ROSA technology helps ease patient’s violent seizures

From the Spring 2020 edition of Vanderbilt Medicine Magazine

Pediatric neurologist Kevin Ess, MD, PhD, left, and pediatric neurosurgeon Robert Naftel, MD, follow up with patient Daniel Lookabaugh, who has epilepsy. Photo by Anne Rayner.

Daniel Lookabaugh, a 20-year-old electrical engineering student who has epilepsy, has never driven a car because of violent seizures and had to put his schooling on hold last year.

His seizures began about age 3. They became more frequent as he got older, then became so intense two years ago that he would dislocate his shoulder and jaw.

In December 2018 he experienced six severe seizures, requiring hospitalization at Monroe Carell Jr. Children’s Hospital at Vanderbilt each time to receive neurological care and intervention from pediatric orthopaedics to reset his jaw and shoulder.

With the help of new technology at Children’s Hospital, a device known as the ROSA (Robotic Stereotactic Assistance) Robot, Lookabaugh’s doctors, pediatric neurologist Kevin Ess, MD, PhD, and pediatric neurosurgeon Robert Naftel, MD, believe he will get the chance to drive and will miss less school.

The ROSA is a robot that assists in inserting EEG electrodes into patients’ heads, helping neurosurgeons precisely identify seizure hotspots safely, effectively and efficiently. Using the device, they can pinpoint precisely where seizures begin by monitoring his brain activity — without having to perform a craniotomy.

Lookabaugh was among the first Children’s Hospital patients to have the ROSA procedure, and was able to have life-changing brain surgery after the ROSA helped identify that his seizures were coming from the left temporal lobe. He was seizure free for five months.

“For epilepsy surgery this has been a paradigm shift in the way we do invasive monitoring,” said Naftel, associate professor of Neurological Surgery. “The robot allows us to do epilepsy monitoring in the safest, most precise, high-tech way available. For our patients, that means they are getting the highest level of care available to determine their epilepsy surgery needs.”

Lookabaugh’s seizures stem from a prenatal stroke that damaged about one-sixth of the left side of his brain. Since that portion of his brain is unused and mainly causing seizures, functions like language that would normally exist there relocated to the right side as his brain developed, a phenomenon known as plasticity.

Ess, chief of the Division of Pediatric Neurology at Children’s Hospital, knew that the only way to help him was to find a way to lessen or stop the seizures.

“He was initially well controlled. Then he was having more seizures, even with increased medicines. I knew that he was a potential candidate for surgery because he had an old, focal lesion from birth and his brain had the opportunity to reorganize itself and have normal function. But to do the surgery, we needed better technology and more information to help nail down the area causing the seizures,” said Ess, the Gerald M. Fenichel Professor of Neurology.

At Children’s Hospital, before surgery is an option, doctors also consider diet interventions as well as medication options to treat seizures. The National Association of Epilepsy Centers identifies Children’s Hospital as Middle Tennessee’s only Level 4 center, offering the highest level of care for epilepsy, which affects about 6 in 1,000 children.

In the past, Naftel and other neurosurgeons removed portions of the skull to insert subdural electrodes attached to a grid — more invasive and providing less detail and data than the ROSA. The patient is then monitored for seizures with invasive electrodes in place during a hospital stay. Children’s Hospital is the only facility in the Midstate with video-EEG monitoring for the evaluation of children for epilepsy surgery.

When other treatment paths don’t work, Ess looks to the neurosurgery team for surgical options. Naftel and Ess create a detailed plan using EEG, MRI and PET scans and patient history to then input into the ROSA computer, which precisely guides where each electrode should be placed.

“With this technology, we can create a personalized plan for every patient,” Naftel said.

Small holes less than 0.8 mm in diameter are drilled and each electrode (which varies in number for each patient) is inserted. Lookabaugh had eight electrodes for a total of 96 contacts inside the brain to record data.

Two weeks passed before a seizure occurred.

“For Daniel, he is no longer having seizures or dislocating his arm and his jaw, and he has a chance now where he could drive,” said Ess. “It’s life changing at this point, but we’re not promising a cure yet. He has had seizures for many years, but his current status is so much better that we are all optimistic for Daniel’s future.”

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