INSTRUMENTATION AND TECHNIQUE

Implantation of Depth Electrodes in Children Using

VarioGuideR
Frameless Navigation System:
Technical Note
Marcelo Budke, MD, PhD BACKGROUND: Electrode placement in epilepsy surgery seeks to locate the sites of ictal
Josue M. Avecillas-Chasin, onset and early propagation. An invasive diagnostic procedure, stereoelectroencephalog-

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MD, PhD
Francisco Villarejo, MD, PhD
Department of Pediatric Neurosurgery,
Hospital Niño Jesus, Madrid, Spain
Correspondence:
Marcelo Budke, MD, PhD,
Departamento de Neurocirugía,
Hospital Infantil Universitario Niño Jesus
Av. Menendez Pelayo 65,
28009 Madrid, Spain.
E-mail: neurobudke@yahoo.es
Received, April 4, 2017.
Accepted, August 5, 2017.
Published Online, September 9, 2017.
Copyright 
C 2017 by the
Congress of Neurological Surgeons
raphy (SEEG) is usually implemented with frame-based methods that can be especially
problematic in young children.
OBJECTIVE: To evaluate the feasibility and accuracy of a new technique for frameless SEEG
in children using the VarioGuide R
system (Brainlab AG, München, Germany).
METHODS: A frameless stereotactic navigation system was used to implant depth
electrodes with percutaneous drilling and bolt insertion in pediatric patients with
medically refractory epilepsy. Data on general demographic information of electrode
implantation, duration, number, and complications were retrospectively collected. To
determine the placement accuracy of the VarioGuide R
frameless system, the mean
Euclidean distances were calculated by comparing the preoperatively planned trajectories
with the final electrode position observed on postoperative computed tomography scans.
RESULTS: From May 2011 to December 2015, 15 patients (8 males, 7 females; mean age: 8 yr,
range: 3-16 yr) underwent SEEG depth electrode implantation of a total of 111 electrodes.
The mean error measured by the Euclidean distance from the center of the entry point
to the intended entry point was 3.64 ± 1.78 mm (range: 0.58-7.59 mm) and the tip of the
electrode to the intended target was 2.96 ± 1.49 mm (range: 0.58-7.82 mm). There were no
significant complications.
CONCLUSION: Depth electrodes can be placed safely and accurately in children using the
VarioGuide R
frameless stereotactic navigation system.
KEY WORDS: VarioGuide
R
, Depth electrodes, Frameless SEEG, Refractory epilepsy

Operative Neurosurgery 15:302–309, 2018 DOI: 10.1093/ons/opx192

S
urgical resection of epileptogenic foci
is the standard treatment for medically
refractory epilepsy. By removing the
epileptogenic zone, the surgery should make
it possible to control the seizures.1 When the
ictal onset zone cannot be recognized with the
information from surface electroencephalogram
(EEG) and magnetic resonance imaging (MRI),
invasive techniques, such as subdural or depth
electrodes (DE), become necessary. Although
ABBREVIATIONS: CT, computed tomography; DE,
depth electrodes; EEG, electroencephalogram;
FLAIR, fluid-attenuated inversion recovery; FNS,
frameless neuronavigation system; MRI, magnetic
resonance imaging; PET-FDG, fluorodeoxyglucose–
positron-emission tomography; SEEG, stereoelec-
troencephalography; 3-D, 3-dimensional
invasive, the stereoelectroencephalography
(SEEG) technique for recording seizures can
provide 3-dimensional (3-D) information on
seizure activity and an accurate identification of
the epileptic foci.
SEEG requires safe and accurate DE implan-
tation to fulfill its role. Frame-based electrode
implantation is known to offer excellent safety
and precision.2 The different techniques for DE
implantation include the use of a stereotactic
frame, robotic systems, or frameless neuronavi-
gation.3-5
The neuronavigation system without a stereo-
tactic frame, known as a frameless neuronavi-
gation system (FNS), offers a precision and safety
similar to that provided by the conventional
frame system, but is faster and more practical.5-7
The VarioGuide R
system (Brainlab AG,
München, Germany) is an FNS with a proximal

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 IMPLANTATION OF DEPTH ELECTRODES IN CHILDREN USING VARIOGUIDE
R
FRAMELESS NAVIGATION SYSTEM

TABLE 1. Patient Characteristics

Case Age/sex Location MRI 3T FDG-PET Electrodes Histology

1 9/M Right frontal Normal Hypo 8 FCD Ib

2 4/F Left frontal Increased T2, FLAIR signal in the cortex Hypo 6 FCD Ib
and subcortical white matter
3 7/F Left Normal Hypo 7 FCD Ib
temporooccipital
4 8/M Right Increased T2 and slightly lower T1 signal Hypo 7 FCD Ib
Parietoccipital in the subcortical white matter
5 7/M Right frontal Cortical blurring of the gray/white Hypo 7 FCD IIa

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matter interface
6 11/F Right Normal Hypo/hyper 9 FCD Ib
temporooccipital
7 10/M Right frontal Increased FLAIR signal Hypo 8 FCD Ia
8 8/M Right Small areas of discrete cortical Hypo 9 FCD Ib
frontotemporal thickening
9 3/F Right Normal Hypo 7 FCD IB
frontoinsular
10 16/F Left frontal Blurring of the gray/white matter Hypo 5 FCD IIa
junction
11 11/F Left Small areas of discrete cortical Hypo 8 FCD IB
frontotemporal thickening
12 7/F Right Multiples subcortical T2/FLAIR Hypo 8 FCD IIb
parietooccipital hyperintensity
Tuberous sclerosis
13 11/M Bilateral Bilateral ulegyria Hypo 9 FCD IIId
frontoparietal
14 5/F Right parietal Increased T2 signal Hypo 8 FCD Ia
15 12/M Left frontal Multiples subcortical T2/FLAIR Hipo/Hyper 5 FCD IIb
hyperintensity
Tuberous sclerosis

lockable ring, which has been demonstrated to be safe and

accurate in DE implantation, biopsies, and other surgical proce-
dures as reported by us and others in different studies.8-10 In this
paper, we report our experience with the use of the VarioGuide R

for DE implantation in children.

METHODS
Patient Population
The institutional review board approved the study and informed
consent was obtained from all parents and patients. Our patient series
consisted of 15 consecutive children (8 males and 7 females, median
age: 8 yr, range: 3-16 yr) who were evaluated between May 2011 and
December 2015 for medically refractory epilepsy. All patients underwent
comprehensive neurological assessment including neurological exami-
nation, 3-T MRI, fluorodeoxyglucose–positron-emission tomography
(PET-FDG), video EEG monitoring, and neuropsychological testing.
The clinical and demographical data are shown in Table 1.

Preoperative Evaluation and Planning

The targets for DE were determined by a clinical neurophysiologist,
neurologist, and neurosurgeon after evaluating the preoperative workup. FIGURE 1. Each electrode trajectory was planned to avoid vessels and sulcal
All patients fulfilled the indications for invasive EEG monitoring spaces.
and all electrodes were implanted using the VarioGuide R
system

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BUDKE ET AL

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FIGURE 2. Method of DE implantation using VarioGuide R
frameless-system (Brainlab AG). A, Under sterile conditions, the VarioGuideR
articulation
arm was fixed to the Mayfield clamp with the dual Mayfield attachment. B, We developed a bone-fixated cannula for DE implantation. This cannula
acted as a reducing sleeve to stabilize the drill. C, Each electrode was implanted using cranial percutaneous trephination with a 2.5 mm power drill. D,
After the dura was coagulated by low-current monopolar coagulation pulse, the implantation bolt was also guided into place. E, The tip of the pointer serves
as a length measuring tool to calculate the correct depth of the electrode. F, A rigid stylet (diameter, 0.8 mm) was advanced through the bolt to create the
intraparenchymal trajectory for the electrode, minimizing subsequent electrode deviation. G, After the stylet had been withdrawn, the electrode was inserted
and advanced to the target. It was fixed to the bolt by a plastic cap.

(Brainlab AG). Prior to surgery, all patients underwent preoperative
T1-weighted volumetric MRI with gadolinium enhancement, 3-D phase
contrast MRI to visualize veins, and computed tomography (CT) angiog-
raphy to visualize arteries. The image data were transferred to the
BrainLAB iPlan R
Net Cranial 3.0.1 workstation. The entry sites, targets,
and trajectories were designed to avoid vessel damage and all 3 dimen-
sions were assessed, as well as trajectory length (Figure 1).
Surgical Implantation of DE
The VarioGuide R
frameless device was used to insert 111 electrodes
in 15 patients. Electrodes were placed with the patient under general
anesthesia. Antibiotic prophylaxis followed our hospital’s guidelines, and
consisted of a single dose of ceftriaxone (50 mg/kg intravenous) at
anesthesia induction.
The patients were positioned according to the surgical plan. The
head was fixed with a 3-point pediatric head clamp; next, the program
registered bony features on both sides of the face and fitted them against
the preoperative MRI data to verify anatomic landmarks.
The VarioGuide R
was fastened to the head clamp (Figure 2A). The
VarioGuide R
system consists of an adjustable mechanical arm with 3
joints that can be fastened to a head clamp or to the operating table. On
the proximal side, the device contains 3 rotational joints and a lockable
ring with instrument adapter. A computer system is used to guide the
overall adjustment according to the planned trajectory. The instrument
adapters will accept tools with diameters ranging between 1.8 and 8
mm. Acceptable alignment of the VarioGuide R
articulated arm permits
a maximum target error of 0.3 mm. A guide cannula is passed through
the double set and fixed to the system (Figure 2B). Each electrode was
implanted using a 2.5-mm power drill for cranial percutaneous trephi-
nation (Figure 2C). Then, dura was coagulated with monopolar coagu-
lation and a hollow titanium guiding bolt (diameter 2.5 mm) was screwed
to the bone. (Figure 2D). The final depth distance for the electrode was

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 IMPLANTATION OF DEPTH ELECTRODES IN CHILDREN USING VARIOGUIDE
FIGURE 3. Postoperative 3-D reconstruction of electrode implantation on
BrainLab software for patient 3 showing temporooccipital implantation.
FIGURE 4. Accuracy was calculated by comparing the preoperatively planned
trajectories (blue line) with the final electrode trajectories extracted from
postoperative CT images. The final errors were measured in 3 different CT
planes (axial, coronal, and sagittal) with the Euclidean distance methodology.
easily calculated with the pointer by the navigation software (Figure 2E).
Next, a stylet (diameter, 0.8 mm) was advanced to the desired target point
(Figure 2F), and once the stylet was withdrawn, the electrode was inserted
and fixed to the guiding bolt with a plastic cap (Figure 2G).
After implantation, a CT scan was obtained in all patients to show
the implanted electrodes and define their actual positions. The scan was
merged with preoperative MRI images to create 3-D reconstructions
(Figure 3). The same CT scan was also used for placement error analysis.
Accuracy Assessment of Electrode Placement
We took a screenshot of the user interface in the axial, coronal, and
sagittal planes to visualize electrode position.
We measured 2 distances, the first from the intended target to the
actual tip of the implanted electrode and the second from the intended
entry point to the center of the implanted entry point on the CT scan
(Figure 4).
To determine the placement accuracy of the VarioGuide R
frameless
system, the mean error of localization was calculated. The accuracy of
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DE placement was evaluated by comparing the preoperatively planned
trajectories, defined by the corresponding planned entry points and the
planned target points, with the final electrode trajectories visualized on
the postoperative CT scans. The coordinates for the preoperative target
and entry point (a) indicated on preoperative MR images and the signal
produced by the tip of the electrode (target) and the actual entry point
(b) indicated on postoperative CT scan images were obtained using the
Brainlab workstation. The planned target coordinates (Xa, Ya, Za) and
actual location coordinates (Xb, Yb, Zb) were recorded. Placement error
was calculated as the Euclidian distance between the planned and actual
placement using the following formula:

Placement error = (X a − X b)2 + (Y a − Y b)2 + (Z a − Z b)2 .
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To describe the placement error data, the normality of the distribution
was tested using the Kolmogorov–Smirnov test with Lilliefors correction,
using the SPSS R
20 statistical package (IBM, Armonk, New York). The
normality of the placement error sample distribution was confirmed for
the entry (P = .066) and for the tip (P = .116). Placement error is given
as the mean ± standard deviation in the Results section.
RESULTS
One hundred eleven electrodes were implanted in 15 patients.
The different brain regions where the electrodes were implanted
are shown in Table 1. The median number of electrodes per
patient was 8 (range: 5-9). All the identified onset zones were
localized, making resective surgery possible in all patients.
The mean duration of DE placement for each electrode
beginning at the start of trajectory alignment until electrode
fixation lasted 15.7 min (range: 8.5-26.6 min). The median
surgical time for implantation was 90 min (range: 70-120 min).
The procedure was well tolerated in all patients and the only
complication was an episode of small and asymptomatic subdural
bleeding that did not require surgical intervention. The electrodes
were within the planned targets after the coregistration of the
preoperative and postoperative images, and the EEG recordings
were adequate.
The mean error measured by the Euclidean distance from the
center of the entry point to the intended entry point was 3.64 ±
1.78 mm (range: 0.58-7.59 mm; Figure 5), and the mean error
measured by the Euclidean distance from the tip of the electrode
to the intended target was 2.96 ± 1.49 mm (range: 0.58-7.82
mm; Figure 6).
DISCUSSION
Invasive monitoring with intracranial electrodes can identify
regions of ictal onset and allow resective surgery in epilepsy.
Accurate electrode placement is fundamental to optimal outcome.
The different techniques for implanting DE include stereo-
tactic frame use, robotic systems, or neuronavigation without a
frame. The present technique offers an alternative to the more
complex and expensive methods for depth electrode placement.
While some centers cannot afford a robot, they can use a
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BUDKE ET AL
FIGURE 5. Euclidean distance of all electrodes per patient measured from the center of the entry point
to the intended entry point. The dot represents the mean, the error bars represent the standard deviation,
and the horizontal red line represents the mean of all electrodes of all patients.
neuronavigation system for DE implantation. Our results indicate
that DE placement in the pediatric population using the
VarioGuide R
system (Brainlab AG) is practicable and its accuracy
is good in comparison to other frameless-based methods (Table 2).
This system employs a proximal lockable ring that allows it
to fix different tools along the planned trajectory without losing
precision. Furthermore, the use of the cannula guiding channel
through the lockable ring can help stabilize the drill along its
trajectory and further increase precision. This guiding system has
been shown to be very useful in some other studies using FNS.5-6
The frameless system can offer precision and safety similar to
that provided by the conventional frame-based system, but is
usually faster and more practical.11-12
The disadvantages of stereotactic frame-based procedures in
children include additional time needed for frame placement and
the difficulty of positioning it appropriately on small patients,
risk of skull fracture, frame dislocation, and the need to move
an anesthetized and intubated patient to the MRI apparatus to
acquire an image with the frame.5-6
A conventional frame-based system provides superior accuracy
although frameless techniques are easier to employ; they can be
appropriate in situations where submillimeter accuracy is not
required. However, the frame-based approach for DE placement
is appropriate when the case requires exceptionally accurate DE
placement. The use of a custom-designed robotic arm produces
superior accuracy. DE implantation using the robotic system has
a median entry point error estimate of 1.2 mm (interquartile
range: 0.78-1.83 mm) and a median target point error of 1.7 mm
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(interquartile range: 1.20-2.30 mm), as calculated in 500 trajec-
tories.13
In most cases requiring invasive monitoring, the targets for
DE are diffuse enough to allow frameless implantation and the
requirements for accuracy in epilepsy are not as stringent as those
for other indications, like Parkinson’s disease.
Many studies on DE implantation have described the quanti-
tative accuracy of frameless neuronavigation as offering between
2.0 and 4.8 mm placement accuracy. Murphy et al8 described the
placement of DEs in 13 patients via occipital burr holes using
the StealthStation Image-Guided System (Medtronic, Dublin,
Ireland). The mean DE placement error was 2.0 mm (1.8-2.5
mm) with a point merge registration technique in 10 cases and
0.9 mm (range: 0.8-1.0 mm) with a surface merge registration in
3 cases.8
Mehta et al,7 using a cannula and the StealthStation Guide
Frame-DT (Medtronic), placed 41 DEs in 51 targets in 20
patients with refractory epilepsy. Ten electrodes were placed
through burr holes and 31 DEs were placed after craniotomy and
grid placement. Recordings were valid in 98% of the patients and
the mean distance between the distal electrode contact and the
intended target was 3.1 mm (range: 0-7 mm).7
In another study, Mascott14 evaluated the in Vivo accuracy of
42 electrodes placed in 7 patients using the image guidance system
with SureTrak accessories (Medtronic). All the electrodes provided
clinically useful EEG recordings with a mean distance between
the distal electrode contact and the distal end of the planned
trajectory for the 42 targets of 3.0 ± 1.5 mm.14
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FIGURE 6. Euclidean distance of all electrodes per patient measured from the tip of the electrode to the
intended target. The dot represents the mean, the error bars represent the standard deviation, and the
horizontal red line represents the mean of all electrodes of all patients.

TABLE 2. Quantitative Accuracy of Frameless Neuronavigation for DE Implantation—A Literature Review

Distance error from the intended target

Author Stereotactic device Trajectories Mean (mm) Range (mm)

Murphy et al8 StealthStation Image-Guided System 208 2.0 1.8-2.5

Mehta et al7 Vertek (Medtronic) 51 3.1 0-7.0
Mascot14 Vertek (Medtronic) 42 3.6 2.4-3.6
Dorfer et al6 Vertek (Medtronic) 26 3.0 0.8-9.4
Nowell et al5 Guide Frame DT (Medtronic) 189 3.6 0.9-6.8
Present study Varioguide (Brainlab) 111 2.96 0.58-7.82

Recently, 2 different groups have published their experience
with this technique using the Vertek articulating arm (Medtronic)
in adults. Both papers used a technique that is comparable to the
one used in our study. Dorfer et al6 reported a mean Euclidean
distance of 3.0 mm (maximum 9.4 mm) for 26 electrodes and
Nowell et al5 reported a lateral shift by the electrode from
its planned trajectory of 3.6 mm (maximum 6.8 mm) in 187
electrodes. The mean accuracy of both studies is similar to our
study. We demonstrate that frameless approaches for DE implan-
tation using VarioGuide are as accurate as other FNS (Table 2).
The integration of multimodal image data for surgical planning
and the roominess of the surgical space are positive aspects of
the FNS for DE implantation. The VarioGuide R
setup does not
interfere with the space needed for a craniotomy if concurrent
subdural grids are required for cortical mapping. It seems that
the use of FNS could overcome some disadvantages of the frame-
based methods in children, such as frame placement, formal
training in stereotactic methodology, difficult management of
a stereotactic apparatus in pediatric patients (example: case 3,
Table 1—a very small 3-year-old patient), limited surgical space,
among others.
The main limitation on the use of FNS concurrent to
craniotomy is the intraoperative brain shift that is presently
unavoidable in any intracranial procedure and that neces-
sitates the use of intraoperative MRI to recalibrate the
image.15
With the SEEG technique, the incidence of complications
ranges from 1% to 5.6%. The most frequently reported are

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BUDKE ET AL
bleeding and infection.16-18 A combination of angio MRI with
an angio CT was used in this series to plan a trajectory avoiding
veins and arteries. One of our patients presented an acute asymp-
tomatic subdural hematoma that did not require surgical inter-
vention. There were no infections, possibly because of the prophy-
lactic protocol and the limited number of patients.
Our intention in this study has been to confirm that frameless-
based implantation using the VarioGuide R
is safe in children and
provides an acceptable accuracy for DE implantation in epilepsy
monitoring. The VarioGuide R
is a good alternative to frame-
based techniques in selected cases and is associated with low
morbidity.
Strengths and Limitations
The strengths of this study are its robust assessment of accuracy
based on actual implanted electrode position, the detailed
measurements of each electrode reporting the Euclidean distance,
and the use of this technique only for SEEG depth electrode
placement. The limitations are that it is a retrospective study
with a limited number of patients. Also, changes in electrode
depth (z-axis) were not included when calculating the TLE
because measuring lateral deviation as the vectorial distance in
a plane orthogonal to the planned electrode track is adequate to
describe TLE.
CONCLUSION
This is the first report to describe DE implantation in children
using the VarioGuide R
frameless system (Brainlab AG). The
system is a safe, accurate, and versatile method to implant DE for
invasive epilepsy monitoring in children. With the VarioGuide R
, 17. Cossu M, Cardinale F, Castana L, et al. Stereoelectroencephalography in the
the absolute error in the placement of DEs was 2.96 mm (range:
0.58-7.82 mm) from the center of the intended target and 3.64
± 1.78 mm (range: 0.58-7.59 mm) from the center of the entry
point. We have demonstrated that the use of FNS for DE implan-
tation in children is a feasible technique with an accuracy that is
comparable to the frame-based method with a low rate of compli-
cations. What is more, it provides an alternative to more complex
methods of DE placement.
Disclosure
The authors have no personal, financial, or institutional interest in any of the
drugs, materials, or devices described in this article.
REFERENCES
1. Lüders HO, Najm I, Nair D, Widdess-Walsh P, Bingman W. The epileptogenic
zone: general principles. Epileptic Disord. 2006;8(2):1-9.
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meta-analysis of stereo-electroencephalography-related complications. Epilepsia.
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3. Guenot M, Isnard J, Ryvlin P, et al. Neurophysiological monitoring for epilepsy
surgery: the Talairach SEEG method. StereoElectroEncephaloGraphy. Indications,
results, complications and therapeutic applications in a series of 100 consecutive
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4. Abhinav K, Prakash S, Sandeman DR. Use of robot-guided stereotactic placement
of intracerebral electrodes for investigation of focal epilepsy: initial experience in
the UK. Br J Neurosurg. 2013;27(5):704-705.
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method for implementation of frameless StereoEEG in epilepsy surgery. Neuro-
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6. Dorfer C, Stefanits H, Pataraia E, Wolfsberger S, Feucht M, Baumgartner
C. Frameless stereotactic drilling for placement of depth electrodes in refractory
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electrodes in epilepsy surgery. J Neurosurg. 2005;102(6):1040-1045.
8. Murphy MA, O’Brien TJ, Cook MJ. Insertion of depth electrodes with or
without subdural grids using frameless stereotactic guidance systems—technique
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and outcome. Br J Neurosurg. 2002;16(2):119-125.
9. Verburg N, Baayen JC, Idema S, et al. In vivo accuracy of a frameless stereotactic
drilling technique for diagnostic biopsies and stereoelectroencephalography depth
electrodes. World Neurosurg. 2016;87:392-398.
10. Avecillas-Chasin JM, Budke M, Villarejo F. Neuroendoscopic intraventricular
biopsy in children with small ventricles using frameless VarioGuide R
system. World
Neurosurg. 2016;87:136-142.
11. Ortler M, Sohm F, Eisner W, et al. Frame-based vs frameless placement of
intrahippocampal depth electrodes in patients with refractory epilepsy: a compar-
ative in vivo (application) study. Neurosurgery. 2011;68(4):881-887.
12. Bjartmarz H, Rehncrona S. Comparison of accuracy and precision between frame-
based and frameless stereotactic navigation for deep brain stimulation electrode
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13. González-Martínez J, Bulacio J, Thompson S, et al. Technique, results, and
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15. Roessler K, Sommer B, Merkel A, et al. A frameless stereotactic implantation
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Acknowledgments
We thank Pablo Lázaro for his help with the statistics and Natalia Calvo who
contributed equally to this work.
COMMENT
T he authors submit a well-written technical report on the use of
a proprietary frameless neuronavigation system for the placement
of EEG depth electrodes in children. They retrospectively reviewed 15
patients in the pediatric age group who underwent SEEG electrode
placement using the VarioGuide R
system (Brainlab AG). The authors’
outcome measures were the errors incurred at the entry point and
target (ie distance between the actual and intended points). The overall
mean error was about 3 mm. At first glance, an error of 3 mm seems
acceptable but it may not be when applied to passing a depth electrode
to avoid cortical or sulcal arteries and veins. In addition, monitoring
deep epileptogenic brain tissue sometimes necessitates submillimeter
accuracy. Nonetheless, a frameless system, such as the VarioGuide
R
, does
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 IMPLANTATION OF DEPTH ELECTRODES IN CHILDREN USING VARIOGUIDE
afford several advantages over frame- and robot-based systems, including
favorable operating room ergonomics and lower cost. The question is
whether these advantages are offset by the biggest limitation of frameless
neuronavigation, higher rate and magnitude of inaccuracy and error.
In summary, as the concept of “minimally-invasive” epilepsy surgery
in children continues to evolve, the authors make a quality contri-
bution to its growing literature. They should be commended for this.
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I look forward to a follow-up study from the authors focusing on
clinical outcomes, ie the safety and efficacy of frameless sEEG placement
using VarioGuide  R
and subsequent treatment/seizure control outcomes,
compared with frame- or robot-based approaches.
Andrew Jea
Indianapolis, Indiana
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