Abstract
Epilepsy affects approximately 70 million people worldwide, and it is a significant contributor to the global burden of neurological disorders. Despite the advent of new AEDs, drug resistant-epilepsy continues to affect 30-40% of PWE. Once identified as having drug-resistant epilepsy, these patients should be referred to a comprehensive epilepsy center for evaluation to establish if they are candidates for potential curative surgeries. Unfortunately, a large proportion of patients with drug-resistant epilepsy are poor surgical candidates due to a seizure focus located in eloquent cortex, multifocal epilepsy or inability to identify the zone of ictal onset. An alternative treatment modality for these patients is neuromodulation. Here we present the evidence, indications and safety considerations for the neuromodulation therapies in vagal nerve stimulation (VNS), responsive neurostimulation (RNS), or deep brain stimulation (DBS).
Highlights
Epilepsy affects approximately 70 million people worldwide, and it is a significant contributor to the global burden of neurological disorders [1, 2]
Drug-resistant epilepsy is defined by the failure of adequate trials of two tolerated, appropriately chosen and used antiepileptic drugs (AEDs) to achieve sustained seizure freedom [7]
A large proportion of patients with drug-resistant epilepsy are poor candidates for resection or laser ablation due to a seizure focus located in eloquent cortex, multifocal epilepsy or inability to identify the ictal onset zone
Summary
Epilepsy affects approximately 70 million people worldwide, and it is a significant contributor to the global burden of neurological disorders [1, 2]. 50% of patients with newly diagnosed epilepsy achieve seizure freedom with the first AED, while only 11% of PWE become seizure free after the second AED, and a mere 3% stop having seizures after failing the second medication trial, leaving 30-40% of PWE with drug-resistant epilepsy [9]. A large proportion of patients with drug-resistant epilepsy are poor candidates for resection or laser ablation due to a seizure focus located in eloquent cortex, multifocal epilepsy or inability to identify the ictal onset zone. Neuromodulation therapies are palliative nonpharmacologic options for patients who are not candidates for surgical resection or ablation These entail electrical stimulation of specific neuroanatomical structures with the aim of affecting. RNS is delivered in a closed-loop approach This monitoring of electrical activity is achieved through electrocorticography (ECoG) with intracranial electrodes which continuously works to identify patterns predictive of ictal activity. This stimulation either prevents the seizure or stops the clinical manifestations of the ictal activity [12,13,14]
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