Thank you very much. The last speaker, Alexander Tucker, discussing the addition of choroid plexus cauterization and may reduce post-hemispherectomy hydrocephalus, early UCLA experience. All right. The last one. So I'm Alex Tucker. I'm from UCLA, and again, I want to talk about choroid plexus cauterization as a strategy to reduce post-hemispherectomy hydrocephalus. Just a second. As I'm sure everybody is aware, hemispherectomy is one of the tools that we use to treat some forms of medically tractable epilepsy. Unfortunately, many patients who have hemispherectomy go on to develop hydrocephalus, and the rate of hydrocephalus is around 30%. That's been both reported from the post-hemispherectomy hydrocephalus work group as well as our own series at UCLA, Gary Mather's series, similar results. So a couple of years ago, we revised our hemispherectomy technique, and in a deliberate attempt to lower that rate of hydrocephalus, we decided to include choroid plexus cauterization as part of that procedure. And so very simply, what I decided to do is go back and look at our cases of hemispherectomy at UCLA in 2016 and 17, and then compare our rate of hydrocephalus to both the reported norms and our own series. What did I find? Well, over those two years, we did 16 HEMIs at UCLA. You can see the etiology underlying the epilepsy on the right, where 40% of our kids had strokes, 25% had corticodysplasia, HEMI-MEG, and SIRT, whoever, and RAS instances make up the rest. The procedure took us about six hours to do. We left ventricular drains in all of these kids that stayed in for about seven days. And 15 of the 16 patients had CPC. The CPC that I'm talking about, many of us are familiar with it endoscopically. We do it regularly. In this case, this is a young girl who had an MCA stroke. But one of the first steps of our hemispherectomy is to open the ventricle widely, and you get that panoramic view of the whole fissure. So finding choroid down by the intercortical point, working your way back all the way to the glomus, and then interiorly with a frame in Monroe, we just rebuzz it with a bipolar and a low setting. What did we find? Well, first of all, these are hemispherectomy patients, right? This is epilepsy surgery. And what we found was that 94% of our kids are seizure-free. That's a really important finding. Next, all these kids in green, these are the 15 of 16 who had CPC at the time of hemispherectomy. And only one of them has required a VP shunt. So we've lowered our overall shunt rate to 7%. Thirdly, there's this one patient on top here. And this is a young child who did not have CPC at the time of his hemispherectomy. And he did actually leave the hospital with a VP shunt. But he did come back to our institution two years after his initial surgery. You can see he had his hemispherectomy on the left. He has his shunt on the right. And we figured because he did not have CPC up front, we decided to do what we often do, which is an endoscopic third ventricular colostomy. Pulled the camera back and did CPC bilaterally, and then removed his shunt and placed a ventric. And we were able to wean his ventricular colostomy, and he's shunt-free to this day. So what we've shown is that in our series, we've lowered our institutional post-hemispherectomy shunt rate from 30% all the way to seven. I think a major caveat here is our follow-up is eight months. And in every major hemispherectomy series, particularly Dr. Mathern's, delayed post-hemispherectomy hydrocephalus is a real thing. And so we're gonna have to sort of stay tuned and follow these patients to see if they unfortunately fall in that category. I hope that they don't. But if this is a durable response, I think it's a significant one. Secondly, in cases of post-hemispherectomy hydrocephalus, in kids who have already been shunted, if they did not have a CPC at the time of the initial surgery, we might be able to apply one of, to use a procedure that we use regularly, which is an ETV CPC, and remove shunts from these kids. Now, obviously, that's not gonna apply to every child with post-hemispherectomy hydrocephalus, but one less shunt in the world is a wonderful thing. And maybe what we showed anecdotally might apply to some patients of yours. And then finally, as we saw in the video, this is a really straightforward procedure. It doesn't take much time. It's very low risk. It doesn't take much to do it. And we advocate making it a standard step in all hemispheric re-procedures. Again, if these results hold, this might be an incredibly efficient way to lower the lifetime morbidity in these patients, many of whom are unfortunately disabled throughout their lives. Thank you very much. Thank you for staying till the end. Come visit us in LA. Thank you.

choroid plexus cauterization

hydrocephalus

hemispherectomy surgery

epilepsy

seizure-free