Predictive Utility of EEG Decrement in Localization for

Resective Surgery
1

Diego Tovar, MD , Patricia McGoldrick , NP, Harriet Kang

, MD, Saadi Ghatan, MD

1-2

, Steven Wolf, MD .

1. Neurology Department, Beth Israel Medical Center, Albert Einstein College of Medicine, New York ,N.Y. 2. Neurological Surgery Columbia University , New York, N.Y.
Case
Epilepsy
Number Classification

Introduction

Localization of seizure onset can be difficult when

analyzing EEG after placement of subdural grid and
strip electrodes for surgical planning. We noted that,
in some cases, onset of voltage decrement can help
define the epileptogenic zone, especially where
seizure onset may be in deeper structures.

Methods
We analyzed fourteen cases of patients ages 2-49
years, thirteen of whom underwent epilepsy resective
surgery with subdural EEG monitoring. One patient
underwent bilateral strip implants for lateralization and
resective surgery is pending.

Focal

Epilepsy Etiology

Multifocal

Idiopathic

Multifocal

Vascular lesion/tumor

Focal

Focal

cerebral palsy/ static

encephalopathy

Focal

Focal

Vascular lesion/tumor

Focal

Focal

Vascular lesion/tumor

Focal

Focal

Vascular lesion/tumor

Focal

Focal

Static encephalopathy

Focal

Focal

Vascular lesion/tumor

Focal

Focal

Idiopathic

10

Focal

Focal

Vascular lesion/tumor

11

Focal

Focal

Idiopathic

Focal

Focal

Vascular lesion/tumor

13

Focal

Focal

Vascular lesion/tumor Neuronal migration

disorder

Focal

Vascular lesion/tumor

Case

Surgery

Modified
Engel
outcome

TIME SINCE
SURGERY
(follow up)

right frontal resection

IIA

2 YEARS

left temporal lobectomy

& parieto-occipital
disconnect

IIA

7.5 YEARS

left temporal lobectomyleft frontal disconnect

IA

1.5 YEARS

left occipital lobectomyleft parieto-occipital

disconnect - left posterior
temporal lobectomy

IB

4.5 YEARS

Onset in medial MST and PST as well as

suboccipital region. Decrement over parietal
occipital and post. temporal region

Inferior and medial

temporal lobe resection .
Occipital lobe
disconnection

IA

4.5 YEARS

Seizure onset in MST,PST,ASO and PSO.

Decrement on post. temporal and occipital
grid.

Removal of tumor,
resection of anterior
temporal lobe, resection
of hipocampus and
parahippocampal
region , resection of
temporal gyrus

IA

2.5 YEARS

Frontal lobe
disconnection

IB

4 MONTHS

Resection of middle
temporal gyrus, inferior
temporal gyrus to behind
lesion to vein of Labbe

IA

5 months

IB

6 weeks

Seizure onset on SPO PSO. Decrement on

parieto occipital grid

Resection of medial
temporal structures and
inferior medial and
temporal gyrus

10

IA

5 YEARS

Medial post subtemporal and suboccipital

medial. Decrement over post temporal grid

left temporal lobectomy

& parieto-occipital
disconnect

11

Left resection

III B

6 YEARS

12

Left medial temporal and

inferior temporal
resection

IA

2 MONTHS

13

Left frontal resection

IA

7 MONTHS

14

anterior temporal
resectionamygdalectomy
hippocampectomy

IA

2 MONTHS

Focal spike and wave Left medial temporal

region. Decrement across lateral temporal
and post temporal region
Seizure onset subtemporal. Decrement
across the frontal grid

Anterior subtemporal and suboccipital onset.

Decrement over temporal lobe
Left medial frontal onset.Decrement across
grid over frontal region
MST and AST onset. Decrement on temporal
grid
AST-MST-PST onset. Decrement over
frontal grid

12

Focal

Subdural EEG Findings

Seizure. onset anterior interhemisferic left
medial frontal region, followed by decrement
across frontal grid

14

Results

MFPE

EEG Findings

Medial subtemporal onset. Decrement over

lateral temporal grid
Frontal Interhemispheric onset. Decrement
over frontal lobe
Medial subtemporal onset. Decrement over
lateral temporal grid

Table 3. Outcome

Table 2. Epilepsy classification

In all described cases, decrement occurred at the

onset of clinical seizure activity that was preceded by
spike and wave complexes or fast beta activity. The
localization of decrement aided in the determination of
the epileptogenic zone and the extent of the resection.
In case# 2 the extent of the resection in the first
surgery did not take into account the entire extent of
the decrement prior to or after the spike onset. This
patient underwent 2nd surgery with ENGEL IIA
outcome. Eight patients achieved Engel Class 1A ,3
patients achieved Engel 1B outcome, two patients
had Engel IIA outcome and one patient had outcome
Engel IIB after resection of the epileptogenic zone
Case

Age

Sex

Age at
seizure

17

13

17 y

2-3/week

No

since birth

15 and 21 months

4-18/day

Yes

21

since birth

19 y

4/month

Yes

21

9y

13 y

2/month

Yes

18

9.5 y

12 y

2/month - clusters
of 3-4 day

Yes

17

1.4 y

17 y

>5/day

No

17

14 y

17 y

< 1/ month

Yes

18 months

6.5 y

1 daily - 1 week

Yes

13

1y

13 y

1/week

No

10

15

since birth

10 y

3/day

Yes

11

20

10 y

13 y

3/day

No

12

31

18 y

26 and 31 y

3-4/day - 1/month

No

13

2.5

8 1/2 weeks

2y

2-3/day

Yes

14

49

42 y

49 y

2-4/month

No

Table 1. Demographics

Age at Surgery

Seizure
frequency

No. of
AEDs

Discussion
Spikes, rhythmic theta and fast beta bursts
are not the only important factors in
determining the seizure onset zone or
epileptogenic zone in epilepsy surgery.
In the analyzed cases an electrodecrement
pattern on the EEG from subdural electrode
placement aided in lateralization, localization
and definition of the epileptogenic zone
extent for surgical resection.
Electrodecrement is a useful marker to aid in
the definition of the extent of resection when
seizure onset may derive from deeper brain
structures.
Our hypothesis is that cortical areas that
show a pattern of EEG decrement are in a
pathologic hyperexitable state that make
these areas susceptible to receive
epileptiform activity originating from deep
structures (such as thalamocortical circuits)
that remain active during periods of
complete EEG flatness.
Therefore, when decrement is noted, the
epileptologist should look for a more
widespread epileptogenic zone. This, in our
experience has led to more extensive
resections and better seizure outcomes.

Bibliography
1.! Amzica, F., Basic physiology of burst-suppression. Epilepsia, 2009. 50 Suppl
12: p. 38-9.
2.! Steriade, M., F. Amzica, and D. Contreras, Cortical and thalamic cellular
correlates of electroencephalographic burst-suppression.
Electroencephalography and clinical neurophysiology, 1994. 90(1): p. 1-16.
3.! Miller, J.W. and A.J. Cole, Is it necessary to define the ictal onset zone with
EEG prior to performing resective epilepsy surgery? Epilepsy & behavior :
E&B, 2011. 20(2): p. 178-81.
4.! Janati, A., et al., Suppression-burst pattern associated with generalized
epileptiform discharges and alpha-theta pattern coma. Clinical EEG, 1986. 17
(2): p. 82-8.
5.! Ohtsuka, Y., et al., Suppression-burst patterns in intractable epilepsy with focal
cortical dysplasia. Brain & development, 2000. 22(2): p. 135-8.
6.! Lee, S.K., et al., The clinical usefulness of ictal surface EEG in neocortical
epilepsy. Epilepsia, 2000. 41(11): p. 1450-5.

AEDs Seizure Developmental

failed
types
delay

Case # 2. Grids and subdural EEG

Case # 8. Grids and Subdural EEG

Case # 14. Grids and subdural EEG