Dear Friends and Colleagues:
These are exciting times for the Allegheny Health Network Neuroscience Institute.
Our neurologists are leading efforts to expand the use of the latest innovations in the diagnosis and treatment of neurologic disorders ranging from amyotrophic lateral sclerosis and epilepsy to movement disorders and multiple sclerosis (MS).
Similarly, our neurosurgeons are incorporating cutting-edge technologies into spine procedures and pioneering new approaches in the field of neurooncology.
We have long maintained busy programs in movement disorders, headache and MS, and we’re now seeing phenomenal growth in spine surgery, interventional stroke, brain tumor and epilepsy, particularly as we recruit some of the best-trained specialists in these areas into our center.
We continue to provide our patients with the best care in the region, and we hope the information on the following pages will help you as you evaluate options for your patients. With our long history in western Pennsylvania, we strongly believe the best possible outcomes depend on our ability to build strong relationships with you and your patients.
It is an honor to partner with you in the delivery of stateof- the-art treatment to your patients, and we are here should our care and services be of value to you.
Donald Whiting, MD
Chief Medical Officer, Allegheny Health Network (AHN)
President, Allegheny Clinic
Chair, AHN Neuroscience Institute
Patients at Allegheny Health Network (AHN) who suffer
ischemic stroke, hemorrhagic stroke and ruptured
brain aneurysms have access to new technologies and
procedures that promise faster care and yield better
In ischemic stroke, neurologists within the network are using several novel medications that are capable of “opening up blood vessels faster and more efficaciously,” according to Russell Cerejo, MD, the medical director for stroke and the co-director of endovascular services at the AHN Cerebrovascular Center.
In addition to these novel therapies, new approaches to magnetic resonance imaging (MRI), such as hyperacute MRI, help better identify ischemic stroke patients who can benefit from treatments by accurately determining the duration of their stroke (including time of onset).
“There have been studies showing that if you use MRIs to characterize the stroke, you can guesstimate when the stroke happened and whether it happened within four hours,” Dr. Cerejo said. “Here at AHN, we’ve been using MRIs for those specific patients who typically would not be candidates for IV thrombolysis.”
In addition to pharmacologic interventions, there are new surgical implants that are designed to open up occluded blood vessels more quickly, added Richard Williamson, MD, the director of the Cerebrovascular Center at AHN. As an example, neurosurgeons at the center are incorporating novel catheter technology into clinical practice. These newer catheter designs can be implanted into increasingly smaller blood vessels safely, according to Dr. Williamson.
“We now have catheters that we can safely put in smaller and smaller vessels in order to perform stroke thrombectomies, where we go through the vessel and actually open up where it has been blocked by a clot or plaque,” he said. Having access to smaller catheters allows surgeons to safely treat more patients who are affected by stroke, he added.
Similar advancements have also improved outcomes in patients with hemorrhagic stroke and ruptured aneurysms, allowing neurosurgeons to use minimally invasive options. For example, AHN neurosurgeons are now using a new technology called the Woven EndoBridge (WEB™; Sequent Medical; pictured) for these notoriously difficult-to-treat aneurysms.
As the name suggests, the WEB™ is an ellipsoid braided-wire embolization device designed to provide flow disruption along the neck of the aneurysm to induce aneurysmal thrombosis.
“Wide-neck aneurysms are probably some of the most challenging aneurysms that we see,” Dr. Williamson said. “The WEB™ device has revolutionized the way that we can treat wide-neck aneurysms. These were typically aneurysms for which we had to do a craniotomy.”
AHN neurosurgeons are also using a noninvasive approach to treat subdural hematomas. The new approach allows surgeons to “embolize or essentially glue off vessels that are going up to that membrane,” meaning patients no longer have to undergo craniotomy for evacuation, according to Dr. Williamson. The Cerebrovascular Center is participating in a clinical trial to evaluate the safety and efficacy of this artery embolization procedure compared with a more traditional approach.
“With just a needlestick in the artery in the wrist, we can go in and block off these vessels and the hematoma will go away over the course of a few weeks,” he said. “This has been a game changer for the neurosurgical field because it’s been such a challenging entity for us to treat. We’ve seen really great results, and patients often don’t need surgery. Even if they do need surgery, they’re much less likely to have problems long term.”
Woven EndoBridge (WEb)™ is a trademark of Sequent Medical and is used with permission.
Across neuroscience, specialists are working to identify
ways to make surgery less invasive and to support faster
and better patient recovery.
“The shorter and less invasive a surgery is, the faster the patient recovers; they do better,” said Alexander Yu, MD, vice chair of neurosurgery with the Allegheny Health Network (AHN).
Neurosurgeons at AHN have long led the way in sameday surgical procedures for the treatment of spine disorders. Emerging technologies that allow surgeons to avoid open procedures can minimize surgical wounds and affect how quickly patients recover postoperatively, according to Dr. Yu.
Indeed, minimally invasive approaches in spine surgery have been associated with a reduced need for opioids, decreased blood loss, shorter hospital length of stay and fewer complications (Table).1.2 Robotic tools, such as the Mazor X™ (Medtronic), enable more efficient surgeries and faster recovery times by assisting preoperative planning and intraoperative guidance, Dr. Yu said.
Pain management is also greatly improved with sameday procedures.
“We have an extended recovery anesthesia protocol,” Dr. Yu noted. “When a patient comes in for surgery, the protocol optimizes the recovery to focus on pain control and optimize function. We’re developing more of these protocols to increase the number of patients that can go home the same day. About 20% of our neurosurgery patients go home the same day—a figure that’s probably doubled in the past five to 10 years.”
Generally, patients recover better at home, Dr. Yu said. However, allowing patients to recover at home means establishing protocols that help them to do so safely.
“Healing is better at home, and that’s where medicine is moving,” he said. “Obviously, the No. 1 goal is always going to be patient safety. As technology improves, we can send more patients home the same day, while keeping them safe.”
1. Global Spine J 2019;9:624-629.
2. Spine [Phila Pa 1976] 2021;46:62-68.
“Healing is better at home, and that’s
where medicine is moving. Obviously, the
No. 1 goal is always going to be patients
safety. As technology improves, we can
send more patients home the same day,
while keeping them safe.”
—Alexander Yu, MD, AHN vice chair of neurosurgery
Table. Postoperative Complications: Minimally Invasive Surgery Versus Open Transforaminal Lumbar Interbody Fusion1
Neurosurgeons at Allegheny Health Network (AHN) are using state-of-the-art technologies that enable them to practice at the leading edge of neuroscience. Examples are described below.
Traditional surgery for tumors of the boney spine is
significantly invasive and requires removing tumor-filled
bone and, often, placing instrumentation into the spine to
stabilize it, said Nestor Tomycz, MD, a neurosurgeon with
the AHN. Medtronic OsteoCool™ uses radiofrequency
energy, delivered via two small probes placed into the
bone, to heat and ablate cancerous and benign tumor
tissue. Circulating water keeps the temperature stable
at the active tip to prevent thermal damage outside
the zone of ablation. The minimally invasive approach
reduces operative time, allowing patients to recover
faster, according to Dr. Tomycz. It can also be combined
with traditional vertebroplasty or kyphoplasty.
“The patient can go home the same day because we can avoid large incisions and reduce blood loss,” he said.
“As a center, we’ve been dedicated to less invasive spinal surgery and faster patient recoveries—it’s part of our overall dogma in spine health.”
Indeed, a post-marketing study showed sustained decreases in pain and increases in quality of life among patients with metastatic bone disease who were treated with OsteoCool™ tumor ablation.1
When a patient presents with an ischemic stroke,
a perfusion scan indicates the extent of damaged
versus salvageable tissue, information that helps
guide treatment decisions. RapidAI® is an automated,
artificial intelligence-driven software platform that
analyzes computed tomography and magnetic
resonance scans, providing critical information to
stroke interventionists and neurosurgeons within
minutes. Physicians at AHN are using the technology
to make treatment decisions when time is of the
essence, according to Russell Cerejo, MD, medical
director for stroke and the co-director of endovascular
services at the health system’s Cerebrovascular
Center. This effectively allows more patients to be
candidates for acute stroke intervention, which can
prevent permanent damage. In two studies presented
by Dr. Cerejo and his colleagues during the 2022
International Stroke Conference, RapidAI® showed
high sensitivity and specificity for detecting large
vessel blockages or severe narrowing as well as
hemorrhagic strokes very quickly, allowing for faster
triage, reducing time to treatment and improving
“When a patient is having a stroke, every minute counts because brain cells are dying,” Dr. Cerejo said. “RapidAI® provides us with automated maps that can tell us what part of the brain is affected.”
Synaptive’s Modus V™ robotic exoscope facilitates
surgical visualization and magnification in
neurosurgical procedures. The exoscope supports better
ergonomics allowing surgeons to comfortably access
and view difficult regions of the brain and spine and
aids in teaching and instruction, according to Richard
Williamson, MD, the director of the Cerebrovascular
Center at AHN.
Modus V™ is a 3D robotic exoscope tool that surgeons can position anywhere in the surgical field, allowing them to view difficult angles with the traditional microscope, he said. The technology enhances surgical ergonomics, meaning procedures can be performed accurately, in less time, and with less physical strain on the surgeon.
“It has broad applications”, said Dr. Williamson. “Anytime we are using an operating microscope or are in a case that requires magnification and illumination to operate precisely—whether that’s in spine surgery, intracranial cerebrovascular surgery or brain tumor surgery—the exoscope is incredibly useful.”
During spinal fusion surgery, screws are placed into the
bone to prevent motion between vertebrae to facilitate
fusion. Mazor X™ (Medtronic) helps surgeons ensure
accurate and efficient screw placement during this spinal
surgery. A major benefit of the Mazor X™ system is that
it allows surgeons to plan a trajectory before surgery
begins, according to Alexander Yu, MD, a neurosurgeon
with the AHN. A meta-analysis found that robotic
guidance with the Mazor X™ yields superior accuracy
and less blood loss compared with computer-assisted
navigation for pedicle screw placement.4
“We’re early adopters in terms of utilizing technology,” Dr. Yu said. “With platforms such as Mazor X™, there are fewer surprises for the surgeon and better outcomes for the patient.”
1. J Vasc Interv Radiol 2020;31:1745-1752.
2. Abstract WMP68: International Stroke Conference 2022.
3. Abstract WP129: International Stroke Conference 2022.
4. World Neurosurg 2021;146:e139-e150.
Osteocool™ is a trademark of Medtronic and is used with permission. RapidAI® is used with permission of RapidAI. Modus V™ is a trademark of Synaptive Medical and is used with permission. Mazor X™ is a trademark of Medtronic and is used with permission.
Advancements in the surgical management of epilepsy
are allowing specialists to offer safe, effective, minimally
invasive treatment options for patients with difficult-totreat
According to the CDC, an estimated 3.4 million people in the United States have epilepsy, and up to 40% of them have drug-resistant disease.1
“Most epilepsy patients will respond to treatment and will be cured, or at least live very functional lives,” said Alexander C. Whiting, MD, a neurosurgeon and the director of epilepsy surgery for Allegheny Health Network (AHN) Neuroscience Institute. “However, a large group of patients with medically refractory epilepsy have a very significant disease that affects their life span, makes it difficult to be employed and greatly complicates their lives. During the past five to 10 years, we have developed some incredible options for treating these people, all of which we offer at AHN.”
The primary diagnostic intervention is robotic stereoelectroencephalography (SEEG), a highly technical procedure that utilizes a robot to place electrodes directly into a patient’s brain. The technique, Dr. Whiting noted, is safe, has a very low complication rate and allows the care team to identify the region of the brain that is triggering a patient’s epilepsy.
“If we can localize where a patient’s epilepsy is coming from, we can treat it,” Dr. Whiting said.
Key to these treatment plans are minimally invasive techniques such as responsive neurostimulation (RNS) and laser interstitial thermal therapy (LiTT).
RNS Therapy, which was approved by the FDA in 2013, is similar in approach to a pacemaker used to control irregular heart rhythms. A brain–computer interface is created, consisting of a small computer and battery that are imbedded under a patient’s skin. Electrodes are then placed in the patient’s brain, targeting the region causing seizures.
When the technology identifies the onset of a seizure, it modulates the seizure, stopping it before it begins.
“RNS can significantly reduce the number of seizures a patient has, sometimes completely stopping them,” Dr. Whiting said.
If patients have epilepsy coming from a deep part of the brain, surrounded by important functional areas, LiTT allows surgeons to remove a seizure focus area with pinpoint accuracy. In LiTT, a laser is placed deep into the brain via a single, small incision, and is targeted toward the region of the brain causing the patient’s seizures, according to Dr. Whiting.
“We are getting much better at using existing technologies, such as RNS, LiTT and SEEG, to tailor treatment, localizing epilepsy for each patient and minimizing the amount of surgery they need,” Dr. Whiting said. “At AHN, we have built out the newest and most innovative technologies, which have given us a whole new toolbox to treat epilepsy.”
1. Medicine [Baltimore] 2019;98:e16402.
The Allegheny Health Network (AHN) Neuroscience
Institute continues to evolve as a major research center.
“Over the past five years, our involvement in clinical trials has grown by 20% to 30% annually, and we expect it to continue to grow,” said Donald Whiting, MD, the chief medical officer of AHN, president of the Allegheny Clinic and chair of the AHN Neuroscience Institute.
Neuroscience Institute researchers are at the
forefront of efforts to expand the use of deep brain
The Institute is leading a small study in which DBS will be used on three patients with opioid use disorder who have relapsed after successful rehabilitation. The Institute, is also leading a small study of DBS in patients with obesity and participating in a multicenter study of this approach in the treatment of Alzheimer’s disease (ADVANCE II).
DBS uses electrodes implanted adjacent to specific deep brain structures. The electrodes are connected to a pacemaker-like device implanted on the chest wall that delivers low levels of electrical stimulation via a subcutaneous wire.
For patients with opioid use disorder and obesity, researchers will be using the approach to target the nucleus accumbens, a brain region believed to be involved in the “reward” process. By delivering electrical pulses there, researchers believe they can help block cravings for opioids and unhealthy foods. In patients with Alzheimer’s, DBS will target the fornix, a brain region involved in memory, to reverse some declines in cognitive function.
“We do a high volume of DBS in Parkinson’s disease, and our experience with the approach has brought us to this point, where we can be taking the lead on studies of its use in new areas,” said Nestor Tomycz, MD, the director of stereotactic and functional neurosurgery. “That says our center is at the forefront of using this technology.”
Neurosurgeons at the Allegheny Health Network (AHN)
Neuroscience Institute are incorporating cutting-edge
surgical techniques designed to improve outcomes in
patients with deep-seated and/or recurrent brain tumors.
Surgeons are using laser interstitial thermal therapy (LITT), a minimally invasive technique developed to treat epilepsy and other seizure disorders, in patients with glioblastoma or metastatic tumors to effectively perform “resection without incision” for faster recovery times, according to Matthew Shepard, MD, the director of brain tumor research at the AHN Neuroscience Institute and a neurosurgeon in the Allegheny Health Network.
“LITT is an emerging option for patients whose tumors may be more challenging for open surgical resection,” Dr. Shepard said. “It also has the added benefit of faster recovery time, which enables them to start adjuvant therapy—whether it’s chemotherapy, radiotherapy or immunotherapy—earlier, which further improves outcomes.”
For patients who require open tumor resection, Dr. Shepard and his colleagues are increasingly performing awake craniotomies, during which patients remain awake for accurate mapping of the tumor.
In addition, they are using state-of-the-art imaging technologies, such as intraoperative ultrasound and tumor fluorescence, to “maximize the degree of surgical resection in these patients,” Dr. Shepard said. Essentially, these technologies enable surgeons to remove more of the tumor tissue without affecting the surrounding nerves and brain tissue, he said.
“Intraoperative ultrasound allows us to look at tumors in real time and to accurately assess degrees of resection, while tumor fluorescence enables better visualization of the tumors intraoperatively, basically by making them glow in the dark,” Dr. Shepard explained. “With these technologies, we are really trying to push the boundary on degree of surgical resection because, in general, we know the more tumor you can remove, the better patients will do in terms of progression-free and overall survival.”
Conversely, these technologies also ensure surgeons remove the “appropriate amount of tumor, without causing a neurologic impairment, such as worsening speech, which would obviate the benefits of resection,” he added.
Another technique seeing increased use at the AHN Neuroscience Institute is neuroendoscopy. According to Jody Leonardo, MD, the director of the AHN Adult Hydrocephalus Center and associate director of endoscopic neurosurgery, the approach allows surgeons to visualize and remove blood clots and brain tumors through a small incision that is “about the size of a nickel.”
“LITT is an emerging option for patients whose tumors may be more challenging for open surgical resection.”
—Matthew Shepard, MD, director, AHN brain tumor research
Dr. Leonardo and her team found particular success
with this approach in adults with hydrocephalus, which
is caused by an accumulation of cerebrospinal fluid in
“With neuroendoscopy, we’re able to individualize patient care and provide treatment in a minimally invasive way, without craniotomy or other open surgery,” Dr. Leonardo said.
As important as these technologies and novel approaches are to surgical outcomes at the AHN Neuroscience Institute, the most important tool the center has is its team of skilled surgeons, according to Dr. Shepard.
“It’s not just having the right technology, but it’s having the right technology in the right hands,” he added. “We have the best surgeons in the tri-state region and we know how to tailor our approaches to get the best outcome for the patient in front of us.”
The team of award-winning experts at the Allegheny
Multiple Sclerosis Treatment Center at Allegheny
General Hospital are involved in clinical trials and
taking “deep dives” into outcomes data to incorporate
the latest treatment options for patients with multiple
“We aim to bring to our patients the latest recommendations and treatments for patients with immune disorders,” said Thomas Scott, MD, the director of the Allegheny Multiple Sclerosis Treatment Center, part of the Allegheny Health Network (AHN). “We’ve been studying pharmacological approaches using preapproval medications for three decades at AHN, and have been collecting data for about 25 years concerning disease behavior.”
“We’ve been studying pharmacological approaches using preapproval medications for three decades at AHN, and have been collecting data for about 25 years concerning disease behavior.”
—Thomas Scott, MD, director, Allegheny Multiple Sclerosis Treatment Center
For example, a new class of immune-altering drugs
that includes Bruton tyrosine kinase inhibitors are being
tested as a potential “missing link” in the management
of MS, due to the fact that they target both innate and
adaptive arms of the immune system.1
While dozens of medications are approved to treat various aspects of MS, investigators are at work studying which drug regimens might be best for individual patients. The TREAT-MS trial,2 which is being conducted at the Johns Hopkins University and counts Dr. Scott as an investigator, is addressing an existing lack of evidence-based guidelines to help clinicians and patients determine which treatment strategy is best for an individual with MS.
TREAT-MS Trial is a randomized, controlled trial that plans to recruit 900 patients from more than 4o sites across the United States, including AHN. In order to be eligible, participants must have relapsing-remitting MS and be between the ages of 18 and 60 years. Participants who have been exposed to one or more MS disease-modifying therapies, or have had prior treatment with rituximab, ocrelizumab, ofatumumab, alemtuzumab and/or an experimental aggressive therapy, for more than six months are not eligible.
The goal of the trial is to determine whether some patients would benefit from early, possibly more risky aggressive therapy or if starting with a less aggressive (and, often, less risky) therapy, followed by a switch if breakthrough disease activity occurs, is optimal. In addition, the study will strive to identify short-term biomarker(s) strongly predictive of long-term disability from MS.
In addition to participation in clinical drug trials, the team is involved with research on disease behavior using data on patient outcomes, looking specifically atrisk factors for disease progression—as well as which of these risk factors may be modifiable.
“My generation of doctors has seen a tremendous improvement in the prognosis of MS patients and have changed the natural history of the disease to greatly reduce outcomes for long-term disability,” Dr. Scott said. “The teaching mission of AHN allows us to teach these up-and-coming doctors the latest regarding how to take care of MS patients.”
1. CNS Drugs 2022;36:1019-1030.
2. The TREAT-MS trial:https://treat-mstrial.org/.
In recent years, advances in both pharmacology and
patient monitoring have enabled breakthroughs in
the management of a notoriously difficult condition—
“Typically, with migraines we’ve had to treat patients both with preventive medications and other drugs aimed at targeting headache attacks,” said Andrea S. Synowiec, DO, the system vice chair for Allegheny Health Network’s (AHN’s) Neuroscience Institute. “Historically, that has meant that patients like the attack medicines because they feel sick and the drugs make them feel better, but you can’t use them too often because they cause worsening of the disorder over time.”
This conundrum, Dr. Synowiec added, amounted to a “huge issue” within the field of management of headaches. “It’s been such an annoying thing for everyone involved in migraine treatment to have to say, ‘Here are some pills that work, but you can only use them so often,’” she said.
Under the leadership of director Dolores Santamaria, MD, the Headache Center at the AHN Neuroscience Institute has incorporated the latest, and perhaps most promising, pharmacotherapies into clinical practice. These treatments include novel agents called calcitonin gene—related peptide receptor antagonists, or gepants, which target pain-signaling molecules in the brain. To date, two gepants have been approved by the FDA for use as prophylaxis and/or treatment for acute migraine, and Dr. Synowiec and her colleagues in the Neuroscience Institute are using both agents, with success (Headache 2020;60:1037-1039).
The Headache Center treats patients with primary headache disorder such as migraine, tension headaches and cluster headaches as well as headaches secondary to other medical conditions, including allergies, traumatic brain injuries and sinus infections.
“These medicines are disease-modifying, meaning that they should prevent acute migraine for those taking them but also address the underlying mechanisms causing the migraine,” Dr. Santamaria said.
In addition to encouraging patients to try these emerging therapies, the AHN neurologists have been using an internal registry of headache patients via data built into electronic health records to monitor symptoms and treatment side effects, such as fatigue, over time.
“This data allows us to look at disease markers such as fatigue, sleep quality—things we don’t always have time to ask about during examinations and can be challenging to quantify,” Dr. Synowiec said. “We are beginning to use this information to look at our patient population and start to ask questions about whether treatments not only improve symptoms but allow patients to live their lives with migraine.”
Throughout their nearly 30-year history, the residency
and fellowship programs offered through the Allegheny
Health Network’s (AHN’s) Neuroscience Institute have
emphasized traditional bedside teaching in all aspects
of the field, from basic neuroscience research to
Specifically, the neurosurgery residency program provides a broad-based education across all neurosurgery subspecialties, and it is delivered via clinical and didactic instruction as well as direct surgical training. In addition, residents in the program are actively involved in research and clinical trials conducted through the Neuroscience Institute and are given leadership training, all with an eye toward preparing them to better serve their patients, communities and leaders in medicine.
“The obvious goal of the program is [to] develop residents into competent surgeons, but we also work with them on their professional and personal development, and position them to be future leaders of the field.” said Jody Leonardo, MD, the director of the AHN Neurosurgery Residency Program and director of the AHN Adult Hydrocephalus Center. “The training is really in keeping with our patient-centric approach to care.”
Through the seven-year program, which enrolls two residents annually from a pool of more than 300 applicants from across the country and around the world, residents are directly engaged in patient care—initially under the guidance of more experienced mentors and faculty—and exposed to all of the neurosurgical specialties offered at the AHN Neuroscience Institute, including endovascular neurosurgery, stereotactic radiosurgery, cerebrovascular neurosurgery, complex spine surgery and skull base surgery.
Neurosurgery residents at AHN are exposed to a wide variety of learning opportunities during their residencies that include clinical and didactic instruction as well as surgical exposure and training. A core group of faculty, all of whom are fellowship trained in specialty ares, instruct and guide residents as they develop and strengthen their clinical acumen while building and enhancing surgical techniques. By the end of the program, residents will have established a strong and solid foundation of neurosurgery through which they will be readily prepared to practice neurosurgery, according to Dr. Leonardo.
The curriculum focuses on practical physician development topics including professionalism, ethics, diversity and socioeconomics. Residents gain practical experience in subspecialties such as plastic surgery, trauma ICU, emergency department, neurocritical care, pediatric neurosurgery, endovascular neurosurgery, neuroradiology, stereotactic radiosurgery, neuropathology and research.
“What we are striving to do through our residency program is push the specialty of neurosurgery forward,” said Alexander Yu, MD, the associate director of the AHN Neurosurgery Residency Program and vice chair of neurosurgery within the network. “You achieve that by training residents with a focus on increasing our knowledge base and improving patient care.”
“The obvious goal of the program is [to] develop residents into competent surgeons, but we also work with them on their professional and personal development, and position them to be future leaders of the field.”
——Jody Leonardo, MD, director, AHN Neurosurgery Residency Program
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