Medical Insider Blog

Innovations in Neurosurgery: Providing Quality Care in South Florida

  • Posted Jul 20, 2015
  • Ali Jourabchi Ghods, MD

In this video, Dr. Ali Jourabchi Ghods, Neurosurgeon in the Holy Cross Neuroscience Institute, discusses how neurosurgery and the technologies involved in treatments of brain cancer and brain tumors have evolved over the years. Dr. Ghods compares Whole Brain Radiation Therapy and compares it with current treatment – Stereotactic Radiosurgery, which uses focused radiation during surgery. He also explains the O-Arm technology and Stealth Navigation and their benefits, which include less radiation and offers 3-D imaging and navigation that improve precision, accuracy, efficiency, and safety during surgery.  Dr. Ghods expresses the importance of being able to offer innovative treatments to ensure that patients do not have to seek quality care outside of their own community: 

Dr. Ali Jourabchi Ghods is a neurosurgeon who practices at Holy Cross Neuroscience Institute (Holy Cross Hospital) in Fort Lauderdale, FL. For referral information, call 954-900-6653.

Contact Sports and Concussions (Part 2)

  • Posted Jun 22, 2015
  • Fernando Manalac, MD, MMM, CAQ...

If you missed “Part 1” of this post on how to prevent concussions, how they occur and symptoms  you may experience, you can read it here.

Concussion Management


Pre-Participation Evalutation (PPE): in my office, we conduct PPEs to establish a medical background from which medical decisions about physical activity may be made and medical clearance may be provided.

Baseline Testing: also available in my practice is a 20-minute computerized neurocognitive test (ImPACT testing) designed to measure the effects of concussion. After an athlete completes a baseline test, his or her data is stored on a secure, HIPAA compliant server. If a concussion is suspected in the future, a follow-up test is administered to see if the results have changed from the baseline. Traditional imaging procedures (CT or MRI) are helpful in identifying serious brain injuries, but they are not able to identify the functional effects of concussion. ImPACT can detect subtle changes in cognitive functioning that cannot be accurately measured by relying on athletes to report symptoms.

Other preseason testing include Maddox Questions (checks for memory), SAC (Standard Assessment of Concussion), BESS (Balance Error Scoring System); Sideline Concussion Assessment Tool (SCAT2); and NFL SCAT.


In addition to any necessary emergency response, the medical personnel on the field may perform various on-field and sideline assessments, such as a physical exam, neurocognitive and balance assessments, Neuropsychological (NP) Testing/Sideline Concussion Testing, and Return to Play evaluation.

At Home

• Dim/Quiet room

• Allow patient to sleep/rest!

• Very limited role of medications (OTC acetaminophen is most commonly prescribed)

• Seek medical attention if symptoms worsen acutely

Return to School/Play

Returning to school or play is a case by case management. Cognitive rest is needed – decreased concentration, reduced academic workloads, days off or shortened school days, extended test taking times and return to full academics when symptom-free. There should also be a progressive return to play: crawl -> walk -> run -> practice -> play. Talk to your doctor about treatments based on symptoms, age and medical history.

Before returning to school or play, there must be a medical clearance, be symptom-free, not taking medications and there must be a return to baseline based on the neurocognitive / physical / balance exams.

Keep in mind that a premature return to play can lead to a more severe concussion/prolonged symptoms. “Second Impact” syndrome is a second episode of brain trauma before the brain heals from the first. Cerebral arteries lose their ability to autoregulate (vasoconstrict), resulting in diffuse brain swelling/increased intracranial pressure. Second Impact syndrome involves a high incidence of brain herniation, coma and/or death.

Chronic Traumatic Encephalopathy

This condition is known in boxing as Dementia Pugilistica or Punch-Drunk Syndrome. It’s a progressive degeneration of the brain secondary to multiple brain injuries (concussions). Symptoms involve a change in mood (depression/suicidal ideation), cognition (memory loss), movement (parkinsonianism/balance dysfunction) and behavior (aggression).

Protect Yourself

Before engaging in activities or sports in which head injuries are common (football, soccer, basketball, volleyball, baseball, hockey, etc.), consult with a sports medicine physician regarding how to prevent head injuries, your risks for concussion, a PPE, and baseline testing to be proactive in managing possible concussions.

Dr. Fernando Manalac is a board certified sports medicine physician who practices at the Holy Cross Orthopedic Institute in Fort Lauderdale, FL. For referral information, call 954-900-6653.

Contact Sports and Concussions (Part 1)

  • Posted Jun 09, 2015
  • Fernando Manalac, MD, MMM, CAQ...

Dr. Manalac with nurse in helmet at concussion lectureContact sports like American football have long been known for brutal head injuries. As much education that our athletes still need today, we have come a long way since the sport’s origins in the 1860s - when the world lacked understanding of concussions and how to care for those with such head injuries. Over the years we have gained a much better understanding of the pathophysiology of concussions, symptoms, management, and more importantly, how to prevent the injury.


How Concussion Occurs

A concussion is caused when there is impact from which the brain shifts within the cerebrospinal fluid and strikes the skull, causing direct injury. The brain then whips back and strikes the opposite side of the skull. Commonly, there are rotational components to the force, which cause “twisting” of the brainstem and is associated with loss of consciousness. Microscopically there is shearing of the axons in the brain and excessive release of neurotransmitters - the brain’s attempt to start repairing itself or reach homeostasis. This is when you will experience a huge imbalance of energy supply and demand needed for recovery. It is also during this time that the brain is most vulnerable to a “Second Impact.”

Preventing Concussions

My patients and their family members may be surprised to know that protective equipment has not shown to reduce the number of concussions. Direct head trauma is not necessary to develop concussion; any impact that causes the brain to strike the skull or a rotation of the brain stem can cause a concussion. Neck strengthening programs may help in theory, but no studies have been done at this time. Limiting contact / cutting down on the number of contact practices has been shown to reduce concussions. Player behavior modification can help to prevent this head injury – educate players, coaches and trainers and adjust the rules to ensure proper technique and injury management.


If you do suffer from a concussion, the most commonly reported symptom is headache. Dizziness and nausea / vomiting may also occur, as well as visual disturbance. Cognitively, there may be memory loss, some have decreased concentration, confusion, and loss of consciousness. You may also experience emotional symptoms such as irritability, depression and anger. It is also common to feel drowsy or tired and have difficulty sleeping (insomnia). It is important to know, however, that with all possible symptoms, it only takes one symptom to constitute a concussion after a head injury.

Check back for Part 2 of this post for details on concussion management.

Dr. Fernando Manalac is a board certified sports medicine physician who practices at the Holy Cross Orthopedic Institute in Fort Lauderdale, FL. For physician referral information, call 954-900-6653.

Brain Aneurysm in Women

  • Posted Jun 02, 2015
  • Laszlo Miskolczi, MD

woman with headache
Brain aneurysm is a balloon-like structure that develops in a weak spot on the wall of a brain artery. Approximately two to five percent of the population has a brain aneurysm. Although only one to two percent of those aneurysms ever rupture, over half of the patients with ruptured aneurysms die within 30 days.

How it affects women

Brain aneurysms occur much more frequently in women. According to a study published in Stroke, the highly regarded journal of the American Heart Association, more than two thirds of all patients with ruptured aneurysms were women. Half of them were between ages 30 and 60.

Aneurysms grow slowly, over decades. Women with aneurysms that ruptured during their retirement already had a well-defined aneurysm before they even reached 60.

The statistics are shocking

Between ages 60 and 69, women are three times more likely to have an aneurysm than men. Between 70 and 79, it is close to five times more likely for women.

Signs and symptoms

Brain aneurysms grow silently from a weak spot of the artery. The most important signs are sudden onset double vision, a hanging eyelid, or a sudden onset severe headache with nausea that may or may not go away. People with any of these symptoms should seek immediate help.

Who is at risk?

Compared with the 230,000 yearly cases of breast cancer, only about 30,000 aneurysm ruptures occur in the United States each year. Therefore, a screening test for the general population would not make sense. However, testing may be important for people with family members who have had brain aneurysms, especially if one relative had more than one brain aneurysm. Patients who smoke or have high blood pressure are also at higher risk of developing and rupturing brain aneurysms.


According to an article published in the American Journal of Neuroradiology, among 65,000 patients reviewed, treatment risk is much lower today than 10 to 20 years ago. Patients who underwent minimally invasive coil embolization had three times less risk for a bad outcome than patients undergoing surgical clipping. It is important, however, that an individual approach based on patient-specific anatomy be followed in every case.

The technological requirements and expertise of diagnosing and treating brain aneurysms are available only at select institutions. Holy Cross Hospital is a comprehensive stroke center that has received the Gold and Gold Plus awards from the American Stroke Association every year since 2009. These are the highest levels of the American Stroke Association’s acknowledgement of excellence in stroke and aneurysm care.

Laszlo Miskolczi, MD, is a world-renowned neurointerventional radiologist who practices at Holy Cross Hospital's Comprehensive Stroke Center. For physician referral information, call 954-900-6653.

I'm Not Sitting this One Out

  • Posted May 14, 2015
  • Fernando Manalac, MD, MMM, CAQ...

How many of you Road Runners have ever experienced pain or soreness in the back of your thigh (hamstrings), in the back of your ankle (Achilles) or the side of your thigh (iliotibial band)?  If so, there’s an excellent chance that it’s caused by a tendinopathy:

Tendon = the white stretchy tissue that attaches muscle to bone 

opathy = condition or disease process.  

There are three main types of tendinopathy: tendon strain (tear), tendinitis and tendinosis. Runners who run long enough will probably experience every type of tendinopathy.

Traditional treatment for tendinopathy

RICE (rest, ice, compression, elevation) and NSAIDS are the mainstay of Mom’s management for the strains and inflammation (the “itis”). However, the degeneration of the tendon, otherwise known as tendinosis, doesn’t always respond to these traditional treatments.

When tendon is not healing

Your race is in three or four weeks, the last thing you want to do is sit this one out. Platelet rich plasma (a.k.a. PrP or blood-spinning) may be an option. PrP is a procedure done in my office where I draw your blood; place that blood into a centrifuge to spin down and separate the platelets from the rest of the blood; and inject only the platelets (which house growth factors) with some plasma with a few white blood cells into an injury site to help heal tissue.

Factors that affect PrP

This procedure has helped some of the biggest professional athletes, as well as non-athletes alike. Research has shown mixed results, and most experts believe this is because not all PrP is created equal. Varying levels of platelets exist in everyone. At your next blood test, compare your platelet level to your family member’s level, or even to your own last blood test results…much different, right? Also, some PrP kits can control the amount of platelets, red blood cells, and white blood cells, which have an affect on success of treatment. 

Taking Advil or Aleve could also render your platelets dysfunctional; stop all NSAIDS before and after the procedure. Not eccentrically loading tendons within the first couple weeks after the procedure has also provided suboptimal results. PrP is very promising - as evidenced by the abundance of available literature and by studies in the pipeline - and may be the right therapy to successfully treat your tendinopathy.

Fernando J. Manalac, M.D., MMM, CAQSM, CMQ, is a fellowship trained non-surgical sports medicine physician at Holy Cross Orthopedic Institute in Fort Lauderdale, FL. Board certified in Internal Medicine, Sports Medicine and Medical Quality, Dr. Manalac specializes in non-operative management of musculoskeletal issues at any age. Learn about the Sports Medicine program at Holy Cross Orthopedic Institute by visiting HolyCrossOrthopedics.com. For physician referral information, call 954-900-6653.

What is a Faith Community Nurse?

  • Posted Apr 20, 2015
  • hchadmin

Nurses are a compassionate and transforming healing presence within our communities.

By building alliances between two healing communities – the medical facilities and faith communities – faith community nurses focus on the intentional care of the spirit as part of the process of promoting holistic health and preventing or minimizing illness; they promote the fullness of life that God intends for each individual.

Guided by the Scope and Standards of Faith Community Nursing, faith community nurses serve in communities that are diverse in denomination, size, race and ethnicity. They assist each community to develop their vision for promoting health as wholeness in the context of the values, beliefs and practices of their faith tradition and to provide support for implementing and sustaining their vision.

Specific services of faith community nurses may include:
• Integrator of faith and health
• Health educator and counselor
• Referral advisor
• Provider of screening tests/risk assessments
• Community liaison and patient advocate
• Coordinator of volunteers
• Facilitator of support groups

Upcoming Continuing Education Opportunity from Holy Cross Hospital's Faith Community Nursing Program:

Advance Directives and End of Life Care
April 27, 2015 | 7:30am – 8:30am  or  5:30pm – 6:30pm
Jim Moran Heart and Vascular Building, 2nd Floor Multi-Purpose Room
Holy Cross Hospital

This activity has been approved by the Florida Board of Nursing for one (1) contact hour. (FBN# 50-951)

RSVP:  Valerie Fox, Faith Community Nursing Coordinator | 954-267-9551

FREE to Holy Cross Associates, community members and students

Treatments for Tendon Pain

  • Posted Mar 05, 2015
  • Fernando Manalac, MD, MMM, CAQ...

What are Tendons?
Tendons are the stretchy, white bands of connective tissue that are at the ends of muscle and connect the muscle to the bone.

How a Tendon Causes Pain
When a tendon is stretched or eccentrically overloaded, the fibers can tear. This is called strain. Other types of tendinopathy (disease of a tendon) include tendinitis and tendinosis. Tendinitis is acute inflammation of a tendon. Tendinosis is degeneration of the tendon fibers from repetitive microtrauma resulting in the development of abnormal tendon tissue. The commonality amongst these tendon problems is that they can all cause significant pain and dysfunction, keeping people from doing the recreational activities they need or the work that needs them.

Treating Tendon Pain
In the not-so-long-ago past, treatment plans for these tendon problems were very limited: rest, ice, compression and elevation were, and still are, the best initial therapeutics. NSAIDS and other medications and modalities are also used to reduce inflammation and can be very beneficial. Prescription medications and cortisone injections may have a limited role in persistent tendon pain or inflammation. However, nothing has been shown to be more effective than eccentric exercise in physical therapy at repairing damaged tendon. 

What if Treatments Have Not Worked?
What do you do if none of these therapeutics have worked? From the 1970s-2000s, advanced treatment for tendinopathy was limited to surgery. Surgery is still the only clear fix for complete ruptures of tendons; meaning, if a tendon is torn in half, the only way to get perfect function is to reattach those two ends. However, performing surgery on strains (partial tears) that won’t heal, or refractory tendinoses, may actually be excessive.

Orthobiologic injections, such as Platelet Rich Plasma and Mesenchymal Stem Cells and minimally invasive techniques, such as percutaneous tenotomy, are revolutionizing the advanced treatment of tendinopathy.

Schedule an appointment with Dr. Manalac to discuss if one of these therapeutics might be appropriate for you and can get rid of your tendon pain once and for all.
Dr. Manalac is a non-surgical sports medicine physician who practices in Fort Lauderdale. For referral information, call 954-900-6653.


Diagnosis and Treatment of Alzheimer’s Disease

  • Posted Jan 29, 2015
  • Eduardo R. Locatelli, MD, MPH

According to the Alzheimer’s Association, someone in the United States develops Alzheimer’s Disease every 67 seconds and by 2050, the number of people age 65 and older with the disease may nearly triple barring the development of medical breakthroughs. In today’s healthcare world, the diagnosis and treatment of this disease involves:

Hearsay Evidence: Talking with the patient and a family member or friend who can corroborate the patient’s memory loss is the first step to determine if physical and cognitive changes are part of the normal aging process or if they are indicative of mild cognitive impairment and Alzheimer's.

Process of Elimination: There is no definitive test for Alzheimer’s despite decades of research. Eliminate other possible causes of memory loss is the first step in diagnosing this disease. Depression is a common disease that occurs as we age and someone with severe depression can appear to have Alzheimer’s. Parkinson’s disease also shares common symptoms. The list goes on, and even sleep medications and analgesics taken for the aches and pains of aging can make us forgetful.

Technology: Not one of the many state-of-the-art medical devices in healthcare today treats Alzheimer’s. They are merely tools we can use to confirm a diagnosis.  MRI brain imaging can help rule out hydrocephalus and benign or malignant tumors as well as damage caused by silent strokes. Low-tech blood tests are used to uncover low thyroid, vitamin deficiencies and liver and kidney conditions that can cause memory loss.

Pills, Patches and Ipods: Although research has failed to give us a good medication, it has created multiple lines of treatment which offer, if anything, modest improvement. The FDA has approved medications from two classes (cholinesterase inhibitors and memantine), and alternative treatments include vitamin and food supplements. While many of these can be quite expensive, increasing socialization, exercise and just listening to music have also shown improvement in brain function. 

Research: As with diagnosing the disease, research to date can be seen as ruling out possible biological markers or genetic profiles. MRI’s are looking at the size of memory centers in the brain as PET scanning is being performed to understand if abnormalities in glucose metabolism create plaques in the brains of older individuals. Genetic research is investigating the apolipoprotein E (APOE) gene found on chromosome 19. According to the NIH’s National Institute on Aging, most researchers believe that APOE testing is useful for studying Alzheimer's disease risk in large groups but not for determining an individual’s risk. In practice, APOE testing is considered for patients with a family history of early-onset Alzheimer's disease but is not generally recommended for people at risk of late-onset Alzheimer's.

Dr. Eduardo R. Locatelli is the medical director of the Holy Cross Neuroscience Institute and of Holy Cross Hospital’s Epilepsy Monitoring Unit. For referral information, call 954-900-6653.

Rare Brain Tumor Removed, Patient on Road to Recovery

  • Posted Jan 22, 2015
  • hchadmin

For months, Kathleen Cruz, 64, would have sudden onset headaches when she bent over. A legal secretary, she attributed her symptoms to stress.

The excruciating headaches on December 16, 2014 sent her to the Emergency Department at Holy Cross Hospital…but only after weeks of headaches accompanied by hand tremors, being off-balance, weight loss and nausea.  

Hemangioblastoma Imaging Photos Two ViewsDoctors found a mass on her cerebellum. The rare tumor – a hemangioblastoma  – was pressing on her brain stem, causing her symptoms and headaches. Of more concern, the tumor was obstructing the passage of spinal fluid from her brain, elevating the pressure in her head—a diagnosis called hydrocephalus, which if left untreated could have killed her in a matter of weeks. Brain surgery was required, not only to remove the tumor but to also relieve the hydrocephalus. Using the StealthStation® Surgical Navigation System, specially designed for surgeries in the complex and delicate areas of the spine and brain, Dr. Ali Jourabchi Ghods removed the mass, later deemed benign.

“When I first saw Mrs. Cruz in the ER after reviewing her CT, I thought she may have a malignant brain tumor or metastasis based on just sheer location and chances,” Dr. Ghods said. “However, after the MRI was completed, it looked suspicious. It had the classic appearance of a hemangioblastoma, which is very rare. In 7 years of training at a large university hospital, I have only seen this type of tumor one time. Additionally, they tend to occur in younger people. I assured both Mrs. Cruz and her husband, Rolando, that based on the MRI, I was hoping we were dealing with a hemangioblastoma because surgery was 100% curative, versus something more aggressive such as metastasis. During surgery, it was obvious this was a vascular tumor and when our pathologist said this was a hemangioblastoma, we had the good news delivered to Rolando. We took the tumor out in its entirety and in the same sitting cured her of her hydrocephalus. She was a champ in the OR and a champ after, and went home without any complications or setbacks.”

“I was comfortable with him,” Mrs. Cruz said of Dr. Ghods. “Everything he said came through. Dr. Michael Rush made sure I got the CAT scan right away. Another 2 to 4 weeks of this and I could have gone into a coma.”

When she came for a follow-up visit three weeks post-surgery, Mrs. Cruz was looking healthy and inquiring about resuming yoga.  Although she works in Fort Lauderdale, Mrs. Cruz’s full-time residence is in Port Charlotte—more than 150 miles away on Florida’s west coast— where she is resting and recovering under the watchful eye of her husband, who is now a Holy Cross enthusiast.  “Thanks to Dr. Rush and Dr. Ghods, Holy Cross is now my first choice,” Mr. Cruz said. “Dr. Ghods is someone very special. He is enthusiastic, caring, aggressive, loving. He was on the money. He knows what he is doing.”  

“She is the Eveready Bunny,“ Mr. Cruz said of his wife. “She never stops.”  And thanks to the team at Holy Cross Hospital, she can keep going. 

Dr. Ali Jourabchi Ghods is a neurosurgeon who practices in Fort Lauderdale, FL and is a member of the Holy Cross Medical Group. For more information on Dr. Ghods, call 954-900-6653.

Healing Diabetic Foot Ulcers: It Takes a Village

  • Posted Jan 14, 2015
  • Carlos O. Guerra, MD, MPH, CWSP

Hyperbaric Oxygen Therapy

In my particular field, infectious diseases, I have the chance to diagnose and treat infected wounds and osteomyelitis in conjunction with hyperbaric oxygen therapy. Along with a panel of wound experts in various specialties, we work together in healing chronic wounds.

Diabetic Foot Ulcer
One of the most challenging types of chronic wounds that I see every day is the diabetic foot ulcer.
A few quick facts:
•    Diabetes affects over 26 million people in the United States.
•    Foot wounds are the most common diabetes-related cause of hospitalization that could result in amputation.
•    Patients with diabetes have a 25 percent higher chance of developing a foot ulcer.
•    Patients with diabetes have a 50 percent higher chance of developing an infection compared to the general

Treating Diabetic Foot Ulcers
A multidisciplinary approach is essential to preventing complications of diabetes. Podiatry services are needed for prevention, education and treatment of diabetic foot ulcers; infectious disease services for diagnosis and treatment of infected wounds and osteomyelitis; and vascular services and general surgery services are also needed because many patients with diabetes have peripheral vascular disease.

The Holy Cross Wound Healing and Hyperbarics Center utilizes the expertise of these wound experts to offer different modalities of wound healing, from appropriate dressings to skin substitutes, periodic surgical debridements, and revascularization procedures for severe peripheral vascular disease ulcers. Hyperbaric Oxygen Therapy is also offered for patients with diabetic foot ulcers with chronic refractory osteomyelitis, often in conjunction with long-term antibiotics. In addition, emphasis on prevention, off-loading and education regarding diabetes and diabetic foot infections is given to all patients. We also follow up with patients at the Center every week until the wound is completely healed.

Dr. Guerra is an infectious disease specialist who practices in Fort Lauderdale, FL and is a member of the Wound Panel at the Holy Cross Wound Healing and Hyperbarics Program. If you or a loved one has a nonhealing wound and would like to speak with Dr. Guerra or learn more about the Holy Cross Wound Healing and Hyperbarics Program, call 954-900-6653.


About Holy Cross Hospital

Holy Cross Hospital is a nonprofit, Catholic hospital in Fort Lauderdale, Florida, dedicated to innovative, high quality and compassionate care. For nearly six decades, Holy Cross has continuously expanded its services to provide leading-edge care for their patients in Florida and for those from elsewhere in the United States. Holy Cross also offers an International Services program to ensure that patients from outside the U.S. receive the care they need.

Blog Categories

Blog Archive