Pediatric neuromodulation for drug-resistant epilepsy: Survey of current practices, techniques, and outcomes across US epilepsy centers

Charuta N Joshi; Cemal Karakas; Krista Eschbach; Debopam Samanta; Kurtis Auguste; Virendra Desai; Rani Singh; Patricia McGoldrick; Steven Wolf; Taylor J Abel; Edward Novotny; Chima Oluigbo; Shilpa B Reddy; Allyson Alexander; Angela Price; Puck Reeders; Nancy Mcnamara; Erin Fedak Romanowski; Ian Mutchnick; Adam P Ostendorf; Ammar Shaikhouni; Andrew Knox; Gewalin Aungaroon; Joffre Olaya; Carrie R Muh

doi:10.1002/epi4.12902

Pediatric neuromodulation for drug-resistant epilepsy: Survey of current practices, techniques, and outcomes across US epilepsy centers

Epilepsia Open. 2024 Apr;9(2):785-792. doi: 10.1002/epi4.12902. Epub 2024 Feb 29.

Authors

Charuta N Joshi¹, Cemal Karakas², Krista Eschbach³, Debopam Samanta⁴, Kurtis Auguste⁵, Virendra Desai⁶, Rani Singh⁷, Patricia McGoldrick⁸, Steven Wolf⁹, Taylor J Abel^{10

11}, Edward Novotny^{12

13}, Chima Oluigbo¹⁴, Shilpa B Reddy¹⁵, Allyson Alexander^{3

16}, Angela Price¹⁷, Puck Reeders¹⁸, Nancy Mcnamara¹⁹, Erin Fedak Romanowski¹⁹, Ian Mutchnick²⁰, Adam P Ostendorf²¹, Ammar Shaikhouni²², Andrew Knox²³, Gewalin Aungaroon²⁴, Joffre Olaya²⁵, Carrie R Muh²⁶

Affiliations

¹ Children's Health, University of Texas Southwest, Dallas, Texas, USA.
² Department of Neurology, Division of Child Neurology, Norton Neuroscience Institute, University of Louisville, Louisville, Kentucky, USA.
³ Department of Pediatrics, Children's Hospital Colorado, Section of Neurology, University of Colorado, Aurora, Colorado, USA.
⁴ University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
⁵ Department of Pediatric Neurosurgery, Benioff Children's Hospital, UCSF Weill Institute for Neurosciences, San Francisco, California, USA.
⁶ Department of Neurosurgery, Section of Pediatric Neurosurgery, Oklahoma Children's Hospital, University of Oklahoma School of Medicine, Oklahoma City, Oklahoma, USA.
⁷ Division of Neurology, Department of Pediatrics, Atrium Health/Levine Children's Hospital, Charlotte, North Carolina, USA.
⁸ Department of Pediatric Neurology, Maria Fareri Children's Hospital, Valhalla, New York, USA.
⁹ Department of Pediatric Neurology, Boston Children's Health Physicians, New York Medical Center, Valhalla, New York, USA.
¹⁰ Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
¹¹ Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
¹² Department of Neurology and Pediatrics, University of Washington, Seattle, Washington, USA.
¹³ Center for Integrative Brain Research Seattle Children's Research Institute, Seattle, Washington, USA.
¹⁴ Department of Neurosurgery, Children's National Hospital, George Washington University School of Medicine, Washington, District of Columbia, USA.
¹⁵ Department of Pediatrics, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
¹⁶ Division of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado, USA.
¹⁷ Division of Pediatric Neurosurgery, UT Southwestern Medical Center, Dallas, Texas, USA.
¹⁸ Department of Neuroscience, Brain Institute, Nicklaus Children's Hospital, Miami, Florida, USA.
¹⁹ Department of Pediatrics, Division of Pediatric Neurology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA.
²⁰ Norton Neuroscience Institute, Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA.
²¹ Department of Pediatrics, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA.
²² Department Neurosurgery, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA.
²³ Department of Neurology, University of Wisconsin, Madison, Wisconsin, USA.
²⁴ Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
²⁵ Division of Neurosurgery, Children's Hospital Orange County, Orange, California, USA.
²⁶ Department of Neurosurgery, Maria Fareri Children's Hospital, New York Medical Center, Valhalla, New York, USA.

Abstract

Neuromodulation via Responsive Neurostimulation (RNS) or Deep Brain Stimulation (DBS) is an emerging treatment strategy for pediatric drug-resistant epilepsy (DRE). Knowledge gaps exist in patient selection, surgical technique, and perioperative care. Here, we use an expert survey to clarify practices. Thirty-two members of the Pediatric Epilepsy Research Consortium were surveyed using REDCap. Respondents were from 17 pediatric epilepsy centers (missing data in one): Four centers implant RNS only while 13 implant both RNS and DBS. Thirteen RNS programs commenced in or before 2020, and 10 of 12 DBS programs began thereafter. The busiest six centers implant 6-10 new RNS devices per year; all DBS programs implant <5 annually. The youngest RNS patient was 3 years old. Most centers (11/12) utilize MP2RAGE and/or FGATIR sequences for planning. Centromedian thalamic nuclei were the unanimous target for Lennox-Gastaut syndrome. Surgeon exposure to neuromodulation occurred mostly in clinical practice (14/17). Clinically significant hemorrhage (n = 2) or infection (n = 3) were rare. Meaningful seizure reduction (>50%) was reported by 81% (13/16) of centers. RNS and DBS are rapidly evolving treatment modalities for safe and effective treatment of pediatric DRE. There is increasing interest in multicenter collaboration to gain knowledge and facilitate dialogue. PLAIN LANGUAGE SUMMARY: We surveyed 32 pediatric epilepsy centers in USA to highlight current practices of intracranial neuromodulation. Of the 17 that replied, we found that most centers are implanting thalamic targets in pediatric drug-resistant epilepsy using the RNS device. DBS device is starting to be used in pediatric epilepsy, especially after 2020. Different strategies for target identification are enumerated. This study serves as a starting point for future collaborative research.

Keywords: DBS; RNS; neuromodulation; outcomes; practices.

Publication types

Multicenter Study

MeSH terms

Child
Child, Preschool
Deep Brain Stimulation* / methods
Drug Resistant Epilepsy* / therapy
Epilepsy* / therapy
Humans
Intralaminar Thalamic Nuclei*
Seizures / therapy