Ilyas A, Sumida A, Pichardo-Rojas PS
… +10 more, Snyder KM, Cho R, Bhattacharjee MB, Slater JD, Kalamangalam GP, Von Allmen GK, Thompson SA, Lhatoo SD, Johnson JA, Tandon N
Orbitofrontal epilepsies (OFE) produce variable clinical semiologies and nonspecific electrographic patterns thereby being challenging to localize. Furthermore, systematic studies of the surgical management and outcomes...Orbitofrontal epilepsies (OFE) produce variable clinical semiologies and nonspecific electrographic patterns thereby being challenging to localize. Furthermore, systematic studies of the surgical management and outcomes in OFE are sparse. The authors review the current literature and discuss the intracranial electroencephalography, microsurgical techniques, and surgical outcomes of patients in the context of a 20-year surgical experience in treating 24 patients with OFE. The authors distinguish between purely orbitofrontal resections (OF-focal, n = 10) and those in whom additional brain regions were concurrently resected (OF-plus, n = 14). These two cohorts were similar with respect to age, duration of epilepsy, and presence of an OF lesion on MRI. Patients frequently reported no auras (OF-focal: 7 [70%], OF-plus: 8 [57%]); generalized tonic-clonic seizures were common (OF-focal: 6 [60%], OF-plus: 7 [50%]); and seizures were often nocturnal (OF-focal: 5 [50%], OF-plus: 8 [57%]). Surgical extensions among the OF-plus group included the prefrontal or frontal pole (67%), temporal pole (11%), and mesial temporal lobe (22%). Durable Engel I to II outcomes at last follow-up (median: 4 years, interquartile range [IQR]: 2-7) were achieved in 5 patients (50%) with OF-focal epilepsies and 8 (57%) patients with OF-plus epilepsies. Among nonlesional cases, 4 of 11 patients (36%) achieved seizure freedom, of whom 3 (75%) underwent OF-plus resection. The most common etiology was malformation of cortical development (58%). Surgical resection of the OFE carries the same seizure-free rates as other neocortical epilepsies and can be done safely with minimal cognitive or functional decline.
The orbitofrontal cortex is central to decision making, reward valuation, emotional regulation, and goal-directed behavior. Although traditional cytoarchitectonic classifications, such as Brodmann map, identified multipl...The orbitofrontal cortex is central to decision making, reward valuation, emotional regulation, and goal-directed behavior. Although traditional cytoarchitectonic classifications, such as Brodmann map, identified multiple cortical areas within the orbitofrontal cortex, recent neuroimaging advancements such as the Human Connectome Project have refined our anatomical understanding in granular detail. This study characterizes the structural and functional connectivity of key orbitofrontal subregions, particularly Brodmann area 11, Brodmann area 13, Brodmann area 14, and Brodmann area 47, corresponding to Human Connectome Project areas 11L, 13L, orbitofrontal cortex (OFC)/polar orbitofrontal cortex, and 47m/47 s/a47r, respectively. Structural connectivity analyses reveal significant large white matter connections with the inferior frontal-occipital fasciculus, uncinate fasciculus, and pathways linking the OFC to the amygdala and temporal cortex. Functionally, 11L is involved in valuation and decision making, 13L contributes to emotion regulation, OFC/polar orbitofrontal cortex plays a key role in reward processing and self-referential cognition, and areas 47 m, 47 s, and a47r have a role in coordinating cognitive and emotional information, as well as language production and semantic processing. These subregions integrate sensory-affective information and support theory of mind and semantic processing. Disruptions in OFC connectivity contribute to neuropsychiatric and neurodegenerative disorders, inducing various symptoms of addiction, obesity, depression, Parkinson disease, and frontotemporal dementia, highlighting the relevance of our improved anatomical understanding of this region for targeted neuromodulation strategies. Importantly, this work leverages an anatomically precise nomenclature from the Human Connectome Project to refine our understanding of the OFC's connectivity, enabling more precise neuromodulatory targeting while improving the reproducibility and sharing of research findings of this region.
INTRODUCTION: Conventional EEG interpretation distinguishes spikes (20-70 ms) versus sharp waves (70-200 ms), but the rationale for this distinction is unclear. This preliminary study endeavors to correlate discharge dur...INTRODUCTION: Conventional EEG interpretation distinguishes spikes (20-70 ms) versus sharp waves (70-200 ms), but the rationale for this distinction is unclear. This preliminary study endeavors to correlate discharge duration with some clinical outcomes. METHODS: We measured spike and sharp wave duration for up to 10 discharges in 100 patients referred for routine, inpatient, or ambulatory EEGs. Excluded were generalized spikes, spike waves, polyspikes, seizures, or lateralized periodic discharges (LPDs). RESULTS: We measured 882 interictal discharges in 100 patients, comprising structural, genetic, autoimmune, and unknown etiologies. Epileptiform discharges, mainly temporal, were unilateral in 64 and bilateral or multifocal in 36 patients. Each record presented 3 to 10 discharges, with 74% having 10 or more. Mean discharge duration was 71.9 ± 31.4, range 15 to 200 ms. Most patients (87%) had mixed sharps and spikes, with 6% having only sharps and 7% having only spikes. Discharge durations within an individual patient were highly variable. Mean discharge duration and seizure frequency were poorly correlated ( r = -0.023, P = 0.82), as were discharge duration and number of antiseizure medications ( r = -0.027, P = 0.80). CONCLUSIONS: In our series, discharge duration did not correlate with seizure frequency or number of antiseizures medicines. Only 13% of patients had exclusive spikes or sharp waves, suggesting that duration of an individual discharge is not a defining characteristic of that person's epilepsy. Although this study is small and preliminary, it suggests that the distinction between spike and sharp waves at 70 ms may not be clinically relevant and perhaps all epileptiform discharges could be called spikes.
PURPOSE: This systematic review and meta-analysis aimed to evaluate the effectiveness of automatic detection systems for tonic seizures, focusing on different noninvasive modalities, algorithms, and performance metrics....PURPOSE: This systematic review and meta-analysis aimed to evaluate the effectiveness of automatic detection systems for tonic seizures, focusing on different noninvasive modalities, algorithms, and performance metrics. METHODS: Following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, a comprehensive search was conducted across PubMed, Scopus, and Wiley databases for studies published between 2014 and 2024. Inclusion criteria targeted studies assessing automatic detection systems for tonic seizures using various modalities. Performance metrics such as sensitivity, specificity, accuracy, and false alarm rates per hour (False-Positive Alarm Rate per hour) were analyzed and recalculated where necessary to ensure comparability. RESULTS: A total of 19 studies met the inclusion criteria. Multimodal systems integrating signals from accelerometry, gyroscopes, and other sensors demonstrated the highest sensitivities (up to 1.0) and accuracies (up to 0.97), significantly outperforming single-modality approaches. False alarm rates were lowest in controlled settings, particularly for ECG-based systems, but real-world applications highlighted variability and challenges with noise and signal acquisition. The findings underscore the potential of combining physiologic and neural signals with machine learning techniques to improve detection accuracy. CONCLUSIONS: Although recent advances in neurotechnology have enabled substantial progress in tonic seizure detection, significant challenges remain, including variability in performance metrics, generalizability to diverse populations, and scalability for real-world applications. Future research should focus on standardizing evaluation frameworks, diversifying training data sets, and validating systems in clinical and outpatient settings.
PURPOSE: To investigate daytime autonomic dysregulation in patients with obstructive sleep apnea (OSA). METHODS: This retrospective study was conducted at Brigham and Women's Faulkner Hospital Autonomic Laboratory and ev...PURPOSE: To investigate daytime autonomic dysregulation in patients with obstructive sleep apnea (OSA). METHODS: This retrospective study was conducted at Brigham and Women's Faulkner Hospital Autonomic Laboratory and evaluated adult patients with a history of orthostatic intolerance and sleep disturbances who completed autonomic testing (deep breathing test, Valsalva maneuver, tilt test) and polysomnography between 2018 and 2024. The Quantitative Scale for Grading of Cardiovascular Autonomic Reflex Tests scoring instrument graded autonomic tests and skin biopsies for the assessment of small fibers. The apnea-hypopnea index was used to assess OSA severity. RESULTS: In total, 138 patients were evaluated in this study. Subjects with OSA (43 with mild and 29 with moderate/severe OSA) were compared with 66 subjects without OSA. Age, body mass index, and the prevalence of hypertension increased with the severity of sleep apnea. At least moderate autonomic failure was identified in 60% of patients without OSA and in 78% of those with OSA. Autonomic failure score was proportional to the severity of OSA (autonomic failure scores: no OSA 4.2 ± 2.54, mild OSA 5.44 ± 3.41, moderate/severe OSA 8.1 ± 4.3, P < 0.001). Small fiber neuropathy was found in 41.8% of patients without OSA and in 70.8% of patients with moderate/severe OSA. CONCLUSIONS: Autonomic failure associated with small fiber autonomic neuropathy is common in patients with OSA, and the degree of autonomic failure is proportional to the severity of sleep apnea. Autonomic failure can be an additional risk factor contributing to the cardiovascular complications observed in OSA.
PURPOSE: The linked quadripolar montage for transcranial electric motor-evoked potentials (qTceMEP) consists of four stimulation electrodes: two linked anodes and two linked cathodes. This montage has grown in popularity...PURPOSE: The linked quadripolar montage for transcranial electric motor-evoked potentials (qTceMEP) consists of four stimulation electrodes: two linked anodes and two linked cathodes. This montage has grown in popularity because it can result in a larger compound muscle action potential amplitude compared with the conventional bipolar montage. Despite the increasing number of centers adopting qTceMEP, no studies have investigated patient safety to date. The aim of this study is to evaluate the safety profile of qTceMEP. METHODS: A total of 3,806 spine surgeries performed at a single institution using intraoperative transcranial electrical motor-evoked potentials (TceMEP) were reviewed. Among them, 1,196 were performed using bipolar TceMEP, while the remaining 2,610 cases were performed using qTceMEP. The incidence of intraoperative seizure, unexpected cardiac events, bite/oral injuries, and movement-related injuries was compared between the two groups, bipolar TceMEP and qTceMEP. The statistical analysis was performed using MedCalc. RESULTS: No seizure activity, cardiac anomalies, or adverse events related to intracranial and cardiac implant devices were reported in either group. The incidence of intraoperative oral injuries was 0.4% in the bipolar TceMEP group and 0.5% in the qTceMEP group. The difference in the incidence of oral injuries between the two groups was not statistically significant. CONCLUSIONS: The use of qTceMEP does not increase or decrease a patient's risk of intraoperative injury. Both bipolar TceMEP and qTceMEP are safe, presenting a small incidence of oral injuries and no other adverse side effects.
PURPOSE: To investigate the prevalence and functional significance of 14 and 6 Hz positive spikes (PS) in children with Self-limited Epilepsy with Centrotemporal spikes and explore their potential correlation with clinic...PURPOSE: To investigate the prevalence and functional significance of 14 and 6 Hz positive spikes (PS) in children with Self-limited Epilepsy with Centrotemporal spikes and explore their potential correlation with clinical features and neurophysiological mechanisms. METHODS: Our study included 52 pediatric Self-limited Epilepsy with Centrotemporal spikes patients and 52 age-matched controls who underwent ≥48-hour video-EEG monitoring in the epilepsy monitoring unit at Oishei Children's Hospital from 2016 to 2024. EEGs were reviewed by blinded epileptologists to identify the presence, localization, and lateralization of 14 and 6 Hz PS. RESULTS: Fourteen and 6 Hz PS were detected in 80.8% ( n = 42) of SeLECTs patients versus 0% of controls ( P < 0.001). No significant lateralization correlation was found between PS and centrotemporal spikes ( P = 0.651); only 28.6% of PS cases matched centrotemporal spikes lateralization. CONCLUSIONS: This study demonstrates a significantly higher prevalence of 14 and 6 Hz PS in children with Self-limited Epilepsy with Centro-temporal spikes. Their high prevalence and similar age-dependent expression and sleep-related activation suggest that PS may reflect developmental immaturity in thalamocortical networks, immature corticolimbic circuits, and heightened cortical excitability. These findings challenge the traditional view of PS as benign and support their potential role in thalamocortical dysregulation in self-limited childhood epilepsies.
Higashikawa H, Hashimoto J, Tanaka Y
… +14 more, Sasaki T, Onuma H, Egawa S, Matsukura Y, Hirai T, Hoshino Y, Watanabe T, Miyano Y, Kaminaka S, Yamamoto Y, Adachi Y, Akaza M, Kawabata S, Yoshii T
PURPOSE: Magnetospinography provides a noninvasive and detailed visualization of neural currents. We previously reported that magnetospinography can be used to evaluate neural function in the lower lumbar spine in respon...PURPOSE: Magnetospinography provides a noninvasive and detailed visualization of neural currents. We previously reported that magnetospinography can be used to evaluate neural function in the lower lumbar spine in response to tibial, peroneal, and sciatic nerve stimulation. However, evaluating the neural function of the upper and middle lumbar spine is often difficult due to lower current intensity. We aimed to visualize the neural activity of the upper and middle lumbar spine using new stimulation methods and assess the foraminal current. METHODS: Neural magnetic fields in 10 healthy volunteers were recorded after stimulation of the lateral femoral cutaneous nerve, saphenous nerve, femoral nerve, and peroneal nerve. The conduction velocity and current intensity in the spinal canal and intervertebral foramen were calculated and compared for each type of nerve stimulation. RESULTS: Magnetospinography visualized the evoked magnetic fields in the lumbar region after each nerve stimulation method in all volunteers. The current intensity in the upper lumbar spine was significantly greater after femoral nerve stimulation. Magnetospinography revealed that action current flowed mainly along the L2 nerve root after lateral femoral cutaneous nerve stimulation and the L4 nerve root after saphenous nerve stimulation. CONCLUSIONS: Using a new stimulation method, magnetospinography enabled the noninvasive visualization of neural currents in the upper and middle lumbar spine. Femoral nerve stimulation is suitable for evaluating the spinal canal of the upper lumbar spine, and lateral femoral cutaneous nerve and saphenous nerve stimulations are suitable for evaluating the upper and middle lumbar intervertebral foramina, respectively.
PURPOSE: The surgical resection of cerebral arteriovenous malformations (AVMs) presents a significant neurosurgical challenge, particularly because of the need to achieve complete obliteration of the nidus while preservi...PURPOSE: The surgical resection of cerebral arteriovenous malformations (AVMs) presents a significant neurosurgical challenge, particularly because of the need to achieve complete obliteration of the nidus while preserving neurologic function. AVMs located within or adjacent to eloquent regions such as the motor or language cortex carry a high risk of postoperative deficits. To mitigate these risks, a variety of intraoperative tools have been developed to enhance surgical safety and decision making. METHODS: Cortical and subcortical mapping is a dynamic technique that helps identify and preserve critical functional areas by applying targeted electrical stimulation to the cortex or subcortical white matter and observing motor or sensory responses. Additional neuromonitoring modalities include electrocorticography (ECoG), somatosensory evoked potentials, and motor evoked potentials, each contributing distinct insights into neural pathway integrity during resection. RESULTS: A systematic review was performed using 2 databases (PubMed/MEDLINE and Scopus), yielding 892 initial results. After applying inclusion and exclusion criteria, six studies were selected for final analysis. These studies collectively included 63 patients who underwent AVM resection with the aid of intraoperative neurophysiologic monitoring or mapping. CONCLUSIONS: Intraoperative neurophysiologic monitoring plays a critical role in the safe resection of high-grade or eloquently located AVMs. Although its routine use in low-grade lesions remains debatable, intraoperative neurophysiologic monitoring offers significant intraoperative value by helping surgeons recognize functional limits in real time. In select cases, it enables a strategic shift toward subtotal resection with planned adjuvant radiosurgery, reducing the risk of permanent neurologic deficits.
PURPOSE: This study aimed to develop and validate magnetoencephalography paradigms for presurgical language mapping in patients with drug-resistant epilepsy. METHODS: This prospective observational study of 30 patients w...PURPOSE: This study aimed to develop and validate magnetoencephalography paradigms for presurgical language mapping in patients with drug-resistant epilepsy. METHODS: This prospective observational study of 30 patients with drug-resistant epilepsy included two trials involving visual picture naming and auditory word recognition tasks. Language activation was analyzed using dynamic statistical parametric mapping for beta desynchronization and a fixed time window (350-500 ms). Concordance across trials, analysis methods, and functional MRI comparisons were also assessed. RESULTS: Primary visual and auditory cortex activation occurred in 66.6 and 80% of the patients, respectively. Language-specific area activation was observed in 56.7% of the picture naming task patients and 70% of the auditory word recognition task patients. Lateralization was predominantly left sided in 41.1% (picture naming) and 61.9% (auditory word recognition) of cases, with some bihemispheric patterns. Beta desynchronization and fixed-time window analyses had comparable detection rates but with limited concordance. Magnetoencephalography-functional MRI lateralization agreement was 56.25% (Cohen kappa = 0.15). No significant correlations were found between the epilepsy parameters and language activation. CONCLUSIONS: Magnetoencephalography provides valuable insights into language localization and functional reorganization in patients with epilepsy. Although task-specific activations highlight their utility, further studies with larger cohorts and gold-standard validations are needed to enhance their clinical applicability in presurgical planning.
Nauman A, Vattoth AL, Melikyan G
… +9 more, Ali M, Othman Y, Mesraoua B, Al Hail H, Dargham SR, Khan F, Alrabi A, Mahfoud Z, Haddad N
J Clin Neurophysiol
· 2026 Apr · PMID 41042970
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PURPOSE: In patients with epilepsy who achieve seizure freedom, physicians may consider discontinuing antiseizure medications, often using EEG beforehand to guide the decision. This study evaluates the gain in detection...PURPOSE: In patients with epilepsy who achieve seizure freedom, physicians may consider discontinuing antiseizure medications, often using EEG beforehand to guide the decision. This study evaluates the gain in detection of epileptiform discharges (EDs) in 24-hour video EEG (VEEG) monitoring in seizure-free patients. METHODS: The authors identified patients with epilepsy who were seizure free on antiseizure medications and had undergone 24-hour VEEG after an unrevealing routine EEG. The authors evaluated the yield and latency of observed EDs in the VEEG study. The authors compared the rate of ED detection during the first 60 minutes versus later in the recording. RESULTS: Of the 27 patients, aged 19 to 51 years, 10 (37%) exhibited EDs on 24-hour VEEG. The latency to the first EDs ranged from 52 to 748 minutes, with a median of 164 minutes. Nine of these 10 patients (90%) had their EDs appear only after the first 60 minutes of recording. In other words, prolonging the EEG beyond 1 hour yielded an additional 33.3% of patients with EDs that a 1-hour recording would have missed. Younger age and presence of EDs on a past EEG were predictive of the presence of EDs on VEEG ( P = 0.040 and P = 0.039 respectively). CONCLUSIONS: The results suggest that 24-hour VEEG is more sensitive in detecting EDs than routine EEG in seizure-free patients and thus may be superior in individualized risk assessments for seizure recurrence on potential antiseizure medication discontinuation.
J Clin Neurophysiol
· 2026 Apr · PMID 41042968
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PURPOSE: To investigate the different regions covered by nasopharyngeal (NPEs) and anterior temporal (anterior temporal electrodes [ATEs]) electrodes in assessing temporal lobe epilepsy, to overcome the limitations of th...PURPOSE: To investigate the different regions covered by nasopharyngeal (NPEs) and anterior temporal (anterior temporal electrodes [ATEs]) electrodes in assessing temporal lobe epilepsy, to overcome the limitations of the 10 to 20 electroencephalography (EEG) in diagnosing the basal and mesial temporal regions. METHODS: EEG data from 229 patients diagnosed with temporal lobe epilepsy were simultaneously analyzed with attached NPEs and ATEs. In case of discrepancies in EEG interpretation, a consensus interpretation was reached among three epilepsy experts. Spike detection was conducted using the Curry9 program for secondary analysis of electric source localization, with source location performed using standard brain MRI data. RESULTS: In total, 2,721 interictal epileptiform discharges (IEDs) from 175 patients were analyzed. Of these, 734 IEDs from 48 patients were detected exclusively with NPEs, while 1,987 IEDs from 127 patients were detected simultaneously by both NPEs and the standard international 10 to 20 electrodes system supplemented with ATEs, respectively. The former IEDs exhibited clustering dipoles in the basal and mesial temporal regions, while the latter were localized solely to the frontotemporal and lateral temporal regions. CONCLUSIONS: Nasopharyngeals can identify IEDs in the mesial and basal temporal region that cannot be detected by ATEs. Nasopharyngeals offer additional diagnostic value in regions not confirmed by the existing 10 to 20 EEG electrode system, including those covered by ATE.
PURPOSE: To report clinical and electrodiagnostic (EDX) findings in ulnar neuropathy at the wrist (UNW). METHODS: This is a monocentric study. We collected demographic and clinical data, history, symptom type, neurologic...PURPOSE: To report clinical and electrodiagnostic (EDX) findings in ulnar neuropathy at the wrist (UNW). METHODS: This is a monocentric study. We collected demographic and clinical data, history, symptom type, neurologic examination findings, EDX results, as well as causes and risk factors of UNW. RESULTS: We enrolled 150 consecutive cases. Based on EDX findings, the most common UNW pattern involved the ulnar nerve at the entrance of Guyon canal, prior to its bifurcation into sensory and motor branches (44% of cases). We identified atypical topographic lesions involving the superficial sensory branch and motor fibers innervating the hypothenar (4.7% of cases) or the interossei muscles (12.8% of cases). The most frequent causes were compressive (20.7%) and traumatic (22%), mainly affecting males, blue-collar workers, and individuals aged ≤60 years. Ganglion was prevalent in females (66.7%). Cases of UNW with unknown etiology were significantly associated with age >60 years, the presence of muscle atrophy, and a history of carpal tunnel syndrome (CTS). CONCLUSIONS: Clinical and EDX characteristics of UNW depend on injury site at wrist or hand palm. It is not possible to determine the cause with certainty based solely on the type, although some causes tend to affect specific sites of nerve injury. The coexistence of Guyon canal syndrome and CTS is confirmed to be a fairly frequent finding. The awareness of the ulnar nerve anatomical variations should not lead to the exclusion of UNW if EDX abnormalities do not fall into any of the five classical types according to Wu's classification.
J Clin Neurophysiol
· 2026 Apr · PMID 40965979
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PURPOSE: The existing literature on the sacral dermatomal evoked potentials (dSEPs) is limited. This study aims to develop stimulating parameters and establish normative values for S2, S3, and S4 sacral dermatomes in hea...PURPOSE: The existing literature on the sacral dermatomal evoked potentials (dSEPs) is limited. This study aims to develop stimulating parameters and establish normative values for S2, S3, and S4 sacral dermatomes in healthy adult populations. METHODS: Twenty healthy adult volunteers were enrolled in the study. The study was ethically approved, and written consent for participation was provided. All participants underwent tibial, pudendal, S2, S3, and S4 dSEPs. Stimulating and recorded parameters were established for all evoked potentials. P40 latency, amplitude, and interpeak parameters were calculated for each waveform. A comparison was made between tibial, pudendal somatosensory evoked potentials, and all sacral dSEPs. Normative values were generated for sacral dSEPs based on various height, age, and Body Mass Index (BMI) parameters. RESULTS: The sacral dSEPs were well tolerated and recorded in all participants. S2 latency was mildly influenced by age and height, while S3 and S4 latencies were unaffected by age or height. BMI does not affect the S2 and S3 latencies but mildly affects the S4 latency. Sacral dSEP latencies were comparable with pudendal SEPS but not with the tibial somatosensory evoked potential. CONCLUSIONS: The S2, S3, and S4 sacral dSEPs can be used as diagnostic tools to evaluate sacral nerve lesions such as cauda equina syndrome and Tarlov cysts, complementary to pudendal and tibial somatosensory evoked potentials.
Epilepsy is not solely a disorder of abnormal brain structure; it is fundamentally a disorder of disrupted brain networks and impaired communication across brain regions. Thalamic neuromodulation, once conceptualized as...Epilepsy is not solely a disorder of abnormal brain structure; it is fundamentally a disorder of disrupted brain networks and impaired communication across brain regions. Thalamic neuromodulation, once conceptualized as a fixed, anatomically guided intervention, is now undergoing a paradigm shift toward dynamic, network-informed modulation. Using tools such as stereo-EEG, diffusion MRI, and advanced connectomic analyses, we are entering a new era where neurostimulation strategies can be individualized, responsive, and aligned with the real-time neurophysiology and structural networks of each patient. By integrating anatomic and functional connectivity data, we are moving toward precision neuromodulation tailored to patient-specific seizure networks. In this review, we highlight the emerging role of functional and structural connectivity in refining our understanding of seizure dynamics and guiding neuromodulation interventions.
Responsive neurostimulation and deep brain stimulation have emerged as effective intracranial neuromodulation therapies for drug-resistant epilepsy when surgical resection is not an option. However, programming these dev...Responsive neurostimulation and deep brain stimulation have emerged as effective intracranial neuromodulation therapies for drug-resistant epilepsy when surgical resection is not an option. However, programming these devices presents unique challenges in epilepsy. Without immediate feedback and a vast programming space, clinicians are often tasked with fine-tuning device settings without clear, mechanistic guidance and limited clinical time. Recent efforts toward individualized programming have shown promise, including the use of nonstandard parameter sets, target-specific stimulation strategies, and patient-tailored adaptations while avoiding unintended interference with critical functions such as emotional regulation. Emerging research in programming is shifting beyond the one-size-fits-all protocols, incorporating closed-loop biomarkers, integrating multimodal data and predictive modeling that hold promise for improving seizure control and reducing adverse effects. This review synthesizes current evidence on standard and individualized programming approaches for deep brain stimulation and responsive neurostimulation in epilepsy, highlighting practical strategies, clinical outcomes, and insights from recent studies. Although emerging tools such as biomarker-guided programming and predictive modeling are gaining interest, the focus of this review is on existing clinical literature shaping programming today.
Open label use of therapies with adult indications raises unique challenges in pediatric DRE. The following review details the landscape of pediatric intracranial neuromodulation. Initially, I discuss available evidence...Open label use of therapies with adult indications raises unique challenges in pediatric DRE. The following review details the landscape of pediatric intracranial neuromodulation. Initially, I discuss available evidence in pediatric neuromodulation while detailing the only randomized clinical trial in a pediatric developmental and epileptic encephalopathy. The reader is then directed to the use of intracranial neuromodulation in special circumstances and the rising trend in StereoEEG implantation of thalamic nuclei during presurgical monitoring in an attempt to further personalize individual therapy while circling back to challenges in getting insurance approval for off-label use in pediatric DRE.