Stereoelectroencephalography (SEEG)

SEEG — also known as stereotactic electroencephalography — is a minimally invasive surgical procedure to precisely locate the areas in your child’s brain where epileptic seizures start. It involves placing electrodes directly into your child’s brain to monitor seizure activity.

It is usually performed on children over age 2 who have been diagnosed with refractory (drug-resistant) epilepsy that has not responded to two or more antiseizure medications.

The goal of SEEG is to learn more about where your child’s seizures start so your child’s epilepsy care team can determine whether your child is a candidate for epilepsy surgery or other treatments.

What are the two types of EEG?

Electroencephalogram (EEG) and stereo-EEG are the two types of EEG.

What is the difference between EEG and stereo-EEG?

Electroencephalogram (EEG) is a noninvasive test that involves attaching electrodes to your child’s skull. It is often the first test performed to try to identify where seizures start in your child’s brain.

SEEG is an invasive test often performed as part of a presurgical evaluation to precisely locate the origin site of seizures. SEEG involves inserting electrodes into your child’s brain.

After your child is registered, they will be taken to a “holding area” where you will meet your child’s pediatric anesthesiologist and neurosurgeon. Your child’s pediatric anesthesiologist — a doctor who specializes in anesthesia for children — will administer medications to make your child sleep during the surgery. At this time, you can ask any questions about the procedure. 

After your questions are answered and the operating room is prepared, your child will be taken into the operating room and given an anesthetic to make them go to sleep.

When your child is asleep, the surgery will begin. Your child’s neurosurgeon will:

• Place a special frame on your child’s head to hold it in place and keep it from moving during the procedure. Depending on the technology used during the procedure, your child’s neurosurgeon may perform the surgery without the need for a frame.
• Load your child’s CT or MRI images into the image-guidance system. These images help your doctor precisely place the electrodes during your child’s procedure.
• Drill several small holes in your child’s scalp. The holes will be about the width of a candle wick and will not cause bleeding. Your child’s neurosurgeon may use a robotic-assisted approach that combines imaging, GPS mapping, and a robotic arm to guide drilling and electrode placement.
• Insert small electrodes through the holes into specific parts of your child’s brain to monitor seizure activity. The electrodes are attached to wires that extend outside your child’s skull and connect to specialized seizure monitoring equipment during their stay in the Epilepsy Monitoring Unit.
• Remove the frame from your child’s head if a frame was used.
• Order a CT scan or MRI of your child’s head to verify that the electrodes are in the correct position.
• Transfer your child to the recovery area. After your child is awake and stable, they will be transferred to the Epilepsy Monitoring Unit.

What are the risks of stereo EEG?

UPMC Children’s takes every precaution to ensure your child’s safety. Risks involved in the surgery include:

• Bleeding in your child’s brain.
• Infection.
• Stroke.

When general anesthesia is needed, there are important rules for eating and drinking that must be followed in the hours before the surgery.

One business day before your child’s surgery, you will receive a phone call from a nurse between the hours of 1 and 9 p.m. (Nurses do not make these calls on weekends or holidays.) Please have paper and a pen ready to write down these important instructions.

The nurse will give you specific eating and drinking instructions for your child based on your child’s age.

The following are the usual instructions given for eating and drinking. No matter what age your child is, you should follow the specific instructions given to you on the phone by the nurse.

For children older than 12 months

• After midnight the night before the surgery, do not give any solid food or non-clear liquids. That includes milk, formula, juices with pulp, coffee, and chewing gum or candy.

For infants under 12 months

• Up to six hours before the scheduled arrival time, formula-fed babies may be given formula.
• Up to four hours before the scheduled arrival time, breastfed babies may nurse.

For all children

• Up to two hours before the scheduled arrival time, give only clear liquids. Clear liquids include water, Pedialyte®, Kool-Aid®, and juices you can see through, such as apple or white grape juice. Milk is not a clear liquid.
• In the 2 hours before the scheduled arrival time, give them nothing to eat or drink.

Once your child has been registered for the surgery, a member of the anesthesia staff will meet with you to take your child’s vital signs, weight, and medical history.

A pediatric anesthesiologist — a doctor who specializes in anesthesia for children — will meet with you before the surgery. They will ask questions about your child’s health and about when your child last ate.

Because your child may have eaten more recently than is usually advised for surgery, the anesthesiologist may make adjustments to your child’s anesthesia. Once admitted, your child will not be able to have anything to eat or drink until after the operation.

• As the parent or legal guardian, you will be asked to sign a consent form before the anesthesia is given.
• If your child is very scared or upset, the doctor may give a special medication to help them relax. This medication is flavored and takes effect in about 10 to 15 minutes.
• If you wish, you may be allowed to go with your child to the room where the surgery will be done and stay while the sleep medication is given.
• Younger children will get their sleep medication through a “space mask” that will carry air mixed with medication. Your child may choose a favorite scent to flavor the air flowing through the mask. There are no shots or needles used while your child is still awake.
• Older children may choose between getting their medication through a mask or directly into a vein through an intravenous (IV) line.
• When your child has fallen asleep, you will be taken to the waiting room. If it has not already been done, an IV will be started so that medication can be given to keep your child sleeping throughout the surgery.

While your child is asleep, their heart rate, blood pressure, temperature, and blood oxygen level will be checked continuously. Your child will have a breathing tube placed while they are asleep. Your child might have a sore throat after the surgery.

To keep your child asleep during the surgery, they might be given anesthetic medication by mask, through the IV tube, or both. When the surgery is over, the medications will be stopped, and your child will begin to wake up.

After surgery, your child will be moved to the recovery room. You will be called so that you can be there as they wake up.

• Children coming out of anesthesia react in different ways. Your child might cry, be fussy or confused, feel sick to his or her stomach, or vomit. These reactions are normal and will go away as the anesthesia wears off.
• While your child is in recovery, your surgeon will talk to you about the surgery. That is a good time to ask questions about pain medications, diet, and activity.
• When your child is awake enough, he or she might be given a Popsicle® or “slushy” to drink in the recovery room. After the anesthesiologist sees that your child can hold down the drink and his or her pain is controlled, your child will be transferred to the Epilepsy Monitoring Unit. This usually takes about an hour.

The most important role of a parent or guardian is to help your child stay calm and relaxed before the surgery. The best way to help your child stay calm is for you to stay calm.

• You are encouraged to talk to your child or hold their hand before the surgery, while sleep medication is given, and while in recovery.
• You may bring along a “comfort” item — such as a favorite stuffed animal or “blankie” — for your child to hold before and after the surgery.

Your child will be given pain medication after the surgery, which will help with discomfort when the anesthesia wears off. Your child’s doctor will give you instructions for how to administer pain medication at home after your child is discharged from the hospital.

After surgery, your child will need to stay in the hospital’s Epilepsy Monitoring Unit (EMU) for several days or weeks. When your child arrives in the EMU, he or she might still be groggy from the surgery.

The EMU staff will connect your child’s electrode wires to specialized equipment to monitor and record seizure activity. The goal of this monitoring is to record your child's typical seizures. The epilepsy team usually needs to record multiple seizures over several days, and the surgical epilepsy team will meet with you and your child frequently throughout the EMU stay.

Additional testing to map the motor and/or language function of your child's brain also may be performed in the EMU at bedside.

Diet

In the EMU, your child’s diet will be restricted to liquids, such as water, Gatorade®, Popsicles®, or Kool-aid® for a couple of hours to ensure their stomach is settled after the surgery. If your child does well with liquids after a couple hours, they may try a light diet and soft foods, such as applesauce, soup, toast, bananas, rice or hot cereal. Your child may resume a normal diet the next day.

Electrode removal

After your child’s SEEG testing is complete, a member of their health care team will remove the electrodes. This procedure is performed by the neurosurgical team in the operating room, under general anesthesia.

Discharge from the hospital

After your child is discharged from the hospital, they should avoid strenuous activities for 24 to 48 hours. Your child’s care team will provide care instructions for your child’s scalp and information about when your child can return to normal activities.

Follow-up care

Your child’s epilepsy doctor will review the SEEG test results and recommend a treatment plan based on the findings. If your child needs a neurosurgical procedure to treat their seizures, your doctor will provide instructions for scheduling the procedure.

Call the doctor right away if your child has:

• A fever higher than 101.4 °F.
• Bleeding or drainage from the incisions.
• Increased tenderness near the incision.
• Increased swelling or redness near the incision.
• Increased pain that is unexplained.
• Nausea, vomiting, diarrhea or constipation that is not improving.

If your child develops symptoms of confusion, weakness on one side of the body, drooping face, difficulty with movement or walking, or problems with vision or speech, dial 911. These could be a sign of a stroke or bleeding in your child’s brain.

If you have any specific questions about your child’s surgery, you should discuss them with the surgeon before the surgery. You may call the Pediatric Neurosurgery Division at UPMC Children’s and ask to speak with your child’s surgeon or speak with them during the presurgical examination on the day of the surgery. Call the division at 412-692-5090.

If your child has any special needs or health issues that the doctor should be aware of, please call the Pediatric Neurosurgery Division at UPMC Children’s before the surgery and ask to speak with a nurse. It’s important to notify us in advance about any special needs your child may have.