RESUMEN
Neurological disorders, including epilepsy, often manifest with altered brain stiffness, particularly in affected regions. The complex relationship between the biomechanical and microstructural characteristics of epileptic brain (EB) is poorly understood and warrants comprehensive research. This study investigates the in vitro viscoelastic properties of surgically excised EB tissues (S = 20) and marginal normal brain (NB) (S = 10) from the same individuals diagnosed with varying epileptogenic substrates. The microstructural characterization including neuron density, myelin and collagen content was also performed. Additionally, in vivo magnetic resonance elastography (MRE) was conducted on one subject to complement the in vitro findings as a pilot investigation. EB exhibited significantly higher stiffness than NB (storage modulus G ' $$ {G}^{\prime } $$ : 6.49 ± $$ \pm $$ 3.83 kPa vs. 1.97 ± $$ \pm $$ 0.40 kPa; loss modulus G ' ' $$ {G}^{\prime \prime } $$ : 1.53 ± $$ \pm $$ 0.93 kPa vs. 0.61 ± $$ \pm $$ 0.31 kPa; p = 0.001). Among pathological subtypes, mesial temporal sclerosis (MTS) tissues were the stiffest ( G ' $$ {G}^{\prime } $$ : 8.42 ± $$ \pm $$ 4.05 kPa and G ' ' $$ {G}^{\prime \prime } $$ : 1.95 ± $$ \pm $$ 1.03 kPa), while focal cortical dysplasia (FCD) tissues were the softest ( G ' $$ {G}^{\prime } $$ : 2.56 ± $$ \pm $$ 0.45 kPa and G ' ' $$ {G}^{\prime \prime } $$ : 0.83 ± $$ \pm $$ 0.41 kPa). Other etiologies fell between these extremes. Microstructural correlations revealed a strong positive relationship between stiffness and neuronal density (r = 0.81), a moderate negative correlation with myelin content (r = -0.52), and no significant association with collagen content (r = 0.15), indicating that cellular composition, rather than extracellular matrix components, predominantly contributes tissue mechanics. The in vivo MRE findings in an FCD lesion ( G ' $$ {G}^{\prime } $$ : 2.65 ± $$ \pm $$ 0.30 kPa; G ' ' $$ {G}^{\prime \prime } $$ : 0.91 ± $$ \pm $$ 0.25 kPa) showed concordance with the in vitro measurement of specimen from same subject ( G ' $$ {G}^{\prime } $$ : 2.50 ± $$ \pm $$ 0.41 kPa; G ' ' $$ {G}^{\prime \prime } $$ : 0.47 ± $$ \pm $$ 0.36 kPa). A deeper understanding of the mechanical differences between EB and NB has implications for personalized surgical planning, the development of high-fidelity computational models, and improved elastography and non-rigid image registration algorithms.
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Encéfalo , Epilepsia Refractaria , Epilepsia , Humanos , Masculino , Femenino , Adulto , Fenómenos Biomecánicos , Encéfalo/cirugía , Encéfalo/patología , Encéfalo/diagnóstico por imagen , Encéfalo/fisiopatología , Epilepsia Refractaria/cirugía , Epilepsia Refractaria/patología , Epilepsia Refractaria/fisiopatología , Epilepsia Refractaria/diagnóstico por imagen , Diagnóstico por Imagen de Elasticidad , Persona de Mediana Edad , Imagen por Resonancia Magnética , Epilepsia/cirugía , Epilepsia/patología , Adulto Joven , Colágeno/metabolismoRESUMEN
Epilepsy surgery remains underutilized in Latin America despite its proven effectiveness for drug-resistant epilepsy. Structural and socioeconomic barriers may contribute to limited access and delayed intervention. To systematically evaluate the clinical characteristics, surgical outcomes, and socioeconomic barriers to accessibility associated with epilepsy surgery in Latin America. A systematic review was conducted following PRISMA guidelines. Searches were performed in PubMed, Scopus, ScienceDirect, Web of Science, and SciELO. Studies were included if they reported original data on epilepsy surgery in Latin American populations. Data on demographics, epilepsy type, and surgical outcomes were extracted and analyzed descriptively. Barriers such as geographic centralization, economic constraints, lack of specialized centers, and limited diagnostic infrastructure were also identified and examined. Of 103 initial records, 10 studies met all inclusion criteria. Most were retrospective observational studies from Colombia, Brazil, Mexico, and Chile. The mean age at surgery was 30.3 years, with an average diagnostic-to-surgery delay of 17.1 years. Mesial temporal lobe epilepsy was the most common subtype. Seizure freedom (Engel Class I) was achieved in 43.7% to 85% of cases. However, only 3.8% of eligible patients underwent surgery in some cohorts. Barriers included geographic centralization, economic constraints, lack of specialized centers, limited diagnostic infrastructure, cultural stigma, and under-referral from physicians. Quality-of-life improvements and psychosocial reintegration were observed postoperatively, yet disparities in access persisted. Despite favorable surgical outcomes, epilepsy surgery in Latin America remains significantly delayed and centralized. Health system limitations and socioeconomic inequities continue to restrict timely and equitable access. Regional policies must prioritize early referral pathways, surgical infrastructure, and financial protection to reduce the epilepsy treatment gap.
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Epilepsia Refractaria , Epilepsia , Accesibilidad a los Servicios de Salud , Procedimientos Neuroquirúrgicos , Humanos , América Latina , Accesibilidad a los Servicios de Salud/economía , Epilepsia/cirugía , Epilepsia/economía , Factores Socioeconómicos , Procedimientos Neuroquirúrgicos/economía , Epilepsia Refractaria/cirugíaRESUMEN
Epilepsy surgery, the treatment of choice for drug-resistant focal epilepsy, is evolving rapidly. This progress is driven by a growing interest in the network theory of epilepsy, advances in data-driven models, and a focus on personalised treatment approaches. As a result, treatment options have expanded to include minimally invasive procedures, neurostimulation devices, and network-based interventions. Predicting surgical outcomes-such as seizure freedom and neuropsychological effects-remains challenging but is improving through advances in computational technology and molecular research, paving the way for more precise surgery. Despite these advancements, disparities in access to treatments persist, particularly in resource-scarce settings, highlighting the need for systemic solutions to improve access. Emerging research into genetic and multi-omic markers might assist in tailoring treatments and improving the prediction of outcomes. Future directions include integrating minimally invasive techniques, refining neuromodulation strategies, and leveraging molecular and computational tools to optimise patient care. Multidisciplinary collaboration will be essential to overcome challenges, reduce disparities, and advance surgical outcomes for patients with drug-resistant epilepsy worldwide.
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Epilepsia Refractaria , Epilepsia , Procedimientos Neuroquirúrgicos , Medicina de Precisión , Humanos , Medicina de Precisión/métodos , Medicina de Precisión/tendencias , Epilepsia Refractaria/cirugía , Procedimientos Neuroquirúrgicos/métodos , Procedimientos Neuroquirúrgicos/tendencias , Epilepsia/cirugíaRESUMEN
BACKGROUND AND OBJECTIVES: Epilepsy surgery outcomes after intracranial EEG remain suboptimal necessitating the discovery of additional biomarkers to define the epileptogenic zone. Fast ripples (FRs) are a promising, new interictal epilepsy biomarker. By analyzing a multicenter data set consisting of overnight stereo-EEG (SEEG) recordings, we aimed at validating FRs as an accurate marker of the epileptogenic zone. We hypothesized that removing ≥60% of total FR events would significantly increase the odds of good postsurgical outcome (Engel class I). In addition, we compared FRs with spikes, and spikes co-occurring with FRs (spike-FRs) as surgery outcome predictors. METHODS: This retrospective cohort study included consecutive patients from 4 epilepsy surgery centers in Canada, Finland, and Denmark, who underwent SEEG followed by resective surgery or a preplanned ablation procedure separate from the SEEG and had at least 1 year of follow-up. We detected FRs and spikes automatically from overnight SEEG recordings edited for artifacts. To calculate resection ratios of the detected events, we determined resected SEEG contacts by superimposing the peri-implantation and postresection images. We evaluated postsurgical seizure outcomes from medical records. RESULTS: Of the 73 included patients (mean age 23 ± 12 years, 41% female), 46 had good and 27 had poor (Engel classes II-IV) outcome at the latest follow-up. Patients with FR resection ratio ≥0.6 were more likely to achieve good postsurgical outcome (p < 0.001, diagnostic odds ratio [DOR] 10, 95% CI 2.7-39). Of those with ≥0.6 FR resection ratio, 26 of 29 (90%, 95% CI 74%-96%) achieved good outcome, whereas of those with <0.6 FR resection ratio, 24 of 44 (55%, 95% CI 46%-63%) had poor outcome, with overall accuracy of 68% (95% CI 57%-79%). In addition, the spike-FR resection ratio ≥0.6 was associated with good postsurgical outcome (p = 0.007, DOR 4.1, 95% CI 1.4-12, accuracy 64%, 95% CI 52%-75%), whereas the spike resection ratio ≥0.6 was not. DISCUSSION: In accordance with our hypothesis, the FR resection ratio ≥0.6 significantly increased the odds of attaining good postsurgical seizure outcome. Although the FR resection ratio ≥0.6 accurately predicted good postsurgical outcome, resecting <0.6 of FRs did not necessarily mean poor outcome. As predictors of postsurgical outcome, spikes fared poorly, whereas spike-FRs were comparable with FRs.
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Electrocorticografía , Electroencefalografía , Epilepsia , Humanos , Femenino , Masculino , Adulto , Estudios Retrospectivos , Adulto Joven , Adolescente , Electroencefalografía/métodos , Niño , Epilepsia/cirugía , Epilepsia/fisiopatología , Epilepsia/diagnóstico , Electrocorticografía/métodos , Resultado del Tratamiento , Estudios de CohortesRESUMEN
Accurate localization of the theoretical epileptogenic zone in cingulate epilepsy is particularly challenging due to the region's deep anatomical location and complex connectivity. While invasive stereoelectroencephalography (sEEG) methodology offers excellent spatiotemporal sampling of deep intracerebral structures, interpretation of these high-dimensional recordings remains largely qualitative and subject to interpretation by clinician experts. To address this limitation, we propose a quantitative, biomarker-based framework using phase-amplitude coupling (PAC) to investigate 25 seizures recorded from four patients with complex cingulate epilepsy who underwent sEEG followed by surgical treatment (either laser ablation or open resection), achieving ≥ 1 year of sustained seizure freedom. PAC values were computed from sEEG electrode contacts across multiple seizures during pre-ictal and ictal phases, employing wide-frequency and band-specific frequency coupling approaches. Among frequency pairs, theta-beta ([Formula: see text]-[Formula: see text]) coupling consistently demonstrated the most robust differentiation between surgically-treated and untreated contact sites. Our findings highlight frequency-specific PAC-based metrics as a potential tool for mapping dynamic epileptiform activity in brain networks, offering quantitative insight that may refine surgical planning and decision-making in challenging cases of cingulate epilepsy.
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Electroencefalografía , Epilepsia , Giro del Cíngulo , Humanos , Giro del Cíngulo/fisiopatología , Giro del Cíngulo/cirugía , Giro del Cíngulo/diagnóstico por imagen , Adulto , Electroencefalografía/métodos , Masculino , Femenino , Técnicas Estereotáxicas , Adulto Joven , Persona de Mediana Edad , Epilepsia/fisiopatología , Epilepsia/cirugía , Mapeo Encefálico/métodosRESUMEN
BACKGROUND AND OBJECTIVES: Thalamic neuromodulation is widely used in epilepsy surgery. However, thalamic sampling in invasive monitoring is not consistently used. We aimed to quantify current trends in thalamic stereoelectroencephalography (SEEG) utilization. METHODS: We performed a survey of epilepsy neurosurgeons and neurologists to gauge their attitudes and experience with thalamic SEEG. We contacted all members of the American Society for Stereotactic and Functional Neurosurgery and American Epilepsy Society organizations using a mailing list. RESULTS: We received 40 responses from centers using SEEG, including 31 neurosurgeons and 9 epileptologists. Among these respondents, 65% (26/40) included thalamic targets in their SEEG plans. The most common clinical rationales were to define the seizure network (22/26, 84.6%) or the high probability of targeted structure being a neuromodulation target (22/26, 84.6%). Over half of the respondents who used thalamic SEEG (15/26, 57.6%) endorsed that the findings informed target selection and feasibility of thalamic neuromodulation. The most commonly implanted thalamic targets included centromedian (23/26) and anterior nucleus of the thalamus (ANT) (22/26), followed by pulvinar (19/26). CONCLUSION: Thalamic SEEG is a diagnostic tool that is being increasingly used across epilepsy centers. This may be an important tool to support the paradigm shifts occurring in the surgical management of epilepsy.
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Electroencefalografía , Epilepsia , Técnicas Estereotáxicas , Tálamo , Humanos , Electroencefalografía/tendencias , Electroencefalografía/métodos , Electroencefalografía/estadística & datos numéricos , Tálamo/cirugía , Tálamo/fisiopatología , Técnicas Estereotáxicas/tendencias , América del Norte , Epilepsia/cirugía , Encuestas y Cuestionarios , Neurocirujanos , Electrodos ImplantadosRESUMEN
PURPOSE: To understand the current state of epilepsy surgery education delivered to epilepsy fellows in the United States. METHODS: An online survey focused on characteristics of epilepsy surgery education was distributed to all 93 epilepsy fellowship program directors listed on the ACGME website (accessed in May 2022). Programs were stratified per the number of fellows currently enrolled: 0 to 3 (group A) and ≥4 (group B). RESULTS: Forty-one of 93 (44%) epilepsy fellowship programs were included in the study. The average number of resective surgeries, ablations, or corpus callosotomies per year was mostly 0 to 30 (54%) in group A and mostly >30 (80%) in group B ( P = 0.05). The average number of intracranial implantations per year was mostly 0 to 20 (58%) in group A and mostly >20 (80%) in group B ( P < 0.05). The average number of neurostimulation implantations per year was 15 (range 0-90; vagal nerve stimulation), 7 (range 0-25; responsive neurostimulation), and 4 (range 0-10; deep brain stimulation). In 78% of programs, fellows are not required to present a minimum number of epilepsy surgery cases in multidisciplinary conference before graduation. Roughly half of programs (51%) reported not using objective measures to assess fellow competency in epilepsy surgery. CONCLUSIONS: Our results suggest significant variability in epilepsy surgery volume and, consequently, fellow exposure to surgical cases and lack of standardized, objective measures in fellow teaching and assessment in the field of epilepsy surgery across programs in the United States. We advocate development of a core epilepsy surgery curriculum including minimum standards at the national level.
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Epilepsia , Becas , Neurocirugia , Procedimientos Neuroquirúrgicos , Humanos , Epilepsia/cirugía , Estados Unidos , Becas/estadística & datos numéricos , Encuestas y Cuestionarios , Neurocirugia/educación , Procedimientos Neuroquirúrgicos/educaciónRESUMEN
Predicting the postoperative outcome of stereoelectroencephalography-guided radiofrequency thermocoagulation (SEEG-guided RF-TC) remains challenging despite its increasing use in epilepsy treatment. Although SEEG-guided RF-TC has attracted extensive clinical interest, reliable biomarkers for treatment efficacy are still lacking. This study aims to address this gap by analyzing the altered brain network to predict postoperative outcome. Thirty-one focal cortical dysplasia epileptic patients who underwent RF-TC based on SEEG were enrolled in this study. They were included in the favorable outcome and poor outcome groups according to the follow-up. Partial Directed Coherence and Directed Transfer Function were applied to construct SEEG brain networks, and then brain network features were extracted. Subsequently, the differences in the presurgical and postsurgical brain network features were compared using the Wilcoxon test in the favorable and poor outcome groups, respectively. Finally, four machine learning models were applied to predict the outcome of RF-TC. After RF-TC surgery, the Characteristic Path Length (L) and average Betweenness Centrality (BC) increased while the average Clustering Coefficient (C) and Assortativity Coefficient (R1, R2) decreased in the favorable outcomes group. In contrast, there were no significant changes in the patient group with poor outcomes. The Support Vector Machine (SVM) model achieved the highest performance, with accuracy, sensitivity, specificity, and ROC values of 0.887, 0.821, 0.920, and 0.879, respectively. This study sheds light on the mechanisms of epilepsy from the perspective of brain networks and introduces a novel therapeutic strategy by altering network features. These feature alterations can also support machine learning models in effectively distinguishing favorable from poor outcomes.
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Encéfalo , Electrocoagulación , Epilepsia , Humanos , Masculino , Femenino , Adulto , Resultado del Tratamiento , Electrocoagulación/métodos , Epilepsia/cirugía , Epilepsia/fisiopatología , Adolescente , Adulto Joven , Encéfalo/fisiopatología , Encéfalo/cirugía , Electroencefalografía/métodos , Niño , Persona de Mediana Edad , Máquina de Vectores de Soporte , Malformaciones del Desarrollo Cortical/cirugía , Malformaciones del Desarrollo Cortical/fisiopatologíaRESUMEN
OBJECTIVE: Type II focal cortical dysplasias (FCDII) present a clear-cut anatomo-electro-clinical profile and are associated with optimal surgical outcome when completely resected. Alongside presurgical planning and neuroimaging, intraoperative electrocorticography (ECoG) can aid in delineating FCDII boundaries. We report outcomes from patients undergoing FCDII resection using 3D-ECoG with an intracerebral electrode guided by intraoperative ultrasound (ioUS). METHODS: Patients with suspected FCDII underwent 3D-ECoG during surgery to record intracerebral interictal epileptiform discharges (IEDs) classified as: 1) rhythmic spikes (RS), and 2) periodic bursts of polyspikes (PBOP). RESULTS: Ten patients (5 male, 5 female; median age 19.5 years, median epilepsy duration 16 years) were included. Bottom-of-sulcus dysplasia (BOSD) was found in 60 %. 3D-ECoG identified RS in 30 % and PBOP in 70 %. Total IED removal was achieved in 60 %. Histopathology revealed FCDII in 80 %, while 20 % had a diagnosis of "no definite FCD on histopathology". After a median 24-month follow-up, 90 % achieved ILAE class 1 outcome (seizure free), 10 % had class 2 (only auras). No major complications occurred. CONCLUSIONS: IoUS-assisted 3D-ECoG is a safe procedure for intraoperative delineation of FCDII, supporting complete resection. SIGNIFICANCE: Integrating IoUS with 3D-ECoG can offer substantial benefits for surgical management of FCDII-related epilepsy.
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Electrocorticografía , Imagenología Tridimensional , Monitorización Neurofisiológica Intraoperatoria , Malformaciones del Desarrollo Cortical de Grupo I , Humanos , Femenino , Masculino , Adulto , Electrocorticografía/métodos , Adolescente , Adulto Joven , Monitorización Neurofisiológica Intraoperatoria/métodos , Malformaciones del Desarrollo Cortical de Grupo I/cirugía , Malformaciones del Desarrollo Cortical de Grupo I/fisiopatología , Malformaciones del Desarrollo Cortical de Grupo I/diagnóstico por imagen , Niño , Imagenología Tridimensional/métodos , Epilepsia/cirugía , Epilepsia/fisiopatología , Ultrasonografía/métodos , Preescolar , Displasia Cortical FocalRESUMEN
BACKGROUND: While epilepsy secondary to vascular insults represents a well-documented cause of drug-resistant epilepsy that requires surgical intervention for optimal management, the prognostic factors for postoperative seizure-freedom among this patient population have not been well-established. This individual-patient data (IPD) meta-analysis aimed to 1) determine prognostic factors associated with seizure-freedom postoperatively and 2) factors associated with postoperative complications. METHODS: This study was a PRISMA-compliant systematic review and IPD meta-analysis involving studies relating to the surgical treatment of post-stroke epilepsy. An IPD meta-analysis was conducted using mixed-effects, multivariable logistic regression models to identify predictors of seizure freedom (Engels class I or International League Against Epilepsy [ILAE] class 1 or 2) and postoperative complications. RESULTS: A total of 11 studies provided patient-level data for our IPD meta-analysis. Our results demonstrated that etiology of cerebrovascular insult, specifically ischemic or hemorrhagic stroke when compared to ulegyria, was significantly and independently associated with higher odds of postoperative seizure-freedom (OR=10.21, pâ¯=â¯0.031). Further, patients with a greater number of years between epilepsy onset and surgical treatment were significantly less likely to experience seizure-freedom postoperatively (OR=0.93, pâ¯=â¯0.023). Patients with ischemic or hemorrhagic strokes were significantly less likely to experience a postoperative complication relative to patients with ulegyria in univariate analysis (OR=0.053, pâ¯=â¯0.015), and this association remained significant in multivariable analysis (OR=0.16, pâ¯=â¯0.035). CONCLUSION: Our findings synthesize the existing literature on the surgical treatment of stroke-related epilepsy and establish important prognostic factors for seizure-freedom in this patient population. We hope our results are useful in guiding future research efforts and further optimizing postoperative outcomes.
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Epilepsia Refractaria , Epilepsia , Procedimientos Neuroquirúrgicos , Accidente Cerebrovascular , Humanos , Epilepsia/cirugía , Epilepsia/etiología , Epilepsia Refractaria/cirugía , Epilepsia Refractaria/etiología , Complicaciones Posoperatorias , Accidente Cerebrovascular/complicacionesRESUMEN
INTRODUCTION: Fourth ventricular hamartomas (FVHs) are extremely rare lesions, and their association with refractory epilepsy is often underrecognized. We present a pediatric case of cerebellar-origin epilepsy with complete seizure remission after surgical resection, followed by a literature-based discussion of diagnostic and therapeutic considerations. CASE REPORT: We describe a 9-year-old female with drug-resistant epilepsy since infancy. She was diagnosed with a fourth ventricular roof hamartoma (FVRH), and after two previous surgeries with no improvement, a third procedure at our institution achieved total resection. The patient has remained seizure-free for 2 years, with significant cognitive and behavioral improvement. DISCUSSION: FVHs may present with focal motor seizures, myoclonus, hemifacial spasms, or neurodevelopmental delay. Diagnosis requires integration of MRI findings, functional imaging (SPECT/PET), and EEG-though these often yield nonspecific results. These lesions are typically resistant to pharmacologic therapy, and surgical resection is associated with high seizure control rates. Emerging minimally invasive techniques, such as laser interstitial thermal therapy (LITT), show promise. Importantly, roof FVHs differ from floor (tegmental) hamartomas in their anatomical origin, clinical presentation, and surgical approach-the latter often being associated with hypothalamic or brainstem symptoms, while roof lesions more commonly manifest with cerebellar-related epileptogenic activity. CONCLUSION: Early recognition of FVRHs as potential epileptogenic foci and timely surgical intervention can lead to seizure freedom and favorable neurodevelopmental outcomes. This case reinforces the role of cerebellar lesions in pediatric epilepsy and supports aggressive surgical management when feasible.
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Epilepsia Refractaria , Epilepsia , Cuarto Ventrículo , Hamartoma , Humanos , Hamartoma/cirugía , Hamartoma/complicaciones , Hamartoma/diagnóstico por imagen , Femenino , Niño , Cuarto Ventrículo/cirugía , Cuarto Ventrículo/diagnóstico por imagen , Cuarto Ventrículo/patología , Epilepsia Refractaria/cirugía , Epilepsia Refractaria/etiología , Epilepsia Refractaria/diagnóstico por imagen , Epilepsia/cirugía , Epilepsia/etiología , Imagen por Resonancia Magnética , Procedimientos Neuroquirúrgicos/métodosRESUMEN
Wilder Penfield (1891-1976) was a Canadian neurosurgeon whose pioneering work left a lasting mark on neuroscience and epilepsy surgery. He advanced knowledge of cortical localization by electrically stimulating the brain under local anesthesia, allowing patients to report sensations and movements. From these observations, he created the famous "homunculus," a functional map of motor and sensory areas. Penfield also developed the Montreal Procedure, a groundbreaking surgical approach for intractable epilepsy. By stimulating the cortex during awake operations, he identified and preserved critical regions for speech and movement while safely removing epileptic foci. His studies also revealed that cortical stimulation could evoke vivid memories and experiences, contributing to research on memory and consciousness. In 1934, Penfield founded the Montreal Neurological Institute (MNI), the first center to integrate clinical care, research, and education in neuroscience. This interdisciplinary model fostered collaboration among neurosurgeons, neurologists, psychologists, and basic scientists, becoming the prototype for modern neuroscience institutes. Through his surgical innovations, scientific insights, and commitment to education, Penfield trained generations of specialists and shaped the field of translational medicine. His legacy continues to influence epilepsy surgery, cortical mapping, and the study of brain-mind relationships.
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Mapeo Encefálico , Corteza Cerebral , Epilepsia , Humanos , Epilepsia/cirugía , Epilepsia/historia , Historia del Siglo XX , Mapeo Encefálico/historia , Historia del Siglo XIX , Corteza Cerebral/cirugíaRESUMEN
BACKGROUND: Laser Interstitial Thermal Therapy (LITT) is a minimally invasive option for treating epilepsy and neuro-oncologic lesions, including those deemed inoperable. However, it does not allow for histomolecular diagnosis. METHODS: We describe our technique for combining stereotactic brain biopsy and LITT, focusing on biopsy sample quantity and its effects on MRI thermometry and ablation quality. CONCLUSION: Stereotactic biopsy can be safely integrated with LITT. Limiting sampling to two specimens minimizes air diffusion and hemorrhagic risk, reducing thermometric artifacts and preserving the accuracy of ablation.
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Neoplasias Encefálicas , Epilepsia , Terapia por Láser , Procedimientos Quirúrgicos Robotizados , Técnicas Estereotáxicas , Humanos , Neoplasias Encefálicas/complicaciones , Neoplasias Encefálicas/patología , Neoplasias Encefálicas/cirugía , Terapia por Láser/métodos , Epilepsia/etiología , Epilepsia/cirugía , Epilepsia/terapia , Epilepsia/patología , Biopsia/métodos , Procedimientos Quirúrgicos Robotizados/métodos , Imagen por Resonancia MagnéticaRESUMEN
Accurate identification of an epileptogenic zone (EZ) is crucial for successful epilepsy surgery. Stereotactic intracranial electroencephalography (SEEG) has contributed to improving surgical outcomes through assessing epileptic networks prior to surgery. However, SEEG data analysis has primarily relied on visual interpretation of epileptologists and clinical features of seizure types, leading to challenges in objective and quantitative surgical planning because it is difficult to visually evaluate High-Frequency Oscillation (HFO) or other epilepsy-related waveforms. Although the Epileptogenicity Index (EI) estimates epileptogenicity quantitatively based on temporal and energy parameters of brain regions, its accuracy is not always high enough. Thus, we propose a new automatic algorithm for detecting the seizure onset, referred to as TAILOR (Tailored Algorithm for Ictal Localization and Onset pRediction), which can determine the order of seizure onsets with high temporal resolution based on each patient's power spectrum patterns for tailor-made. In addition, the epileptic network can be estimated according to the order of seizure onsets determined with the proposed TAILOR. We retrospectively analyzed the clinical SEEG using TAILOR and confirmed that the actual surgical areas were ranked first as surgical areas in six out of eight cases.Clinical Relevance- We propose TAILOR as an automated algorithm for detecting seizure onset based on the power spectrum pattern. Estimating epileptic networks according to detailed seizure onset orders is anticipated to improve the accuracy of epilepsy treatment and surgery.
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Algoritmos , Electrocorticografía , Electroencefalografía , Epilepsia , Convulsiones , Humanos , Convulsiones/fisiopatología , Convulsiones/diagnóstico , Convulsiones/cirugía , Epilepsia/cirugía , Epilepsia/fisiopatología , Epilepsia/diagnóstico , Electroencefalografía/métodos , Electrocorticografía/métodos , Masculino , Femenino , AdultoRESUMEN
PURPOSE: To describe the utilization of epilepsy surgery in children with tuberous sclerosis complex (TSC), its evolution over the years, and the factors that predict epilepsy surgery use. METHODS: Retrospective descriptive study using the Pediatric Health Information System (PHIS) database between 2004 and 2024. Our main outcome was the proportion of children with TSC and drug-resistant epilepsy who received epilepsy surgery. We adjusted for potential confounders with a generalized estimating equation. RESULTS: 2769 children had TSC and drug-resistant epilepsy (53 % males, median (p25-p75) age at first diagnosis of drug-resistant epilepsy: 5.2 (2.2-11.1) years). 802 (29.0 %) children underwent a total of 955 epilepsy surgeries. 307 (32.1 %) children had lobectomy, 599 (62.7 %) children had other excision of brain tissue, 61 (6.4 %) children had laser interstitial thermal therapy, 24 (2.5 %) children had intracranial neuromodulation, and 13 (1.4 %) children had hemispherectomy. Although the absolute number of epilepsy surgeries increased among children with long follow-up, the number of epilepsy surgeries per person-year decreased over the years. Although the cost during the epilepsy surgery admission is high [median (p25-p75): $72,415 ($44,734-$116,353), the healthcare cost per person-year after epilepsy surgery substantially decreased compared to prior to surgery [$9550 ($3408-$22,134) versus $28,268 ($15,936-$46,851)]. Black race, American Indian race, and public insurance were major factors which decreased the probability of receiving epilepsy surgery. CONCLUSION: The proportion of children with TSC and drug-resistant epilepsy who receive epilepsy surgery is low, especially in marginalized populations, and has not increased over the years. Healthcare resource utilization may decrease after epilepsy surgery.
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Epilepsia Refractaria , Epilepsia , Procedimientos Neuroquirúrgicos , Esclerosis Tuberosa , Humanos , Esclerosis Tuberosa/cirugía , Esclerosis Tuberosa/complicaciones , Masculino , Femenino , Niño , Preescolar , Estudios Retrospectivos , Epilepsia Refractaria/cirugía , Epilepsia Refractaria/etiología , Procedimientos Neuroquirúrgicos/tendencias , Procedimientos Neuroquirúrgicos/estadística & datos numéricos , Epilepsia/cirugía , Sistemas de Información en SaludRESUMEN
INTRODUCTION: Risk of cognitive decline following epilepsy surgery can be a significant barrier for patients pursuing surgery, and post-surgical cognitive changes can impact quality of life (QOL), surgical satisfaction and functional independence. Readiness Brain Operation Optimization Training (ReBOOT) is a virtual cognitive prehabilitation intervention that provides patients with psychoeducation and cognitive strategies prior to surgery to increase pre-surgical preparedness and post-surgical functional independence in the circumstance that a patient experiences cognitive decline after surgery. The primary aim of this feasibility trial is to evaluate the acceptability, adherence and procedural feasibility of implementing ReBOOT in patients being evaluated for epilepsy surgery. Secondary, explorative objectives include examining preliminary trends in QOL, compensatory strategy use, cognitive function and psychosocial outcomes to inform a future definitive trial. METHODS AND ANALYSIS: This is a single-centre, parallel-group, feasibility randomised controlled trial of a standardised cognitive prehabilitation programme for patients who are considering epilepsy surgery. Participants are randomly assigned to intervention (n=32) or control groups (n=32). The intervention group is enrolled in ReBOOT, a virtual programme that includes two 1-hour individual sessions and four 1-hour group sessions. Feasibility outcomes include attendance, homework adherence, attrition and participant satisfaction for participants randomised to the intervention group. Exploratory analyses will use longitudinal linear mixed-effects models to describe trends in exploratory outcomes over time. Data will be used to refine procedures and estimate parameters (eg, effect sizes and variance) for a future fully powered trial. ETHICS AND DISSEMINATION: Cleveland Clinic Institutional Review Board approved the study protocol, which is publicly available and registered on the National Institutes of Health ClinicalTrials.gov (NCT05992402) site. Results will be disseminated through conference presentations and academic publications, as well as shared with outside study sponsors (Society for Clinical Neuropsychology-Division 40 of the American Psychological Association; American Epilepsy Society). TRIAL REGISTRATION NUMBER: NCT05992402.
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Disfunción Cognitiva , Epilepsia , Complicaciones Posoperatorias , Cuidados Preoperatorios , Humanos , Estudios de Factibilidad , Epilepsia/cirugía , Epilepsia/psicología , Epilepsia/rehabilitación , Calidad de Vida , Disfunción Cognitiva/prevención & control , Disfunción Cognitiva/etiología , Ensayos Clínicos Controlados Aleatorios como Asunto , Cognición , Femenino , Adulto , Cuidados Preoperatorios/métodos , Complicaciones Posoperatorias/prevención & control , MasculinoRESUMEN
OBJECTIVE: This study aimed to systematically evaluate the application of the Cavitron Ultrasonic Surgical Aspirator (CUSA) system in epilepsy surgery and summarize associated surgical experiences. METHODS: In this retrospective analysis, 70 patients with refractory epilepsy underwent CUSA-assisted resection, while 20 controls underwent conventional surgical resection. Patients were categorized according to surgical scenarios for CUSA application, including lesion-related epilepsy resections, mesial temporal lobe procedures, neocortical resections within eloquent areas, and cases requiring preservation of critical vascular structures. Detailed operative metrics were analyzed for each category. Comparative assessments between the CUSA and conventional groups included surgical efficiency, complication rates, and postoperative seizure outcomes on the basis of the modified Engel classification. RESULTS: CUSA was used for the following procedures: resection of epileptic lesions (n = 26), mesial temporal structures (n = 32), the epileptogenic neocortex (n = 28), and the rolandic cortex (n = 17). Additionally, it was utilized in 6 cases requiring vascular protection during insular resection and in 18 cases involving preservation of cortical dangerous veins. Although the overall surgical efficiency was comparable between the CUSA and conventional groups (68.0 ± 18.2 vs. 61.1 ± 14.7 min, P = 0.180), the CUSA group demonstrated superior efficiency in resecting low-grade tumors (58.6 ± 14.9 vs. 68.1 ± 11.2 min, P = 0.034). Furthermore, the CUSA group presented significantly fewer permanent complications (5.7% vs. 10%, P < 0.0001) and a higher rate of Engel Class I outcomes (82.9% vs. 70.0%, P = 0.278). CONCLUSIONS: The CUSA system represents a suitable and promising surgical tool for resective epilepsy surgery, potentially serving as a valuable option for epilepsy surgeons. Further studies are warranted to validate these findings.
Asunto(s)
Epilepsia Refractaria , Epilepsia , Procedimientos Neuroquirúrgicos , Procedimientos Quirúrgicos Ultrasónicos , Humanos , Femenino , Masculino , Adulto , Estudios Retrospectivos , Epilepsia/cirugía , Persona de Mediana Edad , Adolescente , Adulto Joven , Epilepsia Refractaria/cirugía , Resultado del Tratamiento , Niño , Procedimientos Neuroquirúrgicos/métodos , Procedimientos Neuroquirúrgicos/instrumentación , Procedimientos Quirúrgicos Ultrasónicos/métodos , Procedimientos Quirúrgicos Ultrasónicos/instrumentación , Complicaciones PosoperatoriasRESUMEN
Stereoelectroencephalography (SEEG) is a cornerstone in the presurgical evaluation of drug-resistant focal epilepsy. Despite its growing adoption, variability in outcomes and complication rates suggests the influence of multiple technical, institutional, and contextual factors. A systematic review was conducted in accordance with PRISMA 2020 guidelines and registered in PROSPERO (CRD420251065875). Six databases were searched up to July 2024. Eligible studies included original research in English or Spanish reporting on SEEG procedures in patients with drug-resistant epilepsy, with outcomes related to diagnostic accuracy, complications, and therapeutic interventions. Data were extracted and synthesized narratively across five thematic domains. Fifty studies involving 6,054 patients were included. Most were retrospective and conducted in high-income countries. Epileptogenic zone (EZ) identification rates ranged from 11.6% to 100%, with over 30 studies reporting rates ≥ 90%. A total of 465 SEEG-related complications were reported, predominantly intracranial hemorrhages. Lower complication rates were observed in high-volume centers using robotic or frame-based systems. Post-SEEG interventions, primarily surgical resections, led to favorable outcomes, with Engel Class I achieved in 551 patients. Institutional experience and access to advanced technologies emerged as key determinants of safety and efficacy. SEEG is a highly effective diagnostic and therapeutic modality in epilepsy surgery. However, its performance is strongly influenced by surgical expertise, procedural planning, and institutional context. Standardizing protocols, expanding training, and improving access in underserved regions are essential to optimize outcomes and ensure equitable care.
Asunto(s)
Epilepsia Refractaria , Electroencefalografía , Epilepsia , Técnicas Estereotáxicas , Humanos , Epilepsia Refractaria/cirugía , Epilepsia Refractaria/diagnóstico , Electroencefalografía/métodos , Resultado del Tratamiento , Procedimientos Neuroquirúrgicos/métodos , Epilepsia/cirugía , Epilepsia/diagnósticoRESUMEN
BACKGROUND: Resective epilepsy surgery is an established clinical intervention, but the cost-effectiveness at a national healthcare level is uncertain. This study evaluates the cost-effectiveness of resective epilepsy surgery compared with medical management in adults from national healthcare and personal social services perspectives. METHODS: A de novo decision analytic model was developed, comprising a 1-year decision tree and lifetime Markov model to evaluate lifetime costs and quality-adjusted life years (QALYs). Data were obtained from UK epilepsy surgery centres to evaluate the costs of preoperative assessment and the probability of undergoing resection after presurgical evaluation. Other clinical inputs were obtained from a systematic literature review. The main outcome of the analysis was the incremental cost-effectiveness ratio (ICER), with a cost-effectiveness threshold set at £20 000 cost per QALY gained. RESULTS: Data from 762 patients informed preoperative evaluation costs and the probability of undergoing epilepsy surgery after presurgical evaluation. The total lifetime cost of epilepsy treatment for people who had surgical treatment was £56 911, compared with £32 490 for medical management. Total QALYs per person for surgery were 15.91 and 13.76 for medical management. Resective epilepsy surgery was shown to be cost-effective with an ICER of £11 348 per QALY gained. CONCLUSIONS: Our data inform and strengthen recommendations to prioritise referral of those with drug-refractory epilepsy to surgical centres. We provide a health economic rationale for the development and support of resective epilepsy surgery programmes across national healthcare systems.
Asunto(s)
Epilepsia , Procedimientos Neuroquirúrgicos , Humanos , Análisis Costo-Beneficio , Epilepsia/cirugía , Epilepsia/economía , Años de Vida Ajustados por Calidad de Vida , Adulto , Reino Unido , Procedimientos Neuroquirúrgicos/economía , Cadenas de Markov , Masculino , Femenino , Árboles de Decisión , Persona de Mediana EdadRESUMEN
Epilepsy surgery, particularly dominant temporal lobe resection, poses a significant risk of post-surgical language decline. There is considerable heterogeneity in the language assessment protocols employed across epilepsy surgery centers. This in turn is reflected in the observed variability in the incidence of language decline reported in the literature. We systematically surveyed cognitive outcome literature to critically appraise the nature and frequency of language assessment in order to establish the parameters of the existing evidence base. We found that confrontation naming was the most frequently used paradigm to assess language function (96%), followed by verbal fluency (47%) and language comprehension (13%). Over 75% of studies reported outcomes within the first two years of surgery, and close to 50% used reliable change index (RCI) to measure pre-post change in function, which is considered to be the gold standard. The evidence base is currently saturated with short-term post-surgical language outcomes assessed at single-word level. Future studies employing comprehensive language assessment, longer follow-up intervals, and designs comparing different metrics of pre-post change in function are needed. PLAIN LANGUAGE SUMMARY: Patients undergoing surgery for temporal lobe epilepsy often experience a post-surgical decline in language functions. The degree and frequency of language decline reported in research literature are influenced by the protocols used to assess language functions. Upon reviewing language outcome studies, we note a predominance of naming outcomes at short follow-up intervals. Future studies incorporating comprehensive language testing at longer follow-up intervals are needed to better counsel epilepsy patients of their lifelong risks of language decline, and allow them to make an informed decision.