0:08 Hello, I'm Jim Ausman. I’m introducing this session to you
0:13 for the audio and video portions on epilepsy. One of the most common causes of epilepsy around the world And can you traitors can be to get be treated in your country, And how do you do it? I epilepsy is a very common disease around the world is under treated medically and it's foreign to treated surgically. Some of the simple approaches is a temporal, the Beckley back to me for medial temporal sclerosis, or are not used when they can be curative and parade many patients from a life of misery from repeated epileptic attacks
0:55 on this panel, More in bowling, is the head of neurosurgery at Loma Linda Warren,
1:02 where he had his education in Kentucky was. I spent time at Montreal Neurologic Institute where he learned about epilepsy and also went to Australia, where he learned more about epilepsy stereotactic and functional neurosurgery and radio surgery, and brain tumor surgery is now professor at, and head of neurosurgery at Loma Linda. He's chosen some discuss, since Mario Arturo Alonzo was a neurosurgeon in Mexico City. Mario is known for his work on.
1:38 Epilepsy and how it can be done in the low to middle income countries. She's going to present a talk with data about that and methods that you can use to go ahead and instituted in your country, Costa all the savages in private practice in the United States.
1:54 He's now works for the Spectrum health system in Grand Rapids, Michigan,
1:59 and he settled decades of experience in epilepsy. I'm known costs costs for many years. It is excellent comments, Casey present is a very challenging and interesting case of a case of an elusive, hard to find cause of the epilepsy, which, eventually with a number of studies that were able to find and localized and do a very simple treatment ather eat them, is ahead of neurosurgery and the Aga Khan University in Karachi, Pakistan, and is. Interested in in in the treatment of epilepsy in low to middle income countries, and how it can be done cost as a background, also, and honor a surgery from Henry Ford Hospital in molecular biology, so he's as abroad experience in this area, We hope you enjoy this session. Appreciate your attending welcome. I have an excellent panel of experts and epilepsy surgery. Here today, an international panel
3:10 cost a lease of Ej and Exotic, freed from the United States, T V Victor Fong from Beijing, China, Sad, after you know from Karachi, Pakistan, and Mario, though Alonso from Mexico City.
3:30 Dr. Alonso will start us off with a message from the International League against epilepsy and updated us on the status of epilepsy surgery in Latin America, and then we'll move to presentations, case presentations and expect, and I have a very interesting discussion to follow, so Mario, do you want to start prick your figure? Thank you for the invitation, think of to Professor Jim Argument, and your. You will advance the flight. Right, Yes, great, okay, Would you continue, Wanna talk about? That is a polemic A topic, which is sir, how to establish a A and epilepsy Rica program in low and middle income countries next,
4:22 So the problem that I see here it's a. It's a. A a political one next or there for some reason is coming very slow, but anyway, let's I keep it here. The The the main problem will be that. The that the the economic we have in the countries. In the second one will be probably the most important is the political problems that we having corruption this countries mainly. At what we are all to solve, esa, the steak of the art, which you certification, and this is what we are here. Talking about this. A problem next to corn
5:01 syrup, Be the gap is the difference between the number of people with active epilepsy and the number whose seashores are being appropriately treated in a given population and I give given time, and this a statement that came in ninety ninety eight with epilepsy out of the child by these agencies. It showed that eighty five percent of people with epilepsy are either inappropriately treated or not treated at all despite their low cost of effective treatment for epilepsy and the current treatment gap is over seventy five percent in most low income countries and fifty percent in the majority of middle income countries, but the magnitude of the treatment gap directly reflects the difficulty. In diagnosis of refractory epilepsy, which is the base to provide surgery as a therapeutic option, and lets to say that in two thousand and five years ago we had only thirteen percent of low income countries had access to epilepsy surgery programs. Next distribution gap is attributed to different conditions, but I will talk about the skill, non -powered cost of Friedman, cultural beliefs. And the ability upon the epileptic dogs, and of course, the need to company health system in the ration, in order to improve this gives you the treatment gap in Latin America. This is data from two thousand and eighteen in Asia in Africa, in the great difference between urban and rural areas next,
6:43 so if we look at the data we have we count with. Is that the health system issues are a major obstacle for Visa problem? First of all, we have inequity in the distribution of public health services. We also have poor health system infrastructures and inadequate supplies of antiepileptic drugs, So many low and middle income countries do not have the infrastructure for Bristol decal evaluation and the most affected area. It's a rural. As you can see, in the graphs, that is not very clear, but for example, in enough, believe the ice hundred per cent, the treatment gap next has been estimated at that point to almost point Two percent of patients who should be operated our operate in Latin America, and this is a a pity, But is this a global, rather have been a regional phenomenon, In the answer is no look at the The The B data we have. I enjoy see why diagnosis and treatment
7:54 centers have demonstrated to improve seizure control. Fewer than one percent of people with drug resistant epilepsy or refer to the surface. Him The reference. It's very late. It's over twenty years at the onset of seizures, and then we have other data. Which train of increasing of the realization of your time was not the company as you can see it in the graph by increasing surgeries. Why did this happen? It happens because many of these
8:30 hospitals did have the technology to study the patients, but not to solve the problem and so this is also the experience. The other issue is that the the annual number of preparation. The operation, for example, in Sweden, between ninety one in two thousand and seven, decrease at a rate of two point fighter gear,
8:55 having less than fifty patients per year in two thousand and ten next, Okay, This is a survey, perform or the United Kingdom, and I don't know if you can see very clearly crafts, but let's let, let me mention to you. That there is a decrease the wind, two thousand, and in two thousand and eleven of eleven points for temporal lobe epilepsy, Extra temporal epilepsy is one percent, and the ivies, for it to me, one point, five percent, and finally kind of sodomy only five percent, Whereas there is a major increase for them in the eye, the performance will boggle nervous stimulation and also no leash epilepsy. And one more worry, all Alyssa status, stay there, so so last, or at least in Latin America. We don't have this problem. We are rising, and the results are comparable to those reported in the International lethal richer. Next I will I will love. Give you this exemple. This assembled a program created in Imperial. We shot the agency saw from Ah, the United States, and Canada, and also from Mexico, we prepare the at the at the Instituto Nacional. The scenes were lucky cause, which is a meteor epilepsy, An accent, Excuse me a institute in Lima, Peru, in wish, we created the infrastructure in order to they start having, after forming epilepsy surgery cases, in that the. As far as September two hundred, two thousand and twenty, the hopper, four hundred and fifty cases next,
10:47 but there is always the the mining up, and this is up from a bridge, whom establish that in a paper, if they're asking whether this represents the optimal approach
11:02 to advancing a bill of sicker and services, and this is a very complicated problem. The answer to these is that is a dwell problem faced by epilepsy care, Latin America with the mix. If the mueller, you can profile, and hygienic inequity, but it's evident and the resources, both the optimise, the the treatment gap must be reduce in now, and we have ample evidence that epilepsy surgery is both effective and safe and associated with increase quality of life. With years mortality in the long run cost effective, and this is where we should take into consideration next, so I'm going to Holly, look at the third level and comprehensive pharmacological, Another microsurgical treatment next,
11:59 and I think this is a very important in the sense that the creation of epilepsy surgery programs files, winning the tour level of passion. It requires coordinated effort to assemble a clarity disciplinary team into originally technological set up abraham space of surgical protocols and procedures, and also designed to follow up articles and adequate data databases in law, limited and income countries. It's difficult to cobbled these elements set up at the moment. In time. He has been common practice to build up in his step, who is starting now. In a patient center approached, and this is what we have, but on the next
12:45 hole will be years,
12:47 so the first the first thing we do is assembling a multidisciplinary team in, shall we have to include everybody to participated in this next
12:59 second in. There is the establishment of and integration of the thing logical set up, but also eat in the study algorithm. And you have to adopt this algorithm. Depending upon the technology you have next, we also have these evidence based design of surgical protocols and procedures, and we have to establish classification procedures herself and results next and afford to point to establish Follow protocols are not equate the databases. This is important. We have to know when to withdraw a medication back referrals to treat any relatives. The database established for every single patient and the quality control measures. This is establishing centres with a sufficient number of of and sufficiently, and specifically trained personnel meme of the technical standards and equipment containers, Medical indication of her quakes, etc next,
13:59 so we have these related to health care problems and one of the major problems we have. He's the guy with the white coat us in the sense that we your way to interest ego or ignorance to what's
14:18 involved in the study and treatment of these patient with intractable epilepsy next to main barriers, We have a structural economic and human resources, but also a a next. We have a strategy to increase access to epilepsy surgery, and we have planned these. There isn't as barriers a misconception to earth about surgery. Access issues, lack of knowledge about surgery, but in the other hand we have patients and family. In the answer to this is education.
14:56 Then what they choose to do, or at least contribute
15:03 I online education tools. We didn't information to
15:09 webinars, podcasts, etc, in the end the contribution that we should do as physicians. I called system is also education and resources. In this is very online educational tools, peer review publication guidelines in finally, the society and the community should be involved should be Imbolc. Net, we need education. We need governance, and we need literature. This is why we have been very.
15:41 We have been a very
15:44 er, or a specialized in and promoting epilepsy a soldier with the years following these basic strategies next
15:56 as conclusions, I will say this surgical treatment gap. Is a multifactorial problem into the structural economic drain issues, and is close to hundred percent in low middle income countries in the existence centres, However, surgical outcomes are comparable to international literature and surgery has been proven to be safe, effective and financially responsible, with long term impact on quality of laps. However programs are concentrated in German areas. Leaving the most vulnerable populations underserved, even the most consolidated groups, reference to pre -surgical evaluation remains very limited and this is very limited everywhere next, and this is the final slight.
16:48 The primary area to be a crazy dedication. We should needs to happen both in the Note, professional unprofessional levels, Sears for our practice guidelines and. That are not regionally or locally adapted to specific health systems. Epilepsy Surgery must be developed on a case to case basis, piggy backing on the already existing primary health care services for community based rehabilitation center With identify local interest,
17:20 the inequity and inequality that correct racist healthcare in low middle -income countries must not be. At deterring to developing epilepsy surgery programs, so is imperative to have a comprehensive understanding of the Arctic bear save shots needs and expectations of patients. Some physicians that remained by local condition in sickle, stands for some focus, Kylie, or not mid one of the mutation of human and technological resources, for the greatest possible benefits of patients, many thanks.
18:00 That was outstanding, Mario and a call to action for
18:05 treating our patients were surgically a remedial epilepsy. My. I have a question for a memorial gifts, or do think about Dr. Beer bags comments, and that that the systems shouldn't be optimized for the surgical treatment of epilepsy. My concern is. If we wait for all the systems to be optimized, many patients that could have been treated and will go untreated,
18:36 and I, you know make perhaps are doing some patients a disservice.
18:44 Yes, Yes, No, I think you know call me and I think it's it's it is part of the eye. The Al Islam. We have a software suite. You know, it's a very philosophical thing, but we character. The poor, the poorest the middle income, etc, but I think that everybody should put a a a grain of sand to establish the what's the best benefit for those people who haven't been treated and our obligation assertion have ceased to act worried at this morals and promote the establishment of more centers with is Sarah characteristics. Look at the problem up there in what they might. Not. For example, we establish another center and they have performed over eighteen years and two hundred and fifty cases.
19:34 You have restricted cases. In most of them are temporal lobe epilepsy, and you know so those are people who really came. They have a great is benefit in epilepsy surgery so. I think it sorry for those people who were able to me. You ate it again to society. He paid off everything that we can do for them, and the same thing has happened. You know when I have the The The epilepsy surgery, A program at the National Institute train any different to the students for nothing, America, and in Europe is particularly Spain, and we sure they came, and now we're educated. We saw this province and I think for all those peoples who are really working and institutions the benefits for patients, how to improve it
20:29 other what are your comments about epilepsy surgery, and and Pakistan, are you seeing this being adopted more widely or what's your experience while we're waiting for Author Two. Rejoining us? Why don't we move on to some case presentations cost that I think
20:52 we have the cage. Some of yours here. Do you want to take us through it? Sure enough.
20:58 You know I wanted to present this case in particular, Because
21:03 you know epilepsy disorders, in general, particularly a temporal lobe epilepsy deserves serve some very. What will a review and careful investigation into? Essentially? You know we're looking at cheating and invisible target, Sure we can. We can have a lesion demonstrated by imaging, but lesions can be misleading. At times. They can be several. They can be very large, which essentially means that you can't necessarily identify a part of the lesion that may be responsible. For the upload your generosity, they may mean nothing at all,
21:45 or they may or may not be part of a larger network that is not immediately apparent, so in the end we have to be very careful how we use our imaging. How we use our
22:02 electric graphic information to decide on a particular focus that too, we can. A thinker to reset it and the and get a good result, and so I wanted to highlight this particular case which happened to occur a number of years ago now and in Witcher, a twenty one year old presented with her first ever seizure without any obvious risk factors, and and that, perhaps so was our first clue. That something was going to be a little curious regarding this particular case, She had a typical aura with nausea. Some Malays, Sir, She was dizzy and and
22:53 she had a semi orange in which she would have a deep breathing. She would mumble should begin spitting at times. She'd get up and wander away.
23:05 As there were episodes in which shows, she would rubber nose or pinch her nose with her right hand, and this, so we looked upon as a later realizing factor as well, so we felt you know that she seemed to have a temporal onset type of epilepsy, and so we began our investigation and. I to our discontent to, we saw that much of the imaging was or was not localizing, Do is in effect a little to recommend any aspect of the brain is being troublesome to him, sir, and y'all have to say, subsequently you leave engaged in a great number of different quantitative neuroimaging analyses and. We put this particular patient to the test, and this is red, respectively, obviously, but even that quantitative analysis, we had you know seven or eight different modalities that we looked at in particular.
27:28 The lower channels there a pretty good wave pattern showing up, and there are some
27:36 attributions are listed. There is to win. The seizure. Onset begins electric graphically when she begins to feel a certain
27:48 issues, such as my last indicating that she's still awake at this point towards the end of that to tracing. Go to the next one more. And you know you'll see further evolution of that image in the lower channels, and here she is again, a pinching her nose with her right hand to indicate possibly that this is indeed a right sided answer, so or go to the next slide them,
28:18 so now we implanted her and we implant or Ashley with surface electrodes, and back in those days, I.
28:29 We did a therapy at the surface implants, and we would tend to wrap a strip electrode around the pole of the temporal lobe with good visualization or structures, Says that you're getting some pretty good tracings are taken from the para hippocampus area from the piriform cortex in the light, and what we saw were were numerous. An indirect to have that form discharge as a gypsy. They're in the right to, in this tracing along the strip. After that we had there, we had numerous electrodes elsewhere, but there are fairly quiet and in the next slide
29:14 you see, and now the beginning of a seizure again in the same channel. I made a nice evolution, then go to the next line to warn,
29:28 so with that, we felt fairly confident that we could go ahead with a right sided the temperate polar or reception with, and you're coupled with an easel resection, and you know she did well for seven months, and then she presented to to us were three generalized seizures, and after that. As she began to show some rather habitual seizures reminiscence though the sort of seizures that she had previously, and they were lessened tents, and that perhaps less frequent, but there is still there, and this is, despite her continuing on, her anti epileptics, is too darn close them as the carpet, his opinion, and rebellious, sir, acid him, you know, these are you know. Pretty good medications to have on board and still, she was having breakthrough events and this was after she had a reception that we thought would do her a favor. When we did he G on her. She did show that she had to enter in mid. Temporal. It answer yet again, so and if the lawn in the same place that we had seen previously.
30:52 So what we began to see in her subsequent films wasn't in a small enhancing lesion that was showing up in the pre Cuneo area. You go to the next slide one, so here we see you know a series of
31:12 slides, and the left sided images show a couple of sagittal. Images and you'll see a small I dunno horn. If you could point to her. I'm not sure if you have control over that, but you can see a small
31:30 lesion that is showing up in the retros Plenty of Aaron. And if you recall the axial image, I showed you that area was rather quiet, Looking didn't show any kind of lesion there at all and we wondered ourselves whether this particular site. In the in the ventral, three cuneo area, and you can see it again, It's immediate, said you know within a few centimetres behind the Corpus callosum, whether this had anything to do with her seizure activity, and you can see her down in the right lower quadrant, the coronal image of that same legion, so it's fairly deeply sensual, and and I rather. Innocuous looking at doesn't have much of a massive. They're certainly doesn't produce much of a reaction in the neighboring brain. Go to the next slide one, so we took an interest in this and I decided that we would take her to the operating room and I will do slip a down to me. Lesion itself, we had a robotic unit, arose a unit, then do the first thing we did was electric credit card or and I'll show you the results of that in the next life, so we went from doing an electrocardiography, and then with a kanga in place, though we did a biopsy, and then re a laser ablation of this lesions, and what we found was a pile cilic astrocytoma, but it was amidst legion. Because there was an associated the cortical dysplasia with her, and so after that surgery after about ten weeks touched, she had a single habitual seizure, The single seizure that essentially was the same as she had before.
33:37 But then after that and we kept her on her anti epileptic medication, she remained free of any seizures now for three years, then, Of course we're still watching her, but we've now started to taper her medications as well and she is still not season to go to the next slide, so the first thing that you see on your left -hand side is a coronal section and again that region we did A D. T I.
34:08 Tried to graphy in the vicinity because we are interested to see where the communication was or the connectivity was with regard to this particular leaders, and you know, unfortunately we had it. We had already taken out the right temporal lobe and and so in retrospect, I would have loved to see some productivity there, but we did see fibres heading off in that direction.
34:37 Performing not only a ventral stream, but a dorsal stream from the pre cuneo area, as you might expect, normally anatomically what you see in the middle section is another is a sagittal section and you'll see the ghost of our Kanga descending through the post, your heart of the brain down to the Legions, and you know the. Of course, the first thing we did was said to do and electrocardiography than what you see below is the electrocardiography that we did, performing. You've seen numerous sharp waves and some spikes occurring simply in the in the substance of this lesion, so we felt assured that that this was a troublemaker, and this was somehow coordinating with. At the network that was proving itself to be her problem in the first place, it was a right -sided network of that lifted generosity, but it seemed that the primary node for this network was situated in the pre Cuneo area and not him fact in the temporal lobe, and so after ablation we got a good result, Unfortunately, on the right side, I'm not seeing a lot of the. If the photo micrograph, that that we had the others lesion, but it turned out to be a pilot, select astrocytoma mixed with the teachers over focal cortical dysplasia until we can go into the last like war. I don't wanna is a time. These are post -op images now after awhile and dumb
36:26 on the actual image. You can be back in the area were recreated. The eastern. There's a ghost of a. A small lead, and unfortunately you, you can, you can see it on the size of images on the right hand side, but there a perfect little hole there in the pre Cuneo area where we created the Legion with a laser device, and of course in the middle, you see the surgical resection of the hippocampus and the parent hippocampus region and upper more anteriorly. Is where the temporal lobe was a resected in the polar segment itself and so you know I present his case to Because of you know going back to my initial admonition that we do really have to be careful about how we look at even temporal lobe epilepsy. Everybody talks about extra temporal epilepsy as being complicated, particularly in the non regional
37:30 aspect of it. Even temporal lobe epilepsy the way it presents to us, Samuel logically in the clinic
37:39 may fools. Then do we have to be careful about how we go about
37:47 defining what we think is the network, and aware it is truly saturated now worn. I have another case that item presented in a couple of slides. I'm not sure. If though we should just delete that to the end up, because I want to leave room for the other speakers, but we attack that in a different way, and that also presented like a temple of that epilepsy, but turned out to be something different so we can leave that to two later. I. I want to leave room for the other speakers. Yeah, I agree, But you know that I wanted to comment on this case. This is a fascinating case and you may recall that Fred and Ramen in Montreal. Called occipital lobe epilepsy pseudo temporal epilepsy, and he used, he used to speak about that a lot, and and there's even some early efforts in Montreal to treat temporal lobe epilepsy, Sorry to treat occipital lobe epilepsy with temporal lobe resections, and that was published some time ago, I dunno, if you recall, and but
38:53 beckwith what not, I'm not. Very good success, but you know really mirrors the the case you presented here, the whole concept that pseudo temporal epilepsy, Yeah, and in the long run we, she did have several months of siege a relief, so the temporal lobe certainly proved to be a node in the network was certainly aligned with the network, or altogether is very interesting, you know about the we pay. Minimalistic, a surgery, you achieve a complete the seizure control. In this case, Now it's a beautiful kittens. Literally,
39:35 Yes, we went down the wrong road again without
39:42 thanking cost pleasure. Either you
39:47 reconnected, Yes, I am reconnect at Surrey, Excellent.
39:53 You don't I was just going to comment on your previous point that you mention, and I think Barrio mentioned that too about the, we can try to learn, or teachers are expanding into some very the pain and
40:11 indicate epilepsy surgical techniques, but I think from the pursue from the global perspective if he can just focus on to begin with. Only the temporal lobe epilepsy are selective and a given a compact to meet the one that you dead,
40:29 and he can you excited that of a day wouldn't be enough to actually get up the majority of the patients and the the return that we get from going into epilepsy fellowships of the time you spent the money spent on that thing. The return is not as much as spreading it out to generally resurgence. Get into a simple temporal lobe epilepsy, putting them together. When ought to just stunning the training program like we did. In the beginning.
41:06 He know that probably will give us more desserts as his like reality, so I didn't learn to make that point simple things, temporal lobe epilepsy selective erected over compacting the corporates that sought to me. One other thing we wanted,
41:23 and we, we called temporal lobe epilepsy, The low hanging fruit Gal the time surgically remedial epilepsy, and it has excellent response to medication. It's the majority of patients we see and we even just focused on that would make a huge impact, and
41:42 for when I used to when I was at Kenyon, for you know with Costa, I used to do a lot of face to monitoring. But then since I came back to Pakistan, I have not been able to a singles. Phase two, monitoring, so lie, because the reason is enough to clean your knees are too expensive. Aren't going to the patient over here. They are paying from their own pocket. Staying in that entice you with all that paraphernalia attached to him and the higher rate of infection, so so I have what I have done is do it without any face to monitoring the worst that I have done is. In his is active article crafting with a week to newark me, and that has given good results, so I have omitted faced lurking for the sake of making it cheaper more affordable and more deliberate, so so so you know we have to change things up based on what part of the world beyond,
42:39 Yeah, I, I think a lot of good will come from our ability to refine the way we investigate to the epilepsy and and we've been working on. I think as you may remember, we were starting to work on a quantitative neuroimaging. Yeah, as a means of defining the lesion the lesion site, or at least the the nature of the epilepsy do this, and in so we're getting to a point where we can at least tell whether something's truly a temporal lobe epilepsy or something that is outside of the temporal lobe itself.
43:19 And then your comment, though about the cost of intracranial electoral monitoring, and it's It's valid in other settings as well outside of low middle income countries. When I was working in Australia, the Australian health system did not support, and the the cost of intracranial monitoring. And if you look at you know really great programs at University of Melbourne and Austin, Health and others, they put very few
43:53 electrodes and very little face to monitoring at the end, but it, it's really because the health system does not support the cost of of the Rainey wiring system
44:11 We spend a lot of money on that thinks you know. Will you only use the
44:16 invasive monitoring for those with no leash and I'll epilepsy. Basically. That's the main up a topic that that which we use her. He wasted mind going the rest of the way while directly with electric article, Repeat for every muscle the case at some,
44:32 but then he know your image in the article graph. He is not still still cheap. So the total cost of a blender craniotomy in in a private setting like Barron's kings, may maybe closed you about me four thousand dollars.
44:49 Afford the trip is about is about four hundred about themes of few dollars, so you can imagine that just I just is Chip is adding a canvas and cost of the total graveyard with the whole packet, or you don't a hospital, stay and medications and special care and. Don't you the internet? And whatnot? What are so not that makes me feel about it Need to find cheaper alternatives to those electrodes. Are that we are looking on quote unquote. We don't to refuse. The two are going to leave. You, said a a good option. You know why he was trained in Montreal Tour with a warrant for many years there, and that way your aunt Emma every day. In the ground the will used to make this a call a spider. You know that we put directly into the brain and I tell you, and all I had, I'd have to get over at eleven hundred cases, and they work beautifully. I mean is not even the fanciest thing, but he works very nicely. Thought you. You can keep that in mind any only cost about seven eight thousand dollars.
45:57 Police are still applicable, also a scrubbing with two that the acute depth electrodes, or you can put there, and he's a fantastic her,
46:09 and them, then
46:13 like an orgy my granddaughter little different than that. It's pretty much the same, you all the first grass system. I'll give you the data so you can to the Brian Hayes Ivory soap. So you can contact him directly,
46:29 so so so boring costs and Maria, or can be. Use this opportunity to desta mean, I'm sure that people who are who have joined. What's the word? Then? What have we learned from the training program and the thing that he did arena in in different parts of the world, the way simple way of actually spreading out the epilepsy surgery, and and epilepsy surgery, Something that needs little magnification. He don't even have to have a microscope. You can use lose good lightning. You don't have to use A, cannot you can do with simple? I know ga plenty of being a small incision, and now you can kick it off, None of us. All it requires is a little out of Delhi video conference where someone or like the Michigan liquor stores are you in a low margin. Do you know or anyone else just looks at the E D's. And says Okay, you know this is the case. Go ahead with this.
47:32 So so they can spread out like that, though I think
47:39 Gregory the Great taking advantage of our telecommunications, which is good in even low middle income countries, but what's lacking is the the expertise There's the neurologist, The uplift, colleges. This is often lacking, and, but we can bridge that gap with with that sort of. Networking and telecommunications, We've we've done that. You've done that, and the operation of study, but hundred and thirty million, and we have plenty. I think three, a well trained at the apologists in the country. Rest of the mythologies. I don't have a neuro psychologist to have to with awakened yards. So we have to do then we can wait forever. We don't have ended up authorities in the country. I can wait forever to have all those things in here. All we can say of the situation. What are you going to do it now and he's outta the outskirts of the?
49:48 It's ugliness
49:51 out there. You'll have an interesting case. If you want to take us through it and
50:00 the platform is cutting off
50:06 Yeah, weren't I'm not sure why that's happening. It doesn't it's not. I could see it okay here,
50:12 Okay, so it's okay to go ahead. Stephanie, Yes, Yes, go ahead, Okay, alright.
50:19 I was so low you don't you're testing my memory warrant Because I don't remember all the boy was
50:28 see the young officer. This is this some kind of a test that you know you're going to kindergarten. Looking at my my gallery. I could. I can help. I couldn't help it because I wouldn't play as I. As on the bus
50:44 was twelve year old boy, and you know that he had.
50:49 I love them some so basically it was drop a tax, that was the problem with this kid, and
50:58 he was on multiple multiple and tablet takes and up
51:02 dropping acts that came so bad over time that the parents had to use the helmet, and then somebody had the physical exit the child constantly.
51:14 And bring the dip and apologised movie shit and he, he remembered
51:20 we discussed it several times, and and we decided to just go ahead and do the couplets that assaulted me, so I think incense, and he slighted that you can come up next we we, Because he
51:37 do that,
51:40 or should we should be sure shouldn't be the next slide the award. And I got this one the next one
51:50 the next one the.
51:53 Other says we can see poster Alpha is an actual accomplishment, sagittal view, which shows it very well, so we decided to do a complete corpuscle assault meat, instead of doing pursues her accomplished, I taught me, and that was based on the
52:08 Us. Pop near a psychological assessment of the kid. We did not really think that the child did not have enough potential of assuming at Sca good school had. And the other activities, but the most important thing here was to prevent the drop a task or leaving, because she wanted would have still
52:32 left at a possibility of some failures, So here we decided to just go ahead and move the horse critical for collusion.
52:41 And after that he did very well leave for nine months. He did not happen. You see here thorns up and then develop some devices, but the drop a text to were totally gone. Then dove soap soap, so there was a discussion that we wanted to bring forth out what would be the choice Hell if the child was a, let's say in a Montreal, Would you have thought about doing a complete corporate philosophy, Me on Friday, You stayed in the antiquity, The, as they put four medications.
53:18 Yeah, this is an excellent and very instructive case.
53:23 You know, I am I. What I'm saying in my practice as the neurologist. The younger generation neurologists have forgotten about us sodomy as a treatment for for the drop attacks, and and also for severe generalized epilepsy with status.
53:43 So when I'm having to reeducate my neurologists on devalue this treatment for these patients and patients like this that you presented do very well, excellent results, and usually stops the drop attacks. Usually they're transformed into some less disabling seizure type, maybe a stare or a stiffening, but without a drop I was interesting. I've had to have a few patients as well that have had. At meaningful reduction in their seizure frequency, but that's not the goal. The goal is a palliative goal to stop the drop attacks, and also often has good benefit for severe generalized epilepsy. With what status I'm usually provides could benefit there as well I I in, When when I perform these procedures, I have difficulty reaching all the way to the selenium from a. From an anterior frontal approach unless the head is is small, but in a normal size, said I have I. I do an anterior two thirds, typically from a frontal approach and, but occasionally I can reach back as far as you did, but usually I cannot
54:57 mario. What's your experience and tossed crust When the request,
55:03 Yeah, I.
55:06 I remember back in Montreal, we did a number of these, and that typically we would have, we would undertake a two thirds as much as three quarters, and I tend to think that some of that was dependent on
55:22 how the child was functionally. I think to be efficient to about it, The that are rather significantly impaired.
55:35 It's not just by the seizure, but otherwise I would tend to benefit from exactly what the author has done. There are others that would be of cramps. A more like a candidate, for two thirds
55:51 were to allow them to allow them some
55:57 additional functional opportunity
56:00 while we have our favorite year so. I dig a transom called ceremonies, and certainly will have gotten a two things first of all the cage hacer, epileptic encephalopathy, and if this is progressive, we go for a complete the reception, complete gala ceremony, you the patient, a turn, it has a multiple seizures, or is a Cano file, Lennox -gastaut Syndrome
56:27 by to stable, we rather go for it two turtles as you mentioned before. The other option is that there for example in this sky, the hacer epileptic activity in the occipital area. You can also do. It has been published recently, but we have done it over many years. The posterior approach not eat people still approach to, because of sodomy is published by that, and really show by the only from the ceiling repair many, so it's a. It's a good option to an end. According to them, you know the The. His scheme of the corpus callosum as beat now shown by tractography and immortal area of the Corpus callosum lot of theater of what we thought before, and in a sense you know we, we have upgraded patients with a smaller apples, steer your Corpus callosum, and they still have a a good response, but for for for kids, even ebay, they're twenty years old if they are twenty years old. I will recommend he there in epileptic encephalopathy. A complete corpus saw me, and I'll tell you what I. I don't think that this business source for the The disconnection syndrome is due to court those kind of salami itself, But what I think it's it's by Lee tuning of the year of the cingulate. And and and we we seen it very rarely now, Because the technique has been clearer and nicer more elegant thing. We don't put retractors and things like that, but if you're really sure, the it, the patient you or creek of sodomy, you will have problems with our business, Connect your business, you know, and that they might recuperate over the over the next few months, but their song keeps later. Currently they relocated by by this,
58:29 I agree with you, Mario, and
58:33 them. You probably perform the coolest sodomy the same as Andre did I dunno, but but it was a right -sided craniotomy in the lateral position, with the right side of the head pointing down her,
58:47 so so gravity retracted the brain, and that have continued. To perform the procedure that way, so retract lists
58:59 show I alright, what I also found is that it's very important the expectations of the parents and I learned the hard way. That what are we going again with cancer? What are we not going to gain back an assault me? So that's an important thing as well
59:18 to let them understand that he thought the teachers are not going through the affected effectively as much as the rest of the disability. Because of an engineer with this, This can had multiple bombs on his head and he was presenting the man, so so that's another thing then that I learned in corpuscle. The cases are. Imitate he constantly, man and the continent and his patients,
59:45 and and what a? What are the? What are he talks about the opening the verticals investor, When you do have a vertical little bit here and there, but sometimes there are three large areas of open vertical to the Corpus callosum.
1:00:03 You don't stay in the midline. You'd go on the side of the entrance to the concert. Any technical issues with that, The Hugo well, humbling, Yeah, I find that I opened the ventricle from time to time and
1:00:21 I usually. Put some gel foam over it. I don't know why but.
1:00:27 I have not seen any Am a nation's long -term issues with that, no mile or cost any comments,
1:00:35 Same sorta thing. You know
1:00:40 somebody that you know we've had some interesting results are now because I think we're transitioning and care with regards to Lennox gas stolen from these other. Intractable generalized epilepsy, so we're getting a lot of traction with implanting the thalamus, or implanting
1:01:03 the areas that the piriform
1:01:06 cortex, that there seems to be
1:01:10 a good deal of control being offered
1:01:15 to the point of having no seizures at all. With with these the implants sites, especially the central median and nucleus him in particular, so you know, I say that, because there are options that are seemingly opening up now, but obviously we're at an early stage in trying to define you know how good these other parameters are for treating no test, and the surgeon and associate economics has also to be considered. Are we are talking about deep brain stimulation over here is about the third, not nothing less than about sixteen, seventeen thousand dollars, whereas the cross per capita income of gross national income per capita is about five thousand five hundred to six thousand dollars, and the insurance companies the single digits in terms of the published, so it's all for a pocket. So you know we're stuck with these are simple procedures for at least a couple of decades
1:02:26 the theater? So what is the charge for callouts Army? Then Yeah, it said it, so if it, if it's a, if it's a private institution like when I'm working, it may you may end up with something like a four thousand dollars, or maybe closer than five hundred dollars. Well said that there's a lot of the welfare systems than people in therapy that can pick it up Major portion of that to go into public sector institutions. Was the full. We don't have enough people who had to take care of that stuff. Then the trainer that. But if you do have that, then it's something like five hundred to one thousand dollars total, including medications and everything, but then a pain to the pocket anyway, the.
1:03:17 This is your case. Romario. Just let me just go fast. Growing up on. The next.
1:03:26 This is a five year old female with who started with the for once reflection as Pasm, Yeah, after vaccination, and she had many curses to itchy, did bad over the years was very unstable to walk to a tonic seizures. The language delay and a maintenance to treat type of seizure of people, class dancers, a tonic and mercy seizures to be right, so she had generalized seizures with a with a focal seizures next,
1:04:02 and he had a a very very
1:04:06 fake to the cognitive domain and to develop area fully after she developed Park Galactic and stuff a lot. And the global developmental impairment with severe repercussions in secondary or deletion next, and the next, this is the routine, E G,
1:04:32 so you can see the b, a or b, E g on I awake when she heard a pill, or she had a chart by waves. If only spikes intellect next morning, the left at that in the right
1:04:52 the Ici. He can see the Cpa was a very up up are heavily concentrated in the left, frontal central or dysfunctional activity next as you can see, appear
1:05:08 next work
1:05:13 here on the left. Next,
1:05:17 a very clear, but also how the Yarra at generalize complement to seen that quite often annexed the video, E g perform in April
1:05:29 this year,
1:05:32 he was say, a recorded, quite a few seizures, frequently refuse babies, pretty good, the epileptiform, he charges by lateral frontal central temporal activity. And occasionally appears in births without any accompanying cleaning, suck clinical sites, and she had multiple a drop attacks, The he chose by Lara from the Central Temple epileptiform activity, with a laptop predominance next
1:06:03 heart to see, and the year on the year to the next, appears to be bleeding over with time.
1:06:17 here it is he a left, tackle it before activity more than in written the right, but he had the epileptiform. The charges have we have higher limits ferric next
1:06:30 As you can see it here. I'm sure this is interesting because he had to be having is thought I complete to Lennox -gastaut syndrome. He doesn't have a tiny component, but he had. A tonic -clonic and also how gop attacks, She didn't have an. Occasionally she had my out When exposures to and clonic seizures are up unfrequently next.
1:06:59 Let's let's see if he runs the young.
1:07:04 I don't think it'll run the video. Okay next. Well, I wanted to show you a hair a drop a taxi in the head, drops and the and. And no net drops
1:07:19 Very frequent.
1:07:22 Is very poorly quality urgency next
1:07:28 one more?
1:07:33 So with these elements are what will you conclude? What should we do?
1:07:39 Let's not talk about that. Am I right? I imagine
1:07:44 it sounds like a color sodomy case is what it sounds like it right, But do you think the racing next?
1:07:53 One more.
1:07:55 One more,
1:07:59 but once you see the the imaging eyes quite evident that she has a almost an atmospheric, a leash on in the. I left the hemisphere, Because you have here very clearly
1:08:13 from the pre molar area
1:08:18 annexed, and you see my pointer, the legion heat of every relevant. You can see the people. It's more central front, central, and vital, would you say On the on the left, the second quarter, cause yourself and you see the difference with the white, moderate, left and right here. It's very romantic The trenches. When you hopping the left, the left side
1:08:45 next, This is the year nets as you. This video will it won't run and falcon, but let me tell you we did A A A inexpensive up front on to complete the frontal lobe resection that he groomed the tree. She didn't had any of any language developed so, and she's five year old with a complete kind of sodomy next.
1:09:15 What did the Legion include the primary sensory motor? I on just those that are different from the from while they will? You won't be able to see beyond beyond the evolution. For this is the first one he said Big recession. At two weeks, The Maciel. It's a. It's a dancing next and she has a.
1:09:41 She has developed, or at least you have say five whores. In the last month said she was operated. Next thing. That's a that are less lab located. As the last time I saw you comment this Because you're in order to me. It's really quite interesting and more often often we are seeing these types of patients. You know where we used to do kind of Swami's for these cases, and not where I have noticed over the years is that they didn't do very well with color Saddam's and so we start to do enough. Very extensive resections of the Skied, and apparently the The The Parliament and the Neil development to, and that cognitions in the sky, it improved dramatically with the with the big recessions, in the other issue, at all, in some patients that we have operated over the years that we perform a complete our salami, or treaters, color, sodomy
1:10:40 the seizures, and to eat. Greece, after the procedure, and once you complete the the recession of deletions sire, the he happens that that thoroughly, you know, right from the blues, the kids, the star brewing dramatically. I don't know you have the same.
1:11:03 Have the same experience, but I wanted to show it to show you. These is a very recent case matter to me. I think we have to go for the. For the big bucks, you know an alpha, though. In a palliative procedure, Yeah, that's very instructive. I agree that was a a clear allusion and that it turned out to be neuronal migration.
1:11:29 Yup. Yep, So, Yeah, you know these patients. If you can remove the neuronal migration, Eleven, or malady, you, you can really hit a home run on these patients with catastrophic epilepsy
1:11:44 The the challenge though is the imaging and finding it right, the the
1:11:50 some kind. Yes, Yes, No, no
1:11:55 cost just is interesting, a very nice case manager.
1:12:01 The The he's going after the majority lesion You see, you could see the extent of the the disorder was. It was by hemisphere, there is something that looked like a double cortex syndrome on the on the opposite side, but going after the majority legion, you've actually done the world of good for her. It was something that could be done and and was done in a single surgery, and I effectively done what's right for her, so it'd be very nice. Thank you for all of our distinguished panel for drinking. Are funny
1:12:46 could say new Reddit going by. The.