SEEG-guided RF-thermocoagulation of epileptic foci: a therapeutic alternative for drug-resistant non-operable partial epilepsies.

BACKGROUND: Previous literature includes numerous reports of acute stereotactic ablation for epilepsy. Most reports focus on amygdalotomies or amygdalohippocampotomies, some others focus on various extra-limbic targets. These stereotactic techniques proved to have a less favourable outcome than that of standard surgery, so that their rather disappointing benefit/risk ratio explains why they have been largely abandoned. However, depth electrode recordings may be required in some cases of epilepsy surgery to delineate the best region of cortical resection. We usually implant depth electrodes according to Talairach's stereo electroencephalography (SEEG) methodology. Using these chronically implanted depth electrodes, we are able to perform radiofrequency (RF)-thermolesions of the epileptic foci. This paper reports the technical data required to perform such multiple cortical thermolesions, as well as the results in terms of seizure outcome in a group of 41 patients. TECHNICAL DATA: Lesions are placed in the cortex areas showing either a low amplitude fast pattern or spike-wave discharges at the onset of the seizures. Interictal paroxysmal activities are not considered for planning thermocoagulation sites. All targets are first functionally evaluated using electrical stimulation. Only those showing no clinical response to stimulation are selected for thermolesion, including sites located inside or near primary functional area. Lesions are performed using 120mA bipolar current (50 V), applied for 10-30 sec. Each thermocoagulation produces a 5-7mm diameter cortical lesion. A total of 2-31 lesions were performed in each of the 41 patients. Lesions are placed without anaesthesia. RESULTS: 20 patients (48.7%) experienced a seizure frequency decrease of at least 50% that was more than 80% in eight of them. One patient was seizure free after RF thermocoagulation. In 21 patients, no significant reduction of the seizure frequency was observed. Amongst the characteristics of the disease (age and sex of the patient, lobar localization of the EZ) and the characteristics of the thermocoagulations (topography, lateralization, number, morphology of the lesions on MRI) no factor was significantly linked to the outcome. However, the best results were clearly observed in epilepsies symptomatic of a cortical development malformation (CDM), with 67% of responders in this group of 20 patients (p = 0.052). Three transient post-procedure side-effects, consisting of paraesthetic sensations in the mouth (2 cases), and mild apraxia of the hand, were observed. CONCLUSION: SEEG-guided-RF-thermolesioning is a safe technique. Our results indicate that such lesions can lead to a significant reduction of seizure frequency. Our experience suggests that SEEG-guided RF thermocoagulation should be dedicated to drug-resistant epileptic patients for whom conventional resection surgery is risky or contra-indicated on the basis of invasive pre-surgical evaluation, particularly those suffering from epilepsy symptomatic of cortical development malformation.

Reciprocal thalamocortical connectivity of the medial pulvinar: a depth stimulation and evoked potential study in human brain.

The thalamic medial pulvinar nucleus (PuM) is fully developed only in primates and reaches its greatest extent in humans. To assess the reciprocal functional connectivity between PuM and cortex, we studied intracerebral-evoked responses obtained after PuM and cortical electrical stimulation in 7 epileptic patients undergoing depth electroencephalographic recordings. Cortical-evoked potentials (CEPs) to PuM stimulation were recorded from all explored cortical regions, except striate cortex, anterior cingulated, and postcentral gyrus. Percentages of cortical contacts pairs responding to PuM stimulation (CEPs response rate) ranged from 80% in temporal neocortex, temporoparietal (TP) junction, insula, and frontoparietal opercular cortex to 34% in mesial temporal regions. Reciprocally, PuM-evoked potentials (PEPs) response rates were 14% after cortical stimulation in insula and frontoparietal opercular cortex, 67% in the TP junction, 76% in temporal neocortex, and 80% in mesial temporal regions. Overall, our study of functional PuM connectivity in the human brain converges with most of the data from anatomical studies in monkeys, except for a strong amygdalohippocampal functional projection to PuM and an unexpected imbalance between some of the reciprocal pathways explored. This functional quantitative approach helps to clarify the functional role of PuM as well as its implication in temporal lobe epileptic seizures.