✓ A carrier device has been developed for use with a stereotaxic apparatus. It can be attached to the OBT frame or to any Leksell-type frame. With this carrier, intracranial insertion of commercially available depth electrodes with built-in connectors is possible. By using two different heads mounted on a single carrier, the surgeon can perform a transcutaneous twist-drill trephination and attach the screws through a chuck, adjust the device in the horizontal plane, and then insert and anchor the electrodes by using a small platform with a hinged roof.
Warren Boling, David C. Reutens, and André Olivier
Object. The goal of this study was to establish a reliable method for identification of face and tongue sensory function in the lower central area.
Methods. All positron emission tomography (PET) clinical activation studies performed over a 3-year period at the Montreal Neurological Institute and Hospital were evaluated by coregistering the PET images with three-dimensional reconstructions of magnetic resonance images obtained in the same patients. In addition to stereotactic coordinates and measurements based on distance from the sylvian fissure, gyral and sulcal landmarks were analyzed to determine their reliability in localizing the sensory areas of the tongue and lower face.
The convolutional anatomy of the central area is an important guide to the identification of function. The sensory area of the tongue is recognized as a triangular region at the base of the postcentral gyrus; the sensory area of the lower face resides in the narrowed portion of the postcentral gyrus, immediately above the tongue area.
Conclusions. Cortical landmarks such as the substrata of tongue and face sensory impressions are more reliable guides than stereotactic coordinates or measurements for localizing function.
Warren W. Boling and André Olivier
Object. The goal of this study was to identify a reliable landmark for hand sensory function in the central area.
Methods. Hand sensory activation on positron emission tomography (PET) scans was analyzed in 27 patients. Each PET study was coregistered with the patient's magnetic resonance image and analyzed in two-dimensional and three-dimensional cortical surface reconstructions to define anatomicofunctional relationships.
Conclusions. The substratum of hand sensory function is a prominent fold of cortex elevating the floor of the central sulcus and connecting the pre- and postcentral gyri. Broca named this cortical fold the pli de passage moyen, and hand motor function has been localized to the precentral component of this structure. In this study the authors demonstrate that hand sensory function is highly correlated with the postcentral component of the pli de passage moyen, and that this structure is a reliable cortical landmark for identifying the aforementioned function.
Claude Picard and André Olivier
✓ Extensive data on cortical tongue representation were analyzed in 100 patients who underwent craniotomy and cortical mapping by electrical stimulation for surgical treatment of epilepsy. As noted in the literature, the tongue is extensively represented within the central nervous system with a highly organized sensorimotor system and the data from this study corroborate a large cortical representation of the human tongue over the postcentral gyrus. The tongue was found to have a clear somatotopic organization over the postcentral area and to be represented bilaterally to a significant degree. Furthermore, the tongue appears to have an asymmetrical sensory cortical representation, as cerebral dominance for speech is more extensively represented on the dominant hemisphere. Cortical tongue mapping has proved extremely useful in determining the point of junction of the central and Sylvian sulci, a crucial landmark during surgical cortical resections.
Taner Tanriverdi, Abdulrazag Ajlan, Nicole Poulin, and Andre Olivier
In this paper the authors aimed to provide information related to major and minor surgical and neurological complications encountered following stereoelectroencephalography and epilepsy surgery.
The authors performed a retrospective review of 491 and 1905 patients who underwent intracranial electrode implantation and epilepsy surgery, respectively, between 1976 and 2006 at the Montreal Neurological Institute. All intracranial electrode implantations and surgical procedures were performed by 1 surgeon (A.O.).
A total of 6415 electrode implantations and 2449 surgical procedures were done. There were no deaths related to either procedure. There were no major complications after intracranial electrode implantation, and the risks of infection and intracranial hematoma were found to be 1.8 and 0.8%, respectively. The number of electrodes per lobe (p = 0.05) and number of lobes covered (p = 0.04) were significant risk factors for hematoma and infection. Regarding epilepsy surgery, there were no major surgical complications, and the overall minor complication rate was 2.9%. Infection was the most common complication (1.0%), followed by intracranial hematoma (0.7%). Significant risk factors associated with hematomas and infections were the number of reoperations (p = 0.001) and older patient age (p = 0.03). Minor and major neurological complication rates were 2.7 and 0.5%, respectively, and the rate of overall neurological morbidity was 3.3%. Hemiparesis was the most frequent neurological complication (1.5%).
Based on the authors' experience, intracranial electrode implantation is an effective method with an extremely low morbidity rate. Moreover, epilepsy surgery is safe, especially in experienced hands.
Isabelle M. Germano, Nicole Poulin, and André Olivier
✓ The indications for and the risks and outcome of reoperation for medically refractory temporal lobe epilepsy have not been well documented. A retrospective review is presented of 40 patients who underwent reoperation on the temporal lobe for recurrent seizures. The mean patient age at the first operation was 22 ± 7 years (± standard deviation). Electrocorticography during the first operation showed interictal epileptic abnormalities from surface electrodes in 97% of the cases and from depth electrodes in the mesiotemporal structures in 38%. The seizures recurred with the same pattern within 6 months after the first operation in 60% of patients and within 2 years in 90%. Postoperative neuroimaging studies showed residual mesiotemporal structures in all cases. The mean time between the two operations was 5.5 ± 5 years and the mean patient age at the second operation was 28 ± 8 years. The second operation involved focal resection of the mesiotemporal structures in 30 cases. The mean postoperative follow-up period was 4.8 ± 2.7 years (range 2 to 11 years). After the second operation, 63% of the patients were seizure-free or had rare seizures (one or two per year). There were no permanent neurological complications. Patients who did not benefit from reoperation had electroencephalographic abnormalities in multiple brain areas.
Reoperation for temporal lobe epilepsy effectively controls seizures in the majority of patients, and the procedure is safe if rigorous technical rules are observed. More complete resection of mesiotemporal structures during the first operation, even in the absence of intraoperative electrographic abnormalities, could prevent the need for reoperation in defined cases.
André Olivier and Gilles Bertrand
✓ A stereotaxic device is described for percutaneous twist-drill insertion of depth electrodes for seizure recording and brain biopsy. This apparatus, which permits a lateral orthogonal approach, has been used in conjunction with a Leksell type of stereotaxic frame. Its main advantages are the ample working space it provides at the site of insertion of intracerebral electrodes, and the stable attachment it offers in fixing these electrodes on the skull.
Warren Boling, André Olivier, Richard G. Bittar, and David Reutens
Object. The object of this study was to identify a reliable surface landmark for the hand motor area and to demonstrate that it corresponds to a specific structural component of the precentral gyrus.
Methods. Positron emission tomography (PET) activation studies for hand motor function were reviewed in 12 patients in whom magnetic resonance imaging results were normal. Each patient performed a hand opening and closing task. Using a computer-assisted three-dimensional reconstruction of the surface of each hemisphere studied, the relationship of the hand motor area with cortical surface landmarks was evaluated.
Conclusions. The region of hand motor activation can be reliably identified on the surface of the brain by assessing anatomical relationships to nearby structures. After identification of the central sulcus, the superior and middle frontal gyrus can be seen to arise from the precentral gyrus at a perpendicular angle. A bend or genu in the precentral gyrus is constantly seen between the superior and middle frontal gyrus, which points posteriorly (posteriorly convex). The location of hand motor function, identified using PET activation studies, is within the central sulcus at the apex of this posteriorly pointing genu. The apex of the genu of the precentral gyrus leads to a deep cortical fold connecting the pre- and postcentral gyri and elevating the floor of the central sulcus. This deep fold was described by Paul Broca as the pli de passage fronto-pariétal moyen, and the precentral bank of the pli de passage represents the anatomical substratum of hand motor function. Observers blinded to the results of the activation studies were able to identify the hand motor area reliably after instruction in using these surface landmarks.
Warren Boling, Frederick Andermann, David Reutens, François Dubeau, Laetitia Caporicci, and André Olivier
Object. The goal of this study was to evaluate the efficacy of surgery for temporal lobe epilepsy (TLE) in older (≥ 50 years of age) patients.
Methods. The authors conducted a review of all patients 50 years of age or older with TLE surgically treated at the Montreal Neurological Institute and Hospital since 1981 by one surgeon (A.O.). Only patients without a mass lesion were included. Outcome parameters were compared with those of younger individuals with TLE, who were stratified by age at operation.
In patients aged 50 years and older, the onset of complex partial seizures occurred 5 to 53 years (mean 35 years) prior to the time of surgery. Postoperatively, over a mean follow-up period of 64 months, 15 patients (83%) obtained a meaningful improvement, becoming either free from seizures or only experiencing a rare seizure. Most surgery outcomes were similar in both older and younger individuals, except for a trend to more freedom from seizures and increased likelihood of returning to work or usual activities in the younger patients. Note that a patient's long-standing seizure disorder did not negatively affect their ability to achieve freedom from seizures following surgery.
Conclusions. Surgery for TLE appears to be effective for older individuals, comparing favorably with results in younger age groups, and carries a small risk of postoperative complications.