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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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2
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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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3
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Daquin G, Bonini F. The landscape of drug resistant absence seizures in adolescents and adults: Pathophysiology, electroclinical spectrum and treatment options. Rev Neurol (Paris) 2024; 180:256-270. [PMID: 38413268 DOI: 10.1016/j.neurol.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/17/2023] [Accepted: 11/21/2023] [Indexed: 02/29/2024]
Abstract
The persistence of typical absence seizures (AS) in adolescence and adulthood may reduce the quality of life of patients with genetic generalized epilepsies (GGEs). The prevalence of drug resistant AS is probably underestimated in this patient population, and treatment options are relatively scarce. Similarly, atypical absence seizures in developmental and epileptic encephalopathies (DEEs) may be unrecognized, and often persist into adulthood despite improvement of more severe seizures. These two seemingly distant conditions, represented by typical AS in GGE and atypical AS in DEE, share at least partially overlapping pathophysiological and genetic mechanisms, which may be the target of drug and neurostimulation therapies. In addition, some patients with drug-resistant typical AS may present electroclinical features that lie in between the two extremes represented by these generalized forms of epilepsy.
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Affiliation(s)
- G Daquin
- Epileptology and Cerebral Rythmology, AP-HM, Timone hospital, Marseille, France
| | - F Bonini
- Epileptology and Cerebral Rythmology, AP-HM, Timone hospital, Marseille, France; Aix Marseille Univ, Inserm, INS, Inst Neurosci Syst, Marseille, France.
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Al-Ramadhani R, Hect JL, Abel TJ. The changing landscape of palliative epilepsy surgery for Lennox Gastaut Syndrome. Front Neurol 2024; 15:1380423. [PMID: 38515452 PMCID: PMC10954786 DOI: 10.3389/fneur.2024.1380423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/21/2024] [Indexed: 03/23/2024] Open
Abstract
Lennox Gastaut Syndrome (LGS) is characterized by drug-resistant epilepsy that typically leads to decreased quality of life and deleterious neurodevelopmental comorbidities from medically refractory seizures. In recent years there has been a dramatic increase in the development and availability of novel treatment strategies for Lennox Gastaut Syndrome patient to improve seizure. Recent advances in neuromodulation and minimally invasive magnetic resonance guided laser interstitial thermal therapy (MRgLITT) have paved the way for new treatments strategies including deep brain stimulation (DBS), responsive neurostimulation (RNS), and MRgLITT corpus callosum ablation. These new strategies offer hope for children with drug-resistant generalized epilepsies, but important questions remain about the safety and effectiveness of these new approaches. In this review, we describe the opportunities presented by these new strategies and how each treatment strategy is currently being employed. Next, we will critically assess available evidence for these new approaches compared to traditional palliative epilepsy surgery approaches, such as vagus nerve stimulation (VNS) and open microsurgical corpus callosotomy (CC). Finally, we will describe future directions that would help define which of the available strategies should be employed and when.
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Affiliation(s)
- Ruba Al-Ramadhani
- Department of Pediatrics, Division of Child Neurology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jasmine L. Hect
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Taylor J. Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, United States
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States
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Devinsky O, Elder C, Sivathamboo S, Scheffer IE, Koepp MJ. Idiopathic Generalized Epilepsy: Misunderstandings, Challenges, and Opportunities. Neurology 2024; 102:e208076. [PMID: 38165295 PMCID: PMC11097769 DOI: 10.1212/wnl.0000000000208076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/19/2023] [Indexed: 01/03/2024] Open
Abstract
The idiopathic generalized epilepsies (IGE) make up a fifth of all epilepsies, but <1% of epilepsy research. This skew reflects misperceptions: diagnosis is straightforward, pathophysiology is understood, seizures are easily controlled, epilepsy is outgrown, morbidity and mortality are low, and surgical interventions are impossible. Emerging evidence reveals that patients with IGE may go undiagnosed or misdiagnosed with focal epilepsy if EEG or semiology have asymmetric or focal features. Genetic, electrophysiologic, and neuroimaging studies provide insights into pathophysiology, including overlaps and differences from focal epilepsies. IGE can begin in adulthood and patients have chronic and drug-resistant seizures. Neuromodulatory interventions for drug-resistant IGE are emerging. Rates of psychiatric and other comorbidities, including sudden unexpected death in epilepsy, parallel those in focal epilepsy. IGE is an understudied spectrum for which our diagnostic sensitivity and specificity, scientific understanding, and therapies remain inadequate.
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Affiliation(s)
- Orrin Devinsky
- From the Comprehensive Epilepsy Center (O.D., C.E.), New York University School of Medicine, New York, Department of Neuroscience (S.S.), Central Clinical School, Monash University, Melbourne, Department of Neurology (S.S.), Alfred Health, Melbourne; Departments of Medicine and Neurology, The Royal Melbourne Hospital (S.S.), Epilepsy Research Centre, Department of Medicine, Austin Health (I.E.S.), Murdoch Children's Research Institute (I.E.S.), and Department of Pediatrics (I.E.S.), Royal Children's Hospital, The University of Melbourne; The Florey Institute of Neuroscience and Mental Health (I.E.S.), Melbourne, Victoria, Australia; and Department of Clinical and Experimental Epilepsy (M.J.K.), University College London Institute of Neurology, United Kingdom
| | - Christopher Elder
- From the Comprehensive Epilepsy Center (O.D., C.E.), New York University School of Medicine, New York, Department of Neuroscience (S.S.), Central Clinical School, Monash University, Melbourne, Department of Neurology (S.S.), Alfred Health, Melbourne; Departments of Medicine and Neurology, The Royal Melbourne Hospital (S.S.), Epilepsy Research Centre, Department of Medicine, Austin Health (I.E.S.), Murdoch Children's Research Institute (I.E.S.), and Department of Pediatrics (I.E.S.), Royal Children's Hospital, The University of Melbourne; The Florey Institute of Neuroscience and Mental Health (I.E.S.), Melbourne, Victoria, Australia; and Department of Clinical and Experimental Epilepsy (M.J.K.), University College London Institute of Neurology, United Kingdom
| | - Shobi Sivathamboo
- From the Comprehensive Epilepsy Center (O.D., C.E.), New York University School of Medicine, New York, Department of Neuroscience (S.S.), Central Clinical School, Monash University, Melbourne, Department of Neurology (S.S.), Alfred Health, Melbourne; Departments of Medicine and Neurology, The Royal Melbourne Hospital (S.S.), Epilepsy Research Centre, Department of Medicine, Austin Health (I.E.S.), Murdoch Children's Research Institute (I.E.S.), and Department of Pediatrics (I.E.S.), Royal Children's Hospital, The University of Melbourne; The Florey Institute of Neuroscience and Mental Health (I.E.S.), Melbourne, Victoria, Australia; and Department of Clinical and Experimental Epilepsy (M.J.K.), University College London Institute of Neurology, United Kingdom
| | - Ingrid E Scheffer
- From the Comprehensive Epilepsy Center (O.D., C.E.), New York University School of Medicine, New York, Department of Neuroscience (S.S.), Central Clinical School, Monash University, Melbourne, Department of Neurology (S.S.), Alfred Health, Melbourne; Departments of Medicine and Neurology, The Royal Melbourne Hospital (S.S.), Epilepsy Research Centre, Department of Medicine, Austin Health (I.E.S.), Murdoch Children's Research Institute (I.E.S.), and Department of Pediatrics (I.E.S.), Royal Children's Hospital, The University of Melbourne; The Florey Institute of Neuroscience and Mental Health (I.E.S.), Melbourne, Victoria, Australia; and Department of Clinical and Experimental Epilepsy (M.J.K.), University College London Institute of Neurology, United Kingdom
| | - Matthias J Koepp
- From the Comprehensive Epilepsy Center (O.D., C.E.), New York University School of Medicine, New York, Department of Neuroscience (S.S.), Central Clinical School, Monash University, Melbourne, Department of Neurology (S.S.), Alfred Health, Melbourne; Departments of Medicine and Neurology, The Royal Melbourne Hospital (S.S.), Epilepsy Research Centre, Department of Medicine, Austin Health (I.E.S.), Murdoch Children's Research Institute (I.E.S.), and Department of Pediatrics (I.E.S.), Royal Children's Hospital, The University of Melbourne; The Florey Institute of Neuroscience and Mental Health (I.E.S.), Melbourne, Victoria, Australia; and Department of Clinical and Experimental Epilepsy (M.J.K.), University College London Institute of Neurology, United Kingdom
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Warren AEL, Tobochnik S, Chua MMJ, Singh H, Stamm MA, Rolston JD. Neurostimulation for Generalized Epilepsy: Should Therapy be Syndrome-specific? Neurosurg Clin N Am 2024; 35:27-48. [PMID: 38000840 PMCID: PMC10676463 DOI: 10.1016/j.nec.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Current applications of neurostimulation for generalized epilepsy use a one-target-fits-all approach that is agnostic to the specific epilepsy syndrome and seizure type being treated. The authors describe similarities and differences between the 2 "archetypes" of generalized epilepsy-Lennox-Gastaut syndrome and Idiopathic Generalized Epilepsy-and review recent neuroimaging evidence for syndrome-specific brain networks underlying seizures. Implications for stimulation targeting and programming are discussed using 5 clinical questions: What epilepsy syndrome does the patient have? What brain networks are involved? What is the optimal stimulation target? What is the optimal stimulation paradigm? What is the plan for adjusting stimulation over time?
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Affiliation(s)
- Aaron E L Warren
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Steven Tobochnik
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Melissa M J Chua
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Hargunbir Singh
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michaela A Stamm
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John D Rolston
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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7
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Abstract
Intracranial neuromodulation is an evolving therapy for patients with drug-resistant epilepsy (DRE). Deep brain stimulation (DBS) is now available as a therapy for patients with DRE and focal-onset seizures in select health care systems; however, there remains a substantial need of efficacy data before DBS can be more widely adopted into routine clinical practice. This review and commentary focuses on a particular shifting paradigm: DBS as a therapy for children with generalized-onset seizures.
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Affiliation(s)
- Rory J Piper
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK; Department of Neurosurgery, Great Ormond Street Hospital, London, UK.
| | - George M Ibrahim
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Martin M Tisdall
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK; Department of Neurosurgery, Great Ormond Street Hospital, London, UK
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8
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Nanda P, Richardson RM. Evolution of Stereo-Electroencephalography at Massachusetts General Hospital. Neurosurg Clin N Am 2024; 35:87-94. [PMID: 38000845 DOI: 10.1016/j.nec.2023.09.007] [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
The practice of invasive monitoring for presurgical epilepsy workup has evolved at Massachusetts General Hospital (MGH) in parallel to the evolution in the field's understanding of epilepsy as a network disorder. Implantations have shifted from an emphasis on singularly finding single foci for the purpose of resection to a network-hypothesis-driven approach aiming to delineate patients' seizure networks with the goal of developing surgical interventions that disrupt critical nodes of these networks. Here, the authors review all invasive monitoring cases at MGH from April 2016 through June 2023 to describe how this paradigm shift has taken form.
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Affiliation(s)
- Pranav Nanda
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Neurosurgery, Harvard Medical School, Boston, MA 02115, USA.
| | - R Mark Richardson
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Neurosurgery, Harvard Medical School, Boston, MA 02115, USA
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9
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Levy AS, Bystrom LL, Brown EC, Fajardo M, Wang S. Responsive neurostimulation for treatment of pediatric refractory epilepsy: A pooled analysis of the literature. Clin Neurol Neurosurg 2023; 234:108012. [PMID: 37839147 DOI: 10.1016/j.clineuro.2023.108012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 09/23/2023] [Accepted: 10/06/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Drug-resistant epilepsy (DRE) is a complex medical condition often requiring resective surgery and/or some form of neurostimulation. In recent years responsive neurostimulation (RNS) has shown promising results in adult DRE, however there is a paucity of information regarding outcomes of RNS among pediatric patients treated with DRE. In this individual patient data meta-analysis (IPDMA) we seek to elucidate the effects RNS has on the pediatric population. METHODS Literature regarding management of pediatric DRE via RNS was reviewed in accordance with individual patient data meta-analysis guidelines. Four databases were searched with keywords ((Responsive neurostimulation) AND (epilepsy)) through December of 2022. From 1624 retrieved full text studies, 15 were ultimately included affording a pool of 98 individual participants. RESULTS The median age at implantation was 14 years (n = 95) with 42% of patients having undergone prior resective epilepsy surgery, 18% with prior vagus nerve stimulation (VNS), and 1% with prior RNS. At a median follow up time 12 months, median percent seizure reduction was 75% with 57% of patients achieving Engel Class < 2 outcome, 9.7% of which achieved seizure freedom. We report a postoperative complication rate of 8.4%, half of which were device-related infections. Magnetic resonance imaging (MRI)-negative cases were negatively associated with magnitude of seizure reduction, and direct targeting techniques were associated with stronger treatment response when compared to other methods. CONCLUSIONS This review suggests RNS to be an effective treatment modality for pediatric patients with a postoperative complication rate comparable to that of RNS in adults. Investigation of prognostic clinical variables should be undertaken to augment patient selection. Last, multi-institutional prospective study of long-term effects of RNS on pediatric patients would stand to benefit clinicians in the management of pediatric DRE.
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Affiliation(s)
- Adam S Levy
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, FL, 33136, USA.
| | - Lauren L Bystrom
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - Erik C Brown
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - Marytery Fajardo
- Division of Neurology, Brain Institute, Nicklaus Children's Hospital, 3200 SW 60th Ct Ste 302, Miami, FL, 33155, USA
| | - Shelly Wang
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, FL, 33136, USA; Division of Neurosurgery, Brain Institute, Nicklaus Children's Hospital, 3200 SW 60th Ct Ste 302, Miami, FL, 33155, USA
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10
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Piazza MG, Varga G, Welch W, Abel TJ. The Utility of Responsive Neurostimulation for the Treatment of Pediatric Drug-Resistant Epilepsy. Brain Sci 2023; 13:1455. [PMID: 37891823 PMCID: PMC10605851 DOI: 10.3390/brainsci13101455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/07/2023] [Accepted: 10/09/2023] [Indexed: 10/29/2023] Open
Abstract
Drug-resistant epilepsy (DRE) has a strongly negative impact on quality of life, as well as the development of pediatric patients. Surgical treatments have evolved over time, including more invasive craniotomies for resection or disconnection. More recently, neuromodulation techniques have been employed as a less invasive option for patients. Responsive neurostimulation (RNS) is the first closed-loop technology that allows for both treatment and device data collection, which allows for an internal assessment of the efficacy of treatment. This novel technology has been approved in adults and has been used off label in pediatrics. This review seeks to describe this technology, its history, and future directions.
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Affiliation(s)
- Martin G. Piazza
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA 15260, USA; (M.G.P.); (G.V.)
| | - Gregory Varga
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA 15260, USA; (M.G.P.); (G.V.)
| | - William Welch
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA 15260, USA;
| | - Taylor J. Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA 15260, USA; (M.G.P.); (G.V.)
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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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12
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Fields MC, Eka O, Schreckinger C, Dugan P, Asaad WF, Blum AS, Bullinger K, Willie JT, Burdette DE, Anderson C, Quraishi IH, Gerrard J, Singh A, Lee K, Yoo JY, Ghatan S, Panov F, Marcuse LV. A multicenter retrospective study of patients treated in the thalamus with responsive neurostimulation. Front Neurol 2023; 14:1202631. [PMID: 37745648 PMCID: PMC10516547 DOI: 10.3389/fneur.2023.1202631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 06/19/2023] [Indexed: 09/26/2023] Open
Abstract
Introduction For drug resistant epilepsy patients who are either not candidates for resective surgery or have already failed resective surgery, neuromodulation is a promising option. Neuromodulatory approaches include responsive neurostimulation (RNS), deep brain stimulation (DBS), and vagal nerve stimulation (VNS). Thalamocortical circuits are involved in both generalized and focal onset seizures. This paper explores the use of RNS in the centromedian nucleus of the thalamus (CMN) and in the anterior thalamic nucleus (ANT) of patients with drug resistant epilepsy. Methods This is a retrospective multicenter study from seven different epilepsy centers in the United States. Patients that had unilateral or bilateral thalamic RNS leads implanted in the CMN or ANT for at least 6 months were included. Primary objectives were to describe the implant location and determine changes in the frequency of disabling seizures at 6 months, 1 year, 2 years, and > 2 years. Secondary objectives included documenting seizure free periods, anti-seizure medication regimen changes, stimulation side effects, and serious adverse events. In addition, the global clinical impression scale was completed. Results Twelve patients had at least one lead placed in the CMN, and 13 had at least one lead placed in the ANT. The median baseline seizure frequency was 15 per month. Overall, the median seizure reduction was 33% at 6 months, 55% at 1 year, 65% at 2 years, and 74% at >2 years. Seizure free intervals of at least 3 months occurred in nine patients. Most patients (60%, 15/25) did not have a change in anti-seizure medications post RNS placement. Two serious adverse events were recorded, one related to RNS implantation. Lastly, overall functioning seemed to improve with 88% showing improvement on the global clinical impression scale. Discussion Meaningful seizure reduction was observed in patients who suffer from drug resistant epilepsy with unilateral or bilateral RNS in either the ANT or CMN of the thalamus. Most patients remained on their pre-operative anti-seizure medication regimen. The device was well tolerated with few side effects. There were rare serious adverse events. Most patients showed an improvement in global clinical impression scores.
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Affiliation(s)
- Madeline C Fields
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Onome Eka
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | - Patricia Dugan
- Department of Neurology, Langone Medical Center, New York University, New York, NY, United States
| | - Wael F Asaad
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Providence, RI, United States
| | - Andrew S Blum
- Department of Neurology, Warren Alpert Medical School, Brown University, Providence, RI, United States
| | - Katie Bullinger
- Department of Neurology, School of Medicine, Emory University, Atlanta, GA, United States
| | - Jon T Willie
- Department of Neurosurgery, School of Medicine, Washington University in St Louis, St. Louis, MO, United States
| | - David E Burdette
- Department of Neurosciences, Corewell Health, Grand Rapids, MI, United States
| | - Christopher Anderson
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Imran H Quraishi
- Department of Neurology, School of Medicine, Yale University, New Haven, CT, United States
| | - Jason Gerrard
- Department of Neurosurgery, School of Medicine, Yale University, New Haven, CT, United States
| | - Anuradha Singh
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Kyusang Lee
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Ji Yeoun Yoo
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Saadi Ghatan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Fedor Panov
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Lara V Marcuse
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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13
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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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14
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Lindquist BE, Timbie C, Voskobiynyk Y, Paz JT. Thalamocortical circuits in generalized epilepsy: Pathophysiologic mechanisms and therapeutic targets. Neurobiol Dis 2023; 181:106094. [PMID: 36990364 PMCID: PMC10192143 DOI: 10.1016/j.nbd.2023.106094] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/02/2023] [Accepted: 03/19/2023] [Indexed: 03/29/2023] Open
Abstract
Generalized epilepsy affects 24 million people globally; at least 25% of cases remain medically refractory. The thalamus, with widespread connections throughout the brain, plays a critical role in generalized epilepsy. The intrinsic properties of thalamic neurons and the synaptic connections between populations of neurons in the nucleus reticularis thalami and thalamocortical relay nuclei help generate different firing patterns that influence brain states. In particular, transitions from tonic firing to highly synchronized burst firing mode in thalamic neurons can cause seizures that rapidly generalize and cause altered awareness and unconsciousness. Here, we review the most recent advances in our understanding of how thalamic activity is regulated and discuss the gaps in our understanding of the mechanisms of generalized epilepsy syndromes. Elucidating the role of the thalamus in generalized epilepsy syndromes may lead to new opportunities to better treat pharmaco-resistant generalized epilepsy by thalamic modulation and dietary therapy.
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Affiliation(s)
- Britta E Lindquist
- UCSF Department of Neurology, Division of Neurocritical Care, United States of America; UCSF Department of Neurology, Division of Pediatric Epilepsy, United States of America; UCSF Department of Neurology, United States of America
| | - Clare Timbie
- Gladstone Institute of Neurological Disease, United States of America; UCSF Department of Neurology, Division of Pediatric Epilepsy, United States of America; UCSF Department of Neurology, United States of America
| | - Yuliya Voskobiynyk
- Gladstone Institute of Neurological Disease, United States of America; UCSF Department of Neurology, United States of America
| | - Jeanne T Paz
- Gladstone Institute of Neurological Disease, United States of America; UCSF Department of Neurology, United States of America; Kavli Institute for Fundamental Neuroscience, UCSF, United States of America.
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15
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Fisher RS. Deep brain stimulation of thalamus for epilepsy. Neurobiol Dis 2023; 179:106045. [PMID: 36809846 DOI: 10.1016/j.nbd.2023.106045] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 02/22/2023] Open
Abstract
Neuromodulation (neurostimulation) is a relatively new and rapidly growing treatment for refractory epilepsy. Three varieties are approved in the US: vagus nerve stimulation (VNS), deep brain stimulation (DBS) and responsive neurostimulation (RNS). This article reviews thalamic DBS for epilepsy. Among many thalamic sub-nuclei, DBS for epilepsy has been targeted to the anterior nucleus (ANT), centromedian nucleus (CM), dorsomedial nucleus (DM) and pulvinar (PULV). Only ANT is FDA-approved, based upon a controlled clinical trial. Bilateral stimulation of ANT reduced seizures by 40.5% at three months in the controlled phase (p = .038) and 75% by 5 years in the uncontrolled phase. Side effects related to paresthesias, acute hemorrhage, infection, occasional increased seizures, and usually transient effects on mood and memory. Efficacy was best documented for focal onset seizures in temporal or frontal lobe. CM stimulation may be useful for generalized or multifocal seizures and PULV for posterior limbic seizures. Mechanisms of DBS for epilepsy are largely unknown, but animal work points to changes in receptors, channels, neurotransmitters, synapses, network connectivity and neurogenesis. Personalization of therapies, in terms of connectivity of the seizure onset zone to the thalamic sub- nucleus and individual characteristics of the seizures, might lead to improved efficacy. Many questions remain about DBS, including the best candidates for different types of neuromodulation, the best targets, the best stimulation parameters, how to minimize side effects and how to deliver current noninvasively. Despite the questions, neuromodulation provides useful new opportunities to treat people with refractory seizures not responding to medicines and not amenable to resective surgery.
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Affiliation(s)
- Robert S Fisher
- Department of Neurology and Neurological Sciences and Neurosurgery by Courtesy, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, 213 Quarry Road, Room 4865, Palo Alto, CA 94304, USA.
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16
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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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17
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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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18
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Watson GDR, Kopell BH. Editorial: All roads lead to Rome: Harnessing thalamic neuromodulation for difficult-to-treat neurological disorders. Front Hum Neurosci 2023; 17:1155605. [PMID: 36866119 PMCID: PMC9972085 DOI: 10.3389/fnhum.2023.1155605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 02/16/2023] Open
Affiliation(s)
- Glenn D. R. Watson
- Department of Psychology and Neuroscience, Duke University, Durham, NC, United States,SK Life Science, Inc., Paramus, NJ, United States,*Correspondence: Glenn D. R. Watson ✉
| | - Brian H. Kopell
- Center for Neuromodulation, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States,Nash Family Center for Advanced Circuit Therapeutics, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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19
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Haneef Z, Skrehot HC. Neurostimulation in generalized epilepsy: A systematic review and meta-analysis. Epilepsia 2023; 64:811-820. [PMID: 36727550 DOI: 10.1111/epi.17524] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/03/2023]
Abstract
OBJECTIVE There are three neurostimulation devices available to treat generalized epilepsy: vagus nerve stimulation (VNS), deep brain stimulation (DBS), and responsive neurostimulation (RNS). However, the choice between them is unclear due to lack of head-to-head comparisons. A systematic comparison of neurostimulation outcomes in generalized epilepsy has not been performed previously. The goal of this meta-analysis was to determine whether one of these devices is better than the others to treat generalized epilepsy. METHODS Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review of PubMed, Embase, and Web of Science was performed for studies reporting seizure outcomes following VNS, RNS, and DBS implantation in generalized drug-resistant epilepsy between the first pivotal trial study for each modality through August 2022. Specific search criteria were used for VNS ("vagus", "vagal", or "VNS" in the title and "epilepsy" or "seizure"), DBS ("deep brain stimulation", "DBS", "anterior thalamic nucleus", "centromedian nucleus", or "thalamic stimulation" in the title and "epilepsy" or "seizure"), and RNS ("responsive neurostimulation" or "RNS" in the title and "epilepsy" or "seizure"). From 4409 articles identified, 319 underwent full-text reviews, and 20 studies were included. Data were pooled using a random-effects model using the meta package in R. RESULTS Sufficient data for meta-analysis were available from seven studies for VNS (n = 510) and nine studies for DBS (n = 87). Data from RNS (five studies, n = 18) were insufficient for meta-analysis. The mean (SD) follow-up durations were as follows: VNS, 39.1 (23.4) months; DBS, 23.1 (19.6) months; and RNS, 22.3 (10.6) months. Meta-analysis showed seizure reductions of 48.3% (95% confidence interval [CI] = 38.7%-57.9%) for VNS and 64.8% (95% CI = 54.4%-75.2%) for DBS (p = .02). SIGNIFICANCE Our meta-analysis indicates that the use of DBS may lead to greater seizure reduction than VNS in generalized epilepsy. Results from RNS use are promising, but further research is required.
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Affiliation(s)
- Zulfi Haneef
- Department of Neurology, Baylor College of Medicine, Houston, Texas, USA.,Neurology Care Line, VA Medical Center, Houston, Texas, USA
| | - Henry C Skrehot
- Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
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20
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Zheng B, Liu DD, Theyel BB, Abdulrazeq H, Kimata AR, Lauro PM, Asaad WF. Thalamic neuromodulation in epilepsy: A primer for emerging circuit-based therapies. Expert Rev Neurother 2023; 23:123-140. [PMID: 36731858 DOI: 10.1080/14737175.2023.2176752] [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: 02/04/2023]
Abstract
INTRODUCTION Epilepsy is a common, often debilitating disease of hyperexcitable neural networks. While medically intractable cases may benefit from surgery, there may be no single, well-localized focus for resection or ablation. In such cases, approaching the disease from a network-based perspective may be beneficial. AREAS COVERED Herein, the authors provide a narrative review of normal thalamic anatomy and physiology and propose general strategies for preventing and/or aborting seizures by modulating this structure. Additionally, they make specific recommendations for targeting the thalamus within different contexts, motivated by a more detailed discussion of its distinct nuclei and their respective connectivity. By describing important principles governing thalamic function and its involvement in seizure networks, the authors aim to provide a primer for those now entering this fast-growing field of thalamic neuromodulation for epilepsy. EXPERT OPINION The thalamus is critically involved with the function of many cortical and subcortical areas, suggesting it may serve as a compelling node for preventing or aborting seizures, and so it has increasingly been targeted for the surgical treatment of epilepsy. As various thalamic neuromodulation strategies for seizure control are developed, there is a need to ground such interventions in a mechanistic, circuit-based framework.
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Affiliation(s)
- Bryan Zheng
- The Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - David D Liu
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Brian B Theyel
- Department of Psychiatry, Rhode Island Hospital, Providence, RI, USA.,Department of Neuroscience, Brown University, Providence, RI, USA
| | - Hael Abdulrazeq
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Anna R Kimata
- The Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Peter M Lauro
- The Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Neuroscience, Brown University, Providence, RI, USA
| | - Wael F Asaad
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA.,Department of Neuroscience, Brown University, Providence, RI, USA.,The Carney Institute for Brain Science, Brown University, Providence, RI, USA.,The Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence, RI, USA
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21
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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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22
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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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23
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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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Zillgitt AJ, Haykal MA, Chehab A, Staudt MD. Centromedian thalamic neuromodulation for the treatment of idiopathic generalized epilepsy. Front Hum Neurosci 2022; 16:907716. [PMID: 35992953 PMCID: PMC9381751 DOI: 10.3389/fnhum.2022.907716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 07/13/2022] [Indexed: 11/20/2022] Open
Abstract
Idiopathic generalized epilepsy (IGE) is a common type of epilepsy and despite an increase in the number of available anti-seizure medications, approximately 20–30% of people with IGE continue to experience seizures despite adequate medication trials. Unlike focal epilepsy, resective surgery is not a viable treatment option for IGE; however, neuromodulation may be an effective surgical treatment for people with IGE. Thalamic stimulation through deep brain stimulation (DBS) and responsive neurostimulation (RNS) have been explored for the treatment of generalized and focal epilepsies. Although the data regarding DBS and RNS in IGE is limited to case reports and case series, the results of the published studies have been promising. The current manuscript will review the published literature of DBS and RNS within the centromedian nucleus of the thalamus for the treatment of IGE, as well as highlight an illustrative case.
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Affiliation(s)
- Andrew J. Zillgitt
- Department of Neurology, Beaumont Health Adult Comprehensive Epilepsy Center, Neuroscience Center, Royal Oak, MI, United States
| | - M. Ayman Haykal
- Department of Neurology, Beaumont Health Adult Comprehensive Epilepsy Center, Neuroscience Center, Royal Oak, MI, United States
| | - Ahmad Chehab
- Department of Neurosurgery, Beaumont Neuroscience Center, Royal Oak, MI, United States
| | - Michael D. Staudt
- Department of Neurosurgery, Beaumont Neuroscience Center, Royal Oak, MI, United States
- Department of Neurosurgery, Oakland University William Beaumont School of Medicine, Rochester, MI, United States
- Michigan Head and Spine Institute, Southfield, MI, United States
- *Correspondence: Michael D. Staudt,
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Roa JA, Abramova M, Fields M, Vega-Talbott ML, Yoo J, Marcuse L, Wolf S, McGoldrick P, Ghatan S, Panov F. Responsive Neurostimulation of the Thalamus for the Treatment of Refractory Epilepsy. Front Hum Neurosci 2022; 16:926337. [PMID: 35911594 PMCID: PMC9334749 DOI: 10.3389/fnhum.2022.926337] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/15/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction One-third of patients with epilepsy continue to have seizures despite antiepileptic medications. Some of these refractory patients may not be candidates for surgical resection primarily because the seizure onset zones (SOZs) involve both hemispheres or are located in eloquent areas. The NeuroPace Responsive Neurostimulation System (RNS) is a closed-loop device that uses programmable detection and stimulation to tailor therapy to a patient's individual neurophysiology. Here, we present our single-center experience with the use of RNS in thalamic nuclei to provide long-term seizure control in patients with refractory epilepsy. Methods We performed a prospective single-center study of consecutive refractory epilepsy patients who underwent RNS system implantation in the anterior (ANT) and centromedian (CM) thalamic nuclei from September 2015 to December 2020. Patients were followed postoperatively to evaluate seizure freedom and complications. Results Twenty-three patients underwent placement of 36 RNS thalamic leads (CM = 27 leads, ANT = 9 leads). Mean age at implant was 18.8 ± 11.2 years (range 7.8–62 years-old). Two patients (8.7%) developed infections: 1 improved with antibiotic treatments alone, and 1 required removal with eventual replacement of the system to recover the therapeutic benefit. Mean time from RNS implantation to last follow-up was 22.3 months. Based on overall reduction of seizure frequency, 2 patients (8.7%) had no- to <25% improvement, 6 patients (26.1%) had 25–49% improvement, 14 patients (60.9%) had 50–99% improvement, and 1 patient (4.3%) became seizure-free. All patients reported significant improvement in seizure duration and severity, and 17 patients (74%) reported improved post-ictal state. There was a trend for subjects with SOZs located in the temporal lobe to achieve better outcomes after thalamic RNS compared to those with extratemporal SOZs. Of note, seizure etiology was syndromic in 12 cases (52.2%), and 7 patients (30.4%) had undergone resection/disconnection surgery prior to thalamic RNS therapy. Conclusion Thalamic RNS achieved ≥50% seizure control in ~65% of patients. Infections were the most common complication. This therapeutic modality may be particularly useful for patients affected by aggressive epilepsy syndromes since a young age, those whose seizure foci are located in the mesial temporal lobe, and those who have failed prior surgical interventions.
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Affiliation(s)
- Jorge A. Roa
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Marina Abramova
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Madeline Fields
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Maite La Vega-Talbott
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Jiyeoun Yoo
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Lara Marcuse
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Steven Wolf
- Department of Neurology, Boston Children's Health Physicians, New York Medical College, New York, NY, United States
| | - Patricia McGoldrick
- Department of Neurology, Boston Children's Health Physicians, New York Medical College, New York, NY, United States
| | - Saadi Ghatan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Fedor Panov
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- *Correspondence: Fedor Panov
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Feigen CM, Eskandar EN. Responsive Thalamic Neurostimulation: A Systematic Review of a Promising Approach for Refractory Epilepsy. Front Hum Neurosci 2022; 16:910345. [PMID: 35865353 PMCID: PMC9294465 DOI: 10.3389/fnhum.2022.910345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/25/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Responsive neurostimulation is an evolving therapeutic option for patients with treatment-refractory epilepsy. Open-loop, continuous stimulation of the anterior thalamic nuclei is the only approved modality, yet chronic stimulation rarely induces complete seizure remission and is associated with neuropsychiatric adverse effects. Accounts of off-label responsive stimulation in thalamic nuclei describe significant improvements in patients who have failed multiple drug regimens, vagal nerve stimulation, and other invasive measures. This systematic review surveys the currently available data supporting the use of responsive thalamic neurostimulation in primary and secondary generalized, treatment-refractory epilepsy. Materials and Methods A systematic review was performed using the following combination of keywords and controlled vocabulary: (“Seizures”[Mesh] AND “Thalamus”[Mesh] AND “Deep Brain Stimulation”[Mesh]) OR (responsive neurostim* AND (thalamus[MeSH])) OR [responsive neurostimulation AND thalamus AND (epilepsy OR seizures)]. In addition, a search of the publications listed under the PubMed “cited by” tab was performed for all publications that passed title/abstract screening in addition to manually searching their reference lists. Results Ten publications were identified describing a total of 29 subjects with a broad range of epilepsy disorders treated with closed-loop thalamic neurostimulation. The median age of subjects was 31 years old (range 10–65 years). Of the 29 subjects, 15 were stimulated in the anterior, 11 in the centromedian, and 3 in the pulvinar nuclei. Excluding 5 subjects who were treated for 1 month or less, median time on stimulation was 19 months (range 2.4–54 months). Of these subjects, 17/24 experienced greater than or equal to 50%, 11/24 least 75%, and 9/24 at least 90% reduction in seizures. Although a minority of patients did not exhibit significant clinical improvement by follow-up, there was a general trend of increasing treatment efficacy with longer periods on closed-loop thalamic stimulation. Conclusion The data supporting off-label closed-loop thalamic stimulation for refractory epilepsy is limited to 29 adult and pediatric patients, many of whom experienced significant improvement in seizure duration and frequency. This encouraging progress must be verified in larger studies.
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Surgical Treatment of Drug-Resistant Generalized Epilepsy. Curr Neurol Neurosci Rep 2022; 22:459-465. [PMID: 35713776 DOI: 10.1007/s11910-022-01210-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW To summarize current evidence and recent developments in the surgical treatment of drug-resistant generalized epilepsy. RECENT FINDINGS Current surgical treatments of drug-resistant generalized epilepsy include vagus nerve stimulation (VNS), deep brain stimulation (DBS) and corpus callosotomy (CC). Neurostimulation with VNS and/or DBS has been shown to be effective in reducing seizure frequency in patients with generalized epilepsy. DBS for generalized epilepsy is primarily consisted of open-loop stimulation directed at the centromedian (CM) nucleus in the thalamus, though closed-loop stimulation and additional targets are being explored. CC can be effective in treating some seizure types and can be performed using traditional surgical techniques or with the less invasive methods of laser ablation and radiosurgery. This current literature supports the use of VNS, DBS and CC, alone or in combination, as palliative treatments of drug-resistant generalized epilepsy.
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28
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Agashe S, Burkholder D, Starnes K, Van Gompel JJ, Lundstrom BN, Worrell GA, Gregg NM. Centromedian Nucleus of the Thalamus Deep Brain Stimulation for Genetic Generalized Epilepsy: A Case Report and Review of Literature. Front Hum Neurosci 2022; 16:858413. [PMID: 35669200 PMCID: PMC9164300 DOI: 10.3389/fnhum.2022.858413] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 04/07/2022] [Indexed: 11/13/2022] Open
Abstract
There is a paucity of treatment options for cognitively normal individuals with drug resistant genetic generalized epilepsy (GGE). Centromedian nucleus of the thalamus (CM) deep brain stimulation (DBS) may be a viable treatment for GGE. Here, we present the case of a 27-year-old cognitively normal woman with drug resistant GGE, with childhood onset. Seizure semiology are absence seizures and generalized onset tonic clonic (GTC) seizures. At baseline she had 4–8 GTC seizures per month and weekly absence seizures despite three antiseizure medications and vagus nerve stimulation. A multidisciplinary committee recommended off-label use of CM DBS in this patient. Over 12-months of CM DBS she had two GTC seizure days, which were in the setting of medication withdrawal and illness, and no GTC seizures in the last 6 months. There was no significant change in the burden of absence seizures. Presently, just two studies clearly document CM DBS in cognitively normal individuals with GGE or idiopathic generalized epilepsy (IGE) [in contrast to studies of cognitively impaired individuals with developmental and epileptic encephalopathies (DEE)]. Our results suggest that CM DBS can be an effective treatment for cognitively normal individuals with GGE and underscore the need for prospective studies of CM DBS.
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Affiliation(s)
- Shruti Agashe
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- *Correspondence: Shruti Agashe,
| | - David Burkholder
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Keith Starnes
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | | | | | | | - Nicholas M. Gregg
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Nicholas M. Gregg,
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29
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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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30
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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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31
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Abouelleil M, Deshpande N, Ali R. Emerging Trends in Neuromodulation for Treatment of Drug-Resistant Epilepsy. FRONTIERS IN PAIN RESEARCH 2022; 3:839463. [PMID: 35386582 PMCID: PMC8977768 DOI: 10.3389/fpain.2022.839463] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/21/2022] [Indexed: 01/12/2023] Open
Abstract
Epilepsy is a neurological disorder that affects more than 70 million people globally. A considerable proportion of epilepsy is resistant to anti-epileptic drugs (AED). For patients with drug-resistant epilepsy (DRE), who are not eligible for resective or ablative surgery, neuromodulation has been a palliative option. Since the approval of vagus nerve stimulation (VNS) in 1997, expansion to include other modalities, such as deep brain stimulation (DBS) and responsive neurostimulation (RNS), has led to improved seizure control in this population. In this article, we discuss the current updates and emerging trends on neuromodulation for epilepsy.
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Affiliation(s)
- Mohamed Abouelleil
- Division of Neurological Surgery, Spectrum Health, Grand Rapids, MI, United States
| | - Nachiket Deshpande
- College of Human Medicine, Michigan State University, East Lansing, MI, United States
| | - Rushna Ali
- Division of Neurological Surgery, Spectrum Health, Grand Rapids, MI, United States
- *Correspondence: Rushna Ali
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32
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Warsi NM, Yan H, Suresh H, Wong SM, Arski ON, Gorodetsky C, Zhang K, Gouveia FV, Ibrahim GM. The anterior and centromedian thalamus: anatomy, function, and dysfunction in epilepsy. Epilepsy Res 2022; 182:106913. [DOI: 10.1016/j.eplepsyres.2022.106913] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/07/2022] [Accepted: 03/21/2022] [Indexed: 01/21/2023]
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33
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Richardson RM. Closed-Loop Brain Stimulation and Paradigm Shifts in Epilepsy Surgery. Neurol Clin 2022; 40:355-373. [PMID: 35465880 PMCID: PMC9271409 DOI: 10.1016/j.ncl.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Advances in device technology have created greater flexibility in treating seizures as emergent properties of networks that exist on a local to global continuum. All patients with drug-resistant epilepsy are potential surgical candidates, given that intracranial neuromodulation through deep brain stimulation and responsive neurostimulation can reduce seizures and improve quality of life, even in multifocal and generalized epilepsies. To achieve this goal, indications and strategies for diagnostic epilepsy surgery are evolving. This article describes the state-of-the-art in epilepsy surgery and related changes in how we define indications for diagnostic and therapeutic surgical intervention.
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34
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Hect JL, Fernandez LD, Welch WP, Abel TJ. Deep brain stimulation of the centromedian thalamic nucleus for the treatment of FIRES. Epilepsia Open 2021; 7:187-193. [PMID: 34862854 PMCID: PMC8886094 DOI: 10.1002/epi4.12568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/16/2021] [Accepted: 11/28/2021] [Indexed: 11/10/2022] Open
Abstract
Febrile infection‐related epilepsy syndrome (FIRES) is a rare, life‐threatening complication of febrile illness in previously healthy individuals followed by super‐refractory status epilepticus. Deep brain stimulation (DBS) has been demonstrated to be a promising therapy for the treatment of intractable epilepsy. Here, we present a pediatric patient with FIRES whose seizures were mitigated by acute DBS of the bilateral centromedian thalamic nucleus (CMTN). This is a previously healthy 11‐year‐old female who presented emergently with altered mental status, fever, and malaise after 1 week of lethargy, anorexia, fever, and abdominal pain. The patient began having seizures shortly after admission. After thorough workup for encephalitis and other potential etiologies, this patient was diagnosed with FIRES due to super‐refractory status epilepticus. Status epilepticus persisted despite pharmacologic management, immunotherapy, and vagus nerve stimulation. DBS of the bilateral CMTN (CM‐DBS) was pursued after 56 days of hospitalization, and she demonstrated considerable improvement in baseline mental status 30 days after DBS insertion. This report highlights application of CM‐DBS for super‐refractory status epilepticus in FIRES. This region is a diffusely connected brain region and has been shown to modulate neural networks contributing to seizure propagation and consciousness; therefore, neurostimulation is a potential therapeutic intervention for patients with super‐refractory status epilepticus.
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Affiliation(s)
- Jasmine L Hect
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Luis D Fernandez
- Division of Pediatric Neurology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - William P Welch
- Division of Pediatric Neurology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Bioengineering, University of Pittsburgh Swanson School of Engineering, Pittsburgh, Pennsylvania, USA
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35
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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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