Network-guided Thalamic Neuromodulation for Epilepsy.

PURPOSE OF REVIEW: This review takes a network-based perspective on thalamic neuromodulation for epilepsy, examining how each target (e.g., anterior (ANT), centromedian (CM), and pulvinar (PUL) thalamic nuclei) engage distinct seizure networks, what evidence supports each, and how stimulation/electrophysiologic mapping can guide individualized targeting rather than a fixed, syndrome-based approach.

RECENT FINDINGS: Randomized and prospective trials have expanded the evidence for ANT and CM stimulation, while emerging data support the pulvinar as a target for posterior quadrant and temporal lobe epilepsies. Syndrome-specific sweet-spot analyses reveal distinct optimal sites within the CM for LGS and IGE. Thalamic sEEG with single-pulse stimulation and trials of DBS-style stimulation now enables characterization of seizure network engagement and identification of acute biomarkers that may inform target and parameter selection. Multi-target strategies combining thalamic nuclei, or thalamic and cortical leads, show preliminary promise for broadly distributed seizure networks. No single thalamic target is uniformly effective across epilepsy types; optimal targeting requires individualized, network-informed characterization. This supports a shift toward connectomic and individualized approaches, with future work needed to refine target selection, stimulation paradigms, and individualized optimization using clinical outcomes and electrophysiological biomarkers.