Resection Of Epileptic Focus Research Articles

The effect of propofol on intraoperative electrocorticography and cortical stimulation during awake craniotomies in children.

Propofol has been proposed as a sedative agent during awake craniotomies. However, there are reports of propofol suppressing spontaneous epileptiform electrocorticography (ECoG) activity during seizure surgery, while others describe propofol-induced epileptiform activity. The purpose of this study was to determine if propofol interferes with ECoG and direct cortical stimulation during awake craniotomies in children. Children scheduled for awake craniotomies for resection of epileptic foci or tumours were studied. An intravenous bolus of 1-2 mg.kg-1 followed by infusion of 100-200 microgram.kg-1.min-1 of propofol was administered to induce unconsciousness. Fentanyl (0.5 microgram.kg-1) was administered incrementally to provide analgesia. After the cortex was exposed, the propofol infusion was stopped and the patient permitted to awaken. Cortical electrodes were applied. ECoG was recorded continuously on a Grass polygraph. Motor, sensory, language, and memory testing were done throughout the procedure. The cortex was stimulated with a hand-held electrode using sequential increases in voltage to map the relevant speech and motor areas. We studied 12 children (aged 11-15 years) with intractable seizures. The raw ECoG did not reveal any prolonged beta-waves associated with propofol effect. Electroencephalogram spikes due to spontaneous activity or cortical stimulation were easily detected. Cognitive, memory and speech testing was also successful. We conclude that propofol did not interfere with intraoperative ECoG during awake craniotomies. Using this technique, we were able to fully assess motor, sensory, cognitive, speech and memory function and simultaneously avoid routine airway manipulation.

Human cerebrocortical potentials evoked by stimulation of the dorsal nerve of the penis

Cortical evoked potentials resulting from stimulation of the dorsal nerve of the penis (DNP) provide a unique opportunity to document the cortical localization of sexual sensory representation in man. The DNP supplies sensory axons to the major portion of the human phallus, including the penile shaft and glans. Animal and human studies indicate that this nerve plays a crucial role in erection and ejaculation. Direct cortical evoked responses to DNP electrical stimulation were recorded in patients undergoing preoperative evaluation for resection of epileptic foci. These studies provided evidence that the primary sensory cortex contains a large area of cortex devoted to the afferent fibers of the DNP and that the sensory field is in a different location than previously described. The location and distribution of this response indicated the need for revision of the traditional concept of the sensory cortical homunculus.

Objective method for localization of cortical asymmetries using positron emission tomography to aid surgical resection of epileptic foci

We designed a semiautomated method for the objective detection of abnormal regions of tracer accumulation in the brain. The purpose of the present study was to examine the diagnostic performance of this method by applying it to patients with clinically intractable epilepsy of unilateral origin; they underwent [F-18] deoxyglucose positron emission tomography (PET) prior to surgical resection of epileptic foci. A semiautomated method for assessment of asymmetries in the brain cortex was developed that compares activity concentrations in homotopic cortical areas. When these differences exceeded a predefined threshold, the areas with lower activity were marked and 3-dimensional surface rendered images were created to guide placement of intracranial electrodes (ECoG) followed by surgical resection. The normal amount of asymmetry between small (0.5-0.7 cm2) homotopic cortical regions was determined as 5.9 +/- 4.0% (mean +/- SD). The false-positive fraction was determined for cutoff thresholds of 1 SD (10%), 1.5 SD (12%), and 2 SD (15%) outside the mean and was found to be 89, 44, and 0%, respectively. The obtained sensitivity-specificity pairs for correct localization of epileptogenic lobes based on the ECoG results were best for the 15% threshold (80/94%, accuracy 0.90). This objective PET method allows the accurate determination of cortical asymmetries, and it proved to be highly efficient in guiding epilepsy surgery.

Objective Method for Localization of Cortical Asymmetries Using Positron Emission Tomography to Aid Surgical Resection of Epileptic Foci

We designed a semiautomated method for the objective detection of abnormal regions of tracer accumulation in the brain. The purpose of the present study was to examine die diagnostic performance of this method by applying it to patients with clinically intractable epilepsy of unilateral origin; they underwent [F-18] deoxyglucose positron emission tomography (PET) prior to surgical resection of epileptic foci. A semiautomated method for assessment of asymmetries in the brain cortex was developed that compares activity concentrations in homotopic cortical areas. When these differences exceeded a predefined threshold, the areas with lower activity were marked and 3-dimensional surface rendered images were created to guide placement of intracranial electrodes (ECoG) followed by surgical resection. The normal amount of asymmetry between small (0.5–0.7 cm2) homotopic cortical regions was determined as 5.9 ± 4.0% (mean ± SD). The false-positive fraction was determined for cutoff thresholds of 1 SD (10%), 1.5 SD (12%), and 2 SD (15%) outside the mean and was found to be 89, 44, and 0%, respectively. The obtained sensitivity-specificity pairs for correct localization of epileptogenic lobes based on the ECoG results were best for the 15% threshold (80/94%, accuracy 0.90). This objective PET method allows the accurate determination of cortical asymmetries, and it proved to be highly efficient in guiding epilepsy surgery.

Zygomatic approach for resection of mesial temporal epileptic focus.

By using the zygomatic approach, temporal mesial and polar epileptic foci are easily accessible through an incision in the inferior temporal gyrus. In this approach, a major part of the superior and middle temporal gyrus is preserved, and there is no risk of postoperative dysnomia even on the dominant side for speech. Combined use of depth and subdural electrodes is advisable for precise determination of focus distributions throughout the mesial and lateral structures of the temporal lobe. We have applied this approach in 5 patients with satisfactory results.

Zygomatic Approach for Resection of Mesial Temporal Epileptic Focus

Abstract By using the zygomatic approach, temporal mesial and polar epileptic foci are easily accessible through an incision in the inferior temporal gyrus. In this approach, a major part of the superior and middle temporal gyrus is preserved, and there is no risk of postoperative dysnomia even on the dominant side for speech. Combined use of depth and subdural electrodes is advisable for precise determination of focus distributions throughout the mesial and lateral structures of the temporal lobe. We have applied this approach in 5 patients with satisfactory results.

Monitoring of sensory evoked potentials is highly reliable and helpful in the operating room.

Because short-latency evoked potentials are relatively resistant to anesthetic agents, they can be used to monitor neural pathways during surgical procedures. The use of median nerve somatosensory evoked potentials to localize the central sulcus is an established aid of indisputable value in neurosurgical procedures involving cortical incisions for resection of certain epileptic foci, vascular malformations, or neoplasms near the central area of the brain. Likewise, recording of intraoperative nerve action potentials is currently regarded as indispensable in management of the neuroma-incontinuity after peripheral nerve trauma, as this evoked potential monitoring technique provides the only reliable method of distinguishing between axonotmetic and neurotmetic lesions. Evoked potential monitoring has been of value during many other types of surgical procedures, including cerebral aneurysm clipping, carotid endarterectomy, aortic procedures, microvascular decompression for trigeminal neuralgia and hemifacial spasm, acoustic neuroma resection, and a variety of spinal procedures. A detailed review of the literature is presented on the use of evoked potential monitoring for one of the more common indications: scoliosis surgery. Many orthopedic surgeons use the "wake-up test" only if the somatosensory evoked potentials change during surgery. A detailed review of the few reported cases of "false negative" evoked potentials is presented. The dearth of convincing reports of such phenomena in the face of so many positive experiences should persuade even the skeptical that monitoring of evoked potentials is a highly reliable and helpful intraoperative tool.