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Axial T2 MRI demonstrating a portion of the patient's tubers. Surgical decision-making was influenced by presence of multiple tubers in the left frontal lobe, right frontal lobe, and left temporal lobe (a-c). Sagittal CT demonstrating open anterior fontanelle (d).
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In this patient, the region electrographically implicated in the EZ was contained within her large SEGA, which abutted cortical areas, as well as multiple frontal and temporal tubers of various size and depth (Fig. 1).
An example of left frontal (F3/F7 maximal) seizure onset on scalp EEG captured during phase 1 presurgical evaluation (a). Electrode placement plan diagram for intracranial phase 2 SEEG with the superficial contacts (contacts 8-10) of the electrode in the middle superior frontal gyrus (labeled B) highlighted in red and additional electrodes labeled A and C-J in the approximate locations indicated (b). Near-continuous interictal epileptiform discharges were seen in the superficial contacts (8-10, highlighted in red) of the middle superior frontal gyrus (B) electrodes (c). An example of seizure onset captured during the intracranial phase 2 SEEG arising from the superficial middle superior frontal gyrus (B8-10-- highlighted in red) with spread to other electrodes and evolution in amplitude and frequency (d). Scale bars for all panels: horizontal: 1 s; vertical: 200uV. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
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Scalp EEG (Fig. 2a) revealed left-sided seizures primarily involving F3 and F7 regions at onset, suggesting a left frontotemporal focus or foci. Further, she exhibited interictal discharges which were at times nearly continuous, maximal at the same electrode contact as the ictal onset, typical of TS patients (Fig. 2c).
Patient positioned in the Mayfield frame and attached to the robot (a). SEEG bolts secured to the skull (b). One bolt has been wrapped with the xeroform gauze. One bolt and electrode are placed in the skull to be used for ground and reference, resulting in 11 pictured electrodes. Screenshot from the robotic planning software of T1 post-contrast MRI fused with post-SEEG CT demonstrating the proximity of the longest electrode to its pre-operative plan. Also seen is a nearby electrode monitoring an interface between the enhancing SEGA and cortex and a temporal electrode monitoring an anterior temporal tuber (c). Axial screenshot demonstrating the proximity of the B electrode (blue) and the A electrode (red) and their relationships to the resected tuber (d). For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.
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The Mayfield was affixed to the ROSA  robot (Zimmer Biomet, Warsaw, Indiana) and contactless laser registration of the face was performed using a preoperative CT scan with contrast as a reference scan (Fig. 3a). Xeroform gauze was wrapped around each bolt, and gauze padding was placed around them under a headwrap (Fig. 3b). The distance between the planned target and the center of the electrode is recorded (Fig. 3c).
Preoperative Sagittal T1 MRI demonstrating the left-sided tuber (*) identified as the source of the patient's seizures (a). Postoperative Sagittal T1 MRI demonstrating resection of the left-sided lesion (b). Postoperative coronal T1 MRI demonstrating resection of the left-sided lesion (c).
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SEEG with a minimal rim of perituberal cortex (Fig. 4). Seizures stopped immediately, and she was discharged from the hospital four days after resection.