Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health, Houston.
Mischer Neuroscience Institute, Memorial Hermann Hospital, Texas Medical Center, Houston.
JAMA Neurol. 2019 Jun 1;76(6):672-681. doi: 10.1001/jamaneurol.2019.0098.
A major change has occurred in the evaluation of epilepsy with the availability of robotic stereoelectroencephalography (SEEG) for seizure localization. However, the comparative morbidity and outcomes of this minimally invasive procedure relative to traditional subdural electrode (SDE) implantation are unknown.
To perform a comparative analysis of the relative efficacy, procedural morbidity, and epilepsy outcomes consequent to SEEG and SDE in similar patient populations and performed by a single surgeon at 1 center.
DESIGN, SETTING AND PARTICIPANTS: Overall, 239 patients with medically intractable epilepsy underwent 260 consecutive intracranial electroencephalographic procedures to localize their epilepsy. Procedures were performed from November 1, 2004, through June 30, 2017, and data were analyzed in June 2017 and August 2018.
Implantation of SDE using standard techniques vs SEEG using a stereotactic robot, followed by resection or laser ablation of the seizure focus.
Length of surgical procedure, surgical complications, opiate use, and seizure outcomes using the Engel Epilepsy Surgery Outcome Scale.
Of the 260 cases included in the study (54.6% female; mean [SD] age at evaluation, 30.3 [13.1] years), the SEEG (n = 121) and SDE (n = 139) groups were similar in age (mean [SD], 30.1 [12.2] vs 30.6 [13.8] years), sex (47.1% vs 43.9% male), numbers of failed anticonvulsants (mean [SD], 5.7 [2.5] vs 5.6 [2.5]), and duration of epilepsy (mean [SD], 16.4 [12.0] vs17.2 [12.1] years). A much greater proportion of SDE vs SEEG cases were lesional (99 [71.2%] vs 53 [43.8%]; P < .001). Seven symptomatic hemorrhagic sequelae (1 with permanent neurological deficit) and 3 infections occurred in the SDE cohort with no clinically relevant complications in the SEEG cohort, a marked difference in complication rates (P = .003). A greater proportion of SDE cases resulted in resection or ablation compared with SEEG cases (127 [91.4%] vs 90 [74.4%]; P < .001). Favorable epilepsy outcomes (Engel class I [free of disabling seizures] or II [rare disabling seizures]) were observed in 57 of 75 SEEG cases (76.0%) and 59 of 108 SDE cases (54.6%; P = .003) amongst patients undergoing resection or ablation, at 1 year. An analysis of only nonlesional cases revealed good outcomes in 27 of 39 cases (69.2%) vs 9 of 26 cases (34.6%) at 12 months in SEEG and SDE cohorts, respectively (P = .006). When considering all patients undergoing evaluation, not just those undergoing definitive procedures, favorable outcomes (Engel class I or II) for SEEG compared with SDE were similar (57 of 121 [47.1%] vs 59 of 139 [42.4%] at 1 year; P = .45).
This direct comparison of large matched cohorts undergoing SEEG and SDE implantation reveals distinctly better procedural morbidity favoring SEEG. These modalities intrinsically evaluate somewhat different populations, with SEEG being more versatile and applicable to a range of scenarios, including nonlesional and bilateral cases, than SDE. The significantly favorable adverse effect profile of SEEG should factor into decision making when patients with pharmacoresistant epilepsy are considered for intracranial evaluations.
随着机器人立体脑电图（SEEG）用于癫痫定位，癫痫评估发生了重大变化。然而，相对于传统的硬膜下电极（SDE）植入术，这种微创程序的相对发病率和结果尚不清楚。
在一个中心由同一位外科医生进行的相似患者人群中，对 SEEG 和 SDE 的相对疗效、手术发病率和癫痫结果进行比较分析。
设计、地点和参与者：共有 239 例药物难治性癫痫患者接受了 260 例连续颅内脑电图检查，以定位其癫痫发作。手术于 2004 年 11 月 1 日至 2017 年 6 月 30 日进行，数据于 2017 年 6 月和 2018 年 8 月进行分析。
使用标准技术植入 SDE 与使用立体定向机器人植入 SEEG，然后切除或激光消融癫痫灶。
手术程序的长度、手术并发症、阿片类药物的使用以及 Engel 癫痫手术结果量表的癫痫结果。
在包括的 260 例病例中（54.6%为女性；评估时的平均[SD]年龄，30.3 [13.1]岁），SEEG（n=121）和 SDE（n=139）组在年龄（平均[SD]，30.1 [12.2] vs 30.6 [13.8]岁）、性别（47.1%比 43.9%男性）、抗癫痫药物失败的数量（平均[SD]，5.7 [2.5] vs 5.6 [2.5]）和癫痫持续时间（平均[SD]，16.4 [12.0] vs 17.2 [12.1]年）方面相似。SDE 与 SEEG 相比，SDE 病例中有更多的病变（99 [71.2%]比 53 [43.8%]；P<0.001）。SDE 队列中有 7 例症状性出血性后遗症（1 例伴有永久性神经功能缺损）和 3 例感染，而 SEEG 队列中没有临床相关并发症，并发症发生率差异显著（P=0.003）。与 SEEG 病例相比，SDE 病例中更多的导致切除或消融（127 [91.4%]比 90 [74.4%]；P<0.001）。在接受切除或消融的患者中，SEEG 组有 57 例（76.0%）和 SDE 组有 59 例（54.6%）癫痫发作结果良好（Engel Ⅰ级[无致残性癫痫发作]或Ⅱ级[罕见致残性癫痫发作]）；在进行切除或消融的患者中，1 年时 SEEG 和 SDE 队列分别有 27 例（69.2%）和 9 例（34.6%）的非病变病例具有良好的预后（P=0.006）。当考虑所有接受评估的患者，而不仅仅是接受明确手术的患者时，SEEG 与 SDE 相比，良好的结果（Engel Ⅰ级或Ⅱ级）在 1 年时相似（SEEG 为 57 例[47.1%]，SDE 为 59 例[42.4%]；P=0.45）。
本研究直接比较了接受 SEEG 和 SDE 植入的大型匹配队列，发现 SEEG 的手术发病率明显较低。这两种方法本质上评估了略有不同的人群，与 SDE 相比，SEEG 更加通用，适用于包括非病变和双侧病例在内的各种情况。SEEG 显著有利的不良影响特征应在考虑药物难治性癫痫患者进行颅内评估时纳入决策。
