The feasibility and value of extraoperative and adjuvant intraoperative stereoelectroencephalography in rolandic and perirolandic epilepsies

2021 ◽  
Vol 27 (1) ◽  
pp. 36-46
Author(s):  
Thandar Aung ◽  
Vineet Punia ◽  
Masaya Katagiri ◽  
Richard Prayson ◽  
Irene Wang ◽  
...  
Keyword(s):  
Hybrid Method ◽  
Seizure Control ◽  
Focal Epilepsy ◽  
Plantar Flexion ◽  
Foot Drop ◽  
Seizure Freedom ◽  
Epileptogenic Zone ◽  
The Novel ◽  
Cortical Areas

OBJECTIVEThe objective of this study was to illustrate the feasibility and value of extra- and intraoperative stereoelectroencephalography (SEEG) in patients who underwent resection in rolandic and perirolandic regions.METHODSThe authors retrospectively reviewed all consecutive patients with at least 1 year of postoperative follow-up who underwent extra- and intraoperative SEEG monitoring between January 2015 and January 2017.RESULTSFour patients with pharmacoresistant rolandic and perirolandic focal epilepsy were identified, who underwent conventional extraoperative invasive SEEG evaluations followed by adjuvant intraoperative SEEG recordings. Conventional extraoperative SEEG evaluations demonstrated ictal and interictal epileptiform activities involving eloquent rolandic and perirolandic cortical areas in all patients. Following extraoperative monitoring, patients underwent preplanned staged resections guided by simultaneous and continuous adjuvant intraoperative SEEG monitoring. Resections, guided by electrode contacts of interest in 3D boundaries, were performed while continuous real-time electrographic data from SEEG recordings were obtained. Staged approaches of resections were performed until there was intraoperative resolution of synchronous rolandic/perirolandic cortex epileptic activities. All patients in the cohort achieved complete seizure freedom (Engel class IA) during the follow-up period ranging from 18 to 50 months. Resection resulted in minimal neurological deficit; 3 patients experienced transient, distal plantar flexion weakness (mild foot drop).CONCLUSIONSThe seizure and functional outcome results of this highly preselected group of patients testifies to the feasibility and demonstrates the value of the combined benefits of both intra- and extraoperative SEEG recordings when resecting the rolandic and perirolandic areas. The novel hybrid method allows a more refined and precise identification of the epileptogenic zone. Consequently, tailored resections can be performed to minimize morbidity as well as to achieve adequate seizure control.

Stereoelectroencephalography in Children and Adolescents With Difficult-to-Localize Refractory Focal Epilepsy

Neurosurgery ◽  
2014 ◽  
Vol 75 (3) ◽  
pp. 258-268 ◽  
Author(s):  
Jorge Gonzalez-Martinez ◽  
Jeffrey Mullin ◽  
Juan Bulacio ◽  
Ajay Gupta ◽  
Rei Enatsu ◽  
...  
Keyword(s):  
Children And Adolescents ◽  
Pediatric Patients ◽  
Focal Epilepsy ◽  
Early Experience ◽  
Morbidity Rate ◽  
Seizure Outcome ◽  
Seizure Freedom ◽  
Epileptogenic Zone ◽  
Eloquent Cortex

Abstract BACKGROUND: Although stereoelectroencephalography (SEEG) has been shown to be a valuable tool for preoperative decision making in focal epilepsy, there are few reports addressing the utility and safety of SEEG methodology applied to children and adolescents. OBJECTIVE: To present the results of our early experience using SEEG in pediatric patients with difficult-to-localize epilepsy who were not considered candidates for subdural grid evaluation. METHODS: Thirty children and adolescents with the diagnosis of medically refractory focal epilepsy (not considered ideal candidates for subdural grids and strip placement) underwent SEEG implantation. Demographics, electrophysiological localization of the hypothetical epileptogenic zone, complications, and seizure outcome after resections were analyzed. RESULTS: Eighteen patients (60%) underwent resections after SEEG implantations. In patients who did not undergo resections (12 patients), reasons included failure to localize the epileptogenic zone (4 patients); multifocal epileptogenic zone (4 patients); epileptogenic zone located in eloquent cortex, preventing resection (3 patients); and improvement in seizures after the implantation (1 patient). In patients who subsequently underwent resections, 10 patients (55.5%) were seizure free (Engel class I) and 5 patients (27.7%) experienced seizure improvement (Engel class II or III) at the end of the follow-up period (mean, 25.9 months; range, 12 to 47 months). The complication rate in SEEG implantations was 3%. CONCLUSION: The SEEG methodology is safe and should be considered in children/adolescents with difficult-to-localize epilepsy. When applied to highly complex and difficult-to-localize pediatric patients, SEEG may provide an additional opportunity for seizure freedom in association with a low morbidity rate.

scholarly journals The Impact of Lesional Factors on Seizure Outcome Following Lesionectomy as a Surgical Management of Extratemporal Epilepsy, Case Series from a Developing Country and Review of Literature.

2021 ◽  
Author(s):  
Amr Ali Hasanain ◽  
Mohamed Sawan ◽  
Ahmed Mohamed Ali
Keyword(s):  
Focal Epilepsy ◽  
Focal Lesion ◽  
Seizure Outcome ◽  
Seizure Freedom ◽  
Low Grade ◽  
Epileptogenic Zone ◽  
Seizure Semiology ◽  
Radiological Data ◽  
The Impact

Abstract BACKGROUNDExtratemporal lesional epilepsy can be managed with various surgical techniques such as simple lesionectomy or more extensive resections, all of which aim at targeting the epileptogenic zone which is the key for achieving a favorable outcome. This study aimed at evaluating the effectiveness of lesionectomy in the treatment of extra-temporal epilepsy associated with a lesion on radiological imaging, and to show the effect of lesional factors on seizure outcome including the anatomical location, the relation to cerebral parenchyma, the extent of surgical excision and the histopathological nature of the lesion.METHODSA prospective study on 20 patients presenting with focal epilepsy, or focal epilepsy with secondary generalized seizures with evidence of focal lesion in an extratemporal location on MRI. Lesionectomy was done and we used the Engel’s classification for seizure outcome.RESULTSLesions were mostly tumors (85 %). The frontal lobe is the most frequent locations (60 %). Low-grade glioma represented 35 % while meningioma represented 45 % of all lesions (both intra-axial and extra-axial). Four patients were lost during follow up (mean 23.31 months). For the remaining 16 patients, 13 cases were tumors (81.25%). Lesionectomy achieved seizure freedom in 68.75 %.CONCLUSIONSIn a country with limited resources, lesionectomy is a valid technique for epilepsy surgery as long as the radiological data and the seizure semiology are concordant. Total lesionectomy provides good seizure control when the clinical and radiological data are concordant with seizure semiology, in particular with tumor-related epilepsy. A study comparing postoperative seizure outcome between intra-axial and extra-axial lesions on a larger scale and with a longer follow up period is recommended.

Operative Technique and Lessons Learned From Surgical Implantation of the NeuroPace Responsive Neurostimulation® System in 57 Consecutive Patients

2020 ◽  
Author(s):  
Max O Krucoff ◽  
Thomas A Wozny ◽  
Anthony T Lee ◽  
Vikram R Rao ◽  
Edward F Chang
Keyword(s):  
Operative Technique ◽  
Focal Epilepsy ◽  
Intraoperative Imaging ◽  
Case Series ◽  
Lessons Learned ◽  
Seizure Freedom ◽  
Operative Techniques ◽  
Surgical Positioning ◽  
Intracerebral Hemorrhages

Abstract BACKGROUND The Responsive Neurostimulation (RNS)® System (NeuroPace, Inc) is an implantable device designed to improve seizure control in patients with medically refractory focal epilepsy. Because it is relatively new, surgical pearls and operative techniques optimized from experience beyond a small case series have yet to be described. OBJECTIVE To provide a detailed description of our operative technique and surgical pearls learned from implantation of the RNS System in 57 patients at our institution. We describe our method for frame-based placement of amygdalo-hippocampal depth leads, open implantation of cortical strip leads, and open installation of the neurostimulator. METHODS We outline considerations for patient selection, preoperative planning, surgical positioning, incision planning, stereotactic depth lead implantation, cortical strip lead implantation, craniotomy for neurostimulator implantation, device testing, closure, and intraoperative imaging. RESULTS The median reduction in clinical seizure frequency was 60% (standard deviation 63.1) with 27% of patients achieving seizure freedom at last follow up (median 23.1 mo). No infections, intracerebral hemorrhages, or lead migrations were encountered. Two patients experienced lead fractures, and four lead exchanges have been performed. CONCLUSION The techniques set forth here will help with the safe and efficient implantation of these new devices.

scholarly journals Stereotactic laser ablation for nonlesional cingulate epilepsy: case report

2018 ◽  
Vol 22 (5) ◽  
pp. 481-488 ◽  
Author(s):  
Ahmad Marashly ◽  
Michelle M. Loman ◽  
Sean M. Lew
Keyword(s):  
Laser Ablation ◽  
Right Hemisphere ◽  
Focal Epilepsy ◽  
Mesial Temporal Lobe Epilepsy ◽  
Epileptogenic Zone ◽  
Seizure Onset Zone ◽  
The Right ◽  
Invasive Evaluation ◽  
Motor Areas

Stereotactic laser ablation (SLA) is being increasingly used to treat refractory focal epilepsy, especially mesial temporal lobe epilepsy. However, emerging evidence suggests it can be used for extratemporal lobe epilepsy as well.The authors report the case of a 17-year-old male who presented with refractory nocturnal seizures characterized by bilateral arms stiffening or rhythmic jerking lasting several seconds. Semiology suggested an epileptogenic zone close to one of the supplementary sensory motor areas. Electroencephalography showed seizures arising from the central region without consistent lateralization. Brain imaging showed no abnormality. An invasive evaluation using bilateral stereoelectroencephalography (SEEG) was utilized in 2 steps, first to establish the laterality of seizures, and second to further cover the mesial cingulate region of the right hemisphere. Seizures arose from the middle portion of the right cingulate gyrus. Extraoperative electrical mapping revealed that the seizure onset zone was adjacent to eloquent motor areas. SLA targeting the right midcingulate gyrus was performed. The patient has remained seizure free since immediately after the procedure with no postoperative deficits (follow-up of 17 months).This case highlights the utility of SEEG in evaluating difficult-to-localize, focal epilepsy. It also demonstrates that the use of SLA can be extended to nonlesional, extratemporal epilepsies.

Accuracy and Safety of Customized Stereotactic Fixtures for Stereoelectroencephalography in Pediatric Patients

2020 ◽  
pp. 1-8
Author(s):  
Constantin Pistol ◽  
Andrei Daneasa ◽  
Jean Ciurea ◽  
Alin Rasina ◽  
Andrei Barborica ◽  
...  
Keyword(s):  
Focal Epilepsy ◽  
Perioperative Complications ◽  
Intractable Epilepsy ◽  
Target Point ◽  
Seizure Freedom ◽  
Epileptogenic Zone ◽  
Localization Error ◽  
Temporal Area ◽  
Lateral Entry ◽  
Stereotactic Implantation

Stereoelectroencephalography (SEEG) in children with intractable epilepsy presents particular challenges. Their thin and partially ossified cranium, specifically in the temporal area, is prone to fracture while attaching stereotactic systems to the head or stabilizing the head in robot’s field of action. Postponing SEEG in this special population of patients can have serious consequences, reducing their chances of becoming seizure-free and impacting their social and cognitive development. This study demonstrates the safety and accuracy offered by a frameless personalized 3D printed stereotactic implantation system for SEEG investigations in children under 4 years of age. SEEG was carried out in a 3-year-old patient with drug-resistant focal epilepsy, based on a right temporal-perisylvian epileptogenic zone hypothesis. Fifteen intracerebral electrodes were placed using a StarFix patient-customized stereotactic fixture. The median lateral entry point localization error of the electrodes was 0.90 mm, median lateral target point localization error was 1.86 mm, median target depth error was 0.83 mm, and median target point localization error was 1.96 mm. There were no perioperative complications. SEEG data led to a tailored right temporal-insular-opercular resection, with resulting seizure freedom (Engel IA). In conclusion, patient-customized stereotactic fixtures are a safe and accurate option for SEEG exploration in young children.

scholarly journals Correlation between magnetoencephalography-based “clusterectomy” and postoperative seizure freedom

2013 ◽  
Vol 34 (6) ◽  
pp. E9 ◽  
Author(s):  
Sumeet Vadera ◽  
Lara Jehi ◽  
Richard C. Burgess ◽  
Katherine Shea ◽  
Andreas V. Alexopoulos ◽  
...  
Keyword(s):  
Temporal Lobe ◽  
Focal Epilepsy ◽  
Diagnostic Testing ◽  
Cleveland Clinic ◽  
Seizure Freedom ◽  
Epileptogenic Zone ◽  
Resection Cavity ◽  
Main Cluster ◽  
The Mean ◽  
Postoperative Seizure

Object During the presurgical evaluation of patients with medically intractable focal epilepsy, a variety of noninvasive studies are performed to localize the hypothetical epileptogenic zone and guide the resection. Magnetoencephalography (MEG) is becoming increasingly used in the clinical realm for this purpose. No investigators have previously reported on coregisteration of MEG clusters with postoperative resection cavities to evaluate whether complete “clusterectomy” (resection of the area associated with MEG clusters) was performed or to compare these findings with postoperative seizure-free outcomes. Methods The authors retrospectively reviewed the charts and imaging studies of 65 patients undergoing MEG followed by resective epilepsy surgery from 2009 until 2012 at the Cleveland Clinic. Preoperative MEG studies were fused with postoperative MRI studies to evaluate whether clusters were within the resected area. These data were then correlated with postoperative seizure freedom. Results Sixty-five patients were included in this study. The average duration of follow-up was 13.9 months, the mean age at surgery was 23.1 years, and the mean duration of epilepsy was 13.7 years. In 30 patients, the main cluster was located completely within the resection cavity, in 28 it was completely outside the resection cavity, and in 7 it was partially within the resection cavity. Seventy-four percent of patients were seizure free at 12 months after surgery, and this rate decreased to 60% at 24 months. Improved likelihood of seizure freedom was seen with complete clusterectomy in patients with localization outside the temporal lobe (extra–temporal lobe epilepsy) (p = 0.04). Conclusions In patients with preoperative MEG studies that show clusters in surgically accessible areas outside the temporal lobe, we suggest aggressive resection to improve the chances for seizure freedom. When the cluster is found within the temporal lobe, further diagnostic testing may be required to better localize the epileptogenic zone.

Levetiracetam monotherapy for treatment of structural epilepsy in dogs: 19 cases (2010–2015)

2017 ◽  
Vol 181 (15) ◽  
pp. 401-401 ◽  
Author(s):  
Darren Kelly ◽  
Francesca Raimondi ◽  
Nadia Shihab
Keyword(s):  
Side Effects ◽  
Seizure Control ◽  
Case Series ◽  
Poor Response ◽  
Response To Treatment ◽  
Seizure Freedom ◽  
Retrospective Case ◽  
Cluster Seizures ◽  
Structural Epilepsy

To evaluate the efficacy and tolerability of levetiracetam monotherapy in dogs with structural epilepsy. Retrospective case series. Nineteen client-owned dogs with structural epilepsy. Seizure frequencies after initiation of treatment were used to evaluate the efficacy of levetiracetam monotherapy. Seizure control was considered good if no seizures occurred within three months of starting treatment or poor if seizures returned within one month of starting treatment. Tolerability was evaluated by considering the occurrence and severity of any reported side effects. Ten of the 19 dogs were considered to have a good response to treatment with 7 achieving complete seizure freedom. Nine dogs were considered to have poor response to treatment. There was a statistically significant reduction in the percentage of patients experiencing cluster seizures from 68.4% to 15.8% (p=0.002). Side effects were noted in 8 of the 19 dogs but were considered mild in all cases. Follow-up times ranged from 12 days to 426 days. When used in conjunction with other appropriate therapies, levetiracetam may be an efficacious option for monotherapy in dogs with structural epilepsy. Its tolerability makes it a suitable option for use in a wide variety of patients.

Stereoelectroencephalography-Guided Laser Ablations in Patients With Neocortical Pharmacoresistant Focal Epilepsy: Concept and Operative Technique

2018 ◽  
Vol 15 (6) ◽  
pp. 656-663 ◽  
Author(s):  
Louis Ross ◽  
Ahsan M Naduvil ◽  
Juan C Bulacio ◽  
Imad M Najm ◽  
Jorge A Gonzalez-Martinez
Keyword(s):  
Laser Ablation ◽  
Magnetic Resonance ◽  
Thermal Imaging ◽  
Radiation Necrosis ◽  
Focal Epilepsy ◽  
Magnetic Resonance Images ◽  
The Novel ◽  
Metastatic Brain Tumors ◽  
Magnetic Resonance Imaging Mri

Abstract BACKGROUND Laser ablation surgery has had encouraging results in the treatment of multiple intracranial diseases including primary and metastatic brain tumors, radiation necrosis, and epilepsy. The use of the stereoelectroencephalography (SEEG) method in combination with laser thermocoagulation therapy with the goal of modulating epileptic networks in patients with neocortical nonlesional phamacoresistant epilepsy has not been previously described. OBJECTIVE To describe the novel methodological and conceptual aspects related to SEEG-guided laser ablations in patients with magnetic resonance imaging (MRI)-negative pharmacoresistant neocortical focal epilepsy. METHODS Guided by previous SEEG intracranial data, a laser ablation probe was inserted by using a robotic guidance device in a 17-yr-old medically refractory epilepsy patient with difficult to localize seizures and nonlesional MRI. The laser applicator position was confirmed by MRI, targeting the left mesial rostral superior frontal gyrus. The ablation was performed under multiplanar digital imaging views and real-time thermal imaging and treatment estimates in each plane. A postablation MRI (contrasted T1 sequence) confirmed the ablation's location and size. RESULTS The entire procedure was achieved in approximately 100 min. The actual ablation was performed in less than 3 min. Approximately, additional 30 min preoperatively were used for positioning and robot registration. Precise placement of laser application (in comparison with preplanned trajectories) was achieved using the robotic guidance and confirmed by the intraoperative magnetic resonance images. No complications were reported. The patient has been seizure-free since surgery. The follow-up period is 20 mo. Two additional patients, treated with similar methodology, are also described. CONCLUSION The preliminary experience with the described method shows the feasibility of a unique combination of the SEEG methodology with laser thermocoagulation in patients with neocortical MRI-negative pharmacoresistant focal epilepsy.

Multilobar Epilepsy Surgery in Childhood and Adolescence: Predictors of Long-Term Seizure Freedom

Neurosurgery ◽  
2020 ◽  
Vol 88 (1) ◽  
pp. 174-182
Author(s):  
Evangelos Kogias ◽  
Thomas Bast ◽  
Susanne Schubert-Bast ◽  
Gert Wiegand ◽  
Armin Brandt ◽  
...  
Keyword(s):  
Epilepsy Surgery ◽  
Seizure Control ◽  
Focal Cortical Dysplasia ◽  
Benign Tumors ◽  
Seizure Freedom ◽  
Childhood And Adolescence ◽  
Epileptogenic Zone ◽  
Seizure Recurrence ◽  
Eloquent Cortex

Abstract BACKGROUND Although multilobar resections correspond to one-fifth of pediatric epilepsy surgery, there are little data on long-term seizure control. OBJECTIVE To investigate the long-term seizure outcomes of children and adolescents undergoing multilobar epilepsy surgery and identify their predictors. METHODS In this retrospective study, we considered 69 consecutive patients that underwent multilobar epilepsy surgery at the age of 10.0 ± 5.0 yr (mean ± SD). The magnetic resonance imaging revealed a lesion in all but 2 cases. Resections were temporo-parieto(-occipital) in 30%, temporo-occipital in 41%, parieto-occipital in 16%, and fronto-(temporo)-parietal in 13% cases. Etiologies were determined as focal cortical dysplasia in 67%, perinatal or postnatal ischemic lesions in 23%, and benign tumors in 10% of cases. RESULTS At last follow-up of median 9 yr (range 2.8-14.8), 48% patients were seizure free; 33% were off antiepileptic drugs. 10% of patients, all with dysplastic etiology, required reoperations: 4 of 7 achieved seizure freedom. Seizure recurrence occurred mostly (80%) within the first 6 mo. Among presurgical variables, only an epileptogenic zone far from eloquent cortex independently correlated with significantly higher rates of seizure arrest in multivariate analysis. Among postsurgical variables, the absence of residual lesion and of acute postsurgical seizures was independently associated with significantly higher rates of seizure freedom. CONCLUSION Our study demonstrates that multilobar epilepsy surgery is effective regarding long-term seizure freedom and antiepileptic drug withdrawal in selected pediatric candidates. Epileptogenic zones–and lesions–localized distant from eloquent cortex and, thus, fully resectable predispose for seizure control. Acute postsurgical seizures are critical markers of seizure recurrence that should lead to prompt reevaluation.

New interinstitutional, multimodal presurgical evaluation protocol associated with improved seizure freedom for poorly defined cases of focal epilepsy in children

2021 ◽  
pp. 1-9
Author(s):  
Solon Schur ◽  
Jeremy T. Moreau ◽  
Hui Ming Khoo ◽  
Andreas Koupparis ◽  
Elisabeth Simard Tremblay ◽  
...  
Keyword(s):  
Focal Epilepsy ◽  
Seizure Freedom ◽  
Presurgical Evaluation ◽  
3T Mri ◽  
Evaluation Strategy ◽  
New Strategy ◽  
The Difference ◽  
Highly Correlated ◽  
Intracranial Recording

OBJECTIVE In an attempt to improve postsurgical seizure outcomes for poorly defined cases (PDCs) of pediatric focal epilepsy (i.e., those that are not visible or well defined on 3T MRI), the authors modified their presurgical evaluation strategy. Instead of relying on concordance between video-electroencephalography and 3T MRI and using functional imaging and intracranial recording in select cases, the authors systematically used a multimodal, 3-tiered investigation protocol that also involved new collaborations between their hospital, the Montreal Children’s Hospital, and the Montreal Neurological Institute. In this study, the authors examined how their new strategy has impacted postsurgical outcomes. They hypothesized that it would improve postsurgical seizure outcomes, with the added benefit of identifying a subset of tests contributing the most. METHODS Chart review was performed for children with PDCs who underwent resection following the new strategy (i.e., new protocol [NP]), and for the same number who underwent treatment previously (i.e., preprotocol [PP]); ≥ 1-year follow-up was required for inclusion. Well-defined, multifocal, and diffuse hemispheric cases were excluded. Preoperative demographics and clinical characteristics, resection volumes, and pathology, as well as seizure outcomes (Engel class Ia vs > Ia) at 1 year postsurgery and last follow-up were reviewed. RESULTS Twenty-two consecutive NP patients were compared with 22 PP patients. There was no difference between the two groups for resection volumes, pathology, or preoperative characteristics, except that the NP group underwent more presurgical evaluation tests (p < 0.001). At 1 year postsurgery, 20 of 22 NP patients and 10 of 22 PP patients were seizure free (OR 11.81, 95% CI 2.00–69.68; p = 0.006). Magnetoencephalography and PET/MRI were associated with improved postsurgical seizure outcomes, but both were highly correlated with the protocol group (i.e., independent test effects could not be demonstrated). CONCLUSIONS A new presurgical evaluation strategy for children with PDCs of focal epilepsy led to improved postsurgical seizure freedom. No individual presurgical evaluation test was independently associated with improved outcome, suggesting that it may be the combined systematic protocol and new interinstitutional collaborations that makes the difference rather than any individual test.

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