Molly Ayala
Electrical brain stimulation has been explored as a treatment for epilepsy since the 1950s, with varying stimulation sites, parameters, and results. While the mechanism of action of electrical stimulation on the nervous system is not yet fully understood, it has been shown to increase the seizure threshold in rats. This has been achieved through acute deep brain stimulation (DBS) in various thalamic nuclei and medial temporal lobe structures, as well as vagus nerve stimulation (VNS) and responsive neurostimulation at seizure foci. The kindling model, which involves daily electrical stimulation, is one of the more extensively used models of chronic temporal lobe epilepsy. Transcranial electric stimulation therapy (TEST), previously known as nonconvulsive electrotherapy, is another form of electrical stimulation used to treat seizures associated with depression.
| Characteristics | Values |
|---|---|
| Electrical stimulation treatment for | Epilepsy |
| Types of electrical stimulation treatment | Deep brain stimulation (DBS), Vagus nerve stimulation (VNS), Transcranial electric stimulation therapy (TEST), Electroconvulsive therapy (ECT) |
| DBS treatment sites | Thalamic nuclei, Medial temporal lobe structures, Amygdalohippocampal |
| DBS treatment outcomes | Decrease of seizure counts, Decrease of interictal EEG abnormalities |
| VNS treatment outcomes | Response rates between 40% and 50%, Long-term seizure freedom in 5% to 10% of patients, Low surgical complications and perioperative morbidity |
| TEST treatment procedure | Performed under general anesthesia, Uses FDA-cleared ECT device, Delivers subseizure threshold stimulation doses |
| ECT treatment outcomes | Faster and better than conventional pharmacological interventions, Side effects include memory loss |
| ECT modifications | Changes in where in the brain electricity is administered, Changes in how much electricity is administered |
| ECT technical parameters | Temporal waveform, Electrode placement, Pulse shape, Pulse width, Train frequency, Train duration, Train directionality |
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What You'll Learn
Vagus nerve stimulation
VNS therapy is approved by the U.S. Food and Drug Administration (FDA) as an add-on treatment for adults and children aged four and above. It is designed to treat focal or partial seizures that do not respond to seizure medications, also known as drug-resistant or refractory epilepsy. VNS is an alternative treatment for patients who are not suitable candidates for conventional epilepsy surgery or who have had such surgery without optimal outcomes.
During VNS therapy, a device is implanted under the skin in the left chest area. An electrode or wire is attached to the device and placed under the skin, attaching to or coiling around the vagus nerve in the neck. The device is programmed to deliver pulses or stimulation at regular intervals. If a person is aware of when a seizure happens, they can swipe a magnet over the generator in the left chest area to send an extra burst of stimulation to the brain, which may help stop seizures.
Research has shown that VNS may help control seizures, but the exact mechanism of action is unknown. Long-term VNS studies show response rates between 40% and 50% and long-term seizure freedom in 5% to 10% of patients. VNS therapy can cause side effects such as discomfort in the throat, a cough, difficulty swallowing, and a hoarse voice, but these usually reduce over time. Some people feel that VNS therapy improves their mood, memory, alertness, and overall wellbeing.
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Deep brain stimulation
Electrical neuromodulation has been explored as a treatment for epilepsy since the 1950s. However, the mechanism of action of electrical stimulation on the nervous system remains poorly understood. Deep brain stimulation (DBS) is a type of neurostimulation that enables adjustable and reversible modulation of disease symptoms, including those of epilepsy. DBS has been approved by the US Food and Drug Administration as an add-on treatment for focal epilepsy.
DBS is primarily used to treat movement disorders, such as tremor and Parkinson's disease. It has been shown to exhibit efficacy in seizure suppression, particularly in patients with generalized seizures. In a systematic review by Yassin et al., it was found that DBS was significantly more effective in patients with generalized seizures (93.2% response) compared to those with focal seizures (63.9%). Acute DBS in various thalamic nuclei and medial temporal lobe structures has been shown to be efficacious in small pilot studies. Amygdalohippocampal DBS, for example, has yielded a significant decrease in seizure counts during long-term follow-up.
DBS is a feasible treatment option for patients with drug-resistant epilepsy (DRE) who are not candidates for resective surgery. In a study conducted in Iran, eight patients with DRE who underwent anterior nucleus of the thalamus DBS (ANT-DBS) were evaluated. The results showed clinical improvement in seizure severity at 3 and 6 months of follow-up, indicating that ANT-DBS may help to reduce seizure severity. Another study found that 30 minutes of unilateral ANT DBS enhanced the seizure threshold by increasing the amount of REM sleep and decreasing the progressive enhancement of delta power during non-REM sleep, thereby suppressing spontaneous seizure recurrences.
Vagus nerve stimulation (VNS) is another form of neurostimulation that has been considered for treating refractory epilepsy. It is an alternative treatment for patients with medically refractory epilepsy who are unsuitable candidates for conventional epilepsy surgery or who have not had optimal outcomes. Long-term VNS studies show response rates between 40% and 50% and long-term seizure freedom in 5% to 10% of patients.
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Responsive neurostimulation
With RNS, surgeons implant a small battery-powered device called a neurostimulator in the patient's skull. The neurostimulator is connected to thin wires, called leads, which the surgeon places in the area or areas of the brain where the patient's seizures originate. The neurostimulator monitors the brain's electrical activity, and when activity that could lead to a seizure is detected, it delivers a pulse of electrical stimulation through the leads. The electrical pulse may stop the seizure before it begins.
The neurostimulator's battery generally lasts about two and a half to four years. When the battery is low, the neurostimulator needs to be surgically replaced. The device is usually implanted on the side and towards the back of the head. The device is initially programmed only to record brain activity, without delivering electrical stimulation. It is then programmed to deliver responsive stimulation in a follow-up visit to the centre.
RNS is a "closed-loop" system that continuously monitors the brain's electrical activity and sends a brief pulse of electrical stimulation directly to the brain when a seizure or seizure-like activity is detected. Doctors trained in RNS programme the neurostimulator and gradually train it to detect specific patterns unique to a patient's seizure. In clinical trials, more than half of the patients treated with RNS had 50% or fewer seizures compared to their pre-surgical baseline.
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Electrical brain stimulation
One type of electrical brain stimulation used to treat epilepsy is deep brain stimulation (DBS). DBS involves stimulating various thalamic nuclei and medial temporal lobe structures. Amygdalohippocampal DBS, in particular, has been found to significantly decrease seizure counts and interictal EEG abnormalities during long-term follow-up. Data from pilot studies suggest that chronic DBS for epilepsy is a promising, safe, and effective procedure.
Another type of electrical brain stimulation is vagus nerve stimulation (VNS). VNS is an alternative treatment for patients with medically refractory epilepsy who are not suitable candidates for conventional epilepsy surgery or have not had optimal outcomes with surgery. Long-term VNS studies show response rates between 40% and 50%, with 5-10% of patients achieving long-term seizure freedom. Research has revealed that the thalamus and cortical areas play a crucial role in the mechanism of action of VNS.
In addition to DBS and VNS, other forms of electrical brain stimulation have been investigated for the treatment of epilepsy. These include anterior thalamic deep brain stimulation and responsive neurostimulation at seizure foci, which have shown effectiveness in Class I evidence. Small trials have also targeted other sites in the brain for neurostimulation therapy, such as the hippocampus, mammillary nuclei, and kindling model.
While electrical brain stimulation has shown potential in the treatment of epilepsy, further research is needed to fully understand the mechanism of action and optimize the stimulation parameters for maximum efficacy.
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Transcranial electric stimulation therapy
TEST delivers pulses at a high current amplitude, inducing a brain E-field distribution. However, the frequency and duration of the stimulus are very low compared to electroconvulsive therapy (ECT), preventing the stimulus from inducing a generalised seizure. By eliminating the seizure, TEST aims to limit adverse cognitive effects, such as memory loss, that are associated with ECT.
TEST is not the only form of electrical brain stimulation used to treat epilepsy. Acute deep brain stimulation (DBS) in various thalamic nuclei and medial temporal lobe structures has been shown to be effective in small pilot studies. Amygdalohippocampal DBS, in particular, has yielded a significant decrease in seizure counts and interictal EEG abnormalities during long-term follow-up.
Vagus nerve stimulation (VNS) is another alternative treatment for patients with medically refractory epilepsy who are unsuitable candidates for conventional epilepsy surgery or have had unsuccessful outcomes. Research has revealed a crucial role for the thalamus and cortical areas in the epileptogenic process.
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Frequently asked questions
Electrical stimulation is a treatment for epilepsy that involves the use of electricity to stimulate the brain. This can be done through techniques such as deep brain stimulation (DBS) and vagus nerve stimulation (VNS).
The exact mechanism of action of electrical stimulation on the nervous system is not yet fully understood. However, it is believed that electrical stimulation can modulate disease symptoms, including those of epilepsy, by targeting specific areas of the brain.
Electrical stimulation has been found to be effective in reducing seizure counts and interictal EEG abnormalities during long-term follow-up. It is also a reversible and adjustable treatment option, making it a promising alternative for patients who are not suitable candidates for conventional epilepsy surgery or have experienced adverse effects.
While electrical stimulation has been found to be safe in small pilot studies, further research is needed to fully understand the risks and side effects. One potential adverse effect that has been associated with electroconvulsive therapy (ECT), a type of electrical stimulation, is memory loss.
In addition to DBS and VNS, other electrical stimulation techniques for treating epilepsy include anterior thalamic deep brain stimulation and responsive neurostimulation at seizure foci. These techniques have shown effectiveness in treating epilepsy, as supported by Class I evidence.
