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
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
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
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
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
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
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.
Since the Food and Drug Administration (FDA) approved the Pipeline® Embolization Device (PED) for flow diversion in large or giant wide-necked aneurysms in 2011 after the multicenter Pipeline for Uncoilable or Failed Aneurysms (PUFs) trial proved its safety and efficacy1, the revolutionary device continues to improve treatment of the most complex aneurysms. The latest version, the Pipeline™ Flex, features a vastly improved delivery system. According to Kevin Cockroft, M.D., M.Sc., co-director, Penn State Comprehensive Stroke Center, “We now have the ability to reposition the device, which allows for more precise placement instead of always needing to hit the exact target on the first attempt, and this appears to have shortened the learning curve for clinicians.” Hershey Medical Center was one of the first in the country to offer treatment with the PED, and has performed close to 70 of the procedures to date.
Digital subtraction angiogram in lateral view before and six months after treatment.
Over one million Americans are impacted with a primary autonomic system disorder, and the more common forms of these conditions include Postural Orthostatic Tachycardia Syndrome (POTS), Neurocardiogenic Syncope (NCS), Pure Autonomic Failure (PAF) and Multiple Systems Atrophy (MSA).1 In addition, seemingly vague symptoms such as unexplained palpitations, gastroparesis, orthostatic hypotension, syncope, flushing, unexplained sweating, abnormal nasal secretions or lachrymation, or sexual dysfunction can signal autonomic dysfunction (AD), especially in patients with diabetes. Other conditions commonly associated with AD are Parkinson’s disease and migraine. AD is often underdiagnosed or even dismissed, since patients may not recognize or report their symptoms, but early diagnosis of AD can be crucial. In diabetes patients in particular, AD has been shown to correlate with poor cardiovascular outcomes.2 Patients with any of these conditions who display symptoms of AD should receive testing, as this can show the severity of the dysfunction, indicate which body systems are involved, and direct a treatment plan.
Single-pulse transcranial magnetic stimulation, marketed as SpringTMS™, is indicated for PRN acute management of migraine pain. Image courtesy of ENeura®.
Migraine headaches are among the most common neurological disorders, with an estimated 12 to 23 percent of U.S. adults having had a migraine in the past three months.1 Despite their frequency, migraines are often treated incorrectly, with prevention strategies underutilized and acute therapies used inappropriately.1 Several steps are needed to advance the quality of migraine treatment, says Stephen Ross, M.D., vice chair, Penn State Department of Neurology. “It’s important that both clinicians and patients are more aware of what is available, and clinicians understand that other effective treatment options are available to replace medications such as opioids, which have been shown to be problematic.” Continue reading
Michael Sather, M.D., surgical director, Penn State Hershey Comprehensive Epilepsy Center, performing open surgery to place subdural electrodes directly on the surface of the brain with the ROSA™ system, which allows for precise placement of the relevant electrodes.
Technological improvements to both testing and treatment have revolutionized the field of epilepsy care in recent years. Clinicians seek to pinpoint the location of seizures to administer more targeted treatment. “There is a growing interest in identifying the seizure focus more precisely and noninvasively,” says Jayant Acharya, M.D., medical director, Penn State Hershey Comprehensive Epilepsy Center of Penn State Hershey Neuroscience Institute.
One example of this breakthrough technology is dense-array EEG, a noninvasive diagnostic technique that records electroencephalography with up to 256 electrodes versus standard techniques that typically employ 19-21 scalp electrodes.1 Past research has shown that information is lost unless EEG sampling provides an intersensor distance of no more than 2 cm, which would require 500 EEG channels distributed evenly over the head.2 This 256-channel sampling technology can approximate adequate spatial sampling and identify the precise area of neurological dysfunction.2 Acharya concludes, “In our setting, the most important feature is that it’s much more sensitive and specific in terms of localizing the seizure focus.” Continue reading