1
|
Samanta D, Aungaroon G, Albert GW, Karakas C, Joshi CN, Singh RK, Oluigbo C, Perry MS, Naik S, Reeders PC, Jain P, Abel TJ, Pati S, Shaikhouni A, Haneef Z. Advancing thalamic neuromodulation in epilepsy: Bridging adult data to pediatric care. Epilepsy Res 2024; 205:107407. [PMID: 38996686 DOI: 10.1016/j.eplepsyres.2024.107407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 06/27/2024] [Accepted: 07/01/2024] [Indexed: 07/14/2024]
Abstract
Thalamic neuromodulation has emerged as a treatment option for drug-resistant epilepsy (DRE) with widespread and/or undefined epileptogenic networks. While deep brain stimulation (DBS) and responsive neurostimulation (RNS) depth electrodes offer means for electrical stimulation of the thalamus in adult patients with DRE, the application of thalamic neuromodulation in pediatric epilepsy remains limited. To address this gap, the Neuromodulation Expert Collaborative was established within the Pediatric Epilepsy Research Consortium (PERC) Epilepsy Surgery Special Interest Group. In this expert review, existing evidence and recommendations for thalamic neuromodulation modalities using DBS and RNS are summarized, with a focus on the anterior (ANT), centromedian(CMN), and pulvinar nuclei of the thalamus. To-date, only DBS of the ANT is FDA approved for treatment of DRE in adult patients based on the results of the pivotal SANTE (Stimulation of the Anterior Nucleus of Thalamus for Epilepsy) study. Evidence for other thalamic neurmodulation indications and targets is less abundant. Despite the lack of evidence, positive responses to thalamic stimulation in adults with DRE have led to its off-label use in pediatric patients. Although caution is warranted due to differences between pediatric and adult epilepsy, the efficacy and safety of pediatric neuromodulation appear comparable to that in adults. Indeed, CMN stimulation is increasingly accepted for generalized and diffuse onset epilepsies, with recent completion of one randomized trial. There is also growing interest in using pulvinar stimulation for temporal plus and posterior quadrant epilepsies with one ongoing clinical trial in Europe. The future of thalamic neuromodulation holds promise for revolutionizing the treatment landscape of childhood epilepsy. Ongoing research, technological advancements, and collaborative efforts are poised to refine and improve thalamic neuromodulation strategies, ultimately enhancing the quality of life for children with DRE.
Collapse
Affiliation(s)
- Debopam Samanta
- Division of Child Neurology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Gewalin Aungaroon
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Gregory W Albert
- Department of Neurosurgery, University of Arkansas for Medical Sciences, USA
| | - Cemal Karakas
- Division of Pediatric Neurology, Department of Neurology, Norton Children's Hospital, University of Louisville, Louisville, KY 40202, USA
| | - Charuta N Joshi
- Division of Pediatric Neurology, Childrens Medical Center Dallas, UTSW, USA
| | - Rani K Singh
- Department of Pediatrics, Atrium Health-Levine Children's; Wake Forest University School of Medicine, USA
| | - Chima Oluigbo
- Department of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - M Scott Perry
- Jane and John Justin Institute for Mind Health, Cook Children's Medical Center, Ft Worth, TX, USA
| | - Sunil Naik
- Department of Pediatrics and Neurology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Puck C Reeders
- Brain Institute, Nicklaus Children's Hospital, Miami, FL, USA
| | - Puneet Jain
- Epilepsy Program, Division of Neurology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh School of Medicine and Department of Bioengineering, University of Pittsburgh
| | - Sandipan Pati
- The University of Texas Health Science Center at Houston, USA
| | - Ammar Shaikhouni
- Department of Pediatric Neurosurgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Zulfi Haneef
- Neurology Care Line, VA Medical Center, Houston, TX 77030, USA; Department of Neurology, Baylor College of Medicine, Houston, TX 77030, USA
| |
Collapse
|
2
|
Li Q, Shan Y, Wei P, Zhao G. The comparison of DBS and RNS for adult drug-resistant epilepsy: a systematic review and meta-analysis. Front Hum Neurosci 2024; 18:1429223. [PMID: 38962148 PMCID: PMC11220164 DOI: 10.3389/fnhum.2024.1429223] [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: 05/07/2024] [Accepted: 06/11/2024] [Indexed: 07/05/2024] Open
Abstract
Objective Neuromodulation has been proven to be a promising alternative treatment for adult patients with drug-resistant epilepsy (DRE). Deep brain stimulation (DBS) and responsive neurostimulation (RNS) were approved by many countries for the treatment of DRE. However, there is a lack of systematic studies illustrating the differences between them. This meta-analysis is performed to assess the efficacy and clinical characteristics of DBS and RNS in adult patients with DRE. Methods PubMed, Web of Science, and Embase were retrieved to obtain related studies including adult DRE patients who accepted DBS or RNS. The clinical characteristics of these patients were compiled for the following statistical analysis. Results A total of 55 studies (32 of DBS and 23 of RNS) involving 1,568 adult patients with DRE were included in this meta-analysis. There was no significant difference in seizure reduction and responder rate between DBS and RNS for DRE. The seizure reduction of DBS and RNS were 56% (95% CI 50-62%, p > 0.05) and 61% (95% CI 54-68%, p > 0.05). The responder rate of DBS and RNS were 67% (95% CI 58-76%, p > 0.05) and 71% (95% CI 64-78%, p > 0.05). Different targets of DBS did not show significant effect on seizure reduction (p > 0.05). Patients with DRE who accepted DBS were younger than those of RNS (32.9 years old vs. 37.8 years old, p < 0.01). The mean follow-up time was 47.3 months for DBS and 39.5 months for RNS (p > 0.05). Conclusion Both DBS and RNS are beneficial and alternative therapies for adult DRE patients who are not eligible to accept resection surgery. Further and larger studies are needed to clarify the characteristics of different targets and provide tailored treatment for patients with DRE.
Collapse
Affiliation(s)
- Qinghua Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yongzhi Shan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Penghu Wei
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Guoguang Zhao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy Capital Medical University, Beijing, China
- Beijing Municipal Geriatric Medical Research Center, Beijing, China
| |
Collapse
|
3
|
Suresh S, Chaitanya G, Kachhvah AD, Vashin V, Saranathan M, Pati S. Case report: Nocturnal low-frequency stimulation of the centromedian thalamic nucleus improves sleep quality and seizure control. Front Hum Neurosci 2024; 18:1392100. [PMID: 38903408 PMCID: PMC11188458 DOI: 10.3389/fnhum.2024.1392100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 05/23/2024] [Indexed: 06/22/2024] Open
Abstract
Sleep disturbances and drug-resistant seizures significantly impact people with idiopathic generalized epilepsy (IGE). Thalamic deep brain stimulation (DBS) offers potential treatment, but its effect on sleep and seizure control needs clarification. In this study, we combined wearable sleep monitoring with electroencephalogram (EEG) confirmation to investigate the impact of nocturnal centromedian nucleus (CM) DBS parameters in a patient with drug-resistant IGE. We found that high-frequency (125 Hz) CM stimulation during sleep severely disrupted sleep macro architecture and exacerbated seizures. Conversely, switching to low-frequency (10 Hz) stimulation enhanced both sleep quality and seizure control. This study underscores the critical need to personalize DBS settings, tailoring them to individual patients' sleep patterns to maximize therapeutic benefits. While larger-scale trials are needed, our findings pave the way for patient-centric approaches to thalamic neuromodulation, offering a transformative path to improve treatment outcomes and quality of life for those with refractory epilepsy.
Collapse
Affiliation(s)
- Surya Suresh
- Department of Neurology, Texas Institute of Restorative Neurotechnologies, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Ganne Chaitanya
- Department of Neurology, Texas Institute of Restorative Neurotechnologies, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Ajay Deep Kachhvah
- Department of Neurology, Texas Institute of Restorative Neurotechnologies, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Vladimir Vashin
- Department of Neurology, Texas Institute of Restorative Neurotechnologies, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Manojkumar Saranathan
- Department of Radiology, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Sandipan Pati
- Department of Neurology, Texas Institute of Restorative Neurotechnologies, The University of Texas Health Science Center at Houston, Houston, TX, United States
| |
Collapse
|
4
|
Warren AEL, Butson CR, Hook MP, Dalic LJ, Archer JS, Macdonald-Laurs E, Schaper FLWVJ, Hart LA, Singh H, Johnson L, Bullinger KL, Gross RE, Morrell MJ, Rolston JD. Targeting thalamocortical circuits for closed-loop stimulation in Lennox-Gastaut syndrome. Brain Commun 2024; 6:fcae161. [PMID: 38764777 PMCID: PMC11099664 DOI: 10.1093/braincomms/fcae161] [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: 09/17/2023] [Revised: 03/26/2024] [Accepted: 05/06/2024] [Indexed: 05/21/2024] Open
Abstract
This paper outlines the therapeutic rationale and neurosurgical targeting technique for bilateral, closed-loop, thalamocortical stimulation in Lennox-Gastaut syndrome, a severe form of childhood-onset epilepsy. Thalamic stimulation can be an effective treatment for Lennox-Gastaut syndrome, but complete seizure control is rarely achieved. Outcomes may be improved by stimulating areas beyond the thalamus, including cortex, but the optimal targets are unknown. We aimed to identify a cortical target by synthesizing prior neuroimaging studies, and to use this knowledge to advance a dual thalamic (centromedian) and cortical (frontal) approach for closed-loop stimulation. Multi-modal brain network maps from three group-level studies of Lennox-Gastaut syndrome were averaged to define the area of peak overlap: simultaneous EEG-functional MRI of generalized paroxysmal fast activity, [18F]fluorodeoxyglucose PET of cortical hypometabolism and diffusion MRI structural connectivity associated with clinical efficacy in a previous trial of thalamic deep brain stimulation. The resulting 'hotspot' was used as a seed in a normative functional MRI connectivity analysis to identify connected networks. Intracranial electrophysiology was reviewed in the first two trial patients undergoing bilateral implantations guided by this hotspot. Simultaneous recordings from cortex and thalamus were analysed for presence and synchrony of epileptiform activity. The peak overlap was in bilateral premotor cortex/caudal middle frontal gyrus. Functional connectivity of this hotspot revealed a distributed network of frontoparietal cortex resembling the diffuse abnormalities seen on EEG-functional MRI and PET. Intracranial electrophysiology showed characteristic epileptiform activity of Lennox-Gastaut syndrome in both the cortical hotspot and thalamus; most detected events occurred first in the cortex before appearing in the thalamus. Premotor frontal cortex shows peak involvement in Lennox-Gastaut syndrome and functional connectivity of this region resembles the wider epileptic brain network. Thus, it may be an optimal target for a range of neuromodulation therapies, including thalamocortical stimulation and emerging non-invasive treatments like focused ultrasound or transcranial magnetic stimulation. Compared to thalamus-only approaches, the addition of this cortical target may allow more rapid detections of seizures, more diverse stimulation paradigms and broader modulation of the epileptic network. A prospective, multi-centre trial of closed-loop thalamocortical stimulation for Lennox-Gastaut syndrome is currently underway.
Collapse
Affiliation(s)
- Aaron E L Warren
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Christopher R Butson
- Normal Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL 32608, USA
| | - Matthew P Hook
- Normal Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL 32608, USA
| | - Linda J Dalic
- University of Melbourne, Parkville, VIC 3052, Australia
- Department of Neurology, Austin Health, Heidelberg, VIC 3084, Australia
| | - John S Archer
- University of Melbourne, Parkville, VIC 3052, Australia
- Department of Neurology, Austin Health, Heidelberg, VIC 3084, Australia
| | - Emma Macdonald-Laurs
- University of Melbourne, Parkville, VIC 3052, Australia
- Department of Neurology, Royal Children’s Hospital, Parkville, VIC 3052, Australia
- Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia
| | - Frederic L W V J Schaper
- Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Lauren A Hart
- Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Hargunbir Singh
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | | | - Katie L Bullinger
- Department of Neurology, Emory University Hospital, Atlanta, GA 30322, USA
| | - Robert E Gross
- Department of Neurosurgery, Emory University Hospital, Atlanta, GA 30322, USA
| | - Martha J Morrell
- NeuroPace, Mountain View, CA 94043, USA
- Department of Neurology and Neurological Science, Stanford University, Palo Alto, CA 94304, USA
| | - John D Rolston
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| |
Collapse
|
5
|
Arredondo K, Ostendorf AP, Ahrens S, Beatty CW, Pindrik J, Shaikhouni A. Post-ictal Rhythmic Thalamic Activity of the Centromedian Nucleus. J Clin Neurophysiol 2024; 41:326-333. [PMID: 36893381 DOI: 10.1097/wnp.0000000000000991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
Abstract
INTRODUCTION Deep brain stimulation of the centromedian nucleus of the thalamus (CMN) to treat drug-resistant epilepsy has been of interest for decades. However, little is known about the electrophysiological activity of the CMN during seizures. We describe a novel CMN EEG finding associated with seizure: post-ictal rhythmic thalamic activity. METHODS Five patients with drug-resistant epilepsy of unknown etiology with focal onset seizures underwent stereoelectroencephalography monitoring as part of evaluation for potential resective surgery or neuromodulation. Two patients had previously undergone complete corpus callosotomy and vagus nerve stimulation. A standardized plan for implantation included targets in the bilateral CMN. RESULTS Each patient had frontal onset seizures, and two patients had additional insular, parietal, or mesial temporal onset seizures. Contacts of CMN were involved synchronously or rapidly after onset in most recorded seizures, particularly those with frontal onset. Focal onset hemiclonic and bilateral tonic-clonic seizures spread to involve cortical contacts with high-amplitude rhythmic spiking followed by abrupt offset with diffuse voltage attenuation. A post-ictal rhythmic 1.5 to 2.5 Hz delta frequency pattern, post-ictal rhythmic thalamic activity, emerged in CMN contacts amid the suppression of background activity in cortical contacts. In the two patients with corpus callosotomy, unilateral seizure spread and ipsilateral post-ictal rhythmic thalamic activity were observed. CONCLUSIONS We observed post-ictal rhythmic thalamic activity in five patients with stereoelectroencephalography monitoring of the CMN with convulsive seizures. This rhythm appears late in ictal evolution and may signal an important role of the CMN in seizure termination. Furthermore, this rhythm may help identify CMN involvement in the epileptic network.
Collapse
Affiliation(s)
- Kristen Arredondo
- Department of Neurology, The University of Texas at Austin Dell Medical School, Austin, TX, U.S.A
| | - Adam P Ostendorf
- Division of Neurology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, U.S.A; and
| | - Stephanie Ahrens
- Division of Neurology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, U.S.A; and
| | - Christopher W Beatty
- Division of Neurology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, U.S.A; and
| | - Jonathan Pindrik
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Nationwide Children's Hospital, Columbus, OH, U.S.A
| | - Ammar Shaikhouni
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Nationwide Children's Hospital, Columbus, OH, U.S.A
| |
Collapse
|
6
|
Hamani C, Davidson B, Lipsman N, Abrahao A, Nestor SM, Rabin JS, Giacobbe P, Pagano RL, Campos ACP. Insertional effect following electrode implantation: an underreported but important phenomenon. Brain Commun 2024; 6:fcae093. [PMID: 38707711 PMCID: PMC11069120 DOI: 10.1093/braincomms/fcae093] [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: 09/11/2023] [Revised: 12/08/2023] [Accepted: 03/26/2024] [Indexed: 05/07/2024] Open
Abstract
Deep brain stimulation has revolutionized the treatment of movement disorders and is gaining momentum in the treatment of several other neuropsychiatric disorders. In almost all applications of this therapy, the insertion of electrodes into the target has been shown to induce some degree of clinical improvement prior to stimulation onset. Disregarding this phenomenon, commonly referred to as 'insertional effect', can lead to biased results in clinical trials, as patients receiving sham stimulation may still experience some degree of symptom amelioration. Similar to the clinical scenario, an improvement in behavioural performance following electrode implantation has also been reported in preclinical models. From a neurohistopathologic perspective, the insertion of electrodes into the brain causes an initial trauma and inflammatory response, the activation of astrocytes, a focal release of gliotransmitters, the hyperexcitability of neurons in the vicinity of the implants, as well as neuroplastic and circuitry changes at a distance from the target. Taken together, it would appear that electrode insertion is not an inert process, but rather triggers a cascade of biological processes, and, as such, should be considered alongside the active delivery of stimulation as an active part of the deep brain stimulation therapy.
Collapse
Affiliation(s)
- Clement Hamani
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Benjamin Davidson
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Nir Lipsman
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Agessandro Abrahao
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Sean M Nestor
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Jennifer S Rabin
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto M5G 1V7, Canada
| | - Peter Giacobbe
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Rosana L Pagano
- Laboratory of Neuroscience, Hospital Sírio-Libanês, São Paulo, SP CEP 01308-060, Brazil
| | - Ana Carolina P Campos
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Laboratory of Neuroscience, Hospital Sírio-Libanês, São Paulo, SP CEP 01308-060, Brazil
| |
Collapse
|
7
|
Sharma A, Parfyonov M, Tiefenbach J, Hogue O, Nero N, Jehi L, Serletis D, Bingaman W, Gupta A, Rammo R. Predictors of therapeutic response following thalamic neuromodulation for drug-resistant pediatric epilepsy: A systematic review and individual patient data meta-analysis. Epilepsia 2024; 65:542-555. [PMID: 38265348 DOI: 10.1111/epi.17883] [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: 08/23/2023] [Revised: 12/02/2023] [Accepted: 01/05/2024] [Indexed: 01/25/2024]
Abstract
We sought to perform a systematic review and individual participant data meta-analysis to identify predictors of treatment response following thalamic neuromodulation in pediatric patients with medically refractory epilepsy. Electronic databases (MEDLINE, Ovid, Embase, and Cochrane) were searched, with no language or data restriction, to identify studies reporting seizure outcomes in pediatric populations following deep brain stimulation (DBS) or responsive neurostimulation (RNS) implantation in thalamic nuclei. Studies featuring individual participant data of patients with primary or secondary generalized drug-resistant epilepsy were included. Response to therapy was defined as >50% reduction in seizure frequency from baseline. Of 417 citations, 21 articles reporting on 88 participants were eligible. Mean age at implantation was 13.07 ± 3.49 years. Fifty (57%) patients underwent DBS, and 38 (43%) RNS. Sixty (68%) patients were implanted in centromedian nucleus and 23 (26%) in anterior thalamic nucleus, and five (6%) had both targets implanted. Seventy-four (84%) patients were implanted bilaterally. The median time to last follow-up was 12 months (interquartile range = 6.75-26.25). Sixty-nine percent of patients achieved response to treatment. Age, target, modality, and laterality had no significant association with response in univariate logistic regression. Until thalamic neuromodulation gains widespread approval for use in pediatric patients, data on efficacy will continue to be limited to small retrospective cohorts and case series. The inherent bias of these studies can be overcome by using individual participant data. Thalamic neuromodulation appears to be a safe and effective treatment for epilepsy. Larger, prolonged prospective, multicenter studies are warranted to further evaluate the efficacy of DBS over RNS in this patient population where resection for curative intent is not a safe option.
Collapse
Affiliation(s)
- Akshay Sharma
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Cleveland Clinic Epilepsy Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Maksim Parfyonov
- Cleveland Clinic Epilepsy Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jakov Tiefenbach
- Center for Neurologic Restoration, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Olivia Hogue
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Neil Nero
- Education Institute, Floyd D. Loop Alumni Library, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lara Jehi
- Cleveland Clinic Epilepsy Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Demitre Serletis
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Cleveland Clinic Epilepsy Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - William Bingaman
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Cleveland Clinic Epilepsy Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Ajay Gupta
- Cleveland Clinic Epilepsy Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Richard Rammo
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Cleveland Clinic Epilepsy Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Center for Neurologic Restoration, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| |
Collapse
|
8
|
Drees C, Afra P, Verner R, Kaye L, Keith A, Jiang M, Szaflarski JP, Nichol K. Feasibility study of microburst VNS therapy in drug-resistant focal and generalized epilepsy. Brain Stimul 2024; 17:382-391. [PMID: 38499287 DOI: 10.1016/j.brs.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/31/2024] [Accepted: 03/12/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Vagus nerve stimulation (VNS) at low frequencies (≤30 Hz) has been an established treatment for drug-resistant epilepsy (DRE) for over 25 years. OBJECTIVE To examine the initial safety and efficacy performance of an investigational, high-frequency (≥250 Hz) VNS paradigm herein called "Microburst VNS" (μVNS). μVNS consists of short, high-frequency bursts of electrical pulses believed to preferentially modulate certain brain regions. METHODS Thirty-three (33) participants were enrolled into an exploratory feasibility study, 21 with focal-onset seizures and 12 with generalized-onset seizures. Participants were titrated to a personalized target dose of μVNS using an investigational fMRI protocol. Participants were then followed for up to 12 months, with visits every 3 months, and monitored for side-effects at all time points. This study was registered as NCT03446664 on February 27th, 2018. RESULTS The device was well-tolerated. Reported adverse events were consistent with typical low frequency VNS outcomes and tended to diminish in severity over time, including dysphonia, cough, dyspnea, and implant site pain. After 12 months of μVNS, the mean seizure frequency reduction for all seizures was 61.3% (median reduction: 70.4%; 90% CI of median: 48.9%-83.3%). The 12-month responder rate (≥50% reduction) was 63.3% (90% CI: 46.7%-77.9%) and the super-responder rate (≥80% reduction) was 40% (90% CI: 25.0%-56.6%). Participants with focal-onset seizures appeared to benefit similarly to participants with generalized-onset seizures (mean reduction in seizures at 12 months: 62.6% focal [n = 19], versus 59.0% generalized [n = 11]). CONCLUSION Overall, μVNS appears to be safe and potentially a promising therapeutic alternative to traditional VNS. It merits further investigation in randomized controlled trials which will help determine the impact of investigational variables and which patients are most suitable for this novel therapy.
Collapse
Affiliation(s)
- Cornelia Drees
- Mayo Clinic Arizona, Department of Neurology, Phoenix, AZ, USA; University of Colorado School of Medicine, Department of Neurology, Aurora, CO, USA
| | - Pegah Afra
- University of Utah School of Medicine, Department of Neurology, Salt Lake City, UT, USA; Weill-Cornell Medicine, Department of Neurology, New York, NY, USA; University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Ryan Verner
- LivaNova PLC (or a Subsidiary), Department of Clinical and Medical Affairs, London, UK
| | - Lesley Kaye
- University of Colorado School of Medicine, Department of Neurology, Aurora, CO, USA
| | - Amy Keith
- LivaNova PLC (or a Subsidiary), Department of Clinical and Medical Affairs, London, UK
| | - Mei Jiang
- LivaNova PLC (or a Subsidiary), Department Statistics and Data Science, London, UK
| | - Jerzy P Szaflarski
- University of Alabama at Birmingham School of Medicine, Department of Neurology, Birmingham, AL, USA
| | - Kathryn Nichol
- LivaNova PLC (or a Subsidiary), Department of Clinical and Medical Affairs, London, UK.
| |
Collapse
|
9
|
Chauvin RJ, Newbold DJ, Nielsen AN, Miller RL, Krimmel SR, Metoki A, Wang A, Van AN, Montez DF, Marek S, Suljic V, Baden NJ, Ramirez-Perez N, Scheidter KM, Monk JS, Whiting FI, Adeyemo B, Snyder AZ, Kay BP, Raichle ME, Laumann TO, Gordon EM, Dosenbach NU. Disuse-driven plasticity in the human thalamus and putamen. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2023.11.07.566031. [PMID: 37987000 PMCID: PMC10659348 DOI: 10.1101/2023.11.07.566031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
Motor adaptation in cortico-striato-thalamo-cortical loops has been studied mainly in animals using invasive electrophysiology. Here, we leverage functional neuroimaging in humans to study motor circuit plasticity in the human subcortex. We employed an experimental paradigm that combined two weeks of upper-extremity immobilization with daily resting-state and motor task fMRI before, during, and after the casting period. We previously showed that limb disuse leads to decreased functional connectivity (FC) of the contralateral somatomotor cortex (SM1) with the ipsilateral somatomotor cortex, increased FC with the cingulo-opercular network (CON) as well as the emergence of high amplitude, fMRI signal pulses localized in the contralateral SM1, supplementary motor area and the cerebellum. From our prior observations, it remains unclear whether the disuse plasticity affects the thalamus and striatum. We extended our analysis to include these subcortical regions and found that both exhibit strengthened cortical FC and spontaneous fMRI signal pulses induced by limb disuse. The dorsal posterior putamen and the central thalamus, mainly CM, VLP and VIM nuclei, showed disuse pulses and FC changes that lined up with fmri task activations from the Human connectome project motor system localizer, acquired before casting for each participant. Our findings provide a novel understanding of the role of the cortico-striato-thalamo-cortical loops in human motor plasticity and a potential link with the physiology of sleep regulation. Additionally, similarities with FC observation from Parkinson Disease (PD) questions a pathophysiological link with limb disuse.
Collapse
Affiliation(s)
- Roselyne J. Chauvin
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110
| | - Dillan J. Newbold
- Department of Neurology, New York University Grossman School of Medicine, New York, New York 10016, USA
| | - Ashley N. Nielsen
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110
| | - Ryland L. Miller
- Basque Center on Cognition, Brain and Language, Donostia, Gipuzkoa, Spain
| | - Samuel R. Krimmel
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110
| | - Athanasia Metoki
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110
| | - Anxu Wang
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110
- Department of Biomedical Engineering, Washington University in St. Louis, MO 63130
| | - Andrew N. Van
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110
- Division of Computation and Data Science, Washington University School of Medicine, St. Louis, MO 63110
| | - David F. Montez
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110
| | - Scott Marek
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO 63110
| | - Vahdeta Suljic
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110
| | - Noah J. Baden
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110
| | | | - Kristen M. Scheidter
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110
| | - Julia S. Monk
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110
| | - Forrest I. Whiting
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110
| | - Babatunde Adeyemo
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110
| | - Abraham Z. Snyder
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO 63110
| | - Benjamin P. Kay
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110
| | - Marcus E. Raichle
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO 63110
- Department of Psychological and Brain Sciences, Washington University in St. Louis, St Louis, MO, USA
- Department of Neuroscience, Washington University School of Medicine, St Louis, MO, USA
| | - Timothy O. Laumann
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110
| | - Evan M. Gordon
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO 63110
| | - Nico U.F. Dosenbach
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110
- Department of Biomedical Engineering, Washington University in St. Louis, MO 63130
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO 63110
| |
Collapse
|
10
|
Warren AEL, Tobochnik S, Chua MMJ, Singh H, Stamm MA, Rolston JD. Neurostimulation for Generalized Epilepsy: Should Therapy be Syndrome-specific? Neurosurg Clin N Am 2024; 35:27-48. [PMID: 38000840 PMCID: PMC10676463 DOI: 10.1016/j.nec.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Current applications of neurostimulation for generalized epilepsy use a one-target-fits-all approach that is agnostic to the specific epilepsy syndrome and seizure type being treated. The authors describe similarities and differences between the 2 "archetypes" of generalized epilepsy-Lennox-Gastaut syndrome and Idiopathic Generalized Epilepsy-and review recent neuroimaging evidence for syndrome-specific brain networks underlying seizures. Implications for stimulation targeting and programming are discussed using 5 clinical questions: What epilepsy syndrome does the patient have? What brain networks are involved? What is the optimal stimulation target? What is the optimal stimulation paradigm? What is the plan for adjusting stimulation over time?
Collapse
Affiliation(s)
- Aaron E L Warren
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Steven Tobochnik
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Melissa M J Chua
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Hargunbir Singh
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michaela A Stamm
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John D Rolston
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
11
|
Cukiert A, Cukiert CM, Burattini JA, Guimaraes RB. Combined Neuromodulation (Vagus Nerve Stimulation and Deep Brain Stimulation) in Patients With Refractory Generalized Epilepsy: An Observational Study. Neuromodulation 2023; 26:1742-1746. [PMID: 36109334 DOI: 10.1016/j.neurom.2022.08.449] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/08/2022] [Accepted: 08/08/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION This article describes our findings while treating patients with refractory generalized epilepsy with combined vagus nerve stimulation (VNS) and centro-median deep brain stimulation (CMDBS). MATERIALS AND METHODS A total of 11 consecutive patients with refractory generalized epilepsy (ten with Lennox-Gastaut syndrome) previously submitted to VNS and who subsequently underwent CMDBS were retrospectively studied. The VNS final parameters were 2 to 2.5 mA, 30 Hz, and 500 μs, cycling mode, 30 seconds "on" and 5 minutes "off" for all patients. The CMDBS final parameters were 4 to 5 V, 130 Hz, and 300 μs, bipolar, continuous stimulation in all patients. RESULTS There were eight male participants, ranging in age from eight to 49 years (mean 19 years). Follow-up time after VNS ranged from 18 to 132 months (mean 52 months) and from an additional 18 to 164 months (mean 42 months) during combined VNS-CMDBS. All patients had daily seizures. Atypical absences were noted in eight patients, tonic seizures in seven, bilateral tonic-clonic seizures in four, atonic seizures in three, and myoclonic seizures in two patients. Four patients were initially considered responders to VNS. All these patients also had an additional >50% seizure frequency reduction during combined VNS-CMDBS. Seven patients were not responders to VNS, and of those, four had an additional >50% seizure frequency reduction during combined VNS-CMDBS. Eight patients had an additional >50% reduction in seizure frequency when moved from VNS alone to VNS-CMDBS therapy. There were two nonresponders during combined VNS-CMDBS therapy, and both were nonresponders to VNS alone. Nine patients were considered responders during VNS-CMDBS combined therapy compared with baseline. DISCUSSION This study showed that combined VNS-CMDBS therapy was able to double the number of responders compared with VNS alone in a cohort of patients with refractory generalized epilepsy. We believe these data represent the first evidence that combined neuromodulation may be useful in this quite homogeneous patient population.
Collapse
Affiliation(s)
- Arthur Cukiert
- Department of Neurosurgery, São Paulo Epilepsy Clinic, São Paulo, São Paulo, Brazil.
| | | | | | | |
Collapse
|
12
|
Frauscher B, Bartolomei F, Baud MO, Smith RJ, Worrell G, Lundstrom BN. Stimulation to probe, excite, and inhibit the epileptic brain. Epilepsia 2023; 64 Suppl 3:S49-S61. [PMID: 37194746 PMCID: PMC10654261 DOI: 10.1111/epi.17640] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 05/01/2023] [Accepted: 05/02/2023] [Indexed: 05/18/2023]
Abstract
Direct cortical stimulation has been applied in epilepsy for nearly a century and has experienced a renaissance, given unprecedented opportunities to probe, excite, and inhibit the human brain. Evidence suggests stimulation can increase diagnostic and therapeutic utility in patients with drug-resistant epilepsies. However, choosing appropriate stimulation parameters is not a trivial issue, and is further complicated by epilepsy being characterized by complex brain state dynamics. In this article derived from discussions at the ICTALS 2022 Conference (International Conference on Technology and Analysis for Seizures), we succinctly review the literature on cortical stimulation applied acutely and chronically to the epileptic brain for localization, monitoring, and therapeutic purposes. In particular, we discuss how stimulation is used to probe brain excitability, discuss evidence on the usefulness of stimulation to trigger and stop seizures, review therapeutic applications of stimulation, and finally discuss how stimulation parameters are impacted by brain dynamics. Although research has advanced considerably over the past decade, there are still significant hurdles to optimizing use of this technique. For example, it remains unclear to what extent short timescale diagnostic biomarkers can predict long-term outcomes and to what extent these biomarkers add information to already existing biomarkers from passive electroencephalographic recordings. Further questions include the extent to which closed loop stimulation offers advantages over open loop stimulation, what the optimal closed loop timescales may be, and whether biomarker-informed stimulation can lead to seizure freedom. The ultimate goal of bioelectronic medicine remains not just to stop seizures but rather to cure epilepsy and its comorbidities.
Collapse
Affiliation(s)
- Birgit Frauscher
- Analytical Neurophysiology Lab, Montreal Neurological Institute and Hospital, Montreal, Quebec, Canada
| | - Fabrice Bartolomei
- Institut de Neurosciences des Systèmes, Aix Marseille University, Marseille, France. AP-HM, Service de Neurophysiologie Clinique, Hôpital de la Timone, Marseille, France
| | - Maxime O. Baud
- Sleep-Wake-Epilepsy Center, NeuroTec and Center for Experimental Neurology, Department of Neurology, Inselspital Bern, University Hospital, University of Bern, Bern
| | - Rachel J. Smith
- University of Alabama at Birmingham, Electrical and Computer Engineering Department, Birmingham, Alabama, US. University of Alabama at Birmingham, Neuroengineering Program, Birmingham, Alabama, US
| | - Greg Worrell
- Department of Neurology, Mayo Clinic, Rochester, US
| | | |
Collapse
|
13
|
Yang AI, Raghu ALB, Isbaine F, Alwaki A, Gross RE. Sensing with deep brain stimulation device in epilepsy: Aperiodic changes in thalamic local field potential during seizures. Epilepsia 2023; 64:3025-3035. [PMID: 37607249 DOI: 10.1111/epi.17758] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 08/20/2023] [Accepted: 08/21/2023] [Indexed: 08/24/2023]
Abstract
OBJECTIVE Thalamic deep brain stimulation (DBS) is an effective therapeutic option in patients with drug-resistant epilepsy. Recent DBS devices with sensing capabilities enable chronic, outpatient local field potential (LFP) recordings. Whereas beta oscillations have been demonstrated to be a useful biomarker in movement disorders, the clinical utility of DBS sensing in epilepsy remains unclear. Our aim was to determine LFP features that distinguish ictal from inter-ictal states, which may aid in tracking seizure outcomes with DBS. METHODS Electrophysiology data were obtained from DBS devices implanted in the anterior nucleus (N = 12) or centromedian nucleus (N = 2) of the thalamus. Power spectra recorded during patient/caregiver-marked seizure events were analyzed with a method that quantitatively separates the oscillatory and non-oscillatory/aperiodic components of the LFP using non-parametric statistics, without the need for pre-specification of the frequency bands of interest. Features of the LFP parameterized using this algorithm were compared with those from inter-ictal power spectra recorded in clinic. RESULTS Oscillatory activity in multiple canonical frequency bands was identified from the power spectra in 86.48% of patient-marked seizure events. Delta oscillations were present in all patients, followed by theta (N = 10) and beta (N = 9). Although there were no differences in oscillatory LFP features between the ictal and inter-ictal states, there was a steeper decline in the 1/f slope of the aperiodic component of the LFP during seizures. SIGNIFICANCE Our work highlights the potential and shortcomings of chronic LFP recordings in thalamic DBS for epilepsy. Findings suggest that no single frequency band in isolation clearly differentiates seizures, and that features of aperiodic LFP activity may be clinically-relevant biomarkers of seizures.
Collapse
Affiliation(s)
- Andrew I Yang
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ashley L B Raghu
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Faical Isbaine
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Abdulrahman Alwaki
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Robert E Gross
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| |
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
Campos ACP, Pagano RL, Lipsman N, Hamani C. What do we know about astrocytes and the antidepressant effects of DBS? Exp Neurol 2023; 368:114501. [PMID: 37558154 DOI: 10.1016/j.expneurol.2023.114501] [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: 05/31/2023] [Revised: 07/29/2023] [Accepted: 08/05/2023] [Indexed: 08/11/2023]
Abstract
Treatment-resistant depression (TRD) is a debilitating condition that affects millions of individuals worldwide. Deep brain stimulation (DBS) has been widely used with excellent outcomes in neurological disorders such as Parkinson's disease, tremor, and dystonia. More recently, DBS has been proposed as an adjuvant therapy for TRD. To date, the antidepressant efficacy of DBS is still controversial, and its mechanisms of action remain poorly understood. Astrocytes are the most abundant cells in the nervous system. Once believed to be a "supporting" element for neuronal function, astrocytes are now recognized to play a major role in brain homeostasis, neuroinflammation and neuroplasticity. Because of its many roles in complex multi-factorial disorders, including TRD, understanding the effect of DBS on astrocytes is pivotal to improve our knowledge about the antidepressant effects of this therapy. In depression, the number of astrocytes and the expression of astrocytic markers are decreased. One of the potential consequences of this reduced astrocytic function is the development of aberrant glutamatergic neurotransmission, which has been documented in several models of depression-like behavior. Evidence from preclinical work suggests that DBS may directly influence astrocytic activity, modulating the release of gliotransmitters, reducing neuroinflammation, and altering structural tissue organization. Compelling evidence for an involvement of astrocytes in potential mechanisms of DBS derive from studies suggesting that pharmacological lesions or the inhibition of these cells abolishes the antidepressant-like effect of DBS. In this review, we summarize preclinical data suggesting that the modulation of astrocytes may be an important mechanism for the antidepressant-like effects of DBS.
Collapse
Affiliation(s)
- Ana Carolina P Campos
- Sunnybrook Research Institute, Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Centre, Toronto, Canada; Laboratory of Neuroscience, Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | - Rosana L Pagano
- Laboratory of Neuroscience, Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | - Nir Lipsman
- Sunnybrook Research Institute, Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Centre, Toronto, Canada; Division of Neurosurgery, University of Toronto, Toronto, Canada
| | - Clement Hamani
- Sunnybrook Research Institute, Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Centre, Toronto, Canada; Division of Neurosurgery, University of Toronto, Toronto, Canada.
| |
Collapse
|
16
|
Philipp LR, Kennedy BC. The Wild West of Pediatric Epilepsy-Thalamic Stimulation. World Neurosurg 2023; 178:262-263. [PMID: 37580189 DOI: 10.1016/j.wneu.2023.07.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Affiliation(s)
- Lucas R Philipp
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Benjamin C Kennedy
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
17
|
Venkatesh P, Wolfe C, Lega B. Neuromodulation of the anterior thalamus: Current approaches and opportunities for the future. CURRENT RESEARCH IN NEUROBIOLOGY 2023; 5:100109. [PMID: 38020810 PMCID: PMC10663132 DOI: 10.1016/j.crneur.2023.100109] [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: 05/14/2023] [Revised: 08/28/2023] [Accepted: 08/31/2023] [Indexed: 12/01/2023] Open
Abstract
The role of thalamocortical circuits in memory has driven a recent burst of scholarship, especially in animal models. Investigating this circuitry in humans is more challenging. And yet, the development of new recording and stimulation technologies deployed for clinical indications has created novel opportunities for data collection to elucidate the cognitive roles of thalamic structures. These technologies include stereoelectroencephalography (SEEG), deep brain stimulation (DBS), and responsive neurostimulation (RNS), all of which have been applied to memory-related thalamic regions, specifically for seizure localization and treatment. This review seeks to summarize the existing applications of neuromodulation of the anterior thalamic nuclei (ANT) and highlight several devices and their capabilities that can allow cognitive researchers to design experiments to assay its functionality. Our goal is to introduce to investigators, who may not be familiar with these clinical devices, the capabilities, and limitations of these tools for understanding the neurophysiology of the ANT as it pertains to memory and other behaviors. We also briefly cover the targeting of other thalamic regions including the centromedian (CM) nucleus, dorsomedial (DM) nucleus, and pulvinar, with associated potential avenues of experimentation.
Collapse
Affiliation(s)
- Pooja Venkatesh
- Department of Neurosurgery, University of Texas Southwestern, Dallas, TX, 75390, USA
| | - Cody Wolfe
- Department of Neurosurgery, University of Texas Southwestern, Dallas, TX, 75390, USA
| | - Bradley Lega
- Department of Neurosurgery, University of Texas Southwestern, Dallas, TX, 75390, USA
| | | |
Collapse
|
18
|
Kumar VJ, Scheffler K, Grodd W. The structural connectivity mapping of the intralaminar thalamic nuclei. Sci Rep 2023; 13:11938. [PMID: 37488187 PMCID: PMC10366221 DOI: 10.1038/s41598-023-38967-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/18/2023] [Indexed: 07/26/2023] Open
Abstract
The intralaminar nuclei of the thalamus play a pivotal role in awareness, conscious experience, arousal, sleep, vigilance, as well as in cognitive, sensory, and sexual processing. Nonetheless, in humans, little is known about the direct involvement of these nuclei in such multifaceted functions and their structural connections in the brain. Thus, examining the versatility of structural connectivity of the intralaminar nuclei with the rest of the brain seems reasonable. Herein, we attempt to show the direct structural connectivity of the intralaminar nuclei to diencephalic, mesencephalic, and cortical areas using probabilistic tracking of the diffusion data from the human connectome project. The intralaminar nuclei fiber distributions span a wide range of subcortical and cortical areas. Moreover, the central medial and parafascicular nucleus reveal similar connectivity to the temporal, visual, and frontal cortices with only slight variability. The central lateral nucleus displays a refined projection to the superior colliculus and fornix. The centromedian nucleus seems to be an essential component of the subcortical somatosensory system, as it mainly displays connectivity via the medial and superior cerebellar peduncle to the brainstem and the cerebellar lobules. The subparafascicular nucleus projects to the somatosensory processing areas. It is interesting to note that all intralaminar nuclei have connections to the brainstem. In brief, the structural connectivity of the intralaminar nuclei aligns with the structural core of various functional demands for arousal, emotion, cognition, sensory, vision, and motor processing. This study sheds light on our understanding of the structural connectivity of the intralaminar nuclei with cortical and subcortical structures, which is of great interest to a broader audience in clinical and neuroscience research.
Collapse
Affiliation(s)
| | - Klaus Scheffler
- Max Planck Institute for Biological Cybernetics, Tübingen, Germany
- Department of Biomedical Magnetic Resonance, University Clinic Tübingen, Tübingen, Germany
| | - Wolfgang Grodd
- Max Planck Institute for Biological Cybernetics, Tübingen, Germany
| |
Collapse
|
19
|
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.
Collapse
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.
| |
Collapse
|
20
|
Shlobin NA, Hofmann K, Cohen NT, Koubeissi MZ, Gaillard WD, Oluigbo CO. Deep Brain Stimulation of the Centromedian Nucleus of the Thalamus for Lennox-Gastaut Syndrome: A Systematic Review and Individual Patient Data Analysis. Neurosurgery 2023; 92:703-715. [PMID: 36700706 DOI: 10.1227/neu.0000000000002280] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 09/29/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Lennox-Gastaut syndrome (LGS) is a severe childhood-onset pharmacoresistant epilepsy. Deep brain stimulation (DBS) of the centromedian nucleus of the thalamus (CMN) has been utilized. OBJECTIVE To conduct a systematic review and individual patient data (IPD) analysis to characterize outcomes of DBS of CMN in LGS. METHODS PubMed, Embase, and Scopus were searched per Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Articles were screened by title/abstract then full text. Included articles were reviewed for bibliographic, demographic, and outcome data. IPD were extracted from studies providing IPD for all patients. RESULTS Of 72 resultant articles, 10 studies (114 patients) were included. Six of 7 studies reporting the outcome of ≥50% seizure reduction indicated that ≥50% of patients achieved this, with improved functional ability. Seizure freedom rate was generally <10%. Six studies with 47 patients provided IPD. The mean ages at epilepsy onset and CMN DBS were 3.9 ± 4.5 years and 17.4 ± 8.8 years, respectively. Nineteen of 41 (46.3%) patients had positive MRI findings. Seizure types included atypical absence in 39 (83.0%) patients, generalized tonic-clonic in 32 (68.1%), tonic in 22 (46.8%), and atonic in 20 (42.6%). Thirty-eight (80.9%) patients experienced ≥50% reduction in seizure frequency, and only 3 (6.4%) experienced seizure freedom. The mean seizure reduction was 62.9% ± 31.2% overall. Quality of life improved in 30/34 (88.2%) and was unchanged in the remainder (11.8%). The complication rate was 2/41 (4.9%). The mean length of follow-up was 19.8 ± 26.1 months (IQR: 4-18 months). CONCLUSION Limited data indicate that DBS of the CMN may be effective and safe for people with LGS.
Collapse
Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Katherine Hofmann
- Deparment of Neurosurgery, Children's National Hospital, Washington, District of Columbia, USA
| | - Nathan T Cohen
- Department of Neurology, Children's National Hospital, Washington, District of Columbia, USA
| | - Mohamad Z Koubeissi
- Department of Neurology, The George Washington University, Washington, District of Columbia, USA
| | - William D Gaillard
- Department of Neurology, Children's National Hospital, Washington, District of Columbia, USA
| | - Chima O Oluigbo
- Deparment of Neurosurgery, Children's National Hospital, Washington, District of Columbia, USA
| |
Collapse
|
21
|
Lundstrom BN, Osman GM, Starnes K, Gregg NM, Simpson HD. Emerging approaches in neurostimulation for epilepsy. Curr Opin Neurol 2023; 36:69-76. [PMID: 36762660 PMCID: PMC9992108 DOI: 10.1097/wco.0000000000001138] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW Neurostimulation is a quickly growing treatment approach for epilepsy patients. We summarize recent approaches to provide a perspective on the future of neurostimulation. RECENT FINDINGS Invasive stimulation for treatment of focal epilepsy includes vagus nerve stimulation, responsive neurostimulation of the cortex and deep brain stimulation of the anterior nucleus of the thalamus. A wide range of other targets have been considered, including centromedian, central lateral and pulvinar thalamic nuclei; medial septum, nucleus accumbens, subthalamic nucleus, cerebellum, fornicodorsocommissure and piriform cortex. Stimulation for generalized onset seizures and mixed epilepsies as well as increased efforts focusing on paediatric populations have emerged. Hardware with more permanently implanted lead options and sensing capabilities is emerging. A wider variety of programming approaches than typically used may improve patient outcomes. Finally, noninvasive brain stimulation with its favourable risk profile offers the potential to treat increasingly diverse epilepsy patients. SUMMARY Neurostimulation for the treatment of epilepsy is surprisingly varied. Flexibility and reversibility of neurostimulation allows for rapid innovation. There remains a continued need for excitability biomarkers to guide treatment and innovation. Neurostimulation, a part of bioelectronic medicine, offers distinctive benefits as well as unique challenges.
Collapse
Affiliation(s)
| | | | - Keith Starnes
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Hugh D Simpson
- Department of Neurology, Alfred Health
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
22
|
Frameless Robot-Assisted Asleep Centromedian Thalamic Nucleus Deep Brain Stimulation Surgery in Patients with Drug-Resistant Epilepsy: Technical Description and Short-Term Clinical Results. Neurol Ther 2023; 12:977-993. [PMID: 36892782 DOI: 10.1007/s40120-023-00451-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/02/2023] [Indexed: 03/10/2023] Open
Abstract
INTRODUCTION This purpose of this work is to give a detailed description of a surgical technique for frameless robot-assisted asleep deep brain stimulation (DBS) of the centromedian thalamic nucleus (CMT) in drug-resistant epilepsy (DRE). METHODS Ten consecutively enrolled patients who underwent CMT-DBS were included in the study. The FreeSurfer "Thalamic Kernel Segmentation" module and experience target coordinates were used for locating the CMT, and quantitative susceptibility mapping (QSM) images were used to check the target. The patient's head was secured with a head clip, and electrode implantation was performed with the assistance of the neurosurgical robot Sinovation®. After opening the dura, the burr hole was continuously flushed with physiological saline to stop air from entering the skull. All procedures were performed under general anesthesia without intraoperative microelectrode recording (MER). RESULTS The mean age of the patients at surgery and onset of seizures was 22 years (range 11-41 years) and 11 years (range 1-21 years), respectively. The median duration of seizures before CMT-DBS surgery was 10 years (2-26 years). CMT was successfully segmented, and its position was verified by experience target coordinates and QSM images in all ten patients. The mean surgical time for bilateral CMT-DBS in this cohort was 165 ± 18 min. The mean pneumocephalus volume was 2 cm3. The median absolute errors in the x-, y-, and z-axes were 0.7 mm, 0.5 mm, and 0.9 mm, respectively. The median Euclidean distance (ED) and radial error (RE) was 1.3 ± 0.5 mm and 1.0 ± 0.3 mm, respectively. No significant difference was found between right- and left-sided electrodes regarding the RE nor the ED. After a mean 12-month follow-up, the average reduction in seizures was 61%, and six patients experienced a ≥ 50% reduction in seizures, including one patient who had no seizures after the operation. All patients tolerated the anesthesia operation, and no permanent or serious complications were reported. CONCLUSIONS Frameless robot-assisted asleep surgery is a precise and safe approach for placing CMT electrodes in patients with DRE, shortening the surgery time. The segmentation of the thalamic nuclei enables the precise location of the CMT, and the flow of physiological saline to seal the burr holes is a good way to reduce the influx of air. CMT-DBS is an effective method to reduce seizures.
Collapse
|
23
|
Kalamatianos T, Mavrovounis G, Skouras P, Pandis D, Fountas K, Stranjalis G. Medial Pulvinar Stimulation in Temporal Lobe Epilepsy: A Literature Review and a Hypothesis Based on Neuroanatomical Findings. Cureus 2023; 15:e35772. [PMID: 37025746 PMCID: PMC10071339 DOI: 10.7759/cureus.35772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2023] [Indexed: 03/07/2023] Open
Abstract
While bilateral stimulation of the anterior thalamic nuclei remains the only approved deep brain stimulation (DBS) option for focal epilepsy, two additional thalamic targets have been proposed. Earlier work indicated the potential of centromedian thalamic nucleus stimulation with recent findings highlighting the medial pulvinar nucleus. The latter has been shown to exhibit electrophysiological and imaging alterations in patients with partial status epilepticus and temporal lobe epilepsy. On this basis, recent studies have begun assessing the feasibility and efficacy of pulvinar stimulation, with encouraging results on the reduction of seizure frequency and severity. Building on existing neuroanatomical knowledge, indicating that the medial pulvinar is connected to the temporal lobe via the temporopulvinar bundle of Arnold, we hypothesize that this is one of the routes through which medial pulvinar stimulation affects temporal lobe structures. We suggest that further anatomic, imaging, and electrophysiologic studies are warranted to deepen our understanding of the subject and guide future clinical applications.
Collapse
|
24
|
Arnts H, Coolen SE, Fernandes FW, Schuurman R, Krauss JK, Groenewegen HJ, van den Munckhof P. The intralaminar thalamus: a review of its role as a target in functional neurosurgery. Brain Commun 2023; 5:fcad003. [PMID: 37292456 PMCID: PMC10244065 DOI: 10.1093/braincomms/fcad003] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 10/06/2022] [Accepted: 01/03/2023] [Indexed: 09/29/2023] Open
Abstract
The intralaminar thalamus, in particular the centromedian-parafascicular complex, forms a strategic node between ascending information from the spinal cord and brainstem and forebrain circuitry that involves the cerebral cortex and basal ganglia. A large body of evidence shows that this functionally heterogeneous region regulates information transmission in different cortical circuits, and is involved in a variety of functions, including cognition, arousal, consciousness and processing of pain signals. Not surprisingly, the intralaminar thalamus has been a target area for (radio)surgical ablation and deep brain stimulation (DBS) in different neurological and psychiatric disorders. Historically, ablation and stimulation of the intralaminar thalamus have been explored in patients with pain, epilepsy and Tourette syndrome. Moreover, DBS has been used as an experimental treatment for disorders of consciousness and a variety of movement disorders. In this review, we provide a comprehensive analysis of the underlying mechanisms of stimulation and ablation of the intralaminar nuclei, historical clinical evidence, and more recent (experimental) studies in animals and humans to define the present and future role of the intralaminar thalamus as a target in the treatment of neurological and psychiatric disorders.
Collapse
Affiliation(s)
- Hisse Arnts
- Department of Neurosurgery, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stan E Coolen
- Department of Neurosurgery, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | | | - Rick Schuurman
- Department of Neurosurgery, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Henk J Groenewegen
- Department of Anatomy and Neurosciences, Neuroscience Campus Amsterdam, Amsterdam University Medical Centers, location VU University Medical Center, Amsterdam, The Netherlands
| | - Pepijn van den Munckhof
- Department of Neurosurgery, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
25
|
Simpson HD, Schulze-Bonhage A, Cascino GD, Fisher RS, Jobst BC, Sperling MR, Lundstrom BN. Practical considerations in epilepsy neurostimulation. Epilepsia 2022; 63:2445-2460. [PMID: 35700144 PMCID: PMC9888395 DOI: 10.1111/epi.17329] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 02/02/2023]
Abstract
Neuromodulation is a key therapeutic tool for clinicians managing patients with drug-resistant epilepsy. Multiple devices are available with long-term follow-up and real-world experience. The aim of this review is to give a practical summary of available neuromodulation techniques to guide the selection of modalities, focusing on patient selection for devices, common approaches and techniques for initiation of programming, and outpatient management issues. Vagus nerve stimulation (VNS), deep brain stimulation of the anterior nucleus of the thalamus (DBS-ANT), and responsive neurostimulation (RNS) are all supported by randomized controlled trials that show safety and a significant impact on seizure reduction, as well as a suggestion of reduction in the risk of sudden unexplained death in epilepsy (SUDEP). Significant seizure reductions are observed after 3 months for DBS, RNS, and VNS in randomized controlled trials, and efficacy appears to improve with time out to 7 to 10 years of follow-up for all modalities, albeit in uncontrolled follow-up or retrospective studies. A significant number of patients experience seizure-free intervals of 6 months or more with all three modalities. Number and location of epileptogenic foci are important factors affecting efficacy, and together with comorbidities such as severe mood or sleep disorders, may influence the choice of modality. Programming has evolved-DBS is typically initiated at lower current/voltage than used in the pivotal trial, whereas target charge density is lower with RNS, however generalizable optimal parameters are yet to be defined. Noninvasive brain stimulation is an emerging stimulation modality, although it is currently not used widely. In summary, clinical practice has evolved from those established in pivotal trials. Guidance is now available for clinicians who wish to expand their approach, and choice of neuromodulation technique may be tailored to individual patients based on their epilepsy characteristics, risk tolerance, and preferences.
Collapse
Affiliation(s)
- Hugh D. Simpson
- Division of Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Gregory D. Cascino
- Division of Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Robert S. Fisher
- Department of Neurology, Stanford Neuroscience Health Center, Palo Alto, CA, USA
| | - Barbara C. Jobst
- Geisel School of Medicine at Dartmouth, Department of Neurology, Dartmouth-Hitchcock Medical Center, NH, USA
| | - Michael R. Sperling
- Division of Epilepsy, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Brian N. Lundstrom
- Division of Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
26
|
Zillgitt AJ, Haykal MA, Chehab A, Staudt MD. Centromedian thalamic neuromodulation for the treatment of idiopathic generalized epilepsy. Front Hum Neurosci 2022; 16:907716. [PMID: 35992953 PMCID: PMC9381751 DOI: 10.3389/fnhum.2022.907716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 07/13/2022] [Indexed: 11/20/2022] Open
Abstract
Idiopathic generalized epilepsy (IGE) is a common type of epilepsy and despite an increase in the number of available anti-seizure medications, approximately 20–30% of people with IGE continue to experience seizures despite adequate medication trials. Unlike focal epilepsy, resective surgery is not a viable treatment option for IGE; however, neuromodulation may be an effective surgical treatment for people with IGE. Thalamic stimulation through deep brain stimulation (DBS) and responsive neurostimulation (RNS) have been explored for the treatment of generalized and focal epilepsies. Although the data regarding DBS and RNS in IGE is limited to case reports and case series, the results of the published studies have been promising. The current manuscript will review the published literature of DBS and RNS within the centromedian nucleus of the thalamus for the treatment of IGE, as well as highlight an illustrative case.
Collapse
Affiliation(s)
- Andrew J. Zillgitt
- Department of Neurology, Beaumont Health Adult Comprehensive Epilepsy Center, Neuroscience Center, Royal Oak, MI, United States
| | - M. Ayman Haykal
- Department of Neurology, Beaumont Health Adult Comprehensive Epilepsy Center, Neuroscience Center, Royal Oak, MI, United States
| | - Ahmad Chehab
- Department of Neurosurgery, Beaumont Neuroscience Center, Royal Oak, MI, United States
| | - Michael D. Staudt
- Department of Neurosurgery, Beaumont Neuroscience Center, Royal Oak, MI, United States
- Department of Neurosurgery, Oakland University William Beaumont School of Medicine, Rochester, MI, United States
- Michigan Head and Spine Institute, Southfield, MI, United States
- *Correspondence: Michael D. Staudt,
| |
Collapse
|
27
|
Ilyas A, Tandon N, Lhatoo SD. Thalamic neuromodulation for epilepsy: A clinical perspective. Epilepsy Res 2022; 183:106942. [PMID: 35580382 DOI: 10.1016/j.eplepsyres.2022.106942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/12/2022] [Accepted: 05/06/2022] [Indexed: 11/29/2022]
Abstract
Thalamic neuromodulation can be an effective therapeutic option for select patients with medically refractory epilepsy. However, successful outcome depends on several factors, beginning with appropriate patient and thalamic target selection. Among thalamic targets, the anterior (ANT) and centromedian (CeM) nuclei have the greatest clinical evidence for efficacy. However, the place of thalamic neuromodulation in the treatment armamentarium for intractable seizures is at the tail end of a long list of options. It's relative efficacy, if any, in relation to other treatment modalities however, can be inferred. As we will discuss, considerable work remains to be done in optimal targeting of thalamic nuclei, appropriate to the epilepsy syndrome and seizure type of the individual patient, which may change our current understanding of the place of thalamic neuromodulation on a range of treatment modality efficacies. Currently, it appears that ANT DBS is most efficacious for limbic epilepsies whereas CM, for generalized, multifocal (especially frontotemporal) epilepsies. Based on controlled studies, the efficacy of ANT and CeM DBS is roughly in line with other neuromodulatory therapies (i.e. RNS, VNS) when assessed within the cohort of patients for which the therapy is indicated. Much improvement is needed to render thalamic DBS more efficacious, and use of optimal targeting strategies, especially direct targeting, can positively affect outcomes. Thalamic neuromodulation is still in its infancy; however, clinical advances in this therapy are being realized.
Collapse
Affiliation(s)
- Adeel Ilyas
- Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, AL, USA; Vivian L. Smith Department of Neurosurgery, McGovern Medical School at UT Health Houston, Houston, TX, USA; Texas Institute for Restorative Neurotechnologies, The University of Texas Health Science Center at Houston, Houston, TX, USA.
| | - Nitin Tandon
- Vivian L. Smith Department of Neurosurgery, McGovern Medical School at UT Health Houston, Houston, TX, USA; Texas Institute for Restorative Neurotechnologies, The University of Texas Health Science Center at Houston, Houston, TX, USA; Department of Neurology, McGovern Medical School at UT Health Houston, Houston, TX, USA; Memorial Hermann Hospital, Texas Medical Center, Houston, TX, USA
| | - Samden D Lhatoo
- Texas Institute for Restorative Neurotechnologies, The University of Texas Health Science Center at Houston, Houston, TX, USA; Department of Neurology, McGovern Medical School at UT Health Houston, Houston, TX, USA; Memorial Hermann Hospital, Texas Medical Center, Houston, TX, USA
| |
Collapse
|
28
|
Surgical Treatment of Drug-Resistant Generalized Epilepsy. Curr Neurol Neurosci Rep 2022; 22:459-465. [PMID: 35713776 DOI: 10.1007/s11910-022-01210-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW To summarize current evidence and recent developments in the surgical treatment of drug-resistant generalized epilepsy. RECENT FINDINGS Current surgical treatments of drug-resistant generalized epilepsy include vagus nerve stimulation (VNS), deep brain stimulation (DBS) and corpus callosotomy (CC). Neurostimulation with VNS and/or DBS has been shown to be effective in reducing seizure frequency in patients with generalized epilepsy. DBS for generalized epilepsy is primarily consisted of open-loop stimulation directed at the centromedian (CM) nucleus in the thalamus, though closed-loop stimulation and additional targets are being explored. CC can be effective in treating some seizure types and can be performed using traditional surgical techniques or with the less invasive methods of laser ablation and radiosurgery. This current literature supports the use of VNS, DBS and CC, alone or in combination, as palliative treatments of drug-resistant generalized epilepsy.
Collapse
|
29
|
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.
Collapse
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,
| |
Collapse
|
30
|
Ilyas A, Snyder KM, Pati S, Tandon N. Optimally Targeting the Centromedian Nucleus of the Thalamus for Generalized Epilepsy: A Meta-Analysis. Epilepsy Res 2022; 184:106954. [DOI: 10.1016/j.eplepsyres.2022.106954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/13/2022] [Accepted: 05/25/2022] [Indexed: 12/18/2022]
|
31
|
Warren AE, Dalic LJ, Bulluss KJ, Roten A, Thevathasan W, Archer JS. The optimal target and connectivity for
DBS
in
Lennox‐Gastaut
syndrome. Ann Neurol 2022; 92:61-74. [PMID: 35429045 PMCID: PMC9544037 DOI: 10.1002/ana.26368] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/18/2022] [Accepted: 04/11/2022] [Indexed: 11/23/2022]
Abstract
Objective Deep brain stimulation (DBS) can reduce seizures in Lennox–Gastaut syndrome (LGS). However, little is known about the optimal target and whether efficacy depends on connectivity of the stimulation site. Using outcome data from the ESTEL trial, we aimed to determine the optimal target and connectivity for DBS in LGS. Methods A total of 20 patients underwent bilateral DBS of the thalamic centromedian nucleus (CM). Outcome was percentage seizure reduction from baseline after 3 months of DBS, defined using three measures (monthly seizure diaries, 24‐hour scalp electroencephalography [EEG], and a novel diary‐EEG composite). Probabilistic stimulation mapping identified thalamic locations associated with higher/lower efficacy. Two substitute diffusion MRI datasets (a normative dataset from healthy subjects and a “disease‐matched” dataset from a separate group of LGS patients) were used to calculate structural connectivity between DBS sites and a map of areas known to express epileptic activity in LGS, derived from our previous EEG‐fMRI research. Results Results were similar across the three outcome measures. Stimulation was most efficacious in the anterior and inferolateral “parvocellular” CM border, extending into the ventral lateral nucleus (posterior subdivision). There was a positive association between diary‐EEG composite seizure reduction and connectivity to areas of a priori EEG‐fMRI activation, including premotor and prefrontal cortex, putamen, and pontine brainstem. In contrast, outcomes were not associated with baseline clinical variables. Interpretation Efficacious CM‐DBS for LGS is linked to stimulation of the parvocellular CM and the adjacent ventral lateral nucleus, and is associated with connectivity to, and thus likely modulation of, the “secondary epileptic network” underlying the shared electroclinical manifestations of LGS. ANN NEUROL 2022;92:61–74
Collapse
Affiliation(s)
- Aaron E.L Warren
- Department of Medicine (Austin Health) University of Melbourne Heidelberg Victoria Australia
- Murdoch Children’s Research Institute Parkville Victoria Australia
- The Florey Institute of Neuroscience and Mental Health Heidelberg Victoria Australia
| | - Linda J. Dalic
- Department of Medicine (Austin Health) University of Melbourne Heidelberg Victoria Australia
- Department of Neurology Austin Health Heidelberg Victoria Australia
| | - Kristian J. Bulluss
- Bionics Institute East Melbourne Victoria Australia
- Department of Neurosurgery Austin Health Heidelberg Victoria Australia
- Department of Surgery University of Melbourne Parkville Victoria Australia
| | - Annie Roten
- Department of Neurology Austin Health Heidelberg Victoria Australia
| | - Wesley Thevathasan
- Department of Neurology Austin Health Heidelberg Victoria Australia
- Bionics Institute East Melbourne Victoria Australia
| | - John S. Archer
- Department of Medicine (Austin Health) University of Melbourne Heidelberg Victoria Australia
- Murdoch Children’s Research Institute Parkville Victoria Australia
- The Florey Institute of Neuroscience and Mental Health Heidelberg Victoria Australia
- Department of Neurology Austin Health Heidelberg Victoria Australia
| |
Collapse
|
32
|
Yang JC, Bullinger KL, Isbaine F, Alwaki A, Opri E, Willie JT, Gross RE. Centromedian thalamic deep brain stimulation for drug-resistant epilepsy: single-center experience. J Neurosurg 2022; 137:1591-1600. [PMID: 35395630 DOI: 10.3171/2022.2.jns212237] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 02/07/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Neuromodulation of the centromedian nucleus of the thalamus (CM) has unclear effectiveness in the treatment of drug-resistant epilepsy. Prior reports suggest that it may be more effective in the generalized epilepsies such as Lennox-Gastaut syndrome (LGS). The objective of this study was to determine the outcome of CM deep brain stimulation (DBS) at the authors' institution. METHODS Retrospective chart review was performed for all patients who underwent CM DBS at Emory University, which occurred between December 2018 and May 2021. CM DBS electrodes were implanted using three different surgical methods, including frame-based, robot-assisted, and direct MRI-guided. Seizure frequency, stimulation parameters, and adverse events were recorded from subsequent clinical follow-up visits. RESULTS Fourteen patients underwent CM DBS: 9 had symptomatic generalized epilepsy (including 5 with LGS), 3 had primary or idiopathic generalized epilepsy, and 2 had bifrontal focal epilepsy. At last follow-up (mean [± SEM] 19 ± 5 months, range 4.1-33 months, ≥ 6 months in 11 patients), the median seizure frequency reduction was 91%. Twelve patients (86%) were considered responders (≥ 50% decrease in seizure frequency), including 10 of 12 with generalized epilepsy and both patients with bifrontal epilepsy. Surgical adverse events were rare and included 1 patient with hardware breakage, 1 with a postoperative aspiration event, and 1 with a nonclinically significant intracranial hemorrhage. CONCLUSIONS CM DBS was an effective treatment for drug-resistant generalized and bifrontal epilepsies. Additional studies and analyses may investigate whether CM DBS is best suited for specific epilepsy types, and the relationship of lead location to outcome in different epilepsies.
Collapse
Affiliation(s)
| | - Katie L Bullinger
- 2Neurology, Emory University School of Medicine, Atlanta, Georgia; and
| | | | | | - Enrico Opri
- 2Neurology, Emory University School of Medicine, Atlanta, Georgia; and
| | - Jon T Willie
- 3Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Robert E Gross
- Departments of1Neurosurgery and.,2Neurology, Emory University School of Medicine, Atlanta, Georgia; and
| |
Collapse
|
33
|
Abouelleil M, Deshpande N, Ali R. Emerging Trends in Neuromodulation for Treatment of Drug-Resistant Epilepsy. FRONTIERS IN PAIN RESEARCH 2022; 3:839463. [PMID: 35386582 PMCID: PMC8977768 DOI: 10.3389/fpain.2022.839463] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/21/2022] [Indexed: 01/12/2023] Open
Abstract
Epilepsy is a neurological disorder that affects more than 70 million people globally. A considerable proportion of epilepsy is resistant to anti-epileptic drugs (AED). For patients with drug-resistant epilepsy (DRE), who are not eligible for resective or ablative surgery, neuromodulation has been a palliative option. Since the approval of vagus nerve stimulation (VNS) in 1997, expansion to include other modalities, such as deep brain stimulation (DBS) and responsive neurostimulation (RNS), has led to improved seizure control in this population. In this article, we discuss the current updates and emerging trends on neuromodulation for epilepsy.
Collapse
Affiliation(s)
- Mohamed Abouelleil
- Division of Neurological Surgery, Spectrum Health, Grand Rapids, MI, United States
| | - Nachiket Deshpande
- College of Human Medicine, Michigan State University, East Lansing, MI, United States
| | - Rushna Ali
- Division of Neurological Surgery, Spectrum Health, Grand Rapids, MI, United States
- *Correspondence: Rushna Ali
| |
Collapse
|
34
|
Vetkas A, Fomenko A, Germann J, Sarica C, Iorio-Morin C, Samuel N, Yamamoto K, Milano V, Cheyuo C, Zemmar A, Elias G, Boutet A, Loh A, Santyr B, Gwun D, Tasserie J, Kalia SK, Lozano AM. Deep brain stimulation targets in epilepsy: Systematic review and meta-analysis of anterior and centromedian thalamic nuclei and hippocampus. Epilepsia 2022; 63:513-524. [PMID: 34981509 DOI: 10.1111/epi.17157] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/13/2021] [Accepted: 12/13/2021] [Indexed: 12/11/2022]
Abstract
Deep brain stimulation (DBS) is a neuromodulatory treatment used in patients with drug-resistant epilepsy (DRE). The primary goal of this systematic review and meta-analysis is to describe recent advancements in the field of DBS for epilepsy, to compare the results of published trials, and to clarify the clinical utility of DBS in DRE. A systematic literature search was performed by two independent authors. Forty-four articles were included in the meta-analysis (23 for anterior thalamic nucleus [ANT], 8 for centromedian thalamic nucleus [CMT], and 13 for hippocampus) with a total of 527 patients. The mean seizure reduction after stimulation of the ANT, CMT, and hippocampus in our meta-analysis was 60.8%, 73.4%, and 67.8%, respectively. DBS is an effective and safe therapy in patients with DRE. Based on the results of randomized controlled trials and larger clinical series, the best evidence exists for DBS of the anterior thalamic nucleus. Further randomized trials are required to clarify the role of CMT and hippocampal stimulation. Our analysis suggests more efficient deep brain stimulation of ANT for focal seizures, wider use of CMT for generalized seizures, and hippocampal DBS for temporal lobe seizures. Factors associated with clinical outcome after DBS for epilepsy are electrode location, stimulation parameters, type of epilepsy, and longer time of stimulation. Recent advancements in anatomical targeting, functional neuroimaging, responsive neurostimulation, and sensing of local field potentials could potentially lead to improved outcomes after DBS for epilepsy and reduced sudden, unexpected death of patients with epilepsy. Biomarkers are needed for successful patient selection, targeting of electrodes and optimization of stimulation parameters.
Collapse
Affiliation(s)
- Artur Vetkas
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.,Neurology Clinic, Department of Neurosurgery, Tartu University Hospital, University of Tartu, Tartu, Estonia
| | - Anton Fomenko
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.,Section of Neurosurgery, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Jürgen Germann
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Can Sarica
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Christian Iorio-Morin
- Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Nardin Samuel
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Kazuaki Yamamoto
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Vanessa Milano
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Cletus Cheyuo
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Ajmal Zemmar
- Department of Neurosurgery, University of Louisville, School of Medicine, Louisville, KY, USA
| | - Gavin Elias
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Alexandre Boutet
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.,Joint Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Aaron Loh
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Brendan Santyr
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.,Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Dave Gwun
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Jordy Tasserie
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Suneil K Kalia
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.,Krembil Research Institute, Toronto, ON, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.,Krembil Research Institute, Toronto, ON, Canada
| |
Collapse
|
35
|
Complete callosotomy in children with drop attacks; A retrospective monocentric study of 50 patients. Seizure 2022; 96:34-42. [DOI: 10.1016/j.seizure.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 01/10/2022] [Accepted: 01/12/2022] [Indexed: 11/19/2022] Open
|
36
|
Hect JL, Fernandez LD, Welch WP, Abel TJ. Deep brain stimulation of the centromedian thalamic nucleus for the treatment of FIRES. Epilepsia Open 2021; 7:187-193. [PMID: 34862854 PMCID: PMC8886094 DOI: 10.1002/epi4.12568] [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: 09/03/2021] [Revised: 11/16/2021] [Accepted: 11/28/2021] [Indexed: 11/10/2022] Open
Abstract
Febrile infection‐related epilepsy syndrome (FIRES) is a rare, life‐threatening complication of febrile illness in previously healthy individuals followed by super‐refractory status epilepticus. Deep brain stimulation (DBS) has been demonstrated to be a promising therapy for the treatment of intractable epilepsy. Here, we present a pediatric patient with FIRES whose seizures were mitigated by acute DBS of the bilateral centromedian thalamic nucleus (CMTN). This is a previously healthy 11‐year‐old female who presented emergently with altered mental status, fever, and malaise after 1 week of lethargy, anorexia, fever, and abdominal pain. The patient began having seizures shortly after admission. After thorough workup for encephalitis and other potential etiologies, this patient was diagnosed with FIRES due to super‐refractory status epilepticus. Status epilepticus persisted despite pharmacologic management, immunotherapy, and vagus nerve stimulation. DBS of the bilateral CMTN (CM‐DBS) was pursued after 56 days of hospitalization, and she demonstrated considerable improvement in baseline mental status 30 days after DBS insertion. This report highlights application of CM‐DBS for super‐refractory status epilepticus in FIRES. This region is a diffusely connected brain region and has been shown to modulate neural networks contributing to seizure propagation and consciousness; therefore, neurostimulation is a potential therapeutic intervention for patients with super‐refractory status epilepticus.
Collapse
Affiliation(s)
- Jasmine L Hect
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Luis D Fernandez
- Division of Pediatric Neurology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - William P Welch
- Division of Pediatric Neurology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Bioengineering, University of Pittsburgh Swanson School of Engineering, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
37
|
Fasano A, Eliashiv D, Herman ST, Lundstrom BN, Polnerow D, Henderson JM, Fisher RS. Experience and consensus on stimulation of the anterior nucleus of thalamus for epilepsy. Epilepsia 2021; 62:2883-2898. [PMID: 34697794 DOI: 10.1111/epi.17094] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/31/2021] [Accepted: 09/27/2021] [Indexed: 12/11/2022]
Abstract
Deep brain stimulation of the anterior nuclei of thalamus (ANT-DBS) is effective for reduction of seizures, but little evidence is available to guide practitioners in the practical use of this therapy. In an attempt to fill this gap, a questionnaire with 37 questions was circulated to 578 clinicians who were either engaged in clinical trials of or known users of DBS for epilepsy, with responses from 141, of whom 58.2% were epileptologists and 28.4% neurosurgeons. Multiple regions of the world were represented. The survey found that the best candidates for DBS were considered those with temporal or frontal seizures, refractory to at least two medicines. Motivations for renewing therapy upon battery depletion were reduced convulsive, impaired awareness, and severe seizures and improved quality of life. Targeting of leads mainly was by magnetic resonance imaging, sometimes with intraoperative imaging or microelectrode recording. The majority used transventricular approaches. Stimulation parameters mostly imitated the SANTE study parameters, except for initial stimulation amplitudes in the 2-3-V or -mA range, versus 5 V in the SANTE study. Stimulation intensity was most often increased or reduced, respectively, for lack of efficacy or side effects, but changes in active contacts, cycle time, and pulse duration were also employed. Mood or memory problems or paresthesias were the side effects most responsible for adjustments. Off-label sites stimulated included centromedian thalamus, hippocampus, neocortex, and a few others. Several physicians used DBS in conjunction with vagus nerve stimulation or responsive neurostimulation, although our study did not track efficacy for combined use. Experienced users varied more from published parameters than did inexperienced users. In conclusion, surveys of experts can provide Class IV evidence for the most prevalent practical use of ANT-DBS. We present a flowchart for one protocol combining common practices. Controlled comparisons will be needed to choose the best approach.
Collapse
Affiliation(s)
- Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,Krembil Brain Institute, Toronto, Ontario, Canada.,Center for Advancing Neurotechnological Innovation to Application, Toronto, Ontario, Canada
| | - Dawn Eliashiv
- Department of Neurology, UCLA Seizure Disorders Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Susan T Herman
- Epilepsy Program, Department of Neurology at Barrow Neurological Institute, Phoenix, Arizona, USA
| | | | | | - Jaimie M Henderson
- Department of Neurosurgery and, by courtesy, Neurology and Neurological Sciences, Wu Tsai Neurosciences Institute and Bio-X Institute, Stanford University, Stanford, California, USA
| | - Robert S Fisher
- Department of Neurology & Neurological Sciences and, by courtesy, Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| |
Collapse
|
38
|
Guglielmi G, Eschbach KL, Alexander AL. Smaller Knife, Fewer Seizures? Recent Advances in Minimally Invasive Techniques in Pediatric Epilepsy Surgery. Semin Pediatr Neurol 2021; 39:100913. [PMID: 34620456 DOI: 10.1016/j.spen.2021.100913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 02/02/2023]
Abstract
Children with drug-resistant epilepsy are at high risk for developmental delay, increased mortality, psychiatric comorbidities, and requiring assistance with activities of daily living. Despite the advent of new and effective pharmacologic therapies, about one in 5 children will develop drug-resistant epilepsy, and most of these children continue to have seizures despite trials of other medication. Epilepsy surgery is often a safe and effective option which may offer seizure freedom or at least a significant reduction in seizure burden in many children. However, despite published evidence of safety and efficacy, epilepsy surgery remains underutilized in the pediatric population. Patient and family fears about the risks of surgery may contribute to this gap. Less invasive surgical techniques may be more palatable to children with epilepsy and their caregivers. In this review, we present recent advances in minimally invasive techniques for the surgical treatment of epilepsy as well as intriguing possibilities for the future. We describe the indications for, benefits of, and limits to minimally-invasive techniques including Stereo-encephalography, laser interstitial thermal ablation, deep brain stimulation, focused ultrasound, stereo-encephalography-guided radiofrequency ablation, endoscopic disconnections, and responsive neurostimulation.
Collapse
Affiliation(s)
- Gina Guglielmi
- Graduate Medical Education, Neurological Surgery Residency, Carle BroMenn Medical Center, Normal IL; Section of Pediatric Neurology, Children's Hospital Colorado, Aurora CO; Department of Pediatrics, University of Colorado Anschutz School of Medicine, Aurora CO; Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora CO; Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora CO
| | - Krista L Eschbach
- Graduate Medical Education, Neurological Surgery Residency, Carle BroMenn Medical Center, Normal IL; Section of Pediatric Neurology, Children's Hospital Colorado, Aurora CO; Department of Pediatrics, University of Colorado Anschutz School of Medicine, Aurora CO; Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora CO; Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora CO
| | - Allyson L Alexander
- Graduate Medical Education, Neurological Surgery Residency, Carle BroMenn Medical Center, Normal IL; Section of Pediatric Neurology, Children's Hospital Colorado, Aurora CO; Department of Pediatrics, University of Colorado Anschutz School of Medicine, Aurora CO; Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora CO; Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora CO.
| |
Collapse
|
39
|
Tenney JR, Williamson BJ, Kadis DS. Cross-Frequency Coupling in Childhood Absence Epilepsy. Brain Connect 2021; 12:489-496. [PMID: 34405685 DOI: 10.1089/brain.2021.0119] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: Absence seizures are the prototypic primarily generalized seizures, but there is incomplete understanding regarding their generation and maintenance. A core network for absence seizures has been defined, including focal cortical and thalamic regions that have frequency-dependent interactions. The purpose of this study was to investigate within-frequency coupling and cross-frequency coupling (CFC) during human absence seizures, to identify key regions (hubs) within the absence network that contribute to propagation and maintenance. Methods: Thirteen children with new-onset and untreated childhood absence epilepsy had over 60 typical absence seizures during both electroencephalography-functional magnetic resonance imaging (fMRI) and magnetoencephalography (MEG) recordings. The spatial map of the ictal network was defined using fMRI and used as prior information for MEG connectivity. A multilayer network approach was used to investigate within-frequency coupling and CFC for canonical frequency bands. A rigorous null-modeling approach was used to determine connections outside the noise floor. Results: Strong coupling between beta and gamma frequencies, within the left frontal cortex, and between the left frontal and right parietal regions was observed. There was also strong connectivity between left frontal and right parietal nodes within the gamma band. Multilayer versatility analysis identified a cluster of network hubs in the left frontal region. Interpretation: Cortical regions commonly identified as being critical for absence seizure generation (frontal cortex, precuneus) have strong CFC and within-frequency coupling between beta and gamma bands. As nonpharmacologic treatments, such as neuromodulation, become available for generalized epilepsies, detailed mechanistic understanding of how "diffuse" seizures are generated and maintained will be necessary to provide optimal outcomes.
Collapse
Affiliation(s)
- Jeffrey R Tenney
- Division of Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Brady J Williamson
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Darren S Kadis
- Neurosciences and Mental Health, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
40
|
Foutz T, Wong M. Brain Stimulation Treatments in Epilepsy: Basic Mechanisms and Clinical Advances. Biomed J 2021; 45:27-37. [PMID: 34482013 PMCID: PMC9133258 DOI: 10.1016/j.bj.2021.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/29/2021] [Accepted: 08/30/2021] [Indexed: 12/28/2022] Open
Abstract
Drug-resistant epilepsy, characterized by ongoing seizures despite appropriate trials of anti-seizure medications, affects approximately one-third of people with epilepsy. Brain stimulation has recently become available as an alternative treatment option to reduce symptomatic seizures in short and long-term follow-up studies. Several questions remain on how to optimally develop patient-specific treatments and manage therapy over the long term. This review aims to discuss the clinical use and mechanisms of action of Responsive Neural Stimulation and Deep Brain Stimulation in the treatment of epilepsy and highlight recent advances that may both improve outcomes and present new challenges. Finally, a rational approach to device selection is presented based on current mechanistic understanding, clinical evidence, and device features.
Collapse
Affiliation(s)
- Thomas Foutz
- Department of Neurology, Washington University in St. Louis, USA.
| | - Michael Wong
- Department of Neurology, Washington University in St. Louis, USA.
| |
Collapse
|
41
|
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.
Collapse
Affiliation(s)
| | - Arthur Cukiert
- Department of Neurosurgery, Epilepsy Surgery Program, Clínica Cukiert, São Paulo, Brazil
| |
Collapse
|
42
|
Welch WP, Hect JL, Abel TJ. Case Report: Responsive Neurostimulation of the Centromedian Thalamic Nucleus for the Detection and Treatment of Seizures in Pediatric Primary Generalized Epilepsy. Front Neurol 2021; 12:656585. [PMID: 33995254 PMCID: PMC8113700 DOI: 10.3389/fneur.2021.656585] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/22/2021] [Indexed: 11/13/2022] Open
Abstract
Up to 20% of pediatric patients with primary generalized epilepsy (PGE) will not respond effectively to medication for seizure control. Responsive neurostimulation (RNS) is a promising therapy for pediatric patients with drug-resistant epilepsy and has been shown to be an effective therapy for reducing seizure frequency and severity in adult patients. RNS of the centromedian nucleus of the thalamus may help to prevent loss of awareness during seizure activity in PGE patients with absence seizures. Here we present a 16-year-old male, with drug-resistant PGE with absence seizures, characterized by 3 Hz spike-and-slow-wave discharges on EEG, who achieved a 75% reduction in seizure frequency following bilateral RNS of the centromedian nuclei. At 6-months post-implant, this patient reported complete resolution of the baseline daily absence seizure activity, and decrease from 3-4 generalized convulsive seizures per month to 1 per month. RNS recordings showed well-formed 3 Hz spike-wave discharges in bilateral CM nuclei, further supporting the notion that clinically relevant ictal discharges in PGE can be detected in CM. This report demonstrates that CM RNS can detect PGE-related seizures in the CM nucleus and deliver therapeutic stimulation.
Collapse
Affiliation(s)
- William P Welch
- Division of Pediatric Neurology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Jasmine L Hect
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.,Department of Bioengineering, University of Pittsburgh Swanson School of Engineering, Pittsburgh, PA, United States
| |
Collapse
|