RNS and DBS for Drug-resistant Epilepsy in Pediatric Patients: A Systematic Review and Meta-analysis

Introduction: Intracranial neuromodulation is increasingly used in children and young adults with drug-resistant epilepsy (DRE), yet its comparative effectiveness and safety remain uncertain. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of responsive neurostimulation (RNS) and deep-brain stimulation (DBS) in this age group.

Methods: We systematically searched PubMed, Embase, and CENTRAL through May 2025. RNS or DBS in patients ≤ 24 years with DRE. Data synthesis was performed using R 4.3.2 with random-effects generalised-linear mixed models and Mantel-Haenszel models. Risk of bias was assessed using RoB2, ROBINS-E, and ROBINS-I tools. Certainty of evidence was graded using the GRADE assessment.

Results: Forty-eight studies (1 randomised, 47 observational) comprising 595 patients were included. Across all cohorts, 69.78% of patients achieved at least a 50% reduction in seizure frequency (95% CI, 62.54-76.15). Higher therapeutic responses were also substantial: 53.87% of patients reached a ≥70% reduction (95% CI, 45.74-61.8) and 27.12% achieved a ≥90% reduction (95% CI, 19.47–36.42). Device type did not influence the ≥50% or ≥90% endpoints, but DBS was associated with a higher proportion of patients reaching ≥70 % reduction than RNS (62.8 % vs 46.1 %; interaction p = 0.02), whereas efficacy did not differ by age range.

Conclusion: RNS and DBS provide substantial seizure reduction in pediatric and young-adult DRE, with comparable efficacy and a favourable safety profile. Well-powered randomised trials with long-term follow-up are needed to confirm comparative efficacy and safety impact.