Pulvinar and anterior nucleus of the thalamus dual-network neuromodulation for complex epilepsies.
TL;DR
Combined four-lead ANT/PUL DBS appears safe and effective for patients with drug-resistant posterior quadrant and temporal lobe epilepsies and dual-network neuromodulation may provide greater flexibility to individually optimize neuromodulation for complex seizure networks.
Abstract
Objective
Anterior nucleus of the thalamus (ANT) deep brain stimulation (DBS) is an effective therapy for frontotemporal and limbic drug-resistant focal epilepsies. The pulvinar nucleus (PUL) is an emerging neuromodulation target for seizure networks involving the posterior quadrant and temporal lobe. This study evaluates the safety and effectiveness of combined bilateral ANT plus PUL DBS for posterior quadrant and temporal lobe epilepsies.
Methods
We conducted a single-center retrospective cohort study of patients receiving combined ANT/PUL DBS between 2021 and 2025. Outcomes included median seizure rate reduction (MSR), responder rate (RR; >50% seizure frequency reduction), and stimulation-related side effects, assessed across ANT, PUL, and concurrent ANT/PUL stimulation settings. Acute surgical complications were evaluated. Statistical significance was assessed using two-sided Wilcoxon signed-rank tests with Holm-Bonferroni correction.
Results
Nine patients with combined ANT/PUL DBS were identified, and eight patients had sufficient follow-up for inclusion (median follow-up = 20 months). Posterior predominant structural abnormalities were present in eight of nine patients. There were no acute surgical complications. Three instances of transient stimulation-related side effects resolved with parameter adjustments, whereas one patient required rescue antiseizure medication in addition to programming changes. Eight patients received periods of ANT stimulation, six PUL stimulation, and seven combined ANT/PUL stimulation. Regarding overall outcome, at last follow-up, there was a significant 80.8% MSR (p = .0078) and 87.5% RR, with two patients receiving ANT and six ANT/PUL stimulation. Regarding target-specific MSR, concurrent ANT/PUL DBS (68.8% MSR) showed a trend toward superior performance relative to ANT (43.3%) and PUL DBS (17.5%) alone, although subgroup analysis of target-specific performance did not reach statistical significance.
Significance
Combined four-lead ANT/PUL DBS appears safe and effective for patients with drug-resistant posterior quadrant and temporal lobe epilepsies. Dual-network neuromodulation may provide greater flexibility to individually optimize neuromodulation for complex seizure networks.