Through highly regarded programs and services, Winthrop’s neurology specialists provide expert and compassionate acute and chronic care to inpatients and outpatients with a wide range of diseases and disorders affecting the nervous system. In addition to offering ongoing neurological care, they are available for consultations with patients and physicians, including other neurologists.
Dr. David E. Friedman, Director, Winthrop Comprehensive Epilepsy Center
516.663.4525
Winthrop-University Hospital’s comprehensive Epilepsy Program comprises a multidisciplinary team with experience and expertise in diagnosing, managing and treating all forms of seizures and related disorders.
Coupling this proficiency with highly individualized care tailored to each patient’s specific circumstance, the Epilepsy Program offers a wide range of advanced neuroimaging techniques and electrodiagnostic services, as well as the latest treatment options, including progressive medical care, intricate surgical procedures and minimally invasive neurostimulation.
Dr. Alan B. Ettinger, a prominent epileptologist, and former Director of the LIJ Epilepsy Center, has joined Winthrop and is actively involved in the Epilepsy Program.
What is Epilepsy?
Epilepsy is a complex seizure disorder. Characterized by disabling seizures triggered by abnormal electrical activity in the brain cells, the disease can produce physical convulsions, minor physical signs, thought disturbances or a combination of symptoms. It can be caused by head injuries, brain tumors, lead poisoning, brain developmental problems, genetic and infectious diseases and fevers. In 50% of patients with seizures, no cause can be found. Symptoms, ranging from mild to severe, differ with each patient. At least two unprovoked seizures are required for an epilepsy diagnosis. Several types of seizures are easy to control, and many patients are well enough between episodes to lead normal lives. However, about 30% of the estimated 3 million Americans with epilepsy suffer with persistent seizures.
Diagnosis & Assessment
Diagnosis involves an extensive physical examination, complete medical history and detailed description of past seizures. To identify the affected area(s) and accurately assess patients, Winthrop’s armamentarium of sophisticated diagnostic technology includes computerized tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), single photon emission computed tomography (SPECT) and conventional electroencephalogram (EEG). In addition, neurologists use specialized sleep-deprived EEG, EEG with photic stimuli and long-term EEG monitoring with video telemetry to record brain activity, as well as classify seizures and pinpoint their origin so that effective treatment plans can be implemented.
Treatment Options
Anti-epileptic medications are usually the mainstay of treatment. While many seizures can be managed with one drug, the combination of several medications may be necessary when seizures are difficult to control. The goal is to find the appropriate medication regimen that will provide each patient with optimum seizure control while ensuring the highest possible degree of functional independence.
For patients whose seizures do not respond to medication, or when patients cannot tolerate the medications’ side effects, Winthrop’s neurosurgeons are skilled in the use of vagus nerve stimulation (VNS), which is an advanced treatment option offered by specialized epilepsy programs such as Winthrop’s.
FDA-approved as an adjunctive therapy to reduce seizure intensity and frequency, VNS does not involve invasive brain surgery, is mechanically and electrically safe and has been used in more than 50,000 patients worldwide. The vagus nerve pacemaker-like stimulator is implanted in the chest and inhibits seizures by delivering mild, intermittent electrical pulsed signals to the brain via the vagus nerve. In some cases, direct surgery on appropriate areas in the brain can be used to treat epilepsy.
The Movement Disorders Program at Winthrop is staffed with experts committed to caring for and treating people afflicted with a wide range of conditions, including Parkinson’s disease, essential tremor, other types of tremor, diskinesia and dystonia, Huntington’s disease, ataxia, gait disorders, spasticity and Tourette syndrome. These experts are committed to providing relief, improving quality of life and renewing patients’ independence.
The Program entails close teamwork by neurologists, neurosurgeons, neuropsychologists, neurophysiologists, neuroradiologists and genetics counselors. Understanding that living with a movement disorder affects the entire family, and involves more than the patient’s medical and surgical needs, the team coordinates an integrated program of clinical nursing, nutrition, physical, occupational and speech therapies and social work.
What are Movement Disorders?
A group of complex neurological/neurodegenerative diseases, movement disorders include not only the involuntary slow or diminished movements manifested in conditions such as Parkinson’s disease and essential tremor, but also the fast-paced and frenetic movements seen in dystonia and Tourette syndrome.
Evaluation & Diagnosis
Patients referred to the Program first receive in-depth evaluations and comprehensive diagnostic testing. The initial evaluation consists of a full medical history, thorough physical and neurological examinations and assessments of mental function, psychiatric health, gait, balance, motility, body function and overall health. The state-of-the-art technology available at Winthrop to help pinpoint a movement disorder includes magnetic resonance imaging (MRI), computed tomography (CT) and positron emission tomography (PET) scan brain imaging, as well as electroencephalography (EEG) to examine brain activity, electromyography (EMG) to look at nerve and muscle activity, somatosensory evoked potentials (SSEP) to test brain activity related to sensory stimulation and motor evoked potentials (MEP) to monitor areas of the central nervous system (CNS) controlling movement.
Treatment
Once the diagnosis is made, the movement disorders expert confers with other team specialists, the patient, family and referring physician to create a treatment plan carefully tailored to provide the best therapy for the individual patient’s unique condition and special needs. Many medications work within the complex chemistry of the brain to compensate for some of the imbalances in the brain. These include: L-dopa, as well as newer drugs such as Mirapex and Requip to compensate for the lost dopamine-producing cells in Parkinson’s Disease. Conversely, botulinum toxin injections can selectively relax overactive muscles and spasms in patients with certain types of dystonias.
Medical management can be complex, with a great deal depending on the degree of functional and cognitive impairment, as well as the ability to tolerate the medication. No two patients react the same way to a given drug. Therefore, it takes time, patience and the type of expertise provided by the specialists in the Movement Disorders Program to achieve successful management.
If, or when, medications fail to control or reduce symptoms, or produce side effects that can no longer be tolerated, alternatives are dictated by the type and severity of the disease, as well as the patient’s age and disability level, desires and general medical condition.
While medical therapy is the first line of treatment, surgery is an option for selected patients. Surgical treatments, including thalamic, subthalamic (STN) and globus pallidus (GPi) deep brain stimulation (DBS), are a special area of expertise of the Movement Disorders Program. These procedures — in addition to radiofrequency and radiosurgical ablation, as well as intrathecal (Baclofen) pump surgical placement — can be options for patients who can no longer be adequately managed solely with medical therapy.
Deep Brain Stimulation
Deep brain stimulation (DBS) is a leading functional neurosurgery procedure based on the premise that electronic stimulation of particular regions of the brain can improve the major symptoms of some movement disorders and may permit the team to reduce the amount of medication needed to manage symptoms more effectively.
FDA-approved, DBS is performed in two separate operations. They involve the implantation of a multi-contact electrode lead into the crucial part of the brain considered responsible for — or at least involved in — the pathology of a given disorder and connecting the lead to a pulse generator or “pacemaker” implanted under the skin in the chest. The pulse generator produces a high-frequency pulsed electrical current, which interferes with pathologic brain signals that produce the disabling motor symptoms, such as tremor, rigidity and dyskinesias.
Winthrop Comprehensive Multiple Sclerosis Care Center
The mission of Winthrop’s Multiple Sclerosis (MS) Treatment Center is to provide patients with compassionate care and expertise in the rapidly expanding field of MS therapeutics, promote education about the disease and conduct research to develop increasingly effective and safe therapies that will diminish the impact of the condition on patients and families and enhance the quality of their lives.
Since its inception in 1997, the Center has expanded steadily, now logging about 1,500 patient visits annually. Considered at the forefront of clinical care, the MS Center’s program has received recognition and accreditation from both the National and Long Island MS Societies.
The Center’s team is actively involved in national, state and local organizations responsible for influencing the future direction of MS treatment.
Paralleling the leadership example set by Dr. Gottesman, who serves on the Clinical Advisory Committee of the Long Island MS Society, Sharon Friedman-Urevich, RN, FNP, Coordinator of the Treatment Program, recently founded the Long Island MS Nursing Society, a professional organization whose members share information about clinical care for MS patients, and educate patients about treatment options. She also serves on the Clinical Advisory Committee of the Long Island MS Society.
What is MS?
MS is a chronic inflammatory disease that destroys areas of the protective coating (myelin) that surrounds the nerve fibers in the brain and spinal cord. The cause is unknown. The process (demyelination) disrupts the normal flow of messages through the brain, spinal cord and nerves that control movement, sensation and other neurological functions.
Symptoms vary, reflecting the parts of the brain or spinal cord damaged by the disease. They may come and go or vary in severity from day-to-day and hour-to-hour. The most common early symptoms include: weakness, leg dragging, stiffness, a tendency to drop things, a feeling of heaviness, clumsiness or a lack of coordination. Visual symptoms are also common, including blurred, foggy or hazy vision, eyeball pain, blindness or double vision.
Evaluation & Diagnosis
Disease status can be evaluated only by lengthy detailed physical and cognitive examinations; no diagnostic test (including MRI) can substitute for the clinical examination. However, several tests may help confirm the diagnosis, including: Magnetic resonance imaging (MRI) scan of the brain and spinal cord, lumbar puncture (sometimes called a spinal tap) and cerebrospinal fluid analysis, evoked potential testing, urinary tract tests and neuropsychologic evaluation.
A diagnosis and appropriate treatment plan are established when an experienced clinician has determined that the patient’s history, physical examination and laboratory findings are consistent with MS, and other conditions (“MS mimics”) have been excluded.
Treatment Program
There is no cure for MS. However, medications can reduce the number and severity of attacks, and may slow the progression of the disease. Treatment can also improve quality of life. The level of treatment often depends on how severe symptoms are and how much the disease affects functioning. Treatment may focus on making a relapse shorter or less serious, altering the course of the disease and relieving symptoms.
The Center’s team not only treats the disease, it also helps MS patients manage their physical and psychosocial symptoms. Specialized nursing care – under the direction of Eileen Boylan, RN, and Denise Cheng, RN, nurses certified in MS care – includes training patients and families to inject medications and helping patients manage the often-unpredictable and fluctuating symptoms. Additionally, the team’s relationships with specialists who treat the various symptoms and their ability to expedite referrals, greatly enhances the ability to improve patients’ quality of life.
The Center is one of four registered infusion centers on Long Island to be certified for IV administration of natalizumab (Tysabri®), which has recently been approved by the FDA for return to market. Tysabri® is generally recommended for patients who have had inadequate response to, or are unable to tolerate, other approved MS therapies (such as Copaxone®, Betaseron®, Avonex®, Rebif® and Novantrone®).
Research
Several major research trials are in progress, evaluating the effects of combinations of drugs administered in varying dosages, and by virtue of the clinical research conducted at Winthrop, the Center can offer patients new investigational therapies that would otherwise not be available to them.
The Center’s extensive research includes participating in several multi-center clinical drug trials and studying patient outcomes and risk factors for developing MS. In addition, original research is conducted, including a study of the safety and tolerability of a double dose of Betaseron®, the first FDA-approved medication that effectively reduced the exacerbation rate of MS by one-third.
With new findings highlighting the urgent need to introduce therapeutic agents as soon as MS has been diagnosed, the MS Treatment Center at Winthrop currently participates in several multi-center clinical trials.
The CARES–MSII trial is a Phase III study comparing two annual cycles of intravenous low and high dose Alemtuzumab to three times weekly subcutaneous Interferon Beta –A. Alemtuzumab is a monoclonal antibody. People with Relapsing/Remitting Multiple Sclerosis (RRMS) who have relapsed on therapy are potential candidates for this trial.Winthrop-University Hospital is the only participating study site on Long Island.
The CombiRx trial is a NIH Phase lll evaluation of Avonex® and Copaxone® as monotherapies compared to the combination of both drugs.
For information about participation in a clinical trial at Winthrop’s MS Center, call the Hospital’s Clinical Trail Center at 516.663.9582.
NYS Multiple Sclerosis Consortium (NYSMSC)
Under the rubric of the New York State Multiple Sclerosis Consortium (NYSMSC), the Center is one of 15 facilities collaborating in the study of patient outcomes and risk factors for developing MS. With over 9,000 patients enrolled in this registry, the NYSMSC has amassed one of the world’s largest and most comprehensive epidemiological databases for studying the demographic and clinical aspects of MS. This information has been published and presented at national and international meetings.
Original MS Research Conducted at Winthrop
The Interferon Dose Escalation and Assessment of Safety (IDEAS) extension trial was a study designed and conducted by Dr. Gottesman and Ms. Friedman-Urevich. Patients were monitored for the development of neutralizing antibodies to double dose of Betaseron®.
The original IDEAS trial, designed and conducted solely at Winthrop was a Phase ll study of the safety and tolerability of a double dose of Betaseron®. This was a pilot study to determine if a higher dose of medication is safe, and paved the way for the BEYOND Trial, a large multi-center trial.
Michael Brisman, MD, Co-Director; Chief, Division of Neurosurgery
516.255.9031
Jay Yasen, MD, Director, Neurovascular Laboratory
516.663.4525
Typically, patients with serious neurological problems are treated in medical-surgical ICUs where the traditional orientation is toward the medical or surgical aspects of the patient’s condition. However, neurological diseases and episodes are best treated by experienced specialists highly trained to manage such conditions, which can threaten both survival and brain function.
What is a NeuroICU?
Winthrop-University Hospital’s Neuroscience Intensive Care Unit (NeuroICU) is reserved for patients recovering from complex neurosurgical procedures or those with acute neurological problems. These include: brain hemorrhaging, stroke caused by a blood clot, unremitting epileptic seizures, traumatic brain injury, serious neuromuscular disorders that can cause life-threatening paralysis and tumors or infections of the brain or spinal cord.
Established in 2002 as the first of its kind on Long Island, the Unit includes 14 acute-care beds, six step-down beds, and an expert team of neurosurgeons, neurointensivists, neurologists, nurse practitioners, physician assistants and nurses with extensive training in neurocritical care and the use of advanced monitoring technology. They work as a team to orchestrate the complex range of testing and immediate interventions required to minimize immediate or delayed brain damage and maximize the chances for a full recovery.
Technology
With state-of-the-art technology the NeuroICU staff assess situations such as brain aneurysms, cerebral hemorrhages and strokes. They use:
Continuous EEG Monitoring
Intracranial Pressure Monitoring (ICP)
Licox (Brain Oxygenation) Monitoring
Single Photon Emission Computed Tomography (SPECT)
Procedures
Specialized procedures include:
Hemicraniectomy
Induced Hypothermia
Interventional Neuroradiology Procedures
Plasmapharesis
Specific Pharmacotherapies
Thrombolysis
Ventricular Drainage
Additionally, an array of sophisticated neuroradiology and interventional neuroradiology diagnostic tools are located in close proximity to the NeuroICU. They include:
64-slice Computed Tomography Scanner (CT)
Biplane Digital Angiography system
Computed Tomography Angiography (CTA)
CT Perfusion
Magnetic Resonance Angiograpy (MRA)
Positive Emission Tomography (PET)
Research
Regarding research as vital to the delivery of high-caliber care, the neurological specialists affiliated with the Unit are involved in research to further advance neuroscience. Current studies include:
Apoptosis in intracerebral hemorrhages
Role of activated Factor VII in the acute intracranial bleed
From premature infants in the most precarious health to growing children and adolescents, youngsters receive the full range of care by neurological specialists in Winthrop’s Institute for Neurosciences. Winthrop’s pediatric neurologists are skilled at diagnosing and managing children with a range of neurological issues, including epilepsy, brain tumors, muscular dystrophy and other neuromuscular disorders, Bell's Palsy and other conditions. Long-term management of these often-chronic conditions focuses on meeting each family's individual needs for care and support.
The comprehensive, high quality services provided include:
Neurodevelopmental Screening & Early Intervention
As more and more premature and gravely ill newborns survive, they sometimes do so with neurological or other deficits. These NICU "graduates" are seen on a regular basis in order to ensure early detection of potential developmental lags. A coordinated team of pediatric neurologists, neonatologists, developmental pediatricians and physical therapists performs comprehensive neurodevelopmental evaluations. If developmental delays are detected, arrangements are made to provide appropriate therapy in a variety of settings, including the home, community-based early childhood centers or within the local school system. In addition, every newborn at Winthrop undergoes hearing screening. Early detection of hearing impairment provides the opportunity for early intervention in order to prevent associated language and speech delay.
Diagnosis, Evaluation & Treatment of Seizure Disorders
Tracking down the precise origin of seizures is crucial to prescribing appropriate treatment. Pediatric neurologists have access to the most up-to-date diagnostic techniques to isolate the genesis of seizure disorders, thereby honing in on the most effective medical and/or surgical treatments. With the advent of newer generations of medications, there are now many more options for medical management of seizures with fewer side effects. Children who are not well managed with medication may be candidates for surgical treatments, including resection of seizure focus and/or implantation of a vagus nerve stimulator (to complement or replace medication in the control and prevention of seizures).
Evaluation, Diagnosis & Treatment of Attention Disorders & Learning Disabilities
Pediatric neurologists are part of a multidisciplinary team that provides comprehensive evaluation and diagnosis of children with learning disabilities and attention disorders, including Attention Deficit Hyperactivity Disorder (ADHD). A team approach is emphasized, with close collaboration between pediatric neurologists, teachers and school personnel, behavioral psychologists, and, of course, the family. Recommendations might include counseling, educational assistance, psychological support and medication when appropriate. The ultimate goal is to enable the child to achieve his or her fullest potential.
Treatment of Hydrocephalus & Other Central Nervous System Anomalies
Hydrocephalus, an excessive build-up of cerebrospinal fluid within the brain, can occur in premature or full-term babies. Babies with hydrocephalus as well as those with general disorders of the central nervous system are evaluated and treated by pediatric neurologists and geneticists. In the Institute for Neurosciences, hydrocephalus may be treated with sophisticated endoscopic equipment to assess the cause of the condition and create a pathway (endoscopic third ventriculostomy) to relieve the fluid accumulation, often minimizing the need for a shunt.
Care for Children with Chronic Headaches
Headaches and migraines, common in adults, can affect up to 5% of children, as well. Although more often seen in adolescents, and in girls more than boys, headaches can occur in young children and toddlers. The primary categories are migraines and chronic, recurrent headaches. Headaches in children are rarely linked to more serious underlying conditions. New medications that specifically target migraine pain can be effective in headache management. Preventive medications and techniques can bring relief.
As a regional leader in the field of neuroscience, Winthrop was chosen to be a New York State Stroke Center in 2005. Designated centers include a specialized unit — such as the NeuroICU — dedicated to stroke care with a 24/7, on-call multidisciplinary Stroke Team capable of administering care and adhering to the most up-to-date scientific guidelines and recommendations at a moment’s notice.
Treating more than 500 stroke patients annually, Winthrop recently became the first hospital on Long Island and in Queens to receive the American Heart and American Stroke Associations’ “Gold” level performance achievement award for stroke patient care. To receive the award, the Hospital demonstrated that it aggressively and consistently uses clot-busting medications, (tPA), as well as the Merci® Retriever and Penumbra™ mechanical clot removal systems for emergency patients whose window of opportunity for tPA drug therapy intervention has closed.
Additionally, the Stroke Center offers a Stroke Support Group and a Stroke Peer Visitor Program — the first program of its kind on Long Island — where former stroke patients lend support and encouragement to hospitalized patients.
