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Kovács S, Tóth M, Janszky J, Dóczi T, Fabó D, Boncz I, Botz L, Zemplényi A. Cost-effectiveness analysis of invasive EEG monitoring in drug-resistant epilepsy. Epilepsy Behav 2021; 114:107488. [PMID: 33257296 DOI: 10.1016/j.yebeh.2020.107488] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/07/2020] [Accepted: 09/07/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Our aim was to determine the cost-effectiveness of two intracranial electroencephalography (iEEG) interventions: 1) stereoelectroencephalography (SEEG) and 2) placement of subdural grid electrodes (SDGs) both followed by resective surgery in patients with drug-resistant, partial-onset epilepsy, compared with medical management (MM) in Hungary from payer's perspective. METHODS The incremental health gains and costs of iEEG interventions have been determined with a combination of a decision tree and prevalence Markov process model over a 30-year time horizon in a cost-utility analysis (CUA). To address the effect of parameter uncertainty on the incremental cost-effectiveness ratio (ICER), deterministic and probabilistic sensitivity analyses were performed. RESULTS Our results showed that both SEEG and SDG interventions represent a more expensive but more effective strategy than MM representing the current standard of care. The total discounted cost of SEEG and SDG were € 32,760 and € 25,028 representing € 18,108 and € 10,375 additional cost compared with MM, respectively. However, they provide an additional 3.931 (in SEEG group) and 3.444 quality-adjusted life years (QALYs; in SDG group), correspondingly. Thus, the ICER of SEEG is € 4607 per QALY gain, while the ICER for SDG is € 3013 per QALY gain, compared with MM. At a cost-effectiveness threshold of € 41,058 per QALY in Hungary, both subtypes of iEEG interventions are cost-effective and provide good value for money. SIGNIFICANCE Because of the high cost of implanting electrodes and monitoring, the invasive EEG for patients with refractory epilepsy is currently not available in the Hungarian national healthcare system. Our study demonstrated that these procedures in Hungary are cost-effective compared with the MM. As a result, the introduction of iEEG interventions to the reimbursement list of the National Health Insurance Fund Administration was initiated.
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Affiliation(s)
- Sándor Kovács
- University of Pécs, Centre for Health Technology Assessment, Pécs, Rákóczi u. 2., H-7623, Hungary; University of Pécs, Faculty of Pharmacy, Division of Pharmacoeconomics, Department of Pharmaceutics, Pécs, Rákóczi u. 2., H-7623, Hungary.
| | - Márton Tóth
- University of Pécs, Medical School, Department of Neurology, Pécs, Rét u. 2., H-7623, Hungary
| | - József Janszky
- University of Pécs, Medical School, Department of Neurology, Pécs, Rét u. 2., H-7623, Hungary; MTA-PTE Clinical Neuroscience MRI Research Group, Pécs, Ifjúság u. 20., H-7624, Hungary
| | - Tamás Dóczi
- MTA-PTE Clinical Neuroscience MRI Research Group, Pécs, Ifjúság u. 20., H-7624, Hungary; University of Pécs, Medical School, Department of Neurosurgery, Pécs, Rét u. 2., H-7623, Hungary
| | - Dániel Fabó
- National Institute of Clinical Neurosciences, Budapest, Amerikai u. 57., H-1145, Hungary
| | - Imre Boncz
- University of Pécs, Faculty of Health Sciences, Institute for Health Insurance, Pécs, Mária u. 5-7., H-7621, Hungary
| | - Lajos Botz
- University of Pécs, Faculty of Pharmacy, Department of Pharmaceutics and Central Clinical Pharmacy, Pécs, Honvéd u. 3., H-7624, Hungary
| | - Antal Zemplényi
- University of Pécs, Centre for Health Technology Assessment, Pécs, Rákóczi u. 2., H-7623, Hungary; University of Pécs, Faculty of Pharmacy, Division of Pharmacoeconomics, Department of Pharmaceutics, Pécs, Rákóczi u. 2., H-7623, Hungary
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Roland JL, Akbari SHA, Salehi A, Smyth MD. Corpus callosotomy performed with laser interstitial thermal therapy. J Neurosurg 2021; 134:314-322. [PMID: 31835250 DOI: 10.3171/2019.9.jns191769] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 09/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Corpus callosotomy is a palliative procedure that is effective at reducing seizure burden in patients with medically refractory epilepsy. The procedure is traditionally performed via open craniotomy with interhemispheric microdissection to divide the corpus callosum. Concerns for morbidity associated with craniotomy can be a deterrent to patients, families, and referring physicians for surgical treatment of epilepsy. Laser interstitial thermal therapy (LITT) is a less invasive procedure that has been widely adopted in neurosurgery for the treatment of tumors. In this study, the authors investigated LITT as a less invasive approach for corpus callosotomy. METHODS The authors retrospectively reviewed all patients treated for medically refractory epilepsy by corpus callosotomy, either partial or completion, with LITT. Chart records were analyzed to summarize procedural metrics, length of stay, adverse events, seizure outcomes, and time to follow-up. In select cases, resting-state functional MRI was performed to qualitatively support effective functional disconnection of the cerebral hemispheres. RESULTS Ten patients underwent 11 LITT procedures. Five patients received an anterior two-thirds LITT callosotomy as their first procedure. One patient returned after LITT partial callosotomy for completion of callosotomy by LITT. The median hospital stay was 2 days (IQR 1.5-3 days), and the mean follow-up time was 1.0 year (range 1 month to 2.86 years). Functional outcomes are similar to those of open callosotomy, with the greatest effect in patients with a significant component of drop attacks in their seizure semiology. One patient achieved an Engel class II outcome after anterior two-thirds callosotomy resulting in only rare seizures at the 18-month follow-up. Four others were in Engel class III and 5 were Engel class IV. Hemorrhage occurred in 1 patient at the time of removal of the laser fiber, which was placed through the bone flap of a prior open partial callosotomy. CONCLUSIONS LITT appears to be a safe and effective means for performing corpus callosotomy. Additional data are needed to confirm equipoise between open craniotomy and LITT for corpus callosotomy.
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Affiliation(s)
- Jarod L Roland
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Syed Hassan A Akbari
- 2Department of Neurological Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Afshin Salehi
- 2Department of Neurological Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Matthew D Smyth
- 2Department of Neurological Surgery, Washington University in St. Louis, St. Louis, Missouri
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Faraji AH, Remick M, Abel TJ. Contributions of Robotics to the Safety and Efficacy of Invasive Monitoring With Stereoelectroencephalography. Front Neurol 2020; 11:570010. [PMID: 33391145 PMCID: PMC7772229 DOI: 10.3389/fneur.2020.570010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 11/09/2020] [Indexed: 12/19/2022] Open
Abstract
The purpose of this review is to provide a discussion of the history and utility of robotics in invasive monitoring for epilepsy surgery using stereoelectroencephalography (sEEG). The authors conducted a literature review of available sources to describe how the advent of surgical robotics has improved the efficacy and ease of performing sEEG surgery. The sEEG method integrates anatomic, electrographic, and clinical information to test hypotheses regarding the localization of the epileptogenic zone (EZ) and has been used in Europe since the 1950s. One of the primary benefits of robot-assisted sEEG implantation techniques is the ability to seamlessly transition between both orthogonal and oblique trajectory types using a single technique. Based on available information, it is our view that, when applied appropriately, robotic sEEG can have a low rate of complications and many advantages over both non-robotic sEEG implantation and traditional craniotomy-based invasive monitoring methods.
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Affiliation(s)
- Amir H Faraji
- Department of Neurological Surgery, Houston Methodist Hospital, Houston, TX, United States.,Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Madison Remick
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, United States.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States
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Grande KM, Ihnen SKZ, Arya R. Electrical Stimulation Mapping of Brain Function: A Comparison of Subdural Electrodes and Stereo-EEG. Front Hum Neurosci 2020; 14:611291. [PMID: 33364930 PMCID: PMC7750438 DOI: 10.3389/fnhum.2020.611291] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 11/16/2020] [Indexed: 11/13/2022] Open
Abstract
Despite technological and interpretative advances, the non-invasive modalities used for pre-surgical evaluation of patients with drug-resistant epilepsy (DRE), fail to generate a concordant anatomo-electroclinical hypothesis for the location of the seizure onset zone in many patients. This requires chronic monitoring with intracranial electroencephalography (EEG), which facilitates better localization of the seizure onset zone, and allows evaluation of the functional significance of cortical regions-of-interest by electrical stimulation mapping (ESM). There are two principal modalities for intracranial EEG, namely subdural electrodes and stereotactic depth electrodes (stereo-EEG). Although ESM is considered the gold standard for functional mapping with subdural electrodes, there have been concerns about its utility with stereo-EEG. This is mainly because subdural electrodes allow contiguous sampling of the dorsolateral convexity of cerebral hemispheres, and permit delineation of the extent of eloquent functional areas on the cortical surface. Stereo-EEG, while having relatively sparse sampling on the cortical surface, offers the ability to access the depth of sulci, mesial and basal surfaces of cerebral hemispheres, and deep structures such as the insula, which are largely inaccessible to subdural electrodes. As stereo-EEG is increasingly the preferred modality for intracranial monitoring, we find it opportune to summarize the literature for ESM with stereo-EEG in this narrative review. Emerging evidence shows that ESM for defining functional neuroanatomy is feasible with stereo-EEG, but probably requires a different approach for interpretation and clinical decision making compared to ESM with subdural electrodes. We have also compared ESM with stereo-EEG and subdural electrodes, for current thresholds required to evoke desired functional responses vs. unwanted after-discharges. In this regard, there is preliminary evidence that ESM with stereo-EEG may be safer than ESM with subdural grids. Finally, we have highlighted important unanswered clinical and scientific questions for ESM with stereo-EEG in the hope to encourage future research and collaborative efforts.
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Affiliation(s)
- Krista M. Grande
- Division of Neurology, Comprehensive Epilepsy Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Sarah K. Z. Ihnen
- Division of Neurology, Comprehensive Epilepsy Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Ravindra Arya
- Division of Neurology, Comprehensive Epilepsy Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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Uribe-Cardenas R, Boyke AE, Schwarz JT, Morgenstern PF, Greenfield JP, Schwartz TH, Rutka JT, Drake J, Hoffman CE. Utility of invasive electroencephalography in children 3 years old and younger with refractory epilepsy. J Neurosurg Pediatr 2020; 26:648-653. [PMID: 32947255 DOI: 10.3171/2020.6.peds19504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 06/01/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Early surgical intervention for pediatric refractory epilepsy is increasingly advocated as surgery has become safer and data have demonstrated improved outcomes with early seizure control. There is concern that the risks associated with staged invasive electroencephalography (EEG) in very young children outweigh the potential benefits. Here, the authors present a cohort of children with refractory epilepsy who were referred for invasive monitoring, and they evaluate the role and safety of staged invasive EEG in those 3 years old and younger. METHODS The authors conducted a retrospective review of children 3 years and younger with epilepsy, who had been managed surgically at two institutions between 2001 and 2015. A cohort of pediatric patients older than 3 years of age was used for comparison. Demographics, seizure etiology, surgical management, surgical complications, and adverse events were recorded. Statistical analysis was completed using Stata version 13. A p < 0.05 was considered statistically significant. Fisher's exact test was used to compare proportions. RESULTS Ninety-four patients (45 patients aged ≤ 3 [47.9%]) and 208 procedures were included for analysis. Eighty-six procedures (41.3%) were performed in children younger than 3 years versus 122 in the older cohort (58.7%). Forty-two patients underwent grid placement (14 patients aged ≤ 3 [33.3%]); 3 of them developed complications associated with the implant (3/42 [7.14%]), none of whom were among the younger cohort. Across all procedures, 11 complications occurred in the younger cohort versus 5 in the older patients (11/86 [12.8%] vs 5/122 [4.1%], p = 0.032). Two adverse events occurred in the younger group versus 1 in the older group (2/86 [2.32%] vs 1/122 [0.82%], p = 0.571). Following grid placement, 13/14 younger patients underwent guided resections compared to 20/28 older patients (92.9% vs 71.4%, p = 0.23). CONCLUSIONS While overall complication rates were higher in the younger cohort, subdural grid placement was not associated with an increased risk of surgical complications in that population. Invasive electrocorticography informs management in very young children with refractory, localization-related epilepsy and should therefore be used when clinically indicated.
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Affiliation(s)
- Rafael Uribe-Cardenas
- 1Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York
| | | | - Justin T Schwarz
- 1Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York
| | - Peter F Morgenstern
- 1Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York
| | - Jeffrey P Greenfield
- 1Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York
| | - Theodore H Schwartz
- 1Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York
| | - James T Rutka
- 3Department of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - James Drake
- 3Department of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Caitlin E Hoffman
- 1Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York
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Goodale SE, González HFJ, Johnson GW, Gupta K, Rodriguez WJ, Shults R, Rogers BP, Rolston JD, Dawant BM, Morgan VL, Englot DJ. Resting-State SEEG May Help Localize Epileptogenic Brain Regions. Neurosurgery 2020; 86:792-801. [PMID: 31814011 DOI: 10.1093/neuros/nyz351] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 06/18/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Stereotactic electroencephalography (SEEG) is a minimally invasive neurosurgical method to localize epileptogenic brain regions in epilepsy but requires days in the hospital with interventions to trigger several seizures. OBJECTIVE To make initial progress in the development of network analysis methods to identify epileptogenic brain regions using brief, resting-state SEEG data segments, without requiring seizure recordings. METHODS In a cohort of 15 adult focal epilepsy patients undergoing SEEG, we evaluated functional connectivity (alpha-band imaginary coherence) across sampled regions using brief (2 min) resting-state data segments. Bootstrapped logistic regression was used to generate a model to predict epileptogenicity of individual regions. RESULTS Compared to nonepileptogenic structures, we found increased functional connectivity within epileptogenic regions (P < .05) and between epileptogenic areas and other structures (P < .01, paired t-tests, corrected). Epileptogenic areas also demonstrated higher clustering coefficient (P < .01) and betweenness centrality (P < .01), and greater decay of functional connectivity with distance (P < .05, paired t-tests, corrected). Our functional connectivity model to predict epileptogenicity of individual regions demonstrated an area under the curve of 0.78 and accuracy of 80.4%. CONCLUSION Our study represents a preliminary step towards defining resting-state SEEG functional connectivity patterns to help localize epileptogenic brain regions ahead of neurosurgical treatment without requiring seizure recordings.
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Affiliation(s)
- Sarah E Goodale
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee
| | - Hernán F J González
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee
| | - Graham W Johnson
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee
| | - Kanupriya Gupta
- Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, Tennessee
| | - William J Rodriguez
- Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, Tennessee
| | - Robert Shults
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Baxter P Rogers
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee.,Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John D Rolston
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Benoit M Dawant
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee.,Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, Tennessee
| | - Victoria L Morgan
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Dario J Englot
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee.,Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
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Stereotactic EEG Practices: A Survey of United States Tertiary Referral Epilepsy Centers. J Clin Neurophysiol 2020; 39:474-480. [PMID: 33181594 DOI: 10.1097/wnp.0000000000000794] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Stereotactic EEG (SEEG) is being increasingly used in the intracranial evaluation of refractory epilepsy in the United States. In this study, the authors describe current practice of SEEG among National Association of Epilepsy Centers tertiary referral (level IV) centers. METHODS Using the Survey Monkey platform, a survey was sent to all National Association of Epilepsy Centers level IV center directors. RESULTS Of 192 centers polled, 104 directors completed the survey (54% response rate). Ninety-two percent currently perform SEEG. Of these, 55% of institutions reported that greater than 75% of their invasive electrode cases used SEEG. Stereotactic EEG was commonly used over subdural electrodes in cases of suspected mesial temporal lobe epilepsy (87%), nonlesional frontal lobe epilepsy (79%), insular epilepsy (100%), and individuals with prior epilepsy surgery (74%). Most centers (72%) used single-lead electrocardiogram monitoring concurrently with SEEG, but less than half used continuous pulse oximetry (47%) and only a few used respiratory belts (3%). Other significant intercenter technical variabilities included electrode nomenclature and choice of reference electrode. Patient care protocols varied among centers in patient-to-nurse ratio and allowed patient activity. Half of all centers had personnel who had prior experience in SEEG (50.5%); 20% of centers had adopted SEEG without any formal training. CONCLUSIONS Stereotactic EEG has become the principal method for intracranial EEG monitoring in the majority of epilepsy surgery centers in the United States. Most report similar indications for use of SEEG, though significant variability exists in the utilization of concurrent cardiopulmonary monitoring as well as several technical and patient care practices. There is significant variability in level of background training in SEEG among practitioners. The study highlights the need for consensus statements and guidelines to benchmark SEEG practice and develop uniform standards in the United States.
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Narasimhan S, Kundassery KB, Gupta K, Johnson GW, Wills KE, Goodale SE, Haas K, Rolston JD, Naftel RP, Morgan VL, Dawant BM, González HFJ, Englot DJ. Seizure-onset regions demonstrate high inward directed connectivity during resting-state: An SEEG study in focal epilepsy. Epilepsia 2020; 61:2534-2544. [PMID: 32944945 DOI: 10.1111/epi.16686] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 08/15/2020] [Accepted: 08/17/2020] [Indexed: 01/06/2023]
Abstract
OBJECTIVE In patients with medically refractory focal epilepsy, stereotactic-electroencephalography (SEEG) can aid in localizing epileptogenic regions for surgical treatment. SEEG, however, requires long hospitalizations to record seizures, and ictal interpretation can be incomplete or inaccurate. Our recent work showed that non-directed resting-state analyses may identify brain regions as epileptogenic or uninvolved. Our present objective is to map epileptogenic networks in greater detail and more accurately identify seizure-onset regions using directed resting-state SEEG connectivity. METHODS In 25 patients with focal epilepsy who underwent SEEG, 2 minutes of resting-state, artifact-free, SEEG data were selected and functional connectivity was estimated. Using standard clinical interpretation, brain regions were classified into four categories: ictogenic, early propagation, irritative, or uninvolved. Three non-directed connectivity measures (mutual information [MI] strength, and imaginary coherence between and within regions) and four directed measures (partial directed coherence [PDC] and directed transfer function [DTF], inward and outward strength) were calculated. Logistic regression was used to generate a predictive model of ictogenicity. RESULTS Ictogenic regions had the highest and uninvolved regions had the lowest MI strength. Although both PDC and DTF inward strengths were highest in ictogenic regions, outward strengths did not differ among categories. A model incorporating directed and nondirected connectivity measures demonstrated an area under the receiver-operating characteristic (ROC) curve (AUC) of 0.88 in predicting ictogenicity of individual regions. The AUC of this model was 0.93 when restricted to patients with favorable postsurgical seizure outcomes. SIGNIFICANCE Directed connectivity measures may help identify epileptogenic networks without requiring ictal recordings. Greater inward but not outward connectivity in ictogenic regions at rest may represent broad inhibitory input to prevent seizure generation.
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Affiliation(s)
- Saramati Narasimhan
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Keshav B Kundassery
- Department of Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kanupriya Gupta
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Graham W Johnson
- Department of Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Kristin E Wills
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah E Goodale
- Department of Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Kevin Haas
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - John D Rolston
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Robert P Naftel
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Victoria L Morgan
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA.,Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Benoit M Dawant
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA.,Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, Tennessee, USA
| | - Hernán F J González
- Department of Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Dario J Englot
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA.,Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, Tennessee, USA
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Kundu B, Davis TS, Philip B, Smith EH, Arain A, Peters A, Newman B, Butson CR, Rolston JD. A systematic exploration of parameters affecting evoked intracranial potentials in patients with epilepsy. Brain Stimul 2020; 13:1232-1244. [PMID: 32504827 PMCID: PMC7494632 DOI: 10.1016/j.brs.2020.06.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 05/27/2020] [Accepted: 06/01/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Brain activity is constrained by and evolves over a network of structural and functional connections. Corticocortical evoked potentials (CCEPs) have been used to measure this connectivity and to discern brain areas involved in both brain function and disease. However, how varying stimulation parameters influences the measured CCEP across brain areas has not been well characterized. OBJECTIVE To better understand the factors that influence the amplitude of the CCEPs as well as evoked gamma-band power (70-150 Hz) resulting from single-pulse stimulation via cortical surface and depth electrodes. METHODS CCEPs from 4370 stimulation-response channel pairs were recorded across a range of stimulation parameters and brain regions in 11 patients undergoing long-term monitoring for epilepsy. A generalized mixed-effects model was used to model cortical response amplitudes from 5 to 100 ms post-stimulation. RESULTS Stimulation levels <5.5 mA generated variable CCEPs with low amplitude and reduced spatial spread. Stimulation at ≥5.5 mA yielded a reliable and maximal CCEP across stimulation-response pairs over all regions. These findings were similar when examining the evoked gamma-band power. The amplitude of both measures was inversely correlated with distance. CCEPs and evoked gamma power were largest when measured in the hippocampus compared with other areas. Larger CCEP size and evoked gamma power were measured within the seizure onset zone compared with outside this zone. CONCLUSION These results will help guide future stimulation protocols directed at quantifying network connectivity across cognitive and disease states.
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Affiliation(s)
- Bornali Kundu
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Tyler S Davis
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Brian Philip
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
| | - Elliot H Smith
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Amir Arain
- Department of Neurology, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Angela Peters
- Department of Neurology, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Blake Newman
- Department of Neurology, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Christopher R Butson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA; Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA; Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, USA
| | - John D Rolston
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA; Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA; Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, USA.
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Peedicail JS, Almohawes A, Hader W, Starreveld Y, Singh S, Josephson CB, Murphy W, Federico P, Wiebe S, Pillay N, Agha‐Khani Y, Jette N, Avendano R, Hanna S. Outcomes of stereoelectroencephalography exploration at an epilepsy surgery center. Acta Neurol Scand 2020; 141:463-472. [PMID: 32057089 DOI: 10.1111/ane.13229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 12/13/2019] [Accepted: 02/11/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Epilepsy surgery is offered in resistant focal epilepsy. Non-invasive investigations like scalp video EEG monitoring (SVEM) help delineate epileptogenic zone. Complex cases may require intracranial video EEG monitoring (IVEM). Stereoelectroencephalography (SEEG)-based intracerebral electrode implantation has better spatial resolution, lower morbidity, better tolerance, and superiority in sampling deep structures. Our objectives were to assess IVEM using SEEG with regard to reasoning behind implantation, course, surgical interventions, and outcomes. MATERIALS AND METHODS Seventy-two admissions for SEEG from January 2014 to December 2018 were included in the study. Demographic and clinical data were retrospectively collected. RESULTS The cohort comprised of 69 adults of which 34 (47%) had lesional MRI. Reasons for SEEG considering all cases included non-localizing ictal onset (76%), ictal-interictal discordance (21%), discordant semiology (17%), proximity to eloquent cortex (33%), nuclear imaging discordance (34%), and discordance with neuropsychology (19%). Among lesional cases, additional reasons included SVEM discordance (68%) and dual or multiple pathology (47%). Forty-eight patients (67%) were offered resective surgery, and 41 underwent it. Twenty-three (56%) had at least one year post-surgical follow-up of which 14 (61%) had Engels class I outcome. Of the remaining 23 who were continued on medical management, 4 (17%) became seizure-free and 12 (51%) had reduction in seizure frequency. CONCLUSION SEEG monitoring is an important and safe tool for presurgical evaluation with good surgical and non-surgical outcomes. Whether seizure freedom following non-surgical management could be related to SEEG implantation, medication change, or natural course needs to be determined.
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Affiliation(s)
- Joseph Samuel Peedicail
- Calgary Comprehensive Epilepsy Program Department of Clinical Neurosciences Cumming School of Medicine University of Calgary Calgary Canada
| | - Amal Almohawes
- Calgary Comprehensive Epilepsy Program Department of Clinical Neurosciences Cumming School of Medicine University of Calgary Calgary Canada
| | - Walter Hader
- Calgary Comprehensive Epilepsy Program Department of Clinical Neurosciences Cumming School of Medicine University of Calgary Calgary Canada
| | - Yves Starreveld
- Calgary Comprehensive Epilepsy Program Department of Clinical Neurosciences Cumming School of Medicine University of Calgary Calgary Canada
| | - Shaily Singh
- Calgary Comprehensive Epilepsy Program Department of Clinical Neurosciences Cumming School of Medicine University of Calgary Calgary Canada
| | - Colin Bruce Josephson
- Calgary Comprehensive Epilepsy Program Department of Clinical Neurosciences Cumming School of Medicine University of Calgary Calgary Canada
| | - William Murphy
- Calgary Comprehensive Epilepsy Program Department of Clinical Neurosciences Cumming School of Medicine University of Calgary Calgary Canada
| | - Paolo Federico
- Calgary Comprehensive Epilepsy Program Department of Clinical Neurosciences Cumming School of Medicine University of Calgary Calgary Canada
| | - Samuel Wiebe
- Calgary Comprehensive Epilepsy Program Department of Clinical Neurosciences Cumming School of Medicine University of Calgary Calgary Canada
| | - Neelan Pillay
- Calgary Comprehensive Epilepsy Program Department of Clinical Neurosciences Cumming School of Medicine University of Calgary Calgary Canada
| | - Yahya Agha‐Khani
- Calgary Comprehensive Epilepsy Program Department of Clinical Neurosciences Cumming School of Medicine University of Calgary Calgary Canada
| | - Nathalie Jette
- Calgary Comprehensive Epilepsy Program Department of Clinical Neurosciences Cumming School of Medicine University of Calgary Calgary Canada
| | - Rey Avendano
- Calgary Comprehensive Epilepsy Program Department of Clinical Neurosciences Cumming School of Medicine University of Calgary Calgary Canada
| | - Salma Hanna
- Calgary Comprehensive Epilepsy Program Department of Clinical Neurosciences Cumming School of Medicine University of Calgary Calgary Canada
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Joswig H, Lau JC, Abdallat M, Parrent AG, MacDougall KW, McLachlan RS, Burneo JG, Steven DA. Stereoelectroencephalography Versus Subdural Strip Electrode Implantations: Feasibility, Complications, and Outcomes in 500 Intracranial Monitoring Cases for Drug-Resistant Epilepsy. Neurosurgery 2020; 87:E23-E30. [DOI: 10.1093/neuros/nyaa112] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 02/16/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Both stereoelectroencephalography (SEEG) and subdural strip electrodes (SSE) are used for intracranial electroencephalographic recordings in the invasive investigation of patients with drug-resistant epilepsy.
OBJECTIVE
To compare SEEG and SSE with respect to feasibility, complications, and outcome in this single-center study.
METHODS
Patient characteristics, periprocedural parameters, complications, and outcome were acquired from a pro- and retrospectively managed databank to compare SEEG and SSE cases.
RESULTS
A total of 500 intracranial electroencephalographic monitoring cases in 450 patients were analyzed (145 SEEG and 355 SSE). Both groups were of similar age, gender distribution, and duration of epilepsy. Implantation of each SEEG electrode took 13.9 ± 7.6 min (20 ± 12 min for each SSE; P < .01). Radiation exposure to the patient was 4.3 ± 7.7 s to a dose area product of 14.6 ± 27.9 rad*cm2 for SEEG and 9.4 ± 8.9 s with 21 ± 22.4 rad*cm2 for SSE (P < .01). There was no difference in the length of stay (12.2 ± 7.2 and 12 ± 6.3 d). The complication rate was low in both groups. No infections were seen in SEEG cases (2.3% after SSE). The rate of hemorrhage was 2.8% for SEEG and 1.4% for SSE. Surgical outcome was similar.
CONCLUSION
SEEG allows targeting deeply situated foci with a non-inferior safety profile to SSE and seizure outcome comparable to SSE.
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Affiliation(s)
- Holger Joswig
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Canada
- HMU Health and Medical University Potsdam, Department of Neurosurgery, Ernst von Bergmann Hospital, Potsdam, Germany
| | - Jonathan C Lau
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Mahmoud Abdallat
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Canada
- Department of Neurosurgery, University of Jordan, Amman, Jordan
| | - Andrew G Parrent
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Keith W MacDougall
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Richard S McLachlan
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Jorge G Burneo
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - David A Steven
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Canada
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Foit NA, Bernasconi A, Bernasconi N. Functional Networks in Epilepsy Presurgical Evaluation. Neurosurg Clin N Am 2020; 31:395-405. [PMID: 32475488 DOI: 10.1016/j.nec.2020.03.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Continuing advancements in neuroimaging methodology allow for increasingly detailed in vivo characterization of structural and functional brain networks, leading to the recognition of epilepsy as a disorder of large-scale networks. In surgical candidates, analysis of functional networks has proved invaluable for the identification of eloquent brain areas, such as hemispherical language dominance. More recently, connectome-based biomarkers have demonstrated potential to further inform clinical decision making in drug-refractory epilepsy. This article summarizes current evidence on epilepsy as a network disorder, emphasizing potential benefits of network analysis techniques for preoperative assessments and resection planning.
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Affiliation(s)
- Niels Alexander Foit
- Neuroimaging of Epilepsy Laboratory, McConnell Brain Imaging Centre, Montreal Neurological Institute and Hospital, McGill University, 3801 Rue Université, Montreal, Quebec H3A 2B4, Canada
| | - Andrea Bernasconi
- Neuroimaging of Epilepsy Laboratory, McConnell Brain Imaging Centre, Montreal Neurological Institute and Hospital, McGill University, 3801 Rue Université, Montreal, Quebec H3A 2B4, Canada
| | - Neda Bernasconi
- Neuroimaging of Epilepsy Laboratory, McConnell Brain Imaging Centre, Montreal Neurological Institute and Hospital, McGill University, 3801 Rue Université, Montreal, Quebec H3A 2B4, Canada.
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Abstract
BACKGROUND Stereoelectroencephalography (SEEG) is an invasive diagnostic surgical procedure used to identify specific areas of seizure activity in the brain. SEEG has been shown in both adult and pediatric populations to be a safe and effective tool for preoperative decision making. USES: This is used in patients with medically refractory epilepsy who are potential candidates for brain surgery to control seizures. It is preferred over other invasive diagnostic procedures because of lower risk, reduced discomfort, and shorter operating times. OUTCOMES It has a distinct role in obtaining meaningful data that leads to more precise surgical options. All of this results in better seizure control and improved quality of life for the patients. CONCLUSION Knowledge of the SEEG procedure, its benefits, complications, and the neuroscience nurse's role will improve care for surgical patients and improve outcomes.
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Whiting AC, Catapano JS, Zavala B, Walker CT, Godzik J, Chen T, Smith KA. Doing More with Less: A Minimally Invasive, Cost-Conscious Approach to Stereoelectroencephalography. World Neurosurg 2019; 133:34-40. [PMID: 31541761 DOI: 10.1016/j.wneu.2019.09.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 09/09/2019] [Accepted: 09/10/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Stereoelectroencephalography (SEEG) is a commonly used technique for mapping the epileptogenic zone before epilepsy surgery. Many SEEG depth electrode implantation techniques involve the use of extensive technological equipment and shaving of the patient's entire head before electrode implantation. Our goal was to evaluate an SEEG depth electrode implantation technique that used readily available cost-effective neurosurgical equipment, was minimally invasive in nature, and required negligible hair shaving. METHODS Data on demographic characteristics, operative time, hemorrhagic complications, implantation complications, infection, morbidity, and mortality among patients who underwent this procedure were reviewed retrospectively. RESULTS Between April 2016 and March 2018, 23 patients underwent implantation of 213 depth electrodes with use of this technique. Mean (SD) operative time was 123 (32) minutes (range, 66-181 minutes). A mean (SD) of 9.3 (1.4) electrodes were placed for each patient (range, 8-13 electrodes). Two of the 213 electrodes (0.9%) were associated with postimplantation asymptomatic hemorrhage. One of the 213 electrodes (0.5%) was placed extradurally or incorrectly. None of the 213 electrodes was associated with symptomatic complications. No patients experienced infectious complications at any point in the preoperative, perioperative, or postoperative stages. CONCLUSIONS This minimally invasive, cost-effective technique for SEEG depth electrode implantation is a safe, efficient method that uses readily available basic neurosurgical equipment. This technique may be useful in neurosurgery centers with more limited resources. This study suggests that leaving the patient's hair largely intact throughout the procedure does not pose an additional infection risk.
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Affiliation(s)
- Alexander C Whiting
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Baltazar Zavala
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Corey T Walker
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jakub Godzik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Tsinsue Chen
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kris A Smith
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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Katz JS, Abel TJ. Stereoelectroencephalography Versus Subdural Electrodes for Localization of the Epileptogenic Zone: What Is the Evidence? Neurotherapeutics 2019; 16:59-66. [PMID: 30652253 PMCID: PMC6361059 DOI: 10.1007/s13311-018-00703-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Accurate and safe localization of epileptic foci is the crux of surgical therapy for focal epilepsy. As an initial evaluation, patients with drug-resistant epilepsy often undergo evaluation by noninvasive methods to identify the epileptic focus (i.e., the epileptogenic zone (EZ)). When there is incongruence of noninvasive neuroimaging, electroencephalographic, and clinical data, direct intracranial recordings of the brain are often necessary to delineate the EZ and determine the best course of treatment. Stereoelectroencephalography (SEEG) and subdural electrodes (SDEs) are the 2 most common methods for recording directly from the cortex to delineate the EZ. For the past several decades, SEEG and SDEs have been used almost exclusively in specific geographic regions (i.e., France and Italy for stereo-EEG and elsewhere for SDEs) for virtually the same indications. In the last decade, however, stereo-EEG has started to spread from select centers in Europe to many locations worldwide. Nevertheless, it is still not the preferred method for invasive localization of the EZ at many centers that continue to employ SDEs exclusively. Despite the increased dissemination of the SEEG method throughout the globe, important questions remain unanswered. Which method (SEEG or SDEs) is superior for identification of the EZ and does it depend on the etiology of epilepsy? Which technique is safer and does this hold for all patient populations? Should these 2 methods have equivalent indications or be used selectively for different focal epilepsies? In this review, we seek to address these questions using current invasive monitoring literature. Available meta-analyses of observational data suggest that SEEG is safer than SDEs, but it is less clear from available data which method is more accurate at delineating the EZ.
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Affiliation(s)
- Joel S Katz
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, 15238, USA
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, 15238, USA.
- Department of Neurological Surgery, School of Medicine, University of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA, 15224, USA.
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