Thalamocortical Responsive Neurostimulation for the Treatment of Lennox-Gastaut Syndrome

项目总结/摘要 Lennox-Gastaut综合征（LGS）是一种具有认知功能的儿童癫痫发作的破坏性形式。 功能障碍和非常频繁的全身性发作（GOS），通常导致损伤。由于缺乏 有效的治疗方法以及脑反应刺激在医学上的安全性和有效性 顽固性局灶性发作（FOS），这项研究将测试是否脑反应性神经刺激， 丘脑-皮层神经网络（RNS-TCN）是治疗LGS的可行策略。具体而言，该项目旨在： (1)获得RNS-TCN治疗LGS GOS的安全性和有效性的初步证据;（2）创建一个 基于患者特异性计算网络模型的交互式治疗决策支持系统， 机器学习以识别最佳电极导线放置和刺激参数。 使用FDA批准用于FOS的RNS®系统，将进行早期可行性IDE研究 在6个癫痫中心的20例LGS和药物难治性GOS患者中。患者将入组 两个队列，每组10人，第一个队列的安全性和疗效里程碑决定第二个队列的入组 队列。患者将有两个深度导线放置在丘脑中央中核的两侧， 两个硬膜下带状导线置于内侧前额叶皮质两侧。选择这些目标是因为 它们与LGS中GOS的发生和传播有关。电极导线将位于每个目标内， 在有限元生物物理模型的指导下，刺激最大限度地参与丘脑皮质网络 由结构磁共振成像和扩散加权成像创建。有限元 生物物理模型也将用于识别初始RNS-TCN刺激途径和电流幅度。 在设盲评价期间，患者将随机接受高频短脉冲群治疗， （HFSB）或低频长脉冲串（LFLB）RNS-TCN，然后在交叉到 接受其他治疗条件。在开放标签期间，刺激参数可在以下条件下修改： 医生的判断力。将通过使用贝叶斯优化通知参数调整 专为每位患者开发的模型。所有临床和电生理数据收集过程中， 一项研究将用于确定临床反应的生物标志物;如果找到，这些将有助于未来的癫痫研究 和临床实践。如果安全性是有利的，并且有初步的疗效证据， 今后更大规模的可行性研究的设计将借鉴经验。 除了治疗有需要的人群外，该项目还从事生物标志物的基本发现， 广义网络癫痫，并开发新的自动化治疗选择政策， 改善LGS和其他癫痫发作患者生活的潜力。

Project Summary / Abstract Lennox-Gastaut Syndrome (LGS) is a devastating form of childhood onset epilepsy with cognitive dysfunction and very frequent generalized onset seizures (GOS) often leading to injury. Driven by the lack of effective therapies and the demonstrated safety and efficacy of brain-responsive stimulation for medically intractable focal onset seizures (FOS), this study will test whether brain-responsive neurostimulation of thalamocortical networks (RNS-TCN) is a feasible strategy to treat LGS. Specifically, the project aims to: (1) acquire preliminary evidence for safety and efficacy in treating GOS of LGS with RNS-TCN; (2) create an interactive therapy-decision support system based on patient-specific computational network models and machine learning to identify optimal lead placement and stimulation parameters. Using the RNS® System, which is FDA approved for FOS, an early feasibility IDE study will be conducted at 6 epilepsy centers in 20 patients with LGS and medically intractable GOS. The patients will be enrolled in two cohorts of 10, with safety and efficacy milestones in the first cohort governing the enrollment of the second cohort. Patients will have two depth leads placed bilaterally in the centromedian nucleus of the thalamus and two subdural strip leads placed bilaterally on the medial prefrontal cortex. These targets are selected because they are implicated in the onset and spread of GOS in LGS. Leads will be located within each target such that stimulation maximally engages the thalamocortical network, guided by finite-element biophysical models created from structural magnetic resonance imaging and diffusion weighted imaging. The finite-element biophysical models will also be used to identify the initial RNS-TCN stimulation pathway and current amplitude. During the blinded evaluation period patients will be randomized to receive either high-frequency short burst (HFSB) or low-frequency long burst (LFLB) RNS-TCN, then enter a washout period before crossing over to receive the other treatment condition. During the open label period stimulation parameters can be modified at the discretion of the physician. Parameter adjustments will be informed by using a Bayesian optimization model developed for specifically for each patient. All clinical and electrophysiological data collected during the study will be used to identify a biomarker of clinical response; if found, these will aid future epilepsy research and clinical practice. If safety is favorable and there is preliminary evidence for efficacy, then this early experience will inform the design of a future larger feasibility study. In addition to treating a population in need, this project engages in fundamental discovery of biomarkers in generalized network epilepsies, and develops novel automated therapy selection policies that have the potential to improve the lives of patients with LGS and other seizure disorders.