Future of Neurology & Technology: Stereoelectroencephalography in Presurgical Epilepsy Evaluation

Stereoelectroencephalography (SEEG) is not only a sophisticated and highly technological investigation but a new and better way to conceptualize the spatial and temporal dynamics of epileptic activity. The first intracranial investigations with SEEG were performed in France in the mid-twentieth century; however, its use in North America is much more recent. Given its significantly lower risk of complications and its ability to sample both superficial and deep structures and both hemispheres simultaneously, SEEG has become the preferred method to conduct intracranial EEG monitoring in most comprehensive epilepsy centers in North America. SEEG is an invasive neurophysiologic methodology used for advanced presurgical workup in the 20% of drug-resistant patients with more complex focal epilepsy in whom noninvasive investigations do not allow to decide on surgical candidacy. SEEG uses stereotactically implanted depth electrodes to map the origin and propagation of epileptic seizures by creating a 3-dimensional representation of the abnormal electrical activity in the brain. SEEG analysis takes into account the background, interictal, and ictal activity, as well as the results of cortical electrical stimulation procedures, to reliably delineate the epileptogenic network. By means of a clinical vignette, this article will walk general neurologists, but especially neurology trainees through the immense potential of this methodology. In summary, SEEG enables to accurately identify the epileptogenic zone in patients with drug-resistant focal epilepsy who otherwise would be not amenable to surgical treatment. In this patient population, SEEG is the best way to improve seizure control and achieve seizure freedom.