Introduction: Although deep brain stimulation of the anterior nucleus of the thalamus (ANT-DBS) represents an established third-line therapy for patients with drug-resistant focal epilepsy, guiding reports on practical treatment principles remain scarce. Methods: An Expert Panel (EP) of 10 European neurologists and 4 neurosurgeons was assembled to share their experience with ANT-DBS therapy. The process included a review of the current literature, which served as a basis for an online survey completed by the EP prior to and following a face-to-face meeting (Delphi method). An agreement level of ≥71 % was considered as consensus. Results: Out of 86 reviewed studies, 46 (53 %) were selected to extract information on the most reported criteria for patient selection, management, and outcome. The Delphi process yielded EP consensus on 4 parameters for selection of good candidates and patient management as well as 7 reasons of concern for this therapy. Since it was not possible to give strict device programming advice due to low levels of evidence, the experts shared their clinical practice: all of them start with monopolar stimulation, 79 % using the cycling mode. Most (93 %) EP members set the initial stimulation frequency and pulse width according to the SANTE parameters, while there is more variability in the amplitudes used. Further agreement was achieved on a list of 7 patient outcome parameters to be monitored during the follow-up.

Background and purpose We evaluated two methods to identify mesial temporal sclerosis (MTS): visual inspection by experienced epilepsy neuroradiologists based on structural magnetic resonance imaging sequences and automated hippocampal volumetry provided by a processing pipeline based on the FMRIB Software Library. Methods This retrospective study included patients from the epilepsy monitoring unit database of our institution. All patients underwent brain magnetic resonance imaging in 1.5T and 3T scanners with protocols that included thin coronal T2, T1 and fluid-attenuated inversion recovery and isometric T1 acquisitions. Two neuroradiologists with experience in epilepsy and blinded to clinical data evaluated magnetic resonance images for the diagnosis of MTS. The diagnosis of MTS based on an automated method included the calculation of a volumetric asymmetry index between the two hippocampi of each patient and a threshold value to define the presence of MTS obtained through statistical tests (receiver operating characteristics curve). Hippocampi were segmented for volumetric quantification using the FIRST tool and fslstats from the FMRIB Software Library. Results The final cohort included 19 patients with unilateral MTS (14 left side): 14 women and a mean age of 43.4 ± 10.4 years. Neuroradiologists had a sensitivity of 100% and specificity of 73.3% to detect MTS (gold standard, k = 0.755). Automated hippocampal volumetry had a sensitivity of 84.2% and specificity of 86.7% (k = 0.704). Combined, these methods had a sensitivity of 84.2% and a specificity of 100% (k = 0.825). Conclusions Automated volumetry of the hippocampus could play an important role in temporal lobe epilepsy evaluation, namely on confirmation of unilateral MTS diagnosis in patients with radiological suggestive findings.

The clinical symptoms associated with chromosome 15q duplication syndrome manifest through a heterogeneous group of symptoms characterised by hypotonia, delay in motor skills and language development, cognitive and learning disabilities, autism spectrum disorder and refractory epilepsy. The late development of Lennox-Gastaut syndrome in patients with 15q11q13 duplication is a possibility that physicians should be aware of. We report the case of a 27-year-old man with a neurodevelopmental syndrome due to a 15q duplication, with intellectual disability, psychiatric disturbances, and an epileptic phenotype diagnosed as late-onset Lennox-Gastaut syndrome.

Backgroundand ObjectivesThe efficacy of deep brain stimulation of the anterior nucleus of the thalamus (ANT DBS) in drug resistant epilepsy (DRE) patients was demonstrated in the double-blind Stimulation of theAnterior Nucleus of the Thalamus for Epilepsy (SANTE) randomized controlled trial. The Medtronic Registry for Epilepsy (MORE) aims to understand the safety and longer-term effectiveness of ANT DBS therapy in routine clinical practice.MethodsMORE is an observational registry collecting prospective and retrospective clinical data. Participants were at least 18 years old, with focal DRE recruited across 25 centers from 13 countries. They were followed for at least 2 years in terms of seizure frequency (SF),responder rate (RR), health-related quality of life (Quality of Life in Epilepsy Inventory 31, QOLIE-31), depression, and safety outcomes.ResultsOf the 191 patients recruited 170 (mean (SD) age of 35.6 (10.7) years, 43% female) were implanted with DBS Therapy and met all eligibility criteria. At baseline, 38% of patients reported cognitive impairment. The median monthly SF decreased by 33.1% from 15.8 at baseline to 8.8 at 2 years (P<0.0001) with 32.3% RR. In the subgroup of 47 patients that completed 5 years of follow-up, the median monthly SF decreased by 55.1% from 16 at baseline to 7.9 at 5 years (P<0.0001) with 53.2% RR. Factors influencing SF reduction included number of implants per center. In patients with cognitive impairment, the reduction in median monthly seizure frequency was 26.0% by two years compared with 36.1% in patients without cognitive impairment. The most frequently reported adverse events were changes (e.g. increased frequency/severity) in seizure (16%), memory impairment (patient reported complaint, 15%), depressive mood (patient reported complaint, 13%) and epilepsy (12%). One definite Sudden Death in Epilepsy (SUDEP) case was reported.DiscussionThe MORE registry supports the effectiveness and safety of ANT-DBS therapy in a real-world setting in the 2-years following implantation.

Deep brain stimulation of the Anterior Nucleus of the Thalamus (ANT-DBS) is an effective therapy in epilepsy. Poorer surgical outcomes are related to deviations of the lead from the ANT-target. The target identification relies on the visualization of anatomical structures by medical imaging, which presents some disadvantages. This study aims to research whether ANT-LFPs recorded with the PerceptTM PC neurostimulator can be an asset in the identification of the DBS-target. For this purpose, 17 features were extracted from LFPs recorded from a single patient, who stayed at an Epilepsy Monitoring Unit for a 5-day period. Features were then integrated into two machine learning (ML)-based methodologies, according to different LFP bipolar montages: Pass1 (nonadjacent channels) and Pass2 (adjacent channels). We obtained an accuracy of 76.6% for the Pass1-classifier and 83.33% for the Pass2-classifier in distinguishing locations completely inserted in the target and completely outside. Then, both classifiers were used to predict the target percentage of all combinations, and we found that contacts 3 (left hemisphere) and 2 and 3 (right hemisphere) presented higher signatures of the ANT-target, which agreed with the medical images. This result opens a new window of opportunity for the use of LFPs in the guidance of DBS target identification.