Brain stimulation as a neuromodulatory epilepsy therapy

Brain stimulation is increasingly used in epilepsy patients with insufficient therapeutic response to pharmacological treatment. Whereas vagus nerve stimulation with implanted devices has been used in large and heterogeneous patient groups, new devices also enable targeted brain stimulation at the site of seizure generation (responsive neurostimulation) or at network hubs (thalamic stimulation). Both responsive neurostimulation systems targeting the epileptic focus and the latest vagus nerve stimulators are intended to stimulate during the ictal phase to disrupt clinical seizure manifestation of reduce seizure severity. Furthermore, transcutaneous stimulation approaches are now available, although their efficacy remains uncertain. This review explains the concepts underlying brain stimulation, provides an overview of efficacy and tolerability data and discusses the rational use of the growing spectrum of neuromodulatory strategies available.