Sharma Akshay, Parfyonov Maksim, Tiefenbach Jakov, Hogue Olivia, Nero Neil, Jehi Lara, Serletis Demitre, Bingaman William, Gupta Ajay, Rammo Richard
Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
Cleveland Clinic Epilepsy Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
Epilepsia. 2024 Mar;65(3):542-555. doi: 10.1111/epi.17883. Epub 2024 Jan 24.
We sought to perform a systematic review and individual participant data meta-analysis to identify predictors of treatment response following thalamic neuromodulation in pediatric patients with medically refractory epilepsy. Electronic databases (MEDLINE, Ovid, Embase, and Cochrane) were searched, with no language or data restriction, to identify studies reporting seizure outcomes in pediatric populations following deep brain stimulation (DBS) or responsive neurostimulation (RNS) implantation in thalamic nuclei. Studies featuring individual participant data of patients with primary or secondary generalized drug-resistant epilepsy were included. Response to therapy was defined as >50% reduction in seizure frequency from baseline. Of 417 citations, 21 articles reporting on 88 participants were eligible. Mean age at implantation was 13.07 ± 3.49 years. Fifty (57%) patients underwent DBS, and 38 (43%) RNS. Sixty (68%) patients were implanted in centromedian nucleus and 23 (26%) in anterior thalamic nucleus, and five (6%) had both targets implanted. Seventy-four (84%) patients were implanted bilaterally. The median time to last follow-up was 12 months (interquartile range = 6.75-26.25). Sixty-nine percent of patients achieved response to treatment. Age, target, modality, and laterality had no significant association with response in univariate logistic regression. Until thalamic neuromodulation gains widespread approval for use in pediatric patients, data on efficacy will continue to be limited to small retrospective cohorts and case series. The inherent bias of these studies can be overcome by using individual participant data. Thalamic neuromodulation appears to be a safe and effective treatment for epilepsy. Larger, prolonged prospective, multicenter studies are warranted to further evaluate the efficacy of DBS over RNS in this patient population where resection for curative intent is not a safe option.
我们试图进行一项系统评价和个体参与者数据荟萃分析，以确定难治性癫痫患儿丘脑神经调节治疗反应的预测因素。检索了电子数据库（MEDLINE、Ovid、Embase和Cochrane），没有语言或数据限制，以确定报告丘脑核植入深部脑刺激（DBS）或反应性神经刺激（RNS）后儿科人群癫痫发作结果的研究。纳入了具有原发性或继发性全身性耐药癫痫患者个体参与者数据的研究。治疗反应定义为癫痫发作频率较基线降低>50%。在417篇文献中，21篇报告88名参与者的文章符合条件。植入时的平均年龄为13.07±3.49岁。50名（57%）患者接受了DBS，38名（43%）接受了RNS。60名（68%）患者植入了中央中核，23名（26%）植入了丘脑前核，5名（6%）两个靶点都植入了。74名（84%）患者双侧植入。最后一次随访的中位时间为12个月（四分位间距=6.75-26.25）。69%的患者实现了治疗反应。在单变量逻辑回归中，年龄、靶点、方式和植入侧与反应无显著关联。在丘脑神经调节获得广泛批准用于儿科患者之前，疗效数据将继续局限于小型回顾性队列和病例系列。这些研究的固有偏倚可以通过使用个体参与者数据来克服。丘脑神经调节似乎是一种安全有效的癫痫治疗方法。有必要进行更大规模、长期的前瞻性多中心研究，以进一步评估在该患者群体中DBS相对于RNS的疗效，因为以治愈为目的的切除不是一个安全的选择。
