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Stereoelectroencephalography: Surgical Methodology, Safety, and Stereotactic Application Accuracy in 500 Procedures

Cardinale, Francesco MD, PhD*; Cossu, Massimo MD*; Castana, Laura MD*; Casaceli, Giuseppe MD*,‡; Schiariti, Marco Paolo MD*; Miserocchi, Anna MD*; Fuschillo, Dalila MD*,‡; Moscato, Alessio MSc*,§; Caborni, Chiara MSc; Arnulfo, Gabriele PhD||,#; Lo Russo, Giorgio MD*

doi: 10.1227/NEU.0b013e31827d1161
Research-Human-Clinical Studies: Editor's Choice
Editor's Choice
Press Release

BACKGROUND: Stereoelectroencephalography (SEEG) methodology, originally developed by Talairach and Bancaud, is progressively gaining popularity for the presurgical invasive evaluation of drug-resistant epilepsies.

OBJECTIVE: To describe recent SEEG methodological implementations carried out in our center, to evaluate safety, and to analyze in vivo application accuracy in a consecutive series of 500 procedures with a total of 6496 implanted electrodes.

METHODS: Four hundred nineteen procedures were performed with the traditional 2-step surgical workflow, which was modified for the subsequent 81 procedures. The new workflow entailed acquisition of brain 3-dimensional angiography and magnetic resonance imaging in frameless and markerless conditions, advanced multimodal planning, and robot-assisted implantation. Quantitative analysis for in vivo entry point and target point localization error was performed on a sub--data set of 118 procedures (1567 electrodes).

RESULTS: The methodology allowed successful implantation in all cases. Major complication rate was 12 of 500 (2.4%), including 1 death for indirect morbidity. Median entry point localization error was 1.43 mm (interquartile range, 0.91-2.21 mm) with the traditional workflow and 0.78 mm (interquartile range, 0.49-1.08 mm) with the new one (P < 2.2 × 10−16). Median target point localization errors were 2.69 mm (interquartile range, 1.89-3.67 mm) and 1.77 mm (interquartile range, 1.25-2.51 mm; P < 2.2 × 10−16), respectively.

CONCLUSION: SEEG is a safe and accurate procedure for the invasive assessment of the epileptogenic zone. Traditional Talairach methodology, implemented by multimodal planning and robot-assisted surgery, allows direct electrical recording from superficial and deep-seated brain structures, providing essential information in the most complex cases of drug-resistant epilepsy.

ABBREVIATIONS: DSA, digital subtraction angiography

EP, entry point

EPLE, entry point localization error

EZ, epileptogenic zone

SEEG, stereoelectroencephalography

TP, target point

TPLE, target point localization error

*“Claudio Munari” Centre for Epilepsy and Parkinson Surgery, Niguarda Ca’ Granda Hospital, Milano, Italy

Department of Neurological Sciences, Università degli Studi di Milano, Milano, Italy

§Unit of Medical Physics, Niguarda Ca’ Granda Hospital, Milano, Italy

Politecnico di Milano, Bioengineering Department, Nearlab, Milano, Italy

||Department of Informatics, Bioengineering, Robotics and System Engineering (DIBRIS), Università di Genova, Genova, Italy

#Neuroscience Center, University of Helsinki, Helsinki, Finland

Correspondence: Francesco Cardinale, MD, PhD, Centro per la Chirurgia dell’Epilessia e del Parkinson “Claudio Munari,” Ospedale Niguarda Ca’ Granda, Piazza Ospedale Maggiore, 3, 20162, Milano, Italia. E-mail:

Dr Schiariti is now at the Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy. Dr Miserocchi is now at the Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, United Kingdom.

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Received August 11, 2012

Accepted October 23, 2012

Copyright © by the Congress of Neurological Surgeons