Advancing Pediatric Epilepsy Care Through Neurostimulation at UPMC Children’s Hospital of Pittsburgh
November 17, 2025
The multidisciplinary neurostimulation program for pediatric epilepsy patients at UPMC Children’s Hospital of Pittsburgh, directed by child neurologist William Welch, MD, provides patients and their families with access to the most current neurostimulation options. For children who are not able to achieve adequate seizure control with antiseizure medications or who are not good candidates for surgical resection, neurostimulation techniques may provide an option that can reduce seizure frequency, improve overall quality of life, and lessen the use of antiseizure medications.
The neurostimulation program at UPMC Children’s combines expertise from child neurology and pediatric neurosurgery to offer all three currently approved types of neurostimulation to treat pediatric epilepsy:
- Vagus nerve stimulation (VNS).
- Deep brain stimulation (DBS).
- Responsive neurostimulation (RNS).
The neurostimulation program also is increasingly using and studying regional and thalamic stimulation strategies with DBS and RNS to expand the range of patients who may benefit from these treatment modalities.
“Our program’s neurostimulation options encompass VNS, DBS, and RNS,” Dr. Welch says. “Each modality serves a distinct purpose, and our goal is to select the most appropriate therapy for each child’s epilepsy profile, clinical history, and goals of care.”
Program Development and Treatment Modalities
When neurostimulation was first introduced as a treatment option in children with epilepsy, VNS was the only available option. The device, which indirectly stimulates thalamic networks through the vagus nerve has the longest clinical history in epilepsy management in children. Over time, the program at UPMC Children’s has expanded its clinical offerings to include RNS and DBS, which have shown to be safe and effective in children with epilepsy, and there is a growing body of research to support their use.
“VNS is approved for focal epilepsy, but in children we also use it for a range of generalized and multifocal epilepsies, including epileptic encephalopathies,” Dr. Welch says. “RNS is likewise approved for focal epilepsy, and it allows us to address unifocal epilepsy as well as more regional onsets or complex networks. We also use it for certain forms of generalized epilepsy. DBS is something we have started to use more in the last few years, particularly for epileptic encephalopathy and Lennox-Gastaut syndrome. For a child with focal epilepsy who is not a candidate for resection, or who has undergone a focal resection that was not successful, RNS becomes a straightforward choice because it records data and has very strong evidence of benefit in that context,” Dr. Welch says.
Device implantation and programming are carried out in close collaboration with the pediatric neurosurgery team. The multidisciplinary partnership provides patients a cohesive approach to care, presurgical evaluation through long-term management.
“When I began at UPMC Children’s, VNS was the only established neurostimulation option for pediatric use,” Dr. Welch says. “Since then, we have built a more comprehensive program that incorporates RNS and DBS to expand therapeutic possibilities for children who are not surgical candidates or whose seizures persist after resection and medical therapy”
Defining Regional and Thalamic Stimulation
Regional neurostimulation has become an important part of the program at UPMC Children’s. It is used increasingly in patients whose seizures arise from distributed or multifocal networks. In these types of epilepsy, RNS can be configured to deliver stimulation across a broader cortical field by placing electrodes within interconnected regions or by stimulating between multiple contacts.
Dr. Welch and the team also are able to employ a cortico-thalamic strategy for patients whose seizures propagate through thalamic hubs. In this approach, one lead is positioned in the thalamus, most commonly the centromedian nucleus, and the other in a cortical target. This enables the possibility of modulating a larger epileptogenic network. These techniques continue to be refined and studied in the clinic and in the research lab.
Thalamic stimulation now accounts for more than half of the RNS implantations performed at UPMC Children’s, particularly in children with generalized epilepsy. Stimulation of the centromedian nucleus has proven useful in detecting and modulating generalized discharges, including absence and tonic-clonic seizures.
“In generalized forms of epilepsy, the thalamus often functions as the central node within the seizure network,” Dr. Welch says. “By recording and stimulating in this region, we can influence the broader epileptic circuitry and achieve varying levels of seizure control in cases that were once considered inoperable.”
Integration With Medical Therapy
For any of the neurostimulation approaches, the primary goal is seizure reduction to the greatest extent possible. In contrast to resective surgery, where complete seizure freedom may be achievable, neurostimulation approaches typically aim for substantial reduction in seizure frequency and severity. Medication tapering is pursued, when possible, but most patients continue at least some pharmacologic therapy in conjunction with their neurostimulation therapy.
“Although medication remains an important component of care, neurostimulation can allow us in certain cases the ability to reduce the number of drugs a child needs to take, or lower their dosages,” Dr. Welch says. “Even partial reductions in the medications can significantly lessen side effects and improve daily functioning for patients and their families.”
Surgical Considerations and Device Longevity
VNS, DBS, and RNS share similarities in the surgical approaches to implantation but differ in how they are configured and placed. VNS and DBS both use generators implanted in the chest, connected by tunneled leads to the neck or brain. RNS systems are housed entirely intracranially. The device is placed in a craniotomy tray within the skull, with leads placed in target regions in the brain.
Battery lifespan varies across devices and depends on stimulation settings. VNS typically requires replacement after approximately five years, involving a relatively simple generator exchange. DBS systems are rechargeable, with batteries lasting up to a decade before they need to be replaced. RNS batteries are projected to last about 11 years, though duration may be shorter with high-frequency stimulation needs in certain patients. In all cases, replacements can be performed as same-day procedures, and the devices can remain implanted indefinitely as long as they remain effective and free of complications.
“These systems are designed for long-term use,” Dr. Welch says. “As device and battery technologies evolve over time, we may see the time between placement grow substantially, along with other improvements.”
Recent Research at UPMC Children’s: RNS in Drug-resistant Generalized Epilepsy
Research from Dr. Welch and colleagues, published in Epilepsy Research in 2025, evaluated thalamic RNS in pediatric-onset drug-resistant generalized epilepsy. The retrospective case series included seven patients treated with bilateral centromedian nucleus RNS between 2020 and 2022. Five had genetic generalized epilepsy, and two had Lennox-Gastaut syndrome.
All patients had bilateral depth electrodes placed in the centromedian nucleus. Devices were programmed based on electrophysiology and clinical response. High-frequency stimulation was used initially; low-frequency settings were used for those with suboptimal early response or stimulation-related side effects.
Five of the seven patients achieved a 50% or greater reduction in seizure frequency. One patient was nearly seizure-free for more than one year. Two did not show sustained improvement, reflecting heterogeneity in underlying epilepsy and responsiveness to RNS. No major complications occurred in the cohort.
The study demonstrated that ictal discharges can be consistently detected within the centromedian nuclei and that closed-loop stimulation may influence thalamocortical networks responsible for generalized seizure propagation. The consistency of the recordings and duration of patient follow-up provided the team meaningful insight into how these networks behave in children receiving thalamic RNS.
“With any of the types of neurostimulation currently available, our objective is freedom from seizures to the greatest extent possible for the individual,” Dr. Welch says. “However, outside of a complete response, a clinically meaningful reduction in seizures can lead to improved independence and fewer medication-related effects. These benefits can have a transformative effect on a child’s quality of life and overall health,” Dr. Welch says.
Learn More
Study Reference
Speakes ME, Reznik-Schaefer K, Al-Ramadhani R, Fernandez LD, Hect JL, Abel TJ, Welch WP. Treatment of Pediatric Drug-Resistant Generalized Epilepsy With Responsive Neurostimulation of the Centromedian Nucleus of the Thalamus: A Case Series of Seven Patients. Epilepsy Res. 2025; 210: 107516.
