Thalamic Neuromodulation: New Frontiers

Thalamic neuromodulation for drug-resistant epilepsy has evolved from ablative thalamotomy to network-guided deep-brain stimulation (DBS) and responsive neurostimulation (RNS). Currently, the only Food and Drug Administration-approved DBS target is the anterior thalamic nucleus, which provides substantial and durable seizure reduction, particularly in limbic and temporal epilepsies. There is growing evidence that the centromedian and pulvinar nuclei are implicated in generalized, multifocal, and posterior neocortical epilepsies. Advanced imaging, probabilistic atlases, and connectomics can be used to refine targeting; however, they are limited by patient specificity, acquisition burden, and interatlas variability. Thalamic stereoelectroencephalography may clarify potential neuromodulation target selection by characterizing ictal recruitment, network dynamics, and biomarkers. Although DBS and RNS each have unique benefits, no modality has demonstrated superior. Pediatric data are heterogeneous and scarcer, but seizure reduction and safety profiles are similar to adults. Further studies are needed to optimize neuromodulation target selection and programming paradigms.