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Han M, DiGiovine MP, Armstrong C. An overview of responsive neurostimulation for the pediatrician. Curr Probl Pediatr Adolesc Health Care 2024; 54:101622. [PMID: 38755044 DOI: 10.1016/j.cppeds.2024.101622] [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: 05/18/2024]
Affiliation(s)
- Michelle Han
- Children's Hospital of Philadelphia, Division of Neurology, Philadelphia, PA, USA
| | - Marissa P DiGiovine
- Children's Hospital of Philadelphia, Division of Neurology, Philadelphia, PA, USA; University of Pennsylvania, Division of Neurology, Philadelphia, PA, USA.
| | - Caren Armstrong
- Children's Hospital of Philadelphia, Division of Neurology, Philadelphia, PA, USA
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2
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Dabrowski A, Armstrong C. A pediatrician's guide to epilepsy surgery. Curr Probl Pediatr Adolesc Health Care 2024; 54:101578. [PMID: 38485613 PMCID: PMC11223955 DOI: 10.1016/j.cppeds.2024.101578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
Surgical intervention for epilepsy emerged in the second half of the 20th century as an important option for pediatric patients with medically refractory epilepsy. Both the number of patients undergoing epilepsy surgery and the available surgical procedures for epilepsy have expanded in the last 3 decades, and now range from surgical resection to neuromodulatory device placement1,2 Studies showing that many patients who would be excellent candidates for surgery are still not being offered appropriate interventions have prompted an interest in ensuring that all providers who see patients with epilepsy are aware of the options for epilepsy surgery to facilitate earlier referrals when medications have not been effective3 In this article, we will introduce the pediatrician to the process involved in determining epilepsy surgery candidacy and to surgical outcomes, with the goal of empowering pediatric providers to refer their medically refractory epilepsy patients to a pediatric epilepsy center.
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Affiliation(s)
- Ania Dabrowski
- Children's Hospital of Philadelphia, Division of Neurology, Philadelphia, PA, USA
| | - Caren Armstrong
- Children's Hospital of Philadelphia, Division of Neurology, Philadelphia, PA, USA.
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3
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Wang K, Shan Y, Wei P, Ren L, Chen L, Zhu J, Zhao G. Safety and efficacy of a novel responsive neurostimulation system in China for drug-refractory focal epilepsy: The first-in-man study. Chin Med J (Engl) 2024; 137:1486-1488. [PMID: 37612262 PMCID: PMC11188855 DOI: 10.1097/cm9.0000000000002821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Indexed: 08/25/2023] Open
Affiliation(s)
- Kailiang Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
- International Neuroscience Institute (China-INI), Clinical Research Center for Epilepsy, Capital Medical University, Beijing 100053, China
- China National Medical Center for Neurological Diseases, Beijing 100053, China
| | - Yongzhi Shan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
- International Neuroscience Institute (China-INI), Clinical Research Center for Epilepsy, Capital Medical University, Beijing 100053, China
- China National Medical Center for Neurological Diseases, Beijing 100053, China
| | - Penghu Wei
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
- International Neuroscience Institute (China-INI), Clinical Research Center for Epilepsy, Capital Medical University, Beijing 100053, China
- China National Medical Center for Neurological Diseases, Beijing 100053, China
| | - Liankun Ren
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Liang Chen
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai 200032, China
| | - Junming Zhu
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Guoguang Zhao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
- International Neuroscience Institute (China-INI), Clinical Research Center for Epilepsy, Capital Medical University, Beijing 100053, China
- China National Medical Center for Neurological Diseases, Beijing 100053, China
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4
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Salama H, Salama A, Oscher L, Jallo GI, Shimony N. The role of neuromodulation in the management of drug-resistant epilepsy. Neurol Sci 2024:10.1007/s10072-024-07513-9. [PMID: 38642321 DOI: 10.1007/s10072-024-07513-9] [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: 11/15/2023] [Accepted: 04/02/2024] [Indexed: 04/22/2024]
Abstract
Drug-resistant epilepsy (DRE) poses significant challenges in terms of effective management and seizure control. Neuromodulation techniques have emerged as promising solutions for individuals who are unresponsive to pharmacological treatments, especially for those who are not good surgical candidates for surgical resection or laser interstitial therapy (LiTT). Currently, there are three neuromodulation techniques that are FDA-approved for the management of DRE. These include vagus nerve stimulation (VNS), deep brain stimulation (DBS), and responsive neurostimulation (RNS). Device selection, optimal time, and DBS and RNS target selection can also be challenging. In general, the number and localizability of the epileptic foci, alongside the comorbidities manifested by the patients, substantially influence the selection process. In the past, the general axiom was that DBS and VNS can be used for generalized and localized focal seizures, while RNS is typically reserved for patients with one or two highly localized epileptic foci, especially if they are in eloquent areas of the brain. Nowadays, with the advance in our understanding of thalamic involvement in DRE, RNS is also very effective for general non-focal epilepsy. In this review, we will discuss the underlying mechanisms of action, patient selection criteria, and the evidence supporting the use of each technique. Additionally, we explore emerging technologies and novel approaches in neuromodulation, such as closed-loop systems. Moreover, we examine the challenges and limitations associated with neuromodulation therapies, including adverse effects, complications, and the need for further long-term studies. This comprehensive review aims to provide valuable insights on present and future use of neuromodulation.
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Affiliation(s)
- HusamEddin Salama
- Al-Quds University-School of Medicine, Abu Dis, Jerusalem, Palestine
| | - Ahmed Salama
- Al-Quds University-School of Medicine, Abu Dis, Jerusalem, Palestine
| | - Logan Oscher
- Department of Neurosurgery, Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, 600 5th Street South, St. Petersburg, FL, 33701, USA
| | - George I Jallo
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.
- Department of Neurosurgery, Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, 600 5th Street South, St. Petersburg, FL, 33701, USA.
| | - Nir Shimony
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, USA
- Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, TN, USA
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA
- Semmes-Murphey Clinic, Memphis, TN, USA
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5
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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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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.
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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
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Samfira IMA, Galanopoulou AS, Nariai H, Gursky JM, Moshé SL, Bardakjian BL. EEG-based spatiotemporal dynamics of fast ripple networks and hubs in infantile epileptic spasms. Epilepsia Open 2024; 9:122-137. [PMID: 37743321 PMCID: PMC10839371 DOI: 10.1002/epi4.12831] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 09/17/2023] [Indexed: 09/26/2023] Open
Abstract
OBJECTIVE Infantile epileptic spasms (IS) are epileptic seizures that are associated with increased risk for developmental impairments, adult epilepsies, and mortality. Here, we investigated coherence-based network dynamics in scalp EEG of infants with IS to identify frequency-dependent networks associated with spasms. We hypothesized that there is a network of increased fast ripple connectivity during the electrographic onset of clinical spasms, which is distinct from controls. METHODS We retrospectively analyzed peri-ictal and interictal EEG recordings of 14 IS patients. The data was compared with 9 age-matched controls. Wavelet phase coherence (WPC) was computed between 0.2 and 400 Hz. Frequency- and time-dependent brain networks were constructed using this coherence as the strength of connection between two EEG channels, based on graph theory principles. Connectivity was evaluated through global efficiency (GE) and channel-based closeness centrality (CC), over frequency and time. RESULTS GE in the fast ripple band (251-400 Hz) was significantly greater following the onset of spasms in all patients (P < 0.05). Fast ripple networks during the first 10s from spasm onset show enhanced anteroposterior gradient in connectivity (posterior > central > anterior, Kruskal-Wallis P < 0.001), with maximum CC over the centroparietal channels in 10/14 patients. Additionally, this anteroposterior gradient in CC connectivity is observed during spasms but not during the interictal awake or asleep states of infants with IS. In controls, anteroposterior gradient in fast ripple CC was noted during arousals and wakefulness but not during sleep. There was also a simultaneous decrease in GE in the 5-8 Hz range after the onset of spasms (P < 0.05), of unclear biological significance. SIGNIFICANCE We identified an anteroposterior gradient in the CC connectivity of fast ripple hubs during spasms. This anteroposterior gradient observed during spasms is similar to the anteroposterior gradient in the CC connectivity observed in wakefulness or arousals in controls, suggesting that this state change is related to arousal networks.
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Affiliation(s)
- Ioana M. A. Samfira
- Edward S. Rogers Sr. Department of Electrical and Computer EngineeringUniversity of TorontoTorontoOntarioCanada
| | - Aristea S. Galanopoulou
- Saul R. Korey Department of Neurology and Comprehensive Einstein/Montefiore Epilepsy CenterAlbert Einstein College of MedicineBronxNew YorkUSA
- Isabelle Rapin Division of Child NeurologyAlbert Einstein College of MedicineBronxNew YorkUSA
- Dominick P. Purpura Department of NeuroscienceAlbert Einstein College of MedicineBronxNew YorkUSA
| | - Hiroki Nariai
- Department of PediatricsUCLA Mattel Children's HospitalLos AngelesCaliforniaUSA
| | - Jonathan M. Gursky
- Saul R. Korey Department of Neurology and Comprehensive Einstein/Montefiore Epilepsy CenterAlbert Einstein College of MedicineBronxNew YorkUSA
| | - Solomon L. Moshé
- Saul R. Korey Department of Neurology and Comprehensive Einstein/Montefiore Epilepsy CenterAlbert Einstein College of MedicineBronxNew YorkUSA
- Isabelle Rapin Division of Child NeurologyAlbert Einstein College of MedicineBronxNew YorkUSA
- Dominick P. Purpura Department of NeuroscienceAlbert Einstein College of MedicineBronxNew YorkUSA
- Department of PediatricsEinstein College of MedicineBronxNew YorkUSA
| | - Berj L. Bardakjian
- Edward S. Rogers Sr. Department of Electrical and Computer EngineeringUniversity of TorontoTorontoOntarioCanada
- Institute of Biomedical EngineeringUniversity of TorontoTorontoOntarioCanada
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8
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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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9
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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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Edmonds B, Miyakoshi M, Gianmaria Remore L, Ahn S, Westley Phillips H, Daida A, Salamon N, Bari A, Sankar R, Matsumoto JH, Fallah A, Nariai H. Characteristics of ictal thalamic EEG in pediatric-onset neocortical focal epilepsy. Clin Neurophysiol 2023; 154:116-125. [PMID: 37595481 PMCID: PMC10529874 DOI: 10.1016/j.clinph.2023.07.007] [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: 03/13/2023] [Revised: 07/09/2023] [Accepted: 07/24/2023] [Indexed: 08/20/2023]
Abstract
OBJECTIVE To characterize ictal EEG change in the centromedian (CM) and anterior nucleus (AN) of the thalamus, using stereoelectroencephalography (SEEG) recordings. METHODS Forty habitual seizures were analyzed in nine patients with pediatric-onset neocortical drug-resistant epilepsy who underwent SEEG (age 2-25 y) with thalamic coverage. Both visual and quantitative analysis was used to evaluate ictal EEG signal in the cortex and thalamus. The amplitude and cortico-thalamic latencies of broadband frequencies at ictal onset were measured. RESULTS Visual analysis demonstrated consistent detection of ictal EEG changes in both the CM nucleus and AN nucleus with latency to thalamic ictal EEG changes of less than 400 ms in 95% of seizures, with low-voltage fast activity being the most common ictal pattern. Quantitative broadband amplitude analysis showed consistent power changes across the frequency bands, corresponding to ictal EEG onset, while while ictal EEG latency was variable from -18.0 seconds to 13.2 seconds. There was no significant difference between detection of CM and AN ictal activity on visual or amplitude analysis. Four patients with subsequent thalamic responsive neurostimulation (RNS) demonstrated ictal EEG changes consistent with SEEG findings. CONCLUSIONS Ictal EEG changes were consistently seen at the CM and AN of the thalamus during neocortical seizures. SIGNIFICANCE It may be feasible to use a closed-loop system in the thalamus to detect and modulate seizure activity for neocortical epilepsy.
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Affiliation(s)
- Benjamin Edmonds
- Division of Pediatric Neurology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine, Los Angeles, CA, USA.
| | - Makoto Miyakoshi
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Swartz Center for Computational Neuroscience, Institute for Neural Computation, University of California San Diego, UCSD Medical Center, San Diego, CA, USA.
| | - Luigi Gianmaria Remore
- Department of Neurosurgery, UCLA Medical Center, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Samuel Ahn
- Division of Pediatric Neurology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine, Los Angeles, CA, USA
| | - H Westley Phillips
- Department of Neurosurgery, UCLA Medical Center, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Atsuro Daida
- Division of Pediatric Neurology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Noriko Salamon
- Department of Radiological Sciences, University of California, Los Angeles, CA, USA
| | - Ausaf Bari
- Department of Neurosurgery, UCLA Medical Center, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Raman Sankar
- Division of Pediatric Neurology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine, Los Angeles, CA, USA; The UCLA Children's Discovery and Innovation Institute, Los Angeles, CA, USA
| | - Joyce H Matsumoto
- Division of Pediatric Neurology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Aria Fallah
- Department of Neurosurgery, UCLA Medical Center, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Hiroki Nariai
- Division of Pediatric Neurology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine, Los Angeles, CA, USA; The UCLA Children's Discovery and Innovation Institute, Los Angeles, CA, USA.
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11
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Panchavati S, Daida A, Edmonds B, Miyakoshi M, Oana S, Ahn SS, Arnold C, Salamon N, Sankar R, Fallah A, Speier W, Nariai H. Uncovering Spatiotemporal Dynamics of the Corticothalamic Network during Seizures. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.21.23294382. [PMID: 37662245 PMCID: PMC10473800 DOI: 10.1101/2023.08.21.23294382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Objective Although the clinical efficacy of deep brain stimulation targeting the anterior nucleus (AN) and centromedian nucleus (CM) of the thalamus has been actively investigated for the treatment of medication-resistant epilepsy, few studies have investigated dynamic ictal changes in corticothalamic connectivity in human EEG recording. This study aims to establish the complex spatiotemporal dynamics of the ictal corticothalamic network associated with various seizure foci. Methods We analyzed ten patients (aged 2.7-28.1) with medication-resistant focal epilepsy who underwent stereotactic EEG evaluation with thalamic coverage. We examined both undirected and directed connectivity, incorporating coherence and spectral Granger causality analysis (GCA) between the diverse seizure foci and thalamic nuclei (AN and CM). Results In our analysis of 36 seizures, coherence between seizure onset and thalamic nuclei increased across all frequencies, especially in slower bands (delta, theta, alpha). GCA showed increased information flow from seizure onset to the thalamus across all frequency bands, but outflows from the thalamus were mainly in slower frequencies, particularly delta. In the subgroup analysis based on various seizure foci, the delta coherence showed a more pronounced increase at CM than at AN during frontal lobe seizures. Conversely, in limbic seizures, the delta coherence increase was greater at AN compared to CM. Interpretation It appears that the delta frequency plays a pivotal role in modulating the corticothalamic network during seizures. Our results underscore the significance of comprehending the spatiotemporal dynamics of the corticothalamic network during seizures, and this knowledge could guide personalized neuromodulation treatment strategies.
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Affiliation(s)
- Saarang Panchavati
- Department of Bioengineering, University of California, Los Angeles, CA, USA
- Department of Radiological Sciences, University of California, Los Angeles, CA, USA
| | - Atsuro Daida
- Division of Pediatric Neurology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Benjamin Edmonds
- Division of Pediatric Neurology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Makoto Miyakoshi
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Shingo Oana
- Division of Pediatric Neurology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Samuel S Ahn
- Division of Pediatric Neurology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Corey Arnold
- Department of Bioengineering, University of California, Los Angeles, CA, USA
- Department of Radiological Sciences, University of California, Los Angeles, CA, USA
| | - Noriko Salamon
- Department of Radiology, UCLA Medical Center, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Raman Sankar
- Division of Pediatric Neurology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine, Los Angeles, CA, USA
- The UCLA Children's Discovery and Innovation Institute, Los Angeles, CA, USA
| | - Aria Fallah
- Department of Neurosurgery, UCLA Medical Center, David Geffen School of Medicine, Los Angeles, CA, USA
| | - William Speier
- Department of Bioengineering, University of California, Los Angeles, CA, USA
- Department of Radiological Sciences, University of California, Los Angeles, CA, USA
| | - Hiroki Nariai
- Division of Pediatric Neurology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine, Los Angeles, CA, USA
- The UCLA Children's Discovery and Innovation Institute, Los Angeles, CA, USA
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12
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Edmonds B, Miyakoshi M, Remore LG, Ahn S, Phillips HW, Daida A, Salamon N, Bari A, Sankar R, Matsumoto JH, Fallah A, Nariai H. Characteristics of ictal thalamic EEG in pediatric-onset neocortical focal epilepsy. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.06.22.23291714. [PMID: 37425697 PMCID: PMC10327240 DOI: 10.1101/2023.06.22.23291714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
Objective To characterize ictal EEG change in the centromedian (CM) and anterior nucleus (AN) of the thalamus, using stereoelectroencephalography (SEEG) recordings. Methods Forty habitual seizures were analyzed in nine patients with pediatric-onset neocortical drug-resistant epilepsy who underwent SEEG (age 2-25 y) with thalamic coverage. Both visual and quantitative analysis was used to evaluate ictal EEG signal in the cortex and thalamus. The amplitude and cortico-thalamic latencies of broadband frequencies at ictal onset were measured. Results Visual analysis demonstrated consistent detection of ictal EEG changes in both the CM nucleus and AN nucleus with latency to thalamic ictal EEG changes of less than 400ms in 95% of seizures, with low-voltage fast activity being the most common ictal pattern. Quantitative broadband amplitude analysis showed consistent power changes across the frequency bands, corresponding to ictal EEG onset, while while ictal EEG latency was variable from -18.0 seconds to 13.2 seconds. There was no significant difference between detection of CM and AN ictal activity on visual or amplitude analysis. Four patients with subsequent thalamic responsive neurostimulation (RNS) demonstrated ictal EEG changes consistent with SEEG findings. Conclusions Ictal EEG changes were consistently seen at the CM and AN of the thalamus during neocortical seizures. Significance It may be feasible to use a closed-loop system in the thalamus to detect and modulate seizure activity for neocortical epilepsy.
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Affiliation(s)
- Benjamin Edmonds
- Division of Pediatric Neurology, Department of Pediatrics, UCLA Mattel Children’s Hospital, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Makoto Miyakoshi
- Division of Child and Adolescent Psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Swartz Center for Computational Neuroscience, Institute for Neural Computation, University of California San Diego, UCSD Medical Center, San Diego, CA, USA
| | - Luigi Gianmaria Remore
- Department of Neurosurgery, UCLA Medical Center, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Samuel Ahn
- Division of Pediatric Neurology, Department of Pediatrics, UCLA Mattel Children’s Hospital, David Geffen School of Medicine, Los Angeles, CA, USA
| | - H. Westley Phillips
- Department of Neurosurgery, UCLA Medical Center, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Atsuro Daida
- Division of Pediatric Neurology, Department of Pediatrics, UCLA Mattel Children’s Hospital, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Noriko Salamon
- Department of Radiological Sciences, University of California, Los Angeles, CA, USA
| | - Ausaf Bari
- Department of Neurosurgery, UCLA Medical Center, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Raman Sankar
- Division of Pediatric Neurology, Department of Pediatrics, UCLA Mattel Children’s Hospital, David Geffen School of Medicine, Los Angeles, CA, USA
- The UCLA Children’s Discovery and Innovation Institute, Los Angeles, CA, USA
| | - Joyce H. Matsumoto
- Division of Pediatric Neurology, Department of Pediatrics, UCLA Mattel Children’s Hospital, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Aria Fallah
- Department of Neurosurgery, UCLA Medical Center, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Hiroki Nariai
- Division of Pediatric Neurology, Department of Pediatrics, UCLA Mattel Children’s Hospital, David Geffen School of Medicine, Los Angeles, CA, USA
- The UCLA Children’s Discovery and Innovation Institute, Los Angeles, CA, USA
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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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14
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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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15
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Bergeron D, Iorio-Morin C, Bonizzato M, Lajoie G, Orr Gaucher N, Racine É, Weil AG. Use of Invasive Brain-Computer Interfaces in Pediatric Neurosurgery: Technical and Ethical Considerations. J Child Neurol 2023; 38:223-238. [PMID: 37116888 PMCID: PMC10226009 DOI: 10.1177/08830738231167736] [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] [Received: 09/20/2022] [Revised: 02/11/2023] [Accepted: 03/17/2023] [Indexed: 04/30/2023]
Abstract
Invasive brain-computer interfaces hold promise to alleviate disabilities in individuals with neurologic injury, with fully implantable brain-computer interface systems expected to reach the clinic in the upcoming decade. Children with severe neurologic disabilities, like quadriplegic cerebral palsy or cervical spine trauma, could benefit from this technology. However, they have been excluded from clinical trials of intracortical brain-computer interface to date. In this manuscript, we discuss the ethical considerations related to the use of invasive brain-computer interface in children with severe neurologic disabilities. We first review the technical hardware and software considerations for the application of intracortical brain-computer interface in children. We then discuss ethical issues related to motor brain-computer interface use in pediatric neurosurgery. Finally, based on the input of a multidisciplinary panel of experts in fields related to brain-computer interface (functional and restorative neurosurgery, pediatric neurosurgery, mathematics and artificial intelligence research, neuroengineering, pediatric ethics, and pragmatic ethics), we then formulate initial recommendations regarding the clinical use of invasive brain-computer interfaces in children.
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Affiliation(s)
- David Bergeron
- Division of Neurosurgery, Université de Montréal, Montreal, Québec, Canada
| | | | - Marco Bonizzato
- Electrical Engineering Department, Polytechnique Montréal, Montreal, Québec, Canada
- Neuroscience Department and Centre
interdisciplinaire de recherche sur le cerveau et l’apprentissage (CIRCA), Université de Montréal, Montréal, Québec, Canada
| | - Guillaume Lajoie
- Mathematics and Statistics Department, Université de Montréal, Montreal, Québec, Canada
- Mila - Québec AI Institute, Montréal,
Québec, Canada
| | - Nathalie Orr Gaucher
- Department of Pediatric Emergency
Medicine, CHU Sainte-Justine, Montréal, Québec, Canada
- Bureau de l’Éthique clinique, Faculté
de médecine de l’Université de Montréal, Montreal, Québec, Canada
| | - Éric Racine
- Pragmatic Research Unit, Institute de
Recherche Clinique de Montréal (IRCM), Montreal, Québec, Canada
- Department of Medicine and Department
of Social and Preventative Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Alexander G. Weil
- Division of Neurosurgery, Department
of Surgery, Centre Hospitalier Universitaire Sainte-Justine (CHUSJ), Département de
Pédiatrie, Université de Montréal, Montreal, Québec, Canada
- Department of Neuroscience, Université de Montréal, Montréal, Québec, Canada
- Brain and Development Research Axis,
CHU Sainte-Justine Research Center, Montréal, Québec, Canada
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16
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Koutsouras GW, Hall WA. Surgery for pediatric drug resistant epilepsy: a narrative review of its history, surgical implications, and treatment strategies. Transl Pediatr 2023; 12:245-259. [PMID: 36891373 PMCID: PMC9986775 DOI: 10.21037/tp-22-200] [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: 05/03/2022] [Accepted: 05/26/2022] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Drug-resistant epilepsy (DRE), also known as medically refractory epilepsy, is a disorder of high prevalence and negatively impacts a patients quality of life, neurodevelopment, and life expectancy. Pediatric epilepsy surgery has been conducted since the late 1800s, and randomized controlled trials have demonstrated the marked effectiveness of surgery on seizure reduction and the potential for cure. Despite the strong evidence for pediatric epilepsy surgery, there is also strong evidence describing its underutilization. The objective of this narrative review is to describe the history, strength, and limitations in the evidence of surgery for pediatric drug resistant epilepsy. METHODS This narrative review was conducted utilizing standard search engines to include the relevant articles on the topic of surgery for drug resistant epilepsy in children, with main keywords including surgery in pediatric epilepsy and drug-refractory epilepsy. KEY CONTENT AND FINDINGS The first components describe the historical perspective of pediatric epilepsy surgery and the evidence that highlight the strengths and limitations of epilepsy surgery. We then highlight the importance of presurgical referral and evaluation, followed by a section detailing the surgical options for children with DRE. Lastly, we provide a perspective on the future of pediatric epilepsy surgery. CONCLUSIONS Evidence supports the role for surgery in pediatric medically refractory epilepsy in seizure frequency reduction, improved curative rates, and improvements in neurodevelopment and quality of life.
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Affiliation(s)
- George W Koutsouras
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Walter A Hall
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, NY, USA
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17
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Ali I, Houck KM, Sully K. Neuromodulation in Children with Drug-Resistant Epilepsy. JOURNAL OF PEDIATRIC EPILEPSY 2023. [DOI: 10.1055/s-0042-1760293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
AbstractThe introduction of neuromodulation was a revolutionary advancement in the antiseizure armamentarium for refractory epilepsy. The basic principle of neuromodulation is to deliver an electrical stimulation to the desired neuronal site to modify the neuronal functions not only at the site of delivery but also at distant sites by complex neuronal processes like disrupting the neuronal circuitry and amplifying the functions of marginally functional neurons. The modality is considered open-loop when electrical stimulation is provided at a set time interval or closed-loop when delivered in response to an incipient seizure. Neuromodulation in individuals older than 18 years with epilepsy has proven efficacious and safe. The use of neuromodulation is extended off-label to pediatric patients with epilepsy and the results are promising. Vagus nerve stimulation (VNS), responsive neurostimulation (RNS), and deep brain stimulation (DBS) are Food and Drug Administration-approved therapeutic techniques. The VNS provides retrograde signaling to the central nervous system, whereas DBS and RNS are more target specific in the central nervous system. While DBS is open-loop and approved for stimulation of the anterior nucleus of the thalamus, the RNS is closed-loop and can stimulate any cortical or subcortical structure. We will review different modalities and their clinical efficacy in individuals with epilepsy, with a focus on pediatric patients.
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Affiliation(s)
- Irfan Ali
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States
| | - Kimberly M. Houck
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States
| | - Krystal Sully
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States
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18
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Hartnett SM, Greiner HM, Arya R, Tenney JR, Aungaroon G, Holland K, Leach JL, Air EL, Skoch J, Mangano FT. Responsive neurostimulation device therapy in pediatric patients with complex medically refractory epilepsy. J Neurosurg Pediatr 2022; 30:499-506. [PMID: 36029267 DOI: 10.3171/2022.7.peds2281] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 07/05/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pediatric epilepsy is characterized as drug resistant in 20%-30% of patients and defined as persistent seizures despite adequate treatment with two first-line antiepileptic medications. The American Academy of Neurology advocates surgical options earlier in the treatment of epilepsy to provide long-term seizure reduction. The new development of minimally invasive approaches has recently allowed for surgical options to patients not previously deemed surgical candidates. These may include patients with bilateral, deep, eloquent, or poorly localizing epileptogenic foci. To this end, responsive neurostimulation (RNS) is an FDA-approved closed-loop neuromodulation device for adjuvant treatment of adults with medically intractable epilepsy arising from one or multiple foci. METHODS In this study, the authors describe their initial institutional experience with the use of RNS in pediatric patients with drug-resistant epilepsy. An IRB-approved retrospective review was conducted of 8 pediatric patients who underwent RNS implantation at Cincinnati Children's Hospital Medical Center between 2019 and 2021. RESULTS Eight patients met the inclusion criteria for the study. The average age at the time of surgery was 14.7 years (range 8-18 years) with a mean follow-up of 16.5 months. All patients underwent invasive monitoring with stereo-EEG, subdural grid placement, or a combination of both. All patients had either bilateral or eloquent cortex targets. Trajectories were based on noninvasive (phase 1) and invasive (phase 2) seizure onset zone localization data. Four (50%) of the 8 patients underwent surgical intervention for epilepsy prior to RNS placement. RNS electrodes were placed with robot-assisted guidance in a hybrid operating room with intraoperative CT and electrocorticography. The authors demonstrated individualized RNS electrode trajectory and placement with targets in the amygdala/hippocampus, bilateral insula, bilateral parietal and occipital targets, and frontoparietal regions for a total of 14 implanted electrodes. One adverse event occurred, a wound infection requiring return to the operating room for removal of the RNS implant. All patients demonstrated a reduction in seizure frequency. All patients achieved > 50% reduction in seizure frequency at last follow-up. CONCLUSIONS RNS implantation in carefully selected pediatric patients appears safe and efficacious in reducing seizure burden with a low rate of operative complications.
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Affiliation(s)
- Sara M Hartnett
- 1Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Hansel M Greiner
- 2Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- 3Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ravindra Arya
- 2Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- 3Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jeffrey R Tenney
- 2Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- 3Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Gewalin Aungaroon
- 2Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- 3Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Katherine Holland
- 2Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- 3Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - James L Leach
- 2Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- 3Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ellen L Air
- 4Department of Neurological Surgery, Henry Ford Medical Center, Detroit, Michigan; and
| | - Jesse Skoch
- 1Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- 5Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Francesco T Mangano
- 1Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- 3Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- 5Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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19
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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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20
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Curtis K, Hect JL, Harford E, Welch WP, Abel TJ. Responsive neurostimulation for pediatric patients with drug-resistant epilepsy: a case series and review of the literature. Neurosurg Focus 2022; 53:E10. [PMID: 36183183 DOI: 10.3171/2022.7.focus22331] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/21/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Responsive neurostimulation (RNS) is a promising treatment for pediatric patients with drug-resistant epilepsy for whom resective surgery is not an option. The relative indications and risk for pediatric patients undergoing RNS therapy require further investigation. Here, the authors report their experience with RNS implantation and therapy in pediatric patients. METHODS The authors performed a retrospective chart review to identify patients implanted with RNS depth or strip electrodes for the treatment of drug-resistant epilepsy at their institution between 2020 and 2022. Patient demographics, surgical variables, and patient seizure outcomes (Engel class and International League Against Epilepsy [ILAE] reporting) were evaluated. RESULTS The authors identified 20 pediatric patients ranging in age from 8 to 21 years (mean 15 [SD 4] years), who underwent RNS implantation, including depth electrodes (n = 15), strip electrodes (n = 2), or both (n = 3). Patient seizure semiology, onset, and implantation strategy were heterogeneous, including bilateral centromedian nucleus (n = 5), mesial temporal lobe (n = 4), motor cortex or supplementary motor area (n = 7), or within an extratemporal epileptogenic zone (n = 4). There were no acute complications of RNS implantation (hemorrhage or stroke) or device malfunctions. One patient required rehospitalization for postoperative infection. At the longest follow-up (mean 10 [SD 7] months), 13% patients had Engel class IIB, 38% had Engel class IIIA, 6% had Engel class IIIB, 19% had Engel class IVA, 19% had Engel class IVB, and 6% had Engel class IVC outcomes. Using ILAE metrics, 6% were ILAE class 3, 25% were ILAE class 4, and 69% were ILAE class 5. CONCLUSIONS This case series supports current literature suggesting that RNS is a safe and potentially effective surgical intervention for pediatric patients with drug-resistant epilepsy. The authors report comparable rates of serious adverse events to current RNS literature in pediatric and adult populations. Seizure outcomes may continue to improve with follow-up as stimulation strategy is refined and the chronic neuromodulatory effect evolves, as previously described in patients with RNS. Further large-scale, multicenter case series of RNS in pediatric patients with drug-resistant epilepsy are required to determine long-term pediatric safety and effectiveness.
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Affiliation(s)
- Kendall Curtis
- 1Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh
| | - Jasmine L Hect
- 1Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh
| | - Emily Harford
- 1Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh
| | - William P Welch
- 2Division of Child Neurology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh; and
| | - Taylor J Abel
- 1Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh
- 3Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pennsylvania
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21
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Shlobin NA, Wang A, Phillips HW, Yan H, Ibrahim GM, Elkaim LM, Wang S, Liu X, Cai L, Nguyen DK, Fallah A, Weil AG. Sensorimotor outcomes after resection for perirolandic drug-resistant epilepsy: a systematic review and individual patient data meta-analysis. J Neurosurg Pediatr 2022; 30:410-427. [PMID: 35932272 DOI: 10.3171/2022.6.peds22160] [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: 04/26/2022] [Accepted: 06/22/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The prevalence of long-term postoperative sensorimotor deficits in children undergoing perirolandic resective epilepsy surgery is unclear. The risk of developing these deficits must be weighed against the potential reduction in seizure frequency after surgery. In this study, the authors investigated the prevalence of sensorimotor deficits after resective surgery at ≥ 1 year postoperatively. METHODS A systematic review and individual patient data meta-analysis was conducted using PubMed, Embase, and Scopus databases. Subgroups of patients were identified and categorized according to their outcomes as follows: group A patients were denoted as seizure free with no postoperative sensorimotor deficits; group B patients experienced seizure recurrence with no deficit; group C patients were seizure free with deficits; and group D patients were not seizure free and with deficits. Rates of sensory deficits were examined in patients undergoing postcentral gyrus resection, and rates of motor deficits were aggregated in patients undergoing precentral gyrus resection. RESULTS Of 797 articles resulting from the database searches, 6 articles including 164 pediatric patients at a mean age of 7.7 ± 5.2 years with resection for drug-resistant perirolandic epilepsy were included in the study. Seizure freedom was observed in 118 (72.9%) patients at a mean follow-up of 3.4 ± 1.8 years. In total, 109 (66.5%) patients did not develop sensorimotor deficits at last follow-up, while 55 (33.5%) had permanent deficits. Ten (14.3%) of 70 patients with postcentral gyrus resection had permanent sensory deficits. Of the postcentral gyrus resection patients, 41 (58.6%) patients were included in group A, 19 (27.1%) in group B, 7 (10.0%) in group C, and 3 (4.3%) in group D. Forty (37.7%) of 106 patients with precentral resections had permanent motor deficits. Of the precentral gyrus resection patients, 50 (47.2%) patients were in group A, 16 (15.1%) in group B, 24 (22.6%) in group C, and 16 (15.1%) in group D. Patients without focal cortical dysplasia were more likely to have permanent motor deficits relative to those with focal cortical dysplasia in the precentral surgery cohort (p = 0.02). CONCLUSIONS In total, 58.6% of patients were seizure free without deficit, 27.1% were not seizure free and without deficit, 10.0% were seizure free but with deficit, and 4.3% were not seizure free and with deficit. Future studies with functional and quality-of-life data, particularly for patients who experience seizure recurrence with no deficits (as in group B in the present study) and those who are seizure free with deficits (as in group C) after treatment, are necessary to guide surgical decision-making.
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Affiliation(s)
- Nathan A Shlobin
- 1Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Andrew Wang
- 2Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - H Westley Phillips
- 2Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Han Yan
- 3Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario
| | - George M Ibrahim
- 3Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario
| | - Lior M Elkaim
- 4Division of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Shuang Wang
- 5Pediatric Epilepsy Center, Peking University First Hospital, Beijing, China
| | - Xiaoyan Liu
- 5Pediatric Epilepsy Center, Peking University First Hospital, Beijing, China
| | - Lixin Cai
- 5Pediatric Epilepsy Center, Peking University First Hospital, Beijing, China
| | - Dang K Nguyen
- 6Division of Neurology, University of Montreal Hospital Centre (CHUM), Montreal
- 7CHUM Research Centre, Montreal
- 9Department of Neuroscience, University of Montreal; and
| | - Aria Fallah
- 2Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Alexander G Weil
- 8Division of Neurosurgery, Sainte-Justine University Hospital and University of Montreal Hospital Centre (CHUM), Montreal
- 9Department of Neuroscience, University of Montreal; and
- 10Sainte-Justine Research Centre, University of Montreal, Quebec, Canada
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22
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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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23
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Shao B, Zheng B, Liu DD, Anderson MN, Svokos K, Bartolini L, Asaad WF. Seizure freedom after laser amygdalohippocampotomy guided by bilateral responsive neurostimulation in pediatric epilepsy: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 4:CASE22235. [PMID: 36051773 PMCID: PMC9426349 DOI: 10.3171/case22235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/05/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND
For patients with difficult-to-lateralize temporal lobe epilepsy, the use of chronic recordings as a diagnostic tool to inform subsequent surgical therapy is an emerging paradigm that has been reported in adults but not in children.
OBSERVATIONS
The authors reported the case of a 15-year-old girl with pharmacoresistant temporal lobe epilepsy who was found to have bitemporal epilepsy during a stereoelectroencephalography (sEEG) admission. She underwent placement of a responsive neurostimulator system with bilateral hippocampal depth electrodes. However, over many months, her responsive neurostimulation (RNS) recordings revealed that her typical, chronic seizures were right-sided only. This finding led to a subsequent right-sided laser amygdalohippocampotomy, resulting in seizure freedom.
LESSONS
In this case, RNS chronic recording provided real-world data that enabled more precise seizure localization than inpatient sEEG data, informing surgical decision-making that led to seizure freedom. The use of RNS chronic recordings as a diagnostic adjunct to seizure localization procedures and laser ablation therapies in children is an area with potential for future study.
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Affiliation(s)
| | | | | | | | - Konstantina Svokos
- Departments of Neurosurgery,
- Norman Prince Neurosciences Institute, Rhode Island Hospital & Hasbro Children’s Hospital, Providence, Rhode Island
| | - Luca Bartolini
- Departments of Neurosurgery,
- Neurology, Brown University Alpert Medical School, Providence, Rhode Island
| | - Wael F. Asaad
- Departments of Neurosurgery,
- Department of Neuroscience, Brown University, Providence, Rhode Island
- Norman Prince Neurosciences Institute, Rhode Island Hospital & Hasbro Children’s Hospital, Providence, Rhode Island
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24
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Joris V, Weil AG, Fallah A. Brain Surgery for Medically Intractable Epilepsy. Adv Pediatr 2022; 69:59-74. [PMID: 35985717 DOI: 10.1016/j.yapd.2022.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This review covers the broad topic of brain surgery in the treatment of pediatric intractable epilepsy. The authors review the latest advancements in the presurgical workup as well as the mandatory tests needed to explore the epilepsy workup in these children. They describe the different types of epilepsy from a surgical standpoint (temporal, extratemporal, multifocal, and hemispheric epilepsies) and various surgical procedures that can be proposed depending on the clinical scenario: lesionectomies, lobectomies, hemispherectomies, neuromodulation, and palliative surgeries. They also describe the key differences of the pediatric patient as compared with the adult patient in such pathologic conditions.
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Affiliation(s)
- Vincent Joris
- Fellow, Department of Neurosurgery, Sainte-Justine University Hospital Centre, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, Quebec H3T 1C5, Canada
| | - Alexander G Weil
- Associate Professor, Department of Neurosurgery, Sainte-Justine University Hospital Centre, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, Quebec H3T 1C5, Canada
| | - Aria Fallah
- Associate Professor, Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, 300 Stein Plaza, Suite 525, Los Angeles, CA 90095, USA.
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25
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Beaudreault CP, Muh CR, Naftchi A, Spirollari E, Das A, Vazquez S, Sukul VV, Overby PJ, Tobias ME, McGoldrick PE, Wolf SM. Responsive Neurostimulation Targeting the Anterior, Centromedian and Pulvinar Thalamic Nuclei and the Detection of Electrographic Seizures in Pediatric and Young Adult Patients. Front Hum Neurosci 2022; 16:876204. [PMID: 35496067 PMCID: PMC9039390 DOI: 10.3389/fnhum.2022.876204] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 03/17/2022] [Indexed: 12/18/2022] Open
Abstract
BackgroundResponsive neurostimulation (RNS System) has been utilized as a treatment for intractable epilepsy. The RNS System delivers stimulation in response to detected abnormal activity, via leads covering the seizure foci, in response to detections of predefined epileptiform activity with the goal of decreasing seizure frequency and severity. While thalamic leads are often implanted in combination with cortical strip leads, implantation and stimulation with bilateral thalamic leads alone is less common, and the ability to detect electrographic seizures using RNS System thalamic leads is uncertain.ObjectiveThe present study retrospectively evaluated fourteen patients with RNS System depth leads implanted in the thalamus, with or without concomitant implantation of cortical strip leads, to determine the ability to detect electrographic seizures in the thalamus. Detailed patient presentations and lead trajectories were reviewed alongside electroencephalographic (ECoG) analyses.ResultsAnterior nucleus thalamic (ANT) leads, whether bilateral or unilateral and combined with a cortical strip lead, successfully detected and terminated epileptiform activity, as demonstrated by Cases 2 and 3. Similarly, bilateral centromedian thalamic (CMT) leads or a combination of one centromedian thalamic alongside a cortical strip lead also demonstrated the ability to detect electrographic seizures as seen in Cases 6 and 9. Bilateral pulvinar leads likewise produced reliable seizure detection in Patient 14. Detections of electrographic seizures in thalamic nuclei did not appear to be affected by whether the patient was pediatric or adult at the time of RNS System implantation. Sole thalamic leads paralleled the combination of thalamic and cortical strip leads in terms of preventing the propagation of electrographic seizures.ConclusionThalamic nuclei present a promising target for detection and stimulation via the RNS System for seizures with multifocal or generalized onsets. These areas provide a modifiable, reversible therapeutic option for patients who are not candidates for surgical resection or ablation.
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Affiliation(s)
| | - Carrie R. Muh
- New York Medical College, Valhalla, NY, United States
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, United States
| | | | | | - Ankita Das
- New York Medical College, Valhalla, NY, United States
| | - Sima Vazquez
- New York Medical College, Valhalla, NY, United States
| | - Vishad V. Sukul
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, United States
| | - Philip J. Overby
- New York Medical College, Valhalla, NY, United States
- Division of Pediatric Neurology, Department of Pediatrics, Maria Fareri Children’s Hospital, Valhalla, NY, United States
- Boston Children’s Hospital Physicians, Hawthorne, NY, United States
| | - Michael E. Tobias
- New York Medical College, Valhalla, NY, United States
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, United States
| | - Patricia E. McGoldrick
- New York Medical College, Valhalla, NY, United States
- Division of Pediatric Neurology, Department of Pediatrics, Maria Fareri Children’s Hospital, Valhalla, NY, United States
- Boston Children’s Hospital Physicians, Hawthorne, NY, United States
| | - Steven M. Wolf
- New York Medical College, Valhalla, NY, United States
- Division of Pediatric Neurology, Department of Pediatrics, Maria Fareri Children’s Hospital, Valhalla, NY, United States
- Boston Children’s Hospital Physicians, Hawthorne, NY, United States
- *Correspondence: Steven M. Wolf,
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26
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Kerezoudis P, Gyftopoulos A, Alexander AY, Keith Starnes D, Nickels KC, Worrell GA, Wirrell EC, Lundstrom BN, Van Gompel JJ, Miller KJ. Safety and efficacy of responsive neurostimulation in the pediatric population: Evidence from institutional review and patient-level meta-analysis. Epilepsy Behav 2022; 129:108646. [PMID: 35299087 DOI: 10.1016/j.yebeh.2022.108646] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Responsive neurostimulation (RNS) is a novel technology for drug-resistant epilepsy rising from bilateral hemispheres or eloquent cortex. Although recently approved for adults, its safety and efficacy for pediatric patients is under investigation. METHODS A comprehensive literature search (Pubmed/Medline, Scopus, Cochrane) was conducted for studies on RNS for pediatric epilepsy (<18 y/o) and supplemented by our institutional series (4 cases). Reduction in seizure frequency at last follow-up compared to preoperative baseline comprised the primary endpoint. RESULTS A total of 8 studies (49 patients) were analyzed. Median age at implant was 15 years (interquartile range [IQR] 12-17) and 63% were males. A lesional MRI was noted in 64% (14/22). Prior invasive EEG recording was performed in the majority of patients (90%) and the most common modality was stereoelectroencephalography (57%). The most common implant location (total of 94 RNS leads) was the frontal lobe (27%), followed by mesial temporal structures (23%) and thalamus (17%). At a median follow-up of 22 months, median seizure frequency reduction was 75% (IQR: 50-88%) and 80% were responders (>50% seizure reduction). Responses ranged from 50% for temporal lobe epilepsy to 81-93% for frontal, parietal, and multilobar epilepsy. Four infections were observed (8%) and there were no hematomas or postoperative neurological deficits. CONCLUSION Current evidence, albeit limited by potential publication bias, supports the promising safety and efficacy profile of RNS for medically refractory pediatric epilepsy. Randomized controlled trial data are needed to further establish the role of this intervention in preoperative discussions with patients and their families.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Kai J Miller
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
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27
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Rao VR. Chronic electroencephalography in epilepsy with a responsive neurostimulation device: current status and future prospects. Expert Rev Med Devices 2021; 18:1093-1105. [PMID: 34696676 DOI: 10.1080/17434440.2021.1994388] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Implanted neurostimulation devices are gaining traction as therapeutic options for people with certain forms of drug-resistant focal epilepsy. Some of these devices enable chronic electroencephalography (cEEG), which offers views of the dynamics of brain activity in epilepsy over unprecedented time horizons. AREAS COVERED This review focuses on clinical insights and basic neuroscience discoveries enabled by analyses of cEEG from an exemplar device, the NeuroPace RNS® System. Applications of RNS cEEG covered here include counting and lateralizing seizures, quantifying medication response, characterizing spells, forecasting seizures, and exploring mechanisms of cognition. Limitations of the RNS System are discussed in the context of next-generation devices in development. EXPERT OPINION The wide temporal lens of cEEG helps capture the dynamism of epilepsy, revealing phenomena that cannot be appreciated with short duration recordings. The RNS System is a vanguard device whose diagnostic utility rivals its therapeutic benefits, but emerging minimally invasive devices, including those with subscalp recording electrodes, promise to be more applicable within a broad population of people with epilepsy. Epileptology is on the precipice of a paradigm shift in which cEEG is a standard part of diagnostic evaluations and clinical management is predicated on quantitative observations integrated over long timescales.
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Affiliation(s)
- Vikram R Rao
- Associate Professor of Clinical Neurology, Chief, Epilepsy Division, Department of Neurology and Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
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28
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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.
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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.
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