The American Approach to Depth Electrode Insertion December 4, 2012
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1 The American Approach to Depth Electrode Insertion December 4, 2012 Jonathan Miller, MD Director, Epilepsy Surgery University Hospitals Case Medical Center/Case Western Reserve University Cleveland, Ohio American Epilepsy Society Annual Meeting
2 Disclosure None American Epilepsy Society Annual Meeting 2012
3 Learning Objectives After this session, participants will gain an understanding of SEEG technique and indications American Epilepsy Society Annual Meeting 2012
4 The Goal of SEEG Localization of the Epileptogenic Zone
5 The Goal of SEEG Localization Symptomatogenic Zone of the Irritative Zone Lesion Epileptogenic Zone Seizure Onset Zone Eloquent Tissue
6 The Goal of SEEG Semiology Symptomatogenic Zone MRI PET Lesion Localization of the Epileptogenic Zone Irritative Zone Seizure Onset Zone Eloquent Tissue Interictal EEG Ictal EEG Ictal SPECT fmri WADA Neuropsych.
7 The Goal of SEEG Localization Symptomatogenic Zone of the Irritative Zone Epileptogenic Zone Seizure Onset Zone SEEG Lesion Eloquent Tissue
8 EEG vs. SEEG EZ
9 EEG vs. SEEG EEG EZ
10 EEG vs. SEEG EEG Subdural Grids EZ
11 EEG vs. SEEG EEG Subdural Grids EZ Depth Electrodes
12 EEG vs. SEEG No activity Ictal/interictal activity Eloquent cortex EZ
13 History of SEEG
14 History of SEEG
15 History of SEEG
16 History of SEEG
17 Modern Era: MRI Targetting
18 SEEG Strategies 1. Multi-target SEEG Identify epileptic structures 2. 3D-SEEG Delineate epileptogenic & eloquent zones
19 SEEG Strategies 1. Multi-target SEEG Identify epileptic structures Non-lesional Temporal Lobe Epilepsy: - Hippocampus - Amygdala - Temporal neocortex - Temporal pole - Mesial frontal lobe - Insula - Posterior cingulate gyrus - Posterior temporal lobe 2. 3D-SEEG Delineate epileptogenic & eloquent zones
20 SEEG Strategies 1. Multi-target SEEG Identify epileptic structures 2. 3D-SEEG Delineate epileptogenic & eloquent zones
21 Choose entry point to cover area of interest Can enter from any direction to sample tissue of interest Additional depth electrodes may be added in second stage Multi-Target SEEG
22 SEEG Strategies 1. Multi-target SEEG Identify epileptic structures 2. 3D-SEEG Delineate epileptogenic & eloquent zones
23 3D-SEEG Surround area of interest using threedimensional grid Can enter from any direction; parallel electrodes may be easier to interpret
24 Framed Stereotaxy
25 Framed Stereotaxy arc ring y z x
26 Framed Stereotaxy Ring less limited than arc (-30º to 210º) (30º to 150º) arc ring y z x
27 Positioning Supine (Prone) = from front (back) Lateral = from side
28 Positioning Supine (Prone) = from front (back) Lateral = from side
29 Positioning Ring perpendicular to electrode path Supine (Prone) = from front (back) Lateral = from side
30 Frame Placement Placed low to maximize trajectory options
31 Frame Placement Simultaneous bilateral placement: tilt frame toward dependent side
32 Frame Placement Simultaneous bilateral placement: tilt frame toward dependent side
33 Fluoroscopy Verify correct placement Determine depth of placement
34 Implantation 3 mm stab incision, 2.7 mm drill
35 Implantation 3 mm stab incision, 2.7 mm drill Open dura with monopolar cautery
36 Implantation 3 mm stab incision, 2.7 mm drill Open dura with monopolar cautery Advance stylet to target under x-ray
37 Implantation 3 mm stab incision, 2.7 mm drill Open dura with monopolar cautery Advance stylet to target under x-ray Place anchor bolt Place electrode
38
39 Postoperative Processing Postoperative volumetric CT (1 mm) Fused with preoperative MRI Contour electrodes Anatomic definition of EZ Can import into frameless stereotaxy for resection
40
41 Case Example 32 year old RH man Seizures: déjà vu aura, dialeptic, automotor Etiology: unknown (imaging normal) Location: left temporal (Sp1>P7) Related medical conditions: bipolar disorder
42 Case Example 32 year old RH man Seizures: déjà vu aura, dialeptic, automotor Etiology: unknown (imaging normal) Location: left temporal (Sp1>P7) Related medical conditions: bipolar disorder Posterior Cingulate Posterior Temporal Mesial Frontal Hippocampus Head Hippocampus Body Amygdala Temporal Tip
43 Case Example 32 year old RH man Seizures: déjà vu aura, dialeptic, automotor Etiology: unknown (imaging normal) Location: left temporal (Sp1>P7) Related medical conditions: bipolar disorder Seizure onset zone: Posterior Temporal No activity Interictal Ictal Eloquent
44 Case Example 32 year old RH man Seizures: déjà vu aura, dialeptic, automotor Etiology: unknown (imaging normal) Location: left temporal (Sp1>P7) Related medical conditions: bipolar disorder Additional electrodes placed around active contacts to delineate epileptogenic zone No activity Interictal Ictal Eloquent
45 Case Example 32 year old RH man Seizures: déjà vu aura, dialeptic, automotor Etiology: unknown (imaging normal) Location: left temporal (Sp1>P7) Related medical conditions: bipolar disorder No activity Interictal Ictal Eloquent
46 Case Example 32 year old RH man Seizures: déjà vu aura, dialeptic, automotor Etiology: unknown (imaging normal) Location: left temporal (Sp1>P7) Related medical conditions: bipolar disorder No activity Interictal Ictal Eloquent
47 Case Example 32 year old RH man Seizures: déjà vu aura, dialeptic, automotor Etiology: unknown (imaging normal) Location: left temporal (Sp1>P7) Related medical conditions: bipolar disorder Pathology: Cortical Dysplasia
48 Case Example 57 year old RH woman Seizures: visual aura, aphasia Etiology: cavernous angioma Location: left temporal (Sp1) Related medical conditions: migraine
49 Case Example 57 year old RH woman Seizures: visual aura, aphasia Etiology: cavernous angioma Location: left temporal (Sp1) Related medical conditions: migraine Cavernous angioma
50 Case Example 57 year old RH woman Seizures: visual aura, aphasia Etiology: cavernous angioma Location: left temporal (Sp1) Related medical conditions: migraine Mesial temporal structures Anterior, Posterior, Superior, Inferior, and Lateral to Cavernous Angioma
51 Case Example 57 year old RH woman Seizures: visual aura, aphasia Etiology: cavernous angioma Location: left temporal (Sp1) Related medical conditions: migraine Seizure onset zone only in hippocampus (not perilesional) No activity Interictal Ictal Eloquent Lesion
52 Case Example 57 year old RH woman Seizures: visual aura, aphasia Etiology: cavernous angioma Location: left temporal (Sp1) Related medical conditions: migraine Seizure onset zone only in hippocampus (not perilesional) No activity Interictal Ictal Eloquent Lesion
53 Conclusions Standard stereotactic techniques are used for implantation Goal is improved anatomic delineation of epileptogenic zone; hypothesis is important Provides anatomic information that can be helpful to guide surgical resection
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