TY - JOUR
T1 - Practical considerations in epilepsy neurostimulation
AU - Simpson, Hugh D.
AU - Schulze-Bonhage, Andreas
AU - Cascino, Gregory D.
AU - Fisher, Robert S.
AU - Jobst, Barbara C.
AU - Sperling, Michael R.
AU - Lundstrom, Brian N.
N1 - Funding Information:
Hugh Simpson has no conflicts of interest. Andreas Schulze‐Bonhage has obtained research support from UNEEG and Precisis. Gregory Cascino has no conflicts of interest. Robert Fisher has relevant disclosures of Medtronic consulting, and disclosures not relevant to this article include stock or options in Avails Medical, Cerebral Therapeutics, Irody, Smart‐Monitor, and Zeto. Barbara Jobst has support as the Louis and Ruth Frank Professor of Neurosciences and as Associate Editor of . She has received research support from Neuropace, Inc., Harvard Pilgrim Inc., the National Institutes of Health (NIH), and the Centers for Disease Control and Prevention (CDC). Michael Sperling has received compensation for speaking at continuing medical education (CME) programs from Medscape, Projects for Knowledge, International Medical Press, and Eisai. He has consulted for Medtronic, Neurelis, and Johnson & Johnson. He has received research support from Eisai, Medtronic, Neurelis, SK Life Science, Takeda, Xenon, Cerevel, UCB Pharma, Janssen, and Engage Pharmaceuticals. He has received royalties from Oxford University Press and Cambridge University Press. Brian Lundstrom declares intellectual property licensed to Cadence Neuroscience Inc (contractual rights waived), site investigator (Medtronic EPAS, NeuroPace RESPONSE, Neuroelectrics tDCS for Epilepsy), and industry consultant (Epiminder, Medtronic, Philips Neuro; money to Mayo Clinic). He was funded by the NIH National Institute of Neurological Disorders and Stroke (NINDS; K23NS112339). We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this report is consistent with those guidelines. Neurology
Publisher Copyright:
© 2022 International League Against Epilepsy.
PY - 2022/10
Y1 - 2022/10
N2 - 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.
AB - 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.
KW - brain stimulation
KW - DBS (deep brain stimulation)
KW - neuromodulation
KW - RNS (responsive stimulation)
KW - VNS (vagus nerve stimulation)
UR - http://www.scopus.com/inward/record.url?scp=85136952019&partnerID=8YFLogxK
U2 - 10.1111/epi.17329
DO - 10.1111/epi.17329
M3 - Review Article
C2 - 35700144
AN - SCOPUS:85136952019
SN - 0013-9580
VL - 63
SP - 2445
EP - 2460
JO - Epilepsia
JF - Epilepsia
IS - 10
ER -