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Oliger A, Nerison C, Tan H, Raslan A, Ernst L, Datta P, Kellogg M. Responsive neurostimulation as a therapy for epilepsy following new-onset refractory status epilepticus: Case series and review of the literature. Clin Neurophysiol 2024; 162:151-158. [PMID: 38640819 DOI: 10.1016/j.clinph.2024.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 03/07/2024] [Accepted: 03/24/2024] [Indexed: 04/21/2024]
Abstract
OBJECTIVE To report clinical outcomes of patients who presented with new-onset refractory status epilepticus (NORSE), developed drug-resistant epilepsy (DRE), and were treated with responsive neurostimulation (RNS). METHODS We performed a retrospective review of patients implanted with RNS at our institution and identified three who originally presented with NORSE. Through chart review, we retrieved objective and subjective information related to their presentation, workup, and outcomes including patient-reported seizure frequency. We reviewed electrocorticography (ECoG) data to estimate seizure burden at 3, 6, 12, and 24 months following RNS implantation. We performed a review of literature concerning neurostimulation in NORSE. RESULTS Use of RNS to treat DRE following NORSE was associated with reduced seizure burden and informed care by differentiating epileptic from non-epileptic events. CONCLUSIONS Our single-center experience of three cases suggests that RNS is a safe and potentially effective treatment for DRE following NORSE. SIGNIFICANCE This article reports outcomes of the largest case series of NORSE patients treated with RNS. Since patients with NORSE are at high risk of adverse neuropsychiatric and cognitive sequelae beyond seizures, a unique strength of RNS over other surgical options is the ability to distinguish ictal or peri-ictal from non-epileptic events.
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Affiliation(s)
- Audrey Oliger
- Departments of Neurology, Oregon Health and Science University, Portland, OR, USA.
| | - Caleb Nerison
- Neurological Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Hao Tan
- Neurological Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Ahmed Raslan
- Neurological Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Lia Ernst
- Departments of Neurology, Oregon Health and Science University, Portland, OR, USA
| | - Proleta Datta
- Departments of Neurology, Oregon Health and Science University, Portland, OR, USA
| | - Marissa Kellogg
- Departments of Neurology, Oregon Health and Science University, Portland, OR, USA
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Jha R, Blitz SE, Chua MMJ, Warren AEL, Lee JW, Rolston JD. Surgical management of status epilepticus: A systematic review. Epilepsia Open 2024; 9:850-864. [PMID: 38456595 PMCID: PMC11145616 DOI: 10.1002/epi4.12924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 11/07/2023] [Accepted: 02/09/2024] [Indexed: 03/09/2024] Open
Abstract
Status Epilepticus (SE), unresponsive to medical management, is associated with high morbidity and mortality. Surgical management is typically considered in these refractory cases. The best surgical approach for affected patients remains unclear; however, given the lack of controlled trials exploring the role of surgery. We performed a systematic review according to PRIMSA guidelines, including case reports and series describing surgical interventions for patients in SE. Cases (157 patients, median age 12.9 years) were followed for a median of 12 months. Patients were in SE for a median of 21 days before undergoing procedures including: focal resection (36.9%), functional hemispherectomy (21%), lobar resection (12.7%), vagus nerve stimulation (VNS) (12.7%), deep brain stimulation (DBS) (6.4%), multiple subpial transection (MST) (3.8%), responsive neurostimulation (RNS) (1.9%), and cortical stimulator placement (1.27%), with 24 patients undergoing multiple procedures. Multiple SE semiologies were identified. 47.8% of patients had focal seizures, and 65% of patients had focal structural abnormalities on MRI. SE persisted for 36.8 ± 47.7 days prior to surgical intervention. SE terminated following surgery in 81.5%, terminated with additional adjuncts in 10.2%, continued in 1.9%, and was not specified in 6.4% of patients. Long-term seizure outcomes were favorable, with the majority improved and 51% seizure-free. Eight patients passed away in follow-up, of which three were in SE. Seizures emerging from one hemisphere were both more likely to immediately terminate (OR 4.7) and lead to long-term seizure-free status (OR 3.9) compared to nonunilateral seizures. No other predictors, including seizure focality, SE duration, or choice of surgical procedure, were predictors of SE termination. Surgical treatment of SE can be effective in terminating SE and leading to sustained seizure freedom, with many different procedures showing efficacy if matched appropriately with SE semiology and etiology. PLAIN LANGUAGE SUMMARY: Patients with persistent seizures (Status Epilepticus) that do not stop following medications can be treated effectively with surgery. Here, we systematically review the entirety of existing literature on surgery for treating status epilepticus to better identify how and when surgery is used and what patients do after surgery.
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Affiliation(s)
- Rohan Jha
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Neurosurgery, Harvard Medical SchoolBrigham and Women's HospitalBostonMassachusettsUSA
| | - Sarah E. Blitz
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Neurosurgery, Harvard Medical SchoolBrigham and Women's HospitalBostonMassachusettsUSA
| | - Melissa M. J. Chua
- Department of Neurosurgery, Harvard Medical SchoolBrigham and Women's HospitalBostonMassachusettsUSA
| | - Aaron E. L. Warren
- Department of Neurosurgery, Harvard Medical SchoolBrigham and Women's HospitalBostonMassachusettsUSA
| | - Jong Woo Lee
- Department of Neurology, Harvard Medical SchoolBrigham and Women's HospitalBostonMassachusettsUSA
| | - John D. Rolston
- Department of Neurosurgery, Harvard Medical SchoolBrigham and Women's HospitalBostonMassachusettsUSA
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Daoud M, Durelle C, Fierain A, N EY, Wendling F, Ruffini G, Benquet P, Bartolomei F. Long-term Effect of Multichannel tDCS Protocol in Patients with Central Cortex Epilepsies Associated with Epilepsia Partialis Continua. Brain Topogr 2024:10.1007/s10548-024-01045-3. [PMID: 38446345 DOI: 10.1007/s10548-024-01045-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 02/21/2024] [Indexed: 03/07/2024]
Abstract
Epilepsia partialis continua (EPC) is a rare type of focal motor status epilepticus that causes continuous muscle jerking in a specific part of the body. Experiencing this type of seizure, along with other seizure types, such as focal motor seizures and focal to bilateral tonic-clonic seizures, can result in a disabling situation. Non-invasive brain stimulation methods like transcranial direct current stimulation (tDCS) show promise in reducing seizure frequency (SF) when medications are ineffective. However, research on tDCS for EPC and related seizures is limited. We evaluated personalized multichannel tDCS in drug-resistant EPC of diverse etiologies for long-term clinical efficacy We report three EPC patients undergoing a long-term protocol of multichannel tDCS. The patients received several cycles (11, 9, and 3) of five consecutive days of stimulation at 2 mA for 2 × 20 min, targeting the epileptogenic zone (EZ), including the central motor cortex with cathodal electrodes. The primary measurement was SF changes. In three cases, EPC was due to Rasmussen's Encephalitis (case 1), focal cortical dysplasia (case 2), or remained unknown (case 3). tDCS cycles were administered over 6 to 22 months. The outcomes comprised a reduction of at least 75% in seizure frequency for two patients, and in one case, a complete cessation of severe motor seizures. However, tDCS had no substantial impact on the continuous myoclonus characterizing EPC. No serious side effects were reported. Long-term application of tDCS cycles is well tolerated and can lead to a considerable reduction in disabling seizures in patients with various forms of epilepsy with EPC.
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Affiliation(s)
- M Daoud
- Aix-Marseille Univ, INSERM U1106, Institut de Neurosciences des Systèmes, Marseille, France
| | - C Durelle
- Service d'Epileptologie et de Rythmologie cérébrale, APHM, Timone Hospital, Epileptology and Cerebral Rhythmology, 264 Rue Saint-Pierre, Marseille, 13005, France
| | - A Fierain
- Service d'Epileptologie et de Rythmologie cérébrale, APHM, Timone Hospital, Epileptology and Cerebral Rhythmology, 264 Rue Saint-Pierre, Marseille, 13005, France
| | - El Youssef N
- Service d'Epileptologie et de Rythmologie cérébrale, APHM, Timone Hospital, Epileptology and Cerebral Rhythmology, 264 Rue Saint-Pierre, Marseille, 13005, France
| | - F Wendling
- Univ Rennes, INSERM, LTSI-U1099, Rennes, F-35000, France
| | - G Ruffini
- Neuroelectrics Barcelona, Av. Tibidabo 47 bis, Barcelona, 08035, Spain
| | - P Benquet
- Univ Rennes, INSERM, LTSI-U1099, Rennes, F-35000, France
| | - F Bartolomei
- Aix-Marseille Univ, INSERM U1106, Institut de Neurosciences des Systèmes, Marseille, France.
- Service d'Epileptologie et de Rythmologie cérébrale, APHM, Timone Hospital, Epileptology and Cerebral Rhythmology, 264 Rue Saint-Pierre, Marseille, 13005, France.
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Stavropoulos I, Pak HL, Alarcon G, Valentin A. Neuromodulation Techniques in Children with Super-Refractory Status Epilepticus. Brain Sci 2023; 13:1527. [PMID: 38002487 PMCID: PMC10670094 DOI: 10.3390/brainsci13111527] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/18/2023] [Accepted: 10/24/2023] [Indexed: 11/26/2023] Open
Abstract
Status epilepticus (SE) is a life-threatening condition and medical emergency which can have lifelong consequences, including neuronal death and alteration of neuronal networks, resulting in long-term neurologic and cognitive deficits in children. When standard pharmacological treatment for SE is not successful in controlling seizures, the condition evolves to refractory SE (rSE) and finally to super-refractory SE (srSE) if it exceeds 24 h despite using anaesthetics. In this systematic review, we present literature data on the potential uses of clinical neuromodulation techniques for the management of srSE in children, including electroconvulsive therapy, vagus nerve stimulation, and deep brain stimulation. The evaluation of these techniques is limited by the small number of published paediatric cases (n = 25, one with two techniques) in peer-reviewed articles (n = 18). Although neuromodulation strategies have not been tested through randomised, prospective controlled clinical trials, this review presents the existing data and the potential benefits of neuromodulation therapy, suggesting that these techniques, when available, could be considered at earlier stages within the course of srSE intending to prevent long-term neurologic complications. Clinical trials aiming to establish whether early intervention can prevent long-term sequelae are necessary in order to establish the potential clinical value of neuromodulation techniques for the treatment of srSE in children.
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Affiliation(s)
- Ioannis Stavropoulos
- Department of Clinical Neurophysiology, King’s College Hospital, London SE5 9RS, UK;
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AB, UK
| | - Ho Lim Pak
- Faculty of Life Sciences and Medicine, King’s College London, London SE1 1UL, UK;
| | - Gonzalo Alarcon
- Royal Manchester Children’s Hospital, Manchester M13 9WL, UK;
- Alder Hey Children’s Hospital, Liverpool L12 2AP, UK
| | - Antonio Valentin
- Department of Clinical Neurophysiology, King’s College Hospital, London SE5 9RS, UK;
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AB, UK
- Alder Hey Children’s Hospital, Liverpool L12 2AP, UK
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Lundstrom BN, Osman GM, Starnes K, Gregg NM, Simpson HD. Emerging approaches in neurostimulation for epilepsy. Curr Opin Neurol 2023; 36:69-76. [PMID: 36762660 PMCID: PMC9992108 DOI: 10.1097/wco.0000000000001138] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW Neurostimulation is a quickly growing treatment approach for epilepsy patients. We summarize recent approaches to provide a perspective on the future of neurostimulation. RECENT FINDINGS Invasive stimulation for treatment of focal epilepsy includes vagus nerve stimulation, responsive neurostimulation of the cortex and deep brain stimulation of the anterior nucleus of the thalamus. A wide range of other targets have been considered, including centromedian, central lateral and pulvinar thalamic nuclei; medial septum, nucleus accumbens, subthalamic nucleus, cerebellum, fornicodorsocommissure and piriform cortex. Stimulation for generalized onset seizures and mixed epilepsies as well as increased efforts focusing on paediatric populations have emerged. Hardware with more permanently implanted lead options and sensing capabilities is emerging. A wider variety of programming approaches than typically used may improve patient outcomes. Finally, noninvasive brain stimulation with its favourable risk profile offers the potential to treat increasingly diverse epilepsy patients. SUMMARY Neurostimulation for the treatment of epilepsy is surprisingly varied. Flexibility and reversibility of neurostimulation allows for rapid innovation. There remains a continued need for excitability biomarkers to guide treatment and innovation. Neurostimulation, a part of bioelectronic medicine, offers distinctive benefits as well as unique challenges.
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Affiliation(s)
| | | | - Keith Starnes
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Hugh D Simpson
- Department of Neurology, Alfred Health
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Mamaril-Davis J, Vessell M, Ball T, Palade A, Shafer C, Aguilar-Salinas P, Fowler B, Mirro E, Neimat J, Sagi V, Bina RW. Combined Responsive Neurostimulation and Focal Resection for Super Refractory Status Epilepticus: A Systematic Review and Illustrative Case Report. World Neurosurg 2022; 167:195-204.e7. [PMID: 35948220 DOI: 10.1016/j.wneu.2022.07.141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Super-refractory status epilepticus (SRSE) is a neurologic emergency with high mortality and morbidity. Although medical algorithms typically are effective, when they do fail, options may be limited, and neurosurgical intervention should be considered. METHODS We report a case of SRSE treated acutely with responsive neurostimulation (RNS) and focal surgical resection after intracranial monitoring. We also conducted a systematic review of the literature for neurosurgical treatment of SRSE (e.g., neurostimulation). Only published manuscripts were considered. RESULTS Our patient's seizure semiology consisted of left facial twitching with frequent evolution to bilateral tonic-clonic convulsions. Stereoelectroencephalography and grid monitoring identified multiple seizure foci. The patient underwent right RNS placement with cortical strip leads over the lateral primary motor and premotor cortex as well as simultaneous right superior temporal and frontopolar resection. Status epilepticus resolved 21 days after surgical resection and placement of the RNS. The systematic review revealed 15 case reports describing 17 patients with SRSE who underwent acute neurosurgical intervention. There were 3 patients with SRSE with RNS placement as a single modality, all of whom experienced cessation of SE. Four patients with SRSE received vagus nerve stimulation (3 as a single modality and 1 with combined corpus callosotomy), of whom 1 had SE recurrence at 2weeks. Two patients with SRSE received deep brain stimulation, and the remaining 8 underwent surgical resection; none had recurrence of SE. CONCLUSIONS RNS System placement with or without resection can be a viable treatment option for select patients with SRSE. Early neurosurgical intervention may improve seizure outcomes and reduce complications.
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Affiliation(s)
- James Mamaril-Davis
- College of Medicine, The University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA
| | - Meena Vessell
- Department of Neurosurgery, University of Louisville Restorative Neuroscience, Louisville, Kentucky, USA
| | - Tyler Ball
- Department of Neurosurgery, University of Louisville Restorative Neuroscience, Louisville, Kentucky, USA
| | - Adriana Palade
- Department of Neurology, University of Louisville, Louisville, Kentucky, USA
| | - Christopher Shafer
- Department of Neurology, University of Louisville, Louisville, Kentucky, USA
| | - Pedro Aguilar-Salinas
- Department of Neurosurgery, Banner University Medical Center/The University of Arizona, Tucson, Arizona, USA
| | | | - Emily Mirro
- Neuropace, Inc., Mountain View, California, USA
| | - Joseph Neimat
- Department of Neurosurgery, University of Louisville Restorative Neuroscience, Louisville, Kentucky, USA
| | - Vishwanath Sagi
- Department of Neurology, University of Louisville, Louisville, Kentucky, USA
| | - Robert W Bina
- Department of Neurosurgery, Banner University Medical Center/The University of Arizona-Phoenix, Phoenix, Arizona, USA.
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Migdady I, Rosenthal ES, Cock HR. Management of status epilepticus: a narrative review. Anaesthesia 2022; 77 Suppl 1:78-91. [PMID: 35001380 DOI: 10.1111/anae.15606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2021] [Indexed: 11/26/2022]
Abstract
Status epilepticus causes prolonged or repetitive seizures that, if left untreated, can lead to neuronal injury, severe disability, coma and death in paediatric and adult populations. While convulsive status epilepticus can be diagnosed using clinical features alone, non-convulsive status epilepticus requires confirmation by electroencephalogram. Early seizure control remains key in preventing the complications of status epilepticus. This is especially true for convulsive status epilepticus, which has stronger evidence supporting the benefit of treatment on outcomes. When status epilepticus becomes refractory, often due to gamma-aminobutyric acid and N-methyl-D-aspartate receptor modulation, anaesthetic drugs are needed to suppress seizure activity, of which there is limited evidence regarding the selection, dose or duration of their use. Seizure monitoring with electroencephalogram is often needed when patients do not return to baseline or during anaesthetic wean; however, it is resource-intensive, costly, only available in highly specialised centres and has not been shown to improve functional outcomes. Thus, the treatment goals and aggressiveness of therapy remain under debate, especially for non-convulsive status epilepticus, where prolonged therapeutic coma can lead to severe complications. This review presents an evidence-based, clinically-oriented and comprehensive review of status epilepticus and its definitions, aetiologies, treatments, outcomes and prognosis at different stages of the patient's journey.
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Affiliation(s)
- I Migdady
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - E S Rosenthal
- Department of Neurology, Divisions of Clinical Neurophysiology and Neurocritical Care Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - H R Cock
- Clinical Neurosciences Academic Group, Institute of Molecular and Clinical Sciences, St. George's University of London, London, UK
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Rao VR. Chronic electroencephalography in epilepsy with a responsive neurostimulation device: current status and future prospects. Expert Rev Med Devices 2021; 18:1093-1105. [PMID: 34696676 DOI: 10.1080/17434440.2021.1994388] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Implanted neurostimulation devices are gaining traction as therapeutic options for people with certain forms of drug-resistant focal epilepsy. Some of these devices enable chronic electroencephalography (cEEG), which offers views of the dynamics of brain activity in epilepsy over unprecedented time horizons. AREAS COVERED This review focuses on clinical insights and basic neuroscience discoveries enabled by analyses of cEEG from an exemplar device, the NeuroPace RNS® System. Applications of RNS cEEG covered here include counting and lateralizing seizures, quantifying medication response, characterizing spells, forecasting seizures, and exploring mechanisms of cognition. Limitations of the RNS System are discussed in the context of next-generation devices in development. EXPERT OPINION The wide temporal lens of cEEG helps capture the dynamism of epilepsy, revealing phenomena that cannot be appreciated with short duration recordings. The RNS System is a vanguard device whose diagnostic utility rivals its therapeutic benefits, but emerging minimally invasive devices, including those with subscalp recording electrodes, promise to be more applicable within a broad population of people with epilepsy. Epileptology is on the precipice of a paradigm shift in which cEEG is a standard part of diagnostic evaluations and clinical management is predicated on quantitative observations integrated over long timescales.
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Affiliation(s)
- Vikram R Rao
- Associate Professor of Clinical Neurology, Chief, Epilepsy Division, Department of Neurology and Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
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