Essential standard work and patient care techniques: stereoelectroencephalography, stereotactic targeting, and laser interstitial thermal therapy
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1 Essential standard work and patient care techniques: stereoelectroencephalography, stereotactic targeting, and laser interstitial thermal therapy Jeffrey S. Raskin, Kathryn M. Wagner, Dylan Adams, JoWinsyl Montojo, Howard L. Weiner, Sandi Lam, Daniel J. Curry Division of Pediatric Neurosurgery, Texas Children s Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas USA
2 Conflicts of interest No financial disclosures xxx00.#####.ppt 7/18/2017 7:20:38 AM
3 The very first steps towards success in any occupation is to become interested in it. Sir William Osler
4 What is surgical epilepsy? ` Surgical epilepsy at TCH Standard work tools
5 Surgical Epilepsy Epilepsy = seizure disorder Treatment goal: No seizures, no side effects 30% can not be cured by medications alone Ongoing seizures and medications profoundly affect the developing brain xxx00.#####.ppt 7/18/2017 7:20:40 AM
6 Neuropsychological evalaution Functional Imaging Structural Imaging Surgical Epilepsy Centers Table 1: Phase 1 modalities available in pre-operative surgical epilepsy evaluation Computed tomography / angiography (CT/CTA) Magnetic resonance imaging / angiography (MRI/A) Functional MRI (fmri) Resting state MRI (rsmri) Magnetic resonance spectroscopy (MRS) Diffusion tensor imaging (DTI) Positron emission tomography (PET) Single positron emission computed tomography (SPECT) Brain electrical source analysis (BESA) Standardized low resolution brain electromagnetic tomography (sloreta) Magnetoencephalography (MEG) Intracarotid amobarbital procedure (Wada) xxx00.#####.ppt 7/18/2017 7:20:41 AM
7 Congruent Phase I data surgery xxx00.#####.ppt 7/18/2017 7:20:41 AM
8 xxx00.#####.ppt 7/18/2017 7:20:41 AM medscape.com
9 Phase II ieeg xxx00.#####.ppt 7/18/2017 7:20:41 AM
10 Surgical Management Resective surgery Lesionectomy Lobectomy Quadrantectomy Modulation RNS VNS DBS Disconnective surgery Corpus callosotomy Hemispherectomy/otomy Ablative surgery SLA Focused US xxx00.#####.ppt 7/18/2017 7:20:41 AM
11 What is surgical epilepsy? Surgical epilepsy at ` TCH Standard work tools
12 THE TEAM Operating Room Staff Valentina Briceno, RN Loretta Idlebird, CST JoWinsyl Montojo, RN Hilary Newding, RN Advanced Practice Providers: Rebecca Schultz, PhD, RN, CPNP Teri Baierlipp, PA-C Laura Whittaker, PA-C Kelly Frost, CPNP Mallory Fernandez, CPNP Jessica Frontiero, FNP-C Clinic Nurses/Medical Assistants Pediatric Neurosurgeons Daniel J. Curry, MD Sandi Lam, MD, MBA Howard Weiner, MD (Thomas Luerssen, MD) (William Whitehead, MD) Clinical Program Coordinator Marissa Bragdon, RN Social Workers Neuroradiologists Neuropsychologists Karen Evankovich, PhD Jennifer Haut, PhD Pediatric Epileptologists James Riviello, MD Anne Anderson, MD Laura Masters, MD Michael Quach, MD Elaine Seto, MD Irfan Ali, MD Rohini Coorg, MD Anuranjita Nayak, MD Monika Ummat, MD Dieticians Jillian Davis, RD Lauren Kronisch, RD Neurophysiology Technicians Anestheisiology
13 Stereotaxy Location Surgery type CRW Frame (Integra) 1. Localizer in OR 2. CT scan 3. Back to OR for planning of trajectory, placement of cath/fiber Laser Fibers/ Ablation in MRI 1. Visualase 2. Monteris ROSA (Zimmer) 1. In-bone fiducials in OR then CT scan vs. laser registration only 2. Back to OR for planning of trajectory, placement of cath/fiber SEEG Clearpoint (MRI Interventions) All done in MRI suite Cyst/shunt catheter placement in MRI/OR Biopsy in MRI/OR Curve Navigation (Brainlab) In OR for registration, planning of trajectory, placement of cath/fiber. Scans are done pre-op. Navigation for open cranis, spines in OR Stealth Navigation (Medtronic) In OR for registration, planning of trajectory, placement of cath/fiber. Scans are done pre-op.
14 Stereotaxy Location Surgery type Laser Fibers/ Ablation in MRI 1. Visualase 2. Monteris ROSA (Zimmer) 1. In-bone fiducials in OR then CT scan vs. laser registration only 2. Back to OR for planning of trajectory, placement of cath/fiber SEEG
15 Click to edit Master title style Alternate slide template This is a good background to use when the slide has pictures with white borders.
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18 What is surgical epilepsy? Surgical epilepsy at TCH Standard work tools`
19 xxx00.#####.ppt 7/18/2017 7:20:46 AM
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21 We defined dynamic seeg Dynamic seeg describes the intentional placement of DE along trajectories which are chosen based on cumulative preoperative clinical, radiographic, functional, and electrophysiologic data. Based on all Phase I data, dynamic seeg DE are placed along a trajectory that optimizes the subsequent laser ablation of that SOZ. Currently, no unified naming convention exists to encode the data elements of each trajectory.
22 I. Each trajectory begins with an integer. II. III. IV. Rule set Capital L or R designates lateralization and follows the integer; then a space is inserted. A capital letter or short moniker identifies the anatomical entry point. i. If entry points are similar anatomically and close together, use m (mesial) and l (lateral) preceding the entry point (e.g. mmfg) A capital letter or moniker identifies the anatomical target point; then a space is inserted. i. If the target point and entry point are in the same lobe, only one designation is necessary (orthogonal short middle frontal gyrus, MFG) V. Phase 1 modalities are listed consecutively and alphabetically in lower case (unless specified, e.g. Mc). 1R AntT Sp 2L Occ ad 3R MFG amcp 4R OccT asp 5L mpostcav amc
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27 Table 1: Demographics Epoch 1 Epoch 2 Significance Age (range / mean in yrs) 7-18 / / Gender (N / % male) 3 / / 50 NS Phase II non-seeg (# / %) 8/50 14/50 NS Phase II seeg (# / %) 8/50 14/50 NS Average DE per seeg (#) Average T/DE per seeg (min) / /
28 Time per electrode (min)
29 Summary Coined term dynamic seeg Developed standard work manual Developed naming convention for each trajectory Created intraoperative seeg specific white board Created a seeg planning form for improved global research Reduced time per electrode by 40% xxx00.#####.ppt 7/18/2017 7:20:49 AM
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31 Acknowledgements My patients Surgical mentors Guillermo Aldave Daniel Curry Robert Dauser Andrew Jea Sandi Lam William Whitehead Howard Weiner OR staff JoWinsyl Montojo Loretta Idlebird Valentina Briceno Hilary Newding Baylor, Methodist, and UTMB Neurosurgical Residents NPs and PAs Office staff Epileptologists xxx00.#####.ppt 7/18/2017 7:20:49 AM
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