Traditionally, stroke patients try to regain motor function through physical rehabilitation, where patients re-learn pre-stroke skills, such as eating motions and grasping. However, most patients eventually plateau and stop improving over time.

Now, results of a clinical trial published in The Lancet gives patients new hope in their recovery.

Patients who received a novel treatment that combines vagus nerve stimulation (VNS) and rehabilitation showed improvement in upper body motor impairment compared to those who received sham (inactive form of) stimulation and rehabilitation. Considered a natural antenna to the brain, the vagus nerve runs from the chest and abdomen to the brainstem and regulates many of the body’s functions.

“This is incredibly exciting news for everyone involved in stroke rehabilitation and functional restoration and represents a unique intersection between neurosurgery and neurorehabilitation,” said Charles Liu, MD, PhD, the lead neurosurgeon of the study and director of the USC Neurorestoration Center of Keck Medicine of USC. “These study results are the first of their kind, and open up new possibilities for stroke patients, allowing them to reclaim more arm function even years after having a stroke.”

In this international, multi-center clinical trial, 53 participants with moderate to severe arm weakness nine months to 10 years post-stroke, received rehabilitation paired with VNS. Fifty-five patients within the same parameters received a sham stimulation. The trial was randomized and triple blind.

Those receiving the nerve stimulation had a wire inserted into their neck that wrapped around the vagus nerve. The wire was then connected to a pulse generator device implanted in the chest. Those receiving the sham received placebo implants.

After the surgical procedure, all patients received six weeks of in-clinic therapy, which included tasks such as reaching and grasping, simulated eating and opening and closing containers. After the in-clinic period, patients continued treatment with a course of daily home therapy.

When the two patient groups were compared, those receiving the nerve stimulation scored higher on several standardized measures of upper arm functionality.

“Not only were the results clinically meaningful, the fact that these patients were at least nine months post-stroke and in some instances years out, points to the possibility that meaningful improvements can be achieved even years after a stroke,” said Liu, who also serves as chief of innovation and research and chair of neurosurgery and orthopedics at Rancho Los Amigos National Rehabilitation Center.

The device is thought to work by triggering the release of brain neuromodulators – which regulate the body’s responses – to strengthen motor circuits in the brain associated with movement, enabling the brain to effectively relearn tasks. VNS is already used widely for the treatment of epilepsy and plays an increasing role in the treatment of severe depression.

“For too long, stroke patients have faced limited options for recovery,” said Liu. “This new treatment signifies a breakthrough that could be life-changing for many stroke patients and also represents an approach that will certainly be explored for many other functional restoration applications in the future.”

The VNS system utilized for the study is owned by MicroTransponder Inc., a medical device development company, who sponsored the study.

Lead authors on the study include Jesse Dawson, MD, College of Medical, Veterinary and Life Sciences, University of Glasgow in Scotland; Teresa J. Kimberley, PhD, Massachusetts General Hospital; and Navzer Engineer, MD, PhD, of MicroTransponder Inc.

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For more information about Keck Medicine of USC, please visit news.KeckMedicine.org.

As president, Starnes will lead the AATS as it continues in its commitment to science, education and research, and furthers its mission to promote scholarship, innovation and leadership in thoracic and cardiovascular surgery.

“I’m honored to lead AATS, one of the oldest and most prestigious organizations dedicated to cardiothoracic surgery,” Starnes said. “As we look to the year ahead, AATS will continue in its commitment to encourage, promote and advance the field of cardiothoracic surgery, and further its significant contributions to the care and treatment of cardiothoracic disease.”

In addition to serving as chair of the Department of Surgery, Starnes is a Distinguished Professor of Surgery, executive director of the USC CardioVascular Thoracic Institute and the H. Russell Smith Foundation Chair for Stem Cell and Cardiovascular Thoracic Research at the Keck School of Medicine of USC. Starnes also is president of the USC Care Medical Group. He joined USC in July 1992.

As executive director of the USC CardioVascular Thoracic Institute at Keck Medicine, Starnes has built an interdisciplinary powerhouse composed of clinicians and scientists who are exploring innovative ways to treat heart disease. Under his leadership, USC surgeons have conducted more than 50,000 adult and pediatric open heart surgeries to repair and replace valves, create coronary artery bypasses and repair complex adult and congenital heart defects.

Starnes founded the Heart Institute after joining CHLA in 1992, and launched CHLA’s pediatric heart transplant program a year later. Today, he specializes in treating damaged heart valves with minimally invasive repairs and valve replacements in children.

In 1990, Starnes performed the world’s first lobar transplant, using a lung segment from a living donor. The following year, he performed a heart and lung transplant on a one-month-old infant — the youngest heart-lung transplant patient ever at the time.  Starnes also performed the first living-donor, double-lobar lung transplant on a patient with cystic fibrosis. The operation involved taking lung tissue from each of the child’s parents and transplanting it into the patient.

In addition to his clinical work, Starnes is also a respected researcher. He has an ongoing interest in congenital heart disease, cadaveric and living-donor organ transplantation, repair and replacement of heart valves, coronary bypass grafting and gene therapy techniques to address problems following heart surgery. He also is investigating the use of stem cells to treat rare pediatric cardiac defects.

Starnes earned his medical degree from the University of North Carolina at Chapel Hill and conducted his general surgery training at Vanderbilt University, where he also completed two years of research in cardiothoracic physiology and pharmacology. He went on to complete two years at Stanford University as a resident in cardiovascular surgery and one year as chief resident in cardiac transplantation. He then accepted a prestigious fellowship in pediatric cardiovascular surgery at the Hospital for Sick Children in London. When he returned to Stanford, he was appointed director of its heart-lung transplantation program.

The AATS is an international organization of more than 1,500 of the world's foremost cardiothoracic surgeons, representing 42 countries. Founded in 1917, its members have a proven record of distinction within the specialty and have made significant contributions to the care and treatment of cardiothoracic disease throughout the world.

Delaney, a high school teacher and marathon runner, had initially gone through the screening process to donate to a friend. When his friend’s condition improved, he offered to give part of his liver to a stranger in need.

“When you do a loving act, the act itself is its own reward,” says Delaney. “Anything worthwhile in life is difficult. So no, it’s not an easy thing to step forward and donate, but the level of satisfaction you get is life-changing.”

Shaw, who was on the national organ registry wait list for three years, found even routine tasks like grocery shopping exhausting.

“I’m eternally grateful,” says Shaw. “I’m excited just to get back out into the world. I want to try new things. I want to say yes to everything.”

Whether it’s a friend, relative or like Delaney, an altruistic person willing to donate to a stranger, being matched with a living donor means a patient can have a transplant before they develop liver disease complications that may be fatal.

“Every year, hundreds of people die waiting for an organ,” says Yuri Genyk, MD, director of the liver transplant program at Keck Hospital, and Delaney’s surgeon. “Living donors are the only way we can narrow the gap between the need and availability of organs.”

Shaw is a typical example. She was at the stage where she needed a liver transplant, but she was not sick enough to receive one from the national organ registry of deceased donors.

“Without a living donor, she would have had to wait for the progression of the disease, with multiple hospitalizations and complications,” says Genyk. “She would be at high risk for developing fatal complications and not surviving on the wait list.” 

How the Transplant Works

At Keck Hospital, donor and recipient surgical teams work simultaneously in side-by-side operating rooms to remove a portion of the healthy liver from the donor and immediately transplant it into the person in need. The donor surgery takes 4-to-5 hours; the recipient surgery takes about 9-to-10 hours to remove the diseased liver, transplant the donated one and then connect all of the various blood vessels and bile ducts.

“Donors completely recover after the operation,” says Genyk. “They eventually return to their studies, occupation, hobbies and physical activities.”

And they’ve given the recipient another chance at life.

Keck Medicine of USC is one of the few institutions in the nation that does living-donor liver transplants. Both donor and patient are assigned an entire team, not just for the surgery, but for the entire journey, from screening through long-term recovery.

“Many people aren’t aware that the liver regenerates,” says Navpreet Kaur, MD, the transplant surgeon who performed Breana’s operation. “Within two months, the liver will grow to almost its full size and potential in both the donor and recipient, and will be completely grown within a year. ”

Becoming a Donor

Most people receive an organ from a family member or friend, but anyone could be a match. The screening process starts with a simple blood test.

In the case of Delaney, through his friend’s experience, he realized there were many more people experiencing liver disease. “They have a disease that’s out of their control. Their life is dependent on someone coming forward. If I were in that situation, I’d hope that someone would do that for me.”

He says that it’s made him appreciate the gift of health. Before this operation, he had never spent the night in a hospital. And yet, “I’d do it again in a heartbeat if I could,” says Delaney. “What greater gift is there in life than to do something to benefit someone else, whether it’s a family member or a stranger?”

To learn more about becoming a living donor in Southern California, visit the transplant institute of Keck Medicine of USC and complete the living donor interest form here.

For more information on the liver and liver transplant, please visit Donate Life. 

More Living Donors Needed

Every year, hundreds of people die waiting for an organ transplant. According to the United States Department of Health and Human Services Organ Procurement and Transplantation Network (OPTN):

• Nearly 114,000 people are on the national organ transplant waitlist. Of those, more than 13,000 are on the waitlist for a liver.
• In 2018, nearly 5 percent of liver transplants were made possible thanks to living donors who stepped forward to save lives.

Assessing the Need

To assess a patient’s need for a transplant, patients are assigned a MELD (Model of End-Stage Liver Disease) score from 6 to 40. At MELD 40, you have a 90 percent of chance of dying within three months.

In some parts of the country, people can receive a deceased-donor liver via the national organ registry with a MELD score of 28. According to the National Liver Review Board, in Southern California it’s 35.

Living donors can change this equation.

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Editor’s Note: Link to electronic press kit with video and photo assets: LINK

Building the skills needed to treat complex neurological conditions like stroke, brain tumors or spinal cord injuries requires a highly demanding, seven-year training program. The pressure of that training can sometimes lead to emotional exhaustion, an inability to connect with others or feeling unaccomplished, which are components of burnout. Understanding what factors influence burnout can be a powerful catalyst for change.
“As a patient, you don’t want your doctor to be depressed or demoralized when they’re working on you, because they’re not their best self,” said the study’s lead author Frank Attenello, MD, MS, assistant professor of clinical neurological surgery at the Keck School. “And as a society, we don’t want to discourage people from becoming neurosurgeons, because we have a rapidly aging population in need of neurosurgeons’ skills.”
While research on burnout is gaining steam in many fields, not much attention has been paid to it in neurosurgery until now, Attenello explained.
To better understand it, Attenello and his colleagues surveyed 346 neurosurgery residents across the United States. Using an 86-item questionnaire, the team explored everything from whether residents felt satisfied with different aspects of their training to whether they were considering quitting training or leaving medicine entirely. Burnout was assessed using the Maslach Burnout Inventory, a validated tool that has been used to measure burnout both in health care and other professions.

The study, published Feb. 9 in the Journal of Neurosurgery, found that 81 percent of residents were satisfied with their career, but 41 percent had given serious thought to quitting neurosurgery at some point. The overall burnout rate was 67 percent — more than double the estimated rate of burnout among American workers overall. Predictors of burnout included inadequate exposure to the operating room, hostile faculty, unsatisfactory relationships with mentors and social stressors outside of work.

“Some of the most impressive and energetic medical students enter neurosurgery,” Attenello said. “When they encounter burnout, it limits their considerable potential, both with their patient care and possibly in their academic and research achievements for the field as a whole.”
To help reduce the risk of burnout, Attenello and others at the Keck School have already implemented a new model for mentorship. This year, new residents in the Department of Neurological Surgery will choose their mentors and the school will assign a backup mentor for additional support.

“Our study provided some valuable insights to the prevalence of burnout and some of the pain points in training neurosurgeons,” said study co-author Steven L. Giannotta, MD, chair and professor of neurological surgery at the Keck School. “Recognizing that burnout exists and finding ways to address it are important steps educational institutions can take to mitigate it.”

— Erica Rheinschild