Neurostimulation in children with drug-resistant epilepsy: strategies in subcortical targeting and systematic review of the evidence

Derek D George; Melissa A LoPresti; Maryam N Shahin; Elysa Widjaja; Andrew Wensel; Neena I Marupudi; Jeffrey S Raskin

doi:10.1007/s00381-025-07027-5

Neurostimulation in children with drug-resistant epilepsy: strategies in subcortical targeting and systematic review of the evidence

Childs Nerv Syst. 2025 Dec 9;41(1):411. doi: 10.1007/s00381-025-07027-5.

Authors

Derek D George¹, Melissa A LoPresti², Maryam N Shahin³, Elysa Widjaja⁴, Andrew Wensel¹, Neena I Marupudi⁵, Jeffrey S Raskin⁶

Affiliations

¹ Division of Pediatric Neurosurgery, Departments of Neurosurgery & Public Health Sciences, University of Rochester Medical Center, 601 Elmwood Ave, Box 670, Rochester, NY, 14642, USA.
² Division of Pediatric Neurosurgery, Departments of Neurosurgery & Public Health Sciences, University of Rochester Medical Center, 601 Elmwood Ave, Box 670, Rochester, NY, 14642, USA. Melissa_LoPresti@URMC.Rochester.edu.
³ Department of Neurosurgery, Oregon Health & Sciences University, Portland, OR, USA.
⁴ Division of Pediatric Neuroradiology, Department of Radiology, Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
⁵ Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Michigan, University of Michigan School of Medicine, Ann Arbor, MI, USA.
⁶ Division of Pediatric Neurosurgery, Department of Neurosurgery, Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

PMID: 41364200
DOI: 10.1007/s00381-025-07027-5

Abstract

Objective: The aim of this study is to delineate technical considerations for subcortical electrode targeting in children with DRE and to present a target selection decision-support tool for pediatric neurosurgeons for DBS and RNS.

Methods: A systematic review of studies through age ≤ 19 years reporting DBS or RNS implantation for DRE was performed. Articles were screened for details on trajectory planning, imaging parameters, intraoperative workflows, and direct versus indirect targeting strategies. Primary outcomes were seizure-frequency reduction and responder rate; secondary outcomes included perioperative adverse events and identification of pediatric-specific factors influencing surgical planning.

Results: Seventeen studies (10 DBS, 7 RNS; total n = 333 children) met inclusion criteria. Median age was 16.0 ± 6.35 years; median epilepsy duration was 12.15 ± 7.98 years; 41.4% carried a diagnosis of Lennox-Gastaut syndrome. Frame-based stereotaxy predominated (12/17 studies; 168/238 procedures, 70.6%), with robotic assistance in 20.6% (3/17; 49/238). Thirteen studies specified targeting method-nine direct, four indirect. Targets were the anterior nucleus of the thalamus (ANT; n = 25, 10.4%), centromedian nucleus (CMN; n = 200, 83.3%), pulvinar nucleus (PVN; n = 1, 0.4%), and hippocampus (HC; n = 14, 5.8%). Pooled weighted median seizure reduction was 54.7 ± 9.1% over a median follow-up of 20.4 ± 17.6 months; pooled weighted median responder rate was 63.0 ± 17.3% over the same interval. Subgroup analyses showed target-dependent outcome variability. DBS versus RNS subgroup comparison showed no difference in seizure reduction but did show a difference in responder rates. Complication rate was 13.3%.

Conclusion: Stereotactic subcortical targeting in pediatric DRE achieves meaningful seizure reduction and responder rates, with acceptable safety. Direct and indirect targeting strategies must account for unique pediatric considerations. A practical tool for trajectory planning, imaging selection, and targeting methodology for DBS and RNS in children is provided.

Keywords: Deep brain stimulation; Drug-resistant epilepsy; Neuromodulation; Pediatric neurosurgery; Responsive neurostimulation; Targeting.

Publication types

Systematic Review

MeSH terms

Adolescent
Child
Deep Brain Stimulation* / methods
Drug Resistant Epilepsy* / therapy
Humans