AI-Inspired Future Directions for Epilepsy Surgery

Podcast Transcript

Neuro Pathways Podcast Series

Release Date: January 1, 2024

Expiration Date: January 1, 2025

Estimated Time of Completion: 29 minutes

AI-Inspired Future Directions for Epilepsy Surgery

Demitre Serletis, MD, PhD

Description

Each podcast in the Neurological Institute series provides a brief, review of management strategies related to the topic.

Learning Objectives

• Review up to date and clinically pertinent topics related to neurological disease
• Discuss advances in the field of neurological diseases
• Describe options for the treatment and care of various neurological disease

Target Audience

Physicians and Advanced Practice providers in Family Practice, Internal Medicine & Subspecialties, Neurology, Nursing, Pediatrics, Psychology/Psychiatry, Radiology as well as Professors, Researchers, and Students.

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CREDIT DESIGNATION

• American Medical Association (AMA)

Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Participants claiming CME credit from this activity may submit the credit hours to the American Osteopathic Association for Category 2 credit.

• American Nurses Credentialing Center (ANCC)

Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 ANCC contact hours.

• Certificate of Participation

A certificate of participation will be provided to other health care professionals for requesting credits in accordance with their professional boards and/or associations.

• American Board of Surgery (ABS)

Successful completion of this CME activity enables the learner to earn credit toward the CME requirements of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

Credit will be reported within 30 days of claiming credit.

Podcast Series Director

Imad Najm, MD

Epilepsy Center

Additional Planner/Reviewer

Cindy Willis, DNP

Faculty

Demitre Serletis, MD, PhD

Epilepsy Center

Host

Glen Stevens, DO, PhD

Cleveland Clinic Brain Tumor and Neuro-Oncology Center

Agenda

AI-Inspired Future Directions for Epilepsy Surgery

Demitre Serletis, MD, PhD

Disclosures

In accordance with the Standards for Integrity and Independence issued by the Accreditation Council for Continuing Medical Education (ACCME), The Cleveland Clinic Center for Continuing Education mitigates all relevant conflicts of interest to ensure CME activities are free of commercial bias.

The following faculty have indicated that they may have a relationship, which in the context of their presentation(s), could be perceived as a potential conflict of interest:

Imad Najm, MD	Eisai Advisor or review panel participant NIH Other activities from which remuneration is received or expected: Research Funding LivaNova, PLC Advisor or review panel participant SK Life Science Inc Advisor or review panel participant Teaching and Speaking
Glen Stevens, DO, PhD	DynaMed  Consulting

 The following faculty have indicated they have no relationship which, in the context of their presentation(s), could be perceived as a potential conflict of interest: Cindy Willis, DNP, Demitre Serletis, MD, PhD

CME Disclaimer

The information in this educational activity is provided for general medical education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options of a specific patient's medical condition. The viewpoints expressed in this CME activity are those of the authors/faculty. They do not represent an endorsement by The Cleveland Clinic Foundation. In no event will The Cleveland Clinic Foundation be liable for any decision made or action taken in reliance upon the information provided through this CME activity.

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Go to: Neuro Pathways Podcast Jan 1 2024 to log into myCME and begin the activity evaluation and print your certificate. If you need assistance, contact the CME office at myCME@ccf.org

Copyright © 2024 The Cleveland Clinic Foundation. All Rights Reserved.

Introduction: Neuro Pathways, a Cleveland Clinic podcast exploring the latest research discoveries and clinical advances in the fields of neurology, neurosurgery, neuro rehab, and psychiatry.

Glen Stevens, DO, PhD: For patients with drug-resistant epilepsy, surgery offers the best chance for reduced seizure burden and even seizure freedom. Technological advancements such as brain mapping techniques and minimally invasive approaches have revolutionized the field and made surgery more effective, safe and comfortable for patients. In this episode of Neuro Pathways, we're discussing future directions for epilepsy surgery and treatment, and the technology and research that will pave the way. I'm your host, Glen Stevens, neurologist, neuro oncologist in Cleveland Clinic's Neurological Institute. And joining me for today's conversation is Dr. Demitre Serletis. Dr. Serletis is a neurosurgeon in the Epilepsy Center within Cleveland Clinic's Neurological Institute, and a researcher in the Department of Biomedical Engineering within Cleveland Clinic's Lerner Research Institute. Demitre, welcome to Neuro Pathways.

Demitre Serletis, MD, PhD: Thank you so much.

Glen Stevens, DO, PhD: So, Demitre, why don't you share with myself and the audience a little bit about your background and how you came to the Cleveland Clinic?

Demitre Serletis, MD, PhD: Sounds great, and thank you again for having me here. So, I am a Canadian. I grew up in the north and I did my residency and my PhD studies at the University of Toronto, close by. I was very fortunate in 2012 to come to Cleveland and I did a very significant fellowship in epilepsy neurosurgery at that time. And it was a pivotal time. I learned a lot about surgical resections and also the future. We had the robot, and we were started with stereo EEG and other techniques to explore the brain.

After a year in fellowship, the typical thing is to look for a position somewhere. I found a great spot in Little Rock, Arkansas, a random place for a Canadian to go, but it was actually a very significant move. They had no epileptologists in the state at that time, and I was the only epilepsy surgeon. I was very lucky to spend three and a half years there. We built a small but humble epilepsy surgery program. And then I was recruited back to Winnipeg, Canada in the coldest spot in the country. I spent six more years and I've been now very fortunate to be recruited back to the Cleveland Clinic since last year. So I'm almost at two years now to the day.

Glen Stevens, DO, PhD: So, let's talk about epilepsy a little bit just to set the stage.

Demitre Serletis, MD, PhD: Sure.

Glen Stevens, DO, PhD: So, if we look at what we call, I guess, drug-resistant epilepsy, what percentage of patients on medication have drug resistant epilepsy?

Demitre Serletis, MD, PhD: About one-third of patients with epilepsy are refractory to medications in general. And epilepsy in general is a very common condition. It affects one in 25, one in 26 people. Seizures themselves can happen one out of 10 individuals in fact. So, it's very common. And in fact, epilepsy takes as many lives as breast cancer does, for example. But it's not very well understood or known really about in the community yet. But there are lots of movements underway. And for those patients who are refractory to epilepsy, this is where surgery has great benefits, great promise for those patients.

Glen Stevens, DO, PhD: Yeah, I remember in medical school when I first heard that one in 10 patients will have a seizure, not epilepsy per se, but have a seizure in their lifetime, it's quite an impressive statistic. And if you look at, as you say, the number of patients with epilepsy, you're talking in the several million. So, drug-resistant is probably, if it's a-third of those, is probably a million.

Demitre Serletis, MD, PhD: It's a million.

Glen Stevens, DO, PhD: Patients.

Demitre Serletis, MD, PhD: Almost 2 million perhaps, yeah.

Glen Stevens, DO, PhD: Yeah, which is a lot. And then of course if you look worldwide, you're in the multiple millions as it goes through. So, a very real problem. So, before we get in specifically to the future of epilepsy surgery, give us a brief overview of the current surgical modalities and the major advances that got us here.

Demitre Serletis, MD, PhD: I mean, this is a very, very broad topic, but there are highlights. I mean, the first EEG was performed in 1929, if I recall correctly, by Dr. Berger, a psychiatrist. And from that time on, there've been major leaps and bounds. Classically, epilepsy surgery, we're talking about resections, craniotomies to access the brain and resect in a careful, moderated way, a target that's the source of the seizure onset and early spread. And even that concept has gone through several iterations over time. In the former era, not that long ago, over a decade ago, we used to put grids and strips on the surface of the brain. And I'm glossing over the workup. And I should make a point to that, that allows patients to go forward with epilepsy surgery. We're talking about EEG studies, MR imaging studies, and a host of other nuclear medicine types of tests, neuropsychological tests and so on.

Then when a patient is established as a candidate, many of them will go on to what I was talking about, a resective option. We're in an era where there are other surgical modalities too. Now we have lasers, we use robots in some of these procedures. There are implantable devices like a brain defibrillator for example. It's a neurostimulator of a sort that can be implanted into an epileptic focus too. And there are other types of neuromodulatory paradigms. We are talking about vagal nerve stimulation, deep brain stimulation, those types of treatments also. So that's a quick smattering and overview of the spectrum as it stands. If you were to say which one is the most successful, generally speaking, the more that you're able to remove or ablate, the better a patient can do as long as it's done safely of course.

Glen Stevens, DO, PhD: And are you yourself doing ablations or just resective surgeries?

Demitre Serletis, MD, PhD: I am. I do most of the spectrum. Really the one thing that I don't treat myself is the deep brain stimulation. We have a colleague in our group who does that, extra and he does a fine job with deep brain stimulation. But apart from that, we do offer the entire complement of those services there.

Glen Stevens, DO, PhD: And I guess the other thing that we should mention before we move on is you guys have a very in-depth epilepsy conference where you discuss your cases.

Demitre Serletis, MD, PhD: Absolutely.

Glen Stevens, DO, PhD: Can you just mention that a little bit?

Demitre Serletis, MD, PhD: Yes, I'd love to mention that. I think that is key to a successful epilepsy surgery program. And I say that from a humble standpoint of being in the unique position of eye surgeon having tried to start a program in two underserved parts of the world. The epilepsy surgery conference that we have is multidisciplinary. We have participants from neurology, neurosurgery, radiology, neuropsychology, ethics, pharmacy. The entire team is there. And this is something that allows us to offer recommendations to patients. Not coming now from just one individual, but as a team, as a collective approach. And it makes for the safest and best and most ethical decision-making I've seen.

Glen Stevens, DO, PhD: So, I know we're going to get into AI here in a minute, but what about the efficacy of surgery? So, a third of patients have drug-resistant epilepsy. If we take them to surgery, I'm sure it depends on if it's mesiotemporal lobe or extratemporal and all those types of things. But in general, what's the efficacy from surgery?

Demitre Serletis, MD, PhD: It's a range. In our best-case scenario where we have someone with temporal lobe epilepsy for example, and let's say that there's lesional features on an MRI scan supported for mesial temporal sclerosis, it refers to scarring within the hippocampus and the amygdala, the success rates can be quite high with resection. And we give a range because epilepsy keeps us humble, but it's between 50 to 80 percent. If you convert this into a number needed to treat statistic, it comes out at about two. And you don't see numbers like this in medicine, the number needed to treat for patients suffering from a myocardial infarction, giving them aspirin is 3,500 to prevent one. And so, we're talking about a number needed to treat two to improve one, if not both patients. It's remarkable.

In other parts of the brain, the frontal lobe, the parietal lobe, these are much larger geographic spaces. And so, localization of seizures can be challenging. And to help with this, we have a method called stereo electroencephalography. It's a mouthful, SEEG we call it for short, where we use a method for very careful, precise implantation of electrodes into the brain, avoiding all the blood vessels there too, to record from the depths of the brain. And this has improved our success rates. So, in general, we're speaking anywhere between 50 to 70 percent for most forms of localizable epilepsy.

Glen Stevens, DO, PhD: So, a third of patients have drug-resistant epilepsy. How many patients aren't we touching? Because the numbers in statistics that you present would suggest we probably should be doing more surgery than we're doing.

Demitre Serletis, MD, PhD: I agree with that. And if you look at those numbers, we were talking about epilepsy, from a societal standpoint, less than 1 or 2 percent of the patients who would benefit from surgery in North America ever get referred to a surgeon's office.

Glen Stevens, DO, PhD: And why is that?

Demitre Serletis, MD, PhD: That's a very big question and it's hard to answer. I can tell you, having been in some of the humble origins that I started, there's a lack of awareness starting from, and it's no fault of their own, but family physicians, community neurologists, certain disciplines, radiology, neurosurgery and so forth. And if they have heard of epilepsy surgery, it's usually for a vagal nerve stimulator, something like that. They don't know that there are methods to localize scar tissue in the brain or even localize the epileptogenic zone when the imaging is normal. And we have tools to deal with that now.

Glen Stevens, DO, PhD: You know, as a neuro-oncologist, one of the things that I found beneficial about the Canadian system is that patients get referred to essentially centers of excellence, right? That geographically, everybody that had a tumor would go to a specific cancer center. So, you didn't have 10 regional hospitals doing things. Everything got set. Does epilepsy work the same way?

Demitre Serletis, MD, PhD: It very much does. And there is a formalized classification scheme in terms of levels 1 to 4 epilepsy centers. And level 4 epilepsy centers are those like ourselves, for example, who offer the entire compliment. And so, you could imagine a patient, the average length of time I've heard somewhere, and don't quote me on it per se, but it's about 10 years for them to be referred from the first seizure to the point that they get to a surgeon's office. And this is the typical time course for many patients that we get referred. It's very humbling and you sympathize very much with patients who are in these dire straits.

Glen Stevens, DO, PhD: So, from your perspective as both the neurosurgeon and an engineer, what do you think are the greatest opportunities for the field? And on the other side of it, your greatest challenges?

Demitre Serletis, MD, PhD: That's a great question. If I might explain a little bit, it was the love of neuroengineering and my PhD studies in residency that led me to the field of epilepsy. I liked mathematics very much. I tried to beat the stock market back in high school. I've obviously failed. I'm still here, but you never give up. But these methods have been very exciting to watch as they are now being applied increasingly to large datasets of the sort that we capture in medicine. And epilepsy is one of those spaces. Cardiac electrophysiology is one of those spaces, imaging and so forth. And what we're looking at with these engineering methods is we're trying to extract now in my case, from intracranial EEG recordings, certain mathematical or dynamical markers of change. And the study of dynamics refers to a scientific method of identifying what are the forces within a system guiding that change.

Our current methods of reviewing EEG are largely qualitative. We have clinician experts who review reams of data and there is a fatigability aspect to it. There is an expert aspect to it as well. There's so much more data than meets the eye in these large datasets that we're now able to extract mathematically and study them. And by doing this, we begin to open up the channels of understanding how do seizures start, are we even classifying them correctly. We might actually begin to develop a dynamic profile to capture certain types of epilepsies, which we are doing clinically in a sense, but now we have the tools with computer advances and so on. And now really what I'm talking about is putting this data in a context where you can then organize it and apply machine learning and artificial intelligence and begin to extract some patterns, use it to prognosticate, use it to simulate outcomes based on a resection or an ablation in a certain part of the network.

And for me, one of the other exciting aspects is this will begin to inform how we should neuromodulate. And there is a trend in surgery towards less and less invasive options. And our current methods of neuromodulation are still rather palliative. The outcomes are 30 percent. If you look at vagal nerve stimulation, deep brain stimulation and the responsive neurostimulator, these are characterized by square wave pulses. It's a very machine artificial type artifact. We need to be doing something more elegant. The brain is more elegant than that in order to correct those dynamics. And it's personalized, it's tailored from one patient to the next.

Glen Stevens, DO, PhD: So, you've sort of skirted a little bit, and we'll go into technologies and discoveries that will push the limits here, but I saw some really interesting work published by Kwan. Kwan, big researcher in the field of epilepsy. They published an article in JAMA in 2022 where they looked at AI to try and pick the best anti-seizure medication for a patient. My understanding is that they have a current ongoing study. It's not being done, I think, in the United States. It's being done in several countries out of the United States. But they're looking at newly diagnosed epilepsy patients with the same model, and they're using what they call either machine learning or deep learning to try and understand. So, the story is that you put someone on a seizure medication, they fail it, they have seizures, you then switch them to a second monotherapy and they're seizure free. And the question is, why didn't you put them on the second one first? And can we learn something about rational use of medications? So that sounds really exciting. And then how you are looking at AI from neurosurgical neuroengineering standpoint?

Demitre Serletis, MD, PhD: Exactly. And artificial intelligence, a quick word about that, and machine learning. These methods have been around for a while. We have always mathematicians; engineers have been using and relying on mathematical modeling to simulate data and ultimately to predict. It's caught fire now. It's a buzzword. And these methods are now increasingly used in healthcare to curate a dataset. So, scalp-EEG of the sort that you mentioned is one of those. We're beginning to learn how we can study EEG patterns in the context of sleep, in the context of pharmaceuticals and so on to guide patient care.

In my case, what we're trying to do is actually study, almost now we have 1,000 patients with implanted intracranial electrodes and data. And so, if you look back, we need to learn from this data now. We are literally using data-driven approaches to learn about the data from the data. You can do this with some of these methods. And this is a whole field called data science where you are trying to extract some kind of patterns and trends from a dataset where you don't understand the governing principles and there is no model to fit to this data for example.

In my case, we'd like to learn a little bit more about what are the dynamical principles leading to a seizure start and spread. Can we predict it? As surgeons, we put 15 or 20 electrodes in the brain. There's risk with every single pass, and we're never sure that we're going to be right in the exact spot. So can we extrapolate to better refine the analysis? And ultimately, this will allow us to build a dynamical platform where we are no longer just reviewing clinical data, but also the mathematical and dynamical aspect of this and characterize patients into profiles that allow us to predict who will benefit from what therapy. And at the same time, we will actually have a better way now to inform industry on how to stimulate the brain.

We still don't understand it. We know the methods that exist, like I said. We're putting in square wave pulses and just literally yelling or whispering to the brain, but it's not the language or the syntax that the brain uses. And if we refine those methods, we will find that these less invasive tools improve in their efficacy.

From a philosophical standpoint, I still look at this world, and I hope it doesn't happen for a long time, that this is the era of brain exploration. We open the brain, we resect it, we put gadgets and tools in there, all in a very coordinated and methodical way. We must now start to curate it and learn from this experience. And that will allow us to inform future directions. There will be a point in time where we may no longer be doing such large resections or certain procedure types, and I believe this is the path forward to that. And perhaps if we can refine where we perform these resections, maybe it could be a small set of nodes in a network. These are the types of ideas that are out there potentially down the road.

Glen Stevens, DO, PhD: So, anything else to tell us about the research that you're doing and what you're looking to discover?

Demitre Serletis, MD, PhD: So, I mean, the type of research I talk about encompasses a large range of fields spanning from chaos theory, which talks about certain dynamics being predictable in the short run, but not in the long run. Complexity theory, which says that the brain has both features that are predictable or deterministic and also is random. My PhD thesis was on the study of the background noise. Everybody studies the spikes in the foreground. And there's a lot of meaning in the background noise, which we only now have barely started to scratch the surface to understand what's happening in that context. And it contains a lot of information about the network and transitions towards a seizure state, but also how to stop and how the seizure stops.

Glen Stevens, DO, PhD: So, it sounds like if we can get more patients to the surgical suite that are out there, that we're going to have more data points, we're going to get these answers quicker, right?

Demitre Serletis, MD, PhD: Exactly. But we have to have a platform set up where we can study this information. We already have a large number of patients, but it takes a great amount of work to organize it in such a way that you can apply these methods. And at the same time, the more you put into your models, the better the performance of these classifiers and so forth will be in their performance. So that's ultimately where all of medicine in healthcare is heading right now. Everybody's trying to get on the AI bandwagon. I've heard of universities and institutions using AI to sort their emails, to rank applicants for residency and fellowship. It's a wild west right now, but if we can harness the power of AI and eventually quantum computing as well, I think there is a lot in store for where we're going to go and what we'll be able to do.

This is not only relevant to epilepsy, by the way. It's also relevant to the cognitive neurosciences, understanding how the brain works mechanistically. And so, I think the future holds a lot of potential for patients with Alzheimer's disease, for example, and other neurodegenerative conditions, strokes, things like that. In the industrial world, you have people like Elon Musk who are developing chips and things to restore function, to augment function. I think we're starting to see glimmers of how this may potentially be done in the future. Neurosurgeons will find themselves there. So, one message I have for young trainees is to get into the fray, try and learn some of this skill set. We may very well find ourselves implanting devices like the current ones of course, but also the future ones coming down the pipeline too.

Glen Stevens, DO, PhD: I was just in Vegas, I'm sorry I didn't win the jackpot.

Demitre Serletis, MD, PhD: That's okay.

Glen Stevens, DO, PhD: But let's say I won the jackpot, and I had a big slug of money that I could give you, what do you need? What currently do you need that you don't have? Or you don't know what you don't know?

Demitre Serletis, MD, PhD: That's a great question. I've never been offered something like that, to be honest. But honestly, I think we have most of the tools that we need, to be honest with you. It takes time. It takes patients. Clinically patients, but also just patients of course. That's how research is done. In our lab space, I'm very fortunate to have a couple of great postdocs and a data engineer. We have a very nice platform up now, and we're starting to look at some of those needles in the haystack. We've identified some features in our data. We're working on some nice manuscripts now too. So, I hope that shed some light on future directions.

Glen Stevens, DO, PhD: And in the epilepsy field, how collaborative is it across the country? Or is it a bunch of silos?

Demitre Serletis, MD, PhD: It's both. We are very privileged at our center. We have a very large epilepsy surgery center, and I'm just so grateful to be a part of it at this point. But there are many centers that don't have the same volume. They don't have the same infrastructure or resources. And also, on top of that, they're all doing things a little bit differently. And that's part of the problem. So, you can look at the NIH and other large organizations who are trying to streamline things now and they're offering funding mechanisms for large collaborative groups of people or institutions to gather data in a robust reproducible way and make it available too. In large institutions like ours, we have the privilege of not having necessarily to go that route. So, we're starting with what we have. And depends how things go over the next couple of years here, we may decide to look into some opportunities like that too.

Glen Stevens, DO, PhD: Your dream down the road for the effects that this will have on epilepsy, and I guess, is to increase cures, right?

Demitre Serletis, MD, PhD: Of course. This is all for the patient ultimately. You have patients who are, They've tried 10 medications before they've gotten to the surgeon's office.

Glen Stevens, DO, PhD: But that's a problem too, right?

Demitre Serletis, MD, PhD: It is, of course. Absolutely. So, some of these methods I'm describing will hopefully improve who benefits from what type of medication, who benefits from what type of surgical procedure. There are patients who've had two or three surgical procedures before they come to our doorstep, and we're trying another one for example.

What I hope for the future is that we eventually get to a more data-driven process that helps inform patients, can help predict outcomes, tell the surgeons better where to go, where to implant, how to implant or how to resect as well, and ultimately redefine how we stimulate the brain to stop dynamical disorders at least. We've had much greater success with functional disorders like Parkinson's disease and so on, with lots of progress made. But epilepsy being a network disorder of dynamics, it has broad networks. And so, a single point doesn't necessarily solve the problem. It's going to be multidimensional, multi-spatial. Perhaps a stimulator that has two or three nodes and you just tick them off 1, 2, 3 in a particular way. I can tell you that it'll be personalized and tailored from one patient to the next. There may be some similar types of epilepsies, but for the individual patient, I believe it will be very personalized in that sense.

Glen Stevens, DO, PhD: Well, on a rudimentary level, and I'm going back 30 years, I remember hearing about the kindling theory of epilepsy.

Demitre Serletis, MD, PhD: Yes, exactly.

Glen Stevens, DO, PhD: It was just like a kindling with firewood and the theory that seizures beget seizures. So, the longer you have seizures, the more likely you'll have seizures five years from now, 10 years from now. So, it would seem to me that we really need to get much better at limiting how many drugs we try.

Demitre Serletis, MD, PhD: Yes.

Glen Stevens, DO, PhD: That's easy for me to say. I'm not having surgery.

Demitre Serletis, MD, PhD: Of course.

Glen Stevens, DO, PhD: They say the only minor surgery is surgery that happens to someone else. But maybe there needs to be a limit in the number of anti-seizure medications that are tried before we do something surgical. And maybe the outcomes would just be better if we did that.

Demitre Serletis, MD, PhD: Yes, and that's correct. And that's a great big push not only nationally, but internationally. The recommendations from the International League Against Epilepsy, if someone has failed two or more medical paradigms attempt at medication treatment, they should be referred to a surgical center.

Glen Stevens, DO, PhD: But it would be interesting to see someone do a study to look at what the real-life practice pattern is, because I'm pretty sure it's probably not two medications.

Demitre Serletis, MD, PhD: No, I mean the reality is it's nowhere near that.

Glen Stevens, DO, PhD: Yeah, nowhere near.

Demitre Serletis, MD, PhD: Correct. Yeah.

Glen Stevens, DO, PhD: And again, it's a complicated issue and patients aren't going to be running to do something surgical.

Demitre Serletis, MD, PhD: That's correct.

Glen Stevens, DO, PhD: Especially if it's on their dominant language or memory area.

Demitre Serletis, MD, PhD: Exactly. That's correct.

Glen Stevens, DO, PhD: So, Demitre, things that we haven't touched on that are important that should be discussed?

Demitre Serletis, MD, PhD: I think we've covered a lot of ground. To recap, there's a lot of great things going on now for epilepsy surgery. This is one of the more exciting fields within neurosurgery. Obviously, I'm biased. But at the same time, we use a lot of technology. We are treating patients who have this potentially remediable, sometimes curative condition. We're very fortunate to have that approach where you get that occasional patient where you just cure the seizure and all of the homework that went into figuring out where they started and spread, and a nice surgical plan leads to a successful outcome. And it keeps us going in that sense.

And now we can take the advantage of time looking back at the data. I compare it to the study of the constellations and the stars. When Copernicus was looking at the sky, the heavens, he was collecting data every night measuring these constellations. And from that, he was able to ascertain the orbit of the planets and so on. That's what we need to do. We need to look back in an organized way and learn lessons now that are going to pave the road for the next 10, 20 years.

Glen Stevens, DO, PhD: Well, if I can give a plug for an interaction between our groups, I've learned a lot about tumors and seizures. One thing we realize that with gliomas, those that have an IDH1 mutation have increased risk of seizures.

Demitre Serletis, MD, PhD: Correct.

Glen Stevens, DO, PhD: Which we don't fully understand all of it, but a number of years ago, we started looking at some of our low grade astrocytomas, oligodendrogliomas that were having good survival. Overall, they'd done treatment, their tumor was fairly stable, but they're having intractable epilepsy. And I think that we need to go back and start looking at maybe looking for an epileptogenic focus and seeing if we can resect it because it will really improve the quality of life of these patients. So maybe our departments could look at doing something together down the road.

Demitre Serletis, MD, PhD: Absolutely. I think that's a great example where there could be collaboration. The lines do blur from the tumor to the brain interface and the networks around it as well. And you also mentioned genetics, and that's another exciting field. I'm certainly no expert on genetics, but there's a real push nowadays where we're studying some of the genetic features in the pathological tissues that have been resected. Now we're able to get some additional testing in advance of surgery, which is starting to inform the type of surgery we deliver or some of the type of care medications that we offer these patients. Again, we're learning from the data. So, the theme is very relevant not only to our humble discipline, but to many others out there too.

Glen Stevens, DO, PhD: Well, Demitre, it's been great having you here today. It's been a fascinating discussion and I can't wait to see the great progress that you make. And hopefully we can get involved with some interactions down the line. So, thanks for joining us today.

Demitre Serletis, MD, PhD: That's wonderful. Thank you so much. I'm grateful to be here again. All the best.

Conclusion: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast, or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And don't forget, you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our Consult QD website. That's consultqd.clevelandclinic.org/neuro, or follow us on Twitter @CleClinicMD, all one word. And thank you for listening.