Anesthetic implications in the placement of deep brain electrodes through a stereotactic robot in the study of drug resistant epilepsy

Pacreu, S.; Moltó, L.; Fernández Candil, J.L.; Vilà, E.

doi:10.1016/j.redare.2022.02.006

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Pacreu, L. Moltó, J.L. Fernández Candil, E. Vilà" "autores" => array:4 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Pacreu" "email" => array:1 [ 0 => "94397@parcdesalutmar.cat" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Moltó" ] 2 => array:2 [ "nombre" => "J.L." "apellidos" => "Fernández Candil" ] 3 => array:2 [ "nombre" => "E." 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The remaining 35% suffer from refractory or drug-resistant epilepsy (RDE)<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Due to seizures and antiepileptic drugs (AEDs), RDE is associated with high morbidity and morbidity and a worsening of the patient's quality of life. A pre-surgical evaluation including: video-electroencephalogram (video-EEG), brain magnetic resonance imaging (MRI) and cognitive neurological evaluation should be performed to determine whether a patient who does not respond to medication may benefit from surgery.Stereo-electroencephalography (SEEG) is an invasive diagnostic technique developed in France by Bancaud and Talairach in the 1960s. It allows the three-dimensional localisation of the epileptogenic zone (EPZ) and to explain the anatomical and topographical origin of seizures. It would be indicated in: (a) patients with epileptiform activity in the 2 temporal regions visible by video-EEG, to assess whether the onset of seizures has a dominant side and, decide to perform or rule out surgery; (b) to delimit the EZ and guide resection surgery when there is discordance between the findings found on MRI and EEG<a class="elsevierStyleCrossRef" href="#bib0010">2</a>; c) in cases where limited resection is necessary because there is a suspicion that eloquent areas are involved, and d) in patients with multifocal epilepsy where there is doubt about the onset of seizures.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>The surgical technique consists of the intracranial implantation of multiple deep microelectrodes using percutaneous microtrepanes for functional brain studies of superficial and deep regions. The advantages of deep electrodes include better spatial resolution, reduced electroencephalographic artefacts and the possibility of performing cortical stimulation for language mapping.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> Prior to implantation, angiography is performed and corrected with the structural study of the brain MRI to avoid damaging blood vessels when the electrode is introduced, and the trajectory that the different electrodes will have to follow is planned. In our centre, surgery for SEEG is performed using a stereotactic robot, which provides greater accuracy and speed, and allows more precise trajectories to be planned, reducing the risk of bleeding.The main and most feared complication is cerebral haemorrhage (less than 5%), which occurs when the electrode is inserted.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> For this reason, a postoperative control computed tomography (CT) scan or brain MRI is performed when the electrodes are implanted and prior to recording the SEEG. Our initial protocol, agreed with Neurosurgery, contemplated performing the control CT scan 6 h after the end of surgery. From 2013 to 2017, 49 surgeries were performed, of which one patient presented epileptic seizures and 4 patients were diagnosed with subdural haematoma with clinical-radiological stability. However, following a case of acute subdural haematoma with severe sequelae (right hemiplegia), which was diagnosed in the Resuscitation Unit due to clinical signs of decreased level of consciousness and which required craniotomy to evacuate the haematoma, it was decided to modify the action protocol in 2017. Pre-surgical cerebral arteriography began to be performed and it was decided to perform a control CT scan at the end of surgery with the patient intubated. Despite the pandemic, 39 surgeries have been performed since then and there have been 2 cases of epidural haematoma, with surgical evacuation of the haematoma being necessary in one patient who did not present postoperative neurological focality. No other complications were recorded. Subsequently, they were transferred to the Resuscitation Unit to wake up and remain under observation for 6 h. Once possible postoperative complications have been ruled out, and if they progress well, they are transferred to the Epilepsy Monitoring Unit, where invasive monitoring is carried out for 14–21 days.In line with other reviews, the procedure is performed under general anaesthesia.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> Monitoring in the operating theatre is standard with non-invasive blood pressure, electrocardiogram and pulse oximetry. The airway approach was performed with a ringed endotracheal tube. Nowadays, coinciding with the change of the robotic system (Neuromate®, Renishaw Mayfield SA, Nyon, Switzerland), which incorporates a stereotactic frame that occupies half of the face, and to have easier access to the airway, a laryngeal mask is placed. Intravenous and halogenated hypnotic drugs can be used in this surgery. The various opioids, as well as neuromuscular blocking agents, are safe. It is important to monitor neuromuscular blockade,<a class="elsevierStyleCrossRef" href="#bib0030">6</a> as these patients take many AEDs, which may interfere with the metabolism of the neuromuscular blocking agents, shortening their duration of action and requiring more frequent administration. Regarding the AEDs that patients take daily, the usual dosage will be continued and oral medication will be prioritised. In addition, once the stereotactic frame is fixed with the robotic system, it is recommended to block the operating theatre bed to avoid injuries derived from its mobilisation.Although SEEG offers better surgical results with fewer complications, when complications occur they can be potentially serious, so it is necessary and important to have an action protocol.Conflict of interestsAll the authors have no conflict of interests to declare." 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Dykeman" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1212/WNL.0000000000003509" "Revista" => array:6 [ "tituloSerie" => "Neurology." "fecha" => "2017" "volumen" => "88" "paginaInicial" => "296" "paginaFinal" => "303" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27986877" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The value of diagnostic bilateral intracranial EEG in treatment-resistant focal epilepsy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "T.C. Hill" 1 => "B.A. Rubin" 2 => "V. Tyagi" 3 => "J. Theobald" 4 => "A. Silverberg" 5 => "M. Miceli" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.wneu.2017.01.093" "Revista" => array:7 [ "tituloSerie" => "World Neurosurg." "fecha" => "2017" "volumen" => "103" "paginaInicial" => "1" "paginaFinal" => "10" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28185968" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S1751991820302539" "estado" => "S300" "issn" => "17519918" ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Stereoelectroencephalography: surgical methodology, safety, and stereotactic application accuracy in 500 procedures" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F. Cardinale" 1 => "M. Cossu" 2 => "L. Castana" 3 => "G. Casaceli" 4 => "M.P. Schiariti" 5 => "A. Miserocchi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1227/NEU.0b013e31827d1161" "Revista" => array:6 [ "tituloSerie" => "Neurosurgery." "fecha" => "2013" "volumen" => "72" "paginaInicial" => "353" "paginaFinal" => "366" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23168681" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Electroencephalography in mesial temporal lobe epilepsy: a review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M. Javidan" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Epilepsy Res Treat." "fecha" => "2012" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Is SEEG safe? A systematic review and meta-analysis of stereo-electroencephalography-related complications" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.P. Mullin" 1 => "M. Shriver" 2 => "S. Alomar" 3 => "I. Najm" 4 => "J. Bulacio" 5 => "P. Chauvel" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/epi.13298" "Revista" => array:6 [ "tituloSerie" => "Epilepsia." "fecha" => "2016" "volumen" => "57" "paginaInicial" => "386" "paginaFinal" => "401" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26899389" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anesthetic considerations for stereotactic electroencephalography implantation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C. Rajkalyan" 1 => "A. Tewari" 2 => "S. Rao" 3 => "R. Avitsian" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/joacp.JOACP_342_18" "Revista" => array:6 [ "tituloSerie" => "J Anaesthesiol Clin Pharmacol." "fecha" => "2019" "volumen" => "35" "paginaInicial" => "434" "paginaFinal" => "440" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31920225" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack667603" "titulo" => "Acknowledgements" "texto" => "Our thanks to the nursing team of our operating theatre (Maria Albert and Francisco de Borja Lavin) for their great help and collaboration to ensure that the operating theatre always works.Also, to the neurosurgery team (Dr. Alejandra Narvaez and Dr. Nazaret Infante) for their collaboration in data collection." 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Revista Española de Anestesiología y Reanimación (REDAR) -the Spanish Journal of Anesthesiology and Resuscitation- is the scientific body of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy. This is a monthly journal (10 issues) that publishes scientific articles of all areas within its specialty: clinical anesthesia, resuscitation-intensive medicine and critical care, diagnosis and treatment of acute and chronic pain, urgent care and emergencies and studies on basic science and related fields. The journal accepts work in both Spanish and English.

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