Name:
10.3171/2024.4.FOCVID245
Description:
10.3171/2024.4.FOCVID245
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/e04a4ae0-de25-4f03-825b-cd3ecfcd9cd0/videoscrubberimages/Scrubber_190.jpg
Duration:
T00H07M17S
Embed URL:
https://stream.cadmore.media/player/e04a4ae0-de25-4f03-825b-cd3ecfcd9cd0
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/e04a4ae0-de25-4f03-825b-cd3ecfcd9cd0/18. 24-5.mp4?sv=2019-02-02&sr=c&sig=HKYmHbXgbU18zrcE6qdxrDps1KtHMA%2FN1NAkjbhBtM0%3D&st=2026-04-24T05%3A13%3A49Z&se=2026-04-24T07%3A18%3A49Z&sp=r
Upload Date:
2024-05-16T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: Here, we review our methodology for targeting the centromedian nucleus and surgical procedure for CM-DBS in a patient with intractable generalized epilepsy. CM has high connectivity to cortical and subcortical regions, including sensorimotor cortex, striatum, brainstem, and cerebellum. Efficacy data supporting CM-DBS, including the 2022 ESTEL trial in patients with Lennox-Gastaut syndrome, reveal the importance of accurate target selection.
SPEAKER: The patient is a 33-year-old man with medically intractable epilepsy and intellectual disability with seizure onset occurring at 2 years of age. Video-EEG confirmed electroclinical features consistent with the diagnosis of Lennox-Gastaut syndrome, including multifocal seizure onset with bilateral tonic arm flexion, disorganized EEG background with diffuse polymorphic delta activity, and intermittent generalized paroxysmal fast activity.
SPEAKER: He had other seizure types, including bilateral tonic-clonic seizures, focal seizures, and a recent episode of nonconvulsive status. Seizures did not respond to insertion of a vagal nerve stimulation device at age 24. We plan for CM-DBS following a multidisciplinary epilepsy conference.
SPEAKER 2: CM is difficult to delineate on standard MRI sequences. We obtain a white matter– nulled MPRAGE sequence in preoperative imaging. Then the THOMAS method is used to segment the thalamus into individual nuclei. Here, the CM is labeled in yellow. The CM and the so-called sweet spot defined from the ESTEL investigators are burned into the preoperative films for targeting during surgery.
SPEAKER 2: We plan a trajectory to a point between this sweet spot and the canonical CM. Surgery is performed under general anesthesia. We affix a Leksell frame to the patient's head. A CT scan is obtained with the O-arm, and this new scan is aligned to the preoperative imaging. The patient's head is then affixed to the ROSA robot and secured.
SPEAKER 2: At this point, we unplug the bed to prevent movement of the body as the ROSA holds the head.
SPEAKER 1: ROSA is a robotic stereotactic assistance system that relies on fusion of the obtained O arm scan to the preoperative imaging, including the target, and registration of the scan with fiducial landmarks. Here are the pins of the frame to define the stereotactic space.
SPEAKER 2: We make approximately 3-cm incisions at each of the planned entry points. With the assistance of the ROSA robot, a 3.2-mm burr hole is created at each of these entry points. The ROSA arm was driven to 160 mm above the target in preparation for microelectrode recording. The Alpha Omega microdrive attaches to the ROSA arm and a guide cannula is inserted through the center channel of the Ben-Gun.
SPEAKER 2: At this point, we ensure the blood pressure is low to avoid the risk of hemorrhage. The microelectrode is threaded into the cannula and advanced along the planned trajectory, starting 15 mm superficial to the target. Here's a sample of the microelectrode recording from this case.
SPEAKER 1: At 5 mm above the target, which was the expected entry into CM, we observed a reduction in spiking in background activity, corroborating our trajectory's accuracy, and helping determine the final electrode depth. We've seen this reduction in activity in all CM cases thus far, and it is consistent with the reduced neural density of the structure.
SPEAKER 2: The electrode is placed onto the robot arm and into the brain at the targeted depth. The stylet is removed, and the guide cannula is carefully extracted. On the left side, the electrode is tunneled to the right side and secured in place with a dog-bone plate. The process of microelectrode recording and electrode placement is repeated for the contralateral side.
SPEAKER 2: We then carefully tuck the leads into a subgaleal pocket. The surgical sites are irrigated with saline and instilled with vancomycin powder. The O-arm confirms placement of the electrodes. We visualize this with the planning software. Next, we detach the patient from the robot and reposition him for implantation of the IPG.
SPEAKER 2: In the chest, we dissect a pocket in the subfascial plane. From the scalp incision, a tunneler is passed to this chest incision. We attach the lead extenders, bringing the leads through the tunnel and connect it to the pulse generator. Impedances are reassuring. The scalp and the chest incisions are closed. We obtain a postoperative CT scan. Using the Lead-DBS software, we verify the lead positions.
SPEAKER 2: Here, we placed the electrodes between the CM and the ESTEL sweet spot as we initially planned. Programming settings follow the ESTEL and SANTE trials with pulse width of 90 microseconds and frequency at 145 Hz. Future follow-up will assess the degree of symptomatic improvement.
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