Josh Rosario, age 7, has had epilepsy since early childhood. While his disease has improved under the care of pediatric epileptologist Parrish Winesett, M.D., at All Children’s Hospital Johns Hopkins Medicine, he still has 50 or more seizures each day. Josh has Lennox-Gastaut syndrome, a particularly challenging and treatment-resistant form of epilepsy.
Robin, Josh’s mom, sums it up this way: “His brain pops like popcorn.”
This Naples family hoped that a state-of-the-art robotic neurosurgery system now available at All Children’s will help Josh have far fewer seizures—or perhaps even become seizure-free. All Children’s is the first hospital in Florida to use this new technology, and Josh was the first patient to undergo the new procedure using the robotic neurosurgical assistant.
Winesett, director of pediatric epileptology, and the team of pediatric neurosurgeons use the robot to perform intracranial seizure monitoring to determine where in the brain seizures arise. “Using the robot helps us advance treatment for patients with severe epilepsy,” says Winesett. “This new technology not only assists us in in identifying where in the brain seizures may be occurring, but also helps us target these areas with greater precision to provide families with answers on how to stop the seizures.”
More precise, less invasive
Previously, the team had to perform an invasive and prolonged procedure (called a craniotomy) lasting 3-4 hours to remove a sizeable piece of the skull and place electrodes on the brain’s surface to record seizures. Patients stayed in the hospital’s seizure monitoring unit for up to two weeks for continuous EEG (electroencephalography) to record and map seizure activities. They were often uncomfortable due to the sheets of electrodes remaining on their brain and the pain of recent craniotomy.
“Previously the difficulty of doing bilateral skull surgery and placing plates of electrodes on both sides of the brain made it hard to evaluate patients like Joshua,” explains Winesett, “because we were unsure which side of the brain had the abnormality.”
The new robot uses a stereoencephalography (sEEG) system that combines data from MRI of the brain and from standard EEG to guide the surgeon in drilling tiny holes in the skull and then placing the electrodes both on and inside the brain in one to two hours, with amazing precision.
“The robot acts as a navigation system for the brain,” says pediatric neurosurgeon Gerald Tuite, M.D. “We review areas of abnormal brain activity and enter the data into the robot prior to surgery. During the procedure, the robotic arm guides the electrodes to a pre-planned path that allows the neurosurgeons to make tiny, precise incisions and place electrodes in areas that we suspect may be the source of seizures.”
After the team identifies where the seizures are occurring, they can use the data they’ve acquired to subsequently plan and perform surgery to remove that area of the brain.
The new procedure is less invasive and has the ability to easily monitor both sides of the brain as well as areas that are difficult to assess with traditional grids—such as in the midline or undersurfaces of the brain. Patients are much more comfortable during the monitoring period because the small drill holes cause less pain.
This minimally invasive technique also reduces the amount of time that a child is under anesthesia. The quality of the sEEG data is so helpful that most patients have a significantly shorter hospital stay—and there’s no need for a second invasive surgery to remove the electrodes.
“Only about 20 hospitals in North America are utilizing this robotic system, so we are fortunate here at All Children’s to have this technology to treat some of the most complex brain disorders,” said pediatric neurosurgeon George Jallo, M.D., who joined All Children’s in September to lead the newly established Johns Hopkins All Children’s Institute for Brain Protection Sciences
. He previously led the division of pediatric neurosurgery at the Johns Hopkins University School of Medicine in Baltimore.
Hoping for new answers and the promise of surgery
Josh’s parents had few worries about his being the first patient to undergo the new procedure at All Children’s.
“We have every confidence in Dr. Winesett and the team, and we know that God guided us to Dr. Winesett to help Josh,” Robin said a few days before the procedures. “Our faith, friends and family help us through. We’re hoping that he’ll have plenty of seizures once the electrodes are inserted so that the team can find the answers they need.”
Josh woke up just a few hours after the procedure and soon told his parents he was okay, flashing a thumbs-up sign.
The next morning, as Josh enjoyed pancakes and watched a movie, he’d had numerous small seizures and two grand mal seizures by 10 a.m.—all producing valuable sEEG data. By early afternoon, Winesett was able to identify the area of the brain where most of Josh’s seizures were arising. The team continued to gather valuable information on Josh’s seizure activity until the electrodes were removed on Monday, October 5. Josh and his parents headed home the following day.
The team’s next step was to fully analyze the data and develop a surgical plan for removal of the epileptic focus (the area of the brain where most of the seizures originate). In Josh’s case, the focus is in the brain’s right frontal lobe. In late October, after the tiny drill holes had fully healed, the team performed surgery to remove a portion of this area. Two days later Josh was able to take part in All Children’s Halloween activities for hospitalized patients and then head home. Winesett will evaluate Josh’s progress through follow-up visits.
Though the valuable data that made Josh’s surgery possible was gathered using the new robotic technology, the robot wasn’t part of the epilepsy surgery itself. The neurosurgeons already have years of experience and expertise in epilepsy surgery, and the team will explore options for using the robot to enhance this procedure and other complex brain surgeries in 2016.
“We are very pleased that the new technology expands the range of diagnostic options for our pediatric epilepsy patients in order and makes epilepsy surgery a treatment option for more children,” says Winesett.