A robot helped relieve a Montreal boy of hundreds of seizures a day

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Until last spring, six-year-old Santiago Peña had hundreds of seizures every day, most of which went unnoticed by his parents.

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As a result of a genetic condition called tuberous sclerosis, the seizures continued until Santiago underwent two surgeries at Montreal Children’s Hospital that were planned with the help of a robot.

Santiago’s condition causes hundreds of benign masses (or “tubers”) to grow throughout his body, affecting vital organs such as his eyes, heart, lungs, kidney, and brain.

“In Santiago’s case, he had something called cortical tubercles in his brain that was causing seizures and also causing developmental regression,” said Kenneth Myers, a pediatric neurologist and epileptologist at Montreal Children’s Hospital.

Santiago was referred to Myers after the family moved to Canada in 2019 to obtain affordable care for their son, whose condition appeared to be worsening.

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“One of the things that worried us the most is that he was beginning to learn some things, he had seizures and he forgot the things he learned,” said Santiago’s father, Yonny Peña. “That’s why we start to get really frustrated, because when you see that your child is learning something, he has a seizure and he forgets everything he learns, that is really difficult for us.”

Santiago has been taking a variety of anti-seizure medications his entire life, but the seizures continued. Myers explored whether Santiago could be a candidate for surgery.

“He was quite concerned because he had fairly frequent seizures and had previously been talking and had stopped talking,” Myers said. “And we know that the earlier you can intervene in children, the better their long-term development will be.”

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Once the team discovered that he could operate in Santiago, they began trying to identify which tubers from the dozens of his brain were responsible for his seizures. To do this, he used ROSA, which implants electrodes in the brain to monitor activity. ROSA is the first robot of its kind in a Quebec pediatric hospital.

“Today we use a robot to help with the precision of electrode placement,” said Dr. Roy Dudley, a pediatric neurosurgeon at Montreal Children’s Hospital.

To program ROSA, images of a patient’s brain are loaded into software so the team can map where exactly to insert the electrodes.

“In the case of Santiago, we had 17 electrodes,” Dudley said. “So we designed those electrodes to make sure they go to the areas that we think are causing your seizures.”

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After hours of careful trajectory planning by surgeons, who ensure blood vessels are avoided, ROSA’s arm drills a small hole measuring approximately one millimeter in diameter through the scalp and brain membrane. of the patient.

“Then we screw in an anchor bolt, we pass a stylet to the brain, and that stylet is a small semi-rigid wire that is measured at the distance decided by the robot,” Dudley said. “And then we take out the stylet and implant the electrode that is the same distance from the target for that particular electrode.”

The electrodes, which are used to monitor brain activity for a week or two, have multiple points of contact, Dudley explained.

“We are measuring between 10 and 15 points in the brain with a single electrode, and remember that we are placing between 10 and 18 electrodes,” he said. “The way to think about this is EEG in three dimensions.”

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The electrodes confirmed the neurosurgery team’s hypothesis that most of Santiago’s seizures came from the back left side of his brain, with a few more on the right side that his parents noticed.

Dr. Jean-Pierre Farmer, chief of neurosurgery at Montreal Children’s Hospital, explained that without the means to determine where exactly seizures originate from, especially in patients like Santiago with multiple injuries, in previous years, only the area that It seemed the most active would have been eliminated.

“That would have been the left side, and we probably wouldn’t have gone after the right side that fast,” Farmer said. “We would have seen if he did better and then waited for him to have more seizures, or not, and then we looked at him again now that the main trigger was removed.”

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Before the implantation method, which has been used for decades in adult patients, electrode sheets were placed on the surface of the brain to monitor activity.

“We used to make an incision in almost the entire half of the head, and remove a piece of bone, almost half of the skull … and then open the membrane around the brain,” Dudley said.

Dudley suspects it may have seemed less invasive to parents than running electrodes through their child’s brain, but said that’s not the case, especially with ROSA’s precision.

“That old procedure was fraught with many complications: there would be inflammation of the brain … there was a relatively high rate of infection, there was a leak (of cerebrospinal fluid) because we opened that membrane around the brain and we cannot close it with water. tight because these electrodes are coming off, “he said.

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Santiago’s condition means that he will be monitored regularly for the rest of his life, but both his surgeons and his parents have taken comfort in knowing that he is seizure-free and that he is moving forward with his development.

“As a family he makes us feel very happy because now we can share more time with him,” said Peña. “We are not worried about seizures, we are very happy because his progress in school is (good) and he is more with us as a family.”

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