Frame-based and robot-assisted insular stereo-electroencephalography via an anterior or posterior oblique approach

OBJECTIVE There is an increasing interest in stereo-electroencephalography (SEEG) for invasive evaluation of insular epilepsy. The implantation of insular SEEG electrodes, however, is still challenging due to the anatomical location and complex functional segmentation in both an anteroposterior and ventrodorsal (i.e., superoinferior) direction. While the orthogonal approach (OA) is the shortest trajectory to the insula, it might insufficiently cover these networks. In contrast, the anterior approach (AOA) or posterior oblique approach (POA) has the potential for full insular coverage, with fewer electrodes bearing a risk of being more inaccurate due to the longer trajectory. Here, the authors evaluated the implantation accuracy and the detection of epilepsy-related SEEG activity with AOA and POA insular trajectories. METHODS This retrospective study evaluated the accuracy of 220 SEEG electrodes in 27 patients. Twelve patients underwent a stereotactic frame-based procedure (frame group), and 15 patients underwent a frameless robot-assisted surgery (robot group). In total, 55 insular electrodes were implanted using the AOA or POA considering the insular anteroposterior and ventrodorsal functional organization. The entry point error (EPE) and target point error (TPE) were related to the implantation technique (frame vs robot), the length of the trajectory, and the location of the target (insular vs noninsular). Finally, the spatial distribution of epilepsy-related SEEG activity within the insula is described. RESULTS There were no significant differences in EPE (mean 0.9 ± 0.6 for the nonsinsular electrodes and 1.1 ± 0.7 mm for the insular electrodes) and TPE (1.5 ± 0.8 and 1.6 ± 0.9 mm, respectively), although the length of trajectories differed significantly (34.1 ± 10.9 and 70.1 ± 9.0 mm, repsectively). There was a significantly larger EPE in the frame group than in the robot group (1.5 ± 0.6 vs 0.7 ± 0.5 mm). However, there was no group difference in the TPE (1.5 ± 0.8 vs 1.6 ± 0.8 mm). Epilepsy-related SEEG activity was detected in 42% (23/55) of the insular electrodes. Spatial distribution of this activity showed a clustering in both anteroposterior and ventrodorsal directions. In purely insular onset cases, subsequent insular lesionectomy resulted in a good seizure outcome. CONCLUSIONS The implantation of insular electrodes via the AOA or POA is safe and efficient for SEEG implantation covering both anteroposterior and ventrodorsal functional organization with few electrodes. In this series, there was no decrease in accuracy due to the longer trajectory of insular SEEG electrodes in comparison with noninsular SEEG electrodes. The results of frame-based and robot-assisted implantations were comparable.

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Technique, Results, and Complications Related to Robot-Assisted Stereoelectroencephalography

Neurosurgery ◽

10.1227/neu.0000000000001034 ◽

2015 ◽

Vol 78 (2) ◽

pp. 169-180 ◽

Cited By ~ 121

Author(s):

Jorge González-Martínez ◽

Juan Bulacio ◽

Susan Thompson ◽

John Gale ◽

Saksith Smithason ◽

...

Keyword(s):

Focal Epilepsy ◽

Interquartile Range ◽

Implantation Technique ◽

Target Point ◽

Seizure Outcome ◽

Seizure Freedom ◽

Epileptogenic Zone ◽

Robot Assisted ◽

Depth Electrodes

ABSTRACT BACKGROUND: Robot-assisted stereoelectroencephalography (SEEG) may represent a simplified, precise, and safe alternative to the more traditional SEEG techniques. OBJECTIVE: To report our clinical experience with robotic SEEG implantation and to define its utility in the management of patients with medically refractory epilepsy. METHODS: The prospective observational analyses included all patients with medically refractory focal epilepsy who underwent robot-assisted stereotactic placement of depth electrodes for extraoperative brain monitoring between November 2009 and May 2013. Technical nuances of the robotic implantation technique are presented, as well as an analysis of demographics, time of planning and procedure, seizure outcome, in vivo accuracy, and procedure-related complications. RESULTS: One hundred patients underwent 101 robot-assisted SEEG procedures. Their mean age was 33.2 years. In total, 1245 depth electrodes were implanted. On average, 12.5 electrodes were implanted per patient. The time of implantation planning was 30 minutes on average (range, 15-60 minutes). The average operative time was 130 minutes (range, 45-160 minutes). In vivo accuracy (calculated in 500 trajectories) demonstrated a median entry point error of 1.2 mm (interquartile range, 0.78-1.83 mm) and a median target point error of 1.7 mm (interquartile range, 1.20-2.30 mm). Of the group of patients who underwent resective surgery (68 patients), 45 (66.2%) gained seizure freedom status. Mean follow-up was 18 months. The total complication rate was 4%. CONCLUSION: The robotic SEEG technique and method were demonstrated to be safe, accurate, and efficient in anatomically defining the epileptogenic zone and subsequently promoting sustained seizure freedom status in patients with difficult-to-localize seizures.

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Pediatric stereo-electroencephalography: effects of robot assistance and other variables on seizure outcome and complications

Journal of Neurosurgery Pediatrics ◽

10.3171/2021.2.peds20810 ◽

2021 ◽

pp. 1-12

Author(s):

Ioannis N. Mavridis ◽

William B. Lo ◽

Welege Samantha Buddhika Wimalachandra ◽

Sunny Philip ◽

Shakti Agrawal ◽

...

Keyword(s):

Clinical Outcomes ◽

Epilepsy Surgery ◽

Complication Rate ◽

Seizure Outcome ◽

Robot Assisted ◽

Implanted Electrodes ◽

Anatomy And Physiology ◽

Robot Assistance ◽

The Difference ◽

Robot Group

OBJECTIVE The safety of stereo-electroencephalography (SEEG) has been investigated; however, most studies have not differentiated pediatric and adult populations, which have different anatomy and physiology. The purpose of this study was to assess SEEG safety in the pediatric setting, focusing on surgical complications and the identification of patient and surgical risk factors, if any. The authors also aimed to determine whether robot assistance in SEEG was associated with a change in practice, surgical parameters, and clinical outcomes. METHODS The authors retrospectively studied all SEEG cases performed in their department from December 2014 to March 2020. They analyzed both demographic and surgical variables and noted the types of surgery-related complications and their management. They also studied the clinical outcomes of a subset of the patients in relation to robot-assisted and non–robot-assisted SEEG. RESULTS Sixty-three children had undergone 64 SEEG procedures. Girls were on average 3 years younger than the boys (mean age 11.1 vs 14.1 years, p < 0.01). The overall complication rate was 6.3%, and the complication rate for patients with left-sided electrodes was higher than that for patients with right-sided electrodes (11.1% vs 3.3%), although the difference between the two groups was not statistically significant. The duration of recording was positively correlated to the number of implanted electrodes (r = 0.296, p < 0.05). Robot assistance was associated with a higher number of implanted electrodes (mean 12.6 vs 7.6 electrodes, p < 0.0001). Robot-assisted implantations were more accurate, with a mean error of 1.51 mm at the target compared to 2.98 mm in nonrobot implantations (p < 0.001). Clinical outcomes were assessed in the first 32 patients treated (16 in the nonrobot group and 16 in the robot group), 23 of whom proceeded to further resective surgery. The children who had undergone robot-assisted SEEG had better eventual seizure control following subsequent epilepsy surgery. Of the children who had undergone resective epilepsy surgery, 42% (5/12) in the nonrobot group and 82% (9/11) in the robot group obtained an Engel class IA outcome at 1 year (χ2 = 3.885, p = 0.049). Based on Kaplan-Meier survival analysis, the robot group had a higher seizure-free rate than the nonrobot group at 30 months postoperation (7/11 vs 2/12, p = 0.063). Two complications, whose causes were attributed to the implantation and head-bandaging steps, required surgical intervention. All complications were either transient or reversible. CONCLUSIONS This is the largest single-center, exclusively pediatric SEEG series that includes robot assistance so far. SEEG complications are uncommon and usually transient or treatable. Robot assistance enabled implantation of more electrodes and improved epilepsy surgery outcomes, as compared to those in the non–robot-assisted cases.

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Accuracy of robot-assisted versus optical frameless navigated stereoelectroencephalography electrode placement in children

Journal of Neurosurgery Pediatrics ◽

10.3171/2018.10.peds18227 ◽

2019 ◽

Vol 23 (3) ◽

pp. 297-302 ◽

Cited By ~ 11

Author(s):

Julia D. Sharma ◽

Kiran K. Seunarine ◽

Muhammad Zubair Tahir ◽

Martin M. Tisdall

Keyword(s):

Soft Tissue ◽

Entry Point ◽

Electrode Placement ◽

Target Point ◽

Localization Error ◽

Bone Thickness ◽

Tissue Thickness ◽

Robot Assisted ◽

Soft Tissue Thickness ◽

Safety Margins

OBJECTIVEThe aim of this study was to compare the accuracy of optical frameless neuronavigation (ON) and robot-assisted (RA) stereoelectroencephalography (SEEG) electrode placement in children, and to identify factors that might increase the risk of misplacement.METHODSThe authors undertook a retrospective review of all children who underwent SEEG at their institution. Twenty children were identified who underwent stereotactic placement of a total of 218 electrodes. Six procedures were performed using ON and 14 were placed using a robotic assistant. Placement error was calculated at cortical entry and at the target by calculating the Euclidean distance between the electrode and the planned cortical entry and target points. The Mann-Whitney U-test was used to compare the results for ON and RA placement accuracy. For each electrode placed using robotic assistance, extracranial soft-tissue thickness, bone thickness, and intracranial length were measured. Entry angle of electrode to bone was calculated using stereotactic coordinates. A stepwise linear regression model was used to test for variables that significantly influenced placement error.RESULTSBetween 8 and 17 electrodes (median 10 electrodes) were placed per patient. Median target point localization error was 4.5 mm (interquartile range [IQR] 2.8–6.1 mm) for ON and 1.07 mm (IQR 0.71–1.59) for RA placement. Median entry point localization error was 5.5 mm (IQR 4.0–6.4) for ON and 0.71 mm (IQR 0.47–1.03) for RA placement. The difference in accuracy between Stealth-guided (ON) and RA placement was highly significant for both cortical entry point and target (p < 0.0001 for both). Increased soft-tissue thickness and intracranial length reduced accuracy at the target. Increased soft-tissue thickness, bone thickness, and younger age reduced accuracy at entry. There were no complications.CONCLUSIONSRA stereotactic electrode placement is highly accurate and is significantly more accurate than ON. Larger safety margins away from vascular structures should be used when placing deep electrodes in young children and for trajectories that pass through thicker soft tissues such as the temporal region.

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Stereoelectroencephalography

Neurosurgery ◽

10.1227/neu.0b013e31827d1161 ◽

2012 ◽

Vol 72 (3) ◽

pp. 353-366 ◽

Cited By ~ 267

Author(s):

Francesco Cardinale ◽

Massimo Cossu ◽

Laura Castana ◽

Giuseppe Casaceli ◽

Marco Paolo Schiariti ◽

...

Keyword(s):

Interquartile Range ◽

Entry Point ◽

Target Point ◽

Epileptogenic Zone ◽

Localization Error ◽

Drug Resistant ◽

Robot Assisted ◽

Data Set ◽

Essential Information

Abstract BACKGROUND: Stereoelectroencephalography (SEEG) methodology, originally developed by Talairach and Bancaud, is progressively gaining popularity for the presurgical invasive evaluation of drug-resistant epilepsies. OBJECTIVE: To describe recent SEEG methodological implementations carried out in our center, to evaluate safety, and to analyze in vivo application accuracy in a consecutive series of 500 procedures with a total of 6496 implanted electrodes. METHODS: Four hundred nineteen procedures were performed with the traditional 2-step surgical workflow, which was modified for the subsequent 81 procedures. The new workflow entailed acquisition of brain 3-dimensional angiography and magnetic resonance imaging in frameless and markerless conditions, advanced multimodal planning, and robot-assisted implantation. Quantitative analysis for in vivo entry point and target point localization error was performed on a sub-data set of 118 procedures (1567 electrodes). RESULTS: The methodology allowed successful implantation in all cases. Major complication rate was 12 of 500 (2.4%), including 1 death for indirect morbidity. Median entry point localization error was 1.43 mm (interquartile range, 0.91-2.21 mm) with the traditional workflow and 0.78 mm (interquartile range, 0.49-1.08 mm) with the new one (P < 2.2 × 10−16). Median target point localization errors were 2.69 mm (interquartile range, 1.89-3.67 mm) and 1.77 mm (interquartile range, 1.25-2.51 mm; P < 2.2 × 10−16), respectively. CONCLUSION: SEEG is a safe and accurate procedure for the invasive assessment of the epileptogenic zone. Traditional Talairach methodology, implemented by multimodal planning and robot-assisted surgery, allows direct electrical recording from superficial and deep-seated brain structures, providing essential information in the most complex cases of drug-resistant epilepsy.

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Tool Selectivity in Left Occipitotemporal Cortex Develops without Vision

Journal of Cognitive Neuroscience ◽

10.1162/jocn_a_00411 ◽

2013 ◽

Vol 25 (8) ◽

pp. 1225-1234 ◽

Cited By ~ 48

Author(s):

Marius V. Peelen ◽

Stefania Bracci ◽

Xueming Lu ◽

Chenxi He ◽

Alfonso Caramazza ◽

...

Keyword(s):

Functional Organization ◽

Auditory Task ◽

Anatomical Location ◽

Resting State Functional Connectivity ◽

Frontoparietal Network ◽

Congenitally Blind ◽

Occipitotemporal Cortex ◽

Auditory Tasks ◽

Tool Motion ◽

Selective Activity

Previous studies have provided evidence for a tool-selective region in left lateral occipitotemporal cortex (LOTC). This region responds selectively to pictures of tools and to characteristic visual tool motion. The present human fMRI study tested whether visual experience is required for the development of tool-selective responses in left LOTC. Words referring to tools, animals, and nonmanipulable objects were presented auditorily to 14 congenitally blind and 16 sighted participants. Sighted participants additionally viewed pictures of these objects. In whole-brain group analyses, sighted participants showed tool-selective activity in left LOTC in both visual and auditory tasks. Importantly, virtually identical tool-selective LOTC activity was found in the congenitally blind group performing the auditory task. Furthermore, both groups showed equally strong tool-selective activity for auditory stimuli in a tool-selective LOTC region defined by the picture-viewing task in the sighted group. Detailed analyses in individual participants showed significant tool-selective LOTC activity in 13 of 14 blind participants and 14 of 16 sighted participants. The strength and anatomical location of this activity were indistinguishable across groups. Finally, both blind and sighted groups showed significant resting state functional connectivity between left LOTC and a bilateral frontoparietal network. Together, these results indicate that tool-selective activity in left LOTC develops without ever having seen a tool or its motion. This finding puts constraints on the possible role that this region could have in tool processing and, more generally, provides new insights into the principles shaping the functional organization of OTC.

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Association Between Anatomical Location of Surgically Induced Lesions and Postoperative Seizure Outcome in Temporal Lobe Epilepsy

Neurology ◽

10.1212/wnl.0000000000013033 ◽

2021 ◽

pp. 10.1212/WNL.0000000000013033

Author(s):

Ezequiel Gleichgerrcht ◽

Daniel L. Drane ◽

Simon Sean Keller ◽

Kathryn A. Davis ◽

Robert Gross ◽

...

Keyword(s):

Temporal Lobe Epilepsy ◽

Temporal Lobe ◽

Anterior Commissure ◽

Piriform Cortex ◽

Seizure Outcome ◽

Seizure Freedom ◽

Anatomical Location ◽

Surgical Interventions ◽

Postoperative Seizure ◽

Promising Source

Objective:To determine the association between surgical lesions of distinct grey and white structures and connections with favorable post-operative seizure outcomes.Methods:Patients with drug-resistant temporal lobe epilepsy (TLE) from three epilepsy centers were included. We employed a voxel-based and connectome-based mapping approach to determine the association between favorable outcomes and surgery-induced temporal lesions. Analyses were conducted controlling for multiple confounders, including total surgical resection/ablation volume, hippocampal volumes, side of surgery, and site where the patient was treated.Results:The cohort included 113 patients with TLE [54 women; 86 right-handed; 16.5 (SD = 11.9) age at seizure onset, 54.9% left] who were 61.1% free of disabling seizures (Engel class 1) at follow-up. Postoperative seizure freedom in TLE was associated with 1) surgical lesions that targeted the hippocampus as well as the amygdala-piriform cortex complex and entorhinal cortices; 2) disconnection of temporal, frontal, and limbic regions through loss of white matter tracts within the uncinate fasciculus, anterior commissure, and fornix; and 3) functional disconnection of the frontal (superior and middle frontal gyri, orbitofrontal region) and temporal (superior and middle pole) lobes.Conclusions:Better postoperative seizure freedom are associated with surgical lesions of specific structures and connections throughout the temporal lobes. These findings shed light on the key components of epileptogenic networks in TLE and constitute a promising source of new evidence for future improvements in surgical interventions.Classification of Evidence:This study provides Class II evidence that for patients with temporal lobe epilepsy, postoperative seizure freedom is associated with surgical lesions of specific temporal lobe structures and connections.

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Computer- and Robot-assisted Resection of Thalamic Astrocytomas in Children

Neurosurgery ◽

10.1227/00006123-199107000-00005 ◽

1991 ◽

Vol 29 (1) ◽

pp. 27-33 ◽

Cited By ~ 102

Author(s):

James M. Drake ◽

Michael Joy ◽

Andrew Goldenberg ◽

David Kreindler

Keyword(s):

Three Dimensional ◽

Radical Excision ◽

Neurosurgical Procedures ◽

Robot Assisted ◽

Computed Tomographic ◽

System A ◽

Stereotactic Frame ◽

Three Dimensional Display ◽

Robotic Devices ◽

System Movement

Abstract Six children ranging in age from 2 to 10 years who harbored deep benign astrocytomas were operated upon using a computer- and robot-assisted system. A radical excision was achieved in all cases with no significant morbidity nor any mortality. The system consists of an interactive, three-dimensional display of computed tomographic image contours and digitized cerebral angiograms taken using the Brown-Roberts-Wells stereotactic frame. The surgical retractor is held and manipulated using a PUMA 200 robot. The position and orientation of the surgical retractor is displayed on the three-dimensional display. Preoperative planning and simulation are important features of this system. Movement of the brain after removal of the tumor and cerebrospinal fluid is substantial, so the tumor removal is based on visually defined margins. Enhanced computer graphics and robotic devices are important adjuncts to neurosurgical procedures and will find increasing use in the future. (Neurosurgery 29:27-31, 1991)

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Lesion Network Localization of Seizure Freedom following MR-guided Laser Interstitial Thermal Ablation

Scientific Reports ◽

10.1038/s41598-019-55015-y ◽

2019 ◽

Vol 9 (1) ◽

Cited By ~ 2

Author(s):

Karim Mithani ◽

Alexandre Boutet ◽

Jurgen Germann ◽

Gavin J. B. Elias ◽

Alexander G. Weil ◽

...

Keyword(s):

Resting State ◽

Target Selection ◽

Brain Regions ◽

Seizure Outcome ◽

Seizure Freedom ◽

Anatomical Location ◽

Treatment Resistant ◽

Resting State Functional Connectivity ◽

Network Localization ◽

Subcortical Regions

AbstractTreatment-resistant epilepsy is a common and debilitating neurological condition, for which neurosurgical cure is possible. Despite undergoing nearly identical ablation procedures however, individuals with treatment-resistant epilepsy frequently exhibit heterogeneous outcomes. We hypothesized that treatment response may be related to the brain regions to which MR-guided laser ablation volumes are functionally connected. To test this, we mapped the resting-state functional connectivity of surgical ablations that either resulted in seizure freedom (N = 11) or did not result in seizure freedom (N = 16) in over 1,000 normative connectomes. There was no difference seizure outcome with respect to the anatomical location of the ablations, and very little overlap between ablation areas was identified using the Dice Index. Ablations that did not result in seizure-freedom were preferentially connected to a number of cortical and subcortical regions, as well as multiple canonical resting-state networks. In contrast, ablations that led to seizure-freedom were more functionally connected to prefrontal cortices. Here, we demonstrate that underlying normative neural circuitry may in part explain heterogenous outcomes following ablation procedures in different brain regions. These findings may ultimately inform target selection for ablative epilepsy surgery based on normative intrinsic connectivity of the targeted volume.

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Accuracy of SEEG Electrodes Implanted in Lateral Position Versus Supine Position

Neurosurgery ◽

10.1093/neuros/nyz310_427 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Caio M Matias ◽

Sandeep Kandregula ◽

Chengyuan Wu ◽

Ashwini D Sharan

Keyword(s):

Supine Position ◽

Three Dimensional ◽

Major Complication ◽

Lateral Position ◽

Entry Point ◽

Target Point ◽

Robot Assisted ◽

Dimensional Error ◽

Electrode Implantation ◽

Position Group

Abstract INTRODUCTION Accuracy during SEEG implantations is critical as several electrodes will cross narrow corridors between cerebral blood vessels. Previous studies have compared the accuracy of different techniques such as frame-based, frameless, and robot-assisted implantations and overall SEEG has been reported to be quite safe, with a major complication incidence of less than 1%. Typically, the supine position is utilized for implantation; however, the lateral position may be more comfortable and ergonomic for trajectories with a posterior entry point (eg, posterior approach to the insula). To our knowledge, this is the first study to compare the accuracy of SEEG electrodes implanted in supine position vs lateral position. METHODS About 22 patients who underwent SEEG electrode implantation using Leksell frame fixation and Neuromate robot were included in this study and clustered according to the supine (n = 11) or lateral (n = 11) position. A total of 284 electrodes (Supine: n = 139; Lateral: n = 145) were analyzed. Postoperative Oarm images were co-registered with the preoperative plan on Voxim software. Cartesian coordinates of the entry point (EP) and target point (TP) were obtained from the planned trajectory and the implanted electrode. Three-dimensional error (Euclidian distance) and radial error for EP and TP were calculated. Wilcoxon rank sum test was used to compare lateral versus supine group. RESULTS Radial errors were similar between both groups. EP three-dimensional error was higher in the lateral position group (1.3 mm vs 1.7 mm, P = .004), whereas TP three-dimensional error was higher in the supine position group (2.9 mm vs 1.8 mm, P < .001). CONCLUSION SEEG electrode implantation using frame-based fixation and robot-assisted technique in the lateral position has similar accuracy compared to implantation in the supine position.

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Brain Tumor Resection Aided with Markers Placed Using Stereotaxis Guided by Magnetic Resonance Imaging and Computed Tomography

Neurosurgery ◽

10.1227/00006123-199106000-00003 ◽

1991 ◽

Vol 28 (6) ◽

pp. 801-806 ◽

Cited By ~ 31

Author(s):

Samuel J. Hassenbusch ◽

James S. Anderson ◽

Prem K. Pillay

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Tumor Resection ◽

Skin Incision ◽

Target Point ◽

Resonance Imaging ◽

Computed Tomographic ◽

Stereotactic Frame ◽

Visual Markers ◽

Brain Tumor Resection

Abstract In the operative resection of brain tumors, defining and locating edges of deep-seated tumors or those with indistinct color and consistency can be difficult. This report presents a simple yet precise, alternative method, using the basic Brown-Roberts-Wells or Cosman-Roberts-Wells stereotactic frame, for placement of visual markers to aid in tumor resections. The method can also be extended to the Leksell system. Using routine computed tomographic scanning or magnetic resonance imaging after stereotactic frame application, multiple points along tumor edges were used as target points. In the operating room, standard techniques were used for the skin incision, removal of the bone flap, and opening the dura. At each target point, after opening the dura and using stereotactic coordinates and equipment, a microbiopsy forceps was used to place “micropatties” (each with a string tail) or small catheters with pledgets or catheter tips located at tumor edges. After removing the arc, the tumor resection was accomplished in a conventional nonstereotactic manner by simply following string tails or catheters to the tumor. Gross tumor edges were determined from positions of actual patties or catheter tips. These simple but accurate techniques offer the possibility of tumor resections under stereotactic guidance with equipment readily available to most neurosurgeons. The fidelity of marker placement is also maintained in relation to tumor edges despite shifts in the tumor and/or brain as cystic areas are drained or large amounts of the tumor are resected.

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