Robot-assisted stereoelectroencephalography in children

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OBJECTIVE

The goal in the study was to describe the clinical outcomes associated with robot-assisted stereoelectroencephalography (SEEG) in children.

METHODS

The authors performed a retrospective, single-center study in consecutive children with medically refractory epilepsy who were undergoing robot-assisted SEEG. Kaplan-Meier survival analysis was used to calculate the probability of seizure freedom. Both univariate and multivariate methods were used to analyze the preoperative and operative factors associated with seizure freedom.

RESULTS

Fifty-seven children underwent a total of 64 robot-assisted procedures. The patients’ mean age was 12 years, an average of 6.4 antiepileptic drugs (AEDs) per patient had failed prior to implantation, and in 56% of the patients the disease was considered nonlesional. On average, children had 12.4 electrodes placed per implantation, with an implantation time of 9.6 minutes per electrode and a 10-day postoperative stay. SEEG analysis yielded a definable epileptogenic zone in 51 (89%) patients; 42 (74%) patients underwent surgery, half of whom were seizure free at last follow-up, 19.6 months from resection. In a multivariate generalized linear model, resective surgery, older age, and shorter SEEG-related hospital length of stay were associated with seizure freedom. In a Cox proportional hazards model including only the children who underwent resective surgery, older age was the only significant factor associated with seizure freedom. Complications related to bleeding were the major contributors to morbidity. One patient (1.5%) had a symptomatic hemorrhage resulting in a permanent neurological deficit.

CONCLUSIONS

The authors report one of the largest pediatric-specific SEEG series demonstrating that the modern surgical management of medically refractory epilepsy in children can lead to seizure freedom in many patients, while also highlighting the challenges posed by this difficult patient population.

ABBREVIATIONS AED = antiepileptic drug; EZ = epileptogenic zone; LOS = length of hospital stay; MEG = magnetoencephalography; PMC = patient management conference; SEEG = stereoelectroencephalography.

Article Information

Correspondence Jorge Gonzalez-Martinez: Epilepsy Center, Cleveland Clinic Foundation, Cleveland, OH. gonzalj1@ccf.org.

ACCOMPANYING EDITORIAL DOI: 10.3171/2018.8.PEDS18436.

INCLUDE WHEN CITING Published online December 7, 2018; DOI: 10.3171/2018.7.PEDS18305.

Disclosures Dr. Gonzalez-Martinez is a consultant for Zimmer Biomet. Dr. Gupta is a consultant for Eisai and Mallinckrodt. He is on the professional board for the Tuberous Sclerosis Alliance and on the editorial boards for Epilepsy Currents and Pediatric Neurology.

© AANS, except where prohibited by US copyright law.

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Figures

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    Patient flow diagram outlining the outcome for each patient included in the study.

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    Kaplan-Meier survival analysis of all 42 patients. Figure is available in color online only.

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    Illustrative case. A 16-year-old boy who began having seizures 4 years prior to surgery (head and eyes turn to the right side, then generalized tonic-clonic seizure occurs). Five AEDs failed to control his disease and, preoperatively, he was experiencing approximately 1 seizure per week. Ictal and interictal scalp video EEG monitoring demonstrated epileptiform activity arising mainly from the left frontotemporal region with occasional right frontotemporal sharp waves, and seizures arising from the left frontotemporal region with one arising bifrontally. Volumetric 3-T MRI demonstrated no lesion. A: PET scan shows diffuse cortical hypometabolism, left > right. B: Preimplantation map demonstrates exploratory hypotheses with according electrode implantation plan. MFG = middle frontal gyrus; operc = operculum; SMA = supplementary motor area; STG = superior temporal gyrus; Sup frontal G = superior frontal gyrus. C: Intraoperative images, lateral view, show a bilateral frontotemporal implantation, left > right. D: Ictal SEEG recording sample demonstrates ictal onset involving contacts 5 and 6 from electrode I’ in the left temporal pole with subsequent frontal spread. E: MRI reconstruction with anatomical location of ictal onset region based on SEEG recording. The patient underwent a temporal pole and amygdala resection and remains seizure free 2 years postoperatively. Figure is available in color online only.

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