Stereoelectroencephalography in the “difficult to localize” refractory focal epilepsy: Early experience from a North American epilepsy center

PURPOSE: Stereo-electroencephalography (SEEG) enables precise recordings from deep cortical structures, multiple noncontiguous lobes, as well as bilateral explorations while avoiding large craniotomies. Despite a long reported successful record, its application in the United States has not been widely adopted. We report on our initial experience with the SEEG methodology in the extraoperative mapping of refractory focal epilepsy in patients who were not considered optimal surgical candidates for other methods of invasive monitoring. We focused on the applied surgical technique and its utility and efficacy in this subgroup of patients. METHODS: Between March 2009 and May 2011, 100 patients with the diagnosis of medically refractory focal epilepsy who were not considered optimal candidates for subdural grids and strips placement underwent SEEG implantation at Cleveland Clinic Epilepsy Center. Demographics, noninvasive clinical data, number and location of implanted electrodes, electrophysiologic localization of the epileptic zone, complications, and short-term seizure outcome after resection were prospectively collected and analyzed. KEY FINDINGS: Mean age was 32 years (range 5-68 years); 54 were male and 46 female. The mean follow-up after resection was 15 months. In total, 1,310 electrodes were implanted. Analyses of the SEEG recordings resulted in the electrographic localization of the epileptogenic focus in 96 patients. In the group of 75 patients who underwent resection, only 53 had at least 12 months follow-up. From this group, 33 patients (62.3%) were seizure-free at the end of the follow-up period. The presence of abnormal pathologic finding was strongly associated with postoperative seizure control (p = 0.005). The risk of hemorrhagic complications per electrode was 0.2%. SIGNIFICANCE: In patients who are not considered to be ideal candidates for subdural grids and strips implantation, the SEEG methodology is a safe, useful and reliable alternative option for invasive monitoring in patients with refractory focal epilepsy, providing an additional mean for seizure localization and control in a "difficult to localize" subgroup of patients.