The value of additional electrodes when stereo‐electroencephalography is inconclusive

Abstract Objective Stereo‐electroencephalography (SEEG) is the preferred method for intracranial localization of the seizure‐onset zone (SOZ) in drug‐resistant focal epilepsy. Occasionally SEEG evaluation fails to confirm the pre‐implantation hypothesis. This leads to a decision tree regarding whether the addition of SEEG electrodes (two‐step SEEG – 2sSEEG) or placement of subdural electrodes (SDEs) after SEEG (SEEG2SDE) would help. There is a dearth of literature encompassing this scenario, and here we aimed to characterize outcomes following unplanned two‐step intracranial EEG (iEEG). Methods All 225 adult SEEG cases over 8 years at our institution were reviewed to extract patient data and outcomes following a two‐step evaluation. Three raters independently quantified benefits of additional intracranial electrodes. The relationship between two‐step iEEG benefit and clinical outcome was then analyzed. Results Fourteen patients underwent 2sSEEG and nine underwent SEEG2SDE. In the former cohort, the second SEEG procedure was performed for these reasons—precise localization of the SOZ (36%); defining margins of eloquent cortex (21%); and broadening coverage in the setting of non‐localizable seizure onsets (43% of cases). Sixty‐four percent of 2sSEEG cases were consistently deemed beneficial (Light's κ = 0.80). 2sSEEG performed for the first two indications was much more beneficial than when onsets were not localizable (100% vs 17%, p = .02). In the SEEG2SDE cohort, SDEs identified the SOZ and enabled delineation of margins relative to eloquent cortex in all cases. Significance The two‐step iEEG is useful if the initial evaluation is broadly concordant with the original electroclinical hypothesis, where it can clarify onset zones or delineate safe surgical margins; however, it provides minimal benefit when the implantation hypothesis is erroneous, and we recommend that 2sSEEG not be generally utilized in such cases. SDE implantation after SEEG minimizes the need for SDEs and is helpful in delineating surgical boundaries relative to ictal‐onset zones and eloquent cortex.