Brian Lee, MD, a neurosurgeon at Keck Medicine of USC, provides a comprehensive overview of the latest surgical techniques for the diagnosis and treatment of epilepsy and movement disorders.
Mm mm and yeah, yeah, yeah. Mhm, Mhm. Mhm. Hi. My name is Dr Brian Lee, and I am the director of Stereotype, Actiq and Functional Neurosurgery at USC. Today, I'd like to talk about three topics. Epilepsy, surgery for movement, disorder and some of my research interests. Let's start with epilepsy. Epilepsy is a devastating disease that affects approximately 1% of the population, or 3.4 million people in the United States. In 70 to 85% of patients with epilepsy. Seizure remission occurs with medication alone. However, in the remaining 15 to 30% of patients with medically intractable epilepsy, they can suffer significant morbidity and even death due to uncontrolled seizures. For these patients, identification and removal of the source of the seizures provides the best chance of a cure or long term seizure control at U. S. C. We believe that epilepsy is best approach as a team sport, so we have the USC Comprehensive Epilepsy Consortium. This is where we have a joint, um, team with epileptic ologists, neurosurgeons, neuropsychologist neural radiologists and full patient support staff. Surgery for epilepsy can be divided into surgery for diagnosis of seizures, and the second part is treatment of seizures. Let's start with diagnosis Subdural electrodes On the surface of the brain are common techniques used for detecting seizures, and also the newer technology that we have is using depth electrodes, subdural electrodes or Chicago are electrodes that we place on the surface of the brain after we performed a craniotomy, which means opening up the scalp and the head. This allows us to directly record from the surface of the brain. However, you can see that it does require a incision, and this is challenging for the patient if we need to do this on both sides of the head. However, it is a good technique that has been employed for many decades, and we still use it quite frequently. A newer technology that we have at USC is called Steri attacked IQ E G or stereo E. G. In this technique, we make very small incisions in the head and the bone, and we place electrodes down into the deep areas of the brain. This allows us to record from both sides of the brain and all over the different parts areas that we think that seizures maybe starting from with minimal amounts of discomfort to the patient. Here on the left side, you can see the software where I plan the trajectories of each electrode, and then we then take these trajectories and use a stereotype Actiq frame on the right side of the screen, um, to translate those trajectories into physical locations in the patient's head. Here are some images of what it looks like with the electrodes in the patient's brain, and we use a combination of intra operative X ray and CT scan to confirm the leads are exactly where they want them to be. One of the newer technologies that we offer at USC is the Rosa Surgical Robot. This robot allows us to very precisely place electrodes in all parts of the brain, and it speeds up the surgery by, um, many fold, allowing for a quicker recovery for the patient. Here is a picture of an electrode being placed into the brain using the surgical robots. Once the electrodes have been placed into the brain and we have seizure recordings from the electrodes, we can then figure out where, exactly in the brain the seizures are coming from and then make a plan for treatment on the left side is a picture of what the electrodes look like when they're implanted. And then once we take them out, you can see that there are very small incisions that he'll very quickly after the stereo e g removal in terms of treatment after diagnosis of the seizures and figuring out where the seizures are coming from, we have three main options. The first one is resection, ablation and then neuromodulation, and the treatment that we choose is personalized to each patient's unique clinical condition. In terms of resection, the options are temporal lobe ectomy, selective amygdala, hippocampus ectomy and a focal resection. The anterior temporal lobe ectomy is where we take out the anterior temporal lobe and also the amygdala and hippocampus. This is what you can see in this image. Um, you can see that the left temporal lobe, including the amygdala and hippocampus, have been removed. This is the gold standard and provides the greatest chance of seizure freedom. However, during this prior stereo, e g studies or subdural peacock studies, if we find that the seizures are primarily coming from the Magdala and hippocampus, we can. Then instead of taking out the entire temporal lobe. Just remove the Magdala and hippocampus. Thus the name selective anecdotal hippo camp ectomy. If it turns out that your seizures don't come from the Magdala hippocampus or temporal lobe, we can then remove it using something called a focal resection. In certain patients, where the seizures are coming from deep parts of the brain, we may try something different called laser interstitial thermo therapy. In this procedure, we would make a small incision in the scalp and bone and put a laser into the target. And, using MRI guidance, we can heat up that part of the brain to a blade. It This allows us to reach very sensitive parts of the brain, as you can see on the right side of the screen. Sometimes we're not able to remove the part of the brain or a blade it and this then leads us to neuromodulation. In terms of neuromodulation, we have three key technologies that we use to treat seizures. The vagus nerve stimulator is a device that we place into the chest with an electrode that goes up to the vagus nerve. This device has been used for many years and has been proven to be very effective in reducing the amount of seizures that the patient may have. The next device is the neuro pace RNs, or Responsive Neuro Stimulator. This device is placed into the head, and there are electrodes that are placed at the locations where the seizures are thought to originate from. This device is unique because it listens to the brain and when and when it detects seizure activity, it stimulates the brain when it needs it. DBS is the latest neuromodulation device that has been approved for epilepsy. The deep brain stimulator is placed into the anterior nucleus of the thalamus to help reduce the amount of seizures the patient may have. Now again, Whether you get a DBS, RNs or VNS, it depends on what type of seizures you have and also what we find during intracranial monitoring with either subdural grids or um, stereo E G. Moving on to movement disorders. We treat Parkinson's disease, essential tremor and Estonia. Parkinson's disease is marked by stiffness, slowness and resting tremor. However, Parkinson's disease is not just a movement disorder. Other associated symptoms include depression, anxiety, loss of smell, constipation, insomnia and incontinence. Who should get DBs well medications often control the symptoms of Parkinson's disease. Initially, however, as the disease progresses, the medications can become less effective in an attempt to combat this. The medication doses are oftentimes elevated, and these higher doses of medications can lead to side effects such as dyskinesia. At this point, the patients are often evaluated for deep brain stimulation. The DBS has three parts. The most important part is the part that goes into the brain called the lead. The next part is called the Lead Extension, which connects the lead down to a generator implanted under the skin in the chest. Or this device is called the implantable pulse generator I PG or oftentimes battery. The entire system is placed under the skin, so there is no exposed hardware. We have a comprehensive DVS team to take care of the patients. This is a team approach and this patient is the center of the team. This includes the patient care provider, the neurologist, the neuropsychologist, neurosurgeon, anesthesiologist and DBS programmer. We feel that using a team approach, we can address all the needs of the patients better than a piecemeal approach. In terms of DBS Systems, we offer DBS devices from the three major companies, including Medtronic, Boston Scientific and Abbott. Which device you get depends on each patient specific needs, and we work with you to make sure you get the proper device. In terms of surgical technique, there are two techniques that we offer at U. S. C. We have the traditional awake technique and also a newer, asleep, MRI guided surgery. In the awake technique, the patient is awake throughout the entire surgery. A stereotype Actiq frame, which is shown on the left, is placed on the patient's head and the patient is awake during surgery so we can test for effectiveness of the DBS device in the patient's brain but also test for side effects. So we asked the patients to move their hands to repeat words and to see how they feel. They can report what they are feeling when the DBS is implanted. We use X ray imaging and also Flora Skopje to confirm that the DBS lead is in the proper position. A newer technique that we offer at USC is a sleep clear point DBS surgery, and this is a surgery where the entire surgery is done. Inside the MRI scanner, we use the MRI magnet with real time imaging of the brain lead and target for the most accurate placement of the DBS system. Another benefit is that the patient is under general anesthesia, so they are not awake at all during this entire surgery. Asleep, DBS surgery is ideal for patients who have severe anxiety tremor patients who are unable to hold medications overnight, which is what you need to do with awake surgery, concerns of speaking during surgery and patients who have dystonia with severe contractions. Here is a picture of the MRI scanner, which we use as an operating room. The patient is intubated and placed into the bore of the MRI scanner as seen here. We then scarily draped the entire MRI scanner so that we can perform the surgery Sterile E. We use special software that combines the MRI imaging with trajectory planning so we can determine exactly where the DBS leads need to go, and then we can see in real time the DBS go to the proper location. This allows us to very precisely place the DBS leads exactly where we want them to be. Comparing awake versus asleep. DBs. They have equivalent clinical outcomes. They have equivalent infection rates and also complication rates. Therefore, it's the patient's preference that dictates whether they get awake or asleep. DBS We are proud that we are the only center in Los Angeles that offers a sleep DBS using the clear point system. Now I'd like to talk a little bit about the research that my laboratory performs. We do a lot of clinical research, and we invite our patients to participate if they would like to. This is something that allows us to gain more information about the diseases that we treat, such as epilepsy and movement disorders. My laboratory focuses on human neurophysiology for epilepsy. My laboratory is interested in the network properties of the seizure networks. By understanding the networks, we can better figure out treatment modalities and potentially new devices to help stop epilepsy for movement disorders. We want to understand the circuitry of the basal ganglia so we can see if we can create new stimulation paradigms to improve deep brain stimulation. My laboratory also works on brain computer interfaces. A brain computer interface is a device that recorded signals directly from the brain and uses them to control a robotic arm, a cursor on a screen or any other device you can imagine. This would be useful in patients with stroke, amputations or spinal cord injury. In addition, my laboratory is working on engineering artificial sensation so that we can take signals from the robotic arm or the cursor and send it back into the brain so that the patient can feel what the robotic arm is feeling. Here is an example image on the left side. You can see that there is a grid over Somatosensory area of the hand, and by stimulating specific context of that grid, we can create sensation in the patient's hand. I would like to acknowledge our clinical teams for both the epilepsy and DBS teams. I'd like to acknowledge the laboratory teams, including the Neuro Restoration Center and our Caltech collaborators, and I would also like to thank my funding sources. Thank you for your attention, and please feel free to email me with any questions. Mhm, mhm