Saadi Ghatan, MD, a neurosurgeon specializing in pediatric neurosurgery and epilepsy surgery, reviews Mount Sinai’s epilepsy program, highlighting the progress that has been made in diagnosing and surgically treating epilepsy since the program began almost a decade ago. Later, he discusses several clinical trials taking place at Mount Sinai to further study surgical treatment options for epilepsy.
Chapters (Click to go to chapter start) Review of the epilepsy population and the current evaluation protocol Milestones of Mount Sinai’s Epilepsy Surgery Program History of surgical treatment of epilepsy and how to improve Literature review of various studies and trials on responsive neurostimulation as an epilepsy treatment Studies on stereo EEG (SEEG) as an added component to epilepsy surgery Conclusion and Q&A/discussion before we get started everybody reminder to uh text this number here to let the cmI to get your cmi for this to our period. Um And today we have the privilege of hearing from Dr hold on a second. Sorry there we go. The livestream starts playing and so I can hear my myself speaking. Um I have to stop that. But today we have the pleasure of hearing from Dr Cotton. Um He has said Chair of neurosurgery at Mount Sinai West and Mount Sinai Morningside, professor of neurosurgery pediatrics. Um Director of pediatric neurosurgery here and today is gonna be talking to us about epilepsy surgery and updates on clinical trials. Sorry. Before you begin I just want to say that I have already heard reverberations from around the country on what somebody has done and some of the things he's presenting, he recently presented this in Chicago and or something similar and the feedback is that it's a really highly engaging and um advanced sort of work. So his his work and this work that we're going to hear about now is already why they recognized nationally. Thank you JB. Can everybody hear me? Okay. Yes. Uh and now I'm gonna share my so called presentation here, hold on 1/2. Um you know in that I got to redo that introductory slide chris because there's something in there that I don't like where it says that we do palliative surgery in the form of neuromodulation and callous sodomy and it's it's a measure of how things rapidly things have changed. We don't recognize a lot of the things that we thought of as palliative in a prior era as palliative anymore. In fact it's quite effective treatments which I'll talk about today. But thanks for the opportunity to be able to present. Can everybody see my presentation slide? So the goal today is to give an update in a short period of time about the explosive work that the epilepsy team has done in the health system since really its foundation. Just seven short years ago. I always start with my disclosures and credits where credits due and the disclosures are that I'm an unpaid consultant to neuro pace and I get a small fee for reviewing the complications that are presented in the lantern trial that our very own costumes, hydrogen eases the P. I. For it at Mount Sinai health system. Uh the credit really is is where, what it's all about in this presentation and Jamie, thank you for the kind words about the feedback from the rest of the country. But I'll tell you that none of this is remotely possible without the team effort that leadership in M. S. H. S. Has put together to co localize us with our epileptic ologists and break down the silos that have prevented the kind of collaborative care that we've been able to deliver in the past seven years, which has then led to our collaboration with the FBI and the the Center for Advanced Circuit therapeutics and are neuroscientists. I would say that the most important credit on this slide, however, goes to the patients and their advocates who suffer immeasurably from this condition of medically refractory epilepsy that we, as surgeons see. The amount of courage and the amount of trust that it takes to come and see us in the first place is tremendous but always has to be compared to the amount of endurance and resilience that these people face in their daily lives, living with this condition that has no ability to be predicted and in many cases tremendous difficulty to be controlled. And it's all over the place. You know, just this past weekend, I received an email from one of the periodic nurses at West alerting me to this tragedy. But it tells a sad tale that so many patients with epilepsy must live with this risk of death that is omnipresent with this disease, albeit a small risk. But nonetheless, the tragedy that exists in this very article that just appeared in the post and on the local news about a child who is suffering from epilepsy that's being controlled with medication even is at risk for dying suddenly on a little League field, it doesn't bear thinking about. And despite all of the efforts that the epilepsy community has made to present. Not one but two randomized controlled trials that show the efficacy of epilepsy surgery. We still remain after, Let's call it 50 years of modern epilepsy surgery in a dramatic picture of underserved patients who cannot get appropriate care for their epilepsy. If we take the number of patients who have refractory epilepsy at a million and we see that the number that are referred to our epilepsy centers is about 1/5 of that amount. It's still a possibility who are undergoing epilepsy surgery to be able to help them in a meaningful way, in a scientifically proven way. Now some of it may be the arduous process of getting to the actual point of the therapeutic intervention and you look at this flow chart that's presented by the pediatric neurosurgery community. Dr Jack R. And Miami wrote this in a consensus statement. It's a daunting task to get through this amount of work up to ensure that we're doing the right thing and we're doing it safely. I would say that some of the items on this flow chart are somewhat optional. But at the forefront is our reliance on volumetric imaging an M. R. I. Video eeg. That is able to capture an event and it's important for all of us to remember that even if a patient who is suffering from seizures goes and get gets an E E. G. That says it's read as normal, it doesn't mean that they still don't have epilepsy. They do, but you just didn't capture the event. So it's imperative that those two tests are undertaken and that they are comprehensively done as really a first measure of getting to a discussion of epilepsy surgery and then we're also very reliant on our colleagues in neuropsychology to ensure both preoperative and postoperative assessments of neuropsychological function and a holistic view is taken to the patient so that it's not just a technical exercise of exercising a part of the brain that's causing seizures. Of course we have a great group of epileptic ologists who are like minded with our surgeons and like minded with our radiologists and our pathologists and are psychologists. So we have no trouble getting to an epilepsy conference where we're thinking the same way, albeit with differences of opinion based upon our backgrounds and our experience which makes for a fruitful discussion which I encourage everybody on this call. Two undertake, we do this every Wednesday at four PM and it generally lasts about an hour to an hour and a half and it provides a real good foundation for how a patient gets from suffering from medically refractory epilepsy most of the time. And even sometimes epilepsy that can be controlled with medication and then gets to the point where they are a candidate for epilepsy surgery and we move forward with that process. Mhm. Now we've talked about milestones in our health system in epilepsy surgery before and I want to highlight what ted has presented to us many times and without his collaboration and without his expertise in stereotype axis and his expertise as a thoughtful, careful, mindful neurosurgeon. None of these would have been possible. We did our first stereo E. G implant in 2016 in a way that was somewhat unorthodox with the use of the vertex biopsy arm and stealth navigation which provided us pretty good accuracy down to about 1-2 mm. But in epilepsy surgery where you're trying to make things better and you really cannot afford to make things worse from the patient. That's not good enough. We have to do better and so leadership and the health system saw to it that we had robotics that we were equipped with both sites Mount Sinai hospital, Mount Sinai West. And we did our first robotic stereo E. G implant which transformed and has transformed epilepsy surgery across the country In 2016. Fast forward 2019. TED uses his expertise in clear point and gives us a directional thalamic lead for modulation with deep brain stimulation which we have employed in a young person and has helped her dramatically. We have now implanted about 2000 leads with a very very safe profile. You know, we reflect the same number that the literature shows at about 0.03% risk of bleeding and the number of symptomatic bleeds. And those 2000 electrodes I can tell you is miniscule. Yeah We did our first Calvin our depth electrode for responsive neuro stimulation which we're going to hear more about in terms of how we approach epilepsy which is not palliative but it's actually quite effective. And then just yesterday we did our 131st responsive neuro stimulator implant. And in particular, that was in a young child with autism, which reflects another, I would say a paradigm shift in how epilepsy is being treated across the country and across the world. And these pictures show all that we have at our disposal in this system, the ability to treat Children and adults, the ability to use very expensive technology, particularly the I. M. R. I suite that you see in the, on the right side and the middle panel. And then the best thing of all is this wonderful collaboration with our epileptic ologists. There's laura mark, use jake young Natalie sheet, maddie fields Jenna, you might tell a vega Heidi Bender has departed are shore's been replaced uh more than adequately in the form of Sloan Sheldon and Adam Saad. We're delighted to have them with us. Now, We should all know that in 2001 in Canada, a randomized controlled trial was done. That showed that surgical therapy for temporal lobe epilepsy was superior to medical management alone, randomized and controlled. And they had equipoise in that trial. And it showed definitively in 2001, years ago that temporal lobe epilepsy was better controlled with surgery. And this can be achieved by really just standard methods, the temporal craniotomy, even in the dominant hemisphere does not put language at risk and it does not put memory at such a significant risk that the benefit of seizure freedom would outweigh the cost of that memory problem. And it provides lasting seizure freedom and it's not that difficult to do. But what about those cases that are not so straightforward that are not localized to the temporal lobe? And if you look at the trends across the country and across the world, the number of patients who are being referred for temporal lobe ectomy is temporal lobe epilepsy has declined in fact since that randomized trial from Canada and a second randomized trial from U. C. L. A. And Pete angles group. So why is that? Are people no longer getting temporal lobe epilepsy? No I don't think that's the case. I think that the number of patients who had T. L. E. That were needing therapy got treated but Well has sort of dried up in that world. What has made an advance is the world of pediatric epilepsy surgery where a randomized controlled trial done in 2018 from New Delhi showed similar findings. Epilepsy surgery is superior to medical therapy even for multifocal cases and extra temporal cases that our Children get and these cases in this series are not even ones where intracranial monitoring was performed. So there's no doubt about it. We have superiority with surgical therapy over medical therapy. In fact this is the theme of this year's trip to Mongolia which is upcoming in two weeks where we're headed to do at least eight epilepsy operations. And that study from New Delhi really just shows what the trend has been worldwide. Which is a recognition that where the greatest burden for medically refractory seizures exists. We have a great opportunity to solve this problem. You've heard Ernest speak about this, you've heard others speak about this from developing countries and indeed when I was in Mongolia three years ago I saw a number of patients with medically refractory seizures, temporal lobe epilepsy who weren't being treated. Now it's not because the guy on the left here, dr Abi doesn't have the technical ability to do it. He certainly does. This is a very impressive neurosurgeon. But highlighting what we have is a collaborative effort with neurologist, neuropsychologist, neuro radiologist, neuropathologist that does not yet exist in the developing world. And this is what our aim is to go. They're teaming with neurologists, neurosurgeons and neuropsychologist to give them the holistic expertise to be able to take care of these patients safely. So what can we do to make it better? How can we increase this 1% utilization Pete Engel from U. C. L. A. Suggests that we stop asking the referring neurologists to refer the patients and simply highlight to the patients the benefit of coming to a comprehensive epilepsy center. We, as surgeons are certainly responsible for being able to get a patient in the door and get them well treated. We have to recognize that there is a necessity for surgical therapy. When you failed two medications and adequate doses, we have to makes certain that the patient understands that there's a comprehensive team approach that's taken. We have to demystify neurosurgical intervention which Ted has done a great job of talking about in his prior talks. We have to make sure as part of that demystification process to provide patients with peers who have been through this and who can recognize that it's not just an enthusiastic neurosurgeon sitting behind a desk who wants me to do this. It is somebody who's suffering or has suffered just like I am suffering, who advocates for it now a nurse navigator. We have shown and proven both when we've had one and when we haven't had one, how important they are in getting our patients through the process and towards surgery, we have to be transparent with family and patient about our expectations and then finally, as you'll see in the coming slides, we have to advance the science of epilepsy because we know so little still. Speaking of knowing so little here was the hail Mary case and the reason I say hail marty is because we appealed to marty morel of neuro pace in 2015 for this desperate family and desperate child suffering from Lennox gasto epilepsy, a progressive epileptic encephalopathy, which simply means that if you don't solve this epilepsy issue, this young person will continue to deteriorate from a cognitive perspective and a motor perspective. And when you see this in Children, it is the imperative is all the greater to solve the problem. And yet despite a frontal lobe ectomy done at another center, a callous sodomy done at another center by me a contra lateral temporal lobe. Ectomy performed all of these respective strategies. Didn't do a thing to stop this. Sweet guys epilepsy between 2005 In 2015. So true to the imperative that my colleague matty fields gave me, we had to think outside the box and we thought why not try neural pace? And we put leads on his really remaining neocortex in the left frontal lobe and the right temporal lobe. And we put not knowing what we were doing leads in his anterior nucleus of the thalamus bilaterally. And we gave it a shot and it turned out that in the first six months after this implant, this kid did better than he had done with all those respective strategies combined. So neuromodulation Torrey approach really was the way to go. And it's always appealed to me as a father and it's appealed to me as a surgeon that if I can do something modular Torrey rather than destructive. I'll take it both for a child and an adult. Now we were the first to publish an experience using responsive neuro stimulation and Children. And that young man that I presented was one of the two cases and another was a patient who had a seizure epileptic epileptic zone in her dominant romantic area and in her speech area and she's gone on to have great success with responsive neuro stimulation. While ted ted followed this up with a presentation of our pediatric experience in general, which showed that we had great results with a minimum of infections and significant improvement in seizure control. That actually got better with time. Now. We also had to recognize our limitations. And as I've emphasized time and again, we don't necessarily get the easy cases. We get cases of Lennox gasto where it's a progressive and changing field of epilepsy. Within the same patient, we get patients with comorbidities that dramatically make their epilepsy disorder worse, such as autism. And the aim of this study, where we looked back at our experience of patients with autism was to say that they are just as eligible candidates for epilepsy surgery as a patient who doesn't have autism and in fact they'll can benefit significantly if you can solve the epilepsy problem. And in fact, the majority of them do do very well. But the ones who don't do well are the ones who are non lesion allele, the ones who you may think you have localized their epilepsy to the frontal lobe. But in fact down the line that may shift to a different part of their brain and you'll end up with an abject failure. So we had to think outside the box, we approached now, starting in about 2015, that patients who had autism and Lennox gasto or other epilepsy is that we could approach them with the neuromodulation Torrey approach. We were starting to do stereo E. G. S in those patients to prove that they had multifocal on sets for their seizures and then target the thalamus, a network regulator basically. And in this case the central media nucleus which had a foundation historically from a group in Mexico city from the nineties and has been a target for deep brain stimulation. We had significant success and shoutout to Alex cooper who contributed significantly to this paper that we published during the pandemic about the success of treating this type of refractory epilepsy with the Islamic stimulation. Ted has shown us that we can target the central median nucleus both with robotic navigation and with clear point navigation. With submillimeter trick accuracy and a minimum of side effects that really can be controlled by how the settings are applied with R. N. S. Sometimes there are Descents. These is that people experience when this nucleus and the thalamus is stimulated but that can be overcome in our series. We really have not had that problem. And this has led to our inclusion in a multi center trial that is looking at the application of bilateral responsive neuro stimulators to treat refractory Lennox gasto epilepsy, there is some neuroscience behind this. It's not just that we're following the historical targeting of the central media nucleus, but there is a pretty well established link between the central median nucleus and the frontal cortex. And so along with five other centers in the country, we have been given a grant from NIH and neuro pace to study The treatment of kids and adults 12 and up who have refractory Lennox gasto epilepsy with bilateral responsive neuro stimulators, bilateral central median filament nuclear targets and bilateral medial frontal electrodes as well. We have also, because of our nation leading work with kids where we have probably a tenfold number of kids that have been treated over anybody else been asked to participate in this trial called response. Now we must bear in mind that the trial for the use of R. N. S. In adults took place late in the first decade and through The early part of the second decade of the 2000s but Children eight under 18 do not have FDA approval for this. And we've been using it off label with significant success and significant safe. The FDA insisted that a separate trial be conducted for adolescents and again, a holistic approach is being taken. We can safely say that in adults there's no deterioration in mood. There's certainly no deterioration and in fact an improvement in quality of life when responsive neuro stimulation is being used and it simply makes good sense for kids whose brains are more plastic and amenable to this sort of responsive training. They're going to study these kids for two years. Our aim is to enroll three in the first three months and get another three to participate with the 20 other centers who are doing this. And I'm optimistic that we can continue to lead the country in how pediatric epilepsy is treated from this sort of a neuro modulator torrey approach. I will say we've gone much further than even what this response trial is asking for in that we're treating The network rather than the one or 2 photos I that the FDA is calling for. So I suppose it all depends on how you're going to define the focus of where the epilepsy is. If you say that the focus is on the left central media nucleus of the thalamus, you can place your electrode there with good success as we've shown. But overall the kids who need to be selected for this are ones who have failed prior respective epilepsy surgery, where we're treating an epileptic genic zone in a dominant language area or a sensory motor area where we want to preserve function. There's another group of patients who are suffering immeasurably from their epilepsy and these are relatively high functioning young adults who suffer from idiopathic generalized epilepsy. As the name implies, we don't know what's causing it. As the name implies, it's coming from everywhere, seemingly in the brain and the FDA rapidly enlisted neuro paste to study bilateral central median thalamic targets, which we have been doing in The scores for now four years and This will include patients who are 12 and older as well. I don't think we should have any trouble fulfilling our quota here since we do see a lot of these patients and and are epileptic. Ologists have a number that are still suffering despite maximal medical therapy. Now when I talk about R. N. S, I go back to the fact that the majority of the time we're trying to treat new cortical epilepsy, we're trying to treat areas where either a resection won't work or resection hasn't worked. And we're going back to try to fix it with neuromodulation. Torrey approaches. Our group has really done the vast majority of the thalamic targeting with RNS. Previously this was the domain of deep brain stimulation but are epileptic. Ologists have shown that you can pick up signals that allow you to program with a responsive nature from the from the central media nucleus of the thalamus. We've also done it in the anterior nucleus of the thalamus and as ted has done recently, the pulver in our nucleus of the thalamus, all depending upon what the circuit is that you're trying to treat. Cm. Central median is generally used for frontal and temporal targets. A. N. T. Enter nucleus of the thalamus generally for limbic targets. And paul van are generally for post here quadrant. I will say we know so little yet about the atlantic targeting and its utility has been proven. But the neuroscience behind it is just so limited as to how it really works. Our outcomes I'm proud to say have been quite good. And in line with what the other centers are doing if not better. We are not just palliative in the epilepsy with responsive neuro stimulation. We have a group of super responders that we're still trying to figure out why they're super responders and also figure out why we can't get some of our under responders to perform better. We have followed a general trend in the United States in RNS where we are getting to a faster therapeutic uh effect with R. N. S. And that's one of the arguments why some people still don't really see it as a good solution for Children. It's an imperative to get the seizures under control quickly and a child. And we know that a temporal lobe ectomy will do that sometimes overnight. But we also know that years down the line there's a fall off in success. And yet our trend in success keeps getting better and better. Year by year with responsive neuro stimulation suggesting plasticity benefit to our ongoing brain training. Again, this shows that the longer we're treating the better the results and our fill Amick outcomes are also looking very positive and also looking good with time. Now that's the treatment side which I think is of critical importance because that's really what the patients and their families are desperate for when they come to us. But a byproduct of this trend toward minimal invasion. That has been the buzzword of the second decade of the two thousands and into the third has been in the way we're doing this neuro monitoring. To give us the ideas for how to treat the epilepsy. We've certainly come a long way since the early years in the fifties and sixties of doing stereo E. G. As it was done in europe. We've used it to great effect in our understanding of epileptic networks. We don't just use it and in a derogatory manner for a fishing expedition to try to find out where seizures come from. And by doing this we have enhanced our scientific understanding of epilepsy. You have seen me present these egregious looking slides of hemispheric exposures and the placement of subdural grids strip electrodes to try to simulate a brain sock for the cortex. But this ignores the fact that the cortex goes deep and that there are insular areas that were not monitoring with these techniques. And there are deep sulk all areas that were not monitoring with these techniques and we're not really getting solid information from the amygdala and hippocampus. When we slide electrodes under the brain. And sure we've used depth electrodes in tubers before in tuberous sclerosis in kids to see where the active lesion is. But these methods are invasive and they certainly don't lend themselves to patients being able to help us understand their epilepsy in a neuro scientific manner while they're undergoing invasive monitoring in the hospital. So robotic stereo E. G. Changed all that were able to achieve less painful, less invasive ways of getting deeper structures in both hemispheres investigated in a more comprehensive manner. Both temporally and spatially. I will tell you that that picture that you see on the left is really frowned upon in many epilepsy centers. Uh not only here but in europe because they say you're just fishing for a seizure focus. In fact we're not doing that. We're trying to understand the network better so that we can apply the sorts of neuromodulation torrey strategies we can in a usually thalamic target. And what we're aiming for now is placement of stereo eeg electrodes in the thalamus itself which we've done in a few cases and other centers particularly stanford and um Sameer Shetty text doing this with pretty good regularity and again safety it allows us to test our hypothesis that the thalamus will be a useful therapeutic target while a patient is in the hospital undergoing monitoring. Now it's opened the door to significant scientific exploration um both by our clinician scientists and are neuroscientists and I wanted to highlight a few of the recent papers that have come out of the group. Biblical metrics of this group has really skyrocketed in the last six and 7 years. We are certainly delighted to have Natalie GGT here a world leader in the epidemiology and big data studies of epilepsy. But we also must recognize the outstanding work that our epileptic ologists laura, mark Hughes maddie fields, jenny, you anu Singh. We have blank Jae kyung. The list goes on and on. Have done by applying all of the data that we have gained and gathered from our stereo eeg monitoring and put it together to advance our understanding of epilepsy on the basic levels. For example, in this study where we know that we're missing something with our scalp eeg electrodes, the team has figured out that there is a significant number of seizures that are not seen on surface electrodes that are detected on with depth electrodes. And this has huge implications for how we approach Children and adults. If you think about this problem of epileptic encephalopathy and seizures that are going undetected on E. G. That are contributing to a decline in a child's development or a child's function. It makes a case for being able to establish a better and more sensitive detection system for how seizures are recognized and then how they're treated. We can also apply ai in the broadest sense to all of this data that has been collected and here's a second paper that the group put together that shows that you can use artificial intelligence to detect and predict seizures with significant accuracy based both upon scalp and depth electrode recordings. And then we can ask our colleagues from the FBI and the center for advanced circuit therapeutics to also get involved with our work and kudos to the health system for having recruited the wonderful, Ignacio says to our shore's, he's joined us at Mount Sinai West clinical neurophysiologist who is able to harness the stereo E. G. Studies that we're doing to treat clinical epilepsy to advance the science of human cognition and to be able to understand how epilepsy is affecting this. Now, I'll tell you that uh this is of great benefit to us in the E. M. U. He and his team are able to capitalize on the fact that the patients are able to cooperate with him with stereo eEG studies. And he is utilizing this treasure trove of data over recordings that are made in the course of 6 to 8 days in R. E. M. U. To better understand how cognitive tasks are being undertaken and the impact of epilepsy on those tasks. He's using methods that really are amenable to the patients who are in R. E. M. U. And who can tolerate these tasks and in fact it engages them in a way that they would otherwise not be engaged in sitting there ah in bed waiting for seizures to happen and this I am certain in conjunction with all the data that's already been recorded. The data that's being recorded in a prospective manner by Ignacio and his team as their assessing will answer important questions about how neural stimulation and neuromodulation can better treat neuro pathological processes. Alison Waters as another example is an outstanding neuroscientists on our floor over at west in the center for advanced circuit therapeutics as it's known. And she is collaborating with Ted and Jake Ignacio and the rest of the team from Helen's lab to better understand in receptive processes. And as I had illustrated before with surface electrodes or even electrodes that are placed in the subdural space, we're missing a lot of information. Allison is focused on understanding better how the insula which is hidden by the a particular cortex is involved in inter receptive processing and with ted meditative processing, She's making big advances and has just been funded with an r. to look at how behavioral responses and bodily distress are being modulated by the insula. These examples that I'm giving are just two of many that are being undertaken by our neuroscience team by virtue of the fact that we have been able to move toward these sorts of techniques that are less invasive that are giving us better information and in a collaborative manner with an unseen i load approach bearing significant fruit. Mark Richardson who recently moved from Pittsburgh and outstanding epilepsy surgeon and neuroscientist in his own right, has asked us to collaborate with him on a r 61 R 33 grant which received a very favorable score but was not funded in this cycle to utilize all the data that we have are accessed with neuromodulation and kids to be able to study biomarkers to allow us to advance our programming to get a faster therapeutic response. And as I said before, that's the utmost importance in the treatment of epilepsy and kids. We don't have time to waste while a developmental window is closing and they're suffering from seizures. And so his work with a neurosurgery resident named Nathaniel Sister Susan, where they're using their ai paradigms to better understand what the optimal settings are for R. N. S will certainly advance the field going forward. So I leave you with nothing but thanks and the gratitude for the privilege of working in this kind of a collaborative system where we have neurologists like minded neurosurgeons, neuropsychologist. So neuroscientists that are co localized and this whole approach to epilepsy has been deciliter. I'm very excited about the advances to come in in the future years and if it's anything like the past seven years have been, we have great expectations for how epilepsy will be treated ah in the coming decades. So thank you very much for your attention and I'll be happy to take any questions right. Wonderful talk. The worst part about zoom is that we don't get the stand up standing ovations at the end, you know, and the and the real time. Applause It's it is a, I just have to say from a personal standpoint. Um so satisfying to see that are efforts in LA and attracting, trying to attract localized move heaven and earth to create the centers of excellence. It's working and to recognize the greatness in someone like Saudi early enough on to allow you to work your magic over the years. Um all coming together for those of you who weren't here when the health system merged. Um there was a real question as to how we're gonna manage all this, what do you do with seven hospitals where neurosurgery is being done? Um And you've seen my slides showing the triangles and so on and so forth and what was an idea became a reality. And then as Saudi pointed out the adding on the piling on of eric Nestler, the FBI. Um and the move of brian Kapil was a huge, huge thing which then attracted Helen may berg and the co localization, I'm glad you mentioned Ignacio Saiz, who who's grants by the way are listed under neurosurgery and his the, you know, the increment that his grants brought this year have raised us up to number 20 nationally as far as NIH grant go, I could keep going on. But I have a couple of, you know, specific questions study that I will kick off the discussion with. It's if I could take home one message from this talk, it is the circles chart that you showed in the beginning of a million patients, 1/5 of them getting referred And only 1% getting the definitive treatment. Um and you then listed a bunch of ways that we can get the word out but I did not see social media in europe communication list. Um you know, we have seen how important something like twitter is in the national discourse on politics and the way this country is run. I'm sure you've thought about this, but could you give us some some thoughts about about that? I will tell you that I have a feeling this is one of these old dog new trick types of things where I have not been able to myself do it and I don't know why I don't I don't I don't post you know, I don't, we we invited Leslie actually to our epilepsy group discussions and she's been more than willing to help us with it and I, to be honest with you cannot tell you why we have not caught on to this. But I do think it's very valuable because the majority of the patients that I see are ones that are referred by other people who have heard about it right? But old style social media which is, they know a friend who had this done and who get referred to the center not twitter and not instagram etcetera. So I yeah, I don't know josh, I have to I have to wake up and come back from Mongolia ah willing to take it on. I just have not done it well, yeah, it's not just one person. We are looking into this now. We have an effort in the department. It's going to take about a year To get going. We did see that of the top 100 Twitter users neurosurgery has six as I showed you but I think this is more than any individual. This has to be a campaign a communications campaign so I hope that we can help you with this has E. C. T. Been used in kids by the way because that's been shown I understand to temporarily block bad seizures for awhile. Could could you use something like E. C. T. F. After you've implanted rns to block the acute problem like during that window and then let the rns ramp up. You know Alex Rosenberg who we have not but Alex Rosenberg who I am very hopeful will come and join us here from boston. Children's is a strong proponent of transcranial magnetic stimulation and has shown very nicely the beneficial effect that he can get from that less invasive neuromodulation. Torrey techniques. So TMS really shows a lot of promise. I don't think it gives the same uh um benefit that you're a pace has shown with responsive neuro stimulation. I would think that E. C. T. Would not be something that most parents would embrace. Yeah interesting this concept that you introduced me to today. That window closing during the developmental phase being so important who else has questions. This is what you know, this is an incredible area. Who has comments and questions ted you want to do you have any comments? Yeah. Dr Peterson, I'm sorry. Thank you. This was an excellent talk and I just want to echo and have everyone fight for co localization. It has just been uh changing so much to the program to be on the same floor. Which means you're not setting up a meeting two weeks a month down the road. It's canceled. You walk across with a cup of coffee and you're able to share an idea instantaneously. And that is just so fruitful for growth. Sorry, I have a question uh you having now seen decades of this and the experience all the way back from, oh german days and seeing the changes in this? Similar to Dr Benson's question, if you had a magic wand over the next five years, what is the one thing that you would change about this field, the way that we do it now and anything from patient outreach to the surgeries to the complications. But it'd be great to have your perspective because sometimes we get into the silo and we're so focused on our goals, we lose the big picture. So the one thing that you could change about epilepsy surgery in the next five years, just like that? You know, the it's a great question because what has been vexing to me in my perspective on this And what attracted me to neurosurgery in the first place. Truth be told. I signed up for a project where I had to call 70 patients who had had epilepsy surgery by mitch berger and Giorgio german. And I was so struck by how grateful these patients and their families were for this intervention. I was so naive. I thought they're going to say it was a horrible experience and it was so invasive and they could never do something like this ever again. 70 out of 70 were so eternally grateful for this intervention. And so what I would like in the next 5 to 10 years is a magic wand that the stigmatizes neurosurgery that enables referring physicians to understand its utility and that's not taking safety for granted. I wear the hair shirt for years if I have a complication with these patients, because we're trying to make their life better. But we know that if we don't get them treated, we don't get these Children treated, We don't get the adults treated. We're putting their lives at risk. We're allowing a much more invasive process to take place over years than anything. We would do neurosurgical. E So I would love to see in five years that there is an automatic yeah referral that's made when it's recognized that a patient has failed two medications and that they come to a comprehensive epilepsy center where they understand the benefits of how comprehensive epilepsy centers treat the disorder. It's not just surgery. It could be t m. S. It could be alternative therapies. It could be anything. But please don't stay suffering with PHENobarbital Or phenytoin for 20 years before referral is made mm But I'm preaching to the choir. You know, I think that if social media can convince people that there was no pandemic or no war in Ukraine, we should be able to convince people of the benefit of something that actually works. And I say it, you know lightly but I'm really quite serious about it. So you know, I I really want to invest in our communications going forward. As you pointed out, People like Alyssa and Jillian and Leslie are masters of this. Um so we want to we want to empower them to help our patients by by getting this word out. Yeah. You know I I also I want to say I was remiss in not mentioning my esteemed brian Harris couple. You know, having him there and having him at West and having him demonstrated this model for how important this collaboration is between they neuroscientists and the neurosurgeon. He really is a tremendous role model in that regard. He has brought it a world class clinical program and combined it with the neuro scientific program and then it's just a delight to have Helen martin there. It's who we are very fortunate. So thank you brian Harris copal. What do you mean? How No just kidding brian. Um any other comments or questions from from, from anyone brian? I'm certainly interested in your in your thoughts because it is it is neuromodulation, isn't it? Yeah, yeah. You know like and and it's a funny, it's a funny you know um question you know, now that we're we have this focused ultrasound um you know, installed in there and um while I do think that it's a it's a valuable new tool um you know, I think its initial use of making lesions in the brain, you know, for me as somebody that's dedicated their life to neuromodulation and moving away from the lesions all paradigm, it feels a bit odd. Um I actually think that like focused ultrasound likely will reach fruition in terms of applications of opening up the blood brain barrier and and and things of that nature in order to uh to treat certain neurodegenerative conditions and potentially neuro oncological conditions. Um so um but I as as you well know josh and and Saudi um you know, I I believe that these are diseases of networks, these are diseases of electrical dysrhythmia as and thus treating the electricity is should be the primary goal at all times. Um um and we have assembled a a multidisciplinary team that is second to none anywhere period. Um and I think somebody would agree with that. I don't think that we have a we have a center over there that you cannot point to any other place on the planet that has something like what we have right now. So we have to get the word out josh right? Yeah. Well, I hope that for the residents who are here and others who have passed through Mount Sinai that you'll Look back in 10 and 20, 30 years at your career and realized that you were here in the absolute heyday. You will see, you will see that this will end up having been the the spawning of a new age in neuromodulation for this. And you are very fortunate to have we are all to have this team to work with. So if there are no others, maybe.