Brain stimulation in the management of neurological deficits in pediatric patients with epilepsy

Abstract

Background: Epilepsy is a frequent neurological disorder in childhood, with a significant impact on patients’ development and functionality. Some cases evolve into drug-resistant epilepsy (DRE), defined as persistent seizures regardless of proper treatment, and are associated with increased morbidity and a decreased life quality. In this context, continued diagnostic reevaluation is crucial to identify structural or genetic etiologies and to guide the best therapeutic approach. Given the limitations of pharmacological treatment, intracranial neurostimulation is emerging as a promising therapeutic alternative, especially in patients who are not eligible for resective surgery. Objective: Evaluate the efficacy and safety of brain stimulation techniques in the management of neurological deficits in pediatric patients with epilepsy. Methods: Systematic review guided by the PRISMA checklist, based on database searches in PubMed and ScienceDirect using the keywords “Childhood Epilepsy” AND “Neurological.” An initial 2,217 articles were identified; after applying criteria (publications from the last five years, in Portuguese and English, full-text articles, and open access), 437 papers remained. Following the screening of titles, abstracts, and full-text articles, 5 studies were included for analysis. Results: Surgical resection is the gold standard for the treatment of refractory epilepsy; nevertheless, there are limitations regarding its feasibility and viability in certain patients. Therefore, other therapeutic alternatives are being investigated, such as vagus nerve stimulation (VNS), which is emerging as an alternative treatment for drug-resistant epilepsy, with a significant decrease in seizures, improved cognitive, emotional, and sleep function, as well as a decline in the incidence of long-term side effects. In children, a reduction of more than 70% in seizures was reported in patients treated during long-term follow-up, with response rates ranging from 50% to 70%. Some studies indicate that deep brain stimulation (DBS) and bilateral responsive neurostimulation (BRN), specifically in the centromedian thalamic nucleus, have also proven to be beneficial, with a reduction of approximately 55% in disabling seizures and over-all functional improvement, with a high safety margin. Nevertheless, there are reports of potential adverse effects, including an increased incidence of “bowstring” based on the technique used; a higher incidence of explantation in some groups; and its currently limited and often off-label applications in pediatrics. Conclusion: Brain stimulation represents a very promising alternative in the management of refractory pediatric epilepsy, with a significant positive impact on seizure reduction and quality of life. Even so, its use remains limited and is based on insufficient evidence. More robust and long-term studies are needed to confirm its effectiveness, safety, and clinical applicability in this population.