Advances in Technology to Treat Brain Tumors: Frameless Alternative

Photo displaying front view of the Icon(TM) Leksell Gammaknife

Hershey Medical Center is one of the first in the country to have a new Icon™ Leksell GammaKnife. Image courtesy of Elekta.

Thanks to advances in motion tracking technologies used for years on nonbrain-related cancers, such as lung and liver, precision radiosurgery for treatment of malignant brain tumors can now be performed using a flexible, removable mask placed over the face, instead of the anchored stereotactic headframe, previously required. Penn State Health Milton S. Hershey Medical Center is one of the first in the country to have the new Leksell GammaKnife® upgrade, called the Icon™ (Elekta, Sweden), which offers the motion-tracking mask, as well as the conventional headframe.

The radiation sources and beam technology are unchanged. According to James McInerney, MD, professor of neurosurgery, “Eliminating the need for a stereotactic headframe anchored to the skull opens up treatment possibilities that weren’t feasible in the past. This translates into hope for patients who had certain types of brain tumors that might have had fewer treatment options.” Continue reading

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Limited Spinal Tumor Resection with Stereotactic Radiosurgery

For patients with metastatic spinal cancer, more limited tumor resection paired with very high-dose radiation treatments delivered using stereotactic body radiotherapy (SBRT) marks a major shift in treatment. Previously, the standard was highly invasive spinal surgical procedures and the use of low-dose conventional external beam radiation therapy regimens.¹ The conventional approaches to treatment have traditionally been highly morbid and often involve circumferential tumor resection, conventional external beam radiation therapy over as many as 10 to 15 sessions, and spinal surgery aimed at achieving bone fusion. Brad Zacharia, MD, MS, director, neuro-oncology and skull base surgery, Penn State Neuroscience Institute, notes, “With more aggressive resection and stabilization paired with low-dose radiation, the outcomes are often poor, with long periods of recovery, neurologic complications and inadequate tumor control.”

“Championed by Mark Bilsky, MD, at Memorial Sloan Kettering Cancer Center and now implemented at Penn State Health Milton S. Hershey Medical Center,” Dr. Zacharia explains, “this is a very different way of thinking about metastatic tumors of the spine. Tumor resection is aimed at decompression, stabilization and creating room around the spine to allow safe delivery of high-dose radiation. The main means of tumor control is image-guided SBRT rather than surgical resection.” Continue reading

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Multidisciplinary Specialty Care Imperative for Neurofibromatosis Management

Penn State Health Milton S. Hershey Medical Center specialists are working together to form a center for the comprehensive, multidisciplinary management of patients with neurofibromatosis (NF). Leading the team are Dawit Aregawi, MD, assistant professor, neuro-oncology, Kimberly S. Harbaugh, MD, associate professor of neurosurgery, chief, division of peripheral nerve surgery, and Elias Rizk, MD, assistant professor of neurosurgery. The Hershey Medical Center team is focused on adult NF management for better function preservation, earlier detection of cases with malignant tumor progression and better management of associated comorbidities. Dr. Harbaugh explains, “If patients have access to regular monitoring at an NF specialty center closer to their homes, it’s likely that tumors and associated complications will be detected earlier, possibly helping to avoid significant nerve and soft tissue damage and to preserve function.” Dr. Aregawi says, “Despite the fact that NF is a fairly common autosomal dominant disorder [1 in 3,000]¹, many adult patients are seen by specialists only when a problem arises, with routine follow-up mostly done in the primary care setting.” A major barrier to accessing specialty care is the limited care options closer to patients’ homes, with many required to travel long distances to see an NF specialist. Continue reading

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Raising Awareness of Neurologist Burnout; Defining Paths toward Recovery

With studies revealing that nearly half of neurologists experience at least one symptom of burnout1,2 a special task force was launched in 2016 by the American Academy of Neurology (AAN) to research the problem. According to Sankar Bandyopadhyay, MD, associate professor of neurology, Penn State Health Milton S. Hershey Medical Center, “The first step in solving any problem, including burnout, is to recognize it. Physicians in general tend to deny, even to themselves, that they may be experiencing burnout.” Physician burnout is marked by feeling emotionally exhausted, being less empathetic with patients and being unsatisfied at work; in some cases there may be depression and substance use, abuse or addiction.3 The abbreviated Maslach Burnout Inventory is a validated self-administered questionnaire that identifies the presence and severity of burnout symptoms.4

Graphic of the cyclical process of burnout: Preparedness, response, recovery and mitigation.Dr. Bandyopadhyay points out that there are evidence-based, proven interventions that those experiencing burnout can use to help themselves.5-7 “Maybe the most powerful of these is ‘mindfulness.’ It’s a strategy to reduce stress and re-frame how we think, to experience less frustration and boredom,” he says. In several trials with physician participants, formal mindfulness training significantly decreased depersonalization, emotional exhaustion and overall burnout scores.5-7 Continue reading

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Burnout

I looked at the clock. It showed 2:58 am. The ED hadn’t paged in 30 minutes. No calls from the floor either in at least 15. It was now or never. I hurried over to the refrigerator and threw my microwave dinner in to heat. Two minutes later, I heard the beep. My stomach was growling; I realized I hadn’t eaten anything in about 12 hours. Then, I realize the beeping wasn’t the microwave at all. BRAIN ATTACK arriving with ETA of 5 minutes…. I looked at the microwave and then the door and then back at the microwave. Shall I try to take a few bites before I run down to the ED? Do I bring it with me? Then, the pager goes off again, outside caller trying to reach an on-call doc. Forget it. I grabbed my laptop and ran to the ED to meet the incoming patient. No food, no water. I dial the outside line, “Neurology Emergency Line, this is the on-call doctor…” and my pager goes off a third time as I head down the steps…

Burnout (Noun): 1. The reduction of a fuel or substance to nothing through use or combustion. 2. Physical or mental collapse caused by overwork or stress.1

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Retinal Vasculopathy – A Potential Early Predictor of Stroke Risk

Impaired retinal vasodilator responses may be an early marker of microvascular disease or endothelial dysfunction and a potential predictor of cerebrovascular risk based on findings from studies in diabetic and prediabetic patients.1,2 Kerstin Bettermann, MD, PhD, associate professor, department of neurology, Penn State Health Milton S. Hershey Medical Center, explains, “Retinal blood flow is controlled by autoregulatory metabolic and pressure mechanisms, which are impaired in diabetes. We also know that impairment of the retinal microvasculature is associated with cerebral ischemia.3 Given these two facts, looking at retinal vasodilator responses may be a low-cost, non-invasive strategy to assess risk for stroke and possibly other cerebrovascular risks in a wide range of individuals in the community.” Dr. Bettermann believes that with further validation, screening for retinal vasculopathy may become part of routine eye exams.

Retinal arterial vasoreactivity over time following flicker light stimulation

Retinal arterial vasoreactivity over time following flicker light stimulation

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Fast-tracked Immunotherapies Offer Hope for Aggressive Brain Cancers

Patients with aggressive, high-grade malignant brain cancers, like glioblastoma multiforme (GBM) and anaplastic astrocytoma (AA), have a poor prognosis with no known curative treatment using standard resection, radiation and chemotherapy approaches. With this bleak clinical outlook, the U.S. Food and Drug Administration (FDA) has fast-tracked clinical development of several new therapies.1 According to Brad Zacharia, MD, MS, assistant professor of neurosurgery, Penn State Neuroscience Institute, and co-director of neuro-oncology, Penn State Cancer Institute, “With aggressive tumors like GBM and AA, neuro-oncologists worldwide are exploring biological and immune-targeted therapies, to identify more effective treatments. We (Penn State Health Milton S. Hershey Medical Center) are an investigational site for a number of clinical trials for these types of cancers.” (See chart.) Continue reading

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TeleStroke Program Overcomes Geographical Barriers to Provide Cutting-Edge Neurological Care


Map of Pennsylvania depicting Telestroke Program Regional Partners with a barchart display of the number partnerships from years 2013 to 2016.LionNet
, Penn State Health Milton S. Hershey Medical Center’s virtual telestroke program, partners with 16 regional hospitals. The telestroke network provides stroke patients rapid access to expert stroke neurologists and neurosurgeons, no matter how remote or rural the community hospital. Stroke patients at a partner site emergency department (ED) are assessed in real-time via audio/ video feed by a stroke neurologist or neurosurgeon at Hershey Medical Center; physicians at both sites can share patient imaging, charts, and test results. Since its July 2012 inception, the program has grown exponentially and more than 5,000 patient consults (approximately 2,000 of which were ischemic stroke patients) have now been performed using LionNet. Continue reading

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Capable Kids Program Provides Coordinated Complex Neurological and Medical Care

In January 2016, Penn State Children’s Hospital launched ‘Capable Kids,’ a care coordination program involving more than 200 patients. The program aims to better manage the complex medical needs of children with serious neurological diagnoses and reduce the burden on families. William Trescher, MD, division chief, pediatric neurology and president of the Child Neurology Foundation, says, “This idea stemmed from a Penn State Health Milton S. Hershey Medical Center retreat in 2014 when a number of clinicians from multiple specialties came together to explore ways to provide improved care for our patients and families.” Physicians, including those from pediatric gastroenterology, pulmonology, orthopedics and neurology, participate in the program, working together to address the needs of kids with very debilitating illnesses. Capable Kids is uniquely tailored to the needs and challenges of families in the surrounding community, which is largely rural or semi-rural. Continue reading

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Novel Zebrafish Research Contributes to More Effective Diagnosis, Treatment of Neurodegenerative Disorders

Researchers at Penn State Neuroscience Institute not only conduct pre-human scientific studies of various medical conditions, but also see patients daily, giving these physicians a perspective not found in most laboratories. Mark Stahl, M.D., Ph.D., assistant professor of neurology and neural and behavioral sciences, details one such study involving “molecular tweezers” to break up the aggregation of misfolded proteins known as α -synuclein.1 These aggregated proteins are associated with the development of neurodegenerative disorders such as Parkinson’s disease, for which there are currently symptomatic therapies but no treatments that can alter the disease course.1

Zebrafish research

LEFT: Zebrafish overexpressing neuronal human alpha-synuclein (red) have poor morphology, neuronal death and poor survival. RIGHT: “Molecular tweezers” like CLR-01 can rescue this phenotype.

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