Authors :
Presenting Author: Richard Wang, BS – New York Medical college
Sanjay Patra, MD – Corewell Health; Cameron Beaudreault, BS – Medical Student, New York Medical College; david Burdette, MD – Neuroscience – Corewell Health; Jose Dominguez, BS – New York Medical College; Patricia McGoldrick, NP, MSN, MPA – NP, Child Neurology, Boston Childrens Health Physicians; Carrie Muh, MD, MPH – Chief, Pediatric Neurosurgery, Neurosurgery, Westchester Medical Center; Vishad Sukul, MD – Neurosurgery – Westchester Medical Center; Sima Vasquez, BS – New York Medical College; Steven Wolf, MD – Director Pediatric Epilepsy, Child Neurology, Boston Childrens Health Physicians
Rationale:
Responsive neurostimulation (RNS) of cortical structures effectively reduces seizures in adult patients with drug resistant epilepsy (DRE).1 Limited published clinical experience describes thalamocortical RNS targeting the pulvinar (PUL) nucleus of the thalamus.2 Bilateral centromedian RNS has reported efficacy in idiopathic3 and symptomatic generalized epilepsy4, but there are no reports of bilateral PUL stimulation. Due to broad PUL connectivity, bilateral PUL RNS may be an option for some individuals with broad-onset epilepsy.
Methods:
This study comprises two centers’ experience with bilateral PUL responsive neurostimulation using the RNS System. Patients treated with bilateral PUL RNS at Westchester Medical Center (Valhalla, NY) and Corewell Health (Grand Rapids, MI) between the years [2019-2022] were analyzed and described. Presented here are methods for target selection, device programming, and clinical outcomes.
Results: Two patients with symptomatic generalized epilepsy (aged 13 years [Ohtahara syndrome and Lennox-Gastaut syndrome (LGS)] and 21 years [LGS]) and posteriorly predominant generalized ictal discharges were implanted with bilateral pulvinar electrodes. Two patients (aged 20 and 31 years) with independent left and right occipital broad onsets were implanted with bilateral RNS devices targeting ipsilateral PUL and ipsilateral occipital cortex. Subclinical and clinical seizures were captured by RNS ECoG in all patients. RNS stimulation was well-tolerated without adverse effects. Relative to baseline, both pediatric patients had 50% reduction in disabling seizures and the two adult patients had 71% and 100% reduction in disabling seizures. Stimulation paradigms utilized high frequency stimulation in both symptomatic generalized patients. Low frequency (individualized to the terminal ictal frequencies) stimulation was effective in the two bioccipital patients.
Conclusions: RNS with electrode placement targeting bilateral PUL is safe and no adverse effects have been attributable to the pulvinar electrode placement. PUL responsive stimulation is potentially effective for patients with broad onset, biposteriorly dominant DRE. Both high and low frequency responsive stimulation are treatment options. Longer follow-up will shed light on the ultimate reduction of seizure burden.
Funding: No funding