Advanced Epilepsy Care: From Diagnosis to Brain Stimulation

Epilepsy care has evolved dramatically in recent years. Advances in diagnostics, surgical techniques, and neuromodulation are transforming how physicians treat patients with drug-resistant epilepsy.

In this episode of Baptist Health Doc to Doc, Neurosurgeon and System Chief Executive of Baptist Health Brain & Spine Care and Chief Medical Executive of Miami Neuroscience Institute, Dr. Michael McDermott is joined by epilepsy experts, Dr. Aviva Abosch, deputy director of the Institute as well as director of epilepsy surgery and co-director of functional neurosurgery and Dr. Luis Tornes, neurologist and the director of the epilepsy program at the Miami Neuroscience Institute at Baptist Health South Florida.

Together they explore how multidisciplinary teams diagnose epilepsy, evaluate patients for surgery, and use advanced technologies such as responsive neurostimulation, deep brain stimulation, and stereotactic EEG to improve outcomes.

Topics include:
·         How physicians specialize in epilepsy care
·         The role of epilepsy monitoring units
·         Surgical approaches for drug-resistant epilepsy
·         Neuromodulation technologies like RNS, DBS, and VNS
·         Emerging therapies including biologics and cellular treatments

This conversation offers a deeper look at how neuroscience innovation is improving quality of life for patients living with epilepsy.

Learn more about the Epilepsy Program at Miami Neuroscience Institute: 

baptisthealth.net/neuroscience

Host:

Michael McDermott, M.D.
Neurosurgeon & Chief Medical Executive 
Baptist Health Miami Neuroscience Institute
Chair, Neurosciences, FIU

Guests:

Aviva Abosch, M.D.
Neurosurgeon & Deputy Director 
Baptist Health Miami Neuroscience Institute 

Luis Tornes, M.D. 
Neurologist & Director of the Epilepsy Program 
Baptist Health Miami Neuroscience Institute

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Transcript

SPEAKER_01 0:00

Welcome to Doc to Doc, a podcast where today we bring together leading experts from Baptist Health Cell 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 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.

SPEAKER_02 0:38

Welcome to Baptist Health Doctor Doc, a podcast built for innovation and collaboration by physicians for physicians.

SPEAKER_01 0:47

Hello, I'm Michael McDermott, a neurosurgeon and chief medical executive of Baptist Health Miami Neuroscience Institute. And joining me today are two leading experts in epilepsy, Dr. Viva 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 Dr. Luis Tornes, a neurologist specializing in epilepsy and the director of the epilepsy program at Baptist Health Miami Neuroscience Institute. So let's get started first with discussing training, the foundation of our expertise in various fields and the specialized training to deliver this level of care. Dr. Tornes, can you discuss your training in epilepsy?

SPEAKER_00 1:33

Yeah, of course. And thank you for having me here today. So for my training, I did what every neurologist does, you do a four-year residency training. I happen to do mine at the University of Miami. And then after that, you do a fellowship. As you kind of touched on in the in the intro here, medicine is constantly 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 now really subspecialize and kind of devote additional time to 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. The other path that you could also do is a fellowship in epilepsy. Mine was clinical neurophysiology with a pure focus in epilepsy, as some clinical neurophysiologists devote time to neuromuscular. Mine was purely epilepsy. It's a one to two year fellowship. Some people do two 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 epilepsy because as again, neurology is a pretty broad uh field. There's a lot to it. It's pretty complex. So each one of its subdivisions requires a lot of time and dedication and studying. So 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 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 EEGs, which is another kind of evolving uh field here within epilepsy that's even more complex than scalp EEGs and requires time 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 managing those medications because a lot of them have interactions. And some of these complex patients might be on two, three, four, even five 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 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 it's something not only as a neurologist from your own perspective, but also being able to work as a team because it really is a kind of a team effort when you're looking at these patients 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.

SPEAKER_01 4:08

So, all summed up, how many years of training after medical school?

SPEAKER_00 4:11

After medical school. So that's four years of residency and then one year of fellowship. So five years. Not as much as a neurosurgeon, but still a good amount of time.

SPEAKER_01 4:19

Yeah. Uh Dr. Bosch, tell us about your uh surgical training.

SPEAKER_03 4:24

Sure. So uh I went to the University of Pittsburgh first for uh medical degree and a PhD, a 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 six years of neurosurgery residency training. While a resident, I became fascinated in the area of neurosurgery called stereotectic 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 Dr. Tornas was was saying, you know, as an epilepsy surgery fellow, I spent a fair amount of time immersed in the 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 and then uh uh began my career as an epilepsy surgeon.

SPEAKER_01 5:49

So for the audience in full disclosure, I was a junior faculty member uh that helped train Aviva during her neurosurgical residency. Um next, let's discuss uh some other aspects of epilepsy, particularly the patient population that we're treating and the epilepsy uh epidemiology, meaning how many people in the community have this problem and um, you know, what's the patient burden for the clinician, Dr. Tornes? Could you tell us about that?

SPEAKER_00 6:20

Yeah, of course. So the CDC states that around probably a little over three 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. 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 younger population, the children, the 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 clinic. And that can also range from adolescents, uh, young adults, uh, maybe from a cortical dysplasia, mesiotemporal 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 is 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 this area. And then within South Florida, as I was mentioning, uh, there is a lot of diversity, both culturally and social economically, I think, in our patient population. And that's something that it's really important when considering. Because when you're building 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 a high immigration uh population that we have here. Sometimes they might be underserved, underinsured. And that really limits their access to healthcare, which is really important 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 healthcare. 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. Because 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 on what the community needs are.

SPEAKER_01 9:14

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, et cetera?

SPEAKER_00 9:29

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 uh 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 patients anymore once they kind of age out of their clinic. So we we work in in partnership with the community, uh, either private 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 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, Linux Gusteau, 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.

SPEAKER_01 11:03

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 and um maintain their livelihood.

SPEAKER_00 11:21

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 were 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 a seizure right now. And the multiple epileptologists would be looking at the patient and be like, well, how do you know? It 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.

SPEAKER_01 11:55

Yeah. Mothers know best. I've been in that situation as well, even as 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?

SPEAKER_00 12:16

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 pseudop, risk of overall 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 to 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, a 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 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 to patients more so than internally.

SPEAKER_01 14:17

Yeah, one of the things uh 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?

SPEAKER_00 14:36

Yeah, of course. So the epilepsy monitoring unit is a critical component to a surgical program and to an epilepsy center because 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 it an 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 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 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 want to 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 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 ictal, uh, maybe they're not ictal, and then you're able to capture them. It's very helpful. Uh, but it is a bit of a process, and and we're we're very happy with what we were able to build here with a five-bed EMU, because I I do think it's it's critical, and you really can't have an epilepsy program without it.

SPEAKER_01 16:09

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, Dr. Bosch, can you tell us about the surgical workup for a patient with adult patient with epilepsy?

SPEAKER_03 16:27

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 the patient's seizures are like because the semiology of a patient 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, three 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 from an anatomical standpoint that's awry. Um then in addition to the brain MRI, there's um an ictal pet, 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 Dr. Turnez 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 a centimeter of scalp, a centimeter of bone, and then a lot of brain real estate. You know, if you think about the intense infolding of the cortical surface, that you can be a long way with a scalp electrode from where the seizures 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 the seizure onset zone, removal of that seizure onset zone. If we don't have sufficient information, but we believe the epilepsy is focal in onset in terms of 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 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 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 uh 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 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 re region of the seizure onset zone that I need to be aware of as 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.

SPEAKER_01 21:01

Yeah. Let me give you a clinical scenario. 35-year-old woman with um generalized seizures, two of them, and MR imaging demonstrating uh superior temporal gyrus, anterior two 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 um source of the epilepsy and operate and remove it? So what would you do?

SPEAKER_03 21:30

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 calvinus 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. Surgery, recover, and then we follow the patient in epilepsy neurology clinic and make sure that she's not still having seizures.

SPEAKER_01 22:07

Yeah. Uh okay. Let's turn to neuromodulation now, apart from excising epileptogenic tissue in the brain. Um, can you tell us about neuromodulation, Dr. Tornis, and how you interact with Dr. Abbosh uh for that kind of um method?

SPEAKER_00 22:23

Yeah, of course. So I think neuromodulation is one of the more exciting uh parts now of epilepsy. 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 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 if we're able to do it. Uh, but as Dr. Abosh had mentioned, if it's coming from an eloquent uh cortex, the seizure onset zone, uh, sometimes we can't resect, we can't 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 people patients getting neuromodulation and and they are seizure free, but I tend to not really like to tell the patient that we're aiming for seizure freedom. It's more of a tends to be more of like a 70-ish percent 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 epilepsy. And then we also have the responsive neurostimulation, the neuropace, uh, which is the one that's gained a lot of favor within the community uh for epilepsy. Uh so these are basically three 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, Dr. Abosh is the one who goes ahead and implants that. Uh, I'm not able to implant these, so I don't do surgery. So I work with Dr. Abosh, the neurosur, um, the neuropsychologist, uh, the neuroradiologist, as she was mentioning, in the neuroconference, uh in the surgical conference to determine, well, this person's not a candidate for resection. So 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 depth uh uh uh depth electrode or a strip, and it's actually has uh basically it's an e cog. 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 bit temporal uh lobe epilepsy, you put one strip into each um temporal lobe, one one, one 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 are 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 can say, well, now let's turn it on. And what it does is, well, it can 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 to 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 with 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 astr 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 stimming along your parameters. The DBS is implanted into the thalamus. Uh, the VNS is into the vagal nerve. Uh, that being said, though, there has been a lot of, again, kind of research and expansion in the field 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 um when the person comes in for perhaps a phase two, as Dr. 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 are either going off simiology. So, and simiology 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 pulvenar is 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 are maybe before they were in a uh resective 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.

SPEAKER_01 28:03

Yeah. Very interesting. Um Dr. Bosch, can you talk about the um emerging biologic and cellular therapies that may have a role in the management of epilepsy?

SPEAKER_03 28:14

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 really uh an RNS device, a responsive neural stimulator, which, as Dr. Turnoz 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, an effective uh uh treatment, which is the electrical stimulation. 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 one, two trials uh to look at uh the efficacy, uh 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 three, which is under under uh discussion now. Now I will say that in um early results, um there have been uh really substantial improvements in seizure control for the patients in the phase one, two uh portion of the study. So that's exciting. Uh there have been some adverse uh events uh linked to the immunosuppression that's required for uh the patients to tolerate these stem cells. But those adverse events have been um temporary and and patients have processed through it.

SPEAKER_01 30:44

Yeah, I was very impressed when I saw the presentation by Dr. Kim Birchell 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 the phase one in humans. So that's great. Um okay, to close, Dr. Tornes, uh, what message would you like to share with patients who have epilepsies and their families?

SPEAKER_00 31:08

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 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 in 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 patients. So 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 pharmacal therapies, uh, surgical therapies, diagnostic treatment. So there's always something to do. Uh, 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, because again, um, this does really take a well uh trained team of multiple different specialties uh to really help these patients. Uh, I can't do my job without Dr. Abbas, I can't do my job without the neuro uh radiologist, and I can't do my job without the neuropsychologist. I can only do so much as an epilepsy doctor. Uh I maybe we'd like to think that we can do more than we actually can sometimes, but but we really do need help. Um, and I want the patients to know that we're here to help.

SPEAKER_01 32:49

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 stereotyped EEG, which Dr. Bosch does, and grid mapping to deep brain stimulation and responsive neurostimulation that are transforming outcomes for patients with drug-resistant epilepsy. 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 Cell Florida, visit BaptistHealth.net slash neuroscience. And I'd like to thank Dr. Tornes and Dr. Abosch 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 Dr. Michael McDermott, and thank you for joining us today.

SPEAKER_02 34:07

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