Operative Technique and Nuances for the Stereoelectroencephalographic (SEEG) Methodology Utilizing a Robotic Stereotactic Guidance System.

The SEEG methodology has gained favor in North America over the last decade as a means of localizing the epileptogenic zone (EZ) prior to epilepsy surgery. Recently, the application of a robotic stereotactic guidance system for implantation of SEEG electrodes has become more popular in many epilepsy centers. The technique for the use of the robot requires extreme precision in the pre-surgical planning phase and then the technique is streamlined during the operative portion of the methodology, as the robot and surgeon work in concert to implant the electrodes. Herein is detailed precise operative methodology of using the robot to guide implantation of SEEG electrodes. A major limitation of the procedure, namely its heavy reliance on the ability to register the patient to a preoperative volumetric magnetic resonance image (MRI), is also discussed. Overall, this procedure has been shown to have a low morbidity rate and an extremely low mortality rate. The use of a robotic stereotactic guidance system for the implantation of SEEG electrodes is an efficient, fast, safe, and accurate alternative to conventional manual implantation strategies.

The endoscopic anterior transmaxillary temporal pole approach for mesial temporal lobe epilepsies: a feasibility study.

OBJECTIVE: In mesial temporal lobe epilepsy (MTLE), the ideal surgical approach to achieve seizure freedom and minimize morbidity is an unsolved question. Selective approaches to mesial temporal structures often result in suboptimal seizure outcomes. The authors report the results of a pilot study intended to evaluate the clinical feasibility of using an endoscopic anterior transmaxillary (eATM) approach for minimally invasive management of MTLEs. METHODS: The study is a prospectively collected case series of four consecutive patients who underwent the eATM approach for the treatment of MTLE and were followed for a minimum of 12 months. All participants underwent an epilepsy workup and surgical care at a tertiary referral comprehensive epilepsy center and had medically refractory epilepsy. The noninvasive evaluations and intracranial recordings of these patients confirmed the presence of anatomically restricted epileptogenic zones located in the mesial temporal structures. Data on seizure freedom at 1 year, neuropsychological outcomes, diffusion tractography, and adverse events were collected and analyzed. RESULTS: By applying the eATM technique and approaching the far anterior temporal lobe regions, mesial-basal resections of the temporal polar areas and mesial temporal structures were successfully achieved in all patients (2 with left-sided approaches, 2 with right-sided approaches). No neurological complications or neuropsychological declines were observed. All 4 patients achieved Engel class Ia outcome up to the end of the follow-up period (19, 15, 14, and 12 months). One patient developed hypoesthesia in the left V2 distribution but there were no other adverse events. The low degree of white matter injury from the eATM approach was analyzed using high-definition fiber tractography in 1 patient as a putative mechanism for preserving neuropsychological function. CONCLUSIONS: The described series demonstrates the feasibility and potential safety profile of a novel approach for medically refractory MTLE. The study affirms the feasibility of performing efficacious mesial temporal lobe resections through an eATM approach.

Robotic-Assisted Stereotaxy for Deep Brain Stimulation Lead Implantation in Awake Patients.

BACKGROUND: Robotic-assisted stereotaxy has been increasingly adopted for lead implantation in stereoelectroencephalography based on its efficiency, accuracy, and precision. Despite initially being developed for use in deep brain stimulation (DBS) surgery, adoption for this indication has not been widespread. OBJECTIVE: To describe a recent robotic-assisted stereotaxy experience and workflow for DBS lead implantation in awake patients with and without microelectrode recording (MER), including considerations for intraoperative research using electrocorticography (ECoG). METHODS: A retrospective review of 20 consecutive patients who underwent simultaneous bilateral DBS lead implantation using robotic-assisted stereotaxy was performed. Radial error was determined by comparing the preoperative target with the DBS lead position in the targeting plane on postoperative computed tomography. Information regarding any postoperative complications was obtained by chart review. RESULTS: A novel method for robot coregistration was developed. We describe a standard workflow that allows for MER and/or ECoG research, and a streamlined workflow for cases in which MER is not required. The overall radial error for lead placement across all 20 patients was 1.14 ± 0.11 mm. A significant difference (P = .006) existed between the radial error of the first 10 patients (1.46 ± 0.19 mm) as compared with the second 10 patients (0.86 ± 0.09 mm). No complications were encountered. CONCLUSION: Robotic-assisted stereotaxy has the potential to increase precision and reduce human error, compared to traditional frame-based DBS surgery, without negatively impacting patient safety or the ability to perform awake neurophysiology research.

Differential proinflammatory and angiogenesis-specific cytokine production in human pulmonary endothelial cells, HPMEC-ST1.6R infected with dengue-2 and dengue-3 virus.

In this study, the ability of dengue virus serotypes 2 (DENV-2) and 3 (DENV-3) to infect and induce increased production of proinflammatory cytokines in a pulmonary endothelial cell line (HPMEC-ST1.6R) was investigated. This cell line exhibits the major constitutive and inducible endothelial cell characteristics, as well as angiogenic response. DENV-2 and DENV-3 infection was confirmed by an observed cytopathic effect (CPE), as well as RT-PCR and immunofluorescence assays. Increases in Th-1 and Th-2 cytokines IL-4, IL-8, IL-6, IL-10, GM-CSF, INF-gamma, and tumor necrosis factor (TNF-alpha) within DENV-2- and DENV-3-infected cells were demonstrated using a microbead-based Bio-plex assay. Proinflammatory cytokine increases and the expression of a potent angiogenic inducer protein, VEGF were confirmed by dot-blot analysis using the TranSignal Human Angiogenesis Antibody Array. Dengue virus-infected HPMEC-ST1.6R cells exhibited an elongated cytoplasmic morphology, possibly representing a response to VEGF and activation of angiogenesis. The increased levels of Th-1 cytokines and VEGF in DENV-2 virus infected-HPMEC-ST1.6R could be distinguished from those infected by DENV-3. This suggests that cytokine patterns associated with DENV infections may be serotype and strain-specific. The experimental approaches described here could be developed further into a useful diagnostic tool for the characterization of dengue hemorrhagic fever cases, leading to enhancement of treatment therapy.

In vitro development and characterization of a manatee bronchial cell line.

In the present study, culture conditions that promote the growth and differentiation of manatee respiratory tract epithelial cells toward a mucociliary phenotype were determined. Characterization of a manatee-specific cell line enables investigators to conduct in vitro testing where live-animal experimentation is not possible. Cell cultures were established from both explants and enzymatically dissociated cells that were isolated from manatee bronchial tissue. To modulate their differentiation, bronchial epithelial cells were grown on Transwell collagen membranes either submerged or at an air-liquid interface. Growth on a collagen membrane at an air-liquid interface and medium supplemented with retinoic acid was required to promote a mucociliary phenotype. When cells were grown in submerged cultures without retinoic acid, they appeared more squamous and were not ciliated. Intracellular keratin proteins were detected in both submerged and interface cultures. Cultured manatee bronchial epithelial cells will facilitate future studies to investigate their potential role in pulmonary disease associated with brevetoxicosis after exposure to the red-tide organism, Karenia brevis.