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Samanta D, Aungaroon G, Albert GW, Karakas C, Joshi CN, Singh RK, Oluigbo C, Perry MS, Naik S, Reeders PC, Jain P, Abel TJ, Pati S, Shaikhouni A, Haneef Z. Advancing thalamic neuromodulation in epilepsy: Bridging adult data to pediatric care. Epilepsy Res 2024; 205:107407. [PMID: 38996686 DOI: 10.1016/j.eplepsyres.2024.107407] [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: 04/02/2024] [Revised: 06/27/2024] [Accepted: 07/01/2024] [Indexed: 07/14/2024]
Abstract
Thalamic neuromodulation has emerged as a treatment option for drug-resistant epilepsy (DRE) with widespread and/or undefined epileptogenic networks. While deep brain stimulation (DBS) and responsive neurostimulation (RNS) depth electrodes offer means for electrical stimulation of the thalamus in adult patients with DRE, the application of thalamic neuromodulation in pediatric epilepsy remains limited. To address this gap, the Neuromodulation Expert Collaborative was established within the Pediatric Epilepsy Research Consortium (PERC) Epilepsy Surgery Special Interest Group. In this expert review, existing evidence and recommendations for thalamic neuromodulation modalities using DBS and RNS are summarized, with a focus on the anterior (ANT), centromedian(CMN), and pulvinar nuclei of the thalamus. To-date, only DBS of the ANT is FDA approved for treatment of DRE in adult patients based on the results of the pivotal SANTE (Stimulation of the Anterior Nucleus of Thalamus for Epilepsy) study. Evidence for other thalamic neurmodulation indications and targets is less abundant. Despite the lack of evidence, positive responses to thalamic stimulation in adults with DRE have led to its off-label use in pediatric patients. Although caution is warranted due to differences between pediatric and adult epilepsy, the efficacy and safety of pediatric neuromodulation appear comparable to that in adults. Indeed, CMN stimulation is increasingly accepted for generalized and diffuse onset epilepsies, with recent completion of one randomized trial. There is also growing interest in using pulvinar stimulation for temporal plus and posterior quadrant epilepsies with one ongoing clinical trial in Europe. The future of thalamic neuromodulation holds promise for revolutionizing the treatment landscape of childhood epilepsy. Ongoing research, technological advancements, and collaborative efforts are poised to refine and improve thalamic neuromodulation strategies, ultimately enhancing the quality of life for children with DRE.
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Affiliation(s)
- Debopam Samanta
- Division of Child Neurology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Gewalin Aungaroon
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Gregory W Albert
- Department of Neurosurgery, University of Arkansas for Medical Sciences, USA
| | - Cemal Karakas
- Division of Pediatric Neurology, Department of Neurology, Norton Children's Hospital, University of Louisville, Louisville, KY 40202, USA
| | - Charuta N Joshi
- Division of Pediatric Neurology, Childrens Medical Center Dallas, UTSW, USA
| | - Rani K Singh
- Department of Pediatrics, Atrium Health-Levine Children's; Wake Forest University School of Medicine, USA
| | - Chima Oluigbo
- Department of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - M Scott Perry
- Jane and John Justin Institute for Mind Health, Cook Children's Medical Center, Ft Worth, TX, USA
| | - Sunil Naik
- Department of Pediatrics and Neurology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Puck C Reeders
- Brain Institute, Nicklaus Children's Hospital, Miami, FL, USA
| | - Puneet Jain
- Epilepsy Program, Division of Neurology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh School of Medicine and Department of Bioengineering, University of Pittsburgh
| | - Sandipan Pati
- The University of Texas Health Science Center at Houston, USA
| | - Ammar Shaikhouni
- Department of Pediatric Neurosurgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Zulfi Haneef
- Neurology Care Line, VA Medical Center, Houston, TX 77030, USA; Department of Neurology, Baylor College of Medicine, Houston, TX 77030, USA
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Nathan CL, Gavvala JR, Chaitanya G, Cunningham E, Lee JJ, Adney S, Rosenow J, Schuele S, Gerard E. High-Frequency Stimulation of the Centromedian Thalamic Nucleus Aborts Seizures and Ictal Apnea. J Clin Neurophysiol 2024; 41:570-574. [PMID: 38916942 DOI: 10.1097/wnp.0000000000001098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024] Open
Abstract
SUMMARY A 32-year-old right-handed woman presented with medically and surgically refractory left temporal neocortical epilepsy secondary to focal cortical dysplasia who underwent stereoelectroencephalography involving the centromedian nucleus of the thalamus. With the use of real-time stereoelectroencephalography monitoring, four electroclinical seizures were aborted by administering high-frequency stimulation at the centromedian nucleus at seizure onset. Seizures before stimulation were all associated with ictal apnea, while those with stimulation had no ictal apnea. This case demonstrates how providing high-frequency stimulation to the centromedian nucleus of the thalamus can abort electroclinical seizures and ictal apnea.
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Affiliation(s)
- Cody L Nathan
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Jay R Gavvala
- Department of Neurology, UT Health Houston McGovern School of Medicine, Houston, Texas, U.S.A
| | - Ganne Chaitanya
- Department of Neurology, UT Health Houston McGovern School of Medicine, Houston, Texas, U.S.A
| | - Elizabeth Cunningham
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Jungwha Julia Lee
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A.; and
| | - Scott Adney
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Joshua Rosenow
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Stephan Schuele
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Elizabeth Gerard
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
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Abdulrazeq H, Feler J, Kimata AR, Asaad WF, Malik AN. Robot-assisted, CT-guided placement of responsive neurostimulator system with bilateral centromedian thalamus depth electrodes for multifocal intractable epilepsy. NEUROSURGICAL FOCUS: VIDEO 2024; 11:V17. [PMID: 38957427 PMCID: PMC11216424 DOI: 10.3171/2024.4.focvid243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 04/16/2024] [Indexed: 07/04/2024]
Abstract
The responsive neurostimulator system has become increasingly popular in the surgical management of refractory epilepsy, with targeting of various thalamic nuclei showing promising results in select patients. A 42-year-old female presented for evaluation of refractory epilepsy consisting of generalized tonic-clonic and focal seizures with preserved awareness. Phase I and II monitoring suggested multifocal bilateral epilepsy with bilateral frontal onset, and the patient underwent robot-guided bilateral centromedian thalamic placement of the RNS System. In this operative video, the authors share their institutional experience and protocol utilizing the ExcelsiusGPS robot in the placement of the RNS System in the thalamus. The video can be found here: https://stream.cadmore.media/r10.3171/2024.4.FOCVID243.
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Affiliation(s)
- Hael Abdulrazeq
- Department of Neurosurgery, Rhode Island Hospital, Providence
- The Warren Alpert Medical School of Brown University, Providence
- Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence; and
| | - Josh Feler
- Department of Neurosurgery, Rhode Island Hospital, Providence
- The Warren Alpert Medical School of Brown University, Providence
- Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence; and
| | - Anna R. Kimata
- Department of Neurosurgery, Rhode Island Hospital, Providence
- The Warren Alpert Medical School of Brown University, Providence
- Department of Neuroscience, Brown University, Providence, Rhode Island
| | - Wael F. Asaad
- Department of Neurosurgery, Rhode Island Hospital, Providence
- The Warren Alpert Medical School of Brown University, Providence
- Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence; and
- Department of Neuroscience, Brown University, Providence, Rhode Island
| | - Athar N. Malik
- Department of Neurosurgery, Rhode Island Hospital, Providence
- The Warren Alpert Medical School of Brown University, Providence
- Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence; and
- Department of Neuroscience, Brown University, Providence, Rhode Island
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Castellano JF, Singla S, Barot N, Aronson JP. Stereoelectroencephalography-Guided Radiofrequency Thermocoagulation: Diagnostic and Therapeutic Implications. Brain Sci 2024; 14:110. [PMID: 38391685 PMCID: PMC10887298 DOI: 10.3390/brainsci14020110] [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: 12/28/2023] [Revised: 01/15/2024] [Accepted: 01/21/2024] [Indexed: 02/24/2024] Open
Abstract
Despite recent medical therapeutic advances, approximately one third of patients do not attain seizure freedom with medications. This drug-resistant epilepsy population suffers from heightened morbidity and mortality. In appropriate patients, resective epilepsy surgery is far superior to continued medical therapy. Despite this efficacy, there remain drawbacks to traditional epilepsy surgery, such as the morbidity of open neurosurgical procedures as well as neuropsychological adverse effects. SEEG-guided Radiofrequency Thermocoagulation (SgRFTC) is a minimally invasive, electrophysiology-guided intervention with both diagnostic and therapeutic implications for drug-resistant epilepsy that offers a convenient adjunct or alternative to ablative and resective approaches. We review the international experience with this procedure, including methodologies, diagnostic benefit, therapeutic benefit, and safety considerations. We propose a framework in which SgRFTC may be incorporated into intracranial EEG evaluations alongside passive recording. Lastly, we discuss the potential role of SgRFTC in both delineating and reorganizing epilepsy networks.
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Affiliation(s)
- James F Castellano
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Shobhit Singla
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Niravkumar Barot
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Joshua P Aronson
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
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Abdulrazeq H, Kimata AR, Blum A, Malik AN, Asaad WF. Exploring the Role of the Pulvinar Nucleus of the Thalamus in Occipital Lobe Epilepsy: A Case Report. Cureus 2024; 16:e52534. [PMID: 38371112 PMCID: PMC10874469 DOI: 10.7759/cureus.52534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 02/20/2024] Open
Abstract
Understanding the role of the pulvinar nucleus may be critical for guiding circuit-targeted neurosurgical intervention in some patients. In this report, a 33-year-old female presented with focal onset occipital epilepsy with secondary generalization and with a previously radiated arteriovenous malformation within the right primary visual cortex. Phase II monitoring demonstrated the pulvinar nucleus was not involved in subclinical seizures restricted to the primary visual cortex, but it did become involved in clinical events with more extensive seizure spread into higher visual cortical regions. She underwent responsive neurostimulation (RNS) with implantation of leads within the primary visual cortex. This case demonstrates the late propagation of epileptic activity from the visual cortex to the pulvinar nucleus and illustrates the pulvinar nucleus' connections with higher-order visual areas.
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Affiliation(s)
- Hael Abdulrazeq
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, USA
| | - Anna R Kimata
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, USA
| | - Andrew Blum
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, USA
| | - Athar N Malik
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, USA
- Department of Neuroscience, The Warren Alpert Medical School of Brown University, Providence, USA
| | - Wael F Asaad
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, USA
- Department of Neuroscience, The Warren Alpert Medical School of Brown University, Providence, USA
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Ghatan S. Pediatric Neurostimulation and Practice Evolution. Neurosurg Clin N Am 2024; 35:1-15. [PMID: 38000833 DOI: 10.1016/j.nec.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Since the late nineteenth century, the prevailing view of epilepsy surgery has been to identify a seizure focus in a medically refractory patient and eradicate it. Sadly, only a select number of the many who suffer from uncontrolled seizures benefit from this approach. With the development of safe, efficient stereotactic methods and targeted surgical therapies that can affect deep structures and modulate broad networks in diverse disorders, epilepsy surgery in children has undergone a paradigmatic evolutionary change. With modern diagnostic techniques such as stereo electroencephalography combined with closed loop neuromodulatory systems, pediatric epilepsy surgery can reach a much broader population of underserved patients.
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Affiliation(s)
- Saadi Ghatan
- Neurological Surgery Icahn School of Medicine at Mt Sinai, New York, NY 10128, USA.
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