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Warren AEL, Butson CR, Hook MP, Dalic LJ, Archer JS, Macdonald-Laurs E, Schaper FLWVJ, Hart LA, Singh H, Johnson L, Bullinger KL, Gross RE, Morrell MJ, Rolston JD. Targeting thalamocortical circuits for closed-loop stimulation in Lennox-Gastaut syndrome. Brain Commun 2024; 6:fcae161. [PMID: 38764777 PMCID: PMC11099664 DOI: 10.1093/braincomms/fcae161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 03/26/2024] [Accepted: 05/06/2024] [Indexed: 05/21/2024] Open
Abstract
This paper outlines the therapeutic rationale and neurosurgical targeting technique for bilateral, closed-loop, thalamocortical stimulation in Lennox-Gastaut syndrome, a severe form of childhood-onset epilepsy. Thalamic stimulation can be an effective treatment for Lennox-Gastaut syndrome, but complete seizure control is rarely achieved. Outcomes may be improved by stimulating areas beyond the thalamus, including cortex, but the optimal targets are unknown. We aimed to identify a cortical target by synthesizing prior neuroimaging studies, and to use this knowledge to advance a dual thalamic (centromedian) and cortical (frontal) approach for closed-loop stimulation. Multi-modal brain network maps from three group-level studies of Lennox-Gastaut syndrome were averaged to define the area of peak overlap: simultaneous EEG-functional MRI of generalized paroxysmal fast activity, [18F]fluorodeoxyglucose PET of cortical hypometabolism and diffusion MRI structural connectivity associated with clinical efficacy in a previous trial of thalamic deep brain stimulation. The resulting 'hotspot' was used as a seed in a normative functional MRI connectivity analysis to identify connected networks. Intracranial electrophysiology was reviewed in the first two trial patients undergoing bilateral implantations guided by this hotspot. Simultaneous recordings from cortex and thalamus were analysed for presence and synchrony of epileptiform activity. The peak overlap was in bilateral premotor cortex/caudal middle frontal gyrus. Functional connectivity of this hotspot revealed a distributed network of frontoparietal cortex resembling the diffuse abnormalities seen on EEG-functional MRI and PET. Intracranial electrophysiology showed characteristic epileptiform activity of Lennox-Gastaut syndrome in both the cortical hotspot and thalamus; most detected events occurred first in the cortex before appearing in the thalamus. Premotor frontal cortex shows peak involvement in Lennox-Gastaut syndrome and functional connectivity of this region resembles the wider epileptic brain network. Thus, it may be an optimal target for a range of neuromodulation therapies, including thalamocortical stimulation and emerging non-invasive treatments like focused ultrasound or transcranial magnetic stimulation. Compared to thalamus-only approaches, the addition of this cortical target may allow more rapid detections of seizures, more diverse stimulation paradigms and broader modulation of the epileptic network. A prospective, multi-centre trial of closed-loop thalamocortical stimulation for Lennox-Gastaut syndrome is currently underway.
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Affiliation(s)
- Aaron E L Warren
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Christopher R Butson
- Normal Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL 32608, USA
| | - Matthew P Hook
- Normal Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL 32608, USA
| | - Linda J Dalic
- University of Melbourne, Parkville, VIC 3052, Australia
- Department of Neurology, Austin Health, Heidelberg, VIC 3084, Australia
| | - John S Archer
- University of Melbourne, Parkville, VIC 3052, Australia
- Department of Neurology, Austin Health, Heidelberg, VIC 3084, Australia
| | - Emma Macdonald-Laurs
- University of Melbourne, Parkville, VIC 3052, Australia
- Department of Neurology, Royal Children’s Hospital, Parkville, VIC 3052, Australia
- Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia
| | - Frederic L W V J Schaper
- Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Lauren A Hart
- Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Hargunbir Singh
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | | | - Katie L Bullinger
- Department of Neurology, Emory University Hospital, Atlanta, GA 30322, USA
| | - Robert E Gross
- Department of Neurosurgery, Emory University Hospital, Atlanta, GA 30322, USA
| | - Martha J Morrell
- NeuroPace, Mountain View, CA 94043, USA
- Department of Neurology and Neurological Science, Stanford University, Palo Alto, CA 94304, USA
| | - John D Rolston
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
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Anderson DN, Charlebois CM, Smith EH, Davis TS, Peters AY, Newman BJ, Arain AM, Wilcox KS, Butson CR, Rolston JD. Closed-loop stimulation in periods with less epileptiform activity drives improved epilepsy outcomes. Brain 2024; 147:521-531. [PMID: 37796038 PMCID: PMC10834245 DOI: 10.1093/brain/awad343] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 07/17/2023] [Accepted: 08/28/2023] [Indexed: 10/06/2023] Open
Abstract
In patients with drug-resistant epilepsy, electrical stimulation of the brain in response to epileptiform activity can make seizures less frequent and debilitating. This therapy, known as closed-loop responsive neurostimulation (RNS), aims to directly halt seizure activity via targeted stimulation of a burgeoning seizure. Rather than immediately stopping seizures as they start, many RNS implants produce slower, long-lasting changes in brain dynamics that better predict clinical outcomes. Here we hypothesize that stimulation during brain states with less epileptiform activity drives long-term changes that restore healthy brain networks. To test this, we quantified stimulation episodes during low- and high-risk brain states-that is, stimulation during periods with a lower or higher risk of generating epileptiform activity-in a cohort of 40 patients treated with RNS. More frequent stimulation in tonic low-risk states and out of rhythmic high-risk states predicted seizure reduction. Additionally, stimulation events were more likely to be phase-locked to prolonged episodes of abnormal activity for intermediate and poor responders when compared to super-responders, consistent with the hypothesis that improved outcomes are driven by stimulation during low-risk states. These results support the hypothesis that stimulation during low-risk periods might underlie the mechanisms of RNS, suggesting a relationship between temporal patterns of neuromodulation and plasticity that facilitates long-term seizure reduction.
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Affiliation(s)
- Daria Nesterovich Anderson
- Department of Neurosurgery, University of Utah, Salt Lake City, UT 84132, USA
- Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT 84112, USA
- School of Biomedical Engineering, Faculty of Engineering, The University of Sydney, Darlington, NSW 2008, Australia
| | - Chantel M Charlebois
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 84112, USA
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT 84112, USA
| | - Elliot H Smith
- Department of Neurosurgery, University of Utah, Salt Lake City, UT 84132, USA
| | - Tyler S Davis
- Department of Neurosurgery, University of Utah, Salt Lake City, UT 84132, USA
| | - Angela Y Peters
- Department of Neurology, University of Utah, Salt Lake City, UT 84132, USA
| | - Blake J Newman
- Department of Neurology, University of Utah, Salt Lake City, UT 84132, USA
| | - Amir M Arain
- Department of Neurology, University of Utah, Salt Lake City, UT 84132, USA
| | - Karen S Wilcox
- Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT 84112, USA
| | - Christopher R Butson
- Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL 32608, USA
- Department of Neurology, University of Florida, Gainesville, FL 32611, USA
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
- Department of Biomedical Engineering, University of Florida, Gainesville, FL 32611, USA
| | - John D Rolston
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 84112, USA
- Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA 02115, USA
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Heyndrickx S, Lamquet S, Oerlemans J, Vonck K, Boon P, Van Roost D, Meurs A. Chronic subthreshold cortical stimulation: A promising therapy for motor cortex seizures. Epilepsy Behav Rep 2023; 25:100638. [PMID: 38235016 PMCID: PMC10792751 DOI: 10.1016/j.ebr.2023.100638] [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: 11/01/2023] [Revised: 12/15/2023] [Accepted: 12/17/2023] [Indexed: 01/19/2024] Open
Abstract
Chronic subthreshold cortical stimulation (CSCS) is a form of neurostimulation consisting of continuous or cyclic, open-loop, subthreshold electrical stimulation of a well-defined epileptogenic zone (EZ). CSCS has seen limited clinical use but could be a safe and effective long-term treatment of focal drug resistant epilepsy, in particular when the EZ is located in the motor cortex. We present a case of a 49-year-old woman suffering from debilitating focal motor seizures. Treatment with CSCS resulted in significant clinical improvement, enabling her to walk unaided for the first time in years.
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Affiliation(s)
| | - Simon Lamquet
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Joyce Oerlemans
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Kristl Vonck
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Paul Boon
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Dirk Van Roost
- Department of Neurosurgery, Ghent University Hospital, Ghent, Belgium
| | - Alfred Meurs
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
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4
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Frauscher B, Bartolomei F, Baud MO, Smith RJ, Worrell G, Lundstrom BN. Stimulation to probe, excite, and inhibit the epileptic brain. Epilepsia 2023; 64 Suppl 3:S49-S61. [PMID: 37194746 PMCID: PMC10654261 DOI: 10.1111/epi.17640] [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: 01/13/2023] [Revised: 05/01/2023] [Accepted: 05/02/2023] [Indexed: 05/18/2023]
Abstract
Direct cortical stimulation has been applied in epilepsy for nearly a century and has experienced a renaissance, given unprecedented opportunities to probe, excite, and inhibit the human brain. Evidence suggests stimulation can increase diagnostic and therapeutic utility in patients with drug-resistant epilepsies. However, choosing appropriate stimulation parameters is not a trivial issue, and is further complicated by epilepsy being characterized by complex brain state dynamics. In this article derived from discussions at the ICTALS 2022 Conference (International Conference on Technology and Analysis for Seizures), we succinctly review the literature on cortical stimulation applied acutely and chronically to the epileptic brain for localization, monitoring, and therapeutic purposes. In particular, we discuss how stimulation is used to probe brain excitability, discuss evidence on the usefulness of stimulation to trigger and stop seizures, review therapeutic applications of stimulation, and finally discuss how stimulation parameters are impacted by brain dynamics. Although research has advanced considerably over the past decade, there are still significant hurdles to optimizing use of this technique. For example, it remains unclear to what extent short timescale diagnostic biomarkers can predict long-term outcomes and to what extent these biomarkers add information to already existing biomarkers from passive electroencephalographic recordings. Further questions include the extent to which closed loop stimulation offers advantages over open loop stimulation, what the optimal closed loop timescales may be, and whether biomarker-informed stimulation can lead to seizure freedom. The ultimate goal of bioelectronic medicine remains not just to stop seizures but rather to cure epilepsy and its comorbidities.
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Affiliation(s)
- Birgit Frauscher
- Analytical Neurophysiology Lab, Montreal Neurological Institute and Hospital, Montreal, Quebec, Canada
| | - Fabrice Bartolomei
- Institut de Neurosciences des Systèmes, Aix Marseille University, Marseille, France. AP-HM, Service de Neurophysiologie Clinique, Hôpital de la Timone, Marseille, France
| | - Maxime O. Baud
- Sleep-Wake-Epilepsy Center, NeuroTec and Center for Experimental Neurology, Department of Neurology, Inselspital Bern, University Hospital, University of Bern, Bern
| | - Rachel J. Smith
- University of Alabama at Birmingham, Electrical and Computer Engineering Department, Birmingham, Alabama, US. University of Alabama at Birmingham, Neuroengineering Program, Birmingham, Alabama, US
| | - Greg Worrell
- Department of Neurology, Mayo Clinic, Rochester, US
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Rao VR, Rolston JD. Unearthing the mechanisms of responsive neurostimulation for epilepsy. COMMUNICATIONS MEDICINE 2023; 3:166. [PMID: 37974025 PMCID: PMC10654422 DOI: 10.1038/s43856-023-00401-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 11/03/2023] [Indexed: 11/19/2023] Open
Abstract
Responsive neurostimulation (RNS) is an effective therapy for people with drug-resistant focal epilepsy. In clinical trials, RNS therapy results in a meaningful reduction in median seizure frequency, but the response is highly variable across individuals, with many receiving minimal or no benefit. Understanding why this variability occurs will help improve use of RNS therapy. Here we advocate for a reexamination of the assumptions made about how RNS reduces seizures. This is now possible due to large patient cohorts having used this device, some long-term. Two foundational assumptions have been that the device's intracranial leads should target the seizure focus/foci directly, and that stimulation should be triggered only in response to detected epileptiform activity. Recent studies have called into question both hypotheses. Here, we discuss these exciting new studies and suggest future approaches to patient selection, lead placement, and device programming that could improve clinical outcomes.
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Affiliation(s)
- Vikram R Rao
- Department of Neurology and Weill Institute for Neurosciences, University of California, San Francisco, CA, USA.
| | - John D Rolston
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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6
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Johnson GW, Doss DJ, Morgan VL, Paulo DL, Cai LY, Shless JS, Negi AS, Gummadavelli A, Kang H, Reddy SB, Naftel RP, Bick SK, Williams Roberson S, Dawant BM, Wallace MT, Englot DJ. The Interictal Suppression Hypothesis in focal epilepsy: network-level supporting evidence. Brain 2023; 146:2828-2845. [PMID: 36722219 PMCID: PMC10316780 DOI: 10.1093/brain/awad016] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 12/24/2022] [Accepted: 01/08/2023] [Indexed: 02/02/2023] Open
Abstract
Why are people with focal epilepsy not continuously having seizures? Previous neuronal signalling work has implicated gamma-aminobutyric acid balance as integral to seizure generation and termination, but is a high-level distributed brain network involved in suppressing seizures? Recent intracranial electrographic evidence has suggested that seizure-onset zones have increased inward connectivity that could be associated with interictal suppression of seizure activity. Accordingly, we hypothesize that seizure-onset zones are actively suppressed by the rest of the brain network during interictal states. Full testing of this hypothesis would require collaboration across multiple domains of neuroscience. We focused on partially testing this hypothesis at the electrographic network level within 81 individuals with drug-resistant focal epilepsy undergoing presurgical evaluation. We used intracranial electrographic resting-state and neurostimulation recordings to evaluate the network connectivity of seizure onset, early propagation and non-involved zones. We then used diffusion imaging to acquire estimates of white-matter connectivity to evaluate structure-function coupling effects on connectivity findings. Finally, we generated a resting-state classification model to assist clinicians in detecting seizure-onset and propagation zones without the need for multiple ictal recordings. Our findings indicate that seizure onset and early propagation zones demonstrate markedly increased inwards connectivity and decreased outwards connectivity using both resting-state (one-way ANOVA, P-value = 3.13 × 10-13) and neurostimulation analyses to evaluate evoked responses (one-way ANOVA, P-value = 2.5 × 10-3). When controlling for the distance between regions, the difference between inwards and outwards connectivity remained stable up to 80 mm between brain connections (two-way repeated measures ANOVA, group effect P-value of 2.6 × 10-12). Structure-function coupling analyses revealed that seizure-onset zones exhibit abnormally enhanced coupling (hypercoupling) of surrounding regions compared to presumably healthy tissue (two-way repeated measures ANOVA, interaction effect P-value of 9.76 × 10-21). Using these observations, our support vector classification models achieved a maximum held-out testing set accuracy of 92.0 ± 2.2% to classify early propagation and seizure-onset zones. These results suggest that seizure-onset zones are actively segregated and suppressed by a widespread brain network. Furthermore, this electrographically observed functional suppression is disproportionate to any observed structural connectivity alterations of the seizure-onset zones. These findings have implications for the identification of seizure-onset zones using only brief electrographic recordings to reduce patient morbidity and augment the presurgical evaluation of drug-resistant epilepsy. Further testing of the interictal suppression hypothesis can provide insight into potential new resective, ablative and neuromodulation approaches to improve surgical success rates in those suffering from drug-resistant focal epilepsy.
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Affiliation(s)
- Graham W Johnson
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN 37235, USA
- Vanderbilt University Institute of Imaging Science (VUIIS), Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Vanderbilt Institute for Surgery and Engineering (VISE), Vanderbilt University, Nashville, TN 37235, USA
| | - Derek J Doss
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN 37235, USA
- Vanderbilt University Institute of Imaging Science (VUIIS), Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Vanderbilt Institute for Surgery and Engineering (VISE), Vanderbilt University, Nashville, TN 37235, USA
| | - Victoria L Morgan
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN 37235, USA
- Vanderbilt University Institute of Imaging Science (VUIIS), Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Vanderbilt Institute for Surgery and Engineering (VISE), Vanderbilt University, Nashville, TN 37235, USA
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Department of Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Danika L Paulo
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Leon Y Cai
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN 37235, USA
- Vanderbilt University Institute of Imaging Science (VUIIS), Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Vanderbilt Institute for Surgery and Engineering (VISE), Vanderbilt University, Nashville, TN 37235, USA
| | - Jared S Shless
- Vanderbilt University Institute of Imaging Science (VUIIS), Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Vanderbilt Institute for Surgery and Engineering (VISE), Vanderbilt University, Nashville, TN 37235, USA
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Aarushi S Negi
- Department of Neuroscience, Vanderbilt University, Nashville, TN 37232, USA
| | - Abhijeet Gummadavelli
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Hakmook Kang
- Department of Biostatistics, Vanderbilt University, Nashville, TN 37232, USA
| | - Shilpa B Reddy
- Department of Pediatrics, Vanderbilt Children’s Hospital, Nashville, TN 37232, USA
| | - Robert P Naftel
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Sarah K Bick
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | | | - Benoit M Dawant
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN 37235, USA
- Vanderbilt University Institute of Imaging Science (VUIIS), Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Vanderbilt Institute for Surgery and Engineering (VISE), Vanderbilt University, Nashville, TN 37235, USA
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Department of Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, TN 37235, USA
| | - Mark T Wallace
- Department of Hearing and Speech Sciences, Vanderbilt University, Nashville, TN 37232, USA
- Department of Psychology, Vanderbilt University, Nashville, TN 37232, USA
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University, Nashville, TN 37232, USA
- Department of Pharmacology, Vanderbilt University, Nashville, TN 37232, USA
| | - Dario J Englot
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN 37235, USA
- Vanderbilt University Institute of Imaging Science (VUIIS), Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Vanderbilt Institute for Surgery and Engineering (VISE), Vanderbilt University, Nashville, TN 37235, USA
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Department of Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, TN 37235, USA
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Smith KM, Starnes DK, Brinkmann BH, So E, Cox BC, Marsh WR, Van Gompel JJ, Wirrell E, Britton JW, Burkholder DB, Wong-Kisiel LC. Stereo-EEG localization of midline onset seizures on scalp EEG. Epilepsy Res 2023; 193:107162. [PMID: 37172404 DOI: 10.1016/j.eplepsyres.2023.107162] [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: 02/13/2023] [Revised: 04/06/2023] [Accepted: 05/01/2023] [Indexed: 05/15/2023]
Abstract
PURPOSE The objective of this study was to describe the sEEG-defined seizure onset zone (SOZ), seizure semiology, presurgical evaluations, surgical intervention and outcome in patients with midline onset noninvasive phase I monitoring. METHODS A single center sEEG database was reviewed to identify patients with seizures onset predominantly involving midline electrodes (FZ, CZ, PZ, OZ) on scalp EEG. Data abstracted included clinical factors, seizure semiology graded into lobar segmentation, imaging and electrographic findings, sEEG plan, interventions, and outcome. RESULTS Twelve patients were identified (8 males, median age of sEEG 28 years) out of 100 cases of sEEG performed from January 2015-September 2019. "Frontal lobe" seizure semiology was the most common. sEEG-defined SOZ were frontal (5), diffuse (1), multifocal (1), frontal and insular (1), frontal and cingulate (1), insular (1), cingulate (1), and mesial temporal (1). CZ and/or FZ scalp EEG changes were present for all patients with SOZ involving the frontal, cingulate, and insular regions. PZ/OZ scalp involvement was present in one patient with mesial temporal SOZ. Four patients underwent a definitive resective or ablative surgery, and the remaining patients underwent a palliative intervention. Of those with follow-up information available, 8/11 had seizure reduction by ≥ 50%, including 4 with an Engel I outcome. No clinical factors were associated with outcome. CONCLUSIONS SOZ for midline onset seizures from noninvasive phase I monitoring was most commonly in the frontal, cingulate, and insular regions. A complex cortical network between these regions may explain overlap in semiology and scalp EEG findings. While the number rendered seizure-free was limited, a significant proportion experienced a reasonably favorable outcome justifying use of sEEG to identify surgical options in these patients.
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Affiliation(s)
- Kelsey M Smith
- Department of Neurology, Mayo Clinic, 200 1st St. SW, Rochester, MN 55906, United States.
| | - Donnie K Starnes
- Department of Neurology, Mayo Clinic, 200 1st St. SW, Rochester, MN 55906, United States
| | - Benjamin H Brinkmann
- Department of Neurology, Mayo Clinic, 200 1st St. SW, Rochester, MN 55906, United States
| | - Elson So
- Department of Neurology, Mayo Clinic, 200 1st St. SW, Rochester, MN 55906, United States
| | - Benjamin C Cox
- Department of Neurology, Mayo Clinic, 200 1st St. SW, Rochester, MN 55906, United States
| | - W Richard Marsh
- Department of Neurosurgery, Mayo Clinic, 200 1st St. SW, Rochester, MN 55906, United States
| | - Jamie J Van Gompel
- Department of Neurosurgery, Mayo Clinic, 200 1st St. SW, Rochester, MN 55906, United States
| | - Elaine Wirrell
- Department of Neurology, Mayo Clinic, 200 1st St. SW, Rochester, MN 55906, United States
| | - Jeffrey W Britton
- Department of Neurology, Mayo Clinic, 200 1st St. SW, Rochester, MN 55906, United States
| | - David B Burkholder
- Department of Neurology, Mayo Clinic, 200 1st St. SW, Rochester, MN 55906, United States
| | - Lily C Wong-Kisiel
- Department of Neurology, Mayo Clinic, 200 1st St. SW, Rochester, MN 55906, United States
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8
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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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9
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Alcala-Zermeno JL, Starnes K, Gregg NM, Worrell G, Lundstrom BN. Responsive neurostimulation with low-frequency stimulation. Epilepsia 2023; 64:e16-e22. [PMID: 36385467 PMCID: PMC9970035 DOI: 10.1111/epi.17467] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 11/15/2022] [Accepted: 11/16/2022] [Indexed: 11/18/2022]
Abstract
Deep brain stimulation and responsive neurostimulation (RNS) use high-frequency stimulation (HFS) per the pivotal trials and manufacturer-recommended therapy protocols. However, not all patients respond to HFS. In this retrospective case series, 10 patients implanted with the RNS System were programmed with low-frequency stimulation (LFS) to treat their seizures; nine of these patients were previously treated with HFS (100 Hz or greater). LFS was defined as frequency < 10 Hz. Burst duration was increased to at least 1000 ms. With HFS, patients had a median seizure reduction (MSR) of 13% (interquartile range [IQR] = -67 to 54) after a median of 19 months (IQR = 8-49). In contrast, LFS was associated with a 67% MSR (IQR = 13-95) when compared to HFS and 76% MSR (IQR = 43-91) when compared to baseline prior to implantation. Charge delivered per hour and pulses per day were not significantly different between HFS and LFS, although time stimulated per day was longer for LFS (228 min) than for HFS (7 min). There were no LFS-specific adverse effects reported by any of the patients. LFS could represent an alternative, effective method for delivering stimulation in focal drug-resistant epilepsy patients treated with the RNS System.
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Affiliation(s)
| | - Keith Starnes
- Department of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Greg Worrell
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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10
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Alcala-Zermeno JL, Gregg NM, Starnes K, Mandrekar JN, Van Gompel JJ, Miller K, Worrell G, Lundstrom BN. Invasive neuromodulation for epilepsy: Comparison of multiple approaches from a single center. Epilepsy Behav 2022; 137:108951. [PMID: 36327647 PMCID: PMC9934010 DOI: 10.1016/j.yebeh.2022.108951] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 10/05/2022] [Accepted: 10/07/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Drug-resistant epilepsy (DRE) patients not amenable to epilepsy surgery can benefit from neurostimulation. Few data compare different neuromodulation strategies. OBJECTIVE Compare five invasive neuromodulation strategies for the treatment of DRE: anterior thalamic nuclei deep brain stimulation (ANT-DBS), centromedian thalamic nuclei DBS (CM-DBS), responsive neurostimulation (RNS), chronic subthreshold stimulation (CSS), and vagus nerve stimulation (VNS). METHODS Single center retrospective review and phone survey for patients implanted with invasive neuromodulation for 2004-2021. RESULTS N = 159 (ANT-DBS = 38, CM-DBS = 19, RNS = 30, CSS = 32, VNS = 40). Total median seizure reduction (MSR) was 61 % for the entire cohort (IQR 5-90) and in descending order: CSS (85 %), CM-DBS (63 %), ANT-DBS (52 %), RNS (50 %), and VNS (50 %); p = 0.07. The responder rate was 60 % after a median follow-up time of 26 months. Seizure severity, life satisfaction, and quality of sleep were improved. Cortical stimulation (RNS and CSS) was associated with improved seizure reduction compared to subcortical stimulation (ANT-DBS, CM-DBS, and VNS) (67 % vs. 52 %). Effectiveness was similar for focal epilepsy vs. generalized epilepsy, closed-loop vs. open-loop stimulation, pediatric vs. adult cases, and high frequency (>100 Hz) vs. low frequency (<100 Hz) stimulation settings. Delivered charge per hour varied widely across approaches but was not correlated with improved seizure reduction. CONCLUSIONS Multiple invasive neuromodulation approaches are available to treat DRE, but little evidence compares the approaches. This study used a uniform approach for single-center results and represents an effort to compare neuromodulation approaches.
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Affiliation(s)
- Juan Luis Alcala-Zermeno
- Department of Neurology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA; Department of Neurology, Jefferson Medical College, Thomas Jefferson University, 901 Walnut Street, Suite 400, Philadelphia, PA 19107, USA.
| | - Nicholas M. Gregg
- Department of Neurology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Keith Starnes
- Division of Child and Adolescent Neurology, Department of Neurology, 200 First St SW, Rochester, MN 55905, USA.
| | - Jayawant N. Mandrekar
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Jamie J. Van Gompel
- Department of Neurologic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Kai Miller
- Department of Neurologic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
| | - Greg Worrell
- Department of Neurology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
| | - Brian N. Lundstrom
- Department of Neurology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
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11
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Miller KJ, Fine AL. Decision-making in stereotactic epilepsy surgery. Epilepsia 2022; 63:2782-2801. [PMID: 35908245 PMCID: PMC9669234 DOI: 10.1111/epi.17381] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 11/27/2022]
Abstract
Surgery can cure or significantly improve both the frequency and the intensity of seizures in patients with medication-refractory epilepsy. The set of diagnostic and therapeutic interventions involved in the path from initial consultation to definitive surgery is complex and includes a multidisciplinary team of neurologists, neurosurgeons, neuroradiologists, and neuropsychologists, supported by a very large epilepsy-dedicated clinical architecture. In recent years, new practices and technologies have emerged that dramatically expand the scope of interventions performed. Stereoelectroencephalography has become widely adopted for seizure localization; stereotactic laser ablation has enabled more focal, less invasive, and less destructive interventions; and new brain stimulation devices have unlocked treatment of eloquent foci and multifocal onset etiologies. This article articulates and illustrates the full framework for how epilepsy patients are considered for surgical intervention, with particular attention given to stereotactic approaches.
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Affiliation(s)
- Kai J. Miller
- Neurosurgery, Mayo Clinic, 200 First St., Rochester, MN, 55902
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12
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Simpson HD, Schulze-Bonhage A, Cascino GD, Fisher RS, Jobst BC, Sperling MR, Lundstrom BN. Practical considerations in epilepsy neurostimulation. Epilepsia 2022; 63:2445-2460. [PMID: 35700144 PMCID: PMC9888395 DOI: 10.1111/epi.17329] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 02/02/2023]
Abstract
Neuromodulation is a key therapeutic tool for clinicians managing patients with drug-resistant epilepsy. Multiple devices are available with long-term follow-up and real-world experience. The aim of this review is to give a practical summary of available neuromodulation techniques to guide the selection of modalities, focusing on patient selection for devices, common approaches and techniques for initiation of programming, and outpatient management issues. Vagus nerve stimulation (VNS), deep brain stimulation of the anterior nucleus of the thalamus (DBS-ANT), and responsive neurostimulation (RNS) are all supported by randomized controlled trials that show safety and a significant impact on seizure reduction, as well as a suggestion of reduction in the risk of sudden unexplained death in epilepsy (SUDEP). Significant seizure reductions are observed after 3 months for DBS, RNS, and VNS in randomized controlled trials, and efficacy appears to improve with time out to 7 to 10 years of follow-up for all modalities, albeit in uncontrolled follow-up or retrospective studies. A significant number of patients experience seizure-free intervals of 6 months or more with all three modalities. Number and location of epileptogenic foci are important factors affecting efficacy, and together with comorbidities such as severe mood or sleep disorders, may influence the choice of modality. Programming has evolved-DBS is typically initiated at lower current/voltage than used in the pivotal trial, whereas target charge density is lower with RNS, however generalizable optimal parameters are yet to be defined. Noninvasive brain stimulation is an emerging stimulation modality, although it is currently not used widely. In summary, clinical practice has evolved from those established in pivotal trials. Guidance is now available for clinicians who wish to expand their approach, and choice of neuromodulation technique may be tailored to individual patients based on their epilepsy characteristics, risk tolerance, and preferences.
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Affiliation(s)
- Hugh D. Simpson
- Division of Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Gregory D. Cascino
- Division of Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Robert S. Fisher
- Department of Neurology, Stanford Neuroscience Health Center, Palo Alto, CA, USA
| | - Barbara C. Jobst
- Geisel School of Medicine at Dartmouth, Department of Neurology, Dartmouth-Hitchcock Medical Center, NH, USA
| | - Michael R. Sperling
- Division of Epilepsy, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Brian N. Lundstrom
- Division of Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN, USA
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13
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Kerezoudis P, Lundstrom BN, Meyer FB, Worrell GA, Van Gompel JJ. Surgical approaches to refractory central lobule epilepsy: a systematic review on the role of resection, ablation, and stimulation in the contemporary era. J Neurosurg 2022; 137:735-746. [PMID: 35171813 DOI: 10.3171/2021.10.jns211875] [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: 09/06/2021] [Accepted: 10/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Epilepsy originating from the central lobule (i.e., the primary sensorimotor cortex) is a challenging entity to treat given its involvement of eloquent cortex. The objective of this study was to review available evidence on treatment options for central lobule epilepsy. METHODS A comprehensive literature search (PubMed/Medline, EMBASE, and Scopus) was conducted for studies (1990 to date) investigating postoperative outcomes for central lobule epilepsy. The primary and secondary endpoints were seizure freedom at last follow-up and postoperative neurological deficit, respectively. The following procedures were included: open resection, multiple subpial transections (MSTs), laser and radiofrequency ablation, deep brain stimulation (DBS), responsive neurostimulation (RNS), and continuous subthreshold cortical stimulation (CSCS). RESULTS A total of 52 studies and 504 patients were analyzed. Most evidence was based on open resection, yielding a total of 400 patients (24 studies), of whom 62% achieved seizure freedom at a mean follow-up of 48 months. A new or worsened motor deficit occurred in 44% (permanent in 19%). Forty-six patients underwent MSTs, of whom 16% achieved seizure freedom and 30% had a neurological deficit (permanent in 12%). There were 6 laser ablation cases (cavernomas in 50%) with seizure freedom in 4 patients and 1 patient with temporary motor deficit. There were 5 radiofrequency ablation cases, with 1 patient achieving seizure freedom, 2 patients each with Engel class III and IV outcomes, and 2 patients with motor deficit. The mean seizure frequency reduction at the last follow-up was 79% for RNS (28 patients), 90% for CSCS (15 patients), and 73% for DBS (4 patients). There were no cases of temporary or permanent neurological deficit in the CSCS or DBS group. CONCLUSIONS This review highlights the safety and efficacy profile of resection, ablation, and stimulation for refractory central lobe epilepsy. Resection of localized regions of epilepsy onset zones results in good rates of seizure freedom (62%); however, nearly 20% of patients had permanent motor deficits. The authors hope that this review will be useful to providers and patients when tailoring decision-making for this intricate pathology.
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Affiliation(s)
| | | | - Fredric B Meyer
- 1Department of Neurologic Surgery, Mayo Clinic, Rochester; and
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14
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Nowakowska M, Üçal M, Charalambous M, Bhatti SFM, Denison T, Meller S, Worrell GA, Potschka H, Volk HA. Neurostimulation as a Method of Treatment and a Preventive Measure in Canine Drug-Resistant Epilepsy: Current State and Future Prospects. Front Vet Sci 2022; 9:889561. [PMID: 35782557 PMCID: PMC9244381 DOI: 10.3389/fvets.2022.889561] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/23/2022] [Indexed: 11/28/2022] Open
Abstract
Modulation of neuronal activity for seizure control using various methods of neurostimulation is a rapidly developing field in epileptology, especially in treatment of refractory epilepsy. Promising results in human clinical practice, such as diminished seizure burden, reduced incidence of sudden unexplained death in epilepsy, and improved quality of life has brought neurostimulation into the focus of veterinary medicine as a therapeutic option. This article provides a comprehensive review of available neurostimulation methods for seizure management in drug-resistant epilepsy in canine patients. Recent progress in non-invasive modalities, such as repetitive transcranial magnetic stimulation and transcutaneous vagus nerve stimulation is highlighted. We further discuss potential future advances and their plausible application as means for preventing epileptogenesis in dogs.
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Affiliation(s)
- Marta Nowakowska
- Research Unit of Experimental Neurotraumatology, Department of Neurosurgery, Medical University of Graz, Graz, Austria
| | - Muammer Üçal
- Research Unit of Experimental Neurotraumatology, Department of Neurosurgery, Medical University of Graz, Graz, Austria
| | - Marios Charalambous
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hanover, Germany
| | - Sofie F. M. Bhatti
- Small Animal Department, Faculty of Veterinary Medicine, Small Animal Teaching Hospital, Ghent University, Merelbeke, Belgium
| | - Timothy Denison
- Department of Engineering Science, Institute of Biomedical Engineering, University of Oxford, Oxford, United Kingdom
| | - Sebastian Meller
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hanover, Germany
| | | | - Heidrun Potschka
- Faculty of Veterinary Medicine, Institute of Pharmacology, Toxicology and Pharmacy, Ludwig-Maximilians-University, Munich, Germany
| | - Holger A. Volk
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hanover, Germany
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15
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Bianchi M, De Salvo A, Asplund M, Carli S, Di Lauro M, Schulze‐Bonhage A, Stieglitz T, Fadiga L, Biscarini F. Poly(3,4-ethylenedioxythiophene)-Based Neural Interfaces for Recording and Stimulation: Fundamental Aspects and In Vivo Applications. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2022; 9:e2104701. [PMID: 35191224 PMCID: PMC9036021 DOI: 10.1002/advs.202104701] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/04/2022] [Indexed: 05/29/2023]
Abstract
Next-generation neural interfaces for bidirectional communication with the central nervous system aim to achieve the intimate integration with the neural tissue with minimal neuroinflammatory response, high spatio-temporal resolution, very high sensitivity, and readout stability. The design and manufacturing of devices for low power/low noise neural recording and safe and energy-efficient stimulation that are, at the same time, conformable to the brain, with matched mechanical properties and biocompatibility, is a convergence area of research where neuroscientists, materials scientists, and nanotechnologists operate synergically. The biotic-abiotic neural interface, however, remains a formidable challenge that prompts for new materials platforms and innovation in device layouts. Conductive polymers (CP) are attractive materials to be interfaced with the neural tissue and to be used as sensing/stimulating electrodes because of their mixed ionic-electronic conductivity, their low contact impedance, high charge storage capacitance, chemical versatility, and biocompatibility. This manuscript reviews the state-of-the-art of poly(3,4-ethylenedioxythiophene)-based neural interfaces for extracellular recording and stimulation, focusing on those technological approaches that are successfully demonstrated in vivo. The aim is to highlight the most reliable and ready-for-clinical-use solutions, in terms of materials technology and recording performance, other than spot major limitations and identify future trends in this field.
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Affiliation(s)
- Michele Bianchi
- Center for Translational Neurophysiology of Speech and CommunicationFondazione Istituto Italiano di Tecnologiavia Fossato di Mortara 17Ferrara44121Italy
| | - Anna De Salvo
- Center for Translational Neurophysiology of Speech and CommunicationFondazione Istituto Italiano di Tecnologiavia Fossato di Mortara 17Ferrara44121Italy
- Sezione di FisiologiaUniversità di Ferraravia Fossato di Mortara 17Ferrara44121Italy
| | - Maria Asplund
- Division of Nursing and Medical TechnologyLuleå University of TechnologyLuleå971 87Sweden
- Department of Microsystems Engineering‐IMTEKUniversity of FreiburgFreiburg79110Germany
- BrainLinks‐BrainTools CenterUniversity of FreiburgFreiburg79110Germany
| | - Stefano Carli
- Center for Translational Neurophysiology of Speech and CommunicationFondazione Istituto Italiano di Tecnologiavia Fossato di Mortara 17Ferrara44121Italy
- Present address:
Department of Environmental and Prevention SciencesUniversità di FerraraFerrara44121Italy
| | - Michele Di Lauro
- Center for Translational Neurophysiology of Speech and CommunicationFondazione Istituto Italiano di Tecnologiavia Fossato di Mortara 17Ferrara44121Italy
| | - Andreas Schulze‐Bonhage
- BrainLinks‐BrainTools CenterUniversity of FreiburgFreiburg79110Germany
- Epilepsy CenterFaculty of MedicineUniversity of FreiburgFreiburg79110Germany
| | - Thomas Stieglitz
- Department of Microsystems Engineering‐IMTEKUniversity of FreiburgFreiburg79110Germany
- BrainLinks‐BrainTools CenterUniversity of FreiburgFreiburg79110Germany
| | - Luciano Fadiga
- Center for Translational Neurophysiology of Speech and CommunicationFondazione Istituto Italiano di Tecnologiavia Fossato di Mortara 17Ferrara44121Italy
- Sezione di FisiologiaUniversità di Ferraravia Fossato di Mortara 17Ferrara44121Italy
| | - Fabio Biscarini
- Center for Translational Neurophysiology of Speech and CommunicationFondazione Istituto Italiano di Tecnologiavia Fossato di Mortara 17Ferrara44121Italy
- Life Science DepartmentUniversità di Modena e Reggio EmiliaVia Campi 103Modena41125Italy
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16
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Wong JK, Deuschl G, Wolke R, Bergman H, Muthuraman M, Groppa S, Sheth SA, Bronte-Stewart HM, Wilkins KB, Petrucci MN, Lambert E, Kehnemouyi Y, Starr PA, Little S, Anso J, Gilron R, Poree L, Kalamangalam GP, Worrell GA, Miller KJ, Schiff ND, Butson CR, Henderson JM, Judy JW, Ramirez-Zamora A, Foote KD, Silburn PA, Li L, Oyama G, Kamo H, Sekimoto S, Hattori N, Giordano JJ, DiEuliis D, Shook JR, Doughtery DD, Widge AS, Mayberg HS, Cha J, Choi K, Heisig S, Obatusin M, Opri E, Kaufman SB, Shirvalkar P, Rozell CJ, Alagapan S, Raike RS, Bokil H, Green D, Okun MS. Proceedings of the Ninth Annual Deep Brain Stimulation Think Tank: Advances in Cutting Edge Technologies, Artificial Intelligence, Neuromodulation, Neuroethics, Pain, Interventional Psychiatry, Epilepsy, and Traumatic Brain Injury. Front Hum Neurosci 2022; 16:813387. [PMID: 35308605 PMCID: PMC8931265 DOI: 10.3389/fnhum.2022.813387] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/11/2022] [Indexed: 01/09/2023] Open
Abstract
DBS Think Tank IX was held on August 25-27, 2021 in Orlando FL with US based participants largely in person and overseas participants joining by video conferencing technology. The DBS Think Tank was founded in 2012 and provides an open platform where clinicians, engineers and researchers (from industry and academia) can freely discuss current and emerging deep brain stimulation (DBS) technologies as well as the logistical and ethical issues facing the field. The consensus among the DBS Think Tank IX speakers was that DBS expanded in its scope and has been applied to multiple brain disorders in an effort to modulate neural circuitry. After collectively sharing our experiences, it was estimated that globally more than 230,000 DBS devices have been implanted for neurological and neuropsychiatric disorders. As such, this year's meeting was focused on advances in the following areas: neuromodulation in Europe, Asia and Australia; cutting-edge technologies, neuroethics, interventional psychiatry, adaptive DBS, neuromodulation for pain, network neuromodulation for epilepsy and neuromodulation for traumatic brain injury.
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Affiliation(s)
- Joshua K. Wong
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Günther Deuschl
- Department of Neurology, Christian-Albrechts-University, Kiel, Germany
| | - Robin Wolke
- Department of Neurology, Christian-Albrechts-University, Kiel, Germany
| | - Hagai Bergman
- Department of Medical Neurobiology (Physiology), Institute of Medical Research Israel-Canada, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Muthuraman Muthuraman
- Biomedical Statistics and Multimodal Signal Processing Unit, Section of Movement Disorders and Neurostimulation, Focus Program Translational Neuroscience, Department of Neurology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Sergiu Groppa
- Biomedical Statistics and Multimodal Signal Processing Unit, Section of Movement Disorders and Neurostimulation, Focus Program Translational Neuroscience, Department of Neurology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Sameer A. Sheth
- Department of Neurological Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Helen M. Bronte-Stewart
- The Human Motor Control and Neuromodulation Laboratory, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford University, Stanford, CA, United States
| | - Kevin B. Wilkins
- The Human Motor Control and Neuromodulation Laboratory, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford University, Stanford, CA, United States
| | - Matthew N. Petrucci
- The Human Motor Control and Neuromodulation Laboratory, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford University, Stanford, CA, United States
| | - Emilia Lambert
- The Human Motor Control and Neuromodulation Laboratory, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford University, Stanford, CA, United States
| | - Yasmine Kehnemouyi
- The Human Motor Control and Neuromodulation Laboratory, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford University, Stanford, CA, United States
| | - Philip A. Starr
- Department of Neurological Surgery, Kavli Institute for Fundamental Neuroscience, University of California, San Francisco, San Francisco, CA, United States
| | - Simon Little
- Department of Neurological Surgery, Kavli Institute for Fundamental Neuroscience, University of California, San Francisco, San Francisco, CA, United States
| | - Juan Anso
- Department of Neurological Surgery, Kavli Institute for Fundamental Neuroscience, University of California, San Francisco, San Francisco, CA, United States
| | - Ro’ee Gilron
- Department of Neurological Surgery, Kavli Institute for Fundamental Neuroscience, University of California, San Francisco, San Francisco, CA, United States
| | - Lawrence Poree
- Department of Anesthesia, University of California, San Francisco, San Francisco, CA, United States
| | - Giridhar P. Kalamangalam
- Department of Neurology, Wilder Center for Epilepsy Research, University of Florida, Gainesville, FL, United States
| | | | - Kai J. Miller
- Department of Neurosurgery, Mayo Clinic, Rochester, NY, United States
| | - Nicholas D. Schiff
- Department of Neurology, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, New York, NY, United States
| | - Christopher R. Butson
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Jaimie M. Henderson
- Department of Neurosurgery, Stanford University, Stanford, CA, United States
| | - Jack W. Judy
- Department of Electrical and Computer Engineering, University of Florida, Gainesville, FL, United States
| | - Adolfo Ramirez-Zamora
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Kelly D. Foote
- Department of Neurosurgery, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Peter A. Silburn
- Queensland Brain Institute, University of Queensland and Saint Andrews War Memorial Hospital, Brisbane, QLD, Australia
| | - Luming Li
- National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China
| | - Genko Oyama
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Hikaru Kamo
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Satoko Sekimoto
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Nobutaka Hattori
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - James J. Giordano
- Neuroethics Studies Program, Department of Neurology, Georgetown University Medical Center, Washington, DC, United States
| | - Diane DiEuliis
- US Department of Defense Fort Lesley J. McNair, National Defense University, Washington, DC, United States
| | - John R. Shook
- Department of Philosophy and Science Education, University of Buffalo, Buffalo, NY, United States
| | - Darin D. Doughtery
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Alik S. Widge
- Department of Psychiatry, University of Minnesota, Minneapolis, MN, United States
| | - Helen S. Mayberg
- Department of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Jungho Cha
- Department of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Kisueng Choi
- Department of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Stephen Heisig
- Department of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Mosadolu Obatusin
- Department of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Enrico Opri
- Department of Neurology, Emory University, Atlanta, GA, United States
| | - Scott B. Kaufman
- Department of Psychology, Columbia University, New York, NY, United States
| | - Prasad Shirvalkar
- The Human Motor Control and Neuromodulation Laboratory, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford University, Stanford, CA, United States
- Department of Anesthesiology (Pain Management) and Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Christopher J. Rozell
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA, United States
| | - Sankaraleengam Alagapan
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA, United States
| | - Robert S. Raike
- Restorative Therapies Group Implantables, Research and Core Technology, Medtronic Inc., Minneapolis, MN, United States
| | - Hemant Bokil
- Boston Scientific Neuromodulation Corporation, Valencia, CA, United States
| | - David Green
- NeuroPace, Inc., Mountain View, CA, United States
| | - Michael S. Okun
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
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17
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Starnes K, Britton JW, Burkholder DB, Suchita IA, Gregg NM, Klassen BT, Lundstrom BN. Case Report: Prolonged Effects of Short-Term Transcranial Magnetic Stimulation on EEG Biomarkers, Spectral Power, and Seizure Frequency. Front Neurosci 2022; 16:866212. [PMID: 35757550 PMCID: PMC9232187 DOI: 10.3389/fnins.2022.866212] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/06/2022] [Indexed: 11/30/2022] Open
Abstract
Transcranial magnetic stimulation (TMS) is a non-invasive modality of focal brain stimulation in which a fluctuating magnetic field induces electrical currents within the cortex. It remains unclear to what extent TMS alters EEG biomarkers and how EEG biomarkers may guide treatment of focal epilepsy. We present a case of a 48-year-old man with focal epilepsy, refractory to multiple medication trials, who experienced a dramatic reduction in seizures after targeting the area of seizure onset within the left parietal-occipital region with low-frequency repetitive TMS (rTMS). Prior to treatment, he experienced focal seizures that impacted cognition including apraxia at least 50-60 times daily. MRI of the brain showed a large focal cortical dysplasia with contrast enhancement involving the left occipital-parietal junction. Stimulation for 5 consecutive days was well-tolerated and associated with a day-by-day reduction in seizure frequency. In addition, he was monitored with continuous video EEG, which showed continued and progressive changes in spectral power (decreased broadband power and increased infraslow delta activity) and a gradual reduction in seizure frequency and duration. One month after initial treatment, 2-day ambulatory EEG demonstrated seizure-freedom and MRI showed resolution of focal contrast enhancement. He continues to receive 2-3 days of rTMS every 2-4 months. He was seizure-free for 6 months, and at last follow-up of 17 months was experiencing auras approximately every 2 weeks without progression to disabling seizures. This case demonstrates that rTMS can be a well-tolerated and effective means of controlling medication-refractory seizures, and that EEG biomarkers change gradually in a fashion in association with seizure frequency. TMS influences cortical excitability, is a promising non-invasive means of treating focal epilepsy, and has measurable electrophysiologic effects.
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18
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Gregg NM, Sladky V, Nejedly P, Mivalt F, Kim I, Balzekas I, Sturges BK, Crowe C, Patterson EE, Van Gompel JJ, Lundstrom BN, Leyde K, Denison TJ, Brinkmann BH, Kremen V, Worrell GA. Thalamic deep brain stimulation modulates cycles of seizure risk in epilepsy. Sci Rep 2021; 11:24250. [PMID: 34930926 PMCID: PMC8688461 DOI: 10.1038/s41598-021-03555-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/03/2021] [Indexed: 11/30/2022] Open
Abstract
Chronic brain recordings suggest that seizure risk is not uniform, but rather varies systematically relative to daily (circadian) and multiday (multidien) cycles. Here, one human and seven dogs with naturally occurring epilepsy had continuous intracranial EEG (median 298 days) using novel implantable sensing and stimulation devices. Two pet dogs and the human subject received concurrent thalamic deep brain stimulation (DBS) over multiple months. All subjects had circadian and multiday cycles in the rate of interictal epileptiform spikes (IES). There was seizure phase locking to circadian and multiday IES cycles in five and seven out of eight subjects, respectively. Thalamic DBS modified circadian (all 3 subjects) and multiday (analysis limited to the human participant) IES cycles. DBS modified seizure clustering and circadian phase locking in the human subject. Multiscale cycles in brain excitability and seizure risk are features of human and canine epilepsy and are modifiable by thalamic DBS.
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Affiliation(s)
- Nicholas M Gregg
- Department of Neurology, Bioelectronics Neurophysiology and Engineering Laboratory, Mayo Clinic, Rochester, MN, 55905, USA.
| | - Vladimir Sladky
- Department of Neurology, Bioelectronics Neurophysiology and Engineering Laboratory, Mayo Clinic, Rochester, MN, 55905, USA
- International Clinical Research Center, St. Anne's University Hospital, 656 91, Brno, Czech Republic
- Faculty of Biomedical Engineering, Czech Technical University in Prague, 272 01, Kladno, Czech Republic
| | - Petr Nejedly
- Department of Neurology, Bioelectronics Neurophysiology and Engineering Laboratory, Mayo Clinic, Rochester, MN, 55905, USA
- International Clinical Research Center, St. Anne's University Hospital, 656 91, Brno, Czech Republic
| | - Filip Mivalt
- Department of Neurology, Bioelectronics Neurophysiology and Engineering Laboratory, Mayo Clinic, Rochester, MN, 55905, USA
- International Clinical Research Center, St. Anne's University Hospital, 656 91, Brno, Czech Republic
- Department of Biomedical Engineering, Faculty of Electrical Engineering and Communication, Brno University of Technology, 616 00, Brno, Czech Republic
| | - Inyong Kim
- Department of Neurology, Bioelectronics Neurophysiology and Engineering Laboratory, Mayo Clinic, Rochester, MN, 55905, USA
| | - Irena Balzekas
- Department of Neurology, Bioelectronics Neurophysiology and Engineering Laboratory, Mayo Clinic, Rochester, MN, 55905, USA
- Mayo Clinic School of Medicine and the Medical Scientist Training Program, Mayo Clinic, Rochester, MN, 55905, USA
| | - Beverly K Sturges
- Department of Veterinary Clinical Sciences, University of California, Davis, CA, 95616, USA
| | - Chelsea Crowe
- Department of Veterinary Clinical Sciences, University of California, Davis, CA, 95616, USA
| | - Edward E Patterson
- Department of Veterinary Clinical Sciences, University of Minnesota College of Veterinary Medicine, St. Paul, MN, 55108, USA
| | | | - Brian N Lundstrom
- Department of Neurology, Bioelectronics Neurophysiology and Engineering Laboratory, Mayo Clinic, Rochester, MN, 55905, USA
| | - Kent Leyde
- Cadence Neuroscience, Seattle, WA, 98052, USA
| | - Timothy J Denison
- Institute for Biomedical Engineering, Oxford University, Oxford, OX3 7DQ, UK
| | - Benjamin H Brinkmann
- Department of Neurology, Bioelectronics Neurophysiology and Engineering Laboratory, Mayo Clinic, Rochester, MN, 55905, USA
| | - Vaclav Kremen
- Department of Neurology, Bioelectronics Neurophysiology and Engineering Laboratory, Mayo Clinic, Rochester, MN, 55905, USA
- Czech Institute of Informatics, Robotics, and Cybernetics, Czech Technical University in Prague, 160 00, Prague, Czech Republic
| | - Gregory A Worrell
- Department of Neurology, Bioelectronics Neurophysiology and Engineering Laboratory, Mayo Clinic, Rochester, MN, 55905, USA.
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Abstract
SUMMARY Electrical brain stimulation is an established therapy for movement disorders, epilepsy, obsessive compulsive disorder, and a potential therapy for many other neurologic and psychiatric disorders. Despite significant progress and FDA approvals, there remain significant clinical gaps that can be addressed with next generation systems. Integrating wearable sensors and implantable brain devices with off-the-body computing resources (smart phones and cloud resources) opens a new vista for dense behavioral and physiological signal tracking coupled with adaptive stimulation therapy that should have applications for a range of brain and mind disorders. Here, we briefly review some history and current electrical brain stimulation applications for epilepsy, deep brain stimulation and responsive neurostimulation, and emerging applications for next generation devices and systems.
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Affiliation(s)
- Gregory A Worrell
- Department of Neurology, Mayo Bioelectronics and Neurophysiology Laboratory, Mayo Clinic, Rochester, Minnesota, U.S.A
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20
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Neuromodulation for Intractable Childhood Epilepsy. Semin Pediatr Neurol 2021; 39:100918. [PMID: 34620463 DOI: 10.1016/j.spen.2021.100918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/07/2021] [Accepted: 08/11/2021] [Indexed: 11/22/2022]
Abstract
In the past few years significant advances made in the field of neuromodulation have led to practical therapeutic strategies for children with medically refractory epilepsy. Here, we briefly discuss the various options that are currently available including vagus nerve stimulation, responsive neurostimulation, deep brain stimulation, chronic subthreshold cortical stimulation, as well as repetitive transcranial magnetic and transcranial direct current stimulation. The current indications, proposed mechanisms, method of administration, efficacy, adverse effects, and mention of clinical trials currently in enrollment or development are discussed.
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21
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Abstract
BACKGROUND A large number of patients have epilepsy that is intractable and adversely affects a child's lifelong experience with addition societal burden that is disabling and expensive. The last two decades have seen a major explosion of new antiseizure medication options. Despite these advances, children with epilepsy continue to have intractable seizures. An option that has been long available but little used is epilepsy surgery to control intractable epilepsy. METHODS This article is a review of the literature as well as published opinions. RESULTS Epilepsy surgery in pediatrics is an underused modality to effectively treat children with epilepsy. Adverse effects of medication should be weighed against risks of surgery as well as risks of nonefficacy. CONCLUSIONS We discuss an approach to selecting the appropriate pediatric patient for consideration, a detailed evaluation including necessary evaluation, and the creation of an algorithm to approach patients with both generalized and focal epilepsy. We then discuss surgical options available including outcome data. New modalities are also addressed including high-frequency ultrasound and co-registration techniques including magnetic resonance imaging-guided laser therapy.
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22
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Epilepsy Surgery is a Viable Treatment for Lennox Gastaut Syndrome. Semin Pediatr Neurol 2021; 38:100894. [PMID: 34183143 DOI: 10.1016/j.spen.2021.100894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/09/2021] [Accepted: 04/10/2021] [Indexed: 11/21/2022]
Abstract
Lennox Gastaut Syndrome (LGS) is a severe developmental epileptic encephalopathy with onset in childhood characterized by multiple seizure types and characteristic electroencephalogram findings. The majority of patients develop drug resistant epilepsy, defined as failure of 2 appropriate anti-seizure medications used at adequate doses. Epilepsy surgery can reduce seizure burden, in some cases leading to seizure freedom, and improve neuro-developmental outcomes and quality of life. Epilepsy surgery should be considered for all patients with drug resistant LGS. Herein, we review current surgical treatment options for patients with LGS, both definitive and palliative, including: focal cortical resection, vagus nerve stimulation and corpus callosotomy. Newer neuromodulation techniques will be explored, as well as the concept of LGS as a secondary network disorder.
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23
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Invasive cortical stimulation. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2021; 159:23-45. [PMID: 34446248 DOI: 10.1016/bs.irn.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The field of neuromodulation, at its essence, aims to apply electrical stimulation to the brain to ameliorate various pathology. Many methods of applying this stimulation exist, including invasive and non-invasive means. In the realm of invasive stimulation, stimulation of the cortex remains one of the earliest techniques investigated, yet one of the most underutilized today. Evidence for the efficacy of direct invasive cortical stimulation continues to mount, especially in recent years. In this chapter we will review the evidence for the use of invasive cortical stimulation as it applies to neuropathic pain, epilepsy, psychiatric disease, movement disorders, tinnitus, and post-stroke recovery, as well explore some potential mechanisms and future directions of the technique.
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Mohamed AA, Alawna M. The use of passive cable theory to increase the threshold of nociceptors in people with chronic pain. PHYSICAL THERAPY REVIEWS 2020. [DOI: 10.1080/10833196.2020.1853493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Ayman A. Mohamed
- Department of Physiotherapy, Faculty of Health Sciences, Istanbul Gelisim University, Turkey
| | - Motaz Alawna
- Department of Physiotherapy, Faculty of Health Sciences, Istanbul Gelisim University, Turkey
- Department of Physiotherapy and Rehabilitation, Faculty of Allied Medical Sciences, Arab American University, Jenin, Palestin
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25
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Ellrich J. Cortical stimulation in pharmacoresistant focal epilepsies. Bioelectron Med 2020; 6:19. [PMID: 32984441 PMCID: PMC7517676 DOI: 10.1186/s42234-020-00054-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 08/25/2020] [Indexed: 12/30/2022] Open
Abstract
Pharmacoresistance and adverse drug events designate a considerable group of patients with focal epilepsies that require alternative treatments such as neurosurgical intervention and neurostimulation. Electrical or magnetic stimulations of cortical brain areas for the treatment of pharmacoresistant focal epilepsies emerged from preclinical studies and experience through intraoperative neurophysiological monitoring in patients. Direct neurostimulation of seizure onset zones in neocortical brain areas may specifically affect neuronal networks involved in epileptiform activity without remarkable adverse influence on physiological cortical processing in immediate vicinity. Noninvasive low-frequency transcranial magnetic stimulation and cathodal transcranial direct current stimulation are suggested to be anticonvulsant; however, potential effects are ephemeral and require effect maintenance by ongoing stimulation. Invasive responsive neurostimulation, chronic subthreshold cortical stimulation, and epicranial cortical stimulation cover a broad range of different emerging technologies with intracranial and epicranial approaches that still have limited market access partly due to ongoing clinical development. Despite significant differences, the present bioelectronic technologies share common mode of actions with acute seizure termination by high-frequency stimulation and long-term depression induced by low-frequency magnetic or electrical stimulation or transcranial direct current stimulation.
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Affiliation(s)
- Jens Ellrich
- Medical Faculty, University of Erlangen-Nuremberg, Erlangen, Germany.,Precisis AG, Heidelberg, Germany
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26
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Alcala-Zermeno JL, Gregg NM, Van Gompel JJ, Stead M, Worrell GA, Lundstrom BN. Cortical and thalamic electrode implant followed by temporary continuous subthreshold stimulation yields long-term seizure freedom: A case report. Epilepsy Behav Rep 2020; 14:100390. [PMID: 32995742 PMCID: PMC7501416 DOI: 10.1016/j.ebr.2020.100390] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 07/28/2020] [Accepted: 08/01/2020] [Indexed: 11/27/2022] Open
Abstract
Neuromodulation strategies that target the epileptogenic network are options for treating focal drug-resistant epilepsy. These brain stimulation approaches include responsive neurostimulation and more recently, chronic subthreshold stimulation. Long-term seizure freedom with neuromodulation is uncommon. Seizure control typically requires ongoing froms of electrical stimulation. Here, we present the case of a patient implanted with three cortical electrodes targeting the inferior frontal lobe, insula, and one subcortical electrode targeting the ipsilateral anterior thalamic nucleus. This patient received continuous subthreshold electrical stimulation to the frontal electrodes for 7 months, at which time stimulation was inadvertently stopped. He has now been free of seizures for 42 months. This case suggests the possibility that neuromodulation can alter epileptogenic networks and lead to seizure freedom without ongoing electrical stimulation.
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Affiliation(s)
| | | | | | - Matt Stead
- Dark Horse Neuro, Inc., Bozeman, MT, USA
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27
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Chaitanya G, Toth E, Pizarro D, Irannejad A, Riley K, Pati S. Precision mapping of the epileptogenic network with low- and high-frequency stimulation of anterior nucleus of thalamus. Clin Neurophysiol 2020; 131:2158-2167. [PMID: 32682244 DOI: 10.1016/j.clinph.2020.05.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/18/2020] [Accepted: 05/27/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVE The goal of thalamic deep brain stimulation in epilepsy is to engage and modulate the epileptogenic network. We demonstrate how the anterior nucleus of thalamus (ANT) stimulation engages the epileptogenic network using electrophysiological measures (gamma response and post-stimulation excitability). METHODS Five patients with suspected temporal lobe epilepsy syndrome, undergoing stereo-electroencephalography (SEEG), were enrolled in the IRB approved study to undergo recording and stimulation of the ANT. We analyzed the extent of gamma-band response (activation or suppression) and post-stimulation change in excitability in various cortical regions during low (10 Hz) and high (50 Hz) frequency stimulations. RESULTS 10 Hz stimulation increased cortical gamma, whereas 50 Hz stimulation suppressed the gamma responses. The maximum response to stimuli was in the hippocampus. High epileptogenicity regions were more susceptible to stimulation. Both 10-and 50 Hz stimulations decreased post-stimulation cortical excitability. The greater the gamma-band activation with 10 Hz stimulation, the greater was the decrease in post-stimulation excitability. CONCLUSIONS We define an EEG marker that delineates stimulation-specific nodal engagement. We proved that nodes that were engaged with the thalamus during stimulation were more likely to show a short term decrease in post-stimulation excitability. SIGNIFICANCE Patient-specific engagement patterns during stimulation can be mapped with SEEG that can be used to optimize stimulation parameters.
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Affiliation(s)
- Ganne Chaitanya
- Department of Neurology, University of Alabama at Birmingham, AL, USA; Epilepsy and Cognitive Neurophysiology Laboratory, University of Alabama at Birmingham, AL, USA
| | - Emilia Toth
- Department of Neurology, University of Alabama at Birmingham, AL, USA; Epilepsy and Cognitive Neurophysiology Laboratory, University of Alabama at Birmingham, AL, USA
| | - Diana Pizarro
- Department of Neurology, University of Alabama at Birmingham, AL, USA; Epilepsy and Cognitive Neurophysiology Laboratory, University of Alabama at Birmingham, AL, USA
| | - Auriana Irannejad
- Department of Neurology, University of Alabama at Birmingham, AL, USA; Epilepsy and Cognitive Neurophysiology Laboratory, University of Alabama at Birmingham, AL, USA
| | - Kristen Riley
- Department of Neurosurgery, University of Alabama at Birmingham, AL, USA
| | - Sandipan Pati
- Department of Neurology, University of Alabama at Birmingham, AL, USA; Epilepsy and Cognitive Neurophysiology Laboratory, University of Alabama at Birmingham, AL, USA.
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28
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Starnes K, Miller K, Wong-Kisiel L, Lundstrom BN. A Review of Neurostimulation for Epilepsy in Pediatrics. Brain Sci 2019; 9:brainsci9100283. [PMID: 31635298 PMCID: PMC6826633 DOI: 10.3390/brainsci9100283] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/14/2019] [Accepted: 10/17/2019] [Indexed: 12/16/2022] Open
Abstract
Neurostimulation for epilepsy refers to the application of electricity to affect the central nervous system, with the goal of reducing seizure frequency and severity. We review the available evidence for the use of neurostimulation to treat pediatric epilepsy, including vagus nerve stimulation (VNS), responsive neurostimulation (RNS), deep brain stimulation (DBS), chronic subthreshold cortical stimulation (CSCS), transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS). We consider possible mechanisms of action and safety concerns, and we propose a methodology for selecting between available options. In general, we find neurostimulation is safe and effective, although any high quality evidence applying neurostimulation to pediatrics is lacking. Further research is needed to understand neuromodulatory systems, and to identify biomarkers of response in order to establish optimal stimulation paradigms.
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Affiliation(s)
- Keith Starnes
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA.
| | - Kai Miller
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA.
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