The clinical utility of intraoperative electrocorticography in pediatric epilepsy surgical strategy and planning

Robert Lesko MD 1 , Barbora Benova MD, PhD 2 , Petr Jezdik PhD 3 , Petr Liby MD, PhD 1 , Alena Jahodova MD, PhD 2 , Martin Kudr MD, PhD 2 , Michal Tichy MD, PhD 1 , Josef Zamecnik MD, PhD 4 and Pavel Krsek MD, PhD 2
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  • 1 Departments of Neurosurgery,
  • 2 Paediatric Neurology, and
  • 4 Pathology and Molecular Medicine, Second Faculty of Medicine, Charles University and Motol University Hospital; and
  • 3 Department of Circuit Theory, Faculty of Electrical Engineering, Czech Technical University of Prague, Czech Republic
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OBJECTIVE

In this study, the authors aimed to determine 1) whether the use of intraoperative electrocorticography (ECoG) affects outcomes and complication rates of children undergoing resective epilepsy surgery; 2) which patient- and epilepsy-related variables might influence ECoG-based surgical strategy; and 3) what the predictors of epilepsy surgery outcomes are.

METHODS

Over a period of 12 years, data were collected on pediatric patients who underwent tailored brain resections in the Motol Epilepsy Center. In patients in whom an abnormal ECoG pattern (e.g., spiking, suppression burst, or recruiting rhythm) was not observed beyond presurgically planned resection margins, the authors did not modify the surgical plan (group A). In those with significant abnormal ECoG findings beyond resection margins, the authors either did (group B) or did not (group C) modify the surgical plan, depending on the proximity of the eloquent cortex or potential extent of resection. Using Fisher’s exact test and the chi-square test, the 3 groups were compared in relation to epilepsy surgery outcomes and complication rate. Next, multivariate models were constructed to identify variables associated with each of the groups and with epilepsy surgery outcomes.

RESULTS

Patients in group C achieved significantly lower rates of seizure freedom compared to groups A (OR 30.3, p < 0.001) and B (OR 35.2, p < 0.001); groups A and B did not significantly differ (p = 0.78). Patients in whom the surgical plan was modified suffered from more frequent complications (B vs A+C, OR 3.8, p = 0.01), but these were mostly minor (duration < 3 months; B vs A+C, p = 0.008). In all cases, tissue samples from extended resections were positive for the presence of the original pathology. Patients with intended modification of the surgical plan (groups B+C) suffered more often from daily seizures, had a higher age at first seizure, had intellectual disability, and were regarded as MR-negative (p < 0.001). Unfavorable surgical outcome (Engel class II–IV) was associated with focal cortical dysplasia, incomplete resection based on MRI and/or ECoG findings, negative MRI finding, and inability to modify the surgical plan when indicated.

CONCLUSIONS

Intraoperative ECoG serves as a reliable tool to guide resection and may inform the prognosis for seizure freedom in pediatric patients undergoing epilepsy surgery. ECoG-based modification of the surgical plan is associated with a higher rate of minor complications. Children in whom ECoG-based modification of the surgical plan is indicated but not feasible achieve significantly worse surgical outcomes.

ABBREVIATIONS ECoG = electrocorticography; EZ = epileptogenic zone; FCD = focal cortical dysplasia; iEEG = invasive EEG; LEAT = low-grade epilepsy-associated brain tumor; MCD = malformation of cortical development; SEEG = stereoelectroencephalography; TSC = tuberous sclerosis complex.

Supplementary Materials

    • Supplemental Table1 (PDF 1.08 MB)

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Contributor Notes

Correspondence Pavel Krsek: Charles University in Prague, Second Faculty of Medicine, Motol University Hospital, Prague, Czech Republic. pavel.krsek@post.cz.

INCLUDE WHEN CITING Published online July 31, 2020; DOI: 10.3171/2020.4.PEDS20198.

R.L. and B.B. contributed equally to this work.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

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