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Jiao D, Xu L, Gu Z, Yan H, Shen D, Gu X. Pathogenesis, diagnosis, and treatment of epilepsy: electromagnetic stimulation-mediated neuromodulation therapy and new technologies. Neural Regen Res 2025; 20:917-935. [PMID: 38989927 DOI: 10.4103/nrr.nrr-d-23-01444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/18/2024] [Indexed: 07/12/2024] Open
Abstract
Epilepsy is a severe, relapsing, and multifactorial neurological disorder. Studies regarding the accurate diagnosis, prognosis, and in-depth pathogenesis are crucial for the precise and effective treatment of epilepsy. The pathogenesis of epilepsy is complex and involves alterations in variables such as gene expression, protein expression, ion channel activity, energy metabolites, and gut microbiota composition. Satisfactory results are lacking for conventional treatments for epilepsy. Surgical resection of lesions, drug therapy, and non-drug interventions are mainly used in clinical practice to treat pain associated with epilepsy. Non-pharmacological treatments, such as a ketogenic diet, gene therapy for nerve regeneration, and neural regulation, are currently areas of research focus. This review provides a comprehensive overview of the pathogenesis, diagnostic methods, and treatments of epilepsy. It also elaborates on the theoretical basis, treatment modes, and effects of invasive nerve stimulation in neurotherapy, including percutaneous vagus nerve stimulation, deep brain electrical stimulation, repetitive nerve electrical stimulation, in addition to non-invasive transcranial magnetic stimulation and transcranial direct current stimulation. Numerous studies have shown that electromagnetic stimulation-mediated neuromodulation therapy can markedly improve neurological function and reduce the frequency of epileptic seizures. Additionally, many new technologies for the diagnosis and treatment of epilepsy are being explored. However, current research is mainly focused on analyzing patients' clinical manifestations and exploring relevant diagnostic and treatment methods to study the pathogenesis at a molecular level, which has led to a lack of consensus regarding the mechanisms related to the disease.
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Affiliation(s)
- Dian Jiao
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, China
| | - Lai Xu
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, China
| | - Zhen Gu
- Key Laboratory of Advanced Drug Delivery Systems of Zhejiang Province, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Hua Yan
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, China
| | - Dingding Shen
- Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Xiaosong Gu
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, China
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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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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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Chua MMJ, Vissani M, Liu DD, Schaper FLWVJ, Warren AEL, Caston R, Dworetzky BA, Bubrick EJ, Sarkis RA, Cosgrove GR, Rolston JD. Initial case series of a novel sensing deep brain stimulation device in drug-resistant epilepsy and consistent identification of alpha/beta oscillatory activity: A feasibility study. Epilepsia 2023; 64:2586-2603. [PMID: 37483140 DOI: 10.1111/epi.17722] [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: 03/27/2023] [Revised: 07/18/2023] [Accepted: 07/18/2023] [Indexed: 07/25/2023]
Abstract
OBJECTIVE Here, we report a retrospective, single-center experience with a novel deep brain stimulation (DBS) device capable of chronic local field potential (LFP) recording in drug-resistant epilepsy (DRE) and explore potential electrophysiological biomarkers that may aid DBS programming and outcome tracking. METHODS Five patients with DRE underwent thalamic DBS, targeting either the bilateral anterior (n = 3) or centromedian (n = 2) nuclei. Postoperative electrode lead localizations were visualized in Lead-DBS software. Local field potentials recorded over 12-18 months were tracked, and changes in power were associated with patient events, medication changes, and stimulation. We utilized a combination of lead localization, in-clinic broadband LFP recordings, real-time LFP response to stimulation, and chronic recordings to guide DBS programming. RESULTS Four patients (80%) experienced a >50% reduction in seizure frequency, whereas one patient had no significant reduction. Peaks in the alpha and/or beta frequency range were observed in the thalamic LFPs of each patient. Stimulation suppressed these LFP peaks in a dose-dependent manner. Chronic timeline data identified changes in LFP amplitude associated with stimulation, seizure occurrences, and medication changes. We also noticed a circadian pattern of LFP amplitudes in all patients. Button-presses during seizure events via a mobile application served as a digital seizure diary and were associated with elevations in LFP power. SIGNIFICANCE We describe an initial cohort of patients with DRE utilizing a novel sensing DBS device to characterize potential LFP biomarkers of epilepsy that may be associated with seizure control after DBS in DRE. We also present a new workflow utilizing the Percept device that may optimize DBS programming using real-time and chronic LFP recording.
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Affiliation(s)
- Melissa M J Chua
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Matteo Vissani
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David D Liu
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Frederic L W V J Schaper
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aaron E L Warren
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rose Caston
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah, USA
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Barbara A Dworetzky
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ellen J Bubrick
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rani A Sarkis
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - G Rees Cosgrove
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John D Rolston
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah, USA
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
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5
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Fisher RS. Deep brain stimulation of thalamus for epilepsy. Neurobiol Dis 2023; 179:106045. [PMID: 36809846 DOI: 10.1016/j.nbd.2023.106045] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 02/22/2023] Open
Abstract
Neuromodulation (neurostimulation) is a relatively new and rapidly growing treatment for refractory epilepsy. Three varieties are approved in the US: vagus nerve stimulation (VNS), deep brain stimulation (DBS) and responsive neurostimulation (RNS). This article reviews thalamic DBS for epilepsy. Among many thalamic sub-nuclei, DBS for epilepsy has been targeted to the anterior nucleus (ANT), centromedian nucleus (CM), dorsomedial nucleus (DM) and pulvinar (PULV). Only ANT is FDA-approved, based upon a controlled clinical trial. Bilateral stimulation of ANT reduced seizures by 40.5% at three months in the controlled phase (p = .038) and 75% by 5 years in the uncontrolled phase. Side effects related to paresthesias, acute hemorrhage, infection, occasional increased seizures, and usually transient effects on mood and memory. Efficacy was best documented for focal onset seizures in temporal or frontal lobe. CM stimulation may be useful for generalized or multifocal seizures and PULV for posterior limbic seizures. Mechanisms of DBS for epilepsy are largely unknown, but animal work points to changes in receptors, channels, neurotransmitters, synapses, network connectivity and neurogenesis. Personalization of therapies, in terms of connectivity of the seizure onset zone to the thalamic sub- nucleus and individual characteristics of the seizures, might lead to improved efficacy. Many questions remain about DBS, including the best candidates for different types of neuromodulation, the best targets, the best stimulation parameters, how to minimize side effects and how to deliver current noninvasively. Despite the questions, neuromodulation provides useful new opportunities to treat people with refractory seizures not responding to medicines and not amenable to resective surgery.
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Affiliation(s)
- Robert S Fisher
- Department of Neurology and Neurological Sciences and Neurosurgery by Courtesy, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, 213 Quarry Road, Room 4865, Palo Alto, CA 94304, USA.
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Catron MA, Howe RK, Besing GLK, St. John EK, Potesta CV, Gallagher MJ, Macdonald RL, Zhou C. Sleep slow-wave oscillations trigger seizures in a genetic epilepsy model of Dravet syndrome. Brain Commun 2022; 5:fcac332. [PMID: 36632186 PMCID: PMC9830548 DOI: 10.1093/braincomms/fcac332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/09/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Sleep is the preferential period when epileptic spike-wave discharges appear in human epileptic patients, including genetic epileptic seizures such as Dravet syndrome with multiple mutations including SCN1A mutation and GABAA receptor γ2 subunit Gabrg2Q390X mutation in patients, which presents more severe epileptic symptoms in female patients than male patients. However, the seizure onset mechanism during sleep still remains unknown. Our previous work has shown that the sleep-like state-dependent homeostatic synaptic potentiation can trigger epileptic spike-wave discharges in one transgenic heterozygous Gabrg2+/Q390X knock-in mouse model.1 Here, using this heterozygous knock-in mouse model, we hypothesized that slow-wave oscillations themselves in vivo could trigger epileptic seizures. We found that epileptic spike-wave discharges in heterozygous Gabrg2+/Q390X knock-in mice exhibited preferential incidence during non-rapid eye movement sleep period, accompanied by motor immobility/facial myoclonus/vibrissal twitching and more frequent spike-wave discharge incidence appeared in female heterozygous knock-in mice than male heterozygous knock-in mice. Optogenetically induced slow-wave oscillations in vivo significantly increased epileptic spike-wave discharge incidence in heterozygous Gabrg2+/Q390X knock-in mice with longer duration of non-rapid eye movement sleep or quiet-wakeful states. Furthermore, suppression of slow-wave oscillation-related homeostatic synaptic potentiation by 4-(diethylamino)-benzaldehyde injection (i.p.) greatly attenuated spike-wave discharge incidence in heterozygous knock-in mice, suggesting that slow-wave oscillations in vivo did trigger seizure activity in heterozygous knock-in mice. Meanwhile, sleep spindle generation in wild-type littermates and heterozygous Gabrg2+/Q390X knock-in mice involved the slow-wave oscillation-related homeostatic synaptic potentiation that also contributed to epileptic spike-wave discharge generation in heterozygous Gabrg2+/Q390X knock-in mice. In addition, EEG spectral power of delta frequency (0.1-4 Hz) during non-rapid eye movement sleep was significantly larger in female heterozygous Gabrg2+/Q390X knock-in mice than that in male heterozygous Gabrg2+/Q390X knock-in mice, which likely contributes to the gender difference in seizure incidence during non-rapid eye movement sleep/quiet-wake states of human patients. Overall, all these results indicate that slow-wave oscillations in vivo trigger the seizure onset in heterozygous Gabrg2+/Q390X knock-in mice, preferentially during non-rapid eye movement sleep period and likely generate the sex difference in seizure incidence between male and female heterozygous Gabrg2+/Q390X knock-in mice.
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Affiliation(s)
- Mackenzie A Catron
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Department of Neuroscience Graduate Program, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Rachel K Howe
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Gai-Linn K Besing
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Emily K St. John
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | | | - Martin J Gallagher
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Department of Neuroscience Graduate Program, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Robert L Macdonald
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Department of Neuroscience Graduate Program, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Chengwen Zhou
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Department of Neuroscience Graduate Program, Vanderbilt University Medical Center, Nashville, TN 37232, USA
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Nowakowska M, Üçal M, Charalambous M, Bhatti SFM, Denison T, Meller S, Worrell GA, Potschka H, Volk HA. Neurostimulation as a Method of Treatment and a Preventive Measure in Canine Drug-Resistant Epilepsy: Current State and Future Prospects. Front Vet Sci 2022; 9:889561. [PMID: 35782557 PMCID: PMC9244381 DOI: 10.3389/fvets.2022.889561] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/23/2022] [Indexed: 11/28/2022] Open
Abstract
Modulation of neuronal activity for seizure control using various methods of neurostimulation is a rapidly developing field in epileptology, especially in treatment of refractory epilepsy. Promising results in human clinical practice, such as diminished seizure burden, reduced incidence of sudden unexplained death in epilepsy, and improved quality of life has brought neurostimulation into the focus of veterinary medicine as a therapeutic option. This article provides a comprehensive review of available neurostimulation methods for seizure management in drug-resistant epilepsy in canine patients. Recent progress in non-invasive modalities, such as repetitive transcranial magnetic stimulation and transcutaneous vagus nerve stimulation is highlighted. We further discuss potential future advances and their plausible application as means for preventing epileptogenesis in dogs.
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Affiliation(s)
- Marta Nowakowska
- Research Unit of Experimental Neurotraumatology, Department of Neurosurgery, Medical University of Graz, Graz, Austria
| | - Muammer Üçal
- Research Unit of Experimental Neurotraumatology, Department of Neurosurgery, Medical University of Graz, Graz, Austria
| | - Marios Charalambous
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hanover, Germany
| | - Sofie F. M. Bhatti
- Small Animal Department, Faculty of Veterinary Medicine, Small Animal Teaching Hospital, Ghent University, Merelbeke, Belgium
| | - Timothy Denison
- Department of Engineering Science, Institute of Biomedical Engineering, University of Oxford, Oxford, United Kingdom
| | - Sebastian Meller
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hanover, Germany
| | | | - Heidrun Potschka
- Faculty of Veterinary Medicine, Institute of Pharmacology, Toxicology and Pharmacy, Ludwig-Maximilians-University, Munich, Germany
| | - Holger A. Volk
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hanover, Germany
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Agashe S, Burkholder D, Starnes K, Van Gompel JJ, Lundstrom BN, Worrell GA, Gregg NM. Centromedian Nucleus of the Thalamus Deep Brain Stimulation for Genetic Generalized Epilepsy: A Case Report and Review of Literature. Front Hum Neurosci 2022; 16:858413. [PMID: 35669200 PMCID: PMC9164300 DOI: 10.3389/fnhum.2022.858413] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 04/07/2022] [Indexed: 11/13/2022] Open
Abstract
There is a paucity of treatment options for cognitively normal individuals with drug resistant genetic generalized epilepsy (GGE). Centromedian nucleus of the thalamus (CM) deep brain stimulation (DBS) may be a viable treatment for GGE. Here, we present the case of a 27-year-old cognitively normal woman with drug resistant GGE, with childhood onset. Seizure semiology are absence seizures and generalized onset tonic clonic (GTC) seizures. At baseline she had 4–8 GTC seizures per month and weekly absence seizures despite three antiseizure medications and vagus nerve stimulation. A multidisciplinary committee recommended off-label use of CM DBS in this patient. Over 12-months of CM DBS she had two GTC seizure days, which were in the setting of medication withdrawal and illness, and no GTC seizures in the last 6 months. There was no significant change in the burden of absence seizures. Presently, just two studies clearly document CM DBS in cognitively normal individuals with GGE or idiopathic generalized epilepsy (IGE) [in contrast to studies of cognitively impaired individuals with developmental and epileptic encephalopathies (DEE)]. Our results suggest that CM DBS can be an effective treatment for cognitively normal individuals with GGE and underscore the need for prospective studies of CM DBS.
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Affiliation(s)
- Shruti Agashe
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- *Correspondence: Shruti Agashe,
| | - David Burkholder
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Keith Starnes
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | | | | | | | - Nicholas M. Gregg
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Nicholas M. Gregg,
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Pinto LF, Oliveira JPSD, Midon AM. Status epilepticus: review on diagnosis, monitoring and treatment. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:193-203. [PMID: 35976303 PMCID: PMC9491413 DOI: 10.1590/0004-282x-anp-2022-s113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
Status epilepticus (SE) is a frequent neurological emergency associated with high morbidity and mortality. According to the new ILAE 2015 definition, SE results either from the failure of the mechanisms responsible for seizure termination or initiation, leading to abnormally prolonged seizures. The definition has different time points for convulsive, focal and absence SE. Time is brain. There are changes in synaptic receptors leading to a more proconvulsant state and increased risk of brain lesion and sequelae with long duration. Management of SE must include three pillars: stop seizures, stabilize patients to avoid secondary lesions and treat underlying causes. Convulsive SE is defined after 5 minutes and is a major emergency. Benzodiazepines are the initial treatment, and should be given fast and an adequate dose. Phenytoin/fosphenytoin, levetiracetam and valproic acid are evidence choices for second line treatment. If SE persists, anesthetic drugs are probably the best option for third line treatment, despite lack of evidence. Midazolam is usually the best initial choice and barbiturates should be considered for refractory cases. Nonconvulsive status epilepticus has a similar initial approach, with benzodiazepines and second line intravenous (IV) agents, but after that, aggressiveness should be balanced considering risk of lesion due to seizures and medical complications caused by aggressive treatment. Usually, the best approach is the use of sequential IV antiepileptic drugs (oral/tube are options if IV options are not available). EEG monitoring is crucial for diagnosis of nonconvulsive SE, after initial control of convulsive SE and treatment control. Institutional protocols are advised to improve care.
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Affiliation(s)
- Lecio Figueira Pinto
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, Grupo de Epilepsia, São Paulo SP, Brazil
| | | | - Aston Marques Midon
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil
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Velasco F, Saucedo-Alvarado PE, Reichrath A, Valdés-Quiroz H, Aguado-Carrillo G, Velasco AL. Centromedian Nucleus and Epilepsy. J Clin Neurophysiol 2021; 38:485-493. [PMID: 34261113 DOI: 10.1097/wnp.0000000000000735] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SUMMARY Centromedian thalamic nucleus is an intralaminar nucleus with vast connectivity to cerebral cortex and basal ganglia. It receives afferents from the brain stem through the central tegmental tract and is part of the diffuse thalamic projection system. Because the reticulothalamic system has been related to initiation and propagation of epileptic activity (centroencephalic theory of epilepsy), deep brain stimulation has been proposed to interfere with seizure genesis or propagation. Centromedian thalamic nucleus is a large nucleus laying nearby the anatomical references for stereotaxis and therefore a convenient surgical target to approach. Electrodes are implanted in the anterior ventral lateral part of the nucleus (parvocellular area), guided by intraoperative recruiting responses elicited by unilateral 6 to 8 Hz electrical stimulation delivered through the deep brain stimulation electrode. Therapeutic stimulation is delivered with the following parameters: 60 Hz, 450 μs, 3.0 V. Seizure control runs between 69% and 83% in different reports, decreasing mainly generalized seizures from the start, with significant improvement in neuropsychological performance. Significant decrease in seizure occurs from hours to days after the onset of deep brain stimulation. Some reports refer that seizure improvement may occur by the simple insertion of the deep brain stimulation electrodes, and therefore, it was used to treat refractory epileptic status.
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Affiliation(s)
- Francisco Velasco
- Epilepsy Clinic, Unit for Stereotactic and Functional Neurosurgery, General Hospital of Mexico, Mexico City, Mexico
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11
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Stavropoulos I, Pak HL, Valentin A. Neuromodulation in Super-refractory Status Epilepticus. J Clin Neurophysiol 2021; 38:494-502. [PMID: 34261110 DOI: 10.1097/wnp.0000000000000710] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
SUMMARY Status epilepticus (SE) is a severe condition that needs immediate pharmacological treatment to tackle brain damage and related side effects. In approximately 20% of cases, the standard treatment for SE does not control seizures, and the condition evolves to refractory SE. If refractory status epilepticus lasts more than 24 hours despite the use of anesthetic treatment, the condition is redefined as super-refractory SE (srSE). sRSE is a destructive condition, potentially to cause severe brain damage. In this review, we discuss the clinical neuromodulation techniques for controlling srSE when conventional treatments have failed: electroconvulsive therapy, vagus nerve stimulation, transcranial magnetic stimulation, and deep brain stimulation. Data show that neuromodulation therapies can abort srSE in >80% of patients. However, no randomized, prospective, and controlled trials have been completed, and data are provided only by retrospective small case series and case reports with obvious inclination to publication bias. There is a need for further investigation into the use of neuromodulation techniques as an early treatment of srSE and to address whether an earlier intervention can prevent long-term complications.
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Affiliation(s)
- Ioannis Stavropoulos
- Department of Clinical Neurophysiology, King's College Hospital, London, United Kingdom
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; and
| | - Ho Lim Pak
- Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Antonio Valentin
- Department of Clinical Neurophysiology, King's College Hospital, London, United Kingdom
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; and
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12
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Zamora M, Meller S, Kajin F, Sermon JJ, Toth R, Benjaber M, Dijk DJ, Bogacz R, Worrell GA, Valentin A, Duchet B, Volk HA, Denison T. Case Report: Embedding "Digital Chronotherapy" Into Medical Devices-A Canine Validation for Controlling Status Epilepticus Through Multi-Scale Rhythmic Brain Stimulation. Front Neurosci 2021; 15:734265. [PMID: 34630021 PMCID: PMC8498587 DOI: 10.3389/fnins.2021.734265] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/24/2021] [Indexed: 01/15/2023] Open
Abstract
Circadian and other physiological rhythms play a key role in both normal homeostasis and disease processes. Such is the case of circadian and infradian seizure patterns observed in epilepsy. However, these rhythms are not fully exploited in the design of active implantable medical devices. In this paper we explore a new implantable stimulator that implements chronotherapy as a feedforward input to supplement both open-loop and closed-loop methods. This integrated algorithm allows for stimulation to be adjusted to the ultradian, circadian and infradian patterns observed in patients through slowly-varying temporal adjustments of stimulation and algorithm sub-components, while also enabling adaption of stimulation based on immediate physiological needs such as a breakthrough seizure or change of posture. Embedded physiological sensors in the stimulator can be used to refine the baseline stimulation circadian pattern as a "digital zeitgeber," i.e., a source of stimulus that entrains or synchronizes the subject's natural rhythms. This algorithmic approach is tested on a canine with severe drug-resistant idiopathic generalized epilepsy exhibiting a characteristic diurnal pattern correlated with sleep-wake cycles. Prior to implantation, the canine's cluster seizures evolved to status epilepticus (SE) and required emergency pharmacological intervention. The cranially-mounted system was fully-implanted bilaterally into the centromedian nucleus of the thalamus. Using combinations of time-based modulation, thalamocortical rhythm-specific tuning of frequency parameters as well as fast-adaptive modes based on activity, the canine experienced no further SE events post-implant as of the time of writing (7 months). Importantly, no significant cluster seizures have been observed either, allowing the reduction of rescue medication. The use of digitally-enabled chronotherapy as a feedforward signal to augment adaptive neurostimulators could prove a useful algorithmic method in conditions where sensitivity to temporal patterns are characteristics of the disease state, providing a novel mechanism for tailoring a more patient-specific therapy approach.
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Affiliation(s)
- Mayela Zamora
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
| | - Sebastian Meller
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hanover, Germany
| | - Filip Kajin
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hanover, Germany
| | - James J. Sermon
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
- MRC Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Robert Toth
- MRC Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Moaad Benjaber
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
- MRC Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Derk-Jan Dijk
- Surrey Sleep Research Centre, University of Surrey, Guildford, United Kingdom
- UK Dementia Research Institute, Care Research and Technology Centre, Imperial College London and The University of Surrey, Guildford, United Kingdom
| | - Rafal Bogacz
- MRC Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | | | - Antonio Valentin
- Department of Clinical Neurophysiology, King's College Hospital NHS Trust, London, United Kingdom
| | - Benoit Duchet
- MRC Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Holger A. Volk
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hanover, Germany
| | - Timothy Denison
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
- MRC Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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13
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Sohanian Haghighi H, Markazi AHD. Control of epileptic seizures by electrical stimulation: a model-based study. Biomed Phys Eng Express 2021; 7. [PMID: 34488206 DOI: 10.1088/2057-1976/ac240d] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 09/06/2021] [Indexed: 11/12/2022]
Abstract
High frequency electrical stimulation of brain is commonly used in research experiments and clinical trials as a modern tool for control of epileptic seizures. However, the mechanistic basis by which periodic external stimuli alter the brain state is not well understood. This study provides a computational insight into the mechanism of seizure suppression by high frequency stimulation (HFS). In particular, a modified version of the Jansen-Rit neural mass model is employed, in which EEG signals can be considered as the input. The proposed model reproduces seizure-like activity in the output during the ictal period of the input signal. By applying a control signal to the model, a wide range of stimulation amplitudes and frequencies are systematically explored. Simulation results reveal that HFS can effectively suppress the seizure-like activity. Our results suggest that HFS has the ability of shifting the operating state of neural populations away from a critical condition. Furthermore, a closed-loop control strategy is proposed in this paper. The main objective has been to considerably reduce the control effort needed for blocking abnormal activity of the brain. Such an energy reduction could be of practical importance, to reduce possible side effects and increase battery life for implanted neurostimulators.
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Affiliation(s)
| | - Amir H D Markazi
- 1School of Mechanical Engineering, Iran University of Science and Technology, Tehran 16844, Iran
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14
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Martin RA, Cukiert A, Blumenfeld H. Short-term changes in cortical physiological arousal measured by electroencephalography during thalamic centromedian deep brain stimulation. Epilepsia 2021; 62:2604-2614. [PMID: 34405892 DOI: 10.1111/epi.17042] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/03/2021] [Accepted: 08/03/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The intralaminar thalamus is well implicated in the processes of arousal and attention. Stimulation of the intralaminar thalamus has been used therapeutically to improve level of alertness in minimally conscious individuals and to reduce seizures in refractory epilepsy, both presumably through modulation of thalamocortical function. Little work exists that directly measures the effects of intralaminar thalamic stimulation on cortical physiological arousal in humans. Therefore, our goal was to quantify cortical physiological arousal in individuals with epilepsy receiving thalamic intralaminar deep brain stimulation. METHODS We recorded scalp electroencephalogram (EEG) during thalamic intralaminar centromedian (CM) nucleus stimulation in 11 patients with medically refractory epilepsy. Participants underwent stimulation at 130 Hz and 300 µs for periods of 5 min alternating with 5 min of rest while stimulus voltage was titrated upward from 1 to 5 V. EEG signal power was analyzed in different frequency ranges in relation to stimulus strength and time. RESULTS We found a progressive increase in broadband gamma (25-100 Hz) cortical EEG power (F = 7.64, p < .05) and decrease in alpha (8-13 Hz) power (F = 4.37, p < .05) with thalamic CM stimulation. Topographic maps showed these changes to be widely distributed across the cortical surface rather than localized to one region. SIGNIFICANCE Previous work has shown that broadband increases in gamma frequency power and decreases in alpha frequency power are generally associated with states of cortical activation and increased arousal/attention. Our observed changes therefore support the possible role of cortical activation and increased physiological arousal in therapeutic effects of intralaminar thalamic stimulation for improving both epilepsy and attention. Further investigations with this approach may lead to methods for determining optimal deep brain stimulation parameters to improve clinical outcome in these disorders.
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Affiliation(s)
- Reese A Martin
- Yale Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Hal Blumenfeld
- Yale Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA.,Yale Department of Neuroscience, Yale University School of Medicine, New Haven, Connecticut, USA.,Yale Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
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15
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Yang JC, Harid NM, Nascimento FA, Kokkinos V, Shaughnessy A, Lam AD, Westover MB, Leslie-Mazwi TM, Hochberg LR, Rosenthal ES, Cole AJ, Richardson RM, Cash SS. Responsive neurostimulation for focal motor status epilepticus. Ann Clin Transl Neurol 2021; 8:1353-1361. [PMID: 33955717 PMCID: PMC8164849 DOI: 10.1002/acn3.51318] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/09/2021] [Accepted: 01/25/2021] [Indexed: 12/12/2022] Open
Abstract
No clear evidence‐based treatment paradigm currently exists for refractory and super‐refractory status epilepticus, which can result in significant mortality and morbidity. While patients are typically treated with antiepileptic drugs and anesthetics, neurosurgical neuromodulation techniques can also be considered. We present a novel case in which responsive neurostimulation was used to effectively treat a patient who had developed super‐refractory status epilepticus, later consistent with epilepsia partialis continua, that was refractory to antiepileptic drugs, immunomodulatory therapies, and transcranial magnetic stimulation. This case demonstrates how regional therapy provided by responsive neurostimulation can be effective in treating super‐refractory status epilepticus through neuromodulation of seizure networks.
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Affiliation(s)
- Jimmy C Yang
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nitish M Harid
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Fábio A Nascimento
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vasileios Kokkinos
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Abigail Shaughnessy
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alice D Lam
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Thabele M Leslie-Mazwi
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Leigh R Hochberg
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andrew J Cole
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert M Richardson
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sydney S Cash
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, Massachusetts, USA
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16
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Low frequency centromedian thalamic nuclei deep brain stimulation for the treatment of super refractory status epilepticus: A case report and a review of the literature. Brain Stimul 2020; 14:226-229. [PMID: 33388465 DOI: 10.1016/j.brs.2020.12.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 11/26/2020] [Accepted: 12/28/2020] [Indexed: 11/21/2022] Open
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17
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Deep brain stimulation for the treatment of refractory and super-refractory status epilepticus. Seizure 2020; 81:58-62. [DOI: 10.1016/j.seizure.2020.07.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 02/06/2023] Open
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18
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Trinka E, Brigo F. Neurostimulation in the treatment of refractory and super-refractory status epilepticus. Epilepsy Behav 2019; 101:106551. [PMID: 31676239 DOI: 10.1016/j.yebeh.2019.106551] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 09/07/2019] [Indexed: 01/28/2023]
Abstract
Status epilepticus (SE) is a life-threatening condition with a mortality of up to 60% in the advanced and comatose forms of SE. In one out of five adults, first and second line fails to control epileptic activity, leading to refractory status epilepticus (RSE) and in around 3% to super-refractory status epilepticus (SRSE), where SE continues despite anesthetic treatment for 24 h or more. In this rare but devastating condition, innovative and safe treatments are needed. In a recent review on the use of vagal nerve stimulation in RSE and SRSE, a 74% response rate for abrogation of SE was reported. Here, we review the currently available evidence supporting the use of neurostimulation, including vagal nerve stimulation, direct cortical stimulation, transcranial magnetic stimulation, electroconvulsive therapy, and deep brain stimulation in RSE and SRSE. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".
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Affiliation(s)
- Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria; Center for Cognitive Neuroscience, Salzburg, Austria; Public Health, Health Services Research and HTA, University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria.
| | - Francesco Brigo
- Department of Neuroscience, Biomedicine and Movement, University of Verona, Italy; Department of Neurology, Franz Tappeiner Hospital, Merano, Italy
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19
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Zhou JJ, Chen T, Farber SH, Shetter AG, Ponce FA. Open-loop deep brain stimulation for the treatment of epilepsy: a systematic review of clinical outcomes over the past decade (2008-present). Neurosurg Focus 2019; 45:E5. [PMID: 30064324 DOI: 10.3171/2018.5.focus18161] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The field of deep brain stimulation (DBS) for epilepsy has grown tremendously since its inception in the 1970s and 1980s. The goal of this review is to identify and evaluate all studies published on the topic of open-loop DBS for epilepsy over the past decade (2008 to present). METHODS A PubMed search was conducted to identify all articles reporting clinical outcomes of open-loop DBS for the treatment of epilepsy published since January 1, 2008. The following composite search terms were used: ("epilepsy" [MeSH] OR "seizures" [MeSH] OR "kindling, neurologic" [MeSH] OR epilep* OR seizure* OR convuls*) AND ("deep brain stimulation" [MeSH] OR "deep brain stimulation" OR "DBS") OR ("electric stimulation therapy" [MeSH] OR "electric stimulation therapy" OR "implantable neurostimulators" [MeSH]). RESULTS The authors identified 41 studies that met the criteria for inclusion. The anterior nucleus of the thalamus, centromedian nucleus of the thalamus, and hippocampus were the most frequently evaluated targets. Among the 41 articles, 19 reported on stimulation of the anterior nucleus of the thalamus, 6 evaluated stimulation of the centromedian nucleus of the thalamus, and 9 evaluated stimulation of the hippocampus. The remaining 7 articles reported on the evaluation of alternative DBS targets, including the posterior hypothalamus, subthalamic nucleus, ventral intermediate nucleus of the thalamus, nucleus accumbens, caudal zone incerta, mammillothalamic tract, and fornix. The authors evaluated each study for overall epilepsy response rates as well as adverse events and other significant, nonepilepsy outcomes. CONCLUSIONS Level I evidence supports the safety and efficacy of stimulating the anterior nucleus of the thalamus and the hippocampus for the treatment of medically refractory epilepsy. Level III and IV evidence supports stimulation of other targets for epilepsy. Ongoing research into the efficacy, adverse effects, and mechanisms of open-loop DBS continues to expand the knowledge supporting the use of these treatment modalities in patients with refractory epilepsy.
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20
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Sa M, Singh R, Pujar S, D'Arco F, Desai N, Eltze C, Hughes E, Al Obaidi M, Eleftheriou D, Tisdall M, Selway R, Cross JH, Kaliakatsos M, Valentin A. Centromedian thalamic nuclei deep brain stimulation and Anakinra treatment for FIRES - Two different outcomes. Eur J Paediatr Neurol 2019; 23:749-754. [PMID: 31446001 DOI: 10.1016/j.ejpn.2019.08.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/28/2019] [Accepted: 08/01/2019] [Indexed: 12/25/2022]
Abstract
Febrile infection-related epilepsy syndrome (FIRES) is a severe epilepsy disorder that affects previously healthy children. It carries high likelihood of unfavourable outcome and putative aetiology relates to an auto-inflammatory process. Standard antiepileptic drug therapies including intravenous anaesthetic agents are largely ineffective in controlling status epilepticus in FIRES. Deep brain stimulation of the centromedian thalamic nuclei (CMN-DBS) has been previously used in refractory status epilepticus in only a few cases. The use of Anakinra (a recombinant version of the human interleukin-1 receptor antagonist) has been reported in one case with FIRES with good outcome. Here we describe two male paediatric patients with FIRES unresponsive to multiple anti-epileptic drugs, first-line immune modulation, ketogenic diet and cannabidiol. They both received Anakinra and underwent CMN-DBS. The primary aim for CMN-DBS therapy was to reduce generalized seizures. CMN-DBS abolished generalized seizures in both cases and Anakinra had a positive effect in one. This patient had a favourable outcome whereas the other did not. These are the first reported cases of FIRES where CMN-DBS has been used.
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Affiliation(s)
- Mario Sa
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Rinki Singh
- Department of Clinical Neurophysiology, King's College Hospital NHS Trust, London, UK
| | - Suresh Pujar
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Felice D'Arco
- Department of Neuroradiology, Great Ormond Street Hospital for Children, London, UK
| | - Nivedita Desai
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Christin Eltze
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Elaine Hughes
- Department of Paediatric Neurology, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Muthana Al Obaidi
- Department of Paediatric Rheumatology, Great Ormond Street Hospital for Children, London, UK
| | - Despina Eleftheriou
- Infection, Immunity and Rheumatology Section, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Martin Tisdall
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK
| | - Richard Selway
- Department of Neurosurgery, King's College Hospital NHS Trust, London, UK
| | - J Helen Cross
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK; Clinical Neurosciences, University College London NIHR BRC Great Ormond Street Institute of Child Health, London, UK
| | - Marios Kaliakatsos
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK.
| | - Antonio Valentin
- Department of Clinical Neurophysiology, King's College Hospital NHS Trust, London, UK
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21
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Zangiabadi N, Ladino LD, Sina F, Orozco-Hernández JP, Carter A, Téllez-Zenteno JF. Deep Brain Stimulation and Drug-Resistant Epilepsy: A Review of the Literature. Front Neurol 2019; 10:601. [PMID: 31244761 PMCID: PMC6563690 DOI: 10.3389/fneur.2019.00601] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 05/21/2019] [Indexed: 01/08/2023] Open
Abstract
Introduction: Deep brain stimulation is a safe and effective neurointerventional technique for the treatment of movement disorders. Electrical stimulation of subcortical structures may exert a control on seizure generators initiating epileptic activities. The aim of this review is to present the targets of the deep brain stimulation for the treatment of drug-resistant epilepsy. Methods: We performed a structured review of the literature from 1980 to 2018 using Medline and PubMed. Articles assessing the impact of deep brain stimulation on seizure frequency in patients with DRE were selected. Meta-analyses, randomized controlled trials, and observational studies were included. Results: To date, deep brain stimulation of various neural targets has been investigated in animal experiments and humans. This article presents the use of stimulation of the anterior and centromedian nucleus of the thalamus, hippocampus, basal ganglia, cerebellum and hypothalamus. Anterior thalamic stimulation has demonstrated efficacy and there is evidence to recommend it as the target of choice. Conclusion: Deep brain stimulation for seizures may be an option in patients with drug-resistant epilepsy. Anterior thalamic nucleus stimulation could be recommended over other targets.
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Affiliation(s)
- Nasser Zangiabadi
- Shefa Neuroscience Research Center, Khatam Alanbia Hospital, Tehran, Iran
- Neuroscience Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Lady Diana Ladino
- Epilepsy Program, Hospital Pablo Tobón Uribe, Neuroclinica, University of Antioquia, Medellín, Colombia
| | - Farzad Sina
- Department of Neurology, Rasool Akram Hospital, IUMS, Tehran, Iran
| | - Juan Pablo Orozco-Hernández
- Departamento de Investigación Clínica, Facultad de Ciencias de la Salud, Universidad Tecnológica de Pereira-Clínica Comfamiliar, Pereira, Colombia
| | - Alexandra Carter
- Saskatchewan Epilepsy Program, Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
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22
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San-Juan D, Dávila-Rodríguez DO, Jiménez CR, González MS, Carranza SM, Hernández Mendoza JR, Anschel DJ. Neuromodulation techniques for status epilepticus: A review. Brain Stimul 2019; 12:835-844. [PMID: 31053521 DOI: 10.1016/j.brs.2019.04.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 04/05/2019] [Accepted: 04/14/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Electroconvulsive therapy (ECT), Vagal Nerve Stimulation (VNS), Transcranial Magnetic Stimulation (TMS) and Deep Brain Stimulation (DBS) are neuromodulation therapies that have been used to treat Status Epilepticus (SE). OBJECTIVE Review the literature about the efficacy and safety of neuromodulation therapies in SE in humans. METHODS We searched studies in PubMed, Scopus, Google Scholar and Science Direct (inception to June 2018). Four review authors independently selected the studies, extracted data and assessed the methodological quality of the studies using the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions, PRISMA guidelines, Oxford and GRADE scales, and Murad et al., 2018 methodological quality and synthesis of case series and case reports. RESULTS We analyzed 27 articles (45 patients) with 4 different neuromodulation therapies. In ECT we found 80% rate of disruption of SE and 5% of adverse events was reported. Using iVNS 15/16 (93.7%) patients resolved the SE. All patients who underwent TMS and DBS aborted SE, however, 50% of patients with DBS had severe adverse events. CONCLUSIONS Case series and case reports suggest that neuromodulation therapies can abort SE in 80-100% of patients (Oxford scale and GRADE were level 4 and D) with a wide range of adverse effects, which claims for prospective studies on the relationship be-tween efficacy and safety.
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Affiliation(s)
- Daniel San-Juan
- Neurophysiology Department, National Institute of Neurology and Neurosurgery Manuel Velasco Suárez, Mexico City, Mexico.
| | | | - Christian Ramos Jiménez
- Faculty of Medicine, Autonomous University of State of Mexico, Toluca de Lerdo, State of Mexico, Mexico
| | | | | | - Jesús Ricardo Hernández Mendoza
- Faculty of Medicine Mexicali, Autonomous University of Baja California, Dr. Humberto Torres Sangines, Mexicali, Baja California, Mexico
| | - David J Anschel
- Comprehensive Epilepsy Center of Long Island, Port Jefferson, NY, USA
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23
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Marawar R, Basha M, Mahulikar A, Desai A, Suchdev K, Shah A. Updates in Refractory Status Epilepticus. Crit Care Res Pract 2018; 2018:9768949. [PMID: 29854452 PMCID: PMC5964484 DOI: 10.1155/2018/9768949] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/19/2018] [Indexed: 01/01/2023] Open
Abstract
Refractory status epilepticus is defined as persistent seizures despite appropriate use of two intravenous medications, one of which is a benzodiazepine. It can be seen in up to 40% of cases of status epilepticus with an acute symptomatic etiology as the most likely cause. New-onset refractory status epilepticus (NORSE) is a recently coined term for refractory status epilepticus where no apparent cause is found after initial testing. A large proportion of NORSE cases are eventually found to have an autoimmune etiology needing immunomodulatory treatment. Management of refractory status epilepticus involves treatment of an underlying etiology in addition to intravenous anesthetics and antiepileptic drugs. Alternative treatment options including diet therapies, electroconvulsive therapy, and surgical resection in case of a focal lesion should be considered. Short-term and long-term outcomes tend to be poor with significant morbidity and mortality with only one-third of patients reaching baseline neurological status.
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Affiliation(s)
- Rohit Marawar
- Department of Neurology, Detroit Medical Center and Wayne State University, Detroit, MI 48201, USA
| | - Maysaa Basha
- Department of Neurology, Detroit Medical Center and Wayne State University, Detroit, MI 48201, USA
| | - Advait Mahulikar
- Department of Neurology, Detroit Medical Center and Wayne State University, Detroit, MI 48201, USA
| | - Aaron Desai
- Department of Neurology, Detroit Medical Center and Wayne State University, Detroit, MI 48201, USA
| | - Kushak Suchdev
- Department of Neurology, Detroit Medical Center and Wayne State University, Detroit, MI 48201, USA
| | - Aashit Shah
- Department of Neurology, Detroit Medical Center and Wayne State University, Detroit, MI 48201, USA
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24
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Epilepsy and Neuromodulation-Randomized Controlled Trials. Brain Sci 2018; 8:brainsci8040069. [PMID: 29670050 PMCID: PMC5924405 DOI: 10.3390/brainsci8040069] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 04/05/2018] [Accepted: 04/16/2018] [Indexed: 11/16/2022] Open
Abstract
Neuromodulation is a treatment strategy that is increasingly being utilized in those suffering from drug-resistant epilepsy who are not appropriate for resective surgery. The number of double-blinded RCTs demonstrating the efficacy of neurostimulation in persons with epilepsy is increasing. Although reductions in seizure frequency is common in these trials, obtaining seizure freedom is rare. Invasive neuromodulation procedures (DBS, VNS, and RNS) have been approved as therapeutic measures. However, further investigations are necessary to delineate effective targeting, minimize side effects that are related to chronic implantation and to improve the cost effectiveness of these devices. The RCTs of non-invasive modes of neuromodulation whilst showing much promise (tDCS, eTNS, rTMS), require larger powered studies as well as studies that focus at better targeting techniques. We provide a review of double-blinded randomized clinical trials that have been conducted for neuromodulation in epilepsy.
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25
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Afshari FT, Michael S, Ughratdar I, Samarasekera S. A practical guide to the use of anti-epileptic drugs by neurosurgeons. Br J Neurosurg 2017; 31:551-556. [PMID: 28480741 DOI: 10.1080/02688697.2017.1324618] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Initiation of anti-epileptic drugs is increasingly relevant to daily neurosurgical practice. Intracranial pathologies ranging from brain tumours to subarachnoid haemorrhage and traumatic brain injury are commonly associated with the subsequent development of seizures. The scope and range of anti-epileptic drugs available has increased dramatically in recent years and understanding the evidence base behind this class of drugs in addition to their interaction/side effect profiles is essential. In this review we aim to generate a practical guide for neurosurgeons regarding the use of different anti-epileptic medications in common neurosurgical conditions, including considerations for their use in pregnancy.
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Affiliation(s)
- Fardad T Afshari
- a Department of Neurosurgery , University Hospitals Birmingham , Birmingham , UK
| | - Sophia Michael
- b Department of Neurology , University Hospitals Birmingham , Birmingham , UK
| | - Ismail Ughratdar
- a Department of Neurosurgery , University Hospitals Birmingham , Birmingham , UK
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Lee CY, Lim SN, Wu T, Lee ST. Successful Treatment of Refractory Status Epilepticus Using Anterior Thalamic Nuclei Deep Brain Stimulation. World Neurosurg 2017; 99:14-18. [DOI: 10.1016/j.wneu.2016.11.097] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 11/16/2016] [Accepted: 11/17/2016] [Indexed: 11/30/2022]
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Lehtimäki K, Långsjö JW, Ollikainen J, Heinonen H, Möttönen T, Tähtinen T, Haapasalo J, Tenhunen J, Katisko J, Öhman J, Peltola J. Successful management of super-refractory status epilepticus with thalamic deep brain stimulation. Ann Neurol 2016; 81:142-146. [DOI: 10.1002/ana.24821] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 11/01/2016] [Accepted: 11/02/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Kai Lehtimäki
- Department of Neurosciences and Rehabilitation; Tampere University Hospital; Tampere Finland
| | | | - Jyrki Ollikainen
- Department of Neurosciences and Rehabilitation; Tampere University Hospital; Tampere Finland
| | - Hanna Heinonen
- Department of Clinical Neurophysiology; Tampere University Hospital; Tampere Finland
| | - Timo Möttönen
- Department of Neurosciences and Rehabilitation; Tampere University Hospital; Tampere Finland
| | - Timo Tähtinen
- Department of Neurosciences and Rehabilitation; Tampere University Hospital; Tampere Finland
| | - Joonas Haapasalo
- Department of Neurosciences and Rehabilitation; Tampere University Hospital; Tampere Finland
| | - Jyrki Tenhunen
- Intensive Care Unit; Uppsala University Hospital; Uppsala Sweden
| | - Jani Katisko
- Department of Neurosurgery; Oulu University Hospital; Oulu Finland
| | - Juha Öhman
- Department of Neurosciences and Rehabilitation; Tampere University Hospital; Tampere Finland
| | - Jukka Peltola
- Department of Neurosciences and Rehabilitation; Tampere University Hospital; Tampere Finland
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Gschwind M, Seeck M. Transcranial direct-current stimulation as treatment in epilepsy. Expert Rev Neurother 2016; 16:1427-1441. [DOI: 10.1080/14737175.2016.1209410] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Gummadavelli A, Kundishora AJ, Willie JT, Andrews JP, Gerrard JL, Spencer DD, Blumenfeld H. Neurostimulation to improve level of consciousness in patients with epilepsy. Neurosurg Focus 2016; 38:E10. [PMID: 26030698 DOI: 10.3171/2015.3.focus1535] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
When drug-resistant epilepsy is poorly localized or surgical resection is contraindicated, current neurostimulation strategies such as deep brain stimulation and vagal nerve stimulation can palliate the frequency or severity of seizures. However, despite medical and neuromodulatory therapy, a significant proportion of patients continue to experience disabling seizures that impair awareness, causing disability and risking injury or sudden unexplained death. We propose a novel strategy in which neuromodulation is used not only to reduce seizures but also to ameliorate impaired consciousness when the patient is in the ictal and postictal states. Improving or preventing alterations in level of consciousness may have an effect on morbidity (e.g., accidents, drownings, falls), risk for death, and quality of life. Recent studies may have elucidated underlying networks and mechanisms of impaired consciousness and yield potential novel targets for neuromodulation. The feasibility, benefits, and pitfalls of potential deep brain stimulation targets are illustrated in human and animal studies involving minimally conscious/vegetative states, movement disorders, depth of anesthesia, sleep-wake regulation, and epilepsy. We review evidence that viable therapeutic targets for impaired consciousness associated with seizures may be provided by key nodes of the consciousness system in the brainstem reticular activating system, hypothalamus, basal ganglia, thalamus, and basal forebrain.
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Affiliation(s)
| | | | - Jon T Willie
- 2Departments of Neurosurgery and Neurology, Emory University School of Medicine, Atlanta, Georgia
| | | | | | | | - Hal Blumenfeld
- Departments of 1Neurosurgery.,3Neurology, and.,4Neurobiology, Yale University School of Medicine, New Haven, Connecticut; and
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Grippe TC, Brasil-Neto JP, Boechat-Barros R, Cunha NS, Oliveira PL. Interruption of Epilepsia Partialis Continua by Transcranial Direct Current Stimulation. Brain Stimul 2015; 8:1227-8. [DOI: 10.1016/j.brs.2015.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 08/10/2015] [Indexed: 12/01/2022] Open
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Deep Brain Stimulation of Thalamic Nuclei for Treatment of Intractable Epilepsy. ARCHIVES OF NEUROSCIENCE 2015. [DOI: 10.5812/archneurosci.22285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Valentin A, Ughratdar I, Cheserem B, Morris R, Selway R, Alarcon G. Epilepsia partialis continua responsive to neocortical electrical stimulation. Epilepsia 2015; 56:e104-9. [PMID: 26174165 DOI: 10.1111/epi.13067] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2015] [Indexed: 11/26/2022]
Abstract
Epilepsia partialis continua (EPC), defined as a syndrome of continuous focal jerking, is a rare form of focal status epilepticus that usually affects a distal limb, and when prolonged, can produce long-lasting deficits in limb function. Substantial electrophysiologic evidence links the origin of EPC to the motor cortex; thus surgical resection carries the risk of significant handicap. We present two patients with focal, drug-resistant EPC, who were admitted for intracranial video-electroencephalography monitoring to elucidate the location of the epileptogenic focus and identification of eloquent motor cortex with functional mapping. In both cases, the focus resided at or near eloquent motor cortex and therefore precluded resective surgery. Chronic cortical stimulation delivered through subdural strips at the seizure focus (continuous stimulation at 60-130 Hz, 2-3 mA) resulted in >90% reduction in seizures and abolition of the EPC after a follow-up of 22 months in both patients. Following permanent implantation of cortical stimulators, no adverse effects were noted. EPC restarted when intensity was reduced or batteries depleted. Battery replacement restored previous improvement. This two-case report opens up avenues for the treatment of this debilitating condition.
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Affiliation(s)
- Antonio Valentin
- Department of Clinical Neurophysiology, King's College Hospital, London, United Kingdom.,Department of Human Physiology, Faculty of Medicine, University Complutense, Madrid, Spain.,Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London, London, United Kingdom
| | - Ismail Ughratdar
- Department of Neurosurgery, King's College Hospital, London, United Kingdom
| | - Beverly Cheserem
- Department of Neurosurgery, King's College Hospital, London, United Kingdom
| | - Robert Morris
- Department of Neurosurgery, Addenbrookes Hospital, Cambridge, United Kingdom
| | - Richard Selway
- Department of Neurosurgery, King's College Hospital, London, United Kingdom
| | - Gonzalo Alarcon
- Department of Clinical Neurophysiology, King's College Hospital, London, United Kingdom.,Department of Human Physiology, Faculty of Medicine, University Complutense, Madrid, Spain.,Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London, London, United Kingdom
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Abstract
Neurostimulation enables adjustable and reversible modulation of disease symptoms, including those of epilepsy. Two types of brain neuromodulation, comprising anterior thalamic deep brain stimulation and responsive neurostimulation at seizure foci, are supported by Class I evidence of effectiveness, and many other sites in the brain have been targeted in small trials of neurostimulation therapy for seizures. Animal studies have mainly assisted in the identification of potential neurostimulation sites and parameters, but much of the clinical work is only loosely based on fundamental principles derived from the laboratory, and the mechanisms by which brain neurostimulation reduces seizures remain poorly understood. The benefits of stimulation tend to increase over time, with maximal effect seen typically 1-2 years after implantation. Typical reductions of seizure frequency are approximately 40% acutely, and 50-69% after several years. Seizure intensity might also be reduced. Complications from brain neurostimulation are mainly associated with the implantation procedure and hardware, including stimulation-related paraesthesias, stimulation-site infections, electrode mistargeting and, in some patients, triggered seizures or even status epilepticus. Further preclinical and clinical experience with brain stimulation surgery should lead to improved outcomes by increasing our understanding of the optimal surgical candidates, sites and parameters.
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Affiliation(s)
- Robert S Fisher
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, 300 Pasteur Drive, Room A343, Stanford, CA 94305-5235, USA
| | - Ana Luisa Velasco
- Clinica de Epilepsia, Hospital General de México OD, Calle Dr. Balmis No. 148, Col. Doctores, Cuauhtémoc, 06726 Mexico City, Mexico
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Abstract
Although status epilepticus (SE) does not resemble a domain for neurosurgical indications in single occasions, a microneurosurgical procedure in patients with catastrophic epilepsy and status epilepticus should be considered as an ultimate ratio-choice in these patients. From a personal series of >600 epilepsy surgery procedures in a period from August 1, 1993 until March 13, 2013, 22 patients were identified with catastrophic epilepsy and all of them with at least one episode of status epilepticus. Five of the patients had surgery under ongoing status epilepticus. Twelve patients became seizure-free, two patients had >90% seizure reduction, seven patients >50% seizure reduction, and one patient was unchanged. No surgery-related complications in terms of permanent morbidity were ascertained in the presented series. In the subgroup of the five patients operated in the acute phase of SE one patient became seizure-free (Engel class. I), one showed Engel class II, two Engel class III, and one Engel class IV with no worthwhile improvement. Patients with catastrophic epilepsy including status epilepticus can benefit from resective epilepsy surgery, even with incomplete resection of the epileptogenic lesion.
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Affiliation(s)
- Peter A Winkler
- Department of Neurosurgery, Christian Doppler Medical Center, Research Laboratory for Microsurgical Neuroanatomy, Paracelsus Medical University of Salzburg, Ignaz Harrerstrasse 79, Salzburg, Austria.
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Hocker S, Wijdicks EFM, Rabinstein AA. Refractory status epilepticus: new insights in presentation, treatment, and outcome. Neurol Res 2012; 35:163-8. [PMID: 23336320 DOI: 10.1179/1743132812y.0000000128] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Refractory status epilepticus (RSE), defined as status epilepticus that fails to respond to the acute administration of two antiepileptic medications, occurs in approximately a third of patients with status epilepticus, and is associated with increased hospital length of stay, mortality, and functional disability. Common presentations include: (1) generalized convulsive status epilepticus or complex partial status epilepticus that continue despite initial therapies; (2) stupor or coma following a generalized convulsive or complex partial seizure; or (3) stupor or coma following brain surgery or acute brain injury. When status epilepticus continues or recurs 24 hours or more after the initiation of anesthetic therapy, or recurs on the reduction or withdrawal of anesthesia, it is termed super RSE. Published evidence on optimal management of RSE consists largely of case reports or small series. The mainstay of treatment is the administration of anesthetic agents titrated to electrographic seizure control. Adjunctive therapies include hypothermia and immunosuppression and less commonly, surgery, electrical stimulation therapies, and induction of ketosis. Patients with cardiopulmonary complications and prolonged duration of drug-induced coma tend to have worse post-treatment functional outcomes. However, significant improvement over time can occur in survivors, and thus treatment is justified even in patients who require prolonged anesthetic coma. The strongest predictors of outcome are duration of anesthetic coma, etiology, and development of cardiopulmonary complications.
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Affiliation(s)
- Sara Hocker
- Depatment of Neurology, Mayo Clinic, Rochester, MN 55905, USA.
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Abstract
Deep brain stimulation (DBS) is a method of treatment utilized to control medically refractory epilepsy (RE). Patients with medically refractory epilepsy who do not achieve satisfactory control of seizures with pharmacological treatment or surgical resection of the epileptic focus and those who do not qualify for surgery could benefit from DBS. The most frequently used stereotactic targets for DBS are the anterior thalamic nucleus, subthalamic nucleus, central-medial thalamic nucleus, hippocampus, amygdala and cerebellum. The DBS is believed to be an effective method of treatment for various types of epilepsy among adults and adolescents. Side effects may be associated with implantation of electrodes and with the stimulation itself. An increasing number of publications and growing interest in DBS application for RE may result in standardization of the qualification and treatment protocol for RE with DBS.
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Affiliation(s)
- Tomasz Tykocki
- Department of Neurosurgery, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Tomasz Mandat
- Department of Neurosurgery, Institute of Oncology, Warsaw, Poland
| | | | - Henryk Koziara
- Department of Neurosurgery, Institute of Oncology, Warsaw, Poland
| | - Paweł Nauman
- Department of Neurosurgery, Institute of Psychiatry and Neurology, Warsaw, Poland
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