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Michael F. Barbaro, Kelsi Chesney, Daniel R. Kramer, Spencer Kellis, Terrance Peng, Zack Blumenfeld, Angad S. Gogia, Morgan B. Lee, Janet Greenwood, George Nune, Laura A. Kalayjian, Christianne N. Heck, Charles Y. Liu, and Brian Lee

neurostimulation. The RNS System (NeuroPace), an FDA-approved treatment for patients with medically refractory focal epilepsy, is an important option for patients with partial-onset seizures localized to one or more epileptogenic foci. 2 , 14 Several epilepsy treatment centers have established the safety and efficacy of the RNS System in reducing seizure frequency. 1 , 2 , 5 , 9 RNS System The RNS System is a chronically implanted brain-responsive neurostimulation system. This system was based on an earlier external system tested during intracranial monitoring. 3 , 10 , 12

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Fedor Panov, Sara Ganaha, Jennifer Haskell, Madeline Fields, Maite La Vega-Talbott, Steven Wolf, Patricia McGoldrick, Lara Marcuse, and Saadi Ghatan

, minimally invasive alternative to traditional resection with comparable clinical efficacy. 7–9 Neither resection nor ablation is recommended in cases of multiple seizure foci, a focus in an eloquent area, or poor delineation of the network, a frequent occurrence in pediatric epilepsy. 10–12 These limitations have led to the development of neuromodulatory treatments, such as vagus nerve stimulation (VNS) and deep brain stimulation (DBS). 13 In 2013, the FDA approved the closed-loop responsive neurostimulation (RNS) system (NeuroPace Inc.) as an adjunctive therapy for

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Armin Mortazavi, Ross-Jordon S. Elliott, Tiffany N. Phan, John Schreiber, William D. Gaillard, and Chima O. Oluigbo

not candidates for resective surgery if the seizure focus arises in eloquent cortex and cannot be safely removed. To this end, responsive neurostimulation has recently emerged as a safe and effective treatment for adult patients, although not much is known about this treatment modality in the pediatric setting. The RNS System (NeuroPace, Inc.) is an FDA-approved adjunctive treatment for adults aged 18 years and older with medically intractable partial-onset seizures arising from one or two foci. 2–4 The RNS System is a closed-loop system designed to abort seizure

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Malgosia A. Kokoszka, Fedor Panov, Maite La Vega-Talbott, Patricia E. McGoldrick, Steven M. Wolf, and Saadi Ghatan

T he responsive neurostimulation (RNS) system (NeuroPace), an FDA-approved adjunctive treatment for adults with medically intractable partial-onset seizures arising from 1 or 2 foci, 10 , 17 is not yet approved for children with medically refractory epilepsy (MRE). The device consists of a surgically implanted cranial neurostimulator that is connected to 2 cortical and/or depth leads containing 4 electrodes each that are placed at the putative seizure focus (foci). The neurostimulator continuously senses electrographic activity and is programmed to deliver

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John D. Rolston, Dario J. Englot, Doris D. Wang, Tina Shih, and Edward F. Chang

directly related to the device in the SANTE trial included paresthesias in 18.2%, implant site pain in 10.9%, implant site infections in 9.1%, and lead replacement in 8.2% of patients. Note that these frequencies include the unblinded portion of the trial—the adverse events in the blinded portion are displayed in Table 2 . Adverse events that were significantly different between groups in the blinded phase were depression (14.8% of treated patients) and memory impairment (13.0%). Responsive Neurostimulation The RNS device is designed to detect seizures as they

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Jacob R. Lepard, Esther Dupépé, Matthew Davis, Jennifer DeWolfe, Bonita Agee, J. Nicole Bentley, and Kristen Riley

I nvasive monitoring has long been utilized in the evaluation of patients for epilepsy surgery, providing localizing information to guide resection. 1 In the last 2 decades there have been significant advancements in the diagnosis and surgical treatment of medically refractory epilepsy. Important among these innovations has been the increasing use of stereoelectroencephalography (SEEG) in North America, 2 along with the availability of neuromodulatory therapies such as responsive neurostimulation (RNS), 3 , 4 deep brain stimulation (DBS), 5 and laser

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Neil Klinger and Sandeep Mittal

separate study of 12 patients with intractable epilepsy treated with cerebellar stimulation, no reduction in seizure frequency was reported at 6 months. 75 Responsive Neurostimulation Responsive neurostimulation (RNS) is a unique implantable electrical current delivery method that does not rely on continuous or predefined intermittent stimulation paradigms. The treating physician programs the RNS device to recognize electrocorticographic (ECoG) patterns unique to the patient that may occur prior to ictal onset. When the patient subsequently experiences similar ECoG

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Kai J. Miller, Casey H. Halpern, Mark F. Sedrak, John A. Duncan III, and Gerald A. Grant

fiber-optic probes are used for laser ablation of the hippocampus and adjacent structures under MRI guidance (Visualase/Medtronic or Monteris). C: Recording/stimulating electrodes are placed stereotactically for responsive neurostimulation (Neuropace). Figure is available in color online only. Stereotactic targeting for these approaches is evolving, although it is currently prescribed for general anatomical structures rather than a landmark-based coordinate system. The present standard for directly targeting the amygdalohippocampal complex for SLAH is defined by

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Allen L. Ho, Anne-Mary N. Salib, Arjun V. Pendharkar, Eric S. Sussman, William J. Giardino, and Casey H. Halpern

responsive neurostimulation systems in the treatment of epilepsy has demonstrated the effectiveness of “closed-loop” recording and intermittent stimulation systems for the treatment of episodic electrical pathology within the brain. 45 Consumption-driven disorders of impulsivity may be ideal for this type of closed-loop treatment if stimulation could be delivered during brief windows of anticipation, or so-called moments of weakness prior to the initiation of a binge. 8 , 60 Wu et al. recently published a translational study validating this technique. They were able to

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Erwin Z. Mangubat, Robert G. Kellogg, Timothy J. Harris Jr., and Marvin A. Rossi

has gained momentum for the treatment of pharmaco-resistant epilepsy. The Responsive Neurostimulation System (RNS, NeuroPace, Inc.) is a closed-loop implantable direct neuromodulation technology recently approved by the FDA as an adjunctive therapy in individuals who have pharmaco-resistant focal-onset epilepsy with up to 2 epileptogenic sources. Efficacy of the NeuroPace RNS capitalizes on a closed-loop approach where direct stimulation is delivered to an epileptogenic source upon detection of an evolving electrographic seizure with the goal of inhibiting its