Laser interstitial thermal therapy (LITT), or laser ablation, is among the latest advancements in minimally invasive neurosurgery, allowing surgeons to reach difficult areas of the brain — and offering less risk to patients at the same time.
“Instead of performing a craniotomy, which entails making a large incision and opening up the skull, we place a probe through a small hole in the skull a few millimeters in diameter,” says Dr. Joffre Olaya, pediatric neurosurgeon at CHOC. “Then, under MRI visualization, we deliver heat to the specific area, which destroys the abnormal tissue. Laser ablation is especially useful in patients with small seizure foci or tumors, particularly if they are deep.”
The benefits this minimally invasive approach provides to patients are especially welcoming. “For a craniotomy, patients will be in the hospital for three to five days, in the ICU most likely for a day or two, and they’ll experience discomfort from the skin and muscles on the head,” Dr. Olaya says. “With laser ablation, patients typically go home within a day or two and recover pretty quickly. They also experience less blood loss, pain and side effects overall. Also, laser ablation doesn’t prevent patients from having another procedure. If the tumor is still growing or the seizures are still continuing after ablation, I can go back and perform another laser ablation or a craniotomy.”
To increase surgical precision and accuracy when ablating brain tumors, deep lesions and tissue in the brain where seizures occur, Dr. Olaya employs a ROSA™ (robotic stereotactic assistance) robot.
“We obtain preoperative imaging studies and load those into the ROSA system, which allows us to plan the entry point and trajectory so we can precisely place the laser. This precision helps us to not only locate and effectively ablate our target, but avoid hitting blood vessels or causing unintended damage to surrounding tissues,” Dr. Olaya says. “We were the first pediatric center on the West Coast to have this technology. We use ROSA for multiple conditions, including patients with epilepsy and oncology patients with tumors.”
ROSA’s precision also helps minimize some risks commonly associated with surgery. “ROSA is an amazing tool that yields many benefits for our patients, including less time under anesthesia in the operating room,” Dr. Olaya says. “It also reduces blood loss and risk of infections.”
Although CHOC is at the forefront utilizing the latest technologies to best treat its patients in a minimally invasive manner when possible, Dr. Olaya says CHOC’s team approach to patient care is what sets it apart from other centers in the region.
“I’m really excited that CHOC is investing in this newer technology and it’s available here to provide to our patients, but our team mentality and how well we work together is crucial. Our epileptologists, radiologists, neuropsychologists, all of us really work well together as a team to identify the best candidates for this technology and to provide the best outcomes for our patients.”
Our Care and Commitment to Children Has Been Recognized
CHOC Children’s Hospital was named one of the nation’s best children’s hospitals by U.S. News & World Report in its 2020-21 Best Children’s Hospitals rankings and ranked in the neurology/neurosurgery specialty.
Every morning when she awakes, Sydney Amato begins her daily battle with her body.
If she’s lucky, the 16-year-old will have gotten a handful of hours of uninterrupted sleep – dreaming, perhaps, of doing what most healthy kids her age take for granted:
Hanging out with friends. Going to school. Learning to drive.
Because of a neurological condition called dystonia, Sydney, who is in excellent cognitive health but speaks and walks with some difficulty, suffers from involuntary and near-constant contraction of muscles in her neck, arms, legs and trunk.
Her mind is unable to control the painful jerking that makes most of her body twist and go rigid, her muscles moving out of normal sequence.
Born a right-hander, she can feed herself with some struggle using her left hand. She wants to dress and put on makeup herself, but those normally simple tasks become lengthy ordeals.
“My body fights me all the time,” says Sydney, trying to distract herself in her hospital bed by watching an old episode of “Keeping Up with the Kardashians.” Listening to her favorite music – Ariana Grande, Lauren Daigle, Drake – can only temporarily transport Sydney away from her debilitating condition.
“She knows what she wants to do,” says her father, Louis. “But her body won’t let her.”
Specialists at CHOC Children’s are working hard to change that.
A first for CHOC
On Aug. 14, 2020, a team led by Dr. Terence Sanger, a physician, engineer, and computational neuroscientist who joined CHOC in January 2020 as its first chief scientific officer, and Dr. Joffre E. Olaya, CHOC’s functional restorative neurosurgeon, implanted several temporary electrodes into Sydney’s brain.
The surgery marked the first time a patient with a movement disorder at CHOC underwent a procedure called deep brain stimulation (DBS).
Working in perfect harmony as a team, Dr. Sanger and Dr. Olaya performed the first stage of a three-stage surgery on Sydney. As the surgeon, Dr. Olaya placed the leads following advice from Dr. Sanger, the neurologist, where they should go.
In the procedure, millimeter-thick electrodes were precisely positioned into the basal ganglia region of Sydney’s brain – about three inches deep. The surgery involved the use of the ROSA Robot, the same tool that has been used during brain surgery on epilepsy patients at CHOC since 2015.
Considered one of the most advanced robotized surgical assistants, ROSA includes a computer system and a robotic arm. It’s a minimally invasive surgical tool that improves accuracy and significantly reduces surgery/anesthesia time.
The ROSA Robot helped with implanting and targeting the electrodes, and a portable operating-room CT scanner confirmed their position.
Turning down the volume
DBS is designed to ease Sydney’s condition by sending electrical currents to jam her malfunctioning brain signals.
Think of turning down the volume on your car radio.
“Nobody really understands the cause of dystonia,” Dr. Sanger explains, “but there’s probably too much electrical stimulation going on in the motor areas of the brain. We’re trying to calm down that extra noise.”
Although DBS dates to the 1960s, it wasn’t until the 1980s that the modern era of using it to treat adult patients with tremor and Parkinson’s disease began.
In 2000, Dr. Sanger, working with engineers, data scientists, neurosurgeons, and others, began implanting electrodes in pediatric patients.
Instead of the established method of placing the leads at predetermined sites and hoping they worked, Sanger and his team, just as they did in Sydney’s case, placed temporary leads to best assess where they should go permanently based on patient response.
In 2016, Dr. Sanger began honing DBS to treat children with dystonia. Before the surgery on Sydney, Dr. Sanger had performed DBS on 26 children using the same three-stage technique. He says 80 percent of those children have seen successful results.
Sydney began showing symptoms of dystonia – tremors in her hands — when she was 5 ½ years old.
A year later, she was using a wheelchair. She had her first brain surgery at age 7.
Since then, “she’s been all over the U.S.” seeking the right treatment for her condition after several setbacks, says her father.
But her condition was not improving.
Early this year, a neurologist in Kansas City, Mo., recommended that Sydney see Dr. Sanger.
“I asked him, ‘If Sydney was your kid, where would you go?’ Louis Amato recalls. “He said, ‘Hands down, Dr. Sanger.’”
The COVID-19 pandemic pushed Sydney’s surgery to mid-August.
Sydney already had two electrodes in her brain that were only partially working when she came to CHOC in early August for surgery.
After two extensive run-throughs with their team, Dr. Sanger and Dr. Olaya, in a six-hour procedure that at one point had nearly 20 people in the operating room, implanted more electrodes to give her a total of nine.
On Thursday, Aug. 20, six days after Sydney’s surgery, Dr. Sanger stopped by her room at CHOC Children’s Hospital. The room was decorated in purple, Sydney’s favorite color.
Dr. Sanger greeted her as CHOC staff members, joined by members of Sanger Lab, which conducts research in pediatric movement disorders, prepared to have Sydney walk back and forth down a hallway while connected to electrical equipment programmed to record signals in her brain and muscles.
A thick coil of multicolored wires snaked from under a large white bandage covering Sydney’s head. Extending about 6 feet, the wires were plugged into specialized recording equipment controlled by Jennifer MacLean, a pediatric nurse practitioner whose job was to manipulate the strength of electrical charges affecting the four points of contact on each electrode.
The goal: determine which charges worked best and on which electrodes.
“It could have turned out that the DBS procedure made no difference,” Dr. Sanger says. “But we’ve seen a very good response in Sydney.”
For example, her once mostly useless right hand was working much better.
“It gives you goosebumps,” Louis Amato says.
After taking a bite of a veggie burger and sipping some water, Sydney started to walk.
Following her were seven CHOC and Sanger Lab specialists.
“Go nice and slowly,” Jennifer told Sydney. “You’re going too fast for us!”
Perhaps Sydney was anxious to get back to riding Tigger, a quarter horse, in her hometown of Carthage, Mo. She has been riding him for six months.
“Her balance isn’t bad on the horse,” says Louis Amato.
Sydney also loves to tan by her pool and swim.
What she wants most, however, is to be freed from her body so she can return to school and do what most teens enjoy.
“It’s stressful,” says her mother, Angie. “She has a lot of friends her age, but she can’t do a lot of the things they do. She has her days when she can get really upset.”
Now, however, working with Dr. Sanger, Dr. Olaya and the entire team at CHOC, the Amatos are more optimistic than ever.
“We’re hopeful that this is going to be a big life-changer for her,” Angie Amato says. “That would be the best thing that could ever happen – better than winning the lottery.”
‘The A Team’
After crunching numbers for a week to assess which of the nine electrodes proved to be the most effective based on how Sydney responded to varying degrees of electrical currents, Dr. Sanger and his team settled on four electrodes that were permanently used to treat her condition – three new ones, and one existing one.
The team performed this second surgery on Sydney in late August.
In the third and final surgery, successfully completed in early September, a rechargeable generator that powers the DBS leads was implanted in Sydney’s chest.
“As we get better and better at this,” says Dr. Sanger, “and as the technology progresses, we’ll be able to do this on kids who are less sick than Sydney.”
Dr. Sanger and Dr. Olaya are poised to dramatically improve the lives of many more patients like Sydney at CHOC.
“I’m really excited that we will be doing more of these procedures to help pediatric patients with movement disorders and significantly improve their quality of life,” says Dr. Olaya. “I look forward to continuing to provide this type of personalized care.”
Angie and Louis Amato say Sydney has never gotten this much special attention during her 11-year-plus medical journey.
“Here at CHOC,” Louis Amato says, “we feel like we’re with the A Team.”
Says Sydney: “I’ve never felt this much confidence and this good about treatment before.”
Five-year-old Ian Higginbotham recently enjoyed his best summer yet. He experienced his first family vacation. He learned to swim and ride a bike. He got himself ready for kindergarten. These are milestones most kids and parents, alike, eagerly welcome. But there was a time when Ian’s parents weren’t certain their son, who was born seemingly healthy, would enjoy such happy pastimes.
Ian began talking and walking in his sleep as a toddler. When the episodes, including night terrors, increased in frequency and severity, his mom Lisa made an appointment with the pediatrician. One day, Lisa knew something just wasn’t right and didn’t want to wait for the appointment to get Ian checked out. She and her husband Derek took him to the Julia and George Argyros Emergency Department at CHOC Children’s Hospital. To her surprise, doctors diagnosed her son with epilepsy. Ian’s “sleepwalking” and “night terrors” were actually seizures.
The family was referred to CHOC’s comprehensive epilepsy program. A national leader in pediatric epilepsy care, CHOC’s comprehensive epilepsy program offers cutting-edge diagnostics, innovative medical approaches and advanced surgical interventions. CHOC was the first children’s hospital in the state to be named a Level 4 epilepsy center by the National Association of Epilepsy Centers, signifying the highest-level medical and surgical evaluation and treatment for patients with complex epilepsy.
Ian’s neurologist Dr. Andrew Mower suspected he was experiencing complex partial seizures, which was confirmed by video EEG monitoring. Complex partial seizures start in a small area of the temporal or frontal lobe of the brain, and quickly involve the areas of the brain affecting alertness and awareness. The pattern of Ian’s seizures suggested they were originating from the right frontal lobe. Dr. Mower knew Ian and his family were in for a tough journey.
“I really don’t think the general public understands the impact epilepsy has on a child and his family. Its effects are multifaceted and extensive. Our team’s goal is to reduce or eliminate our patients’ seizures, helping improve their quality of life,” explains Dr. Mower, who placed Ian on a series of medications.
The medications reduced Ian’s seizures, but did not control them. Dr. Mower was concerned about the seizures affecting Ian’s development, and presented his case to the epilepsy team. The multidisciplinary team agreed Ian was a candidate for epilepsy surgery. For children who fail at least two medications, surgery may be considered early in treatment versus as a last resort. Surgery can result in an improvement in seizure control, quality of life, and prevent permanent brain damage. Ian’s surgery was going to be performed by CHOC neurosurgeon Dr. Joffre Olaya.
While the thought of surgery was frightening to Lisa and her husband, they were confident in the team and comforted to know their son was going to benefit from innovative technology, like the ROSA™ Robot. Considered one of the most advanced robotized surgical assistants, ROSA includes a computer system and a robotic arm. The computer system offers 3D brain mapping to aid surgeons in locating the exact areas they need to reach and planning the best surgical paths. The robotic arm is a minimally invasive surgical tool that improves accuracy and significantly reduces surgery/anesthesia time.
Dr. Olaya used ROSA to accurately place electrodes in the area of Ian’s brain suspected to be the source of his seizures. By using the robot, Dr. Olaya avoided performing a craniotomy.
“ROSA is an amazing tool that yields many benefits for our patients, including less time under anesthesia in the operating room. It reduces blood loss and risk of infections. Patients tend to recover faster than they would if they had craniotomy,” says Dr. Olaya.
Lisa was amazed at the outcome. “I couldn’t believe how great Ian looked after the placements of the electrodes with ROSA. He wasn’t in any pain, there was no swelling. It was wonderful!”
She and her husband were also amazed at how well Ian did following his epilepsy surgery.
“We got our boy back,” says Lisa. “There were no more side effects from medication and, more importantly, no more seizures! He started developing again and doing all the things a child his age should do.”
Ian’s care team isn’t surprised by his recovery.
“Children are resilient, and their brains are no different. In fact, the plasticity of a young brain allows it to adapt to changes and heal more easily than an adult brain,” explains Dr. Mower.
Learning to ride a bike and swim were among the first of many milestones Ian quickly reached following surgery. He enjoys playing with his younger brother and his friends. And, whether inspired by his experience with ROSA or not, Ian loves robots.
CHOC Children’s offers the highest level of care for children requiring brachial plexus surgery.
Brachial plexus surgery is a complex procedure that repairs damage to the bundle of connected nerves in the neck region. Damage to these nerves is often caused by birth complications, contact sport collisions and automobile accidents. A severe brachial plexus injury can cause a patient to lose function and sensation in their arm, impairing their ability to perform everyday tasks.
Surgical procedures such as nerve grafts and transfers can restore this function and sensation and help the patient regain their lost quality of life.
“While many patients will regain movement with therapy alone, a small percentage will require nerve surgery,” says Dr. Joffre Olaya, pediatric neurosurgeon at CHOC. “Patients may even need a series of surgeries,” he adds. “The first surgery may be focused on the nerves, where the second would be focused on the transfer of muscle or movement of bones.”
The experienced multidisciplinary team at CHOC is fully equipped to handle all aspects of the repair and guide the patient and their family through every stage of treatment and healing. The surgery is performed in the Tidwell Procedure Center at CHOC, which features seven operating rooms and advanced technology and information systems.
“We like to evaluate patients as early as possible,” says Dr. Amber Leis, a CHOC and UC Irvine plastic surgeon. “We want to be part of the child’s journey and provide long-term care to ensure the best possible outcome.”
Whether or not these patients end up requiring surgery, they all benefit from therapy, explains Dr. Leis. CHOC is proud to offer the latest, research-based physical therapy in one of the most comprehensive rehabilitation centers in the area. Further, depending on their age, diagnosis and treatment plan, some brachial plexus patients may benefit from aquatic physical therapy, which takes place in the center’s pool.
Dr. Olaya and Dr. Leis are committed to building a robust, one-of-a-kind brachial plexus program for children in the region and beyond.
They offer community physicians the following guidelines on when to refer:
As early as possible, after a brachial plexus birth palsy with impaired arm movement.
After a sports or motor vehicle accident with impaired arm movement or sensation.
Though no doubt a staggering consideration, brain surgery would be the next landmark on a long medical history that belied Kara’s short three years of life.
At just 13 months old, she underwent emergency brain surgery after her frontal lobe hemorrhaged, caused by a previously undiscovered vascular malformation. The hemorrhage in Kara’s brain led to right-side hemiplegia, leaving her no use of her right hand and limited the use her right leg.
Kara underwent physical therapy and began walking at age 2. Life was relatively normal for the Sexton family until just after Kara’s third birthday, when she began acting strangely.
At the CHOC Children’s Neuroscience Institute, Kara underwent an electroencephalogram, or EEG, a test that monitors for electrical activity in the brain. Next, she spent six days undergoing long-term video EEG monitoring. From there, Dr. Zupanc, also CHOC’s neurology division chair, made an official diagnosis of epilepsy and prescribed an anti-epileptic medication.
Exploring other options
Nonetheless, Kara’s seizures continued. Kara’s three older siblings were acutely aware of their sister’s disorder, daily counting Kara’s seizures and agonizing over each hospital visit. The family began to placate Kara in hopes of staving off outbursts and tantrums, Heidi said.
“Kara had between two and four seizures a day,” she said. “It really messed with her behaviorally. She’s a lovely kid, but she suffered serious temper tantrums. It was physically and emotionally exhausting.”
A second six-day monitoring session led Dr. Zupanc to change Kara’s medication and, as a precaution, begin evaluating her as a candidate for epilepsy brain surgery.
Further tests and scans revealed that the left hemisphere of Kara’s brain was significantly injured and atrophied – likely related to her earlier hemorrhage. In addition, Kara’s new anti-epileptic medication wasn’t working.
Dr. Zupanc concluded that the next step was a hemispherectomy, a surgical procedure in which one side of the brain is removed or disconnected.
“On scans, Kara’s hemisphere was completely white,” Heidi said. “The only thing her left hemisphere was doing was causing seizures. There was no question.”
A change of course
Nearly 11 months after the seizures first surfaced, Kara underwent surgery at CHOC to remove a portion of her brain’s left side, and disconnect the remaining portion from the right hemisphere. Performed by neurosurgeon Dr. Joffre Olaya, the procedure lasted six hours.
After 16 days recovering in the hospital’s pediatric intensive care unit, Kara went home just after her fourth birthday.
Much to her parents’ and siblings’ relief, Kara hasn’t had a seizure since her surgery eight months ago. Kara still relies on an anti-epileptic medication, but she may be able to stop taking it completely or use a lower dose of medication soon if her progress continues.
Though considering a second brain surgery was daunting for the Sextons, Heidi and her husband knew the procedure was the right choice to help their daughter.
“I looked at it in a sense of quality of life for Kara,” Heidi said. “Hopefully now she’ll be able to drive one day. Continued seizures would have impaired her cognitively forever, and I didn’t want that.”
Though she still requires extensive care, Kara is doing well physically and emotionally and is looking forward to preschool.
Kara isn’t fully aware of her journey in the last year, but she understands the meaning of the scar on her head just above her ear.
“She knows now that she doesn’t have seizures and Dr. Olaya and Dr. Zupanc fixed her,” Heidi said.