Chapters Transcript Video Advanced Epilepsy Care From Diagnosis to Brain Stimulation Welcome to Doc to Doc, a podcast where today we bring together leading experts from Baptist Health South Florida to discuss clinical innovation and excellence. Today we're exploring the epilepsy program and surgical innovations at Miami Neuroscience Institute, a topic that's increasingly important important as advancements in diagnostics monitoring and surgical techniques transform outcomes for adults living with epilepsy. Together we'll discuss the evolution of epilepsy care from patient demographics to development of our new epilepsy monitoring unit and emerging neurosurgical innovations shaping the future of treatment. Welcome to Baptist Health Doctor Doc, a podcast built for innovation and collaboration by physicians for physicians. Hello, I'm Michael McDermott, a neurosurgeon chief medical executive of Baptist Health Miami Neuroscience Institute, and joining me today are two leading experts in epilepsy, Doctor Aviva Bosch. She is a neurosurgeon and serves as deputy director of Baptist Health Miami Neuroscience Institute. As well as the institute's director of epilepsy surgery and co-director of functional neurosurgery, also with us is Doctor Luis Tornas, a neurologist specializing in epilepsy and the director of the epilepsy program at Baptist Health Miami Neuroscience Institute. Um, so let's get started first with discussing, um, training, the foundation of our expertise in various fields and the specialized training to deliver this level of care. Uh, Doctor Tornis, can you discuss your training in epilepsy? Yeah, of course, and thank you for having me here today. So, for my training, I did what every neurologist does. You do a 4-year residency training. I, I happened to do mine at University of Miami, and then after that, you do a fellowship, uh, as you kind of touched on in the, in the intro here, uh, medicine is constantly is evolving, it's constantly changing. There's new things that are constantly coming in, and due to that, it's kind of become very complex. So, people tend to not really subspecialize and kind of devote additional time to your, your field. So you're really well versed in everything that's going on. So, in my case, I did a fellowship in clinical neurophysiology, uh, the other path. That you could also do is a fellowship in epilepsy. Uh, mine was clinical neurophysiology with a pure focus in epilepsy, as some clinical neurophysiologists devote time to neuromuscular. Mine was purely epilepsy. Uh, it's a 1 to 2 year fellowship. Some people do 2 years. They actually do both epilepsy and neurophysiology. They're both ACGME accredited within the neurology world, and it really lets us dive into, really into epilepsy because as again, neurology is a pretty broad, uh, field. There's a lot to it. It's pretty complex. So each one. Its subdivisions requires a lot of time and dedication and studying. So, uh, one thing I don't think people really realize is neurologists don't really know how to read EEGs. You might get a little bit of exposure during residency, but you're not very well versed in coming out and, and comfortable and just reading a normal scalp EEG. So, we're able to dedicate time to learn how to read these EEGs, able to also devote time to reading intracranial EEEGs, which is another kind of evolving, uh, field here within epilepsy that's even more complex than scalp EEGs and requires time to, to kind of really learn and feel comfortable with that. Um, also pharmacologically, there's a lot of advancements. New medications are constantly coming out. Uh, so fellowship really lets us kind of spend time to see all these new medications, feel comfortable, um, managing those medications because a lot of them have interactions and some of these complex patients might be on 234, even 5 medications which are all causing side effects, interactions. So being comfortable kind of titrating those medications, making adjustments when side effects arise, uh, really lets you do that. And then, um, surgical aspect as well of, of epilepsy. So, this is something that continuously is growing. It's become a big focus now in the field of epilepsy and being able to spend the time in the fellowship to kind of focus on that. And, and it's something not only as a neurologist from your own perspective, but also being able to work as a team, cause it really is a kind of a team effort when you're looking at these patients. From a, from a surgical perspective, it's not only the epileptologist that's managing them, but it's also the neurosurgeon, the neuroradiologist, the neuropsychologist. So fellowship also allows you to work with this team, uh, so you know how to kind of make sure that the patient is getting the best outcomes, uh, when you all work together. So all summed up, how many years of training after medical school? After medical school, so that's 4 years of residency and then 1 year of fellowship, so 5 years, not as much as a neurosurgeon, but still a good amount of time. Uh, Doctor Bosch, tell us about your, uh, surgical training. Sure, so, uh, I went to the University of Pittsburgh first for a medical degree and a PhD, PhD in, uh, developmental neurobiology because of a fascination in how the brain works, cognition, uh, systems, neuroscience, that sort of thing, which led me, uh, to, uh, neurosurgery. Uh, and so I went off to University of California San Francisco for 6 years of neurosurgery residency training. While a resident I became fascinated in the area of neurosurgery called stereotactic and functional neurosurgery which includes surgery for epilepsies. uh, because of that interest, I went off to the Montreal Neurologic Institute of McGill University for a year of epilepsy surgery fellowship, but as Doctor Turna was, was saying, you know, as an epilepsy surgery fellow I spent a fair amount of time. Immersed in a multidisciplinary environment working with the epilepsy neurologists, the neuropsychologists, the neuroradiologists who helped take care, manage, evaluate, um, and treat our epilepsy population from there I went to the University of Toronto for fellowship training in stereotactic and functional techniques, uh, and then, uh, uh, began my career as an epilepsy surgeon. Uh, so for the audience in full disclosure, I was a junior faculty member that helped train Aviva during her neurosurgical residency, um, so. Next, let's discuss some other aspects of epilepsy, particularly the patient population that we're treating and the epilepsy epidemiology, meaning how many people in the community have this problem and, uh, you know, what's the patient burden for the clinician, Dr. Tornis? Could you tell us about that? Yeah, of course. So the CDC states that around probably a little over 3 million patients within the United States have epilepsy. It comes out to around 1.1% of the population. So, um, it isn't maybe as common as some other things, but it's still very common within the world of neurology. Uh, so it's kind of one of the bread and butters of neurology. Uh, and that's pretty broad in terms of the spectrum of the actual population base itself. It isn't like some of the other, uh, diseases that we see in neurology, maybe more of the neurodegenerative diseases that tend to be. Uh, seen more in the elderly population in epilepsy, we do have a pretty wide range, so we do have, uh, children and adolescents. Uh, I am an adult, uh, epileptologist, but these patients do grow up and they end up coming to our clinic, so we see those. We also see, uh, older patients. Uh, in terms of the demographics, sometimes it does depend on what type of epilepsy we're dealing with. So if a patient, say, has generalized epilepsy, which you'll usually see more in the, the younger population, the children, the adults. Adolescents, um, but again, those patients do end up in our clinic because they'll, they'll grow up, and then we have more of the focal epilepsies, which is more what we tend to see as an adult epileptologist in our, our clinic, and that can also range from adolescents, uh, young adults, uh, maybe from a cortical dysplasia, mesotemporal sclerosis, but we also have older patients, maybe patients in their 50s, their 60s, uh, their 70s that are coming in because they've had a stroke and now they have epilepsy or they had an intracerebral hemorrhage. And now they have epilepsy secondary to that, uh, worldwide, the leading causes, uh, it's CNS infections as one of the more common ones in the United States we don't see that as much, but actually living in Miami, being to the fact that it's such a diverse community that we have here and it's kind of a hub, uh, for a lot of international patients, we do actually see that quite a bit more than you might see in other places within the United States, which actually is one of the probably the more interesting aspects of practicing here in, in this area. And then within South Florida, as I was mentioning, uh, there is a lot of diversity, both culturally and socioeconomically, I think, in our patient population, and that's something that it's really important when considering, cause when you're building, uh, an epilepsy program or when you're kind of managing the community, you really have to say, well, what do I have to do to meet the needs of this community? Uh, because not every community is the same, which I think is something really important to take into consideration, uh, not only from, say, An underserved population, especially with the high immigration, uh, population that we have here, sometimes they might be underserved, underinsured, and that really limits their, their access to health care, which is really important in the, in the world of epilepsy, especially because a lot of these patients, uh, they're not able to hold a job, they're maybe not able to drive because of their epilepsy which could be very detrimental to their quality of life and ability to get quality access to health care. Um, and that's something we do have to consider, and also just the cultural, uh, kind of stigma that might be associated with epilepsy and the whole thought of medical management where some of these patients from, uh, from other countries. So, it's something that when we're building the program, we take into consideration how we handle these cases, cause I do think, uh, you can't just kind of broad, um, like brush everyone in the community. You really have to kind of focus to what the community needs are. Um, can you talk a little bit about the transition between, uh, the pediatric age group epilepsy patients, uh, when they become adults, in other words, um, 18 and above, and how does that transition happen? What's your involvement, etc. Yeah, so that's actually a really important aspect in the world of neurology. It is actually really hard for these patients. Uh, there's not a lot of neurologists in general, uh, and depending. Where you live it could be even less and then once you're kind of getting into the subspecialties it's even harder to find a a neurologists that are maybe specialized in epilepsy. So we work here with the community to kind of make partnerships with these pediatric neurologists that are following these patients because it does get to a point in time where they're not able to see, uh, their, their patients anymore once they kind of age out of their clinic. So we, we work in, in partnership with the community, uh, either. Of private prac uh practitioners or other hospitals, larger institutions to kind of have a continuity clinic, uh, kind of what we call it, so these patients are signed out to us from these pediatric providers and then they come to us for continued care, uh, so it's important to really work with the, the providers in the community to make sure that these patients aren't lost to follow up. Which is a big concern for some of these patients, uh, because again, it's sometimes hard to find an epilepsy doctor, and I will say, uh, a lot of practitioners are general providers, uh, and a lot of these patients or providers can take care of epilepsy patients, but pediatric patients, in particular, sometimes can be quite complex. Uh, if it's like a Gervais, Lanni Gsteau, they're usually pretty. Refractory, the drug, uh, resistant epilepsy, they're on multiple medications, they might have neuromodulation, maybe they've had surgery before, so they usually do require a specialist, an epileptologist, and sometimes it's hard to find. So it is important making sure these kind of barriers are broken down to make it as easy as possible for the, uh, community providers to refer these patients to our clinic. Um, whenever I see adult patients who obviously grew up with epilepsy, uh, and their families, I'm always impressed with the dedication and support that the families have to give these people to keep them, you know, active in the community and, um, maintain their livelihood. Yeah, I will say that the family, uh, members for some of these patients, it's incredible how well they know the patients. I've had experiences before with, uh, multiple other epilepsy doctors we're examining patients, we have them in the epilepsy monitoring unit and, uh, the patient's mother, I remember this one patient, uh, she would say, oh, he's having. Seizure right now and the multiple epileptologists would be looking at the patient like, well, how do you know he doesn't seem like he's doing anything and when we went back to the scalp EEG, the mom was correct almost every single time that she could tell her son was having a seizure, even when the trained epilepsy doctors are having difficulty clinically distinguishing him having a seizure. Yeah, mothers know best. I've been in that situation as well, even as a, a medical practitioner with my family. My wife's usually when they, when they were children able to pick up the problem before I could. Um, what about, uh, referrals from the community into, um, a specialized clinic like yours? How does that happen? Yeah, so that's another issue that we do have. Uh, we kind of know nationwide that one of the biggest issues with epilepsy patients at times is really the lag that it takes, uh, to get these patients into the surgical centers. Uh, for adults, uh, I will say we're actually worse in the pediatric, uh, epilepsy community. They do tend to do a better job than we do. For adults, it's almost around 20 years, a lot of times for these patients from when they were diagnosed with epilepsy to when they're. Coming in for a surgical evaluation, which is, which is way too long, uh, we know from lots of research that we have that the more you have uncontrolled seizures over time, the cumulative effect it takes, uh, neurocognitive, uh, defects down the road, risk of pseude, risk of overall, uh, mortality and morbidity, just quality of life as well. Here in Miami, uh, public transportation is not the easiest, uh, so not being able to drive is pretty detrimental. Your quality of life, uh, so another big thing that we do here at the Miami Neuroscience Institute is really reaching out into the community and making these partnerships with the community providers because as I, as I mentioned before, uh, you could be a community provider that's very qualified, epilepsy trained and helping these patients, but sometimes you just don't have the facilities that you need, uh, epilepsy monitoring. You might not have a neurosurgeon, the neuroradiologist, the neuropsychologist. So just reaching out into the community because they really are the ones on the front line seeing these patients. They see much more patients than we are and we're help, we're here to basically help them, uh, so we, we go to them and we make sure that they're aware that we're here in the community to, to provide these services for them and let them know that we're, we're here to help in whatever way possible. If they need an epilepsy monitoring unit admission, we can help them with that. If they need the whole surgical workup, we can help them with that. We could, we could do the resective. Surgeries, ablative surgeries, help them with the neuromodulation, even monitor, uh, monitor and manage the device, and they can continue to follow with their community provider for medication management and overall management, but we're just here to help with the surgical component, um, so that's an important, important aspect of the, of building up a program I think in an area it's really building out that, um, that partnership with the community providers because they really are the ones that are sending us the patients, uh, more so than internally. Yeah, one of the things um that, um, I realized and you would expect as an epileptologist would be a specialized epilepsy monitoring unit. Which we built at Baptist Hospital in the main um hospital. Uh, can you talk about what the uh components of the epilepsy monitoring unit are? Yeah, of course. So, the epilepsy monitoring unit is, is a critical component to a surgical program and then an epilepsy center, cause it really is kind of where everything comes from. It's, it's where everything starts, really. And sometimes it's, it's hard for a lot of places even to have prolonged video monitoring. That's not something that you see. In every hospital, um, but the EMU is not really just prolonged video monitoring. There's a lot more that goes into it. So we do have specialized infrastructure in all the epilepsy monitoring rooms. It's not just a, a random room in the hospital. There's also specialized staff, uh, not only are the bedside nurses all trained in, uh, treating patients in the epilepsy monitoring unit, because again, how you approach these patients is much different than when you're on the floor in the epilepsy monitoring unit, we want the patients to have a seizure. I, I tell my patients it's. The only time you're allowed to have a seizure, uh, so that's a very different way of approaching this from when you're on the, say, the ER, the ICU. You don't wanna have seizures in that, in that case. Uh, we also have techs monitoring, so all these patients are connected live, but we also have a tech that's constantly looking at their, at their video overnight, uh, 24/7 in case anything was to happen. Uh, we're able to, to immediately act if need be. And, and this really helps us not only from a surgical perspective start the whole process. Of working this person up to possibly eventually surgery, but even for patients that you might not be sure what's going on, you bring them in because they're having these events, you're not sure if they're Ital, uh, maybe they're not Ital, and then you're able to capture them. It's very helpful, uh, but it is a, a bit of a process, and, and we're, we're very happy with what we were able to build here with a 5-bed EMU because I, I do think it's, it's critical, and you really can't have a, an epilepsy program without it. Yeah, the monitoring, uh, unit which replaces the traditional nursing station is full of recording instrumentation and personnel watching all, all the time, um, so it's a big commitment. Um, Doctor Bosch, can you tell us about the surgical workup for a patient with adult patient with epilepsy? Yeah, um, absolutely. So it actually starts with the epilepsy neurologist, uh, and their first interaction with the patient. And as with everything else in medicine, you start with a very thorough history and then uh a careful exam and finding out really what the patient's seizures are like because the semiology of a patient's seizure, uh encodes information about localization. So, so that's, I, you know, I can't stress that enough. But then when it comes to what to do next, you know, uh, an anatomical brain MRI 3 Tesla, uh, uh, anatomical brain MRI is. Necessary to find uh any potential lesions on the MRI which can then serve as the anchor for what you do next. Brain MRIs can be normal, which is to say we don't see anything um uh from an anatomical standpoint that's awry. Um, then in addition to the brain MRI there's um. An Ital an interictal PET that we do, we're looking for hypoactivity, um, in the patient's brain between seizures because that can indicate an area of damage that might be the seizure onset zone, uh, sometimes an ictal spect, um, which tells us where there's extra activity during a seizure, and that's obviously of, of tremendous utility. Um, the scalp EEG that Doctor Tornas mentioned can have, uh, clues as to, as to lateralization, which hemisphere is involved, if not where in that hemisphere, uh, things are coming from. But if you think about the, the, the complicated wiring diagram that is our brains, things can spread along those wires, seizures can spread along those wires to the other side of the brain to a different lobe very quickly and so the scalp EEG is separated from the seizure onset zone by 1 centimeter of scalp, 1 centimeter of bone, and then a lot of brain real estate, you know, if you think about the intense unfolding of, of the cortical surface. That you can be a long way with a scalp electrode from where the seizures are, are actually arising. So once we have all of that preliminary information, the question is, do we have sufficient information to take the next step, which would be, you know, surgical remediation of, of the seizure onset zone. Removal of that seizure onset zone we don't have sufficient information, but we believe the epilepsy is focal in onset in terms of um where the seizure seizures are arising from. We then have a discussion about what to do next. So all of this information is collected and then discussed, presented and discussed at our multidisciplinary epilepsy conference where the epilepsy neurology team, the neurosurgeon taking care of the, uh, of epilepsy patients, neuroradiology and neuropsychology come to weigh in on, on those data elements. Uh, the decision then might be, well, we, we believe that they're focal based on, uh, the seizure information we have so far, but we need to get closer to the source and so to get closer to the source that, that means a phase two monitoring, uh, which is to say implanting electrodes inside the skull for long-term monitoring. So that's what the the utility of the epilepsy monitoring unit is in the context of surgical localization uh of of seizure onset. Um, the field has shifted away from large craniotomies to implant electrocortical grids, um, uh, ECOG grids on the surface of the patient's brain and, uh, towards stereo EEG, which is the, you know. Attempting to find in three dimensions where the seizure network seizure onset zone is, is, is arising from. And so, uh, if patients are appropriate candidates for intracranial monitoring, then that, um, suggests a different route from, uh, scalp EEG and brain MRI and then to the operating room for surgical resection. So, um, armed with the stereo EEG data, um, from capturing, uh, seizures in the, uh, epilepsy monitoring unit and possibly, um, uh, electrical stimulation mapping to figure out if there's functional cortex in the region of the seizure onset zone that I need to be aware of as, as a, as the epilepsy surgeon. We go back to the multidisciplinary epilepsy conference and repeat the discussion armed with that data and take the next step. Yeah, let me give you a clinical scenario. 35-year-old woman with, um, generalized seizures, 2 of them, and MR imaging demonstrating a superior temporal gyrus anterior 2 centimeter cavernous vascular malformation. Would that patient be recommended to go through the whole workup or would you just approach it? As though that was the source of the epilepsy and operate and remove it, what would you do? So, so it, you know, I'm making many assumptions here. I'm assuming that this isn't a patient um who has, um, you know, uh, uh, seizures based on scalp EEG that would be coming from a remote area of the brain relative to the cavernous vascular malformation. So if the scalp EEG is concordant with the brain imaging, uh, you know, and where the lesion is, then that patient is considered a skip candidate so they would go to the operating room for resection and then subsequently, you know, go through that that surgery, recover, and then we follow the patient in epilepsy neurology clinic and make sure that she's not still having seizures. Uh, OK, let's turn to neuromodulation now, apart from excising epileptogenic tissue in the brain. Um, can you tell us about neuromodulation, Doctor Tornis, and how you interact with Doctor Abash? Uh, for that kind of, um, method. Yeah, of course. So, I think neuromodulation is one of the more exciting, uh, parts now of epilepsy. It, it's one of those that has grown a lot in the last, uh, few years, uh, and it's really changed how we approach and manage these patients, uh, because while we're speaking of neuromodulation, and it's very exciting and I really Have an interest in it. I, I don't want to necessarily say that it's better than surgery because surgery still to this day, it's been around for a long time. That doesn't mean it's bad. It's still the gold standard. That's what we want for our patients and we're able to do it, uh, but as Doctor Abash had mentioned, if it's coming from an eloquent, uh, cortex, uh, seizure onset zone, uh, sometimes we can't resect, we can ablate. So this is where we turn to neuromodulation. Which we usually look at it as a palliative option. Uh, we don't usually want to tell our patients that it's going to be curative. There are some cases of patients getting neuromodulation and, and they are seizure-free, but I, I tend to not really like to, to tell the patient that we're aiming for seizure-freedom. It's more of a, tends to be more of like a 70% reduction with neuromodulation. So I think the one that everyone thinks of when they, when they hear neuromodulation because it's been around for the longest is the vagal nerve stimulator, but we have uh newer devices as well. Uh, we have deep brain stimulation, which has been around for quite a bit within the world of neurology, more so from a movement perspective used in Parkinson's, uh, more recently used now in, in epilepsy, and then we also have the responsive neurostimulation, the neuroace, uh, which is the one that's gained a lot of favor within the community, uh, for epilepsy. Uh, so these are basically 3 devices. I like to almost describe them as like a pacemaker for your brain and stopping seizures. So they're, they're somewhat divided in how they work. So there's a closed loop and an open loop system. So the closed loop system would be the, uh, RNS and basically what that means is that it's actually not just me putting in parameters, it's actually getting. Uh, information from the patient itself. So the RNS basically, uh, Doctor Abash is the one who goes ahead and implants that. Uh, I'm, I'm not able to implant these, so I, I don't do surgery. So I work with Doctor Abash, the neuros, um, the neuropsychologist, uh, the neuroradiologist, as she was mentioning in the neuro conference, uh, in the surgical conference to determine, well, this person is not a candidate for resection. Then let's see if neuromodulation is an option, and it is something that we also have to consider, well, what's the best option for the patient. Um, I will say now most people have tended to lean towards the RNS, and I think the main reason is because it does give you a little bit more information. So the RNS basically is two leads implanted. You could do a, a depth, uh, uh, uh, depth electrode or a strip, and it's actually has, uh, basically it's an ECOG, so it's recording information, so we're actually able to see if the patient's having seizures. Uh, so for the RNS. And I will say this is constantly changing, but for, from an FDA perspective, it was for basically a cortical, uh, source. So you say maybe the person's multifocal, so a bitemporal, uh, lobe epilepsy, you put one strip into each, um, temporal lobe or 111 depth electrode, and then you're able to record, uh, so the patient comes in, they get implanted, we send them home, the device is not on, it's recording, so it's being able to see where the seizures are coming from, and it also is able to detect, well, what do we think. Seizures because it's picking up a lot of information from your brain, which might not necessarily be a seizure. So we program it to make sure what it's capturing is a seizure. And then once we have an idea of, well, these are the seizures that we wanted it to notice, then we could say, well, now let's turn it on. And what it does is, well, it could detect, oh the person's having a seizure. Let me stimulate, let me stimulate. So it's basically disrupting the seizure with its own stimulation. Um, so that's one of the components that the RNS does in addition. That and, and kind of the whole reason why they're called neuromodulators. So outside of aborting the seizure right at the moment when it detects it, this constant stimulation to the neuronal network is disrupting the seizure onsets. So down the road we see with a lot of these devices that over time they have a cumulative effect. Uh, so you see reduction as you go year by year on a lot of these devices. Uh, so that, that would be more of the closed loop system of the RNS. The, the open loop would be more of like the DBS and. I would put an asterisk next to the VNS because now the uh the VNS, uh, more newer systems have a tachycardia component to it. So if the patient's heart, uh, rate hits a certain level, the VNS can stimulate more. So somewhat of a closed loop system, but, uh, kind of when we think about the VNS when it first came out, it was more of an open loop. So that is we're just putting in the parameters. I want you to stim this much, this frequently, and you just kind of let it run. Uh, it's not picking up any seizures. Or anything along that such it's just kind of stemming along your parameters. The DBS is implanted into the thalamus, uh, the VNS is stintovagal nerve. Uh, that being said though, there has been a lot of, again, kind of research and expansion in the field of, of neuromodulation, and now we're starting to implant some of the other devices, particularly the RNS, into the thalamus as well, uh, and in different nuclei in the thalamus and even kind of sampling the thalamus in terms of, uh, when the person comes in for perhaps a Phase two, as Doctor Abbas was mentioning where we implant depth electrodes, we can actually implant the depth electrode into the thalamus and see which nuclei is actually involved in the patient's seizure because otherwise we're either going off semiology. So and semiology still is keen, it's very important. So what we used to do is, well, let's say the person has occipital lobe seizures, so maybe the pulvinar is, is the, the best target in this case, but we don't really know that's just going off semiology. Now we can actually sample it and say, oh yeah. That is the best nuclei. Let's implant the RNS in there. Um, so that's something that's constantly evolving and constantly changing, which I think is really exciting and has really now opened up the opportunities for our patients who were maybe before they were in a receptive candidate, but now with neuromodulation, we're able to have a really dramatic reduction in their seizures and make a huge impact to their quality of life. In addition to, they don't really have those side effects that additional medications a lot of times too, uh, which is another big factor. Very interesting. Um, Doctor Bosch, can you talk about the, um, emerging biologic and cellular therapies that may have a role in the management of epilepsy? Yeah, it's a fascinating area um and I, I will say that one of the things that I find so compelling about epilepsy surgery as a field has been the advent of new technologies, new ways of treating patients with these conditions. And so you know that includes the biologicals. It also includes the brain computer interfaces, one of which is, is really an RNS device, a responsive neuro stimulator, which, as Doctor Turner was saying, you take a biomarker which is the seizure onset, and then um there's a detection arm to detect that and then a therapy arm which then delivers a successful and effective uh uh treatment which is the electrical stimulation. That which isn't to say that there isn't tremendous room to go and with the advances in machine learning, um, our ability to detect accurately the seizure onset. And then deliver a therapy in response to that is is only going to improve. The biologicals include, for instance, the efforts underway now in phase 12 trials uh to look at uh the efficacy at safety and efficacy of, uh, implanting stem cell derived uh inhibitory interneurons into the seizure onset zone and um. It's a failure, you know, when you think about seizure onset seizure spread is a failure of inhibition essentially in the brain and so this is a really novel way to try and gain control of a patient's seizures, uh, long term so more to come, you know that that study is, is entering into the dose escalation phase, uh, and, um, they are processing through subject recruitment and, and, uh, um. Uh, we'll see what, uh, what the results hold for, uh, the phase 3 which is under, under, uh, discussion now. Now I will say that in, um, early results, um. There have been really substantial improvements in seizure control for the patients in the phase 12 portion of the study, so that's exciting. Uh, there have been some adverse events linked to the immunosuppression that's required for the patients to tolerate these, these stem cells, but those adverse events have been, um, temporary, and, and patients have processed through them. Yeah, I was very impressed when I saw the presentation by Doctor Kim Burchell on using the xenograph neuroprogenitor cells. It was, it was very impressive, at least in the mammalian animal model. So I'm glad that it's now transitioned to, uh, phase one in humans. So that's great. Um, OK, to close, Doctor Tornes, uh, what message would you like to share with patients who have epilepsies in their families? Yeah, so this is actually a topic that's pretty near and dear to me. So my father actually had epilepsy and he had epilepsy from a very early age, uh, drug resistant epilepsy, and He actually had a laser ablation, was um, uh, epilepsy, uh, basically cured. He was seizure free after that. So, I think one of the big things is that, again, he, he had epilepsy when the 50s, so a lot has changed since then and even just in the last 20 years, a lot has changed. So, there's a lot of options now for, for patients. So, I, I think sometimes patients think that this is inevitable. I'm just gonna have seizures, there's nothing I can do. Uh, but there's always hope. There's Always, uh, either something to do now or something down the road, uh, because there's always a pipeline of new research, new options for pharmacotherapies, uh, surgical therapies, diagnostic treatments. So there's always something to do. Uh, I, I always like to tell my patients that either we can improve your quality of life with management or potentially cure you. I don't want you to think that there isn't any hope. There's always hope. Uh, sometimes it's just finding the best, uh, the best, basically treatment option, uh, which could be difficult sometimes. And sometimes, uh, you might need a little help. Uh, you might need to go somewhere, uh, where you're basically able to get that kind of multidisciplinary approach, uh, cause again, um, this does really take a, a, a well, uh, trained team of multiple different specialties. Uh, to really help these patients. Uh, I can't do my job without Doctor Abash. I can't do my job without the neuro, uh, radiologist, and I can't do my job without the neuropsychologist. Uh, I can only do so much as an epilepsy doctor. Uh, uh, maybe we'd like to think that we could do more than we actually can sometimes, but, but we really do need help, um, and I, I want the patients to know that we're here to help. Great. Well, today's discussion highlighted how far the field has come from the specialized training of our experts here today, uh, required that are necessary to become an epileptologist, to become an epilepsy surgeon, to the establishment of the comprehensive epilepsy monitoring unit designed for precise diagnosis and individualized treatment. We also explored the remarkable progress in surgical and neuromodulation options from stereotactic EEG, which Doctor Bosch does, and grid grid mapping to deep brain stimulation and responsive neurostimulation that are transforming outcomes for patients with drug resistant epilepsy, uh, as we look forward to the future, the promise of biologic and cell-based therapies offers even more hope for patients living with epilepsy. Reinforcing our commitment to innovation and compassionate multidisciplinary care for our listeners to learn more about the epilepsy program and other neuroscience services at Baptist Health South Florida, visit baptisthealth.net/neuroscience, and I'd like to thank Doctor Torres and Doctor Abash for sharing their expertise today and for the outstanding work that you're doing to advance epilepsy care at the Miami Neuroscience Institute. I'm Doctor Michael McDermott, and thank you for joining us today. 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