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Scotti-Degnan C, Riisen A, Flynn T. The role of psychology and neuropsychology in pediatric epilepsy surgery evaluation. Curr Probl Pediatr Adolesc Health Care 2024; 54:101592. [PMID: 38555234 DOI: 10.1016/j.cppeds.2024.101592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Epilepsy is one of the most common neurological problems affecting 470,000 children in the United States. While most youth will achieve seizure freedom using medication, up to a third will continue to have seizures and are therefore considered to have drug-resistant epilepsy (DRE). Children and adolescents with epilepsy are at higher risk of behavioral, cognitive, and emotional disorders. Youth with DRE are at even greater risk of behavioral and emotional problems impacting quality of life and may need to pursue surgical interventions, including resective surgery or device implantation. Due to advances in the evaluation of candidates and surgical options, epilepsy surgery is more effective and has become second-line treatment for youth with DRE. This paper highlights the importance of exploring, assessing, and treating psychological and neuropsychological factors throughout the three phases of the epilepsy surgery process and ways pediatricians can support youth and families.
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Affiliation(s)
- Carinna Scotti-Degnan
- The Children's Hospital of Philadelphia, Assistant Professor, Department of Psychiatry, Associated Faculty of the Perelman School of Medicine at the University of Pennsylvania, United States.
| | - Amanda Riisen
- The Children's Hospital of Philadelphia, Assistant Professor, Department of Psychiatry, Associated Faculty of the Perelman School of Medicine at the University of Pennsylvania, United States.
| | - Thomas Flynn
- The Children's Hospital of Philadelphia, Section Chief, Neuropsychology & Assessment, United States.
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2
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Rosenberg A, Wang R, Petchpradub M, Beaudreault C, Sacknovitz A, Cozzi FM, Wolf SM, McGoldrick PE, Muh CR. Responsive neurostimulation in pediatric epilepsy: a systematic review and individual patient meta-analysis supplemented by a single institution case series in 105 aggregated patients. Childs Nerv Syst 2024:10.1007/s00381-024-06546-x. [PMID: 39060746 DOI: 10.1007/s00381-024-06546-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024]
Abstract
PURPOSE To assess responsive neurostimulation (RNS) efficacy in pediatric patients with drug-resistant epilepsy, comparing response (≥ 50% reduction in seizure frequency) rates between patients with two or fewer seizure foci and those with multifocal or generalized epilepsy. This study seeks to address the gap in knowledge regarding RNS effectiveness in pediatric populations. METHODS A systematic review and meta-analysis included data from PubMed, Embase, and Web of Science through November 2023, including 17 retrospective studies and a case series of 24 patients from our practice for a total of 105 aggregated patients. The inclusion criteria of patients were age ≤ 18 and diagnosis of DRE. Exclusion criteria were nonhuman subjects and cases where RNS was not utilized to treat DRE. Study inclusion criteria were detailing the use of RNS and comparing patients with ≤ 2 foci with other focalities. Study exclusion criteria were failure to specify RNS lead placement or type of epilepsy. The risk of bias was assessed using the ROBINS-I tool for all non-randomized studies. Effect sizes and variances were aggregated to provide a comprehensive measure of RNS efficacy, and heterogeneity among the studies was assessed using I2 statistics and Cochran's Q test to evaluate the consistency of the findings. Statistical analyses were conducted using IBM SPSS. We analyzed demographics, epilepsy history, treatment outcomes, and RNS details using descriptive and inferential statistics, including Wilcoxon-Mann-Whitney, Fisher's exact, and chi-squared tests. This systematic review was not registered. RESULTS Seventeen retrospective studies and a single-institution case series, encompassing 105 pediatric patients, were analyzed. Effect sizes and confidence intervals were calculated to quantify treatment effects. Analyses revealed that RNS reduces seizure frequency across a spectrum of pediatric epilepsy syndromes, irrespective of the seizures' focal, multifocal, or generalized origins. The effectiveness of RNS was not influenced by the patient's sex, age at epilepsy onset, or presence of neurological and psychiatric comorbidities. Prior vagus nerve stimulation surgery and the presence of an epileptic syndrome were factors associated with a lower likelihood of near-complete seizure remission with RNS, underscoring the complexities of treating patients with generalized epilepsies or previous interventional failures. The necessity of further research into individualized surgical strategies for patients was underscored by the mixed results of comparisons of electrode characteristics with responder rates. Limitations of our study include its reliance on retrospective studies, which introduces potential bias and limits the ability to infer causality. DISCUSSION RNS is a safe and effective treatment in pediatric patients with DRE across demographic, comorbidity, and focality variability. FDA age and focality restrictions, along with patient and physician hesitancy, may be limiting the potential for effective treatment of pediatric DRE with RNS. Prospective randomized trials are recommended to validate these findings.
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Affiliation(s)
- A Rosenberg
- School of Medicine, New York Medical College, Valhalla, NY, USA.
| | - R Wang
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - M Petchpradub
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - C Beaudreault
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - A Sacknovitz
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - F M Cozzi
- Cambridge Brain Tumour Imaging Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - S M Wolf
- School of Medicine, New York Medical College, Valhalla, NY, USA
- Department of Pediatrics, Division of Pediatric Neurology, Maria Fareri Children's Hospital, Valhalla, NY, USA
- Boston Children's Hospital Physicians, Hawthorne, NY, USA
| | - P E McGoldrick
- School of Medicine, New York Medical College, Valhalla, NY, USA
- Department of Pediatrics, Division of Pediatric Neurology, Maria Fareri Children's Hospital, Valhalla, NY, USA
- Boston Children's Hospital Physicians, Hawthorne, NY, USA
| | - C R Muh
- School of Medicine, New York Medical College, Valhalla, NY, USA
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
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3
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Baumgartner ME, Qiu L, Philipp LR, Galligan K, Halpern C, Kennedy BC. Technological advances in pediatric epilepsy surgery. Curr Probl Pediatr Adolesc Health Care 2024; 54:101588. [PMID: 38494391 DOI: 10.1016/j.cppeds.2024.101588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Affiliation(s)
| | - Liming Qiu
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, USA
| | - Lucas R Philipp
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, USA
| | - Kathleen Galligan
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Casey Halpern
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA; Department of Neurosurgery, University of Pennsylvania, Philadelphia, USA
| | - Benjamin C Kennedy
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA; Department of Neurosurgery, University of Pennsylvania, Philadelphia, USA; Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, USA.
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Ueda R, Sakakura K, Mitsuhashi T, Sonoda M, Firestone E, Kuroda N, Kitazawa Y, Uda H, Luat AF, Johnson EL, Ofen N, Asano E. Cortical and white matter substrates supporting visuospatial working memory. Clin Neurophysiol 2024; 162:9-27. [PMID: 38552414 PMCID: PMC11102300 DOI: 10.1016/j.clinph.2024.03.008] [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: 12/28/2023] [Revised: 02/24/2024] [Accepted: 03/11/2024] [Indexed: 05/19/2024]
Abstract
OBJECTIVE In tasks involving new visuospatial information, we rely on working memory, supported by a distributed brain network. We investigated the dynamic interplay between brain regions, including cortical and white matter structures, to understand how neural interactions change with different memory loads and trials, and their subsequent impact on working memory performance. METHODS Patients undertook a task of immediate spatial recall during intracranial EEG monitoring. We charted the dynamics of cortical high-gamma activity and associated functional connectivity modulations in white matter tracts. RESULTS Elevated memory loads were linked to enhanced functional connectivity via occipital longitudinal tracts, yet decreased through arcuate, uncinate, and superior-longitudinal fasciculi. As task familiarity grew, there was increased high-gamma activity in the posterior inferior-frontal gyrus (pIFG) and diminished functional connectivity across a network encompassing frontal, parietal, and temporal lobes. Early pIFG high-gamma activity was predictive of successful recall. Including this metric in a logistic regression model yielded an accuracy of 0.76. CONCLUSIONS Optimizing visuospatial working memory through practice is tied to early pIFG activation and decreased dependence on irrelevant neural pathways. SIGNIFICANCE This study expands our knowledge of human adaptation for visuospatial working memory, showing the spatiotemporal dynamics of cortical network modulations through white matter tracts.
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Affiliation(s)
- Riyo Ueda
- Department of Pediatrics, Children's Hospital of Michigan, Detroit Medical Center, Wayne State University, Detroit, Michigan 48201, USA; National Center Hospital, National Center of Neurology and Psychiatry, Tokyo 1878551, Japan.
| | - Kazuki Sakakura
- Department of Pediatrics, Children's Hospital of Michigan, Detroit Medical Center, Wayne State University, Detroit, Michigan 48201, USA; Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois 60612, USA; Department of Neurosurgery, University of Tsukuba, Tsukuba 3058575, Japan.
| | - Takumi Mitsuhashi
- Department of Pediatrics, Children's Hospital of Michigan, Detroit Medical Center, Wayne State University, Detroit, Michigan 48201, USA; Department of Neurosurgery, Juntendo University, School of Medicine, Tokyo 1138421, Japan.
| | - Masaki Sonoda
- Department of Pediatrics, Children's Hospital of Michigan, Detroit Medical Center, Wayne State University, Detroit, Michigan 48201, USA; Department of Neurosurgery, Yokohama City University, Yokohama 2360004, Japan.
| | - Ethan Firestone
- Department of Physiology, Wayne State University, Detroit, Michigan 48202, USA.
| | - Naoto Kuroda
- Department of Pediatrics, Children's Hospital of Michigan, Detroit Medical Center, Wayne State University, Detroit, Michigan 48201, USA; Department of Epileptology, Tohoku University Graduate School of Medicine, Sendai 9808575, Japan.
| | - Yu Kitazawa
- Department of Pediatrics, Children's Hospital of Michigan, Detroit Medical Center, Wayne State University, Detroit, Michigan 48201, USA; Department of Neurology and Stroke Medicine, Yokohama City University, Yokohama 2360004, Japan.
| | - Hiroshi Uda
- Department of Pediatrics, Children's Hospital of Michigan, Detroit Medical Center, Wayne State University, Detroit, Michigan 48201, USA; Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka 5458585, Japan.
| | - Aimee F Luat
- Department of Pediatrics, Children's Hospital of Michigan, Detroit Medical Center, Wayne State University, Detroit, Michigan 48201, USA; Department of Neurology, Children's Hospital of Michigan, Detroit Medical Center, Wayne State University, Detroit, Michigan 48201, USA; Department of Pediatrics, Central Michigan University, Mt. Pleasant, Michigan 48858, USA.
| | - Elizabeth L Johnson
- Departments of Medical Social Sciences, Pediatrics, and Psychology, Northwestern University, Chicago, Illinois 60611, USA.
| | - Noa Ofen
- Life-Span Cognitive Neuroscience Program, Institute of Gerontology and Merrill Palmer Skillman Institute, Wayne State University, Detroit, Michigan 48202, USA; Department of Psychology, Wayne State University, Detroit, Michigan 48202, USA.
| | - Eishi Asano
- Department of Pediatrics, Children's Hospital of Michigan, Detroit Medical Center, Wayne State University, Detroit, Michigan 48201, USA; Department of Neurology, Children's Hospital of Michigan, Detroit Medical Center, Wayne State University, Detroit, Michigan 48201, USA; Translational Neuroscience Program, Wayne State University, Detroit, Michigan 48201, USA.
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Mertens A, Boon P, Vonck K. Neurostimulation for childhood epilepsy. Dev Med Child Neurol 2024; 66:440-444. [PMID: 37448317 DOI: 10.1111/dmcn.15692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/06/2023] [Indexed: 07/15/2023]
Abstract
The experience with neurostimulation for childhood epilepsy is far less extensive than for adults. Nevertheless, the implementation of these techniques could be of great value, especially considering the detrimental effects of ongoing seizures on the developing brain. In this review, we discuss the available evidence for neurostimulation for childhood epilepsy. Vagus nerve stimulation (VNS) is the most studied neurostimulation modality in children. Based on mostly retrospective, open-label studies, we can conclude that VNS has a similar safety and efficacy profile in children compared to adults. Although there is little available evidence for deep brain stimulation (DBS) and responsive neurostimulation (RNS) in children, both DBS and RNS show promise in reducing seizure frequency with few complications. The implementation of non-invasive techniques with a more appealing safety profile has gained interest. Small randomized control trials and open-label studies have investigated transcranial direct current simulation for childhood epilepsy, demonstrating promising but inconsistent findings.
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Affiliation(s)
- Ann Mertens
- Department of Neurology, 4Brain, Ghent University Hospital, Ghent, Belgium
| | - Paul Boon
- Department of Neurology, 4Brain, Ghent University Hospital, Ghent, Belgium
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Kristl Vonck
- Department of Neurology, 4Brain, Ghent University Hospital, Ghent, Belgium
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Ghaith AK, El-Hajj VG, Sanchez-Garavito JE, Zamanian C, Ghanem M, Bon-Nieves A, Chen B, Drees CN, Miller D, Parker JJ, Almeida JP, Elmi-Terander A, Tatum W, Middlebrooks EH, Bydon M, Van-Gompel JJ, Lundstrom BN, Grewal SS. Trends in the Utilization of Surgical Modalities for the Treatment of Drug-Resistant Epilepsy: A Comprehensive 10-Year Analysis Using the National Inpatient Sample. Neurosurgery 2024:00006123-990000000-01011. [PMID: 38189460 DOI: 10.1227/neu.0000000000002811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 11/10/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Epilepsy is considered one of the most prevalent and severe chronic neurological disorders worldwide. Our study aims to analyze the national trends in different treatment modalities for individuals with drug-resistant epilepsy and investigate the outcomes associated with these procedural trends in the United States. METHODS Using the National Inpatient Sample database from 2010 to 2020, patients with drug-resistant focal epilepsy who underwent laser interstitial thermal therapy (LITT), open surgical resection, vagus nerve stimulation (VNS), or responsive neurostimulation (RNS) were identified. Trend analysis was performed using piecewise joinpoint regression. Propensity score matching was used to compare outcomes between 10 years prepandemic before 2020 and the first peak of the COVID-19 pandemic. RESULTS This study analyzed a total of 33 969 patients with a diagnosis of drug-resistant epilepsy, with 3343 patients receiving surgical resection (78%), VNS (8.21%), RNS (8%), and LITT (6%). Between 2010 and 2020, there was an increase in the use of invasive electroencephalography monitoring for seizure zone localization (P = .003). There was an increase in the use of LITT and RNS (P < .001), while the use of surgical resection and VNS decreased over time (P < .001). Most of these patients (89%) were treated during the pre-COVID pandemic era (2010-2019), while a minority (11%) underwent treatment during the COVID pandemic (2020). After propensity score matching, the rate of pulmonary complications, postprocedural hematoma formation, and mortality were slightly higher during the pandemic compared with the prepandemic period (P = .045, P = .033, and P = .026, respectively). CONCLUSION This study indicates a relative decrease in the use of surgical resections, as a treatment for drug-resistant focal epilepsy. By contrast, newer, minimally invasive surgical approaches including LITT and RNS showed gradual increases in usage.
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Affiliation(s)
- Abdul Karim Ghaith
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Victor Gabriel El-Hajj
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | | | - Cameron Zamanian
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Marc Ghanem
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Antonio Bon-Nieves
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Baibing Chen
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - David Miller
- Department of Diagnostic Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Jonathon J Parker
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Joao Paulo Almeida
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | | | - William Tatum
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Mohamad Bydon
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jamie J Van-Gompel
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Sanjeet S Grewal
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
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7
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Ghatan S. Pediatric Neurostimulation and Practice Evolution. Neurosurg Clin N Am 2024; 35:1-15. [PMID: 38000833 DOI: 10.1016/j.nec.2023.09.006] [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] [Indexed: 11/26/2023]
Abstract
Since the late nineteenth century, the prevailing view of epilepsy surgery has been to identify a seizure focus in a medically refractory patient and eradicate it. Sadly, only a select number of the many who suffer from uncontrolled seizures benefit from this approach. With the development of safe, efficient stereotactic methods and targeted surgical therapies that can affect deep structures and modulate broad networks in diverse disorders, epilepsy surgery in children has undergone a paradigmatic evolutionary change. With modern diagnostic techniques such as stereo electroencephalography combined with closed loop neuromodulatory systems, pediatric epilepsy surgery can reach a much broader population of underserved patients.
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Affiliation(s)
- Saadi Ghatan
- Neurological Surgery Icahn School of Medicine at Mt Sinai, New York, NY 10128, USA.
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8
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Enner S, El-Hallal M, Hogan K, Rodgers S, Karkare S, Kothare S. Safety & feasibility of responsive neurostimulation in children with refractory epilepsy: A single-center experience. Seizure 2024; 114:121-124. [PMID: 38141494 DOI: 10.1016/j.seizure.2023.12.005] [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: 08/28/2023] [Revised: 11/20/2023] [Accepted: 12/07/2023] [Indexed: 12/25/2023] Open
Abstract
OBJECTIVES Responsive neurostimulation (RNS) is a relatively recent addition to the epilepsy surgery armory, gaining FDA approval in 2013 for use in adults with intractable focal epilepsy. Data for the use of RNS system in patients less than 18 years of age is limited. We aim to determine the safety and feasibility of RNS in children with refractory epilepsy. METHODS A retrospective chart review was conducted for all patients who underwent RNS implantation at an urban tertiary children's hospital. Demographics of the patients were obtained, including age at the time of implant, MRI findings, seizure onset zone identification, and RNS targets. RESULTS Out of a fourteen patient cohort, one patient had a post-operative complication of infection at surgical site requiring explantation. Thirteen out of 14 patients had immediate post-operative head imaging that was negative for hemorrhage, infarction, or skull fracture; one patient did not undergo head imaging. No patients reported a worsening clinical seizure frequency at a 6-month follow up visit. In the subset of patients who were implanted with RNS and did not undergo concurrent resections, there was a statistically significant reduction in the average number of long episodes at the most recent visit when compared to the 1-month post-operative visit (p = 0.0268). CONCLUSIONS RNS is a feasible and safe option for children as young as six years with refractory epilepsy when appropriate seizure focus identification has been performed with stereo CT and stereo EEG evaluations, and can be used in conjunction with other surgical epilepsy treatment modalities. Two canister RNS placement is achievable for patients with a broad epileptogenic network or multifocal seizure onset zones.
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Affiliation(s)
- Stephanie Enner
- Division of Child Neurology, Department of Pediatrics, Cohen Children's Medical Center, 2001 Marcus Avenue Suite W290, Lake Success, NY 11042, United States.
| | - Maria El-Hallal
- Division of Child Neurology, Department of Pediatrics, Cohen Children's Medical Center, 2001 Marcus Avenue Suite W290, Lake Success, NY 11042, United States
| | - Katherine Hogan
- Division of Child Neurology, Department of Pediatrics, Cohen Children's Medical Center, 2001 Marcus Avenue Suite W290, Lake Success, NY 11042, United States
| | - Shaun Rodgers
- Division of Pediatric Neurosurgery, Department of Pediatrics, Cohen Children's Medical Center, 410 Lakeville Road, New Hyde Park, NY, United States
| | - Shefali Karkare
- Division of Child Neurology, Department of Pediatrics, Cohen Children's Medical Center, 2001 Marcus Avenue Suite W290, Lake Success, NY 11042, United States
| | - Sanjeev Kothare
- Division of Child Neurology, Department of Pediatrics, Cohen Children's Medical Center, 2001 Marcus Avenue Suite W290, Lake Success, NY 11042, United States
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Levy AS, Bystrom LL, Brown EC, Fajardo M, Wang S. Responsive neurostimulation for treatment of pediatric refractory epilepsy: A pooled analysis of the literature. Clin Neurol Neurosurg 2023; 234:108012. [PMID: 37839147 DOI: 10.1016/j.clineuro.2023.108012] [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: 05/01/2023] [Revised: 09/23/2023] [Accepted: 10/06/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Drug-resistant epilepsy (DRE) is a complex medical condition often requiring resective surgery and/or some form of neurostimulation. In recent years responsive neurostimulation (RNS) has shown promising results in adult DRE, however there is a paucity of information regarding outcomes of RNS among pediatric patients treated with DRE. In this individual patient data meta-analysis (IPDMA) we seek to elucidate the effects RNS has on the pediatric population. METHODS Literature regarding management of pediatric DRE via RNS was reviewed in accordance with individual patient data meta-analysis guidelines. Four databases were searched with keywords ((Responsive neurostimulation) AND (epilepsy)) through December of 2022. From 1624 retrieved full text studies, 15 were ultimately included affording a pool of 98 individual participants. RESULTS The median age at implantation was 14 years (n = 95) with 42% of patients having undergone prior resective epilepsy surgery, 18% with prior vagus nerve stimulation (VNS), and 1% with prior RNS. At a median follow up time 12 months, median percent seizure reduction was 75% with 57% of patients achieving Engel Class < 2 outcome, 9.7% of which achieved seizure freedom. We report a postoperative complication rate of 8.4%, half of which were device-related infections. Magnetic resonance imaging (MRI)-negative cases were negatively associated with magnitude of seizure reduction, and direct targeting techniques were associated with stronger treatment response when compared to other methods. CONCLUSIONS This review suggests RNS to be an effective treatment modality for pediatric patients with a postoperative complication rate comparable to that of RNS in adults. Investigation of prognostic clinical variables should be undertaken to augment patient selection. Last, multi-institutional prospective study of long-term effects of RNS on pediatric patients would stand to benefit clinicians in the management of pediatric DRE.
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Affiliation(s)
- Adam S Levy
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, FL, 33136, USA.
| | - Lauren L Bystrom
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - Erik C Brown
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - Marytery Fajardo
- Division of Neurology, Brain Institute, Nicklaus Children's Hospital, 3200 SW 60th Ct Ste 302, Miami, FL, 33155, USA
| | - Shelly Wang
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, FL, 33136, USA; Division of Neurosurgery, Brain Institute, Nicklaus Children's Hospital, 3200 SW 60th Ct Ste 302, Miami, FL, 33155, USA
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10
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Piazza MG, Varga G, Welch W, Abel TJ. The Utility of Responsive Neurostimulation for the Treatment of Pediatric Drug-Resistant Epilepsy. Brain Sci 2023; 13:1455. [PMID: 37891823 PMCID: PMC10605851 DOI: 10.3390/brainsci13101455] [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: 09/11/2023] [Revised: 10/07/2023] [Accepted: 10/09/2023] [Indexed: 10/29/2023] Open
Abstract
Drug-resistant epilepsy (DRE) has a strongly negative impact on quality of life, as well as the development of pediatric patients. Surgical treatments have evolved over time, including more invasive craniotomies for resection or disconnection. More recently, neuromodulation techniques have been employed as a less invasive option for patients. Responsive neurostimulation (RNS) is the first closed-loop technology that allows for both treatment and device data collection, which allows for an internal assessment of the efficacy of treatment. This novel technology has been approved in adults and has been used off label in pediatrics. This review seeks to describe this technology, its history, and future directions.
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Affiliation(s)
- Martin G. Piazza
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA 15260, USA; (M.G.P.); (G.V.)
| | - Gregory Varga
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA 15260, USA; (M.G.P.); (G.V.)
| | - William Welch
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA 15260, USA;
| | - Taylor J. Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA 15260, USA; (M.G.P.); (G.V.)
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11
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Ghosh S, Sinha JK, Ghosh S, Sharma H, Bhaskar R, Narayanan KB. A Comprehensive Review of Emerging Trends and Innovative Therapies in Epilepsy Management. Brain Sci 2023; 13:1305. [PMID: 37759906 PMCID: PMC10527076 DOI: 10.3390/brainsci13091305] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/09/2023] [Accepted: 09/10/2023] [Indexed: 09/29/2023] Open
Abstract
Epilepsy is a complex neurological disorder affecting millions worldwide, with a substantial number of patients facing drug-resistant epilepsy. This comprehensive review explores innovative therapies for epilepsy management, focusing on their principles, clinical evidence, and potential applications. Traditional antiseizure medications (ASMs) form the cornerstone of epilepsy treatment, but their limitations necessitate alternative approaches. The review delves into cutting-edge therapies such as responsive neurostimulation (RNS), vagus nerve stimulation (VNS), and deep brain stimulation (DBS), highlighting their mechanisms of action and promising clinical outcomes. Additionally, the potential of gene therapies and optogenetics in epilepsy research is discussed, revealing groundbreaking findings that shed light on seizure mechanisms. Insights into cannabidiol (CBD) and the ketogenic diet as adjunctive therapies further broaden the spectrum of epilepsy management. Challenges in achieving seizure control with traditional therapies, including treatment resistance and individual variability, are addressed. The importance of staying updated with emerging trends in epilepsy management is emphasized, along with the hope for improved therapeutic options. Future research directions, such as combining therapies, AI applications, and non-invasive optogenetics, hold promise for personalized and effective epilepsy treatment. As the field advances, collaboration among researchers of natural and synthetic biochemistry, clinicians from different streams and various forms of medicine, and patients will drive progress toward better seizure control and a higher quality of life for individuals living with epilepsy.
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Affiliation(s)
- Shampa Ghosh
- GloNeuro, Sector 107, Vishwakarma Road, Noida 201301, India
- ICMR—National Institute of Nutrition, Tarnaka, Hyderabad 500007, India
| | | | - Soumya Ghosh
- GloNeuro, Sector 107, Vishwakarma Road, Noida 201301, India
| | | | - Rakesh Bhaskar
- School of Chemical Engineering, Yeungnam University, 280 Daehak-Ro, Gyeongsan, Gyeongbuk 38541, Republic of Korea
| | - Kannan Badri Narayanan
- School of Chemical Engineering, Yeungnam University, 280 Daehak-Ro, Gyeongsan, Gyeongbuk 38541, Republic of Korea
- Research Institute of Cell Culture, Yeungnam University, 280 Daehak-Ro, Gyeongsan, Gyeongbuk 38541, Republic of Korea
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Fields MC, Eka O, Schreckinger C, Dugan P, Asaad WF, Blum AS, Bullinger K, Willie JT, Burdette DE, Anderson C, Quraishi IH, Gerrard J, Singh A, Lee K, Yoo JY, Ghatan S, Panov F, Marcuse LV. A multicenter retrospective study of patients treated in the thalamus with responsive neurostimulation. Front Neurol 2023; 14:1202631. [PMID: 37745648 PMCID: PMC10516547 DOI: 10.3389/fneur.2023.1202631] [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: 04/09/2023] [Accepted: 06/19/2023] [Indexed: 09/26/2023] Open
Abstract
Introduction For drug resistant epilepsy patients who are either not candidates for resective surgery or have already failed resective surgery, neuromodulation is a promising option. Neuromodulatory approaches include responsive neurostimulation (RNS), deep brain stimulation (DBS), and vagal nerve stimulation (VNS). Thalamocortical circuits are involved in both generalized and focal onset seizures. This paper explores the use of RNS in the centromedian nucleus of the thalamus (CMN) and in the anterior thalamic nucleus (ANT) of patients with drug resistant epilepsy. Methods This is a retrospective multicenter study from seven different epilepsy centers in the United States. Patients that had unilateral or bilateral thalamic RNS leads implanted in the CMN or ANT for at least 6 months were included. Primary objectives were to describe the implant location and determine changes in the frequency of disabling seizures at 6 months, 1 year, 2 years, and > 2 years. Secondary objectives included documenting seizure free periods, anti-seizure medication regimen changes, stimulation side effects, and serious adverse events. In addition, the global clinical impression scale was completed. Results Twelve patients had at least one lead placed in the CMN, and 13 had at least one lead placed in the ANT. The median baseline seizure frequency was 15 per month. Overall, the median seizure reduction was 33% at 6 months, 55% at 1 year, 65% at 2 years, and 74% at >2 years. Seizure free intervals of at least 3 months occurred in nine patients. Most patients (60%, 15/25) did not have a change in anti-seizure medications post RNS placement. Two serious adverse events were recorded, one related to RNS implantation. Lastly, overall functioning seemed to improve with 88% showing improvement on the global clinical impression scale. Discussion Meaningful seizure reduction was observed in patients who suffer from drug resistant epilepsy with unilateral or bilateral RNS in either the ANT or CMN of the thalamus. Most patients remained on their pre-operative anti-seizure medication regimen. The device was well tolerated with few side effects. There were rare serious adverse events. Most patients showed an improvement in global clinical impression scores.
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Affiliation(s)
- Madeline C Fields
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Onome Eka
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | - Patricia Dugan
- Department of Neurology, Langone Medical Center, New York University, New York, NY, United States
| | - Wael F Asaad
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Providence, RI, United States
| | - Andrew S Blum
- Department of Neurology, Warren Alpert Medical School, Brown University, Providence, RI, United States
| | - Katie Bullinger
- Department of Neurology, School of Medicine, Emory University, Atlanta, GA, United States
| | - Jon T Willie
- Department of Neurosurgery, School of Medicine, Washington University in St Louis, St. Louis, MO, United States
| | - David E Burdette
- Department of Neurosciences, Corewell Health, Grand Rapids, MI, United States
| | - Christopher Anderson
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Imran H Quraishi
- Department of Neurology, School of Medicine, Yale University, New Haven, CT, United States
| | - Jason Gerrard
- Department of Neurosurgery, School of Medicine, Yale University, New Haven, CT, United States
| | - Anuradha Singh
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Kyusang Lee
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Ji Yeoun Yoo
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Saadi Ghatan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Fedor Panov
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Lara V Marcuse
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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13
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Karakas C, Houck K, Handoko M, Trandafir C, Coorg R, Haneef Z, Riviello JJ, Weiner HL, Curry D, Ali I. Responsive Neurostimulation for the Treatment of Children With Drug-Resistant Epilepsy in Tuberous Sclerosis Complex. Pediatr Neurol 2023; 145:97-101. [PMID: 37302216 DOI: 10.1016/j.pediatrneurol.2023.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 02/17/2023] [Accepted: 05/12/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND To review seizure outcomes in children with tuberous sclerosis complex (TSC) and drug-resistant epilepsy (DRE) treated with the responsive neurostimulation (RNS) System. METHODS We retrospectively reviewed children (<21 years old) with TSC implanted with the RNS System at Texas Children's Hospital between July 2016 and May 2022. RESULTS Five patients meeting the search criteria were identified (all female). The median age of the RNS implantation was 13 years (range: 5 to 20 years). The median epilepsy duration before the RNS implantation was 13 years (range: 5 to 20 years). Surgeries before RNS implantation included vagus nerve stimulator placement (n = 2), left parietal resection (n = 1), and corpus callosotomy (n = 1). The median number of antiseizure medications tried before RNS was 8 (range: 5 to 12). The rationale for the RNS System implantation included seizure onset in eloquent cortex (n = 3) and multifocal seizures (n = 2). The maximum current density for each patient ranged between 1.8 and 3.5 μC/cm2, with an average daily stimulation of 2240 (range: 400 to 4200). There was an 86% median seizure reduction (range 0% to 99%) at a median follow-up duration of 25 months (range: 17 to 25 months). No patient experienced implantation or stimulation-related complications. CONCLUSIONS We observed a favorable improvement in seizure frequency in pediatric patients with DRE secondary to TSC treated with the RNS System. The RNS System may be a safe and effective treatment for DRE in children with TSC.
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Affiliation(s)
- Cemal Karakas
- Norton Children's Medical Group, The University of Louisville, Louisville, Kentucky
| | - Kimberly Houck
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Maureen Handoko
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Cristina Trandafir
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Rohini Coorg
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Zulfi Haneef
- Neurology Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - James J Riviello
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Howard L Weiner
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Daniel Curry
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Irfan Ali
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas.
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Kitazawa Y, Sonoda M, Sakakura K, Mitsuhashi T, Firestone E, Ueda R, Kambara T, Iwaki H, Luat AF, Marupudi NI, Sood S, Asano E. Intra- and inter-hemispheric network dynamics supporting object recognition and speech production. Neuroimage 2023; 270:119954. [PMID: 36828156 PMCID: PMC10112006 DOI: 10.1016/j.neuroimage.2023.119954] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 02/14/2023] [Accepted: 02/17/2023] [Indexed: 02/25/2023] Open
Abstract
We built normative brain atlases that animate millisecond-scale intra- and inter-hemispheric white matter-level connectivity dynamics supporting object recognition and speech production. We quantified electrocorticographic modulations during three naming tasks using event-related high-gamma activity from 1,114 nonepileptogenic intracranial electrodes (i.e., non-lesional areas unaffected by epileptiform discharges). Using this electrocorticography data, we visualized functional connectivity modulations defined as significant naming-related high-gamma modulations occurring simultaneously at two sites connected by direct white matter streamlines on diffusion-weighted imaging tractography. Immediately after stimulus onset, intra- and inter-hemispheric functional connectivity enhancements were confined mainly across modality-specific perceptual regions. During response preparation, left intra-hemispheric connectivity enhancements propagated in a posterior-to-anterior direction, involving the left precentral and prefrontal areas. After overt response onset, inter- and intra-hemispheric connectivity enhancements mainly encompassed precentral, postcentral, and superior-temporal (STG) gyri. We found task-specific connectivity enhancements during response preparation as follows. Picture naming enhanced activity along the left arcuate fasciculus between the inferior-temporal and precentral/posterior inferior-frontal (pIFG) gyri. Nonspeech environmental sound naming augmented functional connectivity via the left inferior longitudinal and fronto-occipital fasciculi between the medial-occipital and STG/pIFG. Auditory descriptive naming task enhanced usage of the left frontal U-fibers, involving the middle-frontal gyrus. Taken together, the commonly observed network enhancements include inter-hemispheric connectivity optimizing perceptual processing exerted in each hemisphere, left intra-hemispheric connectivity supporting semantic and lexical processing, and inter-hemispheric connectivity for symmetric oral movements during overt speech. Our atlases improve the currently available models of object recognition and speech production by adding neural dynamics via direct intra- and inter-hemispheric white matter tracts.
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Affiliation(s)
- Yu Kitazawa
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, 48201, USA; Department of Neurology and Stroke Medicine, Yokohama City University, Yokohama, 2360004, Japan
| | - Masaki Sonoda
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, 48201, USA; Department of Neurosurgery, Yokohama City University, Yokohama, 2360004, Japan
| | - Kazuki Sakakura
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, 48201, USA; Department of Neurosurgery, University of Tsukuba, Tsukuba, 3058575, Japan
| | - Takumi Mitsuhashi
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, 48201, USA; Department of Neurosurgery, Juntendo University, Tokyo, 1138421, Japan
| | - Ethan Firestone
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, 48201, USA; Department of Physiology, Wayne State University, Detroit, 48201, USA
| | - Riyo Ueda
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, 48201, USA
| | - Toshimune Kambara
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, 48201, USA; Department of Psychology, Hiroshima University, Hiroshima, 7398524, Japan
| | - Hirotaka Iwaki
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, 48201, USA; Department of Psychiatry, Hachinohe City Hospital, Hachinohe, 0318555, Japan
| | - Aimee F Luat
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, 48201, USA; Department of Neurology, Children's Hospital of Michigan, Wayne State University, Detroit, 48201, USA; Department of Pediatrics, Central Michigan University, Mount Pleasant, 48858, USA
| | - Neena I Marupudi
- Department of Neurosurgery, Children's Hospital of Michigan, Wayne State University, Detroit, 48201, USA
| | - Sandeep Sood
- Department of Neurosurgery, Children's Hospital of Michigan, Wayne State University, Detroit, 48201, USA
| | - Eishi Asano
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, 48201, USA; Department of Neurology, Children's Hospital of Michigan, Wayne State University, Detroit, 48201, USA.
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15
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Singh RK, Eschbach K, Samanta D, Perry MS, Liu G, Alexander AL, Wong-Kisiel L, Ostendorf A, Tatachar P, Reddy SB, McCormack MJ, Manuel CM, Gonzalez-Giraldo E, Numis AL, Wolf S, Karia S, Karakas C, Olaya J, Shrey D, Auguste KI, Depositario-Cabacar D. Responsive Neurostimulation in Drug-Resistant Pediatric Epilepsy: Findings From the Epilepsy Surgery Subgroup of the Pediatric Epilepsy Research Consortium. Pediatr Neurol 2023; 143:106-112. [PMID: 37084698 DOI: 10.1016/j.pediatrneurol.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 01/22/2023] [Accepted: 03/02/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND Responsive neurostimulation (RNS), a closed-loop intracranial electrical stimulation system, is a palliative surgical option for patients with drug-resistant epilepsy (DRE). RNS is approved by the US Food and Drug Administration for patients aged ≥18 years with pharmacoresistant partial seizures. The published experience of RNS in children is limited. METHODS This is a combined prospective and retrospective study of patients aged ≤18 years undergoing RNS placement. Patients were identified from the multicenter Pediatric Epilepsy Research Consortium Surgery Registry from January 2018 to December 2021, and additional data relevant to this study were retrospectively collected and analyzed. RESULTS Fifty-six patients received RNS during the study period. The mean age at implantation was 14.9 years; the mean duration of epilepsy, 8.1 years; and the mean number of previously trialed antiseizure medications, 4.2. Five patients (9%) previously trialed dietary therapy, and 19 patients (34%) underwent prior surgery. Most patients (70%) underwent invasive electroencephalography evaluation before RNS implantation. Complications occurred in three patients (5.3%) including malpositioned leads or transient weakness. Follow-up (mean 11.7 months) was available for 55 patients (one lost), and four were seizure-free with RNS off. Outcome analysis of stimulation efficacy was available for 51 patients: 33 patients (65%) were responders (≥50% reduction in seizure frequency), including five patients (10%) who were seizure free at follow-up. CONCLUSIONS For young patients with focal DRE who are not candidates for surgical resection, neuromodulation should be considered. Although RNS is off-label for patients aged <18 years, this multicenter study suggests that it is a safe and effective palliative option for children with focal DRE.
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Affiliation(s)
- Rani K Singh
- Department of Pediatrics, Atrium Health-Levine Children's Hospital, Charlotte, North Carolina; Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, North Carolina.
| | - Krista Eschbach
- Section of Neurology, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Debopam Samanta
- Child Neurology Section, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Alaska
| | - M Scott Perry
- Jane and John Justin Institute for Mind Health, Neurosciences Center, Cook Children's Medical Center, Ft Worth, Texas
| | - Gang Liu
- Department of Pediatrics, Atrium Health-Levine Children's Hospital, Charlotte, North Carolina
| | - Allyson L Alexander
- Department of Neurosurgery, School of Medicine, Anschutz Medical Campus, University of Colorado, Aurora, Colorado; Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | | | - Adam Ostendorf
- Division of Neurology, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | | | - Shilpa B Reddy
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael J McCormack
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chad M Manuel
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Adam L Numis
- Department of Neurology, University of California, San Francisco, San Francisco, California
| | - Steven Wolf
- Department of Pediatrics, Boston Children's Health Physicians, New York, New York
| | - Samir Karia
- Division of Child Neurology, University of Louisville School of Medicine, Louisville, Kentucky
| | - Cemal Karakas
- Division of Child Neurology, University of Louisville School of Medicine, Louisville, Kentucky
| | - Joffre Olaya
- Department of Neurosurgery, Children's Hospital Orange County, Orange, California
| | - Daniel Shrey
- Department of Neurosciences, Children's Hospital Orange County, Orange, California
| | - Kurtis I Auguste
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California
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16
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Piper RJ, Richardson RM, Worrell G, Carmichael DW, Baldeweg T, Litt B, Denison T, Tisdall MM. Towards network-guided neuromodulation for epilepsy. Brain 2022; 145:3347-3362. [PMID: 35771657 PMCID: PMC9586548 DOI: 10.1093/brain/awac234] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 05/30/2022] [Accepted: 06/16/2022] [Indexed: 11/30/2022] Open
Abstract
Epilepsy is well-recognized as a disorder of brain networks. There is a growing body of research to identify critical nodes within dynamic epileptic networks with the aim to target therapies that halt the onset and propagation of seizures. In parallel, intracranial neuromodulation, including deep brain stimulation and responsive neurostimulation, are well-established and expanding as therapies to reduce seizures in adults with focal-onset epilepsy; and there is emerging evidence for their efficacy in children and generalized-onset seizure disorders. The convergence of these advancing fields is driving an era of 'network-guided neuromodulation' for epilepsy. In this review, we distil the current literature on network mechanisms underlying neurostimulation for epilepsy. We discuss the modulation of key 'propagation points' in the epileptogenic network, focusing primarily on thalamic nuclei targeted in current clinical practice. These include (i) the anterior nucleus of thalamus, now a clinically approved and targeted site for open loop stimulation, and increasingly targeted for responsive neurostimulation; and (ii) the centromedian nucleus of the thalamus, a target for both deep brain stimulation and responsive neurostimulation in generalized-onset epilepsies. We discuss briefly the networks associated with other emerging neuromodulation targets, such as the pulvinar of the thalamus, piriform cortex, septal area, subthalamic nucleus, cerebellum and others. We report synergistic findings garnered from multiple modalities of investigation that have revealed structural and functional networks associated with these propagation points - including scalp and invasive EEG, and diffusion and functional MRI. We also report on intracranial recordings from implanted devices which provide us data on the dynamic networks we are aiming to modulate. Finally, we review the continuing evolution of network-guided neuromodulation for epilepsy to accelerate progress towards two translational goals: (i) to use pre-surgical network analyses to determine patient candidacy for neurostimulation for epilepsy by providing network biomarkers that predict efficacy; and (ii) to deliver precise, personalized and effective antiepileptic stimulation to prevent and arrest seizure propagation through mapping and modulation of each patients' individual epileptogenic networks.
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Affiliation(s)
- Rory J Piper
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - R Mark Richardson
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | | | | | - Torsten Baldeweg
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Brian Litt
- Department of Neurology and Bioengineering, University of Pennsylvania, Philadelphia, USA
| | | | - Martin M Tisdall
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
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Falls N, Arango JI, Adelson PD. Responsive neurostimulation in pediatric patients with drug-resistant epilepsy. Neurosurg Focus 2022; 53:E9. [DOI: 10.3171/2022.7.focus22339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/26/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Medically refractory epilepsy remains a therapeutic challenge when resective surgery is not a practical option and indirect neurostimulation efficacy may be limited. In these instances responsive neurostimulation (RNS) has been used in adults, with good outcomes in most patients. However, the utility of RNS in children and young adults has not been systematically explored. In this study, the authors present a single institution’s experience with RNS in pediatric patients.
METHODS
A single-center retrospective chart review of patients who underwent RNS implantation at Phoenix Children’s Hospital during the 4-year period between January 2018 and December 2021 was performed.
RESULTS
Following evaluation for epilepsy surgery, 22 patients underwent RNS implantation using different anatomical targets depending on the predetermined epileptic focus/network. In the cohort, 59% of patients were male, the mean age at implantation was 16.4 years (range 6–22 years), and the mean follow-up time was 2.7 years (range 1.0–4.3 years). All patients had a preoperative noninvasive evaluation that included MRI, video-electroencephalography, and resting-state functional MRI. Additionally, 13 patients underwent invasive monitoring with stereo-electroencephalography to help determine RNS targets. All patients had variable positive responses with reduction of seizure frequency and/or intensity. Overall, seizure frequency reduction of > 50% was seen in the majority (86%) of patients. There were two complications: one patient experienced transitory weakness and one generator failed, requiring replacement. A patient died of sudden unexpected death in epilepsy 3 years after implantation despite being seizure free during the previous year.
CONCLUSIONS
RNS used in children with medically refractory epilepsy improved seizure control after implantation, with decreases in seizure frequency > 50% from preoperative baseline in the majority of patients. Preliminary findings indicate that functional MRI and stereo-electroencephalography were helpful for RNS targeting and that RNS can be used safely even in young children.
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Affiliation(s)
- Nicole Falls
- Department of Neurosurgery, Barrow Neurological Institute at Phoenix Children’s Hospital, Phoenix; and
- University of Arizona College of Medicine, Phoenix, Arizona
| | - Jorge I. Arango
- Department of Neurosurgery, Barrow Neurological Institute at Phoenix Children’s Hospital, Phoenix; and
| | - P. David Adelson
- Department of Neurosurgery, Barrow Neurological Institute at Phoenix Children’s Hospital, Phoenix; and
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