Intraoperative computed tomography for intracranial electrode implantation surgery in medically refractory epilepsy

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Accurate placement of intracranial depth and subdural electrodes is important in evaluating patients with medically refractory epilepsy for possible resection. Confirming electrode locations on postoperative CT scans does not allow for immediate replacement of malpositioned electrodes, and thus revision surgery is required in select cases. Intraoperative CT (iCT) using the Medtronic O-arm device has been performed to detect electrode locations in deep brain stimulation surgery, but its application in epilepsy surgery has not been explored. In the present study, the authors describe their institutional experience in using the O-arm to facilitate accurate placement of intracranial electrodes for epilepsy monitoring.


In this retrospective study, the authors evaluated consecutive patients who had undergone subdural and/or depth electrode implantation for epilepsy monitoring between November 2010 and September 2012. The O-arm device is used to obtain iCT images, which are then merged with the preoperative planning MRI studies and reviewed by the surgical team to confirm final positioning. Minor modifications in patient positioning and operative field preparation are necessary to safely incorporate the O-arm device into routine intracranial electrode implantation surgery. The device does not obstruct surgeon access for bur hole or craniotomy surgery. Depth and subdural electrode locations are easily identified on iCT, which merge with MRI studies without difficulty, allowing the epilepsy surgical team to intraoperatively confirm lead locations.


Depth and subdural electrodes were implanted in 10 consecutive patients by using routine surgical techniques together with preoperative stereotactic planning and intraoperative neuronavigation. No wound infections or other surgical complications occurred. In one patient, the hippocampal depth electrode was believed to be in a suboptimal position and was repositioned before final wound closure. Additionally, 4 strip electrodes were replaced due to suboptimal positioning. Postoperative CT scans did not differ from iCT studies in the first 3 patients in the series and thus were not obtained in the final 7 patients. Overall, operative time was extended by approximately 10–15 minutes for O-arm positioning, less than 1 minute for image acquisition, and approximately 10 minutes for image transfer, fusion, and intraoperative analysis (total time 21–26 minutes).


The O-arm device can be easily incorporated into routine intracranial electrode implantation surgery in standard-sized operating rooms. The technique provides accurate 3D visualization of depth and subdural electrode contacts, and the intraoperative images can be easily merged with preoperative MRI studies to confirm lead positions before final wound closure. Intraoperative CT obviates the need for routine postoperative CT and has the potential to improve the accuracy of intracranial electroencephalography recordings and may reduce the necessity for revision surgery.

ABBREVIATIONSDBS = deep brain stimulation; EEG = electroencephalography; iCT = intraoperative CT; iMRI = intraoperative MRI.

Article Information

Correspondence Kiarash Shahlaie, Department of Neurological Surgery, University of California, Davis School of Medicine, 4860 Y St., Ste. 3740, Sacramento, CA 95817. email:

INCLUDE WHEN CITING Published online October 31, 2014; DOI: 10.3171/2014.9.JNS13919.

DISCLOSURE The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. This study was supported by the UC Davis Bronte Epilepsy Research Program.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Three-dimensional surface-rendering images created on a Medtronic StealthStation to guide placement of subdural grid and strip electrodes. The preoperative MR image (A) was merged with the iCT study in the operating room for immediate confirmation of subdural lead locations (B). Postoperatively, the merged image was processed to yield a 3D map of electrode locations that could be used for interpreting extraoperative EEG data (C). Blue dots represent strip electrodes, and white dots represent grid points.

  • View in gallery

    Example of operating room setup of the O-arm gantry and intraoperative navigation system. In the operating/surgeon position (A), operative access is maximized, and the navigation equipment is in a midline position that does not interfere with the surgical field (B). In the imaging/anesthesia position (C), the sterility of the operative field is maintained, and navigation and stereotactic equipment are not disturbed.

  • View in gallery

    Images obtained on a Medtronic StealthStation system during subdural and depth electrode placement for invasive epilepsy monitoring. Preoperative MRI was used to develop a plan to place the right hippocampal depth electrode, stereotactic guidance was used to implant the electrode along the planned trajectory, and an intraoperative CT scan was obtained and then merged with the preoperative MRI study to confirm trajectory and depth as well as the final anatomical location of the electrode.


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