Scientific Symposium Stereotactic Electroencephalography (seeg) in the Pre-surgical Investigation of Refractory Focal Epilepsy

Transcription

1 Scientific Symposium Stereotactic Electroencephalography (seeg) in the Pre-surgical Investigation of Refractory Focal Epilepsy Symposium Co-Chairs: Hans O. Lüders, M.D., Ph.D. Epilepsy Center Case Medical Center University Hospitals Cleveland Cleveland, OH and Philippe Kahane, M.D., Ph.D. Neurology Department &INSERM U836 Grenoble University Hospital Grenoble,France Tuesday, December 4, 2012 Convention Center Ballroom 6C, Upper Level 8:30 am 10:00 am

2 OVERVIEW A significant proportion of patients with refractory focal epilepsy who are being evaluated for resective surgery require invasive evaluations with subdural or depth electrode studies in order to better delineate the most likely epileptogenic zone. In most parts of the world that have the expertise and infrastructure to carry out intracranial electrode studies, the preferred method is subdural grid insertion with or without limited, non-stereotactic depth electrodes. A handful of centers in Europe and North America employ the use of stereotactically implanted, multiple-depth electrodes (stereotactic electroencephalography or seeg), which have both advantages and potential limitations. Many centers have noted an increasing complexity of surgical cases presenting for presurgical evaluations, for example, patients who are MRI lesion negative, or who have dual or multiple epileptogenic pathologies. Such patients may be studied best using seeg. This symposium will address the rationale, technology, advantages, risks and outcomes of seeg usage in intractable focal epilepsy. LEARNER OUTCOMES Recognize the usefulness of seeg as an invasive evaluation technique for defining the epileptogenic zone in select patients who are candidates for epilepsy surgery and develop appropriate capacity to perform such studies Recognize the usefulness of seeg as an invasive evaluation technique for defining eloquent cortex in select patients who are candidates for epilepsy surgery and develop the capacity for such studies. TARGET AUDIENCE Advanced: Symposium will address highly technical or complex topics (e.g., neurophysiology, advanced imaging techniques, advanced treatment modalities, including surgery) AGENDA 8:30 8:35 am Introduction and Overview Hans O. Lüders, M.D., Ph.D. 8:35 8:50 am Stereo-EEG methodology: the European Approach Giorgio LoRusso, M.D. 8:50 9:05 am Stereo-EEG Methodology: the North American Approach Jonathan P. Miller, M.D. 9:05 9:20 am Depth Electrodes vs. Stereo-EEG vs. Subdural Electrodes: Relative Advantages and Disadvantages Jorge A. Gonzalez-Martinez, M.D. 9:20 9:35 am Mapping the Epileptogenic Zone with Stereo EEG Philippe Kahane, M.D., Ph.D. 9:35 9:50 am Mapping the Eloquent Cortex with Stereo EEG Samden Lhatoo, M.D. 9:50 10:00 am Round Table and Conclusions Hans Lüders, M.D., Ph.D.

3 ACCREDITATION The American Epilepsy Society is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. CREDIT DESIGNATION The American Epilepsy Society designates this educational activity for a maximum of 1.5 AMA PRA Category 1 Credits TM. Physicians should only claim credit commensurate with the extent of their participation in the activity. NURSING CREDIT EDUPRO Resources LLC is an approved provider of continuing nursing education by Pennsylvania State Nurses Association, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation, Provider number P208-8/ EDUPRO is also an approved provider by the California Board of Registered Nursing, Provider number CEP Disclaimer: Accreditation refers to educational content only and does not imply endorsement of products by PSNA, ANCC, CBRN, or EDUPRO Resources LLC. Nurses may claim up to 1.5 contact hours for this session. PHARMACY ACCREDITATION INFORMATION Projects In Knowledge is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This knowledge-based activity provides up to 1.5 contact hours. Following attendance, completion of the activity evaluation and verification of attendance, participants will be provided an electronic statement of credit. ACPE Universal Activity Number (UAN) is L04-P and provides 1.5 contact hours. International Credits: The American Medical Association has determined that non-u.s. licensed physicians who participate in this CME activity are eligible for AMA PRA Category 1 Credit TM. ABPN Core Competencies The American Board of Psychiatry and Neurology has reviewed the Annual Course and has approved this program as part of a comprehensive lifelong learning program, which is mandated by the ABMS as a necessary component of maintenance of certification. Core Competencies: Medical Knowledge FACULTY/PLANNER DISCLOSURES It is the policy of the AES to make disclosures of financial relationships of faculty, planners and staff involved in the development of educational content transparent to learners. All faculty participating in continuing medical education activities are expected to disclose to the program audience (1) any real or apparent conflict(s) of interest related to the content of their presentation and (2) discussions of unlabeled or unapproved uses of drugs or medical devices. AES carefully reviews reported conflicts of interest (COI) and resolves those conflicts by having an independent reviewer from the Council on Education validate the content of all presentations for fair balance, scientific objectivity, and the

4 absence of commercial bias. The American Epilepsy Society adheres to the ACCME s Essential Areas and Elements regarding industry support of continuing medical education; disclosure by faculty of commercial relationships, if any, and discussions of unlabeled or unapproved uses will be made. FACULTY / PLANNER BIO AND DISCLOSURES Hans Luders, M.D., Ph.D. (Co-Chair) Dr. Lüders is a neurologist with special training in clinical neurophysiology and epilepsy. His main research efforts are in semiology of seizures, classification of epiley, neurophysiology of epileptic seizures and surgical treatment of epilepsy. Throughout his career he has spent cosniderable time in training neurogists interested in clinical epilepsy and clinical neuropphysiology. Hans Luders, M.D., Ph.D. has nothing to disclose. Philippe Kahane, M.D., Ph.D. (Co-Chair) Philippe Kahane, MD, PhD, born in 1962, is a neurologist and neurophysiologist, Hospital Practitioner and University Professor. He is responsible for the clinical epileptology program and the presurgical assessment of epilepsy at the Neurology Department of the Grenoble University Hospital (France). His area of research covers various fields in epileptology and physiology in humans, including the characterization of cognitive and epileptogenic networks using SEEG recordings and stimulation. He has published more than 130 articles in international journals. Philippe Kahane, M.D., Ph.D. discloses receiving support as Consulting/Advisory Board Activity from GSK : consulting activity Actelion; as Honoraria from Commercial Sources from USB. Jorge Gonzalez-Martinez, M.D., Ph.D. Dr. Gonzalez-Martinez is a neurosurgeon specializing in Epilepsy Surgery. His main research efforts are related to surgical techniques in invasive monitoring (including subdural grids methodology and SEEG) and anatomical-electrophysiological connectivity in the epileptic brain. Currently, he is the director of the epilepsy surgery fellowship program at the Cleveland Clinic. Jorge Gonzalez-Martinez, M.D., Ph.D. has nothing to disclose. Samden Lhatoo, M.D. FRCP (Lon) Dr. Lhatoo is an epileptologist engaged in clinical practice and in clinical epilepsy research. HE is Director of the Epilepsy Center at University Hospitals Case Medical Center in Cleveland, Ohio which pioneers the use of stereotactic EEG in epilepsy surgery. He is Principal Investigator of the NINDS funded Prevention and Risk Identification of SUDEP Mortality (PRISM) Project (NINDS P20-NS ). Samden Lhatoo, M.D. FRCP (Lon) discloses receiving support as Speakers Bureau Member (supported by for-profit entities) from Lunbeck Pharmaceuticals. Giorgio Lo Russo, M.D. Director Epilepsy Surgery Centre C Munari (2003-present) Niguarda Hospital Milano Italy. Specialities: 1982 Neurosurgery, 1987 Neurology, Turin University. Trained in Paris (Neurosurgery, Hôpital S.te Anne, ; Pr Talairach, Pr Bancaud) and Grenoble (Neurosurgery, Grenoble University ; Pr Benabid) under the guide of his Mentor Pr Claudio Munari. He contributed to start the program of Epilepsy Surgery in Grenoble and to the founding of the Centre of Milano when Pr. Munari went back in Italy. Experience acquired in the field of epilepsy surgery and particularly in invasive recordings with Stereo-EEG (more than 200 procedures). Giorgio LoRusso, M.D. has nothing to disclose.

5 Jonathan Miller, M.D. Jonathan Miller, MD, is Director of Functional and Restorative Neurosurgery and Director of Epilepsy Surgery at University Hospitals Case Medical Center/Case Western Reserve University. He completed residency training at University Hospitals and fellowship training in functional and epilepsy surgery under Kim Burchiel at Oregon Health & Science University. He has published over 50 peer-reviewed papers and has received 15 national awards. His research interests include development of novel methods of identifying epileptogenic tissue and brain stimulation for epilepsy. Jonathan Miller, M.D. has nothing to disclose. Paul Levisohn (Medical Content Specialist) Dr. Levisohn is Associate Professor of Pediatrics and Neurology at the University of Colorado School of Medicine and Children s Hospital Colorado. He is former medical director of the Epilepsy Monitoring Unit at The Children's Hospital. He has served as chair of the AES Practice Committee, is co-chair of the advisory committee for the National Center for Project Access at the Epilepsy Foundation and is a member of the EF Professional Advisory Board. He currently serves as consultant to AES on medical content of AES continuing medical education activities. Paul Levisohn, M.D. has nothing to disclose. Siddharth Kapoor, MD (Liaison Reviewer) Siddharth Kapoor is an Asst. Professor of Neurology at the University of Kentucky College of Medicine. He completed his neurology residency at NYU, and epilepsy fellowship at University of Michigan. He serves as the Epileptologist for adult patients. He also directs the Headache program, including serving as the program director for an accredited fellowship. He is closely involved with resident education, serving on the RRC, involved with resident evaluation and progression through the various stages. His research interests include Post Ictal headache and the comorbidity of epilepsy and primary headaches. Siddharth Kapoor, M.D. has nothing to disclose. DISCLAIMER Opinions expressed with regard to unapproved uses of products are solely those of the faculty and are not endorsed by the American Epilepsy Society or any manufacturers of pharmaceuticals. MEDICAL EDUCATION EVALUATOR AND CERTIFICATES The Medical Education Evaluator is an online system allows any attendee to self-manage the process of completing course evaluations, tracking credits and printing out the appropriate certificate for either AMA PRA Category 1 Credits TM, CE or ACPE pharmacy statement of credits. Log on to the Evaluator via the AES website at Once you are on the Evaluator, you will be asked to enter your MyAES ID # and password. The certificate(s) are saved to your personal account page which is cumulative. You may print the certificate(s) in PDF format at any time. To help support this process, AES members who want CME will be asked to pay $35 before January 18 and $50 between January 19 and February 28. Non-AES attendees who want CME will be asked to pay $50 before January 18 and $75 between January 19 and February 28. The online Evaluator will be left open through February 28, You must complete the evaluations and credit tracking by that date.

6 By completing this information online, attendees greatly assist the Council on Education and Annual Meeting Committee with important needs assessment data whereby the AES can further plan and address educational gaps to meet the needs of our learners. A meeting attendance certificate will be available for international meeting attendees at the registration desk. SYLLABUS Syllabi for the educational symposia are available to print in the AES Virtual Tote Bag. Paper handouts will not be provided on site.

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10 12/11/12 "#$%$&A6&3>6*45/>&/%43,0* "#$%$&#46K6*F4Z>/4K&5B*T$45*M4.4>%46,B*45-*H* * 7/"$.8&9:&;#662B*F$2%&A2%/$%0*V81*8V8'*8X8B*;<<8* I#*#,>A*K+$*[4#*\$..0*4%%>Z$A*>5*[4%>A*],$%$*,>A* +$5#&%* [42.* ^260* A$5#*,>+* #&*,>A* L%>$5-* T$45* M4.4>%46,D** * M,$*K+$*A3$5#*>5*[4%>A*>5_2$56$-*#,$*\$..0NA* 64%$$%* >5* 4* +4`&%* ]40B* 45-* >5* ;<<8*,$*,4-* #,$*&664A>&5*#&*]%>#$*>5*F$2%&A2%/$%0*1& <&'/6/.$/41=&.,&>2&%0.,.%,=&?/@&"1#&"$5#&A/"1#$&%A&?1/"&?#&,%?&4/66&.>/-#&-5.B#B&@"#$#%"/4C4&@5$-#$2:D& M,$*&%>/>54.*M4.4>%46,NA*$.$6#%&-$A*3.455>5/*45-* >+3.45#4K&5*#$6,5>a2$* ">+3.$* 45-* A4L$* +$45A* L&%* #,$* >5#%&-26K&5* &L* #&&.A* ]>#,&2#* $b#$5a>z$* K&5A* 45-* ]>#,* $4A0* +$45A* &L* 6,$6c>5/* #,$* A4L$#0* &L* #,$* 3$5$#%4K5/*#%46c*#,%&2/,*4*+>5>+4.* &3$5>5/B*#,$*A>d$*&L*#,$*3%&:$D** Y* U* J. Talairach, J. Bancaud Approche nouvelle de la neurochirurgie de l épilepsie Neurochirurgie, T. 20, supplement 1, Juin 1974 =<* E2%%$5#*"(()*H+3.45#4K&5*M$6,5>a2$* * "4L$#0*PC40*=UUX*'*F&Z$+:$%*;<==R* V<<*"(()*3%&6$-2%$A* M&-40*L%&+*;9*#&*O9* [&A>K&5>5/*&L*#,$*/2>->5/* A6%$]A* [&A>K&5>5/*&L*#,$*%&:&#* [&A>K&5>5/*&L*#,$*A#&3* A0A#$+*&5*#,$*-%>..*#&*%$46,* #,$*>5#$%54.*]4..*&L*#,$*Ac2..* 9%>..>5/* Major morbidity M&-40*#,$*+4>5*->4/5&AK6*46a2>A>K&5*4%$*O9* ^2#gg9:;&<5=>&?;'!@=<&9:;&<!';& E&4/2.4K&5*&L*#,$*-2%4* +4#$%*]>#,*4*+&5&3&.4%* 6&4/2.4K5/*$.$6#%&-$* [&A>K&5>5/*&L*#,$*A6%$]* H+3.45#*&L*#,$*$.$6#%&-$A* P25-$%*e'@40*6&5#%&.R* Surgical intracranial Minor intracranial bleeding! bleeding! Cerebritis! Hydrocephalus! Retained broken electrode! Psychotic event! Death! M$+3&%4%0*>5#%&-26K&5*&L* #,$*A#0.$#* H5#%&-26K&5*&L*#,$*$.$6#%&-$* M>/,#$5>5/*&L*#,$*643* ==* 5! 10 (1 with status 500 SEEG! (2 permanent epilepticus)! hemiplegias)!! F. Cardinale et al., Neurosurgery, in press 2! (1 aseptic)! 1! 1! 1! 1! =O*! f>%a#*#,>5c*a#$%$&#4b>6*45-*#,$5*a#$%$&#46k6* =8* 2

11 12/11/12 M,$*3%&:.$+*&L*"&2%6$*?&64.>d4K&5* * f%&5#&*34%>$#4.*"(()*$b3.&%4k&51*+2.k3.454%*z>$]*45-*o9*%$6&5a#%26k&5** F$2%&3,0A>&.&/>64.*>5->Z>-24.*.&64.>d4K&5* 9MH'fM*&L*#,$*E&%K6&*"3>54.*M%46#* "(()*AK+2.4K&5*45-*+&#&%*$Z&c$-*3&#$5K4.A* =X* =h* =Y* The relevance of the 3D exploration ==*0%AD*!* The deep seated lesions =X*0%AD*!* =X*0%AD*!* White-Grey matter bundary surface with FDG- PET overlay =U* ;<* The inflated representation 3

12 12/11/12 =X*0%AD*!* Periventricular Nodular Heterotopia E4A$*=1*;8*0%AD*"* Periventricular Nodular Heterotopia The neurophysiological label of the FCD Rt 11 electr Case 1: 24 yrs.! SEEG exploration J L Lt 2 electr K ;O* ;8* ;V* Periventricular Nodular Heterotopia Case 1: 24 yrs.! SEEG exploration* Periventricular Nodular Heterotopia E4A$*;1*U*0%AD*!* Periventricular Nodular Heterotopia E4A$*;1*U*0%AD*!* "(()*$b3.&%4k&5* i/2%$*-4*a.>6$%*6&5*$.$j%&->*>5#%46$%$:%4.>* ;X* ;h* ;Y* 4

13 12/11/12 Periventricular Nodular Heterotopia E4A$*;1*U*0%AD*!* "(()*$b3.&%4k&5* Periventricular Nodular Heterotopia E4A$*;1*U*0%AD*!* "(()*>6#4.*%$6&%->5/A* Periventricular Nodular Heterotopia E4A$*;1*U*0%AD*!* "(()*/2>-$-*#,$%+&6&4/2.4K&5* Red: the nodule Violet-Green: the CST ;U* O<* O=* Periventricular Nodular Heterotopia E4A$*;1*U*0%AD*!* *"(()*>A*4*+$#,&-&.&/0*L&%*>5Z4A>Z$*(()*%$6&%->5/** *-$i5>k&5*&l*#,$*(3>.$3#&/$5>6*k&5$* *L256K&54.*6&%K64.*45-*A2:6&%K64.*+433>5/* *#,$%+&6&4/2.4K&5*&L*#,$*(3>.$3#&/$5>6*k&5$*** I662%4#$* Z>A24.>d4K&5* &L* 6&5#46#*.&64K&5* P:&#,* 6&%K64.*45-*A2:6&%K64.R*:0*+2.K+&-4.*>+4/>5/D*?>+>#$-*34K$5#NA*->A6&+L&%#D* Il$%* #,$* %$+&Z4.* &L* #,$* $.$6#%&-$AB* 4..* #,$* 6&..$6#$-* "(()* -4#4* 4%$* 4Z4>.4:.$* L&%* 45* 4662%4#$* 45-*#,&2/,m2.*>5#$%3%$#4K&5*:$L&%$*A2%/$%0D* O;* OO* 5

14 11/14/2012 1!"# $%#&'()* $++&,)(" -,.#+-" /0#(-&,1# 2*3#&-',*!"#"$%"& '( )*+),-./01/. 2344"&( 2!!3&"#0-&( 5634"678 9:&;"&8!3&"#0-&( 5634"678 9:&;"&8 <.3="&7308 >-7630/47?/7" B"70"&. C"7"&=" D13- E$"&3#/. 5634"678 9-#3"08 F $**4)0 5##-'*6.'3(0,34&# G-." E$"&3#/. 5634"678 9-#3"08 F $**4)0 5##-'* :#)&*'*6 ;<=#(-'>#3 EH0"& "773-.( 6/&03#36/.07 I344 ;/3. /. :.@"&70/.@3.; -H 955J 0"#1.3K:" /.@ 3.@3#/03-.7 E$"&3#/. 5634"678 9-#3"08 F $**4)0 5##-'* L1" J-/4 -H 955J Localization of the Epileptogenic Zone L1" J-/4 -H 955J Localization of the Symptomatogenic Irritative Zone Epileptogenic Zone Zone Lesion Seizure Onset Zone Eloquent Tissue L1" J-/4 -H 955J Localization of the Symptomatogenic Irritative Zone Semiology Interictal EEG Seizure Onset Zone Epileptogenic Zone Zone Lesion Eloquent Tissue MRI PET Ictal EEG Ictal SPECT fmri WADA Neuropsych.

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17 11/14/2012 +M 2:403 0/&;"0 955J "634"603# 70&:#0:&"7 )M P! 955J!"43."/0" "634"60-;".3# Q "4-K:".0 R-."7 955J 90&/0";3"7 Non-lesional Temporal Lobe Epilepsy: -Hippocampus -Amygdala -Temporal neocortex -Temporal pole -Mesial frontal lobe -Insula -Posterior cingulate gyrus -Posterior temporal lobe +M 2:403 0/&;"0 955J O@".03H8 "634"603# 70&:#0:&"7 )M P! 955J!"43."/0" "634"60-;".3# Q "4-K:".0 R-."7 955J 90&/0";3"7?1--7" ".0& #-="& /&"/ -H 3.0"&"70?/. ".0"& H&-$ 0-7/$64" 0377:" -H "4"#0&-@"7 $/8 %" /@@"@ 3. 7"#-.@ 70/;" 2:403 L/&;"0 955J +M 2:403 0/&;"0 955J O@".03H8 "634"603# 70&:#0:&"7 955J 90&/0";3"7 )M P! 955J!"43."/0" "634"60-;".3# Q "4-K:".0 R-."7 P! 955J 9:&&-:.@ /&"/ -H 3.0"&"70 :73.; ;&3@T V&/$"@ 90"&"-0/W8?/. ".0"& H&-$ 6/&/44"4 "4"#0&-@"7 $/8 %" "/73"& 0-3.0"&6&"0 4

18 11/14/ "&"-0/W8 90"&"-0/W8 Ring less limited than arc (-30º to 210º) (30º to 150º) arc arc ring ring y z y z x x X ; X ; Supine (Prone) = from front (back) Supine (Prone) = from front (back) Lateral = from side Lateral = from side X ; V&/$" X4/#"$".0 Ring perpendicular to electrode path Placed low to maximize trajectory options Supine (Prone) = from front (back) Lateral = from side 5

19 11/14/2012 V&/$" X4/#"$".0 V&/$" X4/#"$".0 Simultaneous bilateral placement: tilt frame toward dependent side Simultaneous bilateral placement: tilt frame toward dependent side V4:-&-7#-68 O$64/.0/03-. P $$ 70/% 3.#373-.( )MY Verify correct placement Determine depth of placement O$64/.0/03-. P $$ 70/% 3.#373-.( )MY I301 $-.-6-4/& #/:0"&8 O$64/.0/03-. P $$ 70/% 3.#373-.( )MY I301 $-.-6-4/& #/:0"&8 E@=/.#" 7084"0 0-0/&;"0 :.@"& W &/8 6

20 11/14/2012 O$64/.0/03-. P $$ 70/% 3.#373-.( )MY I301 $-.-6-4/& #/:0"&8 E@=/.#" 7084"0 0-0/&;"0 :.@"& W &/8 X4/#" /.#1-& %-40 X4/#" "4"#0&-@" X-70-6"&/03=" X&-#"773.; X-70-6"&/03=" =-4:$"0&3#?L Z+ $$[ V:7"@ I301 6&"-6"&/03=" 2CO?-.0-:& "4"#0&-@"7 -H 5\?/. 3$6-& H&/$"4"77 70"&"-0/W8 H-& &"7"#03-.?/7" 5W/$64" 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?/7" 5W/$64" 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 7

21 11/14/2012?/7" 5W/$64" 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?/7" 5W/$64" 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 Seizure onset zone: Posterior Temporal No activity Interictal Ictal Eloquent No activity Interictal Ictal Eloquent?/7" 5W/$64" 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?/7" 5W/$64" 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 No activity Interictal Ictal Eloquent?/7" 5W/$64" 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?/7" 5W/$64" 57 year old RH woman Seizures: visual aura, aphasia Etiology: cavernous angioma Location: left temporal (Sp1) Related medical conditions: migraine Pathology: Cortical Dysplasia 8

22 11/14/2012?/7" 5W/$64" 57 year old RH woman Seizures: visual aura, aphasia Etiology: cavernous angioma Location: left temporal (Sp1) Related medical conditions: migraine?/7" 5W/$64" 57 year old RH woman Seizures: visual aura, aphasia Etiology: cavernous angioma Location: left temporal (Sp1) Related medical conditions: migraine Cavernous angioma Mesial temporal structures Anterior, Posterior, Superior, Inferior, and Lateral to Cavernous Angioma?/7" 5W/$64" 57 year old RH woman Seizures: visual aura, aphasia Etiology: cavernous angioma Location: left temporal (Sp1) Related medical conditions: migraine?/7" 5W/$64" 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) Seizure onset zone only in hippocampus (not perilesional) No activity Interictal Ictal Eloquent Lesion No activity Interictal Ictal Eloquent Lesion?-.#4: "&"-0/#03# 0"#1.3K:"7 /&" H-& 3$64/.0/03-. J-/4 37!#$%&'(" 43! 3 "634"60-;".3# R-."U " $6-&0/.0 X&-=3@"7 /./0-$3# 3.H-&$/ /0 #/. %" 1"46H:4 0- ;:3@" 7:&;3#/4 &"7"#03-. 9

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

24 11/14/2012 CORTICAL STIMULATION,-.#-+&/?2'6(# 4$)&#1&"'&=2) Hand Motor Hand Sensory Face motor Face sensory Ictal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

25 11/14/ ' :+ &$;;)"* (9' <= "'(>./?,330 4$)&#1&"'&=2) B("'$=-(-) )-52+*$%$&/ %(12+&=2 $) 5((+J,-52+*$%$&/ *-"%'$("&/ 7&55$"= $) %6&//2"=$"=8 +2N-$+$"= )52%-/&'$(" (* '62 &"&'(7$%&/ /$7$') (* & )52%$*$% *-"%'$("&/ &+2&J!75+2%$)2 $"'2+*&%2.2'G22" '62 6A5('62'$%&/ 3Z &"# $"'2+*&%2 '62 6A5('62'$%&/ &"# *-"%'$("&/ &+2&) P7&$"/A )522%6SJ C"&'(7$%&/ 2/2%'+(56A)$(/(=$%&/ %(++2/&'$(" &"# '62 T4 &)52%' (* '62 3Z &+2 #$**$%-/' '( -"#2+)'&"#J HU/$"#I %("'+(/ (*!B./22#$"=)J b&"=-&=2?&55$"=, E _ `? O Z Motor Sensory Upper extremity Lower extremity Face Upper extremity Lower extremity Face Eye field Qa Qa Qa YQ YQ YQ Negative Motor YQ Qa Language YQ Stimulated $"A b2)$("&/?o!x b2)$(" $) )-52+*$%$&//A /(%&'2#8 "2&+ (+ $" 2/(N-2"' %(+'2MJ E(+7&/?O!X `A5('62'$%&/ 3Z /(%&'2# $" '62 5+(M$7$'A (* 2/(N-2"' %(+'2M P7&$"/A )522%6SJ C'-."A 4;().",U0,330 b2)$("&/?o!x b2)$(" $),330,U0 G$'6 #225 /(%&'2#J #25'6) E(+7&/?O!X 6A5('62'$%&/ 3Z $) #225/A /(%&'2# (+ /(%&'2# $" "(" 2/(N-2"' &+2&)J E22# *(+ U$/&'2+&/ 2M5/(+&'$(")F+2(52+&'$("),330,U0 G$'6 #25'6) C*'2+,U0 *&$/-+2,330,U0 G$'6 #25'6) E22# *(+ 25$/25'(=2"$% "2'G(+c 7&55$"=J,330,U4 G$'6 #25'6) 3

26 !"#!!#$%!$!"##$%& '() *#$+)#',&)%$-.,%) /$'( 0***1 &'(')*'+ ", $%!$ -./0/11' , 78&8, -.8&8 5'9+:0:;< DEFG H+'?:*0' D?/I'+J/>< 4:J1/>=0, K+=?(' 4$5-+,536) H0=M:B)/>.20/?' 3(>'0/:? -.=+)=('9>/(=0J DNO -.=+)= N:?J90>/?; B1'=P'+ N:?J90>/?; B1'=P'+ 3)'+/(=? 61/0'1J< B:(/'>< L 2%%3"+!))'$%&! 3)'+/(=? 61/0'1J< B:(/'>< L 2%%3"+!))'$%& 7897 $ The epileptogenic zone The epileptogenic zone The minimum amount of cortex that must me resected (inactivated, completely disconnected) to produce seizure freedom (Lüders et al. 2006). How to map it with SEEG? Symptomatogenic zone Seizure spread Functional deficit Symptomatogenic zone Seizure spread Functional deficit Eloquent cortex Ictal onset zone Eloquent cortex Ictal onset zone Irritative zone Epileptogenic lesion Irritative zone Epileptogenic lesion F " The epileptogenic zone Bancaud and Talairach view The epileptogenic zone Bancaud and Talairach view Seizure was the symptom to be cured : it was the region of the cortex generating seizures that had to be defined electrophysiologically, and translated into anatomical terms. SEEG definition (Munari and Bancaud, 1987) : the site of the beginning and of the primary organization of epileptic seizures ZE: ictal onset zone + early seizure spread Q G!

27 !"#!!#$%!$ Ictal onset Fast synchronizing (40-500Hz) discharge at seizure onset (Allen et al. 1992, Fisher et al. 1992, Wendling et al. 2003, Worrel et al. 2004, Jirsch et al 2006) Ictal onset Fast synchronizing (40-500Hz) discharge at seizure onset (Allen et al. 1992, Fisher et al. 1992, Wendling et al. 2003, Worrel et al. 2004, Jirsch et al 2006) R insular seizure :6;< 4=<-> B+$%$-"+,%5)',C '() 5)$D36) R E Ictal onset Fast synchronizing (40-500Hz) discharge at seizure onset (Allen et al. 1992, Fisher et al. 1992, Wendling et al. 2003, Worrel et al. 2004, Jirsch et al 2006) Ictal onset Fast synchronizing (40-500Hz) discharge at seizure onset (Allen et al. 1992, Fisher et al. 1992, Wendling et al. 2003, Worrel et al. 2004, Jirsch et al 2006) 1 sec S R R S S!% Ictal onset Imaging the seizure onset zone with SEEG (David et al. 2011) Ictal onset Imaging the seizure onset zone with SEEG (David et al. 2011) R F lobe seizure M M7 M1 M7 M11!!!$ $

28 !"#!!#$%!$ Ictal onset Imaging the seizure onset zone with SEEG (David et al. 2011) Seizure spread Delay AND Fast discharge TP A Hc HcG T3 :?J'> 35 T- 4( '=+0< J1+'=U T2 T1 FG TOj AG pcg TPj T0 T6 T10 R T lobe seizure T0 T6 T10 4(H T5(M J'(:?U=+< /?I:0I')'?>!F!" Seizure spread Electrically-induced seizures Onset Seizure spread 25 sec Spread Clinical onset (mouth tingling) 1 Hz ES [3ms / 0.2-3mA / 40s] Orbito-F Operc Insula Q R X Mesio-T A B C Lateral T 50 Hz ES [1ms / 0.2-3mA / 5s] Hc ES 1 Hz 3mA electro-clinical seizure Ins ES 50 Hz 1mA aura (mouth tingling)!q!g Seizure spread Seizure spread NH CH V+* K:1 K- A?J Amygd Ant Hc T-basal T-O 2dTG V?J'> B1+'= U Mesio-T 1stTG 60'(>+/(=00< /?U9('U J'/W9+' Amygd Lateral T Ant Hc T-basal 50 Hz 1mA T-O! J'( V?J'> B1+'=U 2dTG 1stTG!R!E F

29 !"#!!#$%!$ Seizure spread Can we go further? Mapping the EZ with SEEG Extra-lesional Lesional NDT 2008 FCD Aubert et al. Brain 2009.!S $% "

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