Comprehensive Summary
The paper looks at the use of neuromodulation therapies for epileptic patients who have a poorly localized seizure focus. The research reviewed multiple clinically relevant evidence for multiple modalities, including vagus nerve stimulation (VNS), deep brain stimulation (DBS), and response neurostimulation (RNS). They found that VNS was the earliest approved therapy in Japan and applicable across multiple types of epilepsy without the need for a craniotomy; however, they had limited efficacy. For DBS, the anterior nucleus of the thalamus showed benefit, and it is known to be involved in seizures associated with limbic structures. Another DBS target for generalized seizures is the centromedian nucleus of the thalamus, but it lacks insurance coverage. RNS could also be beneficial to patients; however, it lacks approval in Japan, while it delivers stimulation in response to the EEG activity that it detects.
Outcomes and Implications
This research is important because it helps structure the options for patients who are unable to have curative surgery for their epilepsy, which is often persistent. The paper clarifies which treatments to choose for each seizure type, depending on target selection, the evidence base, and anatomical constraints. The researchers show the best clinically acceptable option in Japan, along with other options depending on the circumstances. These strategies are a clinically relevant alternative that could help once the technology improves and has more long-term outcome data.