INTRODUCTION
Pediatric epilepsy remains a major global neurological burden, with approximately 20-30% of children developing drug-resistant epilepsy (DRE) despite optimal medical therapy [5,48]. Persistent seizures during critical neurodevelopmental periods are associated with cognitive delay, psychosocial impairment, and increased mortality [6,28,71]. Surgical intervention represents the most effective therapeutic option for carefully selected children with focal epilepsy [24,25]; however, accurate localization of epileptogenic networks is often more challenging in pediatric populations than in adults. Factors contributing to this complexity include multilobar seizure onset patterns, rapidly evolving cortical organization, subtle or magnetic resonance imaging (MRI)-negative lesions, and limitations in tolerance for invasive monitoring [19,42].
Conventionally, invasive evaluation relied primarily on subdural grid and strip electrodes, which require craniotomy and extensive cortical exposure. While subdural recordings provide high spatial resolution for cortical mapping, they are limited in sampling deep structures and carry risks of infection, hemorrhage, and cerebral edema. Over the last two decades, stereoelectroencephalography (SEEG) has emerged as a preferred invasive modality due to its minimally invasive nature, three-dimensional sampling capability, and favorable safety profile. Parallel advances in neuroimaging, computer-assisted planning, and robotic stereotaxy have further accelerated SEEG adoption in pediatric epilepsy centers worldwide [12,23,33,40,60,65,88].
Nathoo et al. [63] presented a comprehensive review and positioned surgical robotics as a natural extension of stereotactic and computer-assisted surgery, emphasizing that the principal value of robotics lies in enhanced precision, reproducibility, motion scaling, and improved access to deep or constrained operative corridors rather than autonomous decision-making. They highlighted early applications including image-guided robotic radiosurgery, robot-assisted neuroendoscopy, and stereotactic interventions, framing robotics as a facilitator of minimally invasive neurosurgical paradigms rather than a replacement for surgeon expertise [63]. Modern systems provide high-precision trajectory alignment, automated collision avoidance, and rapid multi-trajectory repositioning, allowing complex electrode implantation patterns to be executed with consistent accuracy [12,51].
In pediatric epilepsy surgery, robotics has been applied primarily to three domains in which a stereotactic approach is required : 1) SEEG electrode implantation [1,40], 2) stereotactic ablation, most commonly radiofrequency thermocoagulation (RF-TC) [21,34] and magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) [10,89], and 3) emerging neuromodulation procedures including deep brain stimulation (DBS) [54] and responsive neurostimulation (RNS) [38]. Among these, robot-assisted SEEG represents the most evidence-supported application.
While the use of robotics in pediatric epilepsy surgery continues to expand, the existing literature is predominantly retrospective and single-center, with heterogeneous reporting standards. As such, uncertainties remain regarding accuracy, safety, cost-effectiveness, learning curves, and long-term outcomes. This review aims to summarize the current evidence regarding the clinical applications and impact of robotic assistance in pediatric epilepsy surgery and highlights critical knowledge gaps that should inform future research.
ROBOTIC SYSTEMS AND SURGICAL WORKFLOW
Robotic systems
The most commonly used robotic platforms in epilepsy surgery include ROSA® (Zimmer Biomet) [32], Neuromate® (Renishaw) [12], and Stealth AutoguideTM (Medtronic) [22]. All systems provide frameless trajectory guidance using preoperative imaging datasets combined with rigid robotic arms capable of submillimetric positional accuracy. Although hardware architectures differ, the fundamental workflow remains similar : preoperative trajectory planning, patient-to-image registration, robotic alignment, percutaneous drilling and anchor bolt placement, electrode or catheter insertion, and postoperative imaging verification. ROSA® is currently the most widely reported platform in neurosurgery literature. It integrates optical tracking with automated trajectory alignment and supports rapid multi-trajectory execution, making it well suited for high-density SEEG implantation. Neuromate® has a longer historical footprint in functional neurosurgery and remains used in selected centers. Stealth AutoguideTM represents a compact robotic guidance system integrated into navigation systems and has been increasingly evaluated in pediatric cohorts.
Preoperative planning
Trajectory planning is typically performed using fused MRI and vascular imaging (computed tomography angiography, magnetic resonance angiography, or digital subtraction angiography). Advanced planning software enables automated vessel segmentation and collision detection, reducing the risk of vascular injury. In pediatric patients, vessel caliber may be small and cortical veins relatively superficial, emphasizing the importance of meticulous trajectory optimization [12,84]. Electrode trajectories are designed to maximize gray matter sampling while minimizing cortical transgression length and vascular proximity. For deep targets such as insula, cingulate cortex, mesial temporal structures, and hypothalamic lesions, robotic alignment allows steep oblique trajectories that are difficult to achieve reproducibly using manual frameless techniques [1,12,27,39,40].
Registration methods
Registration accuracy directly impacts stereotactic precision. Common methods include bone fiducials, stereotactic frame fiducials, surface laser scanning, and skin fiducials registration. Pediatric patients present unique challenges due to smaller cranial surface area, thinner bone, and limited tolerance for rigid fixation. Surface registration may be less reliable in very young children, whereas the placement of bone fiducials requires skin and skull puncture with associated anesthesia time. Although no study has established a definitive lower age limit or minimum skull thickness threshold for SEEG, including its registration process, a minimal acceptable skull thickness of 2 mm has been pragmatically used, generally corresponding to a minimum age of 18 months [83]. In general, registration accuracy improves from adhesive skin fiducials, to laser facial surface matching, and to implanted skull fiducials or the use of stereotactic frame fiducials [1,40] (Fig. 1).
Intraoperative workflow
Once registration is completed, the robot automatically aligns the guidance sleeve to each planned trajectory. The surgeon performs drilling, anchor bolt placement, and electrode insertion manually through the robotic guide. Depending on the specific surgical procedure, larger drill diameters may be required, and anchor bolt placement is not necessary. Robotic repositioning between trajectories typically requires less than 30 seconds, significantly reducing cumulative setup time compared with frame-based systems. Usually frame-based techniques require manual adjustment of five coordinates—x, y, z, ring angle, arc angle for each trajectory—which is more time-consuming and introduces additional opportunities for submillimetric error. In pediatric cases with large numbers of electrodes, this efficiency advantage becomes clinically meaningful by reducing anesthesia duration and surgeon fatigue. Post-implantation verification is commonly performed using intraoperative computed tomography (CT) or postoperative CT/MRI fusion to confirm electrode position and rule out hemorrhage.
ROBOT-ASSISTED SEEG IN PEDIATRIC EPILEPSY
Indications
Robot-assisted SEEG is particularly advantageous in pediatric patients with complex epileptogenic networks where extensive three-dimensional sampling is required. Typical indications include MRI-negative epilepsy, suspected deep or insular onset, multilobar or bilateral involvement, prior failed resection, and discordant noninvasive data. SEEG allows hypothesis-driven sampling of distributed networks while preserving cortical integrity. Compared with subdural grids, SEEG provides superior access to deep structures and bilateral hemispheric coverage without the morbidity associated with craniotomy. Robotic assistance further enhances the feasibility of high-density implantation by reducing procedural burden and maintaining consistent accuracy across numerous trajectories [1,12,18,33,40,60] (Fig. 2).
Accuracy and efficiency
Accuracy is commonly quantified using entry-point error (EPE), target-point error (TPE), or radial error (RE) measured on postoperative imaging. Systematic reviews and meta-analyses across adult and mixed populations consistently report robotic systems achieving mean EPE approximately 1.0-1.5 mm and TPE approximately 1.5-2.0 mm. These values are comparable or superior to frame-based stereotaxy and significantly better than freehand navigation techniques [12,31,32,66,85]. Pediatric-specific series mirror these findings. Reported mean RE typically range between 1.5 and 2.0 mm, with minimal outliers exceeding clinically meaningful thresholds. Importantly, accuracy appears preserved across age groups when appropriate registration methods are used, suggesting that pediatric anatomical constraints do not fundamentally compromise robotic performance [1,40]. Comparative pediatric studies between robotic platforms have demonstrated similar accuracy profiles, although workflow efficiency, setup complexity, and footprint may differ. Learning curve analyses indicate that operative time per electrode decreases substantially after approximately 20 cases, supporting scalability for high-volume programs [4,45,64,67,76].
One of the most tangible advantages of robotics lies in workflow efficiency. Multi-trajectory implantation using framebased systems requires repeated manual repositioning and verification, which can significantly prolong operative time. Robotic repositioning is automated and rapid, enabling consistent throughput even in cases requiring 12-20 electrodes [32,46,52]. Reported pediatric series demonstrate average implantation times ranging from 8-15 minutes per electrode after the initial learning phase, with total operative times often reduced by 30-40% compared with historical frame-based cohorts. Reduced anesthesia exposure is particularly relevant in younger children and those with comorbidities [40,56].
Clinical impact
The clinical utility of robotic-assisted SEEG extends beyond technical precision, serving as a critical diagnostic bridge to definitive surgical intervention. Recent pediatric cohorts demonstrate that SEEG achieves clinically decision-guiding seizure focus localization in approximately 80-90% of cases, facilitating tailored resections, ablations, or neuromodulations. Post-SEEG surgical outcomes show seizure freedom rates (Engel class I) ranging from approximately 50% to 75%, which are statistically comparable to historical subdural grid monitoring but achieved with significantly lower major morbidity (<2%) and enhanced three-dimensional sampling capabilities [27,32,40,43,55,69,70,81,82] (Table 1). Furthermore, integrated robotic workflows enable a seamless intra-procedural transition from diagnostic mapping to stereotactic interventions, such as MRgLITT or SEEG-guided RF-TC, within a unified planning and navigational environment [36,55].
Complications
Hemorrhage remains the most clinically significant complication of SEEG; however, recent pediatric robotic series report favorable safety profiles, with symptomatic hemorrhage rates occurring in only 0-1% of cases. While total radiographic hemorrhage rates may reach up to 3%, these events are predominantly small, asymptomatic, and typically identified only through routine postoperative imaging. Infection rates are similarly low, generally remaining below 1-2%, which underscores the minimally invasive nature of the robotic approach. Although hardware-related issues—such as electrode bending, bolt loosening, or inaccurate seating—can occur, particularly in pediatric patients with exceptionally thin skulls, these risks are effectively mitigated through meticulous bolt selection and precise drilling techniques. Importantly, current clinical evidence indicates no significant increase in complication rates when utilizing robotic guidance compared to traditional frame-based stereotactic methods [8,20,32,40,55].
Limitations of current evidence
Despite encouraging results, several limitations persist. Most pediatric robotic SEEG studies are retrospective, single-center experiences with heterogeneous reporting standards. Definitions of accuracy metrics, hemorrhage classification, and seizure outcome vary widely, limiting meta-analytic robustness. Direct comparisons between robotic and frame-based or other prior stereotactic approaches in pediatric populations remain scarce. Cost-effectiveness analyses remain sparse and institution-dependent [1,47,49,56,94].
ROBOT-ASSISTED ABLATION
Rationale for stereotactic ablation in pediatric epilepsy
Stereotactic ablation techniques have emerged as minimally invasive alternatives to open resection for selected epileptogenic substrates. In pediatric patients, deep-seated lesions such as hypothalamic hamartomas, periventricular nodular heterotopia, mesial temporal sclerosis, and focal cortical dysplasia located near eloquent cortex pose significant surgical challenges. Open approaches in these regions can be associated with a higher risk of neurovascular injury, endocrinologic disturbance, and postoperative functional morbidity, including physical and cognitive sequelae. RF-TC and MRgLITT allow targeted destruction of epileptogenic tissue while minimizing collateral damage and hospitalization. Robotic guidance enhances the feasibility of these procedures by enabling reproducible trajectory alignment, especially for steep, oblique, or multi-segment trajectories that may be difficult to achieve reliably using conventional frameless navigation [14,16,21,53]. Furthermore, the advantages of robot-assisted ablation techniques have enabled the application of RF-TC and MRgLITT to procedures traditionally performed through open disconnection surgery, such as corpus callosotomy and functional hemispherotomy [11,13,15,57].
SEEG-guided RF-TC
SEEG-guided RF-TC allows focal coagulation through implanted depth electrodes and can be performed without additional surgical access (since RF-TC is not approved for use with all depth electrode platforms, dedicated RF probes may be required when compatible systems are unavailable). In pediatric epilepsy, RF-TC has been explored both as a palliative therapy and as a prognostic tool to predict surgical benefit. Robotic implantation improves electrode spatial accuracy and consistency, indirectly enhancing RF-TC targeting precision [17,34,75]. Recent pediatric series suggest that RF-TC may be a viable curative treatment option for patients with selected focal epilepsies, particularly in periventricular nodular heterotopia and focal cortical dysplasia type 2b [53,78]. However, in the overall focal epilepsy patient population, long-term seizure freedom after standalone SEEG-guided RF-TC remains uncommon (typically ~15-25% at ≥12 months in published series and pooled analyses), supporting its role primarily as an adjunct or bridge to definitive surgery rather than a uniformly curative modality [9,34,72] (Fig. 3).
Robot-assisted MRgLITT
MRgLITT combines stereotactic laser catheter placement with real-time MRI thermometry to achieve controlled thermal ablation. Robotic systems are increasingly used for laser probe insertion due to the need for precise trajectory alignment and minimal angular deviation over long intracranial distances. Pediatric experience with robot-assisted LITT has been most extensively reported in hypothalamic hamartoma (HH), a deep midline lesion classically associated with gelastic seizures and high surgical morbidity using open approaches. Recent pediatric series employing robot-assisted, real-time MRI-guided LITT have demonstrated favorable seizure outcomes, with Engel class I rates approaching 50-70% in carefully selected patients. These studies emphasize that robotic alignment provides sufficient accuracy even in very young patients with small cranial dimensions and narrow working corridors. Importantly, transient neurological deficits, including oculomotor palsy and endocrine disturbances, remain possible and appear correlated with lesion size and proximity to critical hypothalamic structures rather than robotic technique itself. Beyond HH, robotic LITT has been applied to mesial temporal epilepsy, focal cortical dysplasia, and periventricular lesions in pediatric cohorts, although reported numbers remain limited [3,10,41,50,93]. Advantages include reduced blood loss, shorter hospital stay, and faster recovery compared with open surgery. However, ablation volume constraints, heat sink effects near cerebrospinal fluid spaces, and difficulty achieving complete disconnection in large or irregular lesions remain important limitations [10].
Safety considerations
Thermal injury to adjacent eloquent structures remains the principal risk of stereotactic ablation. Robotic accuracy minimizes off-target catheter deviation but does not eliminate risks associated with thermal spread, vascular proximity, or tissue heterogeneity. MRI thermometry and conservative ablation thresholds are essential, particularly in pediatric patients with smaller brain volumes and developing neural circuits [10,79].
ROBOTIC NEUROMODULATION IN PEDIATRIC EPILEPSY
Evolving role of neuromodulation
Neuromodulation therapies, including vagus nerve stimulation (VNS), DBS, and RNS are increasingly utilized in children with DRE who are not candidates for curative resection or ablation. While VNS is U. S. Food and Drug Administration-approved for pediatric use, DBS and RNS remain largely off-label in pediatric populations and are primarily supported by institutional series [44,59,80,87]. Robotic assistance offers theoretical advantages for neuromodulation implantation by improving lead placement accuracy, enabling complex multi-target trajectories, and potentially reducing operative variability. Studies of anterior thalamic nucleus DBS have demonstrated that closer proximity of the active electrode contacts to the intended anatomical target is significantly associated with improved seizure reduction and responder status [35,37]. Robotic stereotactic systems have been shown to enhance targeting precision and reproducibility compared with conventional techniques, thereby improving the reliability of electrode placement. Although robotic assistance primarily improves technical accuracy, these improvements may translate into optimized stimulation delivery and enhanced clinical outcomes by ensuring consistent engagement of therapeutic neural targets [30,54]. However, pediatric-specific evidence directly linking robotics to improved neuromodulation outcomes remains limited.
DBS
Systematic reviews and clinical series have demonstrated that DBS can achieve meaningful seizure reduction in carefully selected pediatric populations, although complete seizure freedom remains uncommon. Yan et al. [90] reported in a systematic review that more than half of pediatric patients experienced significant seizure reduction, with seizure freedom achieved in a minority of cases. Similarly, broader reviews of pediatric neurostimulation have emphasized that DBS offers a viable palliative treatment option in children with refractory epilepsy who lack conventional surgical options, with an acceptable safety profile and relatively low rates of permanent neurological complications [80].
Among available DBS targets, the centromedian nucleus (CM) and anterior nucleus (ANT) of the thalamus have been most extensively studied due to their central roles in thalamocortical network modulation. Recent pediatric and mixed-population cohorts have demonstrated that CM-DBS can significantly reduce seizure frequency and severity while improving quality of life measures, particularly in generalized or multifocal epilepsy syndromes. Meta-analytic and cohort studies have consistently shown that thalamic DBS is associated with sustained seizure reduction over long-term follow-up, although clinical outcomes vary depending on epilepsy subtype, target selection, and electrode positioning [2,58,68,91]. These findings support the role of DBS as a network-modulating therapy that may alter pathological synchronization within distributed epileptogenic circuits. Evidence from adult randomized trials, including the pivotal SANTE (Stimulation of the Anterior Nucleus of the Thalamus for Epilepsy) trial [29], has further established the efficacy and long-term safety of ANT-DBS, demonstrating progressive seizure reduction over extended follow-up periods [73,74]. Although pediatric use remains off-label, current evidence supports DBS as an important adjunctive neuromodulation strategy for pediatric DRE, particularly in patients who are not candidates for resective surgery, while highlighting the need for further prospective studies to optimize target selection, electrode placement accuracy, and patient selection criteria.
Robotic assistance may be particularly advantageous in DBS procedures targeting thalamic nuclei, such as ANT and CM, where precise localization of small, deep-seated targets and reproducible trajectory alignment across bilateral implantations are essential. While adult functional neurosurgery literature supports robotic accuracy in DBS implantation, pediatric extrapolation requires caution due to anatomical variability and growth considerations.
RNS
RNS is a closed-loop neuromodulation therapy that delivers stimulation contingent on detected epileptiform activity, while simultaneously providing chronic ambulatory intracranial electroencephalography that can inform longitudinal seizure-network management. In the United States (US), the RNS System is indicated for adults with focal (partial-onset) DRE, and pediatric use is therefore typically considered off-label and limited to highly selected cases at experienced centers [77]. Adult randomized and long-term prospective studies demonstrate durable seizure reduction over time with acceptable device-related risks, including infections and explantations as the most common serious adverse events, supporting its role as an established option for nonresectable focal epilepsy or patients with eloquent/complex networks [7,59,62]. In China, RNS has also entered early clinical evaluation through domestically developed systems, with first-in-human reports and early multicenter experience published [86,92].
Pediatric clinical reports (primarily retrospective series) suggest that RNS can be feasible in adolescents and selected younger children, often in scenarios such as MRI-negative focal epilepsy, multifocal/bilateral networks, or cases in which resection/ablation is limited by functional cortex. Across reported pediatric cohorts, outcomes are usually presented as median seizure-frequency reduction and responder rates over intermediate followup, and complication profiles resemble adult experience (notably infection/wound complications and hardware revisions), though sample sizes remain modest and heterogeneity is substantial [26,61]. Importantly, current pediatric data do not yet permit strong conclusions regarding comparative effectiveness versus other neuromodulation strategies, nor do they isolate the incremental value of robotics. Nevertheless, robotic stereotaxy is increasingly adopted for depth lead placement—particularly when targeting deep structures or bilateral networks.
CONCLUSIONS
Robotic systems for neurosurgery have fundamentally transformed the surgical management of pediatric DRE by enabling highly precise, minimally invasive access to complex epileptogenic networks. Robot-assisted SEEG has emerged as the most mature and widely adopted application, providing excellent diagnostic yield, submillimetric targeting accuracy, and favorable safety profiles. The integration of robotic guidance has also facilitated the expansion of stereotactic ablative therapies, including RF-TC and MRgLITT, and neuromodulation procedures such as DBS and RNS, allowing treatment of deep, bilateral, or eloquent cortical networks that were historically difficult to access safely.
Despite these advances, important limitations remain. Most pediatric robotic epilepsy surgery studies are retrospective and single-center, with heterogeneous methodologies and limited long-term outcome data. While robotic systems clearly improve technical accuracy and workflow efficiency, definitive evidence linking robotic accuracy directly to improved seizure outcomes in pediatric populations remains limited. Future research should focus on prospective multicenter studies, standardized reporting of accuracy and outcomes, and evaluation of cost-effectiveness and long-term neurodevelopmental impact. As robotic technologies continue to evolve, their integration into pediatric epilepsy surgery is likely to further enhance surgical precision, expand therapeutic options, and improve outcomes for children with DRE.
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