Beth Usher on Life with Half a Brain

Episode Transcript

Dr. Correa:
Saludos and hello, I'm Daniel Correa.

Dr. Nath:
And I'm Audrey Nath.

Dr. Correa:
We're two neurologists and fellow brain geeks hosting the Brain & Life podcast. This show, the Brain & Life Magazine and website are all brought to you by the American Academy of Neurology.

Dr. Nath:
We're so glad you're joining us. We'll be here each week for conversations and interviews with community members, celebrities, and experts on brain health and living with neurologic conditions. Now, let's get to today's show.

Dr. Nath:
Daniel, I got to tell you, I got to speak with somebody who's a part of neurology history. Beth Usher was a little girl back in the 1980s who had really difficult to control epilepsy, who had half of her brain removed and a procedure called a hemispherectomy, and she's alive and well.

Dr. Correa:
That's a serious surgery. Wow.

Dr. Nath:
Yeah, it's a big surgery, and she's alive and well in her 30s and able to tell the tale.

Dr. Correa:
That's amazing. And so, what is the condition that caused her to have to have this major surgery?

Dr. Nath:
So she had a form of very severe epilepsy in a disease called Rasmussen's disease, and this is one where the immune system actually attacks half of the brain and can cause very severe seizures. And back in the 1980s, when Beth Usher was a little girl, they were figuring out that actually removing or disconnecting that half of the brain could stop the seizures and help prevent the seizures from spreading to the good side of the brain. And she's alive and well to tell us about it.

Dr. Correa:
That's amazing. I'm looking forward to hearing from her and her family about that experience, and then to learn more from our medical expert.

Dr. Nath:
Today, we are thrilled to be speaking with someone who has a truly incredible story. As a pediatric epileptologist myself, the person we're speaking with today is a part of history of my field, and I wish every one of my patients could meet with her. Beth Usher is a motivational speaker who has overcome a severe form of epilepsy called Rasmussen's encephalitis, in which, briefly, the body attacks one half of the brain and causes seizures. To treat this, she had half of her brain removed as a child, and she has since been thriving, reaching out to other people with disabilities. She participated in the America's Funniest Laughter competition and worked with the Humor Academy Project. And I think she's living her best life. Beth, it is an honor to have you on our show today, Beth Usher, welcome to the Brain & Life podcast.

Beth Usher:
Oh my gosh. It's such an honor to be here, Dr. Nath. I feel like I'm meeting new members of my family.

Dr. Nath:
Speaking of family, I do just want to say hello to Beth's mother and father. Hi there.

Kathy Usher:
Hi, Dr. Nath. Nice to meet you.

Brian Usher:
Hi doctor.

Dr. Nath:
Nice to meet you guys. Hello. Oh, this is so cool. Oh my goodness. I would like to start actually, yeah, I'll start with Beth's perspective, but I would also like to hear from your parents. For those of you who haven't heard from you before, could you talk about your memory of your first seizure and what you thought was happening?

Beth Usher:
Oh my gosh. Third weekend to kindergarten, I was outside playing on the playground, and I fell off a seesaw. And I had a seizure. My brother rushed me into the nurse's office, and by the time my mom and dad got there, I was in a full blown epileptic seizure.

Dr. Nath:
Oh goodness.

Beth Usher:
Grand mal seizure. I wish I could remember it, but only by stories, I'm sure my mom and dad could fill you in.

Dr. Nath:
Yeah. I'm curious what they remember.

Kathy Usher:
Yeah. Well, I was at work, and Brian was out for a run, and the principal of Beth's school called and said, "We think there's something wrong with Beth."

Dr. Nath:
Oh, nobody wants to hear that.

Kathy Usher:
I know. I mean, I said, "What do you mean something wrong?" And she said, "Well, we're not quite sure what's going on," and I had a friend drive me. And by the time I had gotten to the nurse's office, I had never seen a seizure before, by the way, she was reaching up to me with her left hand and she's right handed. And she said, "Mom-my," so she looked like she was conscious during this whole thing, but she was definitely... She was shaking, having trouble speaking. And we rushed her to our doctor's office who called an ambulance right away, and they took her to the hospital where they sedated her and then did a CAT scan at the time. And the doctor came back and said, "How was her birth and delivery?" And I said, "Fine." "How is her apgar score?" I said, "Great." And she had met all her milestones. She was, I mean, dancing, playing soccer better than her older brother. She was beginning to read and doing math. She was just doing wonderfully, but he told us it appeared that on the CAT scan, she was born with cerebral palsy, that there was a little atrophy on the left side of her brain.

Dr. Nath:
How do you even take that information?

Kathy Usher:
We couldn't believe it. It was crazy. And they sent her home with phenobarbital, and she had severe behavioral issues. She couldn't sit still in school. I mean, her whole personality started to change. And then, about a month later she had another, which looked to us like a grand mal seizure, brought her to the hospital, sent her home with different medication. And then, she'd have these myoclonic jerks where she'd be eating, and her right hand would go flying. And maybe about six months after that, it was a gradual decline, she started losing function on her right side. Then we went in for another CAT scan, and there was more atrophy.

Dr. Nath:
That had to been terrifying.

Kathy Usher:
Oh my gosh, we were out of our minds. It felt like we just were walking around constantly with cement bags on our back, just trying to figure out what was going on.

Dr. Nath:
Because whatever it was was getting worse.

Kathy Usher:
It was getting worse. It was a progressive, but no one, no one knew what was going on. They couldn't tell us. We called everywhere. We couldn't get any answers. Our local pediatric neurologist had her in the hospital, ran all kinds of tests, and he was baffled. Every time they'd give her new medication, it would last for a little bit, and then they'd break through again. And then, sometimes the medication would make it worse, and she'd have such severe reactions that she couldn't even walk. And at one point, she was almost catatonic. She couldn't go to school. It was just crazy. She was having up to 100 seizures a day.

Dr. Nath:
And this was somebody who had never had a seizure before when she was younger. You truly had not seen these before, and then it just started explosively.

Kathy Usher:
No, it was definitely Twilight Zone trying to figure out, we were petrified and you know, when you have a sick child, you expect the whole world to come in and make her better. And you look for help in every area. But yeah, it was the most frightening thing. Sometimes even now looking back, we shudder, we cannot believe that we went through this. And there are definitely people going through similar things and a lot worse. But we were watching this really super intelligent, athletic, perfectly normal child deteriorate, and there was nothing we could do at that time to help her. Like Beth said, she feels like she should remember all this, but she's told the story so many times and has listened to us and other family members that she feels like she was really aware of it all, but I don't think you were.

Beth Usher:
Only by stories. Yeah.

Dr. Nath:
Oh wow. For better or for worse. Right. So-

Kathy Usher:
Exactly.

Dr. Nath:
She might not remember how terrifying that was. But as parents, you do, and there's caregivers that describe having PTSD after events like this, and I believe it.

Kathy Usher:
It was really a frightening, even though I don't think she really remembers, she worked on many coping mechanism to get through it. Like for instance, going for blood work, when she's on all this antiseizure medication, what would you do?

Beth Usher:
I would tell, knock knock jokes and hope the doctors would help me.

Dr. Nath:
Are you serious? Would that help distract you from the needle?

Beth Usher:
It was supposed to.

Kathy Usher:
She would do that with doctors, nurses and technicians who were performing tests.

Dr. Nath:
Oh, that was so cool.

Kathy Usher:
And when I asked her as a five year old, "Why do you do that?" Because it was a constant thing. We'd get in there, and she'd turn it on right away. And she said, "Because if they laugh and like me, they won't hurt me."

Beth Usher:
Boy, was I wrong!

Kathy Usher:
But even in school, we just think back to how frightened the other kids must have been to see their classmate have a seizure, but she would come out of it and tell jokes. And I said why? And she said, "So they would laugh, and they wouldn't be afraid of me."

Dr. Nath:
Oh my goodness. And this is from a little kid. This is a little girl under the age of 10. Oh my goodness.

Kathy Usher:
Yeah.

Dr. Nath:
So you had that connection with the people around you. You wanted them to be okay.

Beth Usher:
Exactly.

Dr. Nath:
Oh, wow.

Kathy Usher:
And that's been the way she's been all her life; trying to make other people feel good and be okay.

Beth Usher:
I try to. I don't think I always succeed, but I definitely try to.

Dr. Nath:
I could see that, because you're a little kid and all of a sudden these events happen, and I'm sure people are staring at you looking really worried. Right?

Beth Usher:
Yeah.

Dr. Nath:
And that was not happening before in your life, and so you came up with a really kind of unique way to deal with that, I think.

Beth Usher:
Exactly.

Dr. Nath:
I have so many questions for you. This affected the left side of your brain. Were you left or right handed before this all began?

Beth Usher:
I was right handed.

Dr. Nath:
Okay. And then, your mama just was mentioning that, because the left side of the brain controls the right side of your body, that you then started to have more marked weakness of the right side of your body and you were right handed. So this probably affected you even more. How have you adapted to the weakness in your right side?

Beth Usher:
My right hand makes a great paperweight now.

Dr. Nath:
That is very glass half full. I love that.

Beth Usher:
I taught myself to draw, and write and punch with my left hand.

Dr. Nath:
You do have two brothers. Yeah, I get it.

Beth Usher:
I have one brother.

Dr. Nath:
One brother.

Beth Usher:
Which I think I could take. Even though he's a Bioman, I think I can take him.

Brian Usher:
It was even prior to the surgery, Beth had evolved and became lefthanded in the course of the two years before we had the surgery. And as she gradually transitioned, she became lefthanded. And prior to that, she really lost use of her right side, and she'd have a lot of foot drops, and she'd fall. She had terrific physical therapy and occupational therapy, and that helped her make some of the adjustments. And certainly after surgery, Beth had to relearn just about everything right there.

Beth Usher:
Yeah.

Dr. Nath:
So I would like to hear a little about how did you get diagnosed? What happened?

Kathy Usher:
We had gone really everywhere. Like Yale, New York, Boston, and she had workups everywhere. And then, ironically, a doctor, a pediatric neurologist at the Yukon Medical Center, we brought her in to see him, and he said, "There's this very, very extremely rare brain disease, which I'm sure she doesn't have." He said, "Rasmussen's encephalitis."

Dr. Nath:
Oh my goodness.

Kathy Usher:
So I wrote to the epilepsy foundation in Washington DC, and I said exactly what I said, there's this thing Rasmussen's encephalitis among some other things. And the librarian wrote back to me, and she said, "I never heard of it, but I'll keep your information on file." And then, maybe a couple of months later, I got a Manila envelope in the mail, and it was from this librarian who now was at the University of Maryland Medical Center library. And it was about a little girl in Denver, Miranda Francisco, who had a hemispherectomy because of Rasmussen's by Dr. Ben Carson in Baltimore. So I called and talked to the Director of Pediatric Neurology, John Freeman, and he said, "Can you send me her latest CAT scan?" So my husband went to Hartford and got the CAT scans. We overnighted them. And he called and said, "How quickly can you get her down here?" And I said, "We can come tomorrow." So we traveled to Hopkins, met with John Freeman and Ben Carson. And within maybe 15 minutes, they said they believe she had Rasmussen's.

Dr. Nath:
Oh my goodness, what a story. This is such a whirlwind. I mean, because she was declining and declining.

Kathy Usher:
Yeah. It was crazy. Because she first had her first seizure in 1985, September. And in the fall of '86, we got to Hopkins, and then surgery was February of '87.

Dr. Nath:
I would like to know from your perspective, since you had never been through something like this before, when you were presented with the option of having half of her brain removed, how did you react to that information?

Kathy Usher:
Oh, we were in total shock and disbelief. And we drove home saying, "There's no way on Earth we could ever do that." I remember talking to a neurosurgeon from Yale, and she told me she wouldn't put a dog through that. She thought it was horrendous. And we said, "Okay, and let's work with the medication and try to deal with that." Kept searching all over the place. I even talked to Dr. Rasmussen himself in Montreal.

Dr. Nath:
Oh wow. Oh my goodness.

Kathy Usher:
And he told me about his early surgeries, and they abandoned it because it wasn't really that successful. But he had thought that with the new medical technology that it might be worth doing. And Dr. Carson, I think Beth was his sixth hemispherectomy. And the others, we were fortunate enough to meet a few of the hemispherectomy patients. And they really seemed to be doing well, And they weren't having seizures.

Dr. Nath:
Oh, that's a relief.

Kathy Usher:
That we were out of our mind with... We couldn't believe it until she started getting progressively worse. And it was, even Brian had to carry her up and down the stairs. She couldn't go to friends' houses, she couldn't go to school. She was so like, seizures were nonstop. We couldn't leave her alone. She has a brother who's two and a half years older, even his life was significantly and drastically impaired because we had to work, and so he had to watch her, like even watching TV, he had to be right next to her. So we, after much soul searching and driving Dr. Carson and Dr. Freeman nuts, even to the fact of canceling surgery, we came to the conclusion that was probably going to be her only chance for a normal life.

Dr. Nath:
I can only imagine. I mean, this was the sixth patient. I mean, you are a piece of history here, and I'm amazed because now and today, these surgeries are done...

Beth Usher:
I feel so old.

Dr. Nath:
Tell your parents that, right?

Beth Usher:
I can only feel how they must feel.

Kathy Usher:
But I know we talked to Beth about it, and the only thing she said to us was, "I dream of having no seizures. No more seizures." That was her main thing. So we finally made the decision.

Dr. Nath:
Beth, I would like to ask you, were you scared?

Beth Usher:
I think I was too young to really understand what was going on.

Dr. Nath:
Yeah. About the surgery and taking out half of your brain. I mean, I guess that's a hard thing for anyone to wrap their minds around. You were a little kid.

Beth Usher:
I think I would be scared now.

Dr. Nath:
Yeah. Okay, I could see that.

Beth Usher:
Yeah.

Brian Usher:
And the quality of her life had really deteriorated, and it was a tough decision. And it was a rocky road after surgery. The surgery was 12 hours, and it came out, they said it was successful. And shortly thereafter, Beth fell into a coma, and she was actually in a coma for close to six weeks, and we were just beyond ourselves. And Dr. Carson assured us that she was coming around, and he kind of likened it to a traumatic brain injury where you gradually come around, and Beth did, but it was a long haul. And the therapy, she's worked really hard over the years, and it's paid off. I mean, she's-

Beth Usher:
I think so.

Brian Usher:
You know-

Dr. Nath:
I think so too.

Brian Usher:
She really did work hard with all of her therapies.

Kathy Usher:
One night I was back at the Ronald McDonald House where we stayed, and Brian was sleeping by a cot in her room and, yeah, tell Dr. Nath What happened?

Beth Usher:
Is it okay with you dad?

Brian Usher:
Sure.

Beth Usher:
And my dad was sleeping on a cot, well resting on a cot filling out the days' happenings in the journal, and all of a sudden he hears, "Dad, my nose itches." So dad jumps up out of the cot, scratches my nose, runs out to the hall, jumping up and down, screaming, "She's awake! She's awake!" at the top of his lungs, only wearing boxer shorts.

Kathy Usher:
With smiley face that Beth had given him for Christmas the Christmas before.

Dr. Nath:
Was that his relatable-

Brian Usher:
Those were her first real words.

Kathy Usher:
And Brian was asking her, "What's your address? Do you remember this? Do you?" And she said, "Dad, I remember everything."

Dr. Nath:
Oh, my goodness.

Brian Usher:
So, yeah, and her long term memory was good. And it took a while for the short term memory was... There were some challenges there. I think the good news, even though it took many years of hard work and therapy, but Beth is seizure free. She's not on any medications.

Dr. Nath:
Wow.

Beth Usher:
And I'm finally in my right mind

Brian Usher:
And Beth can speak to this far better, but she's pretty inspirational to us.

Beth Usher:
Oh, thanks dad. You don't have to say that, though.

Brian Usher:
Yeah. She really does live a full life and has such empathy, and it had a good outcome. It's had a positive outcome, and it was not an easy journey, but it's-

Kathy Usher:
But worth it, right?

Beth Usher:
Absolutely. So worth it.

Dr. Nath:
I mean, you guys paved the way for so many patients now, where this procedure is done quite a bit more, and people are no longer getting a hemispherectomy that are in the single digits of people who have gotten it. And with those support networks, I think it has really helped everybody. So you guys paved the way. Thank you for talking with us. I don't want to take up too much more of your time.

Kathy Usher:
Oh no.

Beth Usher:
No, this is awesome.

Dr. Nath:
If people would like to kind of keep up with what you're doing, or find you on social media, do you have a way for people to catch up with you?

Beth Usher:
Go to Facebook. I have a Facebook page called The Kind Side, where people can post anything about kindness they want and stuff.

Dr. Nath:
Oh gosh. That's so great. I love it. Please go check it out.

Beth Usher:
I belong to an association called AATH (The Association for Applying a Therapeutic Humor), and I find that laughter helped me and still does help me through any tough situation. And I highly recommend checking out this program.

Dr. Nath:
Fantastic. We can put the information in our show notes too. That is fantastic.

Beth Usher:
Yeah, please. Thank you.

Dr. Nath:
Yes, of course.

Beth Usher:
Well, I left this part out during my coma. Well, when I was having seizures, the only way my mom and dad could get ready for work in the morning was to plop me down in front of Mr. Rogers' Neighborhood of Make Believe. And for some reason I wouldn't have one seizure the entire time his show was on.

Dr. Nath:
That is so interesting.

Beth Usher:
And a couple weeks before I went in for surgery, my mom called his studio asking if he would send me a letter or a signed picture. And he called the hospital every day to find out how I was doing.

Dr. Nath:
Oh my goodness, that's so sweet.

Beth Usher:
And when he found out I fell into a coma, he decided to make a trip and come visit me. And I got my very own show with all the puppets from the neighborhood. I just wish I was awake to see it.

Dr. Nath:
Oh my goodness. I would've loved that when I was a kid. That is so cool.

Beth Usher:
Yeah, absolutely.

Brian Usher:
And then, they became lifelong friends and corresponded and-

Dr. Nath:
Well, thank you so much for all three of you joining us today. And yes, now we can include some places where people can keep up with you and the work you do with humor, and healing, and reach out to you guys, because you guys have really paved the way for so many other patients.

Beth Usher:
And thank you so much, Dr. Nath.

Brian Usher:
Thank you.

Beth Usher:
Thank you.

Kathy Usher:
Thanks, Dr. Nath.

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Dr. Nath:
If you don't live in the US, you can still enjoy Brain & Life online at brainandlife.org. To learn more about Rasmussen's encephalitis, I caught up with Dr. Jim Riviello, an epileptologist who has had a career that has taken him all over the country and is now division chief at Texas Children's Hospital. Dr. Riviello, welcome to the Brain & Life podcast.

Dr. Riviello:
No, thank you very much for the invitation.

Dr. Nath:
Do you remember when hemispherectomies or taking out, essentially, half of the brain came on the scene?

Dr. Riviello:
Well, the hemispherectomies have been on the scene for probably about I'm going to say 50, 60 years. They were popularized by the group out of the Montreal Neurological Institute. So they had been around for a while, and actually Dr. Rasmussen who subsequently his name is the eponym for the disease, that's where he was from - the Montreal Neurological Institute. So, hemispherectomies had been around for a while. I think some of the first data that came out that linked Rasmussen's with autoimmune disorders I think was in the early '90s, and in that they had a patient who had plasmapheresis, and they showed that plasmapheresis, which is a way of taking out the plasma from a patient, which would include some of the immune materials, and then separating that from the blood elements and putting the blood elements back, but taking out the immune products, that they showed that did help for the seizures in Rasmussen's. But ultimately, it didn't cure the disease. And that was actually a paper, I think, that came out of Duke and actually out of also Philadelphia. So, I think that was one of the first studies that really linked Rasmussen's with an autoimmune cause.

Dr. Nath:
You know, something that Beth Usher was telling us along with her family, is she had these seizures, they were difficult to treat. And then, they learned that the hemispherectomy would be an option for her, and she was a little kid, and they were really stunned and very scared of the surgery. Her mom mentioned that they had scheduled it and rescheduled it many times because of how scary it seemed. In the beginning, was that something that you were coming across a lot with your patients? People saying, "I can't believe you want to take out half of my brain?"

Dr. Riviello:
Yes. So, many patients, well, when you say that, of course they're afraid of that, the patients and their families. There was even a paper from Hopkins, which the Johns Hopkins Epilepsy Center did a lot in the early workup of Rasmussen's, and they had a paper which basically asked, "How can you take out half the brain? How can you do a hemispherectomy and the patients remain fine?" And part of the reason for that is that if we think about what would happen, if a patient with normal brain function, if we did a operation on one half of their brain, they would be left with a deficit.

Dr. Nath:
Exactly.

Dr. Riviello:
And we generally, for epilepsy surgery, don't take out tissue if we think it's going to leave the person with the deficit. Now, I can back up and say that for epilepsy surgery, the two major things that we need to do if we think the patient is a surgical candidate, is number one, identify the epileptic focus, meaning the area from which the seizures are coming. And number two is then identify the function of that area, what we call mapping. So what we want to do is identify the place where we think the seizures are coming from, and then we want to map that area, and mapping defines what's the function. We've come to use the term, "Eloquent cortex." Eloquent cortex is defined as tissue or cortex that subserves a function that you wouldn't want to lose, like primary motor function, primary sensory function, visual function, auditory function, memory function. And if the focus is not in that area, then we would recommend epilepsy surgery.

Dr. Nath:
I see. So essentially, I think what you're getting at is with these patients with Rasmussen's syndrome, where about half of their brain potentially is being attacked by antibodies and is causing seizures, I think what you're getting at is that half of the brain might not be functioning so hot, so well at baseline?

Dr. Riviello:
Correct. So, if we extend the mapping analogy, then if we were to map out those areas, we would hope that there would be no function there, because therefore the less function there is, or if an area has no function, then we feel comfortable doing a resection because we say it's a silent area of the brain. Now, actually, it's a myth to say that there are silent areas of the brain.

Dr. Nath:
That's right.

Dr. Riviello:
The brain, any area does something, and we may not be able to identify the exact function that a given area does, and therefore, we may say that it's silent, but we refer to the eloquent areas as those that have a function that we wouldn't want to lose. So, the reason that we're able to do a hemispherectomy successfully with Rasmussen's syndrome is because of the underlying disease. The underlying disease has caused dysfunction, or damage or whatever term you want to use to define it, but the hemisphere is already damaged, so the surgery is not damaging it more. The damage has already occurred. So therefore, if you resect or really disconnect that area, then the patient doesn't have additional injury because they've already, in a sense, paid the price for the surgical procedure. So that is why we're able to do it.

Dr. Riviello:
Now, on the other hand, we counsel our families and say that if they're having seizures and limited to one half of the brain, then we're treating them with seizure medications that affect both sides of the brain, and when they have the actual seizures, the seizures are spreading to the other side of the brain, so it actually is better for them that if we're able to cure the epilepsy, they won't have the ongoing potential for damage from the seizures themselves, and they won't have the potential damage from the anti-convulsant medications, which we all know are really toxic in themselves.

Dr. Nath:
I think that's a really important point to bring up, because as extreme as it can sound to be removing or cutting off half of the brain, we actually are, if anything, trying to preserve the function of the good half, even more so. And that there is some degree of time sensitivity to this to try to really protect that other side of the brain.

Dr. Riviello:
I mean, correct. We really do know in epilepsy surgery that the sooner that you get the seizures under control, the better the cognitive outcome for the patient. Now in general, in neurology, we have the term, "Time is brain." And we typically refer to that in stroke, or we refer to that in neurocritical care and acute brain injuries, but it actually applies to epilepsy, and it especially applies to patients with epilepsy surgery, so that if we can control their seizures sooner, we'll promote better brain function.

Dr. Nath:
What do you see coming up in the future for treatment of Rasmussen's encephalitis and other autoimmune encephalitis?

Dr. Riviello:
Now, what is, if I say it's not even on the horizon now, it's in use is, we've developed the techniques that are called minimally invasive epilepsy surgery. And what do we mean by that? Well, we mean, rather than doing an open operation, or what we call a craniotomy, we can now use minimally invasive techniques, such as laser. There's a laser therapy where if you can pinpoint the area that the seizures are coming from, you can insert a laser into the skull and, under MRI guidance, actually you can ablate the focus, rather than having to do an open craniotomy. And people tolerate that a lot better, the laser therapy, than they tolerate an open craniotomy. So we've been doing a lot of those now for various types of epilepsy surgeries and including the disconnections. You can now do hemispherectomy by laser therapy, you can do a hemispherectomy by endoscopy. Endoscopy means putting a small visual scope into the brain and disconnecting that way, minimally invasive. So those are things that we currently are doing. Although for Rasmussen's, we've been tending to do the functional hemispherectomy, but we can do it with some of the minimally invasive techniques.

Dr. Nath:
Even more of a reason that like what you were saying, "Time is brain," and we're really trying to help our patients. Thank you so much, Dr. Riviello for giving us your perspective on Rasmussen's encephalitis and treatments over the decades and towards the future.

Dr. Riviello:
All right. Well, thank you very much for inviting me.

Dr. Correa:
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