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Letter: Responsive Neurostimulation of the Mesial Temporal White Matter in Bilateral Temporal Lobe Epilepsy.

To the Editor: First of all, we want to congratulate the authors on sharing their experience on “Responsive Neurostimulation of the Mesial Temporal White Matter in Bilateral Temporal Lobe Epilepsy.”1 This is really an important surgical modality to be considered in drug-resistant epilepsy cases. We are intrigued to find how helpful they found neurostimulation to be in the management of temporal lobe epilepsy. What we appreciate the most is they could find “hippocampus sparing” equally effective. This point becomes a matter of utmost significance while planning considering bilateral manipulations. With this wonderful study on a potentially useful surgical modality, as expected, several questions arise. As in this study the age range is 32 to 54 yr, we really want to know the opinion of the authors regarding the ideal age group for responsive neurostimulation (RNS). We come across many younger patients2 who can be offered a surgical option; do the authors think this surgery can be safely performed in younger patients? In the study, a highly impressive overall reduction of seizure frequencies of 44.25% has been mentioned, although only 30% of the patients enjoyed complete freedom from seizure activity. As per the definition, for a procedure to be labeled as “definitive,” there should be at least 90% reduction in seizure frequency.3 Although some time has elapsed since the study and we are sure that the authors are following up their patients, it will be really nice if the authors share whether they consider RNS a definitive or a palliative surgery for epilepsy. For the interest of epilepsy practice and research consideration, it will be appreciated if the authors can elaborate any drug regimen changes in the antiepileptic drugs (AEDs) after RNS. Being neurosurgeons, there is indeed a real concern of the safety of removal of the leads if the need arises. The authors had a successful experience, but because they must have planned a strategy, I am sure they can guide us further on lead removal and its possible complications. Can RNS affect electroencephalogram (EEG)4 in a patient with seizure? Another very interesting point here is the safety of this procedure in post-traumatic epilepsy; do they think it can be used in this set of patients? Similarly, for patients with a history of surgical resection of brain lesion, can we consider this modality? There can be epileptic patients who have indications for deep brain stimulation (DBS) for other reasons such as Parkinson disease, obsessive compulsive disorder (OCD), and morbid depression as well, so how can we proceed with RNS in such patients? All these queries do point toward the incredible quality of this paper and plausibility of this surgical modality. We again appreciate the efforts and wish the authors all the best.