Responsive neurostimulation detections: "Recognizing the unseen".
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2025-05
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Abstract
Background
Closed-loop responsive neurostimulation (RNS) is an established non-resective neuromodulatory therapy for individuals with drug-resistant epilepsy (DRE). RNS systems are typically programmed to detect and respond to predefined seizure onset patterns, with detector settings often remaining unchanged for extended periods.Aims
To describe the delayed recognition of a novel seizure onset pattern in the acute and chronic clinical settings.Methods
The case of a 35-year-old female with history of drug-refractory temporal lobe epilepsy who presented with increasing seizure frequency and headaches was reviewed.Results
We demonstrate emergence of a new seizure onset pattern in a 35-year-old female with DRE who had undergone RNS implantation 5.5 years prior to presentation. Guided primarily by strong clinical suspicion, with live electrocorticography (ECoG) serving as a confirmatory tool, we identified a previously unrecognized seizure onset pattern linked to a rare, delayed intraparenchymal hemorrhage associated with an RNS lead. Longitudinal ECoG analysis in this patient, who experienced over a 95% reduction in seizures since implantation, revealed evolving seizure patterns over several years that contributed to delayed detections.Conclusion
This case underscores the risk of misdiagnosis when acute changes in seizure patterns occur, in the context of detections programmed to identify specific patterns. Longitudinal analysis of ECoG in the same patient showed changes in seizure patterns over several years that were detected with delay, highlighting importance of vigilant detection monitoring.Type
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Haskell-Mendoza, Aden P, Praveen Ramani, Roshni Dhoot, Prachi Parikh, Birgit Frauscher, Saurabh R Sinha, Carrie R Muh, Derek Southwell, et al. (2025). Responsive neurostimulation detections: "Recognizing the unseen". Epileptic disorders : international epilepsy journal with videotape. 10.1002/epd2.70049 Retrieved from https://hdl.handle.net/10161/33035.
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Scholars@Duke
Prachi T. Parikh
Birgit Frauscher
Dr. Birgit Frauscher is a clinician scientist whose career is dedicated to improve diagnosis and prognosis of people with epilepsy by developing new methods based on advanced electroencephalography techniques to better localize the epileptic focus in order to improve epilepsy treatment outcomes and ultimately achieve the best possible quality of life. She is currently holding the position of Director of the Duke Comprehensive Epilepsy Center and holds a secondary appointment with the Department of Biomedical Engineering at the Duke Pratt School of Engineering.
Her academic journey started at the Medical University of Innsbruck in Austria, where she accomplished her medical training, residency in neurology, and subspecialty training in electroencephalography, epilepsy and sleep medicine. Early in her career during Medical School she became fascinated by the technique of electroencephalography and how it allows to draw important conclusions on brain function. After completion of her clinical training in 2008, she underwent subsequent research training resulting in the successful completion of her habilitation degree in 2011. To specialize on intracranial EEG and signal analysis, she spent a visiting professorship at the Montreal Neurological Institute and Hospital, McGill University in Canada between 2013 – 2015. Subsequently, she served at the Montreal Neurological Institute and Hospital as an Attending Epileptologist and later as Group Leader of Epilepsy and Professor of Neurology.
Her research interests include i) the development of novel seizure-independent EEG markers for the epileptogenic zone in order to achieve a more accurate diagnosis of epilepsy, ii) the investigation of the important interactions between sleep and epilepsy, and iii) the use of the unique possibility of invasive intracranial EEG for studying brain physiology during wakefulness and sleep in order to better delineate normal from abnormal intracranial EEG activity.
Dr. Frauscher’s publication record holds over 170 peer-reviewed papers dedicated to epilepsy and sleep with a H-index of 62. Her scholarly endeavors have earned her several prestigious awards, including Clinician-Scientist awards of the FRSQ (2018-2023), the Michael Prize of the International League against Epilepsy (2019) and the Ernst Niedermeyer Prize from the Austrian Epilepsy Society (2015). Dr. Frauscher's dedication to pushing the boundaries of epilepsy and sleep research highlights her standing in the field and her significant contributions to advancing clinical knowledge.
Carrie Rebecca Muh
Carrie R. Muh is a Pediatric Neurosurgeon specializing in the surgical treatment of epilepsy. She worked full time at Duke University from 2011 to 2019 and became Adjunct faculty when she moved to New York Medical College in 2019.
Dr. Muh grew up in California and began scientific research in high school as part of the NASA Student Space Biology initiative. She went on to study at the Massachusetts Institute of Technology (MIT) where she earned two Bachelor's degrees, in Biology and Political Science. During her undergraduate studies, she worked in the laboratory of DNA-repair scientist Dr. Graham Walker. Dr. Muh also earned a Master's degree in Political Science with a concentration in health policy. After graduation, she spent 8 months working on liver cancer research at the Shanghai Cancer Institute in Shanghai, China, returning to attend medical school at Columbia University's College of Physicians and Surgeons. While at Columbia, Dr. Muh spent a year working in the Gabriel Bartoli Brain Tumor laboratory run by Dr. Jeffrey Bruce, and she taught the medical student neuroanatomy review course to the more junior medical students.
Dr. Muh did her neurosurgery residency at Emory University Hospital and her fellowship in Pediatric neurosurgery at Emory/Children's Healthcare of Atlanta (CHOA). During her residency, she spent time in the pediatric brain tumor laboratory of Dr. Donald Durden. She started at Duke as an Assistant Professor in Neurosurgery and Pediatrics in the summer of 2011 after finishing her fellowship. While at Duke full time, she was the director of education for the medical students within the Department of Neurosurgery, directing the medical student sub-internships. She also earned a Master of Health Sciences in Clinical Research degree from Duke University, and graduated from the esteemed Pediatrics Leadership Program at Harvard Medical School.
Dr. Muh treats all types of pediatric neurological disorders, including brain and spinal cord tumors, moya moya, craniosynostosis, Chiari malformation, spina bifida and hydrocephalus, though she specializes in and is most well-known for pediatric epilepsy surgery. She has done research and published widely on cortical mapping of the brain in patients with epilepsy and on the use of neurostimulators in pediatric patients with epilepsy.
Dr. Muh also studies new techniques for the treatment of hydrocephalus and noninvasive measurement of intracranial pressure (ICP). She won a Coulter Grant to work with collaborators in the Department of Biomedical Engineering to create a SmartShunt, a CSF-shunt which permits noninvasive measurement of intracranial pressure; a device for which they have been awarded a patent. Dr. Muh was also a team leader on Bass Connections grants to investigate the use of oculomotor assessments to noninvasively diagnose sports-related traumatic brain injury (TBI). She has more than 75 published papers, reviews, commentaries and chapters.
Since moving to NY in 2019, Dr. Muh has maintained an Adjunct status at Duke to facilitate continued research projects with colleagues here.
She is now the Chief of Pediatric Neurosurgery and the Surgical Director of the Epilepsy Program at Westchester Medical Center and Maria Fareri Children's Hospital in New York, as well as an Associate Professor of Neurosurgery and Pediatrics at New York Medical College. She is internationally recognized for her work in pediatric epilepsy surgery. She has been invited to speak internationally multiple times and serves on numerous boards including the Executive Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons (AANS/CNS) Pediatrics Section. She is on the Board of Directors for the New York Society of Neurosurgery, she serves on the International League Against Epilepsy (ILAE) Epilepsy Surgery Education Taskforce, and she is a member of the International Epilepsy Surgery Society.
Derek Southwell
I am a surgeon-scientist specialized in the treatment of epilepsy and movement disorders. My laboratory conducts basic and translational neuroscience research on cortical inhibitory circuits. We are interested in 1) understanding the cellular design of inhibitory circuits in mice and humans, and, 2) advancing interneuron transplantation as a therapeutic strategy for inhibitory circuit repair.
Aatif Mairaj Husain
Shruti Agashe
My patients have motivated me to be involved in clinical research. My interests spans areas such as identification of biomarkers in epilepsy, pre-surgical evaluation in epilepsy including stereoEEG and drugs/ device trials in epilepsy. Given my background in biomedical engineering, I have a special interest in Neuromodulation including deep brain stimulation, responsive neurostimulation, use of Artificial intelligence/machine learning on EEGs as well as developing novel device therapies for use in epilepsy care.
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