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SEEG-guided Radio-Frequency Thermo-Coagulation in epilepsy
Ciurea Jean, Barborica Andrei, Rasina Alin, Gheorghiu Ana, Mandruta Ioana, Popa Irina, Maliia Mihai Dragos, Ene Sabina, Donos Cristi 1 Neurology Department, Epilepsy and Sleep Monitoring Unit, University Emergency Hospital Bucharest 2 Neurosurgery Department, Bagdasar-Arseni Hospital Bucharest 3Physics Department, University of Bucharest, Bucharest, Romania 4 Neurology Department, Neurology and Neurovascular Diseases National Institute, Bucharest, Romania
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Workflow SPES Signal Analysis: Scalp Source Reconstruction
Video-EEG Signal Analysis: Source Reconstruction (BrainStorm) SEEG Implantation Template Electrical Stimulation: Functional Mapping SPES Intracranial Video-EEG Electrode Implantation Frame-based Frameless Signal Analysis: - Visual iEEG analysis - Voltage maps - CCEP response maps - Biomarkers / SPES: - HFO - Delayed responses - Causal Connectivity Thermocoagulation Resection
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Stereotactic implantation of SEEG electrodes
Standard Frames (Elekta) 3D Printed Stereotactic Fixtures (FHC StarFix) Balanescu et al., Stereotact Func Neurosurg 2014
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Thermocoagulation Radio-frequency-thermo-coagulation (RFTC) is produced without anesthesia Radiofrequency lesion generator system model RFG by Radionics Lesions are produced between 2 contiguous contact on the same electrode Parameters: 50 V, 120 mA, 10-40s -> temperature: C Lesion: 5-7 mm diameter RFTC lesion in egg white Catenoix H et al SEEG-guided thermocoagulations: a palliative treatment of nonoperable partial epilepsies Neurology 2008 .
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Indication RFTC is performed at the end of video-SEEG monitoring
Contacts in cortex area showing low voltage fast activity or spike and wave activity at seizure onset Prior electrical stimulation of the contacts did not reveal clinical response The best result are seen in symptomatic epilepsies due to cortical development malformation Catenoix H et al SEEG-guided thermocoagulations: a palliative treatment of nonoperable partial epilepsies Neurology 2008
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Group results 1 F 36 10 L - 9 Middle Cingulate, SMA Engel I A 16 Y 2 M
Nr Sex Age EpilepsyOnset Lateralization MRILesion NumElectrodes SOZ SurgicalOutcome FollowupMonth Initial significant improvment 1 F 36 10 L - 9 Middle Cingulate, SMA Engel I A 16 Y 2 M 30 12 R 15 Prefrontal Lateral (F3) 3 13 Parietal Operculum, Posterior Insula Engel IA 4 7 6 False lateralising (transmantle sign in R hemishere) 19 Middle Cingulate Engel II A 5 18 Bilateral occipital lesions Occipital mesial, supracalcarine gyrus Engel II B 26 SMA & MCC Engel III A paracentral lobule 8 29 17 IIB FCD R SFG Premotor Engel IV B 14 N 41 MOFC Engel IV C 38 B B Orbito-frontal
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Case 1: P.D., female, 30 years old,
Normal birth and development, no febrile convulsions, no CNS infection. Car accident at the age of 10y Seizures started at the age of 11 years (2 months after the accident) with nocturnal attacks AED tried: CBZ - ~10 seizures/night, every night Current AED: CBZ 900mg + LEV 2000mg, LCM 200 – 400mg – no effect Neurological examination normal NPSY – no cognitive deficit, IQ 120
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Seizure semiology SEIZURE
nucal and interscapular and along the spine shivering or paraesthesia – grimacing - warm sensation – sensation in the throat with fear of suffocation – rhythmic blinking - hypermotor automatisms SEIZURE
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Interictal awake scalp EEG:
sharp waves over the midline and frontal region Interictal sleep scalp EEG: Long runs of sharp waves over the midline and F3
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Ictal scalp EEG: no lateralizing or localizing criteria
Clinical onset
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Left insular hypersignal
Right insular cystic lesion
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Implantation chart Left parasagital fronto-parietal and bi-insular implantation Q’: DMPFC - DLPFC X’: MCC – F1 M’: preSMA – F2 K’: MCC – PMC G’: SMA - FEF N’: SMA - R Z’: PCC – S P’: PCL - S R’: aI - OpR Y’: left insula Y: right insula L’: temporal lesion
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Interictal awake SEEG:
Interictal sleep SEEG: Runs of fast activity over the MCC Slow and sharp waves over the parietal
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SEIZURE grimace, blinking, breathing difficulty
CLINICAL ONSET SEIZURE grimace, blinking, breathing difficulty ICTAL ENDING Fast activity at seizure onset over the left MCC and pre SMA, SMA
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Cortico-Cortical Evoked Potentials - CCEP
Early Response (<100ms) analysis for mapping cortical excitability and connectivity Single Pulse Electrical Stimulation (SPES)
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Cortico-Cortical Evoked Potentials
Response maps by recording location Response maps by stimulation location 3D View: 3D View: Projection (MIP) Projection (MIP)
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Ictal onset activation of the epileptiform activity in the gamma band range, displayed as maximum intensity projection voltage maps on patient`s MRI anatomy and MRI after RFTC procedure
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Outcome We recorded between 3-12 seizures/night, that are acknowledged by the patient and no sec gen One week of recordings No medication off Stimulation reproduced aura like symptoms of throat sensation and breathing spell in the K’01-02,06-07, hand (N’ext) and leg (Z’06-07) After a week applied RFTC in K’01-02, 03-04, , 11-12, G’01-02, G’06-07, N’01-02 No further seizures (2 years off-medication)
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THANK YOU!
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The Team Neurosurgery Neurology Dr. Ana Gheorghiu
Dr. Alin Rasina Dr. Jan Ciurea Dr. Ioana Mindruta Dr. Ana Gheorghiu dr. Irina Popa dr. Mihai Maliia dr Anca Arbune dr. Andrei Daneasa Andrei Barborica, PhD Biophysics Dr. Cristian Donos EEG Technicians Mariana Popa Victorita Raiciu Mirela Sabine Ene, PhD stud
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