LORETA Z-score Neurofeedback in Patients with Medically Refractory Epilepsy

Rationale: Published studies suggest that augmentation of the sensorimotor rhythm (SMR), a commonly-used neurofeedback protocol for patients with epilepsy, can be an effective means of reducing seizure frequency, even in patients with medically-refractory seizures. However, SMR protocols are limited to training a few frequency bands over sensorimotor cortex. Newer neurofeedback technology allows for the selection of multiple frequency bands in multiple head regions for training purposes and thus allows for training of neural networks.Functional MRI studies have shown abnormal connectivity within the default mode network (DMN) in patients with both focal-onset and primary generalized epilepsy syndromes. The DMN has also been shown to have altered activity concurrent with interictalepileptiform discharges. The effectiveness of newer neurofeedback techniques in reducing seizure frequency for patients with medically-refractory seizures has not yet been established. This case series explores the potential effectiveness of using LORETA z-score training within the DMN in reducing seizure frequency in patients with medically-refractory seizures. Methods: The records for all consecutive patients seen in the Neurofeedback Clinic at a single academic medical center over a one year period (n=6) were retrospectively reviewed. All patients had medically-refractory epilepsy and were either not candidates for epilepsy surgery (based on consensus decision of the center's faculty) or had refused to consider surgery for personal reasons. Data on patient demographics, duration of epilepsy prior to training, seizure types and frequencies, antiepileptic drugs (AEDs), psychiatric and medical comorbidities, imaging results, neurophysiological results, and the duration of neurofeedback training were abstracted and analyzed. Patient-reported seizure frequency was also analyzed. Results: 125 total training sessions were reviewed. Mean patient age was 33 +/- 6.1 years with mean duration of epilepsy prior to training of 17.2 +/- 3.2 years. Five out of six patients had focal onset epilepsy. None of the patients had a structural lesion on MRI that correlated with their seizure focus. Five out of 6 patients had a history of comorbid mood disorder. No patient had ever been seizure free for more than 1 year. Patients had been trained using LORETA z-score training within the DMN for an average of 20.8 +/- 5.2weeks (1-2 sessions per weekfor 20-30 minutes per session) at the time of analysis. Five out of 6 patients trained had a subjective reduction in reported weekly seizure frequency after LORETA z-score neurofeedback training began. Conclusions: In this small case series, DMN training using LORETA z-score neurofeedback techniques resulted in subjective improvement in seizure frequency from reported baseline for five out of the six patients in this series.Larger studies are needed to more definitively assess the effectiveness of these techniques for reducing seizure frequency in patients with medically-refractory seizures who are not, for either medical or personal reasons, candidates for surgical intervention.