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Dolezalova I, Koritakova E, Souckova L, Chrastina J, Chladek J, Stepanova R, Brazdil M. Prediction of Vagal Nerve Stimulation Efficacy in Drug-Resistant Epilepsy (PRECISE): Prospective Study for Pre-implantation Prediction/Study Design. Front Neurol 2022; 13:839163. [PMID: 35386419 PMCID: PMC8979018 DOI: 10.3389/fneur.2022.839163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 02/16/2022] [Indexed: 12/03/2022] Open
Abstract
Background Vagal nerve stimulation (VNS) can be indicated in patients with drug-resistant epilepsy, who are not eligible for resective epilepsy surgery. In VNS therapy, the responder rate (i.e., percentage of subjects experiencing ≥50% seizure reduction) is ~50%. At the moment, there is no widely-accepted possibility to predict VNS efficacy in a particular patient based on pre-implantation data, which can lead to unnecessary surgery and improper allocation of financial resources. The principal aim of PRediction of vagal nerve stimulation EfficaCy In drug-reSistant Epilepsy (PRECISE) study is to verify the predictability of VNS efficacy by analysis of pre-implantation routine electroencephalogram (EEG). Methods PRECISE is designed as a prospective multicentric study in which patients indicated to VNS therapy will be recruited. Patients will be classified as predicted responders vs. predicted non-responders using pre-implantation EEG analyses. After the first and second year of the study, the real-life outcome (responder vs. non-responder) will be determined. The real-life outcome and predicted outcome will be compared in terms of accuracy, specificity, and sensitivity. In the meantime, the patients will be managed according to the best clinical practice to obtain the best therapeutic response. The primary endpoint will be the accuracy of the statistical model for prediction of response to VNS therapy in terms of responders and non-responders. The secondary endpoint will be the quantification of differences in EEG power spectra (Relative Mean Power, %) between real-life responders and real-life non-responders to VNS therapy in drug-resistant epilepsy and the sensitivity and specificity of the model. Discussion PRECISE relies on the results of our previous work, through which we developed a statistical classifier for VNS response (responders vs. non-responders) based on differences in EEG power spectra dynamics (Pre-X-Stim). Trial Registration www.ClinicalTrials.gov, identifier: NCT04935567.
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Affiliation(s)
- Irena Dolezalova
- The First Department of Neurology, Faculty of Medicine, Masaryk University and St. Anne's University Hospital, Brno, Czechia
| | - Eva Koritakova
- Faculty of Medicine, Institute of Biostatistics and Analyses, Masaryk University, Brno, Czechia
| | - Lenka Souckova
- International Clinical Research Center, St. Anne's University Hospital, Brno, Czechia
- Department of Pharmacology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Jan Chrastina
- Department of Neurosurgery, Faculty of Medicine, Masaryk University and St. Anne's University Hospital, Brno, Czechia
| | - Jan Chladek
- Behavioral and Social Neuroscience Research Group, Central European Institute of Technology, Masaryk University, Brno, Czechia
- Institute of Scientific Instruments of the Czech Academy of Sciences, Brno, Czechia
| | - Radka Stepanova
- Department of Pharmacology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Milan Brazdil
- The First Department of Neurology, Faculty of Medicine, Masaryk University and St. Anne's University Hospital, Brno, Czechia
- Behavioral and Social Neuroscience Research Group, Central European Institute of Technology, Masaryk University, Brno, Czechia
- *Correspondence: Milan Brazdil
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Hajtovic S, LoPresti MA, Zhang L, Katlowitz KA, Kizek DJ, Lam S. The role of vagus nerve stimulation in genetic etiologies of drug-resistant epilepsy: a meta-analysis. J Neurosurg Pediatr 2022:1-14. [PMID: 35303699 DOI: 10.3171/2022.1.peds222] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 01/31/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Drug-resistant epilepsy (DRE) affects many children. Vagus nerve stimulation (VNS) may improve seizure control; however, its role in children with genetic etiologies of epilepsy is not well described. The authors systematically reviewed the literature to examine the effectiveness of VNS in this cohort. METHODS In January 2021, the authors performed a systematic review of the PubMed/MEDLINE, SCOPUS/Embase, Cochrane, and Web of Science databases to investigate the impact of VNS on seizure outcomes in children with genetic etiologies of epilepsy. Primary outcomes included seizure freedom rate, ≥ 90% seizure reduction rate, and ≥ 50% seizure reduction rate. Secondary outcomes were seizure severity and quality of life (QOL), including cognitive, functional, and behavioral outcomes. A random-effects meta-analysis was performed. RESULTS The authors identified 125 articles, of which 47 with 216 nonduplicate patients were analyzed. Common diagnoses were Dravet syndrome (DS) (92/216 patients [42.6%]) and tuberous sclerosis complex (TSC) (63/216 [29.2%]). Seizure freedom was not reported in any patient with DS; the pooled proportion (95% CI) of patients with ≥ 50% seizure reduction was 41% (21%-58%). Secondary cognitive outcomes of VNS were variable in DS patients, but these patients demonstrated benefits in seizure duration and status epilepticus. In TSC patients, the pooled (95% CI) seizure freedom rate was 40% (12%-71%), ≥ 90% seizure reduction rate was 31% (8%-56%), and ≥ 50% reduction rate was 68% (48%-91%). Regarding the secondary outcomes of VNS in TSC patients, several studies reported decreased seizure severity and improved QOL outcomes. There was limited evidence regarding the use of VNS to treat patients with other genetic etiologies of epilepsy, such as mitochondrial disease, Rett syndrome, Doose syndrome, Landau-Kleffner syndrome, Aicardi syndrome, Angelman syndrome, ring chromosome 20 syndrome, and lissencephaly; variable responses were reported in a limited number of cases. CONCLUSIONS The authors conducted a systematic review of VNS outcomes in children with genetic etiologies of DRE. Among the most studied conditions, patients with TSC had substantial seizure reduction and improvements in QOL, whereas those with DS had less robust seizure reduction. Increased testing, diagnosis, and long-term follow-up studies are necessary to better characterize VNS response in these children.
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Affiliation(s)
- Sabastian Hajtovic
- 1Sophie Davis Biomedical Education Program, City College of New York, City University of New York School of Medicine, New York, New York
| | - Melissa A LoPresti
- 2Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas; and
| | - Lu Zhang
- 3Department of Neurosurgery, Division of Pediatric Neurosurgery, Northwestern University, Lurie Children's Hospital, Chicago, Illinois
| | - Kalman A Katlowitz
- 2Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas; and
| | - Dominic J Kizek
- 2Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas; and
| | - Sandi Lam
- 3Department of Neurosurgery, Division of Pediatric Neurosurgery, Northwestern University, Lurie Children's Hospital, Chicago, Illinois
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Caccavella VM, Giordano M, Colicchio G, Izzo A, D’Ercole M, Rapisarda A, Polli FM, Fuggetta F, Olivi A, Montano N. Palliative surgery for drug resistant epilepsy in adult patients. A systematic review of the literature and a pooled analysis of outcomes. World Neurosurg 2022; 163:132-140.e1. [DOI: 10.1016/j.wneu.2022.03.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/13/2022] [Accepted: 03/14/2022] [Indexed: 11/28/2022]
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Santhumayor B, Karkare S, Kothare S, Rodgers S. Evaluating vagus nerve stimulation treatment with heart rate monitoring in pediatric patients with intractable epilepsy. Childs Nerv Syst 2022; 38:547-556. [PMID: 34837500 DOI: 10.1007/s00381-021-05416-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 11/16/2021] [Indexed: 01/11/2023]
Abstract
PURPOSE Vagus nerve stimulators (VNS) have emerged as an effective treatment modality for pediatric patients suffering from intractable, drug-resistant epilepsy. Newer devices, AspireSR™ Model 106 and the SenTiva™ Model 1000 (VNS TherapyⓇ, LivaNova™), contain an "auto-stimulation" feature that detects ictal tachycardia and transmits pulsations to attenuate seizures. However, the exact benefits of auto-stimulation compared to its risks still merit further exploration. This study evaluates the utility of these specific devices in a heterogeneous population of pediatric and young adult patients with intractable epilepsy. METHODS This is a retrospective chart review of 55 patients who underwent either VNS insertion with or without an auto-stimulation-enabled VNS device at a single level four epilepsy center. Seizure frequency, seizure subtype, side effects, and change in anti-seizure medication load both before and after VNS implantations were collected from patient self-reporting at the time of VNS insertion and 12 months following implantation. Information regarding output current, auto-stimulation current, duty cycling, and auto-stimulation threshold of the device was obtained from documented VNS interrogation for patients with auto-stimulation-enabled VNS devices. RESULTS Patients with auto-stimulation-enabled VNS devices had a mean 56.0% (SD = 0.414) seizure frequency reduction 12 months post-VNS insertion, while patients without auto-stimulation-enabled VNS devices had a mean 41.6% (SD = 0.456) seizure frequency reduction during the same interval. The mean seizure frequency reduction 12 months post-VNS insertion for patients with a SenTiva™ 1000 model was 66.0% (SD = 0.426). For patients with auto-stimulation-enabled VNS devices, post-treatment seizure reduction was significantly correlated with daily auto-stimulation activation (R = 0.432, p = 0.025). CONCLUSION This study supports the clinical safety and utility of auto-stimulation-enabled VNS models, specifically the SenTiva™ 1000, in treating pediatric patients with intractable epilepsy of various subtypes and etiologies. Further research is needed to evaluate the sustained impact of auto-stimulation on long-term outcomes (≥ 2 years follow-up post-VNS).
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Affiliation(s)
- Brandon Santhumayor
- Division of Pediatric Neurosurgery, Cohen Children's Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New Hyde Park, NY, USA.
| | - Shefali Karkare
- Division of Pediatric Neurology, Cohen Children's Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New Hyde Park, NY, USA
| | - Sanjeev Kothare
- Division of Pediatric Neurology, Cohen Children's Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New Hyde Park, NY, USA
| | - Shaun Rodgers
- Division of Pediatric Neurosurgery, Cohen Children's Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New Hyde Park, NY, USA
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Zhang Y, Wang X, Tang C, Guan Y, Chen F, Gao Q, Wang J, Zhou J, Zhai F, Boison D, Luan G, Li T. Genetic variations of adenosine kinase as predictable biomarkers of efficacy of vagus nerve stimulation in patients with pharmacoresistant epilepsy. J Neurosurg 2022; 136:726-735. [PMID: 34479194 DOI: 10.3171/2021.3.jns21141] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/02/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Vagus nerve stimulation (VNS) is an alternative treatment option for individuals with refractory epilepsy, with nearly 40% of patients showing no benefit after VNS and only 6%-8% achieving seizure freedom. It is presently unclear why some patients respond to treatment and others do not. Therefore, identification of biomarkers to predict efficacy of VNS is of utmost importance. The objective of this study was to explore whether genetic variations in genes involved in adenosine kinase (ADK), ecto-5'-nucleotidase (NT5E), and adenosine A1 receptor (A1R) are linked to outcome of VNS in patients with refractory epilepsy. METHODS Thirty single-nucleotide polymorphisms (SNPs), including 9 in genes encoding ADK, 3 in genes encoding NT5E, and 18 in genes encoding A1R, were genotyped in 194 refractory epilepsy patients who underwent VNS. The chi-square test and binary logistic regression were used to determine associations between genetic differences and VNS efficacy. RESULTS A significant association between ADK SNPs rs11001109, rs7899674, and rs946185 and seizure reduction with VNS was found. Regardless of sex, age, seizure frequency and type, antiseizure drug use, etiology, and prior surgical history, all patients (10/10 patients [100%]) with minor allele homozygosity at rs11001109 (genotype AA) or rs946185 (AA) achieved > 50% seizure reduction and 4 patients (4/10 [40%]) achieved seizure freedom. VNS therapy demonstrated higher efficacy among carriers of minor allele rs7899674 (CG + GG) (68.3% vs 48.8% for patients with major allele homozygosity). CONCLUSIONS Homozygous ADK SNPs rs11001109 (AA) and rs946185 (AA), as well as minor allele rs7899674 (CG + GG), may serve as useful biomarkers for prediction of VNS therapy outcome.
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Affiliation(s)
- Yifan Zhang
- 2Department of Brain Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Xiongfei Wang
- 1Department of Neurosurgery, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Chongyang Tang
- 1Department of Neurosurgery, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Yuguang Guan
- 1Department of Neurosurgery, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Fan Chen
- 2Department of Brain Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China.,3Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China; and
| | - Qing Gao
- 2Department of Brain Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Jing Wang
- 3Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China; and
| | - Jian Zhou
- 1Department of Neurosurgery, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Feng Zhai
- 1Department of Neurosurgery, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Detlev Boison
- 4Department of Neurosurgery, Robert Wood Johnson & New Jersey Medical Schools, Rutgers University, Piscataway, New Jersey
| | - Guoming Luan
- 1Department of Neurosurgery, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Tianfu Li
- 2Department of Brain Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China.,3Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China; and
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Liu S, Xiong Z, Wang J, Tang C, Deng J, Zhang J, Guo M, Guan Y, Zhou J, Zhai F, Luan G, Li T. Efficacy and potential predictors of vagus nerve stimulation therapy in refractory postencephalitic epilepsy. Ther Adv Chronic Dis 2022; 13:20406223211066738. [PMID: 35070253 PMCID: PMC8771757 DOI: 10.1177/20406223211066738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 11/24/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Vagus nerve stimulation (VNS) is a therapeutic approach for patients with refractory postencephalitic epilepsy (PEE), which is characterized by drug resistance and disappointing surgical outcomes. However, the efficacy of VNS has not yet been studied in patients with refractory PEE. The present study aimed to demonstrate the efficacy of VNS and evaluate potential clinical predictors in patients with refractory PEE. METHODS We retrospectively collected the outcomes of VNS with at least a 1-year follow-up in all patients with refractory PEE. Subgroups were classified as responders and non-responders according to the efficacy of VNS (⩾50% or < 50% reduction in seizure frequency). Preoperative data were analyzed to screen for potential predictors of VNS responsiveness. RESULTS A total of 42 refractory PEE patients who underwent VNS therapy were enrolled, with an average age of 21.13 ± 9.70 years. Seizure frequency was reduced by more than 50% in 64.25% of patients, and 7.14% of patients achieved seizure-free events after VNS therapy. In addition, the response rates increased over time, with 40.5%, 50.0% and 57.1%, respectively at 6 months, 12 months, and 24 months after VNS therapy. Preoperative duration of epilepsy, monthly seizure frequency, and spatial distribution of interictal epileptic discharges (IEDs) were correlated with responders (p < 0.05) in the univariate analysis. Further multivariate regression analysis demonstrated that refractory PEE patients with high monthly seizure frequency or Focal IEDs (focal or multifocal epileptiform discharges) achieved better efficacy on VNS (p = 0.010, p = 0.003, respectively). CONCLUSION VNS is an effective palliative therapy for patients with refractory PEE. Focal IEDs (focal or multifocal epileptiform discharges) and high seizure frequency were potential preoperative predictors of effectiveness after VNS therapy.
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Affiliation(s)
- Siqi Liu
- Department of Brain Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Zhonghua Xiong
- Department of Brain Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Jing Wang
- Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Chongyang Tang
- Department of Brain Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Jiahui Deng
- Department of Brain Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Jing Zhang
- Department of Brain Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Mengyi Guo
- Department of Brain Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Yuguang Guan
- Department of Brain Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Jian Zhou
- Department of Brain Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Feng Zhai
- Department of Brain Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Guoming Luan
- Department of Brain Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Tianfu Li
- Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, XiangshanYikesong 50, Haidian District, Beijing 100093, China
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Yates CF, Riney K, Malone S, Shah U, Coulthard LG, Campbell R, Wallace G, Wood M. Vagus nerve stimulation: a 20-year Australian experience. Acta Neurochir (Wien) 2022; 164:219-227. [PMID: 34755209 DOI: 10.1007/s00701-021-05046-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Vagus nerve stimulation (VNS) therapy was first approved in the mid-1990s in the USA, Europe and Australia, with demonstrable efficacy in paediatric populations. Benefit in seizure frequency reduction can be observed up to 2 years post-intervention; however, few studies assess outcomes beyond this period. Furthermore, paediatric cohort sizes are small, limiting generalisability of outcome assessments. We evaluate VNS insertion outcomes and complications or side-effects in a large paediatric cohort, over a 20-year period from Queensland's first VNS insertion. METHODS A retrospective review was conducted of all paediatric VNS insertions at the Queensland Children's Hospital (QCH) and the Mater Children's Hospital/Mater Children's Private Hospital (MCH/MCPH) Brisbane. A minimum of 1-year follow-up from 1999 to 2020 was required for inclusion. Patients were assessed on demographics, epilepsy details, seizure outcomes and complications or side-effects. RESULTS In this extended follow-up cohort (76 patients, 7.2 ± 5.3 years), 51.3% of patients had ≥ 50% seizure frequency reduction, while 73.7% experienced an Engel III outcome (worthwhile benefit) or better. Eleven patients (14.9%) were seizure-free at follow-up, and 81.6% retained long-term therapy. Stimulation-related side-effects are common (17.1%) but rarely result in stimulation cessation (3.9%). Cessation occurred in 14 patients (18.4%) and most commonly related to minimal benefit (13.2%). Demographics, aetiology, seizure nature and surgical factors did not influence outcomes. CONCLUSION Over extended treatment periods, a large proportion of patients will benefit significantly from VNS therapy. Approximately 4 of 5 patients will retain VNS therapy, and in cases of cessation, this is most commonly related to minimal benefit. Underlying demographics, aetiology or seizure nature do not influence outcomes. This 20-year Queensland assessment of VNS therapy outcomes informs long-term expectation of VNS therapy.
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KHOSRONEJAD A, RAHIMIAN E, RAISZADEH M, NAJAFIZADE S, RANAIE-KENARSARI A, AMIRSALARI S. Magnetic resonance imaging findings in children with intractable epilepsy compared to children with medical responsive epilepsy. IRANIAN JOURNAL OF CHILD NEUROLOGY 2022; 16:53-61. [PMID: 35497100 PMCID: PMC9047846 DOI: 10.22037/ijcn.v16i2.2710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 07/19/2021] [Indexed: 11/18/2022]
Abstract
Objective Epilepsy is a common brain disorder characterized by a persistent tendency to develop seizures in neurological, cognitive, and psychological contents. Magnetic Resonance Imaging (MRI ) is a neuroimaging test facilitating the detection of structural epileptogenic lesions. This study aimed to compare the MRI findings between patients with intractable and drug-responsive epilepsy. Material & Methods This case-control study was conducted from 2007 to 2019. The research population encompassed all 1-16-year-old patients with intractable epilepsy referred to the Shafa Neuroscience Center (n=72) (a case group) and drug-responsive patients referred to the pediatric neurology clinic of Baqiyatallah Hospital (a control group). Results There were 72 (23.5%) patients in the intractable epilepsy group and 200 (76.5%) patients in the drug-responsive group. The participants' mean age was 6.70± 4.13 years, and there were 126 males and 106 females in this study. Normal brain MRI was noticed in 21 (29.16%) patients in the case group and 184 (92.46%) patients in the control group.Neuronal migration disorder (NMD) was also exhibited in 7 (9.72%) patients in the case group and no patient in the control group. There were hippocampal abnormalities and focal lesions (mass, dysplasia, etc.) in 10 (13.88%) patients in the case group and only 1 (0.05%) patient in the control group.Gliosis and porencephalic cysts were presented in 3 (4.16%) patients in the case group and no patient in the control group. Cerebral and cerebellar atrophy was revealed in 8 (11.11%) patients in the case group and 4 (2.01%) patients in the control group. Corpus callosum agenesis, hydrocephalus, brain malacia, and developmental cyst were more frequent in the case group; however, the difference between the groups was not significant. Conclusion The MRI findings such as hippocampal abnormalities, focal lesions (mass, dysplasia), NMD, porencephalic cysts, gliosis, and atrophy are significantly more frequent in children with intractable epilepsy than in those with drug-responsive epilepsy.
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Affiliation(s)
| | - Elham RAHIMIAN
- Neuroradiologist, Haghighat Neuroimaging Center, Tehran, Iran
| | - Mohammad RAISZADEH
- School of Medicine, Trauma Research Center, Bqiyatallah Al-Azam Hospital, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | | | - Alireza RANAIE-KENARSARI
- New Hearing Technologies Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Susan AMIRSALARI
- New Hearing Technologies Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
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Kostov KH, Kostov H, Larsson PG, Henning O, Eckmann CAC, Lossius MI, Peltola J. Norwegian population-based study of long-term effects, safety, and predictors of response of vagus nerve stimulation treatment in drug-resistant epilepsy: The NORPulse study. Epilepsia 2021; 63:414-425. [PMID: 34935136 DOI: 10.1111/epi.17152] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/06/2021] [Accepted: 12/08/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study was undertaken to evaluate the efficacy of vagus nerve stimulation (VNS) over time, and to determine which patient groups derive the most benefit. METHODS Long-term outcomes are reported in 436 epilepsy patients from a VNS quality registry (52.8% adults, 47.2% children), with a median follow-up of 75 months. Patients were stratified according to evolution of response into constant responders, fluctuating responders, and nonresponders. The effect was evaluated at 6, 12, 24, 36, and 60 months. Multivariate regression analysis was used to identify predictors of response. RESULTS The cumulative probability of ≥50% seizure reduction was 60%; however, 15% of patients showed a fluctuating course. Of those becoming responders, 89.5% (230/257) did so within 2 years. A steady increase in effect was observed among constant responders, with 48.7% (19/39) of those becoming seizure-free and 29.3% (39/133) with ≥75% seizure reduction achieving these effects within 2-5 years. Some effect (25%-<50%) at 6 months was a positive predictor of becoming a responder (odds ratio [OR] = 10.18, p < .0001) and having ≥75% reduction at 2 years (OR = 3.34, p = .03). Patients without intellectual disability had ORs of 3.34 and 3.11 of having ≥75% reduction at 2 and 5 years, respectively, and an OR of 6.22 of being seizure-free at last observation. Patients with unchanged antiseizure medication over the observation period showed better responder rates at 2 (63.0% vs. 43.1%, p = .002) and 5 years (63.4% vs. 46.3%, p = .031) than patients whose antiseizure medication was modified. Responder rates were higher for posttraumatic (70.6%, p = .048) and poststroke epilepsies (75.0%, p = .05) than other etiologies (46.5%). SIGNIFICANCE Our data indicate that the effect of VNS increases over time and that there are important clinical decision points at 6 and 24 months for evaluating and adjusting the treatment. There should be better selection of candidates, as certain patient groups and epilepsy etiologies respond more favorably.
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Affiliation(s)
| | - Hrisimir Kostov
- National Center for Epilepsy, Oslo University Hospital, Oslo, Norway
| | | | - Oliver Henning
- National Center for Epilepsy, Oslo University Hospital, Oslo, Norway
| | | | - Morten Ingvar Lossius
- National Center for Epilepsy, Oslo University Hospital, Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jukka Peltola
- Department of Neurology, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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Berger A, Vespa S, Dricot L, Dumoulin M, Iachim E, Doguet P, Vandewalle G, El Tahry R. How Is the Norepinephrine System Involved in the Antiepileptic Effects of Vagus Nerve Stimulation? Front Neurosci 2021; 15:790943. [PMID: 34924947 PMCID: PMC8675889 DOI: 10.3389/fnins.2021.790943] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 11/11/2021] [Indexed: 01/09/2023] Open
Abstract
Vagus Nerve Stimulation (VNS) is an adjunctive treatment for patients suffering from inoperable drug-resistant epilepsy. Although a complete understanding of the mediators involved in the antiepileptic effects of VNS and their complex interactions is lacking, VNS is known to trigger the release of neurotransmitters that have seizure-suppressing effects. In particular, norepinephrine (NE) is a neurotransmitter that has been associated with the clinical effects of VNS by preventing seizure development and by inducing long-term plastic changes that could restore a normal function of the brain circuitry. However, the biological requisites to become responder to VNS are still unknown. In this review, we report evidence of the critical involvement of NE in the antiepileptic effects of VNS in rodents and humans. Moreover, we emphasize the hypothesis that the functional integrity of the noradrenergic system could be a determining factor to obtain clinical benefits from the therapy. Finally, encouraging avenues of research involving NE in VNS treatment are discussed. These could lead to the personalization of the stimulation parameters to maximize the antiepileptic effects and potentially improve the response rate to the therapy.
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Affiliation(s)
- Alexandre Berger
- Institute of Neuroscience, Université catholique de Louvain, Brussels, Belgium.,Synergia Medical SA, Mont-Saint-Guibert, Belgium.,GIGA-Cyclotron Research Center-In Vivo Imaging, University of Liège, Liège, Belgium
| | - Simone Vespa
- Institute of Neuroscience, Université catholique de Louvain, Brussels, Belgium
| | - Laurence Dricot
- Institute of Neuroscience, Université catholique de Louvain, Brussels, Belgium
| | - Manon Dumoulin
- Institute of Neuroscience, Université catholique de Louvain, Brussels, Belgium
| | - Evelina Iachim
- Institute of Neuroscience, Université catholique de Louvain, Brussels, Belgium.,Department of Pediatric Neurology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | | | - Gilles Vandewalle
- GIGA-Cyclotron Research Center-In Vivo Imaging, University of Liège, Liège, Belgium
| | - Riëm El Tahry
- Institute of Neuroscience, Université catholique de Louvain, Brussels, Belgium.,Center for Refractory Epilepsy, Department of Neurology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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Abstract
Three neuromodulation therapies, all using implanted device and electrodes, have been
approved to treat adults with drug-resistant focal epilepsy, namely, the vagus nerve
stimulation in 1995, deep brain stimulation of the anterior nucleus of the thalamus
(ANT-DBS) in 2018 (2010 in Europe), and responsive neurostimulation (RNS) in 2014.
Indications for VNS have more recently extended to children down to age of 4. Limited or
anecdotal data are available in other epilepsy syndromes and refractory/super-refractory
status epilepticus. Overall, neuromodulation therapies are palliative, with only a
minority of patients achieving long-term seizure freedom, justifying favoring such
treatments in patients who are not good candidates for curative epilepsy surgery. About
half of patients implanted with VNS, ANT-DBS, and RNS have 50% or greater reduction in
seizures, with long-term data suggesting increased efficacy over time. Besides their
impact on seizure frequency, neuromodulation therapies are associated with various
benefits and drawbacks in comparison to antiseizure drugs. Yet, we lack high-level
evidence to best position each neuromodulation therapy in the treatment pathways of
persons with difficult-to-treat epilepsy.
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Affiliation(s)
- Philippe Ryvlin
- Department of Clinical Neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Lara E. Jehi
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
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Comparison of traditional and closed loop vagus nerve stimulation for treatment of pediatric drug-resistant epilepsy: A propensity-matched retrospective cohort study. Seizure 2021; 94:74-81. [PMID: 34872020 DOI: 10.1016/j.seizure.2021.11.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/08/2021] [Accepted: 11/23/2021] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE For epilepsy patients with drug-resistant, unresectable epilepsy, vagus nerve stimulation (VNS) is an option for seizure control. Approximately 40-70% of patients will achieve ≥50% seizure reduction with VNS. New closed loop VNS models detect ictal tachycardia and responsively stimulate the vagus nerve. The effectiveness of closed loop VNS compared to traditional VNS for pediatric epilepsy is unknown. METHODS An 11-year retrospective electronic medical record review at Children's Hospital of Pittsburgh was performed. Patients with drug-resistant epilepsy who underwent VNS implantation were included. Patients were divided into groups based on VNS model: traditional versus closed loop. Those who transitioned from traditional to closed loop VNS were excluded. Given potential for selection bias, propensity scores matching was utilized to compare traditional to closed loop VNS patients. Patients with focal versus generalized epilepsy were also separately analyzed. The primary outcome was "VNS response", defined as at least 50% seizure frequency reduction from baseline. RESULTS A total of 320 patients were included in this sample. The percentage of matched patients (total n = 220: n = 179 traditional VNS, n = 41 closed loop VNS) who responded to VNS after one year of therapy was 43% for traditional VNS and 39% for closed loop VNS (p = 0.64). After two years of therapy, a higher proportion of closed loop VNS patients than traditional VNS patients responded to VNS among all subgroups, though no differences were statistically significant (p>0.05). Notably, for those with generalized epilepsy, 73% of closed loop patients responded to VNS compared to only 46% of traditional patients (p = 0.10). After two years of VNS therapy, patients were taking approximately the same quantity of antiseizure medications as baseline (change of +0.074 +/- 0.90 ) with no difference between VNS models (p = 0.87). SIGNIFICANCE Among pediatric patients with drug-resistant epilepsy, closed loop VNS trends towards a higher rate of VNS response after two years of treatment, especially among generalized epilepsy patients. Neither model of VNS allows patients to reduce antiseizure medication quantity after two years.
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Tamura G, Lo WB, Yau I, Vaughan KA, Go C, Singleton WG, Hazon D, Yan H, Otsubo H, Donner EJ, Rutka JT, Ibrahim GM. Patient Characteristics Associated with Seizure Freedom after Vagus Nerve Stimulation in Pediatric Intractable Epilepsy: An Analysis of “Super-Responders”. JOURNAL OF PEDIATRIC EPILEPSY 2021. [DOI: 10.1055/s-0041-1739489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AbstractClinical responses to vagus nerve stimulation (VNS) therapy for intractable epilepsy can be unpredictable, and factors that predict response to therapy are elusive. Minority of children undergoing VNS achieve seizure freedom. The current study aimed to characterize this exceptional patient population, defined as “super-responders” (SRs). Retrospective data were collected from 150 children who underwent VNS at a single pediatric institution. The patients' mean age at VNS device implantation was 12.0 years (range, 3.09–17.9 years). Ten SRs (6.7%) were identified who achieved and maintained seizure freedom for longer than 1 year following implantation. The interval between epilepsy onset and VNS device implantation was significantly shorter in SRs than in the other children (mean epilepsy duration 5.72 vs. 8.44 years, respectively; p = 0.032). SRs also had a significantly shorter proportion of life with epilepsy compared with the other children (mean ratio of epilepsy duration to age at implantation 0.52 vs. 0.71, respectively; p = 0.023). SRs reported their seizure freedom relatively early (six patients within 6 months and all patients within 12 months after implantation) at relatively low device settings (mean output current 0.81 mA at their last follow-up). Compared with conventional models, responsive VNS models with autostimulation features did not increase the ratio of SRs. No other clinical or imaging characteristic difference between SRs and the other children was found in this cohort. The current study showed a significant association between shorter epilepsy duration and shorter proportion of life with epilepsy and seizure freedom after VNS.
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Affiliation(s)
- Goichiro Tamura
- Division of Neurosurgery, University of Toronto, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Division of Pediatric Neurosurgery, Ibaraki Children's Hospital, Mito, Ibaraki, Japan
| | - William B. Lo
- Division of Neurosurgery, University of Toronto, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Department of Neurosurgery, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Ivanna Yau
- Department of Pediatrics, Division of Neurology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Kerry A. Vaughan
- Division of Neurosurgery, University of Toronto, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Cristina Go
- Department of Pediatrics, Division of Neurology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - William G.B. Singleton
- Division of Neurosurgery, University of Toronto, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - David Hazon
- Division of Neurosurgery, University of Toronto, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Han Yan
- Division of Neurosurgery, University of Toronto, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Hiroshi Otsubo
- Department of Pediatrics, Division of Neurology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth J. Donner
- Department of Pediatrics, Division of Neurology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - James T. Rutka
- Division of Neurosurgery, University of Toronto, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - George M. Ibrahim
- Division of Neurosurgery, University of Toronto, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Ryvlin P, Rheims S, Hirsch LJ, Sokolov A, Jehi L. Neuromodulation in epilepsy: state-of-the-art approved therapies. Lancet Neurol 2021; 20:1038-1047. [PMID: 34710360 DOI: 10.1016/s1474-4422(21)00300-8] [Citation(s) in RCA: 101] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 08/22/2021] [Accepted: 09/03/2021] [Indexed: 12/20/2022]
Abstract
Three neuromodulation therapies have been appropriately tested and approved in refractory focal epilepsies: vagus nerve stimulation (VNS), deep brain stimulation of the anterior nucleus of the thalamus (ANT-DBS), and closed-loop responsive neurostimulation of the epileptogenic zone or zones. These therapies are primarily palliative. Only a few individuals have achieved complete freedom from seizures for more than 12 months with these therapies, whereas more than half have benefited from long-term reduction in seizure frequency of more than 50%. Implantation-related adverse events primarily include infection and pain at the implant site. Intracranial haemorrhage is a frequent adverse event for ANT-DBS and responsive neurostimulation. Other stimulation-specific side-effects are observed with VNS and ANT-DBS. Biomarkers to predict response to neuromodulation therapies are not available, and high-level evidence to aid decision making about when and for whom these therapies should be preferred over other antiepileptic treatments is scant. Future studies are thus needed to address these shortfalls in knowledge, approve other forms of neuromodulation, and develop personalised closed-loop therapies with embedded machine learning. Until then, neuromodulation could be considered for individuals with intractable seizures, ideally after the possibility of curative surgical treatment has been carefully assessed and ruled out or judged less appropriate.
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Affiliation(s)
- Philippe Ryvlin
- Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Sylvain Rheims
- Department of Functional Neurology and Epileptology, Hospices Civils de Lyon, Lyon 1 University Lyon Neuroscience Research Center, Institut National de la Santé et de la Recherche Médicale U1028/CNRS UMR 5292 Epilepsy Institute, Lyon, France
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Arseny Sokolov
- Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Lara Jehi
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
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65
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Yang Z, Liu D, Yang Z, Chen X, Cai Y, Liu J, Zhang J, Li S. Efficacy and safety of vagus nerve stimulation in the treatment of refractory epilepsy. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2021; 46:1096-1101. [PMID: 34911839 PMCID: PMC10930241 DOI: 10.11817/j.issn.1672-7347.2021.200209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Vagus nerve stimulation (VNS) is a neuromodulative therapeutic technique for patients with drug-resistant epilepsy who are not suitable for resection or who have experienced a failed resection. This study aims to explore the efficacy and safety of VNS in patients with refractory epilepsy, and to analyze the influential factors for the efficacy. METHODS A retrospective review of clinical data were conducted for 35 patients, who were treated for refractory epilepsy through VNS surgery in the Department of Neurosurgery, Xiangya Hospital, Central South University from April 2016 to August 2019. All patients were analyzed in terms of the clinical and follow-up data. RESULTS After a mean follow-up of 26 months (6-47 months), outcome was as follows: 7 patients were MuHugh class I, 13 patients were MuHugh class II, 8 patients were MuHugh class III, and 7 patients were MuHugh class IV-V. The total efficacy rate in the short duration group was significantly higher than that in the long duration group (77.8% vs 50.0%, P=0.013), whereas different ages (P=0.382), gender (P=0.824), types of seizure (P=0.829), and MRI features (P=0.791) showed no correlation with efficacy. None patients developed permanent complication postoperatively. CONCLUSIONS VNS is a safe and effective option in treating patients with refractory epilepsy, especially for those with short duration.
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Affiliation(s)
- Zhuanyi Yang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha 410008, China.
| | - Dingyang Liu
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Zhiquan Yang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha 410008, China.
| | - Xiaoyu Chen
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Yuxiang Cai
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Jian Liu
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Junmei Zhang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Sushan Li
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha 410008, China
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66
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Cooper CM, Farrand AQ, Andresen MC, Beaumont E. Vagus nerve stimulation activates nucleus of solitary tract neurons via supramedullary pathways. J Physiol 2021; 599:5261-5279. [PMID: 34676533 DOI: 10.1113/jp282064] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 10/12/2021] [Indexed: 01/20/2023] Open
Abstract
Vagus nerve stimulation (VNS) treats patients with drug-resistant epilepsy, depression and heart failure, but the mechanisms responsible are uncertain. The mild stimulus intensities used in chronic VNS suggest activation of myelinated primary visceral afferents projecting to the nucleus of the solitary tract (NTS). Here, we monitored the activity of second and higher order NTS neurons in response to peripheral vagal activation using therapeutic VNS criteria. A bipolar stimulating electrode activated the left cervical vagus nerve, and stereotaxically placed single tungsten electrodes recorded unit activity from the left caudomedial NTS of chloralose-anaesthetized rats. High-intensity single electrical stimuli established vagal afferent conduction velocity (myelinated A-type or unmyelinated C-type) as well as synaptic order (second vs. higher order using paired electrical stimuli) for inputs to single NTS neurons. Then, VNS treatment was applied. A mid-collicular knife cut (KC) divided the brainstem from all supramedullary regions to determine their contribution to NTS activity. Our chief findings indicate that the KC reduced basal spontaneous activity of second-order NTS neurons receiving myelinated vagal input by 85%. In these neurons, acute VNS increased activity similarly in Control and KC animals. Interestingly, the KC interrupted VNS activation of higher order NTS neurons and second-order NTS neurons receiving unmyelinated vagal input, indicating that supramedullary descending projections to NTS are needed to amplify the peripheral neuronal signal from VNS. The present study begins to define the pathways activated during VNS and will help to better identify the central nervous system contributions to the therapeutic benefits of VNS therapy. KEY POINTS: Vagus nerve stimulation is routinely used in the clinic to treat epilepsy and depression, despite our uncertainty about how this treatment works. For this study, the connections between the nucleus of the solitary tract (NTS) and the higher brain regions were severed to learn more about their contribution to activity of these neurons during stimulation. Severing these brain connections reduced baseline activity as well as reducing stimulation-induced activation for NTS neurons receiving myelinated vagal input. Higher brain regions play a significant role in maintaining both normal activity in NTS and indirect mechanisms of enhancing NTS neuronal activity during vagus nerve stimulation.
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Affiliation(s)
- Coty M Cooper
- Department of Biomedical Sciences, Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Ariana Q Farrand
- Department of Biomedical Sciences, Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | | | - Eric Beaumont
- Department of Biomedical Sciences, Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
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67
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Zhu B, Shin U, Shoaran M. Closed-Loop Neural Prostheses With On-Chip Intelligence: A Review and a Low-Latency Machine Learning Model for Brain State Detection. IEEE TRANSACTIONS ON BIOMEDICAL CIRCUITS AND SYSTEMS 2021; 15:877-897. [PMID: 34529573 PMCID: PMC8733782 DOI: 10.1109/tbcas.2021.3112756] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
The application of closed-loop approaches in systems neuroscience and therapeutic stimulation holds great promise for revolutionizing our understanding of the brain and for developing novel neuromodulation therapies to restore lost functions. Neural prostheses capable of multi-channel neural recording, on-site signal processing, rapid symptom detection, and closed-loop stimulation are critical to enabling such novel treatments. However, the existing closed-loop neuromodulation devices are too simplistic and lack sufficient on-chip processing and intelligence. In this paper, we first discuss both commercial and investigational closed-loop neuromodulation devices for brain disorders. Next, we review state-of-the-art neural prostheses with on-chip machine learning, focusing on application-specific integrated circuits (ASIC). System requirements, performance and hardware comparisons, design trade-offs, and hardware optimization techniques are discussed. To facilitate a fair comparison and guide design choices among various on-chip classifiers, we propose a new energy-area (E-A) efficiency figure of merit that evaluates hardware efficiency and multi-channel scalability. Finally, we present several techniques to improve the key design metrics of tree-based on-chip classifiers, both in the context of ensemble methods and oblique structures. A novel Depth-Variant Tree Ensemble (DVTE) is proposed to reduce processing latency (e.g., by 2.5× on seizure detection task). We further develop a cost-aware learning approach to jointly optimize the power and latency metrics. We show that algorithm-hardware co-design enables the energy- and memory-optimized design of tree-based models, while preserving a high accuracy and low latency. Furthermore, we show that our proposed tree-based models feature a highly interpretable decision process that is essential for safety-critical applications such as closed-loop stimulation.
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Vespa S, Heyse J, Stumpp L, Liberati G, Ferrao Santos S, Rooijakkers H, Nonclercq A, Mouraux A, van Mierlo P, El Tahry R. Vagus Nerve Stimulation Elicits Sleep EEG Desynchronization and Network Changes in Responder Patients in Epilepsy. Neurotherapeutics 2021; 18:2623-2638. [PMID: 34668148 PMCID: PMC8804116 DOI: 10.1007/s13311-021-01124-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2021] [Indexed: 12/23/2022] Open
Abstract
Neural desynchronization was shown as a key mechanism of vagus nerve stimulation (VNS) action in epilepsy, and EEG synchronization measures are explored as possible response biomarkers. Since brain functional organization in sleep shows different synchrony and network properties compared to wakefulness, we aimed to explore the effects of acute VNS on EEG-derived measures in the two different states of vigilance. EEG epochs were retrospectively analyzed from twenty-four VNS-treated epileptic patients (11 responders, 13 non-responders) in calm wakefulness and stage N2 sleep. Weighted Phase Lag Index (wPLI) was computed as connectivity measure of synchronization, for VNS OFF and VNS ON conditions. Global efficiency (GE) was computed as a network measure of integration. Ratios OFF/ON were obtained as desynchronization/de-integration index. Values were compared between responders and non-responders, and between EEG states. ROC curve and area-under-the-curve (AUC) analysis was performed for response classification. In responders, stronger VNS-induced theta desynchronization (p < 0.05) and decreased GE (p < 0.05) were found in sleep, but not in wakefulness. Theta sleep wPLI Ratio OFF/ON yielded an AUC of 0.825, and 79% accuracy as a response biomarker if a cut-off value is set at 1.05. Considering all patients, the VNS-induced GE decrease was significantly more important in sleep compared to awake EEG state (p < 0.01). In conclusion, stronger sleep EEG desynchronization in theta band distinguishes responders to VNS therapy from non-responders. VNS-induced reduction of network integration occurs significantly more in sleep than in wakefulness.
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Affiliation(s)
- Simone Vespa
- Institute of Neuroscience (IONS), Université Catholique de Louvain, Avenue Mounier, 53 - 1200, Brussels, Belgium.
| | - Jolan Heyse
- Medical Image and Signal Processing Group (MEDISIP), Ghent University, Ghent, Belgium
| | - Lars Stumpp
- Institute of Neuroscience (IONS), Université Catholique de Louvain, Avenue Mounier, 53 - 1200, Brussels, Belgium
| | - Giulia Liberati
- Institute of Neuroscience (IONS), Université Catholique de Louvain, Avenue Mounier, 53 - 1200, Brussels, Belgium
| | - Susana Ferrao Santos
- Institute of Neuroscience (IONS), Université Catholique de Louvain, Avenue Mounier, 53 - 1200, Brussels, Belgium
- Centre for Refractory Epilepsy, Department of Neurology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Herbert Rooijakkers
- Centre for Refractory Epilepsy, Department of Neurology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Antoine Nonclercq
- Bio, Electro and Mechanical Systems (BEAMS), Université Libre de Bruxelles, Brussels, Belgium
| | - André Mouraux
- Institute of Neuroscience (IONS), Université Catholique de Louvain, Avenue Mounier, 53 - 1200, Brussels, Belgium
| | - Pieter van Mierlo
- Medical Image and Signal Processing Group (MEDISIP), Ghent University, Ghent, Belgium
| | - Riëm El Tahry
- Institute of Neuroscience (IONS), Université Catholique de Louvain, Avenue Mounier, 53 - 1200, Brussels, Belgium
- Centre for Refractory Epilepsy, Department of Neurology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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Pan D, Li X, Jiang J, Luo L. Effect of levetiracetam in combination with topiramate on immune function, cognitive function, and neuronal nutritional status of children with intractable epilepsy. Am J Transl Res 2021; 13:10459-10468. [PMID: 34650715 PMCID: PMC8506992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 05/26/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To determine the effects of levetiracetam in combination with topiramate on immune function, cognitive function, and the neuronal nutritional status of children with intractable epilepsy. METHODS This study enrolled 124 children with intractable epilepsy who were admitted to our hospital. The control group included 58 children treated with topiramate, and the observation group included 66 children treated with levetiracetam and topiramate. Flow cytometry was used to determine CD4+ and CD8+ T cell counts before and after treatment in both groups. RESULTS After treatment, the observation group exhibited significantly higher CD4+ T cell counts and BDNF and NGF levels and significantly lower CD8+ T cell counts and IL-6, IL-1β, and MMP-9 levels than the control group. The FIQ and VIQ of the observation group were also significantly higher than those of the control group. Additionally, the incidence rates of adverse events were not significantly different between the observation and the control groups. Finally, IL-6, IL-1β, and MMP-9 were negatively correlated with full-scale intelligence quotient (FIQ) and virtual inhibitory quotient (VIQ). CONCLUSIONS Levetiracetam in combination with topiramate is associated with reduced inflammatory response and improved immune function, cognitive function, and neuronal nutritional status in children with intractable epilepsy.
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Affiliation(s)
- Danfeng Pan
- Department of Pediatrics, The First People's Hospital of Wenling Wenling 317500, Zhejiang, China
| | - Xiaoxiao Li
- Department of Pediatrics, The First People's Hospital of Wenling Wenling 317500, Zhejiang, China
| | - Jinbiao Jiang
- Department of Pediatrics, The First People's Hospital of Wenling Wenling 317500, Zhejiang, China
| | - Lingling Luo
- Department of Pediatrics, The First People's Hospital of Wenling Wenling 317500, Zhejiang, China
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Sun Y, Chen J, Fang T, Wan L, Shi X, Wang J, Li Z, Wang J, Cui Z, Xu X, Ling Z, Zou L, Yang G. Vagus Nerve Stimulation Therapy for the Treatment of Seizures in Refractory Postencephalitic Epilepsy: A Retrospective Study. Front Neurosci 2021; 15:685685. [PMID: 34489622 PMCID: PMC8418307 DOI: 10.3389/fnins.2021.685685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/31/2021] [Indexed: 11/23/2022] Open
Abstract
Background Vagus nerve stimulation (VNS) has been demonstrated to be safe and effective for patients with refractory epilepsy, but there are few reports on the use of VNS for postencephalitic epilepsy (PEE). This retrospective study aimed to evaluate the efficacy of VNS for refractory PEE. Methods We retrospectively studied 20 patients with refractory PEE who underwent VNS between August 2017 and October 2019 in Chinese PLA General Hospital and Beijing Children’s Hospital. VNS efficacy was evaluated based on seizure reduction, effective rate (percentage of cases with seizure reduction ≥ 50%), McHugh classification, modified Early Childhood Epilepsy Severity Scale (E-Chess) score, and Grand Total EEG (GTE) score. The follow-up time points were 3, 6, and 12 months after VNS. Pre- and postoperative data were compared and analyzed. Results The median [interquartile range (IQR)] seizure reduction rates at 3, 6, and 12 months after VNS were 23.72% (0, 55%), 46.61% (0, 79.04%), and 67.99% (0, 93.78%), respectively. The effective rates were 30% at 3 months, 45% at 6 months, and 70% at 12 months. E-chess scores before the operation and at 3, 6, and 12 months after the operation were 10 (10, 10.75), 9 (9, 10), 9 (9, 9.75), and 9 (8.25, 9) (P < 0.05), respectively. GTE scores before surgery and at 12 months after the operation were 11 (9, 13) and 9 (7, 11) (P < 0.05), respectively. The mean intensity of VNS current was 1.76 ± 0.39 (range: 1.0–2.5) mA. No intraoperative complications or severe post-operative adverse effects were reported. Conclusions Our study shows that VNS can reduce the frequency and severity of seizure in patients with refractory PEE. VNS has a good application prospect in patients with refractory PEE.
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Affiliation(s)
- Yulin Sun
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, China.,Department of Pediatrics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jian Chen
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, China.,Department of Pediatrics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Tie Fang
- Department of Functional Neurosurgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Lin Wan
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, China.,Department of Pediatrics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xiuyu Shi
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, China.,Department of Pediatrics, The First Medical Center, Chinese PLA General Hospital, Beijing, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Jing Wang
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, China.,Department of Pediatrics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Zhichao Li
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, China.,Department of Pediatrics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jiaxin Wang
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, China.,Department of Pediatrics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Zhiqiang Cui
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Xin Xu
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Zhipei Ling
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Liping Zou
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, China.,Department of Pediatrics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Guang Yang
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, China.,Department of Pediatrics, The First Medical Center, Chinese PLA General Hospital, Beijing, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
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71
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Harcourt-Brown TR, Carter M. Implantable vagus nerve stimulator settings and short-term adverse effects in epileptic dogs. J Vet Intern Med 2021; 35:2350-2358. [PMID: 34472639 PMCID: PMC8478022 DOI: 10.1111/jvim.16226] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 07/02/2021] [Accepted: 07/13/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Implantable vagus nerve stimulation (VNS) devices can be used to treat epilepsy in dogs. Adverse effects and short-term complications associated with delivering suggested therapeutic electrical stimulation (>1.5 mA) are not well-described. OBJECTIVES To compare complications and adverse effects observed with standard and rapid protocols of current increase. ANIMALS Sixteen client-owned dogs with idiopathic epilepsy. METHODS Nonrandomized, nonblinded prospective cohort study. Surgical complications, stimulation-related adverse effects, modifications to stimulator settings, number of hospital visits, and time to reach 1.5 mA stimulation current without intolerable adverse effects were described in dogs receiving current increases every 1 to 3 weeks (slow ramping) and dogs receiving current increases every 8 to 12 hours (fast ramping). RESULTS Self-resolving surgery site seromas formed in 6 dogs. No other surgical complications were observed. Fourteen dogs reached 1.5 mA. Coughing (11/14 dogs; 5 slow, 6 fast ramping) was the most common adverse effect. Intolerable coughing that limited current increases despite changing other stimulus parameters occurred in 6/7 of the fast-ramping group and in none of the slow-ramping group. Median time to 1.5 mA was 72 days (range, 28-98) in the slow-ramping group and 77 days (range, 3-152) in the fast-ramping group. Median number of clinic visits was 6 for the slow-ramping group (range, 5-6) and 3 for the fast-ramping group (range, 1-7). CONCLUSIONS AND CLINICAL IMPORTANCE Coughing is a common adverse effect of VNS in dogs and generally is well tolerated, particularly if current is increased slowly and other stimulation parameters are adapted for effect.
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Affiliation(s)
| | - Michael Carter
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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72
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Factors Affecting Vagus Nerve Stimulation Outcomes in Epilepsy. Neurol Res Int 2021; 2021:9927311. [PMID: 34394987 PMCID: PMC8357517 DOI: 10.1155/2021/9927311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/06/2021] [Accepted: 07/30/2021] [Indexed: 11/18/2022] Open
Abstract
Epilepsy as a common neurological disease is mostly managed effectively with antiepileptic medications. One-third of patients do not respond to medical treatments requiring alternative therapies. Vagus nerve stimulation (VNS) has been used in the last decades for the treatment of medically resistant epilepsy. Despite the extensive use of VNS in these patients, factors associated with clinical outcomes of VNS remain to be elucidated. In this study, we evaluated factors affecting VNS outcomes in epileptic patients to have a better understanding of patients who are better candidates for VNS therapy. Several databases including PubMed, Scopus, and Google Scholar were searched through June 2020 for relevant articles. The following factors were assessed in this review: previous surgical history, age at implantation and gender, types of epilepsy, duration of epilepsy, age at epilepsy onset, frequency of attacks, antiepileptic drugs, VNS parameters, EEG findings, MRI findings, and biomarkers. Literature data show that nonresponder rates range between 25% and 65%. Given the complexity and diversity of factors associated with response to VNS, more clinical studies are needed to establish better paradigm for selection of patients for VNS therapy.
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73
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Kulju T, Haapasalo J, Verner R, Dibué-Adjei M, Lehtimäki K, Rainesalo S, Peltola J. Frequency of Automatic Stimulations in Responsive Vagal Nerve Stimulation in Patients With Refractory Epilepsy. Neuromodulation 2021; 23:852-858. [PMID: 32840019 DOI: 10.1111/ner.13238] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/02/2020] [Accepted: 06/15/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND In vagal nerve stimulation (VNS) therapy, the release of VNS model 106 (AspireSR) allowed for responsive VNS (rVNS). rVNS utilizes a cardiac-based seizure detection algorithm to detect seizure-induced tachycardia to trigger additional stimulation. There are some studies suggesting clinical benefits of rVNS over traditional VNS, but the performance and significance of autostimulation mode in clinical practice are poorly understood. OBJECTIVES To assess the effect of initiation of rVNS therapy and altered stimulation settings on the number of daily stimulations and energy consumption in VNS therapy and to compare autostimulation performance in different epilepsy types. MATERIALS AND METHODS Retrospective follow-up of 30 patients with drug-resistant epilepsy treated with rVNS including 17 new implantations and 13 battery replaces at a single center in Finland. Our data consist of 208 different stimulation periods, that is, episodes with defined stimulation settings and both autostimulation and total stimulation performance-related data along with clinical follow-up. RESULTS The variation in autostimulation frequency was highly dependent on the duration of the OFF-time and autostimulation threshold (p < 0.05). There was a large additional effect of autostimulation mode on therapy time and energy consumption with longer OFF-times, but a minor effect with shorter OFF-times. Significantly more autostimulations were triggered in the temporal lobe and multifocal epilepsies than in extratemporal lobe epilepsies. CONCLUSIONS The initiation of autostimulation mode in VNS therapy increased the total number of stimulations. Shortening the OFF-time leads to a decreased number and share of automatic activations. Epilepsy type may affect autostimulation activity.
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Affiliation(s)
- Toni Kulju
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Joonas Haapasalo
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland.,The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Ryan Verner
- LivaNova USA, Neuromodulation Unit, Houston, TX, USA
| | - Maxine Dibué-Adjei
- Neuromodulation Medical Affairs, LivaNova PLC, London, UK.,Department of Neurosurgery, Heinrich Heine University Düsseldorf, Germany
| | - Kai Lehtimäki
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland
| | - Sirpa Rainesalo
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland
| | - Jukka Peltola
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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74
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Fang X, Liu HY, Wang ZY, Yang Z, Cheng TY, Hu CH, Hao HW, Meng FG, Guan YG, Ma YS, Liang SL, Lin JL, Zhao MM, Li LM. Preoperative Heart Rate Variability During Sleep Predicts Vagus Nerve Stimulation Outcome Better in Patients With Drug-Resistant Epilepsy. Front Neurol 2021; 12:691328. [PMID: 34305797 PMCID: PMC8292667 DOI: 10.3389/fneur.2021.691328] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 05/28/2021] [Indexed: 01/03/2023] Open
Abstract
Objective: Vagus nerve stimulation (VNS) is an adjunctive and well-established treatment for patients with drug-resistant epilepsy (DRE). However, it is still difficult to identify patients who may benefit from VNS surgery. Our study aims to propose a VNS outcome prediction model based on machine learning with multidimensional preoperative heart rate variability (HRV) indices. Methods: The preoperative electrocardiography (ECG) of 59 patients with DRE and of 50 healthy controls were analyzed. Responders were defined as having at least 50% average monthly seizure frequency reduction at 1-year follow-up. Time domain, frequency domain, and non-linear indices of HRV were compared between 30 responders and 29 non-responders in awake and sleep states, respectively. For feature selection, univariate filter and recursive feature elimination (RFE) algorithms were performed to assess the importance of different HRV indices to VNS outcome prediction and improve the classification performance. Random forest (RF) was used to train the classifier, and leave-one-out (LOO) cross-validation was performed to evaluate the prediction model. Results: Among 52 HRV indices, 49 showed significant differences between DRE patients and healthy controls. In sleep state, 35 HRV indices of responders were significantly higher than those of non-responders, while 16 of them showed the same differences in awake state. Low-frequency power (LF) ranked first in the importance ranking results by univariate filter and RFE methods, respectively. With HRV indices in sleep state, our model achieved 74.6% accuracy, 80% precision, 70.6% recall, and 75% F1 for VNS outcome prediction, which was better than the optimal performance in awake state (65.3% accuracy, 66.4% precision, 70.5% recall, and 68.4% F1). Significance: With the ECG during sleep state and machine learning techniques, the statistical model based on preoperative HRV could achieve a better performance of VNS outcome prediction and, therefore, help patients who are not suitable for VNS to avoid the high cost of surgery and possible risks of long-term stimulation.
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Affiliation(s)
- Xi Fang
- National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China
| | - Hong-Yun Liu
- National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China.,Medical Innovation Research Division, Research Center for Biomedical Engineering, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Zhi-Yan Wang
- National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China
| | - Zhao Yang
- National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China
| | - Tung-Yang Cheng
- National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China
| | - Chun-Hua Hu
- National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China
| | - Hong-Wei Hao
- National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China
| | - Fan-Gang Meng
- Department of Neurosurgery, Beijing Neurosurgical Institute, Beijing, China.,Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Yu-Guang Guan
- Department of Neurosurgery, Sanbo Brain Hospital Capital Medical University, Beijing, China
| | - Yan-Shan Ma
- Department of Neurosurgery, Peking University First Hospital FengTai Hospital, Beijing, China
| | - Shu-Li Liang
- Department of Neurosurgery, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jiu-Luan Lin
- Department of Neurosurgery, Tsinghua University Yuquan Hospital, Beijing, China
| | - Ming-Ming Zhao
- Department of Neurosurgery, Aerospace Center Hospital, Beijing, China
| | - Lu-Ming Li
- National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China.,Precision Medicine and Healthcare Research Center, Tsinghua-Berkeley Shenzhen Institute, Shenzhen, China.,Institute of Human-Machine, School of Aerospace Engineering, Tsinghua University, Beijing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
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75
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Rincon N, Barr D, Velez-Ruiz N. Neuromodulation in Drug Resistant Epilepsy. Aging Dis 2021; 12:1070-1080. [PMID: 34221550 PMCID: PMC8219496 DOI: 10.14336/ad.2021.0211] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 02/11/2021] [Indexed: 12/26/2022] Open
Abstract
Epilepsy affects approximately 70 million people worldwide, and it is a significant contributor to the global burden of neurological disorders. Despite the advent of new AEDs, drug resistant-epilepsy continues to affect 30-40% of PWE. Once identified as having drug-resistant epilepsy, these patients should be referred to a comprehensive epilepsy center for evaluation to establish if they are candidates for potential curative surgeries. Unfortunately, a large proportion of patients with drug-resistant epilepsy are poor surgical candidates due to a seizure focus located in eloquent cortex, multifocal epilepsy or inability to identify the zone of ictal onset. An alternative treatment modality for these patients is neuromodulation. Here we present the evidence, indications and safety considerations for the neuromodulation therapies in vagal nerve stimulation (VNS), responsive neurostimulation (RNS), or deep brain stimulation (DBS).
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Affiliation(s)
- Natalia Rincon
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Donald Barr
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Naymee Velez-Ruiz
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
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76
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Armstrong C, Marsh ED. Electrophysiological Biomarkers in Genetic Epilepsies. Neurotherapeutics 2021; 18:1458-1467. [PMID: 34642905 PMCID: PMC8609056 DOI: 10.1007/s13311-021-01132-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2021] [Indexed: 02/04/2023] Open
Abstract
Precision treatments for epilepsy targeting the underlying genetic diagnoses are becoming a reality. Historically, the goal of epilepsy treatments was to reduce seizure frequency. In the era of precision medicine, however, outcomes such as prevention of epilepsy progression or even improvements in cognitive functions are both aspirational targets for any intervention. Developing methods, both in clinical trial design and in novel endpoints, will be necessary for measuring, not only seizures, but also the other neurodevelopmental outcomes that are predicted to be targeted by precision treatments. Biomarkers that quantitatively measure disease progression or network level changes are needed to allow for unbiased measurements of the effects of any gene-level treatments. Here, we discuss some of the promising electrophysiological biomarkers that may be of use in clinical trials of precision therapies, as well as the difficulties in implementing them.
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Affiliation(s)
- Caren Armstrong
- Division of Neurology and Pediatric Epilepsy Program, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Eric D Marsh
- Division of Neurology and Pediatric Epilepsy Program, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA.
- Department of Pediatrics and Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.
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77
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von Wrede R, Surges R. Transcutaneous vagus nerve stimulation in the treatment of drug-resistant epilepsy. Auton Neurosci 2021; 235:102840. [PMID: 34246121 DOI: 10.1016/j.autneu.2021.102840] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/22/2021] [Accepted: 06/24/2021] [Indexed: 01/16/2023]
Abstract
Epilepsy is a common chronic neurological disease with a high burden of illness. Invasive vagus nerve stimulation (iVNS) is a well-established treatment option in patients with epilepsy (PWE). More recently, transcutaneous vagus nerve stimulation (tVNS) was introduced, an alternative option which is particularly interesting because it does not require surgery and is instantaneously removable. Here, we thoroughly reviewed clinical data on efficacy and safety of tVNS in epilepsies. Five prospective trials in 118 patients with drug-resistant epilepsies and 3 randomized controlled trials in 280 patients with drug-resistant epilepsies were carried out. Study protocols were heterogeneous in terms of patients' characteristics, used device, stimulation parameters, study duration and endpoints. Seizure reduction amounted up to 64%, with responder rates (seizure reduction ≥50%) up to 65%. Seizure freedom was reached in up to 24%, and even to 31% in a small pediatric study group. Seizure severity scores were provided in 4 studies, showing significant improvement in two of them. Adverse side effects were mostly headache, ear pain and skin alteration and rated as mild to moderate. Drowsiness might be depend on stimulation intensity. Quality of life scores reflecting burden of illness showed significant improvement in two studies. Efficacy and safety of tVNS in PWE has to be interpreted as promising. Multicenter randomized double-blind clinical trials with standardized stimulation protocols and long-term follow-up studies are necessary to finally assess tVNS treatment outcome in drug-resistant epilepsies.
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Affiliation(s)
- Randi von Wrede
- Department of Epileptology, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany.
| | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
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78
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Doddamani RS, Agrawal M, Samala R, Ramanujam B, Chandra PS, Tripathi M. Vagal Nerve Stimulation in the Management of Epilepsy - Recent Concepts. Neurol India 2021; 68:S259-S267. [PMID: 33318360 DOI: 10.4103/0028-3886.302475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Epilepsy surgery currently offers the best treatment for patients with drug-refractory epilepsy (DRE). Resective surgery, in the presence of a well-localized epileptogenic focus, remains the best modality towards achieving seizure freedom. However, localization of the focus may not be possible in all the cases of DRE, despite comprehensive epilepsy workup. Neuromodulation techniques such as vagal nerve stimulation (VNS), deep brain stimulation (DBS) and responsive neurostimulation (RNS) may be a good alternative in these cases. This article intends to provide an overview of VNS in the management of DRE, including indications, comprehensive preoperative workup, exemplified by case illustrations and outcomes by reviewing the evidence available in the literature.
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Affiliation(s)
| | - Mohit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Raghu Samala
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Bhargavi Ramanujam
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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79
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Comparison of efficiency between VNS and ANT-DBS therapy in drug-resistant epilepsy: A one year follow up study. J Clin Neurosci 2021; 90:112-117. [PMID: 34275533 DOI: 10.1016/j.jocn.2021.05.046] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/04/2021] [Accepted: 05/23/2021] [Indexed: 11/19/2022]
Abstract
Vagus nerve stimulation (VNS) and anterior thalamic deep brain stimulation (ANT-DBS) have both been used for treatments of drug-resistant epilepsy (DRE). However, there is no comparative study on the effectiveness of two methods from one single center. 17 patients with DRE who underwent VNS therapy and 18 patients who underwent DBS were enrolled. A retrospective study was performed starting from baseline before operation extending to 12 months after operation. The seizure types, duration of epilepsy, age at implantation, failed numbers of antiepileptic drugs (AEDs) before operation, history of craniotomy, stimulation parameters and response rate were described. The analysis of liner regression on the age of onset, duration of epilepsy, numbers of AEDs, and the seizure reduction at 12 months after operation was applied. The mean seizure reduction in patients with DBS at 3, 6, 9 and 12 months after the operation was 57.22%, 61.61%, 63.94% and 65.28%, and that in cases with VNS was 36.06%, 39.94%, 45.24% and 48.35%, respectively. At 1 year after the operation, the patients with older operation age, focal seizures and older age of onset responded better to VNS; and those older operation age, focal generalized seizures, history of craniotomy and longer duration of disease responded better to DBS. The efficiency of ANT-DBS was higher than that of VNS at each follow up time point. Patients can choose the appropriate treatment according to the individual clinical characteristics.
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80
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Katagiri M, Otsubo H, Kagawa K, Seyama G, Hashizume A, Okamura A, Ishikawa N, Hanaya R, Arita K, Kurisu K, Iida K. Interpersonal communication skills related to seizure outcomes in pediatric patients with vagus nerve stimulation. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.101080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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81
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Jain P, Arya R. Vagus Nerve Stimulation and Seizure Outcomes in Pediatric Refractory Epilepsy: Systematic Review and Meta-analysis. Neurology 2021; 96:1041-1051. [PMID: 33849993 DOI: 10.1212/wnl.0000000000012030] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 02/18/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We synthesized evidence for effectiveness of vagus nerve stimulation (VNS) as adjuvant therapy in pediatric drug-resistant epilepsy (DRE) by obtaining pooled estimates for seizure outcomes and analyzing their determinants. METHODS MEDLINE, EMBASE, and Cochrane databases were searched up to July 2019 for original research on VNS in pediatric (≤18 years of age) epilepsy. The primary outcome was 50% responder rate (50% RR), the proportion of patients with ≥50% seizure reduction, at the last reported follow-up. Other outcomes included a 50% RR and proportion of seizure-free patients at additional reported time points. A random-effects meta-analysis with restricted maximum likelihood estimation was performed to obtain pooled effect estimates. Meta-regression using multiple linear models was performed to obtain determinants of seizure outcomes and sources of heterogeneity. RESULTS A total of 101 studies were included. The pooled prevalence estimates for a 50% RR and seizure freedom at last follow-up (mean 2.54 years) were 56.4% (95% confidence intervals [CIs] 52.4, 60.4) and 11.6% (95% CI 9.6, 13.9), respectively. Fewer antiseizure medications (ASMs) tried before VNS and later age at onset of seizures were associated with better seizure outcomes following VNS implantation. An effect of sex distribution of studies on long-term outcomes and a potential publication bias for short-term outcomes were also observed. CONCLUSION Pooled evidence supports possible effectiveness of VNS in pediatric DRE, although complete seizure freedom is less common. Early referral (fewer trials of ASMs) may be a modifiable factor for desirable seizure outcomes with VNS from a clinical perspective.
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Affiliation(s)
- Puneet Jain
- From the Epilepsy Program (P.J.), Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Division of Pediatric Neurology (P.J.), Department of Pediatrics, Danat Al Emarat Hospital for Women and Children, Abu Dhabi, United Arab Emirates; Comprehensive Epilepsy Center (R.A.), Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; and Department of Pediatrics (R.A.), University of Cincinnati College of Medicine, Cincinnati, OH
| | - Ravindra Arya
- From the Epilepsy Program (P.J.), Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Division of Pediatric Neurology (P.J.), Department of Pediatrics, Danat Al Emarat Hospital for Women and Children, Abu Dhabi, United Arab Emirates; Comprehensive Epilepsy Center (R.A.), Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; and Department of Pediatrics (R.A.), University of Cincinnati College of Medicine, Cincinnati, OH.
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82
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Lampros M, Vlachos N, Zigouris A, Voulgaris S, Alexiou GA. Transcutaneous Vagus Nerve Stimulation (t-VNS) and epilepsy: A systematic review of the literature. Seizure 2021; 91:40-48. [PMID: 34090145 DOI: 10.1016/j.seizure.2021.05.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/19/2021] [Accepted: 05/21/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Transcutaneous auricular vagus nerve stimulation (t-VNS) has been proposed as an alternative method for the treatment of various neurological and psychiatric disorders. Contrary to the classic invasive vagus nerve stimulation (i-VNS), t-VNS does not require surgical intervention. The application of t-VNS for the treatment of epilepsy has been poorly studied. Hence, we performed a systematic review of the literature to elucidate efficacy, adverse effects and technical features of t-VNS in patients with epilepsy. MATERIAL AND METHODS We systematically searched MEDLINE and SCOPUS databases using the following keywords: [TRANSCUTANEOUS VAGUS NERVE STIMULATION OR TRANSCUTANEOUS VAGAL NERVE STIMULATION] AND [EPILEPSY OR SEIZURES]. We searched for observational studies in English concerning the application of t-VNS for the treatment of epilepsy in humans. The full-text version of relevant studies was obtained and reviewed. Technical parameters of the stimulation, percentage of seizure frequency reduction, QOLIE-31(Quality of Life In Epilepsy-31) and LSSS (Liverpool Seizure Severity Scale) questionnaires and adverse effects were recorded and analyzed. RESULTS A total of 10 studies with 350 patients were included. Both bilateral and unilateral placement of the electrode were applied. Stimulation frequency varied from 10-30Hz, while treatment intensity was usually adjusted according to patients' preferences and tolerance (around 1mA) and below the pain threshold. In the clinical trials included in our review, the mean seizure frequency reduction varied from 30 to 65%. Eight and four studies provided information about QOLIE-31 and LSSS questionnaires respectively. Three studies reported a statistically significant (p<0,05) improvement in patients' quality of life and two studies reported statistically significant (p<0,05) seizure severity reduction. The most common side effect was headache (8,9%), followed by skin irritation at the placement site (7,1%) and nasopharyngitis (5,1%). No serious or life-threatening side effects were reported. CONCLUSION Due to the heterogeneity of the included studies, no safe conclusions could be extracted concerning the efficacy of t-VNS. However, the results of this review suggest that patients with epilepsy could possibly benefit from the use of t-VNS. The present study also emphasizes the limitations of previous clinical trials concerning the applications of t-VNS in people with epilepsy and thus could be a guidance for the conduction of future trials.
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Affiliation(s)
- Marios Lampros
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, Greece
| | - Nikolaos Vlachos
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, Greece
| | - Andreas Zigouris
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, Greece
| | - Spyridon Voulgaris
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, Greece
| | - George A Alexiou
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, Greece.
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83
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Korit Áková E, Doležalová I, Chládek J, Jurková T, Chrastina J, Plešinger F, Roman R, Pail M, Jurák P, Shaw DJ, Brázdil M. A Novel Statistical Model for Predicting the Efficacy of Vagal Nerve Stimulation in Patients With Epilepsy (Pre-X-Stim) Is Applicable to Different EEG Systems. Front Neurosci 2021; 15:635787. [PMID: 34045942 PMCID: PMC8144700 DOI: 10.3389/fnins.2021.635787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 03/22/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Identifying patients with intractable epilepsy who would benefit from therapeutic chronic vagal nerve stimulation (VNS) preoperatively remains a major clinical challenge. We have developed a statistical model for predicting VNS efficacy using only routine preimplantation electroencephalogram (EEG) recorded with the TruScan EEG device (Brazdil et al., 2019). It remains to be seen, however, if this model can be applied in different clinical settings. Objective: To validate our model using EEG data acquired with a different recording system. Methods: We identified a validation cohort of eight patients implanted with VNS, whose preimplantation EEG was recorded on the BrainScope device and who underwent the EEG recording according to the protocol. The classifier developed in our earlier work, named Pre-X-Stim, was then employed to classify these patients as predicted responders or non-responders based on the dynamics in EEG power spectra. Predicted and real-world outcomes were compared to establish the applicability of this classifier. In total, two validation experiments were performed using two different validation approaches (single classifier or classifier voting). Results: The classifier achieved 75% accuracy, 67% sensitivity, and 100% specificity. Only two patients, both real-life responders, were classified incorrectly in both validation experiments. Conclusion: We have validated the Pre-X-Stim model on EEGs from a different recording system, which indicates its application under different technical conditions. Our approach, based on preoperative EEG, is easily applied and financially undemanding and presents great potential for real-world clinical use.
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Affiliation(s)
- Eva Korit Áková
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Irena Doležalová
- Brno Epilepsy Center, Department of Neurology and Neurosurgery, St. Anne's University Hospital and Medical Faculty of Masaryk University, Brno, Czechia
| | - Jan Chládek
- Behavioral and Social Neuroscience Research Group, Central European Institute of Technology, Masaryk University, Brno, Czechia.,Institute of Scientific Instruments of the Czech Academy of Sciences, Brno, Czechia
| | - Tereza Jurková
- Brno Epilepsy Center, Department of Neurology and Neurosurgery, St. Anne's University Hospital and Medical Faculty of Masaryk University, Brno, Czechia
| | - Jan Chrastina
- Brno Epilepsy Center, Department of Neurology and Neurosurgery, St. Anne's University Hospital and Medical Faculty of Masaryk University, Brno, Czechia
| | - Filip Plešinger
- Institute of Scientific Instruments of the Czech Academy of Sciences, Brno, Czechia
| | - Robert Roman
- Behavioral and Social Neuroscience Research Group, Central European Institute of Technology, Masaryk University, Brno, Czechia
| | - Martin Pail
- Brno Epilepsy Center, Department of Neurology and Neurosurgery, St. Anne's University Hospital and Medical Faculty of Masaryk University, Brno, Czechia
| | - Pavel Jurák
- Institute of Scientific Instruments of the Czech Academy of Sciences, Brno, Czechia
| | - Daniel J Shaw
- Behavioral and Social Neuroscience Research Group, Central European Institute of Technology, Masaryk University, Brno, Czechia
| | - Milan Brázdil
- Brno Epilepsy Center, Department of Neurology and Neurosurgery, St. Anne's University Hospital and Medical Faculty of Masaryk University, Brno, Czechia.,Behavioral and Social Neuroscience Research Group, Central European Institute of Technology, Masaryk University, Brno, Czechia
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84
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Mezjan I, Gourfinkel-An I, Degos V, Clemenceau S, Navarro V, Masson V, Carpentier A, Mathon B. Outpatient vagus nerve stimulation surgery in patients with drug-resistant epilepsy with severe intellectual disability. Epilepsy Behav 2021; 118:107931. [PMID: 33770612 DOI: 10.1016/j.yebeh.2021.107931] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/03/2021] [Accepted: 03/05/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Vagus nerve stimulation (VNS) implantation is increasingly proposed in outpatient procedure. Some epilepsy syndromes are associated with severe neurodevelopmental disabilities (intellectual disability, autism) and often motor or sensory handicaps, making ambulatory surgery more complex. METHODS We prospectively assessed the feasibility and safety of outpatient VNS implantation in 26 adult patients with drug-resistant epilepsy with severe intellectual disability between December 2017 and October 2020. RESULTS The male-to-female ratio was 0.9 and the mean age on surgery day was 23.1 years. Seventeen patients (65.4%) suffered from epileptic encephalopathy, 7 (26.9%) from cryptogenic or genetic generalized epilepsy, and 2 (7.7%) from severe multifocal epilepsy. Postoperatively, all patients were discharged the day of surgery. No patient was admitted to a hospital or have consulted within one month due to postoperative complications. There was no surgery-related complication during patients' follow-up. CONCLUSION Our study highlights the safety and feasibility of VNS surgery in an outpatient setting for patients with severe intellectual disability. We report detailed protocol and preoperative checklist to optimize outpatient VNS surgery in these not able-bodied patients. Severe disabilities or epilepsy-associated handicaps should not be an exclusion criterion when considering ambulatory VNS implantation.
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Affiliation(s)
- Insafe Mezjan
- APHP, Department of Neurosurgery, Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France
| | - Isabelle Gourfinkel-An
- APHP, Department of Neurology, Epileptology Unit, Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France; APHP, Reference Center for Rare Epilepsies, Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France
| | - Vincent Degos
- APHP, Department of Anesthesia, Critical Care and Peri-Operative Medicine, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France; Clinical Research Group ARPE, Sorbonne University, Paris, France; INSERM UMR 1141, PROTECT, Paris, France
| | - Stéphane Clemenceau
- APHP, Department of Neurosurgery, Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France
| | - Vincent Navarro
- APHP, Department of Neurology, Epileptology Unit, Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France; APHP, Reference Center for Rare Epilepsies, Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France; Paris Brain Institute, INSERM, CNRS, Sorbonne University, UMR S 1127, Paris Brain Institute, ICM, F-75013 Paris, France
| | - Véronique Masson
- APHP, Department of Neurology, Epileptology Unit, Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France
| | - Alexandre Carpentier
- APHP, Department of Neurosurgery, Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France; Paris Brain Institute, INSERM, CNRS, Sorbonne University, UMR S 1127, Paris Brain Institute, ICM, F-75013 Paris, France
| | - Bertrand Mathon
- APHP, Department of Neurosurgery, Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France; Paris Brain Institute, INSERM, CNRS, Sorbonne University, UMR S 1127, Paris Brain Institute, ICM, F-75013 Paris, France.
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85
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Clark AJ, Samuel R, Saez I, Kennedy J, Seyal M, Shahlaie K, Girgis F. The impact of sub specialization within functional neurosurgery on patient outcomes in a comprehensive epilepsy center. Clin Neurol Neurosurg 2021; 205:106636. [PMID: 33984798 DOI: 10.1016/j.clineuro.2021.106636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/19/2021] [Accepted: 04/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND One in three patients with epilepsy are medication-refractory and may benefit from investigations and operative treatment at a comprehensive epilepsy center. However, while these centers have capabilities for advanced seizure monitoring and surgical intervention, they are not required to have a functional neurosurgeon who is primarily focused in epilepsy surgery. Therefore, the objective of this study is to determine the impact of having a sub-specialized, epilepsy-focused functional neurosurgeon on patient outcomes. METHODS We conducted a retrospective chart review for all patients who underwent surgical intervention for medically refractory epilepsy at a Level 4 comprehensive Epilepsy Center from 2008 through 2019. Data was divided into two groups: group 1 comprised patients who had surgery before the hiring of a dedicated epilepsy-focused functional neurosurgeon in 2016, and group 2 was afterwards. We compared surgical procedures, significant complications, and seizure outcomes. RESULTS A total of 101 patients underwent 105 operations (52 in group 1 and 53 in group 2), not including intracranial EEG insertion. Compared to group 1, group 2 had more surgeries performed per year (15.1 vs. 6.5), and a significantly lower Engel score at last follow-up (1.78 vs. 2.57; p < 0.001). There was no difference in percentage of cases undergoing iEEG, and no difference in complication rates. CONCLUSIONS In this series, the hiring of a sub-specialized functional neurosurgeon dedicated to epilepsy surgery in a comprehensive epilepsy center was associated with an increase in surgical volume and improved seizure outcomes.
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Affiliation(s)
- Austin Js Clark
- School of Medicine, University of California Davis, Sacramento, CA 95817, United States; Department of Neurological Surgery, University of California Davis, Sacramento, CA 95817, United States.
| | - Rikki Samuel
- School of Medicine, University of California Davis, Sacramento, CA 95817, United States
| | - Ignacio Saez
- Department of Neurological Surgery, University of California Davis, Sacramento, CA 95817, United States; Center for Neuroscience, University of California Davis, Davis, CA 95618, United States
| | - Jeffrey Kennedy
- Department of Neurology, University of California Davis, Sacramento, CA 95817, United States
| | - Masud Seyal
- Department of Neurology, University of California Davis, Sacramento, CA 95817, United States
| | - Kiarash Shahlaie
- Department of Neurological Surgery, University of California Davis, Sacramento, CA 95817, United States; Center for Neuroscience, University of California Davis, Davis, CA 95618, United States
| | - Fady Girgis
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada T2N 1N4
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86
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Lo WB, Chevill B, Philip S, Agrawal S, Walsh AR. Seizure improvement following vagus nerve stimulator (VNS) battery change with cardiac-based seizure detection automatic stimulation (AutoStim): early experience in a regional paediatric unit. Childs Nerv Syst 2021; 37:1237-1241. [PMID: 33174154 DOI: 10.1007/s00381-020-04962-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 11/03/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE The recent VNS models (AspireSR® Model 106, SenTiva™ Model 1000 (VNS Therapy®, LivaNova)) include a new function of cardiac-based seizure detection (CBSD) automatic stimulation, known as 'AutoStim'. This algorithm uses tachycardia as a proxy to a seizure, and the battery delivers a closed-loop electrical current in addition to its programmed stimulation. This function leads to further seizure reduction in adults, but this advantage has not been reported in the paediatric population. This study aims to investigate whether battery change with AutoStim leads to further seizure reduction in children. METHODS This observational study included the first 10 cases of VNS battery change from non-AutoStim to AutoStim function. During the battery change operation, the new VNS was switched on, with the same normal and magnet mode settings as the previous VNS. The AutoStim mode was activated at the same time. Data on seizure burden were collected at 3 time points: (1) before the first VNS insertion, (2) before battery replacement (post-1st VNS) and (3) 12 months post-battery change (post-AutoStim). The net effect of AutoStim, the only changed parameter, was evaluated by comparing the seizure burden prior to and 12 months following battery change in each child. RESULTS The seizure reduction improved significantly from 60 to 83% following battery change with AutoStim. Categorising the outcome according the McHugh classification, children achieving class I and II outcome (≥ 50% seizure reduction) improved from 70 to 90%. CONCLUSION This is the first study to demonstrate the additional efficacy of AutoStim in children treated with VNS.
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Affiliation(s)
- William B Lo
- Department of Neurosurgery, Birmingham Children's Hospital, Birmingham, B4 6NH, UK.
| | - Bethany Chevill
- Department of Neurology, Birmingham Children's Hospital, Birmingham, B4 6NH, UK
| | - Sunny Philip
- Department of Neurology, Birmingham Children's Hospital, Birmingham, B4 6NH, UK
| | - Shakti Agrawal
- Department of Neurology, Birmingham Children's Hospital, Birmingham, B4 6NH, UK
| | - A Richard Walsh
- Department of Neurosurgery, Birmingham Children's Hospital, Birmingham, B4 6NH, UK
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87
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Russo A, Hyslop A, Gentile V, Chiarello D, Messana T, Miller I, Zucchelli M, Lima M, Ragheb J, Pini A, Cordelli DM, Resnick T, Jayakar P, Duchowny M. Early Implantation as a Main Predictor of Response to Vagus Nerve Stimulation in Childhood-Onset Refractory Epilepsy. J Child Neurol 2021; 36:365-370. [PMID: 33236677 DOI: 10.1177/0883073820974855] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE We describe a multicenter experience with vagus nerve stimulator implantation in pediatric patients with drug-resistant epilepsy. Our goal was to assess vagus nerve stimulation efficacy and identify potential predictors of favorable outcome. METHODS This is a retrospective study. Inclusion criteria: ≤18 years at time of vagus nerve stimulator implantation, at least 1 year of follow-up. All patients were previously found to be unsuitable for an excisional procedure. Favorable clinical outcome and effective vagus nerve stimulation therapy were defined as seizure reduction >50%. Outcome data were reviewed at 1, 2, 3, and 5 years after vagus nerve stimulator implantation. Fisher exact test and multiple logistic regression analysis were employed. RESULTS Eighty-nine patients met inclusion criteria. Responder rate (seizure frequency reduction >50%) at 1-year follow-up was 25.8% (4.5% seizure-free). At last follow-up, 31.5% had a favorable outcome and 5.2% were seizure free. The only factor significantly predicting favorable outcome was time to vagus nerve stimulator implantation, with the best outcome achieved when vagus nerve stimulator implantation was performed within 3 years of seizure onset. Implantation between 3 and 5 years after epilepsy onset correlated with better long-term seizure freedom (13.3% at T5). Overall, 65.2% of patients evidenced improved quality of life at last follow-up. However, 12.4% had adverse events, but most were mild and disappeared after 3-4 months. CONCLUSIONS Early vagus nerve stimulator implantation within 5 years of seizure onset was the only predictor of favorable clinical outcome in pediatric patients. Improved quality of life and a low incidence of significant adverse events were observed.
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Affiliation(s)
- Angelo Russo
- 419170IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Infantile, Bologna, Italy
| | - Ann Hyslop
- Department of Neurology and Comprehensive Epilepsy Program, Brain Institute, 5447Nicklaus Children's Hospital, Miami, FL, USA
| | - Valentina Gentile
- Child Neurology and Psychiatric Unit, Department of Medical and Surgical Science (DIMEC), S. Orsola Hospital, 9296University of Bologna, Bologna, Italy
| | - Daniela Chiarello
- Child Neurology and Psychiatric Unit, Department of Medical and Surgical Science (DIMEC), S. Orsola Hospital, 9296University of Bologna, Bologna, Italy
| | - Tullio Messana
- 419170IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Infantile, Bologna, Italy
| | - Ian Miller
- Department of Neurology and Comprehensive Epilepsy Program, Brain Institute, 5447Nicklaus Children's Hospital, Miami, FL, USA
| | - Mino Zucchelli
- 9296IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neurochirurgia, Bologna, Italy
| | - Mario Lima
- Pediatric Surgery, Department of Medical and Surgical Science (DIMEC), S. Orsola Hospital, University of Bologna, Italy
| | - John Ragheb
- Department of Neurological Surgery, 5447Nicklaus Children's Hospital, Miami, FL, USA
| | - Antonella Pini
- 419170IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Infantile, Bologna, Italy
| | - Duccio Maria Cordelli
- Department of Neurology and Comprehensive Epilepsy Program, Brain Institute, 5447Nicklaus Children's Hospital, Miami, FL, USA
| | - Trevor Resnick
- Child Neurology and Psychiatric Unit, Department of Medical and Surgical Science (DIMEC), S. Orsola Hospital, 9296University of Bologna, Bologna, Italy
| | - Prasanna Jayakar
- Child Neurology and Psychiatric Unit, Department of Medical and Surgical Science (DIMEC), S. Orsola Hospital, 9296University of Bologna, Bologna, Italy
| | - Michael Duchowny
- Department of Neurology and Comprehensive Epilepsy Program, Brain Institute, 5447Nicklaus Children's Hospital, Miami, FL, USA.,Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
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88
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Sadanandan N, Saft M, Gonzales-Portillo B, Borlongan CV. Multipronged Attack of Stem Cell Therapy in Treating the Neurological and Neuropsychiatric Symptoms of Epilepsy. Front Pharmacol 2021; 12:596287. [PMID: 33815100 PMCID: PMC8010689 DOI: 10.3389/fphar.2021.596287] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 01/15/2021] [Indexed: 11/13/2022] Open
Abstract
Epilepsy stands as a life-threatening disease that is characterized by unprovoked seizures. However, an important characteristic of epilepsy that needs to be examined is the neuropsychiatric aspect. Epileptic patients endure aggression, depression, and other psychiatric illnesses. Therapies for epilepsy can be divided into two categories: antiepileptic medications and surgical resection. Antiepileptic drugs are used to attenuate heightened neuronal firing and to lessen seizure frequency. Alternatively, surgery can also be conducted to physically cut out the area of the brain that is assumed to be the root cause for the anomalous firing that triggers seizures. While both treatments serve as viable approaches that aim to regulate seizures and ameliorate the neurological detriments spurred by epilepsy, they do not serve to directly counteract epilepsy's neuropsychiatric traits. To address this concern, a potential new treatment involves the use of stem cells. Stem cell therapy has been employed in experimental models of neurological maladies, such as Parkinson's disease, and neuropsychiatric illnesses like depression. Cell-based treatments for epilepsy utilizing stem cells such as neural stem cells (NSCs), mesenchymal stem cells (MSCs), and interneuron grafts have been explored in preclinical and clinical settings, highlighting both the acute and chronic stages of epilepsy. However, it is difficult to create an animal model to capitalize on all the components of epilepsy due to the challenges in delineating the neuropsychiatric aspect. Therefore, further preclinical investigation into the safety and efficacy of stem cell therapy in addressing both the neurological and the neuropsychiatric components of epilepsy is warranted in order to optimize cell dosage, delivery, and timing of cell transplantation.
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Affiliation(s)
| | | | | | - Cesar V. Borlongan
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, United States
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89
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Wu X, Zhang Y, Luo WT, Mai RR, Hou XY, Xia ZQ, Xu BY, Liu B. Brain Functional Mechanisms Determining the Efficacy of Transcutaneous Auricular Vagus Nerve Stimulation in Primary Insomnia. Front Neurosci 2021; 15:609640. [PMID: 33776631 PMCID: PMC7994340 DOI: 10.3389/fnins.2021.609640] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 02/09/2021] [Indexed: 12/26/2022] Open
Abstract
Transcutaneous auricular vagus nerve stimulation (taVNS) has been reported to be effective in the treatment of primary insomnia (PI); however, its efficacy varies considerably across individuals for reasons that are unclear. In order to clarify the underlying mechanisms, this study investigated the effects of taVNS on spontaneous neuronal activity and autonomic nervous system function by functional magnetic resonance imaging (fMRI) and measurement of heart rate variability (HRV), respectively, in patients with PI. Forty patients with PI were divided into effective (group A) and ineffective (group B) groups based on their response to taVNS as determined by Pittsburgh Sleep Quality Index score reduction rate (group A ≥ 25% and group B < 25%). Spontaneous neuronal activity was measured by fractional amplitude of low-frequency fluctuations (fALFF) and HRV values and was compared between the two groups as well as before vs after taVNS. We then analyzed the correlations among efficacy of taVNS for 4 weeks, the fALFF and HRV values during continuous taVNS state. The results showed that the HRV parameter values (i.e., root mean square of successive differences, percentage of adjacent NN intervals differing by >50 ms, and high frequency) of group A were higher than those of group B during continuous taVNS state. In the fMRI scan, the fALFF values of the right cerebellum, right medial superior frontal gyrus, and bilateral supplementary motor area—which belong to the sensorimotor network (SMN)—were lower in group A than in group B during continuous taVNS state. The correlation analysis revealed that the efficacy of continuous taVNS and HRV and fALFF values were interrelated. These findings demonstrate that differential regulation of the SMN by the autonomic nervous system may be responsible for inter-individual variations in the efficacy of taVNS and suggest that HRV and fALFF are potential biomarkers for predicting PI patients’ response to taVNS treatment.
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Affiliation(s)
- Xiao Wu
- Department of Chinese Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Yue Zhang
- Department of Radiology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wen-Ting Luo
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Run-Ru Mai
- Department of Sleep Disorder, Fangcun Branch, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiao-Yan Hou
- Department of Radiology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zi-Qiang Xia
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Bi-Yun Xu
- Department of Sleep Disorder, Fangcun Branch, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Bo Liu
- Department of Radiology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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90
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Crawford L, Mueller D, Mathews L. Anesthetic Considerations for Functional Neurosurgery. Anesthesiol Clin 2021; 39:227-243. [PMID: 33563384 DOI: 10.1016/j.anclin.2020.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Functional neurosurgery is a rapidly growing field that uses surgical resection, ablation, or neuromodulation to treat an assortment of neurologic and psychiatric disorders, the most common of which are movement disorders and epilepsy. Anesthesiologists caring for patients undergoing neurofunctional procedures should be aware of the anesthetic implications of patients' underlying disease as well as procedure-specific concerns, such as the effects of anesthetics on intraoperative neuromonitoring and limited access to patients due to stereotactic frames or intraoperative imaging.
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Affiliation(s)
- Lane Crawford
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA.
| | - Dorothee Mueller
- Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Ave S, 422 MAB, Nashville, TN 37212, USA
| | - Letha Mathews
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
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91
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Fisher B, DesMarteau JA, Koontz EH, Wilks SJ, Melamed SE. Responsive Vagus Nerve Stimulation for Drug Resistant Epilepsy: A Review of New Features and Practical Guidance for Advanced Practice Providers. Front Neurol 2021; 11:610379. [PMID: 33584511 PMCID: PMC7874068 DOI: 10.3389/fneur.2020.610379] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/14/2020] [Indexed: 01/17/2023] Open
Abstract
Vagus nerve stimulation (VNS) is a safe and effective therapy that has been available for over 20 years for adults and children with drug resistant epilepsy (DRE). Since U.S. Food and Drug Administration approval in 1997, VNS has been implanted in over 100,000 patients including over 30,000 children as an adjunctive therapy in reducing the frequency of seizures in patients 4 years of age and older with focal seizures that are refractory to antiseizure medications. VNS Therapy® has evolved over time and currently offers closed-loop, responsive stimulation as well as advanced features that streamline dosing and patient management. Advanced Practice Providers (APPs) such as nurse practitioners, physician assistants and clinical nurse specialists are integral in a comprehensive healthcare team, and dedicated VNS clinics have formed at comprehensive epilepsy centers across the world that are often managed by APPs. This approach improves access, education, and continuity of care for those with VNS or those considering VNS. Here we provide a review for APPs on the VNS Therapy® system focused on new features, dosing, and troubleshooting strategies with the goal to provide guidance to those managing VNS patients.
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Affiliation(s)
- Breanne Fisher
- Division of Neurology, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Julie A DesMarteau
- Department of Neurosciences, Medical University of South Carolina, Charleston, SC, United States
| | - Elizabeth H Koontz
- Department of Neurosciences, Medical University of South Carolina, Charleston, SC, United States
| | - Seth J Wilks
- Neuromodulation Division, LivaNova, Houston, TX, United States
| | - Susan E Melamed
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
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92
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Ye VC, Mansouri A, Warsi NM, Ibrahim GM. Atonic seizures in children: a meta-analysis comparing corpus callosotomy to vagus nerve stimulation. Childs Nerv Syst 2021; 37:259-267. [PMID: 32529546 DOI: 10.1007/s00381-020-04698-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/21/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Atonic seizures are associated with a particularly poor response to medical treatment. We performed a systematic review and meta-analysis to compare the efficacy of corpus callosotomy (CC) and vagus nerve stimulation (VNS) in the management of atonic seizures in the pediatric population. METHODS A literature search was performed in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and recommendations, focusing on atonic seizures, CC, and VNS in pediatric populations. Pertinent clinical data were extracted and analyzed. Pooled effects between groups were calculated as standardized error (SE) with 95% confidence intervals (CIs). To assess for statistical significance, the Z-test was performed, using the pooled effect size (ES) and 95% CI for each intervention. RESULTS A total of 31 studies met the inclusion criteria, with 24 studies encompassing 425 children treated with CC and 7 studies encompassing 108 children treated with VNS. Twenty-four studies were included in a meta-analysis. There was a statistically significant difference in the primary outcome of atonic seizure control in favor of CC (overall effect size (ES) 0.73, 95% CI 0.69-0.77 for CC, ES 0.4, 95% CI 0.28-0.51 for VNS, p = 0.003). There was a higher rate of complications requiring reoperation in the CC cohort (6.6% vs. 3.8%) and a 14% rate of symptomatic disconnection syndrome. CONCLUSIONS While both techniques are safe, CC provides a much higher chance of effectively managing this morbid seizure type albeit with a higher risk of re-operation and disconnection syndrome.
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Affiliation(s)
- Vincent C Ye
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Canada
| | - Alireza Mansouri
- Department of Neurosurgery, Pennsylvania State University, Hershey, PA, USA
| | - Nebras M Warsi
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Canada
| | - George M Ibrahim
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Canada.
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
- Program in Neurosciences and Mental Health Research Institute, Department of Surgery, Institute of Biomaterials and Biomedical Engineering, The University of Toronto, Toronto, Canada.
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93
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Zhu J, Xu C, Zhang X, Qiao L, Wang X, Zhang X, Yan X, Ni D, Yu T, Zhang G, Li Y. The changes in the topological properties of brain structural network based on diffusion tensor imaging in pediatric epilepsy patients with vagus nerve stimulators: A graph theoretical analysis. Brain Dev 2021; 43:97-105. [PMID: 32713660 DOI: 10.1016/j.braindev.2020.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/06/2020] [Accepted: 07/09/2020] [Indexed: 01/27/2023]
Abstract
PURPOSE This study aimed to analyze the topological characteristics of brain structural network in pediatric epilepsy patients with vagus nerve stimulation (VNS) by applying graph theoretical approaches. METHODS Nine patients with generalized seizures and eight normal controls (NC) were enrolled. Based on diffusion tensor imaging, graph theory analysis was used to characterize the topological properties in preoperative patients (EP-pre), postoperative patients (EP-post) and NC. The global properties included clustering coefficient (Cp), shortest path length (Lp), small-worldness (γ, λ, δ), global network efficiency (Eg) and local network efficiency (Eloc). The regional properties included degree centrality (DC), nodal efficiency (NE), nodal local efficiency (NLE) and nodal shortest path length (Np). Two sample t-test and paired sample t-test were utilized to compare properties difference. RESULTS All three groups followed small-world characteristics. There was no significant difference in small-worldness, Cp, Lp, Eg or Eloc between EP-pre and EP-post. Compared with EP-pre: DC in EP-post decreased in the right cuneus and right temporal gyri, while increased in the right paracentral lobule; NE in EP-post decreased in the left dorsolateral superior frontal gyrus, right cuneus, right supramarginal gyrus, and right rolandic operculum, while increased in the right paracentral lobule; NLE in EP-post decreased in the left posterior cingulate gyrus and right supramarginal gyrus, while increased in the left parahippocampal gyrus; NP in EP-post decreased in the right paracentral lobule, while increased in the right cuneus. CONCLUSION VNS causes topological characteristics changes in pediatric patients with generalized seizures through regulating regional properties in some brain structures.
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Affiliation(s)
- Jin Zhu
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Cuiping Xu
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xi Zhang
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Liang Qiao
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xueyuan Wang
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaohua Zhang
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaoming Yan
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Duanyu Ni
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tao Yu
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Guojun Zhang
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yongjie Li
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
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94
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Kim JS, Kim DY, Jo HJ, Hwang YH, Song JY, Yang KI, Hong SB. Effect of Long-Term Treatment with Vagus Nerve Stimulation on Mood and Quality of Life in Korean Patients with Drug-Resistant Epilepsy. J Clin Neurol 2021; 17:385-392. [PMID: 34184446 PMCID: PMC8242313 DOI: 10.3988/jcn.2021.17.3.385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 01/26/2021] [Accepted: 01/26/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND PURPOSE This study aimed to determine the long-term effects of vagus nerve stimulation (VNS) treatment on suicidality, mood-related symptoms, and quality of life (QOL) in patients with drug-resistant epilepsy (DRE). We also investigated the relationships among these main effects, clinical characteristics, and VNS parameters. METHODS Among 35 epilepsy patients who underwent VNS implantation consecutively in our epilepsy center, 25 patients were recruited to this study for assessing the effects of VNS on suicidality, mood-related symptoms, and QOL. The differences in these variables between before and after VNS treatment were analyzed statistically using paired t-tests. Multiple linear regression analyses were also performed to determine how the patients' demographic and clinical characteristics influenced the variables that showed statistically significant changes after long-term VNS treatment. RESULTS After VNS, our patients showed significant improvements not only in the mean seizure frequency but also in suicidality, depression, and QOL. The reduction in depression was associated with the improvement in QOL and more-severe depression at baseline. The reduction in suicidality was associated with higher suicidality at baseline, smaller changes in depression, and less-severe depression at baseline. Improved QOL was associated with lower suicidality at baseline. CONCLUSIONS This study found that VNS decreased the mean seizure frequency in patients with DRE, and also improved their depression, suicidality, and QOL. These results provide further evidence for therapeutic effect of VNS on psychological comorbidities of patients with DRE.
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Affiliation(s)
- Jeong Sik Kim
- Department of Neurology, Neuroscience Center, Samsung Medical Center, Samsung Biomedical Research Institute, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Yeop Kim
- Department of Neurology, Neuroscience Center, Samsung Medical Center, Samsung Biomedical Research Institute, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Jin Jo
- Department of Neurology, Neuroscience Center, Samsung Medical Center, Samsung Biomedical Research Institute, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoon Ha Hwang
- Department of Neurology, Neuroscience Center, Samsung Medical Center, Samsung Biomedical Research Institute, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo Yeon Song
- Department of Neurology, Neuroscience Center, Samsung Medical Center, Samsung Biomedical Research Institute, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Ik Yang
- Sleep Disorders Center, Department of Neurology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Korea
| | - Seung Bong Hong
- Department of Neurology, Neuroscience Center, Samsung Medical Center, Samsung Biomedical Research Institute, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University School of Medicine, Seoul, Korea.
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95
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Raspin C, Shankar R, Barion F, Pollit V, Murphy J, Sawyer L, Danielson V. An economic evaluation of vagus nerve stimulation as an adjunctive treatment to anti-seizure medications for the treatment of drug-resistant epilepsy in England. J Med Econ 2021; 24:1037-1051. [PMID: 34348576 DOI: 10.1080/13696998.2021.1964306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Anti-seizure medications (ASMs) are commonly used to prevent recurring epileptic seizures, but around a third of people with epilepsy fail to achieve an adequate response. Vagus nerve stimulation (VNS) is clinically recommended for people with drug-resistant epilepsy (DRE) who are not suitable for surgery, but the cost-effectiveness of the intervention has not recently been evaluated. The study objective is to estimate costs and quality-adjusted life-years (QALYs) associated with using VNS as an adjunct to ongoing ASM therapy, compared to the strategy of using only ASMs in the treatment of people with DRE, from an English National Health Service perspective. METHODS A cohort state transition model was developed in Microsoft Excel to simulate costs and QALYs of the VNS + ASM and ASM only strategies. Patients could transition between five health states, using a 3-month cycle length. Health states were defined by an expected percentage reduction in seizure frequency, derived from randomized control trial data. Costs included the VNS device as well as its installation, setup, and removal; ASM therapy; adverse events associated with VNS (dyspnea, hoarseness, and cough); and health-state costs associated with epilepsy including hospitalizations, emergency department visits, neurologist visits, and primary care visits. A range of sensitivity analyses, including probabilistic sensitivity analysis, were run to assess the impact of parameter and structural uncertainty. RESULTS In the base case, VNS + ASM had an estimated incremental cost-effectiveness ratio (ICER) of £17,771 per QALY gained compared to ASMs alone. The cost-effective ICER was driven by relative reductions in expected seizure frequency and the differences in health care resource use associated therewith. Sensitivity analyses found that the amount of resource use per epilepsy-related health state was a key driver of the cost component. CONCLUSIONS VNS is expected to be a cost-effective intervention in the treatment of DRE in the English National Health Service.
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Affiliation(s)
| | - Rohit Shankar
- Faculty of Health, Peninsula Medical School, University of Plymouth, Plymouth, UK
- Cornwall Partnership NHS Foundation Trust, Bodmin, UK
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96
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Alqadi K, Aldhalaan H, Alghamdi A, Bamgadam F, Abu-Jabber A, Baeesa S, Althubaiti I, Baz S. Saudi Arabian Consensus Statement on Vagus Nerve Stimulation for Refractory Epilepsy. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2020; 9:75-81. [PMID: 33519349 PMCID: PMC7839567 DOI: 10.4103/sjmms.sjmms_578_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 08/09/2020] [Accepted: 11/23/2020] [Indexed: 11/04/2022]
Abstract
Vagus nerve stimulation (VNS) is an approved adjunctive therapy for refractory epilepsy and used in patients who are not candidates for resective epilepsy surgery. In Saudi Arabia, VNS device implantation is being performed since 2008 by several comprehensive epilepsy programs, but with variable protocols. Therefore, to standardize the use of VNS, a task force was established to create a national consensus. This group consisted of epileptologists, epilepsy surgeons and a VNS nurse coordinator working in comprehensive epilepsy centers and dealing with refractory epilepsy cases. The group intensively reviewed the literature using Medline, EMBASE, Web of Science and Cochrane Library, in addition to physician's manual. Evidence is reported as three stages: preimplantation and patient selection, a perioperative phase involving all stakeholders and post-operative care with specific programming pathways.
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Affiliation(s)
- Khalid Alqadi
- Department of Neurosciences, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hesham Aldhalaan
- Department of Neurosciences, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Abdulaziz Alghamdi
- Department of Neurosciences, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Fawzia Bamgadam
- Department of Neurosciences, King Fahad Medical Centre, Riyadh, Saudi Arabia
| | - Amal Abu-Jabber
- Department of Neurosciences, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Saleh Baeesa
- Department of Neurosciences, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.,Division of Neurosurgery, Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ibrahim Althubaiti
- Department of Neurosciences, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Salah Baz
- Department of Neurosciences, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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97
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Hasegawa H, Van Gompel JJ, Marsh WR, Wharen RE, Zimmerman RS, Burkholder DB, Lundstrom BN, Britton JW, Meyer FB. Outcomes following surgical management of vagus nerve stimulator-related infection: a retrospective multi-institutional study. J Neurosurg 2020; 135:783-791. [PMID: 33339002 DOI: 10.3171/2020.7.jns201385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/14/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgical site infection (SSI) is a rare but significant complication after vagus nerve stimulator (VNS) placement. Treatment options range from antibiotic therapy alone to hardware removal. The optimal therapeutic strategy remains open to debate. Therefore, the authors conducted this retrospective multicenter analysis to provide insight into the optimal management of VNS-related SSI (VNS-SSI). METHODS Under institutional review board approval and utilizing an institutional database with 641 patients who had undergone 808 VNS-related placement surgeries and 31 patients who had undergone VNS-related hardware removal surgeries, the authors retrospectively analyzed VNS-SSI. RESULTS Sixteen cases of VNS-SSI were identified; 12 of them had undergone the original VNS placement procedure at the authors' institutions. Thus, the incidence of VNS-SSI was calculated as 1.5%. The mean (± standard deviation) time from the most recent VNS-related surgeries to infection was 42 (± 27) days. Methicillin-sensitive staphylococcus was the usual causative bacteria (58%). Initial treatments included antibiotics with or without nonsurgical procedures (n = 6), nonremoval open surgeries for irrigation (n = 3), generator removal (n = 3), and total or near-total removal of hardware (n = 4). Although 2 patients were successfully treated with antibiotics alone or combined with generator removal, removal of both the generator and leads was eventually required in 14 patients. Mild swallowing difficulties and hoarseness occurred in 2 patients with eventual resolution. CONCLUSIONS Removal of the VNS including electrode leads combined with antibiotic administration is the definitive treatment but has a risk of causing dysphagia. If the surgeon finds dense scarring around the vagus nerve, the prudent approach is to snip the electrode close to the nerve as opposed to attempting to unwind the lead completely.
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Affiliation(s)
- Hirotaka Hasegawa
- Departments of1Neurologic Surgery and
- 2Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | | | | | - Robert E Wharen
- 3Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida; and
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98
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Liu DF, Chen YC, Zhu GY, Wang X, Jiang Y, Liu HG, Zhang JG. Effects of anterior thalamic nuclei stimulation on gene expression in a rat model of temporal lobe epilepsy. Acta Neurol Belg 2020; 120:1361-1370. [PMID: 31758405 DOI: 10.1007/s13760-019-01240-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 11/06/2019] [Indexed: 12/13/2022]
Abstract
Deep brain stimulation of the anterior nucleus of the thalamus (ANT-DBS) has been shown to be effective and safe in the long-term treatment of refractory epilepsy. However, the mechanisms by which ANT-DBS controls epilepsy at the gene expression level (e.g., which regulatory mechanisms are altered) is not well understood. Nine rats were randomly assigned to the control group, the kainic acid (KA) group, and the DBS group. Temporal lobe epilepsy in rats was induced by a stereotaxic KA injection (KA group). The DBS group received the KA injection followed by treatment with ANT-DBS. Video-electroencephalogram (EEG) was used to monitor seizures. Total RNA samples were isolated from the hippocampus of three groups. Microarray was used to detect differentially regulated mRNAs. GO and pathway analysis were performed to analyze the functional categories and affected pathways. qPCR was used to prove the reliability of the microarray results. The differentially expressed genes the KA group and the DBS group, relative to the control group, were screened and a total of 2910 genes were identified. These genes were involved in functional categories such as ion channel activity (P = 5.01 × 10-8), gated channel activity (P = 1.42 × 10-7), lipid binding (P = 4.97 × 10-5), and hydrolase activity (P = 5.02 × 10-5) and pathways such as calcium signaling pathway (P = 2.09 × 10-8), glutamatergic synapse (P = 4.09 × 10-8) and NOD-like receptor signaling pathway (P = 2.70 × 10-6). Differentially expressed mRNAs might play a role in the pathogenesis of temporal lobe epilepsy. Calcium signaling pathways, synaptic glutamate, and NOD-like receptor signaling pathway play a central role in normal-epilepsy-ANT-DBS treatment series. ANT-DBS achieves its antiepileptic effects by modulating target genes involved in a variety of functions and pathways.
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Affiliation(s)
- De-Feng Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Tiantan Xili, No.6, Dongcheng, Beijing, 100050, China
| | - Ying-Chuan Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Tiantan Xili, No.6, Dongcheng, Beijing, 100050, China
| | - Guan-Yu Zhu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Tiantan Xili, No.6, Dongcheng, Beijing, 100050, China
| | - Xiu Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Tiantan Xili, No.6, Dongcheng, Beijing, 100050, China
| | - Yin Jiang
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University, Tiantan Xili, No.6, Dongcheng, Beijing, 100050, China
| | - Huan-Guang Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Tiantan Xili, No.6, Dongcheng, Beijing, 100050, China.
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University, Tiantan Xili, No.6, Dongcheng, Beijing, 100050, China.
| | - Jian-Guo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Tiantan Xili, No.6, Dongcheng, Beijing, 100050, China.
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University, Tiantan Xili, No.6, Dongcheng, Beijing, 100050, China.
- Beijing Key Laboratory of Neurostimulation, Beijing, 100050, China.
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99
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Li ST, Chiu NC, Hung KL, Ho CS, Kuo YT, Wu WH, Kuo YT, Wang HS, Lin KL, Hung PC, Chang YC, Hung PL, Fan PC, Lee WT, Yang RC, Ko FJ, Lin LC, Chou PC, Tsai JD, Hung KL, Chen HJ, Chang KP, Hsu TR, Ho CS, Chiu NC, Chen SJ, Fan HC, Lee HT, Shen EY, Kuo HT, Chang MY, Chang TM, Li ST, Yeh GC. Therapeutic effects of children with refractory epilepsy after vagus nerve stimulation in Taiwan. Pediatr Neonatol 2020; 61:606-612. [PMID: 32773364 DOI: 10.1016/j.pedneo.2020.07.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 05/07/2020] [Accepted: 07/10/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Vagus nerve stimulation (VNS) is used as an add-on treatment for epilepsy. This study aimed to use Taiwanese nationwide registry data to analyze the therapeutic effects of VNS in children with refractory epilepsy (RE) and try to explore predictive factors of VNS treatment effectiveness. METHODS This retrospective study collected data from December 2007 to December 2014. Patient variables included gender, age, VNS implantation date, epilepsy duration, seizure frequency, seizure type, etiology, and antiepileptic drug (AED) history. We divided patients into three groups: Group I as seizure frequency >80 times per month, Group II as seizure frequency 24-80 times per month, and Group III as seizure frequency <24 times per month. Multivariate regression analysis was performed to determine predictors of seizure frequency reduction after VNS treatment. RESULTS A total of 80 patients were included in this study. Three or more AED types were prescribed for 61 (77.1%) patients. Seizure frequency decreased significantly at 12 and 24 months after VNS treatment. The mean seizure reduction rates were 44.6% and 50.1% at 12 and 24 months after VNS treatment, with the difference between them reaching statistical significance (p = 0.001). In multivariate linear regression, high seizure frequency (Group I) was a positive predictor of seizure frequency reduction (p < 0.001). The most common complication was coughing (eight patients, 10%) and no patient had early withdrawal or premature termination of VNS use due to complications. CONCLUSION VNS is an effective palliative treatment for children with RE for different seizure types. Seizure reduction rate at 24 months after VNS was better than at 12 months after VNS. High seizure frequency can be regarded as a positive predictor for seizure frequency reduction in children with RE treated with VNS.
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Affiliation(s)
- Sung-Tse Li
- Department of Pediatrics, Hsinchu MacKay Memorial Hospital, Hsinchu, Taiwan; Department of Healthcare Management, Yuanpei University of Medical Technology, Hsinchu, Taiwan; Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
| | - Nan-Chang Chiu
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan; Department of Pediatrics, MacKay Children's Hospital, Taipei, Taiwan.
| | - Kun-Long Hung
- Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan; Department of Pediatrics, Fu-Jen Catholic University Hospital, New Taipei City, Taiwan; School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
| | - Che-Sheng Ho
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan; Department of Pediatrics, MacKay Children's Hospital, Taipei, Taiwan
| | - Yung-Ting Kuo
- Department of Pediatrics, Shuang Ho Hospital, Ministry of Health and Welfare, Taipei Medical University, New Taipei City, Taiwan; Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taiwan
| | - Wen-Hsiang Wu
- Department of Healthcare Management, Yuanpei University of Medical Technology, Hsinchu, Taiwan
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- Vagus Nerve Stimulation Study Group of Taiwan Child Neurology Society, Taiwan
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100
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Sangare A, Marchi A, Pruvost-Robieux E, Soufflet C, Crepon B, Ramdani C, Chassoux F, Turak B, Landre E, Gavaret M. The Effectiveness of Vagus Nerve Stimulation in Drug-Resistant Epilepsy Correlates with Vagus Nerve Stimulation-Induced Electroencephalography Desynchronization. Brain Connect 2020; 10:566-577. [PMID: 33073582 PMCID: PMC7757623 DOI: 10.1089/brain.2020.0798] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Introduction: VNS is an adjunctive neuromodulation therapy for patients with drug-refractory epilepsy. The antiseizure effect of VNS is thought to be related to a diffuse modulation of functional connectivity but remains to be confirmed. Aim: To investigate electroencephalographic (EEG) metrics of functional connectivity in patients with drug-refractory epilepsy treated by vagus nerve stimulation (VNS), between VNS-stimulated “ON” and nonstimulated “OFF” periods and between responder (R) and nonresponder (NR) patients. Methods: Scalp-EEG was performed for 35 patients treated by VNS, using 21 channels and 2 additional electrodes on the neck to detect the VNS stimulation. Patients were defined as VNS responders if a reduction of seizure frequency of ∼50% was documented. We analyzed the synchronization in EEG time series during “ON” and “OFF” periods of stimulation, using average phase lag index (PLI) in signal space and phase-locking value (PLV) between 10 sources. Based on graph theory, we computed brain network models and analyzed minimum spanning tree (MST) for responder and nonresponder patients. Results: Among 35 patients treated by VNS for a median time of 7 years (range 4 months to 22 years), 20 were R and 15 were NR. For responder patients, PLI during ON periods was significantly lower than that during OFF periods in delta (p = 0.009), theta (p = 0.02), and beta (p = 0.04) frequency bands. For nonresponder patients, there were no significant differences between ON and OFF periods. Moreover, variations of seizure frequency with VNS correlated with the PLI OFF/ON ratio in delta (p = 0.02), theta (p = 0.04), and beta (p = 0.03) frequency bands. Our results were confirmed using PLV in theta band (p < 0.05). No significant differences in MST were observed between R and NR patients. Conclusion: The correlation between VNS-induced interictal EEG time-series desynchronization and decrease in seizure frequency suggested that VNS therapeutic impact might be related to changes in interictal functional connectivity.
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Affiliation(s)
- Aude Sangare
- Neurophysiology Department, GHU Paris Psychiatrie et Neurosciences, Sainte-Anne Hospital, Paris, France
| | - Angela Marchi
- Neurophysiology Department, GHU Paris Psychiatrie et Neurosciences, Sainte-Anne Hospital, Paris, France
| | - Estelle Pruvost-Robieux
- Neurophysiology Department, GHU Paris Psychiatrie et Neurosciences, Sainte-Anne Hospital, Paris, France.,Université de Paris, Paris, France
| | - Christine Soufflet
- Neurophysiology Department, GHU Paris Psychiatrie et Neurosciences, Sainte-Anne Hospital, Paris, France
| | - Benoit Crepon
- Neurophysiology Department, GHU Paris Psychiatrie et Neurosciences, Sainte-Anne Hospital, Paris, France
| | - Céline Ramdani
- Institut de Recherche Biomédicale des Armées (IRBA), Paris, France
| | - Francine Chassoux
- Neurosurgery and Epileptology Department, GHU Paris Psychiatrie et Neurosciences, Sainte-Anne Hospital, Paris, France
| | - Baris Turak
- Neurosurgery and Epileptology Department, GHU Paris Psychiatrie et Neurosciences, Sainte-Anne Hospital, Paris, France
| | - Elisabeth Landre
- Neurosurgery and Epileptology Department, GHU Paris Psychiatrie et Neurosciences, Sainte-Anne Hospital, Paris, France
| | - Martine Gavaret
- Neurophysiology Department, GHU Paris Psychiatrie et Neurosciences, Sainte-Anne Hospital, Paris, France.,Université de Paris, Paris, France.,INSERM UMR 1266, IPNP, Paris, France
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