Name: stereo-electro-encephalo-graphy (seeg) with robotic assistance in the presurgical evaluation of medical refractory epilepsy: a technical note
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Description: Watch this Scientific Journal Video about Stereo-Electro-Encephalo-Graphy SEEG With Robotic Assistance in the Presurgical Evaluation of Medical Refractory Epilepsy: A Technical Note at JoVE.com

The authors have no acknowledgements.

Ethical statement: Our protocol follows the guidelines established by our institutional human research ethics committee.
1. Identification of Medically Refractory Epilepsy Patients
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	<li>Prior to invasive monitoring, evaluate allpatientswith noninvasive techniques, such as video-EEG monitoring, MRI, PET, ictalSPECT, and neuropsychological studies as described in 1 After discussion in multi-disciplinary meeting the decision whether or not to pursue invasive monitoring with SEEG...

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	<li>Serletis, D., Bulacio, J., Bingaman, W., Gonzalez-Martinez, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+stereotactic+approach+for+mapping+epileptic+networks:+a+prospective+study+of+200+patients.">The stereotactic approach for mapping epileptic networks: a prospective study of 200 patients.</a> J Neurosurg. 121, 1239-1246 (2014).</li><li>Bancaud, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Epilepsy+after+60+years+of+age.+Experience+in+a+functional+neurosurgical+department.">Epilepsy after 60 years of age. 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N., Olivier, A., Quesney, F., Dubeau, F., Savard, G., Andermann, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy+of+and+morbidity+associated+with+stereoelectroencephalography+using+computerized+tomography-or+magnetic+resonance+imaging-guided+electrode+implantation.">Efficacy of and morbidity associated with stereoelectroencephalography using computerized tomography-or magnetic resonance imaging-guided electrode implantation.</a> J Neurosurg. 104, 483-487 (2006).</li><li>Cossu, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Stereoelectroencephalography+in+the+presurgical+evaluation+of+focal+epilepsy+a+retrospective+analysis+of+215+procedures.">Stereoelectroencephalography in the presurgical evaluation of focal epilepsy a retrospective analysis of 215 procedures.</a> Neurosurgery. 57, 706-718 (2005).</li><li>Gonzalez-Martinez, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+stereotactic+laser+ablation+in+medically+intractable+epilepsy:+operative+technique.">Robot-assisted stereotactic laser ablation in medically intractable epilepsy: operative technique.</a> Neurosurgery. 10, 167-172 (2014).</li><li>Guenot, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Neurophysiological+monitoring+for+epilepsy+surgery:+the+Talairach+SEEG+method.+Indications,+results,+complications+and+therapeutic+applications+in+a+series+of+100+consecutive+cases.">Neurophysiological monitoring for epilepsy surgery: the Talairach SEEG method. Indications, results, complications and therapeutic applications in a series of 100 consecutive cases.</a> Stereotact Funct Neurosurg. 77, 29-32 (2001).</li><li>Kuzniecky, R. I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Multimodality+MRI+in+mesial+temporal+sclerosis:+relative+sensitivity+and+specificity.">Multimodality MRI in mesial temporal sclerosis: relative sensitivity and specificity.</a> Neurology. 49 (3), 774-778 (1997).</li><li>Cardinale, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Stereoelectroencephalography:+surgical+methodology,+safety,+and+stereotacticapplication+accuracy+in+500+procedures.">Stereoelectroencephalography: surgical methodology, safety, and stereotacticapplication accuracy in 500 procedures.</a> Neurosurgery. 72 (3), 353-366 (2013).</li></ol>

Here is presented the technique of SEEG insertion utilizing robotic stereotactic assistance. While SEEG was originally described using other methods of frame based stereotaxis, robot-assisted SEEG offers not only similar safety but superior accuracy and efficiency. The literature reports success at localizing the EZ in over 76% of cases, which is commiserate with other previous studies using alternative techniques.6,13,.
As with any invasive intracranial procedure, SEEG is not witho...

In medically refractory epilepsy there are many non-invasive pre-surgical tools (scalp EEG., magnetic resonance imaging (MRI), functional MRI, single photon emission computed tomography, positron emission topography, and magnetoencephalography). If these non-invasive evaluations fail to sufficiently localize or define the epileptic zone (EZ) then invasive recording may be indicated. Currently, subdural grids or Stereo-electro-encephalo-graphy (SEEG) are the two most prevalent methods of invasive monitoring. SEEG was originally developed in France in the 1950's by Jean Talairach and Jean Bancaud; recently it has mostly been used for invasive monitoring of refractory epilepsy patients in France.2-4 SEEG is the consists of stereotactically inserting intracerebral electrodes into the brain parenchyma to record brain electrical activity for an extended period of time. With the intracerebral electrical recordings many patients are able to have their EZ defined to allow for surgical resection. 
Despite this long history of success SEEG remains relatively rarely used for invasive recording in America. However, SEEG does offer several significant advantages; SEEG allows for 1) recording of deep structures, 2) bihemispheric recordings, 3) another recording option if subdural grids failed, and 4) mapping of epileptic networks in three dimensions, mainly in patients where non-lesional extra-temporal epilepsy is suspected.5-7 All of these benefits are achieved without requiring a large craniotomy. A recent technologic advance in SEEG surgery is the used of robotic guidance. This sophisticated development allows for improved operative times but safer and more accurate surgical implantation of electrodes.Recently published literature reviews the results of using two different techniques for SEEG insertion; a more traditional method utilizing stereotactic frames and a newer technique using robotic assistante for SEEG insertion.1, 8,15 the results were similarly successful with each method. 
With the advent of improved robotic assistance, the SEEG insertion technique has resulted in improved operative times. The robotic system is classified as a supervisory controlled system which means the surgeon plans the operation off line and implicitly specifies the motion the robot must follow to perform the operation.9 The robotic assist results in expedient transitions from one trajectory to the next for the placement of each intracranial electrode.

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			<td height="21" style="height:21px;width:216px;">ROSA</td>
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			<td style="width:167px;">robotic implantation system</td>
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			<td height="21" style="height:21px;width:216px;">electrodes</td>
			<td style="width:71px;">adtech</td>
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stereo-electro-encephalo-graphy (seeg) with robotic assistance in the presurgical evaluation of medical refractory epilepsy: a technical note

SEEG is a method and technique which is used for accurate, invasive recording of seizure activity via three dimensional recordings. In epilepsy patients who are deemed appropriate candidates for invasive recordings, the decision to monitor is made between the subdural grids versus SEEG. Invasive neuromonitoring for epilepsy is pursued in patients with complex, medically refractory epilepsy. The goal of invasive monitoring is to offer resective surgery with the hope of allowing seizure freedom. SEEG&#39;s advantages include access to deep cortical structures, an ability to localize the epileptogenic zone (EZ) when subdural grids have failed to do so, and in patients with non-lesional extra-temporal epilepsies. In this manuscript, we present a succinct historical overview of the SEEG and report on our experience with frameless stereotaxy under robotic. An imperative step of SEEG insertion is planning the electrode trajectories. In order to most effectively record ictal activity via SEEG trajectories should be planned based upon a hypothesis of where the seizure activity originates the presumed epileptogenic zone (EZ). The EZ hypothesis is based on a standardized preoperative workup including video-EEG monitoring, MRI (magnetic resonance imaging), PET (positron emission tomography), ictal SPECT (Single-photon emission computed tomography), and neuropsychological assessment. Using a suspected EZ, SEEG electrodes can be placed minimally invasively yet maintain accuracy and precision. Clinical results showed the ability to localize the EZ in 78% of difficult to localize epileptic patients.1

Recent results indicate that in one consecutive series of 78 patients who underwent SEEG insertion via robotic assistance had successful localization of the EZ in 76.2% of patients.1 That same study showed of the patients who went on to have surgical resection of EZ had grade 1 Engel seizure freedom in 67.8% of patients (Figure 4). Morbidity rate is 2.5%. Permanent morbidity was noticed is 1 patient (1.2%). Per electrode, it was shown to have a wound infection ...

Watch this Scientific Journal Video about Stereo-Electro-Encephalo-Graphy SEEG With Robotic Assistance in the Presurgical Evaluation of Medical Refractory Epilepsy: A Technical Note at JoVE.com

Stereo-Electro-Encephalo-Graphy SEEG With Robotic Assistance in the Presurgical Evaluation of Medical Refractory Epilepsy: A Technical Note

Stereo-electroencephalography (SEEG) aids in localization of epileptogenic zones, however, remains relatively underutilized in the United States. The goal of this abstract is to provide a brief introduction to the technique of SEEG and further a detailed technique of using robotic assistance in the placement of SEEG electrodes.

Stereo-Electro-Encephalo-Graphy (SEEG) With Robotic Assistance in the Presurgical Evaluation of Medical Refractory Epilepsy: A Technical Note

SEEG is a method and technique which is used for accurate, invasive recording of seizure activity via three dimensional recordings. In epilepsy patients ...

The overall goal of this surgical intervention is to localize the patient's epileptogenic focus, potentially allowing further intervention for the ultimate goal of seizure freedom. Stereo-electro-encephalo-graphy, also known as SEEG, it's a method and technique designed to better localize the epileptogenic zone, which is the minimal area in the brain that is responsible for the generation of seizures. The main advantages of SEEG, compared to subdurals, is that SEEG, it's a minimally invasive method that does not require craniotomy.It carries minimal complication rate, and allows the three-dimensional mapping of the epileptogenic brain. After developing an implantation strategy based upon the hypothesized epileptogenic zone, select new patient on the robotic assistance device to create a new encounter. Then, click on create trajectory, and select the appropriate entry and end-points that correspond with the desired trajectory.When the device is ready, arrange the patient on the surgical table in the supine position. After prepping the patient, select register on the robotic assistance device, and follow the prompts to complete the registration process using the surface landmark registration based on the facial features. When the registration is complete, use guidance assistance from the robotic stereotactic system to bore the first bolt-hole in the skull with a 2.5 millimeter drill bit.Then, insert the monopolar coagulator probe to open the dura mater, and use the robotic stereotactic system to screw the first implantation bolt into the skull. Use the implanted bolt to guide the insertion of the stylet probe to create the initial trajectory, and insert the first electrode. Then, secure the electrode to the bolt to prevent further displacement and cerebrospinal fluid leakage.After inserting and connecting the rest of the electrodes in the same manner, place the iodine solution soaked gauze around each of the bolt caps. Then connect the electrodes to the EEG recording machine to confirm their proper function and obtain intraoperative x-rays in the lateral and anterior/posterior skull to confirm that the electrodes have been placed with the correct trajectories. Now, transfer the patient to the epilepsy monitoring unit, and monitor the patient for seizure activity both clinically and electrographically via the stereo-electro-encephalo-graphy electrode recording, administering analgesia as appropriate.Wrap the head. When sufficient ictal data has been recorded, return the patient to the operating room for removal of the stereo-electro-encephalo-graphy electrodes under conscious sedation. Then, after removing the head wrap, and cutting the electrode wires, prep the remaining bolts and tails of the electrodes with iodinated gel, and remove the first bolt cap with twisting.Next, gently pull the corresponding electrode out along the axis of its insertion, and twist out the bolt. Before moving on to the next electrode, close the defect left by the bolt with one stitch of nylon suture. Then, repeat the removal procedure for each of the other electrodes.After all of the electrodes have been removed, cover the stitch areas with antibiotic ointment and a loose head wrap. Finally, image the patient to confirm the absence of any residual hardware. Here, temporal, temporal-occipital, temporo-parietal-occipital, fronto-temporal, fronto-parietal-insular, perisylvian, and bi-temporal and right frontal insertion plans are shown.The black dots represent the entry points of the electrodes implanted in an orthogonal fashion, and the black lines represent the electrodes in oblique trajectories. Recent results indicate that in one consecutive series of 78 patients who underwent stereo-electro-encephalo-graphy insertion via robotic assistance, successful localization of the epileptogenic zone was achieved in 76.2%of patients. In the same study, surgical resection of the epilepogenic zone was demonstrated to impart Grade 1 Engel seizure freedom in 67.8%of patients.Note that the observed morbidity rate of the procedure is 2.5%with a permanent morbidity notice of one patient, or 1.2%Per electrode, wound infection and intracranial hematoma rates of 0.08%were also observed. The SEEG procedure, it should take approximately two to three hours. Although it's considered to be a minimally invasive procedure, it does carry some risks, which are approximately 1%The main risks are intracranial bleedings.While you are watching this movie, you will be able to understand how to perform a robotic SEEG implantation.

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