J Korean Neurosurg Soc.  2024 Nov;67(6):661-674. 10.3340/jkns.2023.0246.

Clinical Applicability and Safety of Conventional Frame-Based Stereotactic Techniques for Stereoelectroencephalography

• Kim J
• Hong SH
• Kim HJ
• Yum MS
• Ko TS
• Koo YS
• Lee SA

• KMID: 2560408
• DOI: http://doi.org/10.3340/jkns.2023.0246

Abstract

Objective
: Stereoelectroencephalography (SEEG) is increasingly being recognized as an important invasive modality for presurgical evaluation of epilepsy. This study focuses on the clinical and technical considerations of SEEG investigations when using conventional frame-based stereotaxy, drawing on institutional experience and a comprehensive review of relevant literature.
Methods
: This retrospective observational study encompassed the surgical implantation of 201 SEEG electrodes in 16 epilepsy patients using a frame-based stereotactic instrument at a single tertiary-level center. We provide detailed descriptions of the operative procedures and technical nuances for bilateral and multiple SEEG insertions, along with several illustrative cases. Additionally, we present a literature review on the technical aspects of the SEEG procedure, discussing its clinical implications and potential risks.
Results
: Frame-based SEEG electrode placements were successfully performed through sagittal arc application, with the majority (81.2%) of cases being bilateral and involving up to 18 electrodes in a single operation. The median skin-to-skin operation time was 162 minutes (interquartile range [IQR], 145–200), with a median of 13 minutes (IQR, 12–15) per electrode placement for time efficiency. There were two occurrences (1.0%) of electrode misplacement and one instance (0.5%) of a postoperative complication, which manifested as a delayed intraparenchymal hemorrhage. Following SEEG investigation, 11 patients proceeded with surgical intervention, resulting in favorable seizure outcomes for nine (81.8%) and complete remission for eight cases (72.7%).
Conclusion
: Conventional frame-based stereotactic techniques remain a reliable and effective option for bilateral and multiple SEEG electrode placements. While SEEG is a suitable approach for selected patients who are strong candidates for epilepsy surgery, it is important to remain vigilant concerning the potential risks of electrode misplacement and hemorrhagic complications.

Keyword

Stereotactic techniques; Stereoelectroencephalography; Intracranial electroencephalography; Drug resistant epilepsy; Epilepsy surgery

Figure

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  Fig. 1. Sagittal application of the stereotactic arc and corresponding angle parameters in the Leksell stereotactic system. A : Lateral-right orientation of the stereotactic arc. B : Sagittal-posterior orientation of the stereotactic arc (for the target in the left hemisphere). For stereoelectroencephalography requiring multiple and bilateral electrode placements, anterior/posterior orientations of the stereotactic arc may be preferred to the common lateralleft orientation. In these configurations, the arc support is attached to the x-axis of the coordinate frame instead of the y-axis. Following the center-of-arc principle, the target coordinate remains unchanged, but the coordinate on the arc axis needs to be set to its appropriate index mark : lateral-left orientation and anterior orientation share the same index, while the index for posterior orientation is obtained by subtracting from 200 mm. For anterior/posterior orientations, the arc axis should be set as the y-axis, which entails an additional adjustment of 15 mm from the x-axis value used for lateral orientations. Additionally, the ‘arc’ and ‘ring’ angle parameters need to be exchanged to maintain the correct entry point, with posterior arch orientation being optimal for the left hemisphere and anterior orientation for the right hemisphere. To convert between anterior and posterior orientations, both the ‘arc’ and ‘ring’ angles are simply subtracted from 180°.

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  Fig. 2. Operative techniques for multiple SEEG electrode placement using frame-based stereotactic system. A : Patient positioning and application of the stereotactic arc (Leksell®; Elekta AB, Stockholm, Sweden). This orientation of the stereotactic arc allows bilateral access under a single surgical drape, though it is worth noting that the arc apparatus may obscure some areas in the occipital region. B : Drilling into the skull using a twist drill. Pre-measured skull depth at the entry point ensures procedure safety. C : Dural puncture with a monopolar cautery. This step proceeds in a blind manner, and practitioners should be vigilant to avoid violations to the brain parenchyma and superficial vessels. D : Fixation of the anchor bolt (Depthalon®; PMT Co., Chanhassen, MN, USA). The depth for electrode advancement is determined by subtracting the measured length between the arc and the fixed anchor point from the working length (typically 190 mm in the demonstrated system).

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  Fig. 3. Postoperative intracranial hemorrhage following SEEG. Pre- and postoperative MRIs and the SEEG planning are presented (case #16). A 49-year-old female with a history of encephalitis and status epilepticus was referred for surgical intervention due to drug-resistant focal epilepsy, despite being on five antiseizure medications. MRI scans revealed bilateral hippocampal sclerosis and sequalae of encephalitis (A). SEEG was conducted to explore both the bilateral mesial temporal and operculo-insular regions (B). Preoperative post-contrast MRIs showed that a trajectory for targeting the left hippocampus was designed to ensure safe entry into brain parenchyma without damaging adjacent vasculature (C, arrowheads). However, during the procedure the SEEG electrode deviated from the planned trajectory, likely due to brain shift, passing through the nearby sulci (D, arrowheads). Initially, the patient tolerated the procedure well and was sent to epilepsy monitoring unit for long-term SEEG monitoring. However, a week later, the patient developed global dysphasia, and a follow-up imaging scans revealed a delayed postoperative hemorrhage (E and F). SEEG : stereoelectroencephalography, MRI : magnetic resonance imaging.

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  Fig. 4. Successful seizure control following SEEG-guided resective surgery. The figure illustrates pre- and postoperative MRIs, SEEG planning, and intraoperative gross inspections from a representative case (case #13). A 15-year-old male with a history of hypoxic-ischemic encephalopathy had bilateral frontal atrophy with encephalomalacia (A, arrowheads). His seizures, characterized by hyperkinetic movements occurring several times a day, remained intractable despite the use of four antiseizure medications, causing significant distress to his caregiver. SEEG monitoring was performed to assess the feasibility of resective surgery (B). During SEEG, seizures were observed to initiate at the left orbitofrontal (C, arrow) and anterior cingulate regions, corresponding to the structural lesion observed in the MRI. The patient underwent a left frontal lobectomy (D and E) and subsequently achieved seizure remission while also reducing the number of medications (Engel Ia). LOF : left orbitofrontal gyrus, LSF : left superior frontal gyrus, LMF : left middle frontal gyrus, LIF : left inferior frontal gyrus, SEEG : stereoelectroencephalography, MRI : magnetic resonance imaging.

Reference

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