Real-time EEG-guided Thalamic Deep Brain Stimulation Achieves Sustained Seizure Freedom in Catastrophic Epilepsy
Objective:
To demonstrate the effectiveness of electroencephalography (EEG)-guided programming of thalamic deep brain stimulation (DBS) in achieving sustained seizure remission in catastrophic epilepsy.
Background:
Thalamic neuromodulation is an established therapy for medication-resistant epilepsy, but DBS programming is typically empirical and lacks objective biomarkers. Real-time EEG feedback offers precision-based strategy for optimizing stimulation.
Design/Methods:
18-year-old female with mosaic tetrasomy 5p syndrome and drug-resistant epilepsy characterized by mixed seizure types consistent with Jeavons syndrome and Lennox-Gastaut syndrome had previously failed multiple antiseizure medications, ketogenic diet, vagus nerve stimulation (VNS), cannabidiol (CBD), and IVIG. She underwent bilateral anterior (ANT) and centromedian (CM) thalamic deep brain stimulation (DBS) at outside institution, but despite multiple empiric programming attempts, she continued to experience over 100 daily seizures, including frequent drop attacks. Upon transfer to our care, given the prior lack of response to conventional strategies, further outpatient adjustments were deferred and she was admitted for inpatient continuous EEG-guided DBS parameter optimization. Six stimulation paradigms including low-, intermediate-, and high-frequency settings across ANT-only, CM-only, and dual-target configurations were tested sequentially for approximately 12 hours each. EEG responses were assessed visually and with quantitative spike detection analytics to guide final setting selection.
Results:
High-frequency cycling stimulation of ANT alone resulted in the most favorable electrographic response, with reduced duration and greater fragmentation of epileptiform discharges. Clinically, this setting produced complete seizure freedom, improved alertness, and no longer required protective headgear. Remission has now been sustained for over 16 months. Follow-up EEG demonstrated near-complete suppression of epileptiform activity.
Conclusions:
This case uniquely illustrates complete seizure remission following EEG-guided DBS adjustments. This is the first reported case in which EEG-guided thalamic stimulation strategy was developed and successfully implemented. Real-time EEG-guided DBS programming can enable individualized neuromodulation in highly refractory epilepsy. EEG-based biomarkers may replace trial-and-error programming and should be incorporated into future DBS optimization protocols.
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