Invasive electroencephalography monitoring: Indications and presurgical planning

Electroencephalography (EEG) remains a “gold standard” for defining seizures; hence identification of epileptogenic zone for surgical treatment of epilepsy requires precise electrographic localization of the seizures. Routine scalp EEG recording is not sufficient in many instances, such as extratemporal lobe epilepsy or non-lesional temporal lobe epilepsy. In these individuals EEG recording from proximity of the seizure focus is necessary, which can be achieved by placing electrodes on the surface or in the substance of the brain. As this process requires invasive procedures (usually necessitating surgical intervention) EEG obtained via these electrodes is defined as invasive electroencephalography (iEEG). As only limited areas of the brain can be covered by these electrodes in an individual, precise targeting of the presumed seizure onset location is crucial. The presurgical planning includes where to place electrodes, which type of the electrodes to choose and planned duration of the intracranial recording. Though there are general principles that guide such endeavor, each center does it slightly differently depending upon the various technologies available to them and expertise and preferences of the epilepsy surgery team. Here we describe our approach to iEEG recording. We briefly describe the background, types of iEEG recording and rationale for each, various electrode types, and scenarios where iEEG might be useful. We also describe planning of iEEG recording once the need has been established as well as our decision making process of deciding about location of electrode placement, type of electrodes to use, length of recording, choice of arrays, mapping of eloquent cortex and finally surgical planning and decisions.