Inpatient continuous thalamic stereo-electroencephalography stimulation in the evaluation of focal epilepsy: illustrative case

BACKGROUND: In patients with drug-resistant epilepsy (DRE) who are not candidates for resective surgery, thalamic neuromodulation targeting structures such as the anterior nucleus of the thalamus (ANT), centromedian nucleus (CM), and pulvinar (PUL) has emerged as a promising therapy. The clinical investigation of these targets' efficacy and side effect profiles is ongoing, complicating discussions between neurosurgeons, neurologists, and patients. The implementation of single-pulse and continuous stimulation protocols to conduct patient-specific side effect screens and generate prognostic biomarkers could offer guidance for target selection. OBSERVATIONS: A 32-year-old male with extensive polymicrogyria and DRE underwent stereo-electroencephalography (SEEG) with multisite thalamic sampling to inform neuromodulation target selection. Single-pulse stimulation was conducted to screen for acute sensorimotor effects, followed by continuous (12- to 24-hour) stimulation using clinically relevant parameters. Intolerable paresthesia occurred during CM single-pulse stimulation, leading to its exclusion as a target. Single-pulse and continuous stimulation of the ANT and PUL were well tolerated. PUL stimulation offered superior suppression of epileptiform discharges during sleep. LESSONS: These findings meaningfully informed the selection of the PUL as a neuromodulation target. This case illustrates the safety, feasibility, and utility of patient-specific single-pulse and continuous stimulation assessments during SEEG monitoring to evaluate efficacy and tolerability prior to chronic neuromodulation, particularly for novel thalamic targets. https://thejns.org/doi/10.3171/CASE25947.