychiatric outpatient care team, which includes a psychiatrist, psychiatric social worker, within the community, our team is currently building off its North American Spine Society (NASS) 2020 Annual Meeting Eurospine 2020 Annual Meeting psychiatric nurse and psychiatric discharge planner, begins inpatient success to develop a Virtual Outpatient Clinic pilot. As Virtual Experience | October 7-10, 2020 Virtual Annual Meeting | October 6-9, 2020 providing psychiatric care while the patient is still on the part of this model, we are exploring having an inpatient see the medical unit. The team immediately begins assessments, family same psychiatrist for follow-up outpatient care, providing a level intervention, medication and scheduling of appointments of familiarity and continuity of care that is especially important for the geriatric population. 2 3 AdventHealth Opens Multidisciplinary Minimally Invasive Brain Surgery Program Studies Brain Tumor Program at Celebration the Long-term Recurrence Rates After Undergoing Endoscopic Endonasal Pituitary Tumor Surgery time between diagnosis and treatment for patients diagnosed with all forms of neurological cancerous and non-cancerous Pituitary tumors are one of the more period, 7 (35%) involved hypersecretory tumors and 4 brain tumors. In a single-day appointment, patients meet with common benign tumors of the skull (20%) involved previously recurrent tumors. Nineteen and are evaluated by a medical oncologist, neurosurgeon and base, representing between 10-15% of (95%) of the recurrent tumors in our series were initially radiation oncologist to create a comprehensive treatment plan all intracranial tumors requiring medical macroadenomas. attention. Although found incidentally close to home. in most people, with growth, they Recurrent/Progressive Disease Herbert Newton, MD The new clinic extends the program currently found at Melvin Field, MD can cause visual loss, diplopia, and with > 4 Year’s Follow-up Medical Director AdventHealth Orlando. Conditions treated at the clinic include Medical Director, Minimally hormonal hyper or hyposecretion. Neuro-Oncology Program Invasive Brain Surgery meningioma, pituitary tumors and skull-base tumors, among AdventHealth Since the mid 1990’s, endoscopic Hypersecretory Disease History of Previous Surgery AdventHealth others. Patients are also be able to undergo screening for Cancer Institute Neuroscience Institute pituitary surgery has continued to gain ACTH — 2/10 — 80% PFS 4/51 — 92% PFS procedures such as Gamma Knife Radiosurgery and the widespread acceptance as the preferred Optune tumor treating field system, previously only available at GH — 4/30 — 85% PFS No History of Previous Surgery A A multidisciplinary neuro-oncology method for removing tumors of pituitary AdventHealth Orlando. origin. Today, most pituitary centers clinic at AdventHealth Celebration PRL — 1/8 — 87.5% PFS 16/249 — 94% PFS around the world consider endoscopic opened on August 12, bringing together For more information or to refer a patient, call Brain pituitary surgery the gold-standard in Macroadenomas Microadenomas leading physicians across multiple Services Navigator Aiko Boggs, BSN, RN, at 407-303-7944. the management of surgical pituitary 19/283 — 93% PFS 1/17 — 94% PFS specialty areas to help decrease the tumor disease. Prior to the endoscopic endonasal pituitary tumor revolution, Figure 1. Progression Free Survival in patients undergoing EEA based on preoperative tumor type with greater than 4 years of microscopic transsphenoidal transseptal follow-up from time of surgery or sublabial approaches were generally performed. Depending New Treatment Options Available for Neurological on the study, recurrence rates vary between 12-40% with these Conclusions traditional techniques. Currently, thousands of publications, Patients: Deep Brain Stimulation, Normal Pressure abstracts, and presentations around the world have argued the • Less than 7% of patients undergoing EEA for pituitary value of endoscopic pituitary surgery, but very few discuss the adenomas with > 4 years of follow-up develop tumor Hydrocephalus Program, Botulinum Toxin Program for long-term outcomes of the approach. Previous studies have recurrence. identified factors associated with recurrence such as Knosp • Four percent of patients undergoing EEA for pituitary Movement Disorders, MR-guided Focused Ultrasound Score, subtotal resection, pre-operative visual loss, and tumor adenomas with > 4 years of follow-up require some form of for Essential Tremor invasion beyond the sella, but in spite of the popularity and additional treatment for recurrent disease. seemingly universal acceptance for this approach, very little • Fourteen percent of patients with symptomatic secretory exists regarding the long-term durability of the procedure. adenomas undergoing EEA with > 4 years of follow-up The AdventHealth Neuroscience Institute After selection, patients undergo DBS surgery with a highly develop tumor recurrence. continues to pursue and implement new trained neurosurgeon (Chandan Reddy, MD) at the AdventHealth The minimally invasive brain surgery team at Advent Health • Previous tumor resection does not predict recurrence when Orlando has been performing the Endoscopic Endonasal Chandan Reddy, MD, technologies and treatments to improve Celebration campus. Successful surgery requires the following undergoing EEA. FAANS the quality of life and clinical outcomes steps: anatomical localization, physiological localization, Approach (EEA) for Pituitary Tumors since 2003. Each year • Tumor recurrence can be seen as early as 3 months after we assess hundreds of pituitary tumor patients through the Neurosurgeon for neurological patients. implantation of a DBS lead, and pulse generator (general surgery but may occur over 7 years from the time of surgery Founder, Deep Brain anesthesia-stage II). Pre- and post-operatively, the patient also program and utilize a multidisciplinary approach in their as well. Stimulation Program Deep Brain Stimulation meets a movement disorder neurologist (Anwar Ahmed, MD) at management in conjunction with neurosurgery, endocrinology, • In our study, patients undergoing EEA for pituitary tumors had AdventHealth AdventHealth in Winter Park. Postoperative DBS care typically otolaryngology, radiation oncology, and interventional significantly lower tumor recurrence rate in comparison to the Neuroscience Institute Deep brain stimulation (DBS) is now a involves careful chronic programming and medication adjustment. neuroradiology. In an attempt to understand the long-term 29.1% long-term tumor recurrence rate cited in literature for standard-of-care treatment option for outcomes and recurrence rates via the endoscopic endonasal transsphenoidal hypophysectomy (χ2(1)=4.08, p <0.05). patients with advanced Parkinson’s approach, we recently reviewed our results in patients with at disease (PD), essential tremor (ET) Normal Pressure Hydrocephalus (NPH) least 4 years of follow-up and compared them to the long-term In summary, the Endoscopic Endonasal Approach is safe and and generalized dystonia. A lead is Program results of those who had undergone traditional approaches effective as a primary neurosurgical treatment for surgical surgically implanted in the subthalamic Through our Normal Pressure Hydrocephalus (NPH) Program, from the published literature. Our results were presented at the pituitary disease. Long-term follow-up suggests a low nucleus (STN) or the internal segment we screen patients with gait difficulty who have additional 9th World Conference of NeuroEndoscopy. recurrence rate when compared to other treatment modalities. of the Globus pallidus (GPi) for PD symptoms of memory loss and urinary control problems. Through The risk of complication was also very low in our series when and in the thalamus for ET, using comprehensive evaluation, patients are selected to undergo Methods compared to other treatment options. This is one of the largest image-guided stereotactic techniques surgical intervention (ventriculoperitoneal shunt placement) Indications for surgery included visual compromise due to series to date looking at the long-term outcomes while utilizing in the awake patient. Leading DBS by our team of providers, including a movement disorder chiasmal/optic nerve compression, hormonally active tumor mechanism researchers postulate that this approach, and our data suggests that the EEA should be neurologist, neurosurgeon and neuropsychologist. Patients not amendable to medical therapy, or documented growth with considered as the gold-standard for the surgical management the chronic delivery of high-frequency undergo an inpatient spinal drain trial and physical therapy pre-existing chiasmal compression in an otherwise healthy of pituitary tumors. electrical pulses modulates disease- evaluation before proceeding for brain shunt placement. individual. A total of 300 patients were included in the study. induced pathological neural activity, All surgeries were done with a Neurosurgical-Otolaryngological both at the site of stimulation and Botox Program for Movement Disorders team and included a pre-operative Navigation Protocol magnetic across the sensorimotor basal ganglia resonance imaging (MRI) and computerized tomography (CT) Our botulinum toxin (Botox) program for movement disorders thalamocortical (BGTC) circuit. Notably, through the sella and skull base. For cases involving recurrent or program offers treatment for a variety of movement disorders clinical outcome is dependent upon multicystic/lobular disease, intraoperative MRI was also utilized. using electromyography (EMG)-guided procedures. Patients precise lead localization (millimeter-scale), Seventeen percent of patients in the study had prior surgery, and with tremors involving certain parts of the body may also Anwar Ahmed, MD, and targeting inaccuracies often limit 16% of patients had symptomatic secretory tumors. Ninety-four gain benefit from Botox injection. In addition, Botox can FAAN therapeutic benefit due to insufficient percent of the tumors in our series were macroadenomas, and also be injected for other indications such as spasticity and Executive Medical Director coverage of the target region itself and/or 26% had radiographic evidence of cavernous sinus involvement. of Neurology the development of stimulation-induced hypersalivation. Our routine postoperative imaging protocol included a MRI Melvin Field, MD (Neurosurgery) and Brian Spector, MD Adventhealth sensorimotor (e.g., paresthesia, muscle pituitary with and without gadolinium contrast medium (Gad) on (Otolaryngology) working together during a routine Endoscopic Neuroscience Institute contractions) or non-motor (e.g., cognitive, MR-guided Focused Ultrasound for postoperative day 1 and then 3 months postoperatively, 1 year, 2 Endonasal Pituitary Tumor resection affective) side-effects. Essential Tremor years, 4 years, and 8 years after surgery. At AdventHealth, we employ advanced Currently FDA-approved for essential tremor (or tremor Results techniques, including stereotactic brain predominant Parkinson’s), MR-guided focused ultrasound imaging and brain mapping, to precisely (MRgFUS) for tremor is a method to lesion the brain without brain With an average follow-up of 8.79 years (range: 48-189 place the DBS lead at the desired target surgery. Concentrated focused ultrasound heats up a specific months), 20 (6.67%) patients developed recurrent disease. for the patient. We also take great care target under MRI guidance where you can see the brain heating The average time to recurrence was 49.25 months (range: in selecting movement disorder patients in real time. The target is > 60 degrees Celsius for a permanent 3-90 months). Twelve patients required additional treatment for DBS surgery. Pre-operative steps lesion and 50 degrees Celsius for a test lesion. This creates a for tumor recurrence (4%) with 2 undergoing re-exploration include neuropsychological testing, physical therapy evaluation, Routine image of a pituitary An example of Image-guided small lacunar infarct. MRgFUS also opens up the blood brain EEA, 5 Gamma Knife Radiosurgery, 2 open craniotomy Neuronavigation being used brain magnetic resonance imaging (MRI), medical clearance, off/on macroadenoma amendable barrier for the delivery of novel drugs, and this method could be due to recurrent disease lateral to the internal carotid to the Endoscopic intraoperatively during an medications responses, videotaping patient movements at baseline, used to improve the therapeutic effect of drugs at the target. artery, 1 fractionated XRT, and 2 medicinal suppressive Endonasal Approach Endoscopic Endonasal Approach and team discussion for patient selection. therapy. Of the 20 recurrences observed during the study 4 to confirm regional anatomy and 5 lateral extent of tumor resection AdventHealth’s Neuromuscular Clinic Grows and Coagulopathy and Bleeding Progression After Achieves National Recognition Isolated Blunt Head Injury

Established in 2019, AdventHealth’s The AdventHealth Neuromuscular Clinic currently serves Traumatic Brain Injury (TBI) is a major Table 1. Outcome in patients with intracranial Neuromuscular Clinic provides patients from more than 22 states across the country, and cause of morbidity and mortality. It bleeding who had coagulopathy at arrival comprehensive, multi-disciplinary care, in early 2021, plans to host its first “Movement is Medicine” is responsible for more than half of with electro-diagnostic and genetic conference in partnership with the HNF. This conference will the approximately 100,000 trauma- 1.3 ≤ INR Outcome INR < 1.3 INR > 1.5 Total testing for patients with amyotrophic bring together patients with hereditary neuropathies (CMT) and related deaths a year in the United ≤ 1.5 lateral sclerosis (ALS), Charcot-Marie- focus on the importance and fun of exercise while fostering States. The incidence of coagulopathy Tooth disease (CMT), spinal muscular new friendships and creating positive energy to promote in TBI is considered high but varies Nivedita Jerath, MD, MS Roland Torres, MD Poor 22.6% (14) 60.0% (6) 80.0% (4) 31.2% (24) Medical Director, atrophy (SMA) and other neuromuscular healing. It will also be a time to celebrate the HNF Center of Neurosurgeon significantly between studies, from 10% Neuromuscular Medicine conditions. The neuromuscular team Excellence designation. to 97.2%, depending on study designs AdventHealth Good 77.4% (48) 40.0% (4) 20.0% (1*) 68.8% (53) AdventHealth is also currently conducting a number Neuroscience Institute and definitions for coagulopathy Neuroscience Institute of hereditary neuropathy research used. Coagulopathy is independently projects, including clinical trials for CMT associated with in-hospital mortality *This patient had INR reduced to 1.4 within 10 hours after and chronic inflammatory demyelinating in patients with severe TBI. The admission.N=77, coagulation tests for 2 other patients had not polyneuropathy (CIDP), and recently association between the presence been performed at arrival. Kruskal-Wallis test p=0.0001 achieved key recognition and of coagulopathy and progression of certification from two important partner traumatic hemorrhagic brain lesions organizations: after the initial injury has been Table 2. Outcome in patients with intracranial described by many authors, but the • Named a Center of Excellence (COE) bleeding who had coagulopathy during the severity of coagulopathy that is clinically by the Hereditary Neuropathy significant has not been specified. first 3 days of hospitalization Foundation (HNF) for providing excellence in clinical care and research and collaborating with the HNF to serve as a From left to right: Laura Patrick, PT; Jeannie Macaluso; Carlos The goal of this study is to describe the frequency and severity 1.3 ≤ INR Outcome INR < 1.3 INR > 1.5 Total patient community hub for clinical Hernandez; Nivedita Jerath, MD, MS; Allison Moore; Ashley of coagulation disorders in patients with isolated, moderate-to- ≤ 1.5 care, community engagement, Hayden; and Craig Brubaker critical traumatic blunt brain injury treated in a Level I trauma research and training/education center, determine the severity of coagulopathy that has clinical Poor 15.0% (6) 33.3% (9) 83.3% (10) 31.6% (25) significance, and assess management of the modifiable factors associated with coagulopathy. This will also help us Good 87.2% (34) 66.7% (18) 16.7% (2) 69.2% (54) to understand how to improve the natural history of ongoing • Named a Certified Clinic by the ALS Association for bleeding and progressive neurological deterioration. providing specialized care based on best practices N= 79, Kruskal-Wallis test p=0.0001 In addition, Neuromuscular Division Director Nivedita Jerath, Methods MD, speaks throughout the country and serves as a national This is a retrospective review of data collected prospectively Finally, we examined other factors possibly associated medical expert advisor for the Periodic Paralysis Association, in a hospital trauma registry. We reviewed the records of 153 with clinical outcome and found that the median time a non-profit organization founded to foster awareness of From left to right: Carlos Bara, R.NCS.T; Amber Parkins, OT; Laura consecutive, admitted patients, who had isolated, moderate- from emergency department (ED) arrival to start of plasma periodic paralyses, promote science-based information Patrick, PT; Nivedita Jerath, MD, MS; Samantha Purlee, LPN; Laura to-severe blunt head injuries (Glasgow coma score [GCS] ≤ 12, transfusion in the patients who had coagulopathy on admission regarding this class of disorder, and champion the interests of Russell, LSW, and behind both Samantha and Laura is Rebekah who had an abbreviated injury score [AIS] ≥2, and who had an and survived was shorter than in those who died (95 min, IQR the periodic paralysis community. Wright (patient access coordinator) extracranial AIS sum ≤ 2) but had no preexisting coagulopathies 70-120 vs. 150 min, IQR 110-210). or a history of anticoagulant therapy. Coagulopathy was defined as an elevated International Normalized Ratio [INR] ≥1.3 Discussion or partial tromboplastin time [PTT] >35 seconds. The degree Our data demonstrate that decreased hematocrit is the factor of coagulopathy was considered mild if INR or PTT was over that most strongly correlates with severity of coagulopathy Taking a Proactive Lifestyle Approach to Promoting upper laboratory norm [ULN] to 1.5 ULN, moderate when INR or in patients with isolated blunt head injury. Hematocrit level PTT was from 1.5 ULN to 2 ULN, and severe if INR or PTT was Brain Health: The Quest for Achieving Neurogenesis in trauma settings reflects severity of blood loss and/or over 2 ULN. and Synaptogenesis hemodilution. Our study also showed that timely replenishment of consumed and lost coagulation factors is of high importance Results in treatment of post-traumatic coagulopathy in patients with It was once believed that the nervous In contrast to this pattern of rescue and repair, many within the We found that 21 of 153 patients (14%) had coagulopathy blunt head injuries. Our data, demonstrating the clinical system was fixed and incapable field of neurology are starting to focus more on prevention and on admission, and 48 of 153 (31.4%) had it by day three of significance of even a mild coagulopathy in patients with of regeneration after embryonic steps that can be taken to proactively promote brain health and hospitalization. Among them, 35 (22.9%) developed a mild intracranial bleeding, is strong evidence for a more aggressive development. However, over the last avert neurological crisis events. Building a better brain begins coagulopathy, and 13 (8.5%) had a moderate or severe coagulation factor replacement strategy beginning immediately two decades, the concepts of ongoing with building a better biology. However, before we can build a coagulopathy. Hematocrit values were used as an indirect on arrival. Glenn Kolluri, MD neurogenisis (growing new neurons) better biology, we must first remove the insults to our patients’ indicator of hemodilution. Among patients with increased INR, Neurologist and synpatogenesis (the formation biology. There are a number of lifestyle modifications that PT or PTT, median hematocrit at admission was significantly Conclusion AdventHealth of synapses between neurons in the healthcare professionals can proactively promote to patients Neuroscience Institute lower than in patients who did not have coagulopathy (31.3 s., nervous system) throughout life have that will improve overall and neurological health. Intertwining Overall, our study demonstrates that low hematocrit, reflecting interquartile range [IQR] 25.8-36.8 vs. 41.3 s., IQR 38.1-44.5). emerged as critical developments in this education into the care that we provide as clinicians is amount of blood loss and hemodilution, correlates stronger Hematocrit was the factor that most strongly associated with the field of neurology. part of keeping our patient at the center of everything we than severity of injury with INR in patients with isolated blunt INR increase. In addition, there was a moderate correlation of do. Creating a high-quality, connected neurology network is head injury, and even mild prolongation of coagulation tests Too often, we are treating patients in INR with severity of injury (ISS and AIS). Tables 1 and 2 show the first step in ensuring that patients leave the hospital with results predicts the occurrence of delayed bleeding in the rescue mode after they are already the relationship between the presence of coagulopathy and timely and appropriate follow-up care in the outpatient setting. patients who already bleed. Earlier coagulopathy diagnostics experiencing a neurological crisis such outcome, analyzed as dichotomized variable with GOS scores This is not always easy, and we need to arm patients with the and a more aggressive coagulation factors replacement as stroke. Our focus as neurologists is on reducing the brain of 4 to 5 representing “good” neurological outcome, and scores education on why this is important. strategy may lead to improved outcomes in patients with of 1 to 3 representing “poor” outcome. from further injury with medication and other interventions. intracranial bleeding after trauma. Once the rescue is over and the patient is recovering, we At the AdventHealth Neuroscience Institute, we are continually focus on repair. In this phase, we use a variety of therapeutics, modifying processes and ways in which patients can best be including medication or surgery, to help restore the patient’s connected and navigated across the neurological continuum. quality of life. We hope to generate neurogenisis and/or We remain committed to not only providing groundbreaking synaptogeneis, but we are rarely ever able to truly cure the treatments and customized care for patients in neurological neurological disease. This leaves us with a focus on disease crisis, but also to proactively promoting neurological health, management and limiting the amount of neurological damage. education, and disease prevention.

6 7 Migraine Treatment Update: Four New Medications Endovascular Neurosurgery Update: Management of Chronic Approved by FDA Subdermal Hematoma Through Endovascular Therapy

Founded in 2019 and led by a board- were significantly greater with ubrogepant 50 mg dose (21.8% Endovascular neurosurgery recurrence fall between 10-20%, with a smaller percentage certified neurologist, who is also responders) in comparison to placebo (14.3% responders). (interventional neuroradiology) is a field resulting in symptoms. Surgeons have tried various methods to board-certified in headache medicine A similar pattern was observed in pain relief at 2 hours: that began in the 1960s as practitioners decrease recurrence such as removal of chronic membranes, by the United Council of Neurologic ubrogepant 50 mg (62.7% responders) versus placebo (48.2% searched for better, less invasive aggressive irrigation, and many other anecdotal solutions. Subspecialties, our Headache Clinic responders). Ubrogepant is also well tolerated with a low solutions for existing problems. The None of these have been proven consistently successful. This specializes in evaluating and treating side-effect profile. The most common adverse reactions desire to improve care for neurosurgical disease process includes a cascade of inflammation that leads to a wide variety of headaches, including are mild nausea, dry mouth, and somnolence. Ubrogepant patients has led to many innovations. angiogenesis and leaking blood vessels. This feedback loop leads Bernadette Nazario- Ravi Gandhi, MD migraines, with a focus on both is contraindicated with co-administration of strong CYP3A4 Now, we present a scenario to apply this to accumulation and mass effect that results in the symptoms. Lopez, MD Neurovascular Medical easing pain and symptoms as well as inhibitors, and it is metabolized via the liver so appropriate technology to an age-old problem. Headache Medicine Director Endovascular therapy has been applied via embolization of the Medical Director, preventing recurrence. Migraines can be considerations and dosage adjustments must be made. AdventHealth Chronic subdural hematoma (cSDH) middle meningeal artery (MMA). This artery runs along the dura, AdventHealth especially debilitating for patients, with Neuroscience Institute is a disease process that is increasing outside of the brain parenchyma. Through a small puncture Neuroscience Institute some episodes lasting for hours or even NURTEC ODTTM in prevalence every year with the in the femoral artery, a catheter is guided into the MMA, and days, and our team continuously stays TM aging population and increasing use polyvinyl alcohol (PVA) particles or Onyx liquid embolic is used on top of the latest science to identify NURTEC ODT (rimegepant) is the second gepant recently of anticoagulation and antiplatelet to occlude the artery. The occlusion of this vascular supply is new safe and effective treatment approved by the FDA for treatment of acute migraine with or medications. It is estimated that by safe and effectively stops the inflammatory-to-angiogenesis-to- methods that will provide our patients without aura in adults. It is a 75 mg, orally-dissolving tablet that 2030, there will be 60,000 new cases leaky-vessels cycle. improved relief and a better quality blocks CGRP receptors. The safety and efficacy of this drug of cSDH per year. The patients have of life. We are excited to report that was evaluated in one clinical trial of 1,351 patients with migraine Endovascular therapy for chronic subdural hematoma has been varying presentations and outcomes within the last year, four new migraine headache. Its benefit was determined based on both the applied as a primary therapy or as an adjunct to surgery. There after traditional treatment. Common medications have been approved by the U.S. Food & Drug percentage of patients who became pain-free within 2 hours have been published case series and one report with historical symptoms include cognitive decline, headache, focal Administration (FDA): compared to placebo as well as elimination of patients’ most controls. Ban et al. reported 98.6% success in embolization weakness, gait difficulties, and seizures. The one-year mortality bothersome migraine symptom within 2 hours of taking the patients compared to 72.5% in the control arm. There is rates are estimated at 30%. VYEPTITM drug. The results of this trial were similar to those obtained with an ongoing randomized clinical trial comparing traditional ubrogepant. In comparison to placebo, 21.2% of the participants The conventional management of cSDH range from conservative surgical and conservative treatment versus middle meningeal TM Vyepti (eptinezumab) is the first IV treatment approved for the on rimegepant were pain free at 2 hours versus 10.9% on management to open craniotomy for surgical evacuation. embolization. The obvious benefits of MMA embolization preventive treatment of episodic and chronic migraine in adults. placebo. Rimegepant should be taken immediately when a The management strategy is dependent on patient-specific in this patient population include the ability to reinstitute It is part of a newer class of drugs called CGRP (calcitonin migraine starts but can also be effective if taken up to 4 hours factors such as the symptoms, medical co-morbidities, and size anticoagulation and antiplatelet medications. gene-related peptide) monoclonal antibody (mAbs) treatments. later. The most common reported side effect is nausea. Like and location of the hematoma. Patients with larger cSDH and Our experience at AdventHealth has mimicked that published During a migraine attack, the cerebral nerves and blood vessels ubrogepant, it is metabolized by CYP3A4. It is contraindicated debilitating symptoms are best suited for surgical evacuation. release substances, including CGRP which is a neuropeptide. with co-administration of strong CYP3A4 inhibitors. in the literature. Middle meningeal artery embolization is a Eptinezumab is a humanized monoclonal antibody that binds Surgical outcomes tend to be favorable. However, a current valuable asset in the armamentarium of management for this to CGRP ligand and blocks its binding to the receptor. Patients REYVOW® obstacle is the tendency for recurrence. The quoted rates of large patient population. receive the medication through a 30-minute IV infusion every 3 months either at a 100 mg or 300 mg dose. Eptinezumab was The FDA also approved Reyvow® (lasmiditan) within the last evaluated through two Phase III clinical trials. These studies year, and it is the first migraine treatment in the class called found that more people were migraine-free for 7 days after their ditans. This class of drugs are serotonin (5-HT) 1F receptor first IV infusion with eptinezumab compared to placebo. The agonists. Available in 50 mg, 100 mg and 200 mg tablets, main distinguishing characteristic of eptinezumab is that we can lasmiditan works similar to a triptan, but is not contraindicated observe clinical results from day one. In the PROMISE-2 trial, in cardiovascular conditions. Its efficacy for the acute treatment 50.3% of patients on the 100 mg dose experienced a reduction of migraine was demonstrated in 2 randomized, double-blind, in migraines in comparison to 27.1% of patients on placebo. In placebo-controlled, single-attack trials of 4,439 patients who addition, 57.6% of people with chronic migraine treated with took 50-mg, 100-mg, or 200-mg doses of lasmiditan or placebo. eptinezumab 100 mg had ≥ 50% reduction in their migraine Researchers found that it could relieve pain and other migraine days, compared to 39.3% with placebo. This drug provides symptoms within 2 hours. In the SPARTAN trial, responder migraine patients, especially those with chronic migraine, a rate for pain relief in 2 hours was significantly higher in the new treatment option, particularly if they are unable to tolerate lasmiditan groups vs placebo: 56% (50 mg dose), 61% (100 mg some of the other injectable preventive medications that are dose), 61% (200 mg dose), and 45% (placebo group). Treatment available. Eptinezumab is well tolerated with nasopharyngitis as emergent adverse events were generally mild to moderate, the most common side effect. and the most frequent included dizziness, fatigue, paresthesia, sedation, nausea and/or vomiting, and muscle weakness. It UBRELVY® is important to mention that lasmiditan can cause significant driving impairment. Patients who use lasmiditan are advised not George Simon, MD, Named Executive Director of Moffitt Cancer Ubrelvy® (ubrogepant) is an oral, non-narcotic medication, to drive or engage in potentially hazardous activities for at least available in 50 mg and 100 mg tablet form, for the acute 8 hours after taking it. Lasmiditan is a non-opioid/non-narcotic, Center-AdventHealth Joint Clinical Research Unit treatment of migraine with or without aura in adults. It is the Schedule V medication that has low abuse potential and no first drug in the class of oral CGRP antagonists called gepants, evidence of physical dependence. which work to block CGRP from attaching to its receptor and The AdventHealth Neuroscience Institute Headache Clinic George Simon, MD, joins Moffitt Cancer Center and AdventHealth as executive medical director of initiating pain signals. Gepants are small molecule CGRP remains dedicated to continually identifying and implementing the joint Moffit Cancer Center-AdventHealth clinical research unit in Celebration. This new facility receptor antagonists, whereas preventive CGRP monoclonal new effective treatment options that will improve the care provides access to the latest in cancer treatments through cutting-edge research as well as access antibodies, like eptinezumab, are large molecules. For more provided to our patients. While our most recent efforts have to investigational early phase clinical trials for Central Florida patients. It is part of a larger partnership than 20 years prior to the approval of ubrogepant, triptans focused on outpatient care, we are also currently working on between Moffitt and AdventHealth focused on enhancing both institutions’ ability to deliver the highest were the primary medications used to treat acute migraine, the development of both ER and inpatient clinical protocols for quality cancer care to patients. but they come with limitations, including cardiovascular the treatment of headaches. contraindications. In addition, some patients taking triptans Dr. Simon brings more than 20 years of clinical oncology translational research experience to this experience reduced effectiveness over time. Gepants are new role. Most recently, he served as section chief of translational research in the Department of not contraindicated in patients with history of cardiovascular Thoracic/Head and Neck Medical Oncology at MD Anderson Cancer Center in Houston. Additionally, disease. Ubrogepant’s effectiveness for the acute treatment he served as medical director of the MD Anderson Cancer Network. He has also held director level of migraine was demonstrated in two randomized, double- positions at Hollings Cancer Center in Charleston, South Carolina, and Fox Chase Cancer Center in blind, placebo-controlled trials. In the ACHIEVE II trial, which Philadelphia. Prior to that, Dr. Simon was a faculty member at Moffitt from 2000 to 2008 as director included 1,686 participants, rates of pain freedom at 2 hours of mesothelioma research and a member of the Department of Thoracic Oncology.

8 9 Preoperative Optimization for Patients Undergoing Secondary Stroke Prevention in the Community

Elective Lumbar Spinal Fusion An estimated 795,000 Americans as a primary point of contact for each patient, providing them experience a new or recurrent stroke not only medical care, but also hope, encouragement, and a As the cost of health care continues to Malnutrition: Poor nutritional status may lead to higher each year. From streamlined emergency second chance. climb, it is imperative that physicians surgical site infections and other wound-related complications. room protocols, expedited diagnostics, Our team of community neurologists stays current on the latest lead the campaign to improve patient Studies have shown low pre-albumin levels increase the rate of and neurological care pathways to research and developments in stroke prevention and post- outcomes while providing high-quality, complications following lumbar surgery. Nutrition programs and dedicated “tele-stroke” physicians who stroke care, incorporating these findings into individualized, cost-effective care. For the first time, protein supplementation are low-cost interventions that can are readily available via telemedicine, evidence-based care plans. Specific services provided include the AdventHealth Spine Governance lead to reduced complications. the AdventHealth Neuroscience Committee brought together physicians the following: Institute (NSI) has worked hard to from multiple specialties to address Hyperglycemia is an independent risk factor for Cory Hartman, MD Diabetes: improve outcomes for stroke patients. pre-operative optimization criteria for increased complication rates following spinal surgery. Glycated • Perform additional diagnostics as needed as well as ongoing Neurosurgeon To complement these efforts, our AdventHealth patients undergoing elective lumbar hemoglobin (A1C) is a marker for blood glucose control over two Jose Garcia-Guerra, MD health monitoring community neurologists are enhancing Neuroscience Institute fusion surgery. This included physicians to three months. Improving a patient’s long-term blood glucose Neurovascular Medical • Supervise medical care and use of drug therapies the continuity of care provided to these from neurosurgery, orthopedic spine control will help decrease complication rates from surgery and Neurologist • Educate patients to make necessary lifestyle interventions AdventHealth Medical patients upon discharge to help address surgery, and pain management as well as other end-stage organ injury secondary to hyperglycemia. such as exercise, smoking cessation, and diet improvements our colleagues in the rehabilitation field. Group Neurology at Palm recurring issues and prevent secondary • Anemia: Perioperative morbidity and mortality are increased Coast stroke. Coordinate care with the patient’s other medical providers First, a thorough literature review on in patients with preoperative anemia. Treating pre-operative such as primary care, cardiology, and endocrinology patient risk factors and complication anemia can potentially avoid blood transfusion and its Patients who suffer a stroke are often • Help patients navigate the healthcare system, including rates in elective lumbar fusion surgery associated risks in the perioperative period. overwhelmed once they are discharged follow-up appointments and access to community resources was conducted. Then the committee from the hospital. In addition to any new challenges they • Empower patients with the knowledge and confidence to voted to create a worksheet containing Smoking: Smoking is another independent risk factor for may have as a result of the stroke, most are also faced with five criteria that a patient must meet take charge of their health increased perioperative complications. It prevents wound healing, chronic diseases such as hypertension, diabetes, obesity, or prior to undergoing elective lumbar fusion. Those criteria spinal fusion, and the ability to fight infections. Providing patients obstructive sleep apnea that require an ongoing, coordinated After suffering a stroke, the risks for experiencing another include levels of obesity, malnutrition, diabetes, anemia and with resources to help them quit smoking can decrease the care plan. AdventHealth’s community neurologists partner stroke are significantly increased. The AdventHealth NSI smoking status (Figure 1). deleterious effects of smoking and improve the healthcare system. with post-stroke patients to identify how chronic conditions are believes preventing secondary stroke through a strong network of patient-focused, community-based neurological care is a Obesity: It has been shown that obese patients report worse Looking Ahead impacting their health and to develop a customized care plan to critical piece of its comprehensive stroke program. outcomes with higher complication rates and patient-reported improve it and prevent another stroke. These physicians serve outcomes. Longer operative times in obese patients also As we strive to improve the quality of care we provide, we will lead to higher risks for the patient. Weight loss programs not continue to review literature and add further criteria to our only help to curb the complication rates, they also can help current list. This is our starting point to bring physicians from patients with other obese-related medical conditions such as multiple groups and demographics together for a common hypertension and diabetes. goal: provide high-quality, cost-effective care for our patients. Cervical Artificial Discs Provide Alternative to Figure 1: Thoracolumbar Fusion: Surgical Optimization Form Cervical Spinal Fusion for Some Patients

Optimization Criteria N/A Optimized Non - Optimized For many years, cervical spinal fusion the FDA approved the first artificial disc for use in the United was the only option for patients States, and the implants have continued to evolve and improve Obesity BMI <30 BMI 30 – 39.9 (weight loss recommended) BMI > 40 undergoing a discectomy to address over the past decade. Pre-albumin < 20mg/dl with nutrition Malnutrition Pre-albumin > 20mg/dl Pre-albumin < 20mg/dl unresolved pain, muscle spasms, enhancement Initiated numbness, or inflammation due Who Can Benefit from Cervical Diabetes Non-diabetic HgbA1C < 7.5 HgbA1C >= 7.5 to cervical disc disease. While still Artificial Discs? Chronic anemia medically treated and optimized considered a safe, effective option Male: Hgb <13 gm/dl Male: Hgb < 13 gm/dl Anemia Male: Hgb <13 gm/dl today, spinal fusion reduces range of While a tremendous advancement, cervical artificial discs Female: Hgb < 12gm/dl Female: Hgb < 12gm/dl Female: Hgb < 12gm/dl motion and can also lead to adjacent are not a valid surgical option for all patients. This approach Smoking Non-smoker Quit Smoking Continues to Smoke Federico Vinas, MD level disease, resulting in degeneration primarily benefits younger patients (under age 60) with disc Neurosurgeon in the discs immediately above and herniation without instability. Counter-indications for cervical AdventHealth below the one that was removed and artificial disc surgery include being over 60 years of age, Neuroscience Institute causing the need for additional surgery osteoporosis, arthritis, bone spurs, deterioration in multiple down the road. Performed in Europe discs, infection, and allergy to titanium. Inter-professional Education for Collaborative Practice for over 25 years, artificial cervical disc replacement has emerged as another Outcomes surgical option for some patients. It Approved by the United Council for comes from different perspectives and can learn about and provides the same pain relief as spinal fusion while protecting Research has demonstrated that use of an artificial disc can Neurologic Subspecialties (UCNS) in from each other, collectively growing the group’s overall improve radiculopathy or cervical pain as safely and effectively 2019 and one of only four such programs competence and strengthening the focus on patient- and the patient’s natural range of motion and helping to prevent as cervical fusion while preserving spine mobility and range of in the state of Florida, AdventHealth’s family-centered neuroscience care. disc degeneration in the adjacent discs. Neurocritical Care Fellowship welcomed motion. In addition, it does not require a bone graft, eliminating Artificial cervical discs were developed to mimic the properties its first group of fellows in July 2020. The fellowship program features a series of interdisciplinary the risk of nonunion (the bone graft not fusing with the spine) and biomechanical function of a healthy human disc. In 2007, With a multi-disciplinary faculty of lectures attended by both faculty and fellows, and the use and often resulting in a quicker recovery. neurointensivists, vascular neurologists, of Microsoft Teams technology has made these educational epileptologists, neurosurgeons, and opportunities accessible to a wider audience of NSI physicians and critical care physicians, the program nurses across the AdventHealth system. In addition, the fellowship Okorie Nduka is not only training its fellows to care program runs the Emergency Neurological Life Support (ENLS) Okorie, MD for patients with a wide variety of course, a two-day, internationally accredited course designed to Neurocritical Care help healthcare professionals improve patient care and outcomes Care Navigation Fellowship Director life-threatening neurological and neurosurgical conditions, it is also during the critical first hours of a patient’s neurological emergency. AdventHealth The course covers interdisciplinary protocols, checklists, decision Neuroscience Institute fostering inter-professional collaboration, education, and development amongst points and communication strategies. Minimally Invasive Brain Surgery (MIBS) 407-303-7944 Parkinson’s Outreach Center 407-303-5295 the entire AdventHealth Neuroscience Future plans for the Neurocritical Care Fellowship program Spine Center 407-303-9102 Alzheimer’s Disease & Dementia 407-392-9237 Institute (NSI) team. include engaging the Fellows in patient care audits and The fellowship program’s guiding philosophy is that inter- additional quality improvement-oriented research. Epilepsy & MEG 407-303-7520 Normal Pressure Hydrocephalus 407-303-3282 professional education is the foundation for competent collaborative care teams. Essentially, learning together, For more information or to apply for the Neurocritical Care Center for Sleep Disorders 407-303-1994 gaining new competencies together, and practicing together Fellowship, contact Fellowship Director Okorie Nduka will enhance overall patient outcomes. Everyone on the team Okorie, MD, at okorie.okorie.md@adventhealth.com. 10 11