Neurostimulation zur Behandlung von Epilepsien

Zusammenfassung

Neurostimulationsverfahren wie die Vagus-Nerv-Stimulation (VNS), die direkte Hirnstimulation und die repetitive transkranielle Magnetstimulation (rTMS) eröffnen therapeutische Optionen für Patienten mit medikamentös therapieresistenten Epilepsien, die für einen epilepsiechirurgischen Eingriff nicht in Frage kommen oder bei denen eine solche Operation nicht zum Erfolg geführt hat. Mit der VNS können Responderraten (Anfallsreduktion > 50 %) von 30 bis 40% erzielt werden. Es besteht eine breite Wirksamkeit gegenüber allen Anfallstypen in allen Altersgruppen. Die antiepileptische Wirksamkeit nimmt über die ersten 18 bis 24 Monate kontinuierlich zu, um dann ein stabiles Plateau zu erreichen. Die VNS zeigt zudem einen positiven Effekt auf Stimmung, Gedächtnis und Lebensqualität. Bei der direkten Hirnstimulation kann einerseits eine direkte Stimulation der epileptogenen Zone und somit kortikaler Strukturen erfolgen, andererseits können auch tiefe Hirnstrukturen mit dem Ziel der Modifikation der Anfallsentstehung und/oder Ausbreitung stimuliert werden. Zudem kann die Stimulation entweder kontinuierlich oder responsiv, das heißt bei Auftreten eines Anfallsmusters im simultan mitregistrierten EEG erfolgen. Die tiefe Hirnstimulation befindet sich allerdings noch in einem experimentellen Stadium und sollte nur in spezialisierten Zentren angewendet werden. Kontrollierte Studien zum Einsatz der TMS bei therapieresistenten Epilepsien ergaben kontroverse Ergebnisse hinsichtlich der Wirksamkeit. Möglicherweise profitieren besonders Patienten mit neokortikalen Foci und Patienten mit fokalen kortikalen Dysplasien von der rTMS. Eine abschließende Empfehlung zu ihrem Einsatz bei Epilepsie kann derzeit noch nicht abgegeben werden.

Summary

Neurostimulation methods including vagus nerve stimulation (VNS), brain stimulation and repetitive transcranial magnetic stimulation (rTMS) offer new treatment options for patients with medically refractory epilepsy who are not candidates for epilepsy surgery or who have failed epilepsy surgery. VNS yields responder rates (seizure reduction > 50%) of 30 to 40% and is effective against all seizure types in all age groups. The efficacy of VNS increases during the first 18 to 24 months after implantation and remains stable thereafter. VNS also exerts positive effects on mood, memory and quality of life. Brain stimulation can be targeted directly on the epileptogenic zone or on subcortical structures modifying seizure initiation and spread. Stimulation can be performed continuously or responsive, i.e. in response to seizure discharges recorded in the ongoing invasive EEG. Brain stimulation is still an experimental technique and should only be applied in specialized centers. Controlled studies investigating the effectiveness of rTMS in refractory epilepsy yielded controversial results. rTMS seems to be especially effective in patients with neocortical foci and with focal cortical dysplasia. The final role of this method needs to be awaited.

Schlüsselwörter

Neurostimulation - Epilepsie - VNS - transkranielle Magnetstimulation - rTMS

Keywords

Neurostimulation - epilepsy - VNS - transcranial magnetic stimulation - rTMS

• Literatur

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