Responsive Cortical Stimulation (e.g. Neuropace)
- Responsive neurostimulator
- Defib the brain
- Clinical result
- Statistically significant result
- Adverse effects:
- 4.7% haemorrhage (3.7% serious)
- But no sequelae
- No neuropsych deterioration
- Qolie89 improved at 1 & 2 years
- Safety management
- 5.2% ‘serious’ infection
- 2.1% explanted
- Is it RNS or just NS (up to 600 stim per day)
- Would better case selection help?
DBS (e.g. STN, anterior thalamus)
- Target
- Part of limbic thalamus — circuit of Papez
- Afferents from mammilothalamic tract
- Efferents to cingulate cortex
- Six patients implanted by Cooper 1979-1982.
- Seizure frequency reduced by >60% in 5 patients
- SANTE pivotal trial by Fisher et al 2010
- Double blind multicentre study
- Anterior thalamic nucleus
- Indication
- Pending
- For partial seizure
- Centromedian nucleus stimulation
- Pioneered by Velasco in Mexico (1987)
- Closely related to the ascending reticular activating pathways and has particularly central and frontal cortical connections
- Appears to benefit patients with generalised seizures
- A small placebo-controlled study of 7 patients (Fisher 1992), showed improvement (30% ON compared with 8% OFF), but not statistically significant.
- However one patient dropped out as seizure free on stimulation and refused turning off!
- For generalised seizure
- Centromedian thalamic stimulation
- Centromedian DBS results
- Clear improvements (>50%) in all patients with generalised epilepsy.
- 3 patients seizure free for more than 12m.
- Worsening when DBS battery OFF (blue arrow).
- Not clear initial effect in patients with frontal epilepsy.
- Some improvement (only 2 with >50%) after trying different stimulation parameters.
- Indication
- If lesion is in eloquent cortex that cannot be safely resected
- Hypothalamic hamartomas
- Chronic hippocampal stimulation
Anterior thalamus stimulation
Long-term efficacy
The median percentage reduction from baseline at 2 years was 56% (n=82) 56.8%, at 3 years (n=75), at 4 years was 66% (n=75) and at 5 years was 75% (n=35).
Overall, 15% (16/110) of all implanted subjects were seizure-free for at least 6 months during the study (inclusive of all post implant phases) and 6 subjects were seizure free for over 2 years.
Centromedian nucleus
Articles | Patients | Seizure type | Seizure reduction | Follow up |
Velasco 1987 | 5 | Generalized, multifocal | 80-100% seizures | 3 months |
Fisher 1992 | 7 | Generalized, focal | 50% patients | 9 months |
Velasco 2000 | 13 | Generalized | 92% patients | 12-94 months |
Chkhonkeli 2004 | 15 | Mesial temporal | 40-80% seizures | < 1.5 years |
Velasco 2006 | 13 | GTCS and absences | 80% patients | 18 months |
Andrade 2006 | 2 | Several types | 0% patients | 5 years |
Cukiert 2009 | 4 | Generalized | 25-95% seizures | > 1 year |
Velasco, 2006 | 13 (9 children) | Lennox-Gastaut syndrome | 12>50% (8>85%) | >18 months |
Chronic cortical lesional stimulation
Vagal nerve stimulator
- Palliative option
Chronic subthreshold subdural cortical stimulation
- New technique
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