As thalamic SEEG provides increasingly patient-specific physiological data, how should that information influence neuromodulation target selection?

Following a dedicated AES 2025 symposium that brought together leaders in epilepsy, a new perspective published in EpilepsyCurrents examines a growing area of epilepsy surgery: using thalamic SEEG to understand the role of individual thalamic nuclei within a patient's epileptic network.

The thalamus is not simply a relay. It's an active participant in cortical excitability and seizure networks, with recruitment varying by seizure type, syndrome, and individual connectivity.

ANT stimulation carries Level I evidence and remains an established therapy. At the same time, current imaging and electrophysiological studies demonstrate early, and sometimes asymmetric, thalamic recruitment in many focal epilepsies, including posterior quadrant, temporal, and perisylvian syndromes. The authors highlight the potential relevance of other nuclei,including the pulvinar, centromedian, and ventral motor thalamus.

That raises an important clinical question:

Which thalamic nucleus is relevant for which patient, and when?

Modern implantation techniques now permit safe, systematic thalamic sampling alongside cortical coverage in the same exploration. Teams can evaluate seizure onset, propagation pathways, thalamic recruitment, and connectivity using direct, patient-specific electrophysiology rather than relying on imaging or anatomical assumptions alone.

As the field investigates multiple thalamic nuclei and increasingly localized electrophysiological signals, higher-density recording configurations such as MICRODEEP PIXEL® provide another option for finer spatial sampling within targeted areas.

The implications extend beyond target selection. The authorshighlight the potential for thalamic recordings and patient-specific biomarkersto inform not only where stimulation should occur, but also its timing,frequency, and pattern.

The authors' conclusion is direct: thalamic SEEG-guided,physiology-informed, adaptive neuromodulation should be viewed as an integral component of modern epilepsy surgery, not a departure from it.

Important questions remain. Is thalamic activity driving the network or reflecting rapid propagation? Which biomarkers matter most? Which nucleus is relevant for which network? And should stimulation be continuous, burst, or adaptive?
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Gonzalez-MartinezJA, et al. Advances in Thalamic Neuromodulation for Epilepsy: From Mechanisms to Clinical Translation. Epilepsy Currents. 2026.

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