1. 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

2. 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

3. Stereotactic implantation of SEEG electrodes
Standard Frames (Elekta)
3D Printed Stereotactic Fixtures (FHC StarFix)
Balanescu et al., Stereotact Func Neurosurg 2014

4. 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 .

5. 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

6. Group results 1 F 36 10 L - 9 Middle Cingulate, SMA Engel I A 16 Y 2 MNr
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

7. 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

8. 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

9. 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

10. Ictal scalp EEG: no lateralizing or localizing criteria
Clinical onset

11. Left insular hypersignal
Right insular cystic lesion

12. 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

13. Interictal awake SEEG:
Interictal sleep SEEG:
Runs of fast activity over the MCC
Slow and sharp waves over the parietal

14. 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

15. Cortico-Cortical Evoked Potentials - CCEP
Early Response (<100ms) analysis for
mapping cortical excitability and connectivity
Single Pulse Electrical Stimulation
(SPES)

16. Cortico-Cortical Evoked Potentials
Response maps by recording location
Response maps by stimulation location
3D View:
3D View:
Projection (MIP)
Projection (MIP)

17. 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

18. 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)

19. THANK YOU!

20. 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