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Review
. 2022 Oct;63(10):2445-2460.
doi: 10.1111/epi.17329. Epub 2022 Aug 9.

Practical considerations in epilepsy neurostimulation

Hugh D Simpson  1 , Andreas Schulze-Bonhage  2 , Gregory D Cascino  1 , Robert S Fisher  3 , Barbara C Jobst  4 , Michael R Sperling  5 , Brian N Lundstrom  1
Affiliations
Review

Practical considerations in epilepsy neurostimulation

Hugh D Simpson et al. Epilepsia. 2022 Oct.

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.

Keywords: DBS (deep brain stimulation); RNS (responsive stimulation); VNS (vagus nerve stimulation); brain stimulation; neuromodulation.

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Figures

Figure 1.
Figure 1.. Brain stimulation techniques for epilepsy.
Left: Primary approved invasive epilepsy neuromodulation techniques: VNS, DBS, and RNS. Right: Primary non-invasive brain stimulation techniques: transcranial magnetic stimulation (TMS), and transcranial direct current electrical stimulation (tDCS).
Figure 2.
Figure 2.. Suggested algorithm for selection of invasive neuromodulation technique.
The primary invasive neuromodulation modalities are included for children (age 4 – 17 years) and adults (≥18 years) who have failed two trials of anti-seizure medications.
See this image and copyright information in PMC

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