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A History of the Barrow Neurological Institute
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Felipe Albuquerque, M.D. Assistant Director of Endovascular Neurosurgery Barrow Neurological Institute
A History of the Barrow Neurological Institute Richard A. Lochhead, Adib A. Abla, Alim P. Mitha, David Fusco, Kaith Almefty, Nader Sanai, Mark E. Oppenlander, Felipe C. Albuquerque
The Barrow Neurological Institute (BNI), founded in 1961, is in partnership with St. Joseph’s Hospital and Medical Center and part of the Catholic Healthcare West system. The BNI is a relative newcomer to academic neuroscience. However, since its inception it has grown to become an international destination for neurologic disease. This article describes the history of the institute as it has grown over the years in its commitment to excellence in patient care, education, and research.
THE BEGINNING: JOHN GREEN
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he BNI was founded through the vision of one neurosurgeon, John Green, M.D. (1915-1990). Doctor Green completed medical school at Northwestern University in 1941 and then trained under Eric Oldberg, Cushing’s last resident, at the Illinois Neuropsychiatric Institute. Green completed a fellowship in epilepsy surgery at the Illinois Neuropsychiatric Institute under Percival Bailey (Figure 1). John Green’s career was interrupted in 1944 when he was called into service by the Navy. While stationed in Leyte, he contracted strep
Key words 䡲 Barrow Neurological Instititue 䡲 History 䡲 Neurosurgery 䡲 Robert Spetzler Abbreviations and Acronyms BNI: Barrow Neurological Institute BBTRC: Barrow Brain Tumor Research Center BRAT: Barrow Ruptured Aneurysm Trial CARF: Commission on Accreditation of Rehabilitative Facilities DBS: Deep brain stimulation FDA: Food and Drug Administration MAPC: Muhammad Ali Parkinson Center MR: Magnetic resonance MDA: Muscular Dystrophy Association NIH: National Institutes of Health
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throat and subsequently developed rheumatic fever and early arthritis. When he returned to Chicago, he noticed that the cold winters worsened his arthritis. In 1947, while looking at a map of currently located neurosurgeons in Dr. Paul Bucy’s office, he noticed an absence of this specialty in Arizona. This fact, coupled with the threat of worsening arthritis, prompted Green to move to the dry and warm climate of Phoenix. He was Arizona’s first neurosurgeon, arriving with a set of surgical instruments, a chief operating room nurse from Chicago, and his wife (5). Green was one of the few neurosurgeons between Los Angeles and Dallas and dreamed of establishing a neurologic institute after the tradition of Penfield’s Montreal Neurological institute. Green’s purpose for the institute was threefold: 1) a center for the diagnosis and treatment of neurologic disease, 2) a center for basic and translational neurologic research, and 3) a center for training neurologic surgeons, neurologists, and neurologic researchers (5). Very few resources were available for Green to establish the institute. Without a philanthropic effort, building the institute would have been impossible. Green initially sought funding from the Rockefeller Foundation, but this possibility fell through after the foundation changed its funding priorities. Fate intervened, however, when a wealthy businessman and philanthropist, Charles Bar-
From the Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, USA To whom correspondence should be addressed: Felipe C. Albuquerque, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2010) 74, 1:71-80. DOI: 10.1016/j.wneu.2010.07.011 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2010 Published by Elsevier Inc.
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Figure 2. Barrow Neurological Institute as it appeared in 1962. Used with permission from Barrow Neurological Institute.
Figure 1. John R. Green, M.D., founder and first medical director of the BNI. Used with permission from Barrow Neurological Institute.
row, brought his wife, originally operated on by Dr. James Gardner at the Cleveland Clinic, to Green for treatment of a recurrent oligodendroglioma. Green debulked the tumor for a total of seven operations and extended her life for 17 years. Barrow subsequently developed a close relationship with Green, Sister Mary Placida, and the other Sisters of Mercy, who administered and owned St. Joseph’s Hospital. In 1958, Charles Barrow initially donated $500,000 under the condition that the funds be matched by a private entity, which it was by the Hill-Burton fund. The $1 million gift resulted in the announcement of the BNI on January 24, 1959, to be built at St. Joseph’s Hospital in honor of Charles Barrow’s father, William. Construction started in 1961 and finished in 1962 (Figure 2). The total cost of construction totaled more than $2.5 million; the Barrows increased the amount of their donation to $1.1 million, and the National Institutes of Health donated $53,695, whereas the Sisters donated in the form of land (worth approx. $800,000). Almost immediately, John Green made it a goal to obtain the latest equipment and technology and asked fellow neurosurgeons to donate $52 per month. He encouraged them to donate and instilled the philosophy that permeates the recent history of the Barrow: to always give first if you want others to donate (5). The plans for the institute were developed with the help of a consultants’ committee that Green created and that included many prominent neurosurgeons such as Percival Bailey, Paul Bucy, and Wilder Penfield. The neurologic institute would focus on patient care, education, and research. It would open with five
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neurologic divisions. John Green was the first chair of neurologic surgery; David Daly was the chair of neurology; James Kernohan was the chair of neuropathology; James T. Riordan was the chair of neuroradiology; and Eduardo Eidelberg was the chair of neurobiology. The BNI continued to grow under Green’s tenure as director. The Sisters of Mercy could not underwrite the research component of the hospital, so Green formed the Barrow Neurological Foundation to provide financial support for neurologic research. Green raised more than $3 million in endowments and sizable donations for capital purchases and research projects. By the end of the institute’s first decade, the number of neurosurgeons had doubled, the number of residents had tripled, the number of neurosurgical procedures had nearly quadrupled, and the number of admissions had increased almost fivefold. In 1972, to accommodate such growth, three new stories were added to the original BNI wing. The first BNI Symposium was held in 1974. In 1976 the Division of Neuroanesthesiology was added under the direction of Elizabeth Wilkinson, M.D., reflecting the increasing need for clinical specialization (5). After 2 decades of devotion to the BNI, Green began his search for a successor. James Atkinson, who established the neurosurgical research laboratory and designed the Stereotactic Operating Room at the BNI, was being groomed for the job. He and his wife, however, tragically died on February 12, 1978, in an airplane crash. Bob Crowell from Harvard was selected as the next neurosurgery chairman but left after two years for personal reasons. After an extensive search, Robert F. Spetzler, M.D., from Case Western Reserve University, who trained as a cerebrovascular surgeon under Charles Wilson, M.D., at the University of California San Francisco (UCSF), became the third chair of neurosurgery at the BNI in 1983 (Figure 3).
1983 TO PRESENT Doctor Spetzler has continued to build on the foundation that Green established with a renewed commitment to clinical and academic
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Figure 3. Robert F. Spetzler, M.D., medical director of BNI, 1983 to the present. Used with permission from Barrow Neurological Institute.
excellence. Spetzler did this by surrounding himself with excellent personnel, a commitment to research and education, and robust fundraising. Today the BNI is an internationally renowned medical center for neurologic disease. The BNI aims to be the model of excellence through dedication to patients, commitment to sound medical practice, and the most advanced neurologic and neurosurgical techniques for the treatment of neurologic disease. The mission is to advance the knowledge and practice of medicine in neuroscience through basic and clinic research, to educate medical professionals, and to develop innovations in clinical techniques and technology.
Vascular and Endovascular Neurosurgery Before coming to the BNI, Spetzler served as associate professor of neurosurgery at Case Western Reserve University. Early in his career he established himself in the forefront of the field with seminal publications on a variety of cerebrovascular disease topics. This oeuvre included the first report of superficial temporal artery-tomiddle cerebral artery onlay grafting, the theory of reperfusion hemorrhage, and numerous other papers on microsurgical bypass surgery for the treatment of cerebrovascular occlusive diseases and aneurysms (11, 13-15). Over the years, the referral base for cerebrovascular cases flourished under Spetzler’s masterful skill and international reputation. In 1986, Spetzler and Neil Martin, a cerebrovascular fellow at the time, proposed a simple yet practical grading system for arterio-
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venous malformations that stratified lesions based on their size, pattern of venous drainage, and eloquence of adjacent brain tissue (12). Designed to predict the morbidity and mortality associated with surgical treatment of arteriovenous malformations, the grading system instantly gained international attention. A 1987 publication describing the magnetic resonance (MR) imaging appearance of cavernous malformations helped the BNI gain recognition in the clinical arena of cerebrovascular diseases (9). Both articles eventually became among the most cited publications in the neurosurgical literature (7). The success of several high-profile neurovascular cases also helped propel the notoriety of the BNI in this area. In 1995, Spetzler led BNI surgeons to perform the world’s first hypothermic circulatory arrest procedure in a pregnant woman for the clipping of a giant basilar tip aneurysm (18). The patient, Cheryl Jones, did well and successfully delivered a healthy boy several months later. In 2002, Spetzler successfully used hypothermic circulatory arrest to operate on a 5-year-old boy who, at that time, was the youngest patient ever to undergo this procedure. Although the BNI is recognized as one of the premier clinical institutes for the treatment of cerebrovascular diseases, its academic contribution to the field has been equally important. The recruitment of Spetzler brought with it a National Institutes of Health (NIH) RO2 grant to evaluate a multitude of stroke therapies (16, 20). Spetzler then established and became director of the cerebrovascular research laboratory, fostering basic science and translational research. In 1994, Spetzler became the youngest neurosurgeon ever chosen as the Honored Guest of the Congress of Neurological Surgeons. Over the years, this unique combination of opportunities in clinical and academic neurosurgery has attracted additional talent that has further raised the profile of the BNI in the treatment of cerebrovascular diseases. Joseph M. Zabramski, M.D., was recruited to the BNI in 1986. Having a particular interest in cavernous malformations, he and researcher Eric W. Johnson, Ph.D., localized the gene believed to be the cause of the familial form of the disease in 1995 (4). Peter Nakaji, M.D., completed his fellowship at the BNI in cerebrovascular and cranial base surgery in 2004 before joining the BNI staff with clinical and academic interests in cerebrovascular surgery as well as in cranial base and endoscopic neurosurgery. Despite its strong roots in open surgery, the BNI was quick to embrace endovascular techniques as a less invasive method of treatment for cerebrovascular diseases. In 1995, Cameron McDougall, M.D., joined the BNI as one of North America’s first neurosurgeons trained in neurointerventional techniques. After completing his neurosurgical residency at the University of Saskatchewan in Canada, he completed a fellowship in endovascular neurosurgery at UCSF under Dr. Grant Hieshima, a renowned pioneer in interventional neuroradiology. McDougall has served as the principal investigator of a number of landmark studies on the efficacy of various endovascular devices and techniques. This work resulted in several publications that led to the Food and Drug Administration’s (FDA’s) approval of new embolic agents, including detachable silicon balloons and n-butyl cyanoacrylate (6). Felipe C. Albuquerque, M.D., completed his residency at the University of Southern California and then joined the BNI in
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1999, where he completed his cerebrovascular and endovascular fellowship training. In 2001, he joined the BNI staff and, together with McDougall, has helped the BNI achieve among the nation’s largest experience of intracranial stenting cases for atherosclerotic disease as well as for Onyx embolization procedures for the treatment of intracranial dural arteriovenous fistulas (1, 2, 17). The BNI continues to make great strides in its clinical and academic contributions to cerebrovascular and endovascular neurosurgery. Its experience with the surgical treatment of intracranial aneurysms is unparalleled: Spetzler alone has treated more than 5600 aneurysms. Likewise, the BNI’s early impact on the fund of knowledge toward the treatment of cavernous malformations has made it a major referral center for lesions located in complex areas of the central nervous system. The BNI surgical experience includes almost 300 brainstem cavernous malformations and more than 80 spinal cord cavernous malformations. Novel indications for existing techniques such as venous stenting for pseudotumor cerebri and innovations in surgical technique such as retractorless surgery and intraoperative confocal microscopy continue to be a focus of the BNI. Similarly, several important clinical studies, including the Barrow Ruptured Aneurysm Trial (BRAT), designed to compare the efficacy and outcome of ruptured aneurysms that are clipped versus coiled, have poised the BNI to continue its tradition of making important contributions to the diagnosis and management of patients with cerebrovascular disorders. Spinal Neurosurgery In the 1960s and 1970s, neurosurgeons made few contributions to the advancement of spinal surgery. Although a small number of neurosurgeons tried to emphasize the importance of spine, academic and organized neurosurgery as a whole was complacent concerning spine. This attitude changed in the 1980s when orthopedic surgery tried to obtain accreditation for spine fellowships. Organized neurosurgery feared the orthopedic community would take over the complete care of spine. During this period, Spetzler recruited Volker K. H. Sonntag, M.D., from a private practice in Phoenix, Arizona, to join him at the BNI and to direct spinal neurosurgery (Figure 4). Sonntag played an active role in bringing spine surgery back into the domain of the practicing and academic neurosurgeon. Sonntag’s interest in spinal instrumentation was met with a high level of scrutiny by others in the medical community. When he began performing thoracolumbar instrumentation, orthopedic surgeons saw his efforts as infringing on their specialty and only after his practice underwent outside review was the matter settled (10). Like Spetzler, Sonntag was a leader in his field both clinically and academically. In 1995, he performed neck surgery on the wife of King Fahd of Saudi Arabia. In 2002 he was chosen as Honored Guest of the Congress of Neurological Surgeons. Sonntag authored more than 500 journal articles, coedited six major textbooks, authored more than 90 textbook chapters, and made 900 presentations with an emphasis on spinal instrumentation, cervical disease, and spine biomechanics. Under the guidance of Sonntag, the Spine Section at the BNI grew prolifically in clinical volume and complexity. Other spine neurosurgeons joined Sonntag and included Curtis Dickman, M.D., Stephen Papadopoulos, M.D., and Nicholas Theodore, M.D. Dickman and Sonntag played central roles as spine surgery faced rampant litiga-
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Figure 4. Volker K. H. Sonntag, M.D., former vice chair of the division of neurologic surgery and former program director of the neurosurgical residency program, retired in 2009. Used with permission from Barrow Neurological Institute.
tion over pedicle screw use in the 1990s (10). Dickman coauthored a paper that was integral in obtaining FDA class 2 recommendation for pedicle screw fixation (19), which led to many malpractice suits being dropped. Dickman also pioneered the use of thoracoscopy for spinal disorders and founded the Spinal Biomechanics Laboratory at BNI. Papadopoulos completed a spine fellowship under Sonntag and helped pioneer the field of image guidance in neurosurgical procedures. Theodore has several studies in the field of spine trauma, spinal cord injury, and complex spinal disorders. Recently, Randall W. Porter, Taro Kaibara, and Steve W. Chang, M.D., have helped develop minimally invasive techniques for spinal decompression and instrumentation. In December 2009, Volker Sonntag retired from practicing neurosurgery. His career focused on excellence in patient care, resident education, and neurosurgical research and serves as an example of what the BNI strives to accomplish. Pediatrics Harold L. Rekate, M.D., has led the Section of Pediatric Neurosurgery at the BNI since he was recruited from Case Western Reserve University in 1984. At that time, he was the first pediatric neurosurgeon in the State of Arizona. Rekate has clinical and research expertise in the fields of spina bifida and cerebrospinal fluid physiology. He has authored over 130 articles with an emphasis on the pathophysiology, treatment, and complications of treatment of various forms of hydrocephalus. In 2003, Rekate became director of the new Hypothalamic Hamartoma Program, a ground-breaking clinical center that focuses on evaluating, diagnosing, treating, and counseling patients with this disorder and their families. In 2008, Ruth Bristol, M.D., joined the BNI with a special interest in pediatric brain tumors, spine tumors, and developmental anomalies. Neuro-Oncology Since its inception, BNI has been a neurologic pioneer, leading the way in the development of cutting-edge treatments and surgical
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procedures, research and the creation of outstanding programs and centers. One of the areas in which BNI has forged numerous advancements is brain tumor diagnosis and neurosurgery. Every year, Barrow treats thousands of patients with brain tumors, including some of the most difficult cases in the world. The BNI has a multidisciplinary team of brain tumor specialists that focuses on each patient’s specific needs to determine the best treatment options. The team’s commitment to patient care is augmented by the newest advances in surgical techniques, radiotherapy, chemotherapy, and neurodiagnostic imaging. Kris Smith, M.D., specializes in the comprehensive management of brain tumors that utilizes stereotaxis, endoscopy, computer image guidance, brain mapping, and Gamma Knife radiosurgery. Randall Porter, M.D., is codirector of the Barrow Acoustic Neuroma Center, which provides comprehensive evaluation, diagnostic testing, and treatment for patients with acoustic neuromas. William White, M.D., joined the BNI in 1976 and directs the Barrow Pituitary Center, which is composed of specialists in endocrinology, neurology, neuro-ophthalmology, neuropathology, neuroradiology, neurosurgery, and radiation oncology. White brought the subspecialty of the transsphenoidal surgical technique to the BNI and has performed more than 1,500 pituitary surgeries. In 2010, the BNI established the Barrow Brain Tumor Research Center (BBTRC), a multidisciplinary research program led by Nader Sanai, M.D., and composed of integrated clinical-translational units that combine neuroscience with neuro-oncology clinical trials. The scientific platform for the BBTRC consists of five independent laboratories, investigating distinct, but interrelated, mechanisms driving brain tumor formation: 1) stem cell neuro-oncology, 2) meningioma biology, 3) bioinformatics and neuro-epidemiology, 4) molecular neuro-oncology, and 5) brain tumor immune-evasion. Each laboratory functions as a collaborative workspace, where teams of graduate students, postdoctoral fellows, and neurosurgery residents work alongside neurosurgeons, neuro-oncologists, neuropathologists, and neuro-imaging specialists to assemble basic science, translational, and clinical research elements into novel strategies for brain tumor diagnostics, therapy, and monitoring. Each laboratory core is designed to feed into the BBTRC’s clinical trials infrastructure, focusing on high-throughput phase I and II studies to develop and validate promising therapies that are then built into larger phase III studies. This interconnected architecture blurs the line between basic science and clinical research, funneling the Barrow’s clinical volume into experimental therapy programs that offer every brain tumor patient at least one investigational therapeutic option, irrespective of diagnosis or stage of disease. Taken together, the BBTRC represents a natural extension of the BNI’s legacies in vascular and spinal neurosurgery, establishing a new substrate for the next generation of neurosurgical innovations from the Barrow. Functional Neurosurgery The BNI’s roots in functional neurosurgery began in 1950 when John Green began performing epilepsy surgery. Green published numerous scientific reports on epilepsy surgery, including temporal lobe operations and epilepsy surgery for children and teenagers. Since then, BNI has become a leader in functional neurosurgery. The Muhammad Ali Parkinson’s Center (Figure 5) focuses on the
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Figure 5. The Muhammad Ali Parkinson’s Center. Used with permission from Barrow Neurological Institute.
diagnosis and treatment of movement disorders and is led by neurologist Abraham Lieberman, M.D. The Epilepsy Center at the BNI offers an epilepsy team that includes neurologists, neurosurgeons, neuropsychologists, neuroscience nurses, and clinical and basic researchers who focus exclusively on the diagnosis and treatment of epilepsy. In 1991, the BNI established a dedicated epilepsy monitoring unit, which is now the most active epilepsy monitoring program in the Southwest and one of the largest diagnostic monitoring units in the United states. In 1998, Barrow researchers, led by Eric Johnson, Ph.D., identified FEB2, one of the genes related to febrile seizures in children (3). Andrew Shetter, M.D., and Kris Smith, M.D., who both completed their neurosurgery residency at the BNI, assist in the treatment of movement disorders and epilepsy with deep brain stimulation, vagal nerve stimulators, radiosurgery, and surgical resection. The BNI has recently proposed to build the Center for Adaptive Brain Function, which is led by a team of world-class medical and research experts to pioneer new paths for treatment of functional brain disorders. The center will work to improve current therapies and expand the uses of deep brain stimulation (DBS) to treat some of the most common, yet destructive neurologic disorders. DBS is used largely to treat Parkinson disease. DBS will be studied and developed into cutting-edge treatment for many conditions, which include bipolar disorder, depression, and Alzheimer disease.
Stroke The Barrow Stroke Center is one of the most experienced and expert stroke programs in the country, caring for more stroke victims than any other center in the southwestern United States. Neurologist James Frey, M.D., directs the BNI stroke team, which is composed of neurologists, vascular and endovascular neurosurgeons, neuroradiologists, neuroscience nurses, case managers, and rehabilitation specialists. The team focuses on quick, aggressive revascularization, stroke prevention, public education and outreach, stroke research, and rehabilitation.
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Neurology The Division of Neurology was one of five original divisions when the BNI opened in 1962. David Daly, M.D., headed the original group of three neurologists and was succeeded by Joseph C. White Jr., M.D., in 1966. In 1988 the Kemper and Ethel Marley Chair of Neurology was established with a $1 million endowment. William Shapiro, M.D., was recruited from Memorial Sloan Kettering Cancer Institute to be the first to hold the new chair. Shapiro recruited Abraham Lieberman, M.D., an internationally recognized leader in Parkinson disease (5). In 1997 Lieberman helped establish the Muhammad Ali Parkinson Center (MAPC) and Movement Disorders Clinic, which is now a National Parkinson Foundation Center of Excellence. The collaboration between neurology and neurosurgery has continued to strengthen the neuro-oncology, epilepsy, stroke, and movement disorder programs. The Division of Child Neurology at the BNI is the largest child neurology group in Arizona and dedicated to the clinical care, education, and research in pediatric neurologic disorders. Multiple sclerosis specialists at the BNI, led by Roberto Bomprezzi, M.D., strive to alleviate patients’ symptoms, to educate patients about their care and the course of their illness, and to find new ways to treat and possibly one day to cure multiple sclerosis. The Barrow MDA Clinic is financially supported by the Muscular Dystrophy Association (MDA) and directed by Doctors Shafeeq Ladha and John Bodensteiner. The clinic coordinates comprehensive physical and psychosocial care for the complex needs of patients with neuromuscular disease. Services include diagnostic testing; regular follow-up evaluations; development of individualized patient care plans; disease education for patients and families; and referrals to support groups, resources, and educational programs. The Laboratory of Neuromuscular Disorders conducts clinical and basic research on the molecular genetics of hereditary neurologic and neuromuscular disorders. The goal of this research is to improve treatment and to identify the causes of these devastating diseases that can result in significant disability or death.
Neuropathology The Division of Neuropathology has been a part of the BNI since its inception. James Kernoham, M.D., from the Mayo Clinic in Rochester served as the first chair of neuropathology until 1964 when John D. Waggener, M.D., assumed the position. Peter C. Johnson, M.D., formerly from Minnesota and the University of Arizona in Tucson, succeeded Waggener in December 1983, becoming the only such board-certified specialist in the state at the time. A second full-time neuropathologist, Stephen Coons, M.D., was added in 1989. In 1996, Coons became the chair of the Division (5). Research from the department focuses primarily on molecular markers of prognosis in gliomas, meningiomas, and pituitary adenomas and the relationship between hypothalamic hamartomas and epileptogenics. Jenny Eschbacher, M.D., joined the program in 2009 with emphasis on exploring intraoperative, confocal microscopy as a clinical tool to provide immediate diagnostic information.
Neuroradiology The Division of Neuroradiology was established with the founding of the BNI. James T. Riordan, M.D., the first chair of neuroradiology,
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was succeeded by Robert E. Flynn, M.D., in 1964. In 1986, Burton P. Drayer, M.D., a leader in neuroimaging, was recruited from Duke to lead new research and education efforts. With Drayer and research physicist Paul Keller, Ph.D., an expert in MR imaging, the BNI became a premier developmental site, especially in MR angiography. The growth in clinical neuroimaging studies was explosive, increasing from approximately 900 in 1985 to approximately 7500 in 1989. A second high-field MR imaging unit was added in 1988 and a third in 1994 (5). Currently, St. Joseph’s is home to four biplane neuroangiography suites, three 3-T MRIs, four 1.5-T MRIs, one 3-T intraoperative MRI, one 7-T research MRI, and multiple CTs. In 2006 the Division of Neuroradiology completed 63,300 examinations, including 43,300 CT scans and 20,000 MR scans and more than 1000 angiograms. There are currently 10 neuroradiologists, 3 physicists, and 9 neuroradiology fellows.
Neurorehabilitation Neurorehabilitative Services at Barrow consists of both in- and outpatient interdisciplinary teams of specialists and offers unparalleled rehabilitative care for individuals with brain and spinal cord diseases, injuries, and conditions. The primary goal of Barrow neurorehabilitation specialists is to enhance patient quality of life through improved skills, maximized independence, and renewed self-esteem. Services include physiatrists; rehabilitation nurses; social workers; case management professionals; physical, occupational, speech, and recreational therapists; and neuropsychologists. Barrow’s unique rehabilitation programs include aquatic therapy, community reintegration, peer mentorship, horticulture, cooking, and ceramics. Eleven neurorehabilitation programs at Barrow have been accredited by the Commission on Accreditation of Rehabilitative Facilities (CARF). In 2009 Barrow Neurological Associates, the private practice of the neurosurgeons, opened the NeuroSpine and Rehab Center, a state-of-the-art facility providing patients with both imaging services and nonsurgical options for the treatment of spine disorders (Figure 6).
Nursing Dedicated neuroscience nursing began at Barrow with its opening in 1962. At that time, the idea of dedicated neuroscience nursing was a relatively new concept. The first nurses at the BNI worked in one of three newly established units: the operating room, the neurosurgical intensive care unit, or the general neurosurgical-neurological ward. In the early 1990s, the BNI began employing nurse practitioners (NPs) to assist in the hospital care of neurosurgical patients. At that time, no other hospitals in the country employed NPs in their division of neurologic surgery. The BNI has more certified neuroscience registered nurses than any other hospital in the country. Like the BNI physicians, the BNI nursing staff is academically active. They have developed course training in neuroscience nursing. Barrow nurses have made more than 100 presentations at national meetings and more than a dozen at international meetings. Three BNI neuroscience registered nurses, Marilyn Ricci, Tobie Anchie, and Virginia Prendergast, have served as president of the American Association of Neuroscience Nurses (8).
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A large source of the philanthropic effort at BNI comes from private foundations, which include the Barrow Women’s Board, NIH, individuals, or public funding. Almost half of all the fundraising dollars go to research.Recently,venturecapitalism and venture philanthropy have helped fund groundbreaking BNI research that can transform intellectual material into patents, inventions, and eventually commercial products. Two of the major fundraising efforts at BNI have been the Celebrity Fight Night and the Lou Grubb Golf Tournament. The Lou Grubb Golf Tournament, an annual golf tournament held in the spring, has raised more than $4.5 million with a record effort of more than $500,000 in 2008. It Figure 6. Opening of the BNA NeuroSpine and Rehab Center in 2009 with guests (left to right) Cody Unser and was established by successful philanthropists Deborah and Bruce Downey. Used with permission from Barrow Neurological Institute. local car dealership businessman, Lou Grubb after he was THE FUNDRAISING EFFORT operated on by Dr. Spetzler for a ruptured posterior inferior cerebellar artery aneurysm in 1986. Later, Catapulting an institute into the prominence that BNI has achieved his annual charity tournament donated its proceeds to BNI as way of cannot be done without certain key elements that go hand and hand showing his gratitude. with this mission, namely, the benefactors and fundraising needed Celebrity Fight Night has been another major fundraising effort. to fund medical progress and to support the building of major hosIt is an annual event that has been held 16 times and has raised pital and research infrastructure. Revenue and local/state governapproximately $60 million. The largest benefactor is the Muhamment funding alone cannot account for all of the financial contribumad Ali Parkinson Research Center, which became the primary tions necessary to build a world-class medical institute; fundraising benefactor in 1997 for the annual event. It is a star-studded night and becomes a necessary and integral component. Medical research is features celebrities, professional athletes, and the featured guest, the core to developing new treatments and requires strong financial Muhammad Ali. The night is filled with live auctions and music support. Securing funding for research depends largely on demonperformances by many of the country’s hottest stars. The event has strating (advertising) the mission and merits of the institution while sought to raise awareness of and to secure funding for research on forming ties with prominent figures who bring an institution into Parkinson disease. It is one of the nation’s largest fundraising onethe national spotlight. night events of its kind. Over the years, showcasing the new, cutting-edge, and lifeIncreasing the national and international reputation of the BNI saving procedures that have been performed at the Barrow Neuhas been key to its growth and fundraising ability. In 1987 the BNI rological Institute has played a crucial role in fundraising. While sponsored America’s Brain Trust as part of its 25th Anniversary touting the advances in both operative technique and neurosurcelebration. This event generated significant publicity and was gical science, the philanthropic effort has been served by increasmoderated by Marvin Kalb, former vice president Walter Moning publicity and society’s awareness of the work being perdale, former president Gerald Ford, and Dr. Henry Kissinger. In formed, encouraging donations in support of a continuous push the same year, Pope John Paul II visited the BNI, the only hospital for excellence. so honored during his 10-day tour of the United States. In 1988, In the beginning, John Green was able to start the BNI after the Loyal Davis Neurosurgical Research Laboratory was estabCharles Barrow made a large donation. However, it has been Spetzlished in Davis’ honor and announced by his step-daughter, the ler’s talent for fundraising that has allowed the BNI to achieve its former first-lady, Nancy Reagan. Loyal Davis had been a neurointernational prominence. Spetzler has led by example with genersurgeon and director of the BNI from 1966 to 1967, and his wife ous monetary donations, and he has treated many of the individuals Edith helped establish the Women’s Board at Barrow. He died in who eventually made significant contributions to the BNI. He has 1982 and she in 1987, and the Research Laboratory was estabgiven tirelessly of his personal time to attend fundraisers, banquets, lished in their memory. Nancy Reagan was invited for the laboraand events, championing this cause.
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Figure 7. The new clinical neuroscience tower opened in 2006. Used with permission from Barrow Neurological Institute.
tory’s dedication, and the Spetzlers later toured the White House, visited with the Reagans in Washington, and attended a state dinner with Dr. Spetzler sitting with Nancy Reagan and the Guest of Honor. Finally, personal donations from physicians, largely from neurosurgeons at the BNI, have been a significant part of the philanthropy, grossing more than $7 million since 1989. The BNI has raised approximately $174 million since 1993 and more than $200 million since 1983.
BUILDING PROJECTS The patient care, research, and educational capacities of the BNI have greatly expanded since its opening in 1962. Critical to this expansion have been several recent additions to the infrastructure of both the BNI and St. Joseph’s Hospital and Medical Center. In 1997, the BNI opened the 70,000-square-foot Neuroscience Research Center with laboratories dedicated to basic research in neuro-oncology, neurobiology, neurochemistry, neurogenetics, pain, and epilepsy. The new Barrow Neurosciences Tower opened its doors in July 2006 with a vision to unite technology, efficiency, comfort, and family-centered care (Figure 7). With the addition of 144 beds, the new Tower helped to make SJMHC the largest provider of inpatient services in Arizona and one of the premier neuroscience centers in the world. The 144 beds dedicated to neuroscience patients consist of 64 ICU-level and 80 ward-level private rooms, with specific sections dedicated to epilepsy, spine, and stroke care. Eleven state-ofthe-art surgical suites are dedicated to neurosurgery and equipped with MED Presence video-conferencing capability, Zeiss stereotaxisintegrated operating microscopes, multidisplay plasma screens, boom-suspended surgical and anesthesia equipment, and access to a 3-T intraoperative MR scanner. Special areas to encourage patient and family comfort and healing include private baths in all rooms, a healing garden, a meditation and prayer room, and a family education center. More than 1000 pieces of inspirational artwork are on display throughout the building. For many neurosurgical patients, a successful surgery or treatment is often just a first step down a long road to recovery. The
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opening of the $24-million Deborah and Bruce Downey Neuro Rehabilitation Center in February 2007 not only enhanced Barrow’s ability to care for these patients but also expanded its capacity. For a unit with a multipage waiting list, the move into a newly renovated space was significant. The new center offers 52 patient beds for the 520 patients it admits each year, with 18 private and 17 semiprivate rooms. The center is the only rehabilitation unit in the state with CARF accreditation for its brain and spinal cord injury programs. Three gyms, a transitional apartment, ceiling lifts, and voice-activated environmental-control units round out the modernized facility. Presently, funds are being raised to incorporate a new aquatic therapy center into the spectrum of rehabilitation services. The Ashlyn Dyer Aquatic Center, led by Dr. Christine Kwasnika, will serve not only inpatients and outpatients needing rehabilitation at Barrow but will provide multiple services to the larger community. Dedicated to developing new medical technology and innovations for improved diagnostic care, the 5000-square-foot, $5.2-million Keller Center for Imaging and Innovation opened in early 2008. The crown jewel of the Keller Center is a 3-T multinuclear MR scanner dedicated to imaging research. In fact, recent data generated from investigations utilizing the multinuclear scanner were crucial to the development of PROPELLER technology, well-known to reduce motion artifact and to improve resolution in many MRI sequences. The clinical partner of the Keller Center is the new 17,000-squarefoot Outpatient Imaging Center, opened in early 2010 to provide comprehensive diagnostic imaging services. The new center offers a team of board-certified radiologists and neuroradiologists, technologists, and staff who supervise digital mammography, MR, CT, positron emission tomography, and nuclear medicine testing for about 1500 patients each month. The original Muhammad Ali Parkinson Center opened in 1997, servicing about 800 new patients annually. In 2009, thanks to the promotion and support of Muhammad Ali, Celebrity Fight Night, and multiple charity funds, the new $4-million Muhammad Ali Parkinson Center initiated a significant expansion of specialized movement disorder services. The new facility is expected to see twice as many new Parkinson patients annually, with thousands more attending bilingual classes in caregiver education, tai chi, ballroom dancing, and golf therapy. The center features 10 examination rooms, a tremor examination room, a botulinum toxin treatment room, a tilt room to help evaluate patients with orthostatic hypertension, and a Balance Laboratory. Long named a Center of Excellence by the National Parkinson’s Foundation, the center is a model both nationally and internationally for providing integrated care in movement disorders. The MED Presence video conference room was finished in 2006. This room allows the surgeon’s view to be viewed by the entire room and allows audio and visual interaction with the surgical suite (Figure 8). This capability improves the educational experience for residents, nurses, and others studying neurosurgery. The MED Presence also allows for a video link via the Internet to locations around the world and is used for interactive conferences, consultation services, live surgery, and education. Further clinical, research, and educational needs continue to arise, and many projects are on the horizon to meet those challenges. In honor of Dr. Volker Sonntag’s many contributions to neurosurgical education at the BNI, a new educational facility will begin construction in early 2011 in his honor. This 3000-square-foot
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1986 to help facilitate academic publications and presentations. That same year the BNI Quarterly was first published and continues to publish on several neuroscience topics. The publications office has grown from one editor and one illustrator to now include a doctorate-holding editor, assistant editor, production editor, two editorial assistants, two master’s-prepared medical illustrators, medical animator, and interactive media specialist. Since 1986, the office has helped produce a dozen textbooks, thousands of articles and manuscript reviews, and has created thousands of medical illustrations to enhance the educational mission of the BNI.
Figure 8. The MED Presence video conference and interactive education room. Used with permission from Barrow Neurological Institute.
state-of-the-art building will have seating for up to 200 people and will be located outside the entrance of the Marley Lobby. It will house the latest electronic audio and video equipment to accommodate lectures and live surgery demonstrations and will provide space for medical devices exhibits and overflow meeting space for some of the many educational conferences that Barrow hosts each year.
RESEARCH AND PUBLICATION Basic science and clinical research programs at the BNI include adult and pediatric neurosurgery, neuropsychology, and neurology. The BNI neurobiology research has a national and international reputation. The BNI also has collaborations with Arizona State University and University of Arizona for research in preclinical imaging, pain, cognitive neurometabolism, neuroengineering, human neurophysiology, neuroimmunology, neurophysiology, ion channel biophysics, and neurochemistry research. The BNI and the Translational Genomics Research Institute (TGen) collaborate to improve understanding of the genetic causes of disease and to translate this knowledge into new diagnostic tests and therapeutics. Mark Preul, M.D., director of neurosurgery research, focuses on new medical technology, cadaveric dissections, 3D reconstructions for education, and coordination with other departments for translation of research to improve patient care. Neil R. Crawford, Ph.D., director of the Spinal Biomechanics Laboratory, studies the mechanical behavior of the spine in its normal condition and after injury, disease, or surgical intervention. The Neuroscience Publications Office was founded by Spetzler in
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NEUROSURGICAL RESIDENT AND FELLOW EDUCATION
In 1961, the BNI began training residents in neurologic surgery and is currently the largest residency training program in the country. The program requires a 7-year commitment and includes training in all neurosurgical specialties: open vascular, endovascular, spine, functional, skull base, oncology, pain and peripheral nerve, radiosurgery, and pediatrics. The breadth of clinical experience is reflected in the volume and complexity of the neurosurgical cases at the BNI. In addition to clinical and surgical excellence, residents learn and participate in neuropathology, neurology, basic and clinical research, academic publishing, grant writing, and academic presentations. Several fellowships are offered at the BNI: cerebrovascular and skull base with Spetzler, endovascular neurosurgery with McDougall and Albuquerque, and complex spine with Sonntag in the past and currently with Theodore. These prestigious neurosurgical fellowships provide excellent training in each respective field. The goal of the training program is to prepare trainees to assume both academic and clinical leadership roles in neurosurgery while fostering excellence in patient care, teaching, and research. Volker Sonntag served as director of the residency program from 1995 to 2009, a role currently assumed by Peter Nakaji. Academic activities are a mandatory part of the BNI. Spetzler holds teaching rounds three times a week, and spine rounds are conducted the other 2 days of the week. Residents regularly prepare presentations for clinical conference and grand rounds. Other conferences focus on tumor treatment, epilepsy, skull base, radiosurgery, and neurosurgical board review preparation. Social maturation and camaraderie are equally integral to the BNI residency training and promote a healthy balance between work, play,
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and family life. There are numerous annual social events at the BNI for the residents and their families. Each fall the academic year begins with a challenging hike through a rugged Arizona canyon termed “the hike from hell” by one of its past participants. In the spring, the annual BNI Olympics are held, which involve a series of competitive events between the attending staff and residents. Each May there is a rim-to-rim hike in the Grand Canyon. In June the BNI attends the Annual Neurosurgery Charity Softball Tournament in New York City and won the tournament in 2010. Other events cherished by the residents and their families include Spetzler’s annual Christmas party, an Oktoberfest celebration at the Sonntag’s, Thanksgiving at the Theodore’s, and a summer swim party at the Nakaji’s.
REFERENCES 1. Albuquerque FC, Levy EI, Turk AS, Niemann DB, agaard-Kienitz B, Pride GL Jr, Purdy PD, Welch BG, Woo HH, Rasmussen PA, Hopkins LN, Masaryk TJ, McDougall CG, Fiorella DJ: Angiographic patterns of Wingspan in-stent restenosis. Neurosurgery 63: 23-7, 2008. 2. Dashti SR, Park MS, Stiefel MF, McDougall CG, Albuquerque FC: Endovascular recanalization of the subacute to chronically occluded basilar artery: initial experience and technical considerations. Neurosurgery 66:825-31, 2010. 3. Johnson EW, Dubovsky J, Rich SS, O’Donovan CA, Orr HT, Anderson VE, Gil-Nagel A, Ahmann P, Dokken CG, Schneider DT, Weber JL: Evidence for a novel gene for familial febrile convulsions, FEB2, linked to chromosome 19p in an extended family from the Midwest. Hum Mol Genet 7:63-67, 1998. 4. Johnson EW, Iyer LM, Rich SS, Orr HT, Gil-Nagel A, Kurth JH, Zabramski JM, Marchuk DA, Weissenbach J, Clericuzio CL, Davis LE, Hart BL, Gusella JF, Kosofsky BE, Louis DN, Morrison LA, Green ED, Weber JL: Refined localization of the cerebral cavernous malformation gene (CCM1) to a 4-cM interval of chromosome 7q contained in a well-defined YAC contig. Genome Res 5:368-80, 1995. 5. Kick SA, Sonntag VK, Spetzler RF: Neurosurgery at the Barrow Neurological Institute. Neurosurgery 41:930-7, 1997. 6. Kim LJ, Albuquerque FC, ziz-Sultan A, Spetzler RF, McDougall CG: Low morbidity associated with use
CONCLUSION Since its inception in 1962, the Barrow Neurological Institute has grown to become an internationally renowned center for neurologic illness. The BNI continues to raise the bar in neuroscience by advancing research, educating tomorrow’s leaders, and providing compassionate, world-class care for patients with neurologic disease. When Dr. Spetzler is asked what he is most proud during his tenure at the BNI, he states, “The commitment to excellence by everyone there and, equally important, the camaraderie that is pervasive from the nurses to the residents and attendings.”
of n-butyl cyanoacrylate liquid adhesive for preoperative transarterial embolization of central nervous system tumors. Neurosurgery 59:98-104, 2006.
15. Spetzler RF, Wilson CB, Weinstein P, Mehdorn M, Townsend J, Telles D: Normal perfusion pressure breakthrough theory. Clin Neurosurg 25:651-72, 1978.
7. Ponce FA, Lozano AM: Highly cited works in neurosurgery. Part I: the 100 top-cited papers in neurosurgical journals. J Neurosurg 112:223-32, 2010.
16. Spetzler RF, Zabramski JM, Kaufman B, Yeung HN: Acute NMR changes during MCA occlusion: a preliminary study in primates. Stroke 14:185-91, 1983.
8. Prendergast V: The history of neuroscience nursing: A Barrow perspective. Barrow Q 19:4-12, 2003. 9. Rigamonti D, Drayer BP, Johnson PC, Hadley MN, Zabramski J, Spetzler RF: The MRI appearance of cavernous malformations (angiomas). J Neurosurg 67:518-24, 1987. 10. Sonntag VK: The development of spinal neurosurgery: a historical perspective. Neurosurgery 60: 587-8, 2007. 11. Spetzler RF: Extracranial-intracranial arterial anastomosis for cerebrovascular disease. Surg Neurol 11: 157-61, 1979. 12. Spetzler RF, Martin NA: A proposed grading system for arteriovenous malformations. J Neurosurg 65: 476-83, 1986. 13. Spetzler RF, Roski RA, Kopaniky DR: Alternative superficial temporal artery to middle cerebral artery revascularization procedure. Neurosurgery 7:484-7, 1980. 14. Spetzler RF, Roski RA, Schuster H, Takaoka Y: The role of EC-IC in the treatment of giant intracranial aneurysms. Neurol Res 2:345-59, 1980.
17. Stiefel MF, Albuquerque FC, Park MS, Dashti SR, McDougall CG: Endovascular treatment of intracranial dural arteriovenous fistulae using Onyx: a case series. Neurosurgery 65:132-9, 2009. 18. Sylvester EJ: The Healing Blade: A Tale of Neurosurgery. Tempe, AZ, Beck Press, 1997. 19. Yuan HA, Garfin SR, Dickman CA, Mardjetko SM: A historical cohort study of pedicle screw fixation in thoracic, lumbar, and sacral spinal fusions. Spine (Phila Pa 1976) 19:2279S-96S, 1994. 20. Zabramski JM, Spetzler RF, Selman WR, Roessmann UR, Hershey LA, Crumrine RC, Macko R: Naloxone therapy during focal cerebral ischemia evaluation in a primate model. Stroke 15:621-7, 1984.
Citation: World Neurosurg. (2010) 74, 1:71-80. DOI: 10.1016/j.wneu.2010.07.011 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2010 Published by Elsevier Inc.
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Felipe Albuquerque, M.D. Assistant Director of Endovascular Neurosurgery Barrow Neurological Institute
A History of the Barrow Neurological Institute Richard A. Lochhead, Adib A. Abla, Alim P. Mitha, David Fusco, Kaith Almefty, Nader Sanai, Mark E. Oppenlander, Felipe C. Albuquerque
The Barrow Neurological Institute (BNI), founded in 1961, is in partnership with St. Joseph’s Hospital and Medical Center and part of the Catholic Healthcare West system. The BNI is a relative newcomer to academic neuroscience. However, since its inception it has grown to become an international destination for neurologic disease. This article describes the history of the institute as it has grown over the years in its commitment to excellence in patient care, education, and research.
THE BEGINNING: JOHN GREEN
T
he BNI was founded through the vision of one neurosurgeon, John Green, M.D. (1915-1990). Doctor Green completed medical school at Northwestern University in 1941 and then trained under Eric Oldberg, Cushing’s last resident, at the Illinois Neuropsychiatric Institute. Green completed a fellowship in epilepsy surgery at the Illinois Neuropsychiatric Institute under Percival Bailey (Figure 1). John Green’s career was interrupted in 1944 when he was called into service by the Navy. While stationed in Leyte, he contracted strep
Key words 䡲 Barrow Neurological Instititue 䡲 History 䡲 Neurosurgery 䡲 Robert Spetzler Abbreviations and Acronyms BNI: Barrow Neurological Institute BBTRC: Barrow Brain Tumor Research Center BRAT: Barrow Ruptured Aneurysm Trial CARF: Commission on Accreditation of Rehabilitative Facilities DBS: Deep brain stimulation FDA: Food and Drug Administration MAPC: Muhammad Ali Parkinson Center MR: Magnetic resonance MDA: Muscular Dystrophy Association NIH: National Institutes of Health
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throat and subsequently developed rheumatic fever and early arthritis. When he returned to Chicago, he noticed that the cold winters worsened his arthritis. In 1947, while looking at a map of currently located neurosurgeons in Dr. Paul Bucy’s office, he noticed an absence of this specialty in Arizona. This fact, coupled with the threat of worsening arthritis, prompted Green to move to the dry and warm climate of Phoenix. He was Arizona’s first neurosurgeon, arriving with a set of surgical instruments, a chief operating room nurse from Chicago, and his wife (5). Green was one of the few neurosurgeons between Los Angeles and Dallas and dreamed of establishing a neurologic institute after the tradition of Penfield’s Montreal Neurological institute. Green’s purpose for the institute was threefold: 1) a center for the diagnosis and treatment of neurologic disease, 2) a center for basic and translational neurologic research, and 3) a center for training neurologic surgeons, neurologists, and neurologic researchers (5). Very few resources were available for Green to establish the institute. Without a philanthropic effort, building the institute would have been impossible. Green initially sought funding from the Rockefeller Foundation, but this possibility fell through after the foundation changed its funding priorities. Fate intervened, however, when a wealthy businessman and philanthropist, Charles Bar-
From the Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, USA To whom correspondence should be addressed: Felipe C. Albuquerque, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2010) 74, 1:71-80. DOI: 10.1016/j.wneu.2010.07.011 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2010 Published by Elsevier Inc.
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Figure 2. Barrow Neurological Institute as it appeared in 1962. Used with permission from Barrow Neurological Institute.
Figure 1. John R. Green, M.D., founder and first medical director of the BNI. Used with permission from Barrow Neurological Institute.
row, brought his wife, originally operated on by Dr. James Gardner at the Cleveland Clinic, to Green for treatment of a recurrent oligodendroglioma. Green debulked the tumor for a total of seven operations and extended her life for 17 years. Barrow subsequently developed a close relationship with Green, Sister Mary Placida, and the other Sisters of Mercy, who administered and owned St. Joseph’s Hospital. In 1958, Charles Barrow initially donated $500,000 under the condition that the funds be matched by a private entity, which it was by the Hill-Burton fund. The $1 million gift resulted in the announcement of the BNI on January 24, 1959, to be built at St. Joseph’s Hospital in honor of Charles Barrow’s father, William. Construction started in 1961 and finished in 1962 (Figure 2). The total cost of construction totaled more than $2.5 million; the Barrows increased the amount of their donation to $1.1 million, and the National Institutes of Health donated $53,695, whereas the Sisters donated in the form of land (worth approx. $800,000). Almost immediately, John Green made it a goal to obtain the latest equipment and technology and asked fellow neurosurgeons to donate $52 per month. He encouraged them to donate and instilled the philosophy that permeates the recent history of the Barrow: to always give first if you want others to donate (5). The plans for the institute were developed with the help of a consultants’ committee that Green created and that included many prominent neurosurgeons such as Percival Bailey, Paul Bucy, and Wilder Penfield. The neurologic institute would focus on patient care, education, and research. It would open with five
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neurologic divisions. John Green was the first chair of neurologic surgery; David Daly was the chair of neurology; James Kernohan was the chair of neuropathology; James T. Riordan was the chair of neuroradiology; and Eduardo Eidelberg was the chair of neurobiology. The BNI continued to grow under Green’s tenure as director. The Sisters of Mercy could not underwrite the research component of the hospital, so Green formed the Barrow Neurological Foundation to provide financial support for neurologic research. Green raised more than $3 million in endowments and sizable donations for capital purchases and research projects. By the end of the institute’s first decade, the number of neurosurgeons had doubled, the number of residents had tripled, the number of neurosurgical procedures had nearly quadrupled, and the number of admissions had increased almost fivefold. In 1972, to accommodate such growth, three new stories were added to the original BNI wing. The first BNI Symposium was held in 1974. In 1976 the Division of Neuroanesthesiology was added under the direction of Elizabeth Wilkinson, M.D., reflecting the increasing need for clinical specialization (5). After 2 decades of devotion to the BNI, Green began his search for a successor. James Atkinson, who established the neurosurgical research laboratory and designed the Stereotactic Operating Room at the BNI, was being groomed for the job. He and his wife, however, tragically died on February 12, 1978, in an airplane crash. Bob Crowell from Harvard was selected as the next neurosurgery chairman but left after two years for personal reasons. After an extensive search, Robert F. Spetzler, M.D., from Case Western Reserve University, who trained as a cerebrovascular surgeon under Charles Wilson, M.D., at the University of California San Francisco (UCSF), became the third chair of neurosurgery at the BNI in 1983 (Figure 3).
1983 TO PRESENT Doctor Spetzler has continued to build on the foundation that Green established with a renewed commitment to clinical and academic
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Figure 3. Robert F. Spetzler, M.D., medical director of BNI, 1983 to the present. Used with permission from Barrow Neurological Institute.
excellence. Spetzler did this by surrounding himself with excellent personnel, a commitment to research and education, and robust fundraising. Today the BNI is an internationally renowned medical center for neurologic disease. The BNI aims to be the model of excellence through dedication to patients, commitment to sound medical practice, and the most advanced neurologic and neurosurgical techniques for the treatment of neurologic disease. The mission is to advance the knowledge and practice of medicine in neuroscience through basic and clinic research, to educate medical professionals, and to develop innovations in clinical techniques and technology.
Vascular and Endovascular Neurosurgery Before coming to the BNI, Spetzler served as associate professor of neurosurgery at Case Western Reserve University. Early in his career he established himself in the forefront of the field with seminal publications on a variety of cerebrovascular disease topics. This oeuvre included the first report of superficial temporal artery-tomiddle cerebral artery onlay grafting, the theory of reperfusion hemorrhage, and numerous other papers on microsurgical bypass surgery for the treatment of cerebrovascular occlusive diseases and aneurysms (11, 13-15). Over the years, the referral base for cerebrovascular cases flourished under Spetzler’s masterful skill and international reputation. In 1986, Spetzler and Neil Martin, a cerebrovascular fellow at the time, proposed a simple yet practical grading system for arterio-
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venous malformations that stratified lesions based on their size, pattern of venous drainage, and eloquence of adjacent brain tissue (12). Designed to predict the morbidity and mortality associated with surgical treatment of arteriovenous malformations, the grading system instantly gained international attention. A 1987 publication describing the magnetic resonance (MR) imaging appearance of cavernous malformations helped the BNI gain recognition in the clinical arena of cerebrovascular diseases (9). Both articles eventually became among the most cited publications in the neurosurgical literature (7). The success of several high-profile neurovascular cases also helped propel the notoriety of the BNI in this area. In 1995, Spetzler led BNI surgeons to perform the world’s first hypothermic circulatory arrest procedure in a pregnant woman for the clipping of a giant basilar tip aneurysm (18). The patient, Cheryl Jones, did well and successfully delivered a healthy boy several months later. In 2002, Spetzler successfully used hypothermic circulatory arrest to operate on a 5-year-old boy who, at that time, was the youngest patient ever to undergo this procedure. Although the BNI is recognized as one of the premier clinical institutes for the treatment of cerebrovascular diseases, its academic contribution to the field has been equally important. The recruitment of Spetzler brought with it a National Institutes of Health (NIH) RO2 grant to evaluate a multitude of stroke therapies (16, 20). Spetzler then established and became director of the cerebrovascular research laboratory, fostering basic science and translational research. In 1994, Spetzler became the youngest neurosurgeon ever chosen as the Honored Guest of the Congress of Neurological Surgeons. Over the years, this unique combination of opportunities in clinical and academic neurosurgery has attracted additional talent that has further raised the profile of the BNI in the treatment of cerebrovascular diseases. Joseph M. Zabramski, M.D., was recruited to the BNI in 1986. Having a particular interest in cavernous malformations, he and researcher Eric W. Johnson, Ph.D., localized the gene believed to be the cause of the familial form of the disease in 1995 (4). Peter Nakaji, M.D., completed his fellowship at the BNI in cerebrovascular and cranial base surgery in 2004 before joining the BNI staff with clinical and academic interests in cerebrovascular surgery as well as in cranial base and endoscopic neurosurgery. Despite its strong roots in open surgery, the BNI was quick to embrace endovascular techniques as a less invasive method of treatment for cerebrovascular diseases. In 1995, Cameron McDougall, M.D., joined the BNI as one of North America’s first neurosurgeons trained in neurointerventional techniques. After completing his neurosurgical residency at the University of Saskatchewan in Canada, he completed a fellowship in endovascular neurosurgery at UCSF under Dr. Grant Hieshima, a renowned pioneer in interventional neuroradiology. McDougall has served as the principal investigator of a number of landmark studies on the efficacy of various endovascular devices and techniques. This work resulted in several publications that led to the Food and Drug Administration’s (FDA’s) approval of new embolic agents, including detachable silicon balloons and n-butyl cyanoacrylate (6). Felipe C. Albuquerque, M.D., completed his residency at the University of Southern California and then joined the BNI in
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1999, where he completed his cerebrovascular and endovascular fellowship training. In 2001, he joined the BNI staff and, together with McDougall, has helped the BNI achieve among the nation’s largest experience of intracranial stenting cases for atherosclerotic disease as well as for Onyx embolization procedures for the treatment of intracranial dural arteriovenous fistulas (1, 2, 17). The BNI continues to make great strides in its clinical and academic contributions to cerebrovascular and endovascular neurosurgery. Its experience with the surgical treatment of intracranial aneurysms is unparalleled: Spetzler alone has treated more than 5600 aneurysms. Likewise, the BNI’s early impact on the fund of knowledge toward the treatment of cavernous malformations has made it a major referral center for lesions located in complex areas of the central nervous system. The BNI surgical experience includes almost 300 brainstem cavernous malformations and more than 80 spinal cord cavernous malformations. Novel indications for existing techniques such as venous stenting for pseudotumor cerebri and innovations in surgical technique such as retractorless surgery and intraoperative confocal microscopy continue to be a focus of the BNI. Similarly, several important clinical studies, including the Barrow Ruptured Aneurysm Trial (BRAT), designed to compare the efficacy and outcome of ruptured aneurysms that are clipped versus coiled, have poised the BNI to continue its tradition of making important contributions to the diagnosis and management of patients with cerebrovascular disorders. Spinal Neurosurgery In the 1960s and 1970s, neurosurgeons made few contributions to the advancement of spinal surgery. Although a small number of neurosurgeons tried to emphasize the importance of spine, academic and organized neurosurgery as a whole was complacent concerning spine. This attitude changed in the 1980s when orthopedic surgery tried to obtain accreditation for spine fellowships. Organized neurosurgery feared the orthopedic community would take over the complete care of spine. During this period, Spetzler recruited Volker K. H. Sonntag, M.D., from a private practice in Phoenix, Arizona, to join him at the BNI and to direct spinal neurosurgery (Figure 4). Sonntag played an active role in bringing spine surgery back into the domain of the practicing and academic neurosurgeon. Sonntag’s interest in spinal instrumentation was met with a high level of scrutiny by others in the medical community. When he began performing thoracolumbar instrumentation, orthopedic surgeons saw his efforts as infringing on their specialty and only after his practice underwent outside review was the matter settled (10). Like Spetzler, Sonntag was a leader in his field both clinically and academically. In 1995, he performed neck surgery on the wife of King Fahd of Saudi Arabia. In 2002 he was chosen as Honored Guest of the Congress of Neurological Surgeons. Sonntag authored more than 500 journal articles, coedited six major textbooks, authored more than 90 textbook chapters, and made 900 presentations with an emphasis on spinal instrumentation, cervical disease, and spine biomechanics. Under the guidance of Sonntag, the Spine Section at the BNI grew prolifically in clinical volume and complexity. Other spine neurosurgeons joined Sonntag and included Curtis Dickman, M.D., Stephen Papadopoulos, M.D., and Nicholas Theodore, M.D. Dickman and Sonntag played central roles as spine surgery faced rampant litiga-
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Figure 4. Volker K. H. Sonntag, M.D., former vice chair of the division of neurologic surgery and former program director of the neurosurgical residency program, retired in 2009. Used with permission from Barrow Neurological Institute.
tion over pedicle screw use in the 1990s (10). Dickman coauthored a paper that was integral in obtaining FDA class 2 recommendation for pedicle screw fixation (19), which led to many malpractice suits being dropped. Dickman also pioneered the use of thoracoscopy for spinal disorders and founded the Spinal Biomechanics Laboratory at BNI. Papadopoulos completed a spine fellowship under Sonntag and helped pioneer the field of image guidance in neurosurgical procedures. Theodore has several studies in the field of spine trauma, spinal cord injury, and complex spinal disorders. Recently, Randall W. Porter, Taro Kaibara, and Steve W. Chang, M.D., have helped develop minimally invasive techniques for spinal decompression and instrumentation. In December 2009, Volker Sonntag retired from practicing neurosurgery. His career focused on excellence in patient care, resident education, and neurosurgical research and serves as an example of what the BNI strives to accomplish. Pediatrics Harold L. Rekate, M.D., has led the Section of Pediatric Neurosurgery at the BNI since he was recruited from Case Western Reserve University in 1984. At that time, he was the first pediatric neurosurgeon in the State of Arizona. Rekate has clinical and research expertise in the fields of spina bifida and cerebrospinal fluid physiology. He has authored over 130 articles with an emphasis on the pathophysiology, treatment, and complications of treatment of various forms of hydrocephalus. In 2003, Rekate became director of the new Hypothalamic Hamartoma Program, a ground-breaking clinical center that focuses on evaluating, diagnosing, treating, and counseling patients with this disorder and their families. In 2008, Ruth Bristol, M.D., joined the BNI with a special interest in pediatric brain tumors, spine tumors, and developmental anomalies. Neuro-Oncology Since its inception, BNI has been a neurologic pioneer, leading the way in the development of cutting-edge treatments and surgical
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procedures, research and the creation of outstanding programs and centers. One of the areas in which BNI has forged numerous advancements is brain tumor diagnosis and neurosurgery. Every year, Barrow treats thousands of patients with brain tumors, including some of the most difficult cases in the world. The BNI has a multidisciplinary team of brain tumor specialists that focuses on each patient’s specific needs to determine the best treatment options. The team’s commitment to patient care is augmented by the newest advances in surgical techniques, radiotherapy, chemotherapy, and neurodiagnostic imaging. Kris Smith, M.D., specializes in the comprehensive management of brain tumors that utilizes stereotaxis, endoscopy, computer image guidance, brain mapping, and Gamma Knife radiosurgery. Randall Porter, M.D., is codirector of the Barrow Acoustic Neuroma Center, which provides comprehensive evaluation, diagnostic testing, and treatment for patients with acoustic neuromas. William White, M.D., joined the BNI in 1976 and directs the Barrow Pituitary Center, which is composed of specialists in endocrinology, neurology, neuro-ophthalmology, neuropathology, neuroradiology, neurosurgery, and radiation oncology. White brought the subspecialty of the transsphenoidal surgical technique to the BNI and has performed more than 1,500 pituitary surgeries. In 2010, the BNI established the Barrow Brain Tumor Research Center (BBTRC), a multidisciplinary research program led by Nader Sanai, M.D., and composed of integrated clinical-translational units that combine neuroscience with neuro-oncology clinical trials. The scientific platform for the BBTRC consists of five independent laboratories, investigating distinct, but interrelated, mechanisms driving brain tumor formation: 1) stem cell neuro-oncology, 2) meningioma biology, 3) bioinformatics and neuro-epidemiology, 4) molecular neuro-oncology, and 5) brain tumor immune-evasion. Each laboratory functions as a collaborative workspace, where teams of graduate students, postdoctoral fellows, and neurosurgery residents work alongside neurosurgeons, neuro-oncologists, neuropathologists, and neuro-imaging specialists to assemble basic science, translational, and clinical research elements into novel strategies for brain tumor diagnostics, therapy, and monitoring. Each laboratory core is designed to feed into the BBTRC’s clinical trials infrastructure, focusing on high-throughput phase I and II studies to develop and validate promising therapies that are then built into larger phase III studies. This interconnected architecture blurs the line between basic science and clinical research, funneling the Barrow’s clinical volume into experimental therapy programs that offer every brain tumor patient at least one investigational therapeutic option, irrespective of diagnosis or stage of disease. Taken together, the BBTRC represents a natural extension of the BNI’s legacies in vascular and spinal neurosurgery, establishing a new substrate for the next generation of neurosurgical innovations from the Barrow. Functional Neurosurgery The BNI’s roots in functional neurosurgery began in 1950 when John Green began performing epilepsy surgery. Green published numerous scientific reports on epilepsy surgery, including temporal lobe operations and epilepsy surgery for children and teenagers. Since then, BNI has become a leader in functional neurosurgery. The Muhammad Ali Parkinson’s Center (Figure 5) focuses on the
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Figure 5. The Muhammad Ali Parkinson’s Center. Used with permission from Barrow Neurological Institute.
diagnosis and treatment of movement disorders and is led by neurologist Abraham Lieberman, M.D. The Epilepsy Center at the BNI offers an epilepsy team that includes neurologists, neurosurgeons, neuropsychologists, neuroscience nurses, and clinical and basic researchers who focus exclusively on the diagnosis and treatment of epilepsy. In 1991, the BNI established a dedicated epilepsy monitoring unit, which is now the most active epilepsy monitoring program in the Southwest and one of the largest diagnostic monitoring units in the United states. In 1998, Barrow researchers, led by Eric Johnson, Ph.D., identified FEB2, one of the genes related to febrile seizures in children (3). Andrew Shetter, M.D., and Kris Smith, M.D., who both completed their neurosurgery residency at the BNI, assist in the treatment of movement disorders and epilepsy with deep brain stimulation, vagal nerve stimulators, radiosurgery, and surgical resection. The BNI has recently proposed to build the Center for Adaptive Brain Function, which is led by a team of world-class medical and research experts to pioneer new paths for treatment of functional brain disorders. The center will work to improve current therapies and expand the uses of deep brain stimulation (DBS) to treat some of the most common, yet destructive neurologic disorders. DBS is used largely to treat Parkinson disease. DBS will be studied and developed into cutting-edge treatment for many conditions, which include bipolar disorder, depression, and Alzheimer disease.
Stroke The Barrow Stroke Center is one of the most experienced and expert stroke programs in the country, caring for more stroke victims than any other center in the southwestern United States. Neurologist James Frey, M.D., directs the BNI stroke team, which is composed of neurologists, vascular and endovascular neurosurgeons, neuroradiologists, neuroscience nurses, case managers, and rehabilitation specialists. The team focuses on quick, aggressive revascularization, stroke prevention, public education and outreach, stroke research, and rehabilitation.
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Neurology The Division of Neurology was one of five original divisions when the BNI opened in 1962. David Daly, M.D., headed the original group of three neurologists and was succeeded by Joseph C. White Jr., M.D., in 1966. In 1988 the Kemper and Ethel Marley Chair of Neurology was established with a $1 million endowment. William Shapiro, M.D., was recruited from Memorial Sloan Kettering Cancer Institute to be the first to hold the new chair. Shapiro recruited Abraham Lieberman, M.D., an internationally recognized leader in Parkinson disease (5). In 1997 Lieberman helped establish the Muhammad Ali Parkinson Center (MAPC) and Movement Disorders Clinic, which is now a National Parkinson Foundation Center of Excellence. The collaboration between neurology and neurosurgery has continued to strengthen the neuro-oncology, epilepsy, stroke, and movement disorder programs. The Division of Child Neurology at the BNI is the largest child neurology group in Arizona and dedicated to the clinical care, education, and research in pediatric neurologic disorders. Multiple sclerosis specialists at the BNI, led by Roberto Bomprezzi, M.D., strive to alleviate patients’ symptoms, to educate patients about their care and the course of their illness, and to find new ways to treat and possibly one day to cure multiple sclerosis. The Barrow MDA Clinic is financially supported by the Muscular Dystrophy Association (MDA) and directed by Doctors Shafeeq Ladha and John Bodensteiner. The clinic coordinates comprehensive physical and psychosocial care for the complex needs of patients with neuromuscular disease. Services include diagnostic testing; regular follow-up evaluations; development of individualized patient care plans; disease education for patients and families; and referrals to support groups, resources, and educational programs. The Laboratory of Neuromuscular Disorders conducts clinical and basic research on the molecular genetics of hereditary neurologic and neuromuscular disorders. The goal of this research is to improve treatment and to identify the causes of these devastating diseases that can result in significant disability or death.
Neuropathology The Division of Neuropathology has been a part of the BNI since its inception. James Kernoham, M.D., from the Mayo Clinic in Rochester served as the first chair of neuropathology until 1964 when John D. Waggener, M.D., assumed the position. Peter C. Johnson, M.D., formerly from Minnesota and the University of Arizona in Tucson, succeeded Waggener in December 1983, becoming the only such board-certified specialist in the state at the time. A second full-time neuropathologist, Stephen Coons, M.D., was added in 1989. In 1996, Coons became the chair of the Division (5). Research from the department focuses primarily on molecular markers of prognosis in gliomas, meningiomas, and pituitary adenomas and the relationship between hypothalamic hamartomas and epileptogenics. Jenny Eschbacher, M.D., joined the program in 2009 with emphasis on exploring intraoperative, confocal microscopy as a clinical tool to provide immediate diagnostic information.
Neuroradiology The Division of Neuroradiology was established with the founding of the BNI. James T. Riordan, M.D., the first chair of neuroradiology,
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was succeeded by Robert E. Flynn, M.D., in 1964. In 1986, Burton P. Drayer, M.D., a leader in neuroimaging, was recruited from Duke to lead new research and education efforts. With Drayer and research physicist Paul Keller, Ph.D., an expert in MR imaging, the BNI became a premier developmental site, especially in MR angiography. The growth in clinical neuroimaging studies was explosive, increasing from approximately 900 in 1985 to approximately 7500 in 1989. A second high-field MR imaging unit was added in 1988 and a third in 1994 (5). Currently, St. Joseph’s is home to four biplane neuroangiography suites, three 3-T MRIs, four 1.5-T MRIs, one 3-T intraoperative MRI, one 7-T research MRI, and multiple CTs. In 2006 the Division of Neuroradiology completed 63,300 examinations, including 43,300 CT scans and 20,000 MR scans and more than 1000 angiograms. There are currently 10 neuroradiologists, 3 physicists, and 9 neuroradiology fellows.
Neurorehabilitation Neurorehabilitative Services at Barrow consists of both in- and outpatient interdisciplinary teams of specialists and offers unparalleled rehabilitative care for individuals with brain and spinal cord diseases, injuries, and conditions. The primary goal of Barrow neurorehabilitation specialists is to enhance patient quality of life through improved skills, maximized independence, and renewed self-esteem. Services include physiatrists; rehabilitation nurses; social workers; case management professionals; physical, occupational, speech, and recreational therapists; and neuropsychologists. Barrow’s unique rehabilitation programs include aquatic therapy, community reintegration, peer mentorship, horticulture, cooking, and ceramics. Eleven neurorehabilitation programs at Barrow have been accredited by the Commission on Accreditation of Rehabilitative Facilities (CARF). In 2009 Barrow Neurological Associates, the private practice of the neurosurgeons, opened the NeuroSpine and Rehab Center, a state-of-the-art facility providing patients with both imaging services and nonsurgical options for the treatment of spine disorders (Figure 6).
Nursing Dedicated neuroscience nursing began at Barrow with its opening in 1962. At that time, the idea of dedicated neuroscience nursing was a relatively new concept. The first nurses at the BNI worked in one of three newly established units: the operating room, the neurosurgical intensive care unit, or the general neurosurgical-neurological ward. In the early 1990s, the BNI began employing nurse practitioners (NPs) to assist in the hospital care of neurosurgical patients. At that time, no other hospitals in the country employed NPs in their division of neurologic surgery. The BNI has more certified neuroscience registered nurses than any other hospital in the country. Like the BNI physicians, the BNI nursing staff is academically active. They have developed course training in neuroscience nursing. Barrow nurses have made more than 100 presentations at national meetings and more than a dozen at international meetings. Three BNI neuroscience registered nurses, Marilyn Ricci, Tobie Anchie, and Virginia Prendergast, have served as president of the American Association of Neuroscience Nurses (8).
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A large source of the philanthropic effort at BNI comes from private foundations, which include the Barrow Women’s Board, NIH, individuals, or public funding. Almost half of all the fundraising dollars go to research.Recently,venturecapitalism and venture philanthropy have helped fund groundbreaking BNI research that can transform intellectual material into patents, inventions, and eventually commercial products. Two of the major fundraising efforts at BNI have been the Celebrity Fight Night and the Lou Grubb Golf Tournament. The Lou Grubb Golf Tournament, an annual golf tournament held in the spring, has raised more than $4.5 million with a record effort of more than $500,000 in 2008. It Figure 6. Opening of the BNA NeuroSpine and Rehab Center in 2009 with guests (left to right) Cody Unser and was established by successful philanthropists Deborah and Bruce Downey. Used with permission from Barrow Neurological Institute. local car dealership businessman, Lou Grubb after he was THE FUNDRAISING EFFORT operated on by Dr. Spetzler for a ruptured posterior inferior cerebellar artery aneurysm in 1986. Later, Catapulting an institute into the prominence that BNI has achieved his annual charity tournament donated its proceeds to BNI as way of cannot be done without certain key elements that go hand and hand showing his gratitude. with this mission, namely, the benefactors and fundraising needed Celebrity Fight Night has been another major fundraising effort. to fund medical progress and to support the building of major hosIt is an annual event that has been held 16 times and has raised pital and research infrastructure. Revenue and local/state governapproximately $60 million. The largest benefactor is the Muhamment funding alone cannot account for all of the financial contribumad Ali Parkinson Research Center, which became the primary tions necessary to build a world-class medical institute; fundraising benefactor in 1997 for the annual event. It is a star-studded night and becomes a necessary and integral component. Medical research is features celebrities, professional athletes, and the featured guest, the core to developing new treatments and requires strong financial Muhammad Ali. The night is filled with live auctions and music support. Securing funding for research depends largely on demonperformances by many of the country’s hottest stars. The event has strating (advertising) the mission and merits of the institution while sought to raise awareness of and to secure funding for research on forming ties with prominent figures who bring an institution into Parkinson disease. It is one of the nation’s largest fundraising onethe national spotlight. night events of its kind. Over the years, showcasing the new, cutting-edge, and lifeIncreasing the national and international reputation of the BNI saving procedures that have been performed at the Barrow Neuhas been key to its growth and fundraising ability. In 1987 the BNI rological Institute has played a crucial role in fundraising. While sponsored America’s Brain Trust as part of its 25th Anniversary touting the advances in both operative technique and neurosurcelebration. This event generated significant publicity and was gical science, the philanthropic effort has been served by increasmoderated by Marvin Kalb, former vice president Walter Moning publicity and society’s awareness of the work being perdale, former president Gerald Ford, and Dr. Henry Kissinger. In formed, encouraging donations in support of a continuous push the same year, Pope John Paul II visited the BNI, the only hospital for excellence. so honored during his 10-day tour of the United States. In 1988, In the beginning, John Green was able to start the BNI after the Loyal Davis Neurosurgical Research Laboratory was estabCharles Barrow made a large donation. However, it has been Spetzlished in Davis’ honor and announced by his step-daughter, the ler’s talent for fundraising that has allowed the BNI to achieve its former first-lady, Nancy Reagan. Loyal Davis had been a neurointernational prominence. Spetzler has led by example with genersurgeon and director of the BNI from 1966 to 1967, and his wife ous monetary donations, and he has treated many of the individuals Edith helped establish the Women’s Board at Barrow. He died in who eventually made significant contributions to the BNI. He has 1982 and she in 1987, and the Research Laboratory was estabgiven tirelessly of his personal time to attend fundraisers, banquets, lished in their memory. Nancy Reagan was invited for the laboraand events, championing this cause.
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Figure 7. The new clinical neuroscience tower opened in 2006. Used with permission from Barrow Neurological Institute.
tory’s dedication, and the Spetzlers later toured the White House, visited with the Reagans in Washington, and attended a state dinner with Dr. Spetzler sitting with Nancy Reagan and the Guest of Honor. Finally, personal donations from physicians, largely from neurosurgeons at the BNI, have been a significant part of the philanthropy, grossing more than $7 million since 1989. The BNI has raised approximately $174 million since 1993 and more than $200 million since 1983.
BUILDING PROJECTS The patient care, research, and educational capacities of the BNI have greatly expanded since its opening in 1962. Critical to this expansion have been several recent additions to the infrastructure of both the BNI and St. Joseph’s Hospital and Medical Center. In 1997, the BNI opened the 70,000-square-foot Neuroscience Research Center with laboratories dedicated to basic research in neuro-oncology, neurobiology, neurochemistry, neurogenetics, pain, and epilepsy. The new Barrow Neurosciences Tower opened its doors in July 2006 with a vision to unite technology, efficiency, comfort, and family-centered care (Figure 7). With the addition of 144 beds, the new Tower helped to make SJMHC the largest provider of inpatient services in Arizona and one of the premier neuroscience centers in the world. The 144 beds dedicated to neuroscience patients consist of 64 ICU-level and 80 ward-level private rooms, with specific sections dedicated to epilepsy, spine, and stroke care. Eleven state-ofthe-art surgical suites are dedicated to neurosurgery and equipped with MED Presence video-conferencing capability, Zeiss stereotaxisintegrated operating microscopes, multidisplay plasma screens, boom-suspended surgical and anesthesia equipment, and access to a 3-T intraoperative MR scanner. Special areas to encourage patient and family comfort and healing include private baths in all rooms, a healing garden, a meditation and prayer room, and a family education center. More than 1000 pieces of inspirational artwork are on display throughout the building. For many neurosurgical patients, a successful surgery or treatment is often just a first step down a long road to recovery. The
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opening of the $24-million Deborah and Bruce Downey Neuro Rehabilitation Center in February 2007 not only enhanced Barrow’s ability to care for these patients but also expanded its capacity. For a unit with a multipage waiting list, the move into a newly renovated space was significant. The new center offers 52 patient beds for the 520 patients it admits each year, with 18 private and 17 semiprivate rooms. The center is the only rehabilitation unit in the state with CARF accreditation for its brain and spinal cord injury programs. Three gyms, a transitional apartment, ceiling lifts, and voice-activated environmental-control units round out the modernized facility. Presently, funds are being raised to incorporate a new aquatic therapy center into the spectrum of rehabilitation services. The Ashlyn Dyer Aquatic Center, led by Dr. Christine Kwasnika, will serve not only inpatients and outpatients needing rehabilitation at Barrow but will provide multiple services to the larger community. Dedicated to developing new medical technology and innovations for improved diagnostic care, the 5000-square-foot, $5.2-million Keller Center for Imaging and Innovation opened in early 2008. The crown jewel of the Keller Center is a 3-T multinuclear MR scanner dedicated to imaging research. In fact, recent data generated from investigations utilizing the multinuclear scanner were crucial to the development of PROPELLER technology, well-known to reduce motion artifact and to improve resolution in many MRI sequences. The clinical partner of the Keller Center is the new 17,000-squarefoot Outpatient Imaging Center, opened in early 2010 to provide comprehensive diagnostic imaging services. The new center offers a team of board-certified radiologists and neuroradiologists, technologists, and staff who supervise digital mammography, MR, CT, positron emission tomography, and nuclear medicine testing for about 1500 patients each month. The original Muhammad Ali Parkinson Center opened in 1997, servicing about 800 new patients annually. In 2009, thanks to the promotion and support of Muhammad Ali, Celebrity Fight Night, and multiple charity funds, the new $4-million Muhammad Ali Parkinson Center initiated a significant expansion of specialized movement disorder services. The new facility is expected to see twice as many new Parkinson patients annually, with thousands more attending bilingual classes in caregiver education, tai chi, ballroom dancing, and golf therapy. The center features 10 examination rooms, a tremor examination room, a botulinum toxin treatment room, a tilt room to help evaluate patients with orthostatic hypertension, and a Balance Laboratory. Long named a Center of Excellence by the National Parkinson’s Foundation, the center is a model both nationally and internationally for providing integrated care in movement disorders. The MED Presence video conference room was finished in 2006. This room allows the surgeon’s view to be viewed by the entire room and allows audio and visual interaction with the surgical suite (Figure 8). This capability improves the educational experience for residents, nurses, and others studying neurosurgery. The MED Presence also allows for a video link via the Internet to locations around the world and is used for interactive conferences, consultation services, live surgery, and education. Further clinical, research, and educational needs continue to arise, and many projects are on the horizon to meet those challenges. In honor of Dr. Volker Sonntag’s many contributions to neurosurgical education at the BNI, a new educational facility will begin construction in early 2011 in his honor. This 3000-square-foot
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1986 to help facilitate academic publications and presentations. That same year the BNI Quarterly was first published and continues to publish on several neuroscience topics. The publications office has grown from one editor and one illustrator to now include a doctorate-holding editor, assistant editor, production editor, two editorial assistants, two master’s-prepared medical illustrators, medical animator, and interactive media specialist. Since 1986, the office has helped produce a dozen textbooks, thousands of articles and manuscript reviews, and has created thousands of medical illustrations to enhance the educational mission of the BNI.
Figure 8. The MED Presence video conference and interactive education room. Used with permission from Barrow Neurological Institute.
state-of-the-art building will have seating for up to 200 people and will be located outside the entrance of the Marley Lobby. It will house the latest electronic audio and video equipment to accommodate lectures and live surgery demonstrations and will provide space for medical devices exhibits and overflow meeting space for some of the many educational conferences that Barrow hosts each year.
RESEARCH AND PUBLICATION Basic science and clinical research programs at the BNI include adult and pediatric neurosurgery, neuropsychology, and neurology. The BNI neurobiology research has a national and international reputation. The BNI also has collaborations with Arizona State University and University of Arizona for research in preclinical imaging, pain, cognitive neurometabolism, neuroengineering, human neurophysiology, neuroimmunology, neurophysiology, ion channel biophysics, and neurochemistry research. The BNI and the Translational Genomics Research Institute (TGen) collaborate to improve understanding of the genetic causes of disease and to translate this knowledge into new diagnostic tests and therapeutics. Mark Preul, M.D., director of neurosurgery research, focuses on new medical technology, cadaveric dissections, 3D reconstructions for education, and coordination with other departments for translation of research to improve patient care. Neil R. Crawford, Ph.D., director of the Spinal Biomechanics Laboratory, studies the mechanical behavior of the spine in its normal condition and after injury, disease, or surgical intervention. The Neuroscience Publications Office was founded by Spetzler in
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In 1961, the BNI began training residents in neurologic surgery and is currently the largest residency training program in the country. The program requires a 7-year commitment and includes training in all neurosurgical specialties: open vascular, endovascular, spine, functional, skull base, oncology, pain and peripheral nerve, radiosurgery, and pediatrics. The breadth of clinical experience is reflected in the volume and complexity of the neurosurgical cases at the BNI. In addition to clinical and surgical excellence, residents learn and participate in neuropathology, neurology, basic and clinical research, academic publishing, grant writing, and academic presentations. Several fellowships are offered at the BNI: cerebrovascular and skull base with Spetzler, endovascular neurosurgery with McDougall and Albuquerque, and complex spine with Sonntag in the past and currently with Theodore. These prestigious neurosurgical fellowships provide excellent training in each respective field. The goal of the training program is to prepare trainees to assume both academic and clinical leadership roles in neurosurgery while fostering excellence in patient care, teaching, and research. Volker Sonntag served as director of the residency program from 1995 to 2009, a role currently assumed by Peter Nakaji. Academic activities are a mandatory part of the BNI. Spetzler holds teaching rounds three times a week, and spine rounds are conducted the other 2 days of the week. Residents regularly prepare presentations for clinical conference and grand rounds. Other conferences focus on tumor treatment, epilepsy, skull base, radiosurgery, and neurosurgical board review preparation. Social maturation and camaraderie are equally integral to the BNI residency training and promote a healthy balance between work, play,
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and family life. There are numerous annual social events at the BNI for the residents and their families. Each fall the academic year begins with a challenging hike through a rugged Arizona canyon termed “the hike from hell” by one of its past participants. In the spring, the annual BNI Olympics are held, which involve a series of competitive events between the attending staff and residents. Each May there is a rim-to-rim hike in the Grand Canyon. In June the BNI attends the Annual Neurosurgery Charity Softball Tournament in New York City and won the tournament in 2010. Other events cherished by the residents and their families include Spetzler’s annual Christmas party, an Oktoberfest celebration at the Sonntag’s, Thanksgiving at the Theodore’s, and a summer swim party at the Nakaji’s.
REFERENCES 1. Albuquerque FC, Levy EI, Turk AS, Niemann DB, agaard-Kienitz B, Pride GL Jr, Purdy PD, Welch BG, Woo HH, Rasmussen PA, Hopkins LN, Masaryk TJ, McDougall CG, Fiorella DJ: Angiographic patterns of Wingspan in-stent restenosis. Neurosurgery 63: 23-7, 2008. 2. Dashti SR, Park MS, Stiefel MF, McDougall CG, Albuquerque FC: Endovascular recanalization of the subacute to chronically occluded basilar artery: initial experience and technical considerations. Neurosurgery 66:825-31, 2010. 3. Johnson EW, Dubovsky J, Rich SS, O’Donovan CA, Orr HT, Anderson VE, Gil-Nagel A, Ahmann P, Dokken CG, Schneider DT, Weber JL: Evidence for a novel gene for familial febrile convulsions, FEB2, linked to chromosome 19p in an extended family from the Midwest. Hum Mol Genet 7:63-67, 1998. 4. Johnson EW, Iyer LM, Rich SS, Orr HT, Gil-Nagel A, Kurth JH, Zabramski JM, Marchuk DA, Weissenbach J, Clericuzio CL, Davis LE, Hart BL, Gusella JF, Kosofsky BE, Louis DN, Morrison LA, Green ED, Weber JL: Refined localization of the cerebral cavernous malformation gene (CCM1) to a 4-cM interval of chromosome 7q contained in a well-defined YAC contig. Genome Res 5:368-80, 1995. 5. Kick SA, Sonntag VK, Spetzler RF: Neurosurgery at the Barrow Neurological Institute. Neurosurgery 41:930-7, 1997. 6. Kim LJ, Albuquerque FC, ziz-Sultan A, Spetzler RF, McDougall CG: Low morbidity associated with use
CONCLUSION Since its inception in 1962, the Barrow Neurological Institute has grown to become an internationally renowned center for neurologic illness. The BNI continues to raise the bar in neuroscience by advancing research, educating tomorrow’s leaders, and providing compassionate, world-class care for patients with neurologic disease. When Dr. Spetzler is asked what he is most proud during his tenure at the BNI, he states, “The commitment to excellence by everyone there and, equally important, the camaraderie that is pervasive from the nurses to the residents and attendings.”
of n-butyl cyanoacrylate liquid adhesive for preoperative transarterial embolization of central nervous system tumors. Neurosurgery 59:98-104, 2006.
15. Spetzler RF, Wilson CB, Weinstein P, Mehdorn M, Townsend J, Telles D: Normal perfusion pressure breakthrough theory. Clin Neurosurg 25:651-72, 1978.
7. Ponce FA, Lozano AM: Highly cited works in neurosurgery. Part I: the 100 top-cited papers in neurosurgical journals. J Neurosurg 112:223-32, 2010.
16. Spetzler RF, Zabramski JM, Kaufman B, Yeung HN: Acute NMR changes during MCA occlusion: a preliminary study in primates. Stroke 14:185-91, 1983.
8. Prendergast V: The history of neuroscience nursing: A Barrow perspective. Barrow Q 19:4-12, 2003. 9. Rigamonti D, Drayer BP, Johnson PC, Hadley MN, Zabramski J, Spetzler RF: The MRI appearance of cavernous malformations (angiomas). J Neurosurg 67:518-24, 1987. 10. Sonntag VK: The development of spinal neurosurgery: a historical perspective. Neurosurgery 60: 587-8, 2007. 11. Spetzler RF: Extracranial-intracranial arterial anastomosis for cerebrovascular disease. Surg Neurol 11: 157-61, 1979. 12. Spetzler RF, Martin NA: A proposed grading system for arteriovenous malformations. J Neurosurg 65: 476-83, 1986. 13. Spetzler RF, Roski RA, Kopaniky DR: Alternative superficial temporal artery to middle cerebral artery revascularization procedure. Neurosurgery 7:484-7, 1980. 14. Spetzler RF, Roski RA, Schuster H, Takaoka Y: The role of EC-IC in the treatment of giant intracranial aneurysms. Neurol Res 2:345-59, 1980.
17. Stiefel MF, Albuquerque FC, Park MS, Dashti SR, McDougall CG: Endovascular treatment of intracranial dural arteriovenous fistulae using Onyx: a case series. Neurosurgery 65:132-9, 2009. 18. Sylvester EJ: The Healing Blade: A Tale of Neurosurgery. Tempe, AZ, Beck Press, 1997. 19. Yuan HA, Garfin SR, Dickman CA, Mardjetko SM: A historical cohort study of pedicle screw fixation in thoracic, lumbar, and sacral spinal fusions. Spine (Phila Pa 1976) 19:2279S-96S, 1994. 20. Zabramski JM, Spetzler RF, Selman WR, Roessmann UR, Hershey LA, Crumrine RC, Macko R: Naloxone therapy during focal cerebral ischemia evaluation in a primate model. Stroke 15:621-7, 1984.
Citation: World Neurosurg. (2010) 74, 1:71-80. DOI: 10.1016/j.wneu.2010.07.011 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2010 Published by Elsevier Inc.
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