2010 Neurological Institute Outcomes - Cleveland Clinic

Neurological Institute 

2010 

Outcomes

To promote quality improvement, Cleveland Clinic has created a series of 

Outcomes books similar to this one for many of its institutes. Designed for a 

physician audience, the Outcomes books contain a summary of our surgical and 

medical trends and approaches, data on patient volumes and outcomes, and a 

review of new technologies and innovations. 

Although we are unable to report all outcomes for all treatments provided at 

Cleveland Clinic — omission of outcomes for a particular treatment does not 

necessarily mean we do not offer that treatment — our goal is to increase 

outcomes reporting each year. When outcomes for a specific treatment are 

unavailable, we often report process measures associated with improved 

outcomes. When process measures are unavailable, we may report volume 

measures; a volume/outcome relationship has been demonstrated for many 

treatments, particularly those involving surgical techniques. 

In addition to our internal efforts to measure clinical quality, Cleveland Clinic 

supports transparent public reporting of healthcare quality data and participates 

in the following public reporting initiatives: 

• Joint Commission Performance Measurement Initiative (qualitycheck.org) 

• Centers for Medicare & Medicaid (CMS) Hospital Compare 

(hospitalcompare.hhs.gov) 

• Ohio Department of Health (ohiohospitalcompare.ohio.gov) 

• Cleveland Clinic Quality Performance Report (clevelandclinic.org/QPR) 

Our commitment to providing accurate, timely information about patient care also 

will help patients and referring physicians make informed healthcare decisions. 

We hope you find these data valuable. To view all our Outcomes books, please 

visit Cleveland Clinic's Quality and Patient Safety website at clevelandclinic.org/ 

quality/outcomes.

2 

Dear Colleague: 

It is my great pleasure to present Cleveland Clinic’s 

annual Outcomes books. The current edition 

includes outcomes and volumes along with recent 

innovations and publications for Cleveland Clinic’s 

clinical services through calendar year 2010. 

Cleveland Clinic is celebrating its 90th Anniversary 

in 2011. Our founders were innovators. They 

created a unique model of medicine based on 

patient care, enhanced by research and education. 

We honor this legacy, measuring quality, reporting 

outcomes and continuously improving the value of 

medical services. 

Cleveland Clinic Outcomes books are offered in 

print and online. Additional data is available 

through our online Quality Performance Report 

(clevelandclinic.org/QPR). The site offers data in 

advance of national and state public reporting sites, 

in key areas including heart attack, heart failure, 

stroke and infection prevention. 

Thank you for your interest in Cleveland Clinic 

Outcomes books. We hope you will find them 

useful and informative. 

Sincerely, 

Delos M. Cosgrove, MD 

CEO and President

Prefer an e-version? 

Visit clevelandclinic.org/OutcomesOnline, and 

we’ll remove you from the hard copy mailing list 

and email you when next year’s books are online. 

what’s inside 

Chairman’s Letter 04 

Institute Overview 

Quality and Outcomes Measures 

06 

Outcomes Overview 14 

Brain Tumors 16 

Cerebrovascular Disease 33 

Cognitive Disorders 41 

Epilepsy 43 

Movement Disorders 63 

Multiple Sclerosis 66 

Neuromuscular Disorders 82 

Pain / Headache 83 

Pediatric Neurological / Neurosurgical Disorders 97 

Psychiatric Disease 102 

Sleep Disorders 109 

Spinal Disease 115 

Physical Medicine and Rehabilitation 120 

Home Care 125 

Neuroimaging 128 

Surgical Quality Improvement 130 

Patient Experience 134 

Selected Publications 138 

Innovations 148 

Staff Listing 164 

Contact Information 174 

Institute Locations 175 

About Cleveland Clinic 178 

Resources 179

4 

Chairman’s Letter 

Dear Colleagues, 

I am pleased to again share with you 

Cleveland Clinic Neurological Institute’s 

annual outcomes data. This report reflects 

an ongoing effort to collect validated health 

status measures through our Knowledge 

Program © to track care longitudinally across 

venues. The process is facilitated by diseasespecific 

care paths that bridge geography, 

unifying our institute and ensuring utilization 

of standardized, evidence-based practices 

throughout our health system. 

To date, our stroke care path is the most 

advanced, integrated in the patient’s 

electronic medical record to guide stroke 

management from the Emergency Department 

through home care. We gather health 

status measures at admission, discharge and when our stroke patients return for ambulatory care. 

In addition to driving improvements in quality and outcomes, this exhaustive data collection is 

enabling better understanding and documentation of stroke etiology in the individuals we see. 

We are developing the same structured approach to traumatic brain injury, another common 

neurodegenerative disorder that has ignited an intensive interdisciplinary research initiative at 

Cleveland Clinic. In collaboration with our colleagues in the Orthopaedic & Rheumatologic Institute 

and Cleveland Clinic Lerner Research Institute, we have embarked on a multi-pronged effort to 

address prevention, diagnosis and treatment of concussion, whether it occurs on the playing field 

or the battlefield. 

Outcomes 2010

Among several research projects under way is a longitudinal study of cognitive and physical function 

in mixed martial artists and boxers. The Neurological Institute’s Lou Ruvo Center for Brain Health, 

co-located in Cleveland and Las Vegas, is working with the Nevada Athletic Commission to administer 

annual physical exams, including brain scans, to volunteer fighters. We expect this information to aid 

in advancing knowledge of brain trauma, concussive injury and neurological health among athletes in 

combative sports. 

While acute episodes of traumatic brain injury tend to occur in youth, chronic traumatic 

encephalopathy and other forms of dementia linked with head trauma are typically diagnosed later 

in life. The common denominator is cognitive dysfunction. Our boxing study reinforces the need for a 

surveillance system to evaluate concussion patients over years, not just in the moments after impact. 

As a result, we are increasingly migrating toward disease management across both venues and time. 

Continued development and refinement of tools such as care paths and the Knowledge Program © 

enable more accurate measurement and reporting of our performance. The message to our patients 

is more visceral: We will be there whenever and wherever you need us, and you can trust us with 

your healthcare. 

Please let us know if we can assist with your patients’ neurological needs. As always, we welcome 

your comments. 

Michael T. Modic, MD, FACR 

Chairman, Neurological Institute 


5

Chairman Letter 


6 

The multidisciplinary Cleveland Clinic Neurological Institute includes more than 300 medical, surgical and research 

specialists dedicated to the diagnosis, treatment and rehabilitation of adult and pediatric patients with neurological and 

psychiatric disorders. The institute model allows patients to access the care they need through specialized, disease-specific 

centers that integrate the expertise of neurologists, neurosurgeons, orthopaedic surgeons, psychiatrists, psychologists, 

physiatrists, neuroradiologists and allied health professionals. This model also facilitates collaboration and improved 

measurement of quality and outcomes on a continuing basis. 

U.S.News & World Report’s “America’s Best Hospitals” survey has consistently ranked both our adult and pediatric neurology 

and neurosurgery programs among the top 10 in the nation. Our neurology, neurosurgery, pediatric neurology/neurosurgery 

and psychiatry programs also hold top ranking in Ohio. 

The Neurological Institute comprises the following centers as well as departments that integrate resident training, academics 

and research: 

Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center 

Center for Behavioral Health 

Lou Ruvo Center for Brain Health 

Cerebrovascular Center 

Cleveland Clinic at Home 

Epilepsy Center 

Mellen Center for Multiple Sclerosis Treatment and Research 

Center for Neuroimaging 

Center for Neurological Restoration 

Neurological Center for Pain 

Neuromuscular Center 

Center for Pediatric Neurology and Neurosurgery 

Department of Physical Medicine and Rehabilitation 

Center for Regional Neurosciences 

Sleep Disorders Center 

Center for Spine Health 



We provide care across the spectrum of neurological and 

psychiatric disorders, including primary and metastatic 

tumors of the brain, spine and nerves; pediatric and adult 

epilepsy; headache, facial pain syndromes and associated 

disorders; movement disorders such as Parkinson’s 

disease, essential tremor and dystonia; neurocognitive 

disorders; cerebral palsy and spasticity; hydrocephalus; 

metabolic and mitochondrial disease; fetal and neonatal 

neurological problems; multiple sclerosis; stroke; cerebral 

aneurysm; brain and spinal vascular malformations; 

carotid stenosis; intracranial atherosclerosis; nerve and 

muscle diseases, including amyotrophic lateral sclerosis, 

peripheral neuropathy, myasthenia gravis and myopathies; 

sleep disorders; mental/behavioral health disorders and 

chemical dependency; impairments and disabilities in the 

areas of mobility, self-care, communication, swallowing and 

cognition. 

Expert, Specialized Diagnosis 

Our Neurological Institute physicians draw on advanced 

diagnostic capabilities and experience. Our imaging services 

include structural and functional MRI, CT, PET, myelography, 

diagnostic cerebral/spinal angiography, interventional 

neuroradiology, and carotid and transcranial Doppler 

ultrasound. Our neuroimaging staff subspecializes in specific 

disease entities such as epilepsy and cerebrovascular 

disease, ensuring accurate, in-depth interpretations. 

Additional diagnostic tools are found in our epilepsy 

monitoring units, sleep laboratories, neuropsychological 

testing facilities, electromyography laboratory, autonomic 

laboratory and cutaneous nerve laboratory. 


The Latest Treatment Modalities 

Patients receive leading-edge treatment options at the 

Neurological Institute, where we continue to advance 

such innovations as deep brain stimulation (DBS), laser 

interstitial thermal therapy (LITT) for brain tumors, 

epilepsy surgery, stereotactic spine radiosurgery, 

endovascular treatment of cerebral aneurysms and 

vascular malformations, and neuroendoscopy. The 

Rose Ella Burkhardt Brain Tumor and Neuro-Oncology 

Center was one of the first such facilities worldwide to 

integrate the newest intraoperative MRI technology with 

its pioneering LITT capability to enhance brain tumor 

treatment. The interventional MRI suite accommodates 

many other neurosurgical procedures as well, including 

DBS surgery. 

Our main campus and four Cleveland Clinic regional 

hospitals are Joint Commission-designated Primary 

Stroke Centers, in line with our initiative to standardize 

stroke treatment protocols across our health system 

so that patients in Northeast Ohio have access to the 

same high-quality stroke care no matter where they live. 

We are developing structured care paths for additional 

disorders – a critical step in bridging geography to 

deliver high-quality, patient-centered care and to 

function as an integrated enterprise. 

7

8 


Relevant Research 

We conduct research directly related to conditions experienced by our patients. A prime example is concussion, a 

signature injury of athletes at all levels of competition as well as military veterans who have served in Iraq and Afghanistan. 

Neurological Institute investigators are active participants in an intense interdisciplinary research effort at Cleveland Clinic to 

better prevent, diagnose and treat concussion. Much of this work is going forward in our Spine Research Laboratory. 

Our neuroscientists pursue translational research, clinical trials of drug and device interventions, neuroimaging research, 

epidemiology and health outcomes, behavioral and psychiatric research, and research into better diagnostic methods. 

Typically, more than 200 clinical research trials are under way in the Neurological Institute. In 2010, we were awarded 

more than $19 million in neurologically based research grants and contracts. 

Convenient Care in the Community 

We are committed to making access to world-class care convenient for all patients. Regional facilities extend advanced 

treatments, technologies and the expertise of Neurological Institute physicians to community hospitals and family health 

centers throughout the Cleveland Clinic health system. As a result, patients can easily access specialists who treat the 

most complex neurological conditions. 

Key components in our regional network include: 

• Cleveland Clinic Neurological Institute at Lakewood and Hillcrest hospitals, which provides comprehensive 

services to Cleveland’s suburban residents. 

• Cleveland Clinic Rehabilitation Hospitals, with a total of 98 adult acute inpatient rehabilitation beds at our 

main campus and two suburban hospitals. 

• Cleveland Clinic Rehabilitation and Sports Therapy, a unique consortium with Cleveland Clinic Orthopaedic 

& Rheumatologic Institute that engages 650-plus physical and occupational therapists throughout the region. 

• Cleveland Clinic at Home, which brings in-home and distance healthcare to individuals in an expansive area 

comprising 14 Ohio counties and provides home infusion/pharmacy services in eight states. 

• Our Sleep Disorders Center, which conducts overnight sleep studies at nine locations throughout the community, 

including eight conveniently located hotels. 

• Cleveland Clinic Pediatric Neurology and Neurosurgery services are provided at Fairview and Hillcrest hospitals, 

as well as several family health centers, our pediatric rehabilitation hospital at Shaker Campus, and the Lerner 

Autism School. 


Extending Our Services 

Neurological Institute services extend beyond the region. 

The Lou Ruvo Center for Brain Health diagnoses, treats and 

researches Alzheimer’s disease and other neurocognitive 

disorders from locations in Cleveland and Lakewood, 

Ohio, and Las Vegas and Reno, Nevada. Diagnostic tests 

performed in Nevada are digitally transferred to Cleveland 

and other Cleveland Clinic sites for interpretation by one 

of the world’s leading neuroimaging centers. At Cleveland 

Clinic Florida, epileptologists work with their colleagues at 

the Cleveland Clinic Epilepsy Center to diagnose and treat 

adults with epilepsy. All Florida epileptologists have dual 

appointments with the Neurological Institute in Cleveland. 

In addition, our Cerebrovascular Center’s Telestroke 

Network offers medical staff at other hospitals remote 

access to patient consultation services from our neurological 

specialists. The network is enabled with a mobile, twoway 

videoconference system and a dedicated link for 

transmitting imaging studies. 

Integrated Nursing 

Nurses in the Neurological Institute rank as respected 

members of the care team. As such, they are encouraged to 

offer input to physicians and administrators and to engage 

in problem solving and process improvement. Patients 

benefit from this integration through improved coordination 

of care and commonly held provider goals. 

Opportunities for further education and career advancement 

are readily available to institute nurses. Their participation is 

welcomed in all continuing education programs, and those 

with at least two years’ experience in the institute can aspire 

to certification in neuroscience nursing. These subspecialists 

staff areas such as the neurological intensive care and 

stepdown units that treat the most complex patients. 

Each November, Cleveland Clinic’s “Innovations in 

Neuroscience” conference convenes in Cleveland. This 

meeting, originally limited to nurses, now includes physician 

assistants and medical assistants as organizers continue to 

work toward increased provider collaboration. 

Pioneering the Collection of Data and Outcomes 

The Neurological Institute’s Knowledge Program © has 

captured data from more than one million self-administered 

patient questionnaires. One of the world’s first interactive 

clinical patient databases, the Knowledge Program © is 

demonstrating its value as it evolves, with collection and 

correlation of electronic information on patient health status, 

quality of life and outcomes. 

We are aggregating this patient-generated data with 

information from other sources, such as imaging results and 

information collected during patient encounters, to optimize 

clinical decision making, quality improvement and research 

opportunities. 

All these data are accessible to physicians through an 

interface with the patient’s electronic medical record. The 

Knowledge Program © is proving to be among our most 

constructive tools for delivering individualized care to 

improve outcomes and quality of life, in line with Cleveland 

Clinic’s guiding principle: Patients First. 

Neurological Institute 9

10 


2010 Statistical Highlights 

Staff Physicians 225 

Clinical Residents and Fellows 145 

Research Fellows 17 

Advanced Practice Nurses 38 

Physician Assistants 15 

Medical Students (NI Rotation) 85 

Inpatient Facilities (Main Campus) 

Inpatient General Neuro Beds 50 

Neuro ICU Beds 22 

Neuro Stepdown Beds 17 

EMU Beds – Pediatrics 9 

EMU Beds – Adult 14 

Chemical Dependency Unit Beds 13 

Inpatient Rehab Beds 12 * 

Inpatient Facilities (Regional) 

Psychiatric Unit Beds 254 

Rehabilitation Beds 81 * 

Skilled Nursing Units 96 

* As of March 2011 


Initial Outpatient Visits** 10,627 

Brain Health 911 

Brain Tumor Neuro-Oncology 405 

Cerebrovascular 353 

Epilepsy 746 

Headache and Pain 920 

Mellen Center 754 

Neurological Restoration 419 

Neurology 654 

Neuromuscular 872 

Pediatric Neurology*** 915 

Pediatric Neurosurgery*** 286 


Psychiatry and Psychology 334 

Regional Neurological Institute 932 

Sleep 194 

Spine 1,503 


Total Outpatient Visits 154,944 

Brain Health 4,214 

Brain Tumor Neuro-Oncology 7,049 

Cerebrovascular 3,141 

Epilepsy 7,384 

Headache and Pain 11,367 

Mellen Center 6,033 

Neurological Restoration 5,237 

Neurology 4,228 

Neuromuscular 5,293 

Pediatric Neurology*** 8,810 

Pediatric Neurosurgery*** 2,841 

Physical Medicine and Rehabilitation 5,465 

Psychiatry and Psychology 31,655 

Regional Neurological Institute 19,769 

Sleep 5,131 

Spine 27,327 

** Initial visits for patients new to Cleveland Clinic 

*** Children and adolescents are also included under Epilepsy, Psychiatry and Psychology, and Sleep 

11


Admissions 15,491 





Neurology 695 

Neurosurgery 360 

Pediatric Neurology* 140 

Pediatric Neurosurgery* 210 

Psychiatry and Psychology 8,617 ** 


Spine 1,378 

Inpatient Days 96,808 





Neurology 3,770 

Neurosurgery 1,891 



Psychiatry and Psychology 60,188 ** 

Regional Neurological Institute 1,213 

Spine 6,524 

* Children and adolescents are also included under Epilepsy, 

Psychiatry and Psychology 

** Includes totals from the following Cleveland Clinic 

regional hospitals: Euclid, Fairview, Huron, 

Lakewood, Lutheran, Marymount and South Pointe 

12 Outcomes 2010

Surgical/Interventional Procedures 8,230 

Brain Tumor Neuro-Oncology 912 


Epilepsy 617 

Headache and Pain 19 


Neuromuscular 91 

Neurosurgery 444 





Spine 3,900 


Neuroimaging Studies*** 98,276 

Total CT Brain Scans 37,000 

Total MR Brain Procedures 56,000 

Total Cerebral Angio Procedures 5,276 

*** Studies performed across the entire Cleveland Clinic 

health system 

13

14 

Outcomes Overview 

Recognizing that the presence of significant comorbidity affects overall care and eventual disease outcome, all Cleveland 

Clinic Neurological Institute patients are assessed for overall health status, including quality of life and presence of 

psychiatric comorbidity such as depression. 

The EuroQOL (EQ-5D) is a five-item, validated, self-reported generic health-related quality-of-life measure that has been 

used to assess individuals with a variety of medical conditions as well as the general population. The EQ-5D assesses five 

domains: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. An EQ-5D index score of 1.0 indicates 

perfect health. 

Quality of Life by Neurological Disease Category 


Chronic Pain (N = 2,056) 

Spinal Disease (N = 22,204) 

Movement Disorders (N = 4,614) 

Neuromuscular Disorders (N = 5,105) 

Multiple Sclerosis (N = 7,628) 

Headache (N = 7,948) 

Cognitive Disorders (N = 3,042) 

Psychiatric & Psychological Disorders (N = 13,472) 

Cerebrovascular Disease (N = 3,086) 

Epilepsy (N = 4,671) 

Sleep Disorders (N = 5,916) 

Neurological Disease Category 

0 0.2 0.4 0.6 

Mean EQ-5D Index Score 

0.8 1.0 

A cross-sectional analysis of quality of life across multiple neurological disease categories suggests the lowest quality of life 

for patients with chronic pain and the highest for those with sleep disorders. 


The Patient Health Questionnaire (PHQ-9) is a nine-item, validated, self-reported measure of depression that is based 

on the nine diagnostic criteria for depressive disorders according to the DSM-IV and yields a measure of depression 

severity. Scores range from 0 to 27 and scores of 5, 10, 15 and 20 reflect mild, moderate, moderately severe and severe 

depression, respectively. 

Depressive Symptoms by Neurological Disease Category 



Cerebrovascular Disease (N = 2,862) 

Epilepsy (N = 4,460) 

Spinal Disease (N = 19,628) 

Multiple Sclerosis (N = 7,164) 

Neuromuscular Disorders (N = 4,437) 

Movement Disorders (N = 4,805) 

Headache (N = 7,653) 

Cognitive Disorders (N = 655) 

Sleep Disorders (N = 5,201) 

Psychiatric & Psychological Disorders (N = 10,986) 

Chronic Pain (N = 1,768) 

Neurological Disease Category 

0 5 10 

Mean PHQ-9 Score 

A cross-sectional analysis of depressive symptoms across multiple neurological disease categories suggests at least mild 

depression in all neurological diseases, with the most severe depression in those with chronic pain. 

15 

15

16 

Brain Tumors 

The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center (BBTC) of the Neurological Institute is one of the largest 

and most comprehensive programs in the country and is dedicated to providing exceptional patient care including surgery, 

radiation, chemotherapy and clinical research trials for brain tumor patients. Patient care is provided by a multidisciplinary 

team consisting of neurosurgeons, radiation oncologists, neuro-oncologists, medical oncologists, psychiatrists and 

neuropsychologists, along with nurses, physician assistants, case managers and social workers who all specialize in 

treating patients with brain tumors. The BBTC is dedicated to bringing novel treatment options emerging from the institute’s 

extensive basic and translational research programs. The center’s primary missions are to offer excellent care through 

state-of-the-art surgical intervention and to conduct clinical research to enhance patient outcomes. BBTC enrolled 233 

patients in research trials in the last five years (2006 – 2010). 

Brain Tumor Diagnosis Distribution (N = 1,999) 


Gliomas remain the most common brain tumor seen in patients, accounting for 44 percent of cases. 

Brain Tumor Procedures (N = 790) 


100% 

100% 

141, 7% Schwannoma 

165, 8% Pituitary Tumor 

354, 18% Meningioma 

450, 23% Metastasis 

889, 44% Glioma 

38, 5% Brain Biopsy 

48, 6% Infratentorial Craniotomy 

78, 10% Pituitary Surgery 

108, 14% Novalis ® 108, 14% Novalis Radiosurgery 

® Radiosurgery 

177, 22% Supratentorial Craniotomy 

341, 43% Gamma Knife ® 341, 43% Gamma Knife Radiosurgery 

® Radiosurgery 

Gamma Knife ® radiosurgery was the most common procedure in 2010, followed by supratentorial craniotomy, 

and Novalis ® stereotactic radiosurgery. 


Brain Tumor Surgical Site Infection Rates 

Rate per 100 Clean Cases (%) 

10 

8 

6 

4 

2 

0 

N = 

2006 

604 

Surgical site infection rates remained under 5 percent in 2010. N = number of clean cases per year. 

Per Centers for Disease Control and Prevention (CDC) guidelines, “clean cases” are defined as uninfected 

operative wounds in which no inflammation is encountered and, in the case of brain tumor surgery, 

neither the respiratory nor the alimentary tract is entered. 


2007 

502 

2008 

451 

2009 

530 


504 

17

18 

Brain Tumors 

Brain Biopsy 

Brain Biopsy: Survival 

Survival (%) 

100 

80 

60 

40 

20 

0 

N = 

2006 

101 

2007 

65 

2008 

51 

Thirty- and 180-day (for first six months of 2010) survival rates for brain biopsies continued to improve, 

reaching 100 percent in both categories. N = number of brain biopsies per year. 

2009 

66 


38 

30-Day 

180-Day 


Supratentorial Craniotomy 

Supratentorial Craniotomy: Inpatient Mortality 

Mortality (%) 

10 

8 

6 

4 

2 

0 

N = 

2006 

298 

Inpatient mortality remained significantly lower than predicted, continuing the trend over the past five 

years. N = number of supratentorial craniotomies performed for brain tumor per year. For this and all 

subsequent graphs, expected mortality is based on national normative data and All Patient Refined 

Diagnosis Related Groups (APR-DRGs), a method of adjusting for severity of patient illness. 1 

Supratentorial Craniotomy: Length of Stay (LOS) 

Mean LOS (Days) 

8 

6 

4 

2 

0 

N = 

2006 

298 

Mean length of stay (LOS) remained lower than expected. For this and all subsequent graphs, expected mean 

LOS is based on national normative data and APR-DRGs, a method of adjusting for severity of patient illness. 1 

1. http://solutions.3m.com/wps/portal/3M/en_US/3M_Health_Information_Systems/HIS/Products/APRDRG_Software/ 


2007 

273 

2007 

273 

2008 

230 

2008 

230 

2009 

277 

2009 

277 


243 


243 

Actual 

Expected 

Actual 

Expected 

19

20 

Brain Tumors 

Supratentorial Craniotomy: Karnofsky Performance Scale (KPS) (N = 139) 

Change in KPS Status within 30 Days of Operative Procedure 


Patients (%) 

100 

80 

60 

40 

20 

0 

Declined Improved No Change 

Performance status, as measured by the KPS, was stable or improved in over 90 percent of patients immediately 

after supratentorial craniotomy. Change in KPS was defined as a change of 20 points or more. 


Supratentorial Craniotomy: Survival by Tumor Type 

Glioma: Survival 

Survival (%) 

100 

80 

60 

40 

20 

0 

2006 

N = 112 

Meningioma: Survival 

Survival (%) 

100 

80 

60 

40 

20 

0 

N = 

Metastasis: Survival 

Survival (%) 

100 

80 

60 

40 

20 

0 

N = 

2006 

34 

2006 

32 

Thirty- and 180-day (for the first six months of 2010) survival rates remained robust in 2010 for 

supratentorial craniotomy independent of tumor type. 


2007 

115 

2007 

30 

2007 

32 

2008 

88 

2008 

25 

2008 

23 

2009 

113 

2009 

35 

2009 

29 


76 


29 


18 

30-Day 

180-Day 

30-Day 

180-Day 

30-Day 

180-Day 

21

22 

Brain Tumors 

Infratentorial Craniotomy 

Infratentorial Craniotomy: Inpatient Mortality 

Mortality (%) 

10 

There have been only four deaths in patients undergoing infratentorial craniotomy at Cleveland Clinic in the past five years, 

which is below the expected number based on national averages. N = number of infratentorial craniotomies performed for 

brain tumor per year. 

Infratentorial Craniotomy: Length of Stay (LOS) 


8 

6 

4 

2 

0 

8 

6 

4 

2 

0 

N = 

N = 

0 0 

0 

2006 

73 

2006 

73 

2007 

69 

2007 

69 

2008 

66 

2008 

66 

2009 

71 

2009 

71 


75 


75 

Actual 

Expected 

Actual 

Expected 


Infratentorial Craniotomy: Change in KPS Status within 30 Days of Operative Procedure (N = 36) 


Patients (%) 

100 

80 

60 

40 

20 

0 

Performance status, as measured by the KPS, was stable or improved in over 94 percent of patients undergoing 

infratentorial craniotomy in 2010. Change in KPS status was defined as a change of 20 points or more. 



23

24 

Brain Tumors 

Infratentorial Craniotomy: Survival by Tumor Type 

Glioma: Survival 

Survival (%) 

100 

75 

50 

25 

0 

N = 

Meningioma: Survival 

Survival (%) 

100 

75 

50 

25 

0 

N = 

2006 

5 

2006 

6 

2007 

10 

2007 

5 

2008 

9 

2008 

5 

2009 

8 

2009 

7 


5 


9 

30-Day 

180-Day 

30-Day 

180-Day 


Metastasis: Survival 

Survival (%) 

100 

75 

50 

25 

0 

N = 

2006 

9 


2007 

6 

2008 

15 

2009 

11 


7 

30-Day 

180-Day 

25

26 

Brain Tumors 

Pituitary Surgery 

Pituitary Surgery: Survival 

Survival (%) 

100 

75 

50 

25 

0 

N = 

Mortality (%) 

1.2 

1.0 

0.8 

0.6 

0.4 

0.2 

0.0 

2006 

99 

2007 

81 

2008 

99 

2009 

74 

0 0 0 0 0 

2006 2007 2008 2009 


78 


30-Day 

180-Day 

Thirty- and 180-day (for the first six months of 2010) survival rates were 100 percent in both categories. N = number of 

pituitary tumor surgeries per year. 

Pituitary Surgery: Inpatient Mortality 

Actual 

Expected 

There have been no inpatient deaths following pituitary surgery over the past five years. 


Pituitary Surgery: Length of Stay (LOS) 


4 

3 

2 

1 

0 

N = 

2006 

96 

Patients (%) 

100 

80 

60 

40 

20 

0 


0 

2007 

82 

2008 

101 

2009 

74 

Actual mean LOS continues to remain close to target LOS. 


73 


Actual 

Expected 

Pituitary Surgery: Change in KPS Status within 30 Days of Operative Procedure (N = 53) 


In 100 percent of patients, performance status, as measured by the KPS, remained stable or improved after pituitary 

surgery. Change in KPS status was defined as a change of 20 points or more. 

27

28 

Brain Tumors 

Stereotactic Radiosurgery: Gamma Knife ® 

Thirty- and 180-day (for the first six months of 2010) survival rates remained robust in 2010 for Gamma Knife ® 

radiosurgery treatment, independent of tumor type. 

Gamma Knife ® Radiosurgery: Meningioma Survival 

Survival (%) 

100 

95 

90 

85 

80 

N = 

Survival (%) 

100 

75 

50 

25 

0 

N = 

2006 

32 

2006 

44 

2007 

27 

2007 

24 

2008 

41 

Gamma Knife ® Radiosurgery: Schwannoma Survival 

2008 

37 

2009 

23 

2009 

36 


31 


31 

30-Day 

180-Day 

30-Day 

180-Day 


Survival (%) 

100 

90 

80 

70 

60 

50 

N = 


Gamma Knife ® Radiosurgery: Metastasis Survival 

Survival (%) 

100 

80 

60 

40 

20 

0 

N = 

2006 

133 

2007 

149 

2008 

151 

2009 

217 

Gamma Knife ® Radiosurgery: Pituitary Tumor Survival 

2006 

10 

2007 

17 

2008 

16 

2009 

14 


189 


13 

30-Day 

180-Day 

30-Day 

180-Day 

29

30 

Brain Tumors 

Stereotactic Radiosurgery: Novalis ® 

Novalis ® Stereotactic Radiosurgery: Survival 

Survival (%) 

100 

80 

60 

40 

N = 

2006 

64 

2007 

80 

2008 

81 

2009 

95 


108 

30-Day 

180-Day 

In 2010, 108 patients were treated with Novalis ® stereotactic radiosurgery. Thirty- and 180-day (for the first six months of 

2010) survival rates for this type of treatment, which is mainly used to treat malignant and metastatic tumors to the spine, 

were 100 percent and 96.3 percent, respectively. 


Novalis ® Stereotactic Radiosurgery: Treatment of Painful Spinal Metastases 

Pain Scores after Stereotactic Spine Radiosurgery for Metastatic Renal Cell Carcinoma (N = 53) 


Brief Pain Inventory Score 

4 

3 

2 

1 

0 Baseline 


1 2 

Week 

0 0 

3 1 3 6 12 

Month 

18 24 

Time from Treatment 

The graph demonstrates pain scores in renal cell carcinoma patients with spinal metastases treated with single fraction 

spine radiosurgery (53 patients at baseline). There is a marked decrease in patient-reported pain scores as early as week 

one post-treatment. Further, this improved pain outcome score persists and pain scores of zero at the treated levels were 

reported by the available patients at both 18 and 24 months. 

31

32 

Brain Tumors 

Glioblastoma Multiforme 

In 2010, 73 patients with newly diagnosed glioblastoma, the most common type of malignant primary brain tumor, 

underwent initial surgical resection and treatment at Cleveland Clinic. Approximately 12,000 cases of glioblastoma are 

diagnosed each year in the United States. 

Glioblastoma: Survival (N = 542) 

2001 – 2007 

Survival (%) 

100 

80 

60 

40 

20 

0 

0 12 24 36 48 60 84 

Months since Diagnosis 

72 

CC 

Reference 

In the graph above, the reference data represent relative survival, while Cleveland Clinic data are observed survival, which 

prevents formal statistical comparison. 

CC = Cleveland Clinic 

Reference = Software: Surveillance Research Program, National Cancer Institute SEER*Stat software (www.seer.cancer.gov/seerstat) 

version 6.6.0 Data: Surveillance, Epidemiology and End Results (SEER) Program (www.seer.cancer.gov) SEER*Stat Database: Incidence 

- SEER 17 Regs Limited-Use + Hurricane Katrina Impacted Louisiana Cases, Nov 2009 Sub (1973-2007 varying) - Linked to County 

Attributes - Total U.S., 1969-2007 Counties, National Cancer Institute, DCCPS, Surveillance Research Program, Cancer Statistics 

Branch, released April 2010, based on the November 2009 submission. 


Cerebrovascular Disease 

Get With The Guidelines ® (GWTG) Stroke Performance and Quality Measures 

Clinical Measure Measure Description 

IV rt-PA 2 Hour 

Early Antithrombotics 

Antithrombotics at 

Discharge 

Anticoagulation for 

Atrial Fibrillation/ 

Atrial Flutter 

Get With The Guidelines ® (GWTG) is the premier hospital-based quality improvement program for the American Heart Association 

and the American Stroke Association, empowering healthcare provider teams to consistently treat stroke patients using current 

evidence-based guidelines. Cleveland Clinic is the recipient of the GWTG Stroke Gold Plus Performance Achievement Award and uses 

the GWTG aggregate comparative data for internal quality improvement. Rates are taken from the GWTG-Joint Commission Primary 

Stroke Center Reporting Tool, “Consensus-GWTG/PAA set,” as of February 15, 2011. 

* Hospitals participating in GWTG for five or more years (N = 2,095). Schwamm LH, Fonarow GC, Reeves MJ, Pan W, Frankel MR, Smith EE, 

Ellrodt G, Cannon CP, Liang L, Peterson E, Labresh KA. Get With The Guidelines-Stroke is associated with sustained improvement in care for 

patients hospitalized with acute stroke or transient ischemic attack. Circulation. 2009 Jan 6;119(1):107-115. 


Acute stroke patients who arrive at the hospital within 

120 minutes (2 hours) of time last known well and for 

whom IV rt-PA was initiated at this hospital within 180 

minutes (3 hours) of time last known well. 

Patients with ischemic stroke or TIA who receive 

antithrombotic therapy by the end of hospital day 2. 

Patients with ischemic stroke or TIA prescribed 

antithrombotic therapy at discharge (e.g., warfarin, 

aspirin, other antiplatelet drug). 

DVT Prophylaxis Patients with ischemic stroke, TIA or a hemorrhagic 

stroke and who are non-ambulatory who receive DVT 

prophylaxis by end of hospital day 2. 

Lipids Measure 

(Statin at Discharge) 

Smoking Cessation 

Counseling 

Ischemic stroke or TIA patients with LDL > 100, or 

LDL not measured, or on cholesterol-reducer prior to 

admission, discharged on cholesterol-reducing drugs. 

Patients with ischemic, TIA or hemorrhagic stroke with 

a history of smoking cigarettes, who are, or whose 

caregivers are, given smoking cessation counseling during 

hospital stay. 

Dysphagia Screening Patients with ischemic or hemorrhagic stroke who 

undergo screen for dysphagia with an evidence-based 

bedside testing protocol approved by the hospital before 

being given any food, fluids, or medications by mouth. 

Stroke Education Patients with ischemic, TIA or hemorrhagic stroke or their 

caregivers who were given education and/or educational 

materials during the hospital stay. 

Rehabilitation 

Considered 

Patients with ischemic stroke or TIA with atrial fibrillation/ 

flutter who are discharged on anticoagulation therapy. 

Patients with ischemic or hemorrhagic stroke who were 

assessed for rehabilitation services. 

GWTG Stroke 

Performance 

Award Goal 

National 

Average* 

85.0% 75.9% 66.7% 

(4/6) 

85.0% 96.7% 97.7% 

(173/177) 

85.0% 97.8% 98.6% 

(352/357) 

85.0% 93.5% 97.2% 

(35/36) 

85.0% 91.8% 93.5% 

(217/232) 

85.0% 89.2% 83.2% 

(228/274) 

85.0% 96.8% 100% 

(101/101) 

2007 2008 2009 

Cleveland Clinic 

88.9% 

(8/9) 

95.3% 

(261/274) 

99.7% 

(346/347) 

98.4% 

(62/63) 

97.4% 

(261/268) 

88.1% 

(230/261) 

92.4% 

(109/118) 

85.0% 78.5% -- 67.9% 

(256/377) 

85.0% 81.3% -- 41.4% 

(164/396) 

85.0% 96.6% 83.3% 

(30/36) 

98.5% 

(393/399) 

78.6% 

(11/14) 

97.5% 

(392/402) 

99.3% 

(534/538) 

98.7% 

(78/79) 

94.8% 

(507/535) 

97.2% 

(350/360) 

92.9% 

(234/252) 

73.7% 

(490/665) 

80.6% 

(286/355) 

96.5% 

(684/709) 


86.7% 

(13/15) 

95.7% 

(396/414) 

99.6% 

(562/564) 

97.7% 

(84/86) 

93.8% 

(410/437) 

97.1% 

(370/381) 

99.5% 

(204/205) 

84.8% 

(519/612) 

89.9% 

(310/345) 

92.5% 

(593/641) 

Clinical Mea 

IV rt-PA 2 Hour 

Early Antithrom 

Antithrombotics 

Discharge 

Anticoagulation 

Atrial Fibrillatio 

Atrial Flutter 

DVT Prophylaxi 

Lipids Measure 

(Statin at Disch 

Smoking Cessa 

Counseling 

Dysphagia Scre 

Stroke Educatio 

Rehabilitation 

Considered 

33

34 


Inpatient Rehabilitation for Stroke 

Length of Stay Efficiency for Stroke Inpatient Rehabilitation 

2007 – 2010 

Change in FIM Score/LOS 

2.5 

2.0 

1.5 

1.0 

N = 

2007 

449 

2008 

478 

2009 

482 


474 


National Average 

Outcomes are shown for all stroke patients at Cleveland Clinic Rehabilitation Hospitals using the Uniform Data System 

for Medical Rehabilitation (UDS-MR) data set (Rehabilitation Impairment Category/RIC Group 01). Length of stay (LOS) 

efficiency compares the functional improvement (FIM) gains made during the rehab stay with the length of stay required 

to make the gains (FIM change/LOS). Data are aggregated from Cleveland Clinic Rehabilitation Hospitals at Fairview 

(25 beds), Lakewood (15 beds) and Euclid (46 beds) hospitals, compared to the national average, and are case-mix 

adjusted by the UDS-MR database. Case mix values for each unit are: 1.51 at Euclid, 1.31 at Fairview and 1.4 at 

Lakewood. Data suggest that Cleveland Clinic Rehabilitation Hospitals return patients to a higher level of function in a 

shorter time than the national average. 


Change in Outcomes after Stroke 


Patients (%) 

100 

80 

60 

40 

20 

0 

N = 

EQ-5D 

630 


Barthel 

437 

SIS-16 

615 

NIHSS 

639 

Rankin 

688 

PHQ-9 

570 

Worsened 

Stable 

Improved 

The graph illustrates changes between first score after stroke and the last follow-up visit. 

Mean duration of follow-up was 187 days. The Barthel Index is a measure of disability widely 

used for stroke. The Stroke Impact Scale (SIS-16) assesses physical function. The National Institutes 

of Health Stroke Scale (NIHSS) is a brief, reliable measure of severity of neurological impairment 

following stroke. The Rankin Scale is a global disability scale for overall assessment of disability. 

35

36 


Change in Neurological Impairment over Acute Hospital Course (N = 128) 

September – December 2010 

Number of Patients 

35 

30 

25 

20 

15 

10 

5 

0 

September – December 2010 

NIHSS 

10 

8 

6 

4 

2 

0 

N = 

9.4% of stroke 

patients worsened 

Small Vessel 

23 

18.7% remained stable 

71.9% of stroke patients improved 

-10 -6 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 16 20 

NIHSS = National Institutes of Health Stroke Scale 

Change in NIHSS Scores from Admission to Hospital Discharge 

Change in Neurological Impairment 30 to 90 Days Postdischarge (N = 128) 

Large Artery 

Atherosclerosis 

Cardioembolism 

40 

40 

Combined 

103 

Baseline 

Postdischarge 

The graph illustrates the change in NIHSS score from acute presentation (Baseline) to follow-up 30 to 90 days after 

hospital discharge (Postdischarge), compared across stroke subtype. Lower scores reflect less impairment. 


Ischemic Stroke 

Ischemic Stroke: Length of Stay (LOS) 


10 

8 

6 

4 

2 

0 

N = 


2007 

434 

2008 

498 

2009 

561 


550 

Number of Deaths SMR 

80 

0.62 

60 

40 

20 

0 

N = 

2007 

434 

2008 

498 

2009 

561 


550 

0.60 

0.58 

0.56 

0.54 

Actual 

Expected 

Actual mean LOS has remained shorter than expected for ischemic stroke. For this and subsequent graphs, 

expected mean LOS is based on national normative data and APR-DRGs. 1 

Ischemic Stroke: Inpatient Mortality 

Actual Deaths 

Expected Deaths 

Standard Mortality Ratio (SMR) 

Among inpatients treated for ischemic stroke at Cleveland Clinic, actual mortality remained below expected. For this 

and subsequent graphs, expected mortality is based on national normative data and APR-DRGs. 1 

1. http://solutions.3m.com/wps/portal/3M/en_US/3M_Health_Information_Systems/HIS/Products/APRDRG_Software/ 

37

38 


Hemorrhagic Stroke 

Intracerebral Hemorrhage: Length of Stay (LOS) 


10 

8 

6 

4 

2 

0 

N = 


60 

1.2 

40 

20 

0 

N = 

2007 

139 

2007 

139 

2008 

161 

2008 

161 

2009 

172 

2009 

172 


167 


167 

0.8 

0.4 

0 

Actual 

Expected 

Among inpatients treated for intracerebral hemorrhage at Cleveland Clinic, actual mean LOS was 

lower than expected. 

Intracerebral Hemorrhage: Inpatient Mortality 

Actual mortality was below expected in 2008, 2009 and 2010. 

Actual Deaths 




Subarachnoid Hemorrhage 

Subarachnoid Hemorrhage: LOS 


15 

10 

5 

0 

N = 


50 

1.0 

40 

30 

20 

10 

0 

N = 

2007 

110 


2007 

110 

2008 

128 

2008 

128 

2009 

143 

Subarachnoid Hemorrhage: Inpatient Mortality 

2009 

143 


157 


157 

0.8 

0.6 

0.4 

0.2 

0 

Actual 

Expected 

Inpatient mortality due to subarachnoid hemorrhage has been consistently below the expected rate. 

Actual Deaths 



39

40 


Intracerebral Hemorrhage, Subarachnoid Hemorrhage and Ischemic Stroke: Discharge Status 


Intracerebral Subarachnoid Ischemic 

Hemorrhage Hemorrhage Stroke 

Acute Rehab 21% 15% 25% 

Home 22% 36% 34% 

Home with Home Health Services 6% 8% 10% 

Skilled Nursing Facility/Interim Care 24% 22% 24% 

Death 25% 15% 7% 

Other 3% 4% 1% 

Total Number of Patients 167 157 550 

The national average for inpatient death following subarachnoid hemorrhage (ruptured aneurysm) was 29.4 percent in 

1990-1991 and 26.5 percent in 2000-2001. 2 

2. Qureshi AI, Suri MF, Nasar A, Kirmani JF, Ezzeddine MA, Divani AA, Giles WH. Changes in cost and outcome among US patients with stroke 

hospitalized in 1990 to 1991 and those hospitalized in 2000 to 2001. Stroke. 2007 Jul;38(7):2180-2184. 


Cognitive Disorders 

Cleveland Clinic’s Lou Ruvo Center for Brain Health (CCLRCBH) provides state-of-the-art care for cognitive disorders and 

for the family members of those who suffer from them. The physicians and staff at the CCLRCBH are working toward the 

development of early diagnosis, conducting clinical trials of promising new medications and advancing understanding of 

cognitive disorders. The ultimate goal is to delay the onset of or prevent Alzheimer’s disease. 

Quality of Life Compared across Different Cognitive Disorders 


Mean EQ-5D Index 

1.0 

0.8 

0.6 

0.4 

0.2 

0 

N = 

Change in Quality of Life Compared across Different Cognitive Disorders 


Patients (%) 

60 

40 

20 

0 

N = 

Alzheimer’s 

Disease 

158 

Alzheimer’s 

Disease 

98 

Over a one-year observation period, patients with Alzheimer’s disease and mild cognitive impairment tended to have an 

improvement or stabilization of their quality of life, as measured with the EQ-5D, while those with frontotemporal dementia 

or other dementia syndromes tended to have worsening quality of life. Mean interval between first and last visits in 2010 

was 97, 64, 96 and 158 days for those with Alzheimer’s disease, mild cognitive impairment, frontotemporal dementia and 

other dementia, respectively. Improvement was defined as any positive change in score. 


Mild Cognitive 

Impairment 

83 


Impairment 

60 

Frontotemporal 

Dementia 

26 


Dementia 

16 

Other 

Dementia 

27 

Other 

Dementia 

19 

Worsened 

Stable 

Improved 

41

42 

Cognitive Disorders 

Depressive symptoms, as measured with the Geriatric Depression Scale (GDS-SF), are common across all cognitive 

disorders and show great variability when followed over time. These symptoms are an important management focus, and 

patients with more severe mood changes should be treated with antidepressants. Mean interval between first and last visits 

in 2010 was 105, 106, 68 and 126 days for those with Alzheimer’s disease, mild cognitive impairment, frontotemporal 

dementia and other dementia, respectively. 

Depression Compared across Different Cognitive Disorders 


Mean GDS-SF Score 

9 

6 

3 

0 

N = 

Patients (%) 

0.8 

0.6 

0.4 

0.2 

0 

N = 

Alzheimer’s 

Disease 

145 

Alzheimer’s 

Disease 

71 


Impairment 

73 


Impairment 

44 


Dementia 

22 

0 


Dementia 

10 

Other 

Dementia 

21 

Change in Depression Compared across Different Cognitive Disorders 


Other 

Dementia 

13 

Worsened 

Stable 

Improved 


Epilepsy 

Epilepsy is a chronic condition, with a wide array of symptoms and implications. Its main effects are determined by the 

frequency and severity of seizures. Cleveland Clinic’s Epilepsy Center is a national and international leader for the diagnosis 

and management of patients with epilepsy. The outcomes below highlight our treatment results using our highly integrated 

multidisciplinary approach. We are reporting our seizure outcomes for the large subgroups of patients treated only with 

medications, as well as the relatively smaller subgroups also treated with epilepsy surgery. 

Seizure Frequency and Severity 

The effect of medical treatment on seizure severity and frequency was assessed using the Liverpool Seizure Severity Scale 

(LSSS), 1 a validated, patient-completed questionnaire developed to quantify the patient’s own perception of change in 

seizure severity. Higher scores reflect more severe seizures. 

Seizure Severity in Medically Treated Adult Epilepsy Patients (N = 723) 


LSSS Score 

100 

80 

60 

40 

20 

0 


Initial Follow-up 

Visit 

Seizure Severity 

Score 

Improved 

Seizure severity improved significantly on medical therapy, with the mean LSSS score improving from 31.3 (± 1.1 s.e.) 

at initial visit to 18.7 (± 1.1 s.e.) at last follow-up (P < 0.0001). Mean duration of follow-up was 15.6 months; minimum 

duration was six months. 

1. Scott-Lennox, Bryant-Comstock L, Lennox R, Baker GA. Reliability, validity and responsiveness of a revised scoring system for the Liverpool Seizure 

Severity Scale. Epilepsy Res. 2001 Apr;44(1):53-63. 

43

44 

Epilepsy 

Seizure Frequency in Medically Treated Adult Epilepsy Patients (N = 765) 


Cleveland Clinic National Data 

Responder Rate (≥ 50% reduction in seizure frequency) 64% 12-29% 

Percent Seizure-free at 6 Months 44% -- 

Percent Seizure-free at 12 Months 53% 17-29% 

Sixty-four percent of our patients seen from 2007 through 2010 and treated with medications alone (N = 765 patients) 

showed a 50 percent or greater reduction in seizure frequency by last follow-up visit (mean duration of follow-up = 10 

months), compared to 12 to 29 percent of patients in a recent meta-analysis of series published from multiple epilepsy 

centers. 2 In terms of seizure freedom, 44 percent of our patients were completely seizure-free at six months and 53 percent 

were completely seizure-free at 12 months. Half of these patients had long-standing intractable epilepsy, and their rate of 

seizure freedom at 12 months based on national data is only 5 to 8 percent, 2-5 and half were newly diagnosed, and their 

rate of seizure freedom at 12 months based on national data varies from 29 to 50 percent. 3-4 As such, the expected rate 

of seizure freedom in our patients at one year based on national data should have been 17 to 29 percent. Instead, we 

achieved seizure freedom in 53 percent. 

2. Nadkarni S, LaJoie J, Devinsky O. Current treatments of epilepsy. Neurology. 2005;64(12 Suppl 3):S2-11. 

3. Glauser T, Ben-Menachem E, Bourgeois B, Cnaan A, Chadwick D, Guerreiro C, Kalviainen R, Mattson R, Perucca E, Tomson T. ILAE treatment 

guidelines: evidence-based analysis of antiepileptic drug efficacy and effectiveness as initial monotherapy for epileptic seizures and syndromes. 

Epilepsia. 2006;47(7):1094-1120. 

4. Begley CE, Famulari M, Annegers JF, Lairson DR, Reynolds TF, Coan S, Dubinsky S, Newmark ME, Leibson C, So EL, Rocca WA. The cost of epilepsy 

in the United States: an estimate from population-based clinical and survey data. Epilepsia. 2000;41(3):342-351. 

5. Wiebe S, Blume WT, Girvin JP, Eliasziw M. Effectiveness and Efficiency of Surgery for Temporal Lobe Epilepsy Study Group: a randomized, controlled 

trial of surgery for temporal-lobe epilepsy. N Engl J Med. 2001;345(5):311-318. 


Seizure Severity in Medically Treated Pediatric Epilepsy Patients (N = 85) 


LSSS Score 

100 

80 

60 

40 

20 

0 



Visit 

Seizure Severity 

Score 

Improved 

In the pediatric age group, the LSSS also showed a significant improvement from the initial visit to the last follow-up in 

patients treated with medications alone (reduction in mean LSSS from 36.4 (± 2.6 s.e. of the mean) to 21.5 (± 2.6 s.e.) 

(P < 0.0001)). N = the number of patients with greater than three months of follow-up. Mean duration of follow-up was 

6.8 months. 

Seizure Frequency in Medically Treated Pediatric Epilepsy Patients (N = 120) 



Responder Rate (≥ 50% reduction in seizure frequency) 61% 

Percent Seizure-free at 6 Months 44% 

Percent Seizure-free at 12 Months 53% 

Pediatric patients also saw a reduction in seizure frequency: 61 percent of the patients seen from 2009 through 2010 had 

a 50 percent or greater reduction in seizure frequency. N = 120 patients with mean duration of follow-up of 5.3 months. 

Forty-four percent became completely seizure-free at six months of follow-up after their initial visit. 

45

46 

Epilepsy 

Seizure Outcomes Following Epilepsy Surgery (Adult and Pediatric Patients) 

Long-term chances of achieving and maintaining seizure freedom following various types of epilepsy surgery are shown in 

the following graphs. Whenever possible, our data were compared to national published data. We used the widely accepted 

Engel classification 6 of seizure freedom to classify our seizure outcomes (seizure-free = Engel class 1). 

Long-Term Seizure Freedom in Adult and Pediatric Patients Following Epilepsy Surgery (N = 1,594) 

Surgical Dates: 1996 – 2010 

Seizure-free (%) 

100 

80 

60 

40 

20 

0 

0 1 2 3 4 5 6 7 8 9 10 11 12 

Years from Surgery 

Pediatric Epilepsy Patients 

Adult Epilepsy Patients 

Combined Cohort 

Years from Surgery 1 Year 2 Years 5 Years 10 Years 12 Years 

% Seizure-free (overall group) 76% 71% 62% 50% 44% 

% Seizure-free (adult epilepsy) 72% 66% 56% 48% 43% 

% Seizure-free (pediatric epilepsy) 80% 76% 67% 50% 44% 

Forty-four percent of patients with previously medically intractable epilepsy remained seizure-free 12 years after surgical 

treatment at Cleveland Clinic’s Epilepsy Center. The overall curve of seizure outcomes shows similar long-term chances of 

seizure freedom in adult and pediatric patients who underwent epilepsy surgery at the center from 1996 through 2010. 

6. Engel J Jr., Van Ness PC, Rasmussen TB, Ojemann LM. Outcome with respect to epileptic seizures. In Surgical Treatment of the Epilepsies 

(Engle J Jr., editor). 2nd ed. New York, NY:Raven Press; 1993:609-621. 


Long-Term Seizure Freedom Following Temporal Lobe Epilepsy Surgery (N = 830) 



100 

80 

60 

40 

20 

0 

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 


Temporal lobe epilepsy surgery is the most common type of brain surgery performed for the treatment of intractable 

epilepsy. The graph illustrates the percent of adult and pediatric patients who were seizure-free up to 10 – 15 years 

following a temporal lobe resection. National averages represent a weighted average of recent studies conducted in 

the United States. 7-13 


Cleveland Clinic Epilepsy Center 


Years from Surgery 1 Year 2 Years 5 Years 10 Years 15 Years 

% Seizure-free (Cleveland Clinic) 77% 72% 63% 57% 40% 

% Seizure-free (national average) 72% 54% 59% 51% NA 

7. Erickson JC, Ellenbogen RG, Khajevi K, Mulligan L, Ford GC, Jabbari B. Temporal lobectomy for refractory epilepsy in the U.S. military. Mil Med. 

2005;170:201-205. 

8. Spencer SS, Berg AT, Vickrey BG, Sperling MR, Bazil CW, Shinnar S, Langfitt JT, Walczak TS, Pacia SV. Multicenter Study of Epilepsy Surgery. 

Predicting long-term seizure outcome after resective epilepsy surgery: the multicenter study. Neurology. 2005;65:912-918. 

9. Kelley K, Theodore WH. Prognosis 30 years after temporal lobectomy. Neurology. 2005;64:1974-1976. 

10. Yoon HH, Kwon HL, Mattson RH, Spencer DD, Spencer SS. Long-term seizure outcome in patients initially seizure-free after resective epilepsy surgery. 

Neurology. 2003;61:445-450. 

11. Foldvary N, Nashold B, Mascha E, Thompson EA, Lee N, McNamara JO, Lewis DV, Luther JS, Friedman AH, Radtke RA. Seizure outcome after 

temporal lobectomy for temporal lobe epilepsy: a Kaplan-Meier survival analysis. Neurology. 2000;54:630-634. 

12. Salanova V, Markand O, Worth R. Longitudinal follow-up in 145 patients with medically refractory temporal lobe epilepsy treated 

surgically between 1984 and 1995. Epilepsia. 1999;40:1417-1423. 

13. Sperling MR, O’Connor MJ, Saykin AJ, Plummer C. Temporal lobectomy for refractory epilepsy. JAMA. 1996;276:470-475. 

47

48 

Epilepsy 

Frontal lobe resection is the second most commonly performed epilepsy surgery procedure. This type of epilepsy surgery is 

traditionally considered the most challenging. The graph reflects seizure outcome in 324 adult and pediatric patients with 

previously medically intractable frontal lobe epilepsy operated on between 1997 and 2010. 

Long-Term Seizure Freedom Following Frontal Lobe Epilepsy Surgery (N = 324) 



100 

80 

60 

40 

20 

0 

0 1 2 3 4 5 6 7 8 9 10 


Years from Surgery 1 Year 2 Years 5 Years 10 Years 

% Seizure-free 63% 56% 45% 31% 


Improvement in Frontal Lobe Epilepsy Surgical Outcomes over the Years (N = 324) 



100 

80 

60 

40 

20 

0 

0 1 2 3 4 5 



2000 or after 

Before 2000 

Surgical outcomes for frontal lobe epilepsy surgery have improved over time, likely due to the introduction and use of 

state-of-the-art diagnostic and surgical techniques. Close to one-half of the patients operated on after 2000 are seizure-free 

at five years, compared to one-third of those operated on before 2000. 

Years from Surgery 1 Year 2 Years 5 Years 

% Seizure-free - 2000 or After 65% 58% 47% 

% Seizure-free - Before 2000 53% 48% 33% 

49

50 

Epilepsy 

Long-Term Seizure Freedom Following Posterior Quadrant Resection (N = 111) 



100 

80 

60 

40 

20 

0 

0 1 2 3 4 5 6 7 8 


Posterior quadrant resection is used to treat intractable epilepsy involving the posterior temporal, parietal, and/or occipital 

regions. The graph reflects the percent of patients who continue to be completely seizure-free up to eight years following a 

posterior quadrant resection. 


% Seizure-free 81% 79% 75% 75% 


Long-Term Seizure Freedom Following Hemispherectomy (N = 207) 



100 

80 

60 

40 

20 

0 

0 1 2 3 4 5 6 7 8 


Patients with life-threatening, catastrophic epilepsy may be candidates for hemispherectomy, one of the most demanding 

types of epilepsy surgery. The graph reflects the percent of patients who continue to be completely seizure-free up to eight 

years following a hemispherectomy. 


% Seizure-free 88% 83% 75% 69% 


51

52 

Epilepsy 

Epilepsy Outcomes Beyond Seizure Frequency and Severity 

At the Epilepsy Center, we strongly believe that the burden of epilepsy extends beyond a “seizure count” and that the 

effect of the multidisciplinary and highly integrated care we provide (either medical or surgical) should be long-lasting and 

extend beyond simply treating seizures. As a result, the Outcomes Research Program was established in 2008 to provide 

a systematic long-term follow-up of patients undergoing epilepsy surgery and to create a mechanism for a comprehensive 

360º assessment of our treatment outcomes during every outpatient clinic visit, including an evaluation of quality of life, 

mood and psychosocial functioning, in addition to seizure frequency and severity. 

Adult Epilepsy: Effect of Treatment on Quality of Life 

A successful epilepsy treatment should translate into a better quality of life, and not simply fewer seizures. We assess 

quality of life in every outpatient clinic visit using the Quality of Life in Epilepsy questionnaire (QOLIE-10), a 10-item 

validated patient-completed questionnaire covering general and epilepsy-specific domains: epilepsy effects (memory, 

physical effects and mental effects of medication), mental health (energy, depression, overall quality of life) and role 

functioning (seizure worry, work, driving, social limits). Lower scores reflect a better quality of life. Quality of life improved 

in both the medical and surgical groups. 

Quality of Life in Medically Treated Adult Epilepsy Patients (N = 595) 


QOLIE-10 Score 

50 

40 

30 

20 

10 

0 


Visit 

Quality of Life 

Improved 

In the medically treated group, the mean QOLIE-10 score improved from 23.1 (± 0.4) at the initial visit to 20.9 (± 0.4) 

at the last follow-up (P < 0.0001). The standard box plots reflect the median and the 25th and 75th quartiles. N = adult 

epilepsy patients treated with medications only and with greater than six months of follow-up. Mean duration of follow-up 

was 15.2 months. 


Quality of Life in Surgically Treated Adult Epilepsy Patients (N = 168) 


QOLIE-10 Score 

50 

40 

30 

20 

10 

0 


Before After 

Surgery 

Quality of Life 

Improved 

In the surgically treated patients, the mean QOLIE-10 score also improved from 27.9 (± 0.7) at the initial visit to 

22.3 (± 0.6) at the last follow-up (P < 0.0001). The standard box plots reflect the median and the 25th and 75th 

quartiles. N = adult epilepsy patients with greater than six months of follow-up after epilepsy surgery. Mean duration 

of follow-up was 15.7 months. 

53

54 

Epilepsy 

Adult Epilepsy: Effect of Treatment on Mood 

Mood disorders, especially depression, are very common in patients with epilepsy. We routinely screen for depressive 

symptoms using the PHQ-9 in order to identify and actively treat depression as soon as possible, using Primary Care 

Depression Treatment Guidelines. 14 Early identification and treatment should result in improvement in our patients’ 

care, given the significant impact of depression on quality of life. In fact, mood did improve in both the medical and 

surgical groups. 

Improvement in Depressive Symptoms in Surgically Treated Patients (N = 116) 


PHQ-9 Score 

27 

20 

10 

0 

Before After 

Surgery 

Depression 

Improved 

The mean PHQ-9 score was 8.4 (± 0.6) before surgery as opposed to 6.5 (± 0.6) at the last follow-up visit, reflecting 

a 23 percent reduction in score severity (P = 0.03). The main improvement was observed in patients with moderate to 

severe depression at their initial visit. The standard box plots reflect the median and the 25th and 75th quartiles. 

N = adult epilepsy patients with greater than six months of follow-up after epilepsy surgery. Mean duration of follow-up 

was 13.1 months. 

14. Pignone MP, Gaynes BN, Rushton JL, Burchell CM, Orleans CT, Mulrow CD, Lohr KN. Screening for depression in adults: a summary of the evidence 

for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;136:765-776. 


Improvement in Depressive Symptoms in Medically Treated Patients (N = 447) 


PHQ-9 Score 

27 

20 

10 

0 



Visit 

Depression 

Improved 

The mean PHQ-9 score improved from 7.9 (± 0.3) at the initial visit to 6.0 (± 0.3) at the last follow-up visit, reflecting 

a 25 percent reduction in depression score severity (P < 0.0001). The standard box plots reflect the median and the 

25th and 75th quartiles. N = adult epilepsy patients treated with medications only and with greater than six months of 

follow-up. Mean duration of follow-up was 12.4 months. 

55

56 

Epilepsy 

Adult Epilepsy: Effect of Treatment on Anxiety 

Improvement in Anxiety Symptoms in Surgically Treated Patients (N = 91) 


GAD-7 Score 

30 

20 

10 

0 

Before After 

Surgery 

Anxiety 

Improved 

Anxiety was assessed using the Generalized Anxiety Disorder questionnaire (GAD-7), a patient-completed validated measure 

screening for symptoms of anxiety. The mean GAD-7 score improved from 6.2 (± 0.6) before surgery to 4.7 (± 0.6) at 

the last follow-up visit in patients who underwent epilepsy surgery (P = 0.09). The standard box plots reflect the median 

and the 25th and 75th quartiles. N = adult epilepsy patients with greater than six months of follow-up. Mean duration of 

follow-up was 11.7 months. 


Improvement in Anxiety Symptoms in Medically Treated Patients (N = 336) 


GAD-7 Score 

30 

20 

10 

0 



Visit 

Anxiety 

Improved 

Anxiety also improved in adult patients treated with medications alone: the mean GAD-7 score at the initial visit was 

5.7 (± 0.3), significantly higher than the mean score of 4.5 (± 0.3) seen at last follow-up (P = 0.007). The standard 

box plots reflect the median and the 25th and 75th quartiles. N = adult epilepsy patients with greater than six months 

of follow-up. Mean duration of follow-up was 11.2 months. 

57

58 

Epilepsy 

Change in Driving Status in Adult Epilepsy Patients 

Driving Status in Surgically Treated Patients (N = 205) 


Patients Driving (%) 

100 

80 

60 

40 

20 

0 

Before After 

Surgery 

Driving 

Not Driving 

Driving restrictions are a significant limitation for patients with uncontrolled epilepsy. Recovering the ability to drive is 

mostly dependent on the ability to regain seizure control. While only 9 percent of our surgical patients were driving before 

surgery, 29 percent were doing so after six months (P < 0.0001). N = adult epilepsy patients with greater than six months 

of follow-up. Mean duration of follow-up was 15.4 months. 


Driving Status in Medically Treated Patients (N = 784) 


Patients Driving (%) 

100 

80 

60 

40 

20 

0 



Visit 

Driving 

Not Driving 

In the medical group, 37 percent were driving at their first visit as opposed to 48 percent at last follow-up (P < 0.0001). 

N = adult epilepsy patients with greater than six months of follow-up. Mean duration of follow-up was 15.1 months. 

59

60 

Epilepsy 

Pediatric Epilepsy: Effect of Treatment on Healthcare Utilization 

Treatment benefits for patients in the pediatric age group also extended beyond the improvements seen in 

seizure frequency and severity. 

Hospitalizations in Surgically Treated Pediatric Epilepsy Patients (N = 66) 


Number of Hospitalizations 

3 

2 

1 

0 

Before After 

Surgery 

Healthcare utilization improved significantly from the initial visit to the last follow-up. This was determined based on 

a reduction in the number of hospitalizations in the three months preceding the visit, which decreased from a mean 

of 0.41 hospitalizations over three months (± 0.07) at initial visit to a mean of 0.11 (± 0.01) at last visit (P = 0.0034). 

This represents an approximately 75 percent reduction in frequency of hospitalization. N = pediatric patients with greater 

than three months of follow-up. Mean duration of follow-up was 10.5 months. 


Emergency Room Visits in Surgically Treated Pediatric Epilepsy Patients (N = 65) 


Number of ER Visits 

1.0 

0.5 

0 


Before After 

Surgery 

Although not statistically significant, there was a reduction in the frequency of emergency room visits, from a mean 

of 0.22 emergency room visits (± 0.07) in the three months preceding the initial visit to 0.05 (± 0.07) at last 

follow-up visit (P = 0.11). N = pediatric patients with greater than three months of follow-up. Mean duration of 

follow-up was 10.5 months. 

61

62 

Epilepsy 

Pediatric Epilepsy: Effect of Treatment on Functional Outcome 

School Days Missed in Surgically Treated Pediatric Epilepsy Patients (N = 47) 


Number of Days Missed 

15 

10 

5 

0 

Before After 

Surgery 

Following surgery, there was a nearly 75 percent reduction in the number of days a child missed from school in the three 

months preceding the initial visit, from a mean of 6.3 days (± 1.3) at initial visit to 1.5 days (± 1.3) at last follow-up 

visit (P = 0.009). N = pediatric patients with greater than six months of follow-up. 


Movement Disorders 

Improvement in Motor Symptoms of Parkinson’s Disease before and after Deep Brain Stimulation (N = 42) 

Surgical Dates: January 2010 – February 2011 

UPDRS II Score 

25 

20 

15 

10 

5 

0 


Before After 

Surgery 

The Unified Parkinson’s Disease Rating Scale Part II 

(UPDRS II) is a self-administered scale with items covering 

activities of daily living, including speech, swallowing, 

washing, dressing, feeding, writing, hobbies and workrelated 

activities, moving in bed, standing from a chair 

and walking. The scale also includes items more related to 

common movement disorders: functional impact of tremor, 

drooling, and freezing of gait. Higher numbers reflect worse 

symptoms. There is improvement in Parkinson's disease 

motor symptoms following deep brain stimulation (DBS) 

surgery. The graph shows UPDRS II scores (mean and 

s.e.) preoperatively and at most recent follow-up. Average 

duration of follow-up was 113 days. 

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64 

Movement Disorders 

Change in Motor Symptoms over Time for All Movement Disorder Patients 



40 

35 

30 

25 

20 

15 

10 

5 

0 

10 

5 

0 

1.2-1 


15 

0 

1.2-1 

0.8-0.6 0.4-0.2 0.1-0 

1-0.8 0.6-0.4 0.2-0.1 

0 

0-0.1 0.2-0.4 0.6-0.8 

0.1-0.2 0.4-0.6 0.8-1 

Mean Change in UPDRS II Score (Log 10 Ratio) from Visit 1 to Visit 2 

0.8-0.6 0.4-0.2 0.1-0 

1-0.8 0.6-0.4 0.2-0.1 

0 

0 

0 0 

1-1.2 

0 0 

0-0.1 0.2-0.4 0.6-0.8 1-1.2 

0.1-0.2 0.4-0.6 0.8-1 

Mean Change in UPDRS II Score (Log 10 Ratio) from Visit 1 to Visit 3 

Visit 2 (N = 218) 

Improved 

Stable 

Worsened 

Visit 3 (N = 77) 

Improved 

Stable 

Worsened 

The top graph shows the change in UPDRS II activities of daily living score, from visit one to visit two, for all movement 

disorder diagnoses; the bottom graph depicts the change from visit one to visit three. Most diagnoses are progressive 

conditions with symptoms expected to worsen over time. Despite this, evaluation and treatment in Movement Disorders 

clinic, on average, improves symptoms, as assessed by ability to perform daily activities. Average interval between visits 

was 85 days between visits 1 and 2, and 174 days between visits 1 and 3. Mean change for visit 2 was 20 percent 

improvement, and the mean change for visit 3 was 29 percent. 


Improvement with Botulinum Toxin Injections (N = 82) 


Global Improvement Score (GIS) 

100 

80 

60 

40 

20 

Hemifacial Spasm Blepharospasm Sialorrhea Torticollis 

Botulinum toxin injection was used for four indications: hemifacial spasm (HFS), blepharospasm, sialorrhea and torticollis 

(cervical dystonia). Each circle represents one patient. At the time of their most recent follow-up appointment, patients 

rated the overall improvement in symptoms since the last injection using the Global Improvement Score (GIS), which ranges 

from 0 to 100 percent, with 0 percent indicating no improvement and 100 percent indicating complete resolution 

of symptoms. 


65

66 

Multiple Sclerosis 

Mellen Center Patient Characteristics 

Demographic Patients (N = 3,369) 

Female 73% 

Caucasian 84% 

Mean Age 48 years 

Married 64% 

Multiple Sclerosis Subtype 

Relapsing-Remitting 61% 

Secondary Progressive without Relapses 14% 

Secondary Progressive with Relapses 7% 

Primary Progressive 6% 

Changes in Health Status over Time 

Multiple sclerosis (MS) is a disease of great variability and it is difficult to advise individuals about how their 

disease will progress over time. To better understand how health status and well-being change over time, we 

collected and analyzed five health status measures (EQ-5D, PHQ-9, Multiple Sclerosis Performance Scale (MSPS), 

Timed 25-Foot Walk (T25FW) and Timed 9-Hole Peg Test) in 2010 and segmented that data by time since 

diagnosis in five-year increments. 


Depression in 5-Year Increments since MS Diagnosis 



10 

8 

6 

4 

2 

0 

N = 

Mean EQ-5D Score 

1.0 

0.8 

0.6 

0.4 

0.2 

0 

N = 


0-4.99 5-9.99 10-14.99 15-19.99 >20 

1,179 846 623 322 354 

Years since Diagnosis 

Quality of Life in 5-Year Increments since MS Diagnosis 


0-4.99 5-9.99 10-14.99 15-19.99 >20 

1,205 855 630 323 356 


Cross-sectional analysis of PHQ-9 scores 

shows gradual decline in depression scores 

by years since diagnosis with significantly 

worse values in individuals with disease 

duration of 10 to 14.99 years compared 

to those who have had MS for five years or 

less (P = 0.007). 

EQ-5D scores gradually decline by years 

since diagnosis, with significantly worse 

values in individuals with disease duration 

of 15 to 19.99 years, compared to those 

who have had MS for five years or less 

(P = 0.025). 

67

68 


MS-Related Disability in 5-Year Increments since MS Diagnosis 


Mean MSPS Score 

40 

30 

20 

10 

0 

N = 

14 

12 

10 

8 

6 

4 

2 

0 

N = 

0-4.99 5-9.99 10-14.99 15-19.99 >20 

1,163 819 590 313 333 

Mean T25FW Score (Seconds) 


Lower Extremity Function in 5-Year Increments since MS Diagnosis 


0-4.99 5-9.99 10-14.99 15-19.99 >20 

1,014 745 532 265 261 


The MSPS is a validated measure of 

MS-related disability with higher scores 

indicating worse functioning. In this 

cohort, scores are significantly worsened 

with every five-year increment from time 

of diagnosis. 

The T25FW is a measure of lower 

extremity disability with higher scores 

indicating worse functioning. In this 

cohort, scores are significantly worsened 

with every five-year increment from time 

of diagnosis. 


Upper Extremity Function in 5-Year Increments since MS Diagnosis 


Mean 9-Hole Peg Test (Seconds) 

40 

30 

20 

10 

0 

N = 


0-4.99 5-9.99 10-14.99 15-19.99 >20 

589 409 339 183 197 


The 9-Hole Peg Test is a measure of 

upper extremity disability with higher 

scores indicating worse functioning. 

These data demonstrate gradual 

worsening in upper extremity function 

by years since diagnosis; such function 

is significantly worse for individuals 

with disease duration of 10 to 14.99 

years compared to those who have 

had MS for five years or less 

(P = 0.007). 

69

70 


Establishing Health Status Measure Benchmarks for Multiple Sclerosis 

There are no established health status measure benchmarks for clinical MS populations. Development and confirmation 

of such benchmarks are important for purposes of comparative effectiveness research and the development of symptom 

severity comparisons across different sites. Here we compare the relative stability of the overall scores for the PHQ-9, 

EQ-5D, MSPS, T25FW and 9-Hole Peg Test, health status measures used at the Mellen Center, over a three-year period. 

A mixed model ANOVA was used to make these comparisons. 

Consistency of Depression Scores over Years 


10 

8 

6 

4 

2 

0 

N = 

2008 

743 

2009 

3,138 


3,324 

PHQ-9 scores were significantly higher in 2008 (P = 0.002), while the scores remained stable over 2009 and 2010. 

The increasing sample size and longitudinal data are informative for interpreting these results. 


Quality of Life Scores over Years 


1.0 

0.8 

0.6 

0.4 

0.2 

0 

N = 


40 

30 

20 

10 

0 


2008 

1,533 

2008 

1,461 

2009 

3,203 

2009 

3,149 


3,369 

Quality of life, as measured with the EQ-5D, remained stable over the three-year period (overall P = 0.335). 

MS-Related Disability Scores over Years 

N = 


3,218 

MS-related disability scores, as measured with the MSPS, remained stable over the three-year period (overall P = 0.086). 

71

72 


Lower Extremity Function Scores over Years 


14 

12 

10 

8 

6 

4 

2 

0 

2008 

N = 

1,208 

Mean 9-Hole Peg Test (Seconds) 

40 

30 

20 

10 

0 

2008 

831 

2009 

2,757 

Upper Extremity Function Scores over Years 

N = 

2009 

1,983 


2,817 


1,717 

Gait or lower extremity function, 

as measured with the T25FW, 

was significantly worse in 2010 

(overall P = 0.009), but the 

actual change in value was 

relatively low. 

Arm function, as measured by 

the 9-Hole Peg Test, remained 

stable over the three-year period 

(overall P = 0.065). 


Disease-Modifying Therapy for Multiple Sclerosis 

A major initiative at the Mellen Center is to monitor and document patients’ self-reported adherence to their MS diseasemodifying 

therapies (DMT). These medications, most of which are injectable, are proven to slow disease progression, and it 

is important that they are taken routinely. We set a target goal of patients achieving greater than 75 percent adherence from 

one office visit to the next, usually at six-month intervals. 

Patients Adherent (%) 

100 

80 

60 

40 

20 

0 

Total Patients 1,058 


No Side Effects Side Effects 

N % 

Patients not Receiving DMT 367 35% 

Patients Receiving DMT 691 65% 

No Doses Missed 570 82.5% 

At Least 75% Adherent 677 97% 

Adherence to MS Disease-Modifying Therapy (N = 691) 


As expected, patients experiencing side effects from therapy are less likely to be adherent. 

73


Treatment with Natalizumab (Tysabri ® ) 

Natalizumab (Tysabri ® ) is an FDA-approved disease-modifying therapy for multiple sclerosis, which is often used 

when other MS treatments have failed. It is infused on a monthly basis. While it is associated with a rare complication 

(progressive multifocal leukoencephalopathy) that has occurred in 1 in 1,000 cases, it has also demonstrated the ability 

to improve MS health status. We evaluated health status before treatment initiation and again six months after, using 

the EQ-5D, PHQ-9, MSPS, T25FW and 9-Hole Peg Test. Our inability to demonstrate significant change on any of these 

measures is most likely due to the small sample size. 

Quality of Life before and after Tysabri ® Treatment (N = 29) 

Treatment Start Dates: July 1, 2009 – June 30, 2010 


1.0 

0.8 

0.6 

0.4 

0.2 

0 

Before Six Months After 

Treatment 

Quality of life, as measured with 

the EQ-5D, was stable after six 

months of treatment (P = 0.24). 


Depressive Symptoms before and after Tysabri ® Treatment (N = 29) 



8 

6 

4 

2 

0 


16 

12 

8 

4 

0 



Treatment 

Disability before and after Tysabri ® Treatment (N = 27) 



Treatment 

Likewise, depressive symptoms, as 

measured with the PHQ-9, were 

less after six months of treatment, 

but the difference did not reach 

statistical significance (P = 0.28). 

Data suggest an improvement in 

MS-related disability (lower scores 

indicate less disability) after six 

months of treatment, but did 

not reach statistical significance 

(P = 0.06). 

75


Walking Times before and after Tysabri ® Treatment (N = 29) 



8 

6 

4 

2 

0 

Mean 9-Hole Peg Test Score 

30 

20 

10 

0 


Treatment 

Arm Function before and after Tysabri ® Treatment (N = 29) 



Treatment 

Data suggest an improvement in 

gait (decrease in walking times with 

the T25FW) following six months of 

treatment, but we were not able to 

demonstrate a statistically significant 

change (P = 0.23), likely due to the 

small sample size. 

Arm function, as measured with the 

9-Hole Peg Test, was stable after six 

months of treatment (P = 0.57). 


Treatment with Dalfampridine (Ampyra ® ) 

Walking is limited in most MS patients, and lower limb function has been rated the most important bodily function by 

MS patients. Dalfampridine (Ampyra ® ) is an extended-release form of 4-aminopyridine, which was approved by the FDA 

to improve walking in patients with MS, based on an improvement of walking speed in two phase III clinical trials. 

Walking speed was measured with the T25FW. The average improvement in T25FW among responders to dalfampridine 

was 25 percent. A change of 20 percent on the T25FW has been identified as clinically significant. 1 

We analyzed data on 122 Mellen Center patients with MS who started dalfampridine since FDA approval, and who had 

at least one follow-up visit after starting the medication. The T25FW was systematically performed and collected at all 

clinic visits, as part of routine clinical care. We analyzed the change in T25FW between baseline and the first follow-up 

visit on treatment. 

Dalfampridine Patient Characteristics 

Characteristic Value 

Total Subjects 122 

Age Mean = 53.1, range = 28 - 74 

Gender Females = 73 (60%) 


Males = 49 (40%) 

MS Subtype Relapsing-Remitting = 31 (25%) 

Secondary Progressive = 68 (56%) 

Primary Progressive = 19 (16%) 

Progressive-Relapsing = 4 (3%) 

Disease Duration Mean = 18.0 years, range = 2 - 51 

Time on Dalfampridine before Assessment Mean = 77.8 days, range = 3 - 246 

Time between Gait Assessments (pre/post) Mean = 164.2 days, range = 23 - 658 

Pre-dalfampridine T25FW Score Mean = 17.6 seconds; range = 3.9 - 194.2 

1. Schwid SR, Goodman AD, McDermott MP, Bever CF, Cook SD. Quantitative functional measures in MS: what is a reliable change? 

Neurology 2002;58:1294–1296. 

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78 


Distribution of Change in T25FW Score between Baseline and Follow-up after Dalfampridine Treatment (N = 22) 


Percent Change in T25FW Score 

60 

50 

40 

30 

20 

10 

0 

-10 

-20 

-30 

-40 

-50 

-60 

-70 

0 

0 10 20 30 


>20% Improvement 

Using a 20 percent change as 

clinically significant, 22 percent 

of patients (N = 27) exhibited a 

clinically significant improvement 

on the T25FW between baseline and 

the first follow-up visit on treatment. 

A logistic regression analysis showed 

that baseline walking time is a 

significant predictor of response 

to dalfampridine (P = 0.003), 

with slower walkers at baseline 

being more likely to have a clinically 

significant improvement (5 percent 

increase for each second). 


Intrathecal Baclofen Therapy 

Intrathecal baclofen (ITB) therapy is approved by the FDA for the treatment of severe spasticity of spinal or cerebral origin 

refractory to other treatment modalities. The Mellen Center has been using this therapeutic modality since its approval, 

with over 300 patients treated since 1990. The intrathecal infusion device (baclofen pump) is implanted by neurosurgeons 

in the Center for Neurological Restoration at Cleveland Clinic. Patient selection, testing and postoperative management are 

performed in the Mellen Center Spasticity Clinic. 

From January 2007 to October 2010, 81 patients underwent implantation of a baclofen pump. 


Diagnosis/Indication for ITB Number of Patients 

Multiple Sclerosis 41 

Motor Neuron Disease 5 

Cerebral Palsy 8 

Traumatic Brain Injury 2 

Spinal Cord Injury 6 

Stroke 4 

Myelopathy 10 

Other (stiff person syndrome, cerebral arteritis, 

anoxic brain injury, adrenomyeloneuropathy) 5 

Total 81 

79

80 


Spasticity before and after Intrathecal Baclofen 

January 2007 – October 2010 

Mean Spasticity Score 

4 

3 

2 

1 

0 

N = 

Mean Spasm Frequency Score 

4 

3 

2 

1 

0 

N = 

Before Treatment 

81 


81 

Early Follow-up 

77 

Spasm Frequency before and after Intrathecal Baclofen 



77 

Last Follow-up 

46 


46 

Spasticity scores on the Modified 

Ashworth Scale (0 = no increase in 

tone, 4 = severe increase in tone) 

indicate improvement after ITB 

therapy. There was a statistically 

significant (P < 0.0001, paired t-test) 

reduction in spasticity at early followup. 

Average follow-up was 145 and 

718 days for early and last 

follow-up, respectively. 

Spasm Frequency Scale scores 

(0 = no spasms, 4 = more than 

10 spasms/hour) before treatment, 

at early follow-up and at last follow-up 

show statistically significant reductions 

after ITB treatment (P < 0.0001). 

Average follow-up was 145 and 

718 days for early and last 



Pain Score before and after Intrathecal Baclofen 


Mean Pain Score 

10 

8 

6 

4 

2 

0 

N = 



81 

Ambulating Following ITB 


30 

20 

10 

0 

N = 


81 


77 


77 


46 


46 

Pain scores (0 = no pain, 10 = worst 

pain possible) before and after ITB 

therapy show a statistically significant 

reduction in pain at early follow-up 

(P = 0.007). Average follow-up was 

145 and 718 days for early and last 


The Mellen Center has developed expertise in the use of ITB therapy in ambulatory patients. ITB therapy in this population 

has the same potential benefits in terms of reduction of bothersome spasticity that may interfere with activities of daily 

living, sleep and quality of life in general. However, a common concern about ITB is that it may cause increased weakness 

with loss of function. 

Gait Speed before and after Intrathecal Baclofen 


Following ITB, there was no statistically 

significant change in mean gait speed, 

as measured with the T25FW for the 

patients who remained ambulatory. 

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82 

Neuromuscular Disorders 

Quality of Life in Myasthenia Gravis Patients (N = 26) 


Mean MG-QOL15 Score 

25 

20 

15 

10 

5 

0 

Mean MG-ADL Score 

5 

4 

3 

2 

1 

0 

First Last 

Visit 

Myasthenia Gravis Functional Status (N = 95) 


First Last 

Visit 

The MG-QOL15 is a quality-of-life 

questionnaire specific to myasthenia 

gravis (MG) that assesses both physical 

and psychological aspects of function. 

The MG-QOL15 has been shown to 

correlate well with clinical outcomes 

using physician impression as the gold 

standard. There is a reduction in mean 

MG-QOL15 from first to last visit. Average 

time between visits was 88 days. 

The MG-ADL profile is a simple eightitem 

questionnaire that focuses on 

common symptoms reported in MG. 

The graph shows the average score of 

95 patients with MG who were seen in 

the outpatient clinic by neuromuscular 

staff and who had complete MG-ADL 

assessments on at least two occasions 

in 2009-2010. There was a significant 

reduction in MG-related symptoms 

(P < 0.0001). Average time between 

visits was 189 days. Higher scores 

indicate greater disability. 


Pain / Headache 

The Headache Program, within the Neurological Center for Pain, utilizes the Headache Impact Test (HIT-6) as a 

standard health status measure for all patients treated in the center. HIT-6 is a disease-specific survey that captures 

the effects of headache and its treatment on functional health and well-being. 

Chronic Migraine 

Chronic migraine refers to migraine headaches occurring at least 15 days per month, frequently associated with significant 

functional impairment and depression. Patients with chronic migraine often present for treatment with excessive and 

prolonged use of opioids, triptans or other analgesics, which can exacerbate the headache in the long term. 

Functional Impairment: New Chronic Migraine Patients with and without Medication Overuse Headache (MOH) 


Mean HIT-6 Score 

76 

72 

68 

64 

60 

56 

N = 


18 

15 

12 

9 

6 

3 

0 

Patients without MOH 

N = 

59 


Patients without MOH 

58 

Patients with MOH 

42 

Depression: New Chronic Migraine Patients with and without MOH 


Patients with MOH 

41 

2009 First Visit 

2009 Interval Visit 

2010 Last Visit 

2009 First Visit 

2009 Interval Visit 

2010 Last Visit 

Functional impairment, as measured 

with the HIT-6, in chronic migraine 

patients seen for the first time at 

Cleveland Clinic’s Neurological 

Center for Pain in 2009 and 

followed into 2010 showed 

improvement over time, in patients 

with medication overuse headache 

(MOH) as well as those without 

(P < 0.0001). Those patients 

with MOH were more impaired, in 

general, than those without. 

Depressive symptoms, as measured 

with the PHQ-9, improved in 

chronic migraine patients initially 

seen in 2009 and followed into 

2010 in patients with MOH as well 

as those without (P < 0.0001). 

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Infusion Therapy for Headache 

Headache patients with status migrainosis, transformed migraine, cluster headache and MOH may receive intravenous 

infusion therapy with a number of different medications, including dihydroergotamine, magnesium, antiemetics, Robaxin ® , 

Depacon ® , Toradol ® and/or steroids, lasting one to five days. This treatment provides a less expensive alternative to 

emergency department care and can be useful as a component of a comprehensive headache management strategy. 

Pain Ratings before and after Infusion Therapy (N = 454) 


Pain Score 

(0 = No Pain, 10 = Worst Possible Pain) 

10 

8 

6 

4 

2 

0 

Before After 

Infusion 

Headache severity decreased following infusion therapy (P < 0.0001). Average treatment duration was 2.2 days. 


Interdisciplinary Method for the Assessment and Treatment of Chronic Headache (IMATCH) 

One of only a few such programs in the country, IMATCH is an intensive, multidisciplinary outpatient program for chronic 

headache patients who have exhausted other treatment options. 

Pain Ratings before and after IMATCH (N = 92) 


Pain Score 


10 

8 

6 

4 

2 

0 


Average Least 

Worst 

Current 

Pain 

Admission 

Discharge 

Pain scores (mean ± s.d.) decreased following completion of the IMATCH program (P < 0.0001). To obtain a more 

comprehensive assessment of their pain, patients were asked to rate their current pain as well as pain over the preceding 

week. Current pain is the level of pain at that moment; average, least and worst levels of pain are reported for the preceding 

week. Information is based on patients who completed IMATCH in 2010. 

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86 


Depression, Anxiety and Stress before and after IMATCH (N = 92) 


Depression Anxiety Stress Scale (DASS) Score 

25 

20 

15 

10 

5 

0 

Satisfaction Score 

5 

4 

3 

2 

1 

0 

Depression Anxiety 

Whole 

Program 

Admission 

Discharge 

DASS Subscale (0 - 42) 

Patient Satisfaction with IMATCH (N = 92) 


Medical 

Treatment 

Psychological 

Treatment 

Program Components 

Stress 

Physical 

Therapy 

Scores on measures of stress, 

anxiety and depression all 

decreased following IMATCH, 

indicating improvement 

(P < 0.0001). Mean DASS-42 

subscale scores are plotted with 

their standard deviations. 

Average scores on the Treatment 

Helpfulness Questionnaire 

(maximum score = 5) indicate 

high rates of patient satisfaction. 


As part of IMATCH, patients are seen daily by physical therapists in the Department of Physical Medicine and 

Rehabilitation for group cardiovascular, strengthening and stretching exercises. Patients also meet twice each week 

with physical therapists specially trained in the treatment of headaches and neck pain for individualized exercise and 

manual techniques aimed at reducing their symptoms. In addition to the Headache Impact Test and Pain Disability Index, 

disability is measured with the Headache Disability Index (HDI), the Dizziness Handicap Index (DHI) and the 

Neck Disability Index (NDI). 

Disability Status before and after Physical Therapy with IMATCH (N = 92) 


Disability Score 

100 

80 

60 

40 

20 

0 

Headache 

Impact Test 

(36-72) 


Pain 

Disability 

(0-70) 

Headache 

Disability 

(0-100) 

Index 

Dizziness 

Handicap 

(0-100) 

Neck 

Disability 

(0-100) 

Admission 

Discharge 

Pain disability, measured across multiple instruments, decreased following completion of the IMATCH program 

(all P < 0.0001). Lower scores indicate less severe disability. 

87


Cleveland Clinic Chronic Pain Rehabilitation Program 

The Chronic Pain Rehabilitation Program (CPRP), within the Neurological Center for Pain, is a comprehensive, 

interdisciplinary program designed to treat patients with disabling chronic pain. 

CPRP Patient Characteristics 2008 2009 2010 

Number of Patients Enrolled 207 229 287 

Number of Patients Completing 184 171 230 

Number of Patients Identified with Addiction 71 85 86 

Percent Female 62.8 65.1 66.2 

Mean Age (s.d.) 43.4 (15.02) 48.1 (13.09) 46.7 (12.58) 

Each year, a number of patients enroll in the CPRP but fail to complete the full daily, three- to four-week program for a 

variety of medical and nonmedical reasons. 

In recognition of the increasing number of patients with both chronic pain and addiction, and the dearth of pain treatment 

programs to address the needs of this population, the CPRP in late 2009 started a treatment track designed specifically to 

help patients with both pain and addiction. Although this is not a chemical dependency treatment program, patients in this 

track receive education about addiction and the role it has played in their lives and their pain. This education helps them 

start to plan the substance abuse treatment that follows completion of the CPRP. 


Pain Intensity before and after CPRP 



10 

8 

6 

4 

2 

0 

N = 


2008 

207 

Mean Depression Score 

25 

20 

15 

10 

5 

0 

N = 

2008 

207 

2009 

229 

2009 

229 


287 


287 

Admission 

Discharge 

6-Month Follow-up 

1-Year Follow-up 

Mean pain scores decreased following participation in the CPRP. A two-point change is considered clinically significant. 

One-year follow-up was not yet available for 2010. N = number of patients enrolled in the program. 

Depression before and after CPRP 

Admission 

Discharge 



Depressive symptoms, as measured with the DASS depression subscale, improved following participation in the CPRP. 

Higher scores on the 0 to 36 scale indicate more severe depression. Mean admission scores suggest moderate depression, 

while all discharge and follow-up scores suggest mild depression or no depression. One-year follow-up was not yet available 

for 2010. N = number of patients enrolled in the program. 

89


Anxiety before and after CPRP 

Mean Anxiety Score 

16 

12 

8 

4 

0 

N = 

2008 

207 

Mean Pain Disability Index Score 

50 

40 

30 

20 

10 

0 

N = 

2008 

207 

2009 

229 

2009 

229 

90 

Outcomes 2010 


287 


287 

Admission 

Discharge 



Anxiety symptoms, as measured with the DASS anxiety subscale, improved following participation in the CPRP. Higher 

scores on the 0 to 26 scale indicate more severe anxiety. Mean admission scores suggest moderate anxiety, while mean 

discharge scores are in the normal range or show mild anxiety. One-year follow-up was not yet available for 2010. 

N = number of patients enrolled in the program. 

Pain Disability before and after CPRP 

Admission 

Discharge 



Functional status, as measured with the Pain Disability Index (PDI), improved at discharge, six months and one year after 

participation in the CPRP compared with prior to treatment. Higher scores on the 0 to 70 scale indicate greater disability. 

One-year follow-up was not yet available for 2010. N = number of patients enrolled in the program.

CPRP Outcomes in Patients with Fibromyalgia 

Pain Intensity before and after CPRP for Fibromyalgia vs. Other Chronic Pain 




10 

8 

6 

4 

2 

0 

Both patients with fibromyalgia and patients with other chronic pain disorders attained clinically significant reductions in 

pain following participation in CPRP. 

Pain Disability before and after CPRP for Fibromyalgia vs. Other Chronic Pain 



50 

40 

30 

20 

10 

N = 

0 

N = 


Fibromyalgia 

103 

Fibromyalgia 

103 

Other Chronic Pain Disorders 

187 

Other Chronic Pain Disorders 

187 

Admission 

Discharge 

Admission 

Discharge 

Both patients with fibromyalgia and patients with other chronic pain disorders attained clinically significant reductions in 

disability due to pain following participation in CPRP. 

91


CPRP Outcomes in Multiple Sclerosis Patients 

Patients (%) 

100 

80 

60 

40 

20 

0 

Multiple Sclerosis Patient Characteristics: 2000 - 2009 

Number of MS Patients Enrolled 21 

Mean Age at Diagnosis of MS 35.2 

Mean Age at Enrollment 48.5 

Percent Female 81 

MS Subtype N (%) 

Relapsing-Remitting 13 (62%) 

Primary Progressive 4 (19%) 

Secondary Progressive 

Comorbid Pain Diagnosis 

4 (19%) 

Neuropathic Pain 7 (33%) 

Fibromyalgia 3 (14%) 

Other 

Comorbid Psychiatric Diagnosis 

11 (52%) 

Depression 6 (29%) 

Substance Abuse 6 (29%) 

Other 9 (43%) 

Depression before and after CPRP in MS Patients (N = 12) 

2000 – 2009 

Improvement 

of Mood 

No Change 

in Mood 

0 

Worsening 

of Mood 

Mood was measured with either the DASS or Beck 

Depression Inventory (BDI) and categorized as normal 

mood, mild depression, moderate depression or 

severe depression. A change in mood was defined 

as a change of two or more categories. Among those 

with depressive symptoms before CPRP, 67 percent 

showed improvement of mood following completion of 

the program. N = number of patients who completed 

both admission and discharge mood data and who 

had evidence of depression on admission. 


Pain Intensity before and after CPRP for MS Patients vs. All CPRP Patients 

2000 – 2009 



10 

8 

6 

4 

2 

0 

Mean PDI Score 

50 

40 

30 

20 

10 

0 


Admission Discharge 

Pain Disability before and after CPRP for MS Patients vs. All CPRP Patients 

2000 – 2009 

Admission Discharge 

MS Patients (N = 21) 

All Patients (N = 2,030) 

MS Patients (N = 21) 

All Patients (N = 2,030) 

93

94 


CPRP Outcomes in Patients with Low Back Pain 

Depression, Anxiety and Stress before and after CPRP for Patients with Low Back Pain 


DASS Subscale Score 

25 

20 

15 

10 

5 

0 

Admission Discharge 6 Months 1 Year 


(0 = No Pain, 10 = Worst Possible Pain) Mean PDI Score 

8 

80 

6 

4 

2 

0 


60 

40 

20 

0 

Depression 

Anxiety 

Stress 

Pain Intensity and Pain Disability before and after CPRP for Patients with Low Back Pain 



CPRP Outcomes in Patients at Risk for Substance Use Disorders 

Program Completion Rates in Patients at Risk for Substance Use Disorders 


Completion Rate 

1.0 

0.8 

0.6 

0.4 

0.2 

0 

N = 

Mean Depression Score 

25 

20 

15 

10 

5 

0 


Substance Use 

CPRP Group 

175 

Non-Substance Use 

CPRP Group 

262 

Depression before and after CPRP in Patients at Risk for Substance Use Disorders 


SUD 

Non-SUD 


Program completion rates tend to be lower 

for those identified at risk for substance use 

disorders. N = total number of patients 

initially enrolled in CPRP in 2009 and 

2010. Although patients with substance use 

disorders are much more likely to drop out 

of treatment, those who complete treatment 

do as well as patients without comorbidity. 

The program is making efforts to understand 

and improve the problem of program 

dropout. In fact, Cleveland Clinic data 

suggest that 30 percent of patients with 

substance abuse disorders who drop out of 

CPRP do so because they do not want to 

give up the addictive substance. 

Depressive symptoms, as measured with 

the DASS depression subscale, improve 

following participation in CPRP. Higher 

scores on the 0 to 36 scale indicate more 

severe depression. Depressive symptoms 

tend to be higher in those patients identified 

at risk for substance use disorders. For this 

and subsequent graphs, SUD = patients 

enrolled in a Substance Use Disorders 

Education Track for those identified at risk 

for substance use disorders. 

95


Anxiety before and after CPRP in Patients at Risk for Substance Use Disorders 


Mean Anxiety Score 

16 

12 

8 

4 

0 

SUD 

Non-SUD 


Pain Intensity before and after CPRP in Patients at Risk for Substance Use Disorders 


Mean Pain Score (0 = No Pain, 10 = Worst Possible Pain) 

7 

6 

5 

4 

3 

2 

SUD 

1 

0 

Non-SUD 


Pain Disability before and after CPRP in Patients at Risk for Substance Use Disorders 



50 

40 

30 

20 

10 

0 

SUD 

Non-SUD 


Anxiety symptoms, as measured 

with the DASS anxiety subscale, 

improve following participation 

in CPRP. Higher scores on the 

0 to 26 scale indicate more 

severe anxiety. Again, anxiety 

symptoms tend to be higher in 

those patients identified at risk 

for substance use disorders. 

Clinically significant change in 

average pain intensity ratings 

(a 3-point change or more) 

occurred from admission to 

discharge in both groups, but 

at no other times. 

Functional status is measured here 

with the Pain Disability Index. 

Higher scores on the 0 to 70 scale 

indicate greater disability. Clinically 

significant improvement, a shift 

from one category to another 

(for instance, from moderate to 

mild disability) occurred in both 

SUD and non-SUD groups at all 

intervals following admission. 


Pediatric Neurological / Neurosurgical Disorders 

Pediatric Neurometabolic Clinic 

The term “idiopathic developmental delay” is used to define some 3 percent of the population that has unexplained 

neurologic and developmental symptoms, including autism and epilepsy. Until recently, this population of children and 

adults, some with progression of their symptoms for unexplained reasons, remained largely without a diagnosis. With 

advances in technology and improving diagnostic skills, the ability to reach a conclusive diagnosis in this population has 

steadily improved. While there is no national standard, tertiary care centers such as ours have the potential to reach a 

diagnosis 30 to 50 percent of the time. 1 

Neurometabolic Clinic Diagnostic Yield 



250 

200 

150 

100 

50 

0 


New Patient Consults Diagnosis Established via 

Muscle, Genetic or 

Cerebrospinal Fluid Testing 

In 2010 our Neurometabolic Clinic evaluated 232 patients presenting with unexplained neurologic and/or 

developmental symptoms, and we were able to establish a diagnosis in 67 patients (31 genetic/syndromic and 

36 metabolic), or 29 percent. 

1. van Karnebeek CD, Scheper FY, Abeling NG, Alders M, Barth PG, Hoovers JM, Koevoets C, Wanders RJ, Hennekam RC. Etiology of mental retardation 

in children referred to a tertiary care center: a prospective study. Am J Ment Retard. 2005 Jul;110(4):253-67. 

97


Pediatric Neuromuscular Disease 

Pediatric Electromyography (EMG) 

Number of Studies 

80 

60 

40 

20 

0 

2006 2007 2008 2009 

PedsMIDAS 

30 

© Score/Number of School Days Missed 

20 

10 

0 

98 Outcomes 2010 


PedsMIDAS © Score Number of School Days Missed 

Total EMGs 

EMGs with OR/Sedation 

There are only a few medical centers in the country that provide high-quality EMG for the pediatric population with the 

option of EMG under sedation, resulting in a more comprehensive examination and less discomfort for the patient. 

Pediatric Headache 

Improvement in Headache Disability (N = 216) 



After Treatment 

Pediatric patients treated for headache in 2010 showed an improvement in PedsMIDAS © (Migraine Disability Assessment 

Score) of 39 percent. There was also a 50 percent reduction in school days missed in the preceding three months. Mean 

duration of follow-up was 160 days.

Pediatric Spasticity and Dystonia 

Spasm before and after Botulinum Toxin Injection (N = 47) 

July 2010 – February 2011 

Mean Spasm Score 

2.0 

1.5 

1.0 

0.5 

0 


First Follow-up 

Visit 

Pain Intensity before and after Botulinum Toxin Injection (N = 47) 




5 

4 

3 

2 

1 

0 

First Follow-up 

Visit 

Data reflect the outcome of 

botulinum toxin injection for 

spasticity and dystonia in children 

treated since July 2010. 

The decrease in spasm score 

between first and second visits 

was not statistically significant 

(P = 0.095). Mean duration 

of follow-up between first and 

second visits is 105 days. 

Data reflect the mean pain score 

decreases following botulinum 

toxin injection (P = 0.019). Mean 

duration of follow-up between first 

and second visits is 105 days. 

99

100 


Goal Attainment Scale (GAS) after Botulinum Toxin Injection (N = 47) 



20 

15 

10 

5 

0 

0 0 

-3 -2 

Outcomes for pediatric 

epilepsy are included 

in the epilepsy section. 

Children and adolescents 

are also seen in the 

Center for Behavioral 

Health and the Sleep 

Disorders Center. 

-1 0 1 2 

GAS Score 

The GAS measures how well 

goals were satisfied after the 

last botulinum toxin injection, 

with the scale ranging from 

-3 = much worse than expected 

to 2 = much better than 

expected. Goal satisfaction 

was as expected or above in 

all but three patients (who had 

minimal worsening of spasticity). 


Pediatric Neurosurgery 

Surgical site infection rates decreased in 2010, at least partly due to efforts to improve perioperative antibiotic timing. 

Infection rates in primary shunts decreased from 12 percent in 2009 to zero in 2010. 

Surgical Site Infection Rate for Primary Shunts 


15 

10 

5 

0 

N = 

2007 

18 


2008 

15 

Surgical Site Infection Rate for Shunt Revisions 


18 

12 

6 

0 

N = 

2007 

34 

2008 

18 

2009 

17 

2009 

26 

0 


12 


28 

N = number of clean cases per 

year. Per Centers for Disease 

Control and Prevention (CDC) 

guidelines, “clean cases” are 

defined as uninfected operative 

wounds in which no inflammation 

is encountered and, in the case of 

brain tumor surgery, neither the 

respiratory nor the alimentary tract 

is entered. 

101

Psychiatric Disease 

Outpatient Treatment for Depression 

Change in Health Status from Initial Assessment (N = 189) 


Patients (%) 

80 

60 

40 

20 

0 

PHQ-9 CGI EQ-5D 

Improved 

Stable 

Worsened 

More than 50 percent of adult outpatients demonstrated improvement in depressive symptoms, severity of illness and 

overall quality of life based on the change in PHQ-9 scores (Patient Health Questionnaire), CGI (Clinical Global Impression 

Scale) and EQ-5D (European Quality of Life Scale), respectively, from initial evaluation for major depression to the last 

follow-up visit (defined as occurring 90 or more days from the initial evaluation). Improvement is defined as a 50 percent 

or greater reduction in score. Patients were treated with outpatient psychotherapy and/or medication management. 

N = all patients seen for initial evaluation of major depression from January 1 through December 31, 2010, for whom 

both initial and follow-up data were available. Mean duration of follow-up was 90 days. 


Consultation Liaison Inpatient Psychiatry Service 

The Consultation Liaison (CL) Psychiatry Service specializes in the interface between medicine and psychiatry. The role 

of the consultation-liaison psychiatrist is to evaluate patients currently admitted as a general medical inpatient at the 

request of the treating medical or surgical team. The reasons for consultation are varied and may include assistance in 

the management of delirium, mood, anxiety and adjustment disorders, as well as addiction and capacity evaluations. 

At Cleveland Clinic, the CL Psychiatry Service provides over 3,000 consults annually to adult and pediatric inpatients 

admitted to medical services. 

Reduction in Illness Severity following Inpatient Psychiatry Consultation (N = 110) 

November – December 2010 

CGI Mean Scale Score 

6 

4 

2 

0 



Assessment 

The Clinical Global Impression (CGI) Severity of Illness is a standardized clinician-rated seven-point metric widely used 

in behavioral health to measure severity of mental symptoms, with higher scores indicating greater severity of illness. 

Mean group scores at baseline inpatient assessment and at last follow-up inpatient visit are displayed for all adult 

inpatients evaluated and treated by the CL service from November 1 to December 30, 2010. The most common reasons 

for psychiatric consultation in this patient sample are depression/anxiety in 50 percent, delirium in 40 percent and a 

combination of substance abuse, adjustment disorders and capacity evaluations in the remainder. On average, patients 

experienced a significant reduction in overall severity of illness following psychiatric consultation (P = 0.0001). Mean 

duration of follow-up from initial consultation to last inpatient psychiatric evaluation was four days. 

103


Women’s Mental Health Management Group for Depression (N = 62) 

January – July 2010 

Patients (%) 

80 

60 

40 

20 

0 

Improved Stable Worsened 

The data reflect patients’ perception of improvement with Shared Medical Appointments for Depression based on the 

Clinical Global Impression-Improvement (CGI-I) scale, a seven-point, self-rated, widely used instrument that requires the 

patient to assess improvement or worsening of symptoms relative to a baseline state at the beginning of the intervention. 

Aggregate results are presented as proportions of patients who reported improvement (very much improved, much 

improved or minimally improved), no change or worsening of symptoms (minimally worse, much worse or very much 

worse). Mean duration of intervention was three months. 


Inpatient Treatment for Depression 

The Mood Disorders Inpatient Unit at Lutheran Hospital opened in late January 2008. Data are presented for patients 

admitted to this unit in 2010 who consented to complete admission and discharge mood rating scales as part of an 

IRB-approved research mood disorder registry. Nearly 70 percent of patients were diagnosed with major depression and 

23 percent with bipolar disorder (Type I, II, NOS). 

Change in Depressive Symptoms before and after Treatment (N = 251) 


Mean Score 

40 

30 

20 

10 

0 


Hamilton 

Depression Scale 

(Range 0 - 52) 

Montgomery-Asberg 

Depression Rating Scale 

(Range 0 - 60) 

Admission 

Discharge 

Both the Hamilton Depression Scale (Ham-D) and the Montgomery-Asberg Depression Rating Scale (MADRS) are widely 

accepted and validated instruments to measure severity of depression and response to treatment. Mean group scores on 

admission and discharge are displayed for patients admitted to the Mood Disorders Unit from January 1 through December 

31, 2010. For both scales, there was a statistically significant reduction in mean severity of depression from admission to 

discharge (P = 0.001). Mean duration of hospitalization was 5.6 days. 

105

106 


Illness Severity and Manic Symptoms before and after Treatment (N = 251) 


Mean Score 

6 

5 

4 

3 

2 

1 

0 

Clinical Global Impression 

Severity Scale 

Young Mania 

Rating Scale 

Admission 

Discharge 

In 2010, patients treated on the Mood Disorders Unit experienced, on average, a reduction of more than two points on 

the CGI severity of illness scale (P = 0.0001). A CGI severity of illness score of 2 equates with “minimally ill.” The Young 

Mania Rating Scale (YMRS) measures the presence of manic or hypomanic symptoms. In this sample, the majority of 

patients did not experience excessive activation either at presentation or with treatment as reflected by low YMRS scores 

at admission and on discharge. YMRS scores of less than 8 are considered normal. 


Electroconvulsive Therapy (ECT) 

Cleveland Clinic offers electroconvulsive therapy (ECT) services at its main campus as well as at Lutheran Hospital for 

both inpatients and outpatients. ECT is an effective, safe, traditional form of neuromodulation therapy. ECT may be 

recommended for individuals with a diagnosis of depression, mania, psychosis or schizophrenia. The ECT service includes a 

team of specially trained professionals, including psychiatrists, anesthesiologists and nurses. 

Depressive Symptoms before and after ECT (N = 93) 


Mean Score 

50 

40 

30 

20 

10 

0 

Patients show a significant decrease in depressive symptoms with ECT based on the PHQ-9 and MADRS scores 

(P < 0.0001). 


PHQ-9 Scale 

(Range 0 - 27) 

Montgomery-Asberg 

Depression Rating Scale 

(Range 0 - 60) 

Admisssion 

Discharge 

107

108 


Alcohol and Drug Rehabilitation 

The Alcohol and Drug Rehabilitation Center (ADRC) provides a multidisciplinary team approach to the evaluation and 

treatment of chemical dependency. The ADRC is designed to help patients confront and overcome their chemical and/or 

alcohol dependency, and to assist in developing strategies for maintaining a chemical-free lifestyle. 

Treatment of Opioid Dependence 

Buprenorphine (Subutex ® ) and buprenorphine/naloxone (Suboxone ® ) offer a safer and arguably more effective treatment 

alternative to methadone for dependence on opioids such as heroin, Oxycontin ® , Percocet ® and Vicodin ® . Buprenorphine 

attenuates withdrawal symptoms and decreases cravings by partially stimulating the opioid receptor while blocking the 

effects of other opioids. To further support the recovery of patients in medication-assisted treatment with buprenorphine and 

buprenorphine/naloxone, support group sessions targeted to the special challenges of this population are required for those 

early in treatment and encouraged for those with more established sobriety. 

Depressive Symptoms in Patients Newly Admitted for Chemical Dependency (N = 410) vs. Patients Treated with 

Buprenorphine (N = 436) 

July – December 2010 


12 

8 

4 

0 

New Patients Buprenorphine Patients 

Patients already participating in the outpatient buprenorphine or buprenorphine/naloxone program show less depressive 

symptomatology, as measured with the PHQ-9, compared to patients newly admitted to the ADRC not currently treated 

with buprenorphine or buprenorphine/naloxone (P < 0.0001). 


Sleep Disorders 

Cleveland Clinic’s Sleep Disorders Center provides multidisciplinary care for patients of all ages with sleep and wake 

disorders. Comprehensive care is provided through integration of specialists in Neurology, Internal Medicine, Pulmonary and 

Critical Care Medicine, Psychiatry and Psychology, Pediatrics, Otolaryngology and Dentistry. 

Adult Sleep Studies 



5,000 

4,000 

3,000 

2,000 

1,000 

0 


600 

500 

400 

300 

200 

100 

0 


2006 2007 2008 

2009 

2006 2007 2008 2009 2010 


PSG/EEG 

CPAP/BiPAP 

Split 

MSLT/MWT 

The number of adult sleep studies performed in nine locations across Northeast Ohio has continued to increase over the 

past five years. 

Pediatric Sleep Studies 


The number of pediatric sleep studies continually increased during each of the past five years. Children ages 12 and older 

without special needs may be tested in any one of the nine sleep laboratory locations. 

109

110 


Sleep Apnea 

Obstructive sleep apnea syndrome affects millions of people, with an estimated prevalence of 24 percent in men and 

9 percent in women. Untreated sleep apnea is associated with a variety of medical and psychosocial problems, including 

hypertension, heart disease, depression and obesity, as well as daytime sleepiness, occupational and academic difficulties 

and motor vehicle accidents. Positive airway pressure (PAP) therapy is a first-line treatment for sleep apnea, shown to 

reduce or reverse these adverse consequences. 

Positive Airway Pressure (PAP) Compliance in Patients with Sleep Apnea 


Mean Score 

50 

40 

30 

20 

10 

Cleveland Clinic National Average 

Compliance Rate 

(percent of sleep apnea patients using PAP ≥ 4 hours/night) 78% 50% 

PAP therapy compliance is most commonly defined as four or more hours of use per night. Most studies report PAP 

compliance rates in the range of 50 percent in patients with sleep apnea. Patients with sleep apnea treated in the Sleep 

Disorders Center in 2010 had higher compliance rates compared to the national average, due in part to the implementation 

of a standardized care pathway that ensures regular follow-up visits with health status assessments, aggressive troubleshooting 

for challenging cases and integration of Cleveland Clinic Home Care therapists into the treatment team. 

Sleepiness and Fatigue before and after Treatment 


0 

N = 

Epworth Sleepiness Scale 

392 

Fatigue Severity Scale 

390 



Daytime sleepiness, as measured with the Epworth Sleepiness Scale (ESS), decreased in sleep apnea patients who were 

compliant with PAP therapy (P < 0.0001). Lower ESS scores indicate less sleepiness (ESS < 10 is considered normal). 

Similarly, fatigue, as measured with the Fatigue Severity Scale (FSS), decreased in sleep apnea patients who were 

compliant with PAP therapy (P < 0.0001). Lower FSS scores suggest lower fatigue levels during the day. 


Functional Status and Depressive Symptoms before and after Treatment 


Mean Score 

20 

15 

10 

5 

0 

N = 

Mean Subscale Score 

4 

3 

2 

1 

0 


FOSQ 

392 

General Social 

Outcomes 

Activity 

Level 

FOSQ Subscale 



PHQ-9 

358 

Functional Status Subscales before and after Treatment (N = 392) 


Before PAP 

After PAP 

Vigilance Intimate 

Relationships 

Functional status, as measured by the 

Functional Outcomes of Sleep Questionnaire 

(FOSQ), improved among sleep apnea 

patients who were compliant with PAP 

treatment (P < 0.0001). The FOSQ is a 

condition-specific functional status measure 

designed to evaluate the effects of sleep 

disorders on activities of daily living. Higher 

scores indicate higher levels of quality of life. 

Depressive symptoms, as measured with the 

PHQ-9, improved in sleep apnea patients 

who were compliant with PAP therapy 

(P < 0.0001). Lower scores indicate fewer 

depressive symptoms. A score less than 

5 is considered normal. 

Sleep apnea patients who were compliant 

with PAP therapy showed improvement 

in all five domains of functional status 

as measured by the FOSQ subscales 

(P < 0.0001). Higher scores indicate 

higher levels of functioning. 

111


The 2011 National Sleep Foundation’s Sleep in America poll found that during the week, 39 percent of respondents sleep 

less than seven hours per night, and 14 percent sleep less than six hours per night. Sleep disorders, such as sleep apnea 

and insomnia, increase the risk for inadequate sleep. Chronic sleep deprivation is associated with a variety of health and 

social consequences including cognitive impairment, mood disorders, obesity, reduced productivity and drowsy driving. 

Total Sleep Time before and after Treatment (N = 398) 


Mean Total Sleep Time (Hours) 

7.0 

6.8 

6.6 

6.4 

6.2 

6.0 

Before After 

Treatment 

Patients with sleep apnea who were 

compliant with PAP therapy slept an average 

of 30 minutes more per night after treatment 

(P < 0.0001). A multifaceted treatment 

plan that includes lifestyle changes, good 

sleep hygiene and PAP therapy is required to 

optimize sleep quality and quantity in patients 

with sleep apnea. 


Sleepiness and Fatigue in Patients with REM-Related Sleep Apnea before and after Treatment 


Mean Score 

50 


40 


30 

20 

10 

0 

N = 

Mean Score 

20 

15 

10 

5 

0 

N = 


Epworth Sleepiness Scale 

130 

FOSQ 

127 

Fatigue Severity Scale 

128 



PHQ-9 

120 

In approximately 25 percent of cases, sleep apnea occurs 

exclusively or nearly so in rapid eye movement (REM) 

sleep, a stage that is believed to be important for cognitive 

restoration and memory consolidation. Patients with 

REM-related sleep apnea are often not offered the same 

treatment options. No studies have addressed functional 

outcomes in this subset of sleep apnea. Investigators at 

Cleveland Clinic analyzed health status measures before 

and after PAP therapy in patients with REM-related sleep 

apnea. Improvements in sleepiness, as measured by the 

ESS, and fatigue, as measured by the FSS, were observed 

in patients with REM-related sleep apnea, comparable to 

those observed in sleep apnea patients overall 

(P < 0.0005). 

Functional Status and Depressive Symptoms in Patients with REM-Related Sleep Apnea before and after Treatment 


Similarly, patients with REM-related sleep apnea treated 

with PAP experienced a significant increase in FOSQ 

scores, suggesting improved quality of life, and a significant 

decrease in depressive symptoms as measured by the 

PHQ-9 (P < 0.0005). 

113

114 


Insomnia 

It is estimated that as many as 50 percent of adults have occasional episodes of insomnia and that 10 percent of adults 

experience chronic insomnia. Insomnia is associated with many comorbidities, both psychiatric and medical, and it 

imposes an economic burden related to increased healthcare utilization and time away from work. 

Total Sleep Time before and after Cognitive Behavioral Therapy for Insomnia (N = 249) 


Mean Total Sleep Time (Hours) 

7.0 

6.5 

6.0 

5.5 

5.0 

Before After 

Treatment 

Patients who were evaluated and treated for insomnia by a behavioral sleep medicine expert experienced an increase in 

total sleep time of over 30 minutes per night (P < 0.0001) after three months of treatment. Over an average of five visits, 

patients were treated with a variety of Cognitive Behavioral Therapy for Insomnia (CBT-I) strategies, including progressive 

muscle relaxation, stimulus control, sleep restriction, sleep hygiene education and biofeedback. CBT-I can be individualized 

or can take place in a group setting. Meta-analyses report better outcomes in insomnia patients using CBT-I than sedativehypnotic 

medications alone. 


Spinal Disease 

The Center for Spine Health provides a comprehensive continuum of care for spinal disorders, including medical 

management, surgical interventions, minimally invasive injection procedures, specialized exercise programs, acupuncture, 

osteopathic manipulation and referral to functional restoration programs, all of which are intended to maximize return to 

participation in vocational, family and recreational activities. In 2010, Cleveland Clinic began a comprehensive attempt to 

extend computerized outcomes data gathering to all centers throughout the entire system with a phase-in of data gathering 

capabilities for all visits and targeted outcomes monitoring for continuous practice improvement within the Center for 

Spine Health. 

Lumbar Disc Herniation 

Improvement in Functional Status Following Lumbar Microdiskectomy for Disc Herniation 


Patients (%) 

100 

80 

60 

40 

20 

0 

N = 

EQ-5D 

92 


PHQ-9 

89 

0 

PDQ 

54 

Rankin 

121 

Worsened 

Stable 

Improved 

The EQ-5D and PHQ-9 measure quality of life and depressive symptoms, respectively, as explained in more detail in 

the Outcomes Overview. The PDQ (Pain Disability Questionnaire) measures the effects of pain on 15 aspects of function 

including work, recreation, travel, need for medical visits, reliance on social support, income, lifting, and personal care. 

On each item, patients rate their performance from 0 to 10 (worst), with cumulative scores ranging from 0 to 150. Higher 

scores indicate greater disability due to pain. The Rankin is a commonly used scale for measuring the degree of disability 

or dependence in daily activities. Over 80 percent of patients experienced greater-than-expected functional improvement 

after surgery (elective lumbar microdiskectomy for disc herniation), based on two separate measures of functional status, 

the EuroQOL (EQ-5D) and the Pain Disability Questionnaire (PDQ). The specific degrees of improvement are shown in 

subsequent graphs. 

115

116 


Improvement in Quality of Life Following Lumbar Microdiskectomy for Disc Herniation (N = 92) 



1.0 

0.8 

0.6 

0.4 

0.2 

0 

Mean PDQ Score 

100 

80 

60 

40 

20 

0 

Before After 

Surgery 

Before After 

Surgery 

Patients reported 

improvement in quality 

of life after lumbar 

microdiskectomy for 

disc herniation. 

Improvement in Pain Disability Following Lumbar Microdiskectomy for Disc Herniation (N = 54) 


Patients reported improvement 

in pain disability, as measured 

with the PDQ, after lumbar 

spine surgery. Higher scores 

indicate greater disability. 


Cervical Myelopathy 

An area of special interest is treatment of patients with cervical spondylotic myelopathy (CSM). This disease tends to 

be a progressive, often painless, loss of hand, leg and bladder function related to compression of the spinal cord from 

degenerative change in the cervical spine. The diagnosis of CSM requires a high index of suspicion and generally requires 

surgical decompression to minimize the risk of irreversible damage. 

Improvement in Quality of Life Following Spinal Decompression for Cervical Myelopathy (N = 48) 



1.0 

0.8 

0.6 

0.4 

0.2 

0 

Mean PDQ Score 

100 

80 

60 

40 

20 

0 


Before After 

Surgery 

Before After 

Surgery 

Quality of life improved following 

spinal decompression. 

Improvement in Pain Disability Following Spinal Decompression for Cervical Myelopathy (N = 48) 


Objective measures of function 

improved after surgical 

decompression of the cervical 

spinal cord with greater function 

in almost all domains. 

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118 


Degenerative Spondylolisthesis and Spinal Stenosis 

Surgical Treatment 

Lumbar degenerative spondylolisthesis is a slippage of one or more vertebral bodies relative to the adjacent vertebral body. 

This slippage may cause back and leg pain from neurological compression (stenosis) that may impair walking, standing and 

many aspects of daily function. Surgical treatment typically involves decompression and instrumented fusion. 

Improvement in Quality of Life Following Laminectomy and Fusion for Spinal Stenosis (N = 37) 



1.0 

0.8 

0.6 

0.4 

0.2 

0 

Before After 

Surgery 

Quality of life improved following spinal 

surgery for spinal stenosis. 

Improvement in Depressive Symptoms Following Laminectomy and Fusion for Spinal Stenosis (N = 37) 



Loss of normal function is often associated 

10 

with distress. This distress can be measured 

8 

6 

on psychological tests and often manifests 

as increased family strife, negative selfperception, 

trouble sleeping and depression. 

4 

Following lumbar laminectomy and fusion for 

2 

symptomatic stenosis, distress associated 

0 

Before 

Surgery 

After 

with functional impairments, as measured 

by PHQ-9, decreased to levels near those 

seen in the general population. 


Spinal Injections 

Symptomatic lumbar spinal stenosis may produce leg pain with walking or standing. In carefully selected patients, 

particularly those who are older and have significant comorbidities, spinal epidural steroid injections performed by a 

Center for Spine Health interventionalist may provide an effective alternative to surgery. 

Improvement in Quality of Life Following Spinal Injections for Spinal Stenosis (N = 36) 



1.0 

0.8 

0.6 

0.4 

0.2 

0 

Before After 

Treatment 

Improvement in Depressive Symptoms Following Spinal Injections for Spinal Stenosis (N = 32) 



Depressive symptoms and psychological distress 

12 

would be expected due to loss of independence 

10 

related to difficulty walking from spinal stenosis. 

8 

6 

Depressive symptoms, as measured by the 

4 

PHQ-9, were reduced following spinal injections 

2 

and nearly returned to baseline based on age- 

0 

related comorbidities. 

Before After 

Treatment 

Improvement in Functional Status Following Injections for Spinal Stenosis 


Patients (%) 

100 

80 

60 

40 

20 

0 

N = 

EQ-5D 

36 


PHQ-9 

32 

Worsened 

Stable 

Improved 

0 

PDQ 

21 

Patients had improved objective measurements 

of function more than two months following 

spinal injection for lumbar spinal stenosis. 

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120 

Physical Medicine and Rehabilitation 

Outpatient Physical Medicine and Rehabilitation 

Improvement in Quality of Life Following Outpatient Physical Medicine and Rehabilitation 



1.0 

0.8 

0.6 

0.4 

0.2 

0 

N = 

Musculoskeletal 

615 


10 

8 

6 

4 

2 

0 

N = 

Musculoskeletal 

494 

Neurological 

79 

Neurological 

68 

Initial Visit 

Follow-up Visit 

Improvement in Depressive Symptoms Following Outpatient Physical Medicine and Rehabilitation 


Initial Visit 

Follow-up Visit 

Both the Musculoskeletal and Neurological 

patient groups experienced statistically significant 

(P < 0.05) improvement in quality of life, as 

measured with the EQ-5D. Mean duration 

between visits was 86.1 days for Musculoskeletal 

and 111.4 days for Neurological patient groups. 

Musculoskeletal diagnoses include spondylosis, 

lumbago, back pain, disc disorders, spinal 

stenosis, and joint disorders, with spine-related 

disorders accounting for more than 

45 percent of all outpatient encounters with 

board-certified physiatrists. Neurological 

conditions include disorders of the central 

nervous system (hemiplegia, multiple sclerosis, 

cerebral palsy, movement disorders), disorders 

of the peripheral nervous system (muscular 

dystrophy, peripheral neuropathy, mononeuritis), 

and pain. 

At last follow-up visit, both the Musculoskeletal 

and Neurological patient groups experienced 

statistically significant (P < 0.05) improvement 

in depressive symptoms, as measured with the 

PHQ-9. Mean duration between visits was 96.2 

days for Musculoskeletal and 120.1 days for 

Neurological patient groups. 


Occupational Rehabilitation Program 

The Work Conditioning Program is accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF). 

Meeting three to five times per week for up to eight weeks, the program uses physical reconditioning and job simulation/real 

work tasks to help injured workers regain optimal function so they can return to work. 

The Occupational Rehabilitation Program is a CARF-accredited multidisciplinary, individualized therapy program (five 

days per week, up to eight weeks). The program assists injured workers in returning to work through progressive physical 

conditioning, work simulation and vocational and psychosocial interventions. An on-site job analysis is performed and 

recommendations for accommodation to the work environment are made to minimize the risk of reinjury. 

Work Readiness Following the Work Conditioning and Occupational Rehabilitation Programs 


Patients Work Ready (%) 

100 

80 

60 

40 

20 

0 

N = 


After Completing 

Work Conditioning 

23 

After Completing 

Occupational Rehabilitation 

15 

Patients in both programs had primarily musculoskeletal (spine, upper extremity and lower extremity) diagnoses. “Work 

ready” indicates the percentage of patients who either returned to work, are in search of a job or are otherwise unemployed 

but capable of working upon discharge from their respective program. Some patients progress from the Work Conditioning 

Program to an occupational rehabilitation program prior to returning to work. 

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Inpatient Physical Therapy 

Improvement in Functional Status Following Inpatient Physical Therapy 


Patients (%) 

100 

80 

60 

40 

20 

0 

N = 

Bed Mobility 

4,026 


5,000 

4,000 

3,000 

2,000 

1,000 

0 

Dressing 

1,786 


Visit 

Improved 

Stable 

Worsened 

Transfer 

519 

Independent 

or Supervised 

Moderate to 

Minimum Assist 

Total or 

Maximum Assist 

The graph illustrates the changes in our patients’ 

ability to perform certain functional tasks such 

as bed mobility, dressing and transfer. Patients 

admitted to the acute hospital were evaluated at 

admission to the acute care unit and at discharge. 

Fifty percent of our acute care patients improved 

their ability to perform the three functional tasks. 

Data were obtained from MediLinks rehabilitation 

clinical information system. 

For the following three graphs, the patient’s ability to independently perform these tasks was scored as follows: independent 

or supervised = patient was able to perform the task independently or with some supervision; moderate to minimum assist 

= patient required assistance; and total or maximum assist = patient required total to maximum assistance from caregivers 

to perform the task. The goal of rehabilitation is to enable patients to become more independent in performing activities of 

daily living. Data were obtained from MediLinks rehabilitation clinical information system. 

Improvement in Bed Mobility Following Inpatient Acute Rehabilitation (N = 4,026) 


The ability to perform bed mobility, a functional 

task, was evaluated at admission to the acute 

care unit and at discharge from the unit. At 

the end of the acute hospital stay, the number 

of patients with a high level of independence 

doubled and the number of patients with a 

medium level of independence decreased from 85 

percent at admission to 68 percent. 


Improvement in Ability to Dress Following Inpatient Acute Rehabilitation (N = 1,786) 



2,500 

2,000 

1,500 

1,000 

5000 

0 



Visit 


700 

600 

500 

400 

300 

200 

100 

0 


Visit 

Independent 

or Supervised 

Moderate to 


Total or 


Improvement in Ability to Perform Transfers Following Inpatient Acute Rehabilitation (N = 519) 


Independent 

or Supervised 

Moderate to 


Total or 


The ability to dress independently, a functional 

task, was evaluated at admission to the acute 

care unit and at discharge from the unit. At 

the end of the acute hospital stay, the number 

of patients with a high level of independence 

increased three-fold, and the number of patients 

with a medium level of independence decreased 

from 91 percent at admission to 70 percent. 

The ability to transfer, a functional task, was 

evaluated at admission to the acute care unit 

and at discharge from the unit. At the end of 

the acute hospital stay, the number of patients 

with a high level of independence doubled and 

the number of patients with a medium level of 

independence decreased from 75 percent at 

admission to 49 percent. 

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124 


Occupational Therapy 

Improvement in Upper Limb Disability Following Therapy (N = 596) 


Mean QuickDASH Score 

50 

40 

30 

20 

10 

0 


Visit 

QuickDASH (Disabilities of the Arm, Shoulder and Hand) is a widely used tool in both clinical and research settings and has 

proven to be a useful self-report outcome measure for people with musculoskeletal upper-limb disorders. The QuickDASH 

uses 11 items to measure physical function and symptoms in people with one or more multiple musculoskeletal disorders of 

the upper limb. The scores range from 0 to 100, and a higher score indicates greater disability. Patients seen by Cleveland 

Clinic occupational therapists had an initial QuickDASH score of 45.6. At discharge, the score had decreased significantly 

(P < 0.005) to 13.9. Mean duration between visits was 85 days. 


Home Care 

Cleveland Clinic Care at Home 

Cleveland Clinic Care at Home: Hospital Readmission Rates 

March 2008 – March 2010 

Readmission Rate (%) 

32 

30 

28 

26 

24 

22 

20 

March 

2008 


June 

2008 

March 

2009 

September 

2009 

December 

2009 

March 


State Average 



Care at Home 

Cleveland Clinic Care at Home compared favorably with other home healthcare providers nationally and within the state 

of Ohio, in terms of percent of home healthcare patients requiring readmission to the hospital. The leading causes for 

readmission were cardiopulmonary disease and wound complications. On average, 2,880 patients per quarter are served by 

Cleveland Clinic Care at Home. Transitional Care Programs, such as Heart Care at Home and Go Right Home focus care on 

transitioning patients successfully to the home after acute care discharge. The data above demonstrate a level of success in 

our ability to keep our patients at home once they are discharged from the hospital. 

Source: www.medicare.gov/HomeHealthCompare 

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126 

Home Care 

Cleveland Clinic Hospice at Home 

Patient Satisfaction (N = 10) 

December 2010 

Patients Responding Favorably (%) 

100 

80 

60 

40 

20 

0 

Provide 

Coordination 

of Care 

Attend to 

Family 

Needs 

Inform and 

Communicate 

about Patients 

Provide 

Information 

about 

Symptoms 

Overall Quality 

of Care 

Response to 

Eve/Weekend 

Hospice of 


National 

Benchmark 

Providing information and communicating with patients and families are critical for optimal patient outcomes. Hospice at 

Home has met or exceeded all national benchmarks from the National Hospice and Palliative Care Organization (NHPCO). 


Cleveland Clinic Infusion Pharmacy at Home 

Infusion Pharmacy at Home is a licensed pharmacy that provides medications, nutritional support, infusion pumps, supplies 

and comprehensive infusion therapy management to patients in their homes. Traditional infusion pharmacy services include 

antibiotics, chemotherapy, immune globulin, pain medications and enteral/parenteral nutrition. Diagnoses of patients served 

include infections, multiple sclerosis, cancer and cancer-related pain, gastrointestinal disease, nutritional deficiencies, 

congestive heart failure and immune disorders. 

Patient Satisfaction with Infusion Pharmacy Services 


Patients Rating Overall Service 

as Very Good or Excellent (%) 

100 

80 

60 

40 

20 

0 

1st Quarter 2nd Quarter 



N = 69 

77 

Respiratory Therapy at Home 

Patients Rating Overall Service 

as Very Good or Excellent (%) 

100 

80 

60 

40 

20 

0 

1st Quarter 2nd Quarter 



N = 66 

59 


3rd Quarter 


72 

Patient Satisfaction with Home Respiratory Therapy 


3rd Quarter 


63 

4th Quarter 


85 

4th Quarter 


85 

Traditional respiratory services include 

home oxygen, nebulizers and aerosol 

medications for treatment of obstructive 

sleep apnea, emphysema, chronic 

bronchitis, asthma and compromised 

heart function. Cleveland Clinic provides 

a growing population of sleep apnea 

patients with CPAP and BiPAP equipment 

and supplies. 

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128 

Neuroimaging 

Brain Attack Head CT Reporting (N = 334) 


Patients (%) 

100 

80 

60 

40 

20 

0 

Notification of Results within 

20 Minutes of Exam 

Notification of Results within 

45 Minutes of Exam Ordered 

Current guidelines dictate that a patient presenting with an acute stroke (brain attack) should receive a noncontrast head CT 

within 25 minutes of arrival and the study must be interpreted within 20 minutes of exam completion. Because inpatients 

are also commonly entered into the same algorithm when they present with symptoms of an acute stroke, our goal is to 

provide test results within 45 minutes from the time the head CT is ordered. In 2010, the exam-to-notification metric was 

met in 95 percent of cases and the order-to-notification metric in 96 percent. 


Critical Results Reporting (N = 168) 


Patients (%) 

100 

80 

60 

40 

20 

0 

Jan 


Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 

Enterprise Report Turnaround Time 


Median Turnaround Time (Minutes) 

100 

80 

60 

40 

20 

0 

Jan 

CT 

MRI 

Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 

Although a number of neuroradiology 

results yield information urgently important 

to clinical care, Cleveland Clinic has 

determined that acute intracranial 

hemorrhage and severe intracranial mass 

effect are considered “critical,” and results 

should be communicated to a responsible 

licensed caregiver within 90 minutes of 

test interpretation. Compliance with these 

guidelines was 99 percent for 168 cases 

across the entire year, with only two studies 

in February and July that failed to meet 

these targets. 

Turnaround time is defined as the time 

from exam completion to the time the 

report is finalized. In 2010, more than 

37,000 neurological CT and 56,000 

neurological MRI exams were completed 

across the entire Cleveland Clinic health 

system, with median turnaround times of 

approximately one hour for both types of 

exams. This enables our referring services 

to expedite patient management in inpatient 

and outpatient settings. 

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130 

Surgical Quality Improvement 

Surgical Care Improvement Program (SCIP) — 

National Hospital Quality Measures and 

Overall Appropriateness of Care 


Process Measures (often referred to as “core” 

measures) Surgical care performance measures 

are available online at hospitalcompare.hhs.gov, a 

consumer-oriented website hosted by the Centers 

for Medicare & Medicaid Services (CMS). Hospitals 

submit surgery process-of-care data that show 

how consistently recommended care was provided 

to adult patients, irrespective of payer. Cleveland 

Clinic’s National Hospital Quality Measure surgical 

care data appear on the opposite page. 

Appropriateness of Care Measure To supplement 

process-specific measures, Cleveland Clinic 

generates “appropriateness of care” data. We 

calculate how often we provided every recommended 

surgical care process intervention for which each 

individual patient was eligible. The results, also 

shown on the opposite page, are generated on a perpatient, 

“all or nothing” basis. 


Prophylactic Antibiotic Received within 1 Hour 

Prior to Surgical Incision 

Cleveland Clinic data source: hospitalcompare.hhs.gov 

Visit clevelandclinic.org/QPR to view Cleveland Clinic’s current Quality Performance Report. 

* Benchmarks: National average for discharges, April 2009 through June 2010, hospitalcompare.hhs.gov 

(except Urinary Catheter Removal, January through March 2010) 

** Applies to all surgical patients, irrespective of age or payer; includes pediatric patients 

Notes: A national average for Perioperative Temperature is not available. 

An overall “Appropriateness of Care” national average is not available for the group of surgical care measures shown above. 

National Hospital Quality Measure (NHQM) volumes are based on NHQM inclusion/exclusion criteria and sampling methodologies. 


Appropriate Prophylactic Antibiotic 

Selected for Surgical Patients 

Prophylactic Antibiotic Discontinued within 

24 Hours After Surgery End Time 

Surgery Patients with Appropriate Hair Removal 

Surgery Patients on Beta-Blocker Therapy Prior to 

Arrival Who Received a Beta-Blocker During 

the Perioperative Period 

Surgery Patients with Recommended Venous 

Thromboembolism Prophylaxis Ordered 

Surgery Patients Who Received Appropriate 

Venous Thromboembolism Prophylaxis within 24 

Hours Prior to Surgery to 24 Hours After Surgery 

Urinary Catheter Removed on Postop Day 1 or 2 

(day of surgery = day zero) 

**Surgery Patients with Perioperative 

Temperature Management 

Overall Appropriateness of Surgical Care 


Benchmark* 

0 20 40 60 80 100 

Percent of Patients 

N 

1,049 

1,072 

1,024 

1,479 

541 

441 

440 

596 

1,039 

1,501 

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132 

Surgical Quality Improvement 

National Surgical Quality Improvement Program 

The American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) is a national 

program that objectively measures and reports risk-adjusted surgical outcomes based on a defined sampling and 

abstraction methodology. Cleveland Clinic has participated in multispecialty NSQIP since May 2008, and the 

outcome data below reflect our surgical cases between July 1, 2009, and June 30, 2010. 

Overall Multispecialty 30-Day Mortality (N = 4,518) 

July 2009 – June 2010 

Percent 

16 

14 

12 

10 

8 

6 

4 

2 

0 

Observed 

Expected 

Overall multispecialty mortality was lower than expected; 

however, the difference was not statistically significant. 

Overall Multispecialty 30-Day Morbidity (N = 4,518) 


Percent 

16 

14 

12 

10 

8 

6 

4 

2 

0 

Observed 

Expected 

Overall multispecialty morbidity was higher than expected; 

the difference was statistically significant. 


Neurosurgery 30-Day Mortality 


Percent 

16 

14 

12 

10 

8 

6 

4 

2 

0 


Observed 

N = 514 

Comparison* 

N = 3,430 

* Academic/teaching facilities with 500 or more beds 

Risk-adjusted Neurosurgery-specific NSQIP mortality data is 

not available. Raw Neurosurgery-specific data is provided. 

Neurosurgery 30-Day Morbidity (N = 514) 


Percent 

16 

14 

12 

10 

8 

6 

4 

2 

0 

Observed 

Expected 

Neurosurgery morbidity was higher than expected; however, 

the difference was not statistically significant. 

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Patient Experience 

“Patients First” is the guiding principle of Cleveland Clinic. 

Patient experience is a key component of Cleveland Clinic’s 

strategic plan to achieve a coordinated delivery model that 

integrates patient and family-centered care with clinical 

outcomes, quality, safety and employee experience. 

The Office of Patient Experience’s mission is to ensure 

consistent, patient-centered care by partnering with 

caregivers to exceed the expectations of patients and 

families. Programs and services include: 

• Expertise for critical initiatives throughout the 

organization to ensure the consistent delivery of 

patient-centered care 

• Patient satisfaction data analysis, HCAHPS education 

and resources 

• Identification and sharing of sustainable best practices 

• Support of employee experience and recognition initiatives 

Outpatient – Neurological Institute 

Overall Rating of Outpatient Care and Services During Outpatient Visit (N = 2,682) 


Percent 

100 

80 

60 

40 

20 

0 

Very Good Good Fair Poor Very Poor 

Source: Press Ganey, a national hospital survey vendor 

• Customer service education programs, including the 

Respond with H.E.A.R.T. ® service recovery program, to 

positively impact the Cleveland Clinic culture and support 

caregivers in providing outstanding service to patients, 

families and colleagues 

• Personalized, holistic Healing Services for patients, 

families and employees including light massage, Reiki, 

Healing Touch, reflexology, personal aromatherapy, 

guided imagery, spiritual support, Code Lavender first- 

response holistic care service and others 

• Health literacy education and solutions 

• Voice of the Patient Advisory Councils, an advisory 

resource that empowers patients and families to take 

an active role in improving the patient experience by 

providing real-time feedback and creative solutions to 

specific challenges 

• Ombudsman Office, which serves as a centralized 

complaint center 


Rating of Outpatient Care Provider (N = 2,682) 


Percent 

100 

80 

60 

40 

20 

0 

Likelihood of Recommending Outpatient Care Provider (N = 2,682) 





Percent 

100 

80 

60 

40 

20 

0 



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136 

Patient Experience 

Inpatient – Neurological Institute 

With the support of the Centers for Medicare & Medicaid Services (CMS) and its partner organizations, the 

first national standard patient experience hospital survey (HCAHPS) was implemented in late 2006. Results 

collected for reporting are available at hospitalcompare.hhs.gov. 

HCAHPS Overall Assessment 


Percent 

100 

80 

60 

40 

20 

0 

65% 

72% 

Rate Hospital Would Recommend 

% 9 or 10 

(0-10 scale) 

% “definitely yes” 


HCAHPS Domains of Care 


Percent 

100 

80 

60 

40 

20 

0 

Discharge 

Information Given 

% yes 

Doctor 

Communication 

Nurse 

Communication 


2009 (N = 1,478) 

2010 (N = 1,528) 

74% 

80% 

Pain 

Room New Medications 

Management Clean 

% always 

Communication 

(Options: always, usually, sometimes, never) 

2009 (N = 1,478) 

2010 (N = 1,528) 

Responsiveness 

to Needs 

Quiet at 

Night 


Cleveland Clinic Experience — Our Mission, Vision and Values 

In 2010, the Office of Patient Experience worked in collaboration with several departments, including the Office of 

Learning and Performance Development, to introduce “Cleveland Clinic Experience” to every employee across the 

organization. Cleveland Clinic Experience is an initiative designed to enhance and transform the culture at Cleveland 

Clinic by integrating exceptional employee and patient experiences. Interactive learning sessions taught caregivers the 

Cleveland Clinic expected service behaviors, how to positively respond to patient and family concerns, and what it 

means to live the Cleveland Clinic mission, vision and values on the job every day. 


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138 

Selected Publications 

“The Neurological Institute 

staff authored more than 

650 publications in 2010.” 

For a complete list of publications 

authored by 


staff in 2010, go to 

clevelandclinic.org/quality/outcomes 

Brain Tumor and Neuro-Oncology Center 

Cai R, Barnett GH, Novak E, Chao ST, Suh JH. Principal 

risk of peritumoral edema after stereotactic radiosurgery for 

intracranial meningioma is tumor-brain contact interface 

area. Neurosurgery. 2010 Mar;66(3):513-522. 

Harel R, Chao S, Krishnaney A, Emch T, Benzel EC, 

Angelov L. Spine instrumentation failure after spine tumor 

resection and radiation: Comparing conventional radiotherapy 

with stereotactic radiosurgery outcomes. World Neurosurg. 

2010 Oct;74(4-5):517-522. 

Lathia JD, Gallagher J, Heddleston JM, Wang J, Eyler CE, 

MacSwords J, Wu Q, Vasanji A, McLendon RE, Hjelmeland 

AB, Rich JN. Integrin alpha 6 regulates glioblastoma stem 

cells. Cell Stem Cell. 2010 May 7;6(5):421-432. 

Marko NF, Prayson RA, Barnett GH, Weil RJ. Integrated 

molecular analysis suggests a three-class model for lowgrade 

gliomas: a proof-of-concept study. Genomics. 2010 

Jan;95(1):16-24. 

Peereboom DM, Shepard DR, Ahluwalia MS, Brewer CJ, 

Agarwal N, Stevens GHJ, Suh JH, Toms SA, Vogelbaum MA, 

Weil RJ, Elson P, Barnett GH. Phase II trial of erlotinib with 

temozolomide and radiation in patients with newly diagnosed 

glioblastoma multiforme. J Neurooncol. 2010 May;98(1): 

93-99. 

Robinson CG, Palomo JM, Rahmathulla G, McGraw M, 

Donze J, Liu L, Vogelbaum MA. Effect of alternative 

temozolomide schedules on glioblastoma O(6)methylguanine-DNA 

methyltransferase activity and survival. 

Br J Cancer. 2010 Aug 10;103(4):498-504. 

Suh JH. Stereotactic radiosurgery for the management 

of brain metastases. N Engl J Med. 2010 Mar 

25;362(12):1119-1127. 


Wen PY, Macdonald DR, Reardon DA, Cloughesy TF, 

Sorensen AG, Galanis E, Degroot J, Wick W, Gilbert MR, 

Lassman AB, Tsien C, Mikkelsen T, Wong ET, 

Chamberlain MC, Stupp R, Lamborn KR, Vogelbaum MA, 

van den Bent MJ, Chang SM. Updated response 

assessment criteria for high-grade gliomas: response 

assessment in neuro-oncology working group. J Clin Oncol. 

2010 Apr 10;28(11):1963-1972. 

Zerikly RK, Amiri L, Faiman C, Gupta M, Singh RJ, 

Nutter B, Kennedy L, Hatipoglu B, Weil RJ, 

Hamrahian AH. Diagnostic characteristics of late-night 

salivary cortisol using liquid chromatography-tandem 

mass spectrometry. J Clin Endocrinol Metab. 2010 

Oct;95(10):4555-4559. 


Bain M, Hussain MS, Gonugunta V, Moskowitz S, Hui FK, 

Gupta R. Indirect reperfusion in the setting of symptomatic 

carotid occlusion by treatment of bilateral vertebral 

artery origin stenoses. J Stroke Cerebrovasc Dis. 2010 

May;19(3):241-246. 

Bain MD, Moskowitz SI, Rasmussen PA, Hui FK. Targeted 

extracranial-intracranial bypass with intra-aneurysmal 

administration of indocyanine green: case report. 

Neurosurgery. 2010 Dec;67(2 Suppl Operative):527-531. 

Cleves C, Friedman NR, Rothner AD, Hussain MS. 

Genetically confirmed CADASIL in a pediatric patient. 

Pediatrics. 2010 Dec;126(6):e1603-e1607. 

Hussain MS, Cheng-Ching E, Bain M, Spiotta AM, 

Sivapatham T, Hui F, Moskowitz SI, Gupta R. Initial 

experience with angioplasty of symptomatic M2 MCA 

atheromatous lesions. J Neurointerv Surg. 2010 

Sep;2(3):192-194. 


Hussain MS, Lin R, Moskowitz S, Bain M, Gonugunta V, 

Rasmussen PA, Masaryk TJ, Horowitz MB, Jovin T, 

Gupta R. Symptomatic delayed reocclusion after initial 

successful revascularization in acute ischemic stroke. 

J Stroke Cerebrovasc Dis. 2010 Jan;19(1):36-39. 

Marchi N, Gonzalez-Martinez J, Nguyen MT, Granata T, 

Janigro D. Transporters in drug-refractory epilepsy: clinical 

significance. Clin Pharmacol Ther. 2010 Jan;87(1):13-15. 

Marchi N, Teng Q, Ghosh C, Fan Q, Nguyen MT, Desai NK, 

Bawa H, Rasmussen P, Masaryk TK, Janigro D. Bloodbrain 

barrier damage, but not parenchymal white blood 

cells, is a hallmark of seizure activity. Brain Res. 2010 Sep 

24;1353:176-186. 

Moskowitz SI, Davros WJ, Kelly ME, Fiorella D, 

Rasmussen PA, Masaryk TJ. Cumulative radiation dose 

during hospitalization for aneurysmal subarachnoid 

hemorrhage. AJNR Am J Neuroradiol. 2010 

Sep;31(8):1377-1382. 

Provencio JJ, Fu X, Siu A, Rasmussen PA, Hazen SL, 

Ransohoff RM. CSF neutrophils are implicated in the 

development of vasospasm in subarachnoid hemorrhage. 

Neurocrit Care. 2010 Apr;12(2):244-251. 

139

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Falcone T, Fazio V, Lee C, Simon B, Franco K, Marchi N, 

Janigro D. Serum S100B: a potential biomarker for 

suicidality in adolescents? PLoS ONE. 2010;5(6):e11089. 

Ghosh C, Gonzalez-Martinez J, Hossain M, Cucullo L, 

Fazio V, Janigro D, Marchi N. Pattern of P450 expression at 

the human blood-brain barrier: Roles of epileptic condition 

and laminar flow. Epilepsia. 2010 Aug;51(8):1408-1417. 

Gowda S, Salazar F, Bingaman WE, Kotagal P, Lachhwani 

DL, Gupta A, Davis S, Niezgoda J, Wyllie E. Surgery 

for catastrophic epilepsy in infants 6 months of age and 

younger. J Neurosurg Pediatr. 2010 Jun;5(6):603-607. 

Hirfanoglu T, Gupta A. Tuberous sclerosis complex with 

a single brain lesion on MRI mimicking focal cortical 

dysplasia. Pediatr Neurol. 2010 May;42(5):343-347. 

Iwasaki M, Enatsu R, Matsumoto R, Novak E, 

Thankappen B, Piao Z, O’Connor RT, Horning K, Bingaman 

W, Nair D. Accentuated cortico-cortical evoked potentials in 

neocortical epilepsy in areas of ictal onset. Epileptic Disord. 

2010 Dec;12(4):292-302. 

Jehi L, Sarkis R, Bingaman W, Kotagal P, Najm I. When is 

a postoperative seizure equivalent to “epilepsy recurrence” 

after epilepsy surgery? Epilepsia. 2010 Jun 1;51(6): 

994-1003. 

Jehi LE, Silveira DC, Bingaman W, Najm I. Temporal lobe 

epilepsy surgery failures: predictors of seizure recurrence, 

yield of reevaluation, and outcome following reoperation. 

J Neurosurg. 2010 Dec;113(6):1186-1194. 

Sarkis RA, Jehi LE, Bingaman WE, Najm IM. Surgical 

outcome following resection of rolandic focal cortical 

dysplasia. Epilepsy Res. 2010 Aug;90(3):240-247. 

Schuele SU, Bermeo AC, Alexopoulos AV, Burgess RC. 

Anoxia-ischemia: A mechanism of seizure termination in 

ictal asystole. Epilepsia. 2010 Jan;51(1):170-173. 


Apostolova LG, Beyer M, Green AE, Hwang KS, Morra JH, 

Chou YY, Avedissian C, Aarsland D, Janvin CC, Larsen JP, 

Cummings JL, Thompson PM. Hippocampal, caudate, and 

ventricular changes in Parkinson’s disease with and without 

dementia. Mov Disord. 2010 Apr 30;25(6):687-688. 

Apostolova LG, Hwang KS, Andrawis JP, Green AE, 

Babakchanian S, Morra JH, Cummings JL, Toga AW, 

Trojanowski JQ, Shaw LM, Jack CR, Jr., Petersen RC, 

Aisen PS, Jagust WJ, Koeppe RA, Mathis CA, Weiner MW, 

Thompson PM. 3D PIB and CSF biomarker associations 

with hippocampal atrophy in ADNI subjects. Neurobiol 

Aging. 2010 Aug;31(8):1284-1303. 

Cummings J, Jones R, Wilkinson D, Lopez O, Gauthier S, 

Waldemar G, Zhang R, Xu Y, Sun Y, Richardson S, 

Mackell J. Effect of donepezil on cognition in severe 

Alzheimer’s disease: a pooled data analysis. J Alzheimers 

Dis. 2010;21(3):843-851. 

Cummings JL. Integrating ADNI results into Alzheimer’s 

disease drug development programs. Neurobiol Aging. 2010 

Aug;31(8):1481-1492. 

Dubois B, Feldman HH, Jacova C, Cummings JL, Dekosky 

ST, Barberger-Gateau P, Delacourte A, Frisoni G, Fox NC, 

Galasko D, Gauthier S, Hampel H, Jicha GA, Meguro K, 

O’Brien J, Pasquier F, Robert P, Rossor M, Salloway S, 

Sarazin M, de Souza LC, Stern Y, Visser PJ, Scheltens P. 

Revising the definition of Alzheimer’s disease: a new lexicon. 

Lancet Neurol. 2010 Nov;9(11):1118-1127. 

Harrington DL, Zimbelman JL, Hinton SC, Rao SM. Neural 

modulation of temporal encoding, maintenance, and decision 

processes. Cereb Cortex. 2010 Jun;20(6):1274-1285. 

Pioro EP, Brooks BR, Cummings J, Schiffer R, Thisted RA, 

Wynn D, Hepner A, Kaye R. Dextromethorphan plus ultra 

low-dose quinidine reduces pseudobulbar affect. Ann Neurol. 

2010 Nov;68(5):693-702. 


Teng E, Becker BW, Woo E, Cummings JL, Lu PH. Subtle deficits in instrumental activities 

of daily living in subtypes of mild cognitive impairment. Dement Geriatr Cogn Disord. 

2010;30(3):189-197. 

Woodard JL, Seidenberg M, Nielson KA, Smith JC, Antuono P, Durgerian S, Guidotti L, Zhang Q, 

Butts A, Hantke N, Lancaster M, Rao SM. Prediction of cognitive decline in healthy older adults 

using fMRI. J Alzheimers Dis. 2010;21(3):871-885. 

Mellen Center for Multiple Sclerosis Treatment and Research 

Bermel RA, Weinstock-Guttman B, Bourdette D, Foulds P, You X, Rudick RA. Intramuscular 

interferon beta-1a therapy in patients with relapsing-remitting multiple sclerosis: a 15-year 

follow-up study. Mult Scler. 2010 May;16(5):588-596. 

Cohen JA, Barkhof F, Comi G, Hartung HP, Khatri BO, Montalban X, Pelletier J, Capra R, Gallo 

P, Izquierdo G, Tiel-Wilck K, De Vera A, Jin J, Stites T, Wu S, Aradhye S, Kappos L. Oral 

fingolimod or intramuscular interferon for relapsing multiple sclerosis. N Engl J Med. 2010 

Feb 4;362(5):402-415. 

Conklyn D, Stough D, Novak E, Paczak S, Chemali K, Bethoux F. A home-based walking 

program using rhythmic auditory stimulation improves gait performance in patients with multiple 

sclerosis: a pilot study. Neurorehabil Neural Repair. 2010 Nov-Dec;24(9):835-842. 

Conway D, Cohen JA. Emerging oral therapies in multiple sclerosis. Curr Neurol Neurosci Rep. 

2010 Sep;10(5):381-388. 

Kiryu-Seo S, Ohno N, Kidd GJ, Komuro H, Trapp BD. Demyelination increases axonal stationary 

mitochondrial size and the speed of axonal mitochondrial transport. J Neurosci. 2010 May 

12;30(19):6658-6666. 

Liu L, Belkadi A, Darnall L, Hu T, Drescher C, Cotleur AC, Padovani-Claudio D, He T, Choi K, 

Lane TE, Miller RH, Ransohoff RM. CXCR2-positive neutrophils are essential for cuprizoneinduced 

demyelination: relevance to multiple sclerosis. Nat Neurosci. 2010 Mar;13(3): 

319-326. 

Marrie RA, Rudick R, Horwitz R, Cutter G, Tyry T, Campagnolo D, Vollmer T. Vascular 

comorbidity is associated with more rapid disability progression in multiple sclerosis. Neurology. 

2010 Mar 30;74(13):1041-1047. 

Ransohoff RM, Cardona AE. The myeloid cells of the central nervous system parenchyma. 

Nature. 2010 Nov 11;468(7321):253-262. 


141


Rudick RA, O’Connor PW, Polman CH, Goodman AD, 

Ray SS, Griffith NM, Jurgensen SA, Gorelik L, Forrestal F, 

Sandrock AW, Goelz SE. Assessment of JC virus DNA in 

blood and urine from natalizumab-treated patients. Ann 

Neurol. 2010 Sep;68(3):304-310. 


Beall EB, Lowe MJ. The non-separability of physiologic 

noise in functional connectivity MRI with spatial ICA at 3T. 

J Neurosci Methods. 2010 Aug 30;191(2):263-276. 

Diehl B, Tkach J, Piao Z, Ruggieri P, LaPresto E, Liu P, 

Fisher E, Bingaman W, Najm I. Diffusion tensor imaging 

in patients with focal epilepsy due to cortical dysplasia in 

the temporo-occipital region: electro-clinico-pathological 

correlations. Epilepsy Res. 2010 Aug;90(3):178-187. 

Douglas-Akinwande AC, Rydberg J, Shah MV, Phillips MD, 

Caldemeyer KS, Lurito JT, Ying J, Mathews VP. Accuracy 

of contrast-enhanced MDCT and MRI for identifying the 

severity and cause of neural foraminal stenosis in cervical 

radiculopathy: a prospective study. AJR Am J Roentgenol. 

2010 Jan;194(1):55-61. 

Goshe JM, Schoenfield L, Emch T, Singh AD. Myelomaassociated 

orbital amyloidosis. Orbit. 2010 Oct;29(5): 

274-277. 

Hallbook T, Ruggieri P, Adina C, Lachhwani DK, Gupta A, 

Kotagal P, Bingaman WE, Wyllie E. Contralateral MRI 

abnormalities in candidates for hemispherectomy for 

refractory epilepsy. Epilepsia. 2010 Apr;51(4):556-563. 


Angelov L. Spine instrumentation failure after spine 

tumor resection and radiation: Comparing conventional 

radiotherapy with stereotactic radiosurgery outcomes. 

World Neurosurg. 2010 Oct;74(4-5):517-522. 

Lowe MJ. A historical perspective on the evolution of restingstate 

functional connectivity with MRI. MAGMA. 2010 

Dec;23(5-6):279-288. 

Marchi N, Teng Q, Nguyen MT, Franic L, Desai NK, 

Masaryk T, Rasmussen P, Trasciatti S, Janigro D. Multimodal 

investigations of trans-endothelial cell trafficking under 

condition of disrupted blood-brain barrier integrity. BMC 

Neurosci. 2010 Mar 9;11:34. 


Ansarinia M, Rezai A, Tepper SJ, Steiner CP, Stump J, 

Stanton-Hicks M, Machado A, Narouze S. Electrical 

stimulation of sphenopalatine ganglion for acute treatment of 

cluster headaches. Headache. 2010 Jul;50(7):1164-1174. 

Baker KB, Lee JYK, Mavinkurve G, Russo GS, Walter B, 

DeLong MR, Bakay RA, Vitek JL. Somatotopic organization 

in the internal segment of the globus pallidus in Parkinson’s 

disease. Exp Neurol. 2010 Apr;222(2):219-225. 

Baker KB, Schuster D, Cooperrider J, Machado AG. Deep 

brain stimulation of the lateral cerebellar nucleus produces 

frequency-specific alterations in motor evoked potentials in 

the rat in vivo. Exp Neurol. 2010 Dec;226(2):259-264. 

Frankemolle AMM, Wu J, Noecker AM, Voelcker-Rehage C, 

Ho JC, Vitek JL, McIntyre CC, Alberts JL. Reversing cognitivemotor 

impairments in Parkinson’s disease patients using a 

computational modelling approach to deep brain stimulation 

programming. Brain. 2010 Mar;133(Pt 3):746-761. 

Greenberg BD, Gabriels LA, Malone DA, Jr., Rezai AR, Friehs 

GM, Okun MS, Shapira NA, Foote KD, Cosyns PR, Kubu CS, 

Malloy PF, Salloway SP, Giftakis JE, Rise MT, Machado AG, 

Baker KB, Stypulkowski PH, Goodman WK, Rasmussen SA, 

Nuttin BJ. Deep brain stimulation of the ventral internal 

capsule/ventral striatum for obsessive-compulsive disorder: 

worldwide experience. Mol Psychiatry. 2010 Jan;15(1):64-79. 


Lewitt PA, Gostkowski MT. “Sensory trick” in hemichoreahemiballism 

and in Parkinson’s disease tremor. Mov Disord. 

2010 Jul 15;25(9):1312-1313. 

Malone DA, Jr. Use of deep brain stimulation in treatmentresistant 

depression. Cleve Clin J Med. 2010 Jul;77 Suppl 

3:S77-S80. 


Cho SC, Ferrante MA, Levin KH, Harmon RL, So YT. Utility 

of electrodiagnostic testing in evaluating patients with 

lumbosacral radiculopathy: An evidence-based review. 

Muscle Nerve. 2010 Aug;42(2):276-282. 

Pioro EP, Brooks BR, Cummings J, Schiffer R, Thisted RA, 

Wynn D, Hepner A, Kaye R. Dextromethorphan plus ultra 

low-dose quinidine reduces pseudobulbar affect. 

Ann Neurol. 2010 Nov;68(5):693-702. 

Saechao C, Valles-Ayoub Y, Esfandiarifard S, Haghighatgoo A, 

No D, Shook S, Mendell JR, Rosales-Quintero X, 

Felice KJ, Morel CF, Pietruska M, Darvish D. Novel GNE 

mutations in hereditary inclusion body myopathy patients 

of non-Middle Eastern descent. Genet Test Mol Biomarkers. 

2010 Apr;14(2):157-162. 

Tavee J, Stone L. Healing the mind: meditation and multiple 

sclerosis. Neurology. 2010 Sep 28;75(13):1130-1131. 

Zhou L, Lu H. Targeting fibrosis in Duchenne muscular 

dystrophy. J Neuropathol Exp Neurol. 2010 Aug;69(8): 

771-776. 



Cleves C, Friedman NR, Rothner AD, Hussain MS. 

Genetically confirmed CADASIL in a pediatric patient. 

Pediatrics. 2010 Dec;126(6):e1603-e1607. 

Cleves C, Parikh S, Rothner AD, Tepper SJ. Link between 

confusional migraine, hemiplegic migraine and episodic 

ataxia type 2: hypothesis, family genealogy, gene typing and 

classification. Cephalalgia. 2010 Jun;30(6):740-743. 

Friedman N. Pediatric cardiovascular disease and stroke. 

J Pediatr Neurol. 2010;8(3):259-265. 

Friedman NR. Small vessel childhood primary angiitis of the 

CNS: first steps toward a standardised treatment regimen. 

Lancet Neurol. 2010 Nov;9(11):1042-1044. 

Gowda S, Salazar F, Bingaman WE, Kotagal P, 

Lachhwani DL, Gupta A, Davis S, Niezgoda J, Wyllie E. 

Surgery for catastrophic epilepsy in infants 6 months of age 

and younger. J Neurosurg Pediatr. 2010 Jun;5(6):603-607. 

Hallbook T, Ruggieri P, Adina C, Lachhwani DK, Gupta A, 

Kotagal P, Bingaman WE, Wyllie E. Contralateral MRI 

abnormalities in candidates for hemispherectomy for 

refractory epilepsy. Epilepsia. 2010 Apr;51(4):556-563. 

Hicks CW, Kay B, Worley SE, Moodley M. A clinical picture 

of Guillain-Barre syndrome in children in the United States. 

J Child Neurol. 2010 Dec;25(12):1504-1510. 

Sachdeva R, Rothner DA, Traboulsi EI, Hayden BC, 

Rychwalski PJ. Astrocytic hamartoma of the optic 

disc and multiple cafe-au-lait macules in a child with 

neurofibromatosis type 2. Ophthalmic Genet. 2010 

Dec;31(4):209-214. 

Sarkis R, Wyllie E, Burgess RC, Loddenkemper T. 

Neuroimaging findings in children with benign focal 

epileptiform discharges. Epilepsy Res. 2010 Jun;90 

(1-2):91-98. 

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144 



Ansarinia M, Rezai A, Tepper SJ, Steiner CP, Stump J, 

Stanton-Hicks M, Machado A, Narouze S. Electrical 

stimulation of sphenopalatine ganglion for acute treatment 

of cluster headaches. Headache. 2010 Jul;50(7): 

1164-1174. 

Ashkenazi A, Blumenfeld A, Napchan U, Narouze S, 

Grosberg B, Nett R, DePalma T, Rosenthal B, Tepper S, 

Lipton RB. Peripheral nerve blocks and trigger point 

injections in headache management - a systematic review 

and suggestions for future research. Headache. 2010 

Jun;50(6):943-952. 

Baron EP, Tepper SJ. Revisiting the role of ergots in the 

treatment of migraine and headache. Headache. 2010 

Sep;50(8):1353-1361. 

Baron EP, Tepper SJ, Mays M, Cherian N. Acute treatment 

of basilar-type migraine with greater occipital nerve 

blockade. Headache. 2010 Jun;50(6):1057-1059. 

Cleves C, Parikh S, Rothner AD, Tepper SJ. Link between 

confusional migraine, hemiplegic migraine and episodic 

ataxia type 2: hypothesis, family genealogy, gene typing and 

classification. Cephalalgia. 2010 Jun;30(6):740-743. 

Evans RW, Tepper SJ, Shapiro RE, Sun-Edelstein C, 

Tietjen GE. The FDA alert on serotonin syndrome with 

use of triptans combined with selective serotonin reuptake 

inhibitors or selective serotonin-norepinephrine reuptake 

inhibitors: American Headache Society position paper. 

Headache. 2010 Jun;50(6):1089-1099. 

Sullivan AB, Covington E, Scheman J. Immediate benefits 

of a brief 10-minute exercise protocol in a chronic pain 

population: a pilot study. Pain Med. 2010 Apr;11(4): 

524-529. 

Tepper SJ, Tepper DE. Breaking the cycle of medication 

overuse headache. Cleve Clin J Med. 2010 Apr;77(4): 

236-242. 


Harrington DL, Zimbelman JL, Hinton SC, Rao SM. 

Neural modulation of temporal encoding, maintenance, 

and decision processes. Cereb Cortex. 2010 

Jun;20(6):1274-1285. 

Landers SH. Why health care is going home. N Engl J Med. 

2010 Oct 28;363(18):1690-1691. 

Landers SH, Suter P, Hennessey B. Bringing home the 

‘medical home’ for older adults. Cleve Clin J Med. 2010 

Oct;77(10):661-675. 

Lee YS, Zdunowski S, Edgerton VR, Roy RR, Zhong H, 

Hsiao I, Lin VW. Improvement of gait patterns in steptrained, 

complete spinal cord-transected rats treated with 

a peripheral nerve graft and acidic fibroblast growth factor. 

Exp Neurol. 2010 Aug;224(2):429-437. 

Malladi N, Micklesen PJ, Hou J, Robinson LR. Correlation 

between the combined sensory index and clinical outcome 

after carpal tunnel decompression: a retrospective review. 

Muscle Nerve. 2010 Apr;41(4):453-457. 

Nicholson C, Paz JC. Total artificial heart and physical 

therapy management. Cardiopulm Phys Ther J. 2010 

Jun;21(2):13-21. 

Yang Q, Siemionow V, Sahgal V, Yue GH. Single-Trial EEG- 

EMG coherence analysis reveals muscle fatigue-related 

progressive alterations in corticomuscular coupling. IEEE 

Trans Neural Syst Rehabil Eng. 2010 Apr;18(2):97-106. 

Zimbelman JL, Juraschek SP, Zhang X, Lin VWH. Physical 

therapy workforce in the United States: forecasting 

nationwide shortages. PM R. 2010 Nov;2(11):1021-1029. 


Department of Psychiatry and Psychology 

Coffman KL, Gordon C, Siemionow M. Psychological 

outcomes with face transplantation: overview and case 

report. Curr Opin Organ Transplant. 2010 Apr;15(2): 

236-240. 

Falcone T, Fazio V, Lee C, Simon B, Franco K, Marchi N, 

Janigro D. Serum S100B: a potential biomarker for 

suicidality in adolescents? PLoS ONE. 2010;5(6):e11089. 

Greenberg BD, Gabriels LA, Malone DA, Jr., Rezai AR, 

Friehs GM, Okun MS, Shapira NA, Foote KD, Cosyns PR, 

Kubu CS, Malloy PF, Salloway SP, Giftakis JE, Rise MT, 

Machado AG, Baker KB, Stypulkowski PH, Goodman WK, 

Rasmussen SA, Nuttin BJ. Deep brain stimulation of the 

ventral internal capsule/ventral striatum for obsessivecompulsive 

disorder: worldwide experience. Mol Psychiatry. 


Harrington DL, Zimbelman JL, Hinton SC, Rao SM. 

Neural modulation of temporal encoding, maintenance, 

and decision processes. Cereb Cortex. 2010 

Jun;20(6):1274-1285. 


Heinberg LJ, Keating K, Simonelli L. Discrepancy between 

ideal and realistic goal weights in three bariatric procedures: 

who is likely to be unrealistic? Obes Surg. 2010 

Feb;20(2):148-153. 

Nielson KA, Seidenberg M, Woodard JL, Durgerian S, 

Zhang Q, Gross WL, Gander A, Guidotti LM, Antuono P, 

Rao SM. Common neural systems associated with the 

recognition of famous faces and names: an event-related 

fMRI study. Brain Cogn. 2010 Apr;72(3):491-498. 

Viguera AC, Cohen LS, Whitfield T, Reminick AM, 

Bromfield E, Baldessarini RJ. Perinatal use of 

anticonvulsants: differences in attitudes and 

recommendations among neurologists and psychiatrists. 

Arch Womens Ment Health. 2010 Apr;13(2):175-178. 

Woodard JL, Seidenberg M, Nielson KA, Smith JC, 

Antuono P, Durgerian S, Guidotti L, Zhang Q, Butts A, 

Hantke N, Lancaster M, Rao SM. Prediction of cognitive 

decline in healthy older adults using fMRI. J Alzheimers 

Dis. 2010;21(3):871-885. 

Zhang JP, Pozuelo L, Brennan DM, Hoar B, Hoogwerf BJ. 

Association of SF-36 with coronary artery disease risk 

factors and mortality: a PreCIS study. Prev Cardiol. 

2010;13(3):122-129. 

145

146 



Buysse DJ, Cheng Y, Germain A, Moul DE, Franzen PL, 

Fletcher M, Monk TH. Night-to-night sleep variability in 

older adults with and without chronic insomnia. Sleep Med. 


Buysse DJ, Yu L, Moul DE, Germain A, Stover A, Dodds NE, 

Johnston KL, Shablesky-Cade MA, Pilkonis PA. 

Development and validation of patient-reported outcome 

measures for sleep disturbance and sleep-related 

impairments. Sleep. 2010 Jun 1;33(6):781-792. 

Jaimchariyatam N, Rodriguez CL, Budur K. Does CPAP 

treatment in mild obstructive sleep apnea affect blood 

pressure? Sleep Med. 2010 Oct;11(9):837-842. 

Moul DE. Pathologies of awakenings: the clinical problem 

of insomnia considered from multiple theory levels. Int Rev 

Neurobiol. 2010;93:193-228. 

Theerakittikul T, Ricaurte B, Aboussouan LS. Noninvasive 

positive pressure ventilation for stable outpatients: CPAP and 

beyond. Cleve Clin J Med. 2010 Oct;77(10):705-714. 

Unnwongse K, Wehner T, Bingaman W, Foldvary-Schaefer N. 

Gelastic seizures and the anteromesial frontal lobe: a case 

report and review of intracranial EEG recording and 

electrocortical stimulation case studies. Epilepsia. 2010 

Oct;51(10):2195-2198. 



Agosti CD, Bell KM, Plazek DJ, Larson J, Kang JD, 

Gilbertson LG, Smolinski P. Analysis of power law models 

for the creep of nucleus pulposus tissue. Biorheology. 2010 

Jan 1;47(2):143-151. 

Bartels RHMA, Verbeek ALM, Benzel EC, Fehlings MG, 

Guiot BH. Validation of a translated version of the modified 

Japanese orthopaedic association score to assess outcomes 

in cervical spondylotic myelopathy: an approach to 

globalize outcomes assessment tools. Neurosurgery. 2010 

May;66(5):1013-1016. 

Harel R, Angelov L. Spine metastases: Current 

treatments and future directions. Eur J Cancer. 2010 

Oct;46(15):2696-2707. 


Angelov L. Spine instrumentation failure after spine 

tumor resection and radiation: Comparing conventional 

radiotherapy with stereotactic radiosurgery outcomes. 

World Neurosurg. 2010 Oct;74(4-5):517-522. 


Mroz TE, Wang JC, Hashimoto R, Norvell DC. 

Complications related to osteobiologics use in spine 

surgery: a systematic review. Spine. 2010 Apr 20;35(9 

Suppl):S86-S104. 

Refai D, Shin JH, Iannotti C, Benzel EC. Dorsal approaches 

to intradural extramedullary tumors of the craniovertebral 

junction. J Craniovertebr Junction Spine. 2010 

Jan;1(1):49-54. 

Shin JH, Krishnaney AA. Idiopathic ventral spinal cord 

herniation: a rare presentation of tethered cord. Neurosurg 

Focus. 2010 Jul;29(1):E10. 

Steinmetz MP, Mroz TE, Benzel EC. Craniovertebral 

junction: biomechanical considerations. Neurosurgery. 

2010 Mar;66(3 Suppl):7-12. 

Emergency Services Institute Selected Publications 

Mace SE. Central nervous system infections as a cause of 

an altered mental status? what is the pathogen growing in 

your central nervous system? Emerg Med Clin North Am. 

2010 Aug;28(3):535-570. 

147

148 

Innovations 


Launching a Brain Metastasis Initiative: the B-Aware SM Program 

An estimated 140,000 to 170,000 patients with common systemic cancers are diagnosed with brain 

metastasis every year in the United States. In particular, patients with breast, lung and renal cancers and 

melanoma are affected. Historically, brain metastasis has been considered a uniformly fatal condition, 

and treatments have been limited to palliative brain radiation. Over the last two decades, however, more 

aggressive approaches have been developed that can lead to local cure or sustained control of the disease 

in some patients. Nevertheless, cancer patients may be poorly informed about the risks of developing brain 

metastasis, its early warning signs and modern therapeutic options beyond whole brain radiation. Likewise, 

physicians may not be fully aware of new treatment options. 

To address this issue, the Burkhardt Brain Tumor Center has launched the B-Aware SM program, which 

educates and empowers patients with information on the risks, symptoms and treatment options that may 

increase their life spans and improve quality of life. In addition, the center is actively engaged in developing 

physician awareness, and is collaborating with the American Cancer Society to promote the B-Aware SM 

program on the society’s website. The program is believed to be the first initiative of its kind to directly 

educate cancer patients on the health issues of brain metastasis. 

An important component of the program is educating cancer patients to recognize early warning signs of 

brain metastasis. Aggressive therapies may improve outcomes when brain metastasis is diagnosed in its early 

stages. Traditional treatments such as whole brain radiation and glucocorticoids still play important roles in 

the treatment of brain metastasis. However, for many patients, whole brain radiation is inadequate to achieve 

sustained control and quality of life. In fact, in some cases, whole brain radiation may best be reserved for 

later use. 

Alternatively, research has shown that aggressive treatments such as minimal access surgery and radiosurgery 

can help an appreciable number of patients survive up to five years and, in some cases, up to 10 years. 

For patients with new or recurrent metastatic tumors following radiotherapy, surgery in conjunction with the 

placement of carmustine wafers in the tumor cavity, or radiosurgery to the tumor cavity, may preclude local 

recurrence. In addition, Cleveland Clinic Gamma Knife ® Center uses state-of-the-art stereotactic radiosurgery 

to treat metastatic tumors. Lesions are typically small (< 3 cm at presentation) and spherical, so they 

displace rather than infiltrate the brain. Results from radiosurgery appear comparable to those achieved 

by surgery with radiotherapy, and allow for effective treatment even of surgically inaccessible secondary 

brain tumors. Often, by applying a combination of these aggressive therapies, it is possible to control brain 

metastasis for an extended period of time and improve quality of life. 


Developing a Rapid Test for MGMT Activity in Gliomas 

Methylguanine methyltransferase (MGMT) is a DNA 

repair enzyme that is responsible for the resistance of 

multiple cancers to certain types of chemotherapy. Current 

methodology for determining the level of MGMT in a tumor 

specimen requires several days after a tumor sample 

is submitted to provide useful information. More timely 

intraoperative assessment of tumor MGMT levels during 

surgery may provide essential information necessary to 

determine whether a patient might benefit from instillation 

into the tumor or tumor cavity of agents aimed at 

decreasing MGMT activity, or whether the patient is likely to 

benefit from chemotherapy placed into the surgical cavity. 

The Burkhardt Brain Tumor Center has developed a rapid, 

highly quantitative method for determining the level of 

MGMT activity in a tumor with use of just a small piece 

of tumor tissue. This assay, which requires only about 

one hour for results, can be performed in the operating 

room or in an adjacent pathology laboratory. The novel 

technique for performing this assay has been submitted 

for a patent, and was recently reported in the journal 

Analytical Biochemistry. 1 

1. Robinson C, Palomo J, Vogelbaum MA. Thin layer 

chromatography-based assay of O(6)-methylguanine-DNA 

methyltransferase activity in tissue. Anal Biochem. 2010 Oct 

15;405(2):263-265. 


149

150 

Innovations 


Improving Access to Acute Stroke Care with the Telestroke Network 

The Cerebrovascular Center is creating partnerships throughout Northeast Ohio 

and Pennsylvania with its new Telestroke Network. The network provides 

round-the-clock specialist coverage to assist medical centers in the 

assessment and treatment of their stroke patients. Each medical center 

is outfitted with a two-way portable videoconferencing system 

as well as a dedicated link between imaging systems, allowing 

physicians to connect and evaluate the patient within minutes. 

The Telestroke Network currently partners with Ashtabula County 

Medical Center, Huron Hospital, and Medina Hospital in Ohio, 

and Sharon Regional Health System and Saint Vincent 

Health System in Pennsylvania. 


Implementing a Stroke Care Pathway 

Cleveland Clinic recently integrated its own Stroke 

CarePath into the electronic medical record (EMR) to 

guide the comprehensive care of stroke patients, from 

acute presentation in the Emergency Department through 

the hospital stay and post-discharge care. The Stroke 

CarePath is based on multiple sources, including evidencebased 

guidelines, practice parameters, regulatory and 

organizational policies and procedures, as well as local 

clinical expertise. Clinical documentation and standard 

orders are defined and relevant outcomes and cost metrics 

are collected systematically for every patient. 

As patients present with acute stroke, providers are offered 

suggestions, based on the best current evidence relative to 

patient care. Moreover, disease-specific clinical documents 

have been developed and incorporated into the EMR so 

that key processes and clinical variables can be routinely 

captured and measured. As a result, clinical documentation 

will mirror the standard of care and provide a common 

platform for reporting. 

Stroke CarePath 

Hospital Discharge 

Hyperacute course 

planning Rehabilitation Outpatient 


Health status measures 

Structured documentation 

Process / alerts 

Cost 

Patient Satisfaction 

Care pathways are a critical component of Cleveland Clinic’s efforts to deliver 

a broad menu of solutions to a networked community of providers. 

CarePath Allows Individual Review of Clinical and 

Performance Measures 

NIH Stroke Scale (NIHSS) 

40 

35 

30 

25 

20 

15 

10 

5 

0 

Number 

35 

30 

25 

20 

15 

10 

5 

0 

Inpatient National Institutes of Health Stroke Scale Rehab 

NIHSS 

18 

17 

17 

15 

O/P 

NIHSS 

0 1 2 3 4 5 28 60 

11.6% stroke patients 

worsened 

13 

Days from Last Known Well 

NIHSS = National Institutes of Health Stroke Scale 

17.4% remained stable 

12 

70.9% stroke patients improved 

6 

5 

Performance Measure Completed 

Anti-thrombolytic by Hospital Day 2 

Patient Education 

Smoking Cessation 

Swallow Screen 

OT/PT 

DVT Prophylaxis 

D/C Statin 

D/C Anti-thrombolytic 

D/C Anti-coagulant 

Change in Neurological Impairment over Hospital Course 

Sep 2010 – Jan 2011 

-10 -6 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 16 18 20 

Reduction in NIHSS from admission to discharge 

151

152 

Innovations 


Building an Innovative Network to Improve Alzheimer’s Disease Care 

Cleveland Clinic Lou Ruvo Center for Brain Health is building an innovative network to advance patient care through 

discovery of new therapies for Alzheimer’s disease and other neurocognitive disorders. The network concept takes 

advantage of the multisite distribution of Cleveland Clinic. The institution has expanded to Nevada and Florida, creating 

the opportunity to conduct research at all these sites within the Cleveland Clinic framework, with one leadership, one 

set of operational guidelines, the same data collection approaches and one institutional review board for research 

approval. 

The center is capitalizing on this infrastructure to establish a clinical trials network that can more rapidly advance the 

development of new therapies for Alzheimer’s disease and other disorders of cognition. This approach is unique. The 

Lou Ruvo Center for Brain Health clinical trials network will position the center as a leader in advancing new therapies, 

developing new biomarkers and initiating novel programs for patients and caregivers. This program will serve as a 

model for how healthcare systems can embrace clinical trials, empowering patients to help defeat the diseases from 

which they suffer and helping to solve the problem of slow trial recruitment and slow emergence of new therapies. 



Introducing a Hyperacute Stroke MRI Protocol 

Our “brain attack” program typically relies on noncontrast 

computed tomography (CT) of the head, CT 

angiography (CTA) and CT perfusion (CTP) studies to 

evaluate for a central ischemic core and a surrounding 

ischemic penumbra, the latter of which is potentially 

salvageable through aggressive intravenous and/or 

intra-arterial intervention. While the distinction between 

these two regions generally relies, in part, on the CTP 

study, a host of patient and technical factors makes 

this exam potentially unreliable. We recently introduced 

magnetic resonance imaging (MRI) into a hyperacute 

stroke protocol in an effort to make more informed 

decisions for therapy and extend the therapeutic 

window for acute stroke patients. While this strategy 

places additional logistical and safety demands on the 

acute workup of these patients, the benefits in patient 

management seem to outweigh the disadvantages. In 

view of the success on our main campus, this 

MRI protocol will shortly be exported to Lakewood 

and Hillcrest hospitals within our Cleveland Clinic 

health system. 

Developing an Electronic MR Safety Screening Tool 

Safety demands a careful screening process for patients 

prior to any MRI exam. Historically, this meant that 

each patient was required to complete an extensive 

paper questionnaire. We initiated a pilot project in the 

Neurological ICU, in which an electronic version was 

created for the electronic medical record. Preliminary 

data demonstrate significant reductions in the time 

intervals from the placement of the MRI order to exam 

completion and final report. Shortly, this form will be 

completed by all Neurological Institute inpatients upon 

admission, and it will travel with them across inpatient 

and outpatient venues. 


Improving Methods of Mapping White Matter Tracts for 

Surgical Planning 

Tractography is an advanced application of MR diffusion 

imaging to map the course of white matter tracts in the 

brain for surgical planning purposes, most commonly for 

tumor and epilepsy surgery. While the application performs 

reasonably well with larger tracts in normal volunteers, 

results can be quite variable, hence unreliable, in patients 

with a number of central nervous system disorders. Our 

physicists developed a probabilistic method to detect the 

course of eloquent and non-eloquent white matter tracts in 

the brain, even in the presence of central nervous system 

disease states that cause lesions in the brain’s white matter, 

as seen in the figure below. This same group developed a 

means for quantifying the connectivity or strength of the 

white matter connections between different areas in the 

brain. Previously introduced methods for this assessment 

have been limited by a strong bias that depends on the 

distance between different structures. The newly introduced 

normalization procedure permits the assessment of 

connections between neighboring subcortical regions, 

which is independent of the conventional biases. 

153

Innovations 

Applying MRI Motion Correction 

Researchers have developed two new methods for correcting motion during relatively long MRI exams, which are more 

prone to compromise by gross patient motion. One retrospective method is a broadly applicable, iterative approach to 

motion correction. This post-processing technique provides quantitative metrics for the quality of the motion correction, 

and should prove helpful for long fMRI exams and high-resolution diffusion tensor imaging. The second method is used to 

perform motion correction and assessment during the data acquisition, and is set up to alarm when the motion rises above 

a threshold. This latter method provides the technologist the opportunity to interrupt the study, give feedback to the patient 

and repeat the acquisition to increase the likelihood of producing clinically useful MRI exams. 

Using Intraoperative MRI to Guide Insertion of Deep Brain Stimulators 

The Section of Neuroradiology recently introduced an interventional MRI suite attached to a conventional operating room. 

This suite initially was utilized for intraoperative guidance of intracranial tumor surgery. The same technology would seem 

ideal for the placement of deep brain stimulators, as it would be expected to improve accuracy and greatly reduce the time 

necessary to place the stimulators compared with standard OR practices. Previously, we conducted extensive testing with 

industry to identify safe methods for MR scanning of patients who have deep brain stimulators in place. Neuroradiologists 

have also worked with our functional neurosurgeons to develop methods to implant these deep brain stimulators safely 

within the MRI environment, thus enabling our colleagues to take full advantage of the new facility. 


Implementing High-Resolution Magnetic Resonance Angiography 

The resolution of conventional MRI is about 1-2 mm, depending on the MRI sequence 

used. This size scale is at the limit for diagnostic imaging of most intracranial vessels, 

particularly the larger cerebral arteries that provide almost all inflow to the brain. Many 

disease processes affect these vessels and smaller vessels. The current gold standard is 

conventional angiography, but it carries a non-negligible risk of serious complications, 

such as stroke. Furthermore, this technique cannot image the vessel wall, only its lumen. 

Another alternative is computed tomography angiography (CTA), but it carries a radiation 

burden and cannot easily be repeated. 

At Cleveland Clinic, we have implemented a new MRI sequence called high-resolution 

magnetic resonance angiography (HR-MRA), which utilizes the high-performance 

capabilities of our cutting-edge MRI machines. With this technique, we can image the 

lumen and vessel wall of the cerebral arteries, and strikingly show pathologic states that 

manifest as abnormal wall thickening with concomitant lumenal narrowing. An example of 

this technique is shown in the figure. The left panel shows a conventional MRA, with an 

arrow pointing to abnormal narrowing of the basilar artery in a patient with known cerebral 

vasculopathy. The middle panel shows an axial HR-MRA example through this artery, 

demonstrating lumenal narrowing with vessel wall thickening and enhancement suggesting 

inflammation. For comparison, on the right, is an example of a normal basilar artery. 

Abnormal Normal 


155

Innovations 


Improving the Implantation of Depth Electrodes with 

Image-Guided Robotic Neurosurgery 

Epilepsy is one of the most common adult brain disorders. 

In the United States, epilepsy affects 3 million people, 

with 200,000 new cases per year. In some patients with 

medically refractory epilepsy, surgery is an option. The 

ultimate goal of epilepsy surgery is the complete removal 

of the epileptogenic zone with the preservation of eloquent 

brain parenchyma. In some patients, invasive brain mapping 

is required for further characterization of the epileptogenic 

zone. 

At Cleveland Clinic Epilepsy Center, subdural grids 

and strips or stereotactically placed depth electrodes 

(stereoelectroencephalography, or SEEG) are the current 

surgical techniques for invasive brain mapping. As a 

possible alternative, frameless, image-guided robotic 

placement of depth electrodes may offer additional 

advantages, making the implantation of depth electrodes 

more precise and safer. The technique also allows the 

combination of subdural grids and stereotactically placed 

depth electrodes, providing a precise spatial mapping of the 

superficial and deep structures in the brain, with optimal 

3D understanding of the epileptic neuronal network and its 

relation to cortical brain function. 


Collaboration for Outreach and Prevention Education (COPE) 

for Children and Adolescents with Epilepsy 

Empowering patients with epilepsy and their families 

is a crucial element of continued medical care. As part 

of Cleveland Clinic Epilepsy Center’s commitment to 

community outreach, education and improved access to 

mental healthcare in patients with epilepsy, Project COPE: 

Collaboration for Outreach and Prevention Education for 

Children and Adolescents with Epilepsy, received NIH 

funding and was implemented in 2010. The primary goal 

of this project is to increase awareness of mental health 

issues in children with epilepsy; decrease the stigma of 

accessing mental healthcare; and educate families, children, 

caregivers, schools, peers and the medical community on the 

need to refer epileptic youth struggling with mental health 

problems to the appropriate level of care. The program 

targets at-risk Latino and African-American children with 

epilepsy, in addition to the general population of individuals 

with epilepsy in Greater Cleveland. 

The project is designed to improve access to mental 

healthcare by developing a community-based, culturally 

and linguistically competent mental healthcare outreach 

model. It is essential to educate stakeholders (providers 

and patients) about psychiatric comorbidities in youth with 

epilepsy. Project COPE consists of a series of educational 

talks (workshops) for epileptic children and their families, in 

addition to workshops for classrooms that include children 

with epilepsy. Another part of Project COPE is an antibullying 

workshop, to be conducted in school for classmates 

and teachers. Project COPE collaborates with the Epilepsy 

Association of Cleveland, the Cleveland Metropolitan School 

District and the National Alliance on Mental Illness – Greater 

Cleveland to increase knowledge of mental health issues in 

children with epilepsy. 


Mellen Center for Multiple Sclerosis Treatment and 

Research 

Studying a New Vascular Theory of Multiple Sclerosis 

Mellen Center investigators and collaborators from 

cerebrovascular medicine, radiology, vascular medicine and 

neuropathology were awarded funding from the National 

Multiple Sclerosis Society to study a new vascular theory 

of multiple sclerosis, called chronic cerebrospinal venous 

insufficiency (CCSVI). This two-year multidisciplinary study 

will evaluate CCSVI in more than 150 multiple sclerosis 

(MS) patients and non-MS controls, and will also evaluate 

vascular tissue obtained at autopsy. 

157

158 

Innovations 

Designing the Hip Flexion Assist Device 

The Hip Flexion Assist Device (HFAD) was designed through 

a collaboration between a Mellen Center physical therapist 

and local orthotists to help patients with multiple sclerosis 

who suffer from unilateral or bilateral hip flexor, knee flexor 

and ankle dorsiflexor weakness. The typical presenting gait 

includes “dragging” of the leg, which in some cases may be 

corrected with an ankle foot orthosis (AFO) if the weakness 

is primarily in the ankle dorsiflexors. In many other cases, 

however, due to weakness in the flexors of the hip and knee, 

an AFO is insufficient and the user may still present with an 

unsatisfactory dragging of the leg. This combination of distal 

and proximal weakness is the scenario in which the HFAD 

is most effective. 

The HFAD uses elastic tension bands that anchor proximally 

to a waist belt and attach distally to a strap that fits under 

the shoelaces. The tension may be adjusted 

to allow symmetrical toe clearance between 

each leg as the user swings the leg through 

during normal gait. The device can be 

worn with or without a popliteal strap. 

The popliteal strap connects the tension 

bands posterior to the knee and improves 

knee flexion as the toe pushes off from 

the floor to take a step. For example, 

the popliteal strap is quite effective for 

patients with prominent extensor tone 

in the affected leg, which may impair 

effective knee flexion. The device is 

most effective when combined with 

gait training with a physical therapist. 

The Hip Flexion Assist Device (HFAD) 

anchors to a waist belt and attaches 

distally to a shoelace strap. 

An uncontrolled pilot study conducted at the Mellen Center 

found the HFAD to be safe and effective in improving 

ambulation speed, endurance and quality of life. The Mellen 

Center is currently enrolling patients in a randomized, 

controlled study to further examine the safety and efficacy 

of the HFAD to improve walking in MS patients. This 

two-year study plans to enroll 88 participants and 

is funded through a grant from the National Multiple 

Sclerosis Society. 

The HFAD with 

popliteal strap 



Treating Chronic Central Pain with Deep Brain Stimulation 

The Center for Neurological Restoration has been 

funded to investigate a novel treatment approach for 

managing patients with central thalamic pain syndrome, 

a particularly severe form of pain. In this pilot study, 

deep brain stimulation (DBS) of the ventral capsular/ 

ventral striatal (VC/VS) area will be utilized to modulate 

the affective component in patients with refractory pain 

and, consequently, to reduce pain-related disability. 

This approach departs from the traditional practice of 

intervening in the sensory-discriminative neural pathways 

of pain transmission to produce analgesia. This research 

marks the first use of DBS of the VC/VS for management 

of central pain and builds upon the work of a multicenter 

collaborative, including Cleveland Clinic, that has evaluated 

stimulation of the VC/VS for treatment of disabling 

depression and obsessive-compulsive disorders. 


Developing an Interdisciplinary Peripheral Nerve and 

Plexus Surgery Program 

The Cleveland Clinic Peripheral Nerve and Plexus Surgery 

Program is a specialized, multidisciplinary clinic designed 

to diagnose and treat brachial and lumbosacral plexus 

disorders and focal neuropathies of the upper and lower 

extremities, including peripheral nerve tumors, trauma 

and entrapment. The program incorporates expert clinical 

evaluation, world-class electrodiagnostic testing, stateof-the-art 

imaging technology, cutting-edge surgical 

management options, and postoperative rehabilitation and 

pain management services. 


The program offers the unique advantage of allowing select 

patients to undergo a prearranged same-day evaluation, 

including electrodiagnostic evaluation, imaging, and 

assessment by a neurologist and neurosurgeon with 

expertise in treating these disorders. In some cases, 

evaluation over two days is required. An interdisciplinary 

approach is utilized in order to provide a tailored treatment 

plan for each patient. 

Assessing the Autonomic Nervous System with the 

Thermoregulatory Sweat Test 

The thermoregulatory sweat test is a measure of a patient’s 

ability to sweat when stimulated by a warm and humid 

environment. This test assesses both the central and 

peripheral autonomic nervous systems’ control of sweating 

and body temperature regulation (thermoregulation). The 

pattern of sweating abnormality detected by this test can 

be helpful in diagnosing a variety of neurological and 

autonomic disorders that may cause reduced sweating 

(anhidrosis) or excessive sweating (hyperhidrosis). These 

disorders include small-fiber and autonomic neuropathies, 

radiculopathies and central autonomic disorders, including 

multiple system atrophy, Parkinson’s disease with 

autonomic dysfunction and pure autonomic failure. 

159

160 

Innovations 


Utilizing Sphenopalatine Ganglion Stimulation to Treat Migraine 

Outflow of signals from the brainstem to the meninges through the 

sphenopalatine ganglion (SPG) may lead to the mechanisms of migraine pain. 

Inhibitory stimulation of the SPG and blocks of the SPG show promise in 

terminating primary headaches. 1,2 The Neurological Center for Pain and the 

Center for Neurological Restoration have teamed with the Department of Pain 

Management to obtain an Investigational Device Exemption from the Food and 

Drug Administration for a study of SPG stimulation for acute treatment and 

prevention of episodic migraine. Patients in the study will be implanted with a 

permanent SPG stimulator, and they will stimulate acute migraine attacks to 

see if this device can terminate migraines. After three months, doctors in the 

study will activate the stimulator chronically to see if continuous stimulation 

will prevent migraines. Patients will be able to use a second program in the 

device to terminate any attacks that break through the prevention. 

References: 

1. Tepper SJ, Rezai A, Narouze S, Steiner C, Mohajer P, Ansarinia M. Acute 

treatment of intractable migraine with sphenopalatine ganglion electrical 

stimulation. Headache. 2009 Jul;49(7):983-989. 

2. Ansarinia M, Rezai A, Tepper SJ, Steiner CP, Stump J, Stanton-Hicks M, 

Machado A, Narouze, S. Electrical stimulation of sphenopalatine 

ganglion (SPG) for acute treatment of cluster headaches. Headache. 

2010 Jul;50(7):1164-1174. 



Developing New Methods of Treating Chronic Pain after 

Spinal Cord Injury 

Chronic pain, which disturbs behavioral function and 

reduces quality of life, has emerged as a major challenge in 

treating spinal cord injury (SCI). There is currently no cure 

for chronic pain and oral pharmaceutical interventions are 

often inadequate, commonly resulting in a slight reduction 

in pain intensity. Furthermore, addiction and abuse due to 

continuous administration have become important clinical 

issues. These facts signal an urgent need to develop a new 

intervention to treat chronic SCI pain. 

After single extracellular matrix (ECM) treatment in the 

animal SCI model, we developed a novel and effective ECM 

strategy to inhibit mechanical allodynia, an indicator of 

chronic SCI pain, over an eight-month observation period. 

The data, when compared with the vehicle-treated group, 

showed less blood-spinal cord barrier (BSB) permeability 

and decreased glial fibrillary acidic protein (GFAP)- and 

ED1-immunopositive reactivity at the lesion site as well 

as the areas both rostral and caudal to the lesion site. 

Additionally, this treatment can modulate the sprouting 

of 5-HT- and CGRP-positive fibers in laminae I and II of 

the spinal dorsal horn that mediate pain. Collectively, 

results from our studies have demonstrated that onetime 

ECM treatment can modulate nociceptive signaling 

and lessen inflammation, offering a potential therapeutic 

strategy to treat chronic pain development after SCI and 

the neuropathic and/or inflammatory pain caused by other 

diseases. 

Investigating a New Modality to Prevent Deep Vein 

Thrombosis and Enhance Fibrinolysis 

Each year, 600,000 patients experience venous 

thromboembolism, with at least 50,000 and perhaps as 


many as 200,000 dying from blood clots that obstruct 

blood flow to their lungs (pulmonary embolism). The total 

cost per patient for objective diagnosis and treatment of 

acute venous thromboembolic disease has been estimated 

at approximately $4,000, and does not include costs for 

patients who incur long-term sequelae. Functional magnetic 

stimulation (FMS) using a magnetic coil and applying a 

time-varying magnetic field has been demonstrated to be an 

effective modality for preventing deep vein thrombosis (DVT) 

and enhancing fibrinolysis. 

Vernon Lin, MD, PhD, and his team have demonstrated 

that FMS can produce a sustained enhancement of 

systemic fibrinolysis that may prove useful in DVT 

prophylaxis. The advantages of FMS include painless 

and noninvasive stimulation because the magnetic field 

generated can penetrate high-resistance structures such 

as bone, fat, skin, clothes and leg casts. 

However, the device used for FMS is bulky and difficult to 

secure to a patient during clinical applications. In the case 

of DVT, the coils must be secured in an optimal location, 

between the knee and ankle, to provide the desired 

stimulative effect. Also, the FMS coils generate heat 

during stimulation and can cause blisters if they touch 

the patient’s skin. 

We have proposed a design that provides a method for 

securing the coil in an optimal position, prevents any 

contact with the skin and dissipates the heat generated by 

the coil during stimulation. The components of this design 

include magnetic stimulator (any commercially available 

model), stimulating coil (commercially available circular 

model), contoured coil positioning and securing system, 

cooling system and control unit. The proposed design can 

easily be adjusted to various body sizes and applications 

and is portable, reusable and easy to maintain. 

161

Innovations 


Measuring Head Impact with the Intelligent Mouthguard 

Concussion and traumatic brain injury (TBI) are brain health 

issues on a geopolitical scale. Almost daily, headlines emerge 

regarding concussion in football players, deteriorating mental 

capacity in boxers, TBI in soldiers returning from Iraq and 

Afghanistan, and the long-term risk of head impact in the 

forms of dementia, Alzheimer’s disease and Parkinson’s 

disease. Currently, the only proven method to assess 

concussion or TBI is a neurological examination by an 

experienced physician. This method, however, has been 

hindered by subjective patient input. Absent a robust, 

accurate and objective concussion and TBI assessment 

system, clinicians still struggle to answer basic questions 

about concussion and TBI, such as: 

1. When is it necessary to remove an athlete or soldier 

from competition or military duty after subconcussive 

or concussive head impacts? 

2. How does one identify TBI in an athlete or soldier with 

normal physical and neurological diagnostic examination 

and imaging studies? 

3. When is it safe to return an athlete or soldier to 

competition or the battlefield after concussion 

and/or TBI? 

Supported by the Cleveland Clinic Product Development Fund, 

Cleveland Clinic Spine Research Laboratory and Cleveland 

Clinic Neurological Institute, the Intelligent Mouthguard was 

conceived in 2008 as a method to measure head impact 

dosage via an instrumented mouthguard. Between 2008 and 

early 2011, work on the project rapidly progressed with the 

development and delivery of several wireless prototypes. 

Intelligent Mouthguard – prototypes 


Prototype ‘V1a’ was a robust laboratory version that 

incorporated off-the-shelf sensors and Bluetooth data 

transmission. Prototype ‘V1b’ was approximately 

40 percent smaller than ‘V1a.’ Both prototypes, 

provided valuable insights into clinical data requirements, 

data collection, Bluetooth proof of concept and 

measurement algorithm validation from within the 

laboratory setting. After construction, these prototypes 

were mounted to a crash test dummy head form and 

put through a battery of validation experiments, resulting 

in the July 2010 filing of a provisional patent (“Detection 

and Characterization of Head Impacts”) based on a 

proprietary algorithm to wirelessly relate mouth-measured 

impact dosage to clinically relevant data. 

Intelligent Mouthguard wirelessly collects and characterizes head 

impact dosage. 


Prototype ‘V2a’ was the first “mouthable” prototype and 

was delivered in 2010. Whereas both ‘V1a’ and ‘V1b’ were 

mounted on custom-printed circuit boards and required 

hand-soldered components, prototype ‘V2a’ incorporated 

an off-the-shelf mouthguard provided by collaborator 

Sportsguard Laboratories, Inc., as well as a customdesigned 

six-degrees-of-freedom microelectromechanical 

systems (MEMS) sensor package from collaborator Virtus 

Advanced Sensors. Key differences were that the robust 

laboratory prototypes ‘V1a’ and ‘V1b’ were high-g (~250g) 

but could not fit in the mouth, and ‘V2a’ was low-g (~3g) 

but able to fit into the mouth. In 2011, the Cleveland 

Clinic Neurological Institute team and collaborators will be 

conducting further development work to produce additional 

pre-commercial Intelligent Mouthguard prototypes, such as 

prototype ‘V3’, which will provide a more favorable mouth 

form and also collect high-g impacts. 

Intelligent Mouthguard ‘V3’ 

With the collection of initial head impact dosage data in 

boxers and football players under an NFL Charities grant, 

“Examining the Role of Cervical Spine in Football-Related 

Concussions” (anticipated Fall 2011), the Intelligent 

Mouthguard will for the first time allow widespread, 

accurate and objective assessment of the head impact 

dosage responsible for concussion and TBI. 

163

Staff Listing 

Institute Chairman 


Institute Vice Chairman, Clinical Areas 

William Bingaman, MD 

Institute Vice Chairman, Research and Development 

Richard Rudick, MD 

Institute Quality Improvement Officer 

Jocelyn Bautista, MD 

Institute Patient Experience Officer 

Adrienne Boissy, MD 

Lou Ruvo Center for Brain Heath 

Jeffrey Cummings, MD 

Director 

Charles Bernick, MD 

Donna Munic-Miller, PhD 

Richard Naugle, PhD 

Michael Parsons, PhD 

Alexander Rae-Grant, MD, FRCP(C) 

Stephen Rao, PhD, ABPP-CN 

Director, Schey Foundation Center for Advanced 

Cognitive Function 

Patrick Sweeney, MD 

Dylan Wint, MD 

Xue (Kate) Zhong, MD, MSc 

LR 


Gene Barnett, MD, FACS, MBA 

Director 

Manmeet Ahluwalia, MD 

Lilyana Angelov, MD, FRCS(C) 

Samuel Chao, MD 

Bruce H. Cohen, MD 

Joung Lee, MD 


David Peereboom, MD 

Baisakhi Raychaudhuri, PhD 

Violette Recinos, MD 

Jeremy Rich, MD 

Glen Stevens, DO, PhD 

John Suh, MD 

Tanya Tekautz, MD 

Michael Vogelbaum, MD, PhD 

Robert Weil, MD 


Peter Rasmussen, MD, FAHA, FAANS 

Director 

Luca Cucullo, PhD 

Dhimant Dani, MD 

Stefan Dupont, MD, PhD 

Darlene Floden, PhD 

Neil Friedman, MBChB 

164 


James Gebel, MD 

Joao Gomes, MD 

Ferdinand Hui, MD 

M. Shazam Hussain, MD, FRCPC 

Damir Janigro, PhD 

Irene Katzan, MD, MS 

Ajit Krishnaney, MD 

John Lee, MD 

Mei Lu, MD, PhD 

Gwendolyn Lynch, MD 

Edward Manno, MD 

Thomas Masaryk, MD, FACR 

Laurie McWilliams, MD 

Shaye Moskowitz, MD, PhD 

J. Javier Provencio, MD, FCCM 

Susan Samuel, MD 

Gabor Toth, MD 

Ken Uchino, MD 

Cleveland Clinic at Home 

Steven Landers, MD, MPH 

Director 

Mohammed Ahmed Khan, MD 

Mona Gupta, MD 

Bridget Reidy, MD 

Ethel Smith, MD 



Imad Najm, MD 

Director 

Andreas Alexopoulos, MD, MPH 

Jocelyn Bautista, MD 


Juan Bulacio, MD 

Richard Burgess, MD, PhD 

Robyn Busch, PhD 

Tatiana Falcone, MD 

Nancy Foldvary-Schaefer, DO, MS 

Paul Ford, PhD 

Jorge Gonzalez-Martinez, MD, PhD 

Ajay Gupta, MD 

Stephen Hantus, MD 

Jennifer Haut, PhD, ABPP-CN 

Lara Jehi, MD 

Stephen E. Jones, MD, PhD 

Patricia Klaas, PhD 

Prakash Kotagal, MD 

Deepak Lachhwani, MBBS, MD 

John Mosher, PhD 

Dileep Nair, MD 


Silvia Neme-Mercante, MD 

Paul Ruggieri, MD 

Norman So, MD 

165

166 

Staff Listing 

Epilepsy Center (cont’d) 

Andrey Stojic, MD, PhD 

George E. Tesar, MD 

Guiyun Wu, MD 

Elaine Wyllie, MD 

Zhong Ying, MD, PhD 


Edward Covington, MD 

Director 

Cynthia Bamford, MD 

Neil Cherian, MD 

Kelly Huffman, PhD 

Steven Krause, PhD, MBA 

Jennifer Kriegler, MD 

Jahangir Maleki, MD, PhD 

Manu Mathews, MD 

MaryAnn Mays, MD 

Judith Scheman, PhD 

Roderick Spears, MD 

Mark Stillman, MD 

Deborah Tepper, MD 

Stewart Tepper, MD 

Mellen Center for Multiple Sclerosis Treatment 

and Research 

Richard Rudick, MD 

Director 

Robert Bermel, MD 

Francois Bethoux, MD 

Adrienne Boissy, MD 

Jeffrey Cohen, MD 

Robert Fox, MD, MS 

Keith McKee, MD 

Deborah Miller, PhD 


Richard M. Ransohoff, MD 

Mary Rensel, MD 

Lael Stone, MD 

Amy Sullivan, PsyD 


Paul Ruggieri, MD 

Director 

Manzoor Ahmed, MD 

Todd M. Emch, MD 

C. Nicholas Fetko, MD 

Ramin Hamidi, DO 

Virginia Hill, MD 

Rebecca Johnson, MD 

Stephen E. Jones, MD, PhD 

Daniel Lockwood, MD 

Mark Lowe, PhD 


Thomas Masaryk, MD, FACR 

Parvez Masood, MD 


Doksu Moon, MD 

Micheal Phillips, MD 

Alison Smith, MD 

Todd Stultz, DDS, MD 

Andrew Tievsky, MD 


Andre Machado, MD, PhD 

Director 

Anwar Ahmed, MD 

Jay Alberts, PhD 

Scott Cooper, MD, PhD 

Milind Deogaonkar, MD 

Hubert Fernandez, MD 


John Gale, PhD 

Michal Gostkowski, DO 

Ilia Itin, MD 

Cynthia S. Kubu, PhD, ABPP-CN 

Richard Lederman, MD, PhD 

Donald A. Malone Jr., MD 

Cameron McIntyre, PhD 

Mayur Pandya, DO 

Joseph Rudolph, MD 




Kerry Levin, MD 

Director 

Dina Boutros, MD 

Kamal Chémali, MD 


Debabrata Ghosh, MD, DM 

Zulfiqar Hussain, MD 

Rebecca Kuenzler, MD 

Mei Lu, MD, PhD 

Manikum Moodley, MD 

Erik Pioro, MD, PhD 

David Polston, MD 

Robert Shields Jr., MD 

Steven Shook, MD 

Jinny Tavee, MD 

Nimish Thakore, MD 

Lan Zhou, MD, PhD 

167

Referral Staff Listing Contact Information 

168 


Elaine Wyllie, MD 

Director, Center for Pediatric Neurology 

Mark Luciano, MD, PhD 

Director, Center for Pediatric Neurosurgery 

Bruce H. Cohen, MD 

Stephen Dombrowski, PhD 

Gerald Erenberg, MD 


Debabrata Ghosh, MD, DM 

Gary Hsich, MD 

Irwin Jacobs, MD 

Kambiz Kamian, MD 

Sudeshna Mitra, MD 

Manikum Moodley, MBChB, FCP, FRCP 

Sumit Parikh, MD 

Violette Recinos, MD 

A. David Rothner, MD 

Tanya Tekautz, MD 

Center for Behavioral Health 

Donald A. Malone Jr., MD 

Chairman, Department of Psychiatry and Psychology 

Director, Center for Behavioral Health 

Susan Albers-Bowling, PsyD 

Kathleen Ashton, PhD 

Joseph M. Austerman, DO 

Joseph Baskin, MD 

Scott Bea, PsyD 

Minnie Bowers, MD 

Dana Brendza, PsyD 

Karen Broer, PhD 

Robyn Busch, PhD 

Kathy Coffman, MD 

Gregory Collins, MD 


Roman Dale, MD 

Syma Dar, MD 

Beth Dixon, PsyD 

Judy Dodds, PhD 

Michelle Drerup, PsyD 

Jin El-Mallawany, MD 

Tatiana Falcone, MD 

Lara Feldman, DO 


Kathleen Franco, MD 

Margo Funk, MD 

John P. Glazer, MD 

Lilian Gonsalves, MD 

J. Robert Gribble, PhD 

Jennifer Haut, PhD, ABPP-CN 

Leslie Heinberg, PhD 

Kelly Huffman, PhD 

Karen Jacobs, DO 


Joseph W. Janesz, PhD, LICDC 

Amir Jassani, PhD 

Jason Jerry, MD 

Regina Josell, PsyD 

Elias Khawan, MD 

Patricia Klaas, PhD 

Olga Kostenko, MD 

Steven Krause, PhD, MBA 

Cynthia S. Kubu, PhD, ABPP-CN 

Michael McKee, PhD 

Gene Morris, PhD 

Kathryn Muzina, MD 


Mayur Pandya, DO 


Leo Pozuelo, MD 

Kathleen Quinn, MD 

Ted Raddell, PhD 

Robert Rowney, DO 

Balaji Saravanan, MD 


Isabel Schuermeyer, MD 

Cynthia Seng, MD 

Jean Simmons, PhD 

Barry Simon, DO 

Catherine Stenroos, PhD 


David Streem, MD 

Amy Sullivan, PsyD 

George E. Tesar, MD 

Mackenzie Varkula, DO 

Adele Viguera, MD, MPH 

John Vitkus, PhD 

Cynthia White, PsyD 

Amy Windover, PhD 

Center for Regional Neurosciences 

Stephen Samples, MD 

Director 

Jeremy Amps, MD 

C. Daniel Ansevin, MD 

Toomas Anton, MD 

Charles Bae, MD 

Cynthia Bamford, MD 

Eric Baron, DO 

Francois Bethoux, MD 

Samuel Borsellino, MD 

A. Romeo Craciun, MD 

Atef Eltomey, MD 

James Gebel, MD 

Juliet Hou, MD 

Dulara Hussain, MD 


Abdul Itani, MD 

169

170 

Staff Listing 

Center for Regional Neurosciences (cont’d) 

Ilia Itin, MD 

Kambiz Kamian, MD 

Deepak Lachhwani, MBBS, MD 

Roseanna Lechner, MD 

Jahangir Maleki, MD, PhD 

MaryAnn Mays, MD 

Michael Mervart, MD 



Mary Rensel, MD 

Carlos Rodriguez, MD 

Sheila Rubin, MD 

Teresa Ruch, MD 

Joseph Rudolph, MD 

Roderick Spears, MD 

Andrey Stojic, MD, PhD 

Diana Tanase, MD, PhD 


Samuel Tobias, MD 

Jennifer Ui, MD 

Jessica Vensel-Rundo, MD, MS 

Tina Waters, MD 

Joseph Zayat, MD 


Frederick Frost, MD 

Interim Chairman 

Raghavendra Allareddy, MD 

Michael Felver, MD 

Juliet Hou, MD 

Lynn Jedlicka MD 

John Lee, MD 

Vernon Lin, MD, PhD 

Carey Miklavcic, DO 

Anantha Reddy, MD 

Michael Schaefer, MD 

Patrick Schmitt, DO 

Kalyani Shah, MD 

Maria Tsarouhas, DO 

Deborah Venesy, MD 

General Adult Neurology 

Kerry Levin, MD 

Chairman, Department of Neurology 

C. Daniel Ansevin, MD 

Dina Boutros, MD 

Esteban Cheng-Ching, MD 

Thomas E. Gretter, MD 


Richard Lederman, MD, PhD 


Diana Tanase, MD, PhD 




Nancy Foldvary-Schaefer, DO, MS 

Director 

Loutfi Aboussouan, MD 

Charles Bae, MD 

Michelle Drerup, PsyD 

Sally Ibrahim, MD 

Alan Kominsky, MD 

Jyoti Krishna, MD 

Omar Minai, MD 

Douglas Moul, MD, MPH, FAASM 


Carlos Rodriguez, MD 

Jessica Vensel-Rundo, MD, MS 

Tina Waters, MD 

Sleep Consultant Staff 

David Berzon, MD 

A. Romeo Craciun, MD 

Anand V. Khandelwal, MD, FCCP, D’ABSM 

Nizar Nader, MD 

Raymond Salomone, MD 



Gordon Bell, MD 

Director 

Daniel Mazanec, MD 

Associate Director 

Lilyana Angelov, MD, FRCS(C) 

Toomas Anton, MD 

Thomas Bauer, MD, PhD 

Edward Benzel, MD 


Samuel Borsellino, MD 

Edwin Capulong, MD 

Alfred Cianflocco, MD 


Russell DeMicco, DO 

Michael Eppig, MD 

Frederick Frost, MD 

Lars Gilbertson, PhD 

Augusto Hsia Jr., MD 

Abdul Itani, MD 

Iain Kalfas, MD 

Tagreed Khalaf, MD 

Ajit Krishnaney, MD 

Thomas Kuivila, MD 

E. Kano Mayer, MD 

Robert McLain, MD 

Thomas Mroz, MD 

171

172 

Staff Listing 

Center for Spine Health (Cont’d) 

R. Douglas Orr, MD 

Anantha Reddy, MD 

Teresa Ruch, MD 

Joseph Scharpf, MD 


Richard Schlenk, MD 

Michael Steinmetz, MD 

Santhosh Thomas, DO, MBA 

Deborah Venesy, MD 

Fredrick Wilson, DO 

Adrian Zachary, DO, MPH 

Anesthesia Institute 

Neurosurgical Anesthesiology 

Rafi Avitsian, MD 

Section Head 

Matvey Bobylev, MD 

Juan Cata, MD 

Zeyd Ebrahim, MD 

Ehab Farag, MD, FRCA 

Brock Gretter, MD 

Samuel Irefin, MD 

Allen Keebler, DO 

Paul Kempen, MD, PhD 

Reem Khatib, MD 

Mariel Manlapaz, MD 

Marco Maurtua, MD 

Stacy Ritzman, MD 

Leif Saager, MD 

David Traul, MD, PhD 

Guangxiang Yu, MD 

Lerner Research Institute 

Department of Neurosciences 

Bruce Trapp, PhD 

Chairman 

Cornelia Bergmann, PhD 

Jianguo Cheng, MD, PhD 

John Gale, PhD 

James Kaltenbach, PhD 

Hitoshi Komuro, PhD 

Bruce Lamb, PhD 

Yu-Shang Lee, PhD 

Ching-Yi Lin, PhD 

Yoav Littner, MD 

Andre Machado, MD, PhD 

Sanjay W. Pimplikar, PhD 

Erik Pioro, MD, PhD 

J. Javier Provencio, MD, FCCM 

Richard M. Ransohoff, MD 

Susan Staugaitis, MD, PhD 

Michael Steinmetz, MD 

Stephen Stohlman, PhD 


Dawn Taylor, PhD 

Riqiang Yan, PhD 

Lan Zhou, MD, PhD 


Biomedical Engineering 

Jay Alberts, PhD 

Yin Fang, PhD 

Elizabeth Fisher, PhD 

Aaron Fleischman, PhD 

Zong-Ming Li, PhD 

Cameron McIntyre, PhD 

Ela B. Plow, PhD, PT 

Matthew Plow, PhD 

Vlodek Siemionow, PhD 

Weidong Xu, MD 

Guang Yue, PhD 


Cell Biology 

Damir Janigro, PhD 


Pathology and Laboratory Medicine Institute 

Anatomic Pathology 

Richard Prayson, MD 

Some physicians may practice in multiple locations. 

For a detailed list including staff photos, please visit 

clevelandclinic.org/staff. 

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174 

Contact Information 

General Patient Referral 

24/7 hospital transfers or physician consults 

800.553.5056 

Neurological Institute Appointments/Referrals 

216.636.5860 or toll-free 866.588.2264 

On the Web at clevelandclinic.org/neuroscience 

Additional Contact Information 

General Information 

216.444.2200 

Hospital Patient Information 

216.444.2000 

General Patient Appointments 

216.444.2273 or 800.223.2273 

Referring Physician Center 

For help with service issues, information about clinical 

specialists and services, details about CME opportunities 

and more 

216.448.0900 or 888.637.0568, or email refdr@ccf.org 

Request for Medical Records 

216.444.2640 or 800.223.2273, ext. 42640 

Medical Concierge 

Complimentary assistance for out-of-state patients and 

families 800.223.2273, ext. 55580, or email 

medicalconcierge@ccf.org 

Global Patient Services/International Center 

Complimentary assistance for international patients and 

families 001.216.444.8184 or visit clevelandclinic.org/gps 

Cleveland Clinic Florida 

Toll-free 866.293.7866 

For address corrections or changes, please call 

800.890.2467 


Institute Locations 

Cleveland Clinic Neurological Institute physicians see 

patients at the locations below. Please inquire about 

the availability of specific services at each location 

when calling. 

Cleveland Clinic Main Campus 

9500 Euclid Ave. 

Cleveland, OH 44195 

Toll-free 866.588.2264 

Avon Lake Family Health Center 

450 Avon Belden Road 

Avon Lake, OH 44012 

440.930.6800 

Beachwood Family Health and Surgery Center 

26900 Cedar Road 

Beachwood, OH 44122 

216.839.3000 

Broadview Heights Family Health Center 

2001 East Royalton Road 

Broadview Heights, OH 44147 

216.986.4000 


Brunswick Family Health Center 

3574 Center Road 

Brunswick, OH 44212 

330.225.8886 

Chagrin Falls Family Health Center 

551 E. Washington St. 

Chagrin Falls, OH 44022 

440.893.9393 

Cleveland Clinic Children’s Hospital Shaker Campus 

2801 Martin Luther King Jr. Drive 


216.721.5400 

Cleveland Clinic Nevada 


888 W. Bonneville Ave. 

Las Vegas, NV 89106 

702.483.6000 

Cleveland Clinic Nevada 


890 Mill St., Suite 102 

Reno, NV 89502 

775.337.6200 

175

176 

Institute Locations 

Euclid Hospital 

18901 Lake Shore Blvd. 

Euclid, OH 44119 

216.692.8586 

Fairview Hospital 

18101 Lorain Ave. 


216.476.7000 

Hillcrest Hospital 

6780 Mayfield Road 

Mayfield Heights, OH 44124 

440.312.4500 

Huron Hospital 

13951 Terrace Road 

East Cleveland, OH 44112 

216.761.3300 

Independence Family Health Center 

5001 Rockside Road 

Crown Centre II 

Independence, OH 44131 

216.986.4000 

Lakewood Hospital 

14519 Detroit Ave. 

Lakewood, OH 44107 

216.529.7110 

Lorain Family Health and Surgery Center 

5700 Cooper Foster Park Road 

Lorain, OH 44053 

440.204.7400 

Lutheran Hospital 

1730 W. 25th St. 


216.696.4300 

Marymount Hospital 

12300 McCracken Road 

Garfield Heights, OH 44125 

216.581.0500 

Medina Hospital 

1000 E. Washington St. 

Medina, OH 44256 

330.725.1000 


Solon Family Health Center 

29800 Bainbridge Road 

Solon, OH 44139 

440.519.6800 

South Pointe Hospital 

20000 Harvard Ave. 

Warrensville Heights, OH 44122 

216.491.6000 

Strongsville Family Health and Surgery Center 

16761 SouthPark Center 

Strongsville, OH 44136 

440.878.2500 

Twinsburg Family Health and Surgery Center 

8701 Darrow Road 

Twinsburg, OH 44087 

330.888.4000 

Westlake Family Health Center 

30033 Clemens Road 

Westlake, OH 44145 

440.899.5555 


Willoughby Hills Family Health Center 

2570 SOM Center Road 

Willoughby Hills, OH 44094 

440.943.2500 

Wooster Family Health and Surgery Center 

1739 Cleveland Road 

Wooster, OH 44691 

330.287.4500 

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178 

About Cleveland Clinic 

Overview 

Cleveland Clinic is a nonprofit multispecialty academic 

medical center that integrates clinical and hospital care 

with research and education. Today, more than 2,500 

Cleveland Clinic physicians and scientists practice in more 

than 100 medical specialties and subspecialties, annually 

recording more than 1.5 million physician visits and more 

than 70,000 surgeries. Cleveland Clinic currently has the 

highest CMS case-mix index in America. Patients come 

for treatment from every state and from more than 80 

countries annually. 

Cleveland Clinic's main campus, with 50 buildings on 

180 acres in Cleveland, Ohio, includes a 1,300-bed 

hospital, outpatient clinic, specialty institutes and 

supporting labs and facilities. Cleveland Clinic also 

operates 16 family health centers, nine community 

hospitals, one affiliate hospital, a rehabilitation hospital for 

children, Cleveland Clinic Florida, the Lou Ruvo Center for 

Brain Health in Las Vegas, and Cleveland Clinic Canada. 

Cleveland Clinic Abu Dhabi (United Arab Emirates), a 

multispecialty care hospital and clinic, is scheduled to 

open in 2012. With 41,000 employees, Cleveland Clinic 

is the second largest employer in Ohio, and is responsible 

for an estimated $9 billion of economic activity every year. 

The Cleveland Clinic Model 

Cleveland Clinic was founded in 1921 by four physicians 

who had served in World War One and hoped to replicate 

the organizational efficiency of military medicine. The 

organization has grown through the years by adhering to 

the model set forth by the founders. All Cleveland Clinic 

staff physicians receive a straight salary with no bonuses 

or other financial incentives. The hospital and physicians 

share a financial interest in controlling costs and profits 

are reinvested in research and education. 

In 2007, Cleveland Clinic restructured its practice, 

bundling all clinical specialties into integrated practice 

units called institutes. An institute combines all the 

specialties surrounding a specific organ or disease system 

under a single roof. Each institute has a single leader and 

focuses the energies of multiple professionals onto the 

patient. From access and communication to billing and 

point-of-care service, institutes are improving the patient 

experience at Cleveland Clinic. 

Cleveland Clinic Lerner Research Institute 

At the Cleveland Clinic Lerner Research Institute, hundreds 

of principal investigators, project scientists, research 

associates and postdoctoral fellows are involved in 

laboratory-based, translational and clinical research. Total 

annual research expenditures exceed $272 million from 

federal agencies, non-federal societies and associations, 

endowment funds and other sources. 

Cleveland Clinic physicians, scientists, fellows, residents 

and other employees are involved in more than 3,000 

human-subject research activities at any given time. 

Cleveland Clinic Lerner College of Medicine 

Now in its seventh year of existence, Cleveland Clinic 

Lerner College of Medicine of Case Western Reserve 

University offers all students full-tuition scholarships. 

The program graduated its first 29 students as physicianscientists 

in 2009. 

U.S.News & World Report Ranking 

Cleveland Clinic is consistently ranked among the top 

hospitals in America by U.S.News & World Report, and 

our heart and heart surgery program has been ranked 

No. 1 since 1995. 

For more information about Cleveland Clinic, please visit 

clevelandclinic.org. 


Resources 

Referring Physician Center 

For help with service-related issues, information about 

our clinical specialists and services, details about 

CME opportunities and more, contact the Referring 

Physician Center at refdr@ccf.org, or 216.448.0900 or 

888.637.0568. 

Critical Care Transport Worldwide 

Cleveland Clinic’s critical care transport team and fleet of 

mobile ICU vehicles, helicopters and fixed-wing aircraft 

serve critically ill and highly complex patients across 

the globe. 

To arrange a transfer for STEMI (ST elevated myocardial 

infarction), acute stroke, ICH (intracerebral hemorrhage), 

SAH (subarachnoid hemorrhage) or aortic syndromes, 

call 877.379.CODE (2633). 

For all other critical care transfers, call 216.444.8302 or 

800.553.5056. 

Request Medical Records 

216.444.2640 or 800.223.2273, ext. 42640 

Track Your Patient’s Care Online 

DrConnect offers referring physicians secure access to 

their patients’ treatment progress while at Cleveland 

Clinic. To establish a DrConnect account, visit 

clevelandclinic.org/drconnect or email drconnect@ccf.org. 

Medical Records Online 

Cleveland Clinic continues to expand and improve 

electronic medical records (EMRs) to provide faster, more 

efficient and accurate care by sharing patient data through 

a highly secure network. Patients using MyChart can 


renew prescriptions and review test results and medications 

from their own personal computer. MyChart offers a secure 

connection to Google Health, where users can securely 

share personal health information with Cleveland Clinic 

and record and share details of their Cleveland Clinic 

treatment with the physicians and healthcare providers 

of their choice. To establish a MyChart account, visit 

clevelandclinic.org/mychart. 

Remote Consults 

Online medical second opinions from Cleveland Clinic’s 

MyConsult are particularly valuable for patients who wish 

to avoid the time and expense of travel. Cleveland Clinic 

offers online medical second opinions for more than 1,000 

life-threatening and life-altering diagnoses. For more 

information, visit clevelandclinic.org/myconsult, email 

eclevelandclinic@ccf.org or call 800.223.2273, 

ext. 43223. 

CME Opportunities: Live and Online 

Cleveland Clinic’s Center for Continuing Education operates 

one of the largest and most successful CME programs 

in the country. The center’s website (ccfcme.com) is an 

educational resource for healthcare providers and the 

public. Available 24/7, it houses programs that cover 

topics in 30 areas — if not from A to Z, at least from 

Allergy to Wellness — with a worldwide reach. Among 

other resources, the website contains a virtual textbook 

of medicine (Disease Management Project), a medical 

newsfeed refreshed daily, and myCME, a system for 

physicians to manage their CME portfolios. Live courses, 

however, remain the backbone of the center’s CME 

operation. Most live courses are held in Cleveland, but 

outreach plans are under way. In 2010, the center offered 

11 simultaneous courses at Arab Health, a major world 

healthcare forum, in Dubai, United Arab Emirates. 

179

This project would not have been possible 

without the commitment and expertise of 

many individuals, but in particular 

Jocelyn Bautista, MD; Irene Katzan, MD; 

Christine Moore; and John Urchek.

9500 Euclid Avenue, Cleveland, OH 44195 ClevelandClinic.org

2010 Neurological Institute Outcomes - Cleveland Clinic

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