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Name:
10.3171/2024.4.FOCVID2427
Description:
10.3171/2024.4.FOCVID2427
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/08e86760-e225-4b36-8457-7c176b14afb5/videoscrubberimages/Scrubber_235.jpg
Duration:
T00H10M28S
Embed URL:
https://stream.cadmore.media/player/08e86760-e225-4b36-8457-7c176b14afb5
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/08e86760-e225-4b36-8457-7c176b14afb5/4. 24-27.mp4?sv=2019-02-02&sr=c&sig=uOqj2GIqcoB8AIPN8w8VC485a%2BthZFGumdd0kPWn7VQ%3D&st=2026-04-24T16%3A11%3A20Z&se=2026-04-24T18%3A16%3A20Z&sp=r
Upload Date:
2024-05-16T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: Stereo EEG was introduced in the 1950s at Sainte-Anne Hospital in Paris by Jean Talairach and Jean Bancaud. It is a methodology that allows 3D exploration of the brain regions capable of generating seizures, thus better understanding how seizures begin and spread. This provides a better comprehension of the patient epileptogenic zone, defined as the site of the beginning of epileptic seizures and of the primary organization.
SPEAKER: Stereo EEG is indicated when noninvasive, presurgical study failed to find patients epileptogenic zone because anatomo-electro-clinical correlations appear discordant. It's very useful to study the relationship that the EEG may have with eloquent areas. It can also provide information about the patient's postsurgical prognosis and perform a proper risk-benefit assessment. In this video, we present our surgical workup through the presentation of an illustrative clinical case.
SPEAKER: This is the case of a 50-year-old male patient whose noninvasive assessment allowed us to pursue a cryptogenic right parietal lobe epilepsy. All patients are imaged by a 3D MRI and a 3D cone beam CT digital subtraction angiography in frameless and markerless conditions days or weeks before implantation. In our center, traditional Tailairach technique has been progressively updated. Since 2009, we adopted an image-guided surgery workflow fully based on 3D imaging and robotic assistance.
SPEAKER: Stereotactic trajectories are planned with Voxim. Entry point and target point were defined for each trajectory by inspecting multiplanar reconstruction, brain, and vasculature surface rendering. In our experience, 3D angiography is used as the stereotactic space where coordinates of entry and target point are stored. Because of its reliability, it is possible to check also for the smallest vessel, thus increasing safety.
SPEAKER: Planned trajectories could be reformatted according to the planned vector. Because most hemorrhagic events originate mainly at the entry point, we usually set a radius of safe entry region of 2 mm, at least along the first third of the trajectory. Furthermore, it is useful to avoid trajectories too tangent to the skull surface. The quality and thickness of the bone itself have to be considered.
SPEAKER: In this case a right centroparietal exploration was planned with the aim of also checking for possible seizure involvement of the sensory-motor cortex. Surgery consists in an image-guided and robot assistant electrode implantation. The procedure is performed with the patient under general anesthesia on supine position, being the head in neutral position. The disinfection of the entire scalp is performed before the head fixation.
SPEAKER: The robotic system is then advanced toward the patient's head with a sterile Leksell frame attached to it. The frame is used to support the head, with no stereotactic purpose, as shown later in the video. The frame is fixed to the patient's head and the frameless and touchless patient registration procedure is started. Two skin fiducials were also placed, one on each side of the head.
SPEAKER: The Neurolocate system is placed on the robotic arm and manually moved closer to the patient's head. A cone-beam CT 3D scan with the O-arm system is then acquired. A specific software model is used to complete the registration, selecting the center of the neurolocate fiducials in the multiplanar reconstruction provided by the Voxim stereotaxic planning software. True trajectories pointing the skin markers are then planned in order to verify the registration.
SPEAKER: The planning software can compute the transformation matrix from the planning space to the robot space. Once the registration has been completed, the robotic arm can align the tool holder with the vector of the planning trajectories. The implementation starts by piercing the skin and subcutaneous tissue with a very thin drill of 1 mm of diameter, which also performs a little indentation in the external cortical bone as an invitation for the proper bone drill of 2.1 mm of diameter.
SPEAKER: The bone is then drilled through its entire thickness without perforating the dura mater. This is because the length of the drill was previously obtained, subtracting the distance between the robot tool holder and the trajectory target point minus the distance between the inner cortical layer of the bone and the target point itself. The distance from the tool holder to the skin is measured, which leads to the choice of screw length, subtracting this last measure to the drill length.
SPEAKER: The dura is coagulated and perforated with a monopolar coagulator. The appropriate screw is placed and the distance from the tool holder to the screw is measured. Previous recorded distance from the tool holder to the target point minus the distance from the tool holder to the screw will determine the length of the electrode.
SPEAKER: Process is repeated for each screw. Profuse washing of the hole with saline helps to remove any small bone fragments remaining. In a few cases, a cap can be placed to prevent excessive CSF leakage. Once all guidance screw are fixed, the skin is disinfected and cleaned, then the frame is removed.
SPEAKER: The relative position of each screw is recognized, and electrodes can be inserted on the radioscopic control. First, a previously measured, rigid stylet is placed and an X-ray image is obtained. Later, the electron is introduced and another X-ray image is obtained.
SPEAKER: This technique is of utmost importance as it not only creates the path for the electrode, which is semi-rigid, but also provides the position and depth reference to be comparing the radiographic image obtained after the electrode is introduced. Electrode securing is achieved by tightening the cap of each screw. Once all electrodes are in place, a new intraoperative CT scan is acquired and score registered to the preoperative planning in order to compare each electrode with its planned trajectory, the yellow line.
SPEAKER: Meanwhile, verification of proper electrode function is performed in the operating room by an epileptologist experienced in stereo EEG signal interpretation. At the end, sterile wrapping is performed, surrounding all screws with gauze for isolation and comfort purposes, followed by band dressing the head. The patient is then awakened and transferred to the inpatient ward.
SPEAKER: The day after implantation, the patient is accepted to the recording laboratory for video stereo EEG monitoring. A multimodal chain is produced that the team can recognize the electrodes and the location of each lead in the different brain structures explored. Regarding this illustrative case, after 8 days of stereo EEG monitoring, both wakefulness and sleep, cortical stimulation, and neurophysiological assessment of sensorimotor areas, the conclusion was a complex nonlesional, epileptogenic zone involving primary sensory cortex.
SPEAKER: After all useful data are obtained to define the epileptogenic zone, electrode removal is performed in the patient bedside. An exception is made for children for whom electrode removal is done in the operating room under sedation. After removal of the head dressing, the gauze is removed in a sterile manner, exposing the screw and the electrode caps.
SPEAKER: The electrodes are detached from the screw and carefully removed, verifying their integrity, after which the screw are removed from the skull using available tools from different electrode companies. After all electrodes and screws are removed, skin brushing is performed to occlude any communication with the internal space. If necessary, a simple skin seam with absorbable suture is applied.
SPEAKER: A new head dressing is placed on. If there are no complications clinical or of the follow-up CT scan of the brain performed after the last procedure, the patient is usually discharged the next day. We recently published our single- center experience. From 1996 to 2018, it has been performed 742 implantations, 43.5% of them with the 3D IRA workflow. 524 patients underwent resective or disconnective surgery,
SPEAKER: and 53.2% of them are in Engel class I. Overall complication rate was 1.8%, with better safety profile of the 3D IRA workflow. Good procedural accuracy has been demonstrated in another recent paper of our group. To date, we have performed 970 implantations. According to the criteria of our last publication, there were four complications being two infections, one TMJ dysfunction, and one electrode breaking that needed subsequent surgery.
SPEAKER: No major complications were registered in the last four years. Stereo EEG is a safe and effective procedure for the invasive assessment of the epileptogenic zone. The electrode trajectories are carefully planned individually for each patient in order to gather information from the region of interest through their sampling, and the possibility to perform cortical stimulation. Well-defined steps, narrow imaging, multimodal planning, and robot-assisted surgery increase the accuracy and safety of the procedure.
SPEAKER: Finally, postoperative 3D reconstruction of electrodes provide neurophysiologists a tool for better interpretation of the EZ spatio-temporal dynamic.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: Stereo EEG was introduced in the 1950s at Sainte-Anne Hospital in Paris by Jean Talairach and Jean Bancaud. It is a methodology that allows 3D exploration of the brain regions capable of generating seizures, thus better understanding how seizures begin and spread. This provides a better comprehension of the patient epileptogenic zone, defined as the site of the beginning of epileptic seizures and of the primary organization.
SPEAKER: Stereo EEG is indicated when noninvasive, presurgical study failed to find patients epileptogenic zone because anatomo-electro-clinical correlations appear discordant. It's very useful to study the relationship that the EEG may have with eloquent areas. It can also provide information about the patient's postsurgical prognosis and perform a proper risk-benefit assessment. In this video, we present our surgical workup through the presentation of an illustrative clinical case.
SPEAKER: This is the case of a 50-year-old male patient whose noninvasive assessment allowed us to pursue a cryptogenic right parietal lobe epilepsy. All patients are imaged by a 3D MRI and a 3D cone beam CT digital subtraction angiography in frameless and markerless conditions days or weeks before implantation. In our center, traditional Tailairach technique has been progressively updated. Since 2009, we adopted an image-guided surgery workflow fully based on 3D imaging and robotic assistance.
SPEAKER: Stereotactic trajectories are planned with Voxim. Entry point and target point were defined for each trajectory by inspecting multiplanar reconstruction, brain, and vasculature surface rendering. In our experience, 3D angiography is used as the stereotactic space where coordinates of entry and target point are stored. Because of its reliability, it is possible to check also for the smallest vessel, thus increasing safety.
SPEAKER: Planned trajectories could be reformatted according to the planned vector. Because most hemorrhagic events originate mainly at the entry point, we usually set a radius of safe entry region of 2 mm, at least along the first third of the trajectory. Furthermore, it is useful to avoid trajectories too tangent to the skull surface. The quality and thickness of the bone itself have to be considered.
SPEAKER: In this case a right centroparietal exploration was planned with the aim of also checking for possible seizure involvement of the sensory-motor cortex. Surgery consists in an image-guided and robot assistant electrode implantation. The procedure is performed with the patient under general anesthesia on supine position, being the head in neutral position. The disinfection of the entire scalp is performed before the head fixation.
SPEAKER: The robotic system is then advanced toward the patient's head with a sterile Leksell frame attached to it. The frame is used to support the head, with no stereotactic purpose, as shown later in the video. The frame is fixed to the patient's head and the frameless and touchless patient registration procedure is started. Two skin fiducials were also placed, one on each side of the head.
SPEAKER: The Neurolocate system is placed on the robotic arm and manually moved closer to the patient's head. A cone-beam CT 3D scan with the O-arm system is then acquired. A specific software model is used to complete the registration, selecting the center of the neurolocate fiducials in the multiplanar reconstruction provided by the Voxim stereotaxic planning software. True trajectories pointing the skin markers are then planned in order to verify the registration.
SPEAKER: The planning software can compute the transformation matrix from the planning space to the robot space. Once the registration has been completed, the robotic arm can align the tool holder with the vector of the planning trajectories. The implementation starts by piercing the skin and subcutaneous tissue with a very thin drill of 1 mm of diameter, which also performs a little indentation in the external cortical bone as an invitation for the proper bone drill of 2.1 mm of diameter.
SPEAKER: The bone is then drilled through its entire thickness without perforating the dura mater. This is because the length of the drill was previously obtained, subtracting the distance between the robot tool holder and the trajectory target point minus the distance between the inner cortical layer of the bone and the target point itself. The distance from the tool holder to the skin is measured, which leads to the choice of screw length, subtracting this last measure to the drill length.
SPEAKER: The dura is coagulated and perforated with a monopolar coagulator. The appropriate screw is placed and the distance from the tool holder to the screw is measured. Previous recorded distance from the tool holder to the target point minus the distance from the tool holder to the screw will determine the length of the electrode.
SPEAKER: Process is repeated for each screw. Profuse washing of the hole with saline helps to remove any small bone fragments remaining. In a few cases, a cap can be placed to prevent excessive CSF leakage. Once all guidance screw are fixed, the skin is disinfected and cleaned, then the frame is removed.
SPEAKER: The relative position of each screw is recognized, and electrodes can be inserted on the radioscopic control. First, a previously measured, rigid stylet is placed and an X-ray image is obtained. Later, the electron is introduced and another X-ray image is obtained.
SPEAKER: This technique is of utmost importance as it not only creates the path for the electrode, which is semi-rigid, but also provides the position and depth reference to be comparing the radiographic image obtained after the electrode is introduced. Electrode securing is achieved by tightening the cap of each screw. Once all electrodes are in place, a new intraoperative CT scan is acquired and score registered to the preoperative planning in order to compare each electrode with its planned trajectory, the yellow line.
SPEAKER: Meanwhile, verification of proper electrode function is performed in the operating room by an epileptologist experienced in stereo EEG signal interpretation. At the end, sterile wrapping is performed, surrounding all screws with gauze for isolation and comfort purposes, followed by band dressing the head. The patient is then awakened and transferred to the inpatient ward.
SPEAKER: The day after implantation, the patient is accepted to the recording laboratory for video stereo EEG monitoring. A multimodal chain is produced that the team can recognize the electrodes and the location of each lead in the different brain structures explored. Regarding this illustrative case, after 8 days of stereo EEG monitoring, both wakefulness and sleep, cortical stimulation, and neurophysiological assessment of sensorimotor areas, the conclusion was a complex nonlesional, epileptogenic zone involving primary sensory cortex.
SPEAKER: After all useful data are obtained to define the epileptogenic zone, electrode removal is performed in the patient bedside. An exception is made for children for whom electrode removal is done in the operating room under sedation. After removal of the head dressing, the gauze is removed in a sterile manner, exposing the screw and the electrode caps.
SPEAKER: The electrodes are detached from the screw and carefully removed, verifying their integrity, after which the screw are removed from the skull using available tools from different electrode companies. After all electrodes and screws are removed, skin brushing is performed to occlude any communication with the internal space. If necessary, a simple skin seam with absorbable suture is applied.
SPEAKER: A new head dressing is placed on. If there are no complications clinical or of the follow-up CT scan of the brain performed after the last procedure, the patient is usually discharged the next day. We recently published our single- center experience. From 1996 to 2018, it has been performed 742 implantations, 43.5% of them with the 3D IRA workflow. 524 patients underwent resective or disconnective surgery,
SPEAKER: and 53.2% of them are in Engel class I. Overall complication rate was 1.8%, with better safety profile of the 3D IRA workflow. Good procedural accuracy has been demonstrated in another recent paper of our group. To date, we have performed 970 implantations. According to the criteria of our last publication, there were four complications being two infections, one TMJ dysfunction, and one electrode breaking that needed subsequent surgery.
SPEAKER: No major complications were registered in the last four years. Stereo EEG is a safe and effective procedure for the invasive assessment of the epileptogenic zone. The electrode trajectories are carefully planned individually for each patient in order to gather information from the region of interest through their sampling, and the possibility to perform cortical stimulation. Well-defined steps, narrow imaging, multimodal planning, and robot-assisted surgery increase the accuracy and safety of the procedure.
SPEAKER: Finally, postoperative 3D reconstruction of electrodes provide neurophysiologists a tool for better interpretation of the EZ spatio-temporal dynamic.
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