Case report
Anaesthesia management in epilepsy surgery with intraoperative electrocorticography
Manejo anestésico en la cirugía de epilepsia con electrocorticografía intraoperatoria
S. Pacreu
, E. Vilà, L. Moltó, D. Bande, M. Rueda, J.L. Fernández Candil
Corresponding author
Servicio de Anestesiología y Reanimación, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
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Pacreu, E. Vilà, L. Moltó, D. Bande, M. Rueda, J.L. Fernández Candil" "autores" => array:6 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Pacreu" "email" => array:1 [ 0 => "94397@parcdesalutmar.cat" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Vilà" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Moltó" ] 3 => array:2 [ "nombre" => "D." "apellidos" => "Bande" ] 4 => array:2 [ "nombre" => "M." "apellidos" => "Rueda" ] 5 => array:2 [ "nombre" => "J.L." "apellidos" => "Fernández Candil" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Manejo anestésico en la cirugía de epilepsia con electrocorticografía intraoperatoria" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Epilepsy is a neurological disease characterised by recurrent seizures due to excessive or hypersynchronous neuronal activity in the brain, which often results in neurobiological, cognitive, psychological and social consequences. It is among the most common chronic neurological diseases, and affects 0.5–1% of the population. An epileptic seizure is the onset of transient neurological signs or symptoms, with or without decreased alertness, with or without convulsions and other clinical manifestations. Seizures may manifest in different ways, depending on the location of the neurons affected. Although most epilepsies are controlled with drugs, 30% of patients continue to manifest seizures, and are diagnosed with drug-resistant epilepsy. In these cases, surgical resection of the epileptogenic lesion should be considered. The success of this procedure depends mainly on the location of the epileptic focus. Many techniques have been used to locate epileptogenic foci, including neuroimaging tests (to detect structural abnormalities), electrophysiological studies, and neuropsychological tests. However, in the case of intractable partial epilepsy, or when the lesion does not coincide with the epileptic focus,<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1–3</span></a> intraoperative electrocorticography (ECoG) is performed. In these cases, it is important to consider the anaesthetic strategies explained in this case study of a patient scheduled for ECoG-guided right selective amygdalohippocampectomy.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case study</span><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 57-year-old man, Glasgow 15, ASA II, with drug-resistant epilepsy from the age of 19. He presented focal crises with altered consciousness, oral and bimanual automatisms and ictal vocalisations at a rate of 8 crises per month, and 1 episode of status epilepticus. These symptoms were facilitated by the appearance of periods of stress followed by relaxation, usually at night. His usual treatment consisted of phenobarbital (100<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h), lacosamide (200–300<span class="elsevierStyleHsp" style=""></span>mg), pregabalin (300<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h). He was scheduled for ECoG-guided excision of the epileptogenic lesion. The patient consented to the publication of his case.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Before surgery, he was admitted to the Epilepsy Unit for video-EEG monitoring. During his stay in the unit he presented 9 crises, all originating in the right anterior temporal lobe. The surgeons decided to perform hippocampal ECoG-guided right selective amygdalohippocampectomy for refractory epilepsy secondary to right mesial sclerosis.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Electrocardiogram, non-invasive blood pressure and pulse oximetry monitoring were started on arrival in the operating room. A bilateral BIS sensor was placed according to the international 10–20 system, and the BIS Vista was used to record the BIS values. General anaesthesia was induced with dexmedetomidine perfusion (0.3<span class="elsevierStyleHsp" style=""></span>μg<span class="elsevierStyleHsp" style=""></span>kg<span class="elsevierStyleSup">−1</span><span class="elsevierStyleHsp" style=""></span>h<span class="elsevierStyleSup">−1</span>), fentanyl (300<span class="elsevierStyleHsp" style=""></span>μg), propofol (110<span class="elsevierStyleHsp" style=""></span>mg) and rocuronium (40<span class="elsevierStyleHsp" style=""></span>mg) to facilitate endotracheal intubation. A line was placed in right internal jugular vein and also in the left radial artery for invasive monitoring of arterial pressure. As the patient required intraoperative neurophysiological monitoring, anaesthesia was maintained with propofol (741<span class="elsevierStyleHsp" style=""></span>mg), remifentanil (0.06<span class="elsevierStyleHsp" style=""></span>μ<span class="elsevierStyleHsp" style=""></span>g<span class="elsevierStyleHsp" style=""></span>kg<span class="elsevierStyleSup">−1</span><span class="elsevierStyleHsp" style=""></span>min<span class="elsevierStyleSup">−1</span>), and dexmedetomidine (0.3<span class="elsevierStyleHsp" style=""></span>μg<span class="elsevierStyleHsp" style=""></span>kg<span class="elsevierStyleSup">−1</span><span class="elsevierStyleHsp" style=""></span>h<span class="elsevierStyleSup">−1</span>) to maintain BIS values between 45 and 60. Rocuronium (0.3<span class="elsevierStyleHsp" style=""></span>mg<span class="elsevierStyleHsp" style=""></span>kg<span class="elsevierStyleSup">−1</span><span class="elsevierStyleHsp" style=""></span>h<span class="elsevierStyleSup">−1</span>) was also administered for motor blockade. Before the start of intraoperative ECoG monitoring, dexmedetomidine and rocuronium perfusion was maintained and propofol and remifentanil were decreased to reduce the depth of anaesthesia while maintaining motor blockade and to facilitate electrocorticographic recording. ECoG monitoring was successful, and the surgeons resected the epileptic lesion. The patient was extubated in the operating room and transferred to the post-anaesthesia care unit. He was discharged home 5 days later.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">ECoG is an invasive electrophysiological procedure first used in 1950 by Penfield and Jasper in Montreal to map the cerebral cortex in humans undergoing epilepsy surgery. The aim is to: (a) identify the focus and limits of the epileptogenic zone; (b) assess the extension of the resection and (c) verify complete removal of the epileptic lesion after resection.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> All this is achieved without causing neurological damage. Intraoperative ECoG is recorded by means of electrodes placed directly on the exposed cerebral cortex, at the subdural or deep level. This recording may vary depending on the location of the electrodes, the existence of pre-existing lesions, and the effect of preoperative medication and different anaesthetic drugs.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> Many of the anaesthetic drugs used in surgery affect neurotransmission and have an important inhibitory and excitatory effect on cerebral cortical activity. Awake craniotomy, which minimises this dual effect, is the procedure of choice. In patients under general anaesthesia, the anaesthesiologist faces the challenge of maintaining adequate anaesthetic depth and neuromuscular blockade without interfering with ECoG recording.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In patients requiring further study, or in cases where intraoperative recording is inconclusive, subdural grids or deep electrodes can be placed under anaesthesia and left in place until ECoG can be performed outside the operating room, with the patient awake.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Chui et al. conducted a review in 2013 to evaluated anaesthetic strategies used during intraoperative ECoG, and put forward a number of recommendations,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> including understanding the location of the seizure and the effect of different anaesthetic drugs on intraoperative ECoG. The success of this technique depends to a large extent on using the right anaesthetic drugs for sedation and general anaesthesia (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Anaesthetics that can suppress brain electrical activity, especially barbiturates and benzodiazepines, should be avoided as far as possible.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Propofol, one of the most widely used anaesthetic drugs, has shown little effect on spontaneous epileptiform interictal activity (defined as the electroencephalogram obtained in the intervals between clinical seizures) and is considered safe in seizure surgery.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Dexmedetomidine is a selective α-2 receptor agonist with a broad spectrum of pharmacological properties. These include sedation (mediated by the inhibition of the locus coeruleus, the predominant noradrenergic nucleus, located in the brain stem), analgesia, and sparing of anaesthetic/analgesic drugs such as propofol and remifentanil<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> (due to its noradrenergic inhibitory action). Many studies have shown that dexmedetomidine does not affect spontaneous interictal epileptiform activity,<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">7–9</span></a> does not stimulate motor activity, and does not interfere with ECoG recording.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Studies have shown that low-dose or continuous infusion of opioids does not affect spontaneous epileptiform interictal activity.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Our hospital is a referral centre for epilepsy, and intraoperative ECoG has been used in epilepsy surgery and for the resection of tumours causing epileptic seizures. All patients received general anaesthesia following an ECoG-guided craniotomy and epileptogenic lesion resection protocol formulated in consensus with the Epilepsy Unit. This protocol differs from that used in patients not requiring neurophysiological monitoring. In patients requiring neurophysiological monitoring, we administer continuous infusion of dexmedetomidine (0.4<span class="elsevierStyleHsp" style=""></span>μg<span class="elsevierStyleHsp" style=""></span>kg<span class="elsevierStyleSup">−1</span><span class="elsevierStyleHsp" style=""></span>h<span class="elsevierStyleSup">−1</span>)<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>propofol to maintain BIS values between 45 and 60<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>remifentanil infusion.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In patients not requiring neurophysiological monitoring, we use dexmedetomidine (0.4<span class="elsevierStyleHsp" style=""></span>μg<span class="elsevierStyleHsp" style=""></span>kg<span class="elsevierStyleSup">−1</span><span class="elsevierStyleHsp" style=""></span>h<span class="elsevierStyleSup">−1</span>)<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>0.5 MAC of sevoflurane to maintain BIS values between 45 and 60<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>remifentanil<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>neuromuscular blocker to prevent movement. Low-dose sevoflurane has been proved safe in ECoG-guided epilepsy surgery.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Dexmedetomidine reduces other anaesthetic induction and maintenance drug requirements. When administered in combination with halogenated and intravenous anaesthetics, dexmedetomidine reduces the dosage needed, and consequently, the anaesthetic depth. High frequency, low amplitude waves predominate during superficial anaesthesia, making it ideal for intraoperative ECoG.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> This may be due to α-2 agonist-mediated inhibition of central noradrenergic transmission, although α-2 agonists also act outside presynaptic autoreceptors of noradrenergic pathways, and this would explain the minimum alveolar concentration-sparing action of α-2 agonists in volatile anaesthetics.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">If no interictal discharges occur during intraoperative ECoG monitoring, they may need to be provoked. For this purpose, drugs such as alfentanil<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> can be used to activate the epileptogenic area. This is the most widely studied of all such drugs, and at high doses (20–100<span class="elsevierStyleHsp" style=""></span>μg<span class="elsevierStyleHsp" style=""></span>kg<span class="elsevierStyleSup">−1</span>) will activate seizures in 83–100% of cases. Another effective activator of epileptogenic activity is etomidate (0.2<span class="elsevierStyleHsp" style=""></span>mg<span class="elsevierStyleHsp" style=""></span>kg<span class="elsevierStyleSup">−1</span>), which is effective in 75% of cases.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The anaesthesiologist plays an important role in optimising the intraoperative quality of the focus during epilepsy surgery. Successful resection of the epileptic lesion depends to a large extent on good electrophysiological signalling and the use of appropriate anaesthetic drugs while the patient is under general anaesthesia.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical responsibilities</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols implemented in their place of work regarding the use of patient data in publications.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflict of interests</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres982027" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec949613" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres982028" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec949612" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case study" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-05-25" "fechaAceptado" => "2017-07-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec949613" "palabras" => array:3 [ 0 => "Drug-resistant epilepsy" 1 => "Intraoperative electrocorticography" 2 => "Anaesthesia" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec949612" "palabras" => array:3 [ 0 => "Epilepsia farmacorresistente" 1 => "Electrocorticografía intraoperatoria" 2 => "Anestesia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Epilepsy surgery is a well-established treatment for patients with drug-resistant epilepsy. The success of surgery depends on precise presurgical localisation of the epileptogenic zone. There are different techniques to determine its location and extension. Despite the improvements in non-invasive diagnostic tests, in patients for whom these tests are inconclusive, invasive techniques such intraoperative electrocorticography will be needed.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Intraoperative electrocorticography is used to guide surgical resection of the epileptogenic lesion and to verify that the resection has been completed. However, it can be affected by some of the anaesthetic drugs used by the anaesthesiologist. Our objective with this case is to review which drugs can be used in epilepsy surgery with intraoperative electrocorticography.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La cirugía de la epilepsia es un tratamiento bien establecido para pacientes con epilepsia farmacorresistente. El éxito de la cirugía depende de una localización prequirúrgica precisa de la zona epileptógena. Existen diferentes técnicas para determinar su localización y extensión. A pesar de las mejoras en los tests diagnósticos no invasivos, en aquellos pacientes en los que no son concluyentes, se necesitarán técnicas más invasivas como la electrocorticografía intraoperatoria.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La electrocorticografía intraoperatoria se utiliza para guiar la resección quirúrgica de la lesión epileptógena y para comprobar que la resección ha sido completa. Sin embargo, se puede ver afectada por algunos de los fármacos anestésicos que utilizamos. Nuestro objetivo con este caso clínico es revisar qué fármacos se pueden utilizar en la cirugía de epilepsia con electrocorticografía intraoperatoria.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pacreu S, Vilà E, Moltó L, Bande D, Rueda M, Fernández Candil JL. Manejo anestésico en la cirugía de epilepsia con electrocorticografía intraoperatoria. Rev Esp Anestesiol Reanim. 2018;65:108–111.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">EIA: spontaneous epileptiform interictal activity.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Drug \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SEIA \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Propofol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Minimum effect on EIA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Etomidate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Activates the epileptogenic area Can induce seizures \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Benzodiazepines \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Marked reduction in EIA. It can interfere with ECoG \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dexmedetomidine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Minimum effect on EIA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sevoflurane \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">At low concentrations it minimises the inhibitory effect and facilitates ECoG \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Remifentanil, fentanyl, sufentanil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Do not affect EIA at low doses or in perfusion \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1662912.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Effect of anaesthetic drugs on spontaneous epileptiform interictal activity.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "[Chapter 165]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intraoperative electrocorticography" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "G.E. 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