Commentary
Video
Advances in Surgical and Neuromodulation Strategies for Epilepsy Management: Satyanarayana Gedela, MD
WATCH TIME: 6 minutes
"Not every patient will be a surgical candidate. If we cannot safely remove that particular part of the brain, then we have to look at other neuromodulation options."
Neuromodulation has emerged as a pivotal approach in managing drug-resistant epilepsy in children, especially when surgical resection may not be feasible.1 Techniques such as vagus nerve stimulation (VNS), deep brain stimulation (DBS), and responsive neurostimulation (RNS) have been employed to modulate neural circuits and reduce seizure frequency. Recent studies highlight the efficacy of these interventions; for instance, VNS has demonstrated a significant reduction in seizure frequency in pediatric patients. Similarly, DBS targeting specific thalamic nuclei has shown promise in conditions like Lennox-Gastaut syndrome, offering seizure control and cognitive improvements.2 RNS, a closed-loop system, can provide real-time seizure detection and intervention, tailoring therapy to individual patient needs.3
Complementing neuromodulation, dietary interventions like the ketogenic diet (KD) have been integral in managing pediatric epilepsy. The KD, characterized by high-fat and low-carbohydrate intake, induces a state of ketosis, which has been associated with reduced neuronal excitability and seizure control.4 Recent reviews affirmed the KD's efficacy, noting significant seizure reduction in children with refractory epilepsy. Moreover, modified versions of the diet, such as the Modified Atkins Diet and Low Glycemic Index Treatment, could offer comparable benefits with improved tolerability. Although the exact mechanisms remain under investigation, the KD's role in altering energy metabolism and neurotransmitter activity is believed to underpin its therapeutic effects.
Expanding on these advances, Satyanarayana Gedela, MD, chief of neurology at Nemours Children’s Hospital, Florida, offered insights to reflect the broader shift toward precision medicine in pediatric epilepsy care. In a recent conversation with NeurologyLive®, Gedela, who also serves as a professor of pediatrics at the University of Central Florida School of Medicine, highlighted the complexities of modern epilepsy management, noting the move from straightforward surgical cases to those requiring intracranial monitoring and individualized strategies. He explains the use of technologies like stereotactic EEG, RNS, DBS, and KD as part of a precision medicine approach. Gedela emphasized the importance of tailoring treatment to each patient’s unique seizure patterns and brain anatomy to optimize outcomes as well as to minimize cognitive and functional risks.
REFERENCES
1. Samanta D, Aungaroon G, Albert GW, et al. Advancing thalamic neuromodulation in epilepsy: Bridging adult data to pediatric care. Epilepsy Res. 2024;205:107407. doi:10.1016/j.eplepsyres.2024.107407
2. Samanta D, Haneef Z, Albert GW, et al. Neuromodulation strategies in developmental and epileptic encephalopathies. Epilepsy Behav. 2024;160:110067. doi:10.1016/j.yebeh.2024.110067
3. Chang V, Reeders PC, Blackwood ER, et al. A Scoping Review of Responsive Neurostimulation in Focal Cortical Dysplasia-Related Epilepsy. Epilepsy Behav. 2025;166:110362. doi:10.1016/j.yebeh.2025.110362
4. Sourbron J, Klinkenberg S, van Kuijk SMJ, et al. Ketogenic diet for the treatment of pediatric epilepsy: review and meta-analysis. Childs Nerv Syst. 2020;36(6):1099-1109. doi:10.1007/s00381-020-04578-7
