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The role of neuromodulation in the management of drug-resistant epilepsy

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Abstract

Drug-resistant epilepsy (DRE) poses significant challenges in terms of effective management and seizure control. Neuromodulation techniques have emerged as promising solutions for individuals who are unresponsive to pharmacological treatments, especially for those who are not good surgical candidates for surgical resection or laser interstitial therapy (LiTT). Currently, there are three neuromodulation techniques that are FDA-approved for the management of DRE. These include vagus nerve stimulation (VNS), deep brain stimulation (DBS), and responsive neurostimulation (RNS). Device selection, optimal time, and DBS and RNS target selection can also be challenging. In general, the number and localizability of the epileptic foci, alongside the comorbidities manifested by the patients, substantially influence the selection process. In the past, the general axiom was that DBS and VNS can be used for generalized and localized focal seizures, while RNS is typically reserved for patients with one or two highly localized epileptic foci, especially if they are in eloquent areas of the brain. Nowadays, with the advance in our understanding of thalamic involvement in DRE, RNS is also very effective for general non-focal epilepsy. In this review, we will discuss the underlying mechanisms of action, patient selection criteria, and the evidence supporting the use of each technique. Additionally, we explore emerging technologies and novel approaches in neuromodulation, such as closed-loop systems. Moreover, we examine the challenges and limitations associated with neuromodulation therapies, including adverse effects, complications, and the need for further long-term studies. This comprehensive review aims to provide valuable insights on present and future use of neuromodulation.

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Author notes

  1. HusamEddin Salama and Ahmed Salama contributed equally to the work.

Authors and Affiliations

  1. Al-Quds University-School of Medicine, Abu Dis, Jerusalem, Palestine

    HusamEddin Salama & Ahmed Salama

  2. Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA

    George I. Jallo & Nir Shimony

  3. Department of Neurosurgery, Institute for Brain Protection Sciences, Johns Hopkins All Children’s Hospital, 600 5th Street South, St. Petersburg, FL, 33701, USA

    Logan Oscher & George I. Jallo

  4. Department of Surgery, St. Jude Children’s Research Hospital, Memphis, TN, USA

    Nir Shimony

  5. Le Bonheur Neuroscience Institute, Le Bonheur Children’s Hospital, Memphis, TN, USA

    Nir Shimony

  6. Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA

    Nir Shimony

  7. Semmes-Murphey Clinic, Memphis, TN, USA

    Nir Shimony

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NS and JG conceptualized the study. HS and AS performed the literature search and synthesis of the evidence. HS, AS, and LO wrote the first draft of the manuscript. NS and JG revised and edited the manuscript. JG supervised the drafting of the manuscript. All authors have read, edited, and approved the final version of the manuscript.

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Salama, H., Salama, A., Oscher, L. et al. The role of neuromodulation in the management of drug-resistant epilepsy. Neurol Sci (2024). https://doi.org/10.1007/s10072-024-07513-9

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