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Review
. 2023 Apr 1;36(2):69-76.
doi: 10.1097/WCO.0000000000001138. Epub 2023 Feb 7.

Emerging approaches in neurostimulation for epilepsy

Brian Nils Lundstrom  1 , Gamaleldin M Osman  1 , Keith Starnes  1 , Nicholas M Gregg  1 , Hugh D Simpson  2   3
Affiliations
Review

Emerging approaches in neurostimulation for epilepsy

Brian Nils Lundstrom et al. Curr Opin Neurol. .

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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Figures

Figure 1:
Figure 1:
Neurostimulation for epilepsy includes invasive (left side) and non-invasive (right side) approaches including: responsive neurostimulation (RNS), deep brain stimulation (DBS), vagus nerve stimulation (VNS), chronic subthreshold stimulation (CSS), transcranial electrical stimulation (tES), trigeminal nerve stimulation (TNS), transcutaneous vagus nerve stimulation (tVNS), transcranial direct current stimulation (tDCS), transcranial magnetic stimulation (TMS), and low intensity focused ultrasound. Used with permission of Mayo Foundation for Medical Education and Research.
Figure 2:
Figure 2:
Targets for neurostimulation include the neocortex, cerebellum, other cortical regions, and a variety of subcortical structures. Used with permission of Mayo Foundation for Medical Education and Research
See this image and copyright information in PMC

References

    1. Simpson HD, Schulze-Bonhage A, Cascino GD, Fisher RS, Jobst BC, Sperling MR, et al. Practical considerations in epilepsy neurostimulation. Epilepsia. 2022. Jun 14; - PMC - PubMed

    2. A review article summarizing common practices various practical aspects of neuromodulation in epilepsy including planning, targeting and programming strategies for various neuromodulation modalities.

    1. Ryvlin P, Rheims S, Hirsch LJ, Sokolov A, Jehi L. Neuromodulation in epilepsy: state-of-the-art approved therapies. Lancet Neurol. 2021. Dec;20(12):1038–47. - PubMed

    2. This review summarizing the FDA-approved options for stimulation for epilepsy with helpful images, tables, and flowcharts.

    1. Burdette D, Mirro EA, Lawrence M, Patra SE. Brain-responsive corticothalamic stimulation in the pulvinar nucleus for the treatment of regional neocortical epilepsy: A case series. Epilepsia Open. 2021. Sep;6(3):611–7. - PMC - PubMed

    2. This is one of the few studies published describing chronic pulvinar thalamic stimulation. Three patients with posterior quadrant focal epilepsy underwent combined cortical and pulvinar thalamic implants with RNS, and all three were responders.

    1. Lundstrom BN, Gompel JV, Khadjevand F, Worrell G, Stead M. Chronic subthreshold cortical stimulation and stimulation-related EEG biomarkers for focal epilepsy. Brain Commun. 2019;1(1):fcz010. - PMC - PubMed

    2. The largest series to date on chronic subthreshold stimulation, an important stimulation technique for focal epilepsy arising from eloquent cortex. Detail on trial stimulation in selecting patients, and EEG biomarkers predicting response are analyzed.

    1. Herlopian A, Cash SS, Eskandar EM, Jennings T, Cole AJ. Responsive neurostimulation targeting anterior thalamic nucleus in generalized epilepsy. Ann Clin Transl Neurol. 2019. Oct;6(10):2104–9. - PMC - PubMed

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