Optimizations and Nuances in Neurosurgical Technique for the Minimization of Complications in Subdural Electrode Placement for Epilepsy Surgery.

BACKGROUND: Surgical intervention is an important therapeutic option for patients with intractable epilepsy and a well-characterized epileptogenic focus. Invasive monitoring with subdural electrodes is an effective technique for localizing epileptogenic foci. Previous studies reported varying complication rates, and these may deter more widespread adoption. We present potentially valuable technical nuances that may be associated with low complication rates. We assess the potential contribution of specific aspects of surgical technique to the reduction of complication rates. METHODS: We retrospectively reviewed patients from the Rush University Surgical Epilepsy database who underwent craniotomies for invasive electroencephalography monitoring for medically intractable epilepsy using our technique. We analyzed and compared complication rates and techniques with those reported elsewhere. RESULTS: The sample group comprised 127 consecutive patients who underwent electrode implantation. The average monitoring period was 6 days. There were 5 complications (3.9%), including 1 subdural hematoma requiring surgery (0.8%), 1 infection (0.8%), 2 pulmonary emboli (1.6%), and 1 deep vein thrombosis (0.8%). There were no symptomatic cerebrospinal fluid leaks or permanent neurologic complications. These results compare favorably with published results. Analysis and comparison of our technique anecdotally suggest the importance of use of a subgaleal drain throughout the monitoring period, postoperative antibiotic coverage for 1 week, meticulous hemostasis, and secure suturing of the electrodes to the dura mater to minimize trauma to superficial vessels as potential contributors to improved complication rates. CONCLUSIONS: A very low incidence of major morbidity can be achieved in invasive electroencephalography monitoring with this protocol.

Delayed endovascular revascularization in a patient with progressive neurological deterioration from bilateral intracranial vertebral artery occlusions: case report.

BACKGROUND AND IMPORTANCE: This article describes delayed endovascular revascularization in a patient with clinical and radiographic evidence of posterior circulation hemodynamic failure in the setting of intracranial occlusive lesions. CLINICAL PRESENTATION: A 48-year-old man presented with a 6-week history of progressive headache, nausea, and ataxia. Bilateral intracranial vertebral artery occlusions and a left posterior inferior cerebellar artery stroke were diagnosed, and the patient began warfarin therapy. Despite these measures, the patient developed dense lower cranial neuropathies, including severe dysarthria, decreased left-sided hearing acuity, and left facial droop. He presented at this point for endovascular evaluation. The patient underwent successful revascularization with intravascular Wingspan stents (Boston Scientific, Natick, Massachusetts) in a delayed fashion (approximately 6 weeks after his initial stroke presentation). His neurological syndrome stabilized and began to improve slowly. CONCLUSION: Patients with arterial occlusion should be evaluated acutely for potential revascularization. In the posterior circulation, clinical progression may supplant physiological imaging in the assessment of hemodynamic collapse. A subpopulation of patients will present with progressive deficits distinct from extracranial manifestations of vertebrobasilar insufficiency; these patients should be considered for delayed revascularization.