Multiple SEEG-guided RF-thermolesions of epileptogenic foci

In many patients with drug-resistant partial epilepsy, depth electrode recordings may be required to delineate the best region for cortical resection. We usually implant depth electrodes according to Talairach's stereoelectroencephalography (SEEG) methodology. Using these chronically-implanted depth electrodes, it is possible to generate radiofrequency (RF) thermolesions of the epileptic foci and networks. The advantages of this type of technique are supported by several lines of evidence, in particular, the high number of implanted electrodes makes it possible to generate several thermolesions, whereas the bleeding risk is null, since no additional electrode trajectory is required. Lesions are generated using 100- to 120-mA bipolar current (50V), applied for 10-40s within the epileptogenic zone, as identified by the SEEG recordings. No general or neurological complication occurred during the procedures. Forty-three patients investigated with video-SEEG recordings for presurgical assessment of drug-resistant partial epilepsy were treated using SEEG-guided RF-thermolesions of the epileptic foci between 2001 and 2006, with a follow-up ranging from 12 to 66 months. Three patients were seizure-free and 52% of the patients had a decrease in their seizure frequency of at least 50%. Of the patients presenting a malformation of cortical development etiology (i.e. dysplasia or heterotopia), 70% were classified as responders (at least a 50% decrease in seizure frequency) (p=0.052), whereas the results were less favorable in patients with a cryptogenic and hippocampal sclerosis etiology. Twenty patients underwent conventional cortectomy in a second step, 18 of whom are in Engel class I. In conclusion, SEEG-guided RF-thermolesions of the epileptic foci and networks proved to be a safe therapeutic procedure capable of providing an immediate benefit in terms of seizure control, especially in patients with epilepsy symptomatic of cortical development malformation. Such thermolesions do not preclude subsequent conventional surgery in case of failure, which can be proposed as an alternative procedure if no resective surgery is possible.     

Epilepsy and insula

The insula is the only cortical part of the brain that is not visible on the surface of the hemisphere, because it is totally covered by the frontoparietal and temporal opercula. The insula is triangular in shape and is separated from the opercula by the anterior, superior, and inferior peri-insular sulci. It is morphologically divided into two parts by the central insular sulcus. The anterior part of the insula bears three short gyri, and its posterior part contains two long gyri. The vascular supply of the insula is mainly provided by the M2 segment of the middle cerebral artery, a substantial obstacle to any open or stereotactic procedure aiming at the insular region. The insula is functionally involved in cardiac rhythm and arterial blood pressure control, as well as in visceromotor control and in viscerosensitive functions. There is substantial evidence that the insula is involved as a somesthetic area, including a major role in the processing of nociceptive input. The role of the insula in some epilepsies was recently investigated by means of depth electrode recordings made following Talairach's stereoelectroencephalography (SEEG) methodology. It appears that ictal signs associated with an insular discharge are very similar to those usually attributed to mesial temporal lobe seizures. Ictal symptoms associated with insular discharges are mainly made up of respiratory, viscerosensitive (chest or abdominal constriction), or oroalimentary (chewing or swallowing) manifestations. Unpleasant somatosensory manifestations, always opposite the discharging side, are also frequent. Ictal signs arising from the insula occur in full consciousness; these are always simple partial seizures. Seizures arising from the temporal lobe always invade the insular region, but in approximately 10% of cases, the seizures originate in the insular cortex itself. These data explain that there has been a rebirth of interest in the insula from a surgical perspective over the past few years. The literature contains no reports of cases of resection of insular cortex alone; most insular resections are performed in the context of temporal resection, when there is some evidence of seizures originating in the insula itself. Such procedures are risky and their efficacy, in terms of postoperative surgical outcome, has not yet been clearly assessed. In this context, less invasive procedures, such as SEEG-guided radiofrequency thermolesions of the insular cortex, are under investigation.     

输尿管病变与结石并存的诊治探讨

本文报告51例输尿管病变与结石并存病例,通过对X线影象、B超检查、手术所见及病理学的资料研究,发现先天性病变以瓣膜多见,炎症性以肉芽肿多见,增殖性以息肉多见。对输尿管病变和结石的关系、诊断及鉴别诊断作讨论,认为采用充分切除病变段加整形吻合术效果最佳,输尿管镜的应用对处理此类疾病有优势。     

全胸腔镜下Box Lesion双极射频治疗心房颤动

目的探索一种新的全胸腔镜外科手术方法治疗单纯性心房颤动的疗效,以寻求更好的疗效、更小的创伤、更易于操作的微创手术方式。方法 2011年6月华西医院心血管外科在全胸腔镜下行Box Lesion双极射频（双侧肺静脉＋左心房后壁隔离）治疗3例单纯性心房颤动患者,均为女性,年龄分别为40岁、60岁和66岁。手术在全胸腔镜下进行,在双侧胸壁肋间隙各行3个5～10mm的小切口;观察患者术后早期窦性心律的转复情况及并发症发生情况。结果 3例患者手术时间分别为140min、170min和155min,均在术后即刻转复为稳定窦性心律,术中平均失血量约80ml,术后住ICU 1d,术后平均住院7d,无手术死亡,无严重并发症。3例患者分别于术后1周、1个月复查心电图,均为窦性心律。结论本组手术初步显示Box Lesion双极射频心房颤动治疗术创伤小、术后恢复快,疗效满意,值得进一步研究、推广     

Presurgical evaluation of intractable epilepsy using stereo-electro-encephalography methodology: principles, technique and morbidity

In the stereo-electro-encephalography (SEEG) methodology developed by Talairach and Bancaud in Sainte-Anne Hospital in Paris, France, the objective of placing depth electrode recordings in presurgical evaluation is to study the spatial and temporal organization of a seizure. This defines for each patient the cortical onset zone, the propagation pattern of the seizure, and the possible involvement of eloquent areas of the cortex. This methodology requires a meticulous stereotactic surgical technique. We report here the SEEG methodology, surgical technique, and morbidity.     

Recent Advancement of Technologies and the Transition to New Concepts in Epilepsy Surgery

Fruitful progress and change have been accomplished in epilepsy surgery as science and technology advance. Stereotactic electroencephalography (SEEG) was originally developed by Talairach and Bancaud at Hôspital Sainte-Anne in the middle of the 20th century. SEEG has survived, and is now being recognized once again, especially with the development of neurosurgical robots. Many epilepsy centers have already replaced invasive monitoring with subdural electrodes (SDEs) by SEEG with depth electrodes worldwide. SEEG has advantages in terms of complication rates as shown in the previous reports. However, it would be more indispensable to demonstrate how much SEEG has contributed to improving seizure outcomes in epilepsy surgery. Vagus nerve stimulation (VNS) has been an only implantable device since 1990s, and has obtained the autostimulation mode which responds to ictal tachycardia. In addition to VNS, responsive neurostimulator (RNS) joined in the options of palliative treatment for medically refractory epilepsy. RNS is winning popularity in the United States because the device has abilities of both neurostimulation and recording of ambulatory electrocorticography (ECoG). Deep brain stimulation (DBS) has also attained approval as an adjunctive therapy in Europe and the United States. Ablative procedures such as SEEG-guided radiofrequency thermocoagulation (RF-TC) and laser interstitial thermal therapy (LITT) have been developed as less invasive options in epilepsy surgery. There will be more alternatives and tools in this field than ever before. Consequently, we will need to define benefits, indications, and limitations of these new technologies and concepts while adjusting ourselves to a period of fundamental transition in our foreseeable future.     

椎动态MRA在预椎病变中的应用

目的：探讨椎动脉核磁共振血管成像（Magnetic resonace angiographyMRA)在颈椎病变中的应用价值,方法：本组8例,男5例,女3例。年龄7－42岁,平均26岁。病变范围C1－C6,X线片及CT显示椎体均有破坏,其中4例侵犯－侧横突,横突孔被包裹在病灶组织内。术后病理证实颈椎结核4例,慢性炎症1例,嗜酸性肉芽肿2例,血管瘤1例。全部患者术前行椎动态MRA检查,观察双侧椎动脉成像及走行。结果：3例患侧椎动脉发生扭曲并偏移向中线,2例椎动脉局部受压,3例椎动脉平直行走无扭曲。无1例椎动脉阻塞、管壁侵蚀,假性动脉瘤形成。结论：结椎病变如肿瘤,结核,炎症等常造成椎动脉走行变异,前瞻性MRA检查是预防中椎动脉损伤的有效方法。     

The accuracy of a novel self-tapping bone fiducial marker for frameless robot-assisted stereo-electro-encephalography implantation and registration techniques

Background

We aimed to evaluate the accuracy and safety of a novel self-tapping bone fiducial as a registration technique for stereoelectroencephalography (SEEG) implantation.

Methods

Each patient was installed with five bone fiducial markers. All procedures were performed using the same Sinovation robot system. The accuracy was determined by calculating the target point error (TPE) and the entry point error (EPE) of electrodes.

Results

Fourteen patients underwent SEEG implantation surgery; and the average installation time of the markers per patient was 86.1 s. In the operating theatre, the average registration time was 206.6 s, and the average registration error was 0.18 mm. The average TPE of 174 electrodes was 1.98 mm and the average EPE was 0.88 mm.

Conclusion

Our study provided a bone fiducial marker installation and registration technique that was convenient and fast, highly accurate in registration, and highly tolerated by patients.     

Epilepsy surgery in children: from a multidisciplinary network to the creation of an expertise and care centre

We report on the experience of a network created in 1994 to evaluate children with drug-resistant epilepsies who are candidates for surgical treatment. The network includes epilepsy units from several university hospitals in France that decided to share not only their clinical expertise to better respond to the need for a multidisciplinary approach of epilepsy surgery in children, but also all the technical and human resources available in the various teams. This mode of operation has certainly provided concrete proof of its efficacy since it undoubtedly facilitated, and even accelerated, access to optimal presurgical evaluation and epilepsy surgery for hundreds of children. However, after 10 years of this very enriching practice it became evident that our approach was certainly necessary but not sufficient. It is estimated that every year in France nearly 500 children are candidates for surgical treatment, and following a presurgical evaluation, 50% of them could be operated on. Today, only 150-200 children have access to a presurgical evaluation every year. This is a highly paradoxical situation since, even if the human suffering component that such a situation generates is set aside, the direct and indirect life-time costs for every 100 nonoperated patients is estimated at 40 million euros. As a result of our cumulated experience, in 2004 we proposed a different operating model with the creation of an expertise center that will combine not only medical care services provided by a fully equipped multidisciplinary team, but also a pole of applied clinical and fundamental research, a medicosocial center managed by a lay association and an industrial development pole. The project has been recently validated by the Ministry of Health and is supported by a number of national and regional institutions. The Institute for Children and Adolescents with Epilepsy--IDEE--is designed to accelerate diagnostic procedures and, when indicated, access to optimal presurgical evaluation, while also serving as a model for a medical and economic evaluation of epilepsy care in children.     

Primary Experiences with Robot-assisted Navigation-based Frameless Stereo-electroencephalography: Higher Accuracy than Neuronavigation-guided Manual Adjustment

The use of robot-assisted frameless stereotactic electroencephalography (SEEG) is becoming more common. Among available robotic arms, Stealth Autoguide (SA) (Medtronic, Minneapolis, MN, USA) functions as an optional instrument of the neuronavigation system. The aims of this study were to present our primary experiences with SEEG using SA and to compare the accuracy of implantation between SA and navigation-guided manual adjustment (MA). Seventeen electrodes from two patients who underwent SEEG with SA and 18 electrodes from four patients with MA were retrospectively reviewed. We measured the distance between the planned location and the actual location at entry (De) and the target (Dt) in each electrode. The length of the trajectory did not show a strong correlation with Dt in SA (Pearson''s correlation coefficient [r] = 0.099, p = 0.706) or MA (r = 0.233, p = 0.351). De and Dt in SA were shorter than those in MA (1.99 ± 0.90 vs 4.29 ± 1.92 mm, p = 0.0002; 3.59 ± 2.22 vs 5.12 ± 1.40 mm, p = 0.0065, respectively). SA offered higher accuracy than MA both at entry and target. Surgical times per electrode were 38.9 and 32 min in the two patients with SA and ranged from 51.6 to 88.5 min in the four patients with MA. During the implantation period of 10.3 ± 3.6 days, no patients experienced any complications.     

Temporo-mesial epilepsy surgery: outcome and complications in 100 consecutive adult patients

Summary Background. We studied the surgical outcome, and the complications in a group of 100 consecutive adult patients with medically refractory epilepsy arising from the temporo-mesial structures. Methods. Hundred patients were treated surgically between 1994 and 2003 for drug-resistant epilepsy involving the temporo-mesial structures. All of them underwent a comprehensive noninvasive presurgical evaluation. Fourty-eight of them underwent depth electrodes recordings (according to the Talairach’s StereoElectroEncephaloGraphic (SEEG) methodology) because the noninvasive investigations were not congruent enough to identify the epileptic zone. The patients presenting with any space-occupying lesion, or with a cavernoma, or with a strictly lateral neocortical epileptic focus, were excluded. The MRI-examination was abnormal in 87 cases, displaying a hippocampal atrophy in 69 cases. The extent of temporal resection was planned according to the results of the presurgical investigation in each particular patient. Consequently, this “tailored” resection varied from selective amygdalo-hippocampectomy (6 cases), to anterior temporal lobectomy (76 cases), or to total temporal lobectomy (18 cases). Findings. The mean post-operative follow-up period was 53 months. 85 patients were found to be in Engel’s class I post-operatively (free of disabling seizures), among them 74 were in class Ia (totally seizure free). Nine patients were in Engel’s class II and six were in Engel’s class III or IV (failures). There was no surgical mortality. Three patients had a postoperative hematoma; two patients required a shunt insertion; in three patients meningitis occured; and two patients had postoperative ischaemia of the anterior choroidal artery territory, which resulted in a mild permanent hemiparesis. Neuropsychological complications are not addressed in detail in this article. Conclusions. These data indicate that “tailored” resective surgery for temporo-mesial epilepsy can be performed with a low rate of morbidity, and is highly efficacious. The use of invasive presurgical investigation (SEEG) may explain this high rate of success.     

Excision of Nonpalpable Breast Cancer with Indocyanine Green Fluorescence-Guided Occult Lesion Localization (IFOLL)

BACKGROUND: Currently employed techniques for the localization of nonpalpable breast lesions suffer from various limitations. In this paper, we report on 2 patients in order to introduce an alternative technique, indocyanine green fluorescence-guided occult lesion localization (IFOLL), and determine its applicability for the surgical removal of this type of breast lesions. CASE REPORTS: Preoperatively, one of the patients had a needle biopsy-proven diagnosis of breast cancer, and the other one had suspicious findings for malignancy. Lesion localization was performed within 1 h before surgery under ultrasonography control by injecting 2 ml and 0.2 ml of indocyanine green into the lesion and its subcutaneous tissue projection, respectively. During surgery, the site of skin incision and the resection margins were identified by observing the area of indocyanine-derived fluorescence under the guidance of a near-infrared-sensitive camera. In both cases, the breast lesion was correctly localized, and the area of fluorescence corresponded well to the site of the lesions. Subsequent surgical excision was successful with no complications. On histopathologic examination, the surgical margins were found to be clear. CONCLUSION: IFOLL seems to be a technically applicable and clinically acceptable procedure for the removal of nonpalpable breast cancer.     

The epileptogenic zone

The definition of the epileptogenic zone is a concept proposed by Jean Bancaud and Jean Talairach based on the anatomical, electrical and clinical correlations established from stereoelectroencephalographic recordings. They believed the epileptogenic zone to be the "region of the beginning and the primary organization" of ictal discharges. The opinion of North American authors is different: the epileptogenic zone is the "what to remove area" to produce freedom from seizures. This surgical definition assumes postsurgical validation. The aim of this paper is to show how to define the epileptogenic zone from all the stereoelectroencephalographic recording data.     

综合护理对宫颈癌放疗后皮肤溃烂患者皮损症状评分的影响

目的 探究宫颈癌放疗后皮肤溃烂患者实施综合护理的临床效果。方法 选取2020年10月-2022年 12月联勤保障部队第九〇一医院肿瘤科收治的宫颈癌放疗后发生皮肤溃烂的60例患者为研究对象。采用随 机数字表法分为对照组和观察组,对照组实施常规护理,观察组实施综合护理,比较两组皮肤损伤症状、 皮肤美观度、生活质量及护理满意度。结果 观察组护理后皮肤损伤症状评分低于对照组,差异有统计学 意义（ P ＜0.05）;观察组CS评分、QLQ-C30评分高于对照组,差异有统计学意义（ P ＜0.05）;观察组护 理满意度高于对照组,差异有统计学意义（ P ＜0.05）。结论 对于宫颈癌放疗后发生皮肤溃烂的患者,综 合护理能取得良好的效果,可有效改善皮损症状,提高皮肤美观度,提升患者生活质量。     

胸骨后甲状腺病变的诊断和治疗

目的 探讨提高胸骨后甲状腺(retrosternal thyroid，RT)的诊治水平。方法 回顾性分析115例RT患，其邻近器官压迫为常见症状，有甲亢症状16例，主要体征为不能触及下极的颈部包块、气管移位、颈胸静脉扩张，吞咽时多数不能扪及甲状腺下极。首次手术110例，5例为颈部术后复发再次手术。结果 105例颈部低位领状切口，7例加劈开胸骨5cm，3例气管内麻醉下开胸手术。行预防性气管切开12例。术中术后无死亡病例。病理结果显示：良性病变83例，其中3例复发；32例恶性病变，其中2例未分化癌术后4月死于全身转移，1例髓样癌术后18个月死亡，余均术后生存超过3年，其中22例超过5年。结论 RT诊断并不困难：颈胸部X线检查、放射性核素扫描及CT检查可明确程度及性质；RT为手术绝对适应证，对无症状患也应早期手术；多数病例可采用颈部切口，少数需劈开胸骨，而迷走性RT则需开胸手术；合并气管软化预防性气管切开有助于避免术后呼吸道梗阻。     

Horsley was the first to use electrical stimulation of the human cerebral cortex intraoperatively

Fedor Krause has previously been credited with being the first surgeon to use electrical stimulation to define epileptic foci in the human cerebral cortex before extirpation. We provide evidence indicating that Krause was probably preceded by Horsley, and Bidwell and Sherrington in England, and by Keen in the United States. Sir Victor Horsley apparently first used electrical stimulation diagnostically in 1884 and slightly later (1886) to define epileptic foci.     

Temporal mediobasal tumors: a proposal for classification according to surgical anatomy

Objective  Development of a classification for temporal mediobasal tumors based on anatomical and neuroradiological aspects to help evaluate surgical accessibility and risk. Methods  Preoperative magnetic resonance imaging, surgical approaches and outcomes of 235 patients with a temporal mediobasal tumor were analyzed retrospectively. Surgical landmarks were defined in accordance with operative anatomy. Previous classifications of these tumors were reviewed and a new classification system was developed. Results  The new classification system recognises four types of temporal mediobasal tumor based on anatomical landmarks, location, and size. Type A comprises lesions confined to the uncus, hippocampus, parahippocampus, and/or amygdala. Type B comprises lesions in the area immediately lateral to the structures where type A tumors are located but sparing lateral gyri. Type C tumors are larger lesions, which occupy the area of type A and type B simultaneously. Type D tumors originate from the temporal mediobasal region and invade into the adjacent structures of the temporal stem, insular cortex, claustrum, putamen, or pallidum. The area occupied by a tumor in the axial plane was divided into anterior (a) and posterior (p) subregions. Progressive grading from A to D and from “a” to “p” was based on the view that larger and more posteriorly growing tumors were more difficult to remove. Lesions located in the anterior subregion (n = 173) were easier to remove by the transsylvian route (39%) or after partial anterior lobectomy (32%). For the posterior lesions (n = 62), a subtemporal approach was more appropriate (75%). Conclusions  Based on a series of 235 temporal mediobasal tumors, a classification system was designed to aid in decision making about operability, surgical risk, and approach.