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. 2025 Apr 8:12:1569360.
doi: 10.3389/fsurg.2025.1569360. eCollection 2025.

Intracranial neuromodulation for pediatric drug-resistant epilepsy: early institutional experience

Julie Uchitel  1 , Austin Lui  2 , Juliet Knowles  3   4 , Jonathon J Parker  5 , H Westley Phillips  1   6 , Casey H Halpern  7 , Gerald A Grant  8 , Vivek P Buch  1   6 , Ann Hyslop  3   4 , Kevin K Kumar  9
Affiliations

Intracranial neuromodulation for pediatric drug-resistant epilepsy: early institutional experience

Julie Uchitel et al. Front Surg. .

Abstract

Introduction: Pediatric drug-resistant epilepsy (DRE) is defined as epilepsy that is not controlled by two or more appropriately chosen and dosed anti-seizure medications (ASMs). When alternative therapies or surgical intervention is not viable or efficacious, advanced options like deep brain stimulation (DBS) or responsive neurostimulation (RNS) may be considered.

Objective: Describe the Stanford early institutional experience with DBS and RNS in pediatric DRE patients.

Methods: Retrospective chart review of seizure characteristics, prior therapies, neurosurgical operative reports, and postoperative outcome data in pediatric DRE patients who underwent DBS or RNS placement.

Results: Nine patients had DBS at 16.0 ± 0.9 years and 8 had RNS at 15.3 ± 1.7 years (mean ± SE). DBS targets included the centromedian nucleus of the thalamus (78% of DBS patients), anterior nucleus of the thalamus (11%), and pulvinar (11%). RNS placement was guided by stereo-EEG and/or intracranial monitoring in all RNS patients (100%). RNS targets included specific seizure onset zones (63% of RNS patients), bilateral hippocampi (25%) and bilateral temporal lobes (12%). Only DBS patients had prior trials of ketogenic diet (56%) and VNS therapy (67%). Four DBS patients (44%) had prior neurosurgical interventions, including callosotomy (22%) and focal resection (11%). One RNS patient (13%) and one DBS patient (11%) required revision surgery. Two DBS patients (22%) developed postoperative complications. Three RNS patients (38%) underwent additional resections; one RNS patient had electrocorticography recordings for seizure mapping before surgery. For patients with a follow-up of at ≥1 year (n = 7 for DBS and n = 5 for RNS), all patients had reduced seizure burden. Clinical seizure freedom was achieved in 80% of RNS patients and 20% had a >90% reduction in seizure burden. The majority (71%) of DBS patients had a ≥50% reduction in seizures. No patients experienced no change or worsening of seizure frequency.

Conclusion: In the early Stanford experience, DBS was used as a palliatively for generalized or mixed DRE refractory to other resective or modulatory approaches. RNS was used for multifocal DRE with a clear seizure focus on stereo-EEG and no prior surgical interventions. Both modalities reduced seizure burden across all patients. RNS offers the additional benefit of providing data to guide future surgical planning.

Keywords: DBS; RNS; VNS; epilepsy; neuromodulation; pediatric epilepsy.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Overview of neuromodulation targets in patients with pediatric drug-resistant epilepsy. Targets for DBS include the centromedian nucleus of the thalamus (CMN), anterior nucleus (ANT), and pulvinar. Targets for RNS include the bilateral hippocampi, bilateral temporal lobes, or another seizure focus or foci identified on sEEG. These targets specifically are in the right insula and right frontal operculum, right motor cortex, left anterior parietal cortex, canthus and middle temporal gyrus, and the bilateral temporal and occipital lobes.
Figure 2
Figure 2
DBS in the CMN of the thalamus in a pediatric patient with drug-resistant epilepsy. Postoperative MRI scans from Patient 1 for visualization of DBS lead placement. DBS leads can be seen as black circles targeting the centromedian nucleus of the thalamus (CMN). The left image is dorsal to the right image.
See this image and copyright information in PMC

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