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Anderson DN, Charlebois CM, Smith EH, Davis TS, Peters AY, Newman BJ, Arain AM, Wilcox KS, Butson CR, Rolston JD. Closed-loop stimulation in periods with less epileptiform activity drives improved epilepsy outcomes. Brain 2024; 147:521-531. [PMID: 37796038 PMCID: PMC10834245 DOI: 10.1093/brain/awad343] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 07/17/2023] [Accepted: 08/28/2023] [Indexed: 10/06/2023] Open
Abstract
In patients with drug-resistant epilepsy, electrical stimulation of the brain in response to epileptiform activity can make seizures less frequent and debilitating. This therapy, known as closed-loop responsive neurostimulation (RNS), aims to directly halt seizure activity via targeted stimulation of a burgeoning seizure. Rather than immediately stopping seizures as they start, many RNS implants produce slower, long-lasting changes in brain dynamics that better predict clinical outcomes. Here we hypothesize that stimulation during brain states with less epileptiform activity drives long-term changes that restore healthy brain networks. To test this, we quantified stimulation episodes during low- and high-risk brain states-that is, stimulation during periods with a lower or higher risk of generating epileptiform activity-in a cohort of 40 patients treated with RNS. More frequent stimulation in tonic low-risk states and out of rhythmic high-risk states predicted seizure reduction. Additionally, stimulation events were more likely to be phase-locked to prolonged episodes of abnormal activity for intermediate and poor responders when compared to super-responders, consistent with the hypothesis that improved outcomes are driven by stimulation during low-risk states. These results support the hypothesis that stimulation during low-risk periods might underlie the mechanisms of RNS, suggesting a relationship between temporal patterns of neuromodulation and plasticity that facilitates long-term seizure reduction.
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Affiliation(s)
- Daria Nesterovich Anderson
- Department of Neurosurgery, University of Utah, Salt Lake City, UT 84132, USA
- Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT 84112, USA
- School of Biomedical Engineering, Faculty of Engineering, The University of Sydney, Darlington, NSW 2008, Australia
| | - Chantel M Charlebois
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 84112, USA
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT 84112, USA
| | - Elliot H Smith
- Department of Neurosurgery, University of Utah, Salt Lake City, UT 84132, USA
| | - Tyler S Davis
- Department of Neurosurgery, University of Utah, Salt Lake City, UT 84132, USA
| | - Angela Y Peters
- Department of Neurology, University of Utah, Salt Lake City, UT 84132, USA
| | - Blake J Newman
- Department of Neurology, University of Utah, Salt Lake City, UT 84132, USA
| | - Amir M Arain
- Department of Neurology, University of Utah, Salt Lake City, UT 84132, USA
| | - Karen S Wilcox
- Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT 84112, USA
| | - Christopher R Butson
- Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL 32608, USA
- Department of Neurology, University of Florida, Gainesville, FL 32611, USA
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
- Department of Biomedical Engineering, University of Florida, Gainesville, FL 32611, USA
| | - John D Rolston
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 84112, USA
- Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA 02115, USA
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Abdulrazeq H, Kimata AR, Blum A, Malik AN, Asaad WF. Exploring the Role of the Pulvinar Nucleus of the Thalamus in Occipital Lobe Epilepsy: A Case Report. Cureus 2024; 16:e52534. [PMID: 38371112 PMCID: PMC10874469 DOI: 10.7759/cureus.52534] [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] [Accepted: 01/18/2024] [Indexed: 02/20/2024] Open
Abstract
Understanding the role of the pulvinar nucleus may be critical for guiding circuit-targeted neurosurgical intervention in some patients. In this report, a 33-year-old female presented with focal onset occipital epilepsy with secondary generalization and with a previously radiated arteriovenous malformation within the right primary visual cortex. Phase II monitoring demonstrated the pulvinar nucleus was not involved in subclinical seizures restricted to the primary visual cortex, but it did become involved in clinical events with more extensive seizure spread into higher visual cortical regions. She underwent responsive neurostimulation (RNS) with implantation of leads within the primary visual cortex. This case demonstrates the late propagation of epileptic activity from the visual cortex to the pulvinar nucleus and illustrates the pulvinar nucleus' connections with higher-order visual areas.
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Affiliation(s)
- Hael Abdulrazeq
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, USA
| | - Anna R Kimata
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, USA
| | - Andrew Blum
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, USA
| | - Athar N Malik
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, USA
- Department of Neuroscience, The Warren Alpert Medical School of Brown University, Providence, USA
| | - Wael F Asaad
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, USA
- Department of Neuroscience, The Warren Alpert Medical School of Brown University, Providence, USA
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Whitebirch AC, Santoro B, Barnett A, Lisgaras CP, Scharfman HE, Siegelbaum SA. Reduced Cholecystokinin-Expressing Interneuron Input Contributes to Disinhibition of the Hippocampal CA2 Region in a Mouse Model of Temporal Lobe Epilepsy. J Neurosci 2023; 43:6930-6949. [PMID: 37643861 PMCID: PMC10573827 DOI: 10.1523/jneurosci.2091-22.2023] [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: 11/09/2022] [Revised: 08/04/2023] [Accepted: 08/15/2023] [Indexed: 08/31/2023] Open
Abstract
A significant proportion of temporal lobe epilepsy (TLE) patients experience drug-resistant seizures associated with mesial temporal sclerosis, in which there is extensive cell loss in the hippocampal CA1 and CA3 subfields, with a relative sparing of dentate gyrus granule cells and CA2 pyramidal neurons (PNs). A role for CA2 in seizure generation was suggested based on findings of a reduction in CA2 synaptic inhibition (Williamson and Spencer, 1994) and the presence of interictal-like spike activity in CA2 in resected hippocampal tissue from TLE patients (Wittner et al., 2009). We recently found that in the pilocarpine-induced status epilepticus (PILO-SE) mouse model of TLE there was an increase in CA2 intrinsic excitability associated with a loss of CA2 synaptic inhibition. Furthermore, chemogenetic silencing of CA2 significantly reduced seizure frequency, consistent with a role of CA2 in promoting seizure generation and/or propagation (Whitebirch et al., 2022). In the present study, we explored the cellular basis of this inhibitory deficit using immunohistochemical and electrophysiological approaches in PILO-SE male and female mice. We report a widespread decrease in the density of pro-cholecystokinin-immunopositive (CCK+) interneurons and a functional impairment of CCK+ interneuron-mediated inhibition of CA2 PNs. We also found a disruption in the perisomatic perineuronal net in the CA2 stratum pyramidale. Such pathologic alterations may contribute to an enhanced excitation of CA2 PNs and CA2-dependent seizure activity in the PILO-SE mouse model.SIGNIFICANCE STATEMENT Impaired synaptic inhibition in hippocampal circuits has been identified as a key feature that contributes to the emergence and propagation of seizure activity in human patients and animal models of temporal lobe epilepsy (TLE). Among the hippocampal subfields, the CA2 region is particularly resilient to seizure-associated neurodegeneration and has been suggested to play a key role in seizure activity in TLE. Here we report that perisomatic inhibition of CA2 pyramidal neurons mediated by cholecystokinin-expressing interneurons is selectively reduced in acute hippocampal slices from epileptic mice. Parvalbumin-expressing interneurons, in contrast, appear relatively conserved in epileptic mice. These findings advance our understanding of the cellular mechanisms underlying inhibitory disruption in hippocampal circuits in a mouse model of spontaneous recurring seizures.
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Affiliation(s)
- Alexander C Whitebirch
- Departments of Neuroscience and Pharmacology, Kavli Institute for Brain Science, Mortimer B. Zuckerman Mind Brain Behavior Institute, Columbia University Irving Medical Center, New York, New York 10027
| | - Bina Santoro
- Departments of Neuroscience and Pharmacology, Kavli Institute for Brain Science, Mortimer B. Zuckerman Mind Brain Behavior Institute, Columbia University Irving Medical Center, New York, New York 10027
| | - Anastasia Barnett
- Departments of Neuroscience and Pharmacology, Kavli Institute for Brain Science, Mortimer B. Zuckerman Mind Brain Behavior Institute, Columbia University Irving Medical Center, New York, New York 10027
| | - Christos Panagiotis Lisgaras
- Department of Child & Adolescent Psychiatry, New York University Langone Health, New York, New York 10016
- Department of Neuroscience & Physiology, New York University Langone Health, New York, New York 10016
- Department of Psychiatry, New York University Langone Health, New York, New York 10016
- The Nathan S. Kline Institute for Psychiatric Research, Orangeburg, New York 10962
| | - Helen E Scharfman
- Department of Child & Adolescent Psychiatry, New York University Langone Health, New York, New York 10016
- Department of Neuroscience & Physiology, New York University Langone Health, New York, New York 10016
- Department of Psychiatry, New York University Langone Health, New York, New York 10016
- The Nathan S. Kline Institute for Psychiatric Research, Orangeburg, New York 10962
| | - Steven A Siegelbaum
- Departments of Neuroscience and Pharmacology, Kavli Institute for Brain Science, Mortimer B. Zuckerman Mind Brain Behavior Institute, Columbia University Irving Medical Center, New York, New York 10027
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Campos-Rodriguez C, Palmer D, Forcelli PA. Optogenetic stimulation of the superior colliculus suppresses genetic absence seizures. Brain 2023; 146:4320-4335. [PMID: 37192344 PMCID: PMC11004938 DOI: 10.1093/brain/awad166] [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: 10/01/2022] [Revised: 04/18/2023] [Accepted: 05/01/2023] [Indexed: 05/18/2023] Open
Abstract
While anti-seizure medications are effective for many patients, nearly one-third of individuals have seizures that are refractory to pharmacotherapy. Prior studies using evoked preclinical seizure models have shown that pharmacological activation or excitatory optogenetic stimulation of the deep and intermediate layers of the superior colliculus (DLSC) display multi-potent anti-seizure effects. Here we monitored and modulated DLSC activity to suppress spontaneous seizures in the WAG/Rij genetic model of absence epilepsy. Female and male WAG/Rij adult rats were employed as study subjects. For electrophysiology studies, we recorded single unit activity from microwire arrays placed within the DLSC. For optogenetic experiments, animals were injected with virus coding for channelrhodopsin-2 or a control vector, and we compared the efficacy of continuous neuromodulation to that of closed-loop neuromodulation paradigms. For each, we compared three stimulation frequencies on a within-subject basis (5, 20, 100 Hz). For closed-loop stimulation, we detected seizures in real time based on the EEG power within the characteristic frequency band of spike-and-wave discharges (SWDs). We quantified the number and duration of each SWD during each 2 h-observation period. Following completion of the experiment, virus expression and fibre-optic placement was confirmed. We found that single-unit activity within the DLSC decreased seconds prior to SWD onset and increased during and after seizures. Nearly 40% of neurons displayed suppression of firing in response to the start of SWDs. Continuous optogenetic stimulation of the DLSC (at each of the three frequencies) resulted in a significant reduction of SWDs in males and was without effect in females. In contrast, closed-loop neuromodulation was effective in both females and males at all three frequencies. These data demonstrate that activity within the DLSC is suppressed prior to SWD onset, increases at SWD onset, and that excitatory optogenetic stimulation of the DLSC exerts anti-seizure effects against absence seizures. The striking difference between open- and closed-loop neuromodulation approaches underscores the importance of the stimulation paradigm in determining therapeutic effects.
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Affiliation(s)
| | - Devin Palmer
- Department of Pharmacology and Physiology, Georgetown University, Washington, DC 20007, USA
- Interdisciplinary Program in Neuroscience, Georgetown University, Washington, DC 20007, USA
| | - Patrick A Forcelli
- Department of Pharmacology and Physiology, Georgetown University, Washington, DC 20007, USA
- Interdisciplinary Program in Neuroscience, Georgetown University, Washington, DC 20007, USA
- Department of Neuroscience, Georgetown University, Washington, DC 20007, USA
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Skelton HM, Brandman DM, Bullinger K, Isbaine F, Gross RE. Distinct Biomarkers of ANT Stimulation and Seizure Freedom in an Epilepsy Patient with Ambulatory Hippocampal Electrocorticography. Stereotact Funct Neurosurg 2023; 101:349-358. [PMID: 37742626 DOI: 10.1159/000533680] [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: 05/01/2023] [Accepted: 08/15/2023] [Indexed: 09/26/2023]
Abstract
INTRODUCTION Deep brain stimulation (DBS) of the anterior nucleus of the thalamus (ANT) and responsive neurostimulation (RNS) of the hippocampus are the predominant approaches to brain stimulation for treating mesial temporal lobe epilepsy (MTLE). Both are similarly effective at reducing seizures in drug-resistant patients, but the underlying mechanisms are poorly understood. In rare cases where it is clinically indicated to use RNS and DBS simultaneously, ambulatory electrophysiology from RNS may provide the opportunity to measure the effects of ANT DBS in the putative seizure onset zone and identify biomarkers associated with clinical improvement. Here, one such patient became seizure free, allowing us to identify and compare the changes in hippocampal electrophysiology associated with ANT stimulation and seizure freedom. METHODS Ambulatory electrocorticography and clinical history were retrospectively analyzed for a patient treated with RNS and DBS for MTLE. DBS artifacts were used to identify ANT stimulation periods on RNS recordings and measure peri-stimulus electrographic changes. Clinical history was used to determine the chronic electrographic changes associated with seizure freedom. RESULTS ANT stimulation acutely suppressed hippocampal gamma (25-90Hz) power, with minimal theta (4-8Hz) suppression and without clear effects on seizure frequency. Eventually, the patient became seizure free alongside the emergence of chronic gamma increase and theta suppression, which started at the same time as clobazam was introduced. Both seizure freedom and the associated electrophysiology persisted after inadvertent DBS discontinuation, further implicating the clobazam relationship. Unexpectedly, RNS detections and long episodes increased, although they were not considered to be electrographic seizures, and the patient remained clinically seizure free. CONCLUSION ANT stimulation and seizure freedom were associated with distinct, dissimilar spectral changes in RNS-derived electrophysiology. The time course of these changes supported a new medication as the most likely cause of clinical improvement. Broadly, this work showcases the use of RNS recordings to interpret the effects of multimodal therapy. Specifically, it lends additional credence to hippocampal theta suppression as a biomarker previously associated with seizure reduction in RNS patients.
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Affiliation(s)
- Henry M Skelton
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA,
- Morehouse School of Medicine, Atlanta, Georgia, USA,
| | - David M Brandman
- Department of Neurosurgery, University of California, Davis, California, USA
| | - Katie Bullinger
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Faical Isbaine
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Robert E Gross
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
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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: 5] [Impact Index Per Article: 5.0] [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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Lundstrom BN, Osman GM, Starnes K, Gregg NM, Simpson HD. Emerging approaches in neurostimulation for epilepsy. Curr Opin Neurol 2023; 36:69-76. [PMID: 36762660 PMCID: PMC9992108 DOI: 10.1097/wco.0000000000001138] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW Neurostimulation is a quickly growing treatment approach for epilepsy patients. We summarize recent approaches to provide a perspective on the future of neurostimulation. RECENT FINDINGS Invasive stimulation for treatment of focal epilepsy includes vagus nerve stimulation, responsive neurostimulation of the cortex and deep brain stimulation of the anterior nucleus of the thalamus. A wide range of other targets have been considered, including centromedian, central lateral and pulvinar thalamic nuclei; medial septum, nucleus accumbens, subthalamic nucleus, cerebellum, fornicodorsocommissure and piriform cortex. Stimulation for generalized onset seizures and mixed epilepsies as well as increased efforts focusing on paediatric populations have emerged. Hardware with more permanently implanted lead options and sensing capabilities is emerging. A wider variety of programming approaches than typically used may improve patient outcomes. Finally, noninvasive brain stimulation with its favourable risk profile offers the potential to treat increasingly diverse epilepsy patients. SUMMARY Neurostimulation for the treatment of epilepsy is surprisingly varied. Flexibility and reversibility of neurostimulation allows for rapid innovation. There remains a continued need for excitability biomarkers to guide treatment and innovation. Neurostimulation, a part of bioelectronic medicine, offers distinctive benefits as well as unique challenges.
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Affiliation(s)
| | | | - Keith Starnes
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Hugh D Simpson
- Department of Neurology, Alfred Health
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Skrehot HC, Englot DJ, Haneef Z. Neuro-stimulation in focal epilepsy: A systematic review and meta-analysis. Epilepsy Behav 2023; 142:109182. [PMID: 36972642 DOI: 10.1016/j.yebeh.2023.109182] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/10/2023] [Accepted: 03/12/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVES Different neurostimulation modalities are available to treat drug-resistant focal epilepsy when surgery is not an option including vagus nerve stimulation (VNS), responsive neurostimulation (RNS), and deep brain stimulation (DBS). Head-to-head comparisons of efficacy do not exist between them nor are likely to be available in the future. We performed a meta-analysis on VNS, RNS, and DBS outcomes to compare seizure reduction efficacy for focal epilepsy. METHODS We systematically reviewed the literature for reported seizure outcomes following implantation with VNS, RNS, and DBS in focal-onset seizures and performed a meta-analysis. Prospective or retrospective clinical studies were included. RESULTS Sufficient data were available at years one (n = 642, two (n = 480), and three (n = 385) for comparing the three modalities with each other. Seizure reduction for the devices at years one, two, and three respectively were: RNS: 66.3%, 56.0%, 68.4%; DBS- 58.4%, 57.5%, 63.8%; VNS 32.9%, 44.4%, 53.5%. Seizure reduction at year one was greater for RNS (p < 0.01) and DBS (p < 0.01) compared to VNS. CONCLUSIONS Our findings indicate the seizure reduction efficacy of RNS is similar to DBS, and both had greater seizure reductions compared to VNS in the first-year post-implantation, with the differences diminishing with longer-term follow-up. SIGNIFICANCE The results help guide neuromodulation treatment in eligible patients with drug-resistant focal epilepsy.
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Affiliation(s)
- Henry C Skrehot
- Department of Neurology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Dario J Englot
- Departments of Neurological Surgery, Neurology, Radiology, Electrical Engineering, and Biomedical Engineering, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Zulfi Haneef
- Department of Neurology, Baylor College of Medicine, Houston, TX 77030, USA; Neurology Care Line, VA Medical Center, Houston, TX 77030, USA.
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Alcala-Zermeno JL, Gregg NM, Starnes K, Mandrekar JN, Van Gompel JJ, Miller K, Worrell G, Lundstrom BN. Invasive neuromodulation for epilepsy: Comparison of multiple approaches from a single center. Epilepsy Behav 2022; 137:108951. [PMID: 36327647 PMCID: PMC9934010 DOI: 10.1016/j.yebeh.2022.108951] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 10/05/2022] [Accepted: 10/07/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Drug-resistant epilepsy (DRE) patients not amenable to epilepsy surgery can benefit from neurostimulation. Few data compare different neuromodulation strategies. OBJECTIVE Compare five invasive neuromodulation strategies for the treatment of DRE: anterior thalamic nuclei deep brain stimulation (ANT-DBS), centromedian thalamic nuclei DBS (CM-DBS), responsive neurostimulation (RNS), chronic subthreshold stimulation (CSS), and vagus nerve stimulation (VNS). METHODS Single center retrospective review and phone survey for patients implanted with invasive neuromodulation for 2004-2021. RESULTS N = 159 (ANT-DBS = 38, CM-DBS = 19, RNS = 30, CSS = 32, VNS = 40). Total median seizure reduction (MSR) was 61 % for the entire cohort (IQR 5-90) and in descending order: CSS (85 %), CM-DBS (63 %), ANT-DBS (52 %), RNS (50 %), and VNS (50 %); p = 0.07. The responder rate was 60 % after a median follow-up time of 26 months. Seizure severity, life satisfaction, and quality of sleep were improved. Cortical stimulation (RNS and CSS) was associated with improved seizure reduction compared to subcortical stimulation (ANT-DBS, CM-DBS, and VNS) (67 % vs. 52 %). Effectiveness was similar for focal epilepsy vs. generalized epilepsy, closed-loop vs. open-loop stimulation, pediatric vs. adult cases, and high frequency (>100 Hz) vs. low frequency (<100 Hz) stimulation settings. Delivered charge per hour varied widely across approaches but was not correlated with improved seizure reduction. CONCLUSIONS Multiple invasive neuromodulation approaches are available to treat DRE, but little evidence compares the approaches. This study used a uniform approach for single-center results and represents an effort to compare neuromodulation approaches.
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Affiliation(s)
- Juan Luis Alcala-Zermeno
- Department of Neurology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA; Department of Neurology, Jefferson Medical College, Thomas Jefferson University, 901 Walnut Street, Suite 400, Philadelphia, PA 19107, USA.
| | - Nicholas M. Gregg
- Department of Neurology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Keith Starnes
- Division of Child and Adolescent Neurology, Department of Neurology, 200 First St SW, Rochester, MN 55905, USA.
| | - Jayawant N. Mandrekar
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Jamie J. Van Gompel
- Department of Neurologic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Kai Miller
- Department of Neurologic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
| | - Greg Worrell
- Department of Neurology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
| | - Brian N. Lundstrom
- Department of Neurology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
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