Responsive neurostimulation device therapy in pediatric patients with complex medically refractory epilepsy

Sara M. HartnettDivision of Pediatric Neurosurgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;

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Hansel M. GreinerComprehensive Epilepsy Center, Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;
Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio;

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Ravindra AryaComprehensive Epilepsy Center, Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;
Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio;

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Jeffrey R. TenneyComprehensive Epilepsy Center, Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;
Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio;

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Gewalin AungaroonComprehensive Epilepsy Center, Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;
Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio;

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Katherine HollandComprehensive Epilepsy Center, Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;
Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio;

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James L. LeachComprehensive Epilepsy Center, Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;
Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio;

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Ellen L. AirDepartment of Neurological Surgery, Henry Ford Medical Center, Detroit, Michigan; and

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Jesse SkochDivision of Pediatric Neurosurgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;
Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio

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Francesco T. ManganoDivision of Pediatric Neurosurgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;
Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio;
Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio

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OBJECTIVE

Pediatric epilepsy is characterized as drug resistant in 20%–30% of patients and defined as persistent seizures despite adequate treatment with two first-line antiepileptic medications. The American Academy of Neurology advocates surgical options earlier in the treatment of epilepsy to provide long-term seizure reduction. The new development of minimally invasive approaches has recently allowed for surgical options to patients not previously deemed surgical candidates. These may include patients with bilateral, deep, eloquent, or poorly localizing epileptogenic foci. To this end, responsive neurostimulation (RNS) is an FDA-approved closed-loop neuromodulation device for adjuvant treatment of adults with medically intractable epilepsy arising from one or multiple foci.

METHODS

In this study, the authors describe their initial institutional experience with the use of RNS in pediatric patients with drug-resistant epilepsy. An IRB-approved retrospective review was conducted of 8 pediatric patients who underwent RNS implantation at Cincinnati Children’s Hospital Medical Center between 2019 and 2021.

RESULTS

Eight patients met the inclusion criteria for the study. The average age at the time of surgery was 14.7 years (range 8–18 years) with a mean follow-up of 16.5 months. All patients underwent invasive monitoring with stereo-EEG, subdural grid placement, or a combination of both. All patients had either bilateral or eloquent cortex targets. Trajectories were based on noninvasive (phase 1) and invasive (phase 2) seizure onset zone localization data. Four (50%) of the 8 patients underwent surgical intervention for epilepsy prior to RNS placement. RNS electrodes were placed with robot-assisted guidance in a hybrid operating room with intraoperative CT and electrocorticography. The authors demonstrated individualized RNS electrode trajectory and placement with targets in the amygdala/hippocampus, bilateral insula, bilateral parietal and occipital targets, and frontoparietal regions for a total of 14 implanted electrodes. One adverse event occurred, a wound infection requiring return to the operating room for removal of the RNS implant. All patients demonstrated a reduction in seizure frequency. All patients achieved > 50% reduction in seizure frequency at last follow-up.

CONCLUSIONS

RNS implantation in carefully selected pediatric patients appears safe and efficacious in reducing seizure burden with a low rate of operative complications.

ABBREVIATIONS

fMRI = functional MRI; RNS = responsive neurostimulation; SDG = subdural grid; SEEG = stereo-EEG.
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Illustration from Wang et al. (pp 538–546). © Ju-lei Wang, published with permission.

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