annual report - Department of Neurosurgery University of Florida

Letter From The ChairmanQuality is part of everything we do at the University of Florida Departmentof Neurosurgery. It’s the thread that runs through our three-part mission toprovide outstanding and compassionate care, to educate residents, fellowsand practicing physicians in the art and science of neurosurgery, and toexplore and develop new and better treatments for neurosurgical disorders.professor and chairmanWilliam A. Friedman, M.D.In this annual report, we will share with you our excitement about progress ineach of these areas. In particular, we will highlight our efforts to continuallyimprove quality and patient safety.In the UF Department of Neurosurgery, quality and patient safety are Job 1.As others have noted, medicine has much to learn from other industries thathave achieved very high quality standards. Commercial aviation has one ofthe lowest error rates of any industry. But that was not always the case. Theirtransformation in quality resulted from two major innovations: checklists andcrew resource management. The airlines have a checklist for every phase ofnormal flight and for every possible emergency. These checklists have beenpainstakingly prepared and revised, based on the best available evidence.Crew resource management refers to the airlines’ insistence on “flatteningof the environment” during flight. The captain, co-pilot, flight engineer andflight attendants are trained and required to function as a team.Within our department, we have tried very hard to adapt these principles intoour quality/safety structure. The department has two quality conferences permonth. Residents and faculty are divided into multiple teams and currentlyare engaged in many additional quality improvement projects.In this report, we highlight the overall quality of care our neurosurgeonsprovide as well as several key quality improvement initiatives.Whether you are a physician, prospective resident or patient, we hope you willfind the information in this report helpful.For much more detail, please visit our website: neurosurgery.ufl.edu.UF Neurosurgery Quality Projects››Ventriculostomy infection eliminationOur checklist-driven process haseliminated ventriculostomy infection(no infections for 18 months).››Surgical site infection reductionSince initiating a monthly infectioncontrol conference and a checklistapproach in the OR, we have reducedSSIs by two-thirds.››Hyponatremia protocolThis evidence-based published protocolgreatly reduced variation in care.››Anticoagulation reversal protocolThis evidence-based checklist improved thespeed of coagulation correction, eliminatedfluid overload and reduced unnecessaryconsultations.››Mobility improvementThis evidence-based checklist protocolimproved mobility by 300 percent.William A. Friedman, M.D.Professor and Chairman2 352.273.9000 learn more at neurosurgery.ufl.edu learn more at neurosurgery.ufl.edu 352.273.9000 3

.FacultyThe 22 faculty members of theUniversity of Florida Departmentof Neurosurgery are nationally andinternationally renowned in the diagnosisand treatment of diseases of the brainand spine, as well as for their work inadvancing neurosurgical care throughclinical and basic science research. Withexpertise that encompasses virtuallyevery clinical specialty in neurosurgery,they are dedicated to deliveringadvanced treatment in the most caring,accessible environment possible.➊ ➋ ➌ ➍ ➎ ➏➐ ➑ ➒ ➓ •• ••● = Faculty ● = Education Faculty ● = Research Faculty•• •• •• •• •••• •• •• ••➊ William A. Friedman, M.D.Professor & Chairman➋ Spiros Blackburn, M.D.Assistant Professor➌ Erin M. Dunbar, M.D.Assistant Professor➍ Kelly D. Foote, M.D.Associate Professor➎ Brian L. Hoh, M.D.Associate Professor➏ Daniel J. Hoh, M.D.Assistant Professor➐ R. Patrick Jacob, M.D.Professor➑ J. Richard Lister, M.D., M.B.A.Professor & Associate Chairman➒ Gregory J. A. Murad, M.D.Assistant Professor•• David W. Pincus, M.D., Ph.D.Professor⓫ Albert L. Rhoton Jr., M.D.Professor & Chairman Emeritus⓬ Steven N. Roper, M.D.Professor⓭ Maryam Rahman, M.D.Clinical Lecturer⓮ Gwen Lombard, R.N., Ph.DAssistantProfessor⓯ Frank J. Bova, Ph.DProfessor⓰ Didier A. Rajon, Ph.DAssistant Scientist⓱ Tong Zheng, Ph.DResearch Assistant Professor⓲ Loic Deleyrolle, Ph.DResearch Assistant Professor⓳ Brent A. Reynolds, Ph.DAssociateProfessor⓴ Florian Siebzehnrubl, Ph.DResearch Assistant Professor•• Dennis Steindler, Ph.DProfessor•• Mu Yang, M.S(not pictured)•• Fuwen Zhou, Ph.D(not pictured)4 352.273.9000 learn more at neurosurgery.ufl.edu learn more at neurosurgery.ufl.edu 352.273.9000 5

Our regional manager of physician relations, Kelly Flowers, increased the number of educational andpromotional activities in the department, coordinated 43 UF physician visits with referring physiciansand increased readership of the monthly neurosurgery e-newsletter. Patient transfer requests increased11 percent over last year and transfer admissions went up 10 percent. Additionally, we expanded ourstrategic partnerships and affiliations with neurosurgeons and hospitals throughout the state.The Lillian S. Wells Foundation Inc. donated $10 millionto the University of Florida Department of Neurosurgeryto help medical scientists better understand the causesof brain tumors, develop effective treatments andimprove quality of life for patients. In recognition of thisthe department has been renamed the Lillian S. WellsDepartment of Neurosurgery.Faculty member MaryamRahman, M.D., wasawarded the Congress ofNeurological SurgeonsAward for residents,fellows or fully trainedneurosurgeons interestedUF neurosurgeons continue to advance the level of care andpractice in their field through significant publications andnotable papers in leading national and international journals.Some notable contributions and papers are mentionedthroughout the report. For more information about these andall of our publications, go to www.ncbi.nlm.gov/pubmed andsearch “University of Florida Neurosurgery.”Kelly Flowers, regional manager of physician relationsThe department celebrated the life’s work of Albert L.Rhoton Jr., M.D., founder of the University of FloridaDepartment of Neurosurgery and an expert in the field ofmicroneurosurgery. “Dr. Rhoton took a relatively unknowndivision and turned it into one of the best neurosurgerydepartments in the world,” said William Friedman,M.D., the Albert L. Rhoton Jr. professor and chairman ofneurosurgery. “He is the reason I came to UF to train.”in clinical, translational orbasic science with a focuson tumor research.Maryam Rahman, M.D.,William A. Friedman, M.D.,attended the Institute forHealthcare Improvement(IHI) executive leadershipprogram, which had afocus on quality andsafety. Friedman has beena leader in implementingquality initiatives atShands at UF for morethan six years and wasinstrumental in being partof the UF&Shands teamthat helped establish 4-Starstatus for the institution in2011, as recognized by theUniversity HealthsystemConsortium.Randy Harmatz, M.B.A.The department sponsored a quality retreat for residents and faculty. The program includedkeynote speaker Randy Harmatz, M.B.A., chief quality officer for UF&Shands, and severalUF neurosurgeons who presented five recent quality initiatives, including: enhanced staffcommunication and reduced near-miss errors with a neurointerventional procedural checklist;management of anticoagulation; protocol for Halo management; parameters for extubation; andDVT prophylaxis post-craniotomy. Since 2006, UF neurosurgeons have chaired and sponsoredmore than 15 quality projects, many resulting in evidence-based protocols.Michael Waters, M.D., Ph.D., a UF neurologist and Shands atUF Stroke Program director, received the Gold Plus QualityAchievement Award from the American Heart/AmericanStroke Association. Shands at UF is the only AHCA-designatedComprehensive Stroke Center in north central Florida.William A. Friedman, M.D.Albert L. Rhoton Jr., M.D.Michael Waters, M.D., Ph.D.A Year In ReviewMajor Events in the UF Department of Neurosurgery6 352.273.9000 learn more at neurosurgery.ufl.edu learn more at neurosurgery.ufl.edu 352.273.9000 7

Austin’s Case“There’s not too manywords that can reallydescribe how muchAustin has progressed...”- Colson Streitmatter, older brotherPatient: Austin Streitmatter | Age:11 | Diagnosis: Dystonia8 352.273.9000 learn more at neurosurgery.ufl.edulearn more at neurosurgery.ufl.edu 352.273.9000 9

March 2010Begins treatment at Centerfor Movement Disorders andNeurorestoration and is placedon a program of medicationand physical therapyNovember 16, 2011Deep brain stimulationsurgery at Shands at UFAustin’s CaseNovember 26, 2009Movement symptoms worsenMay 11, 2012Six-month checkupDecember 9, 2011Neurostimulatorsimplanted and connectedDecember 2009 - January 2010Diagnosed with dystoniaaustin’s timeline2009 2010 2011 2012It seemed as if it would be a completelyordinary holiday, that Thanksgiving in 2009.John and Michele Streitmatter were athome near Tampa with their threeyoung sons. Dinner was on the tableand a family memory was in the making.But it was not the memory they expected.During the meal, their middleson, Austin, continually movedhis leg and had trouble sitting. Hewouldn’t have been the first 8-yearoldto ever fidget at the table, butthis was different — his body wasmoving on its own.Before the end of 2009, Austinhad been diagnosed withdystonia, the third most commonmovement disorder behindParkinson’s disease and tremor. Itpits a patient’s muscles against oneanother in prolonged, involuntarycontractions, making it impossibleto walk or even sit in a chair.After considering the medicaloptions, the Streitmatters cameto the Center for MovementDisorders and Neurorestoration atUF. In 2011, neurosurgeon KellyFoote, M.D., implanted two tinyelectrodes in areas of Austin’s brainthat control movement as part ofa procedure known as deep brainstimulation.“I remember thinking, this is kindof cool, people putting wires inmy head, this is interesting,” Austinsaid. “At the same time, I was a littleworried. I didn’t know what toexpect.”Foote, with neurologist MichaelOkun, M.D., co-directs the Centerfor Movement Disorders andNeurorestoration and is a pioneerin the use of deep brain stimulationfor dystonia, Parkinson’s diseaseand even behavioral problems.Endovascular neurosurgeon The center is staffed by a completeStroke neurologistNurses range of specialists to provideTechnicians patient-centered service and isPediatric immunologistallied with Tyler’s Hope for a Cure, afundraising enterprise devoted tosupporting clinical and laboratorydystonia research.At 11, Austin is a new kid.When Tropical Storm Debbypelted Tampa with rain in 2012,this child, once too disabled tosit, lie down or even touch hisfingertips together, was outside,running through raindrops,joyfully playing soccer with hisbrothers, Colson and Dalton.“There’s not too many words thatcan really describe how muchAustin has progressed,” saidolder brother Colson. “His backis straighter, we were playingfootball and basketball earlier —he’s progressed so muchit’s unbelievable.”Download an ibook with Austin’scase study at www.urlwillgohere.comB A R B I E ’ S TEAMaustin’s team1 Neurologists 6 Nurses2 Neurosurgeon 7 Neuropathologists3 Neuroscientists 8 Computer scientists4 Neuropsychologists5 Physical therapistsand rehabilitation experts

movement disordersa coordinated approach:Diagnosistreatment optionsrehabilitationrestoration of functionThe University of Florida Center for MovementDisorders and Neurorestoration offers the highest levelof integrated, interdisciplinary care for patients withmovement and neuropsychiatric disorders. At this uniquecenter, University of Florida faculty and researchers from14 different specialty and subspecialty areas providemotor, cognitive and behavioral diagnosis and treatmentto patients at one central location. The result is a trulycoordinated approach that addresses the full spectrum ofpatient needs, from diagnosis and treatment options torehabilitation and restoration of function.What We DoConditions we treat• Parkinson’s disease• Parkinsonism• Tremor disorders• Dystonia• Chorea• Tic disorders• Myoclonus• Ataxias• NeuropsychiatricdisordersMore than 800 deep brain stimulation procedureshave been performed at the center. Since itscreation less than a decade ago, the center hastreated more than 5,000 patients.800+| deep brain stimulation procedures |have been performed at the centerDuring deep brain stimulation, UF expertsrecord and identify in the brain the abnormaloscillation leading to tremor. This series ofphotos shows drawings a patient madebefore and after activation of the DBS device.10 352.273.9000 learn more at neurosurgery.ufl.edulearn more at neurosurgery.ufl.edu 352.273.9000 11

movement disorderswho we are:shands rehabilitationCenter for Movement Disorders and Neurorestorationtyler's hope centerclinical trials centernational parkinson foundation center of excellencetourette syndrome and tic clinicCo-directors Kelly Foote, M.D., a UF neurosurgeon, and Michael Okun, M.D.,a UF neurologist, lead a team of UF physicians from multiple specialties:Shands rehabilitation specialists; physical, occupational and speechtherapists; social workers; and neuropsychologists. Ramon L. Rodriguez,M.D., directs the clinical operations of the Center for Movement Disordersand Neurorestoration, the Tyler’s Hope Center for ComprehensiveDystonia Care and the clinical trials center, which includes more than30 active research studies. Irene Malaty, M.D., directs our NationalParkinson Foundation Center of Excellence and the Tourette syndromeinterdisciplinary clinic.our discoveries: a selection of recent publications1. “Subthalamic deepbrain stimulation with aconstant-current devicein Parkinson’s disease: Anopen-label randomisedcontrolled trial. ”TheLancet Neurology, 2012Feb;11(2):140-9. Erratumin: The Lancet Neurology,2012. Authors: Okun MS,Gallo BV, Mandybur G,Jagid J, Foote KD, RevillaFJ, Alterman R, JankovicJ, Simpson R, Junn F,Verhagen L, Arle JE, Ford B,Goodman RR, Stewart RM,Horn S, Baltuch GH, KopellBH, Marshall F, Peichel D,Pahwa R, Lyons KE, TrösterAI, Vitek JL, Tagliati M, andthe SJM DBS Study Group2. “Parkinson’s diseaseDBS: What, when, whoand why? The timehas come to tailor DBStargets. ”Expert Review ofNeurotherapeutics, 2010.Authors: Okun MS andFoote KD3. “Deep brain stimulationfor intractable obsessivecompulsive disorder: Pilotstudy using a blinded,staggered-onset design.”Biological Psychiatry,2010. Authors: GoodmanWK, Foote KD, GreenbergBD, Ricciuti N, Bauer R,Ward H, Shapira NA, WuSS, Hill CL, Rasmussen SA,Okun MS4. “A high resolutionand high contrast MRIfor differentiation ofsubcortical structures forDBS targeting: The FastGray Matter AcquisitionT1 Inversion Recovery(FGATIR).” Neuroimage,2009. Authors:Sudhyadhom A, Haq IU,Foote KD, Okun MS,Bova FJ5. “Cognition and moodin Parkinson’s diseasein subthalamic nucleusversus globus pallidusinterna deep brainstimulation: The COMPAREtrial.” Annals of Neurology,2009. Authors: Okun MS,Fernandez HH, Wu SS,Kirsch-Darrow L, BowersD, Bova F, Suelter M,Jacobson CE 4th, Wang X,Gordon CW Jr, Zeilman P,Romrell J, Martin P, WardH, Rodriguez RL, Foote KD12 352.273.9000 learn more at neurosurgery.ufl.edulearn more at neurosurgery.ufl.edu 352.273.9000 13

department overviewWHO WE ARE:The 22 faculty members of the University of FloridaDepartment of Neurosurgery are nationally andinternationally renowned in the diagnosis and treatmentof diseases of the brain and spine, as well as for their workin advancing neurosurgical care through clinical andbasic science research. With expertise that encompassesvirtually every clinical specialty in neurosurgery, they arededicated to delivering advanced treatment in the mostcaring, accessible environment possible. More than 4,000procedures are performed at UF every year.4,000+procedures performed at UF | every year |O-ArmtechnologyTrilogyradiosurgerysystemBiplanefluoro roomsThirty-bedNeuro IntensiveCare UnitNew ShandsCancer Hospitalat UFEducation and training: Education for residents and practicingneurosurgeons is a key part of our mission. Our residency training programrecently celebrated its 50th anniversary. We currently accept three traineeseach year for seven years of training. In addition, our faculty members givelectures at many national and international neurosurgical meetings.HD videorecordingsystemAdvancedendoscopicequipmentShands CriticalCare Center14 352.273.9000 learn more at neurosurgery.ufl.edulearn more at neurosurgery.ufl.edu 352.273.9000 15

department overviewImproving care through discovery: At the Evelyn F. and William L. McKnight Brain Instituteof the University of Florida, UF neurosurgeons collaborate with scientists from a broad spectrumof disciplines. Our researchers are focused on making discoveries that will lead to innovationand advances in neurosurgical treatment, with a clear goal of enhancing patient care.Conditions we treat• Non-hormonalmacroadenoma tumors• Hormone-secreting tumors• Acromegaly• Cushing’s disease• ProlactinomaPituitary SurgeryPediatricNeurosurgeryConditions we treat• Brain and spinal cord tumors• Craniosynostosis• Congenital anomalies andmalformations (such asChiari malformation,Moya Moya disease andVein of Galen malformation)• Spina bifida• Spasticity• Epilepsy• Trauma• HydrocephalusThe Pituitary Tumor Center offerspatients comprehensive care thatincludes advanced neurosurgicaltreatment. Because of the impactof the pituitary gland on theentire body, patients at the centeralso receive care from a varietyof other medical specialists,including endocrinologists,radiologists and others, toenhance outcomes and quality oflife. UF neurosurgeon Steven N.Roper, M.D., specializes in pituitarytumor surgery and has performedmore than 650 procedures.The University of Florida pediatricneurosurgery team, under theleadership of David W. Pincus,M.D., Ph.D., performs more than300 procedures annually onpatients, ranging in age fromnewborn to 21. The division is aregional center for the treatmentof pediatric brain tumors and avariety of congenital disorders.UF neurosurgeon Steven N. Roper, M.D.David Pincus (left), M.D., Ph.D., leads the pediatric neurosurgery team.quality initiativeImproving MobilityWilliam Friedman, M.D., and Kati Harlan, R.N., M.S.N., a senior quality improvement specialist,led a task force to provide a multidisciplinary approach to patient mobility at the bedside.The Shands nursing team and rehabilitation services took lead roles in this initiative. Supporttechs were hired for every floor, and guidelines were implemented for referring patients tophysical and occupational therapists. The task force increased mobility among Neuro ICUpatients by 300 percent, and improvements have been linked to reductions in lengths of ICUand hospital stays, hospital-acquired infections and more.300% increase in mobility| reductions in length of stay || no increase in adverse events |18 352.273.9000 learn more at neurosurgery.ufl.edu learn more at neurosurgery.ufl.edu 352.273.9000 19

department overviewConditions we treat• Cervical, thoracicand lumbar disc disease• Degenerative spinaldisorders• Spinal trauma• Spinal and spinalcord tumorsSpine and SpinalCord SurgeryUF neurosurgeons R. PatrickJacob, M.D., and Daniel J. Hoh,M.D., are experts in complexspinal reconstruction andinstrumentation. The UF spineteam performs more than750 procedures each year. Asleaders in the development andapplication of image-guided andmicroscope-assisted minimallyinvasive spine surgery, UFneurosurgeons routinely usethese techniques to performlaminectomy, discectomy, andspinal instrumentation and fusionsurgery. In addition, the team usessophisticated new real-time spinalnavigation for the placementof percutaneous screws. Thisinvolves stereotactic guidancedirected by intraoperative CTimaging and allows for the useof multiple small incisions ratherthan one large incision.UF neurosurgeons R. Patrick Jacob, M.D., and Daniel J. Hoh, M.D.William A. Friedman, M.D.Trigeminal NeuralgiaThe primary treatment fortrigeminal neuralgia is medical.But when medicine fails, surgeryis very effective. UF neurosurgeonand department chair William A.Friedman, M.D., is an expert in allsurgical approaches for treatingtrigeminal neuralgia. Everyyear we operate on more than150 patients suffering from theexcruciating pain of trigeminalneuralgia.Our approachWe offer three different surgicalapproaches for the treatment oftrigeminal neuralgia:• Microvasculardecompression —This 45-minute procedureidentifies and moves arterialcompression away from thetrigeminal nerve, resultingin pain relief without facialnumbness.• Radiofrequency lesion —This 10-minute outpatientprocedure eliminates pain byburning the trigeminal ganglion,leading to facial numbness.• Radiosurgery —This outpatient procedureproduces pain relief byfocusing hundreds of smallbeams of radiation on the nerve.quality initiativeReducing InfectionsIn April 2012, the Journal of Neurosurgery published results from a UF quality initiative called“Reduction of Catheter-associated Urinary Tract Infections Among Patients in a Neurological IntensiveCare Unit: A single Institution’s Success.” This study concluded that a comprehensive urinary tractinfection prevention bundle, along with a continuous quality improvement program, can significantlyreduce the duration of urinary catheterization and rate of catheter-associated UTI in a neuro ICU.Number of 2 NS Catheter-Associated Urinary TractInfections Rate 2008-2012CA-UTI/1000 Urinary Catheter Days1412108642011.964th Q/201011.439.758.47 8.444th Q/20093rd Q/20092nd Q/20091st Q/20097.51st Q/20108.72nd Q/20104.0 4.13rd Q/20104th Q/20105.51st Q/20110.82rd Q/20113rd Q/20119.84th Q /20114.41st Q/20128.52nd Q/2012Number of CA-UTI/1000Urinary Catheter DaysLinear Number of CA-UTI/1000Urinary Catheter Days20 352.273.9000 learn more at neurosurgery.ufl.edu learn more at neurosurgery.ufl.edu 352.273.9000 21

Barbie’s Case“Everything good thatcould have happened,happened, all the rightdoctors were there.”- Barbie Diaz, patientPatient: Barbie Diaz | Age:18 | Diagnosis: Stroke22 352.273.9000 learn more at neurosurgery.ufl.edu learn more at neurosurgery.ufl.edu 352.273.9000 23

Barbie’s CaseNovember 17, 2010Suffered a stroke,underwent angioplastyJuly 2012Doing wellFebruary 2011Diagnosed with Takayasu arteritisNovember 18, 2010Woke up in Neuro ICUNovember 21, 2010Walked out of Shands at UFBarbie’s timeline2010 2011 2012She’d spent the afternoon at the mall, shoppingfor a birthday present for a friend. But as shewas driving back to her dormitory on theUniversity of Florida campus, Barbie Diaz feltsomething on her face, a crawling sensation, likea spider inching across her cheek. She slapped itaway, realizing as she did, that she was slappingaway her own left hand. At age 18, Barbie, thena UF freshman, was having a stroke.“I ended up running into themedian and hitting another car,not head on. I hit their bumper,but it stopped the car,” Barbieremembered. “I was thinking,‘Would they be mad if I just fellasleep right now?’”She was unable to move the leftside of her body, and that side ofher face drooped. Having studiedhealth extensively in high school,Barbie quickly recognized thesigns of a stroke and was able totell emergency responders, whobrought her to Shands at theUniversity of Florida.After an angiogram revealed ablood clot obstructing her rightcarotid artery and right middlecerebral artery, endovascularsurgeon Brian Hoh, M.D.,performed balloon angioplastyto open the right internal carotidartery. He then used a Penumbraclot aspiration catheter to removethe clot. Afterward, function wasalmost fully restored to her leftside, which had been paralyzedduring the stroke.As it turned out, Barbie’sunusual stroke stemmed from arare autoimmune disease calledTakayasu arteritis, which causesinflammation in the arteries.Endovascular neurosurgeonShe now takes medicationStroke neurologistand visits Nurses the hospital once amonth Technicians for infusions to keepPediatric immunologistthe inflammation at bay. Hohand Barbie’s stroke neurologist,Michael Waters, M.D., director ofthe Shands at UF Stroke Program,also monitor her closely to ensureshe does not suffer anotherstroke.Two years have passed, andluckily, Barbie has few physicaleffects from the stroke. She’s ontrack to go to nursing school at UFand hopes to conduct research onher disease.“Everything good that couldhave happened, happened,”Barbie said. “All the right doctorswere there.”Download an ibook with Barbie’scase study at www.urlwillgohere.comB A R B I E ’ S TEAMBarbie’s team1 Endovascular neurosurgeon2 Stroke neurologist3 Nurses4 Technicians5 Pediatric immunologist

strokewho we are:24/7 availability ofstroke neurologistsand endovascular neurosurgeonsThe Shands at the University of Florida Stroke Program is dedicated to theprevention, diagnosis and treatment of strokes. Our experts provide thelatest technology and medications and care for the stroke patient’s entireneeds. The optimal treatment for ischemic stroke requires 24/7 availabilityof stroke neurologists and endovascular neurosurgeons. The goal is to takethe stroke patient, as rapidly as possible, for diagnostic imaging. Advancedtreatments, including intravenous tissue plasminogen activator and-mostimportantly-intravascular mechanical retrieval of clots from major brainarteries, can lead to previously unachievable patient outcomes. Surgicalintervention for stroke is directed by Brian L. Hoh, M.D., who works withstroke neurologist Michael Waters, M.D. Dr. Hoh provides neurosurgicalevaluations of hemorrhagic stroke patients and performs endovascularprocedures, including the removal of artery-blocking blood clots, coilingof cerebral aneurysms and carotid artery stenting, as well as opencerebrovascular surgical procedures, such as aneurysm clipping, carotidendarterectomy and removal of arteriovenous malformations. UF treats thethird largest number of subarachnoid hemorrhage patients in the countryand is the only comprehensive stroke program in north central florida.| 24/7 availability | of stroke neurologistsand endovascular neurosurgeons.The Shands at UF Stroke Program has beenrecognized by these health care industry leaders:➊➋Left MCA stenosis pre-opLeft MCA stent and angioplasty post-op➊➋For the third year in arow, the American HeartAssociation/AmericanStroke Associationhonored the Shands atthe University of FloridaStroke Program with itsGet With The GuidelinesStroke Gold PerformanceAward. The Stroke Programalso received the Target:Stroke Honor Rolethis year, an elevateddistinction. Only currentGet with the GuidelinesStroke AchievementAward-winning hospitalsare eligible for this honor.The Agency for HealthCare Administration hasaccredited Shands atUF as a PrimaryStroke Center,meeting the criteria ofthe Joint Commission.The UF Department ofNeurosurgery is hometo one of just twoneurosurgical endovascularfellowships approved bythe Accreditation Councilfor Graduate MedicalEducation in the country.Quarter/Year24 352.273.9000 learn more at neurosurgery.ufl.edu learn more learn at more @ neurosurgery.ufl.edu 352.273.9000 25

strokewho we are:Brian Hoh, M.D.Michael Waters, M.D., Ph.D.Brian Hoh, M.D., is a board-certified neurosurgeon who specializes in all aspects ofcerebrovascular and endovascular neurosurgery. In addition to his work with the Shands atUF Stroke Program, Dr. Hoh is program director of neurosurgery, leads the neuroendovascularfellowship program, and is the chief principal investigator of an international multicentertrial for patients with large and giant intracranial aneurysms. He has published more than120 scientific papers in leading journals, and his research is funded by the National Institutesof Health. Dr. Hoh serves as treasurer for the Joint Association of American NeurologicalSurgeons/Congress of Neurological Surgeons Cerebrovascular Section. He also is on theeditorial board of the Journal of Neurosurgery.Michael Waters, M.D., Ph.D., is a board-certified vascular neurologist and director of theShands at UF Stroke Program. He leads the acute stroke team, helping to ensure thatUF&Shands remains at the forefront of acute stroke care. With other members of the stroketeam, Dr. Waters directs the implementation of the American Stroke Association’s Get with theGuidelines national stroke database and quality assurance program and serves as site principalinvestigator for clinical trials designed to improve clinical outcomes in stroke. Dr. Waters’researched is funded by the National Institutes of Health.Other members of the Shands at UF Stroke Program team include UF neurosurgeon SpirosBlackburn, M.D., and UF neurologists Anna Khanna, M.D., Vishnumuthy Shushrutha Hedna,M.D., and Bayard Miller, M.D.our discoveries: a selection of recent publications1. “Effect of WeekendCompared to WeekdayStroke Admission onThrombolytic Use,In-Hospital Mortality,Discharge Disposition,Hospital Charges, andLength of Stay in theNationwide InpatientSample Database: 2002-2007.” Stroke, 2010.Authors: Hoh BL, ChiYY, Waters MF, Mocco J,Barker FG II2. “Monocyte ChemotacticProtein-1 PromotesInflammatory VascularRepair of MurineCarotid Aneurysmsvia a MacrophageInflammatory Protein-1α and MacrophageInflammatory Protein-2-Dependent Pathway.”Circulation, 2011.Authors: Hoh BL, HosakaK, Downes DP, NowickiKW, Fernandez CE, BatichCD, Scott EW3. “Stenting versusaggressive medicaltherapy for intracranialarterial stenosis.” TheNew England Journalof Medicine 365(11):993-1003, 2011. Authors:Chimowitz MI, LynnMJ, Derdeyn CP, TuranTN, Fiorella D, Lane BF,Janis LS, Lutsep HL,Barnwell SL, Waters MF,Hoh BL, Hourihane JM,Levy EI, AlexandrovAV, Harrigan MR, ChiuD, Klucznik RP, ClarkJM, McDougall CG,Johnson MD, Pride GL Jr,Torbey MT, Zaidat OO,Rumboldt Z, Cloft HJ,and the SAMMPRIS TrialInvestigators4. “Guidelines for theManagement ofAneurysmal SubarachnoidHemorrhage: A Guidelinefor the Management ofAneurysmal SubarachnoidHemorrhage: AGuideline for HealthcareProfessionals fromthe American HeartAssociation/AmericanStroke Association.”Stroke, 2012. Authors:Connolly ES Jr, RabinsteinAA, Carhuapoma JR,Derdeyn CP, Dion J,Higashida RT, Hoh BL,Kirkness CJ, NaidechAM, Ogilvy CS, Patel AB,Thompson BG, Vespa P26 352.273.9000 learn more at neurosurgery.ufl.edu learn more learn at more @ neurosurgery.ufl.edu 352.273.9000 27

•volumesExtramural Funding(excluding Shands andVA housestaff andFoundation funding)2007-2012Clinical Trials: $398,626•Research Grants: $1,368,196Number of Procedures 2011includes adult and pediatric casesperformed at Shands at UF andthe Malcom Randall VeteransAffairs Medical Center2011-121,766,82220101,700,000159Shunt3012009695,380Spine/Degenerative7942008381,105Spine/Tumor1072007861,666Spine/Trauma35Spine/Other59Trigeminal Neuralgia145Foundation FundingInvested value of donations toUF Neurosurgery as of Feb. 1, 20122011-12Radiosurgery•Endowed Income: $2,144,456Endowed Principal: $33,471,87335,616,329 millionCranial/VascularDeep Brain StimulationCranial/TraumaCranial/TumorCranial/OtherPeripheral Nerve7994195337407855201032 millionOther94200927.6 million200830.7 million200729 million28 352.273.9000 learn more at neurosurgery.ufl.edulearn more at neurosurgery.ufl.edu 352.273.9000 29

Nicapnicap: excellence through collaborationThe Neuromedicine Interdisciplinary Clinical andAcademic Program, or NICAP, is a unique programdeveloped to improve the patient experience throughoutthe continuum of care by focusing on safety and qualityconcerns. It creates a team of faculty and hospital staffmembers who are charged with allocating faculty andhospital resources to deliver the greatest improvementin terms of quality, operations and finances. Led byWilliam A. Friedman, M.D., chair of the Department ofNeurosurgery, NICAP brings together experts from:Neuromedicine ICAP DefinedAll UF College of Medicine Clinical activites within the Deparmtent of Neurology and NeurosurgeryAll Shands Hospital at UF Clinical activity associated with Neurology and Neurosurgery ServicesAll research activities within the Departments of Neurology and NeurosurgeryAll education activities within the Departments of Neuorlogy and Neurosurgery| Neuromedicine Interdisciplinary Clinical Programs |• Neurosurgery• Neurology• Neuroradiology• Neuroanesthesiology• Critical care• Resident programs• Nursing• Rehabilitation• Shands administrationNeuro-oncologyCare ServicesNeurodegenerativeCare ServicesEpilepsy CareServicesCerebrovascularCare ServicesThe NICAP Mission is to achieve| the perfect patient experience |Spine CareServicesNeurorehabilitationCare ServicesNeurocriticalCare Services30 352.273.9000 learn more at neurosurgery.ufl.edu learn more at neurosurgery.ufl.edu 352.273.9000 31

Judi’s Case“Life is short. I just feelwe all have to work hardto have joy in our lives.”- Judi Rembert, patientPatient: Judi Rembert | Age: 69 | Diagnosis: Glioblastoma32 learn more @ neurosurgery.ufl.edu 352.273.9000learn more at neurosurgery.ufl.edu 352.273.9000 33

July 23Suffered seizure, diagnosedwith stage 4 glioblastomaJuly 26Moved to ShandsRehab HospitalJuly 29Headed home to AlachuaAugust 13Started radiationAugust 19Started chemotherapyJuly 24Underwent surgery to remove tumorAugust 25Celebrated 52ndwedding anniversaryjudi’s timelineFourth weekJuly 2012Fifth weekJuly 2012Third weekAugust 2012Fourth weekAugust 2012In the days leading up to her summervacation in the mountains of North Carolina, JudiRembert started forgetting how to walk.She veered to the left side and began todrag her left leg. Once, on a walk with a friend,the other woman had to remind her how to move,urging her forward saying, “Heel, toe … heel,toe… heel, toe.” Judi visited a neurologist but putoff further testing until after her vacation. But inNorth Carolina, things grew worse.“I kept walking more to the left. Ikept walking into people. I would bedriving down the road and look upand see a car coming at me. I knowthe Lord was watching out for me,”she said. “It got to the point where Icould not even button my clothes.I knew I was really in trouble. I said,‘We have to go home.’”Thirty minutes after arriving homeat their farm in Alachua, she had aseizure.Judi was rushed to Shands at UF,where testing revealed she had astage 4 glioblastoma, a plum-sizedtumor affecting the left side of herbrain. The diagnosis came just fiveyears after the Remberts led effortsto raise money for construction ofthe new Shands Cancer Hospital atUF and donated $5 million to thecause themselves.After her diagnosis, the Rembertsmet with UF neuro-oncologist ErinDunbar, M.D., who co-directs thePreston Wells Jr. Center for BrainTumor Therapy with neurosurgeonWilliam A. Friedman, M.D. Together,they developed a plan of attack.After Friedman operated to removethe tumor, Judi went to ShandsRehab Hospital, where therapistshelped her recover some of thefunction she lost in her left side. InEndovascular August, she neurosurgeon started chemotherapyStroke and radiation.neurologistNursesTechnicians Just two months after herPediatric diagnosis, immunologist she has regained muchof her function in her left side. Withcancer, the road ahead is alwaysuncertain, but a born giver, she’salready making plans for how shecan help people. She wants tovolunteer at Shands Rehab Hospitaland bring people fuzzy blankets likethe one her daughter, Mary, gaveher when she was in the hospital.Other than that, she is justenjoying life with her family. Sheand husband Davis just celebratedtheir 52nd wedding anniversary inAugust.“Life is short,” Judi said. “I just feelwe all have to work hard to have joyin our lives. That is what I am goingto do as long as I can.”Download an ibook with Judi’scase study at www.urlwillgohere.comB A R B I E ’ S TEAMjudi’s team1 Neurosurgeon2 Neuro-oncologist3 Neurologist4 Dedicated nurse navigator5 Nurses6 Radiation oncologist7 Speech therapist8 Occupational therapist

ain tumorcomprehensive careThe physicians in the University of Florida Department ofNeurosurgery treat every type of brain tumor using noveltechniques and devising comprehensive treatment plans to tackleeach patient’s complex case. The neurosurgical team performsmore than 500 brain tumor procedures annually. In addition tothese renowned neurosurgeons, the Brain Tumor Board alsoincludes medical oncologists, radiation oncologists and otherspecialists to provide complete treatment for each patient.Frank Bova, Ph.D., holds a custompatient surgical guide, which providessurgeons with the precise locationof an intracranial target. The mold isdesigned from a CT or MR scan andprovides surgical guidance at a fractionof the cost of other techniques.Pre-op MeningiomaConditions we treat• Brain and spinal cord tumors• Craniosynostosis• Congenital anomalies and malformations(such as Chiari malformation, Moya Moyadisease and Vein of Galen malformation)• Spina bifida• Spasticity• Epilepsy• Trauma• HydrocephalusPost-op MeningiomaMeasures Of ExcellenceAs established leaders in the use of radiosurgeryfor the treatment of neurological disorders, facultymembers in the UF Department of Neurosurgeryhave achieved a high level of quality patientoutcomes in terms of cure and complication rates.Pathology:Cure Rate:ComplicationRate:Arteriovenous Malformations 85% 2%Vestibular Schwannoma 90% 1%Meningioma 95% 2%Metastatic Tumor 85% 5%linac scalpelA linear accelerator-based radiosurgical system developed at the University of Florida Departmentof Neurosurgery has become one of the most popular commercial radiosurgery systems worldwide.The system, known as the LINAC Scalpel, assists with localizing, planning and treating intracranialtumors using computer software and a specially designed linear accelerator. Frank J. Bova, Ph.D.,and William A. Friedman, M.D., created the system, which has improved the accuracy of high-doseradiation delivered to brain tumors with very little of the dose reaching normal brain structures.34 352.273.9000 learn more at neurosurgery.ufl.edulearn more at neurosurgery.ufl.edu 352.273.9000 35

ain tumorwho we are:William A. Friedman, M.Dfrank j. bova, Ph.D.erin m. dunbar, m.d.UF neurosurgeon and department chair William A. Friedman, M.D., and UF professorof neurosurgery Frank J. Bova, Ph.D., pioneered the development of many of thecomputer-guided surgical devices used worldwide to make brain tumor surgery lessinvasive, including the patented UF radiosurgery system.UF neurosurgeon Brian L. Hoh, M.D., provides preoperative endovascular treatment toreduce bleeding risk in select brain tumor patients.Friedman, together with UF otolaryngologists Patrick J. Antonelli, M.D., and John W. Werning,M.D., offers skull base surgical options and endoscopic approaches for brain tumor patients.UF medical neuro-oncologist Erin M. Dunbar, M.D., leads a team that provides comprehensivecare for all brain tumor patients as part of the Preston Wells Jr. Center for Brain Tumor Therapy.In 2012, the Lillian Wells Foundation donated an additional $10 million to the center, whichcombined with other funding sources, launched a $20 million initiative to help speed newbrain tumor therapies to patients.On the research front, renowned scientists Brent Reynolds, Ph.D., is known for his pioneeringwork studying stem cell approaches to brain tumor therapy.our discoveries: a selection of recent publications1. “Radiographic responseof brain metastasisafter linear acceleratorradiosurgery.” StereotacticFunctional Neurosurgery,2012. Authors: Rahman M,Cox JF, Chi YY, Carter JH,Friedman WA.2. “Radiosurgery forMalignant Brain Tumors.”Youman’s NeurologicalSurgery, Sixth Edition,2011. Authors: Murad GJA,Friedman WA: Editors:Winn HR, Saunders.3. “Can standard magneticresonance imaging reliablydistinguish recurrenttumor from radiationnecrosis after radiosurgeryfor brain metastases?”Neurosurgery, 2008.Authors: Dequesada IM,Quisling RG, Yachnis A,Friedman WA.4. “Radiosurgery formetastatic brain tumors:The University of Floridaexperience.” Neurosurgery,2008. Authors: Swinson B,Friedman WA.5. “Linear acceleratorradiosurgery forvestibular schwannomas.”Journal of Neurosurgery,2006. Authors: FriedmanWA, Bradshaw P, Myers A,Bova FJ.36 352.273.9000 learn more at neurosurgery.ufl.edulearn more at neurosurgery.ufl.edu 352.273.9000 37

UF&Shands, the University of Florida Academic Health CenterUF&Shands, the University of Florida Academic Health Center, is the mostcomprehensive center of its kind in the Southeast. It comprises the colleges ofDentistry, Public Health and Health Professions, Medicine, Nursing, Pharmacy andVeterinary Medicine, and an academic campus in Jacksonville that offers graduateeducation programs in medicine, nursing and pharmacy. Patient care activities, underthe banner UF&Shands, are provided through teaching hospitals and a network ofphysician practices in Gainesville and Jacksonville. The Academic Health Center alsohas a statewide presence through satellite medical, dental and nursing clinics staffedby UF health professionals; and affiliations with community-based health-care facilitiesstretching from Hialeah and Miami to the Florida Panhandle.Shands at the University of FloridaShands at UF is one of the Southeast’s premier teaching hospitals and the state’sleading medical referral center. More than 900 expert UF College of Medicine andcommunity physicians along with 7,297 skilled Shands nursing and support staffprovide comprehensive high-quality patient care, from primary care and familymedicine to subspecialty tertiary and quaternary services for patients with highlycomplex medical conditions. Shands at UF includes Shands Hospital for Children, theShands Pediatric Emergency Room, Shands Cancer Hospital and Shands Critical CareCenter. Shands at UF also operates the health system’s two specialty hospitals, ShandsRehab Hospital and Shands Vista, both located in Gainesville.National AcclaimShands at UF consistently earns top-50 rankings in multiple medical specialties inthe annual listing of America’s Best Hospitals, published by U.S. News & World Report.Shands Hospital for Children at the University of Florida has been recognized amongthe nation’s best in seven medical specialties in the 2012-2013 U.S. News Best Children’sHospitals rankings. Neurosurgery was ranked 32nd in 2012, the highest in the state ofFlorida. Our hospitals and programs have earned “Magnet” designation by the AmericanNurses Credentialing Center, the nursing profession’s most prestigious honor.38 352.273.9000 learn more at neurosurgery.ufl.edu