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  • Updated 08.08.2023
  • Released 04.12.2021
  • Expires For CME 08.08.2026

Brain stimulation for epilepsy



Brain stimulation for epilepsy provides an alternative to pharmacotherapy and resective, ablative, or disconnection surgery for patients with medication-resistant epilepsy. Although relatively rarely achieving seizure freedom, these therapies can provide substantial benefits to quality of life, reducing the risk of sudden unexpected death in epilepsy, reducing the burden of common comorbidities, and occasionally reducing antiseizure medications with their associated adverse effects. They also can provide unique insights into epilepsy through ultra-long-term monitoring. Stimulation routes include vagus nerve stimulation, deep brain stimulation, responsive neurostimulation system, and other novel targets. Based on FDA approval in the United States, this article focuses on vagus nerve stimulation, deep brain stimulation, and responsive neurostimulation system.

Key points

• Responsive neurostimulation system provides targeted stimulation to up to two locations in the brain.

• Responsive neurostimulation system can augment typical inpatient intracranial EEG monitoring before subsequent neurosurgery.

• Deep brain stimulation requires less precise localization while also substantially improving seizure frequency and perhaps neurocognitive outcomes.

• Vagus nerve stimulation provides an alternative to intracranial surgery while also providing both seizure frequency improvement and reducing rates of sudden unexpected death in epilepsy.

Historical note and terminology

The first neurostimulation therapy was vagus nerve stimulation, which began in 1988 and was licensed in 1997. Subsequently, responsive neurostimulation and deep brain stimulation were shown to be alternatives. Although numerous other targets have been explored, these three have earned U.S. Food and Drug Administration approval. More recently, other techniques and targets are being explored as adjunctive therapies for epilepsy, including focused ultrasound, trigeminal nerve stimulation, transcranial magnetic stimulation, transcranial direct current stimulation, and chronic subthreshold cortical stimulation.

These technologies share common goals to modify the abnormal network associated with epileptic seizures. By stimulating these networks, modulation of the network activity is achieved, and ideally, acute stimulation can stop, shorten, or reduce the spread of epileptic seizures. Chronic stimulation may cause network modification to reduce the propensity for epileptic seizures. In this way, the onset of action can be delayed, and the maximum efficacy of neurostimulation or neuromodulation technologies can be years after initiation of treatment. The term neuromodulation reflects how the stimulation from these technologies can modify the epileptic network. The unique perspective of each technology can also provide supplemental information about the pathophysiology of epilepsy both on an individual and population level.

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