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Han CL, Chou CC, Chen HH, Chen YH, Lin CF, Chen C, Yu HY, Chen YW, Lee CC. Frame-based versus robot-assisted stereo-electro-encephalography for drug-resistant epilepsy. Acta Neurochir (Wien) 2024; 166:85. [PMID: 38361129 DOI: 10.1007/s00701-024-05983-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/11/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Stereoelectroencephalography (SEEG) is an effective presurgical invasive evaluation for drug-resistant epilepsies. The introduction of robotic devices provides a simplified, accurate, and safe alternative to the conventional SEEG technique. We report our institutional experience with robot-assisted SEEG and compare its in vivo accuracy, operation efficiency, and safety with the more traditional SEEG workflow. METHODS All patients with medically refractory focal epilepsy who underwent SEEG depth electrode implantation between 2014 and 2022 were included in this study. Technical advancements of the robot-assisted technique are described. Analyses of patient demographics, electrode implantation accuracy, operation time, and procedure-related complications were performed. RESULTS One hundred and sixty-six patients underwent 167 SEEG procedures. The first 141 procedures were performed using a conventional approach involving a Leksell stereotactic system, and the last 26 procedures were robot-assisted. Among the 1726 depth electrodes that were inserted, the median entry point localization error was as follows: conventional (1.0 mm; range, 0.1-33.5 mm) and robot-assisted (1.1 mm; range, 0-4.8 mm) (P = 0.17). The median target point localization error was as follows: conventional (2.8 mm; range, 0.1-49 mm) and robot-assisted (1.8 mm; range, 0-30.3 mm) (P < 0.001). The median operation time was significantly reduced with the robot-assisted workflow (90 min vs. 77.5 min; P < 0.01). Total complication rates were as follows: conventional (17.7%) and robot-assisted (11.5%) (P = 0.57). Major complication rates were 3.5% and 7.7% (P = 0.77), respectively. CONCLUSIONS SEEG is a safe and highly accurate method that provides essential guidance for epilepsy surgery. Implementing SEEG in conjunction with multimodal planning systems and robotic devices can further increase safety margin, surgical efficiency, and accuracy.
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Affiliation(s)
- Chang-Lin Han
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chien-Chen Chou
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hsin-Hung Chen
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Hsiu Chen
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chun-Fu Lin
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chien Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hsiang-Yu Yu
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yu-Wei Chen
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Winter F, Krueger MT, Delev D, Theys T, Van Roost DMP, Fountas K, Schijns OE, Roessler K. Current state of the art of traditional and minimal invasive epilepsy surgery approaches. BRAIN & SPINE 2024; 4:102755. [PMID: 38510599 PMCID: PMC10951767 DOI: 10.1016/j.bas.2024.102755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 01/11/2024] [Accepted: 01/21/2024] [Indexed: 03/22/2024]
Abstract
Introduction Open resective surgery remains the main treatment modality for refractory epilepsy, but is often considered a last resort option due to its invasiveness. Research question This manuscript aims to provide an overview on traditional as well as minimally invasive surgical approaches in modern state of the art epilepsy surgery. Materials and methods This narrative review addresses both historical and contemporary as well as minimal invasive surgical approaches in epilepsy surgery. Peer-reviewed published articles were retrieved from PubMed and Scopus. Only articles written in English were considered for this work. A range of traditional and minimally invasive surgical approaches in epilepsy surgery were examined, and their respective advantages and disadvantages have been summarized. Results The following approaches and techniques are discussed: minimally invasive diagnostics in epilepsy surgery, anterior temporal lobectomy, functional temporal lobectomy, selective amygdalohippocampectomy through a transsylvian, transcortical, or subtemporal approach, insulo-opercular corticectomies compared to laser interstitial thermal therapy, radiofrequency thermocoagulation, stereotactic radiosurgery, neuromodulation, high intensity focused ultrasound, and disconnection surgery including callosotomy, hemispherotomy, and subpial transections. Discussion and conclusion Understanding the benefits and disadvantages of different surgical approaches and strategies in traditional and minimal invasive epilepsy surgery might improve the surgical decision tree, as not all procedures are appropriate for all patients.
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Affiliation(s)
- Fabian Winter
- Department of Neurosurgery, Medical University of Vienna, Austria
| | - Marie T. Krueger
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Stereotactic and Functional Neurosurgery, Medical Center of the University of Freiburg, Freiburg, Germany
| | - Daniel Delev
- Department of Neurosurgery, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
- Center for Integrated Oncology, Universities Aachen, Bonn, Cologne, Düsseldorf (CIO ABCD), Germany
| | - Tom Theys
- Department of Neurosurgery, Universitair Ziekenhuis Leuven, UZ Leuven, Belgium
| | | | - Kostas Fountas
- Department of Neurosurgery, University of Thessaly, Greece
| | - Olaf E.M.G. Schijns
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, the Netherlands
- School for Mental Health and Neuroscience (MHeNS), University Maastricht, Maastricht, the Netherlands
- Academic Center for Epileptology, Maastricht University Medical Center & Kempenhaeghe, Maastricht, Heeze, the Netherlands
| | - Karl Roessler
- Department of Neurosurgery, Medical University of Vienna, Austria
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Winter F, Wilken T, Bammerlin M, Shawarba J, Dorfer C, Roessler K. Navigated, Robot-Driven Laser Craniotomy for SEEG Application Using Optical Coherence Tomography in an Animal Model. Front Robot AI 2021; 8:695363. [PMID: 34277720 PMCID: PMC8278282 DOI: 10.3389/frobt.2021.695363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 06/21/2021] [Indexed: 11/29/2022] Open
Abstract
Objectives: We recently introduced a navigated, robot-driven laser beam craniotomy for use with stereoelectroencephalography (SEEG) applications. This method was intended to substitute the hand-held electric power drill in an ex vivo study. The purpose of this in vivo non-recovery pilot study was to acquire data for the depth control unit of this laser device, to test the feasibility of cutting bone channels, and to assess dura perforation and possible cortex damage related to cold ablation. Methods: Multiple holes suitable for SEEG bone channels were planned for the superior portion of two pig craniums using surgical planning software and a frameless, navigated technique. The trajectories were planned to avoid cortical blood vessels using magnetic resonance angiography. Each trajectory was converted into a series of circular paths to cut bone channels. The cutting strategy for each hole involved two modes: a remaining bone thickness mode and a cut through mode (CTR). The remaining bone thickness mode is an automatic coarse approach where the cutting depth is measured in real time using optical coherence tomography (OCT). In this mode, a pre-set measurement, in mm, of the remaining bone is left over by automatically comparing the bone thickness from computed tomography with the OCT depth. In the CTR mode, the cut through at lower cutting energies is managed by observing the cutting site with real-time video. Results: Both anesthesia protocols did not show any irregularities. In total, 19 bone channels were cut in both specimens. All channels were executed according to the planned cutting strategy using the frameless navigation of the robot-driven laser device. The dura showed minor damage after one laser beam and severe damage after two and three laser beams. The cortex was not damaged. As soon as the cut through was obtained, we observed that moderate cerebrospinal fluid leakage impeded the cutting efficiency and interfered with the visualization for depth control. The coaxial camera showed a live video feed in which cut through of the bone could be identified in 84%. Conclusion: Inflowing cerebrospinal fluid disturbed OCT signals, and, therefore, the current CTR method could not be reliably applied. Video imaging is a candidate for observing a successful cut through. OCT and video imaging may be used for depth control to implement an updated SEEG bone channel cutting strategy in the future.
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Affiliation(s)
- Fabian Winter
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | | | | | - Julia Shawarba
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Christian Dorfer
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Karl Roessler
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
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Ladisich B, Machegger L, Romagna A, Krainz H, Steinbacher J, Leitinger M, Kalss G, Thon N, Trinka E, Winkler PA, Schwartz C. VarioGuide® frameless neuronavigation-guided stereoelectroencephalography in adult epilepsy patients: technique, accuracy and clinical experience. Acta Neurochir (Wien) 2021; 163:1355-1364. [PMID: 33580853 PMCID: PMC8053662 DOI: 10.1007/s00701-021-04755-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 02/01/2021] [Indexed: 12/12/2022]
Abstract
Background Stereoelectroencephalography (SEEG) allows the identification of deep-seated seizure foci and determination of the epileptogenic zone (EZ) in drug-resistant epilepsy (DRE) patients. We evaluated the accuracy and treatment-associated morbidity of frameless VarioGuide® (VG) neuronavigation-guided depth electrode (DE) implantations. Methods We retrospectively identified all consecutive adult DRE patients, who underwent VG-neuronavigation DE implantations, between March 2013 and April 2019. Clinical data were extracted from the electronic patient charts. An interdisciplinary team agreed upon all treatment decisions. We performed trajectory planning with iPlan® Cranial software and DE implantations with the VG system. Each electrode’s accuracy was assessed at the entry (EP), the centre (CP) and the target point (TP). We conducted correlation analyses to identify factors associated with accuracy. Results The study population comprised 17 patients (10 women) with a median age of 32.0 years (range 21.0–54.0). In total, 220 DEs (median length 49.3 mm, range 25.1–93.8) were implanted in 21 SEEG procedures (range 3–16 DEs/surgery). Adequate signals for postoperative SEEG were detected for all but one implanted DEs (99.5%); in 15/17 (88.2%) patients, the EZ was identified and 8/17 (47.1%) eventually underwent focus resection. The mean deviations were 3.2 ± 2.4 mm for EP, 3.0 ± 2.2 mm for CP and 2.7 ± 2.0 mm for TP. One patient suffered from postoperative SEEG-associated morbidity (i.e. conservatively treated delayed bacterial meningitis). No mortality or new neurological deficits were recorded. Conclusions The accuracy of VG-SEEG proved sufficient to identify EZ in DRE patients and associated with a good risk-profile. It is a viable and safe alternative to frame-based or robotic systems. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-021-04755-w.
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Affiliation(s)
- Barbara Ladisich
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, A-5020, Salzburg, Austria
| | - Lukas Machegger
- University Institute of Neuroradiology, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, 5020, Salzburg, Austria
| | - Alexander Romagna
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, A-5020, Salzburg, Austria
- Department of Neurosurgery, München Klinik Bogenhausen, Englschalkingerstr. 77, 81925, Munich, Germany
| | - Herbert Krainz
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, A-5020, Salzburg, Austria
| | - Jürgen Steinbacher
- University Institute of Neuroradiology, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, 5020, Salzburg, Austria
| | - Markus Leitinger
- Department of Neurology, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, 5020, Salzburg, Austria
| | - Gudrun Kalss
- Department of Neurology, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, 5020, Salzburg, Austria
| | - Niklas Thon
- Department of Neurosurgery, University Hospital Munich, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Eugen Trinka
- Department of Neurology, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, 5020, Salzburg, Austria
| | - Peter A Winkler
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, A-5020, Salzburg, Austria
| | - Christoph Schwartz
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, A-5020, Salzburg, Austria.
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Fujimoto A, Masuda Y, Ichikawa N, Sato K, Baba S, Itamura S, Nishimura M, Enoki H, Okanishi T. Side Slit Guide Pipe for Precise Placement of Depth Electrodes. World Neurosurg 2019; 126:291-295. [PMID: 30885874 DOI: 10.1016/j.wneu.2019.03.067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 03/06/2019] [Accepted: 03/07/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Using a stereotactic technique, surgeons can accurately place a depth electrode (DE), but sometimes the DE deviates from the intended target due to movement of the electrode or leakage of cerebrospinal fluid when placing the electrode. If DEs can be anchored before removing the catheter insertion guide pipe, more accurate placement may be possible. METHODS We made a side slit guide pipe. When the DEs were anchored to the dura or the edge of the burr hole, the DE did not move when the guide pipe was removed. We measured the distance between the planned target and the tip of the electrode in 13 patients (3 female and 10 male patients; age range, 7-43 years; mean age 23.0 years; median age 27 years) with medically intractable epilepsy who underwent DE placement with stereotactic neuronavigation guidance. RESULTS There were 30 DEs implanted. The mean distance from the planned target to the tip of the DE was 0.570 mm (range, 0.3-1.2 mm; median 0.5 mm; SD 0.212). The mean distance from the planned target to the tip of the DE with dural anchoring was 0.467 mm (range, 0.3-0.6 mm; median 0.45 mm; SD 0.121) and with burr hole edge anchoring was 0.596 mm (range, 0.3-1.2 mm; median 0.50 mm; SD 0.224; P = 0.205). CONCLUSIONS DEs can be anchored using the side slit guide pipe for more precise placement.
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Affiliation(s)
- Ayataka Fujimoto
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan.
| | - Yosuke Masuda
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Naoki Ichikawa
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Keishiro Sato
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Shimpei Baba
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Shinji Itamura
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Mitsuyo Nishimura
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Hideo Enoki
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Tohru Okanishi
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
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Minchev G, Kronreif G, Ptacek W, Dorfer C, Micko A, Maschke S, Legnani FG, Widhalm G, Knosp E, Wolfsberger S. A novel robot-guided minimally invasive technique for brain tumor biopsies. J Neurosurg 2019; 132:150-158. [PMID: 30660122 DOI: 10.3171/2018.8.jns182096] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 08/28/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE As decisions regarding tumor diagnosis and subsequent treatment are increasingly based on molecular pathology, the frequency of brain biopsies is increasing. Robotic devices overcome limitations of frame-based and frameless techniques in terms of accuracy and usability. The aim of the present study was to present a novel, minimally invasive, robot-guided biopsy technique and compare the results with those of standard burr hole biopsy. METHODS A tubular minimally invasive instrument set was custom-designed for the iSYS-1 robot-guided biopsies. Feasibility, accuracy, duration, and outcome were compared in a consecutive series of 66 cases of robot-guided stereotactic biopsies between the minimally invasive (32 patients) and standard (34 patients) procedures. RESULTS Application of the minimally invasive instrument set was feasible in all patients. Compared with the standard burr hole technique, accuracy was significantly higher both at entry (median 1.5 mm [range 0.2-3.2 mm] vs 1.7 mm [range 0.8-5.1 mm], p = 0.008) and at target (median 1.5 mm [range 0.4-3.4 mm] vs 2.0 mm [range 0.8-3.9 mm], p = 0.019). The incision-to-suture time was significantly shorter (median 30 minutes [range 15-50 minutes] vs 37.5 minutes [range 25-105 minutes], p < 0.001). The skin incision was significantly shorter (median 16.3 mm [range 12.7-23.4 mm] vs 28.4 mm [range 20-42.2 mm], p = 0.002). A diagnostic tissue sample was obtained in all cases. CONCLUSIONS Application of the novel instrument set was feasible in all patients. According to the authors' data, the minimally invasive robot-guidance procedure can significantly improve accuracy, reduce operating time, and improve the cosmetic result of stereotactic biopsies.
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Affiliation(s)
- Georgi Minchev
- 1Department of Neurosurgery, Medical University of Vienna
| | - Gernot Kronreif
- 2Austrian Center of Medical Innovation and Technology (ACMIT), Wiener Neustadt, Austria; and
| | - Wolfgang Ptacek
- 2Austrian Center of Medical Innovation and Technology (ACMIT), Wiener Neustadt, Austria; and
| | | | | | - Svenja Maschke
- 1Department of Neurosurgery, Medical University of Vienna
| | - Federico G Legnani
- 3Department of Neurosurgery, Fondazione IRCCS Instituto degli Neurologica C. Besta, Milan, Italy
| | - Georg Widhalm
- 1Department of Neurosurgery, Medical University of Vienna
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Abstract
The goal of any epilepsy surgery is to improve patient's quality of life by achieving seizure freedom or by reducing the frequency of severely debilitating seizures. To achieve this goal, non-invasive and invasive diagnostic methods must precisely delineate the epileptogenic zone (EZ), which is defined as the area that needs to be resected to obtain seizure freedom. At the same time, the correct identification of eloquent brain areas is inevitable to avoid new neurological deficits from surgery. In recent years, the technical advances in diagnostics have enabled us to achieve these goals in an increasing number of cases. As a consequence, and with new surgical treatment options available, the number of patients who might benefit from epilepsy surgery is constantly increasing. Especially in pediatric epilepsy, early surgical intervention is becoming frequently advocated as it has been shown to improve cognitive and behavioral outcome. Specialized epilepsy centers and multidisciplinary teams are required to provide adequate care and treatment. The goal of this review is to describe important diseases that are accessible to epilepsy surgery and to give an overview of current diagnostic methods. The focus lies on established as well as novel techniques in epilepsy surgery. The presurgical work-up and patient selection is outlined.
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Affiliation(s)
- Johannes Herta
- Department of Neurosurgery, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Christian Dorfer
- Department of Neurosurgery, Vienna General Hospital, Medical University of Vienna, Vienna, Austria -
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Sankey EW, Butler E, Sampson JH. Accuracy of Novel Computed Tomography–Guided Frameless Stereotactic Drilling and Catheter System in Human Cadavers. World Neurosurg 2017; 106:757-763. [DOI: 10.1016/j.wneu.2017.07.098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 07/16/2017] [Accepted: 07/17/2017] [Indexed: 10/19/2022]
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Budke M, Avecillas-Chasin JM, Villarejo F. Implantation of Depth Electrodes in Children Using VarioGuide® Frameless Navigation System: Technical Note. Oper Neurosurg (Hagerstown) 2017; 15:302-309. [DOI: 10.1093/ons/opx192] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 08/05/2017] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Electrode placement in epilepsy surgery seeks to locate the sites of ictal onset and early propagation. An invasive diagnostic procedure, stereoelectroencephalography (SEEG) is usually implemented with frame-based methods that can be especially problematic in young children.
OBJECTIVE
To evaluate the feasibility and accuracy of a new technique for frameless SEEG in children using the VarioGuide® system (Brainlab AG, München, Germany).
METHODS
A frameless stereotactic navigation system was used to implant depth electrodes with percutaneous drilling and bolt insertion in pediatric patients with medically refractory epilepsy. Data on general demographic information of electrode implantation, duration, number, and complications were retrospectively collected. To determine the placement accuracy of the VarioGuide® frameless system, the mean Euclidean distances were calculated by comparing the preoperatively planned trajectories with the final electrode position observed on postoperative computed tomography scans.
RESULTS
From May 2011 to December 2015, 15 patients (8 males, 7 females; mean age: 8 yr, range: 3-16 yr) underwent SEEG depth electrode implantation of a total of 111 electrodes. The mean error measured by the Euclidean distance from the center of the entry point to the intended entry point was 3.64 ± 1.78 mm (range: 0.58-7.59 mm) and the tip of the electrode to the intended target was 2.96 ± 1.49 mm (range: 0.58-7.82 mm). There were no significant complications.
CONCLUSION
Depth electrodes can be placed safely and accurately in children using the VarioGuide® frameless stereotactic navigation system.
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Affiliation(s)
- Marcelo Budke
- Department of Pediatric Neurosurgery, Hospital Niño Jesus, Madrid, Spain
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Fujimoto A, Okanishi T, Kanai S, Sato K, Nishimura M, Enoki H. Neuronavigation-guided Frameless Stereoelectroencephalography (SEEG). Neurol Med Chir (Tokyo) 2017; 57:496-502. [PMID: 28768920 PMCID: PMC5638794 DOI: 10.2176/nmc.tn.2017-0110] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Stereoelectroencephalography (SEEG) is an invasive surgical procedure used to identify epileptogenic zones. The combination of both subdural grids and depth electrodes (DEs) is currently used for invasive intracranial monitoring in many epilepsy centers. To perform DE implantation, some centers use frame-based stereotactic techniques and others use stereotactic robotic techniques. However, not all epilepsy centers have access to these tools. We hypothesized that DE implantation using a neuronavigation system can be utilized for subsequent epilepsy surgery. Between April 2016 and April 2017, we performed invasive monitoring for 26 patients. Among these, 17 patients (8 females, 9 males; mean age, 21.2 years; range, 3–51 years) underwent DE implantation. We divided patients into three groups: Group 1 (7 patients), a free-hand implantation group; Group 2 (7 patients), a frameless stereotactic implantation group; and Group 3 (3 patients), a computed tomography (CT)-guided auto image registration system with the stereotactic implantation group. Group 3 showed the closest distance from planned target to DE tip, followed by Group 2. Fourteen of the 17 patients underwent subsequent epilepsy surgery referring to the results of DE studies. DE placement using a neuronavigation system without stereotactic robotic equipment or frame-based stereotactic techniques can be utilized for subsequent epilepsy surgery.
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Affiliation(s)
- Ayataka Fujimoto
- Seirei Hamamatsu General Hospital, Comprehensive Epilepsy Center
| | - Tohru Okanishi
- Seirei Hamamatsu General Hospital, Comprehensive Epilepsy Center
| | - Sotaro Kanai
- Seirei Hamamatsu General Hospital, Comprehensive Epilepsy Center
| | - Keishiro Sato
- Seirei Hamamatsu General Hospital, Comprehensive Epilepsy Center
| | | | - Hideo Enoki
- Seirei Hamamatsu General Hospital, Comprehensive Epilepsy Center
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Abstract
Stereoelectroencephalography (SEEG) is a method for invasive study of patients with refractory epilepsy. Localization of the epileptogenic zone in SEEG relied on the hypothesis of anatomo-electro-clinical analysis limited by X-ray, analog electroencephalography (EEG), and seizure semiology in the 1950s. Modern neuroimaging studies and digital video-EEG have developed the hypothesis aiming at more precise localization of the epileptic network. Certain clinical scenarios favor SEEG over subdural EEG (SDEEG). SEEG can cover extensive areas of bilateral hemispheres with highly accurate sampling from sulcal areas and deep brain structures. A hybrid technique of SEEG and subdural strip electrode placement has been reported to overcome the SEEG limitations of poor functional mapping. Technological advances including acquisition of three-dimensional angiography and magnetic resonance image (MRI) in frameless conditions, advanced multimodal planning, and robot-assisted implantation have contributed to the accuracy and safety of electrode implantation in a simplified fashion. A recent meta-analysis of the safety of SEEG concluded the low value of the pooled prevalence for all complications. The complications of SEEG were significantly less than those of SDEEG. The removal of electrodes for SEEG was much simpler than for SDEEG and allowed sufficient time for data analysis, discussion, and consensus for both patients and physicians before the proceeding treatment. Furthermore, SEEG is applicable as a therapeutic alternative for deep-seated lesions, e.g., nodular heterotopia, in nonoperative epilepsies using SEEG-guided radiofrequency thermocoagulation. We review the SEEG method with technological advances for planning and implantation of electrodes. We highlight the indication and efficacy, advantages and disadvantages of SEEG compared with SDEEG.
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Affiliation(s)
- Koji Iida
- Department of Neurosurgery, Hiroshima University Hospital.,Epilepsy Center, Hiroshima University Hospital
| | - Hiroshi Otsubo
- Neurophysiology Laboratory, Division of Neurology, The Hospital for Sick Children
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Stereotactic Electroencephalography Is a Safe Procedure, Including for Insular Implantations. World Neurosurg 2016; 99:353-361. [PMID: 28003163 DOI: 10.1016/j.wneu.2016.12.025] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 12/05/2016] [Accepted: 12/08/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND In some cases of drug-resistant focal epilepsy, noninvasive presurgical investigation may be insufficient to identify the ictal onset zone and the eloquent cortical areas. In such situations, invasive investigations are proposed using either stereotactic electroencephalography (SEEG) or subdural grid electrodes. Meta-analysis suggests that SEEG is safer than subdural grid electrodes, but insular implantation of SEEG electrodes has been thought to carry an additional risk of intraparenchymal hemorrhagic complications. Our objectives were to determine whether an insular SEEG trajectory is a risk factor for intracranial hematoma and to report the global safety of the procedure and provide some guidelines to prevent and detect complications. METHODS In a retrospective analysis of a surgical series of 525 consecutive procedures between 1995 and 2015, all electrodes were classified according to their insular or extrainsular trajectory. All complications were classified as major or minor according to their potential consequences regarding patient neurologic status. RESULTS Four intraparenchymal hematomas, all related to extrainsular electrodes (4/4974; 0.08%) were reported; no hematoma was found along insular electrodes (0/1042; 0%). There were 8 major complications (1.52%): 7 intracranial hematomas (1.33%) and 1 case of meningitis. Two patients had long-term neurologic impairment (0.38%), and 1 death (not directly related to the procedure) occurred (0.19%). Eleven minor complications (2.09%) were encountered, including broken electrode (1.52%), acute pneumocephalus (0.38%), and local cutaneous infection (0.19%). CONCLUSIONS SEEG is a safe procedure. Insular trajectories cannot be considered an additional risk of intracranial bleeding.
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Cardinale F, Casaceli G, Raneri F, Miller J, Lo Russo G. Implantation of Stereoelectroencephalography Electrodes. J Clin Neurophysiol 2016; 33:490-502. [DOI: 10.1097/wnp.0000000000000249] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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Dorfer C, Minchev G, Czech T, Stefanits H, Feucht M, Pataraia E, Baumgartner C, Kronreif G, Wolfsberger S. A novel miniature robotic device for frameless implantation of depth electrodes in refractory epilepsy. J Neurosurg 2016; 126:1622-1628. [PMID: 27494814 DOI: 10.3171/2016.5.jns16388] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors' group recently published a novel technique for a navigation-guided frameless stereotactic approach for the placement of depth electrodes in epilepsy patients. To improve the accuracy of the trajectory and enhance the procedural workflow, the authors implemented the iSys1 miniature robotic device in the present study into this routine. METHODS As a first step, a preclinical phantom study was performed using a human skull model, and the accuracy and timing between 5 electrodes implanted with the manual technique and 5 with the aid of the robot were compared. After this phantom study showed an increased accuracy with robot-assisted electrode placement and confirmed the robot's ability to maintain stability despite the rotational forces and the leverage effect from drilling and screwing, patients were enrolled and analyzed for robot-assisted depth electrode placement at the authors' institution from January 2014 to December 2015. All procedures were performed with the S7 Surgical Navigation System with Synergy Cranial software and the iSys1 miniature robotic device. RESULTS Ninety-three electrodes were implanted in 16 patients (median age 33 years, range 3-55 years; 9 females, 7 males). The authors saw a significant increase in accuracy compared with their manual technique, with a median deviation from the planned entry and target points of 1.3 mm (range 0.1-3.4 mm) and 1.5 mm (range 0.3-6.7 mm), respectively. For the last 5 patients (31 electrodes) of this series the authors modified their technique in placing a guide for implantation of depth electrodes (GIDE) on the bone and saw a significant further increase in the accuracy at the entry point to 1.18 ± 0.5 mm (mean ± SD) compared with 1.54 ± 0.8 mm for the first 11 patients (p = 0.021). The median length of the trajectories was 45.4 mm (range 19-102.6 mm). The mean duration of depth electrode placement from the start of trajectory alignment to fixation of the electrode was 15.7 minutes (range 8.5-26.6 minutes), which was significantly faster than with the manual technique. In 12 patients, depth electrode placement was combined with subdural electrode placement. The procedure was well tolerated in all patients. The authors did not encounter any case of hemorrhage or neurological deficit related to the electrode placement. In 1 patient with a psoriasis vulgaris, a superficial wound infection was encountered. Adequate physiological recordings were obtained from all electrodes. No additional electrodes had to be implanted because of misplacement. CONCLUSIONS The iSys1 robotic device is a versatile and easy to use tool for frameless implantation of depth electrodes for the treatment of epilepsy. It increased the accuracy of the authors' manual technique by 60% at the entry point and over 30% at the target. It further enhanced and expedited the authors' procedural workflow.
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Affiliation(s)
| | | | | | | | - Martha Feucht
- Departments of 2 Pediatrics and Adolescence Medicine and
| | | | | | - Gernot Kronreif
- Austrian Center of Medical Innovation and Technology (ACMIT), Wiener Neustadt, Austria
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Roessler K, Sommer B, Merkel A, Rampp S, Gollwitzer S, Hamer HM, Buchfelder M. A Frameless Stereotactic Implantation Technique for Depth Electrodes in Refractory Epilepsy Using Intraoperative Magnetic Resonance Imaging. World Neurosurg 2016; 94:206-210. [PMID: 27389940 DOI: 10.1016/j.wneu.2016.06.114] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Revised: 06/25/2016] [Accepted: 06/27/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Various complex techniques for depth electrode insertion in refractory epilepsy using preoperative imaging have been investigated. We evaluated a simple, accurate, cost-effective, and timesaving method using intraoperative magnetic resonance imaging (MRI). METHODS A neuronavigation-guided insertion tube attached to bone facilitated the placement of stereotactic percutaneous drill holes, bolt implantation, and frameless stereotactic insertion of depth electrodes. Image registration was carried out by head coil fiducials with trajectory planning and intraoperative electrode correction. RESULTS In 6 patients with refractory epilepsy (3 women and 3 men; mean age, 30.0 years; range, 20-37 years), 58 depth electrodes (9-11 per patient) were placed. The mean length of the inserted electrodes was 37.3 mm ± 8.8 (mean ± SD) (range, 22.1-84.4 mm). The overall target point accuracy was 3.2 mm ± 2.2 (range, 0-8.6 mm), which was significantly different from the overall entry point accuracy of 1.4 mm ± 1.2 (P < 0.0001). All electrodes functioned perfectly, enabling high-quality stereo-electroencephalography recordings over a period of 7.3 days ± 0.5 (range, 7-8 days). The mean implantation time for 9-11 electrodes per patient was 115 minutes ± 36.3 (range, 75-160 minutes; 12 minutes for 1 electrode on average) including the intraoperative MRI (T1 three-dimensional magnetization-prepared rapid acquisition gradient echo, T2, and diffusion tensor imaging). There was no hemorrhage, infection, or neurologic deficit related to the procedure. CONCLUSIONS Our frameless technique of depth electrode insertion using intraoperative MRI guidance is an accurate, reliable, cost-effective, and timesaving method for stereo-electroencephalography.
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Affiliation(s)
- Karl Roessler
- Department of Neurosurgery, Epilepsy Centre, University Hospital Erlangen, Erlangen, Germany.
| | - Björn Sommer
- Department of Neurosurgery, Epilepsy Centre, University Hospital Erlangen, Erlangen, Germany
| | - Andreas Merkel
- Department of Neurosurgery, Epilepsy Centre, University Hospital Erlangen, Erlangen, Germany
| | - Stefan Rampp
- Department of Neurosurgery, Epilepsy Centre, University Hospital Erlangen, Erlangen, Germany
| | - Stephanie Gollwitzer
- Department of Neurology, Epilepsy Centre, University Hospital Erlangen, Erlangen, Germany
| | - Hajo M Hamer
- Department of Neurology, Epilepsy Centre, University Hospital Erlangen, Erlangen, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, Epilepsy Centre, University Hospital Erlangen, Erlangen, Germany
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Mullin JP, Shriver M, Alomar S, Najm I, Bulacio J, Chauvel P, Gonzalez-Martinez J. Is SEEG safe? A systematic review and meta-analysis of stereo-electroencephalography-related complications. Epilepsia 2016; 57:386-401. [DOI: 10.1111/epi.13298] [Citation(s) in RCA: 250] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2015] [Indexed: 12/18/2022]
Affiliation(s)
- Jeffrey P. Mullin
- Department of Neurosurgery; Neurological Institute; Cleveland Clinic; Cleveland Ohio U.S.A
| | - Michael Shriver
- Case Western Reserve University School of Medicine; Cleveland Ohio U.S.A
| | - Soha Alomar
- Department of Neurosurgery; Neurological Institute; Cleveland Clinic; Cleveland Ohio U.S.A
| | - Imad Najm
- Case Western Reserve University School of Medicine; Cleveland Ohio U.S.A
| | - Juan Bulacio
- Case Western Reserve University School of Medicine; Cleveland Ohio U.S.A
| | - Patrick Chauvel
- Case Western Reserve University School of Medicine; Cleveland Ohio U.S.A
| | - Jorge Gonzalez-Martinez
- Department of Neurosurgery; Neurological Institute; Cleveland Clinic; Cleveland Ohio U.S.A
- Epilepsy Center; Neurological Institute; Cleveland Clinic; Cleveland Ohio U.S.A
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Avecillas-Chasin JM, Budke M, Villarejo F. Neuroendoscopic Intraventricular Biopsy in Children with Small Ventricles Using Frameless VarioGuide System. World Neurosurg 2016; 87:136-42. [PMID: 26723291 DOI: 10.1016/j.wneu.2015.12.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 12/18/2015] [Accepted: 12/18/2015] [Indexed: 11/15/2022]
Abstract
Endoscopic biopsy for intraventricular tumors in pediatric patients with small ventricles is a challenging procedure because of the risk of morbidity during the intraventricular approach. We describe the use of the VarioGuide system for intraventricular endoscopic biopsy in 9 consecutive pediatric patients with intraventricular lesions and small ventricular size. All patients had lesions in the anterior part of the third ventricle with a median frontal and occipital horn ratio of 0.33. Patients presented with growth failure (n = 4), visual disturbances (n = 4), and seizures (n = 1). The VarioGuide system consists of an ergonomic arm with 3 joints for gross adjustment. The 3 rotational joints on the distal side of the system are adjusted according to the angles of the planned trajectory. The endoscope is adjusted to the distal side of the VarioGuide and inserted through the ring, previously set for the diameter of the endoscope and for the planned trajectory. The accuracy of the trajectory and correct ventricular cannulation are confirmed under endoscopic guidance. The biopsy is carried out according to the standard technique. In all cases, the biopsy sample provided the definitive diagnosis. Diagnoses included germinomas in 4 patients, hamartoma in 1 patient, hypothalamic astrocytoma in 2 patients, and craniopharyngioma in 2 patients. The use of the VarioGuide system for intraventricular endoscopic biopsy is highly recommended for pediatric patients with small ventricle size. This technique may help minimize the risk of unnecessary brain damage during the entrance to small ventricles.
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Affiliation(s)
| | - Marcelo Budke
- Department of Neurosurgery, Hospital Infantil Universitario Niño Jesus, Madrid, Spain.
| | - Francisco Villarejo
- Department of Neurosurgery, Hospital Infantil Universitario Niño Jesus, Madrid, Spain
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Verburg N, Baayen JC, Idema S, Klitsie MAJ, Claus S, de Jonge CS, Vandertop WP, de Witt Hamer PC. In Vivo Accuracy of a Frameless Stereotactic Drilling Technique for Diagnostic Biopsies and Stereoelectroencephalography Depth Electrodes. World Neurosurg 2015; 87:392-8. [PMID: 26700749 DOI: 10.1016/j.wneu.2015.11.041] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 11/29/2015] [Accepted: 11/30/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Accurate frameless neuronavigation is highly important in cranial neurosurgery. The accuracy demonstrated in phantom models might not be representative for results in patients. Few studies describe the in vivo quantitative accuracy of neuronavigation in patients. The use of a frameless stereotactic drilling technique for stereoelectroencephalography depth electrode implantation in epilepsy patients, as well as diagnostic biopsies, provides a unique opportunity to assess the accuracy with postoperative imaging of preoperatively planned trajectories. METHODS In 7 patients with refractory epilepsy, 89 depth electrodes were implanted using a frameless stereotactic drilling technique. Each electrode was planned on a preoperative magnetic resonance and computed tomographic scan, and verified on postoperative computed tomographic scan. After fusion of preoperative and postoperative imaging, the accuracy for each electrode was calculated as the Euclidean distance between the planned and observed position of the electrode tip. RESULTS The median Euclidean distance between planned and observed electrode implantations was 3.5 mm (95% confidence interval, 2.9-3.9 mm) with a range of 1.2-13.7 mm. CONCLUSIONS In this study, we showed that the in vivo accuracy of our frameless stereotactic drilling technique, suitable for stereoelectroencephalography depth electrode placement and diagnostic brain biopsies, was 3.5 mm.
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Affiliation(s)
- Niels Verburg
- Neurosurgical Center Amsterdam, VU Medical Centre, Amsterdam, The Netherlands.
| | - Johannes C Baayen
- Neurosurgical Center Amsterdam, VU Medical Centre, Amsterdam, The Netherlands
| | - Sander Idema
- Neurosurgical Center Amsterdam, VU Medical Centre, Amsterdam, The Netherlands
| | - Michiel A J Klitsie
- Neurosurgical Center Amsterdam, VU Medical Centre, Amsterdam, The Netherlands
| | - Steven Claus
- Department of Clinical Neurophysiology, Stichting Epilepsy Instellingen Nederland, Epilepsy Institutes in The Netherlands, SEIN, Heemstede, The Netherlands
| | | | - W Peter Vandertop
- Neurosurgical Center Amsterdam, VU Medical Centre, Amsterdam, The Netherlands
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