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Gorbachuk M, Machetanz K, Weinbrenner E, Grimm F, Wuttke TV, Wang S, Ethofer S, Tatagiba M, Rona S, Honegger J, Naros G. Robot-assisted stereoencephalography vs subdural electrodes in the evaluation of temporal lobe epilepsy. Epilepsia Open 2023; 8:888-897. [PMID: 37149851 PMCID: PMC10472365 DOI: 10.1002/epi4.12756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 04/30/2023] [Indexed: 05/09/2023] Open
Abstract
OBJECTIVE Invasive video-electroencephalography (iVEEG) is the gold standard for evaluation of refractory temporal lobe epilepsy before second stage resective surgery (SSRS). Traditionally, the presumed seizure onset zone (SOZ) has been covered with subdural electrodes (SDE), a very invasive procedure prone to complications. Temporal stereoelectroencephalography (SEEG) with conventional frame-based stereotaxy is time-consuming and impeded by the geometry of the frame. The introduction of robotic assistance promised a simplification of temporal SEEG implantation. However, the efficacy of temporal SEEG in iVEEG remains unclear. The aim of this study was therefore to describe the efficiency and efficacy of SEEG in iVEEG of temporal lobe epilepsy. METHODS This retrospective study enrolled 60 consecutive patients with medically intractable epilepsy who underwent iVEEG of a potential temporal SOZ by SDE (n = 40) or SEEG (n = 20). Surgical time efficiency was analyzed by the skin-to-skin time (STS) and the total procedure time (TPT) and compared between groups (SDE vs SEEG). Surgical risk was depicted by the 90-day complication rate. Temporal SOZ were treated by SSRS. Favorable outcome (Engel°1) was assessed after 1 year of follow-up. RESULTS Robot-assisted SEEG significantly reduced the duration of surgery (STS and TPT) compared to SDE implantations. There was no significant difference in complication rates. Notably, all surgical revisions in this study were attributed to SDE. Unilateral temporal SOZ was detected in 34/60 cases. Of the 34 patients, 30 underwent second stage SSRS. Both SDE and SEEG had a good predictive value for the outcome of temporal SSRS with no significant group difference. SIGNIFICANCE Robot-assisted SEEG improves the accessibility of the temporal lobe for iVEEG by increasing surgical time efficiency and by simplifying trajectory selection without losing its predictive value for SSRS.
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Affiliation(s)
- Mykola Gorbachuk
- Neurosurgical Clinic, Department of Neurosurgery and NeurotechnologyEberhard Karls UniversityTuebingenGermany
| | - Kathrin Machetanz
- Neurosurgical Clinic, Department of Neurosurgery and NeurotechnologyEberhard Karls UniversityTuebingenGermany
| | - Eliane Weinbrenner
- Neurosurgical Clinic, Department of Neurosurgery and NeurotechnologyEberhard Karls UniversityTuebingenGermany
| | - Florian Grimm
- Neurosurgical Clinic, Department of Neurosurgery and NeurotechnologyEberhard Karls UniversityTuebingenGermany
| | - Thomas V. Wuttke
- Neurosurgical Clinic, Department of Neurosurgery and NeurotechnologyEberhard Karls UniversityTuebingenGermany
| | - Sophie Wang
- Neurosurgical Clinic, Department of Neurosurgery and NeurotechnologyEberhard Karls UniversityTuebingenGermany
| | - Silke Ethofer
- Neurosurgical Clinic, Department of Neurosurgery and NeurotechnologyEberhard Karls UniversityTuebingenGermany
| | - Marcos Tatagiba
- Neurosurgical Clinic, Department of Neurosurgery and NeurotechnologyEberhard Karls UniversityTuebingenGermany
| | - Sabine Rona
- Neurosurgical Clinic, Department of Neurosurgery and NeurotechnologyEberhard Karls UniversityTuebingenGermany
| | - Jürgen Honegger
- Neurosurgical Clinic, Department of Neurosurgery and NeurotechnologyEberhard Karls UniversityTuebingenGermany
| | - Georgios Naros
- Neurosurgical Clinic, Department of Neurosurgery and NeurotechnologyEberhard Karls UniversityTuebingenGermany
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Obaid S, Chen JS, Ibrahim GM, Bouthillier A, Dimentberg E, Surbeck W, Guadagno E, Brunette-Clément T, Shlobin NA, Shulkin A, Hale AT, Tomycz LD, Von Lehe M, Perry MS, Chassoux F, Bouilleret V, Taussig D, Fohlen M, Dorfmuller G, Hagiwara K, Isnard J, Oluigbo CO, Ikegaya N, Nguyen DK, Fallah A, Weil AG. Predictors of outcomes after surgery for medically intractable insular epilepsy: A systematic review and individual participant data meta-analysis. Epilepsia Open 2023; 8:12-31. [PMID: 36263454 PMCID: PMC9978079 DOI: 10.1002/epi4.12663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 09/28/2022] [Indexed: 11/11/2022] Open
Abstract
Insular epilepsy (IE) is an increasingly recognized cause of drug-resistant epilepsy amenable to surgery. However, concerns of suboptimal seizure control and permanent neurological morbidity hamper widespread adoption of surgery for IE. We performed a systematic review and individual participant data meta-analysis to determine the efficacy and safety profile of surgery for IE and identify predictors of outcomes. Of 2483 unique citations, 24 retrospective studies reporting on 312 participants were eligible for inclusion. The median follow-up duration was 2.58 years (range, 0-17 years), and 206 (66.7%) patients were seizure-free at last follow-up. Younger age at surgery (≤18 years; HR = 1.70, 95% CI = 1.09-2.66, P = .022) and invasive EEG monitoring (HR = 1.97, 95% CI = 1.04-3.74, P = .039) were significantly associated with shorter time to seizure recurrence. Performing MR-guided laser ablation or radiofrequency ablation instead of open resection (OR = 2.05, 95% CI = 1.08-3.89, P = .028) was independently associated with suboptimal or poor seizure outcome (Engel II-IV) at last follow-up. Postoperative neurological complications occurred in 42.5% of patients, most commonly motor deficits (29.9%). Permanent neurological complications occurred in 7.8% of surgeries, including 5% and 1.4% rate of permanent motor deficits and dysphasia, respectively. Resection of the frontal operculum was independently associated with greater odds of motor deficits (OR = 2.75, 95% CI = 1.46-5.15, P = .002). Dominant-hemisphere resections were independently associated with dysphasia (OR = 13.09, 95% CI = 2.22-77.14, P = .005) albeit none of the observed language deficits were permanent. Surgery for IE is associated with a good efficacy/safety profile. Most patients experience seizure freedom, and neurological deficits are predominantly transient. Pediatric patients and those requiring invasive monitoring or undergoing stereotactic ablation procedures experience lower rates of seizure freedom. Transgression of the frontal operculum should be avoided if it is not deemed part of the epileptogenic zone. Well-selected candidates undergoing dominant-hemisphere resection are more likely to exhibit transient language deficits; however, the risk of permanent deficit is very low.
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Affiliation(s)
- Sami Obaid
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Quebec, Montreal, Canada.,Division of Neurosurgery, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Jia-Shu Chen
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - George M Ibrahim
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Alain Bouthillier
- Division of Neurosurgery, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Evan Dimentberg
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Quebec, Montreal, Canada.,Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
| | - Werner Surbeck
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital of the University of Zurich, Zurich, Switzerland
| | - Elena Guadagno
- Harvey E. Beardmore Division of Pediatric Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Tristan Brunette-Clément
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Quebec, Montreal, Canada.,Division of Neurosurgery, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Nathan A Shlobin
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Aidan Shulkin
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Quebec, Montreal, Canada
| | - Andrew T Hale
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Luke D Tomycz
- The Epilepsy Institute of New Jersey, Jersey City, New Jersey, USA
| | - Marec Von Lehe
- Department of Neurosurgery, Brandenburg Medical School, Neuruppin, Germany
| | - Michael Scott Perry
- Comprehensive Epilepsy Program, Jane and John Justin Neuroscience Center, Cook Children's Medical Center, Fort Worth, Texas, USA
| | - Francine Chassoux
- Service de Neurochirurgie, GHU Paris Psychiatrie et Neurosciences, Université Paris-Descartes Paris, Paris, France
| | - Viviane Bouilleret
- Université Paris Saclay-APHP, Unité de Neurophysiologie Clinique et d'Épileptologie(UNCE), Le Kremlin Bicêtre, France
| | - Delphine Taussig
- Université Paris Saclay-APHP, Unité de Neurophysiologie Clinique et d'Épileptologie(UNCE), Le Kremlin Bicêtre, France.,Pediatric Neurosurgery Department, Rothschild Foundation Hospital, Paris, France
| | - Martine Fohlen
- Pediatric Neurosurgery Department, Rothschild Foundation Hospital, Paris, France
| | - Georg Dorfmuller
- Pediatric Neurosurgery Department, Rothschild Foundation Hospital, Paris, France
| | - Koichi Hagiwara
- Epilepsy and Sleep Center, Fukuoka Sanno Hospital, Fukuoka, Japan
| | - Jean Isnard
- Department of Functional Neurology and Epileptology, Hospices Civils de Lyon, Hospital for Neurology and Neurosurgery, Lyon, France
| | - Chima O Oluigbo
- Department of Neurosurgery, Children's National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Naoki Ikegaya
- Departments of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Dang K Nguyen
- Division of Neurology, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Aria Fallah
- Department of Neurosurgery and Pediatrics, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Alexander G Weil
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Quebec, Montreal, Canada.,Division of Neurosurgery, University of Montreal Hospital Center, Montreal, Quebec, Canada.,Department of Neuroscience, University of Montreal, Montreal, Quebec, Canada
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3
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Solanki C, Williams J, Andrews C, Fayed I, Wu C. Insula in epilepsy - "untying the gordian knot": A systematic review. Seizure 2023; 106:148-161. [PMID: 36878050 DOI: 10.1016/j.seizure.2023.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 02/23/2023] [Accepted: 02/25/2023] [Indexed: 03/02/2023] Open
Abstract
PURPOSE Despite significant advances in epileptology, there are still many uncertainties about the role of the insula in epilepsy. Until recently, most insular onset seizures were wrongly attributed to the temporal lobe. Further, there are no standardised approaches to the diagnosis and treatment of insular onset seizures. This systematic review gathers the available information about insular epilepsy and synthesizes current knowledge as a basis for future research. METHOD Adhering to the PRISMA guidelines, studies were meticulously extracted from the PubMed database. The empirical data pertaining to the semiology of insular seizures, insular networks in epilepsy, techniques of mapping the insula, and the surgical intricacies of non-lesional insular epilepsy were reviewed from published studies. The corpus of information available was then subjected to a process of concise summarization and astute synthesis. RESULTS Out of 235 studies identified for full-text review, 86 studies were included in the systematic review. The insula emerges as a brain region with a number of functional subdivisions. The semiology of insular seizures is diverse and depends on the involvement of particular subdivisions. The semiological heterogeneity of insular seizures is explained by the extensive connectivity of the insula and its subdivisions with all four lobes of the brain, deep grey matter structures, and remote brainstem areas. The mainstay of the diagnosis of seizure onset in the insula is stereoelectroencephalography (SEEG). The surgical resection of the insular epileptogenic zone (when possible) is the most effective treatment. Open surgery on the insula is challenging but magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) also holds promise. CONCLUSION The physiological and functional roles of the insula in epilepsy have remained obfuscated. The dearth of precisely defined diagnostic and therapeutic protocols acts as an impediment to scientific advancement. This review could potentially facilitate forthcoming research endeavours by establishing a foundational framework for uniform data collection protocols, thereby enhancing the feasibility of comparing findings across future studies and promoting progress in this domain.
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Affiliation(s)
- Chirag Solanki
- Consultant Neurosurgeon, Department of Neurosurgery, Sterling Hospital, Ahmedabad, Gujarat, India.
| | - Justin Williams
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, United States.
| | - Carrie Andrews
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, United States.
| | - Islam Fayed
- Stereotactic and Functional Neurosurgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, United States.
| | - Chengyuan Wu
- Associate Professor of Neurosurgery and Radiology, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, United States.
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Dai Y, Zhang H, Fan X, Wei P, Shan Y, Zhao G. Optimized SEEG-guided three-dimensional radiofrequency thermocoagulation for insular epilepsy. Acta Neurochir (Wien) 2023; 165:249-258. [PMID: 36342542 DOI: 10.1007/s00701-022-05401-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/20/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE The high risk of resection surgery for drug-resistant insular epilepsy has driven interest in new treatment techniques. Stereo-electroencephalography-guided three-dimensional radiofrequency thermocoagulation (SEEG-3D RFTC) offers an alternative option. Herein, we present the detailed protocol and investigation of the efficacy and safety of a preliminary observational study. METHODS From February 2017 to April 2021, ten patients diagnosed with insular epilepsy were enrolled in the study. They underwent implantation of a combination of SEEG electrodes to form a high-density focal stereo-array in insula, including oblique electrodes through the long axis of insula and orthogonal electrodes to widely cover the medial and lateral insula. SEEG-3D RFTC was performed between two contiguous contacts of the same electrode, or between two adjacent contacts of different electrodes. RESULTS Surgical procedures were well tolerated, with no related long-term complications. Seizure-free outcome was achieved in seven patients (70%), including ILAE I in four and ILAE II in three. Two other (20%) patients had rare seizures (ILAE III). One (10%) patient experienced an ILAE IV outcome (follow-up = 12--63 months). The responder rate (including ILAE I-IV) was 100%. CONCLUSION The optimized SEEG-3D RFTC is an effective and safe option for the treatment of drug-resistant insular epilepsy.
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Affiliation(s)
- Yang Dai
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun St., Xicheng District, Beijing, 100053, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, 100053, China
| | - Huaqiang Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun St., Xicheng District, Beijing, 100053, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, 100053, China
| | - Xiaotong Fan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun St., Xicheng District, Beijing, 100053, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, 100053, China
| | - Penghu Wei
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun St., Xicheng District, Beijing, 100053, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, 100053, China
| | - Yongzhi Shan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun St., Xicheng District, Beijing, 100053, China.
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, 100053, China.
| | - Guoguang Zhao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun St., Xicheng District, Beijing, 100053, China.
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, 100053, China.
- National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China.
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5
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Chilukuri AS, Awkwayena E, Abel TJ. Insulo-opercular stereoelectroencephalography exploration in children and young adults: Indications, techniques, and safety. Epilepsia Open 2022; 7:729-736. [PMID: 36161288 PMCID: PMC9712468 DOI: 10.1002/epi4.12651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 09/21/2022] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE Sampling the insulo-opercular region with invasive recordings is crucial given the importance of this region in epileptic networks and a variety of electroclinical presentations. However, implantation of the insulo-opercular region via stereoelectroencephalography (sEEG) is considered technically challenging given complex vascular and gray matter relationships in this region. We investigated the safety of insulo-opercular sEEG exploration in children and young adults using standard sEEG approaches: (1) orthogonal insulo-opercular (including the pseudo-orthogonal insulo-opercular approach) and (2) medial-lateral insular oblique approach. METHODS We performed a retrospective cohort study of 30 consecutive patients who underwent 33 sEEG implantations. All patients had drug-resistant focal epilepsy, were between the ages of 4 and 21, and were operated at one institution between January 2019 and March 2021. Medical records and neuroimaging were reviewed. Hemorrhage, infection, and other complications were considered as outcome variables. RESULTS A total of 519 electrodes were placed. Eighty-one were placed orthogonally into the temporal operculum, 53 orthogonally into the frontal operculum, and 19 obliquely into the insula. sEEG electrodes localized seizure onset to the insulo-opercular region in eight patients, leading to a resection three times, an ablation four times, and one peri-insular hemispherectomy. Of the 519 electrodes placed, none of them exhibited hemorrhage or serious complications. Of the 153 electrodes placed into the insula, none had any permanent deficits or complications and one had minor bleeding due to the electrode breaking. SIGNIFICANCE These results demonstrate that the orthogonal (including pseudo-orthogonal) and medial approaches to sampling the insula are safe.
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Affiliation(s)
| | - Emefa Awkwayena
- Department of Neurological SurgeryUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Taylor J. Abel
- Department of Neurological SurgeryUniversity of PittsburghPittsburghPennsylvaniaUSA,Department of BioengineeringUniversity of PittsburghPittsburghPennsylvaniaUSA
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Zhang D, Cui X, Zheng J, Zhang S, Wang M, Lu W, Sang L, Li W. Neurosurgical robot-assistant stereoelectroencephalography system: Operability and accuracy. Brain Behav 2021; 11:e2347. [PMID: 34520631 PMCID: PMC8553331 DOI: 10.1002/brb3.2347] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/18/2021] [Accepted: 08/18/2021] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Fine operation has been an eternal topic in neurosurgery. There were many problems in functional neurosurgery field with high precision requirements. Our study aims to explore the operability, accuracy and postoperative effect of robot-assisted stereoelectroencephalography (SEEG) in neurosurgery. METHODS We conducted a retrospective analysis of patients with epilepsy who underwent electrode implantation in our hospital. From 2016 to 2019, the epilepsy center of Hebei people's hospital implanted electrodes in neurosurgery on 24 patients, including 20 with SINO robot-assisted SEEG system and eight with frame-SEEG technology. RESULT Robot-assisted SEEG neurosurgery had higher accuracy, and the mean error of entry and target point was smaller than that of frame SEEG surgery. No bleeding or infection occurred postoperatively, and two patients who underwent robot-assisted SEEG neurosurgery had electrode displacement. Electrode displacement was observed in two patients, both the entry points were orbital frontal, one in the frame system and one in the robot assistant system. The average placement time of each electrode in robot assisted system surgery was less than that in frame system surgery. CONCLUSION The SINO SEEG electrode implantation assisted by surgical robot-assistant system manufactured in China is safe, accurate and mature.
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Affiliation(s)
- Di Zhang
- Neurosurgery Department of Epilepsy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xuehua Cui
- Neurosurgery Department of Epilepsy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jie Zheng
- Neurosurgery Department of Epilepsy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Shunyao Zhang
- Neurosurgery Department of Epilepsy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Meng Wang
- Neurosurgery Department of Epilepsy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Wenpeng Lu
- Neurosurgery Department of Epilepsy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Linxia Sang
- Neurosurgery Department of Epilepsy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Wenling Li
- Neurosurgery Department of Epilepsy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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Kandregula S, Matias CM, Malla BR, Sperling MR, Wu C, Sharan AD. Accuracy of Electrode Insertion Using Frame-Based With Robot Guidance Technique in Stereotactic Electroencephalography: Supine Versus Lateral Position. World Neurosurg 2021; 154:e325-e332. [PMID: 34284161 DOI: 10.1016/j.wneu.2021.07.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 07/07/2021] [Accepted: 07/08/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Placing the patient in lateral position is an option for implantation of stereoelectroencephalography (SEEG) electrodes that have a posterior entry point. Previous studies reported the accuracy of SEEG electrodes but not specifically in relation to position. The aim of this study was to analyze accuracy of SEEG electrodes by position. METHODS Entry point and target accuracy of electrodes implanted in lateral position were compared with electrodes implanted in supine position using a frame-based with robot guidance technique. Subgroup analysis was performed for insular versus noninsular electrodes. RESULTS Analysis included 23 consecutive patients (11 in lateral position) with 294 electrodes. The entry point error was similar between lateral (median 1.3 mm [interquartile range 0.8-1.9]) and supine (1.2 mm [0.8-1.7]; P = 0.360) position. Target accuracy was better in lateral (1.8 mm [1.3-2.7]) than supine (2.9 mm [2.0-4.4]; P < 0.001) position. For noninsular electrodes, the median entry point error in lateral and supine position was 1.3 mm (0.8-1.9) and 1.2 mm (0.8-1.7; P = 0.43), respectively. The accuracy was better in lateral position (median 1.7 mm [1.2-2.6]) compared with supine position (2.9 mm [2.0-4.4]; P < 0.001). The accuracy of insular electrodes was similar in both positions for entry point (lateral: median radial error 1.4 mm, [0.7-1.9]; supine: 1.1 mm [0.6-1.8]; P = 0.833) and target (lateral: median three-dimensional error 2.3 mm [1.6-3.2]; supine: 2.9 mm [2.4-4.5]; P = 0.07). CONCLUSIONS SEEG leads implanted in lateral position exhibit an accuracy and safety profile in accordance with previous studies. In this cohort, target error was smaller in the lateral position, particularly in noninsular electrodes.
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Affiliation(s)
- Sandeep Kandregula
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India
| | - Caio M Matias
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
| | - Bhasakara Rao Malla
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India
| | - Michael R Sperling
- Baldwin Keyes Professor of Neurology, Thomas Jefferson University, Jefferson Comprehensive Epilepsy Center, Philadelphia, Pennsylvania, USA
| | - Chengyuan Wu
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Aswhini D Sharan
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Bottan JS, Rubino PA, Lau JC, MacDougall KW, Parrent AG, Burneo JG, Steven DA. Robot-Assisted Insular Depth Electrode Implantation Through Oblique Trajectories: 3-Dimensional Anatomical Nuances, Technique, Accuracy, and Safety. Oper Neurosurg (Hagerstown) 2021; 18:278-283. [PMID: 31245818 DOI: 10.1093/ons/opz154] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 03/15/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The insula is a deep cortical structure that has renewed interest in epilepsy investigation. Invasive EEG recordings of this region have been challenging. Robot-assisted stereotactic electroencephalography has improved feasibility and safety of such procedures. OBJECTIVE To describe technical nuances of three-dimensional (3D) oblique trajectories for insular robot-assisted depth electrode implantation. METHODS Fifty patients who underwent robot-assisted depth electrode implantation between June 2017 and December 2018 were retrospectively analyzed. Insular electrodes were implanted through oblique, orthogonal, or parasagittal trajectories. Type of trajectories, accuracy, number of contacts within insular cortex, imaging, and complication rates were analyzed. Cadaveric and computerized tomography/magnetic resonance imaging 3D reconstructions were used to visualize insular anatomy and the technical implications of oblique trajectories. RESULTS Forty-one patients (98 insular electrodes) were included. Thirty (73.2%) patients had unilateral insular coverage. Average insular electrodes per patient was 2.4. The mean number of contacts was 7.1 (SD ± 2.91) for all trajectories and 8.3 (SD ± 1.51) for oblique insular trajectories. The most frequently used was the oblique trajectory (85 electrodes). Mean entry point error was 1.5 mm (0.2-2.8) and target error was 2.4 mm (0.8-4.0), 2.0 mm (1.1-2.9) for anterior oblique and 2.8 mm (0.8-4.9) for posterior oblique trajectories. There were no complications related to insular electrodes. CONCLUSION Oblique trajectories are the preferred method for insular investigation at our institution, maximizing the number of contacts within insular cortex without traversing through sulci or major CSF fissures. Robot-assisted procedures are safe and efficient. 3D understanding of the insula's unique anatomical features can help the surgeon to improve targeting of this structure.
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Affiliation(s)
- Juan S Bottan
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Canada.,Division of Neurosurgery, Hospital General de Niños "Pedro De Elizalde," Ciudad Autónoma de Buenos Aires, Argentina
| | - Pablo A Rubino
- Hospital de Alta Complejidad en Red "El Cruce," Florencio Varela, Argentina
| | - Jonathan C Lau
- 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
| | - Andrew G Parrent
- 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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9
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Ladisich B, Machegger L, Romagna A, Krainz H, Steinbacher J, Leitinger M, Kalss G, Thon N, Trinka E, Winkler PA, Schwartz C. VarioGuide® frameless neuronavigation-guided stereoelectroencephalography in adult epilepsy patients: technique, accuracy and clinical experience. Acta Neurochir (Wien) 2021; 163:1355-1364. [PMID: 33580853 PMCID: PMC8053662 DOI: 10.1007/s00701-021-04755-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 02/01/2021] [Indexed: 12/12/2022]
Abstract
Background Stereoelectroencephalography (SEEG) allows the identification of deep-seated seizure foci and determination of the epileptogenic zone (EZ) in drug-resistant epilepsy (DRE) patients. We evaluated the accuracy and treatment-associated morbidity of frameless VarioGuide® (VG) neuronavigation-guided depth electrode (DE) implantations. Methods We retrospectively identified all consecutive adult DRE patients, who underwent VG-neuronavigation DE implantations, between March 2013 and April 2019. Clinical data were extracted from the electronic patient charts. An interdisciplinary team agreed upon all treatment decisions. We performed trajectory planning with iPlan® Cranial software and DE implantations with the VG system. Each electrode’s accuracy was assessed at the entry (EP), the centre (CP) and the target point (TP). We conducted correlation analyses to identify factors associated with accuracy. Results The study population comprised 17 patients (10 women) with a median age of 32.0 years (range 21.0–54.0). In total, 220 DEs (median length 49.3 mm, range 25.1–93.8) were implanted in 21 SEEG procedures (range 3–16 DEs/surgery). Adequate signals for postoperative SEEG were detected for all but one implanted DEs (99.5%); in 15/17 (88.2%) patients, the EZ was identified and 8/17 (47.1%) eventually underwent focus resection. The mean deviations were 3.2 ± 2.4 mm for EP, 3.0 ± 2.2 mm for CP and 2.7 ± 2.0 mm for TP. One patient suffered from postoperative SEEG-associated morbidity (i.e. conservatively treated delayed bacterial meningitis). No mortality or new neurological deficits were recorded. Conclusions The accuracy of VG-SEEG proved sufficient to identify EZ in DRE patients and associated with a good risk-profile. It is a viable and safe alternative to frame-based or robotic systems. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-021-04755-w.
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Affiliation(s)
- Barbara Ladisich
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, A-5020, Salzburg, Austria
| | - Lukas Machegger
- University Institute of Neuroradiology, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, 5020, Salzburg, Austria
| | - Alexander Romagna
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, A-5020, Salzburg, Austria
- Department of Neurosurgery, München Klinik Bogenhausen, Englschalkingerstr. 77, 81925, Munich, Germany
| | - Herbert Krainz
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, A-5020, Salzburg, Austria
| | - Jürgen Steinbacher
- University Institute of Neuroradiology, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, 5020, Salzburg, Austria
| | - Markus Leitinger
- Department of Neurology, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, 5020, Salzburg, Austria
| | - Gudrun Kalss
- Department of Neurology, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, 5020, Salzburg, Austria
| | - Niklas Thon
- Department of Neurosurgery, University Hospital Munich, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Eugen Trinka
- Department of Neurology, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, 5020, Salzburg, Austria
| | - Peter A Winkler
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, A-5020, Salzburg, Austria
| | - Christoph Schwartz
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, A-5020, Salzburg, Austria.
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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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De Barros A, Zaldivar-Jolissaint JF, Hoffmann D, Job-Chapron AS, Minotti L, Kahane P, De Schlichting E, Chabardès S. Indications, Techniques, and Outcomes of Robot-Assisted Insular Stereo-Electro-Encephalography: A Review. Front Neurol 2020; 11:1033. [PMID: 33041978 PMCID: PMC7527495 DOI: 10.3389/fneur.2020.01033] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/07/2020] [Indexed: 01/04/2023] Open
Abstract
Stereo-electro-encephalography (SEEG) is an invasive, surgical, and electrophysiological method for three-dimensional registration and mapping of seizure activity in drug-resistant epilepsy. It allows the accurate analysis of spatio-temporal seizure activity by multiple intraparenchymal depth electrodes. The technique requires rigorous non-invasive pre-SEEG evaluation (clinical, video-EEG, and neuroimaging investigations) in order to plan the insertion of the SEEG electrodes with minimal risk and maximal recording accuracy. The resulting recordings are used to precisely define the surgical limits of resection of the epileptogenic zone in relation to adjacent eloquent structures. Since the initial description of the technique by Talairach and Bancaud in the 1950's, several techniques of electrode insertion have been used with accuracy and relatively few complications. In the last decade, robot-assisted surgery has emerged as a safe, accurate, and time-saving electrode insertion technique due to its unparalleled potential for orthogonal and oblique insertion trajectories, guided by rigorous computer-assisted planning. SEEG exploration of the insular cortex remains difficult due to its anatomical location, hidden by the temporal and frontoparietal opercula. Furthermore, the close vicinity of Sylvian vessels makes surgical electrode insertion challenging. Some epilepsy surgery teams remain cautious about insular exploration due to the potential of neurovascular injury. However, several authors have published encouraging results regarding the technique's accuracy and safety in both children and adults. We will review the indications, techniques, and outcomes of insular SEEG exploration with emphasis on robot-assisted implantation.
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Affiliation(s)
- Amaury De Barros
- Department of Neurosurgery, Toulouse University Hospital, Toulouse, France
| | | | - Dominique Hoffmann
- CHU Grenoble Alpes, Clinical University of Neurosurgery, Grenoble, France
| | | | - Lorella Minotti
- CHU Grenoble Alpes, Clinical University of Neurology, Grenoble, France
| | - Philippe Kahane
- CHU Grenoble Alpes, Clinical University of Neurology, Grenoble, France
| | | | - Stephan Chabardès
- CHU Grenoble Alpes, Clinical University of Neurosurgery, Grenoble, France
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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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Spyrantis A, Cattani A, Woebbecke T, Konczalla J, Strzelczyk A, Rosenow F, Wagner M, Seifert V, Kudernatsch M, Freiman TM. Electrode placement accuracy in robot-assisted epilepsy surgery: A comparison of different referencing techniques including frame-based CT versus facial laser scan based on CT or MRI. Epilepsy Behav 2019; 91:38-47. [PMID: 30497893 DOI: 10.1016/j.yebeh.2018.11.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 10/16/2018] [Accepted: 11/01/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Precise robotic or stereotactic implantation of stereoelectroencephalography (sEEG) electrodes relies on the exact referencing of the planning images in order to match the patient's anatomy to the stereotactic device or robot. We compared the accuracy of sEEG electrode implantation with stereotactic frame versus laser scanning of the face based on computed tomography (CT) or magnetic resonance imaging (MRI) datasets for referencing. METHODS The accuracy was determined by calculating the Euclidian distance between the planned trajectory and the postoperative position of the sEEG electrode, defining the entry point error (EPE) and the target point error (TPE). The sEEG electrodes (n = 171) were implanted with the robotic surgery assistant (ROSA) in 19 patients. Preoperative trajectory planning was performed on three-dimensional (3D) MRI datasets. Referencing was accomplished either by performing (A) 1.25-mm slice CT with the patient's head fixed in a Leksell stereotactic frame (CT-frame, n = 49), fused with a 3D-T1-weighted, contrast enhanced- and T2-weighted 1.5 Tesla (T) MRI; (B) 1.25 mm CT (CT-laser, n = 60), fused with 3D-3.0-T MRI; (C) 3.0-T MRI T1-based laser scan (3.0-T MRI-laser, n = 56) or (D) in one single patient, because of a pacemaker, 3D-1.5-T MRI T1-based laser scan (1.5-T MRI-laser, n = 6). RESULTS In (A) CT-frame referencing, the mean EPE amounted to 0.86 mm and the mean TPE amounted to 2.28 mm (n = 49). In (B) CT-laser referencing, the EPE amounted to 1.85 mm and the TPE to 2.41 mm (n = 60). In (C) 3.0-T MRI-laser referencing, the mean EPE amounted to 3.02 mm and the mean TPE to 3.51 mm (n = 56). In (D) 1.5-T MRI, surprisingly the mean EPE amounted only to 0.97 mm and the TPE to 1.71 mm (n = 6). In 3 cases using CT-laser and 1 case using 3.0 T MRI-laser for referencing, small asymptomatic intracerebral hemorrhages were detected. No further complications were observed. CONCLUSION Robot-guided sEEG electrode implantation using CT-frame referencing and CT-laser-based referencing is most accurate and can serve for high precision placement of electrodes. In contrast, 3.0-T MRI-laser-based referencing is less accurate, but saves radiation. Most trajectories can be reached if alternative routes over less vascularized brain areas are used. This article is part of the Special Issue "Individualized Epilepsy Management: Medicines, Surgery and Beyond".
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Affiliation(s)
- Andrea Spyrantis
- Department of Neurosurgery, University Hospital Frankfurt - Goethe-University, Frankfurt am Main, Germany.
| | - Adriano Cattani
- Department of Neurosurgery, University Hospital Frankfurt - Goethe-University, Frankfurt am Main, Germany
| | - Tirza Woebbecke
- Department of Neurosurgery, University Hospital Frankfurt - Goethe-University, Frankfurt am Main, Germany
| | - Jürgen Konczalla
- Department of Neurosurgery, University Hospital Frankfurt - Goethe-University, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, University Hospital Frankfurt - Goethe-University, Frankfurt am Main, Germany; LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, University Hospital Frankfurt - Goethe-University, Frankfurt am Main, Germany; LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University, Frankfurt am Main, Germany
| | - Marlies Wagner
- Department of Neuroradiology, University Hospital Frankfurt - Goethe-University, Frankfurt am Main, Germany; LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, University Hospital Frankfurt - Goethe-University, Frankfurt am Main, Germany
| | | | - Thomas M Freiman
- Department of Neurosurgery, University Hospital Frankfurt - Goethe-University, Frankfurt am Main, Germany; LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University, Frankfurt am Main, Germany
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15
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Ding H, Zhou J, Guan Y, Zhai F, Wang M, Wang J, Luang G. Bipolar electro-coagulation with cortextomy in the treatment of insular and insulo-opercular epilepsy explored by stereoelectro-encephalography. Epilepsy Res 2018; 145:18-26. [DOI: 10.1016/j.eplepsyres.2018.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 02/16/2018] [Accepted: 05/14/2018] [Indexed: 11/26/2022]
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18
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Laoprasert P, Ojemann JG, Handler MH. Insular epilepsy surgery. Epilepsia 2017; 58 Suppl 1:35-45. [PMID: 28386920 DOI: 10.1111/epi.13682] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2016] [Indexed: 11/29/2022]
Abstract
Since it was originally described nearly 70 years ago, insular epilepsy has been increasingly recognized and may explain failures after apparently well-planned operations. We review the history of awareness of the phenomenon, techniques for its assessment, and its surgical management. Insular epilepsy can mimic features of frontal, parietal, or temporal seizures. It should be considered when a combination of somatosensory, visceral, and motor symptoms is observed early in a seizure. Extraoperative intracranial recordings are required to accurately diagnose insular seizures. Stereo-electroencephalography (EEG) or craniotomy with implantation of surface and depth electrodes have been used successfully to identify insular onset of seizures. Surgical resection of an insular focus may be performed with good success and acceptable risk.
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Affiliation(s)
- Pramote Laoprasert
- Division of Neurology, Department of Pediatrics, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Jeffrey G Ojemann
- Department of Neurosurgery, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Michael H Handler
- Department of Neurosurgery, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado, U.S.A
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Abstract
Stereoelectroencephalography (SEEG) is a method for invasive study of patients with refractory epilepsy. Localization of the epileptogenic zone in SEEG relied on the hypothesis of anatomo-electro-clinical analysis limited by X-ray, analog electroencephalography (EEG), and seizure semiology in the 1950s. Modern neuroimaging studies and digital video-EEG have developed the hypothesis aiming at more precise localization of the epileptic network. Certain clinical scenarios favor SEEG over subdural EEG (SDEEG). SEEG can cover extensive areas of bilateral hemispheres with highly accurate sampling from sulcal areas and deep brain structures. A hybrid technique of SEEG and subdural strip electrode placement has been reported to overcome the SEEG limitations of poor functional mapping. Technological advances including acquisition of three-dimensional angiography and magnetic resonance image (MRI) in frameless conditions, advanced multimodal planning, and robot-assisted implantation have contributed to the accuracy and safety of electrode implantation in a simplified fashion. A recent meta-analysis of the safety of SEEG concluded the low value of the pooled prevalence for all complications. The complications of SEEG were significantly less than those of SDEEG. The removal of electrodes for SEEG was much simpler than for SDEEG and allowed sufficient time for data analysis, discussion, and consensus for both patients and physicians before the proceeding treatment. Furthermore, SEEG is applicable as a therapeutic alternative for deep-seated lesions, e.g., nodular heterotopia, in nonoperative epilepsies using SEEG-guided radiofrequency thermocoagulation. We review the SEEG method with technological advances for planning and implantation of electrodes. We highlight the indication and efficacy, advantages and disadvantages of SEEG compared with SDEEG.
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Affiliation(s)
- Koji Iida
- Department of Neurosurgery, Hiroshima University Hospital.,Epilepsy Center, Hiroshima University Hospital
| | - Hiroshi Otsubo
- Neurophysiology Laboratory, Division of Neurology, The Hospital for Sick Children
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20
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Alomar S, Mullin JP, Smithason S, Gonzalez-Martinez J. Indications, technique, and safety profile of insular stereoelectroencephalography electrode implantation in medically intractable epilepsy. J Neurosurg 2017. [PMID: 28621621 DOI: 10.3171/2017.1.jns161070] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Insular epilepsy is relatively rare; however, exploring the insular cortex when preoperative workup raises the suspicion of insular epilepsy is of paramount importance for accurate localization of the epileptogenic zone and achievement of seizure freedom. The authors review their clinical experience with stereoelectroencephalography (SEEG) electrode implantation in patients with medically intractable epilepsy and suspected insular involvement. METHODS A total of 198 consecutive cases in which patients underwent SEEG implantation with a total of 1556 electrodes between June 2009 and April 2013 were reviewed. The authors identified patients with suspected insular involvement based on seizure semiology, scalp EEG data, and preoperative imaging (MRI, PET, and SPECT or magnetoencephalography [MEG]). Patients with at least 1 insular electrode based on the postoperative 3D reconstruction of CT fused with the preoperative MRI were included. RESULTS One hundred thirty-five patients with suspected insular epilepsy underwent insular implantation of a total of 303 electrodes (1-6 insular electrodes per patient) with a total of 562 contacts. Two hundred sixty-eight electrodes (88.5%) were implanted orthogonally through the frontoparietal or temporal operculum (420 contacts). Thirty-five electrodes (11.5%) were implanted by means of an oblique trajectory either through a frontal or a parietal entry point (142 contacts). Nineteen patients (14.07%) had insular electrodes placed bilaterally. Twenty-three patients (17.04% of the insular implantation group and 11.6% of the whole SEEG cohort) were confirmed by SEEG to have ictal onset zones in the insula. None of the patients experienced any intracerebral hemorrhage related to the insular electrodes. After insular resection, 5 patients (33.3%) had Engel Class I outcomes, 6 patients (40%) had Engel Class II, 3 patients (20%) had Engel Class III, and 1 patient (6.66%) had Engel Class IV. CONCLUSIONS Insula exploration with stereotactically placed depth electrodes is a safe technique. Orthogonal electrodes are implanted when the hypothesis suggests opercular involvement; however, oblique electrodes allow a higher insular sampling rate.
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Affiliation(s)
- Soha Alomar
- 1Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio; and.,2King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Jeffrey P Mullin
- 1Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio; and
| | - Saksith Smithason
- 1Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio; and
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Salado AL, Koessler L, De Mijolla G, Schmitt E, Vignal JP, Civit T, Tyvaert L, Jonas J, Maillard LG, Colnat-Coulbois S. sEEG is a Safe Procedure for a Comprehensive Anatomic Exploration of the Insula: A Retrospective Study of 108 Procedures Representing 254 Transopercular Insular Electrodes. Oper Neurosurg (Hagerstown) 2017; 14:1-8. [DOI: 10.1093/ons/opx106] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 04/03/2017] [Indexed: 12/18/2022] Open
Abstract
Abstract
BACKGROUND
The exploration of the insula in pre-surgical evaluation of epilepsy is considered to be associated with a high vascular risk resulting in an incomplete exploration of the insular cortex.
OBJECTIVE
To report a retrospective observational study of insular exploration using stereoelectroencephalography (sEEG) with transopercular and parasagittal oblique intracerebral electrodes from January 2008 to January 2016. The first purpose of this study was to evaluate the surgical risks of insular cortex sEEG exploration. The second purpose was to define the ability of placing intracerebral contacts in the whole insular cortex.
METHODS
Ninety-nine patients underwent 108 magnetic resonance imaging (MRI)-guided stereotactic implantations of intracerebral electrodes in the context of preoperative assessment of drug-resistant epilepsy, including at least 1 electrode placed in the insular cortex. On postoperative computed tomography images co-registered with MRI, followed by MRI segmentation and application of a transformation matrix, intracerebral contact coordinates of the insular electrodes’ contacts were anatomically localized in the Talairach space. Finally, dispersion and clustering analysis was performed.
RESULTS
There was no morbidity, in particular hemorrhagic complications, or mortality related to insular electrodes. Statistical comparison of intracerebral contact positions demonstrated that whole insula exploration is possible on the left and right sides. In addition, the clustering analysis showed the homogeneous distribution of the electrodes within the insular cortex.
CONCLUSION
In the presurgical evaluation of drug-resistant epilepsy, the insular cortex can be explored safely and comprehensively using transopercular sEEG electrodes. Parasagittal oblique trajectories may also be associated to achieve an optimal exploration.
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Affiliation(s)
- Anne Laure Salado
- Neurosurgery Department, University Hospital of Liège, Liège, Belgium
| | - Laurent Koessler
- CNRS CRAN UMR 7039, Vandœuvre-lès-Nancy, France
- Université de Lorraine, CRAN, UMR 7039, Vandœuvre-lès-Nancy, France
- Neurosurgery Department, University Hospital of Nancy, Nancy, France
| | | | | | - Jean-Pierre Vignal
- CNRS CRAN UMR 7039, Vandœuvre-lès-Nancy, France
- Université de Lorraine, CRAN, UMR 7039, Vandœuvre-lès-Nancy, France
- Neurosurgery Department, University Hospital of Nancy, Nancy, France
| | - Thierry Civit
- Neurosurgery Department, University Hospital of Nancy, Nancy, France
- Neurosurgery Department, University Hospital of Nancy, Nancy, France
| | - Louise Tyvaert
- CNRS CRAN UMR 7039, Vandœuvre-lès-Nancy, France
- Université de Lorraine, CRAN, UMR 7039, Vandœuvre-lès-Nancy, France
- Neurosurgery Department, University Hospital of Nancy, Nancy, France
| | - Jacques Jonas
- CNRS CRAN UMR 7039, Vandœuvre-lès-Nancy, France
- Université de Lorraine, CRAN, UMR 7039, Vandœuvre-lès-Nancy, France
- Neurosurgery Department, University Hospital of Nancy, Nancy, France
| | - Louis Georges Maillard
- CNRS CRAN UMR 7039, Vandœuvre-lès-Nancy, France
- Université de Lorraine, CRAN, UMR 7039, Vandœuvre-lès-Nancy, France
- Neurosurgery Department, University Hospital of Nancy, Nancy, France
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Cardinale F, Casaceli G, Raneri F, Miller J, Lo Russo G. Implantation of Stereoelectroencephalography Electrodes. J Clin Neurophysiol 2016; 33:490-502. [DOI: 10.1097/wnp.0000000000000249] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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23
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Weil AG, Fallah A, Lewis EC, Bhatia S. Medically resistant pediatric insular-opercular/perisylvian epilepsy. Part 1: invasive monitoring using the parasagittal transinsular apex depth electrode. J Neurosurg Pediatr 2016; 18:511-522. [PMID: 27472667 DOI: 10.3171/2016.4.peds15636] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Insular lobe epilepsy (ILE) is an under-recognized cause of extratemporal epilepsy and explains some epilepsy surgery failures in children with drug-resistant epilepsy. The diagnosis of ILE usually requires invasive investigation with insular sampling; however, the location of the insula below the opercula and the dense middle cerebral artery vasculature renders its sampling challenging. Several techniques have been described, ranging from open direct placement of orthogonal subpial depth and strip electrodes through a craniotomy to frame-based stereotactic placement of orthogonal or oblique electrodes using stereo-electroencephalography principles. The authors describe an alternative method for sampling the insula, which involves placing insular depth electrodes along the long axis of the insula through the insular apex following dissection of the sylvian fissure in conjunction with subdural electrodes over the lateral hemispheric/opercular region. The authors report the feasibility, advantages, disadvantages, and role of this approach in investigating pediatric insular-opercular refractory epilepsy. METHODS The authors performed a retrospective analysis of all children (< 18 years old) who underwent invasive intracranial studies involving the insula between 2002 and 2015. RESULTS Eleven patients were included in the study (5 boys). The mean age at surgery was 7.6 years (range 0.5-16 years). All patients had drug-resistant epilepsy as defined by the International League Against Epilepsy and underwent comprehensive noninvasive epilepsy surgery workup. Intracranial monitoring was performed in all patients using 1 parasagittal insular electrode (1 patient had 2 electrodes) in addition to subdural grids and strips tailored to the suspected epileptogenic zone. In 10 patients, extraoperative monitoring was used; in 1 patient, intraoperative electrocorticography was used alone without extraoperative monitoring. The mean number of insular contacts was 6.8 (range 4-8), and the mean number of fronto-parieto-temporal hemispheric contacts was 61.7 (range 40-92). There were no complications related to placement of these depth electrodes. All 11 patients underwent subsequent resective surgery involving the insula. CONCLUSIONS Parasagittal transinsular apex depth electrode placement is a feasible alternative to orthogonally placed open or oblique-placed stereotactic methodologies. This method is safe and best suited for suspected unilateral cases with a possible extensive insular-opercular epileptogenic zone.
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Affiliation(s)
| | | | - Evan C Lewis
- Pediatric Neurology, Miami (Nicklaus) Children's Hospital, Miami, Florida
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Gras-Combe G, Minotti L, Hoffmann D, Krainik A, Kahane P, Chabardes S. Surgery for Nontumoral Insular Epilepsy Explored by Stereoelectroencephalography. Neurosurgery 2016; 79:578-88. [DOI: 10.1227/neu.0000000000001257] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
Hidden by the perisylvian operculi, insular cortex has long been underexplored in the context of epilepsy surgery. Recent studies advocated stereoelectroencephalography (SEEG) as a reliable tool to explore insular cortex and its involvement in intractable epilepsy and suggested that insular seizures could be an underestimated entity. However, the results of insular resection to treat pharmacoresistant epilepsy are rarely reported.
OBJECTIVE
We report 6 consecutive cases of right insular resection performed based on anatomoelectroclinical correlations provided by SEEG.
METHODS
Six right-handed patients (3 male, 3 female) with drug-resistant epilepsy underwent comprehensive presurgical evaluation. Based on video electroencephalographic recordings, they all underwent SEEG evaluation with bilateral (n = 4) or unilateral right (n = 2) insular depth electrode placement. All patients had both orthogonal and oblique (1 anterior, 1 posterior) insular electrodes (n = 4-6 electrodes). Preoperative magnetic resonance imaging findings were normal in 4 patients, 1 patient had right insular focal cortical dysplasia, and 1 patient had a right opercular postoperative scar (cavernous angioma). All patients underwent right partial insular corticectomy via the subpial transopercular approach.
RESULTS
Intracerebral recordings demonstrated an epileptogenic zone confined to the right insula in all patients. After selective insular resection, 5 of 6 patients were seizure free (Engel class I) with a mean follow-up of 36.2 months (range, 18-68 months). Histological findings revealed focal cortical dysplasia in 5 patients and a gliosis scar in 1 patient. All patients had minor transient neurological deficit (eg, facial paresis, dysarthria).
CONCLUSION
Insular resection based on SEEG findings can be performed safely with a significant chance of seizure freedom.
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Affiliation(s)
- Guillaume Gras-Combe
- INSERM U1216, Grenoble Institut des Neurosciences, Grenoble, France
- Département de Neurochirurgie, Hôpital Gui de Chauliac, Centre Hospitalier Universitaire, Montpellier, France
| | - Lorella Minotti
- Clinique de Neurologie, Centre Hospitalier Universitaire, Grenoble, France
| | - Dominique Hoffmann
- Clinique de Neurochirurgie, Centre Hospitalier Universitaire, Grenoble, France
| | - Alexandre Krainik
- Clinique de Neurochirurgie, Centre Hospitalier Universitaire, Grenoble, France
- Clinique de Neuroradiologie, Centre Hospitalier Universitaire, Grenoble, France
- University Grenoble Alpes, Grenoble, France
| | - Philippe Kahane
- INSERM U1216, Grenoble Institut des Neurosciences, Grenoble, France
- Clinique de Neurochirurgie, Centre Hospitalier Universitaire, Grenoble, France
- University Grenoble Alpes, Grenoble, France
| | - Stephan Chabardes
- INSERM U1216, Grenoble Institut des Neurosciences, Grenoble, France
- Clinique de Neuroradiologie, Centre Hospitalier Universitaire, Grenoble, France
- University Grenoble Alpes, Grenoble, France
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Lacuey N, Zonjy B, Kahriman ES, Marashly A, Miller J, Lhatoo SD, Lüders HO. Homotopic reciprocal functional connectivity between anterior human insulae. Brain Struct Funct 2015; 221:2695-701. [PMID: 25993901 DOI: 10.1007/s00429-015-1065-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 05/12/2015] [Indexed: 11/30/2022]
Abstract
The aim of this study was to investigate functional connectivity between right and left insulae in the human brain. We studied a patient with implanted depth electrodes for epilepsy surgery evaluation with stereotactically placed symmetric depth electrodes in both insulae. Bipolar 1 Hz electrical stimulation of the right and left posterior short gyri in the anterior insula evoked responses in the contralateral insular structures. These responses showed a latency of 8-24 ms. This report demonstrates for the first time bi-directional homotopic and heterotopic functional connectivity between right and left anterior insulae. The short latency of the evoked responses suggests mono- or oligo-synaptic connections, most likely via the corpus callosum.
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Affiliation(s)
- Nuria Lacuey
- Epilepsy Center, UH Case Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
| | - Bilal Zonjy
- Epilepsy Center, UH Case Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Emine S Kahriman
- Epilepsy Center, UH Case Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Ahmad Marashly
- Epilepsy Center, UH Case Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Jonathan Miller
- Epilepsy Center, UH Case Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Samden D Lhatoo
- Epilepsy Center, UH Case Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Hans O Lüders
- Epilepsy Center, UH Case Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
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Somatosensory and pharyngolaryngeal auras in temporal lobe epilepsy surgeries. ISRN NEUROLOGY 2013; 2013:148519. [PMID: 23862072 PMCID: PMC3686131 DOI: 10.1155/2013/148519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 05/08/2013] [Indexed: 12/04/2022]
Abstract
Purpose. Somatosensory (SSA) and pharyngolaryngeal auras (PLA) may suggest an extratemporal onset (e.g., insula, second somatosensory area). We sought to determine the prognostic significance of SSA and PLA in temporal lobe epilepsy (TLE) patients undergoing epilepsy surgery. Methods. Retrospective review of all patients operated for refractory TLE at our institution between January 1980 and July 2007 comparing outcome between patients with SSA/PLA to those without. Results. 158 patients underwent surgery for pharmacoresistant TLE in our institution. Eleven (7%) experienced SSA/PLA as part of their seizures. All but one had lesional (including hippocampal atrophy/sclerosis) TLE. Compared to patients without SSA or PLA, these patients were older (P = 0.049), had a higher prevalence of early ictal motor symptoms (P = 0.022) and prior CNS infection (P = 0.022), and were less likely to have a localizing SPECT study (P = 0.025). A favorable outcome was achieved in 81.8% of patients with SSA and/or PLA and 90.4% of those without SSA or PLA (P > 0.05). Conclusion. Most patients with pharmacoresistant lesional TLE appear to have a favorable outcome following temporal lobectomy, even in the presence of SSA and PLA.
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Contralateral insular involvement producing false lateralizing signs in bitemporal epilepsy: A stereo-encephalography case report. Seizure 2012; 21:816-9. [DOI: 10.1016/j.seizure.2012.08.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 08/30/2012] [Accepted: 08/31/2012] [Indexed: 11/23/2022] Open
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Intracranial electrodes in the presurgical evaluation of epilepsy. Neurol Sci 2012; 33:723-9. [PMID: 22460695 DOI: 10.1007/s10072-012-1020-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Accepted: 03/13/2012] [Indexed: 10/28/2022]
Abstract
The resection of the epileptogenic area of brain is very important and useful for the treatment of uncontrolled epilepsy, especially for the patients with stereotyped partial seizures. The critical point for successful epilepsy surgery is the precise identification of epileptogenic zone. Actually, we cannot precisely localize the epileptogenic zone in about 25 % of patient with refractory seizures based on the noninvasive examination; thus for these patients, we mainly use the intracranial EEG to localize the epileptogenic zone which could be useful in 10-15 % of surgical candidates. The intracranial electrodes which are most used currently are depth electrodes, subdural strip electrodes, and subdural grid electrodes. The subject of this paper is to discuss and compare the indications, construction, insertion, interpretation, limitations, risks and accuracy of each of these methods.
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Desai A, Bekelis K, Darcey TM, Roberts DW. Surgical techniques for investigating the role of the insula in epilepsy: a review. Neurosurg Focus 2012; 32:E6. [DOI: 10.3171/2012.1.focus11325] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intracranial electroencephalography monitoring of the insula is an important tool in the investigation of the insula in medically intractable epilepsy and has been shown to be safe and reliable. Several methods of placing electrodes for insular coverage have been reported and include open craniotomy as well as stereotactic orthogonal and stereotactic anterior and posterior oblique trajectories. The authors review each of these techniques with respect to current concepts in insular epilepsy.
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Proserpio P, Cossu M, Francione S, Tassi L, Mai R, Didato G, Castana L, Cardinale F, Sartori I, Gozzo F, Citterio A, Schiariti M, Russo GL, Nobili L. Insular-opercular seizures manifesting with sleep-related paroxysmal motor behaviors: A stereo-EEG study. Epilepsia 2011; 52:1781-91. [DOI: 10.1111/j.1528-1167.2011.03254.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Surbeck W, Bouthillier A, Weil AG, Crevier L, Carmant L, Lortie A, Major P, Nguyen DK. The combination of subdural and depth electrodes for intracranial EEG investigation of suspected insular (perisylvian) epilepsy. Epilepsia 2011; 52:458-66. [DOI: 10.1111/j.1528-1167.2010.02910.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Mavridis I, Boviatsis E, Anagnostopoulou S. Exploring the neurosurgical anatomy of the human insula: a combined and comparative anatomic-radiologic study. Surg Radiol Anat 2010; 33:319-28. [PMID: 20623284 DOI: 10.1007/s00276-010-0699-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2010] [Accepted: 06/29/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE The human insula constitutes the invaginated portion of the cerebral cortex and is less well understood than other cortical areas because of its hidden location. Our purpose was to study the neurosurgical anatomy of the human insula via a combined and comparative study of its gross and imaging anatomy. METHODS We totally studied the anatomy of 148 normal insulae in anatomic specimens and radiologic images. We evaluated the number of all insular gyri (short and long), we statistically analyzed our results, and we made comparisons among hemispheres and gender. We also compared the two studies. Finally, we searched in the literature to make comparisons with other authors and to add our experience to the today existing knowledge of the insular anatomy. RESULTS We found a significantly greater value of the insular gyri number for males, potential underestimation of the real insular gyri number by MRI and that the classic insular gyri pattern can rarely be absent. The middle short insular gyrus can be indistinguishable more likely on MRIs than during surgery, the long insular gyri are less curved than the short gyri, and finally, the insular perforating vessels usually originate at the inferior insular part. CONCLUSIONS Deep knowledge of the gross, imaging, and surgical anatomy of the insula is of paramount importance for neurosurgeons dealing with disorders in this area. The male insula is larger (increased gyri pattern) than the female. Moreover, the classic insular gyri pattern can rarely be absent, probably as a normal anatomic variation.
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Affiliation(s)
- Ioannis Mavridis
- Department of Anatomy, University of Athens School of Medicine, Mikras Assias str. 75, Goudi, 11527 Athens, Greece.
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