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all key Radiology. So Specialties learn more

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at MRI online.com today. We're honored to

0:43

welcome Dr. Mama adean for a lecture on Imaging

0:46

of the neuromodulation and surgical interventions for epilepsy Dr.

0:49

Dean is an assistant professor at Yale

0:52

medical school department of radiology in biomedical Imaging

0:55

his clinical practice focus is Emergency and

0:58

Trauma Imaging and neural Radiology with his research

1:01

focuses on multimodality clinical Neuro Imaging

1:04

and nuclear Radiology.

1:06

He is fellowship-trained neuroradiology and nuclear Radiology.

1:10

At the end of the lecture, please join Dr. Adean in

1:13

a Q&A session where he will address any questions you may have on today's topic.

1:16

Please remember to use the Q&A feature to submit

1:19

your questions so that we can get to as many as we can before our time is

1:22

up.

1:22

But that being said we are ready to begin today's lecture Dr.

1:25

Adean. Please take it from here.

1:28

Hello. Thanks for introduction. And thanks to

1:31

you thank you for having me here today. I am going to

1:34

share my screen.

1:37

If you guys in a second, thank you

1:40

for showing up today. Thank you for joining us. Today. We

1:43

are going to talk about Imaging of normal modulation and

1:46

surgical interventions for epilepsy.

1:50

so here at Yale, we are prominent Epilepsy Center

1:53

and we have a comprehensive epilepsy program and

1:56

I would like to share our experiences with

1:59

you and then we'll

2:04

and as our understanding of Imaging of surgical interventions

2:07

for epilepsy. Sorry, let me

2:10

figure out the screen and then

2:13

I'll be briefly going over the intracranial electrodes

2:16

and respective surgeries non-resective surgeries normal

2:19

modulation. And then finally, I'd like to show you

2:22

a multiple cases of longitudinal Imaging

2:25

findings of the Journey of epilepsy

2:28

patients.

2:30

That I find remarkable. All right,

2:33

so a little bit of history of epilepsy. So we

2:36

all know epilepsy is indeed an ancient disease the first

2:40

description of epilepsy can we actually found in the Babylonian tablets

2:43

and strikingly to very details

2:46

are that we noted that the different stage

2:49

of types. We recognize have been very beautiful described in

2:52

some of these tablets. Unfortunately epilepsy has

2:55

been described as a supernatural disease that was

2:58

a primarily associated with evil or

3:01

some gods or Spirits. Therefore the treatment

3:04

was largely spiritual matter rather than

3:07

an actual disease treatment until very recently and

3:10

a revolutionary view came from hypocris, which

3:13

actually say that the epilepsy

3:16

was a disorder of the brain and was chronic

3:19

it's incurable, which is not entirely incorrect. Unfortunately

3:22

in some cases but it's treatable most

3:25

of the times these days but his views

3:28

did not actually take place until I

3:31

think or 19th century. It was still treated as

3:34

a supernatural disease, which was

3:37

primarily treated with

3:39

With religious figure or spiritual figures here.

3:42

We see a masterpiece from sansevarino

3:45

a release of a woman from possession by the devil.

3:48

We can see there are a few religious figures

3:51

that are trying to treat if

3:54

you will a seizing woman in here and

3:57

then we can see there are some Spirits in

4:00

here evil spirits. I don't know why a woman

4:03

was depicted here because we know that epilepsy is

4:06

actually more common in males and this is

4:09

a different discussion. So let's

4:12

talk a little bit about the epidemiology of

4:15

epilepsy. We know that if a combo sclerosis

4:18

is accounting for up to like 70% of cases in

4:21

intractable. Let's see, but recently there has

4:24

really been a decline in the in the amount of people compost surgery

4:27

is that are being performed. It's not because the the actual

4:30

number of people sperosis has decreased but

4:33

we started seeing more non-legional extra

4:36

temporal epilepsy cases and surgery and then improvements.

4:39

Editing helped us understand better this

4:42

disease and then find new possible.

4:46

Lesions that are foresight that can

4:49

actually cause the patient's epilepsy.

4:52

Which eventually increase our treatment success about the

4:56

the epilepsy interactive treatment? So

4:59

historically we thought that epilepsy was

5:02

focal versus generalized types. But today

5:05

we know that actually epilepsy is a brain

5:08

Network disorders that has that propagate into

5:11

common Pathways of well-defined brain networks with

5:14

some stereotypical phenotypes, which will

5:17

describe some of them.

5:20

Um, so in about one third of cases seizure control

5:23

cannot be achieved with medications alone. And this

5:26

is why we need surgeries or interventions. So the

5:29

respective surgery is most likely an intermission

5:32

to prove to produce a seizure freedom in

5:35

this patients, but which are sometimes

5:38

called pharmaco resistant epilepsy, but but

5:41

it's it's always not possible as I will show

5:44

momentarily in some patients. It's impossible to

5:47

perform respective surgery. That's why we we

5:50

continuously evolve in terms of treatment and

5:53

we came up with multiple.

5:56

treatment options that are not actually surgical but

5:59

International

6:02

So the availability of this intervention has

6:05

increased recently in the last few

6:08

decades and Radiologists. And also other people who are

6:11

interpreting. The inner Imaging studies had really need

6:14

to be familiar with this findings the complications and

6:17

then these obviously brings some unique challenges

6:20

to us and we have to be aware what what

6:23

we are doing in terms of treatment to better evaluate these

6:26

patients films and be more helpful to them.

6:29

so the main question indeed is is whether

6:32

we are going to operate on on this patients or

6:35

not, and it's not always easy and it's not that binary

6:38

always every patient has a unique treatment course

6:41

and as we will see these are

6:46

As initially I said there are epilepsy programs

6:49

in many territory academic centers that are extensively investigating

6:52

in mostly disciplinary fashion. These patients

6:56

are being worked up extensively trying to understand where the

6:59

actual focus of it tell activities

7:02

coming from as I said

7:05

not always possible but most of the

7:08

times these are very successful and there

7:11

are faces of pre-operative workup

7:14

for epilepsy treatment phase one

7:17

phase 103. All Diagnostic Imaging tests are basically

7:20

some centers include weather also in

7:23

the phase one, but but all Interventional phases

7:26

are workouts are actually invasive

7:29

treatment. Some of them are interoperative or

7:32

preoperative International.

7:35

EEG studies that are trying to figure out where the

7:38

focus of of Caesar is coming from. So this

7:41

is our real algorithm for Diagnostic and

7:44

therapeutic decision for pharmacare resistant epilepsy.

7:47

I want to briefly go over this so and we'll

7:50

as I said with all the non-invasive workup

7:53

minus our plus weather which we

7:56

know that we are trying to it's a neural Interventional technique of

7:59

multidisciplinary trying to

8:02

understand the the memory

8:05

of patient and hippocampal activities.

8:08

Basically, I will not go into detail of this. It's

8:11

not super common, but it's still being performed in many

8:14

centers. So once the lesion

8:17

is Unilever and such as teamwork and

8:20

cephology or carbonoma and then it's a coordinates with

8:23

seizure semiology and prayer operative work up

8:26

then functional cortex. If nothing involved, it's just different

8:29

treatment is very straightforward and it's less generally take

8:32

out the legion and patient.

8:35

most of the times get seizure freedom

8:38

and the functional cortex involved you do

8:41

functional mapping which is a functional MRI

8:44

or most of times. It's actually a and in

8:47

a surgical technique which I will show momentarily

8:50

the examples of this technique and

8:53

then you do guided with Section trying to

8:56

protect the the functional cortex

8:59

or I'm late if such as

9:02

lid or or in normal modulation techniques such as RNs, which

9:05

I will cover momentarily.

9:07

And then if there is mesial temporal sclerosis, as

9:10

I said, this is the most common pharmacoresistant ideology

9:13

for the epilepsy IF hippocampal function

9:16

preserved, which we can understand in what as

9:19

I said and rnas or lit will be performed because

9:22

you don't want to cut patients.

9:25

Functioning hippocampus and you know, like causing all different

9:28

kinds of surgical outcomes complications in

9:31

terms of psychological or memory or cognitive

9:34

or so, you try to

9:37

basically preserve the functioning hippo campus

9:40

if hipo Campbell function is not preserved. Then

9:43

temporal lobectum is the way to go or sometimes you can

9:46

still do like ablative treatment

9:49

in late. Sometimes patients would not want

9:52

to go undergo surgery if in

9:55

case of malformation of

9:58

cortical development which are congenital most of

10:01

the times well all the time but these are

10:04

actually some of the hardest cases to treat because they

10:07

could be the fuse or multifocal lesions. You could

10:10

find and normal MRI, which I will be showing how dramatic

10:13

it can be throughout their course.

10:16

It could be completely normal looking but patiently seizing

10:19

constantly. It's very deviliating as

10:22

you can imagine. The treatment is not unfortunately very

10:25

straightforward. If there is a unifocal asset and

10:28

functional cortex not involved resection still possible. If functional

10:31

cortex is involved then we do

10:34

RNs. This is responsive nurse stimulation, which

10:37

I will be discussing soon. If there

10:40

is a multifocal Network onset again, you can't really

10:43

do Surgical and resection because you

10:46

don't really know where the the epileptic activity is coming

10:49

from. This is when you do normal modulation, sometimes I

10:52

call them blind shot, especially for VNS, which is vagus nerve

10:55

stimulation.

10:58

so here's

11:01

the let's talk about the intracranial electrodes. So there are mainly two

11:04

types of electrodes. These are called strip act

11:07

which are superficial electrons or depth

11:10

electrodes. So superficial electrons are basically strip electrons

11:13

that can combination of which creates

11:16

a grid. I will show next in

11:19

next slide and then there are also depth electrode

11:22

with our which are actually orthogonal to the Head surface and

11:25

they are going into deep into the brain matter and then here

11:28

we can see at that electrode with microfibers. Each

11:31

fiber has a different EEG.

11:34

Address basically you can you can understand where they

11:37

are coming from here. These are little GPS

11:40

map of surgeons and neurologists to

11:43

understand where the the epileptic activity is coming from here

11:46

is one of our patients interoperative image you can

11:49

see this is the grid along the suspected area,

11:52

which is also electron with a

11:55

special region in this particular patient that pink

11:58

multiple strips creating a great

12:01

electron and there are also still multiple strip Electro

12:04

as we can see along these areas and they

12:07

all have different numbers as I say, these are literal GPS and

12:10

they all go into the EEG that you can evaluate and

12:13

try to understand where they actually is coming from

12:17

So it's always not possible to see the brain

12:21

matter like the soft tissue

12:24

on City because of the strict artifacts

12:27

that are creating being created by this electrodes. That's

12:30

why on this particular image. I call

12:33

registered the MRI and CT that way that's very

12:36

helpful. We can see the electrons on by virtue of

12:39

city and then also you can see the soft tissue

12:42

in that particular patient. There was a supper pendulator of your

12:45

gray matter to be over here. We can see depth electronic is going into the

12:48

into the the Excel activity

12:51

region.

12:53

And then again, this is the mid image of from City

12:56

showing the same grid along the visual special

12:59

cortex. So how neuro modulation started. I

13:02

think we all know from the medical school that the electric structure

13:05

that that frog ex create like twitching. I did

13:08

it myself. I don't know if they're being done still in the

13:11

medical school. But this was done by Luigi galvani, which

13:14

was the pioneering of bioelectricity in the 1780

13:17

and then his nephew Giovanni Aldine

13:20

actually.

13:22

came up with the idea of treating a

13:25

patients with electrical activity, which we

13:28

call Melancholy treatment, but that was actually

13:31

indeed a

13:33

Pioneering of the neuromodulation and I

13:36

think it's it's the way to go these days.

13:39

What we are performing is basically an Interventional

13:42

but I think in my opinion the the ideal

13:45

neuromagination would be something that doesn't have any

13:48

intervention to brain and doesn't cause any harm

13:51

it's wireless and it can be controlled remotely.

13:54

I don't know maybe this is a big imagination but

13:57

I it might be possible actually recently in

14:00

some monkey studies. I think have shown

14:03

that focused in transcranial Ultrasound

14:06

with subtermal activity can actually help

14:09

in some of

14:11

These animals electrical epileptic activity.

14:15

So we'll see hopefully how it

14:18

goes. So it's surgical resection

14:21

of the seizure focus is is an effective treatment

14:24

option, but it's all sometimes it's inadequate especially

14:27

as I said in patient with multiple malformation of

14:30

cortical development multifocal or diffuse

14:33

disease or does within accessible CG fossil. You can't

14:36

really for decision the surgery and this

14:39

is when you need to know modulation,

14:42

So basically they all have the same ideas not

14:45

only for for epilepsy treatment, but

14:48

neural stimulator device are typically working in

14:51

the same fashion, but entirely different purposes. So

14:54

there is a typical post generator, which

14:57

is the home of electrical activity and mechanical control and

15:00

there's also a lid which is an insulated wire that

15:03

connects the pulse generator with the final component, which

15:06

is the electrode an electron is a non-insulated segment

15:09

that basically delivers the the electrical

15:12

activity the currently the final Target whatever

15:15

it is, it's muscle times. It's brain or it could

15:18

be vagus as they will be showing momentarily. I

15:21

think this is the first question we have to we have

15:24

a polling here Olivia if you can pull it up, so I

15:27

want you to describe what they see please. I

15:30

just want you to I just want to see how the group like,

15:33

how is your approaching this? Like how

15:36

aware are you of this medical devices the top

15:39

the top three images?

15:42

Are describing what kind of Hardware can you

15:46

please respond to poll? They are all Anonymous just

15:49

don't hesitate to pull in. Whatever you think they

15:52

are true. Yes, Olivia. I think we can go with

15:55

the poll now.

15:56

This is just basically trying to

15:59

try to understand the group because I will show all of this patients later

16:02

on again. I know they're they're very new

16:05

to some of you guys are some of you maybe very knowledgeable

16:09

about this, but I just want to see the groups approach.

16:15

Oh, very good. Very good. So, yeah, the answer

16:18

is actually a

16:22

The this is a VMS device and this is

16:25

DBS. We can see it's going into the brain and this

16:28

actually goes along the left vagus

16:31

nerve and this is a neuro responsive nerve

16:34

stimulation device, which is a closed loop

16:37

in the cranium. All of these will

16:40

be shown later on and the bottom

16:43

row we can see the DVS device

16:46

on the right side. You can see how thick there

16:49

there wires. Are there going into the cranium and

16:52

then here is the

16:54

The terminal determination of

16:57

the Adept electrodes for a for this

17:01

DBS device. This was an epilepsy patient.

17:04

However, these are these are ending

17:07

in the anterior talamic nuclear, which is a typical Focus Target

17:10

for the epilepsy treatment. These are

17:13

however going into the subtomet nuclei in

17:16

that particular patient. The clinical situation was

17:19

actually parkinsonian syndrome, which is much more

17:22

commonly performed than the

17:25

the epileptic treatment in the so you are more

17:28

likely to see in clinic on the subtle magnetic there.

17:33

Um stimulation rather than the ant which is

17:36

a terratomic nucleus stimulation. I will show

17:39

all of this later.

17:41

All right.

17:42

Okay, cool, so basically there

17:45

is a stimulating electrode implanted around the left vagus nerves

17:48

this is because we don't want to mess with the scenario activity

17:51

from the right of August nerve

17:54

which is stimulating the heart that is why it's almost

17:57

always done for the left virus

18:01

Um, so there's a waveform generator typically implanted in

18:04

the subclavical region. We don't

18:07

really know how it works. But what it does likely desynchronize

18:10

the network activity and then and

18:13

thereby saying the epileptic seizure so

18:16

here is here are the two images that I showed initially in

18:19

that patient. You can see there are actually two devices. This was

18:22

the an older version of the VNS device

18:25

which is more of long in shape and we can see

18:28

the wire over here and then going into the Electoral that

18:31

are surrounding the left vagus nerve that hyperness little

18:34

structures are actually the lecturers

18:37

sometimes called reborn electrodes and

18:40

then this was abandoned because patient became resistant

18:43

to treatment and then he was treated with

18:46

DBS the brain stimulation which has

18:49

typical Square shaped a larger generator and

18:52

and thicker wires that also doesn't

18:55

end in the Vegas. They're going all the

18:58

way into the brain.

18:59

And on the left side, this is one of this is

19:02

an aspired device one of the new new devices we

19:05

can see it's more avoid in shape

19:08

and the wire is actually barely perceptible. There is

19:11

a wiring here a lead that is some subcutaneous tunnels

19:15

into the left virus. We can see these little

19:18

hypertonicity again are the ribbon electrodes that

19:21

are delivering the activity to the left of August nerve.

19:24

So RNs is a closed responsive nurse

19:27

simulation is a closed loop system. That

19:30

is somewhat similar to the cardiac defibrillator. It

19:33

does have a both stimulating and recording activities.

19:36

So it has a subdural electrode strip electrode

19:39

and it also has a deep brain a depth electron

19:42

that is going into the epileptogenic region.

19:45

This is a interoperative image. We can

19:48

see how dramatic it can be at. The color volume is is open

19:51

in here and the device itself is actually embedded in

19:54

the color volume and then here we can see

19:57

the generator in here. And then the electrode

20:00

is going into the left temple love in

20:03

this particular patient. This is the depth electron in

20:06

here. And then this is the subdural strip electrode

20:09

which are also communicating to the

20:12

generator. So basically once the electrical the

20:15

epileptic activity is perceived by this subdural

20:18

electrodes, it goes to generator and Generator generates the

20:21

current and implements the on

20:24

Electrical activity to the temporal lobe in this

20:27

particular patient there why this synchronizing the network and then and

20:30

then aborting the decision activity

20:33

here is why I show the initial image of

20:36

MRI and City core registration because basically on City

20:39

it's too hard to see the surrounding structure because

20:42

of all these three artifacts in here. This is the same

20:45

patient. Basically we can see

20:48

and the electrode in here is going this is the depth

20:51

electron in the brain and there are also subdural strips in

20:54

here, which we don't really appreciate on the Excel but

20:57

on coronal it's somewhat more visible in here. We can

21:00

see the subdural strapping

21:03

stripper electrons in this particular patient.

21:07

Okay, let's move on to DBS different stimulation. It's

21:10

different as the name suggests from other forms

21:13

of neuro modulation in that the stimulated actor

21:16

is actually implanted deep within the normal tissue and

21:19

namely most of times it's it's talents right the

21:22

central medium. I'm sorry the anterior Atomic layer

21:25

and sometimes recently we have been seeing also

21:28

Central medium thalamic

21:31

Stimulation there are other forms also that

21:34

are being done for like stop telling nuclear. As I said,

21:37

they are mostly done for movement is or

21:40

there's like in parkinsonian syndromes or intentional Tremors

21:43

and there there are

21:46

other techniques that are being used for cow technique. They are hippocampus

21:49

and whatnot. But the main idea in here

21:52

is to deliver activity and this synchronize the

21:55

the and the network and then basically

22:00

Prevent decision activities so it's remarkable how this was

22:03

first discovered discovered actually. So in

22:06

Monkey models when they

22:09

were someone studying the epilepsy epilepsy in

22:12

monkeys and then creating epileptic activity on monkeys trying

22:15

to understand the

22:18

The epilepsy and then one of the researchers actually

22:21

observed that one of the monkeys had

22:24

a left temporal lesion. I'm sorry left thalamic

22:27

lesion and the this monkey was like resistant

22:30

to the epileptogenic. I like

22:33

like purpose epileptogenic activity. So

22:36

the threshold of creating a seizure for

22:39

that particular monkey was higher than the others and they

22:42

figured out this might be this whatever is this

22:45

causing this lesion in the thalamus is probably decreasing

22:48

the you know, the epilogenic

22:52

Function of this this monkey and then

22:55

we started creating creating lesion ourselves while

22:58

not lesion but you know, like stimulation with

23:01

electrical current and this is when it

23:04

first discovered actually and now we are using it

23:07

for the for that purpose.

23:09

And then this is again the same place that I showed earlier we

23:12

can see on the skull radiograph. The depth electrodes

23:15

are targeting the thalamus in here. This is

23:18

that patient we can see they are going to the South teleia

23:21

by literally. This is a patient with Parkinson's disease.

23:24

And then again, this is

23:27

another patient which is a seizure an epilepsy

23:30

patient in that case. The electrodes are terminating in

23:33

the entire McPlay. Why literally we can

23:36

see there is no more cephalos in that particular patient which

23:39

tells us that this is actually recently operated. If you

23:42

look more carefully you can actually see there is left them

23:45

left temple crying ectomy. Also

23:48

cranial also in this patient. We tell us that this patient

23:51

was treated with something else initially and it probably

23:54

failed and now the patient is undergoing to

23:57

DBS treatment.

24:00

Here's a fairly recent technique called

24:03

Fast gray matter acquisition theorem inversion recovery that

24:06

is used for basically. It's knowing the

24:09

white matter and making white matter blacker than it

24:12

looks on other sequences and helping us to

24:15

see the brain autonomic brain

24:18

tracks and such as in Marvel

24:21

Atomic tracking that particular scenario on

24:24

the size of we can see the track

24:27

over here. And then on top of the track, there is a

24:30

high parent that's Focus, which is actually on terror Atomic

24:33

nucleus. We can actually be very precise in

24:36

where we are targeting and sometimes we

24:39

do this interoperatively as well which helps tremendously for

24:42

the surgical outcome. As you can imagine. These are very

24:45

small structure and millimeter offset can or a

24:48

few minutes can actually change the clinical outcome. So

24:51

we have to be very careful.

24:53

So that was it about neuromodulation. I will

24:56

go back to the Imaging examples. But for now

24:59

that was it now, let's talk a little bit about the surgical treatment

25:02

of epilepsy.

25:04

So the traditional surgical resective techniques now

25:07

actually expanded and include ablative techniques as

25:10

well as limited transaction techniques. So typically the

25:13

most common surgery for epilepsy is wrong law

25:16

is Temple over section. Sometimes called ATL and temporal

25:19

law resection. And then this is

25:22

basically focal resection of a disease region, which

25:25

could be most of the times is missile temporal

25:28

sclerosis, or it could be a lesion that is creating

25:31

the similar outcomes.

25:35

But we also do extra temporal section these days

25:38

in front of parallel or expeddle loves which can

25:41

sometimes be complementary to the initial treatment.

25:47

So and then the the section is

25:51

actually

25:52

Not only done by itself some

25:55

days. It could be complementary also to the multiple subfield

25:59

transactions as is the

26:02

Illustrated in illustrations shows on

26:05

the right side. We can see a surgeon is creating a

26:08

purpose transactions over the surface of brain.

26:11

In this case. We are trying to basically take benefit

26:14

of the columnar organization of the brain matter.

26:17

The radial vessels are radial oriented

26:20

and we are trying to if you will this could

26:23

be accepted as a I think

26:26

and it's surgical neuromagnation because basically you're

26:29

creating little Cuts over the surface of brain trying to cut

26:32

the imaginary wires that are writing along

26:35

the brain and causing the propagation of seizure like

26:38

epileptic activity.

26:41

And then this is how it basically works. And the

26:44

way the way we performed is mostly it's it's

26:47

obviously for patients who are not a manual

26:50

to resection. For example, if this is in the samata sensory

26:53

cortex or if this is like a dominant language cortex,

26:56

you can't really cut brain but but this

26:59

is an alternative technique to that but still

27:02

sometimes these are being complemented by by also

27:05

the respective techniques,

27:08

which I also Show an example of it, but the

27:11

surgery can also be that actually without cutting

27:14

can be done with ablation, which is called

27:17

laser-intestinal thermal therapy within this

27:20

lit, this is another technique that can be used in

27:23

Leo of the surgical resection. Sometimes I

27:26

will show examples of it again.

27:28

Functional hemispherectomy is pretty dramatic surgery which

27:31

has been initially that was anatomical hemispherectomy.

27:34

Then it went to functional hemispherectomy. Now

27:37

stage stage functional hemispherectum is

27:40

being performed.

27:42

So this is a very dramatic surgery. Obviously. It's

27:45

only Resort for this patients like have severe

27:48

intellectual disabilities such as in Heming against the follicular

27:51

sclerosis or other different diseases that

27:54

can really

27:56

cannot afford any other surgeries and

27:59

there is a dramatic life alternating

28:03

disease, which is

28:06

typically basically and unfortunately a

28:09

palliative technique right? So there's

28:12

also Corpus colors. I don't know which can also be sometimes performed

28:15

with laser ablation.

28:18

The the idea in

28:21

here is basically to create like to to

28:24

basically disrupt the connection of two hemisphere

28:27

so that thereby decreasing the the propagation

28:30

of seizure activity. There's also stereotypical surgery

28:33

which is being done by it's actually

28:36

a controversial technique and the effective of which

28:39

which is not really clear and there are

28:42

I think like a few centers trying this one of

28:45

which is in Italy, so I don't have a good example of

28:48

that on my presentation. You could look

28:51

it up if you're interested in knowing more about it.

28:54

So let's talk about the temporal

28:57

lobectomy ATL surgery. So we mostly see

29:00

enhancement of the surgical margin as a linear enhancement

29:03

within the first few few days of

29:06

the surgery, then it becomes tickliner or nodular during

29:09

the first weeks and then hopefully disappears sometimes

29:12

it will not disappear and I also examples you can

29:15

see restricted diffusion in the prank email in the

29:19

dream restriction within the atlas section

29:22

side in 50% of patients within 24 hours.

29:25

But if you have a more significant in moment, obviously,

29:28

you might think about any vascular injury, you

29:31

know that posterior communicating artery poster several

29:34

arteries are close to this section side

29:37

and opting opting nerves can

29:40

can be actually Myers Loop

29:43

and an optic radiation. I can be close

29:46

to the surgical side. And these are important findings. We have

29:49

to be careful when are in interpreting this images.

29:52

So the extra bank will find

29:54

Will include dual enhancement as I said, which sometimes

29:57

may actually last years you can

30:00

see extractual fluid lasting and one or two nemocephals obviously

30:03

should resolve within few few

30:06

few days. Sometimes it can persist.

30:09

Sometimes it can come back. This is the worst news.

30:12

If you have a normal cephal is the complete

30:15

the result and then came back after surgery. You might really think

30:18

about an infection or assets in the Search for cavity, which

30:21

will also present with other clinical findings that

30:25

And that sometimes devastating which I

30:28

will show examples. So you also see enlargement segging

30:31

and enhancement in the ipsilateral correct plexus which is

30:34

an interesting phenomenon. I will show examples again there is

30:37

obviously always it's lateral temporal horn xvical dilation because

30:40

you are taking out a good chunk of brain matter and then

30:43

it's causing the X Factor abilitation of the lateral ventricle.

30:46

So here it is a patient with ATL surgery.

30:49

We can see nodular enhancement of the of the

30:53

during here and these pretty

30:56

thick enhancement here is another patient again post ACL

30:59

surgery, by the way, the upper one was like within a

31:02

few weeks after surgery and this one

31:05

is actually a few months after surgery we

31:08

can see

31:10

the thick but linear enhancement of the dura and

31:13

then on top of it, you can also actually press the

31:16

correlate plexus enhancement and modularity in

31:19

this particular patient, which I will

31:22

show another example on axial image also, so here is

31:25

um, so here's like a premier basically

31:28

a drawing I've made to describe the

31:31

the laser ablative surgical outcomes,

31:34

which is pretty remarkable and it's actually pretty

31:37

technically technological you can

31:40

almost always see the same thing depending on

31:43

the underlying reason sometimes if you have an underlying lesion these

31:46

findings can change but basically the idea is

31:49

there is a central to hyperintense focus, which is

31:52

basically removed track of the catheter that

31:55

has

31:57

That has CSF filled in and it will obviously look bright on

32:00

T2 weighted image as I showed in here.

32:03

And then there is a surrounding area which is called central

32:06

zone. That is T2 dark that is basically

32:09

irrevers the irreversible coagulative necrosis.

32:12

That is that brain matter

32:15

in here. It will look to dark and

32:18

T1, right and the surrounding to this there is

32:21

this T2 Hyperion test peripheral Zone, which

32:24

is necrotizing edema, which is

32:27

also unfortunately not well fortunately because

32:30

this is a purposeful treatment, right? So

32:33

there is a T2 hyperintestinal. This is

32:36

will appear to T1 High Point test and T2 High

32:39

currents. This is an edema, but it's an irreversible sound that

32:43

keep in mind centrally. It's alsoever irreversible, but

32:46

then there is also this surrounding ring which

32:49

is T2 high point then sometimes it's thicker than what what I

32:52

draw in here. So there will be enhancement on

32:55

post contrast.

32:57

These are blood products basically or hemostly.

33:00

They're in that are pulling around the the non-viable

33:03

surgical cavity and a

33:06

surrounding to this. We can see a large white matter edema,

33:09

which is vasogenic in demand. This brain is healthy and

33:12

is recurring but this edema will be there for some

33:15

times after surgery and then eventually if you

33:18

it will disappear as I will show examples. So

33:21

here's a patient. So here is

33:24

again as I say, sometimes this will be like oblong in shape

33:27

the central hyperintensity. Sometimes it will be run depending on the

33:30

surgical course of the problem of the catheter if it's

33:33

moved inside the create like elliptical shape,

33:36

but it's it's typically around like that. You can see

33:39

there is a tiny bit of hyperintensity which is signal fluid signal

33:42

and CSS signal inside in here. There's surrounding

33:45

T2 High Point test area, which

33:48

is called a different crosses and then T2 High pay intense

33:51

area, which is necrotizing in Dima. Both of these reasons

33:54

are nonviable and there is very fine.

33:57

Through High Point tests ring, which will enhance

34:00

on postcontrast images and then

34:03

here on flare. This is the same patient. We

34:06

can actually see edema better on T2 on

34:09

T2 player images surrounding vasogenic Dima.

34:12

This is outside. This is

34:14

Inside the the rim and

34:17

this is actually it was a genetic Demi area and then

34:20

here is the false contrast image. We can see the ring is actually enhancing.

34:23

It's a little irregular but it depends on the shape of

34:26

the surgical planning and

34:29

and the purpose of the surgery in this

34:32

particular person. It can be different sometimes but it's mostly similar

34:35

to each other and I will show a video of surgery

34:38

which is right over here. I this is

34:41

the most trading the delivery of leather in testicial

34:45

basically the time of therapy if your patient with temporal love epilepsy, there

34:48

is a stepwise thermal oblation. There's

34:51

delivered with catheter sequentially move posteriorly the

34:54

category you'll see now it's moving closely. There is

34:57

like is hypodest line which is which are marking the

35:00

the temperature you can see it's gradually increasing

35:03

the way like surgeon delivers the the ablation in

35:06

here and then here are the

35:09

The temperature marks basically green

35:12

area is this so you hit a lot of brain, but

35:15

you don't really burn a lot of it. So this is

35:18

the marker of the burned brain. Basically if you will in

35:21

here, let's move forward

35:24

and look at the the end result in this particular patient.

35:31

Okay. This is an interoperative image of the same patient. We

35:34

can see even interoperative setting we

35:37

can see the T1 high paying test surrounding the

35:40

central catheter area, which is called related in

35:43

according area along the along the left left hippo

35:46

campus in that particular patient. And then

35:49

it's also enhancing as we can see there is

35:52

enhancement of the surrounding ring and then

35:55

also in here it's really visible, but it's

35:58

there.

36:01

All right. So let's move on to on to

36:04

the longitudinal Imaging of

36:07

cases of different

36:10

journeys of different patients. Sometimes encompassing

36:13

years and years decades. Unfortunately, I'll

36:16

show examples of them.

36:19

But before that I wanted to show that kind

36:22

of like nice picture that I took last year in our campus

36:25

when I was like putting this in

36:28

my Powers PowerPoint computer, I'll text

36:31

saying a group of people leaning against

36:34

a wall. So it seems like AI is like finding

36:37

something but it's it's true but it's

36:40

also false. So there is there is some hope in there hopefully. Okay.

36:43

Let's go to our first patient 65 year

36:46

old male with left temporal cover Noma. This patient

36:49

has a dominant language Center on the left side and

36:52

we will see momentarily patient underwent to

36:55

laser ability treatment. But first, I want to show

36:58

you the cover Norm as we can see very typical.

37:00

Bubbly appearance and surrounding ring in

37:03

here and there is a hemo Seether and rings around it.

37:06

We can see in this susceptibility weighted image GRE, which

37:09

is very sensitive to the blood product.

37:13

Okay, here is a Chrono T2 and

37:16

axial postcode contrasting one with images. We can

37:19

see the catheter track is very much visible in here. There's

37:22

surrounding edema along the catheter tract

37:25

and there is significant white matter hyper hyperintensity

37:28

on T2 weighted

37:31

images as I say earlier. This is

37:34

this is normal. What's a

37:38

genetic intima? Not normal, but this is rising demand. This brain

37:41

is is viable but inside

37:44

that High Point intense ring that brain is

37:47

non-viable unfortunately, and then the

37:50

centrally we can see there is some heterogeneity. It's not as like

37:53

uniform as the one I showed earlier because that

37:56

person has an underlying lesion as you can imagine with

37:59

helmets and everything in here creating this

38:02

heterogeneous to lesion and

38:05

then here the lesion against surrounding

38:08

High Point High Point density on

38:11

posting on weighted images.

38:13

There's obviously you can notice that how it's enlarging. So

38:16

this was like a week after the Lesser ablation

38:19

initially that will these lesions will enlarge and

38:22

then after a month or so that they will start decreasing

38:25

in size as we can see in here one year after

38:28

ablation and a patient has

38:31

Tijuana hyperintense pre-contrast lesion and

38:35

then prayerfully it's enhancing again. So it's really important

38:38

for us to know like what was done

38:41

to patients. That's why the prior Imaging or or history

38:44

is very important. If this patient comes to me without knowing

38:47

anything about the priority surgery, I would

38:50

probably just say this is like me I don't know all of us would

38:53

say like this could be like, I'm a metastasis or some other

38:56

other reasons that are causing T1 shortening in

38:59

the brain.

39:02

So we have to be very careful about the history.

39:05

And prior Imaging so here's another patient 43 year

39:08

old female had seizures since Age 2, but did not really cease between

39:11

a 6 and 24. There was

39:14

no focus on Imaging. This is a normal brain MRI

39:17

we can see and then the infernal EEG

39:20

was done. We can see Stripes all over the the convexity

39:23

on this call x-ray this

39:26

space in other words a combination of multiple subtitle

39:29

transactions and also additional section

39:33

was done. I will show it later because basically the

39:36

there was poorly localized seizure

39:39

activity in this patient and

39:42

then it was along the the electron cortex.

39:46

So there is section was not done in this area we can

39:49

see this is early post surgical safety. There

39:52

are small areas or purposefully created

39:55

hemorigin here. You can see this hyperness this very small

39:58

here again white matter

40:01

edema, and then if

40:03

Few years after surgery we can see there

40:06

is involution of brain parenchyma illiotic chains in

40:09

subcultural white matter. There are still hemorrhagic materials that can

40:12

be visible in here. How much is there in the positions?

40:16

And then this is 10 and 13 year follow-up. We you can

40:19

really appreciate their significant loss in the brain matter

40:22

in here. This patient was also partially respected outside

40:25

the the universe the the electron

40:28

cortex. We can see there's involution of

40:32

prankima juliosis and also very

40:35

typical appearance of radial transactions that

40:38

were surgically done that are still containing hemisphere in

40:41

rings on this susceptibility waited Excel images

40:44

we can very well see them. This is very

40:47

typical. Once you see this you can't really forget it. If you

40:50

see this this patient has prior epilepsy surgery.

40:53

So here's another person 25 year old male with

40:56

civilian intellectual disability. As I said Corpus Callos.

40:59

Atomy are usually done with this severe intellectual disability cases.

41:02

It's a palliative technique in that

41:05

particular patient. There was no identifier or seizure Focus after extensive

41:08

investigation and decision was made to

41:11

proceed with color zotomy and then we can see this

41:14

is it interoperative images on the

41:17

cathered catter that track with single void

41:20

is seen in here surrounding hyperintensity, which

41:23

is very similar to what I showed initially and then

41:26

a few years later. This is a one year

41:29

later exactly. You can see how there

41:32

is significantly involution of corpus callosum. Basically, the

41:35

corpuscon was entirely involuted

41:38

and in not functioning anymore and this

41:41

patient has a significant clinical outcome better

41:44

outcoming in terms of severe seizure

41:47

activities.

41:50

Here is another corpuscalazotomy. But this time this is a conventional

41:53

surgery you can see there is CSF field

41:56

and it's very important in this patient to really document

41:59

the the entire disconnection because the entire idea

42:02

is this connection if you look at only on sides

42:05

little images and if there are section side is undulating it's really

42:08

tough to understand if it's entirely disconnected or

42:11

not. So you you have to look at the NPR images and

42:14

you look at all the the coronal and acts

42:17

images to understand if this is still connecting or not

42:20

in that particular patient, you can see posterior Corpus callers

42:24

or tell me what's performed and it was successful clinically. All

42:27

right, so I'm gonna show

42:30

this video of that 31 year old female with intractable epilepsy.

42:33

Please try to see the legion if

42:36

any in that patient and then and then a

42:39

poll will will follow this and let's see what you think

42:42

about it.

42:53

All right one more time.

42:56

I know it's a little fast but

43:17

All right. Let's proceed with the new

43:20

question, Olivia.

43:25

All right. So where is the abnormality?

43:28

Is it in the right temporal lobe? Is it in the right preventical or

43:31

white matter cerebellum, left temporal lobe or

43:34

all of the above?

43:40

All right, very nice. So yeah, so

43:43

all of the above was actually the correct answer.

43:46

So let's let's go further and

43:50

Okay, so that was a very complex case patient has

43:53

heterotopic gray matter in the right temporal law and we can see over

43:56

here and congratulations to those who actually saw

43:59

that you can see support collector Utopia

44:02

in the right temporal law here. It's also seen

44:05

but this was not the only finding that

44:08

patient also has parenting or white matter hyperintensity in

44:11

here and they also had presumed and

44:14

simple Malaysia in the right cerebellum. And then guess

44:17

what this patient also had left hippo composting

44:20

the Roses. This is a few actual pan

44:23

City image shows decrease FDA update in the

44:26

left temporal law, which is typical in the middle temples the Roses

44:29

we can see this is

44:32

the the same image basically. Sorry the

44:35

same image basically in here the architecture

44:38

of the Corpus of the of the hippocampus is

44:41

lost. We don't see the gray white matter differentiation. It's

44:44

blurred there is slightly involution.

44:48

And here is a drawing from our recent publication. We can

44:51

really see there is a decrease in the

44:54

core in the in the volume of left hippocampus and

44:57

you'll see like a grain white

45:01

matter blurring which is really dismal myelination

45:04

and there's always temporal volume loss

45:07

in this particular patient, which I

45:10

will show another example, so, okay, so that patient has

45:13

too many lesions. So which one is the corporate like

45:16

why patient is seizing how do we understand this pretty dramatic?

45:19

Look at that too many stripes and

45:22

electrodes in basically literally all the surface of

45:25

rain is covered with electrons. We are here trying to understand

45:28

where the seizure is coming from and unfortunately

45:31

in that patient, there was no single corporate

45:34

and it was poorly localized and

45:37

the treatment was was the decision was

45:40

made to proceed with the treatment of basically the

45:43

blind shot vagus nerve stimulation. We

45:46

can see again partially visible.

45:48

is a generator on the left chest subclerical region

45:51

and then here is

45:54

Very fine wire and I think the electrodes are better

45:57

appreciated on a lateral view here hyperdense small the NS electrodes

46:00

surrounding the left vagus nerve and there's a

46:03

these are called Rebel electrot, right? So let's

46:06

go to another patient. This is

46:09

a 50 year old female with hippocampus sclerosis. Again. Remember

46:12

that illustration. I showed there is

46:15

decreasing the volume there is decrease in the constituity of

46:19

inter internal architecture of the left hippocampus on

46:22

the right side. You can very well see the gray matter within the hippocampus but

46:25

on the left it's not visible. There is increasing the volume

46:28

is blurring of the cortex. Someone blurring of the cortex is

46:31

actually principle in here. We can see how the it's better

46:34

in the in the in the zoom

46:37

in image. And again, this is the same patient

46:40

we can see the crease activity ftg uptake

46:43

in the left terminal law on the right side. You can see very nicely

46:46

increased normal ftg update on the left

46:49

is the craze in FDA update. This patient has measure temporal

46:52

sclerosis. So what happened to

46:54

station obviously on their temporal lobectomy was performed and

46:57

then

47:00

And then patient underwent the surgery and

47:03

this is soon after surgery. I think this was

47:06

like second week and patient presented with fever headache

47:09

and whatnot. So

47:13

Is there like an infection in here or is there no infection very

47:16

tough question extensive clinical investigation was

47:19

made in terms of radiology. We

47:22

see very blurry enhancement along the surgical cavity. There

47:25

was no restricted diffusion. Thankfully there was

47:28

no Fleet collection. No peripheral enhancing Fleet collection.

47:31

So the decision was was made

47:34

basically clinically because radiolically this was

47:37

there was nothing to suggest infection, but we cannot exclude

47:40

the infection all because of these enhancement around

47:43

the the surgical cavity which can be completely normal

47:46

but slightly thicker than expect. I would expect for

47:49

the early posterical time.

47:52

And then we can see this patient was conservatively treated

47:56

and completely completely recovered

47:59

without any necessity of any intervention again, as

48:02

I say earlier, there is a

48:05

modular enhancing clumped correct places on the left

48:08

side slightly sagging into the cavity surgical cavity.

48:11

This is a an expected post surgical finding

48:14

this was an answer temporal lobectomy patient

48:17

if this was a let's say GBA GBM surgery

48:20

patient that will be very concerning for a recurrent or

48:24

relapse right in the surgical cavity. We have

48:27

to keep in mind that this could also happen after the tumor surgery.

48:31

It's not just related to the temporal or vectomy

48:34

for the epilepsy, but it's good also happen for other

48:37

entities that have and black resection

48:40

of the left temporal law.

48:43

So here's another 44 year old female with hippocampus sclerosis

48:46

temporalobectomy 10 year later

48:49

that was failed and then that patient was

48:52

perceived with VNS and unfortunately VNS failed two

48:55

years later and then that time patient was was treated

48:58

with DBS as we can. See these are very dramatic

49:01

remarkable Journeys throughout years age

49:04

throughout their entire life decades.

49:07

Sometimes it can

49:10

just come back all of a sudden

49:13

even after decade of successful treatment. We can see this

49:16

patient. We can understand that this is actually

49:19

immediate possible at City. There is air fleet leveling nemocephalos expected

49:22

in the first few days to weeks, maybe

49:25

but as I say if there is there is

49:28

no most cephalus it's it's fine initially, but

49:31

then if it increases or or after it

49:34

disappeared or decreased it started increasing again

49:37

or reappearing then this is when you actually need

49:40

to raise a suspicion and especially if

49:43

On two weeks after surgery you can see again in

49:46

here the surgical cavities fluid field. This is

49:49

a few years later.

49:52

After the section again, there are electrodes to

49:56

understand where the activity is coming

49:59

from as I say this patient relapse, unfortunately, and then

50:02

this is again Pet City. We can see the quiz activities surrounding

50:05

the the surgical Capital as well. And again,

50:08

this is also pet this

50:11

is fused with City, but this is a pet with Quantified

50:14

ftg uptake the purple color in our

50:17

system. We are using here is typically for the quiz activity

50:20

update.

50:22

so

50:24

Let's move on to.

50:27

Some of the things that can actually go wrong for us

50:30

for patients for surgeons for for neurologists for

50:33

for everybody that is involved in the in the treatment. Right? So we

50:36

have to bear them and we have to understand them and if

50:39

we know them better, that's way how we can actually

50:43

tackle them and then prevent any

50:47

Unwanted outcome. So let's go with with the

50:50

first case of patient with

50:53

we can see there is how many megalencephaly on that particular

50:56

patient functional functional hemispherectomy

50:59

was performed. But unfortunately this

51:02

patient sees again and then

51:06

The reason was a very tiny connection between the

51:09

insula and the Oxford the lobe and the patient underwent and

51:12

other surgery and this time patient recovered from

51:15

the from severe seizures, but unfortunately, another unwanted

51:18

complication happened patients had

51:21

a severe scenariosis, which is one of the reason

51:24

that these surgeries are not being performed very often

51:27

and it's very

51:30

dramatic we can see the brain stem is basically

51:33

almost like drawn like with them with

51:36

a charcoal pencil. It's entirely black and these

51:39

have as you can imagine severe out a clinical outcomes including

51:42

that.

51:44

There is another person with electoral complication we can see the

51:47

electorate is here. They're surrounding subarachnoid hemores or

51:50

bright on flare which is typical only kids that

51:53

are kind of hammerage and then in here we can see surrounding edema

51:56

and other patient both of these patients were not infected possibly

51:59

the time we're actually possible related

52:02

to vascular injury on that one and then

52:05

in demand here, they both resolved after conservative treatment.

52:08

Here's another patient. Can we

52:11

get the next question like a few

52:14

seconds later Olivia? So this is a patient post-servative second

52:17

week for followed by confusion and Amnesia, we

52:20

can see the fact is over here. There's surrounding enhancement

52:23

and then Dima and then

52:26

again, there's players demand here surrounding catheter track.

52:29

So I want to to know whether what you think

52:32

about this person is infected or not infected very simple question.

52:38

All right. Fantastic. So based on this image. It's

52:41

really tough to understand if there is infection or no infection.

52:44

So that patient was extensively explored

52:47

and and surgical wound was

52:50

cleared and the borehole was opened. Everything was was

52:53

clear. There was no there was no

52:56

the cultures were negative. No past nothing

52:59

in the in the in the track of the surgery.

53:02

So the the decision was made to proceed

53:05

with conservative treatment without antibiotics and then actually this

53:08

patient recovered without any any unwanted outcomes.

53:14

Here is another patient. This is

53:17

a post-opped seventh week this time basically after

53:21

DBS developed fever and confusion in

53:24

this patient.

53:27

We can skip this question. I guess basically the same

53:30

question. I wanted to honest like show how it can be difficult to

53:33

understand this patient again has like enhancements surrounding

53:36

these area. There is the catheter in

53:39

the center is severe severe flares

53:42

signal surrounding it, but very remarkable. There's actually

53:45

ventricular and signal in

53:48

here. Also, you can see enhancement is actually going along the

53:51

appendable surface on the left side. There is slightest layer

53:54

single, but it looks pretty normal. And this patient was

53:57

the wound was explored and immediately after opening the wound past

54:00

and an assets was coming out. So the entire

54:03

entire Hardware head

54:06

to remove head to remove them. Unfortunately, this patient was lost.

54:10

So here's another patient.

54:13

Can we skip to fifth question Olivia, please? I want you

54:16

to tell me whether so here is

54:19

the area of the catheter whether there is

54:22

a catheter or there is no catheter or if there is a catheter, where

54:25

is the catheter the first image or the second image?

54:32

There's a letter on first semester. That is very true.

54:36

All right. Congratulations.

54:38

Everybody whoever responded to this there is electron on

54:41

the first image we can see there is

54:44

signal void in the center and it's slightly Dimas are running it in the

54:47

second image. That is the same patient was electrode was

54:50

actually removed. We don't see that dark that dark

54:53

that in the center in this

54:56

particular patient initially the report actually initially saved

54:59

depth electrod in place on both images, which was

55:02

incorrect. That's why we have to be careful and look at the The Continuous

55:05

signal void along the candidate track we can

55:08

see just like in here in that patient. This was

55:11

removed the catheter you can see the center of this track

55:14

is like a Time Track. It's actually empty and we'll

55:17

see there is carrying the cathered attract. But if there

55:20

was a real category in here, this would be just like entirely black sometimes

55:23

this is very dramatic. It's not always that dark

55:26

like that it will like skip in sometimes it

55:29

will quiet and it will become smaller than it was. That's why

55:32

it's very important to compare with priorities and look at the EMR carefully

55:35

or if you don't understand still like it's

55:38

I think would really help to understand it.

55:40

Here is another patient presented with

55:43

left foot weakness. And this artery occurred three months after

55:46

bilateral DBS for refractory essential tremors is

55:49

not an epilepsy case, but they can have the same same complications

55:52

where they're basically the same thing we

55:55

can see there is significantly demo on the right side the left side

55:58

look pretty fine. Right. So there must be something during the

56:01

interaction that happened and in this

56:04

patient has developed like that assisting structure in

56:07

here. It's still too bright. There was no science of infection nor

56:10

restricted decision. No enhancement there is surrounding edema,

56:13

and then this we can

56:16

see it's actually gradually decreased and then I didn't show

56:19

here but this patient actually actually completely recovered that's

56:22

this thing appearance entirely disappeared on

56:25

follow-up image. This patient was also interestingly treated

56:28

with steroid. That's how they recovered.

56:32

So here's another example. I just wanted to show briefly

56:35

that how quantification can sometimes

56:38

actually still be qualitative for us because our brain is

56:41

like wired to compare stuff visually.

56:44

So this was an ictal spec City that's

56:47

showing in this particular patient with epilepsy showing the

56:50

the report says increased left-sided activity.

56:53

This is an actual spec in ictal

56:56

Spec. You are trying to measure the blood flow to the

56:59

the Atlantic region if there is an increased blood flow to a site

57:02

and it's lateral if lateral

57:05

temporal load basically, you can understand

57:08

that this was probably the reason why

57:11

patient was seizing and this is the interactal Pet

57:14

City.

57:17

We can see this time. It was actually described as

57:20

decrease activity on the right side, which means that

57:23

patient might be seizing from the right side. As

57:26

I said, the quiz activity means the focus of seizure, right?

57:29

So and this is the quantitative MRI actually

57:32

showing that there is there is decreased volume on

57:35

the right side. This is another Quant image, which is

57:38

basically computer is generating volume for you. But hey, this

57:41

is a crazy. It appears to be crazy on the right side, but indeed the

57:44

left side is larger not the right thing is

57:47

smaller we can see there is increased signal on the flare

57:50

and there is some what Global or appearance that particular patient differential

57:53

like noses was very wide this place. Yeah versus two

57:56

more verses and stuff like this or even into vascular lymphoma and it

57:59

turn out to be it turn

58:02

out to be actually

58:04

Erasmussenencephalitis with chronic inflammation

58:07

and recreational microphage activation no evidence

58:10

of intravascular lymphoma and this patient was treated with

58:13

anterior Atomic and Nicholas and different

58:16

stimulation treatment in here. We can see again. There

58:19

are terminating in the NT.

58:24

Okay, finally, let's show the last thing is in here.

58:27

This is like very complex looking

58:30

we can see there is a DBS. There is a

58:33

sorry. There is a ICD which cardiac device

58:36

and then there's also a VNS but then it's very

58:39

interesting that the DBS one of the DBS wire is

58:42

actually going into the heart. So this is like an investigative

58:45

technique that these assumption is

58:49

that right the virus actually depression

58:52

is cause of one of the some of

58:55

the the post-mi arithmia and

58:59

and in the in the heart failure patients is

59:02

a heart failure patient and this is very interesting. We have

59:05

to be very careful when we look at these images on clinic so

59:08

they look like basically two different devices, but

59:11

the VMS unexpectively goes into

59:14

the heart is from the cardio if you study as

59:17

I said,

59:18

So basically a few take home notes, as I said already all of them epilepsy is

59:22

treatment. It blessed treatment is a long journey and every individual

59:25

walks through a different path and we have to understand this and we

59:28

have to be aware of surgical techniques and what they're

59:31

putting and diagnostic procedures and location

59:34

and complications are very important. We have to carefully evaluate them

59:38

and we have to understand that these are little GPS directions for

59:41

clinicians and surgeons and you can and and

59:44

this is for for people who are mainly reading the easiest studies

59:47

that you can actually find epileptogenic fossil

59:50

on dry head City and be first diagnose it

59:53

and then change our life, sometimes it's unusual

59:56

clinical presentation. I've seen that being actually

59:59

epilepsy cases for example patient comes

60:02

with repeat Syncopy, but when you carefully look at the head City, you can

60:05

actually see there's no temples there is and avoiding

60:08

potential pitfalls as I showed are very important. We need

60:11

to know the surgical timing. We need to know the treatment and then

60:14

cross modality evaluation is important and most importantly

60:18

Imaging is important, but not just like looking at prior Imaging

60:21

and then just thinking whatever they say as I

60:24

showed in one example, they can remove catheter or replace or

60:27

put in another place. So we have to be careful where they

60:30

are. They're amazing every single time when we look at them and we

60:33

synthesize all the data points and provide our opinion because this

60:36

is what clinicians are wanting from us. We need

60:39

to give our opinion to help them.

60:42

All right last and but not least. So these are so

60:46

this code is from a very eminent behavioral neurologist

60:49

saying that the the temporal seizure temporal

60:52

the seizures can actually strengthen neural

60:56

connections between visual object and face area and

60:59

amygdal and Nicholas and humans and then enabling enabling

61:02

him to attend to a certain critical Dimensions that

61:05

more than you and I or anybody else can

61:08

achieve this code this this were words

61:11

are by this nor biologists are actually

61:14

for one call which was a

61:17

remarkable artist and and unfortunately suffering some

61:20

seizure activities not necessarily epilepsy, but

61:23

that's seizures.

61:25

And then thank you very much everybody for your attention

61:28

and for joining us today. I'm

61:31

ready to get any of questions that you have. Please

61:34

don't hesitate to ask us

61:37

your question.

61:39

All right, seeing if there are no questions, thank you so much for that. Great talk

61:42

doctor aene. I learned a lot and thanks to all her participation and

61:45

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62:06

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62:09

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62:12

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62:21

Thanks so much.