How I do it: a standardized robotic workflow for image-guided stereo-electroencephalography: technical description and institutional experience

BACKGROUND: Stereo-electroencephalography (SEEG) is a key technique for the presurgical evaluation of drug-resistant focal epilepsy [2]. Robotic assistance facilitates precise multi-trajectory stereotactic implantation and allows workflow standardization [1, 3, 5, 9]. We describe a reproducible image-based robotic SEEG implantation protocol and report our institutional experience. METHODS: An image-based robot-assisted SEEG technique using the Neuromate® system combined with intraoperative 3D imaging is presented. The workflow includes hypothesis-driven trajectory planning, alphabetical trajectory sequencing, laser-verified stereotactic registration, trajectory-specific skull thickness measurement with depth-controlled drilling, reducer-guided bolt placement, and intraoperative imaging verification. Institutional procedural data were reviewed to illustrate workflow performance and safety. RESULTS: Sixty-eight patients underwent implantation of 952 SEEG depth electrodes (mean 14 electrodes per patient). Mean robotic implantation time was 198 min (SD 54.9; range 80-280), corresponding to 14.1 min per electrode. Mean stereotactic registration error was 1.7 mm. Three patients (4.4%) developed intracranial hemorrhage, with one symptomatic case (1.47%) requiring surgical evacuation. This event occurred during electrode removal rather than implantation. No hemorrhage occurred during robotic electrode insertion, and no electrode repositioning or reintervention was required. CONCLUSION: Image-based robot-assisted SEEG enables accurate and reproducible multi-trajectory implantation with efficient workflow and low complication rates. Structured trajectory planning and systematic intraoperative verification may improve procedural safety and standardization.