Neuromodulation - Science and Practice in Epilepsy: Vagus Nerve Stimulation, Thalamic Deep Brain Stimulation, and Responsive NeuroStimulation

ABSTRACT

Introduction: Neuromodulation devices can be safe and effective for the treatment of drug-resistant epilepsy. A body of scientific work supports peripheral, subcortical and cortical targets, each with different fundamental methods of action.

Areas covered: High-quality evidence is available for vagal nerve stimulation (VNS), deep brain stimulation (DBS), and responsive neurostimulation (RNS). Mechanistic research in animals and human studies are reviewed, along with key data from VNS, DBS, and RNS clinical trials. Specifically, the authors review some of the science behind the most frequently used medical devices for neuromodulation, the evidence that lead to their adoption, a delineation of the populations that often benefit from these devices, and perspectives on clinical practice to optimize benefit in treatment of seizures.

Expert Commentary: Neuromodulation is increasingly used to complement medical management of refractory epilepsy. Device preference will be made on the basis of patient preference, physician familiarity and other individualized factors. Right now, the field is very new and decision-making will improve with experience.

KEYWORDS:

• Neurostimulation
• neuromodulation
• vagus nerve stimulation (VNS)
• deep brain stimulation (DBS)
• responsive neurostimulation (RNS)
• epilepsy
• closed loop
• neuromodulation
• brain interface

Declaration of Interest

Dr. Fisher has received research grant funding from Eisai and Medtronic and has a consulting relationship with Medtronic. Dr. Fisher also has a financial relationship with SmartMonitor, Avails Medical, Cerebral Therapeutics and Zeto. Dr. Markert has received travel and educational funding from Medtronic, and has a consulting relationship with Ceribell. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer Disclosures

One referee has stock and IP involved in a company that is making a 64-channel cortical stimulation device for epilepsy. They also have a cofounded research award with Medtronic working on stimulation with RC + S for thalamic stimulation and is also an investigator on the SLATE trial. Another referee has prior speaking engagements for NeuroPace.

Additional information

Funding

The authors are supported by the Maslah Saul MD Chair, the James & Carrie Anderson Fund for Epilepsy, the Steve Chen Epilepsy Research Fund, and the Susan Horngren Fund.