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Krishna V, Mindel J, Sammartino F, Block C, Dwivedi AK, Van Gompel JJ, Fountain N, Fisher R. A phase 1 open-label trial evaluating focused ultrasound unilateral anterior thalamotomy for focal onset epilepsy. Epilepsia 2023; 64:831-842. [PMID: 36745000 DOI: 10.1111/epi.17535] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 01/16/2023] [Accepted: 02/03/2023] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Focused ultrasound ablation (FUSA) is an emerging treatment for neurological and psychiatric diseases. We describe the initial experience from a pilot, open-label, single-center clinical trial of unilateral anterior nucleus of the thalamus (ANT) FUSA in patients with treatment-refractory epilepsy. METHODS Two adult subjects with treatment-refractory, focal onset epilepsy were recruited. The subjects received ANT FUSA using the Exablate Neuro (Insightec) system. We determined the safety and feasibility (primary outcomes), and changes in seizure frequency (secondary outcome) at 3, 6, and 12 months. Safety was assessed by the absence of side effects, that is, new onset neurological deficits or performance deterioration on neuropsychological testing. Feasibility was defined as the ability to create a lesion within the anterior nucleus. The monthly seizure frequency was compared between baseline and postthalamotomy. RESULTS The patients tolerated the procedure well, without neurological deficits or serious adverse events. One patient experienced a decline in verbal fluency, attention/working memory, and immediate verbal memory. Seizure frequency reduced significantly in both patients; one patient was seizure-free at 12 months, and in the second patient, the frequency reduced from 90-100 seizures per month to 3-6 seizures per month. SIGNIFICANCE This is the first known clinical trial to assess the safety, feasibility, and preliminary efficacy of ANT FUSA in adult patients with treatment-refractory focal onset epilepsy.
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Affiliation(s)
- Vibhor Krishna
- Department of Neurosurgery, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jesse Mindel
- Department of Neurology, Ohio State University, Columbus, Ohio, USA
| | - Francesco Sammartino
- Department of Physical Medicine and Rehabilitation, Ohio State University, Columbus, Ohio, USA
| | - Cady Block
- Department of Neurology, Emory University, Atlanta, Georgia, USA
| | - Alok Kumar Dwivedi
- Division of Biostatistics and Epidemiology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Jamie J Van Gompel
- Department of Neurosurgery and Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nathan Fountain
- Department of Neurology, University of Virginia, Charlottesville, Virginia, USA
| | - Robert Fisher
- Department of Neurology, Stanford University, Stanford, California, USA
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Mansouri AM, Germann J, Boutet A, Elias GJB, Mithani K, Chow CT, Karmur B, Ibrahim GM, McAndrews MP, Lozano AM, Zadeh G, Valiante TA. Identification of neural networks preferentially engaged by epileptogenic mass lesions through lesion network mapping analysis. Sci Rep 2020; 10:10989. [PMID: 32620922 PMCID: PMC7335039 DOI: 10.1038/s41598-020-67626-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 06/09/2020] [Indexed: 11/09/2022] Open
Abstract
Lesion network mapping (LNM) has been applied to true lesions (e.g., cerebrovascular lesions in stroke) to identify functionally connected brain networks. No previous studies have utilized LNM for analysis of intra-axial mass lesions. Here, we implemented LNM for identification of potentially vulnerable epileptogenic networks in mass lesions causing medically-refractory epilepsy (MRE). Intra-axial brain lesions were manually segmented in patients with MRE seen at our institution (EL_INST). These lesions were then normalized to standard space and used as seeds in a high-resolution normative resting state functional magnetic resonance imaging template. The resulting connectivity maps were first thresholded (pBonferroni_cor < 0.05) and binarized; the thresholded binarized connectivity maps were subsequently summed to produce overall group connectivity maps, which were compared with established resting-state networks to identify potential networks prone to epileptogenicity. To validate our data, this approach was also applied to an external dataset of epileptogenic lesions identified from the literature (EL_LIT). As an additional exploratory analysis, we also segmented and computed the connectivity of institutional non-epileptogenic lesions (NEL_INST), calculating voxel-wise odds ratios (VORs) to identify voxels more likely to be functionally-connected with EL_INST versus NEL_INST. To ensure connectivity results were not driven by anatomical overlap, the extent of lesion overlap between EL_INST, and EL_LIT and NEL_INST was assessed using the Dice Similarity Coefficient (DSC, lower index ~ less overlap). Twenty-eight patients from our institution were included (EL_INST: 17 patients, 17 lesions, 10 low-grade glioma, 3 cavernoma, 4 focal cortical dysplasia; NEL_INST: 11 patients, 33 lesions, all brain metastases). An additional 23 cases (25 lesions) with similar characteristics to the EL_INST data were identified from the literature (EL_LIT). Despite minimal anatomical overlap of lesions, both EL_INST and EL_LIT showed greatest functional connectivity overlap with structures in the Default Mode Network, Frontoparietal Network, Ventral Attention Network, and the Limbic Network-with percentage volume overlap of 19.5%, 19.1%, 19.1%, and 12.5%, respectively-suggesting them as networks consistently engaged by epileptogenic mass lesions. Our exploratory analysis moreover showed that the mesial frontal lobes, parahippocampal gyrus, and lateral temporal neocortex were at least twice as likely to be functionally connected with the EL_INST compared to the NEL_INST group (i.e. Peak VOR > 2.0); canonical resting-state networks preferentially engaged by EL_INSTs were the Limbic and the Frontoparietal Networks (Mean VOR > 1.5). In this proof of concept study, we demonstrate the feasibility of LNM for intra-axial mass lesions by showing that ELs have discrete functional connections and may preferentially engage in discrete resting-state networks. Thus, the underlying normative neural circuitry may, in part, explain the propensity of particular lesions toward the development of MRE. If prospectively validated, this has ramifications for patient counseling along with both approach and timing of surgery for lesions in locations prone to development of MRE.
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Affiliation(s)
| | | | - Alexandre Boutet
- University Health Network, Toronto, ON, USA.,Joint Department of Medical Imaging, University of Toronto, Toronto, ON, USA
| | | | - Karim Mithani
- Faculty of Medicine, University of Toronto, Toronto, ON, USA
| | | | - Brij Karmur
- Faculty of Medicine, University of Toronto, Toronto, ON, USA
| | - George M Ibrahim
- Program in Neuroscience and Mental Health, Sickkids Research Institute, Toronto, ON, USA.,Division of Neurosurgery, The Hospital for Sick Children, Toronto, ON, USA.,Department of Surgery, Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON, USA
| | - Mary Pat McAndrews
- Department of Neuropsychology, University Health Network, Toronto, ON, USA
| | - Andres M Lozano
- Division of Neurosurgery, University Health Network, Toronto, ON, USA
| | - Gelareh Zadeh
- Division of Neurosurgery, University Health Network, Toronto, ON, USA
| | - Taufik A Valiante
- Division of Neurosurgery, University Health Network, Toronto, ON, USA
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So RQ, Krishna V, King NKK, Yang H, Zhang Z, Sammartino F, Lozano AM, Wennberg RA, Guan C. Prediction and detection of seizures from simultaneous thalamic and scalp electroencephalography recordings. J Neurosurg 2016; 126:2036-2044. [PMID: 27715438 DOI: 10.3171/2016.7.jns161282] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors explored the feasibility of seizure detection and prediction using signals recorded from the anterior thalamic nucleus, a major target for deep brain stimulation (DBS) in the treatment of epilepsy. METHODS Using data from 5 patients (13 seizures in total), the authors performed a feasibility study and analyzed the performance of a seizure prediction and detection algorithm applied to simultaneously acquired scalp and thalamic electroencephalography (EEG). The thalamic signal was obtained from DBS electrodes. The applied algorithm used the similarity index as a nonlinear measure for seizure identification, with patient-specific channel and threshold selection. Receiver operating characteristic (ROC) curves were calculated using data from all patients and channels to compare the performance between DBS and EEG recordings. RESULTS Thalamic DBS recordings were associated with a mean prediction rate of 84%, detection rate of 97%, and false-alarm rate of 0.79/hr. In comparison, scalp EEG recordings were associated with a mean prediction rate of 71%, detection rate of 100%, and false-alarm rate of 1.01/hr. From the ROC curves, when considering all channels, DBS outperformed EEG for both detection and prediction of seizures. CONCLUSIONS This is the first study to compare automated seizure detection and prediction from simultaneous thalamic and scalp EEG recordings. The authors have demonstrated that signals recorded from DBS leads are more robust than EEG recordings and can be used to predict and detect seizures. These results indicate feasibility for future designs of closed-loop anterior nucleus DBS systems for the treatment of epilepsy.
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Affiliation(s)
| | - Vibhor Krishna
- Department of Neurosurgery, Center for Neuromodulation, and.,Department of Neuroscience, The Ohio State University, Columbus, Ohio; and
| | | | | | | | | | | | - Richard A Wennberg
- Neurology, Krembil Neuroscience Centre, University of Toronto, Ontario, Canada
| | - Cuntai Guan
- Institute for Infocomm Research.,Nanyang Technological University, Singapore
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Siniatchkin M, Capovilla G. Functional neuroimaging in epileptic encephalopathies. Epilepsia 2013; 54 Suppl 8:27-33. [DOI: 10.1111/epi.12420] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Michael Siniatchkin
- Clinic of Child and Adolescents Psychiatry; Goethe-University of Frankfurt; Frankfurt Germany
| | - Giuseppe Capovilla
- Department of Child Neuropsychiatry; Epilepsy Center; C. Poma Hospital; Mantova Italy
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Moeller F, Stephani U, Siniatchkin M. Simultaneous EEG and fMRI recordings (EEG-fMRI) in children with epilepsy. Epilepsia 2013; 54:971-82. [PMID: 23647021 DOI: 10.1111/epi.12197] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2013] [Indexed: 11/27/2022]
Abstract
By combining electroencephalography (EEG) with functional magnetic resonance imaging (fMRI) it is possible to describe blood oxygenation level-dependent (BOLD) signal changes related to EEG patterns. This way, EEG-pattern-associated networks of hemodynamic changes can be detected anywhere in the brain with good spatial resolution. This review summarizes EEG-fMRI studies that have been performed in children with epilepsy. EEG-fMRI studies in focal epilepsy (structural and nonlesional cases, benign epilepsy with centrotemporal spikes), generalized epilepsy (especially absence epilepsy), and epileptic encephalopathies (West syndrome, Lennox-Gastaut syndrome, continuous spike and waves during slow sleep, and Dravet syndrome) are presented. Although EEG-fMRI was applied mainly to localize the region presumably generating focal interictal discharges in focal epilepsies, EEG-fMRI identified underlying networks in patients with generalized epilepsies and thereby contributed to a better understanding of these epilepsies. In epileptic encephalopathies a specific fingerprint of hemodynamic changes associated with the particular syndrome was detected. The value of the EEG-fMRI technique for diagnosis and investigation of pathogenetic mechanisms of different forms of epilepsy is discussed.
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Affiliation(s)
- Friederike Moeller
- Department of Neuropediatrics, Christian-Albrechts-University, Kiel, Germany.
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Wu C, Sharan AD. Neurostimulation for the Treatment of Epilepsy: A Review of Current Surgical Interventions. Neuromodulation 2012; 16:10-24; discussion 24. [DOI: 10.1111/j.1525-1403.2012.00501.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Abstract
Neuromodulation strategies have been proposed to treat a variety of neurological disorders, including medication-resistant epilepsy. Electrical stimulation of both central and peripheral nervous systems has emerged as a possible alternative for patients who are not deemed to be good candidates for resective procedures. In addition to well-established treatments such as vagus nerve stimulation, epilepsy centers around the world are investigating the safety and efficacy of neurostimulation at different brain targets, including the hippocampus, thalamus, and subthalamic nucleus. Also promising are the preliminary results of responsive neuromodulation studies, which involve the delivery of stimulation to the brain in response to detected epileptiform or preepileptiform activity. In addition to electrical stimulation, novel therapeutic methods that may open new horizons in the management of epilepsy include transcranial magnetic stimulation, focal drug delivery, cellular transplantation, and gene therapy. We review the current strategies and future applications of neuromodulation in epilepsy.
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Affiliation(s)
- Faisal A Al-Otaibi
- King Faisal Specialist Hospital & Research Centre, Neurosciences Department, Riyadh, Saudi Arabia
| | - Clement Hamani
- Division of Neurosurgery, Toronto Western Hospital, Toronto Western Research Institute, Ontario, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Toronto Western Hospital, Toronto Western Research Institute, Ontario, Canada
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Siniatchkin M, Coropceanu D, Moeller F, Boor R, Stephani U. EEG-fMRI reveals activation of brainstem and thalamus in patients with Lennox-Gastaut syndrome. Epilepsia 2011; 52:766-74. [PMID: 21275978 DOI: 10.1111/j.1528-1167.2010.02948.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE Even if etiologies of Lennox-Gastaut syndrome (LGS) are diverse, the multiple causes converge into a final common pathway that results in this specific epilepsy phenotype. There is little knowledge, however, about neuronal networks that may be a part of this pathway. METHODS To investigate these networks, 11 children with LGS and 9 control children with multifocal epileptic activity were investigated using simultaneous recordings of EEG and functional MRI (EEG-fMRI) in a 3 Tesla scanner. KEY FINDINGS Individual and group analyses revealed significant activation of brainstem and thalamus (especially centromedian and anterior thalamus) associated with epileptiform discharges in patients with LGS. None of the patients with multifocal epileptic activity presented with the same hemodynamic activation pattern. SIGNIFICANCE Because brainstem activation has been associated with infantile spasms, which often evolve into LGS, and thalamus activation has been observed in patients with primary (idiopathic generalized syndromes) and secondary (focal epilepsies) bilateral synchrony, the described network in LGS may represent the common pathogenetic pathway of these different conditions.
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Affiliation(s)
- Michael Siniatchkin
- Department of Neuropediatrics, Christian-Albrechts-University, Kiel, Germany.
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Khan S, Wright I, Javed S, Sharples P, Jardine P, Carter M, Gill SS. High frequency stimulation of the mamillothalamic tract for the treatment of resistant seizures associated with hypothalamic hamartoma. Epilepsia 2009; 50:1608-11. [PMID: 19243422 DOI: 10.1111/j.1528-1167.2008.01995.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
We investigate the clinical outcome from stimulation of the mamillothalamic tract in two patients with intractable epilepsy secondary to hypothalamic hamartomas. One patient has a left-sided and the other a right-sided tumor. Both patients presented with a history of gelastic and complex partial seizures resistant to multiple antiepileptic drugs. Both patients underwent insertion of a single deep brain-stimulating electrode ipsilateral to the site of the tumor, lying adjacent to the mamillothalamic tract. Postoperatively they both had a significant reduction in seizure frequency, with one patient being seizure free for the last 10 months. An improvement in mood was reported by the patient's primary carers and demonstrated on quality of life questionnaires.
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Affiliation(s)
- Sadaquate Khan
- Institute of Neurosciences, Frenchay Hospital, Bristol, United Kingdom
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Kuramoto S, Yasuhara T, Agari T, Kondo A, Matsui T, Miyoshi Y, Shingo T, Date I. Injection of muscimol, a GABAa agonist into the anterior thalamic nucleus, suppresses hippocampal neurogenesis in amygdala-kindled rats. Neurol Res 2008; 31:407-13. [PMID: 18826756 DOI: 10.1179/174313208x346125] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
The relationship between neurogenesis and epilepsy remains to be solved so far, although aberrant electric circuit recognized in epilepsy might be involved in neurogenesis. In this study, neurogenesis and the proliferation of astrocytes in the subgranular zone of the hippocampus were explored using unilateral amygdala-kindled rats with or without muscimol, a gamma-aminobutyric acid a (GABAa) agonist injection into the bilateral anterior thalamic nuclei (AN). Muscimol injection significantly ameliorated the behavioral scores of epilepsy without any significant alteration on the electroencephalography recorded at the stimulated basolateral amygdala, thus suggesting that muscimol injection might affect the secondary generalization, but not the initial discharge itself. The number of bromodeoxyuridine (BrdU), BrdU/doublecortin and BrdU/glial fibrillary acidic protein-positive cells in the subgranular zone of kindled animals increased markedly. Muscimol injection significantly suppressed neurogenesis, but not the proliferation of astrocyte, in the subgranular zone of the non-stimulated side, probably through the suppression of secondary generalization via AN. The results might indicate the underlying relationships between neurogenesis and epilepsy, that epileptic propagation in unilateral amygdala-kindled rats might go through AN into the contralateral side with subsequent neurogenesis, although further studies need to clarify the hypothesis.
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Affiliation(s)
- Satoshi Kuramoto
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Abstract
Many patients who suffer from medically refractory epilepsy are not candidates for resective brain surgery. Success of deep brain stimulation (DBS) in relieving a significant number of symptoms of various movement disorders paved the way for investigations into this modality for epilepsy. Open-label and small blinded trials have provided promising evidence for the use of DBS in refractory seizures, and the first randomized control trial of DBS of the anterior thalamic nucleus is currently underway. There are multiple potential targets, because many neural regions have been implicated in seizure propagation. Thus, it is difficult as yet to make any definitive judgments about the efficacy of DBS for seizure control. Future study is necessary to identify a patient population for whom this technique would be indicated, the most efficacious target, and optimal stimulation parameters.
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Affiliation(s)
- Casey H. Halpern
- grid.412713.20000000404351019Department of Neurosurgery, Center for Functional and Restorative Neurosurgery, University of Pennsylvania Medical Center, 19104 Philadelphia, Pennsylvania
| | - Uzma Samadani
- grid.412713.20000000404351019Department of Neurosurgery, Center for Functional and Restorative Neurosurgery, University of Pennsylvania Medical Center, 19104 Philadelphia, Pennsylvania
| | - Brian Litt
- grid.412713.20000000404351019Department of Neurology, Center for Functional and Restorative Neurosurgery, University of Pennsylvania Medical Center, 19104 Philadelphia, Pennsylvania
| | - Jurg L. Jaggi
- grid.412713.20000000404351019Department of Neurosurgery, Center for Functional and Restorative Neurosurgery, University of Pennsylvania Medical Center, 19104 Philadelphia, Pennsylvania
| | - Gordon H. Baltuch
- grid.412713.20000000404351019Department of Neurosurgery, Center for Functional and Restorative Neurosurgery, University of Pennsylvania Medical Center, 19104 Philadelphia, Pennsylvania
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