February 14, 2022 • 19 mins
The threat of a Russian invasion in Ukraine is still keeping Western officials on high alert. President Biden and Vladimir Putin held an hour-long discussion over the weekend where Biden said there would be "swift and severe" consequences should they attack Ukraine. In the meantime, Russia has other ways of maintaining pressure through a destabilization campaign of cyber attacks, fake bomb threats, and economic disruption. Ginger Gibson, deputy Washington digital editor at NBC News, joins us for this and former President Trump's penchant for destroying records.
Next, a woman in San Antonio named Jane became one of the first to undergo surgery for a treatment of Alzheimer's called deep brain stimulation. This is not a treatment to reverse the disease, rather it is aimed at helping people maintain their memories and independence. The surgery involved implanting electrodes in the brain to keep the memory areas stimulated. The process uses a very sophisticated robotic system to make the precise movements needed while the patient is awake. Dr. Alexander Papanastassiou, associate professor of neurosurgery at UT Health San Antonio, was involved in this surgery and joins us for how it all works.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
It's Monday, February four. I'm Oscar Ramiers in Los Angeles,
and this is the daily Dive. The thread of a
Russian invasion in Ukraine is still keeping Western officials on
high alert. President Biden and Vladimir Putin held an hour
long discussion over the weekend, where Biden said there would
(00:20):
be swift and severe consequences should they attack Ukraine. In
the meantime, Russia has other ways of maintaining pressure through
a destabilization campaign of cyber attacks, state bomb threats, and
economic disruption. Giner Gibson, Deputy Washington Digital editor at NBC News,
joins us for this and former President Trump's penchant for
destroying records. Next, a woman in San Antonio named Jane
(00:43):
became one of the first to undergo surgery for a
treatment of Alzheimer's called deep brain stimulation. This is not
a treatment to reverse the disease. Rather, it is aimed
at helping people maintain their memories and independence. The surgery
involves in planting electrodes in the brain to keep the
memory areas stimulate. The process uses a very sophisticated robotic
system to make the precise movements needed while the patient
(01:06):
is awake. Dr Alexander Popinastasio, Associate Professor of neurosurgery at
ut Hell san Antonio, was involved in the surgery and
joined us for how it all works. It's news without
the noise. Let's dive into Yes. I do believe that
he has prepared for an invasion. I also understand why
(01:26):
the president of Ukraine wants to keep people calm and
and that he wants his economy and not to suffer.
Joining us now, as Ginger Gibson, Deputy Washington Digital editor
at NBC News, thanks for joining us, Ginger, thanks for
having me. Well. There's a lot of action over the
weekend with the Russia Ukraine crisis, but still no ultimate action.
(01:47):
Officials are increasingly worried that Russia will invade. It just
hasn't happened yet. The forces on the Russian side on
the Ukraine border, they just keep getting more and more
troops there. I think they're at a hundred troops something
like that about of the force that they need to invade,
and National Security Advisor Jake Sullivan over the weekend said that,
(02:08):
you know, if an invasion began, it could be missiles
and bombs followed by ground forces. Jake Sullivan gave a
pretty stark warning on Friday from the White House press room,
saying that the United States, while believing Putin hasn't made
up a final decision on whether or not he's going
to invade Ukraine, that the possibility was imminent that it
could happen before the Olympics are over, which is something
(02:32):
there has been a lot of speculation that people thought
that Putin would wait until after the Olympics so as
not to cast a shadow over the Olympics being hosted
by his ally in China. President g except for now,
we think that it could happen sooner. And so there
was a real stark warning from Sullivan encouraging Americans to
leave the country if they are in Ukraine, telling them
(02:53):
we won't be able to send troops and to rescue them,
and so really turning up the pressure, it seems on
what is this building what we think is building too,
which is an eventual Russian invasion of Ukraine. And President
Biden and Putin did speak on Saturday also, they had
a call instead. It was about an hour long, and
President Biden warned him, said there's going to be swift
(03:14):
and severe action or consequences if they do invade. They
want to keep the option of diplomacy. They hope to
solve something like that, but Biden said they're ready for
other scenarios. Now. If something happens, U s forces would
be used only through NATO, or we would send an
individual force there. How how would that look like? So
(03:34):
Ukraine is not a NATO country. In fact, that's probably
why all of this is happening, because we have said
Ukraine can join NATO and Putin doesn't want them in there.
But there are other nearby NATO countries. Poland Romania are
two of the of the ones that are nearby, and
our NATO treaty says that if one of them is attacked,
we have to go help defend them. So an attack
on their next door neighbors something cause of alarm, and
(03:57):
so if that happens, we will have troops in NATO
countries in a defensive posture, meaning they're they're making sure
Russia doesn't get to their borders. But President Biden and
Jake Sullivan and get on Friday reiterated the US will
not send troops to Ukraine to help the Ukrainians. Write
the Russians. We've sent equipment, we've sent weapons, but we
won't be sending troops. And they don't anticipate American troops fighting.
(04:20):
You create Russian troops on behalf of Ukraine. And and
to your point that you made last week, right, you know,
Russia has other ways of maintaining pressure on Ukraine through
cyber attacks of fake bomb threats. There's reports of hundreds
of fake bomb threats. Economic disruption, that's one big thing
they're they're super vulnerable on the economic side Ukraines, that's right,
(04:40):
and so we expect that if they do attack to
see um cyber uh in full you know attacks as well,
not just in Ukraine, but potentially in other NATO allied countries.
Germany is when where they're quite concerned about it, given
its proximity, that they could try to further disrupt the
Allies by by using cyber attacks agains them. And there
(05:01):
was also a piece on NBC dot com that was
interesting NBC News dot com that was interesting too. This says,
you know, a lot of the residents in Ukraine are
kind of in this calm, standby mode. They've been under
the looming threat of Russia for a long time now,
and they don't think that Putin will invade, but you know,
it's they're kind of ready for anything, but they're kind
(05:21):
of still just living their daily lives. I guess there's
really nothing else to do there. Yeah, that's that's correct.
You know, our folks on the ground and Kiev, we're
telling us that the people there don't seem alarmed. They're
not out panic buying, um and they're not evacuating, mostly
because they seem to think it's not going to happen,
and if it does happen, they'll have time to get away. Finally,
(05:42):
for the week, I just wanted to talk about President Trump.
There's a lot of reports that he had a habit
of destroying documents, including flushing Sun down the toilet. I
guess he took about fifteen boxes of items from the
White House that the National Archives wanted back. President Trump
for himself said that they were magazines, articles, uh, some
of those love letters to North Korea, things like that.
(06:04):
But uh, you know, once again, it's all kind of
on the cusp of illegality um and and President Trump,
you know, just maintaining more innocence on that. That's right.
You know, these records laws, the presidential Records Preservation Act
really are things that there's not much of an enforcement mechanism.
It's very difficult to prosecute someone for breaking these laws.
It's really just been followed in the spirit by the
(06:25):
presidents since they've been enacted. And President Trump doesn't really
follow things in the spirit very often. We found while
he was president and now that he's left off as
still not quite interested in always following things that require
sort of the spirit of the law. And so the
Archives was, which he said was a very agreeable situation,
took some of these records back. There were reports that
he might have flushed some down the toilet. We knew
(06:45):
for a long time that he liked to rip things up,
so uh might not have had the best preservation practices
in his White House. Ginger Gibson, Deputy Washington Digital editor
at NBC News, Thank you very much for joining us.
Thanks for having me. It's supposed to know. It sounds
(07:08):
really unique when you first hear about it, the idea
of doing awake brain surgery, but it turns out to
be a very routine thing that's been done since the
nineteen twenties and nineteen thirties, routinely. Joining us now is
Dr Alexander Popinastasio, Associate Professor of Neurosurgery at the University
of Texas Health Science Center at San Antonio. Thanks for
(07:28):
joining us. Dr Papinastasio, Hi, I'm happy to be here.
I want to talk about some really interesting work that
you guys are doing their UT Health San Antonio, working
on Alzheimer's and people are trying to help maybe not
to the regression of the disease, but at least manage
the symptoms. And what's going on, and what we're talking
about is DBS. So this is deep brain stimulation and
(07:52):
what you guys are doing. I guess you guys are
gonna be doing this with a number of people, but
you just performed the first surgery for this, where you're
I hunting a device in a person's brain with early
mild Alzheimer's in hope of stimulating the brain and as
I mentioned, is keeping those symptoms to a minimum as
best as possible. Some really interesting stuff. So, Dr, if
(08:13):
you could help us walk through some of this, what
are we doing with this well? So the first point,
of course is that you know there are medical treatments
for Alzheimer's, but but they don't delay progression and help
with some of the symptoms. And so, you know, one
of the holy grails in the field of medicine is
to try and find a better treatment for Alzheimer's disease,
and that's what we're after. And it turned out that,
(08:35):
you know, this was found a little bit serendipitously when
Dr Lozano in Toronto was looking for a target for
treating obesity with deep brain stimulation. He was at a
target that was right next to the for next and
people that he implanted for that pilot trial said there,
thinking seemed a little bit clearer, and their memories seemed
a little bit better, and he had an aha moment
(08:56):
where he said, oh, I wonder if we could use
this for memory just orders. And then they began trying
to target the fornis in particular to see if I
could help in patients with Alzheimer's, which is a memory
disorder of course, among other deficits that go along with Alzheimer's.
So that was sort of the genesis of the study.
And then they did a pilot study with I believe
(09:19):
about six people and from there they went to the
first advanced trial called Advance one and The purpose of
advanced one was to look at safety. So it's always
the first step in any medical trial for a device trial, Uh,
you know, was it possible to target the structure in
a safe way. It turns out that the technique that
we're using, deep brain stimulation is a very common technique
(09:40):
for other disorders. It's the standard of care for Parkinson's
disease as well as essential tremor. It's also a well
known and well used technique for epilepsy that doesn't respond
to medicines and can't be cured by taking out a
part of the brain. Deep brain stimulation of the thalamus
is helpful for epilepsy as well. And so among neurosurgeons
(10:02):
there's a so specialty called stereotactic and functional neurosurgery, and
we get we're the sort of nersurgeons who get used
to using special techniques to minimally invasively place electrodes or
other catheters or probes in the brain to treat disorders
like what we just described above. And so the first
surgery that you guys performed, you were you helped, you
(10:23):
were part of this whole team. It was a woman
from San Antonio in her seventies. She goes by the
name of Jane. Tell me a little bit about her
and and her condition and why she was a good
candidate for this. Well, the first off is that you know,
for early Alzheimer's, you know, she had noticed problems with
her memory, which is why she originally went to her
(10:43):
doctor to get a diagnosis and see if she had
an issue. But if you were to meet you know,
she's a very charming person and you wouldn't be able
to tell just talking to her, you know, she can
certainly you remember, you know, most things about his life,
and in normal conversation you wouldn't notice anything. But part
of the team includes a nerve psychologist and they do
a formal assessment of somebody's memory using various scales and
(11:08):
tests that have been developed, and then they're able to detect,
you know, what type of memory problem she has. Also,
prior to entering the trial, a person first has to
be on the stable dose of one of the medicines
for Alzheimer's disease. Those are the steel colleen inhibitors and
have the mild Alzheimer's and then that's a reason to
move forward. As part of the study, they also have
(11:29):
a lumbar puncture where we look at cerebra spinal fluid
to see if it has typical markers of Alzheimer's in
it as well. So she was a good candidates. And
this has to be done with people with mild Alzheimer's.
I mean again, I guess if the progression has gone
too far, you can't really slow down enough, right, That's
our understanding at this time. We wanted to start with
people who had mild Alzheimer's to try and make their
(11:49):
memory better. The further the disease progresses, the harder it
is to treat. And so in a trial like this
where we're trying to establish this as a new treatment,
we thought that, you know, the best target was early
all timer's, where you'd be more likely to be able
to have an impact with a treatment like this, especially
one that you know, as far as we know, is
not expected to delay progression or cure. It is just
expected to help with memory and minimize symptoms. Tell me
(12:13):
a little bit more about the actual procedure, because as
I mentioned, you were involved in this. You guys use
a state of the art robotic system you know, working
in the brain is obviously very very delicate work, and
you use this robot to make the precision implantation of
the device and the brain. Yeah, that's right. So the
technique that we're using is it is called stereotaxi, and
(12:35):
the general principle of it is that, of course we
can get a brain m r I to see the
structures in the brain that we would like to target,
in this particular case, the fornix. And then what we
do is we apply what's called a stereotactic frame and
we fit that to the patient. And what that means
in lay terms, as you can imagine, there are four
pins that go through the skin and fix the frame
(12:57):
to the bone so that there's a rigid transformation between
the patient in the patient's head and this frame. And
then then what you can do is you can do
an interoperative image with a localizer on the frame and
then you can know where that frame is in three
D space. And once you've done that image to know
where your frame is and the frame is fixed to
(13:17):
the person's head, well, then of course you can know
where things are in three D space underneath the skin,
deep within someone's brain. Because the whole point of this
is that we need to get an electrode far into
the brain and we want to do that as minimally
and basically as possible. So we're not actually gonna see
where the electrode goes. We're just going to know where
it goes based on this system. And what the robot
adds to that is that the robot is a robotic arm.
(13:39):
Where this is the renaischean Neuromte robot. It has very
high accuracy of less than zero point five millimeters of error.
That's a very small error. And what it is is
it's a robotic arm that we can push a button
and the robotic arm goes into just the right position
to deliver the electrode to the right spot with minimal airror.
And so that's the use of robot for the procedure.
(14:02):
And you mentioned how it's minimally invasive, right, Yeah, I
think for my understanding, depending on you know, the hairline
of the subject and all, you might not even see anything,
maybe a small bump or something like that. So I
really don't see too much of the after effects. Yeah,
that's right. So there's a there's a small incision and
then we make a dime sized opening uh in the bone,
which is what we put the electrode through, and in
(14:25):
that opening we have a little plastic fixture that secures
the electrode in place so that it it will be at
the right depth. And that fixture has a little cap
to it, and that's the teeny little bump. So for
a person who's bald like myself, you might see the
small bump, or you might see the healed incision. But
for somebody who's got a full head of hair, well,
of course it's behind the hairline and you wouldn't notice
(14:45):
it at all unless unless you were looking for it
and knew it was there. Okay, so we've got this
device implanted into Jane. How is she doing now, and
what's the rest of the study looking like? Well, actually,
before we go on to that, before we leave the procedure.
One of the things that's interesting and unique about the
procedures that it's done awake, and we also look for
responses during the surgery. You know, it sounds really unique
(15:07):
when you first hear about it, the idea of doing
awake brain surgery, but it turns out to be a
very routine thing that's been done since the nineteen twenties
and nineteen thirties. Routinely, and so the first point that
most people might be familiar with is that the brain
doesn't have sensation, and so it's not going to hurt
as you put an electrode through the brain. The parts
that can hurt are the scalp and the covering of
(15:28):
the brain, and the scalp can be anesthetized with local
and aesthetic. So the first thing we do is we
sedate somebody and apply a local anesthetic all around the
scalp and and to where the incision is going to be,
and then we let the sedation to wear off, and
then people are awake, usually with you know, minimal or
no pain um and then you know, we go through
the procedure of you know, making the small incision and
opening the whole. You know. The one thing is that
(15:50):
when we use the drill, it can be a little
bit like going to a dentist where the vibration of
the drill you can hear it because it vibrates through
your bone near the near the bones of the ear
of course as well, so it sounds kind of loud,
but it didn't hurt. And then once we place the electrode,
we're looking for confirmation that we're in the right place.
So we have this scary tactic system with a robotic arm,
but we also want to confirm through other ways that
(16:12):
we got to the right place. And the first thing
is that when we start to stimulate through the electrode,
sometimes people have memories or vague memories, and that was
true for Jane. She did have some vague memories when
we turned the stimulator on, and that helped us know
that we were near the fornix, because there are very
few places in the rain where you would expect a
response like that. The other thing is that the fornis
is right next to an area called the hypothalamus, and
(16:34):
the hypothalamus is involved in controlling heart rate and blood pressure.
So when we turned the stimulator on, if we're in
the right place, we expect to see the heart rate
go up a little bit and the blood pressure we
expect to see that go up a little bit too,
And so we saw both those things, you know, in
her case, that helped us know we were in the
right place. And then once we feel confident that we've
(16:54):
got to the right place, then we take another image
with something called an o arm. It's like an introvert
ct scan and then we can see where the electrode
is and confirmed that where we wanted it to go.
So then and then of course after that then we
uh and can we can close up. And one of
the things that's nice about being able to do this
awake is certainly the idea of being able to have
confirmation that you got to the right place. It's also
(17:15):
nice to be able to avoid general anesthesia, which makes
the recovery easier, and sometimes people with dementia can feel
like their memory got a little bit worse after general anesthesia.
It's certainly safe to do generally ansthesia. It has to
be done all the time for various procedures, but the
less we can do it the better, And so that's
sort of a the wrap up of how it is awake.
But it's also very similar to other awake procedures we do,
(17:37):
for example, mapping where someone's language is to take out
of brain tumor or in movement disorder, surgery testing where
a lead is to treat Parkinson's disease or essential tremor,
and a lot of those procedures can also be done asleep.
But there's certainly a possibility of doing awake as well
and so and as I mentioned, just to to wrap
it every all up, you know, the ongoing study, what
are we looking for as far as James progression and
(18:00):
all that. So we all want to know as soon
as possible is it gonna work? And the answers we're
not going to know because the endpoint for the study
is called the Integrated Alzheimer's Disease Rating Scale. It's another
one of those tools that the psychologists used. That's our
primary endpoint for the study. And the time that we're
gonna be looking at is one year after the implant
and stimulator has been on. And of course the progression
(18:21):
of Alzheimer's is slow, and so over one year there
should be enough progression that we can tell a difference
between patients where the stimulators on and hopefully to slow
it down versus patients where it hasn't been slowed down.
But ideally the patient and we ourselves will not know
if it's on or not. Of course it's a double
blinded study, so you know, I won't know if the
things on or not, and she won't be able to tell.
(18:42):
And uh progression of the disorder is slow enough. So
I think the big picture here is that we won't
know for about a year, and once there's enough people,
there's gonna be ninety patients in the first part of
the study in two total. Once all to ten have
gotten to a year, then that's when we unblinded and
tell people, hey, you were on or you were off.
After a year, everybody can be turned on, so it
(19:03):
won't be that people had a procedure and won't have
any stimulation at all. Dr Alexander Papanastasio, Associate Professor of
Neurosurgery at the University of Texas Health Science Center at
San Antonio, thank you very much for joining us. Thank you.
(19:25):
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The Daily Divers produced by Victor Wright and engineered by
Tony Sargantino. I'm Oscar Ramirez and this was her Daily
(19:47):
Dive
It's Monday, February four. I'm Oscar Ramiers in Los Angeles,
and this is the daily Dive. The thread of a
Russian invasion in Ukraine is still keeping Western officials on
high alert. President Biden and Vladimir Putin held an hour
long discussion over the weekend, where Biden said there would
(00:20):
be swift and severe consequences should they attack Ukraine. In
the meantime, Russia has other ways of maintaining pressure through
a destabilization campaign of cyber attacks, state bomb threats, and
economic disruption. Giner Gibson, Deputy Washington Digital editor at NBC News,
joins us for this and former President Trump's penchant for
destroying records. Next, a woman in San Antonio named Jane
(00:43):
became one of the first to undergo surgery for a
treatment of Alzheimer's called deep brain stimulation. This is not
a treatment to reverse the disease. Rather, it is aimed
at helping people maintain their memories and independence. The surgery
involves in planting electrodes in the brain to keep the
memory areas stimulate. The process uses a very sophisticated robotic
system to make the precise movements needed while the patient
(01:06):
is awake. Dr Alexander Popinastasio, Associate Professor of neurosurgery at
ut Hell san Antonio, was involved in the surgery and
joined us for how it all works. It's news without
the noise. Let's dive into Yes. I do believe that
he has prepared for an invasion. I also understand why
(01:26):
the president of Ukraine wants to keep people calm and
and that he wants his economy and not to suffer.
Joining us now, as Ginger Gibson, Deputy Washington Digital editor
at NBC News, thanks for joining us, Ginger, thanks for
having me. Well. There's a lot of action over the
weekend with the Russia Ukraine crisis, but still no ultimate action.
(01:47):
Officials are increasingly worried that Russia will invade. It just
hasn't happened yet. The forces on the Russian side on
the Ukraine border, they just keep getting more and more
troops there. I think they're at a hundred troops something
like that about of the force that they need to invade,
and National Security Advisor Jake Sullivan over the weekend said that,
(02:08):
you know, if an invasion began, it could be missiles
and bombs followed by ground forces. Jake Sullivan gave a
pretty stark warning on Friday from the White House press room,
saying that the United States, while believing Putin hasn't made
up a final decision on whether or not he's going
to invade Ukraine, that the possibility was imminent that it
could happen before the Olympics are over, which is something
(02:32):
there has been a lot of speculation that people thought
that Putin would wait until after the Olympics so as
not to cast a shadow over the Olympics being hosted
by his ally in China. President g except for now,
we think that it could happen sooner. And so there
was a real stark warning from Sullivan encouraging Americans to
leave the country if they are in Ukraine, telling them
(02:53):
we won't be able to send troops and to rescue them,
and so really turning up the pressure, it seems on
what is this building what we think is building too,
which is an eventual Russian invasion of Ukraine. And President
Biden and Putin did speak on Saturday also, they had
a call instead. It was about an hour long, and
President Biden warned him, said there's going to be swift
(03:14):
and severe action or consequences if they do invade. They
want to keep the option of diplomacy. They hope to
solve something like that, but Biden said they're ready for
other scenarios. Now. If something happens, U s forces would
be used only through NATO, or we would send an
individual force there. How how would that look like? So
(03:34):
Ukraine is not a NATO country. In fact, that's probably
why all of this is happening, because we have said
Ukraine can join NATO and Putin doesn't want them in there.
But there are other nearby NATO countries. Poland Romania are
two of the of the ones that are nearby, and
our NATO treaty says that if one of them is attacked,
we have to go help defend them. So an attack
on their next door neighbors something cause of alarm, and
(03:57):
so if that happens, we will have troops in NATO
countries in a defensive posture, meaning they're they're making sure
Russia doesn't get to their borders. But President Biden and
Jake Sullivan and get on Friday reiterated the US will
not send troops to Ukraine to help the Ukrainians. Write
the Russians. We've sent equipment, we've sent weapons, but we
won't be sending troops. And they don't anticipate American troops fighting.
(04:20):
You create Russian troops on behalf of Ukraine. And and
to your point that you made last week, right, you know,
Russia has other ways of maintaining pressure on Ukraine through
cyber attacks of fake bomb threats. There's reports of hundreds
of fake bomb threats. Economic disruption, that's one big thing
they're they're super vulnerable on the economic side Ukraines, that's right,
(04:40):
and so we expect that if they do attack to
see um cyber uh in full you know attacks as well,
not just in Ukraine, but potentially in other NATO allied countries.
Germany is when where they're quite concerned about it, given
its proximity, that they could try to further disrupt the
Allies by by using cyber attacks agains them. And there
(05:01):
was also a piece on NBC dot com that was
interesting NBC News dot com that was interesting too. This says,
you know, a lot of the residents in Ukraine are
kind of in this calm, standby mode. They've been under
the looming threat of Russia for a long time now,
and they don't think that Putin will invade, but you know,
it's they're kind of ready for anything, but they're kind
(05:21):
of still just living their daily lives. I guess there's
really nothing else to do there. Yeah, that's that's correct.
You know, our folks on the ground and Kiev, we're
telling us that the people there don't seem alarmed. They're
not out panic buying, um and they're not evacuating, mostly
because they seem to think it's not going to happen,
and if it does happen, they'll have time to get away. Finally,
(05:42):
for the week, I just wanted to talk about President Trump.
There's a lot of reports that he had a habit
of destroying documents, including flushing Sun down the toilet. I
guess he took about fifteen boxes of items from the
White House that the National Archives wanted back. President Trump
for himself said that they were magazines, articles, uh, some
of those love letters to North Korea, things like that.
(06:04):
But uh, you know, once again, it's all kind of
on the cusp of illegality um and and President Trump,
you know, just maintaining more innocence on that. That's right.
You know, these records laws, the presidential Records Preservation Act
really are things that there's not much of an enforcement mechanism.
It's very difficult to prosecute someone for breaking these laws.
It's really just been followed in the spirit by the
(06:25):
presidents since they've been enacted. And President Trump doesn't really
follow things in the spirit very often. We found while
he was president and now that he's left off as
still not quite interested in always following things that require
sort of the spirit of the law. And so the
Archives was, which he said was a very agreeable situation,
took some of these records back. There were reports that
he might have flushed some down the toilet. We knew
(06:45):
for a long time that he liked to rip things up,
so uh might not have had the best preservation practices
in his White House. Ginger Gibson, Deputy Washington Digital editor
at NBC News, Thank you very much for joining us.
Thanks for having me. It's supposed to know. It sounds
(07:08):
really unique when you first hear about it, the idea
of doing awake brain surgery, but it turns out to
be a very routine thing that's been done since the
nineteen twenties and nineteen thirties, routinely. Joining us now is
Dr Alexander Popinastasio, Associate Professor of Neurosurgery at the University
of Texas Health Science Center at San Antonio. Thanks for
(07:28):
joining us. Dr Papinastasio, Hi, I'm happy to be here.
I want to talk about some really interesting work that
you guys are doing their UT Health San Antonio, working
on Alzheimer's and people are trying to help maybe not
to the regression of the disease, but at least manage
the symptoms. And what's going on, and what we're talking
about is DBS. So this is deep brain stimulation and
(07:52):
what you guys are doing. I guess you guys are
gonna be doing this with a number of people, but
you just performed the first surgery for this, where you're
I hunting a device in a person's brain with early
mild Alzheimer's in hope of stimulating the brain and as
I mentioned, is keeping those symptoms to a minimum as
best as possible. Some really interesting stuff. So, Dr, if
(08:13):
you could help us walk through some of this, what
are we doing with this well? So the first point,
of course is that you know there are medical treatments
for Alzheimer's, but but they don't delay progression and help
with some of the symptoms. And so, you know, one
of the holy grails in the field of medicine is
to try and find a better treatment for Alzheimer's disease,
and that's what we're after. And it turned out that,
(08:35):
you know, this was found a little bit serendipitously when
Dr Lozano in Toronto was looking for a target for
treating obesity with deep brain stimulation. He was at a
target that was right next to the for next and
people that he implanted for that pilot trial said there,
thinking seemed a little bit clearer, and their memories seemed
a little bit better, and he had an aha moment
(08:56):
where he said, oh, I wonder if we could use
this for memory just orders. And then they began trying
to target the fornis in particular to see if I
could help in patients with Alzheimer's, which is a memory
disorder of course, among other deficits that go along with Alzheimer's.
So that was sort of the genesis of the study.
And then they did a pilot study with I believe
(09:19):
about six people and from there they went to the
first advanced trial called Advance one and The purpose of
advanced one was to look at safety. So it's always
the first step in any medical trial for a device trial, Uh,
you know, was it possible to target the structure in
a safe way. It turns out that the technique that
we're using, deep brain stimulation is a very common technique
(09:40):
for other disorders. It's the standard of care for Parkinson's
disease as well as essential tremor. It's also a well
known and well used technique for epilepsy that doesn't respond
to medicines and can't be cured by taking out a
part of the brain. Deep brain stimulation of the thalamus
is helpful for epilepsy as well. And so among neurosurgeons
(10:02):
there's a so specialty called stereotactic and functional neurosurgery, and
we get we're the sort of nersurgeons who get used
to using special techniques to minimally invasively place electrodes or
other catheters or probes in the brain to treat disorders
like what we just described above. And so the first
surgery that you guys performed, you were you helped, you
(10:23):
were part of this whole team. It was a woman
from San Antonio in her seventies. She goes by the
name of Jane. Tell me a little bit about her
and and her condition and why she was a good
candidate for this. Well, the first off is that you know,
for early Alzheimer's, you know, she had noticed problems with
her memory, which is why she originally went to her
(10:43):
doctor to get a diagnosis and see if she had
an issue. But if you were to meet you know,
she's a very charming person and you wouldn't be able
to tell just talking to her, you know, she can
certainly you remember, you know, most things about his life,
and in normal conversation you wouldn't notice anything. But part
of the team includes a nerve psychologist and they do
a formal assessment of somebody's memory using various scales and
(11:08):
tests that have been developed, and then they're able to detect,
you know, what type of memory problem she has. Also,
prior to entering the trial, a person first has to
be on the stable dose of one of the medicines
for Alzheimer's disease. Those are the steel colleen inhibitors and
have the mild Alzheimer's and then that's a reason to
move forward. As part of the study, they also have
(11:29):
a lumbar puncture where we look at cerebra spinal fluid
to see if it has typical markers of Alzheimer's in
it as well. So she was a good candidates. And
this has to be done with people with mild Alzheimer's.
I mean again, I guess if the progression has gone
too far, you can't really slow down enough, right, That's
our understanding at this time. We wanted to start with
people who had mild Alzheimer's to try and make their
(11:49):
memory better. The further the disease progresses, the harder it
is to treat. And so in a trial like this
where we're trying to establish this as a new treatment,
we thought that, you know, the best target was early
all timer's, where you'd be more likely to be able
to have an impact with a treatment like this, especially
one that you know, as far as we know, is
not expected to delay progression or cure. It is just
expected to help with memory and minimize symptoms. Tell me
(12:13):
a little bit more about the actual procedure, because as
I mentioned, you were involved in this. You guys use
a state of the art robotic system you know, working
in the brain is obviously very very delicate work, and
you use this robot to make the precision implantation of
the device and the brain. Yeah, that's right. So the
technique that we're using is it is called stereotaxi, and
(12:35):
the general principle of it is that, of course we
can get a brain m r I to see the
structures in the brain that we would like to target,
in this particular case, the fornix. And then what we
do is we apply what's called a stereotactic frame and
we fit that to the patient. And what that means
in lay terms, as you can imagine, there are four
pins that go through the skin and fix the frame
(12:57):
to the bone so that there's a rigid transformation between
the patient in the patient's head and this frame. And
then then what you can do is you can do
an interoperative image with a localizer on the frame and
then you can know where that frame is in three
D space. And once you've done that image to know
where your frame is and the frame is fixed to
(13:17):
the person's head, well, then of course you can know
where things are in three D space underneath the skin,
deep within someone's brain. Because the whole point of this
is that we need to get an electrode far into
the brain and we want to do that as minimally
and basically as possible. So we're not actually gonna see
where the electrode goes. We're just going to know where
it goes based on this system. And what the robot
adds to that is that the robot is a robotic arm.
(13:39):
Where this is the renaischean Neuromte robot. It has very
high accuracy of less than zero point five millimeters of error.
That's a very small error. And what it is is
it's a robotic arm that we can push a button
and the robotic arm goes into just the right position
to deliver the electrode to the right spot with minimal airror.
And so that's the use of robot for the procedure.
(14:02):
And you mentioned how it's minimally invasive, right, Yeah, I
think for my understanding, depending on you know, the hairline
of the subject and all, you might not even see anything,
maybe a small bump or something like that. So I
really don't see too much of the after effects. Yeah,
that's right. So there's a there's a small incision and
then we make a dime sized opening uh in the bone,
which is what we put the electrode through, and in
(14:25):
that opening we have a little plastic fixture that secures
the electrode in place so that it it will be at
the right depth. And that fixture has a little cap
to it, and that's the teeny little bump. So for
a person who's bald like myself, you might see the
small bump, or you might see the healed incision. But
for somebody who's got a full head of hair, well,
of course it's behind the hairline and you wouldn't notice
(14:45):
it at all unless unless you were looking for it
and knew it was there. Okay, so we've got this
device implanted into Jane. How is she doing now, and
what's the rest of the study looking like? Well, actually,
before we go on to that, before we leave the procedure.
One of the things that's interesting and unique about the
procedures that it's done awake, and we also look for
responses during the surgery. You know, it sounds really unique
(15:07):
when you first hear about it, the idea of doing
awake brain surgery, but it turns out to be a
very routine thing that's been done since the nineteen twenties
and nineteen thirties. Routinely, and so the first point that
most people might be familiar with is that the brain
doesn't have sensation, and so it's not going to hurt
as you put an electrode through the brain. The parts
that can hurt are the scalp and the covering of
(15:28):
the brain, and the scalp can be anesthetized with local
and aesthetic. So the first thing we do is we
sedate somebody and apply a local anesthetic all around the
scalp and and to where the incision is going to be,
and then we let the sedation to wear off, and
then people are awake, usually with you know, minimal or
no pain um and then you know, we go through
the procedure of you know, making the small incision and
opening the whole. You know. The one thing is that
(15:50):
when we use the drill, it can be a little
bit like going to a dentist where the vibration of
the drill you can hear it because it vibrates through
your bone near the near the bones of the ear
of course as well, so it sounds kind of loud,
but it didn't hurt. And then once we place the electrode,
we're looking for confirmation that we're in the right place.
So we have this scary tactic system with a robotic arm,
but we also want to confirm through other ways that
(16:12):
we got to the right place. And the first thing
is that when we start to stimulate through the electrode,
sometimes people have memories or vague memories, and that was
true for Jane. She did have some vague memories when
we turned the stimulator on, and that helped us know
that we were near the fornix, because there are very
few places in the rain where you would expect a
response like that. The other thing is that the fornis
is right next to an area called the hypothalamus, and
(16:34):
the hypothalamus is involved in controlling heart rate and blood pressure.
So when we turned the stimulator on, if we're in
the right place, we expect to see the heart rate
go up a little bit and the blood pressure we
expect to see that go up a little bit too,
And so we saw both those things, you know, in
her case, that helped us know we were in the
right place. And then once we feel confident that we've
(16:54):
got to the right place, then we take another image
with something called an o arm. It's like an introvert
ct scan and then we can see where the electrode
is and confirmed that where we wanted it to go.
So then and then of course after that then we
uh and can we can close up. And one of
the things that's nice about being able to do this
awake is certainly the idea of being able to have
confirmation that you got to the right place. It's also
(17:15):
nice to be able to avoid general anesthesia, which makes
the recovery easier, and sometimes people with dementia can feel
like their memory got a little bit worse after general anesthesia.
It's certainly safe to do generally ansthesia. It has to
be done all the time for various procedures, but the
less we can do it the better, And so that's
sort of a the wrap up of how it is awake.
But it's also very similar to other awake procedures we do,
(17:37):
for example, mapping where someone's language is to take out
of brain tumor or in movement disorder, surgery testing where
a lead is to treat Parkinson's disease or essential tremor,
and a lot of those procedures can also be done asleep.
But there's certainly a possibility of doing awake as well
and so and as I mentioned, just to to wrap
it every all up, you know, the ongoing study, what
are we looking for as far as James progression and
(18:00):
all that. So we all want to know as soon
as possible is it gonna work? And the answers we're
not going to know because the endpoint for the study
is called the Integrated Alzheimer's Disease Rating Scale. It's another
one of those tools that the psychologists used. That's our
primary endpoint for the study. And the time that we're
gonna be looking at is one year after the implant
and stimulator has been on. And of course the progression
(18:21):
of Alzheimer's is slow, and so over one year there
should be enough progression that we can tell a difference
between patients where the stimulators on and hopefully to slow
it down versus patients where it hasn't been slowed down.
But ideally the patient and we ourselves will not know
if it's on or not. Of course it's a double
blinded study, so you know, I won't know if the
things on or not, and she won't be able to tell.
(18:42):
And uh progression of the disorder is slow enough. So
I think the big picture here is that we won't
know for about a year, and once there's enough people,
there's gonna be ninety patients in the first part of
the study in two total. Once all to ten have
gotten to a year, then that's when we unblinded and
tell people, hey, you were on or you were off.
After a year, everybody can be turned on, so it
(19:03):
won't be that people had a procedure and won't have
any stimulation at all. Dr Alexander Papanastasio, Associate Professor of
Neurosurgery at the University of Texas Health Science Center at
San Antonio, thank you very much for joining us. Thank you.
(19:25):
That's it for today. Join us on social media at
Daily Dive pod on both Twitter and Instagram. Leave us
a comment, give us a rating, and tell us the
stories that you're interested in. Follow us on our Heart radio,
or subscribe wherever you get your podcast. This episode of
The Daily Divers produced by Victor Wright and engineered by
Tony Sargantino. I'm Oscar Ramirez and this was her Daily
(19:47):
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