EPILEPSY 2018: UPDATE ON MODERN SURGICAL MANAGEMENT. Robert Kellogg, MD Advocate Children s Hospital Park Ridge, IL April 20, 2018

Transcription

1 EPILEPSY 2018: UPDATE ON MODERN SURGICAL MANAGEMENT Robert Kellogg, MD Advocate Children s Hospital Park Ridge, IL April 20, 2018

2 No disclosures

3 OBJECTIVES Brief history of epilepsy surgery Pre-operative evaluation Invasive monitoring strategies Outcomes after surgery Future directions

4 BACKGROUND Epilepsy affects ~1% Fourth most common neurological disorder In the U.S., between 1.3 and 2.2 million people Pediatrics ~750,00 in the U.S. Prevalence per 100,000 Extra-temporal epileptogenic zone Seizure duration before surgery = 5.7 years 10-20% of this population refractory to drug therapy

5 BACKGROUND Common pediatric epilepsies Stafstrom et al

6 BACKGROUND Surgery 2004 ILAE Survey Harvey et al

7 EPILEPSY SURGERY HISTORY Epilepsy therapies date back ~5000 years Diet, herbs, surgery? Trephination Evident from the Neolithic period (~10,000 to 2,000 BC) Oldest procedure for which there is evidence Used to treat a variety of conditions Victorian era Victor Horsley ( ) Post traumatic epilepsy Reportedly good outcomes (~50% seizure control)

8 EPILEPSY SURGERY HISTORY Twentieth Century Development of EEG in 1928 Temporal lobe resections Penfield and Jasper William Scoville H.M.

9 JEAN TALAIRACH Practiced psychiatry at Hospital Sainte Anne in Paris Psychosurgery is too important to be left to the neurosurgeon Head of department of stereotactic surgery After L-Dopa transitioned to epilepsy Partnered with neurologist Jean Baucaud In 1962 published on new technique and method called Stereo-ElectroEncephalography

10

11 INVASIVE MONITORING Why monitor in the first place? Failure to identify/define the epileptic network Eloquent cortex Goal is resection (disconnection) of cortical area responsible for generation of seizures Epileptic zone

12 MONITORING OPTIONS Depth Electrodes Subdural Grid/Strips

13 INVASIVE MONITORING Indications MRI negative cases MRI lesion not concordant with the electro-clinical hypothesis Especially in FCD spikes may be more diffuse than appreciated by visual inspection or MRI Two or more lesions And it is unclear which, if either, if responsible The electro-clinical hypothesis involves eloquent cortex Techniques Subdural Grids and Strips Depth electrodes Stereo EEG (SEEG) Gonzalez-Martinez et al

14 INVASIVE MONITORING Subdural grids/strips Limitations Incomplete intrasulcal, deep brain, interhemispheric coverage Multilobar coverage Best outcomes in patients with a clear cortical lesion who underwent grid placement for functional mapping

15 INVASIVE MONITORING Stereo EEG Enables precise recording for deep cortical and subcortical areas Multiple lobes/areas No large craniotomy Indications Difficult to cover location Failed previous subdural grid Bihemispheric monitoring

16 INVASIVE MONITORING Intra-operative electrocorticography Localize focal anatomic area of seizure onset Guide the extent of resection Functional mapping

17 INVASIVE MONITORING Complications Wide range of reports Grids 0-3% Depth electrodes 3-6% Onal et al

18

19 STEREOELECTROENCEPHALOGRAPHY (SEEG) What is old becomes new First reported in 1949 Pioneered in France in the 1960s Talairach improved implantation technique and used pneumoencephalogram to aide visualization Allowed for longer term chronic monitoring This was the gold standard for invasive monitoring until the early 1980s Difficult to achieve accurate placement

20 EPILEPSY SURGERY IN THE 21 ST CENTURY A. De Benedictis et al. ntracranial implantation of electrodes for SEEG. A: Screenshot of the preoperative planning. The imported images can lized according to different projections. To avoid hemorrhagic complications, the safest trajectories are built and verified d T1-weighted sequence. The 3D rendering gives a useful general overview of the trajectories; the surgeon can verify the istance between the electrodes (left). Different tools for both the image rendering and trajectory planning (right). B and gistration of the MR image with the postoperative CT verification of the correspondence between the planned trajectory implanted electrode, especially at the entry point (B) and the target point (C). D: Intraoperative photograph of the final

21 STEREOELECTROENCEPHALOGRAPHY Multiple depth electrodes Individualized implantation Anatomo-electro-clinical correlation 3-dimensional spatial-temporal organization of the epileptic discharge Allows for recording along entire trajectory and in deep locations

22 Frontal-parietal PREOPERATIVE WORK FLOW Phase 1 Imaging MRI Brain T1 w contrast CT angiogram Trajectory planning Multidisciplinary team Forming an Anatomo-Electro-Clinical hypothesis Targeting Networks Multiple lesions Limbic Periventricular nodular heterotopia Polymicrogyria Mesial temporal Insula Orbital frontal Posterior cingulate

23 INTRAOPERATIVE WORK FLOW General anesthesia Intraoperative imaging registration Obtain trajectory Steinman pin/stab incision 2.5mm drill Place bolt in line with trajectory Measure depth to target Pierce dura Place cap Lead to target Tighten cap

24 POST-OPERATIVE WORK FLOW CT scan Taken to ICU Continue IV Ancef while leads are in place Wean AED Monitoring in EMU 7-21 days Stimulation for EZ localization 50Hz, 0.5 ms, ma, 1-5 seconds Synchronizing the epileptogenic network False Negative Small area of tissue stimulated, AED level False Positive Hippocampus and motor cortex Stimulation for functional mapping Return to OR for lead removal Case discussed in multidisciplinary epilepsy conference 6 weeks before resection/implantation

25 SUBDURAL VS SEEG I. Podkorytova et al Neurosurg Clin N Am 27 (2016)

26 IS IT SAFE 30 studies 2624 patients electrodes 1.3% risk of surgical morbidity 0.6% risk of permanent neurological deficit 21 studies 2542 patients 7.1% risk of infection 4.0% risk of intracranial hemorrhage 2.4% risk increased ICP

27 68% seizure free at 1 year 44%-68% freedom

28 ROBOT-ASSISTED PROCEDURES Applications for epilepsy surgery Stereo EEG Laser interstitial thermotherapy (LITT) Robot-assisted surgery for pediatric epilepsy and neurooncolo FIG. 1. Operating room configuration of the ROSA system. The patient s head is secured in a Mayfield head holder that is attached

29 ROBOT-ASSISTED PROCEDURES ROSA System Computer controlled arm Used for frameless stereotactic surgery Allows for highly accurate placement of electrodes LITT Utilizes a robotic arm Intra operative MRI

30 LASER INTERSTITIAL THERMAL THERAPY Lasers (light amplification by stimulated emission of radiation) First report of laser use in neurosurgery in 1966 by Rosomoff and Carroll Continued to be used as a hand held tool Bown SG. Phototherapy in tumors published in 1983 Sugiyama et al first to describe LITT in the treatment of brain tumors in 1990

31 MR Thermography Real-time assessment of lesion size Controlled lesioning < 45 C reversible C controlled > 60 C rapid > 90 C charring, gas

32 LASER INTERSTITIAL THERMAL THERAPY Visualase 980-nm FDA approval 2007 Neuroblate 1064 nm lasers FDA approval in 2009 Mahmood Rezapour, Eric C. Leuthardt and Jenna L. Gorlewicz [+] Author and Article Information J. Med. Devices 10(3), (Aug 01, 2016)

33

34

35

36 REFERENCES