Is Spontaneity Overrated? The Value of Cortical Stimulation–Induced Seizures

Abstract

Association of Cortical Stimulation-Induced Seziure With Surgical Outcome in Patients With Focal Drug-Resistant Epilepsy Cuello Oderiz C, von Ellenrieder N, Dubeau F, et al. JAMA Neurol. 2019. Importance: Cortical stimulation is used during presurgical epilepsy evaluation for functional mapping and for defining the cortical area responsible for seizure generation. Despite wide use of cortical stimulation, the association between cortical stimulation–induced seizures and surgical outcome remains unknown. Objective: To assess whether the removal of the seizure-onset zone resulting from cortical stimulation is associated with a good surgical outcome. Design, Setting, and Participants: This cohort study used data from 2 tertiary epilepsy centers: Montreal Neurological Institute in Montreal, Quebec, Canada, and Grenoble Alpes University Hospital in Grenoble, France. Participants included consecutive patients (n = 103) with focal drug-resistant epilepsy who underwent stereoelectroencephalography between January 1, 2007, and January 1, 2017. Participant selection criteria were cortical stimulation during implantation, subsequent open surgical procedure with a follow-up of 1 or more years, and complete neuroimaging data sets for superimposition between intracranial electrodes and the resection. Main Outcomes and Measures: Cortical stimulation–induced typical electroclinical seizures, the volume of the surgical resection, and the percentage of resected electrode contacts inducing a seizure or encompassing the cortical stimulation–informed and spontaneous seizure-onset zones were identified. These measures were correlated with good (Engel class I) and poor (Engel classes II-IV) surgical outcomes. Electroclinical characteristics associated with cortical stimulation–induced seizures were analyzed. Results: In total, 103 patients were included, of whom 54 (52.4%) were female, and the mean (standard deviation) age was 31 (11) years. Fifty-nine (57.3%) patients had cortical stimulation–induced seizures. The percentage of patients with cortical stimulation–induced electroclinical seizures was higher in the good outcome group than in the poor outcome group (31 [70.5%] of 44 vs 28 [47.5%] of 59; P =.02). The percentage of the resected contacts encompassing the cortical stimulation–informed seizure-onset zone correlated with surgical outcome (median [range] percentage in good vs poor outcome: 63.2% [0%-100%] vs 33.3% [0%-84.6%]; Spearman ρ = 0.38; P =.003). A similar result was observed for spontaneous seizures (median [range] percentage in good vs poor outcome: 57.1% [0%-100%] vs 32.7% [0%-100%]; Spearman ρ = 0.32; P =.002). Longer elapsed time since the most recent seizure was associated with a higher likelihood of inducing seizures (>24 hours: 64.7% vs <24 hours: 27.3%; P =.04). Conclusions and Relevance: Seizure induction by cortical stimulation appears to identify the epileptic generator as reliably as spontaneous seizures do; this finding might lead to a more time-efficient intracranial presurgical investigation of focal epilepsy as the need to record spontaneous seizures is reduced.