Expanding Frontiers of Intracranial Neuromodulation in Pediatric Drug-Resistant Epilepsy: A Retrospective Cohort Study

Abstract

Background: Pediatric drug-resistant epilepsy  remains a major therapeutic challenge and is associated with substantial impairment in neurodevelopment, cognition, behavior, and quality of life. When resective epilepsy surgery is not feasible, intracranial neuromodulation with deep brain stimulation  or responsive neurostimulation  may offer meaningful seizure reduction. However, pediatric data remain limited, particularly in low- and middle-income settings.

Objective: To evaluate the single-center experience with DBS and RNS in children with DRE, with emphasis on seizure outcomes, safety, and neurocognitive changes following treatment.

Methods: This retrospective observational cohort study was conducted at multiple tertiary care centers across Pakistan. Medical records of pediatric patients aged 3 to 18 years with DRE who underwent DBS or RNS implantation between January 2020 and December 2025 were reviewed. Eligible patients had at least 12 months of postoperative follow-up and were not considered candidates for resective surgery after multidisciplinary evaluation. Data collected included demographic characteristics, seizure outcomes, responder rates, postoperative complications, and available neurocognitive assessments.

Results: A total of 30 pediatric patients met the inclusion criteria, including 14 treated with DBS and 16 with RNS. The mean age at implantation was 11.0 years overall, with mean ages of 12.29 years in the DBS group and 9.88 years in the RNS group. Mean seizure reduction was 57.73% in the DBS group and 57.31% in the RNS group. Responder rates, defined as at least  reduction in seizure frequency, were 64.29% for DBS and 68.75% for RNS. Overall complications occurred in 7 of 30 patients , with infection  and lead migration  being the most common adverse events; device failure occurred in 1 patient . No mortality was observed. In the subgroup with available neurocognitive follow-up, mean IQ scores increased modestly from 81.35 to 83.82 in the DBS group and from 82.85 to 86.83 in the RNS group.

Conclusion: Intracranial neuromodulation appears to be a feasible and clinically meaningful palliative treatment option for selected pediatric patients with DRE who are not candidates for resective surgery. In this single-center cohort, both DBS and RNS were associated with substantial seizure reduction and acceptable safety profiles, with stable to modestly improved neurocognitive performance in the assessed subgroup. Larger prospective multicenter studies are needed to better define patient selection, comparative effectiveness, long-term safety, and developmental outcomes.