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Name:
10.3171/2024.4.FOCVID2419
Description:
10.3171/2024.4.FOCVID2419
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/78dec98c-31bb-4ddf-ab34-08eaa6cf2d39/videoscrubberimages/Scrubber_457.jpg?sv=2019-02-02&sr=c&sig=ZX33K1qnYLHorvLV5dWmfzopx6J93Xte5CGoaYwKITg%3D&st=2026-04-28T16%3A54%3A57Z&se=2026-04-28T20%3A59%3A57Z&sp=r
Duration:
T00H09M36S
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https://stream.cadmore.media/player/78dec98c-31bb-4ddf-ab34-08eaa6cf2d39
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https://cadmoreoriginalmedia.blob.core.windows.net/78dec98c-31bb-4ddf-ab34-08eaa6cf2d39/5. 24-19.mp4?sv=2019-02-02&sr=c&sig=Xp78xPjOa1QaDouV0zEaGZN9WSivvUorTZbYjqxonZY%3D&st=2026-04-28T16%3A54%3A57Z&se=2026-04-28T18%3A59%3A57Z&sp=r
Upload Date:
2024-05-30T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
INSTRUCTOR: Stereoelectroencephelography is the gold standard to investigate epileptogenic networks in drug-resistant epilepsy. This technique was introduced for the first time at Sainte-Anne Hospital on May 3rd, 1957, by Dr. Bancaud and Dr. Talairach, and progressively adopted worldwide. Since its introduction in our institution, this procedure was being performed 1536 times. The aim of this surgical procedure is to record cortical activity thanks to deep electrodes implanted under stereotactic conditions, allowing to understand the implications of specific brain cortical zones in seizure onset and/or propagation.
INSTRUCTOR: The SEEG procedure has numerous advantages that make it the gold standard. One, the ability to record and monitor simultaneously multiple brain zones, even bilaterally or deep-seated. Two, the low morbidity due to a mini-invasive approach without craniotomy. Three, the potential use of implanted electrodes as a curative treatment via radiofrequency thermocoagulation.
INSTRUCTOR: At the beginning, SEEG's main aim was to circumscribe an epileptogenic zone and to determine if this zone was accessible for surgical treatment via cordectomy. Due to developments and refinements of the procedure, SEEG is nowadays used to investigate epileptogenic networks surgically to interrupt and/or disrupt epileptogenic aberrant loops.
INSTRUCTOR: This software used to plan the trajectories is Brainlab Elements. Brainlab Elements is a surgical software allowing to perform image coregistration, DTI analysis, and trajectory planning. Nonenhanced T1-weighted 3D fast spin echo MRI is used as a reference series. Vascular and functional images are co-registered toward this reference series.
INSTRUCTOR: The lead trajectories are defined as a straight line between one entry point, EP, and one target point, TP, in agreement with the surgical epileptologist during a preoperative multidisciplinary board meeting. The definition of the epileptogenic zone is based on a preparative noninvasive investigations, at first, results of the video-EEG recordings; clinical examination with a competent neuropsychological assessment;
INSTRUCTOR: then, the imaging data with 3 Tesla, 7 Tesla, and functional MRI; and finally, the metabolic imaging with the PET-MRI. This workup must lead to a first delimitation of a quite restricted possible seizure onset zone and spatial temporal seizure propagation pattern. The electrodes' trajectories are then placed in the corresponding anatomical structure, keeping in mind its low spatial resolution.
INSTRUCTOR: The trajectories are also planned with a 2-mm margin distance from at-risk zones (vessels and sulci) by two neurosurgeons blind to each other. Vascular images, in particular 3D angiography sequences, are acquired for each patient and used to adjust the trajectories. The idea is to avoid and lower as much as possible a risk of hematoma and bleeding during and/or after the procedure.
INSTRUCTOR: The trajectories are validated during dual consensus. In our experience, a dozen electrodes per SEEG is sufficient to investigate the delimitated epileptic area. If the epileptogenic zone hypothesis is not supported by the SEEG analysis, a second SEEG procedure could be performed to investigate the second zone. The increase in number of implanted electrodes does not necessarily increase by identification of an epileptogenic zone and could complicate the understanding of the procedure by the patient.
INSTRUCTOR: Delimitate a well-defined area to perform a cortectomy. Once a definitive trajectory is validated, the DICOM coordinates of each trajectory are transferred to the neuromate robot control station. Surgical setup consists in positioning the patient's head in a Talairach head clamp. The Talariach head clamp is still in use at Saint-Anne hospital,
INSTRUCTOR: but the neuromate robot can be used with other head fixation systems such as the Leksell frame G. During this step, it is important to maintain the head in a neutral position and include as much as possible a skull base in the O-arm field of view. The aim is the coregistration between the 3D O-arm series acquired intraoperatively and those of the preoperative MRI. Positioning and intraoperative planning procedure is similar to the robot-assisted stereotactic biopsy performed in our institution.
INSTRUCTOR: Artifacts due to Talairach head clamp or any other head fixation system should be taken into consideration during intraoperative imaging acquisition. As for a classical CT scan, one profile and one anterior posterior X-ray images are acquired to position the head at the center of the O-arm field of view, the final O-arm position, there registered.
INSTRUCTOR: Before starting a surgical procedure, the robot is to be checked. On the robot control station, the NMControl program is switched on and a test procedure is started. During this phase, the accuracy of the robot, the system communication, different reference positions, the anti-collision system and the remote control are verified. If the test is passed, the robot can be used.
INSTRUCTOR: The laser tool holder is installed on the robotic arm. It has to be firmly attached thanks to two fixation screws. The neurolocator registration module is positioned on the laser tool holder. This is the frameless system consisting of five ruby spheres, enabling intraoperative registration, without the need for bone or skin anchored fiducials. It is of utmost importance to have it correctly aligned because it will position the robot into the operative room space.
INSTRUCTOR: The neurolocator registration tool must be positioned as close to the patient's head as possible and aligned with the calvaria on the vertex, reducing the space between the skin and the neurolocate ruby spheres. The 3D O-arm acquisition is made and verified. All the 5 ruby spheres must be identified. The 3D acquisition is performed at a low-dose level to minimize patient irradiation.
INSTRUCTOR: The image is co-registered to preparative MRI. The imaging coregistration is roughly made manually and then refined by automatic algorithm. The quality of the coregistration process is verified by two neurosurgeons and the planned trajectories and controlled again. An additional safety check is realized. The robot is positioned into one trajectory axis.
INSTRUCTOR: A wire metallic pin inserted into the standard tool holder is put in contact with the patient's skin. A 3D O-arm series is acquired, then coregistered with preoperative MRI. There O-arm metallic pin has to be precisely aligned with the planned trajectory. This allows the final evaluation of the robot accuracy. The O-arm can be moved away from the surgical field,
INSTRUCTOR: thanks to the registration of its position during the first steps of the procedure. For each trajectory, the robotic arm is aligned on the trajectory axis. A minimal hair shaving is performed around the EP located on the skin. The robotic arm is then moved as close as possible to the patient's head to minimize mechanical deviation during the drilling process.
INSTRUCTOR: The drill hole is performed with a 2.5-mm-diameter drill bit. The drilling movement must be as smooth as possible and the bit as sharp as possible. The length of the drill bit is defined to perforate exclusively the bone without damaging the dura matter. A locking device is secured on the drill to execute the procedure with minimal risk. Once the bone hole is made,
INSTRUCTOR: the durotomy is realized thanks to a thin monopolar coagulation. The guiding screw dimension is chosen according to a homemade software, SEEGGapp and then secured into the skull. The distance between the distal part of the guiding screw and the target point located in the brain parenchyma guides the choice of the electrode length and number of contacts. A stylet is introduced before the electrode;
INSTRUCTOR: this preliminary trajectory minimizes trajectory deviation due to the electrode's flexibility. The electrode is slowly pushed into parenchyma and fixed thanks to the guided screw. The procedure is repeated in the same manner for each electrode. Once all the electrodes are positioned, the new 3D O-arm series is acquired using the registered O-arm position.
INSTRUCTOR: The new image is fused to the preoperative MRI and the trajectories are compared. If an electrode presents an important deviation of the target points, more than 2 mm, the corresponding electrode is removed, the length is adjusted, and then is replaced. Another 3D O-arm series is performed. This procedure is repeated until the trajectory is respective to the preparative planification.
INSTRUCTOR: The robot is moved to park position. The electrodes cables are fastened to the skull by surgical stitches. Lastly, the Talairach head clamp is removed, starting from the interior pins, moving subsequently to the posterior ones.
Segment:0 .
[MUSIC PLAYING]
INSTRUCTOR: Stereoelectroencephelography is the gold standard to investigate epileptogenic networks in drug-resistant epilepsy. This technique was introduced for the first time at Sainte-Anne Hospital on May 3rd, 1957, by Dr. Bancaud and Dr. Talairach, and progressively adopted worldwide. Since its introduction in our institution, this procedure was being performed 1536 times. The aim of this surgical procedure is to record cortical activity thanks to deep electrodes implanted under stereotactic conditions, allowing to understand the implications of specific brain cortical zones in seizure onset and/or propagation.
INSTRUCTOR: The SEEG procedure has numerous advantages that make it the gold standard. One, the ability to record and monitor simultaneously multiple brain zones, even bilaterally or deep-seated. Two, the low morbidity due to a mini-invasive approach without craniotomy. Three, the potential use of implanted electrodes as a curative treatment via radiofrequency thermocoagulation.
INSTRUCTOR: At the beginning, SEEG's main aim was to circumscribe an epileptogenic zone and to determine if this zone was accessible for surgical treatment via cordectomy. Due to developments and refinements of the procedure, SEEG is nowadays used to investigate epileptogenic networks surgically to interrupt and/or disrupt epileptogenic aberrant loops.
INSTRUCTOR: This software used to plan the trajectories is Brainlab Elements. Brainlab Elements is a surgical software allowing to perform image coregistration, DTI analysis, and trajectory planning. Nonenhanced T1-weighted 3D fast spin echo MRI is used as a reference series. Vascular and functional images are co-registered toward this reference series.
INSTRUCTOR: The lead trajectories are defined as a straight line between one entry point, EP, and one target point, TP, in agreement with the surgical epileptologist during a preoperative multidisciplinary board meeting. The definition of the epileptogenic zone is based on a preparative noninvasive investigations, at first, results of the video-EEG recordings; clinical examination with a competent neuropsychological assessment;
INSTRUCTOR: then, the imaging data with 3 Tesla, 7 Tesla, and functional MRI; and finally, the metabolic imaging with the PET-MRI. This workup must lead to a first delimitation of a quite restricted possible seizure onset zone and spatial temporal seizure propagation pattern. The electrodes' trajectories are then placed in the corresponding anatomical structure, keeping in mind its low spatial resolution.
INSTRUCTOR: The trajectories are also planned with a 2-mm margin distance from at-risk zones (vessels and sulci) by two neurosurgeons blind to each other. Vascular images, in particular 3D angiography sequences, are acquired for each patient and used to adjust the trajectories. The idea is to avoid and lower as much as possible a risk of hematoma and bleeding during and/or after the procedure.
INSTRUCTOR: The trajectories are validated during dual consensus. In our experience, a dozen electrodes per SEEG is sufficient to investigate the delimitated epileptic area. If the epileptogenic zone hypothesis is not supported by the SEEG analysis, a second SEEG procedure could be performed to investigate the second zone. The increase in number of implanted electrodes does not necessarily increase by identification of an epileptogenic zone and could complicate the understanding of the procedure by the patient.
INSTRUCTOR: Delimitate a well-defined area to perform a cortectomy. Once a definitive trajectory is validated, the DICOM coordinates of each trajectory are transferred to the neuromate robot control station. Surgical setup consists in positioning the patient's head in a Talairach head clamp. The Talariach head clamp is still in use at Saint-Anne hospital,
INSTRUCTOR: but the neuromate robot can be used with other head fixation systems such as the Leksell frame G. During this step, it is important to maintain the head in a neutral position and include as much as possible a skull base in the O-arm field of view. The aim is the coregistration between the 3D O-arm series acquired intraoperatively and those of the preoperative MRI. Positioning and intraoperative planning procedure is similar to the robot-assisted stereotactic biopsy performed in our institution.
INSTRUCTOR: Artifacts due to Talairach head clamp or any other head fixation system should be taken into consideration during intraoperative imaging acquisition. As for a classical CT scan, one profile and one anterior posterior X-ray images are acquired to position the head at the center of the O-arm field of view, the final O-arm position, there registered.
INSTRUCTOR: Before starting a surgical procedure, the robot is to be checked. On the robot control station, the NMControl program is switched on and a test procedure is started. During this phase, the accuracy of the robot, the system communication, different reference positions, the anti-collision system and the remote control are verified. If the test is passed, the robot can be used.
INSTRUCTOR: The laser tool holder is installed on the robotic arm. It has to be firmly attached thanks to two fixation screws. The neurolocator registration module is positioned on the laser tool holder. This is the frameless system consisting of five ruby spheres, enabling intraoperative registration, without the need for bone or skin anchored fiducials. It is of utmost importance to have it correctly aligned because it will position the robot into the operative room space.
INSTRUCTOR: The neurolocator registration tool must be positioned as close to the patient's head as possible and aligned with the calvaria on the vertex, reducing the space between the skin and the neurolocate ruby spheres. The 3D O-arm acquisition is made and verified. All the 5 ruby spheres must be identified. The 3D acquisition is performed at a low-dose level to minimize patient irradiation.
INSTRUCTOR: The image is co-registered to preparative MRI. The imaging coregistration is roughly made manually and then refined by automatic algorithm. The quality of the coregistration process is verified by two neurosurgeons and the planned trajectories and controlled again. An additional safety check is realized. The robot is positioned into one trajectory axis.
INSTRUCTOR: A wire metallic pin inserted into the standard tool holder is put in contact with the patient's skin. A 3D O-arm series is acquired, then coregistered with preoperative MRI. There O-arm metallic pin has to be precisely aligned with the planned trajectory. This allows the final evaluation of the robot accuracy. The O-arm can be moved away from the surgical field,
INSTRUCTOR: thanks to the registration of its position during the first steps of the procedure. For each trajectory, the robotic arm is aligned on the trajectory axis. A minimal hair shaving is performed around the EP located on the skin. The robotic arm is then moved as close as possible to the patient's head to minimize mechanical deviation during the drilling process.
INSTRUCTOR: The drill hole is performed with a 2.5-mm-diameter drill bit. The drilling movement must be as smooth as possible and the bit as sharp as possible. The length of the drill bit is defined to perforate exclusively the bone without damaging the dura matter. A locking device is secured on the drill to execute the procedure with minimal risk. Once the bone hole is made,
INSTRUCTOR: the durotomy is realized thanks to a thin monopolar coagulation. The guiding screw dimension is chosen according to a homemade software, SEEGGapp and then secured into the skull. The distance between the distal part of the guiding screw and the target point located in the brain parenchyma guides the choice of the electrode length and number of contacts. A stylet is introduced before the electrode;
INSTRUCTOR: this preliminary trajectory minimizes trajectory deviation due to the electrode's flexibility. The electrode is slowly pushed into parenchyma and fixed thanks to the guided screw. The procedure is repeated in the same manner for each electrode. Once all the electrodes are positioned, the new 3D O-arm series is acquired using the registered O-arm position.
INSTRUCTOR: The new image is fused to the preoperative MRI and the trajectories are compared. If an electrode presents an important deviation of the target points, more than 2 mm, the corresponding electrode is removed, the length is adjusted, and then is replaced. Another 3D O-arm series is performed. This procedure is repeated until the trajectory is respective to the preparative planification.
INSTRUCTOR: The robot is moved to park position. The electrodes cables are fastened to the skull by surgical stitches. Lastly, the Talairach head clamp is removed, starting from the interior pins, moving subsequently to the posterior ones.
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