Experience and consensus on stimulation of the anterior nucleus of thalamus for epilepsy

Alfonso Fasano; Dawn Eliashiv; Susan T. Herman; Brian N. Lundstrom; Dara Polnerow; Jaimie M. Henderson; Robert S. Fisher

doi:10.1111/epi.17094

Experience and consensus on stimulation of the anterior nucleus of thalamus for epilepsy

Alfonso Fasano, Dawn Eliashiv, Susan T. Herman, Brian N. Lundstrom, Dara Polnerow, Jaimie M. Henderson, Robert S. Fisher

Neurology

Research output: Contribution to journal › Article › peer-review

Abstract

Deep brain stimulation of the anterior nuclei of thalamus (ANT-DBS) is effective for reduction of seizures, but little evidence is available to guide practitioners in the practical use of this therapy. In an attempt to fill this gap, a questionnaire with 37 questions was circulated to 578 clinicians who were either engaged in clinical trials of or known users of DBS for epilepsy, with responses from 141, of whom 58.2% were epileptologists and 28.4% neurosurgeons. Multiple regions of the world were represented. The survey found that the best candidates for DBS were considered those with temporal or frontal seizures, refractory to at least two medicines. Motivations for renewing therapy upon battery depletion were reduced convulsive, impaired awareness, and severe seizures and improved quality of life. Targeting of leads mainly was by magnetic resonance imaging, sometimes with intraoperative imaging or microelectrode recording. The majority used transventricular approaches. Stimulation parameters mostly imitated the SANTE study parameters, except for initial stimulation amplitudes in the 2–3-V or -mA range, versus 5 V in the SANTE study. Stimulation intensity was most often increased or reduced, respectively, for lack of efficacy or side effects, but changes in active contacts, cycle time, and pulse duration were also employed. Mood or memory problems or paresthesias were the side effects most responsible for adjustments. Off-label sites stimulated included centromedian thalamus, hippocampus, neocortex, and a few others. Several physicians used DBS in conjunction with vagus nerve stimulation or responsive neurostimulation, although our study did not track efficacy for combined use. Experienced users varied more from published parameters than did inexperienced users. In conclusion, surveys of experts can provide Class IV evidence for the most prevalent practical use of ANT-DBS. We present a flowchart for one protocol combining common practices. Controlled comparisons will be needed to choose the best approach.

Original language	English (US)
Pages (from-to)	2883-2898
Number of pages	16
Journal	Epilepsia
Volume	62
Issue number	12
DOIs	https://doi.org/10.1111/epi.17094
State	Published - Dec 2021

Keywords

anterior thalamus
consensus
epilepsy
neuromodulation
neurostimulation
seizure

ASJC Scopus subject areas

Neurology
Clinical Neurology

Access to Document

10.1111/epi.17094

Cite this

@article{f817f69dfe784a91952df15328024498,

title = "Experience and consensus on stimulation of the anterior nucleus of thalamus for epilepsy",

abstract = "Deep brain stimulation of the anterior nuclei of thalamus (ANT-DBS) is effective for reduction of seizures, but little evidence is available to guide practitioners in the practical use of this therapy. In an attempt to fill this gap, a questionnaire with 37 questions was circulated to 578 clinicians who were either engaged in clinical trials of or known users of DBS for epilepsy, with responses from 141, of whom 58.2% were epileptologists and 28.4% neurosurgeons. Multiple regions of the world were represented. The survey found that the best candidates for DBS were considered those with temporal or frontal seizures, refractory to at least two medicines. Motivations for renewing therapy upon battery depletion were reduced convulsive, impaired awareness, and severe seizures and improved quality of life. Targeting of leads mainly was by magnetic resonance imaging, sometimes with intraoperative imaging or microelectrode recording. The majority used transventricular approaches. Stimulation parameters mostly imitated the SANTE study parameters, except for initial stimulation amplitudes in the 2–3-V or -mA range, versus 5 V in the SANTE study. Stimulation intensity was most often increased or reduced, respectively, for lack of efficacy or side effects, but changes in active contacts, cycle time, and pulse duration were also employed. Mood or memory problems or paresthesias were the side effects most responsible for adjustments. Off-label sites stimulated included centromedian thalamus, hippocampus, neocortex, and a few others. Several physicians used DBS in conjunction with vagus nerve stimulation or responsive neurostimulation, although our study did not track efficacy for combined use. Experienced users varied more from published parameters than did inexperienced users. In conclusion, surveys of experts can provide Class IV evidence for the most prevalent practical use of ANT-DBS. We present a flowchart for one protocol combining common practices. Controlled comparisons will be needed to choose the best approach.",

keywords = "anterior thalamus, consensus, epilepsy, neuromodulation, neurostimulation, seizure",

author = "Alfonso Fasano and Dawn Eliashiv and Herman, {Susan T.} and Lundstrom, {Brian N.} and Dara Polnerow and Henderson, {Jaimie M.} and Fisher, {Robert S.}",

note = "Funding Information: This study was partly funded by the University of Toronto and University Health Network Chair in Neuromodulation and Multidisciplinary Care to A.F. R.F. gratefully acknowledges support by the James and Carrie Fund for Epilepsy, the Maslah Saul MD Chair and the Steve Chen Epilepsy Research Fund. The authors are grateful to the 141 participants who completed the survey. Fifty-eight wished to be listed in the “DBS for Epilepsy Practice Group”: Christopher Todd Anderson, MD, Medical College of Wisconsin, Froedtert Hospital, Milwaukee, WI, USA; Jacqueline J. Ardesch MD, neurologist, Stichting Epilepsie Instellingen Nederland, Zwolle, the Netherlands; Thandar Aung, MD, Assistant Professor of Neurology, Comprehensive Epilepsy Center, Comprehensive Epilepsy Center, Department of Neurology, Barrow Neurological Institute, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA; Anto I. Bagi{\'c}, MD, PhD, FAES, FACNS, University of Pittsburgh Comprehensive Epilepsy Center (UPCEC); Pittsburgh, PA, USA; Ausaf A. Bari, MD, Department of Neurosurgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA; Funding Information: This study was partly funded by the University of Toronto and University Health Network Chair in Neuromodulation and Multidisciplinary Care to A.F. R.F. gratefully acknowledges support by the James and Carrie Fund for Epilepsy, the Maslah Saul MD Chair and the Steve Chen Epilepsy Research Fund. The authors are grateful to the 141 participants who completed the survey. Fifty‐eight wished to be listed in the “DBS for Epilepsy Practice Group”: Christopher Todd Anderson, MD, Medical College of Wisconsin, Froedtert Hospital, Milwaukee, WI, USA; Jacqueline J. Ardesch MD, neurologist, Stichting Epilepsie Instellingen Nederland, Zwolle, the Netherlands; Thandar Aung, MD, Assistant Professor of Neurology, Comprehensive Epilepsy Center, Comprehensive Epilepsy Center, Department of Neurology, Barrow Neurological Institute, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA; Anto I. Bagi{\'c}, MD, PhD, FAES, FACNS, University of Pittsburgh Comprehensive Epilepsy Center (UPCEC); Pittsburgh, PA, USA; Ausaf A. Bari, MD, Department of Neurosurgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA; Selim R. Benbadis, MD, FAAN, FACNS, FAES, Comprehensive Epilepsy Program, University of South Florida and Tampa General Hospital, Tampa, FL, USA; Carla Bentes, MD, PhD, Department of Neurosciences and Mental Health (Neurology), Centro Hospital Universit{\'a}rio Lisboa Norte (CHULN‐HSM), Faculdade de Medicina da Universidade de Lisboa, Centro de Refer{\^e}ncia para Epilepsias Refrat{\'a}rias do CHULN‐HSM, Lisbon, Portugal; Magdalena Bosak, MD, PhD, Jagiellonian University Medical College, Department of Neurology, Krak{\'o}w, Poland; Katie Bullinger, MD, PhD, Epilepsy Division, Emory Department of Neurology, Atlanta, GA, USA; Albert J. Colon, MD, ACE Kempenhaeghe/MUMC+, Heeze, the Netherlands; Arthur Cukiert, MD, PhD, Epilepsy Surgery Program Head, Clinica de Epilepsia de Sao Paulo, Sao Paulo, Brazil; Lorand Er{\H o}ss, MD, PhD, FIPP, Department of Functional Neurosurgery and Center of Neuromodulation, National Institute of Clinical Neuroscience, Budapest, Hungary; Daniel Fabo, MD, PhD, Department of Neurology, NICN, Budapest, Hungary; Dr. Howard J. Faulkner, Neurologist and Epileptologist, North Bristol NHS Trust, Bristol, UK; David M. Ficker, MD, University of Cincinnati Academic Health Center, Department of Neurology, Cincinnati, OH, USA; Thomas J. Foutz, Department of Neurology, Division of Pediatric Neurology, Washington University, St. Louis, MO, USA; Janita M. Glastra‐Zwiers, MSc, Stichting Epilepsie Instellingen Nederland, Heemstede and Zwolle, the Netherlands; Robert L. Glover, MD, Department of Neurology, University at Buffalo, Buffalo, NY, USA; Cristina Go, MD, ABPN‐Neurology & Epilepsy, CSCN (EEG), FAES, Neurology‐Epilepsy & Clinical Neurophysiology, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada; Kevin D. Graber, MD, Clinical Professor of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA; Sanjeet S. Grewal, MD, Director of Epilepsy Surgery, Department of Neurologic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA; Thomas R. Henry, MD, Department of Neurology, University of Minnesota, Minneapolis, MN, USA; George M. Ibrahim, MD, Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada; Suneil K. Kalia, MD, PhD, FAANS, FRCSC, Toronto Western Hospital, Krembil Research Institute and KITE, University of Toronto, Toronto, Ontario, Canada; Elisabeth Kaufmann, MD, Epilepsy Center, Department of Neurology, University Hospital, LMU Munich, Munich, Germany; Jeffrey Kennedy, MD, FACNS, Department of Neurology, University of California, Davis, Davis, CA, USA; David King‐Stephens, MD, Professor of Neurology, Yale University, New Haven, CT, USA; Norbert Kovacs, MD, PhD, DSc, University of Pecs, Pecs, Hungary; Kai Lehtim{\"a}ki, Associate Professor in Neurosurgery, Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland; Christian Lettieri, MD, Neurology and Neurophysiopathology Unit, S. Maria della Misericordia University Hospital, Udine, Italy; Andres Lozano, Chairman of Neurosurgery, University of Toronto, Toronto, Ontario, Canada; Fiona Lynn, APN‐BC, Rush University Medical Center, Neurosurgery, Chicago, IL, USA; Herika Negri, Hospital Memorial S{\~a}o Jos{\'e}, Recife, Brazil; Dipali Nemade, MD, MPH, Marshall University, Huntington, WV, USA; Soheyl Noachtar, MD, FEAN, Epilepsy Center, Department of Neurology, University of Munich Hospital, Ludwig Maximilian University, Munich, Germany; Viktoras Palys, MD, Comprehensive Epilepsy Center, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Sandipan Pati, MD, Associate Professor in Neurology, University of Alabama Medical Center, Birmingham, AL, USA; Jukka Peltola, Professor, Department of Neurology, Tampere University and Tampere University Hospital, Tampere, Finland; Ana Rita Peralta, MD, Hospital de Santa Maria, Centro Hospitalar Universit{\'a}rio Lisboa Norte, Faculdade de Medicina, Universidade de Lisboa, Centro de Referencia Para a {\'A}rea das Epilepsias Refract{\'a}rias, EPICARE, Lisbon, Portugal; Imran Quraishi, MD, PhD, Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, USA; Abigail J. Rao, MD, Norton Neuroscience Institute, Norton Healthcare, Louisville, KY, USA; Vikram R. Rao, MD, PhD, Epilepsy Division, University of California, San Francisco, San Francisco, CA, USA; Ricardo Rego, MD, Neurology Department and Neurophysiology Unit, Centro Hospitalar Universit{\'a}rio de S{\~a}o Jo{\~a}o, Porto, Portugal; John Rolston, MD, PhD, Departments of Neurosurgery and Biomedical Engineering, Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, USA; Frederic L. W. V. J. Schaper, MD, PhD, A. Berenson‐Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA and Department of Neurology, Maastricht University Medical Center, Maastricht, the Netherlands; Jason M. Schwalb, MD, FAANS, FACS, Surgical Director, Movement Disorders and Comprehensive Epilepsy Centers, Associate Program Director, Neurosurgery Residency, Henry Ford Medical Group, Wayne State University, West Bloomfield, MI, USA; Sameer A. Sheth, MD, PhD, Associate Professor, Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA; Palak Shah, MD, Minnesota Epilepsy Group, St. Paul, MN, USA; Derek Southwell, MD, PhD, Duke University, Durham, NC, USA; Shraddha Srinivasan, MD, Columbia University Medical Center, Neurological Institute of New York, New York, NY, USA; William Stacey, MD, PhD, FAES, FACNS, Department of Neurology, Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA; Pasquale Striano, MD, Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto Giannina Gaslini and Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy; Diane L. Teagarden, Emory Healthcare, Atlanta, GA, USA; Yasin Temel, MD, PhD, Department of Neurosurgery, Maastricht University Medical Center, School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands; Tom Theys, MD, PhD, Department of Neurosurgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium. Dr. Francisco Alberto Villegas‐L{\'o}pez, Functional Nuerosurgeon, Hospital General de Mexico Eduardo Liceaga, Ciudad de M{\'e}xico, CDMX, Mexico; Richard Wennberg, MD, MSc, PhD, FRCPC, Professor of Medicine (Neurology), University of Toronto, Director, Clinical Neurophysiology Laboratory, Director, Mitchell Goldhar Magnetoencephalography Unit, University Health Network, Toronto Western Hospital, Toronto, Ontario, Canada; Gregory A. Worrell, MD, PhD, Mayo Clinic, Department of Neurology, Rochester, MN, USA. Funding Information: A.F. has received honoraria from AbbVie, Abbott, Boston Scientific, Ceregate, Ipsen, Medtronic, and UCB and research support from AbbVie, Boston Scientific, and Medtronic. B.N.L. is a named inventor for intellectual property developed at Mayo Clinic and licensed to Cadence Neuroscience. B.N.L. has waived contractual rights to royalties; he is a principal investigator for the Medtronic Deep Brain Stimulation Therapy for Epilepsy Post‐Approval Study (EPAS) and investigator for Mayo Clinic Medtronic NIH Public Private Partnership (UH3‐NS95495); Mayo Clinic has received consulting fees on behalf of BNL from Medtronic and Philips. D.P. is a training and education employee of Medtronic. J.M.H. is a consultant for Neuralink, and serves on the medical advisory board of Enspire DBS. R.S.F. consults for Medtronic and has stock or options from Avails Medical, Cerebral Therapeutics, Eysz, Irody, Smart Monitor, and Zeto. Neither of the other authors has any conflict of interest to disclose. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this report is consistent with those guidelines. Publisher Copyright: {\textcopyright} 2021 International League Against Epilepsy.",

year = "2021",

month = dec,

doi = "10.1111/epi.17094",

language = "English (US)",

volume = "62",

pages = "2883--2898",

journal = "Epilepsia",

issn = "0013-9580",

publisher = "Wiley-Blackwell",

number = "12",

}

TY - JOUR

T1 - Experience and consensus on stimulation of the anterior nucleus of thalamus for epilepsy

AU - Fasano, Alfonso

AU - Eliashiv, Dawn

AU - Herman, Susan T.

AU - Lundstrom, Brian N.

AU - Polnerow, Dara

AU - Henderson, Jaimie M.

AU - Fisher, Robert S.

N1 - Funding Information: This study was partly funded by the University of Toronto and University Health Network Chair in Neuromodulation and Multidisciplinary Care to A.F. R.F. gratefully acknowledges support by the James and Carrie Fund for Epilepsy, the Maslah Saul MD Chair and the Steve Chen Epilepsy Research Fund. The authors are grateful to the 141 participants who completed the survey. Fifty-eight wished to be listed in the “DBS for Epilepsy Practice Group”: Christopher Todd Anderson, MD, Medical College of Wisconsin, Froedtert Hospital, Milwaukee, WI, USA; Jacqueline J. Ardesch MD, neurologist, Stichting Epilepsie Instellingen Nederland, Zwolle, the Netherlands; Thandar Aung, MD, Assistant Professor of Neurology, Comprehensive Epilepsy Center, Comprehensive Epilepsy Center, Department of Neurology, Barrow Neurological Institute, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA; Anto I. Bagić, MD, PhD, FAES, FACNS, University of Pittsburgh Comprehensive Epilepsy Center (UPCEC); Pittsburgh, PA, USA; Ausaf A. Bari, MD, Department of Neurosurgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA; Funding Information: This study was partly funded by the University of Toronto and University Health Network Chair in Neuromodulation and Multidisciplinary Care to A.F. R.F. gratefully acknowledges support by the James and Carrie Fund for Epilepsy, the Maslah Saul MD Chair and the Steve Chen Epilepsy Research Fund. The authors are grateful to the 141 participants who completed the survey. Fifty‐eight wished to be listed in the “DBS for Epilepsy Practice Group”: Christopher Todd Anderson, MD, Medical College of Wisconsin, Froedtert Hospital, Milwaukee, WI, USA; Jacqueline J. Ardesch MD, neurologist, Stichting Epilepsie Instellingen Nederland, Zwolle, the Netherlands; Thandar Aung, MD, Assistant Professor of Neurology, Comprehensive Epilepsy Center, Comprehensive Epilepsy Center, Department of Neurology, Barrow Neurological Institute, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA; Anto I. Bagić, MD, PhD, FAES, FACNS, University of Pittsburgh Comprehensive Epilepsy Center (UPCEC); Pittsburgh, PA, USA; Ausaf A. Bari, MD, Department of Neurosurgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA; Selim R. Benbadis, MD, FAAN, FACNS, FAES, Comprehensive Epilepsy Program, University of South Florida and Tampa General Hospital, Tampa, FL, USA; Carla Bentes, MD, PhD, Department of Neurosciences and Mental Health (Neurology), Centro Hospital Universitário Lisboa Norte (CHULN‐HSM), Faculdade de Medicina da Universidade de Lisboa, Centro de Referência para Epilepsias Refratárias do CHULN‐HSM, Lisbon, Portugal; Magdalena Bosak, MD, PhD, Jagiellonian University Medical College, Department of Neurology, Kraków, Poland; Katie Bullinger, MD, PhD, Epilepsy Division, Emory Department of Neurology, Atlanta, GA, USA; Albert J. Colon, MD, ACE Kempenhaeghe/MUMC+, Heeze, the Netherlands; Arthur Cukiert, MD, PhD, Epilepsy Surgery Program Head, Clinica de Epilepsia de Sao Paulo, Sao Paulo, Brazil; Lorand Erőss, MD, PhD, FIPP, Department of Functional Neurosurgery and Center of Neuromodulation, National Institute of Clinical Neuroscience, Budapest, Hungary; Daniel Fabo, MD, PhD, Department of Neurology, NICN, Budapest, Hungary; Dr. Howard J. Faulkner, Neurologist and Epileptologist, North Bristol NHS Trust, Bristol, UK; David M. Ficker, MD, University of Cincinnati Academic Health Center, Department of Neurology, Cincinnati, OH, USA; Thomas J. Foutz, Department of Neurology, Division of Pediatric Neurology, Washington University, St. Louis, MO, USA; Janita M. Glastra‐Zwiers, MSc, Stichting Epilepsie Instellingen Nederland, Heemstede and Zwolle, the Netherlands; Robert L. Glover, MD, Department of Neurology, University at Buffalo, Buffalo, NY, USA; Cristina Go, MD, ABPN‐Neurology & Epilepsy, CSCN (EEG), FAES, Neurology‐Epilepsy & Clinical Neurophysiology, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada; Kevin D. Graber, MD, Clinical Professor of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA; Sanjeet S. Grewal, MD, Director of Epilepsy Surgery, Department of Neurologic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA; Thomas R. Henry, MD, Department of Neurology, University of Minnesota, Minneapolis, MN, USA; George M. Ibrahim, MD, Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada; Suneil K. Kalia, MD, PhD, FAANS, FRCSC, Toronto Western Hospital, Krembil Research Institute and KITE, University of Toronto, Toronto, Ontario, Canada; Elisabeth Kaufmann, MD, Epilepsy Center, Department of Neurology, University Hospital, LMU Munich, Munich, Germany; Jeffrey Kennedy, MD, FACNS, Department of Neurology, University of California, Davis, Davis, CA, USA; David King‐Stephens, MD, Professor of Neurology, Yale University, New Haven, CT, USA; Norbert Kovacs, MD, PhD, DSc, University of Pecs, Pecs, Hungary; Kai Lehtimäki, Associate Professor in Neurosurgery, Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland; Christian Lettieri, MD, Neurology and Neurophysiopathology Unit, S. Maria della Misericordia University Hospital, Udine, Italy; Andres Lozano, Chairman of Neurosurgery, University of Toronto, Toronto, Ontario, Canada; Fiona Lynn, APN‐BC, Rush University Medical Center, Neurosurgery, Chicago, IL, USA; Herika Negri, Hospital Memorial São José, Recife, Brazil; Dipali Nemade, MD, MPH, Marshall University, Huntington, WV, USA; Soheyl Noachtar, MD, FEAN, Epilepsy Center, Department of Neurology, University of Munich Hospital, Ludwig Maximilian University, Munich, Germany; Viktoras Palys, MD, Comprehensive Epilepsy Center, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Sandipan Pati, MD, Associate Professor in Neurology, University of Alabama Medical Center, Birmingham, AL, USA; Jukka Peltola, Professor, Department of Neurology, Tampere University and Tampere University Hospital, Tampere, Finland; Ana Rita Peralta, MD, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Faculdade de Medicina, Universidade de Lisboa, Centro de Referencia Para a Área das Epilepsias Refractárias, EPICARE, Lisbon, Portugal; Imran Quraishi, MD, PhD, Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, USA; Abigail J. Rao, MD, Norton Neuroscience Institute, Norton Healthcare, Louisville, KY, USA; Vikram R. Rao, MD, PhD, Epilepsy Division, University of California, San Francisco, San Francisco, CA, USA; Ricardo Rego, MD, Neurology Department and Neurophysiology Unit, Centro Hospitalar Universitário de São João, Porto, Portugal; John Rolston, MD, PhD, Departments of Neurosurgery and Biomedical Engineering, Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, USA; Frederic L. W. V. J. Schaper, MD, PhD, A. Berenson‐Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA and Department of Neurology, Maastricht University Medical Center, Maastricht, the Netherlands; Jason M. Schwalb, MD, FAANS, FACS, Surgical Director, Movement Disorders and Comprehensive Epilepsy Centers, Associate Program Director, Neurosurgery Residency, Henry Ford Medical Group, Wayne State University, West Bloomfield, MI, USA; Sameer A. Sheth, MD, PhD, Associate Professor, Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA; Palak Shah, MD, Minnesota Epilepsy Group, St. Paul, MN, USA; Derek Southwell, MD, PhD, Duke University, Durham, NC, USA; Shraddha Srinivasan, MD, Columbia University Medical Center, Neurological Institute of New York, New York, NY, USA; William Stacey, MD, PhD, FAES, FACNS, Department of Neurology, Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA; Pasquale Striano, MD, Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto Giannina Gaslini and Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy; Diane L. Teagarden, Emory Healthcare, Atlanta, GA, USA; Yasin Temel, MD, PhD, Department of Neurosurgery, Maastricht University Medical Center, School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands; Tom Theys, MD, PhD, Department of Neurosurgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium. Dr. Francisco Alberto Villegas‐López, Functional Nuerosurgeon, Hospital General de Mexico Eduardo Liceaga, Ciudad de México, CDMX, Mexico; Richard Wennberg, MD, MSc, PhD, FRCPC, Professor of Medicine (Neurology), University of Toronto, Director, Clinical Neurophysiology Laboratory, Director, Mitchell Goldhar Magnetoencephalography Unit, University Health Network, Toronto Western Hospital, Toronto, Ontario, Canada; Gregory A. Worrell, MD, PhD, Mayo Clinic, Department of Neurology, Rochester, MN, USA. Funding Information: A.F. has received honoraria from AbbVie, Abbott, Boston Scientific, Ceregate, Ipsen, Medtronic, and UCB and research support from AbbVie, Boston Scientific, and Medtronic. B.N.L. is a named inventor for intellectual property developed at Mayo Clinic and licensed to Cadence Neuroscience. B.N.L. has waived contractual rights to royalties; he is a principal investigator for the Medtronic Deep Brain Stimulation Therapy for Epilepsy Post‐Approval Study (EPAS) and investigator for Mayo Clinic Medtronic NIH Public Private Partnership (UH3‐NS95495); Mayo Clinic has received consulting fees on behalf of BNL from Medtronic and Philips. D.P. is a training and education employee of Medtronic. J.M.H. is a consultant for Neuralink, and serves on the medical advisory board of Enspire DBS. R.S.F. consults for Medtronic and has stock or options from Avails Medical, Cerebral Therapeutics, Eysz, Irody, Smart Monitor, and Zeto. Neither of the other authors has any conflict of interest to disclose. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this report is consistent with those guidelines. Publisher Copyright: © 2021 International League Against Epilepsy.

PY - 2021/12

Y1 - 2021/12

N2 - Deep brain stimulation of the anterior nuclei of thalamus (ANT-DBS) is effective for reduction of seizures, but little evidence is available to guide practitioners in the practical use of this therapy. In an attempt to fill this gap, a questionnaire with 37 questions was circulated to 578 clinicians who were either engaged in clinical trials of or known users of DBS for epilepsy, with responses from 141, of whom 58.2% were epileptologists and 28.4% neurosurgeons. Multiple regions of the world were represented. The survey found that the best candidates for DBS were considered those with temporal or frontal seizures, refractory to at least two medicines. Motivations for renewing therapy upon battery depletion were reduced convulsive, impaired awareness, and severe seizures and improved quality of life. Targeting of leads mainly was by magnetic resonance imaging, sometimes with intraoperative imaging or microelectrode recording. The majority used transventricular approaches. Stimulation parameters mostly imitated the SANTE study parameters, except for initial stimulation amplitudes in the 2–3-V or -mA range, versus 5 V in the SANTE study. Stimulation intensity was most often increased or reduced, respectively, for lack of efficacy or side effects, but changes in active contacts, cycle time, and pulse duration were also employed. Mood or memory problems or paresthesias were the side effects most responsible for adjustments. Off-label sites stimulated included centromedian thalamus, hippocampus, neocortex, and a few others. Several physicians used DBS in conjunction with vagus nerve stimulation or responsive neurostimulation, although our study did not track efficacy for combined use. Experienced users varied more from published parameters than did inexperienced users. In conclusion, surveys of experts can provide Class IV evidence for the most prevalent practical use of ANT-DBS. We present a flowchart for one protocol combining common practices. Controlled comparisons will be needed to choose the best approach.

AB - Deep brain stimulation of the anterior nuclei of thalamus (ANT-DBS) is effective for reduction of seizures, but little evidence is available to guide practitioners in the practical use of this therapy. In an attempt to fill this gap, a questionnaire with 37 questions was circulated to 578 clinicians who were either engaged in clinical trials of or known users of DBS for epilepsy, with responses from 141, of whom 58.2% were epileptologists and 28.4% neurosurgeons. Multiple regions of the world were represented. The survey found that the best candidates for DBS were considered those with temporal or frontal seizures, refractory to at least two medicines. Motivations for renewing therapy upon battery depletion were reduced convulsive, impaired awareness, and severe seizures and improved quality of life. Targeting of leads mainly was by magnetic resonance imaging, sometimes with intraoperative imaging or microelectrode recording. The majority used transventricular approaches. Stimulation parameters mostly imitated the SANTE study parameters, except for initial stimulation amplitudes in the 2–3-V or -mA range, versus 5 V in the SANTE study. Stimulation intensity was most often increased or reduced, respectively, for lack of efficacy or side effects, but changes in active contacts, cycle time, and pulse duration were also employed. Mood or memory problems or paresthesias were the side effects most responsible for adjustments. Off-label sites stimulated included centromedian thalamus, hippocampus, neocortex, and a few others. Several physicians used DBS in conjunction with vagus nerve stimulation or responsive neurostimulation, although our study did not track efficacy for combined use. Experienced users varied more from published parameters than did inexperienced users. In conclusion, surveys of experts can provide Class IV evidence for the most prevalent practical use of ANT-DBS. We present a flowchart for one protocol combining common practices. Controlled comparisons will be needed to choose the best approach.

KW - anterior thalamus

KW - consensus

KW - epilepsy

KW - neuromodulation

KW - neurostimulation

KW - seizure

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UR - http://www.scopus.com/inward/citedby.url?scp=85118149541&partnerID=8YFLogxK

U2 - 10.1111/epi.17094

DO - 10.1111/epi.17094

M3 - Article

C2 - 34697794

AN - SCOPUS:85118149541

SN - 0013-9580

VL - 62

SP - 2883

EP - 2898

JO - Epilepsia

JF - Epilepsia

IS - 12

ER -

Experience and consensus on stimulation of the anterior nucleus of thalamus for epilepsy

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