Robotic image-guided depth electrode implantation in the evaluation of medically intractable epilepsy

2008 ◽  
Vol 25 (3) ◽  
pp. E19 ◽  
Author(s):  
William J. Spire ◽  
Barbara C. Jobst ◽  
Vijay M. Thadani ◽  
Peter D. Williamson ◽  
Terrance M. Darcey ◽  
...  
Keyword(s):  
Intractable Epilepsy ◽  
Robotic System ◽  
Electrode Placement ◽  
Seizure Onset ◽  
Electrode Implantation ◽  
Grid Electrode ◽  
Image Guided ◽  
Depth Electrodes ◽  
Depth Electrode ◽  
Time Period

Object The authors describe their experience with a technique for robotic implantation of depth electrodes in patients concurrently undergoing craniotomy and placement of subdural monitoring electrodes for the evaluation of intractable epilepsy. Methods Patients included in this study underwent evaluation in the Dartmouth Surgical Epilepsy Program and were recommended for invasive seizure monitoring with depth electrodes between 2006 and the present. In all cases an image-guided robotic system was used during craniotomy for concurrent subdural grid electrode placement. A total of 7 electrodes were placed in 4 patients within the time period. Results Three of 4 patients had successful localization of seizure onset, and 2 underwent subsequent resection. Of the patients who underwent resection, 1 is now seizure free, and the second has only auras. There was 1 complication after subpial grid placement but no complications related to the depth electrodes. Conclusions Robotic image-guided placement of depth electrodes with concurrent craniotomy is feasible, and the technique is safe, accurate, and efficient.

Robotic Navigated Laser Craniotomy for Depth Electrode Implantation in Epilepsy Surgery: A Cadaver Lab Study

2020 ◽  
Author(s):  
Karl Roessler ◽  
Fabian Winter ◽  
Tobias Wilken ◽  
Ekaterina Pataraia ◽  
Magdalena Mueller-Gerbl ◽  
...  
Keyword(s):  
Laser Beam ◽  
Epilepsy Surgery ◽  
Entry Point ◽  
Occipital Bone ◽  
Electrode Placement ◽  
Target Point ◽  
Twist Drill ◽  
Electrode Implantation ◽  
Depth Electrodes ◽  
Depth Electrode

Abstract Objective Depth electrode implantation for invasive monitoring in epilepsy surgery has become a standard procedure. We describe a new frameless stereotactic intervention using robot-guided laser beam for making precise bone channels for depth electrode placement. Methods A laboratory investigation on a head cadaver specimen was performed using a CT scan planning of depth electrodes in various positions. Precise bone channels were made by a navigated robot-driven laser beam (erbium:yttrium aluminum garnet [Er:YAG], 2.94-μm wavelength,) instead of twist drill holes. Entry point and target point precision was calculated using postimplantation CT scans and comparison to the preoperative trajectory plan. Results Frontal, parietal, and occipital bone channels for bolt implantation were made. The occipital bone channel had an angulation of more than 60 degrees to the surface. Bolts and depth electrodes were implanted solely guided by the trajectory given by the precise bone channels. The mean depth electrode length was 45.5 mm. Entry point deviation was 0.73 mm (±0.66 mm SD) and target point deviation was 2.0 mm (±0.64 mm SD). Bone channel laser time was ∼30 seconds per channel. Altogether, the implantation time was ∼10 to 15 minutes per electrode. Conclusion Navigated robot-assisted laser for making precise bone channels for depth electrode implantation in epilepsy surgery is a promising new, exact and straightforward implantation technique and may have many advantages over twist drill hole implantation.

The 3-Dimensional Grid

2015 ◽  
Vol 11 (1) ◽  
pp. 127-134 ◽  
Author(s):  
Charles Munyon ◽  
Jennifer Sweet ◽  
Hans Luders ◽  
Samden Lhatoo ◽  
Jonathan Miller
Keyword(s):  
Intractable Epilepsy ◽  
Infectious Complications ◽  
Electrode Placement ◽  
Frameless Stereotaxy ◽  
Seizure Onset ◽  
3 Dimensional ◽  
Eloquent Areas ◽  
Depth Electrodes ◽  
Rectangular Pattern ◽  
Permanent Neurological Deficit

Abstract BACKGROUND Successful surgical treatment of epilepsy requires accurate definition of areas of ictal onset and eloquent brain. Although invasive monitoring can help, subdural grids cannot sample sulci or subcortical tissue; traditional stereoelectroencephalography depth electrodes are usually placed too far apart to provide sufficient resolution for mapping. OBJECTIVE To report a strategy of depth electrode placement in a dense array to allow precise anatomic localization of epileptic and eloquent cortex. METHODS Twenty patients with medically intractable epilepsy either poorly localized or found to arise adjacent to eloquent areas underwent placement of arrays of depth electrodes into and around the putative area of seizure onset with the use of framed stereotaxy. Each array consisted of a “grid” of parallel electrodes in a rectangular pattern with 1 cm between entry sites. In a subset of patients, a few electrodes were placed initially, with additional electrodes placed in a second stage. Trajectories were modified to avoid cortical vessels defined on magnetic resonance imaging. Patients were monitored for 4 to 21 days to establish the precise location of seizure onset. Stimulation was performed to map cortical and subcortical eloquent regions. Electrode locations were coregistered for frameless stereotaxy during subsequent resection of seizure focus. RESULTS Two hundred fifty-four electrodes were implanted. Discrete regions of seizure onset and functional cortex were identified, which were used during resection to remove epileptogenic tissue while preserving eloquent areas. There were no hemorrhagic or infectious complications; no patient suffered permanent neurological deficit. CONCLUSION The 3-dimensional intraparenchymal grid is useful for identifying the location and extent of epileptic and eloquent brain.

Freehand placement of depth electrodes using electromagnetic frameless stereotactic guidance

2011 ◽  
Vol 8 (5) ◽  
pp. 464-467 ◽  
Author(s):  
Carter D. Wray ◽  
Diana L. Kraemer ◽  
Tong Yang ◽  
Sandra L. Poliachik ◽  
Andrew L. Ko ◽  
...  
Keyword(s):  
Electrode Placement ◽  
Frameless Stereotaxy ◽  
Seizure Onset ◽  
Presurgical Evaluation ◽  
Electromagnetic System ◽  
Depth Electrodes ◽  
Depth Electrode ◽  
Stereotactic Frame ◽  
Stereotactic Guidance ◽  
Patients With Epilepsy

The presurgical evaluation of patients with epilepsy often requires an intracranial study in which both subdural grid electrodes and depth electrodes are needed. Performing a craniotomy for grid placement with a stereotactic frame in place can be problematic, especially in young children, leading some surgeons to consider frameless stereotaxy for such surgery. The authors report on the use of a system that uses electromagnetic impulses to track the tip of the depth electrode. Ten pediatric patients with medically refractory focal lobar epilepsy required placement of both subdural grid and intraparenchymal depth electrodes to map seizure onset. Presurgical frameless stereotaxic targeting was performed using a commercially available electromagnetic image-guided system. Freehand depth electrode placement was then performed with intraoperative guidance using an electromagnetic system that provided imaging of the tip of the electrode, something that has not been possible using visually or sonically based systems. Accuracy of placement of depth electrodes within the deep structures of interest was confirmed postoperatively using CT and CT/MR imaging fusion. Depth electrodes were appropriately placed in all patients. Electromagnetic-tracking–based stereotactic targeting improves the accuracy of freehand placement of depth electrodes in patients with medically refractory epilepsy. The ability to track the electrode tip, rather than the electrode tail, is a major feature that enhances accuracy. Additional advantages of electromagnetic frameless guidance are discussed.

Invasive Insular Sampling in Pediatric Epilepsy: A Single-Institution Experience

2017 ◽  
Vol 15 (3) ◽  
pp. 310-317 ◽  
Author(s):  
Luke D Tomycz ◽  
Andrew T Hale ◽  
Ali S Haider ◽  
Dave F Clarke ◽  
Mark R Lee
Keyword(s):  
Insular Cortex ◽  
Clinical Information ◽  
Electrode Placement ◽  
Pediatric Epilepsy ◽  
Seizure Onset ◽  
Single Institution ◽  
Invasive Treatment ◽  
Depth Electrodes ◽  
Depth Electrode ◽  
Electrode Insertion

Abstract BACKGROUND It has been increasingly recognized that the insular cortex plays an important role in frontotemporal-parietal epilepsy in children. The insula, however, cannot be properly interrogated with conventional subdural grids, and its anatomy makes it difficult to implicate the insula with semiology or noninvasive modalities. Frame-based, stereotactic placement of insular depth electrodes for direct extraoperative monitoring is a relatively low-risk maneuver that allows for conclusive interrogation of this region, and, in select cases, can easily be replaced with a laser applicator for minimally invasive treatment via thermoablation. OBJECTIVE To describe the largest reported series of pediatric patients with refractory epilepsy undergoing insular depth electrode placement. METHODS We used current procedural terminology billing records to identify cases of depth electrode insertion performed at our institution. Clinical information from patients undergoing invasive insular sampling was then retrospectively collected. RESULTS Seventy-four insular depth electrodes were placed in 49 patients for extraoperative, inpatient monitoring. The decision to place insular depth electrodes was determined by a multidisciplinary epilepsy team. In 65.3% of cases, direct invasive sampling implicated the insula in seizure onset and prompted either thermoablation or surgical resection of some portion of the insula. There were no serious adverse effects or complications associated with the placement of insular depth electrodes. CONCLUSION Given the low morbidity of insular depth electrode insertion and the high proportion of patients who exhibited insular involvement, it is worth considering whether insular depth electrodes should be part of the standard presurgical evaluation in children with treatment-refractory frontotemporal-parietal epilepsy.

Stereotactic placement of depth electrodes in medically intractable epilepsy

2014 ◽  
Vol 120 (3) ◽  
pp. 639-644 ◽  
Author(s):  
Jorge Gonzalez-Martinez ◽  
Jeffrey Mullin ◽  
Sumeet Vadera ◽  
Juan Bulacio ◽  
Gwyneth Hughes ◽  
...  
Keyword(s):  
Focal Epilepsy ◽  
Cleveland Clinic ◽  
Intractable Epilepsy ◽  
Seizure Outcome ◽  
Widespread Application ◽  
Electrode Implantation ◽  
Implanted Electrodes ◽  
Depth Electrodes ◽  
Depth Electrode ◽  
Calculated Risk

Object Despite its long-reported successful record, with almost 60 years of clinical use, the technical complexity regarding the placement of stereoelectroencephalography (SEEG) depth electrodes may have contributed to the limited widespread application of the technique in centers outside Europe. The authors report on a simplified and novel SEEG surgical technique in the extraoperative mapping of refractory focal epilepsy. Methods The proposed technique was applied in patients with medically refractory focal epilepsy. Data regarding general demographic information, method of electrode implantation, time of implantation, number of implanted electrodes, seizure outcome after SEEG-guided resections, and complications were prospectively collected. Results From March 2009 to April 2012, 122 patients underwent SEEG depth electrode implantation at the Cleveland Clinic Epilepsy Center in which the authors' technique was used. There were 65 male and 57 female patients whose mean age was 33 years (range 5–68 years). The group included 21 pediatric patients (younger than 18 years). Planning and implantations were performed in a single stage. The time for planning was, on average, 33 minutes (range 20–47 minutes), and the time for implantation was, on average, 107 minutes (range 47–150 minutes). Complications related to the SEEG technique were observed in 3 patients. The calculated risk of complications per electrode was 0.18%. The seizure-free rate after SEEG-guided resections was 62% in a mean follow-up period of 12 months. Conclusions The authors report on a safe, simplified, and less time-consuming method of SEEG depth electrode implantation, using standard and widely available surgical tools, making the technique a reasonable option for extraoperative monitoring of patients with medically intractable epilepsy in centers lacking the Talairach stereotactic armamentarium.

Utility of depth electrode placement in the neurosurgical management of bottom-of-sulcus lesions: technical note

2019 ◽  
Vol 24 (3) ◽  
pp. 284-292
Author(s):  
Eisha A. Christian ◽  
Elysa Widjaja ◽  
Ayako Ochi ◽  
Hiroshi Otsubo ◽  
Stephanie Holowka ◽  
...  
Keyword(s):  
Pediatric Patients ◽  
Focal Cortical Dysplasia ◽  
Target Identification ◽  
Cortical Dysplasia ◽  
Technical Note ◽  
Electrode Placement ◽  
Electrode Implantation ◽  
Depth Electrodes ◽  
Intracranial Electrode ◽  
The Brain

OBJECTIVESmall lesions at the depth of the sulcus, such as with bottom-of-sulcus focal cortical dysplasia, are not visible from the surface of the brain and can therefore be technically challenging to resect. In this technical note, the authors describe their method of using depth electrodes as landmarks for the subsequent resection of these exacting lesions.METHODSA retrospective review was performed on pediatric patients who had undergone invasive electroencephalography with depth electrodes that were subsequently used as guides for resection in the period between July 2015 and June 2017.RESULTSTen patients (3–15 years old) met the criteria for this study. At the same time as invasive subdural grid and/or strip insertion, between 2 and 4 depth electrodes were placed using a hand-held frameless neuronavigation technique. Of the total 28 depth electrodes inserted, all were found within the targeted locations on postoperative imaging. There was 1 patient in whom an asymptomatic subarachnoid hemorrhage was demonstrated on postprocedural imaging. Depth electrodes aided in target identification in all 10 cases.CONCLUSIONSDepth electrodes placed at the time of invasive intracranial electrode implantation can be used to help localize, target, and resect primary zones of epileptogenesis caused by bottom-of-sulcus lesions.

scholarly journals Medically resistant pediatric insular-opercular/perisylvian epilepsy. Part 1: invasive monitoring using the parasagittal transinsular apex depth electrode

2016 ◽  
Vol 18 (5) ◽  
pp. 511-522 ◽  
Author(s):  
Alexander G. Weil ◽  
Aria Fallah ◽  
Evan C. Lewis ◽  
Sanjiv Bhatia
Keyword(s):  
Epilepsy Surgery ◽  
Electrode Placement ◽  
Epileptogenic Zone ◽  
Drug Resistant ◽  
Depth Electrodes ◽  
Depth Electrode ◽  
Age At Surgery ◽  
Feasible Alternative ◽  
The Mean ◽  
Drug Resistant Epilepsy

OBJECTIVE Insular lobe epilepsy (ILE) is an under-recognized cause of extratemporal epilepsy and explains some epilepsy surgery failures in children with drug-resistant epilepsy. The diagnosis of ILE usually requires invasive investigation with insular sampling; however, the location of the insula below the opercula and the dense middle cerebral artery vasculature renders its sampling challenging. Several techniques have been described, ranging from open direct placement of orthogonal subpial depth and strip electrodes through a craniotomy to frame-based stereotactic placement of orthogonal or oblique electrodes using stereo-electroencephalography principles. The authors describe an alternative method for sampling the insula, which involves placing insular depth electrodes along the long axis of the insula through the insular apex following dissection of the sylvian fissure in conjunction with subdural electrodes over the lateral hemispheric/opercular region. The authors report the feasibility, advantages, disadvantages, and role of this approach in investigating pediatric insular-opercular refractory epilepsy. METHODS The authors performed a retrospective analysis of all children (< 18 years old) who underwent invasive intracranial studies involving the insula between 2002 and 2015. RESULTS Eleven patients were included in the study (5 boys). The mean age at surgery was 7.6 years (range 0.5–16 years). All patients had drug-resistant epilepsy as defined by the International League Against Epilepsy and underwent comprehensive noninvasive epilepsy surgery workup. Intracranial monitoring was performed in all patients using 1 parasagittal insular electrode (1 patient had 2 electrodes) in addition to subdural grids and strips tailored to the suspected epileptogenic zone. In 10 patients, extraoperative monitoring was used; in 1 patient, intraoperative electrocorticography was used alone without extraoperative monitoring. The mean number of insular contacts was 6.8 (range 4–8), and the mean number of fronto-parieto-temporal hemispheric contacts was 61.7 (range 40–92). There were no complications related to placement of these depth electrodes. All 11 patients underwent subsequent resective surgery involving the insula. CONCLUSIONS Parasagittal transinsular apex depth electrode placement is a feasible alternative to orthogonally placed open or oblique-placed stereotactic methodologies. This method is safe and best suited for suspected unilateral cases with a possible extensive insular-opercular epileptogenic zone.

Depth Electrodes: Approaches and Complications

2018 ◽  
pp. 50-62
Author(s):  
Thomas Ostergard ◽  
Jonathan P. Miller
Keyword(s):  
Intracranial Haemorrhage ◽  
Electrode Placement ◽  
Frameless Stereotaxy ◽  
Electrode Implantation ◽  
Depth Electrodes ◽  
Stereotactic Frame ◽  
Electrode Length ◽  
Using Data ◽  
Intracranial Electrode ◽  
Neurosurgical Operation

Depth electrode placement is an invaluable technique in treating patients with refractory epilepsy. Like any neurosurgical operation, planning is the most important phase of the procedure. The seizure focus should first be grossly localized using data from scalp electrodes and seizure semiology. This gross localization will guide placement of invasive electrophysiological hardware. All electrode implantation methods rely on Talairach’s principles of stereotaxis. Traditional electrode implantation is performed with a stereotactic frame. Evolving techniques use frameless stereotaxy or neuroendoscopy for implantation. The most worrisome complication of electrode placement is electrode-associated intracranial haemorrhage. Electrode deviation is a much more common complication, which can be minimized by avoiding extreme insertion angles, minimizing intracranial electrode length, and maximizing entry point accuracy.

Subdural Grid Electrode Placement: Approaches and Complications

2018 ◽  
pp. 38-49
Author(s):  
Robert A. McGovern ◽  
Guy M. McKhann
Keyword(s):  
Surgical Technique ◽  
Electrode Placement ◽  
Epileptic Focus ◽  
Invasive Monitoring ◽  
Seizure Onset ◽  
Effective Technique ◽  
Grid Electrode ◽  
Specific Approach ◽  
Non Invasive ◽  
Data Registry

Subdural grid electrode placement is a safe and effective technique for localizing an epileptic focus in medically refractory patients with discordant non-invasive testing. The specific approach taken is individualized on a patient-by-patient basis. However, the two goals of invasive monitoring with subdural electrodes are the same for every patient: define the volume of cortical tissue responsible for seizure onset and ‘map’ regions of functional tissue that may be impacted by resection of the epileptic focus. While complications are an accepted aspect of the procedure, they can be minimized through meticulous surgical technique, generous duroplasty, and careful postoperative sterility. Because of the heterogeneity of the published literature, we advocate standardized and data-registry-based outcome and complication measurements so that data can be more freely combined and analysed in the future.

scholarly journals Stereotactic electroencephalography with temporal grid and mesial temporal depth electrode coverage: does technique of depth electrode placement affect outcome?

2010 ◽  
Vol 113 (1) ◽  
pp. 32-38 ◽  
Author(s):  
Jamie J. Van Gompel ◽  
Fredric B. Meyer ◽  
W. Richard Marsh ◽  
Kendall H. Lee ◽  
Gregory A. Worrell
Keyword(s):  
Temporal Lobe ◽  
Middle Temporal Gyrus ◽  
Electrode Implantation ◽  
Middle Temporal ◽  
Contact Depth ◽  
Depth Electrodes ◽  
Depth Electrode ◽  
Group A ◽  
Group B ◽  
Seizure Localization

Object Intracranial monitoring for temporal lobe seizure localization to differentiate neocortical from mesial temporal onset seizures requires both neocortical subdural grids and hippocampal depth electrode implantation. There are 2 basic techniques for hippocampal depth electrode implantation. This first technique uses a stereotactically guided 8-contact depth electrode directed along the long axis of the hippocampus to the amygdala via an occipital bur hole. The second technique involves direct placement of 2 or 3 4-contact depth electrodes perpendicular to the temporal lobe through the middle temporal gyrus and overlying subdural grid. The purpose of this study was to determine whether one technique was superior to the other by examining monitoring success and complications. Methods Between 1997 and 2005, 41 patients underwent invasive seizure monitoring with both temporal subdural grids and depth electrodes placed in 2 ways. Patients in Group A underwent the first technique, and patients in Group B underwent the second technique. Results Group A consisted of 26 patients and Group B 15 patients. There were no statistically significant differences between Groups A and B regarding demographics, monitoring duration, seizure localization, or outcome (Engel classification). There was a statistically significant difference at the point in time at which these techniques were used: Group A represented more patients earlier in the series than Group B (p < 0.05). The complication rate attributable to the grids and depth electrodes was 0% in each group. It was more likely that the depth electrodes were placed through the grid if there was a prior resection and the patient was undergoing a new evaluation (p < 0.05). Furthermore, Group A procedures took significantly longer than Group B procedures. Conclusions In this patient series, there was no difference in efficacy of monitoring, complications, or outcome between hippocampal depth electrodes placed laterally through temporal grids or using an occipital bur hole stereotactic approach. Placement of the depth electrodes perpendicularly through the grids and middle temporal gyrus is technically more practical because multiple head positions and redraping are unnecessary, resulting in shorter operative times with comparable results.

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