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Sobstyl M, Kowalska M, Konopko M, Wierzbicka A, Karamon K, Nagańska E. Deep brain stimulation of the subiculum in the treatment for refractory temporal lobe epilepsy due to unilateral mesial temporal lobe sclerosis. Epilepsy Behav Rep 2024; 27:100677. [PMID: 38845792 PMCID: PMC11153886 DOI: 10.1016/j.ebr.2024.100677] [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: 02/20/2024] [Revised: 05/15/2024] [Accepted: 05/23/2024] [Indexed: 06/09/2024] Open
Abstract
Temporal lobe epilepsy (TLE) is the most common form of drug-resistant epilepsy. The main pathological changes primarily involve hippocampal sclerosis (HS). Early resective surgery of the sclerotic hippocampus is typically associated with favorable clinical outcomes. However, not all patients are suitable candidates for resective surgery of mesial temporal lobe structures. Therefore, alternative treatment modalities should be considered. We present the case of a 50-year-old right-handed woman with left HS who underwent unilateral subiculum stimulation for drug-resistant epilepsy (DRE). Since the age of 10, the patient had been experiencing focal to bilateral tonic-clonic seizures (FBTCS). Despite multiple antiseizure medications, she experienced 12 to 17 FBTCS per month in the last two years. Due to concerns about potential memory decline and personal preferences, she refused resective surgery. As an alternative, the patient underwent left unilateral subiculum stimulation. The stimulation resulted in a nearly 67 % reduction in seizure frequency at the last follow-up (20 months after surgery). This case highlights that drug-resistant epilepsy may be effectively treated with subicular stimulation in patients with HS.
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Affiliation(s)
- Michał Sobstyl
- Department of Neurosurgery, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957 Warsaw, Poland
| | - Magdalena Kowalska
- Department of Neurology and Epileptology, Independent Public Clinical Hospital, Medical Center for Postgraduate Education, Czerniakowska 231 Street, 00-416 Warsaw, Poland
| | - Magdalena Konopko
- 1st Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957 Warsaw, Poland
| | - Aleksandra Wierzbicka
- Department of Neurophysiology, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957 Warsaw, Poland
| | - Karol Karamon
- Department of Radiology, Institute of Psychiatry and Neurology, Sobieskiego 9 Street, 02-957 Warsaw, Poland
| | - Ewa Nagańska
- Department of Neurology and Epileptology, Independent Public Clinical Hospital, Medical Center for Postgraduate Education, Czerniakowska 231 Street, 00-416 Warsaw, Poland
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Kusyk DM, Meinert J, Stabingas KC, Yin Y, Whiting AC. Systematic Review and Meta-Analysis of Responsive Neurostimulation in Epilepsy. World Neurosurg 2022; 167:e70-e78. [PMID: 35948217 DOI: 10.1016/j.wneu.2022.07.147] [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: 05/14/2022] [Revised: 07/20/2022] [Accepted: 07/21/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Neuromodulatory implants provide promising alternatives for patients with drug-resistant epilepsy (DRE) in whom resective or ablative surgery is not an option. Responsive neurostimulation (RNS) operates a unique "closed-loop" system of electrocorticography-triggered stimulation for seizure control. A comprehensive review of the current literature would be valuable to guide clinical decision-making regarding RNS. METHODS Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocols, a systematic PubMed literature review was performed to identify appropriate studies involving patients undergoing RNS for DRE. Full texts of included studies were analyzed and extracted data regarding demographics, seizure reduction rate, responder rate (defined as patients with >50% seizure reduction), and complications were compiled for comprehensive statistical analysis. RESULTS A total of 313 studies were screened, and 17 studies were included in the final review, representative of 541 patients. Mean seizure reduction rate was 68% (95% confidence interval 61%-76%), and the mean responder rate was 68% (95% confidence interval 60%-75%). Complications occurred in 102 of 541 patients, for a complication rate of 18.9%. A strong publication bias toward greater seizure reduction rate and increased responder rate was demonstrated among included literature. CONCLUSIONS A meta-analysis of recent RNS for DRE literature demonstrates seizure reduction and responder rates comparable with other neuromodulatory implants for epilepsy, demonstrating both the value of this intervention and the need for further research to delineate the optimal patient populations. This analysis also demonstrates a strong publication bias toward positive primary outcomes, highlighting the limitations of current literature. Currently, RNS data are optimistic for the treatment of DRE but should be interpreted cautiously.
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Affiliation(s)
- Dorian M Kusyk
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Justin Meinert
- College of Medicine, Drexel University, Philadelphia, Pennsylvania, USA
| | | | - Yue Yin
- Allegheny-Singer Research Institute, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Alexander C Whiting
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.
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Krucoff MO, Wozny TA, Lee AT, Rao VR, Chang EF. Operative Technique and Lessons Learned From Surgical Implantation of the NeuroPace Responsive Neurostimulation® System in 57 Consecutive Patients. Oper Neurosurg (Hagerstown) 2021; 20:E98-E109. [PMID: 33074294 DOI: 10.1093/ons/opaa300] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 07/13/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The Responsive Neurostimulation (RNS)® System (NeuroPace, Inc) is an implantable device designed to improve seizure control in patients with medically refractory focal epilepsy. Because it is relatively new, surgical pearls and operative techniques optimized from experience beyond a small case series have yet to be described. OBJECTIVE To provide a detailed description of our operative technique and surgical pearls learned from implantation of the RNS System in 57 patients at our institution. We describe our method for frame-based placement of amygdalo-hippocampal depth leads, open implantation of cortical strip leads, and open installation of the neurostimulator. METHODS We outline considerations for patient selection, preoperative planning, surgical positioning, incision planning, stereotactic depth lead implantation, cortical strip lead implantation, craniotomy for neurostimulator implantation, device testing, closure, and intraoperative imaging. RESULTS The median reduction in clinical seizure frequency was 60% (standard deviation 63.1) with 27% of patients achieving seizure freedom at last follow up (median 23.1 mo). No infections, intracerebral hemorrhages, or lead migrations were encountered. Two patients experienced lead fractures, and four lead exchanges have been performed. CONCLUSION The techniques set forth here will help with the safe and efficient implantation of these new devices.
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Affiliation(s)
- Max O Krucoff
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California.,Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Thomas A Wozny
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | - Anthony T Lee
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | - Vikram R Rao
- Department of Neurology and Weill Institute for Neuroscience, University of California, San Francisco, San Francisco, California
| | - Edward F Chang
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California
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Jarosiewicz B, Morrell M. The RNS System: brain-responsive neurostimulation for the treatment of epilepsy. Expert Rev Med Devices 2020; 18:129-138. [PMID: 32936673 DOI: 10.1080/17434440.2019.1683445] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Introduction: Epilepsy affects more than 1% of the US population, and over 30% of adults with epilepsy do not respond to antiseizure medications without life-impacting medication-related side effects. Resection of the seizure focus is not an option for many patients because it would cause unacceptable neurological or cognitive harm. For these patients, neuromodulation has emerged as a nondestructive, effective, and safe alternative. The NeuroPace® RNS® System, the only brain-responsive neurostimulation device, records neural activity from leads placed at one or two seizure foci. When the neurostimulator detects epileptiform activity, as defined for each patient by his or her physician, brief pulses of electrical stimulation are delivered to normalize the activity.Areas covered: This review describes the RNS System, the results of multi-year clinical trials, and the research discoveries enabled by the chronic ambulatory brain data collected by the RNS System.Expert commentary: Brain-responsive neurostimulation could potentially be used to treat any episodic neurological disorder that's accompanied by a neurophysiological biomarker of severity. Combining advanced machine learning approaches with the chronic ambulatory brain data collected by the RNS System could eventually enable automatic fine-tuning of detection and stimulation for each patient, creating a general-purpose neurotechnological platform for precision medicine.
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Affiliation(s)
| | - Martha Morrell
- NeuroPace, Inc, Mountain View, CA, USA.,Neurology & Neurological Sciences, Stanford University, Stanford Neuroscience Health Center, Palo Alto, CA, USA
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Hoffman CE, Parker WE, Rapoport BI, Zhao M, Ma H, Schwartz TH. Innovations in the Neurosurgical Management of Epilepsy. World Neurosurg 2020; 139:775-788. [PMID: 32689698 DOI: 10.1016/j.wneu.2020.03.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 03/02/2020] [Indexed: 10/23/2022]
Abstract
Technical limitations and clinical challenges have historically limited the diagnostic tools and treatment methods available for surgical approaches to the management of epilepsy. By contrast, recent technological innovations in several areas hold significant promise in improving outcomes and decreasing morbidity. We review innovations in the neurosurgical management of epilepsy in several areas, including wireless recording and stimulation systems (particularly responsive neurostimulation [NeuroPace]), conformal electrodes for high-resolution electrocorticography, robot-assisted stereotactic surgery, optogenetics and optical imaging methods, novel positron emission tomography ligands, and new applications of focused ultrasonography. Investigation into genetic causes of and susceptibilities to epilepsy has introduced a new era of precision medicine, enabling the understanding of cell signaling mechanisms underlying epileptic activity as well as patient-specific molecularly targeted treatment options. We discuss the emerging path to individualized treatment plans, predicted outcomes, and improved selection of effective interventions, on the basis of these developments.
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Affiliation(s)
- Caitlin E Hoffman
- Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA.
| | - Whitney E Parker
- Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Benjamin I Rapoport
- Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Mingrui Zhao
- Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Hongtao Ma
- Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Theodore H Schwartz
- Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
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Brandmeir N. Commentary: Frameless ROSA® Robot-Assisted Lead Implantation for Deep Brain Stimulation: Technique and Accuracy. Oper Neurosurg (Hagerstown) 2020; 19:E21. [PMID: 31647107 DOI: 10.1093/ons/opz325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 09/02/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Nicholas Brandmeir
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia
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Tran DK, Paff M, Mnatsakanyan L, Sen-Gupta I, Lin JJ, Hsu FPK, Vadera S. A Novel Robotic-Assisted Technique to Implant the Responsive Neurostimulation System. Oper Neurosurg (Hagerstown) 2019; 18:728-735. [DOI: 10.1093/ons/opz226] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 05/29/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
The responsive neurostimulation system (RNS) (NeuroPace Inc, Mountain View, California) was approved as an adjunctive therapy for medically refractory focal epilepsy. RNS detects epileptiform patterns and delivers electrical stimulation to abort seizures.
OBJECTIVE
To describe a novel technique of RNS lead implantation using robotic-assisted targeting of ictal-onset zones based on stereoelectroencephalography (sEEG) localization. Secondary objectives are to report the accuracy of robotic-assisted lead implantation using the ROSA robot as well as to report the clinical outcome achieved after RNS implantation by this method.
METHODS
A total of 16 patients with medically refractory focal epilepsy underwent sEEG implantation for ictal-onset localization followed by robotic RNS implantation. The electrode most correlative with ictal onset on sEEG was chosen as the target for the RNS electrode. Seizure control was measured at 6-mo and 1-yr follow-up. Ictal-onset electrocorticography (ECoG) data from RNS were compared with ictal onset from sEEG leads based on calculations of lead target to actual lead location from the ROSA robot.
RESULTS
At 6-mo follow-up, the average percent seizure reduction was 82% based upon self-reported seizure diaries. At 1-yr follow-up, 8 patients had an average of 90% seizure reduction. The location of seizure onset from ECoG data show similar onset from sEEG leads within 0.165-mm discrepancy.
CONCLUSION
The ROSA robot provides an ideal method for targeting subcortical ictal-onset zones. This method of RNS lead implantation achieves high accuracy and is associated with favorable clinical outcomes.
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Affiliation(s)
- Diem Kieu Tran
- Department of Neurological Surgery, School of Medicine, University of California, Irvine, Orange, California
| | - Michelle Paff
- Department of Neurological Surgery, School of Medicine, University of California, Irvine, Orange, California
| | - Lilit Mnatsakanyan
- Department of Neurology, School of Medicine, University of California, Irvine, Orange, California
| | - Indranil Sen-Gupta
- Department of Neurology, School of Medicine, University of California, Irvine, Orange, California
| | - Jack J Lin
- Department of Neurology, School of Medicine, University of California, Irvine, Orange, California
| | - Frank P K Hsu
- Department of Neurological Surgery, School of Medicine, University of California, Irvine, Orange, California
| | - Sumeet Vadera
- Department of Neurological Surgery, School of Medicine, University of California, Irvine, Orange, California
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Abstract
There are a significant number of patients with epilepsy who are drug-resistant and for whom resective procedures are not an option. For these patients, neuromodulation may be an option, including closed-loop stimulation, such as responsive neurostimulation (RNS). The RNS System is a programmable and responsive device that consists of leads, a pulse generator, and an external programmer. An algorithm detects specific patterns of epileptogenic activity and triggers focal stimulation to interrupt a seizure. RNS is an effective and safe adjunctive therapy that in addition to seizure frequency reduction may have other applications, such as drug-response evaluation and long-term electrocorticography recording.
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Affiliation(s)
- Caio M Matias
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, USA; Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.
| | - Ashwini Sharan
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Chengyuan Wu
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
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9
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Ma BB, Rao VR. Responsive neurostimulation: Candidates and considerations. Epilepsy Behav 2018; 88:388-395. [PMID: 30355456 DOI: 10.1016/j.yebeh.2018.09.032] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 09/22/2018] [Accepted: 09/23/2018] [Indexed: 01/22/2023]
Abstract
Responsive neurostimulation (RNS) has recently emerged as a safe and effective treatment for some patients with medically refractory focal epilepsy who are not candidates for surgical resection. Responsive neurostimulation involves an implanted neurostimulator and intracranial leads that detect incipient seizures and respond with electrical counterstimulation. Over 1800 patients have been treated with RNS since its FDA approval in 2013. Despite its widespread use, however, RNS presents distinct challenges for clinicians. What types of patients are most well-suited for treatment with RNS? Given the availability of two other neurostimulation modalities, vagus nerve stimulation (VNS) and thalamic deep brain stimulation (DBS), what patient characteristics favor or disfavor RNS? Once RNS candidates are identified, lead placement presents another challenge. Unlike VNS and thalamic DBS, which both involve prespecified electrode locations, RNS involves intracranial strip and/or depth electrodes that can be flexibly configured based on knowledge of the seizure onset zone. The efficacy of RNS may depend on optimal lead configuration, but there are few resources to guide clinicians in formulating lead placement strategies. Here, we address these challenges, first by reviewing clinical trial data supporting the safety and efficacy of RNS. Then, through a series of clinical vignettes from our center, we provide a framework for RNS patient selection. For each clinical scenario, we illustrate typical strategies for RNS lead placement. We outline considerations for choosing among available neurostimulation devices based on their intrinsic features. For example, a unique feature of RNS is that the neurostimulator provides chronic electrocorticography (ECoG), which has powerful diagnostic potential. We highlight emerging applications of chronic ECoG, and we discuss how the limitations of RNS will inform development of next-generation devices.
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Affiliation(s)
- Brandy B Ma
- Department of Neurology and Weill Institute for Neurosciences, University of California, San Francisco, CA 94143, USA
| | - Vikram R Rao
- Department of Neurology and Weill Institute for Neurosciences, University of California, San Francisco, CA 94143, USA.
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McGovern RA, Alomar S, Bingaman WE, Gonzalez-Martinez J. Robot-Assisted Responsive Neurostimulator System Placement in Medically Intractable Epilepsy: Instrumentation and Technique. Oper Neurosurg (Hagerstown) 2018; 16:455-464. [DOI: 10.1093/ons/opy112] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 04/17/2018] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
The management of medically refractory epilepsy patients who are not surgical candidates has remained challenging. Closed loop—or responsive—neurostimulation (RNS) is now an established therapy for the treatment of epilepsy with specific indications. The RNS® system (NeuroPace Inc, Mountainview, California) has recently been shown to be effective in reducing the seizure frequency of partial onset seizures. The electrode design consists of either intracerebral depth electrodes or subdural strip electrodes, and stereotaxis is typically used to guide placement into the EZ. Details on the operative techniques used to place these electrodes have been lacking.
OBJECTIVE
To address the advantage of using a robotic-assisted technique to place depth electrodes for RNS® system placement compared to the typical frame-based or frameless stereotactic systems.
METHODS
We retrospectively reviewed our single center, technical operative experience with RNS® system placement using robotic assistance from 2014 to 2016 via chart review.
RESULTS
Twelve patients underwent RNS® system placement using robotic assistance. Mean operative time was 121 min for a median of 2 depth electrodes with mean deviation from intended target of ∼3 mm in x, y, and z planes. Two patients developed wound infections, 1 of whom was reimplanted. Seizures were reduced by ∼40% at 2 yr, similar to the results seen in the open label portion of the pivotal RNS trial.
CONCLUSION
Robotic-assisted stereotaxis can be used to provide a stable and accurate stereotactic platform for insertion of intracerebral RNS electrodes, representing a safe, efficient and accurate procedure.
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Affiliation(s)
- Robert A McGovern
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Soha Alomar
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
- King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - William E Bingaman
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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