Authors :
Presenting Author: charuta joshi, MD – UTSW, Childrens Health Dallas
Allyson Alexander, MD – Neurosurgery – Childrens Colorado; Krista Eschbach, MD – Pediatric Neurology – Childrens Colorado; Erin Fedak Romonowski, MD – Pediatric Neurology – Michigan Medicine; cemal Karakas, MD – Norton Childrens Hospital, Louisville KY; Samir Karia, MD – Norton Childrens Hospital, Louisville KY; Patricia McGoldrick, NP, MSN – Pediatric Neurology – Boston Childrens Health Physicians; Nancy Mcnamara, MD – Pediatric Neurology – Michigan Medicine; Carrie Muh, MD – Neurosurgery – Westchester Medical Center; Ian Mutchnick, MD – Norton Childrens Hospital, Louisville KY; Edward Novotny, MD – Pediatric Neurology – University of Washington; Joffre Olaya, MD – Neurosurgery – Childrens Hospital Orange Couunty; Chima Oluigbo, MD, FRCS, FAANS – Professor, Neurosurgery, Childrens National Hospital; Adam Osterndorf, MD – Pediatric Neurology – Nationwide Childrens Hospoital; Angela Price, MD – Associate Professor, Neurosurgery, UTSW, Childrens Health Dallas; Shilpa Reddy, MD – Pediatric Neurology – Vanderbilt University; Ammar Shaikhouni, MD – Neurosurgery – Nationwide Childrens Hospoital; Rani Singh, MD – Pediatric Neurology – Atrium Health; Saige Teti, BS – CRC, Childrens National Hospital; Steven Wolf, MD – Pediatric Neurology – Boston Childrens Health Physicians
Rationale:
Pediatric Neuromodulation using Responsive Neuro Stimulation (RNS) or Deep Brain Stimulation (DBS) is rapidly being embraced as a palliative technique in the treatment of drug resistant (DRE) focal and multifocal epilepsy in pediatric patients. Significant knowledge gaps persist regarding common practices in patient selection, surgical technique, postoperative care, and complications for pediatric RNS and DBS. This study addresses these gaps by surveying academic epilepsy centers, aiming to clarify current practices and facilitate dialogue for standardization to improve patient outcomes.
Methods:
Survey with multiple choice questions was sent to members of the neurosurgery Special Interest Group (SIG)/neuromodulation sub-SIG of the Pediatric Epilepsy Research Consortium.
Results:
Data were obtained from 11 centers. Most centers (9/11) use both DBS and RNS while two centers use exclusively RNS to treat DRE. Prior to 2020, more centers used RNS in DRE ( n=6 versus n=4) while DBS has been used in more centers since 2020 (n=8). Most centers (7/11 versus 11/11) report using either RNS/ DBS in < 5 cases per year in children less than 18 years. None of the centers reported being involved in research. Centers were divided about having a minimum age as a preference for implantation though the youngest age implanted was four years with a range for the youngest patient between four to nine years. All centers except one place thalamic (versus neocortical only) RNS electrodes. FGATIR ( 9/11) and MPRAGE (8/11) were the most common neuroimaging techniques used for surgical planning of thalamic electrode placement. Most centers use direct visualization with MRI/CT guided stereotactic placement while one center used an Atlas with coordinates. Bilateral centromedian nuclei of the thalamus is the most common target in patients with Lennox Gastaut Syndrome (LGS) patients. Less than half the centers reported their surgeons obtaining training for neuromodulation techniques during residency or fellowship (5/11) while most (8/11) have obtained experience in practice. Seven centers are placing SEEG electrodes into the thalamus as a screening tool if considering a future RNS implantation. Surgical practices regarding systemic/topical antibiotic use were varied as were practices for return to school/activities after RNS (range one to six weeks). Overall rates of clinically insignificant hemorrhage were uniformly under 10%, with no center reporting symptomatic hemorrhage. Non-significant infection rates varied from 0-16%. Rates of infection needing operative procedure to remove device range from 0-8%.78% felt that neuromodulation afforded > 50% seizure reduction.
Conclusions:
RNS and DBS are rapidly gaining traction as a safe technique for meaningful seizure reduction in DRE. There is increasing interest in multicenter collaboration to gain knowledge about practices that guide patient selection and techniques for best outcomes.
Funding: None