Pediatric neurosurgeon Kurtis Auguste, MD, who directs the UCSF Pediatric Epilepsy Surgery Program, discusses in-use options that boost accuracy and safety for managing seizures. Helping PCPs counsel appropriately following an epilepsy diagnosis, Auguste describes an implantable device that reduces seizures when resection isn’t possible; MR-guided laser ablation that leaves no scar; EEGs that are less painful and more precise; and imaging technologies that help kids feel less afraid and more engaged.
I want to share kind of what's been going on of late with how we've been treating pediatric epilepsy in the operating room. And um, you know, when I, when I used to give epilepsy talks epilepsy surgery talks when I first started on staff out of training, um, about 13 going on 14 years ago. Um, the list of procedures that we would talk about was very different. And this is, This is kind of a sampling of, of where we were back in 2008 with respect to kind of the array of how we approached problems surgically for for kids with seizures. Big procedures like a hemispheric to me were actually eliminating a whole half of the brain or taking out entire lobes or disconnecting left and right with the corpus callosum sodomy. Um, or maybe refining it a bit and just finding a seizure focus. Um, and respecting that one piece of tissue that's seizing. If we couldn't take out tissue, we could do what's called multiple sub field transactions and interrupt those seizure pathways. And then our level of sophistication with devices really uh ended with a device called a vagus nerve stimulator where we place a wire on the vagus nerve and, And it's, it's kind of like a pacemaker for the brain for lack of a better analogy. Um, and that's, that was kind of the pinnacle of the sophistication that we had back in 2008. Um, and the things I'm going to talk about are not anything on this list. It's, it's interesting because all the things I want to share with you today weren't really in common practice when I started my my my current practice and it looks looks more like more like this where um we're changing the game a bit about how we approach these problems and um we're quickly migrating away from much bigger procedures, more invasive procedures to less invasive procedures. And being a bit more sophisticated with how we not only treat but listen to seizures. Um And and also how we study them. So this is just a a quick a running list of the things I wanted to just quickly go over about how how my practice has evolved in the past decade or so that I've been I'm here at UCSF. Um So I wanted to kind of get us started with this this topic of of neuromodulation. Um You might have heard of a of a device called an R. N. S. Um uh is generated by a company called Euro Pace. Um here is the actual device uh This is actually sitting in the palm of my hand which isn't very big at all. Um It's pretty flat flatter than your cell phone. Um And um it's it's a device that's basically like a watchdog. It's something that's implanted um intracranial e as opposed to in a subcutaneous pocket. Like a vagal nerve stimulator. And what it is is um it's a device that can accept up to two electrodes. They can be strip electrodes that can be depth electrodes but you only get to uh so that's kind of the where we are right now with this device and how how where it's flexibility is. So it does mean you have to choose wisely and you have to know where you're headed and what your what your what your goals are for treatment. Um, the ideal patient and whenever possible possible, I'm going to kind of spilling where where in the front lines and primary care. Um some of this might be pertinent. Um much of what I'm talking about really wouldn't pertain to the primary care office, but I just think you being well versed in and some of the current technology kind of gets the ball rolling for these discussions about how we might treat seizures down the road. I think the process of getting patients and families and parents at ease, which is the concept of treating epilepsy starts in your office is not in mind. Um, and so the more well versed you are with some of these newer techniques, I think that the better, the better all of our patients will do. But a patient who was a candidate for something like this, the neuro pace, the RNS Is someone who has been in at least two meds and failed them and it's still seizing at least three seizures per month and ideally doesn't have more than two seizure fossa. And that that that magic number is again dictated by where we are with this device. The device only gives us two ports to place electrodes. We've tried to be creative for those patients who have three fosse or even four fosse where we picked the two of the most compelling fosse and and implant those first. Um And we will also place the other electrodes and but let them leave them idle and capped so that if the first two aren't getting exactly what we want, we have the ability to do a very limited opening of an incision and just unplug and re plug and switching and swap some electrodes inside too. So that's one way we've gotten around for the patients who maybe not meeting this criteria. Um This is a device that is meant for patients who could not otherwise get a safe resection. If you have a piece of tissue that's in a dangerous place to operate or deep seated and you have to go through a lot of normal tissue to get there or it's eloquent cortex, it's speech cortex, it's your hand, motor cortex. It's it's tissue that you don't want to take out. Well, rather than being that barbaric and just removing tissue that leaves a patient with a permanent neurologic deficit. We rather just leave it in place and and modulate that tissue instead. And this is this is kind of ushering in a new phase of epilepsy treatment where we're no longer just respecting and taking out tissue. We're leaving it in place and modulating it in place. So some of the early data from the EuroPass Group was that when they first implanted these devices, and this was one of the earliest numbers that they were uh populating where 21% reduction in seizures after implantation compared to the control group. And the way it works is this device is basically a watchdog. It's waiting, it's listening. The electrodes are in place either in or on top of seizure fosse and when a seizure happens, this watchdog detects it um and it gives an electrical stimulation and interrupts that seizure wave and stops it in its tracks. Um So it's it's constantly at work. It's waiting and watching and then it's just sitting idle until the next seizure. So it's a it's a smart device in that regard and it's it's certainly a step up from our vagal nerve stimulators, which wasn't necessarily responding to seizure activity per se. It was more of a rhythm rhythm maker. A drum drum beat that the brain then follows and and becomes more coordinated because of that drumbeat. So that's how the VNS work. This is a much more sophisticated device was actually listening directly where the seizures start and tries to interrupt them. So this is extended data now the same group, but further out. So initial initial data showed that 21% of patients had a reduction in seizures compared to the control group. And when they did a bigger study, they found that that actually was an underestimation they actually with more patients, it was actually more like 38%. So now closer to 40% seizure reduction with first implantation compared to the control or sham. Um and then looking at these patients over a year or two years, you saw that number increased over time. So the results, the positive benefit from the RNS was summited over time where more and more and more of these abnormal networks are being recruited um and being um controlled with neuromodulation rather than and a blade of or a destructive technique. Um And despite the fact that there's all this activity going on, all the stimulation happening. Um there were no reported adverse effects either on neuropsychological testing or or the patient's moves so well tolerated. Um So just to give you some background, how how do we even determine how to plant these? We have to have to determine where the seizures are coming from. And in this case, in one of our pediatric patients, this is someone who's seizure focus um outlined in red Was completely co localizing with her speech cortex. And that's this is the left frontal lobe per column. So this is where brokers, there would be. This is not an area where I have the option of actually respecting tissue and this this 15, 20 years ago would be a patient who would unfortunately had to close after doing an extensive mapping like this and and and say and apologize that there isn't really a surgical procedure that we can offer. So now fast forward to now where we have this information where, yes, this this tissue is eloquent. It's not respectable. Rather than removing it, We now have the option of removing this series of electrodes and in its place, leaving behind the R. N. S. Or neuro pace electrodes over the seizure focus, um and then closing up um the dura plugging in these two cables to the EuroPass device. And now this is waiting and watching for seizures. And when those seizures occur, it will interrupt those seizures with a pulse. It's not it's not typically something that the the patients can consents or or be aware of occasionally for the highest settings they can feel like a little twinge, but that's very, very rare. It's actually very well tolerated tolerated device. Um So we were the first to publish our experience with our with impedes in pediatrics. This is the first pediatric RNS implantation and this is showing uh an example of a patient who both had a strip and a depth. So there was a lesion deep to her warning keys area. Um and then overlying her because we had a place of strip and then this is just examples of her having some seizure activity, a stimulus happening and then interrupting that seizure activity. Um Since then, there have been some groups that have published their experience with RNS Is this is a group out of Children's national five patients no complications. And and and they reported 64% reduction in seizures. Another group uh reported similar numbers where uh six Children total Um well Taiwan removed for an infection to patients were greater than 75% reduction in seizures. Two or 50 to 75 1 25 to 50. And then the biggest so far I'm serious today came out of new york 27 patients, three infections. Um Only one of the patients were angle once. This is your free um seven angle to 13 angle three. Um And just you know, comparing it to our experience. Our our six patients so far have been pretty evenly distributed across um angle classifications and no no complications so well tolerated. But you know, this is a steep learning curve and and and we're still trying to figure out what are what are the best parameters and who are the best patients. And um it's but it's very promising to uh to now have something as an alternative for those patients who unfortunately not candidates for the traditional respective surgeries. So again, we're moving away from those bigger a blade of respective procedures and and more towards these modular story um techniques. So I've mentioned um in the word ablation so far and and um I want to just spend a little bit more time talking about that. And again the goal would be to move away from the much bigger procedures where you're actually removing whole lobed or entire hemispheres. Um And um unsightly to just burning the tissue that is um that is seizing And I can't think of a more ideal candidate for a technique like this than someone who has a hypothalamic hematoma which you see here um in the center of this child's brain. And um the way I would treat these in 2008 is vastly different than now when we did not have laser ablation is a technique. The only way to get to this lesion would be with an open craniotomy. Either a sub temporal or in some places trans cortical approach. Um There are other places that actually would float endoscopes down to the ventricle but it's very confining and you can't see all the the angles that you want. And if you have any bleeding it's a very tight corridor. It's even a tight corridor with an open craniotomy. And one of my earliest hammer toma patients who I performed a craniotomy on, she did well. Um And the radiographic result was beautiful. It was exactly everything I wanted came right across the attachment of the hammer toma removed the hematoma completely. She did well for about six months and then her procedures rickard. And so she was she was effectively where she was initially despite having had a very big procedure and a scar and extended hospital stay and you know it really made me think that we just have to do better than this. And and even with an ideal craniotomy and even a case that goes exactly where I want in the operating room and we're still left with the same seizures. Then then I don't know that we were doing our patients justice. So I was very happy to to to welcome in this new approach um where instead of a craniotomy, we we we try to be a little bit um uh more more sophisticated than that. So um what it is is you have to have a target that's well defined and discreet. You need to have borders. You need to know exactly what you're bleeding because the ablation field for these little wires that we're implanting is limited. So you need to have also a limited target. What you do is you place an MRI compatible frame on the patient. You do targeting, create a trajectory. Um Use the coordinates on the frame that you've placed to get you to where you need to be. Um Use a little twist your whole so no big craniotomy anymore. Just a small hole in the skull um and you uh use an anchor bolt to slide a laser into place. You then transport the patient to the MRI suite and under direct maar visualization. Using thermal imaging, you can oblate these lesions in real time and actually monitor your progress and then afterwards you you do a post resection or post ablation scan with gadolinium um and make sure there's no vascular injury, make sure there's no ischemia but also get a sense of what tissue is a bladed and then you remove the head frame. This is how this procedure in this technique is performed in most centers. This is not how we do it here at UCSF. I'll show you, I'll show you a bit more, but this is this is how laser ablation is done across the country right now. This is an example of the anchor bolt that I was mentioning. And um for example, this patient didn't even need a head shave. Uh This is the where the twist drill hole was so vastly different than the patients so far who would have gotten a traditional craniotomy and cranial scar for an open reception of ham Artemus. Already vastly different. Um We published our experience with our hammer tone is using a little bit of a different technique where there there isn't a full on head frame and that's not all this movement of patients with frames back and forth from operating room to M. R. I. Scanner and back and forth. Um The problem with that technique is that you don't know where your laser has arrived until you're in that scanner. And if it's not where you wanted it to be, you have to take the patient out of the scan and bring them back to the operating room, take out your wire and start all over again. And um and so uh I I felt very uncomfortable with that that workflow. And so it's very great to be um a staff member at UCSF. And you have all of this expertise literally down the hallway. And so a good friend and partner of mine dr Phil star as a movement disorder specialists here in our department of surgery and he and his team actually developed their own technique to deliver electrodes into deep nuclei of the brain from movement disorders like parkinsonism and so on. And it's called the smart frame. We use a software program called Clear Point to use our court to generate our coordinates. But this is a completely MRI compatible device that doesn't require an actual mounting or frame on patient. It actually pins to the scalper, cutaneous lee and um find screws get implanted into the skull but it's all MRI compatible. And these colored dials are coordinate adjusters. And um in the MRI scanner you can adjust your trajectory on the fly and so as your first planning your trajectory to get it exactly where you were. If there's something about the patient's anatomy or their tissue is is deviating your electrode or in this case the laser fiber in the in a plane or a trajectory. You don't like on the fly millimeter by millimeter. You can adjust your X, Y and Z coordinates um to deliver these these ablation fibers to their destination. And and we don't require sub millimeter accuracy for our laser ablation techniques. But dr Starr and his movement disorder team certainly does need sub millimeter accuracy for their their deep brain stimulator placements. And so I I thought this was a perfect application for it in our kids because lack of frame, everything is done in the scanner and they wake up with just these little pinholes in their scout. Um so this is how we uh we approach laser ablation techniques, especially hematomas uh in the hypothalamus for kids using the smart frame. So this is just some imaging from the scanner, what you would see at the time of the laser ablation. We have marched this laser applicator down millimeter by millimeter and checked our trajectory and made sure we were happy on the fly and if necessary. Made are appropriate adjustments with the goal of delivering the end of this laser applicator into the heart of this hammer toma. Um and so this is across all of you and the sergeant and you can see it in multiple planes. Next thing is this is an MRI scanner with thermography capability. So as we turn on our laser, we're actually measuring the temperature within the hammer toma itself within the periphery of the hammer toma ablation field. And then of course equally important, if not more important, the temperature of the tissue surrounding the hammer to me because what is this hammer tone attached to. But the hypothalamus which is a very delicate structure and we certainly don't want to have any injury occur. So before we actually oblate, we can actually assign thermal safeguards all around our ablation field. Such that if these thermal safeguards are triggered, any one of these are triggered above a certain temperature, the laser immediately cuts off. Um And so we could not even if we wanted to deliver any heat or ablation or damage to the surrounding anatomy really, it's just to where we want it to be. And then the company that generates these fibers also has its own proprietary software that in real time is providing an estimate of your ablation field. So in orange, it will tell you what we think. We've we've successfully a bladed given the temperatures and the length of obligation. So this is going to be rapidly sped up film footage from our MRI scanner on the left column here is the temperature slowly climbing um uh to achieve ablation and then this is the orange slowly accumulating over time showing you an estimate of just how much tissue you've a bladed. Um And uh you're able to eliminate these hematomas in part because the laser tends to respect density planes. Hammer thomas tend to be very different density than the surrounding anatomy, especially the hypothalamus. And uh it's pretty impressive how the ablation field will expand, Reach a boundary between hammer tone and hypothalamus and often just stop there. But the ablation will be continuing to oblate the denser tissue deep d to it. But even if that wasn't the case, we had our, we will have our thermal safeguards up above to make sure that hypothalamus is continuing to be happy and healthy. Um But this is the kind of footage that we're looking for um while we're plating. Um So the group that has clearly taken the lead on using the laser for pretty much everything is is the texas Children's group. Um And uh they published their by far the largest series on hypothalamic ham martoma is both adults and kids. Um And uh they had very good results, very rare complications. One amnesia. One um worsening of pre existing diabetes precipitous most of the time when patients present with hypothalamic hematoma, it's with these funny seizures called elastic seizures. And um I know the textbooks say that it's laughing spells. They giggle. They laugh, but it could be a little titter our little it'll kind of tick. Um Not necessarily the textbook laugh. Um And you know, for a lot of these kids who are in school, it's just misdiagnosed as bad behavior. And uh And so these plastics can be, you know, can take a while to diagnose. And so they're often very troublesome. But they are also frequently the presenting symptoms. So very good uh success rates and resolving the elastic seizures um depending on the size of the the hematoma or the morphology of the shape of it. It might require more than one ablation? So in their case a series a quarter of them required more than one. And then in our case series um not not quite as large as they have experienced but um similarly very well tolerated. One patient had some persistent D. I. Um but otherwise complete resolution of all the kids who had released elastic seizures. And um and our our re ablation rate is a bit a little bit lower and it remains to be seen as we get more and more numbers. Is that have anything to do with the fact that we are able to adjust our our trajectory and our our delivery of the fiber on the fly with our smart frame. I think time will tell. Okay so um moving on. Um something yet another technique um uh trick and tool in the O. R. That didn't really exist in in large quantities. When I when I started my my practice was was stereo E. G. A much more refined way to listen to the brain. Um Using very fine electrodes as opposed to large craniotomy. I've already shown you some images of of what those that can look like. Um when we had a patient where seizure localization was a problem. And that that really is the whole name of the game for pediatric epilepsy or epilepsy surgery in general is is to answer the question of where um where are these seizures starting? Not not spreading, know how not how much tissue is involved. But what is the first domino that falls? Where is that first domino? And sometimes we we have a hard time even determining based on traditional techniques of the E. G. Which side left to right is seizing first. Especially for patients who have midline. Apparently midline seizure focus. Sometimes those that seizure activities travel so fast that it's very difficult to distinguish left versus the right on set. And so when I started, my friend, we were still using a technique like this where we would make multiple burr holes in the skull and slide strip electrodes and fan them out from the burr hole and kind of just like being in a fishing boat and casting a giant net and hoping that we catch a bite. But it's not specific. And there's no way I would be able to design a surgery off of the information we have for this, but it's really just to determine left versus right. Um And um we had other techniques as well to cast large and that's maybe we know that this patient's seizures are coming from the left hemisphere. But sometimes determining which lobe is involved can be the challenge. And so they don't get the fishing expedition of burr holes and strips. They get a bigger procedure like this where they had sheets of electrodes placed on the brain and for those little nooks and crannies that we can't visually see. But we can slide electrodes to, we will put strip electrodes. But even this is a little bit you know rudimentary and it doesn't take into consideration that you know, we are deploying these two dimensional electrodes onto a three dimensional structure. And you have to appreciate that that that epilepsy and seizure fosse uh is a three dimensional problem. And if a patient has a big big grid mapping procedure like this goes on to have a reception and it's still seizing. It could be that you're just underrepresented of three dimensionality of these networks and the seizure focuses. So this this has been the tried and true technique for decades. But um you know I think we are we are watching the field evolve. Um And we we are uh including a newer approach to this this three dimensional problem. So um this technique, stereo E. G. What it is is instead of that picture, I just showed you where it's a giant cranial incision and open craniotomy endure a wide open where on for example on monday the patients get a craniotomy and have all those electrodes implanted on friday. If we're lucky we got everything we need they can come out and we can respect um Sometimes their patients are left with these grids in place for two weeks three weeks. Um Instead of that approach what has become much more popular and is actually kind of supplanting the grid approach is stereo E. G. And what it is is very fine twist drill holes are made in the skull and depth electrodes are floated down. Um Using coordinate systems similar to how the laser ablation fibers are delivered. Um Because it's just little nicks in the scalp and twist your holes as you might imagine. Um It's a much less painful experience and as a result the patients bounced back much quicker um from a listening uh period with stereo eEG versus a grid. You need to have a very clear idea however, of where your seizures are coming from. So localizing where the onset of the seizures is that everything is based on a very sound hypothesis. So all the time you spend in pre op planning is time well spent. But the beauty of this technique in a way that the grids were never gonna match is that we now have access to much deeper structures. And we are really respecting this three dimensional object in the way it should have been respected all along. Um And so three dimensional electro physiologic monitoring is now much more robust as opposed to the two dimensional and you can be misled in terms of the trajectory of these these um These these seizure waves, it also makes it much much easier to study multiple lobes and even both lobes simultaneously. We would be very reticent to do a bilateral open craniotomy. In fact we never would do something like that. But sometimes you have bilateral questions and this allows you in a much more refined way to to answer a lot of those bilateral questions and multilayered questions with these little fine twist rolls. Um You can place them either with the frame I described before or in our institution. We use a frame a frame less um technique to float these down. Very good risk profile. Um low infection globally. Great. Um It's it's completely directly related to how much time you spend. However, planning every single trajectory. Using every possible technique to study the three dimensional anatomy which includes the vasculature. And I'm gonna show you some some ways that we at UCSF are kind of pushing the envelope a little bit on how we explore the three dimensionality of that of that anatomy. Um So uh this is a mock up of um when we first started doing steroids E. G. How we would plan these surgeries. This is a patient who had a paranormal infarct, so here's an area of tensorflow militia. Um So as you might imagine, his E. E. G. Made all of this paralegal um uh tissue involved or suspicious for a seizure onset. But it was really hard to distinguish the parietal versus occipital scalp eeg recordings and even once in a while would have an occasional frontal um spike. So our plan was to deploy electrodes to all these areas. Um So this is a two dimensional slice and you can already see the challenge here. This this is one slice of the patient's brain but clearly all of these electrodes aren't in this one slice, you're seeing them all interlaced together. That gives no idea of depth and and three dimensionality. Um We we did make some progress with creating three dimensional objects to give that depth to it. And also even have the ability to label things like cortical spinal tract an optic radiations. And so it gives us a chance to kind of thread the needle among you know, all this different eloquent cortex and anatomy so that we're not skewering anything important. Um And and includes that discussion is vasculature. So this is how we would initially planned these procedures and and to plan and try to chart a safe course to all this anatomy. This is in the operating room. And so for each of those trajectories that you just saw, we're using a effectively a GPS um uh frameless steri attacked navigate neuro navigation system where the wand is moved along the patient's scalp. And you can see a green line that's the wand moving in all planes. Um And then I would mark first mark where all the entry points are. And then I use a special arm, frameless arm to line up to the east trajectory twist real whole um float the anchor bolt down. Uh and then place the electrode and just do that sequentially. And then this is what the finished product looks like. And again this is still very very different in appearance and um and workflow than the big question mark, craniotomy scar. Um Big craniotomy and all the discomfort that goes along with it. Um So as a segue um into uh advanced imaging uh you know this stereo E. G. Case is a good example of you know how we could make this the planning better. Um But I want to tell you a little story about how we arrived at this. Um This is I was just given to me by a cashier at american eagle outfitters because I took my nieces christmas shopping a few years ago. And um the cashier said congratulations sir because you spent over $200 on jeans on your teenage nieces. Um You get this and she came with this box and it was a virtual reality headset. It's not really what it is is it's a it's a holder for your phone and you have to download an app and you put the phone in the headset and you can play, you know, play videos and log on to VR sites and do all these things that are just phone based. But you know, it dawned on me that we have all this technology floating around, you know, clearly in the gaming industry, VR gaming has taken off but it's it's hit retail. Um You know we have architects now planning building designs and people are shopping clothes and cars using virtual reality. And it dawned on me, it's like if it's an if it's an american eagle outfitters, store helping, helping um customers uh try on jeans. Why aren't we using this technology in the operating room where it really, really, really matters. Um and so that was so um thankfully that technology actually does exist. And we started working with a group to develop, further, develop this technology and adapted to our world, um to to the surgical world and to the pediatric world. So this is uh some footage. This is one of my residents um wearing Ar VR headset. And we had already made a plan in a three dimensional planning software module uh to get down to this patient's corpus callosum and we had some different options of how to do that. And so he's he's wearing this this headset because he is in this virtual space at the size of a mosquito. And he's using these hand controllers to fly around. So, um, days and weeks before surgery. Now, I have the ability to take any patients two dimensional images, create a three dimensional model and fly around the anatomy and rehearse and and try different approaches and and see what little pitfalls and little little surprises might be awaiting us. Um days or weeks in advance, so that I am not finding those things out On the operating table and not having to uh make adjustments on the fly. Um so it has been a really incredible tool and advantage to have this kind of technology now. Um to to really carefully plan out my my 30. So as it relates to this patient for example, this is how I would have planned before, where I am using two dimensional slices and in my mind's eye trying to figure out which slices the yellow in again and which is the green in. And even in this three D. Model, I can rotate this but it's not giving me a sense of depth and I can't really mimic what I would see under my operating loops or microscopic lenses or even under the microscope. I can't mimic those things. Um But let me show you some footage of what you would see if you're wearing the headsets on this patient. So play this footage here. This is now this patients had reconstructed and I can see all of my electrodes and where they enter. And I'm slowly going to peel away the anatomy that I don't really need to see. But I want to make sure I can see things like cortical spinal tract optic radiations and even a little blood vessels. That may be one of my electrodes is tagging because that trajectory is a little bit too close for comfort. It's definitely one. I got to go back and maybe adjust. But in the meantime, I can check all the other ones and make sure I'm threading the needle between and among all these beautiful blood vessels and make sure that cortical spinal tract is happy. Um, but it's just a totally different experience um, to be immersed in the anatomy in a three dimensional sense because I cannot think of a more three dimensional task than brain surgery. And it's time for us as a discipline to evolve from preparing ourselves for surgery, using being locked into a two dimensional platform. It's time that we we we move and migrate into something more more like this. So that was kind of, you know, just my thoughts on, on how I'm I'm using innovation and technology to make my job better and easier and safer. Um, and frankly more enjoyable. It's it's uh it's great to have this, this virtual experience, especially, you know, I grew up on Atari and Coleco vision and uh later on came Nintendo. But you know, I think that this, this, you know, it harkens back to the, to the kid in me and but you realize that who we care for are still kids and as sophisticated as we think we are with these headsets. Uh you know, we think when I, when I share this with the kids in the beginning, I thought I'm sharing my technology with these kids. Um what these kids have shown me since we started using it though is that this ain't my world, this is their world and they're and they're sharing it with us. Um, and uh once you put the headset on on them um it's a totally different interaction between doctor and patient. I can almost guarantee you that the same headsets that we're using um in clinic and planning for surgery are sitting on these kids coffee tables already. And they and and they they are frequently teaching me things about these headsets and handsets in ways that I wasn't fully aware of. Um this is their world, this is their language and what these kids are teaching me is that this is an incredible communication tool because when you're a pediatric sub specialists. Um The one thing that is the hardest sometimes the hardest thing to establish is a report with your with your patient um you sometimes just don't get that opportunity, especially when we come in with our white coats and we start looking at black and white images that make no sense left versus riding up and down. But you put these headsets on and you immerse them in this virtual fantasy world in a language that they speak by the way very well better than you. Um all of a sudden I'm not that scary guy with the white coat, I'm this cool guy who has this this gaming system in his in his office and um I love it when my my my parents come to my office and say, oh doctor Augusta, I'm so so thankful this this clinic appointment finally happened ever since we had our last visit. He can't stop telling me asking me, when are we going to go see dr Augusta again? Um that's just music to my ears to have a child want to go see his brain surgeon again. I mean what what Children want to see their brain surgeon? And this makes this, this happened. So this is the this is one of the epiphany moments. I uh this is our first my first patient who I actually trialed the VR system with. This is two days before her brain surgery and I wanted to show her brain tumor and that was causing her epilepsy. She had a deep seated tumor that was causing her to seize. And so I wanted to show her the reason while she was seizing. So this is her and her headset. So I'm flying her down into her brain and then in the middle of it she reaches up and she tries to grab her tumor and she starts to laugh and you don't, you can't see it cause they're off the field but her parents are behind her. Um and this was a really stressful thing for them. Um and here she was two days before her open cranial surgery and she's laughing and her parents all of a sudden start laughing and it was like this tremendous weight lifted and it changed everything. And um and I and that's when I realized that we uh we have an opportunity here to to really engage both families and most important kids about their own health and getting them involved in this conversation. Um and you realize that many times these kids are just sitting there quietly and we're talking over them like adults. This is, it's got to change. We have, we have to get these patients, these kids involved in their own health care, they got to know what's going on and be invested. Um so um this is uh this is that was a little girl girl, she was 11 at the time and you know, it then opened up a lot of questions, you know, I said, well, how young can we take this? You know, is this that was an 11 year old? I mean um is there any value in and pushing the age lower and lower? And this is this is the so far youngest patient he's for. Um and what I found is that, you know, I mean, a four year old is not going to get out of this experience with an 11 year old is going to get, but they still get something out of it and they're still having fun. Um and and getting engaged in and they get more than you think. Um and uh and we can get these headsets to stay, so we're just gonna keep trolley and you know, it's sort of self select which patients want to do in which which don't, but I've not had anything but positive feedback about the experience and that's a good thing to leave, leave a patient encounter like this with a positive feeling in a positive experience. So um next set of questions. Okay. So now we know it's they enjoy it. You know, next we know um you can use it on kids of all ages. Um The idea I had was if I can do this alone and plan for surgery and then I can put the headset on my kids and let them fly on their own. Is there any way we can link up these headsets? Um and fly together? Um And so this is some footage of what we do now regularly in our office is the shared VR experience where it's nice for me to take you on a tour on a screen or even putting the headset on you. But it's so much better when we all have our own headsets on um you're gonna see some footage where floating in in in virtual space. Are these these bodies basically they called avatars and above each avatar is the name of the, of the participants. So you have one for dad, you have one for mom, the patient has heard um we've upgraded since two more age specific and we even have ethnically and culturally appropriate avatars. Um but it's a very personalized experience. First of all, when you put the headset on and you look over and see your mom and dad and their names are above. Um, so this is just some footage of us. I'm flying. So I'll let you listen to the conversation. Mom and dad see me. We're going all the way inside jade's right. Tell me when you get there, I'm gonna turn up. Okay? All right. So, if you can actually fly past, hey dad, if you're gonna actually fly past me, um, and get yourselves on either side of me so that I'm not blocking you. But there's something I want to show you even more even more. I'm gonna go a little bit. Okay. And then dad, can you look over your right shoulder all the way behind you? You could keep going, keep going, keep going. Can you see this arrow that I'm pointing up all you guys? So I'm pointing the tumor, but on top of the tumor there's this blue thing like shaped like an S that's yet another blood vessel that's hiding on the other side of your tumor, meaning like it's actually hidden meaning. If I went through your tumor jade and I kept going. Going going eventually. I'm gonna hit this guy. That's my stop sign. So, there are things that I can explain in in a VR space that I just there's just no way to replicate in a two dimensional format. I mean, you all have, you know, probably tried to to navigate some families through cat scans or ultrasounds or extra. It's just it's it's gibberish to them. Um This is has has depth. It's it's vivid, it's colorful. It's again and for pedes it's a it's a fantasy world that they can relate to. And there is so much better at having that momentary suspension of disbelief and pretending that they're in the brain and it's an incredibly rich experience. So last question I had for these kids um is um it seems like they're getting, getting it. You know they get the technology not just that it seems like they're actually listening and learning in a way that maybe they weren't catching the details in the in the old way with the two D. So this is a patient of mine who I will I asked I asked myself the question and I want to answer how much is he getting? You know? So we did a VR tour and then I wanted a quiz. Um I want to see how much did you actually retain of the stuff that I was I was telling you and teaching you about your this patient had presented with a seizure but he actually had an underlying arteriovenous malformation. So I'm quizzing him on his um his A. B. M. So here here's the discussion point to your baby mm. There it is. And then can you point to that vessel that was feeding the alien. It goes right there. It is, how you got it. Let's let's let's pull that maybe I'm a little bit closer to us and I want you to kind of rock it left and right and take a good look at it, look at you so good. Thanks and look to your left a little bit. There you go. Now. It's going to send that what we see. Good job man, you're you're basically a brain surgeon. So he did phenomenally well I I didn't get actually get to all the questions that I'd ask him, but he nailed everything. And and so not only did he nail everything because he was the primary participant, what I wasn't expecting. I don't know if you could hear it in the background is what when I was quizzing him, his six year old brother and his mother, we're fighting over each other to answer the questions that I was asking the patient. Um So even though I was like laser focused on my patient and teaching my patient using virtual reality, um I wasn't even fully appreciating that there was all this learning and absorption going on using this format around the room who weren't even in the VR space. Um So so clearly above and beyond. Um what I was expecting and and and very likely a totally underutilized way um to engage with kids, teach families, communicate information and really have everybody understand what the problem is and how we're gonna fix it. Okay. So um I wanted to leave some time for for for questions. Um you know the take home really is that we're migrating, We're evolving um in a good way away from the kind of the barbaric. Just go in there and hack out tissue to being much more sophisticated and leaving that tissue in place if possible and just getting it to do what we want and and getting it to behave. And so neuromodulation is here to stay and it's only gonna get better. Um I hope you have a sense that we're better at what we do and we're able to achieve more with less. Um So we're using a lot more minimally invasive techniques such as steri G. And laser ablation to get the job done. Um And then I hope, I hope you can see that. Um It's time, it's time for innovation and technology to benefit our kids. And and we were using that in our space using virtual reality. I didn't have a chance to show you some of the footage but the next step and this is going to be not virtual reality but augmented reality, where these holograms are all nice and everything. And I like I like looking at them ahead of time, but it will be really helpful is while I'm operating under the microscope if that hologram is superimposed and locked in three dimensional space to what to the real anatomy. So even though I'm looking at the surface of the brain, it's almost like I have x ray vision and I can see the hologram in my heads up display that's augmented reality, it's superimposed on reality. So that's the next stage of the game. So it's totally helped how I plan for surgeries and super super powerful communication tool. But really, you know, as a pediatric specialist, it's fun, it's fun for me, but it's so fun for these kids um and and it's it's just it's so important to plant the seed in their brain that they need to be involved. You know, this is their this is their brain and and I want them to embrace what's going on and not be so scared of it and and this has been a great way to achieve that goal. So um that's it, that's all I wanted to share with you guys today and and uh I love to take some um some questions. I want to introduce you to the other members of my team here, all the surgeons who participate in in R. O. R. For different kinds of pathology and different kinds of neurosurgical problems.