Stefano Francione - ta-service

1° EPODES Course
on Epilepsy Surgery
Epilepsies of of the the
posterior posterior part part of of the the brain: brain:
a a semeiological study study from from a a
surgical surgical perspective
Stefano Francione
“Claudio Claudio Munari” Munari
Epilepsy Surgery Centre

The “C.Munari C.Munari Epilepsy Surgery Centre”
Centre
Clinical Neurophysiology
Laura Tassi
Stefano Francione
Roberto Mai
Lino Nobili
Ivana Sartori
Neuroradiology
Nadia Colombo
Alberto Citterio
Giuseppe Scialfa
Neuropathology
Carlo Galli
Manuela Bramerio
Functional Neurosurgery
Alim L. Benabid
Giorgio Lo Russo
Massimo Cossu
Francesco Cardinale
Laura Castana
Neuropsychology
Gabriella Bottini
Pina Scarpa
LT Monitoring Unit
Maurizio Rossi
Elena Casiraghi
Antonio Menna
Debora Meroni
Lucia Gargano
Physics
Alberto Torresin
Marco Minella

41 pts
26 pts
27 pts
42 pts

Eye Eye movement movement control control by by by the the cerebral cerebral cortex. cortex. Pierrot Pierrot-Deseilligny Pierrot Deseilligny Deseilligny et et al. al. 2004
2004

Study Population
o 750 pts operated on from May ’96 96 to October ’07 07
o 123 (16.4%) with a resection including an occipital
and/or parietal structure (+/- (+/ temporal).
o 78 males, 45 females
o Age at surgery: 1 – 54 yrs (24.8 +/- +/ 13);
o Epilepsy onset: birth – 26 yrs (6.9 +/- +/ 5.2);
o Epilepsy duration: 1 – 46 yrs (17.9 +/- +/ 11.6).
o Seizure frequency :
►Monthly: Monthly: 18 pts (15.2%)
►Weekly: Weekly: 55 pts (44.8%)
►Daily: Daily: 50 pts (40.0%)

General characteristics
o Family history (epilepsy or FC): + in 35 (28%)
o Personal history: + in 56 (44.8%)
►Pregnancy: Pregnancy:
18 pts
►Delivery Delivery (peri-natal):
(peri natal): 27 pts
►CNS CNS infections: 4 pts
►Head Head trauma: 1 pt
►Febrile Febrile Convulsions: 6 pts
o Neurological examination: + in 37 (29.6%)
►Lat Lat somato-sensory:
somato sensory: 14 pts (+oc mot 4; + vf 1)
►Visual Visual Field: 8 pts
►Ocular Ocular motility: 7 pts
►Other: Other:
8 pts

SEEG in F: 66.1%
o Detailed
Pre-surgical Diagnostic work-up
SEEG in T: 19.6%
Detailed
anamnesis;
Inter-ictal ictal EEG (+/-
ictal EEG);
Neuroimaging
(CTscan; MRI) MRI
Neuropsychological
evaluation;
o Inter
o Neuroimaging
o Neuropsychological
5 pts
11 pts
21 pts
VEEG monitoring
Stereo-EEG exploration
fMR: 31 pts
Wada test: 19 pts
91 pts 72.8%
Surgery: lesionectomy,
Corticectomy +/- lesionectomy

MRI
o Negative: 16 pts (12.8%)
o Positive: 109 pts (87.2%)
Subtle: 9 cases
Extended: 11 cases
Multiple or bilateral: 7 cases

Stereo-EEG Stereo EEG in 69pts
o Unilateral in 63pts; bilateral asymmetric in 6 cases;
o 6-19 19 electrodes per pt (with a mean of 12):
►7 7 pts with less than 10 electrodes, 9 with more than 15.
o Implanted lobes:
2 in 1 pt: CP
3 in 17 pts: 4 in 26 pts
POT
►POT+C POT+C in 20 pts; POT+F in 2pts; PO+FC in 2 pts; PT+FC in 1pt.
5 in 19 pts

Parietal (+/- PoCG)
34 pts (26.8%)
Occipital
8 pts (6.5%)
Temporo-occipital
42 pts (34.2%)
Resection Topography
Temporo-parietal
11 pts (8.9%)
Parieto-occipital
10 pts (8.1%)
Temp-par-occipital
18 pts (14.6%)

Gr1: Gr1:
Gr1:
Gr1: Parietal (+/- (+/ PoCG) Resections (34 pts)
Aura:
None: 12 pts
Sensory loc: 8 pts
Visceral: 6 pts
Exp: 3 pts
Vis asp: 4 pts
•17 cases:
•Head (isolated in 1 case) + eyes deviation (+/- preceded
by staring or grimace)
•In 15 homolateral (4 with eyes controlateral, 1
both); in 2 controlateral;
•7 cases:
• Controlateral somatomotor
•4 cases:
• spasms
•5 cases:
•Staring isolated (3) or followed by fall (2) or OAA (1)

S1-2
13-14
N1-2
11-12
X3-4
6-7
10-11
L1-2
6-7
12-13
Q1-2
13-14
K1-2
14-15
P7-8
J4-5
10-11
15-16
V1-2
10-11
O1-2
10-11
E1-2
10-11
D1-2
12-13
C3-4
13-14
F10-11
W8-9
U6-7
SEEG:
spontaneous
seizure

S1-2
13-14
N1-2
11-12
X3-4
6-7
10-11
L1-2
6-7
12-13
Q1-2
13-14
K1-2
14-15
P7-8
J4-5
10-11
15-16
V1-2
10-11
O1-2
10-11
E1-2
10-11
D1-2
12-13
C3-4
13-14
F10-11
W8-9
U6-7
SEEG: SEEG: SEEG: seizure seizure induced induced induced by
by
intracerebral intracerebral electrical
electrical
stimulation stimulation (L11 (L11-12) (L11 12) 1mA 1mA
1mA

PD. Post-op Post op MRi

M.M.
RM

M.M. Schema

M.M. spontaneous seizure

Pz destrimane con ulegiria centro-parietale destra

Pz destrimane con ulegiria centro-parietale
destra
Task motorio di finger tapping
FT mano DX FT mano SX

Pz destrimane con
ulegiria centroparietale
destra
Task sensitivo
Spazzolamento mano sin.
Spazzolamento mano dx

M.R. SEEG - Scheme

Mas. Re.

Mas. Re. Crisi1 – fpa 53

Mas. Re. Crisi3_a

Mas. Re. Crisi3_c

Mas. Re. I.C.

Mas. Re. P.I.

M.R. Post-op Post op MRi

Gr2:
Gr2:
Gr2:
Gr2:
Gr2: Occipito ccipito-temporal temporal resections (42 pts)
Aura:
None: 12 cases
Visual asp: 14 cases
Visual spec: 5 cases
Temporal: 11 cases
17 cases:
- Homolateral eyes (isolated in 3 cases) + Head
deviation (+/- preceded by staring or blinks)
12 cases:
- Controlateral eyes (isolated in 2 cases) + Head
(isolated in 1 cases) deviation (+/- preceded by blinks)
1 case:
– eyes deviation both in homo or controlateral
11 cases:
- Staring followed by temporal signs (8) or
hyperkinetic seizure
1 case: spasms with dissociated eyes movements

Ale. Sar.
o Surgery for cardiac malformation when 1 yr, after numerous
anoxic-ischemic anoxic ischemic episodes
o Epilepsy onset 4 yr
o Age at surgery 15 yr
o Symptomatology contra lateral eyes and head
deviation, loss of contact, fall
o Visual field normal
o VEEG right temporo-parieto
temporo parieto-occipital occipital
o RM right occipital and centro-parietal
centro parietal
signal alterations

Ale.Sar.

Ale. Sar.

V 1-2
V 4-5
V 9-10
L 1-2
L 3-4
L 4-5
L 9-10
F 1-2
F 3-4
F 11-12
E 1-2
E 7-8
D 1-2
D 4-5
D 10-11
C 1-2
C 10-11
W 5-6
Z 2-3
Z 12-13
S 1-2
S 11-12
N 2-3
N 8-9
X 3-4
X 10-11
P 3-4
P 10-11
Ale. Sar.

V1-2 V1 2 3mA
Cx sottocalcarina

Gr3:
Gr3:
Gr3:
Gr3:
Gr3: Parieto-occipital
Parieto occipital Resections (10 pts)
5 cases:
- Controlateral eyes (isolated in 2) and head
deviation
4 cases:
- staring isolated (1 pt) or followed by
automatisms
1 case:
Aura:
None: 4 pts
Sensory loc + vis(2): 3 pts
Visual + sens(1) or T(2): 3 pts
– lateralized spasms

Gr4:
Gr4:
Gr4:
Gr4:
Gr4: Occipital resection (8 pts)
5 cases:
- controlateral eyes (monocular 1pt) and
head (isolated 1pt) deviation
1 case:
2 case:
Aura:
Visual + eye mov(2): 6 pts
Temporal: 2 pts
- homolateral eyes and head deviation
- staring and automatisms

Left occipital seizures

Gr5:
Gr5:
Gr5:
Gr5:
Gr5: Temporo-parietal
Temporo parietal Resections (11 pts)
Aura:
None: 3 pts
Visual: 3 pts
Temporal (mostly aud): 4 pts
Postural: 1 pt
7 cases:
- eyes and head deviation both homo and
controlateral isolated or conjugate
1 case:
- head flexion
3 cases :
- staring isolated (1) + oral commissure
attraction (2)

Ger. N. 16 yrs old
o No fam or pers atcds
o Szrs onset: 9yrs= aud hall, loc, vomit.
o Aura= very complex features including aud
hall and hill and something visceral
o Signs= able to warn, calling or by gest, “idiot idiot
smiling” smiling during loc sometime associated
with left mouth clonic.
o 12-24 12 24 szrs/month

Ger. N. pre-op pre op MRi

Ger. N. post-op post op MRi

Ger. N. post-op post op MRi

Gr6:
Gr6:
Gr6:
Gr6:
Gr6: Occipito ccipito-parieto parieto-temporal temporal Resections(18 pts)
Aura:
None: 6 pts
Visual: 6 pts
asp: 4 pts
lat: 2 pts
Temp: 5
Multisens: 1
6 cases:
- homolateral eyes and head deviation
6 cases:
- controlateral eyes and head deviation
2 case:
- both homo or controlateral eyes deviation
1 case:
- blinks, loc
3 case:
Asymmetric spasms:

B.G.: RM

B.G.: i.c.

B.G.: Video-EEG Video EEG

Bus. Gio. SEEG summary

Bus.Gio. Post-op Post op CTscan

Surgical Outcome
Follow up: 6 – 136 (55.3+/- 25.1)
o Class I: 81pts (65.8%)
►Ia: Ia: 59 pts (47.8%)
►Ib: Ib: 8 pts
►Ic: Ic: 9 pts
►Id: Id: 5 pts
o Class II: 15 pts (12.2%)
o Class III: 9 pts (7.3%)
o Class IV: 18 pts (14.6%)

Post-surgical Post surgical Deficits
o Hemianopia: 21 pts
o Quadrantanopia: 30 pts
o Somatosensory 4 pts always trans
o NPS: 9 pts always trans

Histhology (+5 nd)
Histhology
o Cryptogenic: 9 pts
o Scars: 16 pts
o Ulegyria: 4 pts
o Neoplastic: 33 pts
►Ganglioglioma: Ganglioglioma: 16 cases
►DNt: DNt:
11 cases
►Glial: Glial:
6 cases
Malformative: 60 pts
o Malformative:
►CVM: CVM:
3 cases
►Double Double cx: 3 cases
►Heterotopia: Heterotopia: 9 cases
►Arch Arch Dyspl: 10 cases
►CytoArch: CytoArch:
9 cases
►Taylor: Taylor:
19 cases
►ST: ST:
4 cases

Outcome vs topography
Class I
o 34 P: 22 pts (64.7%) 6 pts (17.6%) 5 pts (14.7%) (14.7%)
o 41T-O: 41T O: 32 pts (78%) 6 pts (14.3%) 3 pts (7.7%)
o 10 P-O: P O: 6 pts (60%) 3 pts (30%) 1 pt (10%)
o 7 O: 7 pts (100%)
Class II/ III
Class IV
o 11 T-P: T P: 4 pts (36.7%) 6 pts (54.3%) 1 pt (9%)
o 18 TPO: 7 pts (38.9%) 5 pts (27.8%) 6 pts (33.3%) (33. 3%)

Conclusions……
Conclusions…….
o Not episodical kind of surgery: 16.4%.
o Often requiring invasive recordings: 72.8%.
o Frequently multilobar: 61.6%.
o Possible good post-operative post operative results, mainly
In temporo-occipital temporo occipital and occipital localization.
Semiology……
Semiology……