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Sobstyl M, Kożuch N, Iwaniuk-Gugała M, Stapińska-Syniec A, Konopko M, Jezierski P. Deep brain stimulation in a patient with progressive myoclonic epilepsy and ataxia due to potassium channel mutation (MEAK). A case report and review of the literature. Epilepsy Behav Rep 2023; 24:100627. [PMID: 37928363 PMCID: PMC10624572 DOI: 10.1016/j.ebr.2023.100627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/05/2023] [Accepted: 10/10/2023] [Indexed: 11/07/2023] Open
Abstract
Progressive myoclonic epilepsy (PME) is characterized by prominent myoclonus, generalized tonic-clonic seizures, and less often focal, tonic, or absence seizures. The KCNC1 mutation is responsible for specific clinical phenotype of PME which has been defined as myoclonic epilepsy and ataxia due to potassium channel mutation (MEAK). We present a case of a 44 years-old male patient with genetically proven MEAK who underwent subthalamic nucleus/substantia nigra (STN/SNr) deep brain stimulation (DBS) for his pharmacological-refractory myoclonus and drug-resistant epilepsy (DRE). Since the age of 4-5 years, the patient had been suffering from intention tremor, and later the myoclonic jerks, ataxia involving the upper limbs and walking difficulties worsened. The first bilateral tonic-clonic seizure (BTCS) occurred at the age of 22. The patient agreed to staged bilateral implantation of DBS electrodes placed in the STN/SNr region. The follow-up lasts more than 24 months. The myoclonic jerks assessed by Unified Myoclonus Rating Scale (UMRS) were reduced by nearly 70 % and BTCS was completely abolished. The patient's ataxia and dysarthria did not improve. Early diagnosis with genetic testing may significantly help in counseling patients with PME and enables to undertake the surgical approach targeting the STN/SNr.
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Affiliation(s)
- Michał Sobstyl
- Department of Neurosurgery, Institute of Psychiatry and Neurology, Sobieskiego 9 Street 02-957, Warsaw, Poland
| | - Nina Kożuch
- 1st Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9 Street, 02-957 Warsaw, Poland
| | - Magdalena Iwaniuk-Gugała
- 1st Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9 Street, 02-957 Warsaw, Poland
| | - Angelika Stapińska-Syniec
- Department of Neurosurgery, Institute of Psychiatry and Neurology, Sobieskiego 9 Street 02-957, Warsaw, Poland
| | - Magdalena Konopko
- 1st Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9 Street, 02-957 Warsaw, Poland
| | - Paweł Jezierski
- 1st Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9 Street, 02-957 Warsaw, Poland
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Cui Z, Wang J, Mao Z, Ling Z, Zhang J, Chen T. Long-term efficacy of deep brain stimulation of the subthalamic nucleus in patients with pharmacologically intractable epilepsy: A case series of six patients. Epileptic Disord 2023; 25:712-723. [PMID: 37518904 DOI: 10.1002/epd2.20129] [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: 11/17/2022] [Revised: 06/14/2023] [Accepted: 07/10/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVE Epilepsy is one of the widespread neurological illnesses, and about 20%-40% of epilepsy patients are pharmacoresistant. We aimed to assess the long-term efficacy of subthalamic nucleus (STN) deep brain stimulation (DBS) for drug-resistant epilepsy. METHODS We included pharmacologically intractable epilepsy patients who had STN-DBS at the Chinese People's Liberation Army General Hospital between June 2016 and December 2018. We retrospectively evaluated pre- and postoperative clinical outcomes, including seizure frequency, seizure type, anti-seizure medication, cognitive function, anatomical target coordinates, stimulation parameters, and adverse events following the surgical procedure. Six patients with a mean follow-up of 49.3 ± 10.2 months, were included. RESULTS Seizure frequency decreased by an average of 64.0% after STN-DBS at last year follow-up (p = .046), and one patient (1/6) achieved seizure-free status. For seizure type, anti-seizure medication, and cognitive function, there were no significant differences between pre-and post-operation (p > .05). In terms of stimulation parameters, the pulse width, amplitude, and frequency were 58.3 ± 9.4 μs, 2.5 ± .7 V, and 122.5 ± 15.7 Hz, respectively. None of the patients showed normal electroencephalography during the electroencephalography reexamination. There were no surgery-related complications, and chronic STN stimulation was generally well tolerated in five patients. However, one patient (1/6) had a difficulty of dyskinesia in the right arm. SIGNIFICANCE In conclusion, neuromodulation of the STN by DBS is a promising option for patients with pharmacologically intractable epilepsy, especially for whose epileptic zone originates mainly from the frontoparietal region and who are unsuitable for resective surgery. Further prospective multicenter studies with a larger sample size are necessary for further exploration.
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Affiliation(s)
- Zhiqiang Cui
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Jian Wang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Zhiqi Mao
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Zhipei Ling
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Jianning Zhang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Tong Chen
- Department of Neurology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
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Yan H, Ren L, Yu T. Deep brain stimulation of the subthalamic nucleus for epilepsy. Acta Neurol Scand 2022; 146:798-804. [PMID: 36134756 DOI: 10.1111/ane.13707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/04/2022] [Indexed: 12/16/2022]
Abstract
Deep brain stimulation of the subthalamic nucleus (STN-DBS) is a promising palliative option for patients with refractory epilepsy. However, crucial questions remain unanswered: Which patients are the optimal candidates? How, where, and when to stimulate the STN? And what is the mechanism of STN-DBS action on epilepsy? Thus, we reviewed the clinical evidence on the antiepileptic effects of STN-DBS and its possible mechanisms on drug-resistant epilepsy, its safety, and the factors influencing stimulation outcomes. This information may guide clinical decision-making. In addition, based on the current knowledge on the effect of STN-DBS on epilepsy, we suggest research that needs to be carried out in the future.
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Affiliation(s)
- Hao Yan
- Department of Functional Neurosurgery, Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Liankun Ren
- Department of Neurology, Comprehensive Epilepsy Center of Beijing, Beijing Key Laboratory of Neuromodulation, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tao Yu
- Department of Functional Neurosurgery, Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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Khan M, Paktiawal J, Piper RJ, Chari A, Tisdall MM. Intracranial neuromodulation with deep brain stimulation and responsive neurostimulation in children with drug-resistant epilepsy: a systematic review. J Neurosurg Pediatr 2022; 29:208-217. [PMID: 34678764 DOI: 10.3171/2021.8.peds21201] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/02/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In children with drug-resistant epilepsy (DRE), resective, ablative, and disconnective surgery may not be feasible or may fail. Neuromodulation in the form of deep brain stimulation (DBS) and responsive neurostimulation (RNS) may be viable treatment options, however evidence for their efficacies in children is currently limited. This systematic review aimed to summarize the literature on DBS and RNS for the treatment of DRE in the pediatric population. Specifically, the authors focused on currently available data for reported indications, neuromodulation targets, clinical efficacy, and safety outcomes. METHODS PRISMA guidelines were followed throughout this systematic review (PROSPERO no. CRD42020180669). Electronic databases, including PubMed, Embase, Cochrane Library, OpenGrey, and CINAHL Plus, were searched from their inception to February 19, 2021. Inclusion criteria were 1) studies with at least 1 pediatric patient (age < 19 years) who underwent DBS and/or RNS for DRE; and 2) retrospective, prospective, randomized, or nonrandomized controlled studies, case series, and case reports. Exclusion criteria were 1) letters, commentaries, conference abstracts, and reviews; and 2) studies without full text available. Risk of bias of the included studies was assessed using the Cochrane ROBINS-I (Risk of Bias in Non-randomised Studies - of Interventions) tool. RESULTS A total of 35 studies were selected that identified 72 and 46 patients who underwent DBS and RNS, respectively (age range 4-18 years). Various epilepsy etiologies and seizure types were described in both cohorts. Overall, 75% of patients had seizure reduction > 50% after DBS (among whom 6 were seizure free) at a median (range) follow-up of 14 (1-100) months. In an exploratory univariate analysis of factors associated with favorable response, the follow-up duration was shorter in those patients with a favorable response (18 vs 33 months, p < 0.05). In the RNS cohort, 73.2% of patients had seizure reduction > 50% after RNS at a median (range) follow-up of 22 (5-39) months. On closer inspection, 83.3% of patients who had > 50% reduction in seizures actually had > 75% reduction, with 4 patients being seizure free. CONCLUSIONS Overall, both DBS and RNS showed favorable response rates, indicating that both techniques should be considered for pediatric patients with DRE. However, serious risks of overall bias were found in all included studies. Many research needs in this area would be addressed by conducting high-quality clinical trials and establishing an international registry of patients who have undergone pediatric neuromodulation, thereby ensuring robust prospective collection of predictive variables and outcomes.
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Affiliation(s)
- Mehdi Khan
- 1University College London Medical School, London, United Kingdom
- 3Department of Neurosurgery, Great Ormond Street Hospital, London, United Kingdom; and
| | - Jaber Paktiawal
- 2Medical University Pleven, Pleven, Bulgaria
- 3Department of Neurosurgery, Great Ormond Street Hospital, London, United Kingdom; and
| | - Rory J Piper
- 3Department of Neurosurgery, Great Ormond Street Hospital, London, United Kingdom; and
- 4Developmental Neuroscience, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Aswin Chari
- 3Department of Neurosurgery, Great Ormond Street Hospital, London, United Kingdom; and
- 4Developmental Neuroscience, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Martin M Tisdall
- 3Department of Neurosurgery, Great Ormond Street Hospital, London, United Kingdom; and
- 4Developmental Neuroscience, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
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de Oliveira TVHF, Cukiert A. Deep Brain Stimulation for Treatment of Refractory Epilepsy. Neurol India 2021; 68:S268-S277. [PMID: 33318361 DOI: 10.4103/0028-3886.302454] [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] [Indexed: 11/04/2022]
Abstract
Deep brain stimulation (DBS) has been used in the treatment of motor diseases with remarkable safety and efficacy, which abet the interest of its application in the management of other neurologic and psychiatric disorders such as epilepsy. Experimental data demonstrated that electric current could modulate distinct brain circuits and decrease the neuronal hypersynchronization seen in epileptic activity. The ability to carefully choose the most suitable anatomical target as well as to define the most reasonable stimulation parameters is highly dependable on the comprehension of the underlying mechanisms of action, which remain unclear. This review aimed to explore the relevant clinical data regarding the use of DBS in the treatment of refractory epilepsy.
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Affiliation(s)
| | - Arthur Cukiert
- Department of Neurosurgery, Epilepsy Surgery Program, Clínica Cukiert, São Paulo, Brazil
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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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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: 99] [Impact Index Per Article: 19.8] [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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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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Li MCH, Cook MJ. Deep brain stimulation for drug-resistant epilepsy. Epilepsia 2017; 59:273-290. [PMID: 29218702 DOI: 10.1111/epi.13964] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To review clinical evidence on the antiepileptic effects of deep brain stimulation (DBS) for drug-resistant epilepsy, its safety, and the factors influencing individual outcomes. METHODS A comprehensive search of the medical literature (PubMed, Medline) was conducted to identify relevant articles investigating DBS therapy for drug-resistant epilepsy. Reference lists of these articles were used to source further articles. RESULTS Stimulation of the anterior nucleus of the thalamus (ANT) and hippocampus (HC) has been shown to decrease the frequency of refractory seizures. Half of all patients from clinical studies experienced a 46%-90% seizure reduction with ANT-DBS, and a 48%-95% seizure reduction with HC-DBS. The efficacy of stimulating other targets remains inconclusive due to lack of evidence. Approximately three-fourths of patients receiving ANT, HC, or centromedian nucleus of the thalamus (CMT) stimulation are responders-experiencing a seizure reduction of at least 50%. The time course of clinical benefit varies dramatically, with both an initial lesional effect and ongoing stimulation effect at play. Improved quality of life and changes to cognition or mood may also occur. Side effects are similar in nature to those reported from DBS therapy for movement disorders. Several factors are potentially associated with stimulation efficacy, including an absence of structural abnormality on imaging for ANT and HC stimulation, and electrode position relative to the target. Certain seizure types or syndromes may respond more favorably to specific targets, including ANT stimulation for deep temporal or limbic seizures, and CMT stimulation for generalized seizures and Lennox-Gastaut syndrome. SIGNIFICANCE We have identified several patient, disease, and stimulation factors that potentially predict seizure outcome following DBS. More large-scale clinical trials are needed to explore different stimulation parameters, reevaluate the indications for DBS, and identify robust predictors of patient response.
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Affiliation(s)
- Michael C H Li
- The Graeme Clark Institute, University of Melbourne, Parkville, Vic., Australia
| | - Mark J Cook
- The Graeme Clark Institute, University of Melbourne, Parkville, Vic., Australia
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Abstract
The revolution in theory, swift technological developments, and invention of new devices have driven tremendous progress in neurostimulation as a third‐line treatment for epilepsy. Over the past decades, neurostimulation took its place in the field of epilepsy as an advanced treatment technique and opened up a new world. Numerous animal studies have proven the physical efficacy of stimulation of the brain and peripheral nerves. Based on this optimistic fundamental research, new advanced techniques are being explored in clinical practice. Over the past century, drawing on the benefits brought about by vagus nerve stimulation for the treatment of epilepsy, various new neurostimulation modalities have been developed to control seizures. Clinical studies including case reports, case series, and clinical trials have been booming in the past several years. This article gives a comprehensive review of most of these clinical studies. In addition to highlighting the advantages of neurostimulation for the treatment of epilepsy, concerns with this modality and future development directions are also discussed. The biggest advantage of neurostimulation over pharmacological treatments for epilepsy is the modulation of the epilepsy network by delivering stimuli at a specific target or the “hub.” Conversely, however, a lack of knowledge of epilepsy networks and the mechanisms of neurostimulation may hinder further development. Therefore, theoretical research on the mechanism of epileptogenesis and epilepsy networks is needed in the future. Within the multiple modalities of neuromodulation, the final choice should be made after full discussion with a multidisciplinary team at a presurgical conference. Furthermore, the establishment of a neurostimulation system with standardized parameters and rigorous guidelines is another important issue. To achieve this goal, a worldwide collaboration of epilepsy centers is also suggested in the future.
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Affiliation(s)
- Yicong Lin
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China.,Beijing Key Laboratory of Neuromodulation Beijing China.,Center of Epilepsy Beijing Institute for Brain Disorders Capital Medical University Beijing China
| | - Yuping Wang
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China.,Beijing Key Laboratory of Neuromodulation Beijing China.,Center of Epilepsy Beijing Institute for Brain Disorders Capital Medical University Beijing China
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Tung JK, Berglund K, Gross RE. Optogenetic Approaches for Controlling Seizure Activity. Brain Stimul 2016; 9:801-810. [PMID: 27496002 PMCID: PMC5143193 DOI: 10.1016/j.brs.2016.06.055] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 06/21/2016] [Accepted: 06/28/2016] [Indexed: 01/01/2023] Open
Abstract
Optogenetics, a technique that utilizes light-sensitive ion channels or pumps to activate or inhibit neurons, has allowed scientists unprecedented precision and control for manipulating neuronal activity. With the clinical need to develop more precise and effective therapies for patients with drug-resistant epilepsy, these tools have recently been explored as a novel treatment for halting seizure activity in various animal models. In this review, we provide a detailed and current summary of these optogenetic approaches and provide a perspective on their future clinical application as a potential neuromodulatory therapy.
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Affiliation(s)
- Jack K Tung
- Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA; Department of Neurosurgery, Emory University, Atlanta, GA
| | - Ken Berglund
- Department of Neurosurgery, Emory University, Atlanta, GA
| | - Robert E Gross
- Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA; Department of Neurosurgery, Emory University, Atlanta, GA.
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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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Unterberger I, Bauer R, Walser G, Bauer G. Corpus callosum and epilepsies. Seizure 2016; 37:55-60. [DOI: 10.1016/j.seizure.2016.02.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 02/01/2016] [Accepted: 02/25/2016] [Indexed: 11/16/2022] Open
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Abstract
In the approximately 1% of children affected by epilepsy, pharmacoresistance and early age of seizure onset are strongly correlated with poor cognitive outcomes, depression, anxiety, developmental delay, and impaired activities of daily living. These children often require multiple surgical procedures, including invasive diagnostic procedures with intracranial electrodes to identify the seizure-onset zone. The recent development of minimally invasive surgical techniques, including stereotactic electroencephalography (SEEG) and MRI-guided laser interstitial thermal therapy (MRgLITT), and new applications of neurostimulation, such as responsive neurostimulation (RNS), are quickly changing the landscape of the surgical management of pediatric epilepsy. In this review, the authors discuss these various technologies, their current applications, and limitations in the treatment of pediatric drug-resistant epilepsy, as well as areas for future research. The development of minimally invasive diagnostic and ablative surgical techniques together with new paradigms in neurostimulation hold vast potential to improve the efficacy and reduce the morbidity of the surgical management of children with drug-resistant epilepsy.
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Affiliation(s)
- Michael Karsy
- 1 Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, USA ; 2 Division of Neurosurgery, University of Vermont, Burlington, USA ; 3 Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, USA
| | - Jian Guan
- 1 Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, USA ; 2 Division of Neurosurgery, University of Vermont, Burlington, USA ; 3 Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, USA
| | - Katrina Ducis
- 1 Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, USA ; 2 Division of Neurosurgery, University of Vermont, Burlington, USA ; 3 Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, USA
| | - Robert J Bollo
- 1 Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, USA ; 2 Division of Neurosurgery, University of Vermont, Burlington, USA ; 3 Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, USA
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Klinger NV, Mittal S. Clinical efficacy of deep brain stimulation for the treatment of medically refractory epilepsy. Clin Neurol Neurosurg 2016; 140:11-25. [DOI: 10.1016/j.clineuro.2015.11.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 10/26/2015] [Accepted: 11/12/2015] [Indexed: 10/22/2022]
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Kocabicak E, Temel Y, Höllig A, Falkenburger B, Tan SK. Current perspectives on deep brain stimulation for severe neurological and psychiatric disorders. Neuropsychiatr Dis Treat 2015; 11:1051-66. [PMID: 25914538 PMCID: PMC4399519 DOI: 10.2147/ndt.s46583] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Deep brain stimulation (DBS) has become a well-accepted therapy to treat movement disorders, including Parkinson's disease, essential tremor, and dystonia. Long-term follow-up studies have demonstrated sustained improvement in motor symptoms and quality of life. DBS offers the opportunity to selectively modulate the targeted brain regions and related networks. Moreover, stimulation can be adjusted according to individual patients' demands, and stimulation is reversible. This has led to the introduction of DBS as a treatment for further neurological and psychiatric disorders and many clinical studies investigating the efficacy of stimulating various brain regions in order to alleviate severe neurological or psychiatric disorders including epilepsy, major depression, and obsessive-compulsive disorder. In this review, we provide an overview of accepted and experimental indications for DBS therapy and the corresponding anatomical targets.
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Affiliation(s)
- Ersoy Kocabicak
- Department of Neurosurgery, Maastricht University Medical Centre, Maastricht, the Netherlands ; Department of Neuroscience, Maastricht University, Maastricht, the Netherlands ; Department of Neurosurgery, Ondokuz Mayıs University, Samsun, Turkey
| | - Yasin Temel
- Department of Neurosurgery, Maastricht University Medical Centre, Maastricht, the Netherlands ; Department of Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Anke Höllig
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | | | - Sonny Kh Tan
- Department of Neuroscience, Maastricht University, Maastricht, the Netherlands ; Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
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Prabhu S, Chabardès S, Sherdil A, Devergnas A, Michallat S, Bhattacharjee M, Mathieu H, David O, Piallat B. Effect of subthalamic nucleus stimulation on penicillin induced focal motor seizures in primate. Brain Stimul 2014; 8:177-84. [PMID: 25511796 DOI: 10.1016/j.brs.2014.10.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 09/13/2014] [Accepted: 10/26/2014] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Drug-resistant motor epilepsies are particularly incapacitating for the patients. In a primate model of focal motor seizures induced by intracortical injection of penicillin, we recently showed that seizures propagated from the motor cortex towards the basal ganglia. OBJECTIVE Using the same animal model here, we hypothesized that disruption of subthalamic nucleus (STN) activity by chronic high frequency stimulation (HFS) could modify pathological excessive cortical synchronisation occurring during focal motor seizures, and therefore could reduce seizure activity. METHODS Two monkeys were chronically implanted with one electrode positioned into the STN. In each experiment, seizures were induced during 6 hours by injecting penicillin into the motor cortex. During stimulation sessions, HFS-STN was applied at the beginning of penicillin injection. RESULTS Our results indicate that HFS-STN improved focal motor seizures by delaying the occurrence of the first seizure, by decreasing the number of seizures by 47% and therefore the total time spent seizing by 53% compared to control. These results argue for a therapeutic use of HFS-STN in motor seizures because they were obtained in a very severe primate model of motor status similar to that seen in human. Furthermore, HFS-STN was much more efficient than direct cortical HFS of the epileptic focus, which we already tested in the same primate model. CONCLUSIONS The present study suggests that HFS-STN could be used as an experimental therapy when other therapeutic strategies are not possible or have failed in humans suffering from motor epilepsy but the present study still warrants controlled studies in humans.
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Affiliation(s)
- S Prabhu
- Univ Grenoble Alpes, GIN, F-38000 Grenoble, France; INSERM, U836, F-38000 Grenoble, France
| | - S Chabardès
- Univ Grenoble Alpes, GIN, F-38000 Grenoble, France; INSERM, U836, F-38000 Grenoble, France; CHU de Grenoble, Hôpital Michallon F-38000 Grenoble, France
| | - A Sherdil
- Univ Grenoble Alpes, GIN, F-38000 Grenoble, France; INSERM, U836, F-38000 Grenoble, France
| | | | | | - M Bhattacharjee
- Univ Grenoble Alpes, GIN, F-38000 Grenoble, France; INSERM, U836, F-38000 Grenoble, France
| | - H Mathieu
- UMS IRMaGe, F-38000 Grenoble, France
| | - O David
- Univ Grenoble Alpes, GIN, F-38000 Grenoble, France; INSERM, U836, F-38000 Grenoble, France
| | - B Piallat
- Univ Grenoble Alpes, GIN, F-38000 Grenoble, France; INSERM, U836, F-38000 Grenoble, France.
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Laxpati NG, Kasoff WS, Gross RE. Deep brain stimulation for the treatment of epilepsy: circuits, targets, and trials. Neurotherapeutics 2014; 11:508-26. [PMID: 24957200 PMCID: PMC4121455 DOI: 10.1007/s13311-014-0279-9] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Deep brain stimulation (DBS) has proven remarkably safe and effective in the treatment of movement disorders. As a result, it is being increasingly applied to a range of neurologic and psychiatric disorders, including medically refractory epilepsy. This review will examine the use of DBS in epilepsy, including known targets, mechanisms of neuromodulation and seizure control, published clinical evidence, and novel technologies. Cortical and deep neuromodulation for epilepsy has a long experimental history, but only recently have better understanding of epileptogenic networks, precise stereotactic techniques, and rigorous trial design combined to improve the quality of available evidence and make DBS a viable treatment option. Nonetheless, underlying mechanisms, anatomical targets, and stimulation parameters remain areas of active investigation.
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Affiliation(s)
- Nealen G. Laxpati
- />Department of Neurosurgery, Emory University School of Medicine, 1365 Clifton Road NE, Atlanta, GA 30322 USA
- />Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA USA
| | - Willard S. Kasoff
- />Division of Neurosurgery, Department of Surgery, University of Arizona, Tucson, AZ USA
| | - Robert E. Gross
- />Department of Neurosurgery, Emory University School of Medicine, 1365 Clifton Road NE, Atlanta, GA 30322 USA
- />Department of Neurology, Emory University School of Medicine, Atlanta, GA USA
- />Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA USA
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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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20
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Cox JH, Seri S, Cavanna AE. Clinical utility of implantable neurostimulation devices as adjunctive treatment of uncontrolled seizures. Neuropsychiatr Dis Treat 2014; 10:2191-200. [PMID: 25484587 PMCID: PMC4238748 DOI: 10.2147/ndt.s60854] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
About one third of patients with epilepsy are refractory to medical treatment. For these patients, alternative treatment options include implantable neurostimulation devices such as vagus nerve stimulation (VNS), deep brain stimulation (DBS), and responsive neurostimulation systems (RNS). We conducted a systematic literature review to assess the available evidence on the clinical efficacy of these devices in patients with refractory epilepsy across their lifespan. VNS has the largest evidence base, and numerous randomized controlled trials and open-label studies support its use in the treatment of refractory epilepsy. It was approved by the US Food and Drug Administration in 1997 for treatment of partial seizures, but has also shown significant benefit in the treatment of generalized seizures. Results in adult populations have been more encouraging than in pediatric populations, where more studies are required. VNS is considered a safe and well-tolerated treatment, and serious side effects are rare. DBS is a well-established treatment for several movement disorders, and has a small evidence base for treatment of refractory epilepsy. Stimulation of the anterior nucleus of the thalamus has shown the most encouraging results, where significant decreases in seizure frequency were reported. Other potential targets include the centromedian thalamic nucleus, hippocampus, cerebellum, and basal ganglia structures. Preliminary results on RNS, new-generation implantable neurostimulation devices which stimulate brain structures only when epileptic activity is detected, are encouraging. Overall, implantable neurostimulation devices appear to be a safe and beneficial treatment option for patients in whom medical treatment has failed to adequately control their epilepsy. Further large-scale randomized controlled trials are required to provide a sufficient evidence base for the inclusion of DBS and RNS in clinical guidelines.
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Affiliation(s)
- Joanna H Cox
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Stefano Seri
- School of Life and Health Sciences, Aston Brain Centre, Aston University, Birmingham, UK ; Children's Epilepsy Surgery Programme, The Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Andrea E Cavanna
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK ; School of Life and Health Sciences, Aston Brain Centre, Aston University, Birmingham, UK ; Department of Neuropsychiatry, Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK ; Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology and UCL, London, UK
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Sillay KA, Rutecki P, Cicora K, Worrell G, Drazkowski J, Shih JJ, Sharan AD, Morrell MJ, Williams J, Wingeier B. Long-Term Measurement of Impedance in Chronically Implanted Depth and Subdural Electrodes During Responsive Neurostimulation in Humans. Brain Stimul 2013; 6:718-26. [DOI: 10.1016/j.brs.2013.02.001] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 02/07/2013] [Accepted: 02/20/2013] [Indexed: 01/22/2023] Open
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Abstract
Deep brain stimulation for seizures has been applied to cerebellum, caudate, locus coeruleus, subthalamic nucleus, mammillary bodies, centromedian thalamus, anterior nucleus of thalamus, hippocampus and amygdala, hippocampal commissure, corpus callosum, neocortex, and occasionally to other sites. Animal and clinical studies have primarily investigated seizure prevention and, to a lessersmaller extent, seizure interruption. No studies have yet shown stimulation able to cure epilepsy. A wide variety of stimulation parameters have been employed in multiple different combinations of frequencies, amplitudes, and durations. Literature review identifies at least 52 clinical studies of brain stimulation for epilepsy in 817 patients. Two studies were large, randomized, and controlled, one in the anterior nucleus of thalamus and another at the cortical or hippocampal seizure focus; both of these studies showed efficacy and tolerability of stimulation. Many questions remain. We do not know the mechanisms, the best stimulation parameters, the best patient population, or how to predict benefit in advance. We do not know why benefit of neurostimulation for epilepsy seems to increase over time or whether there are long-term deleterious effects. All of these questions may be answerable with a combination of laboratory research and clinical experience.
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Affiliation(s)
- Robert S Fisher
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA.
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Taira T, Goto S. Validation and perspectives of neuromodulation in Japan. Neurol Med Chir (Tokyo) 2012; 52:457-62. [PMID: 22850492 DOI: 10.2176/nmc.52.457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Neuromodulation in functional neurosurgery is closely related to the development and availability of devices such as implantable electric stimulators and pumps. All such devices used in Japan are developed and made in foreign countries, and no made-in-Japan device exists. Introduction and approval by the government took many years for most devices, during which time many patients had to continue to live in our medically conservative country. The history of neuromodulation is summarized in Japan and the problems surrounding neuromodulation pointed out. Everyone has to aware of such circumstances and make every effort to improve the internationally unusual situation of neuromodulation in Japan. Otherwise, Japan will become a medically isolated country in the near future.
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Affiliation(s)
- Takaomi Taira
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan.
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