Department of Neurosurgery, University of California Los Angeles, Los Angeles, 300 Stein Plaza Driveway, CA 90095, USA; University of Milan "LA STATALE", Milan, Italy.
Department of Neurosurgery, University of California Los Angeles, Los Angeles, 300 Stein Plaza Driveway, CA 90095, USA.
Seizure. 2023 Feb;105:22-28. doi: 10.1016/j.seizure.2023.01.009. Epub 2023 Jan 15.
Deep brain stimulation (DBS) of the thalamic nuclei for the treatment of drug-resistant epilepsy (DRE) has been investigated for decades. In recent years, DBS targeting the anterior nucleus of the thalamus (ANT) was approved by CE and FDA for the treatment of focal-onset DRE in light of the results from the multicentric randomized controlled SANTE trial. However, stereotactic targeting of thalamic nuclei is not straightforward because of the low contrast definition among thalamic nuclei on the current MRI sequences. When the FGATIR sequence is added to the preoperative MRI protocol, the mammillothalamic tract can be identified and used as a visible landmark to directly target ANT. According to the current evidence, the trans-ventricular trajectory allows the placement of stimulating contact into the nucleus more frequently than the trans-cortical trajectory. Another thalamic nucleus whose stimulation for the treatment of generalized DRE is receiving increasing attention is the centromedian nucleus (CM). CM-DBS seems to be particularly efficacious in patients suffering from Lennox-Gastault syndrome (LGS) and the recent monocentric randomized controlled ESTEL trial also described a beneficial "sweet-spot". However, CM targeting is still based on indirect stereotactic coordinates, since acquisition times and post-processing techniques of the actual MRI sequences are not applicable in clinical practice. Moreover, the results of the ESTEL trial await confirmation from similar studies accounting for epileptic syndromes other than LGS. Therefore, novel neuroimaging approaches are advisable to improve the surgical targeting of CM and potentially tailor the stimulation based on the patient's specific epileptic phenotype.
深部脑刺激（DBS）丘脑核治疗耐药性癫痫（DRE）已经研究了几十年。近年来，鉴于多中心随机对照 SANTE 试验的结果，CE 和 FDA 批准 DBS 靶向丘脑前核（ANT）治疗局灶性 DRE。然而，由于当前 MRI 序列中丘脑核之间的对比度定义较低，因此丘脑核的立体定向靶向并不简单。当将 FGATIR 序列添加到术前 MRI 方案中时，可以识别出乳头丘脑束并将其用作直接靶向 ANT 的可见标记。根据目前的证据，与经皮质轨迹相比，经脑室轨迹允许更频繁地将刺激接触放置在核内。另一个刺激治疗广泛性 DRE 的丘脑核越来越受到关注，即中央中核（CM）。CM-DBS 似乎对 Lennox-Gastault 综合征（LGS）患者特别有效，最近的单中心随机对照 ESTEL 试验还描述了一个有益的“甜蜜点”。然而，CM 靶向仍然基于间接立体定向坐标，因为实际 MRI 序列的采集时间和后处理技术在临床实践中不可用。此外，ESTEL 试验的结果还需要其他类似研究来证实，这些研究需要考虑除 LGS 以外的癫痫综合征。因此，建议采用新的神经影像学方法来改善 CM 的手术靶向，并根据患者特定的癫痫表型进行个性化刺激。
