Invasive EEG studies in tumor-related epilepsy: When are they indicated and with what kind of electrodes?

Patients with tumor-related epilepsy (TRE) represent an important proportion of epilepsy surgery cases. Recently established independent negative predictors of postoperative seizure outcome are long duration of epilepsy, presence of generalized tonic-clonic seizures, and incomplete tumor resection. In temporal lobe cases, additional hippocampectomy or corticectomy may further improve outcome. Invasive electroencephalography (EEG) recordings (IEEG) may be indicated to guide the resection by defining eloquent cortex (EC) or to determine the extent of potentially magnetic resonance imaging (MRI)-negative epileptogenic tissue. In fact, invasive recordings are reportedly used in up to 10% of patients who are undergoing epilepsy surgery for TRE. Following careful consideration of the concepts underlying epilepsy surgery, the current use of IEEG, and the predictors of outcome in extratemporal and temporal tumors in TRE, we postulate the following> (1) In patients with extratemporal TRE, IEEG is necessary only if the MRI lesion (and if feasible a rim around it) cannot be completely resected because of adjacent or overlapping EC. In these cases, EC should be mapped to determine its relationships to the lesion, the irritative, and seizure-onset zones in order to maximize the extent of the lesionectomy. (2) In patients with nondominant temporal TRE, data suggest that if epileptogenic tumors (ETs) are encroaching on mesial temporal structures, if epilepsy duration is long, and seizures are frequent and disabling, these structures should be included in the resection. (3) In patients with dominant temporal TRE, we suggest leaving the mesial structures in place if they are functionally and structurally intact and to consider resecting these structures only if they are structurally and functionally abnormal. There is insufficient evidence justifying the use of IEEG to define the extent of the epileptogenic zone in such cases. This should be reserved for cases where an initial lesionectomy has failed.