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Obaid S, Guberman GI, St-Onge E, Campbell E, Edde M, Lamsam L, Bouthillier A, Weil AG, Daducci A, Rheault F, Nguyen DK, Descoteaux M. Progressive remodeling of structural networks following surgery for operculo-insular epilepsy. Front Neurol 2024; 15:1400601. [PMID: 39144703 PMCID: PMC11322451 DOI: 10.3389/fneur.2024.1400601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 07/15/2024] [Indexed: 08/16/2024] Open
Abstract
Introduction Operculo-insular epilepsy (OIE) is a rare condition amenable to surgery in well-selected cases. Despite the high rate of neurological complications associated with OIE surgery, most postoperative deficits recover fully and rapidly. We provide insights into this peculiar pattern of functional recovery by investigating the longitudinal reorganization of structural networks after surgery for OIE in 10 patients. Methods Structural T1 and diffusion-weighted MRIs were performed before surgery (t0) and at 6 months (t1) and 12 months (t2) postoperatively. These images were processed with an original, comprehensive structural connectivity pipeline. Using our method, we performed comparisons between the t0 and t1 timepoints and between the t1 and t2 timepoints to characterize the progressive structural remodeling. Results We found a widespread pattern of postoperative changes primarily in the surgical hemisphere, most of which consisted of reductions in connectivity strength (CS) and regional graph theoretic measures (rGTM) that reflect local connectivity. We also observed increases in CS and rGTMs predominantly in regions located near the resection cavity and in the contralateral healthy hemisphere. Finally, most structural changes arose in the first six months following surgery (i.e., between t0 and t1). Discussion To our knowledge, this study provides the first description of postoperative structural connectivity changes following surgery for OIE. The ipsilateral reductions in connectivity unveiled by our analysis may result from the reversal of seizure-related structural alterations following postoperative seizure control. Moreover, the strengthening of connections in peri-resection areas and in the contralateral hemisphere may be compatible with compensatory structural plasticity, a process that could contribute to the recovery of functions seen following operculo-insular resections for focal epilepsy.
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Affiliation(s)
- Sami Obaid
- Department of Neurosciences, University of Montreal, Montreal, QC, Canada
- University of Montreal Hospital Research Center (CRCHUM), Montreal, QC, Canada
- Division of Neurosurgery, Department of Surgery, University of Montreal Hospital Center (CHUM), Montreal, QC, Canada
- Sherbrooke Connectivity Imaging Lab (SCIL), Sherbrooke University, Sherbrooke, QC, Canada
| | - Guido I. Guberman
- Department of Neurology and Neurosurgery, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Etienne St-Onge
- Department of Computer Science and Engineering, Université du Québec en Outaouais, Montreal, QC, Canada
| | - Emma Campbell
- Department of Psychology, University of Montreal, Montreal, QC, Canada
| | - Manon Edde
- Sherbrooke Connectivity Imaging Lab (SCIL), Sherbrooke University, Sherbrooke, QC, Canada
| | - Layton Lamsam
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, CT, United States
| | - Alain Bouthillier
- Division of Neurosurgery, Department of Surgery, University of Montreal Hospital Center (CHUM), Montreal, QC, Canada
| | - Alexander G. Weil
- Department of Neurosciences, University of Montreal, Montreal, QC, Canada
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Montreal, QC, Canada
| | | | - François Rheault
- Medical Imaging and Neuroimaging (MINi) Lab, Sherbrooke University, Sherbrooke, QC, Canada
| | - Dang K. Nguyen
- Department of Neurosciences, University of Montreal, Montreal, QC, Canada
- University of Montreal Hospital Research Center (CRCHUM), Montreal, QC, Canada
- Division of Neurology, University of Montreal Hospital Center (CHUM), Montreal, QC, Canada
| | - Maxime Descoteaux
- Sherbrooke Connectivity Imaging Lab (SCIL), Sherbrooke University, Sherbrooke, QC, Canada
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Jayapaul P, Gopinath S, Pillai A. Outcome following surgery for insulo-opercular epilepsies. J Neurosurg 2022; 137:1226-1236. [PMID: 35276652 DOI: 10.3171/2021.12.jns212220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the clinical outcome in patients with medically refractory epilepsy who had undergone resective or ablative surgery for suspected insulo-opercular epileptogenic foci. METHODS The prospectively maintained database of patients undergoing epilepsy surgery was reviewed, and all patients who underwent insulo-opercular surgery for medically refractory epilepsy with a minimum of 12 months of postoperative follow-up were identified, excluding those who had insulo-opercular resection in combination with temporal lobectomy. The presurgical electroclinicoradiological data, stereo-EEG (SEEG) findings, resection/ablation patterns, surgical pathology, postoperative seizure outcome, and neurological complications were analyzed. RESULTS Of 407 patients undergoing epilepsy surgery in a 5-year period at the Amrita Advanced Centre for Epilepsy, 24 patients (5.9%) who underwent exclusive insulo-opercular interventions were included in the study. Eleven (46%) underwent surgery on the right side, 12 (50%) on the left side, and the operation was bilateral in 1 (4%). The mean age at surgery was 24.5 ± 12.75 years. Onset of seizures occurred on average at 10.6 ± 9.7 years of life. Characteristic auras were identified in 66% and predominant seizure type was hypermotor (15.4%), automotor (15.4%), hypomotor (11.5%), or a mixed pattern. Seventy-five percent of the seizures recorded on scalp video-EEG occurred during sleep. The 3T MRI results were normal in 12 patients (50%). Direct single-stage surgery was undertaken in 5 patients, and SEEG followed by intervention in 19. Eighteen patients (75%) underwent exclusive resective surgery, 4 (16.7%) underwent exclusive volumetric radiofrequency ablation, and 2 (8.3%) underwent staged radiofrequency ablation and resective surgery. Immediate postoperative neurological deficits occurred in 10/24 (42%), which persisted beyond 12 postoperative months in 3 (12.5%). With a mean follow-up of 25.9 ± 14.6 months, 18 patients (75%) had Engel class I outcome, 3 (12.5%) had Engel class II, and 3 (12.5%) had Engel class III or IV. There was no statistically significant difference in outcomes between MRI-positive versus MRI-negative cases. CONCLUSIONS Surgery for medically refractory epilepsy in insulo-opercular foci is less common and remains a challenge to epilepsy surgery centers. Localization is aided significantly by a careful study of auras and semiology followed by EEG and imaging. The requirement for SEEG is generally high. Satisfactory rates of seizure freedom were achievable independent of the MRI lesional/nonlesional status. Morbidity is higher for insulo-opercular epilepsy surgery compared to other focal epilepsies; hence, the practice and development of minimally invasive strategies for this subgroup of patients undergoing epilepsy surgery is perhaps most important.
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Affiliation(s)
| | - Siby Gopinath
- 2Department of Neurology, Amrita Advanced Centre for Epilepsy, Amrita Institute of Medical Sciences & Research Centre, Kochi, India
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Takayama Y, Kimura Y, Iijima K, Yokosako S, Kosugi K, Yamamoto K, Shimizu-Motohashi Y, Kaneko Y, Yamamoto T, Iwasaki M. Volume-Based Radiofrequency Thermocoagulation for Pediatric Insulo-Opercular Epilepsy: A Feasibility Study. Oper Neurosurg (Hagerstown) 2022; 23:241-249. [PMID: 35972088 DOI: 10.1227/ons.0000000000000294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 04/03/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Stereotactic ablation surgeries including radiofrequency thermocoagulation (RFTC) and laser interstitial thermal therapy are recent less invasive treatment methods for insular epilepsy. Volume-based RFTC after stereoelectroencephalography was first proposed by a French group as a more effective method for seizure relief in insular epilepsy patients than stereoelectroencephalography-guided RFTC. OBJECTIVE To describe the feasibility and technical details about volume-based RFTC in patients with insulo-opercular epilepsy. METHODS We successfully treated 3- and 6-year-old patients with medically refractory insulo-opercular epilepsy with volume-based RFTC, in which the target volume of coagulation was flexibly designed by combining multiple spherical models of 5-mm diameter which is smaller than reported previously. RESULTS The insula was targeted by oblique trajectory from the frontoparietal area in one case, and the opercular cortex was targeted by perpendicular trajectories from the perisylvian cortex in the other case. The use of the small sphere model required more trajectories and manipulations but enabled more exhaustive coagulation of the epileptogenic zone, with 70% to 78% of the planned target volume coagulated without complications, and daily seizures disappeared after RFTC in both patients. CONCLUSION Volume-based RFTC planned with small multiple sphere models may improve the completeness of lesioning for patients with insulo-opercular epilepsy. Careful planning is necessary to reduce the risks of vascular injuries.
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Affiliation(s)
- Yutaro Takayama
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Japan.,Department of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yuiko Kimura
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Keiya Iijima
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Suguru Yokosako
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Kenzo Kosugi
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Kaoru Yamamoto
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Yuko Shimizu-Motohashi
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Yuu Kaneko
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Masaki Iwasaki
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Japan
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Li D, Podkorytova I, Dieppa M, Perven G. Pearls & Oy-sters: Two Cases of Stereotactic EEG-Proven Insular Epilepsy With Non-localizing Scalp EEG and Interesting Semiologies. Neurology 2022; 99:437-441. [PMID: 35764400 DOI: 10.1212/wnl.0000000000200993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 06/03/2022] [Indexed: 11/15/2022] Open
Abstract
Insular epilepsy is a great mimicker and can be mistaken for seizures originating from other areas of the brain or as non-epileptic spells. The semiology of insular epilepsy can include, but is not limited to, auditory illusions, paresthesias, gastric rising, laryngeal constriction, and hyperkinetic movements. These arise from both the functions of the insula itself and its extensive connections with other regions of the brain. Noninvasive workup can be negative or non-localizing due to the insula's location deep within the lateral sulcus. Stereotactic EEG can therefore be an important tool in cases of insular epilepsy so that patients may be appropriately diagnosed and evaluated for potential surgical treatment. We present two cases of epilepsy with non-localizing scalp EEG and challenging semiologies, the workup undertaken to identify them as cases of insular epilepsy, and subsequent surgical treatment and outcomes.
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Affiliation(s)
- Denise Li
- Adult Neurology Residency Program, University of Texas Southwestern Medical Center
| | - Irina Podkorytova
- Department of Neurology, University of Texas Southwestern Medical Center
| | - Marisara Dieppa
- Department of Neurology, University of Texas Southwestern Medical Center
| | - Ghazala Perven
- Department of Neurology, University of Texas Southwestern Medical Center
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Passos GAR, Silvado CES, Borba LAB. Drug resistant epilepsy of the insular lobe: A review and update article. Surg Neurol Int 2022; 13:197. [PMID: 35673654 PMCID: PMC9168288 DOI: 10.25259/sni_58_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 03/24/2022] [Indexed: 12/02/2022] Open
Abstract
Background: Epilepsy is a chronic disease that affects millions of people around the world generating great expenses and psychosocial problems burdening the public health in different ways. A considerable number of patients are refractory to the drug treatment requiring a more detailed and specialized investigation to establish the most appropriate therapeutic option. Insular epilepsy is a rare form of focal epilepsy commonly drug resistant and has much of its investigation and treatment involved with the surgical management at some point. The insula or the insular lobe is a portion of the cerebral cortex located in the depth of the lateral sulcus of the brain; its triangular in shape and connects with the other adjacent lobes. The insular lobe is a very interesting and complex portion of the brain related with different functions. Insula in Latin means Island and was initially described in the 18th century but its relation with epilepsy was first reported in the 1940–1950s. Insular lobe epilepsy is generally difficult to identify and confirm due to its depth and interconnections. Initial non-invasive studies generally demonstrate frustrating or incoherent information about the origin of the ictal event. Technological evolution made this pathology to be progressively better recognized and understood enabling professionals to perform the correct diagnosis and choose the ideal treatment for the affected population. Methods: A literature review was performed using MEDLINE/PubMed, Scopus, and Web of Science databases. The terms epilepsy/epileptic seizure of the insula and surgical treatment was used in various combinations. We included studies that were published in English, French, or Portuguese; performed in humans with insular epilepsy who underwent some surgical treatment (microsurgery, laser ablation, or radiofrequency thermocoagulation). Results: Initial search results in 1267 articles. After removing the duplicates 710 remaining articles were analyzed for titles and abstracts applying the inclusion and exclusion criteria. 70 studies met all inclusion criteria and were selected. Conclusion: At present, the main interests and efforts are in the attempt to achieve and standardize the adequate management of the patient with refractory epilepsy of the insular lobe and for that purpose several forms of investigation and treatment were developed. In this paper, we will discuss the characteristics and information regarding the pathology and gather data to identify and choose the best therapeutic option for each case.
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Affiliation(s)
- Gustavo A. R. Passos
- UFPR Post Graduate Program in Internal Medicine, Department of Neurosurgery, Mackenzie University Hospital,
| | - Carlos E. S. Silvado
- UFPR Post Graduate Program in Internal Medicine, Department of Neurology, Hospital de Clínicas da Universidade Federal do Paraná,
| | - Luis Alencar B. Borba
- Department of Neurosurgery, Hospital de Clínicas da Universidade Federal do Paraná/Mackenzie University Hospital, Curitiba, Brazil
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Li M, Ma X, Mai C, Fan Z, Wang Y, Ren Y. Knowledge Atlas of Insular Epilepsy: A Bibliometric Analysis. Neuropsychiatr Dis Treat 2022; 18:2891-2903. [PMID: 36540673 PMCID: PMC9760072 DOI: 10.2147/ndt.s392953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE In order to determine research hotspots and prospective directions, this work used VOSviewer and CiteSpace to assess the current state of insular epilepsy research. METHODS We looked for pertinent research about insular epilepsy published between the first of January 2000 and the thirtieth of April 2022 in the Web of Science Core Collection (WoSCC) database. CiteSpace and VOSviewer were used to build a knowledge atlas by analyzing authors, institutions, countries, keywords with citation bursts, keyword clustering, keyword co-occurrence, publishing journals, reference co-citation patterns, and other factors. RESULTS A total of 305 publications on insular epilepsy were found. Nguyen DK had the most articles published (37), whereas Mauguière F and Isnard J had the highest average number of citations/publications (39.37 and 38.09, respectively). The leading countries and institutions in this field were the United States (82 papers) and Université de Montréal (40 papers). Authors, countries, and institutions appear to be actively collaborating. Hot topics and research frontiers included surgical treatment, functional network connectivity, and the application of neuroimaging methods to study insular epilepsy. CONCLUSION In summary, the most influential articles, authors, journals, organizations, and countries on the subject of insular epilepsy were determined by this analysis. This study investigated the area of insular epilepsy research and forecasted upcoming trends using co-occurrence and evolution methods.
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Affiliation(s)
- Manli Li
- Department of Physiology, Sanquan College of Xinxiang Medical University, Xinxiang, People's Republic of China
| | - Xiaoli Ma
- Department of Physiology, Sanquan College of Xinxiang Medical University, Xinxiang, People's Republic of China
| | - Chendi Mai
- Department of Physiology, Sanquan College of Xinxiang Medical University, Xinxiang, People's Republic of China
| | - Zhiru Fan
- Department of Physiology, Sanquan College of Xinxiang Medical University, Xinxiang, People's Republic of China
| | - Yangyang Wang
- Ningxia Key Laboratory of Cerebrocranial Disease, Ningxia Medical University, Yinchuan, People's Republic of China
| | - Yankai Ren
- Department of Physiology, Sanquan College of Xinxiang Medical University, Xinxiang, People's Republic of China
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Huang Y, Li Q, Yang Q, Huang Z, Gao H, Xu Y, Liao L. Early Prediction of Refractory Epilepsy in Children Under Artificial Intelligence Neural Network. Front Neurorobot 2021; 15:690220. [PMID: 34220480 PMCID: PMC8245758 DOI: 10.3389/fnbot.2021.690220] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/18/2021] [Indexed: 11/13/2022] Open
Abstract
In order to realize the early prediction of refractory epilepsy in children, data preprocessing technology was used to improve the data quality, and the detection model of refractory epilepsy in children based on convolutional neural network (CNN) was established. Then, the data in the epilepsy electroencephalography (EEG) signal public data set was used for model training and the diagnosis of refractory epilepsy in children. Moreover, back propagation neural network (BPNN), support vector machine (SVM), XGBoost, gradient boosting decision tree (GBDT), AdaBoost algorithm were introduced for comparison. The results showed that the early prediction accuracy of BP, SVM, XGBoost, GBDT, AdaBoost, and the algorithm in this study for refractory epilepsy in children were 0.745, 0.778, 0.885, 0.846, 0.874, and 0.941, respectively. The sensitivities were 0.81, 0.826, 0.822, 0.84, 0.859, and 0.918, respectively. The specificities were 0.683, 0.696, 0.743, 0.792, 0.84, and 0.905, respectively. The accuracy was 0.707, 0.732, 0.765, 0.802, 0.839, and 0.881, respectively. The recall rates were 0.69, 0.716, 0.753, 0.784, 0.813, and 0.877, respectively. F1 scores were 0.698, 0.724, 0.759, 0.793, 0.826, and 0.879, respectively. Through the comparisons of the above six indicators, the algorithm proposed in this study was significantly higher than other algorithms, suggesting that the proposed algorithm was more accurate in early prediction of refractory epilepsy in children. Analysis of the EEG characteristics and magnetic resonance imaging (MRI) images of refractory epilepsy in children suggested that the MRI images of patients' brains under this algorithm had obvious characteristics. The reason for the prediction error of the algorithm was that the duration of epilepsy was too short or the EEG of the patient didn't change notably during the epileptic seizure. In summary, the prediction method of refractory epilepsy in children based on CNN was accurate, which had broad adoption prospects in assisting clinicians in the examination and diagnosis of refractory epilepsy in children.
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Affiliation(s)
- Yueyan Huang
- Department of Pediatrics, Affiliated Hospital of Youjiang Medical College for Nationalities, Baise, China
| | - Qingfeng Li
- Department of Radiology, Affiliated Hospital of Youjiang Medical College for Nationalities, Baise, China
| | - Qian Yang
- Center for Diagnosis and Research of Pathological Diseases, Affiliated Hospital of Youjiang Medical College for Nationalities, Baise, China
| | - Zhijing Huang
- Department of Pediatrics, Affiliated Hospital of Youjiang Medical College for Nationalities, Baise, China
| | - Hongbo Gao
- Department of Pediatrics, Affiliated Hospital of Youjiang Medical College for Nationalities, Baise, China
| | - Yunan Xu
- Department of Pediatrics, Affiliated Hospital of Youjiang Medical College for Nationalities, Baise, China
| | - Lianghua Liao
- Department of Pediatrics, Affiliated Hospital of Youjiang Medical College for Nationalities, Baise, China
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Seizure Freedom in Temporal Plus Epilepsy Surgery Following Stereo-Electroencephalography. Can J Neurol Sci 2021; 47:374-381. [PMID: 32036799 DOI: 10.1017/cjn.2020.26] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND "Temporal plus" epilepsy (TPE) is a term that is used when the epileptogenic zone (EZ) extends beyond the boundaries of the temporal lobe. Stereotactic electroencephalography (SEEG) has been essential to identify additional EZs in adjacent structures that might be part of the temporal lobe/limbic network. OBJECTIVE We present a small case series of temporal plus cases successfully identified by SEEG who were seizure-free after resective surgery. METHODS We conducted a retrospective analysis of 156 patients who underwent SEEG in 5 years. Six cases had TPE and underwent anterior temporal lobectomy (ATL) with additional extra-temporal resections. RESULTS Five cases had a focus on the right hemisphere and one on the left. Three cases were non-lesional and three were lesional. Mean follow-up time since surgery was 2.9 years (SD ± 1.8). Three patients had subdural electrodes investigation prior or in addition to SEEG. All patients underwent standard ATL and additional extra-temporal resections during the same procedure or at a later date. All patients were seizure-free at their last follow-up appointment (Engel Ia = 3; Engel Ib = 2; Engel Ic = 1). Pathology was nonspecific/gliosis for all six cases. CONCLUSION TPE might explain some of the failures in temporal lobe epilepsy surgery. We present a small case series of six patients in whom SEEG successfully identified this phenomenon and surgery proved effective.
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Ikegaya N, Iwasaki M, Kaneko Y, Kaido T, Kimura Y, Yamamoto T, Sumitomo N, Saito T, Nakagawa E, Sugai K, Sasaki M, Takahashi A, Otsuki T. Cognitive and developmental outcomes after pediatric insular epilepsy surgery for focal cortical dysplasia. J Neurosurg Pediatr 2020; 26:543-551. [PMID: 32764180 DOI: 10.3171/2020.5.peds2058] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 05/07/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cognitive risk associated with insular cortex resection is not well understood. The authors reviewed cognitive and developmental outcomes in pediatric patients who underwent resection of the epileptogenic zone involving the insula. METHODS A review was conducted of 15 patients who underwent resective epilepsy surgery involving the insular cortex for focal cortical dysplasia, with a minimum follow-up of 12 months. The median age at surgery was 5.6 years (range 0.3-13.6 years). Developmental/intelligence quotient (DQ/IQ) scores were evaluated before surgery, within 4 months after surgery, and at 12 months or more after surgery. Repeated measures multivariate ANOVA was used to evaluate the effects on outcomes of the within-subject factor (time) and between-subject factors (resection side, anterior insular resection, seizure control, and antiepileptic drug [AED] reduction). RESULTS The mean preoperative DQ/IQ score was 60.7 ± 22.8. Left-side resection and anterior insular resection were performed in 9 patients each. Favorable seizure control (International League Against Epilepsy class 1-3) was achieved in 8 patients. Postoperative motor deficits were observed in 9 patients (permanent in 6, transient in 3). Within-subject changes in DQ/IQ were not significantly affected by insular resection (p = 0.13). Postoperative changes in DQ/IQ were not significantly affected by surgical side, anterior insular resection, AED reduction, or seizure outcome. Only verbal function showed no significant changes before and after surgery and no significant effects of within-subject factors. CONCLUSIONS Resection involving the insula in children with impaired development or intelligence can be performed without significant reduction in DQ/IQ, but carries the risk of postoperative motor deficits.
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Affiliation(s)
- Naoki Ikegaya
- Departments of1Neurosurgery and
- 2Department of Neurosurgery, Epilepsy Center, Yokohama City University School of Medicine, Yokohama, Kanagawa
| | | | | | - Takanobu Kaido
- Departments of1Neurosurgery and
- 3Department of Health and Nutrition, Faculty of Health and Nutrition, Osaka Shoin Women's University, Higashi-Osaka, Osaka
| | | | - Tetsuya Yamamoto
- 2Department of Neurosurgery, Epilepsy Center, Yokohama City University School of Medicine, Yokohama, Kanagawa
| | - Noriko Sumitomo
- 4Child Neurology, Epilepsy Center, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Kodaira, Tokyo
| | - Takashi Saito
- 4Child Neurology, Epilepsy Center, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Kodaira, Tokyo
| | - Eiji Nakagawa
- 4Child Neurology, Epilepsy Center, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Kodaira, Tokyo
| | - Kenji Sugai
- 4Child Neurology, Epilepsy Center, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Kodaira, Tokyo
| | - Masayuki Sasaki
- 4Child Neurology, Epilepsy Center, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Kodaira, Tokyo
| | - Akio Takahashi
- Departments of1Neurosurgery and
- 5Department of Neurosurgery, Shibukawa Medical Center, Shibukawa, Gunma; and
| | - Taisuke Otsuki
- Departments of1Neurosurgery and
- 6Epilepsy Hospital Bethel Japan, Iwanuma, Miyagi, Japan
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Kappen P, Eltze C, Tisdall M, Cross JH, Thornton R, Moeller F. Stereo-EEG exploration in the insula/operculum in paediatric patients with refractory epilepsy. Seizure 2020; 78:63-70. [PMID: 32203882 DOI: 10.1016/j.seizure.2020.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 02/09/2020] [Accepted: 02/12/2020] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Failure to recognise involvement of the insula / opercula (I/O) region is associated with poor outcome in epilepsy surgery. Recognition is challenging due to high connectivity with adjacent structures resulting in variable and misleading semiology, often subjective and therefore likely to be underreported by children. In this study we explored prevalence and characteristics of I/O involvement in paediatric patients undergoing sEEG exploration. METHOD We retrospectively included all consecutive patients undergoing sEEG at our centre between 11/2014 and 01/2018 with at least three contacts within I/O and excluded those with undetermined seizure onset zone (SOZ) by sEEG. We divided patients into three groups: 1) SOZ in I/O, 2) spread to I/O and 3) no I/O involvement. We compared pre-invasive characteristics, sEEG results, surgery and outcome for each group. RESULTS 29 of all 53 consecutive patients had an identified SOZ by sEEG and at least three contacts within the I/O and were included. 41% had I/O SOZ, 38% had I/O spread and 21% had no I/O involvement. Insula associated symptoms described in adult literature were not statistically different between the three groups. Complications due to sEEG were low (2 of 53 patients). Following I/O surgery, 63% were seizure free while an additional 26% of patients achieved seizure reduction. Postoperative deficits were seen in 75% of the patients but completely resolved in all but one patient. CONCLUSIONS Our data suggest an important role of the I/O region with frequent onset or propagation to the I/O region (at least 64% of all 53 sEEG cases). Semiology appears less specific than in adults. Insula depth electrode insertion is safe with subsequent good surgical outcomes albeit common transient deficits.
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Affiliation(s)
- Pablo Kappen
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London, United Kingdom; Department of (Child) Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Christin Eltze
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Martin Tisdall
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - J Helen Cross
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London, United Kingdom; University College London Institute of Child Health, London, United Kingdom
| | - Rachel Thornton
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Friederike Moeller
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London, United Kingdom
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Alexander H, Cobourn K, Fayed I, Oluigbo CO. Magnetic Resonance-Guided Laser Interstitial Thermal Therapy for the Treatment of Nonlesional Insular Epilepsy in Pediatric Patients: Technical Considerations. Pediatr Neurosurg 2020; 55:155-162. [PMID: 32750699 DOI: 10.1159/000509006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 05/26/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The insula presents anatomic challenges to surgical exploration and intervention. Open neurosurgical intervention is associated with high rates of complications despite improved seizure control. Minimally invasive techniques using novel energy delivery methods have gained popularity due to their relative safety and ability to overcome access-related barriers. The goal of this paper is to present an operative technical report and methodological considerations on the application of magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) for the treatment of nonlesional, medically refractory, insular epilepsy in pediatric patients. METHODS Visualase laser probe(s) were implanted using ROSA robotic stereotactic guidance into the insula using a parasagittal trajectory. After confirmation of placement using intraoperative MRI, thermal energy was delivered under real-time MR guidance. Laser wire pullback was performed when the initial dose of thermal energy was insufficient to ablate the target in its entirety. Thermal ablation within the intended target was confirmed using gadolinium-enhanced brain MRI. Following removal of laser wires, a final T1-weighted axial brain MRI was performed to confirm no evidence of hemorrhage. RESULTS Three patients underwent MRgLITT of nonlesional insular epilepsy over an 11-month period. The epileptogenic focus was localized to the insula using stereoelectroencephalography. The anterior and middle portions of the insula were accessed using a parasagittal trajectory. Laser ablation was performed for up to 3 min using an output of 10.5 W. No complications were encountered, and all patients were discharged within 24 h after the surgery. At the most recent follow-up, all patients had an Engel I outcome without any new neurologic deficits. CONCLUSION This small cohort shows that insular ablation can be achieved safely with promising seizure outcomes in the short term.
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Affiliation(s)
- Hepzibha Alexander
- Division of Neurosurgery, Children's National Medical Center, Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Kelsey Cobourn
- Division of Neurosurgery, Children's National Medical Center, Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Islam Fayed
- Division of Neurosurgery, Children's National Medical Center, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Chima O Oluigbo
- Division of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA,
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Alexander H, Cobourn K, Fayed I, Depositario-Cabacar D, Keating RF, Gaillard WD, Oluigbo CO. Magnetic resonance-guided laser interstitial thermal therapy for the treatment of non-lesional insular epilepsy in pediatric patients: thermal dynamic and volumetric factors influencing seizure outcomes. Childs Nerv Syst 2019; 35:453-461. [PMID: 30627771 DOI: 10.1007/s00381-019-04051-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 01/03/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE To investigate the safety and efficacy of stereoelectroencephalography (sEEG) directed magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) in medically refractory insular epilepsy in pediatric patients, define the relationship between ablation volumes and seizure control, and analyze the relationship between thermal energy and ablation volumes. METHODS A single-institution, retrospective review of pediatric patients with insular epilepsy who underwent sEEG directed MRgLITT over a 10-month period was performed. Perioperative, imaging, and outcome data were analyzed. Seizure outcomes were determined based on Engel score (Engel I versus Engel II-IV). Insula and ablation volumes were measured, and the proportion of insula volume ablated was calculated. Thermal energy was calculated in joules. RESULTS Four patients underwent sEEG directed MRgLITT of insular epileptogenic foci. The ablation volume was higher in patients with Engel I outcome (3.93 cm3) compared to Engel II-IV outcome (1.02 cm3). The proportion of ablation to insula volume was lowest in patients with Engel II-IV outcome (25.09%). The mean energy requirement to create a unit volume of ablation in the insula is 1205.86 J. A linear trend was noted between thermal ablation energy and ablation volume (R2 = 0.884). Over a mean follow-up period of 104 days, three patients were seizure-free (Engel I), and one patient saw significant improvement in seizure frequency (Engel III). CONCLUSIONS The proportion of insula ablated, as well as the volume of ablation, are related to seizure outcome with increasing ablation volumes corresponding to improved seizure control. Further analysis of insula laser ablation thermal dynamics and volumes is needed.
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Affiliation(s)
- Hepzibha Alexander
- Division of Neurosurgery, Children's National Medical Center, Georgetown University School of Medicine, Washington, DC, USA
| | - Kelsey Cobourn
- Division of Neurosurgery, Children's National Medical Center, Georgetown University School of Medicine, Washington, DC, USA
| | - Islam Fayed
- Division of Neurosurgery, Children's National Medical Center, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Dewi Depositario-Cabacar
- Division of Neurology, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Robert F Keating
- Division of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - William D Gaillard
- Division of Neurology, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Chima O Oluigbo
- Division of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
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Jobst BC, Gonzalez-Martinez J, Isnard J, Kahane P, Lacuey N, Lahtoo SD, Nguyen DK, Wu C, Lado F. The Insula and Its Epilepsies. Epilepsy Curr 2019; 19:11-21. [PMID: 30838920 PMCID: PMC6610377 DOI: 10.1177/1535759718822847] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Insular seizures are great mimickers of seizures originating elsewhere in the
brain. The insula is a highly connected brain structure. Seizures may only
become clinically evident after ictal activity propagates out of the insula with
semiology that reflects the propagation pattern. Insular seizures with
perisylvian spread, for example, manifest first as throat constriction, followed
next by perioral and hemisensory symptoms, and then by unilateral motor
symptoms. On the other hand, insular seizures may spread instead to the temporal
and frontal lobes and present like seizures originating from these regions. Due
to the location of the insula deep in the brain, interictal and ictal scalp
electroencephalogram (EEG) changes can be variable and misleading. Magnetic
resonance imaging, magnetic resonance spectroscopy, magnetoencephalography,
positron emission tomography, and single-photon computed tomography imaging may
assist in establishing a diagnosis of insular epilepsy. Intracranial EEG
recordings from within the insula, using stereo-EEG or depth electrode
techniques, can prove insular seizure origin. Seizure onset, most commonly seen
as low-voltage, fast gamma activity, however, can be highly localized and easily
missed if the insula is only sparsely sampled. Moreover, seizure spread to the
contralateral insula and other brain regions may occur rapidly. Extensive
sampling of the insula with multiple electrode trajectories is necessary to
avoid these pitfalls. Understanding the functional organization of the insula is
helpful when interpreting the semiology produced by insular seizures. Electrical
stimulation mapping around the central sulcus of the insula results in
paresthesias, while stimulation of the posterior insula typically produces
painful sensations. Visceral sensations are the next most common result of
insular stimulation. Treatment of insular epilepsy is evolving, but poses
challenges. Surgical resections of the insula are effective but risk significant
morbidity if not carefully planned. Neurostimulation is an emerging option for
treatment, especially for seizures with onset in the posterior insula. The close
association of the insula with marked autonomic changes has led to interest in
the role of the insula in sudden unexpected death in epilepsy and warrants
additional study with larger patient cohorts.
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Affiliation(s)
| | | | - Jean Isnard
- 3 Hospices Civils de Lyon, Hospital for Neurology and Neurosurgery, Lyon, France
| | | | - Nuria Lacuey
- 5 University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Samden D Lahtoo
- 5 University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | - Chengyuan Wu
- 7 Thomas Jefferson University, Philadelphia, PA, USA
| | - Fred Lado
- 8 Northwell Health, Great Neck, NY, USA
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d'Orio P, Rizzi M, Mariani V, Pelliccia V, Lo Russo G, Cardinale F, Nichelatti M, Nobili L, Cossu M. Surgery in patients with childhood-onset epilepsy: analysis of complications and predictive risk factors for a severely complicated course. J Neurol Neurosurg Psychiatry 2019; 90:84-89. [PMID: 30100551 DOI: 10.1136/jnnp-2018-318282] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 07/12/2018] [Accepted: 07/15/2018] [Indexed: 11/03/2022]
Abstract
OBJECT To compare the occurrence of surgery-related complications in patients with childhood-onset focal epilepsy operated on in the paediatric or in the adult age. To investigate risk factors for surgery-related complications in the whole cohort, with special attention to age at surgery and severe morbidity. METHODS A cohort of 1282 patients operated on for childhood-onset focal epilepsy was retrospectively analysed. Occurrence of surgery-related complications, including a severely complicated course (SCC: surgical complication requiring reoperation and/or permanent neurological deficit and/or death), was compared between patients operated on in the paediatric age (<16 year-old; 452 cases) and, respectively, in adulthood (≥16 year-old; 830 cases). The whole cohort of patients was also evaluated for risk factors for a SCC. RESULTS At last contact (median follow-up 98 months), 74.5% of patients were in Engel's class I (78.0% of children and 73.0% of adults). One hundred patients (7.8%) presented a SCC (6.4% for children and 8.6% for adult patients). Postoperative intracranial haemorrhages occurred more frequently in adult cases. At multivariate analysis, increasing age at operation, multilobar surgery, resections in the rolandic/perirolandic and in insulo-opercular regions were independent risk factors for a SCC. CONCLUSIONS Surgery for childhood-onset focal epilepsy provides excellent results on seizures and an acceptable safety profile at any age. Nevertheless, our results suggest that increasing age at surgery is associated with an increase in odds of developing severe surgery-related complications. These findings support the recommendation that children with drug-resistant, symptomatic (or presumed symptomatic) focal epilepsy should be referred for a surgical evaluation as early as possible after seizure onset.
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Affiliation(s)
- Piergiorgio d'Orio
- "Claudio Munari" Epilepsy Surgery Centre, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Michele Rizzi
- "Claudio Munari" Epilepsy Surgery Centre, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milano, Italy.,Department of Neuroscience, University of Parma, Parma, Italy
| | - Valeria Mariani
- "Claudio Munari" Epilepsy Surgery Centre, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Veronica Pelliccia
- "Claudio Munari" Epilepsy Surgery Centre, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Giorgio Lo Russo
- "Claudio Munari" Epilepsy Surgery Centre, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Francesco Cardinale
- "Claudio Munari" Epilepsy Surgery Centre, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Michele Nichelatti
- Service of Biostatistics, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Lino Nobili
- "Claudio Munari" Epilepsy Surgery Centre, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milano, Italy.,Child Neuropsychiatry Unit, DINOGMI, University of Genoa, Genoa, Italy, Istituto Giannina Gaslini, Genova, Italy
| | - Massimo Cossu
- "Claudio Munari" Epilepsy Surgery Centre, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milano, Italy
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Pizarro D, Ilyas A, Toth E, Romeo A, Riley KO, Esteller R, Vlachos I, Pati S. Automated detection of mesial temporal and temporoperisylvian seizures in the anterior thalamic nucleus. Epilepsy Res 2018; 146:17-20. [PMID: 30055392 DOI: 10.1016/j.eplepsyres.2018.07.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 06/21/2018] [Accepted: 07/22/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND PURPOSE Focal seizures can arise from coordinated activity across large-scale epileptic networks and propagate to regions that are not functionally altered but are recruited by epileptiform discharges. In preclinical models of focal epilepsy, the thalamus is recruited by cortical onset seizures, but it remains to be demonstrated in clinical studies. In this pilot study, the authors investigate whether seizures with onset within and outside the mesial temporal structures are detected in the anterior thalamus (ATN). METHODS After written consent, three subjects with suspected temporal lobe epilepsy undergoing stereotactic electrode implantation were recruited prospectively for thalamocortical depth EEG recordings. Three seizure detection metrics (line length-LL, Laplace operator-Lap; Teager energy-TE) were studied within the seizure onset zone and ATN. RESULTS The LL, Lap, and TE metrics detected 40 (95%) seizures each in the ATN before the behavioral manifestation. Rates of detection in the seizure onset zone were 40 (95%), 42 (100%), and 41 (98%), respectively. The mean detection latency in ATN from SOZ ranged from 0.25 to 5.17 s. Seizures were localized to amygdala-hippocampus, temporal pole, anterior insula and superior temporal gyrus. CONCLUSIONS The pilot study demonstrates that seizures in mesial temporal and temporal-plus epilepsies (i.e., temporoperisylvian) can be detected reliably in the ATN. Further studies are needed to validate these findings.
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Affiliation(s)
- Diana Pizarro
- Department of Neurology, University of Alabama at Birmingham, AL, United States; Epilepsy and Cognitive Neurophysiology Laboratory, University of Alabama at Birmingham, AL, United States
| | - Adeel Ilyas
- Department of Neurosurgery, University of Alabama at Birmingham, AL, United States; Epilepsy and Cognitive Neurophysiology Laboratory, University of Alabama at Birmingham, AL, United States
| | - Emilia Toth
- Department of Neurology, University of Alabama at Birmingham, AL, United States; Epilepsy and Cognitive Neurophysiology Laboratory, University of Alabama at Birmingham, AL, United States
| | - Andrew Romeo
- Department of Neurosurgery, University of Alabama at Birmingham, AL, United States
| | - Kristen O Riley
- Department of Neurosurgery, University of Alabama at Birmingham, AL, United States
| | - Rosana Esteller
- Department of Neurology, University of Alabama at Birmingham, AL, United States
| | - Ioannis Vlachos
- Department of Mathematics and Statistics, Louisiana Tech University, Ruston, LA, United States
| | - Sandipan Pati
- Department of Neurology, University of Alabama at Birmingham, AL, United States; Epilepsy and Cognitive Neurophysiology Laboratory, University of Alabama at Birmingham, AL, United States.
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