Seizure Detection/Prediction Devices and Therapies

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1 Seizure Detection/Prediction Devices and Therapies Gregory Worrell MD, PhD Mayo Clinic American Epilepsy Society Annual Meeting

2 Disclosure Company Neuralynx Inc. NeuroPace Inc. Medtronic Inc. NeuroVista Inc. NIH Relationship Research Scientific Advisory Board Clinical trial Scientific Advisory Board R01- NS063039, U01-NS & U24-NS American Epilepsy Society 2013 Annual Meeting

3 Learning Objectives Epilepsy Devices: State of Art Big Data Applications Seizures are not Random American Epilepsy Society 2013 Annual Meeting

4 Challenges in Epileptology Detection: Seizures & Quantification Epilepsy Diagnosis & Therapy Diary & EMU Epilepsy Therapies Drugs, Surgery & Stimulation Forecasting: Seizures are not Random Spatial Predictability Temporal Predictability

5 Devices for Epilepsy Duty Cycle Stimulation Responsive Stimulation Forecasting Vagus Nerve Stimulation Cyberonics Inc. Stimulation Anterior Nuc. Medtronic Responsive PC + S (sensing Neurostimulation & stim) NeuroPace Medtronic Forecasting SAS NeuroVista Brain Stimulation and Prediction Devices not approved for Epilepsy

6 Responsive Neurostimulation Responsive Neurostimulation System NeuroPace Inc

7 Seizure detection & stimulation J. Echauz, AES 2001 B. Wingeier EMBS 2011

8 Implant Responsive Neurostimulation System M. Morrell et al. Neurology months Therapy ON Therapy OFF Baseline Trial Phase Open Label Phase Patients 32 Centers 240 implants 191 pts yrs Failed 2 AED 3 Sz/month 20y epilepsy End of 3 Month 94 Sham & 97 Tx Stim-on: % Stim-off: % p=0.012 Safety: >275 pt-yrs Last 3 month Outcome 51% RR (61 patients) 58% Hippocampus 46% Neocortical 11% w/90% reduction

9 Bilateral Independent TLE Spencer et al. Epilepsy Research 2011 D. King-Stephens et. al. AES 2013 Left Right Jun Jul Aug

10 The Value of Forecasting Person with uncontrolled seizures Time in seizure ~ minutes/yr 99.9% seizure free Drugs Daily Uncertainty = Disability Uncertainty = Injury Courtesy of NeuroVista Inc. Prediction Devices not approved for Epilepsy

11 Are Seizures Random? Deterministic Seizures are predictable (9:45 AM May 17) Time Dependent Probability Pre-ictal state Seizure Forecasting possible Precursory Signal

12 Seizure often Clusters S. Haut Epilepsy & Behavior 2006 Kadam et al. J. Neurosci 2010 Kadam S D et al. J. Neurosci. 2010

13 Prediction of Natural Phenomena Complicated Problem Physics known Good Big Data - multiple scales Good predictions Weather Prediction-Big success

14 Earthquake Prediction 1906 Earthquake San Francisco California 1989 Earthquake San Francisco, CA

15 Seizure Prediction Mormann etal. Brain 2006 Prediction is difficult especially when it is about the future Nils Bohr

16 Forecasting Seizures Probabilistic prediction (forecasting) Increased risk of seizure (red-light) Decreased risk of seizure (blue-light) Observation of a precursory signal State change: InterIctal PreIctal Ictal Utility Warn patient (minutes, hours, days?) Deliver pre-emptive therapy (AED, Stim.)

17 Pre-Ictal State? D. Snyder et al. JNeural Eng t t t t InterIctal Pre-ictal State Ictal State

Electrophysiology Feature Extraction Classifier Training Training Data Feature selection

18 Machine Learning Classification Mirowski EpilepsyRes 2009 Netoff Epilepsia 2011, Howbert PLOS-One 2013 Signal Required Understanding Physiology Big Data Pre-Processing Electrophysiology Feature Extraction Classifier Training Training Data Feature selection Interictal Preictal Ictal PostIctal Classifier Optimization Performance Measures Classify Test Set

19 Forecasting Seizures Cook, O Brien, Berkovic et al. Lancet Neurology 2013 NeuroVista Inc. Prediction Devices not approved for Epilepsy PAD Data Card

20 Forecasting Seizures Cook, OBrien, Berkovic et al. Lancet Neurology patients enrolled

21 Forecasting Seizures Cook, OBrien, Berkovic et al. Lancet Neurology People w/ Epilepsy Responsive Seizure Diaries AED Only 5/11 correlate Seizure Diaries

Epilepsy Res. 2011 Coles et al. Epilepsy Res.

22 Forecasting Canine Seizures NIH-U01 Team: NeuroVista, UMinn, UPenn, Mayo Davis et al. Epilepsy Res Coles et al. Epilepsy Res Howbert et al. Plos-One 2013 PAD Data Card

23 Forecasting Seizures Howbert PLOS-One 2013 & Brinkman 2013

24 Spatial Scales of interest Human Brain Electrophysiology ~ 10,000 mm 1000 mm 10 mm Frequency Scales of interest

25 Electrophysiological Biomarkers Goldensohn 1975; Schevon 2008; Stead 2010 Pathological Micro-domains ~300 mm Time (seconds)

26 Clinical Impact The Future 2025: Big Data & Machines Data to guide treatment Forecasting Risk for Epilepsy (Epileptogenesis) Prevention Spatial Forecasting (Localization) Surgery & Stimulation Temporal Forecasting Neurophysiologically based therapy

27 Path to Future: Machines & Data Devices, Data & Tools NIH EEG Portal (ieeg.org) Share Data (Reproducible Results) Contest (2014 AES Presidential Symposium) Seizure Detection (Human ieeg recordings ) Seizure Forecasting (Canines & Humans)

EPILEPSY. New Ideas about an Old Disease. Gregory D. Cascino, MD

EPILEPSY. New Ideas about an Old Disease. Gregory D. Cascino, MD EPILEPSY New Ideas about an Old Disease Gregory D. Cascino, MD Disclosure Research-Educational Grants Neuro Pace, Inc. American Epilepsy Society American Academy of Neurology Neurology (Associate Editor)