Hartnett Sara M, Greiner Hansel M, Arya Ravindra, Tenney Jeffrey R, Aungaroon Gewalin, Holland Katherine, Leach James L, Air Ellen L, Skoch Jesse, Mangano Francesco T
1Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
2Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
J Neurosurg Pediatr. 2022 Aug 26;30(5):499-506. doi: 10.3171/2022.7.PEDS2281. Print 2022 Nov 1.
Pediatric epilepsy is characterized as drug resistant in 20%-30% of patients and defined as persistent seizures despite adequate treatment with two first-line antiepileptic medications. The American Academy of Neurology advocates surgical options earlier in the treatment of epilepsy to provide long-term seizure reduction. The new development of minimally invasive approaches has recently allowed for surgical options to patients not previously deemed surgical candidates. These may include patients with bilateral, deep, eloquent, or poorly localizing epileptogenic foci. To this end, responsive neurostimulation (RNS) is an FDA-approved closed-loop neuromodulation device for adjuvant treatment of adults with medically intractable epilepsy arising from one or multiple foci.
In this study, the authors describe their initial institutional experience with the use of RNS in pediatric patients with drug-resistant epilepsy. An IRB-approved retrospective review was conducted of 8 pediatric patients who underwent RNS implantation at Cincinnati Children's Hospital Medical Center between 2019 and 2021.
Eight patients met the inclusion criteria for the study. The average age at the time of surgery was 14.7 years (range 8-18 years) with a mean follow-up of 16.5 months. All patients underwent invasive monitoring with stereo-EEG, subdural grid placement, or a combination of both. All patients had either bilateral or eloquent cortex targets. Trajectories were based on noninvasive (phase 1) and invasive (phase 2) seizure onset zone localization data. Four (50%) of the 8 patients underwent surgical intervention for epilepsy prior to RNS placement. RNS electrodes were placed with robot-assisted guidance in a hybrid operating room with intraoperative CT and electrocorticography. The authors demonstrated individualized RNS electrode trajectory and placement with targets in the amygdala/hippocampus, bilateral insula, bilateral parietal and occipital targets, and frontoparietal regions for a total of 14 implanted electrodes. One adverse event occurred, a wound infection requiring return to the operating room for removal of the RNS implant. All patients demonstrated a reduction in seizure frequency. All patients achieved > 50% reduction in seizure frequency at last follow-up.
RNS implantation in carefully selected pediatric patients appears safe and efficacious in reducing seizure burden with a low rate of operative complications.
20%-30%的小儿癫痫患者具有耐药性，其定义为尽管使用两种一线抗癫痫药物进行了充分治疗，但仍有持续性癫痫发作。美国神经病学学会主张在癫痫治疗早期采用手术方案，以长期减少癫痫发作。微创方法的新进展最近使以前被认为不适合手术的患者也有了手术选择。这些患者可能包括双侧、深部、明确或定位不佳的致痫灶患者。为此，响应性神经刺激（RNS）是一种经美国食品药品监督管理局（FDA）批准的闭环神经调节装置，用于辅助治疗由一个或多个病灶引起的药物难治性成人癫痫。
在本研究中，作者描述了他们在小儿耐药性癫痫患者中使用RNS的初步机构经验。对2019年至2021年期间在辛辛那提儿童医院医疗中心接受RNS植入的8例儿科患者进行了一项经机构审查委员会（IRB）批准的回顾性研究。
8例患者符合该研究的纳入标准。手术时的平均年龄为14.7岁（范围8-18岁），平均随访16.5个月。所有患者均接受了立体脑电图、硬膜下网格置入或两者结合的侵入性监测。所有患者的靶点均为双侧或明确的皮质靶点。轨迹基于非侵入性（1期）和侵入性（2期）癫痫发作起始区定位数据。8例患者中有4例（50%）在植入RNS之前接受了癫痫手术干预。在配备术中CT和皮层脑电图的混合手术室中，在机器人辅助引导下放置RNS电极。作者展示了个性化的RNS电极轨迹和放置位置，靶点位于杏仁核/海马体、双侧岛叶、双侧顶叶和枕叶靶点以及额顶叶区域，共植入14个电极。发生了1例不良事件，即伤口感染，需要返回手术室取出RNS植入物。所有患者的癫痫发作频率均有所降低。在最后一次随访时，所有患者的癫痫发作频率均降低了>50%。
在精心挑选的儿科患者中植入RNS似乎安全有效，可减轻癫痫发作负担，手术并发症发生率较低。
