New techniques have not only made treating seizures safer but can help kids understand what’s happening in their own brains. Pediatric neurosurgeon Kurtis Auguste, MD, discusses using the latest tools to localize seizure foci, plan and perform procedures, and educate patients. Bonus: help figuring out when it’s time to consider surgery and an update on neurostimulator devices.
thanks for joining. Like they talk a bit about how things have changed in my practice over the past 12. Going on 13 years now, where we've been changing how we manage epilepsy patients specifically how we image on how we treat them in the operating room. We are in the midst of an evolution of sorts being much more sophisticated with how we we investigate these parents, these patients and and much less invasive with how we treat I wanna kinda share with you some of the more recent advancements. Mhm. So we have some objectives to cover for the evening. I provided them ahead of time and you've probably seen already. But I wanted you to be able to differentiate among some of the different imaging modalities we use for seizure. Focus. Localization. By the end of the talk, I want to show you some of the minimally invasive techniques that we're using right now diagnosed to treat the seizure focus side that we find. I'm looking forward to you guys seeing how some of our advanced imaging techniques were being used now to plan for surgery to train our residents and medical students. Andi also to engage our patients in a much more meaningful and fun way, and I want to show you how we're using some of these tools to communicate all this information. A lot of it's really complex. We're talking about three dimensional, um, anatomy. It's really hard to communicate those things with traditional, more traditional means. Andi, Um, some of our advanced techniques can really cross barriers of race and ethnicity and educational and socio economic status. So, um, um, this is really what we're gonna try and cover here. My disclosures I felt obligated to before launching into the advances. Just that the few words about childhood epilepsy because these are these are common questions. I'm sure most of you get and I I still get even though I'm in a coronary care facility, and by the time patients see me there, they're pretty much ready for surgery. But e think it's important we kind of take a step back and rewind a little bit and answer just some very fundamental questions about childhood epilepsy before they even get to me just to kind of help you along the along with answering those questions as well in your practices. So let's start first by just talking about the natural head of childhood epilepsy. Because the question comes along a lot. What's the likelihood? You know, Johnny's had his first seizure. What's the likelihood that he's gonna have a lifetime of seizures? And so this is a study from 2000 that followed about 150 patients, and they showed that about 30% of patients enter a mission in that very first year of being treated for procedures of almost 20% of these patients are resistant to any kind of medication from the very beginning. But overall, two thirds of patients will eventually achieve. Terminal remission will eventually stop seizing their childhood epilepsy will end, and of that, two thirds of the vast 80 for 6% of them won't need any meds to stay seizure free. So the good news here is that just because you had some seizures as a kid and maybe you've had a couple and you actually required medications that you actually stand a good chance, Oh, effectively outgrow your epilepsy and won't need tohave medications as you get older. So that's the good news for a very words that the parents who are managing seizures for the first time. Yeah, a common question that we get is alright, so I'm on seizure meds. Um, and they're not working, So should we just keep trying? I mean, we go into the second or the third, and this is actually a paper out of the noon journal from 2000 had close to 500 patients, and it showed that after the first drug, more than half of them were still having seizures. And then if you look at the population that we don't have a second drug, I'm 40% of those patients will still have seizures. Third drug, 36%. So you're getting diminishing returns with each drug. And so what I often tell patients is that once you've started drifting into the 2nd and 3rd drug, the expectation isn't really that Ah, fourth, the fifth on trials is really going to make much of a difference. In fact, it's less likely as you try more and more intense. Another question is Okay, well, we have had medications were still season. Do I really, really need surgery? And to answer that question, we really only think about searching for patients who are medically refractory, where, despite the medication trials, they're still seizing. What would we use this criteria for failure? So for us, if a patient's tried to trials of one drug or one trial of multiple drugs, then in our for our intents and purposes, they are kind of pushing their way into this medically refractory of status. Andi, the studies have shown that about 5% of patients on Lee will have six months, three seizure free periods with each additional e d trial. So that's 90% patients won't even get to six months or seizure freedom with additional on medication. So for our purposes, once you get past that second, that second med or that probably that Polly trial. I'm your medically refractory, and we should really I'm sorry. Yeah, So you now have gotten to the point where you don't feel you've outgrown your childhood epilepsy or the side effect profile from the medications is very high or you've tried all the drugs and you failed. Um, we are thinking now, Maura, about surgery. Well, how do we get to a point where we can consider someone a sort of a candidate? Eso the very big question that we have to answer is where where the cedars air coming from. And so we have to employ a Siris of test to answer that question. And the most common, of course, is gonna be the EEG and a Z. You might imagine where we're going to sit with these patients for a little while to understand geographically, Where do we think the Cesaire coming from? Um, it zits. Not enough, though, to just listen to the the electrophysiology of the brain. It's very important that the first hear that introductory pass of creating these patients should involve Ah, very good quality Emery and most centers now have access to three Tesla memorized. 1.5 is the first preliminary passes is typically sufficient. Andi memory is gonna look for religions. Is there some kind of tumor? Could there be some kind of focal cortical dysplasia or distortion of the great white junctions? Just something anatomically that would explain why this patient is seizure. And our hope would be that if we see even it actually co localizes to where the electro physiologic abnormality was on the EEG. Um, if you have things that are starting to line up on you, but you still have questions about the extent of the location of the seizures source. Then there's a second tier of testing, and this is These are some of the typical test that we use at UCSF. The PET Scan and SPECT scan are basically physical tests to look for changes in metabolism. Andi. Those changes in metabolism light up differently on the screen, and those will be indications of where the soldiers were coming from. So the PET Scan and spect scan are tests to look for where the seizures air coming from. So when when we're answer the question where we don't wanna just know, where is the seizure coming from? Where is the bad brain? It's also pretty important that we answer the question, and to do that, we have to start texting the brain to see where the what we call eloquent court Texas or the functional Court Texas. And for that purpose, we employ functional memories for patients who can participate, and we actually have them do tasks in an armory scanner, and as they are using those those parts of their brains, those parts, their brains physiologically light up, they their metabolism increases, and so we can label those parts and then another way, toe kind of physiologically answer. Where is the good brain is with an M E G scan or a magneto insightful Agrium and the M G is nice because you can not only test for function in these scanner, You can also answer the question of where, where this is coming from us. Well, so I'm not going to show you the images of pet scans Respect scans again, Those are just physiologic bright and dark spots that we're looking for. And the honest truth is pet and SPECT scans alone aren't enough to guide me a surgeon to the very precise spot of where soldiers are coming from. And I can't plan a surgery solely on a pet or spect scan, so I won't go into any detail about those. But I just want to kind of, uh, spent a couple of words on FM arena mixed skin. Um, this is just a little bit more background on for the first year Pre surgical video, E g s, um, this is for the purposes of preparing. Nice to you might see in clinic about Well, you know, If we go and we get a longer video e g a 3 to 7 day inpatient admission, what's that gonna look like? Um, that's for the patients who don't seize very frequently. Um, and May May may need a little bit of help to coax their seizures out, so to do so, we want to have them admit it. We in their medications, perhaps we may actually also want to sleep deprived them. We basically want Thio, in effect, provoke them to have a seizure. But we want to do it in a controlled setting like and so we would often admit them. And it's essential because when a patient sees is the way that seizure manifest the scene theology of that, that seizure can be a tip off as to which part of the brain is actually involved on DSO, we wanna get many of their typical seizures is possible, not something that's kind of a flavor of their seizures. But it's the it's their absolute a stereotypical seizures, because that's the one that's most accurately gonna tell us hopefully which side decisions coming from but ideally, which region are part of the brain is season, so to complete the the comprehensive evaluation of AH, pre surgical work up at U. C. We also add the nearest to see where patients baseline deficit strengths and weaknesses are, um, It can also give us a new idea of how well are they gonna tolerate surgery, that some of the neuropsychological tests will tell which parts of the the brain are most involved with their functions and by doing surgery and those those looks, we may actually create some processing problems or concentration problems or memory problems. It also helps us tell helps, tell us if we have to do mapping on these patients, uh, bringing room or outside the operating in how cooperative would they be or how how successful with that testing be? And then, obviously, if we have a baseline understanding of what their strengths and weaknesses are before surgery, hopefully, after we are able to do a surgery, we can do the same time and monitor some kind of improvements. Um, if, for example, we have localized or partially localized someone seizure focus to their speech centers, we really now need to know how closer there's their speech centers. Um, to do that, we do language assessment with a classic test called the Water Test. What's an invasive testing? Effectively put half of the brain to sleep while we're asking patients to do language testing one side of the time on gets through its use. Use that using an interventional radiology technique. Less invasive means, which we're using more and more again involved the F Emory in the M E G, which I want to tell you about now. So here are just some pictures some examples of what these machines look like. Patients are lying either in their memory scanner, and they are given a button thio signal when they are answering questions. Appropriately, On the right is a picture of an M E G machine, where that will cut out on the top pieces where the patient's head fits these air noninvasive test. They give you the ability to do the test multiple times to confirm your findings so you could pass with multiple trials on get a really consistent data. We obviously want to try, uh, to lateral eyes where patients problems are, but ideally, if we can localize and get much more specific, we'd love to do that, and it's it's nice to have FM arrives for localization and lateral ization of language and MDGs for seizures and function. The weaknesses that these machines will show you which parts are involved, but not really how how involved are they? It doesn't really differentiate differentiate between what's necessary versus sufficient on dso. That's a bit of a drawback. Eso we don't typically just rely on f m r I r m e g data to to tell the whole story these air tests that are kind of adjuncts to the other tests that I mentioned. So this is an example of what a functional emery, um, scan looks like. They're very vivid, colorful pictures where a patient is doing a task and those elements of the brain light up corresponding to the parts of the brain that they're using. So on the left, there, all those areas, those pertinent areas lighting up on two dimensional slices. And as you might imagine, we can then take all these two dimensional slices and line them up and construct on the right a three dimensional model and then this. These three dimensional models are much mawr pertinent to my world, where I have 23 dimensionally plan and in my mind's eye rehearse surgery. And this this kind of three dimensional ization is really key and optimizing what when we go toe to the operating them. So this is this is someone's speech cortex for NFL Marie. The next set of images of M E. G on DWhite NME G does, is it. It takes advantage of the fact that when neurons fire, they create a distortion of a magnetic field distortion. And these tiny little devices called squids can detect those distortions. And so, every time ah, function happens in the in the appropriate neuron fires, these little squids detect those distortions. So that's a way that we can design tasks to a map. Their motor cortex. We can map their sensory cortex. We also have modules for auditory and visual cortex. Little by little, we're understanding language, mapping better with MGs. I wouldn't say that it's the gold standard by any means, but those paradigms are evolving. Um, it's a nice way, by the way, to not just map the brain functionally, but we can also run an EEG simultaneously, and we can map those big spikes in addition to those pertinent areas of function on the same pictures, and all these pictures can be added to what's called frameless stereo taxi or neuron navigation. And I'll show you what those are those. This is a very, very useful. It's basically the standard of care in a contemporary neurosurgery operating room. Neuron navigation is key, so M E G scans and FMRI scans. Both of those scans can be loaded to my operating room images and Austria picture of those. So, um, this is an example of what happens when we do MBG motor mapping. This is, uh, tasks of the right hand where we're asking their the patient to move their index finger on the left or their pinkie finger on the right. And those will correspond to firing of the first dorsal interest on neurosis muscle Andi Abductor Digital Mini Me, respectively. And when those neurons fire, the squids will detect that firing and label on the brain in stereo tactic manner where those spikes are. So this is a way for us toe map and then label where the person parts on. So that that green 1.2 you're seeing is actually this patient's hand motor knob on the left side by moving his right head. Ondas I mentioned the nice, but the M E G is that we're not just mapping their court texts for function. We can also run the E G simultaneously in those spikes can be put on the same images. So this is an example of a patient who has seizure spikes on visible on the right hemisphere and then this amount of sensory vote field on the Left Hemisphere. So this is a picture of what your navigation looks like. This is actually a picture from our our neurosurgery O. R. In Oakland Children's Hospital. That's one of the few ours with the window, which is one of the nice things to watch the sunset as we're drifting into the evening, whether surgeries but in my hand is a wand. There are four gray, um, spheres that a camera can see and that camera projects to that screen that I'm looking at. That screen is this patient's emery. So as I'm moving that that wand with my right hand in real time, the images on the TV screen are moving and it's basically like GPS for brain surgery. So I I use this to find out where the problem is on. Based on that information, I could design the perfect craniotomy based on the craniotomy. I could design the perfect decision. So everything is custom made. Now it can tailor made it's it's not. It's not a one size fits all surgery by any means. It's exactly what that individual patient needs, and it's also very helpful as you're actually performing the surgery. So, for example, if we're taking a tumor and we want to monitor our progress, we can place this one into the tumor bed and see how far along we are and how much tumor maybe left. So when I was discussing the F Emery name E G. Just know that the screen that I'm looking at, we have the ability to label all that information and take it with us to the operating room. So it's it's taking a lot of the guesswork, and it's out of the surgery, and it's keeping us very, very safe. So the next part of the talk is about localization. Eso we've now again, we're taking patients in the operating room, and the answer still is where, and we attempted to answer that question with imaging and advanced imaging alone. FM arrives mgs pet spect But sometimes that's still not enough and way need even more precise mapping of the brain to answer the question. Where and so what we would typically employ if we wanted to be thorough about it is we would design a surgery where we would make an exposure of the area of the brain in question, and we would lay down a sheet of electrodes like the one you see on the right here. And as you can see, each of these electrodes has a number associated with them. It's a see through grid eso. What would happen is we would place this grip and then we would actually close the craniotomy leave the grid in place, having taken pictures as a guide to and thought this would happen on Monday for exam. And typically we would then listen for Tuesday and Wednesday or Thursday. Onda listen and wait for seizures, and as the seizures happen from a particular gyrus of the brain, it would light up the corresponding electrode over it. And now we have a number of map of where the bad brain is the seizures. Air coming from. We also have the ability to one by one stimulate each of these electrodes while patients are doing tasks. So, for example, if they're counting and we stimulate electrode 24 and while they're counting their counting stops and then when we stop stimulating Number 24 they're counting restarts. We know that Number 24 is overlying on area of brain that that patient is using for speaking. And for counting on, we would label that as good brain. So over the course of the two or three days, we can map both the good and the bad, and we would take that map back to the operating room, remove this sheet of electrodes and then remove that one place of the brain that might be seizing. And I often explain this to the families that I've seen a bit a bit much to have to take out brain tissue. But you have to remember that this tissue, the only purpose of this this tissue has now is to be a seizure generator, and it Zaveri rare that the good and the bad co localized um, for those situations. We'll talk a little bit later and talk about what we do for those patients, but this is just to give you an example if we still don't know where all the seizures air coming from and we still needed to do, um, or deep dive into where this is one means of doing it. But as you can see, this is this is a pretty big deal. This is a pretty big surgery. It's a it's a decently sized exposure. It's two surgeries. It's a surgery on a child. It's an inpatient stay with wires attached to the child. They can't leave the ice you. So if there is a means of answering that question, where through a less invasive technique and we're all for it and s, I wanna begin Thio tell you a little bit of how we made inroads in that regard. So this is what we would call grid and strip electrode mapping. Um, this is an example of one of the maps that we would get from the grids where the red part is, where the bad brain is the seizing brain. Andi. That's what we would plan on respecting and in the colored parts respond to where the patient had a fait Jha when we stimulated in purple, where their frontal I fields stimulated some eye movements in green. And then where we map the patient's motor cortex, their thumb moved. There are moved their risk movement. We stimulated those yellow electrodes, so this is an example of the map that shows the good in the bed. But again, I'll bring your attention to the fact that this is quite and extensive exposure, and it's a It's a big surgery if there's a way to get get the information through other means that we should try. So, um, Thio, answer the question of where, specifically which side one of the older techniques was to do very small burr holes. Andi, I'm not sure if you could see my arrow, my cursor moving. But, um, on this X ray shows a little grace circles. Those are actually holding the skull that we float strips kind of like if you've ever seen people doing ice fishing where they carve a hole in the ice and they put their fishing lines in and hope to get some fish, we basically a carve the hole in the idea, and we slide these strips in multiple locations. Um, and each of these is like fishing lines, and we're hoping to catch the fish. The problem with this, even though it's relatively minimally invasive, small incisions, little hole is that we have really no particular control over where these strips end up. We don't know which particular gyre I they correspond to. Thes strips are flash strips, and they're just sitting on the surface. So it's on Lee giving us two dimensional information of a very limited territory. It gives us no three dimensional information eso to fan out and and answer the question of where using strips is long outdated. But it was an attempt, at least to be a bit more minimally invasive, if it all possible. So let's fast forward to now and talk about how we are advancing the field with a much more minimally invasive technique. But with, um, with much more precise data extracted, this is a figure from a paper we are that's in review right now, Um, that's looking at stereo E G. Stereo E. G is a technique where we use these long electrodes that are very thin. They usually taken incision. That's about a millimeter or two in the skin. Um, and we flow these wires down into the actual tissue itself. Now you might think that, you know, is there some danger involved there Will? Sure there is. But we spend a lot of time studying the pick the memories ahead of time to see where the patients vasculature is, and we use narrow navigation and stereo taxes to thread the needle between all those important structures so that we could do three dimensional recording now of multiple lobes. And if we wanted to, both hemispheres simultaneously. So this this address is a lot of the shortcomings of that last picture I showed you where it's that was only two dimensions and there's no precision as to what you're listening to. This is quite the opposite. This is very precisely placed deliberately placed electrodes into multiple locations safely. So this this concept of stereo e g, this is this is currently the wave of the present. I would call it where most centers are moving wholesale over to stereo E. G. As an investigation for where, where where are the seizures? Coming from in these patients, instead of doing big craniotomy is like I showed you with large incisions, Um, and the associated discomfort and pain that might be associate ID and the associated risk of infection. We make these very fine twist RL holes in the skull through again. 122 millimeter Nixon. The scalp because there's no big incision is much. It's painful, and the recovery from the little nicks in the scalp is much quicker. The planning is very precise because we are studying this patient's memorized in detail for days ahead of time, and we're using the computer software to navigate our way through the sea of blood vessels to precisely placed each and every one of these electrodes. It thereby gives us access to the very deep, three dimensional structures that we couldn't see with either grids or strips. Um, and it allows us to study multiple lobes bilaterally if we want Thio. I showed you our technique, which is frameless. There are some centers that place these with frames lexical frame, C R W frames Onda. Good news here is that there's actually quite a low risk of infection bond hemorrhage. Our rate is about less than 1% on the reason why we keep that rates so low is because we do spend a lot of time having these patients undergo the appropriate and geographic tests ahead of time, like an M R angiogram or C T angiogram, and we use our software to get a step safely. This is an example of one of our plans for one of our patients where you can see that this patient had a prior neonatal infarct. Anita stroke Andi the e g, the surface EEG implicated Ah, lot of this right hemisphere. So the question was what really which? Which parts of this right hemisphere are really involved? Where is the seizure generator? Where does the seizure starting? Where does it travel? Because those those those parts of the puzzle matter. And so we deployed. We had this plan of deploying this array of depth electrodes. Um, this is a two dimensional representation of the model on the left. This is a three dimensional model of of the of the patient on the right. You can see we put in our interior the patient's motor attracts and his yellow visual trucks, and we use this software in this technique to thread the needle between those structures so that we would avoid the patient's motor cortex and the visual cortex on deliver these electrodes safely. So this is what it looks like in the operating room. So again, instead of a big, large question mark incision with a shave and a lot of pain associated with it, we make these little postage stamp shaved and the hair just so that I can get a really clean, sterile spot. Um, the purple kind of overestimates how much of a nick in the skin you need, But I've gone ahead and marked where each of our planned electrodes will be ultimately on this patient and then after I placed them. This is what they look like. They are, for lack of a better analogy, like little tiny Frankenstein bolts that that sit without moving, fixated to the skull. And when it's time to remove them, these caps come off, they aren't true, and some places just put a little bit of skin glue. I'd like to put a little bit of stitch. I like to do it in the operating room, and it takes about, you know, three or four minutes per per removal, and patients go home the very next day. Very very different than the grid and even the strip patients on DSO we have employed stereo e g more and more, and this is one of the primary, minimally invasive ways of answering the question. Stereo E. Okay, so we talked a little bit about how we are in a minimally invasive mean by by a minimally invasive means answering a question of were studying the patient monitoring the patient. What about delivering kit? What about actually treating epilepsy through a minimally invasive means? So I want to talk a little bit about how we are approaching that. Um So this is some smart cover work from one of our papers from 2018 where we discussed very deep seated lesions that cause epilepsy, specifically a type of epilepsy called jal ASIC seizures. The hypothalamic martoma you can see on this coronal memory in the very center of the head. Here, there very light gray mass that's attached to the underside, primarily the underside of the left hypothalamus here and this is very classic appearance for ah hypothalamic martoma. And you might not be a neurosurgeon if I would ask you how would you treat this, and how would you get there? I mean, just looking at this picture you, I'm sure are disturbed by the fact is in the very center of the head. So all the structures are surrounding it. There's no way to get to this. No way to get toe abnormal tissue without going through normal tissue s There's a lot of risk. One thing you should know about doing open brain surgery is that the deeper you go, the narrow your gets, just you're effectively working in a cone and that already would be challenging. It's dealing with bleeding or problems that may surprise you in a very narrow space that really injuries can happen. And so, um, even though we have open surgical options for this is this is how we used to treat it may be taken 10 years ago, we would elevate the temporal lobe and slide in this space and try to get this out from underneath. We've completely abandon that because we have access to a very of sophisticated, minimally invasive approach of deploying a laser. So laser ablation is something that we continue to test the bounds of how useful it can be. So most centers will place thes with ahead frame. So we need stereotyped it coordinates to place these very carefully and most places use frames. We at UCSF, we use a a scalp mounted head frame. So it's not a frame that goes entirely over the whole head. It's just right over the location of where we're gonna be, um, implanting this'll laser. We use the Emory scan to target to create a target to create a trajectory. To get our laser in place, the laser is inserted through a very small twist troll. Not not very different than the twister holds that we use for stereo E g. Um, usually patients have to have a head frame place in the operating room, and then they're transported to the memory scanner, um, to see where their laser ended up. But we have the advantage of having an inter operative emery sweet, um, at Mission Bay. And so when we do these cases, we actually do everything from start to finish in the actual sweetened. The patient doesn't have to move. Everything is right there. Ready, Andi. Advantage of that is that instead of transporting a patient with a laser already in their head, that may have been placed incorrectly and then has to go back to the operating room to have a new laser place. We don't find that problem because we actually watch our lasers be placed on the fly. And so, if any adjustments need to be made were already in the intra operative Marie Sweet. And so it lets it lets us take care of any adjustments right then and there. Um And then once the laser is deployed and the seizure focuses, burn, everything is removed and they go to the I C U for recovery. And those patients usually stay in the hospital for about two days. So this is an example of some of the anchors that we used to secure the laser in place. Um, so in this case, there wasn't even a minimal head shape. There's no need for it because the nick and the skin is so small. This is a picture from our Inter operative Emery. We've all I've already gone ahead and gotten the laser all the way down. This is ah, wire applicator. Basically. Ah, hollow bore needle, long needle that delivers this laser to the hematoma. Um, and so we can watch it go on its way down, and if it deviates a little bit, we can adjust on the fly and get it to its destination. We then tell the module, um, where we want the heat. The laser to burn on DWI also can assign these thermal safeguards. These air basically do not burn areas. These X marks are constantly measuring temperature. And should the temperature elevate beyond a dangerous, um, level that could potentially hurt important structures, the machine automatically turns off. So riel time M r thermography is being performed on the lesion. We're safeguarding the structures around them and then a little by little, the software is estimating how much tissue we've actually a belated how much of the seizure focus has actually been heated so high for so long that that tissue has now been effectively erased. So this is a very sped up video of both the M R. Thermography in blue and green, and you might see a little flash of different colors to show that the heat lighting up in the center and then on the right, you're seeing pixel by pixel a little a little island of orange. Um, that's the ablation um, a bladed tissue, the a bladed hematoma from within. And it's all done through this 122 millimeter twist drill hole. So very, very different than when we when I first started treating these and in 2000 and eight by traditional means which would require a much more extensive incision and much longer hospital stay. So we are kind of walking our way down the continuum of less invasive, not just less invasive listening and monitoring, but less invasive therapy. I've shown you the current state of affairs for minimally invasive laser ablation, but there may be cases where we don't even want thio oblate the tissue. We don't want our sect it with an open surgery. We don't even wanna oblate it with a fine laser. Perhaps you wanna leave the tissue in place and do what we can to modulate the neural activity to, uh, to modulate the circuits, that air firing in an inappropriate way. And you may have already gotten a taste of that that kind of approach with the device called the vagus nerve stimulator. Um and this is some of our work from 2000 and 12. Um, the VNS is an implantable device that sits in a pocket in the in the in front of the pectoral s muscle. So it's just underneath the skin. It's above the muscle. I'm showing you two examples of the VNS. This big rounder one is, uh, is the older model, which we no longer implant. This smaller one is the shape of the current model. The Model 1000 sent Eva on Duh. It's a little bit smaller than an egg effectively, and it's it's thinner than your cell phone on git sits in a pocket in the in the chest wall, um, it za device that we implant for patients who are not candidates for any cranial surgery but are still medically refractory. Um, the exact pathway, the exact mechanism of how this device works is not entirely known. We do know that the stimulation travels in a retrograde fashion from the vagus nerve through the brain stem up into the courtesies. Um, it's effectively for lack of a better analogy, like a pacemaker for the brain, and it's it's providing a drumbeat. Ah, march. It's a march, a little marching band for the for a chaotic environment of an epileptic brain so little. By little thes chaotic circuits would rather march to the beat of the VNS drum and be organized by the rhythm of the V N s, then to chaotically um, discharge in their epileptic fashion. And that's the best way I found to kind of describe this function and generic terms to our families, who I'm trying to understand how this works is it's just it's providing a rhythm. It's providing cadence to the brain, but it's doing so in between seizures. The primary function of the VNS is interruptible discharges, its intellectually in between seizures, providing a pattern. It's not. It's not typically doing anything during seizures. That is the that is the prior way, the and the only way that the VNS used to work. Um, and we talked to the device through the skin. Batteries tend to last somewhere between 6 to 8 years if we were just talking about the intellectual device. But the newer devices sent Eva that I mentioned is not just interruptible, um, so it uses heart rate elevations as a surrogate marker for a seizure. That's coming. And the reason why this is important is because leaving over the company that distributes these devices released a report that, on the order on the order of about 80 3 84% of patients before they have a very large seizure will have a statistically significant elevation in their heart rate. And so that's this device is not specifically listening for a seizure per se, but it is using the heart rate elevation that most epileptics have as a surrogate marker for a seizure to come. And then when it detects that heart rate elevation, it will provide an extra stimulus much like a magnet. These patients who get VNS or sent home with magnets and they're taught to swipe across the face of the VNS with the magnet in the event that they're having a big seizure, and they try to use it like a rescue mint. Um, but the heart rate stimulation the heart detection function of the device is like an automatic magnet. It basically stimulates when it detects that heart rate elevation on git does so interactive. Leah's well, eso that function is also listening for actual seizures, so it has anecdotal element to it as well. You can pre programmed listen TVA so out of convenience for families who are traveling from a foreign. It's especially pertinent during this covert era where we're trying to minimize how many trips these families have to make. You can pre program this device, um, Thio graduate to the next settings automatically. We still have to coordinate with the families and and check in with them that these the most recent adjustment was okay and this side effects. But we can cut down on the number of its, um, that we have toe schedule. And a lot of these graduated steps can be done remotely or automatically. I should say there is a another function that is not quite yet gone. Live Leonova hasn't yet activated, but there is a function of the device because it is positional e sensitive, much like our cell phones are. If a patient is having a seizure in this device, Texas and the patient is prone and this device to text the patient is prone. It has the ability to alert caregivers again that hasn't gone live. But it's one of those functions that I was told this is in the device and they can activate it when they get clearance, and it just hasn't hasn't had eso. The VNS is our our our first foray into this. This is, um, treatment approach of neuromodulation. We're not taking any tissue out. We're trying to corral and take care of the circuits without respecting them or blading them. Um, when we looked at, uh, the literature on VNS and we did our own Met analysis of VNS literature in 2011, we found that on average 45 there's a 45% reduction and seizures for patients to get these devices. And there is actually significant benefit for patients who have both generalized epilepsy and who are Children, which is good news for our practice. Also good news for our practices that patients who have a history of tuberous sclerosis also do a bit better with these devices. And and so many of our kids, especially our Oakland campus Children who were the Oakland campuses, a tuberculosis center. Um, they do particularly well with the NSS and the last group to do very well our post traumatic epilepsy patients. It's very rare, and I make I make it a point to be very clear with the families that it's very rare to be completely seizure free with these devices, and I tend to quote on the order of about 5% of patients will be completely seizure free. And that's a moving target. It's It's really hard. Thio predict who will be seizure free. About a quarter of patients we found didn't have any particular benefit. Just as an aside, um, sometimes patients won't have these devices implanted. Um, because if if they fall into that 25% category, they are being told that once this device is in, it's in, it's never coming out. And if there's any remnant of V N S n, even if someone attempt to take it out, they can never get a memory. And which is true? Um, but I always had a problem with that, and, ah, while back I had a patient who absolutely needed to have their VNS out to be enrolled in a epilepsy study, and eh? So I decided to do my best to take off the entire device. And, um, that was the first one that that I did in 2000 and eight, and now 27 patients later of complete VNS removal. I no longer tell families that once it's been it's in, Um, it's actually inaccurate to say that we're publishing one of our papers are checked. Michael knows to show How do you safely take these out? I don't want I don't want for that to be a potential deterrent for patients to not receive VNS is that well, if it's in, I can't ever having a memory again. That's not That's not true, and it's important that families know that. So the next wave of neuromodulation the smarter of the two implantable CNS devices, is the neuro pace, the neuro stimulator. This is actually the device sitting in my hand. It's about the same thicknesses of VNS and just a little bit longer than the device. You can't tell from the picture per se, but it has a curvature to it. And the reason why it has a curvature is because this is not implanted in the subcutaneous tissue of of the chest wall. It's actually implanted along the surface of the cult. On goes four wings that you're seeing at 10 to 4 and seven o'clock. Those with little wings screw into the bone. Um, surrounding it. You have to carve out a little shape for this in the skull and that sits in that depression in the skull and coming out of this this this little gray port here are plug ins for up to two electrodes. So So what does the neuro patient and what does it do? So narrow paces? The responsive neuro stimulator. This is not a device, um, that is meant for patients who are responding to medications. Um, it's for for patients who failed at least two meds and have had at least three seizures per month. Um, ideally, you wanna have one seizure focus or at most two senior policy. And the reason why is because I showed you there's only, um, ability to put into electrics. You can put into strips or to depths or one of each. But if you put it any more than that, you're just gonna have to cap it and leave it in place. And, um, what we've been doing, actually, for even more complicated patients, is sometimes we do in fact do that if we are limited to, will put in as many as we can and only use the two most likely wires. But at least we can save a patient additional surgery if there's a potential for the use of a third or fourth and we leave those caps so you plug two electrodes and at the time, these air for medically refractory patients. And if you remember and think back to the scenario that I discussed with our grid and are stripped electrode mapping patients most of the time the good brain and the bad brain are completely separate areas of the brain. We will accept if they're right next door to each other. But what we don't want and think that we don't see very often is if they co localize. If eloquent cortex and seizure focus is one of the same, sometimes we can get away with removing even that tissue. If that's your tongue. Motor cortex, where your face motor cortex. We actually have a pretty potential a pretty significant potential to recoup that function from the contra lateral side, but you cannot do that with hand motor cortex. You cannot do that with leg or and you certainly can't do that with speech. So what do you do for those cold, localizing areas of the brain so you can place thes strip electrodes or these depth electrodes into our on those areas of the brain plugged them into the RNs. And this this e g recording will show you, um, here at the beginning of the recording is spontaneous seizure, which this device detects once it to text it. It immediately provides an electrical stimulation to the electro that's embedded in or are sitting on top of this year. Focus. And then, as you can see, it interrupts that that seizure wave all you need to do is basically train these thes hyperactive circuits to not propagate, and it will not manifest into a full on seizure. And what they found with the European group found with longer term data, is that, um although they had 38% reduction in seizures when the euro pace was first place, when they when you first put in the narrow pace, that's how much you get reduction. After a year, it bumps up to 44%. After two years, it bumps up to 53%. So you're seeing this phenomenon as you give this epileptic brain mawr time to listen and work. With this device, you achieve mawr and mawr seizure control and we've put in quite a few for our kids now. Unfortunately, it's not fully FDA approved for Children, and it's a case by case from physician to physician clearance process. But we're working on. We're gonna be part of a trial. Hopefully soon Thio bump that age limitation down from 18 to at least 14 so that more and more of our kids can get these FDA color. So the last element of this talk that I wanted to chat with you about the fun part of the job is, um is really advancing our our ability to image these patients and to not just image them, but explore the imaging and share the image ing in a fun way that doesn't require big words and and fancy terms. Um, and we've been using more and more immersive virtual reality to study these patients and to operate these patients and to share with these patients their problems. So this is, ah, picture of one of our trainees who has a new immersive VR headset on. He's holding a hand controller, and he's actually navigating through a case that we recently did where we were going to implant some electrodes into a patient singular gyrus. This is that kind of sherbert color, uh, sausage shaped structure here where we had a couple of wires implanted and he's actually going to be flying down virtually into this patient's brain on traveling along the planned trajectory. So this is a way to rehearse your potential surgical corridors. This is a way toe way, one option versus another. Well before the patients under anesthesia, The last thing you want to do is find out on your way toe, so a path that the path is obstructed. It's much better if you can rehearse all these things ahead of time and save save the patient any undue risk. Eso We use this routinely to practice and rehearsal surgeries. We share the cases with our our Chinese. But the really fun part is to share it with our kids. And a question I have is, Well, how young can you go? Obviously the teens and Tweens, they most likely already have one of these headsets in these controllers on there kitchen table or coffee table. Already they already even more well versed in the use of these devices than we are. Um, but this is a picture of one of our four year old. He's currently one of our youngest, the four or four year old navigating. And of course you can. This is different things that a four year old will get out of the experience in a 14 year old. But each of the family members that the patient is Mom, you're not seeing it. But Dad and I all have headsets and all have controllers. Um, and it's a very vivid, uh, participatory experience to fly through anatomy. So this is an example of the kind of fly through that you would see. This is that stereo E g patient that I showed you before we have a little Frankenstein bolt on the skull. This this fly through gave me an opportunity to check on all my electrodes. And what I found with this fly through is that number two. The red one here is tagging one of these vessels right there. So number two, that red electrode was one that I had to adjust before I took this patient to the operating them. But all the other electrodes threaded the needle really nicely. Among the blood vessels, the motor tracks, the optic tracks. Um, and so it's a really reassuring way to know that we were staying out of danger before we implanted all of these. Um, these electrodes. Um, but what about sharing all of this with the patient? And this is meaningful to me as a pediatrics of specialist because we often ignore the patients, the Children, during our patient engagement sessions. But it's it's time we change that. This is this is an example of us of us changing that This is a this is, ah, video capture of me walking through a patient's brain, showing her her red tumor. Um, that was causing her seizures. I'm we're flying through the brain. There are little avatars that each of us can see of each other. This is Dad. This is my patient. This is me, and Mom is floating out there, and there should be some narration here. I'm hoping you can hear it. Mom and Dad say me, we're going all the way inside. Jade's, right. I mean, when you get there and I'm a tariff Well, all right. So you can actually fly past a debt if you can actually fly capacity, um, and get yourselves on either side of me says that I'm not blocking you. There's something I want to show you even more, Even more. I'm gonna go away a little bit, okay? And then deck. And you look over your right shoulder all the way behind you. Keep going, going, going. And you see this arrow that I'm pointing up all you guys because I'm pointing the tumor. But on top of the tumor, there's this blue like things like shaped like an s that's yet another blood votes that's hiding on the other side of your tumor, meaning like it's actually hidden. Meaning If I went through your tumor, Jade and I kept going, going, going to eventually gonna hit this guy. That's my stop sign. So imagine. Imagine. Imagine you had a brain tumor and someone's pointing to a flat gray and white picture on a screen and Marie screen. And then you were given an opportunity to actually fly into your brain as a as a as a child. And I've seen this firsthand. Um, it is such more than inviting experience, and it's an empowering experience for them. They feel they have ownership of this thing. They understand where it is and what the surgeon is gonna do. We actually create little fly throughs. Little mock travels through their brains and we mail them card. We can mail them cardboard boxes that turn into VR headsets with their phones, and then they can fly through their own brain anytime they want. And they can share it with, you know, Uncle Bob and Aunt Jo whenever they want, Who didn't get to come to clinic appointment. So it's It's really a nice way Thio to share that this otherwise really scary experience with them on and teach them about their own anatomy. So I try to make sure that we stay within our time frame and stay within our I wanna say thanks to the many, many players, team players, both in Oakland and San Francisco. This is a comprehensive list of all the names that you may come across if you if you call either of my offices its's very difficult to be brain surgery, and the only way we could get it done is with a really fantastic team in both sides. Okay, I'd like this This this to thes two of us here. Um, anytime you want to send a patient our way. Welcome. Any referrals or second opinions? Um, 877 You see, child is the is the fastest way to our pediatric access center. And, you know, in this era of Covic way are very, very sensitive to keeping our kids safe. Our parents safe our staff safe. We have a, you know, a job to do. And we can't. We can't risk anyone safety to do so. And, you know, as of right now, about 90% of our outpatient practices, um, is all telehealth and all remote. And so that's certainly an option that we would make available Thio all of our families. And until I figure out how to do brain surgery remotely, the surgery will still have to happen in person. But we found pretty creative ways. Thio do everything else remotely so