long-term neuromonitoring

In Walter Isaacson’s New York Times bestselling book, The Innovators (a narrative about the people who created the computer and internet), he makes the following profound observation:

“First and foremost is that creativity is a collaborative process. Innovation comes from teams more than from the lightbulb moment of lone geniuses. This was true of every era of creative ferment. The Scientific Revolution, the Enlightenment, and the Industrial Revolution all had their institutions for collaborative work and their networks for sharing ideas.”

Not only has collaboration lead to innovation in the tech world, it has also been influential in the world of medicine. The Human Genome Project made up of international teams is a classic example of how collaboration contributes to advancements in medicine. Globalized collaboration has become a new and valuable trend for hospitals in recent years. Children’s of Alabama (COA) began a globalized collaborative surgery program in 2014. The COA Global Surgery Program partners with pediatric hospitals around the world, and one of these partnerships is with the National Children’s Hospital in Hanoi, Vietnam. This particular partnership is focused on pediatric patients with intractable epilepsy and expanding surgical treatment of epileptogenic foci, especially non-lesional epilepsy.  Currently there are 3 processes in this collaboration: teams traveling to train medical personal in Vietnam, fellowships for Vietnamese medical personal at COA, and remote telecollaboration.

The COA team that travels to the National Children’s Hospital in Hanoi  consists of a neurosurgeon, neurologist, neurosurgery fellow, and neurophysiology technologist. The neurosurgeon, Dr. Brandon Rocque, works with the neurosurgeons in Hanoi and focuses on surgical resections like corpus callosotomy. Dr. Rocque performed the first corpus callosotomy for treatment of epilepsy in Vietnam in 2015. Dr. Pongkiat Kankirawatana (Dr. Pong) consults with the neurologists on epilepsy patients and teaches methods on localizing seizure foci. He also trains the Vietnamese neurologist to interpret ECOG (electrocorticography) and phase reversal SSEPs. The neurophysiology technologist is training the EEG nursing staff to perform ECOG and phase reversal SSEPs along with working in the EEG department to help enhance recording techniques to improve localization of epileptogenic foci. While in Hanoi, the COA team provides daily lectures. A one-day symposium is also held on many of the different modalities in clinical neurophysiology like IONM, NCS, long-term monitoring in epilepsy, etc. Many neurologists and EEG nurses travel great distances from all over Vietnam to come to the symposium. Some travel all night by train. The next step in the collaborative effort is travel to the United States for a three-month fellowship at COA.

The Vietnamese team that travels to COA has consisted of a neurosurgeon, neurologist, and EEG nurse. The neurosurgeon and neurologist train and observe epilepsy resections, grid implant surgery, and SEEG. They also participate in epilepsy conference that is held once each week. Each week, patients who are candidates for epilepsy surgery are discussed by our neurosurgeons, neurologists, neuroradiologists, and neuropsychologists. The visiting team gets to observe the process COA uses to decide whether a patient is a good candidate for surgery. The Vietnamese team also has some of their patients presented during the conference and discussed. The neurologist along with the EEG nurse train and observe in the COA Neurophysiology Department. They round with the epileptologist in the epilepsy monitoring unit (EMU), and sit with the epileptologist while they read EEGs. They also observe the EEG technologists while they connect patients, monitor patients, and other procedures like ictal SPECT, cortical stimulation for mapping, and phase reversal SSEPs. COA also has an in-house education program for EEG technologists, and the Vietnamese team participates and observes the didactic sessions. In 2016, the Vietnamese team was also taken to the ASET annual conference as part of their fellowship.

Telecollaboration has been a vital tool for this program. Telecollaboration for this program consists of using remote monitoring technology to communicate between the two teams during epilepsy surgeries in Vietnam. Some of this technology is state of the art and uses augmented reality or immersive technology to perform what might be called virtual surgery. This type of technology creates a user interface where it actually seems as if the person on the other end of the world is reaching through the camera and pointing out the waveforms on the screen. The possibilities that this type of technology opens up are exponential. It can be used to help with troubleshooting, and has closed the gap on some of the issues that occur from only being able to use email and cell phones to collaborate with one another.

There have been three patients who have undergone epilepsy surgery guided by ECOG and phase reversal SSEPs without the COA team present in Hanoi, and two of the three of these patients are seizure-free at this time. Partnerships like this in developing countries have proven in many instances to be very beneficial for all parties involved. The impact that these types of collaborations have are far-reaching as can be evidenced by other collaborations like the Human Genome Project. This is an exciting time to be in the field of Neurophysiology and witness the advancements as they are happening and the impact they have on the patients we care so much about. Without these types of collaborations, many patients might never get the medical treatments they need. And after all, that is why we do what we do.

This article was written by Trei King III BA, R. EEG T., CNIM.