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Phan TN, Prakash KJ, Elliott RJS, Pasupuleti A, Gaillard WD, Keating RF, Oluigbo CO. Virtual reality-based 3-dimensional localization of stereotactic EEG (SEEG) depth electrodes and related brain anatomy in pediatric epilepsy surgery. Childs Nerv Syst 2022; 38:537-546. [PMID: 34718866 DOI: 10.1007/s00381-021-05403-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/23/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The increasing use of stereoelectroencephalography (SEEG) in the USA and the need for three-dimensional (3D) appreciation of complex spatial relationships between implanted stereotactic EEG depth electrodes and surrounding brain and cerebral vasculature are a challenge to clinicians who are used to two-dimensional (2D) appreciation of cortical anatomy having been traditionally trained on 2D radiologic imaging. Virtual reality and its 3D renderings have grown increasingly common in the multifaceted practice of neurosurgery. However, there exists a paucity in the literature regarding this emerging technology in its utilization of epilepsy surgery. METHODS An IRB-approved, single-center retrospective study identifying all SEEG pediatric patients in which virtual reality was applied was observed. RESULTS Of the 46 patients identified who underwent an SEEG procedure, 43.5% (20/46) had a 3D rendering (3DR) of their SEEG depth electrodes. All 3DRs were used during patient-family education and discussion among the Epilepsy multidisciplinary team meetings, while 35% (7/20) were used during neuronavigation in surgery. Three successful representative cases of its application were presented. DISCUSSION Our institution's experience regarding virtual reality in the 3D representation of SEEG depth electrodes and the application to pre-surgical planning, patient-family education, multidisciplinary communication, and intraoperative neuronavigation demonstrate its applicability in comprehensive epilepsy patient care.
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Affiliation(s)
- Tiffany N Phan
- Department of Neurosurgery, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | | | - Ross-Jordon S Elliott
- Department of Neurological Surgery, George Washington University, Washington, DC, USA
| | - Archana Pasupuleti
- Department of Neurology, Children's National Hospital, Washington, DC, USA
| | - William D Gaillard
- Department of Neurology, Children's National Hospital, Washington, DC, USA
| | - Robert F Keating
- Department of Neurosurgery, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Chima O Oluigbo
- Department of Neurosurgery, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA.
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Ball T, González-Martínez J, Zemmar A, Sweid A, Chandra S, VanSickle D, Neimat JS, Jabbour P, Wu C. Robotic Applications in Cranial Neurosurgery: Current and Future. Oper Neurosurg (Hagerstown) 2021; 21:371-379. [PMID: 34192764 DOI: 10.1093/ons/opab217] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 05/16/2021] [Indexed: 12/19/2022] Open
Abstract
Robotics applied to cranial surgery is a fast-moving and fascinating field, which is transforming the practice of neurosurgery. With exponential increases in computing power, improvements in connectivity, artificial intelligence, and enhanced precision of accessing target structures, robots are likely to be incorporated into more areas of neurosurgery in the future-making procedures safer and more efficient. Overall, improved efficiency can offset upfront costs and potentially prove cost-effective. In this narrative review, we aim to translate a broad clinical experience into practical information for the incorporation of robotics into neurosurgical practice. We begin with procedures where robotics take the role of a stereotactic frame and guide instruments along a linear trajectory. Next, we discuss robotics in endoscopic surgery, where the robot functions similar to a surgical assistant by holding the endoscope and providing retraction, supplemental lighting, and correlation of the surgical field with navigation. Then, we look at early experience with endovascular robots, where robots carry out tasks of the primary surgeon while the surgeon directs these movements remotely. We briefly discuss a novel microsurgical robot that can perform many of the critical operative steps (with potential for fine motor augmentation) remotely. Finally, we highlight 2 innovative technologies that allow instruments to take nonlinear, predetermined paths to an intracranial destination and allow magnetic control of instruments for real-time adjustment of trajectories. We believe that robots will play an increasingly important role in the future of neurosurgery and aim to cover some of the aspects that this field holds for neurosurgical innovation.
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Affiliation(s)
- Tyler Ball
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | | | - Ajmal Zemmar
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA.,Department of Neurosurgery, People's Hospital of Zhengzhou University, Henan Provincial People's Hospital, Henan University People's Hospital, Henan University School of Medicine, Zhengzhou, China
| | - Ahmad Sweid
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sarat Chandra
- Department of Neurosurgery, All India Institute of Medical Science, New Delhi, India
| | | | - Joseph S Neimat
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Chengyuan Wu
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Krucoff MO, Wozny TA, Lee AT, Rao VR, Chang EF. Operative Technique and Lessons Learned From Surgical Implantation of the NeuroPace Responsive Neurostimulation® System in 57 Consecutive Patients. Oper Neurosurg (Hagerstown) 2021; 20:E98-E109. [PMID: 33074294 DOI: 10.1093/ons/opaa300] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 07/13/2020] [Indexed: 12/27/2022] Open
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.
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Affiliation(s)
- Max O Krucoff
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California.,Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Thomas A Wozny
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | - Anthony T Lee
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | - Vikram R Rao
- Department of Neurology and Weill Institute for Neuroscience, University of California, San Francisco, San Francisco, California
| | - Edward F Chang
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California
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Panov F, Ganaha S, Haskell J, Fields M, La Vega-Talbott M, Wolf S, McGoldrick P, Marcuse L, Ghatan S. Safety of responsive neurostimulation in pediatric patients with medically refractory epilepsy. J Neurosurg Pediatr 2020; 26:525-532. [PMID: 33861559 DOI: 10.3171/2020.5.peds20118] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Approximately 75% of pediatric patients who suffer from epilepsy are successfully treated with antiepileptic drugs, while the disease is drug resistant in the remaining patients, who continue to have seizures. Patients with drug-resistant epilepsy (DRE) may have options to undergo invasive treatment such as resection, laser ablation of the epileptogenic focus, or vagus nerve stimulation. To date, treatment with responsive neurostimulation (RNS) has not been sufficiently studied in the pediatric population because the FDA has not approved the RNS device for patients younger than 18 years of age. Here, the authors sought to investigate the safety of RNS in pediatric patients. METHODS The authors performed a retrospective single-center study of consecutive patients with DRE who had undergone RNS system implantation from September 2015 to December 2019. Patients were followed up postoperatively to evaluate seizure freedom and complications. RESULTS Of the 27 patients studied, 3 developed infections and were treated with antibiotics. Of these 3 patients, one required partial removal and salvaging of a functioning system, and one required complete removal of the RNS device. No other complications, such as intracranial hemorrhage, stroke, or device malfunction, were seen. The average follow-up period was 22 months. All patients showed improvement in seizure frequency. CONCLUSIONS The authors demonstrated the safety and efficacy of RNS in pediatric patients, with infections being the main complication. ABBREVIATIONS DBS = deep brain stimulation; DRE = drug-resistant epilepsy; MDC = multidisciplinary conference; MER = microelectrode recording; MSHS = Mount Sinai Health System; RNS = responsive neurostimulation; SEEG = stereo-EEG; VNS = vagus nerve stimulation.
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Affiliation(s)
- Fedor Panov
- 1Department of Neurosurgery, Mount Sinai West; and
| | - Sara Ganaha
- 1Department of Neurosurgery, Mount Sinai West; and
| | | | - Madeline Fields
- 2Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Maite La Vega-Talbott
- 2Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Steven Wolf
- 2Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Patricia McGoldrick
- 2Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lara Marcuse
- 2Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Saadi Ghatan
- 1Department of Neurosurgery, Mount Sinai West; and
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Hoffman CE, Parker WE, Rapoport BI, Zhao M, Ma H, Schwartz TH. Innovations in the Neurosurgical Management of Epilepsy. World Neurosurg 2020; 139:775-788. [PMID: 32689698 DOI: 10.1016/j.wneu.2020.03.031] [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: 09/30/2019] [Accepted: 03/02/2020] [Indexed: 10/23/2022]
Abstract
Technical limitations and clinical challenges have historically limited the diagnostic tools and treatment methods available for surgical approaches to the management of epilepsy. By contrast, recent technological innovations in several areas hold significant promise in improving outcomes and decreasing morbidity. We review innovations in the neurosurgical management of epilepsy in several areas, including wireless recording and stimulation systems (particularly responsive neurostimulation [NeuroPace]), conformal electrodes for high-resolution electrocorticography, robot-assisted stereotactic surgery, optogenetics and optical imaging methods, novel positron emission tomography ligands, and new applications of focused ultrasonography. Investigation into genetic causes of and susceptibilities to epilepsy has introduced a new era of precision medicine, enabling the understanding of cell signaling mechanisms underlying epileptic activity as well as patient-specific molecularly targeted treatment options. We discuss the emerging path to individualized treatment plans, predicted outcomes, and improved selection of effective interventions, on the basis of these developments.
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Affiliation(s)
- Caitlin E Hoffman
- Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA.
| | - Whitney E Parker
- Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Benjamin I Rapoport
- Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Mingrui Zhao
- Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Hongtao Ma
- Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Theodore H Schwartz
- Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
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Tran DK, Paff M, Mnatsakanyan L, Sen-Gupta I, Lin JJ, Hsu FPK, Vadera S. A Novel Robotic-Assisted Technique to Implant the Responsive Neurostimulation System. Oper Neurosurg (Hagerstown) 2019; 18:728-735. [DOI: 10.1093/ons/opz226] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 05/29/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
The responsive neurostimulation system (RNS) (NeuroPace Inc, Mountain View, California) was approved as an adjunctive therapy for medically refractory focal epilepsy. RNS detects epileptiform patterns and delivers electrical stimulation to abort seizures.
OBJECTIVE
To describe a novel technique of RNS lead implantation using robotic-assisted targeting of ictal-onset zones based on stereoelectroencephalography (sEEG) localization. Secondary objectives are to report the accuracy of robotic-assisted lead implantation using the ROSA robot as well as to report the clinical outcome achieved after RNS implantation by this method.
METHODS
A total of 16 patients with medically refractory focal epilepsy underwent sEEG implantation for ictal-onset localization followed by robotic RNS implantation. The electrode most correlative with ictal onset on sEEG was chosen as the target for the RNS electrode. Seizure control was measured at 6-mo and 1-yr follow-up. Ictal-onset electrocorticography (ECoG) data from RNS were compared with ictal onset from sEEG leads based on calculations of lead target to actual lead location from the ROSA robot.
RESULTS
At 6-mo follow-up, the average percent seizure reduction was 82% based upon self-reported seizure diaries. At 1-yr follow-up, 8 patients had an average of 90% seizure reduction. The location of seizure onset from ECoG data show similar onset from sEEG leads within 0.165-mm discrepancy.
CONCLUSION
The ROSA robot provides an ideal method for targeting subcortical ictal-onset zones. This method of RNS lead implantation achieves high accuracy and is associated with favorable clinical outcomes.
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Affiliation(s)
- Diem Kieu Tran
- Department of Neurological Surgery, School of Medicine, University of California, Irvine, Orange, California
| | - Michelle Paff
- Department of Neurological Surgery, School of Medicine, University of California, Irvine, Orange, California
| | - Lilit Mnatsakanyan
- Department of Neurology, School of Medicine, University of California, Irvine, Orange, California
| | - Indranil Sen-Gupta
- Department of Neurology, School of Medicine, University of California, Irvine, Orange, California
| | - Jack J Lin
- Department of Neurology, School of Medicine, University of California, Irvine, Orange, California
| | - Frank P K Hsu
- Department of Neurological Surgery, School of Medicine, University of California, Irvine, Orange, California
| | - Sumeet Vadera
- Department of Neurological Surgery, School of Medicine, University of California, Irvine, Orange, California
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Candela-Cantó S, Aparicio J, López JM, Baños-Carrasco P, Ramírez-Camacho A, Climent A, Alamar M, Jou C, Rumià J, San Antonio-Arce V, Arzimanoglou A, Ferrer E. Frameless robot-assisted stereoelectroencephalography for refractory epilepsy in pediatric patients: accuracy, usefulness, and technical issues. Acta Neurochir (Wien) 2018; 160:2489-2500. [PMID: 30413938 DOI: 10.1007/s00701-018-3720-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 10/27/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Stereoelectroencephalography (SEEG) is an effective technique to help to locate and to delimit the epileptogenic area and/or to define relationships with functional cortical areas. We intend to describe the surgical technique and verify the accuracy, safety, and effectiveness of robot-assisted SEEG in a newly created SEEG program in a pediatric center. We focus on the technical difficulties encountered at the early stages of this program. METHODS We prospectively collected SEEG indication, intraoperative events, accuracy calculated by fusion of postoperative CT with preoperative planning, complications, and usefulness of SEEG in terms of answering preimplantation hypothesis. RESULTS Fourteen patients between the ages of 5 and 18 years old (mean 10 years) with drug-resistant epilepsy were operated on between April 2016 and April 2018. One hundred sixty-four electrodes were implanted in total. The median entry point localization error (EPLE) was 1.57 mm (1-2.25 mm) and the median target point localization error (TPLE) was 1.77 mm (1.2-2.6 mm). We recorded seven intraoperative technical issues. Two patients suffered complications: meningitis without demonstrated germ in one patient and a right frontal hematoma in the other. In all cases, the SEEG was useful for the therapeutic decision-making. CONCLUSION SEEG has been useful for decision-making in all our pediatric patients. The robotic arm is an accurate tool for the insertion of the deep electrodes. Nevertheless, it is an invasive technique not risk-free and many problems can appear at the beginning of a robotic arm-assisted SEEG program that must be taken into account beforehand.
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Affiliation(s)
- Santiago Candela-Cantó
- Pediatric Neurosurgery Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Passeig de Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain.
- Pediatric Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Barcelona, Spain.
| | - Javier Aparicio
- Pediatric Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Barcelona, Spain
| | - Jordi Muchart López
- Pediatric Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Barcelona, Spain
- Diagnostic Imaging Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain
| | - Pilar Baños-Carrasco
- Pediatric Neurosurgery Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Passeig de Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
- Pediatric Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Barcelona, Spain
| | - Alia Ramírez-Camacho
- Pediatric Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Barcelona, Spain
| | - Alejandra Climent
- Pediatric Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Barcelona, Spain
| | - Mariana Alamar
- Pediatric Neurosurgery Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Passeig de Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
- Pediatric Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Barcelona, Spain
| | - Cristina Jou
- Pediatric Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Barcelona, Spain
- Pathology Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain
| | - Jordi Rumià
- Pediatric Neurosurgery Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Passeig de Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
- Pediatric Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Barcelona, Spain
- Neurosurgery Department, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | | | - Alexis Arzimanoglou
- Pediatric Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Barcelona, Spain
- Pediatric Epilepsy, Sleep and Neurophisiology Department, Centre Hospitalier Universitaire de Lyon and Hospital Femme-Mère-Enfant, Lyon, France
| | - Enrique Ferrer
- Pediatric Neurosurgery Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Passeig de Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
- Pediatric Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Barcelona, Spain
- Neurosurgery Department, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
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