Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA.
Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts, USA.
Epilepsia. 2024 Sep;65(9):2626-2640. doi: 10.1111/epi.18070. Epub 2024 Jul 25.
OBJECTIVE: Although >30% of epilepsy patients have drug-resistant epilepsy (DRE), typically those with generalized or multifocal disease have not traditionally been considered surgical candidates. Responsive neurostimulation (RNS) of the centromedian (CM) region of the thalamus now appears to be a promising therapeutic option for this patient population. We present outcomes following CM RNS for 13 patients with idiopathic generalized epilepsy (IGE) and eight with multifocal onsets that rapidly generalize to bilateral tonic-clonic (focal to bilateral tonic-clonic [FBTC]) seizures. METHODS: A retrospective review of all patients undergoing bilateral CM RNS by the senior author through July 2022 were reviewed. Electrodes were localized and volumes of tissue activation were modeled in Lead-DBS. Changes in patient seizure frequency were extracted from electronic medical records. RESULTS: Twenty-one patients with DRE underwent bilateral CM RNS implantation. For 17 patients with at least 1 year of postimplantation follow-up, average seizure reduction from preoperative baseline was 82.6% (SD = 19.0%, median = 91.7%), with 18% of patients Engel class 1, 29% Engel class 2, 53% Engel class 3, and 0% Engel class 4. There was a trend for average seizure reduction to be greater for patients with nonlesional FBTC seizures than for other patients. For patients achieving at least Engel class 3 outcome, median time to worthwhile seizure reduction was 203.5 days (interquartile range = 110.5-343.75 days). Patients with IGE with myoclonic seizures had a significantly shorter time to worthwhile seizure reduction than other patients. The surgical targeting strategy evolved after the first four subjects to achieve greater anatomic accuracy. SIGNIFICANCE: Patients with both primary and rapidly generalized epilepsy who underwent CM RNS experienced substantial seizure relief. Subsets of these patient populations may particularly benefit from CM RNS. The refinement of lead targeting, tuning of RNS system parameters, and patient selection are ongoing areas of investigation.
目的：尽管 >30%的癫痫患者患有耐药性癫痫（DRE），但通常那些患有全身性或多灶性疾病的患者传统上不被视为手术候选者。丘脑中央中核（CM）区域的反应性神经刺激（RNS）现在似乎是治疗这一患者群体的有前途的治疗选择。我们介绍了对 13 名特发性全面性癫痫（IGE）和 8 名快速广泛双侧强直阵挛（局灶性双侧强直阵挛[FBTC]）发作的多灶性发作患者进行 CM RNS 治疗后的结果。
方法：回顾性分析了截至 2022 年 7 月由资深作者对所有接受双侧 CM RNS 治疗的患者的研究。在 Lead-DBS 中定位电极并模拟组织激活体积。从电子病历中提取患者癫痫发作频率的变化。
结果：21 名 DRE 患者接受了双侧 CM RNS 植入。对于 17 名至少有 1 年植入后随访的患者，与术前基线相比，平均癫痫发作减少了 82.6%（SD=19.0%，中位数=91.7%），18%的患者为 Engel 1 级，29%为 Engel 2 级，53%为 Engel 3 级，0%为 Engel 4 级。对于非病变性 FBTC 发作的患者，平均癫痫发作减少趋势更大。对于达到至少 Engel 3 级结果的患者，中位达到有意义的癫痫发作减少的时间为 203.5 天（四分位距=110.5-343.75 天）。有肌阵挛发作的 IGE 患者达到有意义的癫痫发作减少的时间明显短于其他患者。在实现更高解剖精度的前四个研究对象之后，手术靶向策略得到了发展。
意义：接受 CM RNS 治疗的原发性和快速广泛癫痫患者均经历了显著的癫痫缓解。这些患者群体的亚组可能特别受益于 CM RNS。正在对导线靶向、RNS 系统参数调整和患者选择进行改进。
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