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Peltola J, Surges R, Voges B, von Oertzen TJ. Expert opinion on diagnosis and management of epilepsy-associated comorbidities. Epilepsia Open 2024; 9:15-32. [PMID: 37876310 PMCID: PMC10839328 DOI: 10.1002/epi4.12851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 09/25/2023] [Indexed: 10/26/2023] Open
Abstract
Apart from seizure freedom, the presence of comorbidities related to neurological, cardiovascular, or psychiatric disorders is the largest determinant of a reduced health-related quality of life in people with epilepsy (PwE). However, comorbidities are often underrecognized and undertreated, and clinical management of comorbid conditions can be challenging. The focus of a comprehensive treatment regimen should maximize seizure control while optimizing clinical management of treatable comorbidities to improve a person's quality of life and overall health. A panel of four European epileptologists with expertise in their respective fields of epilepsy-related comorbidities combined the latest available scientific evidence with clinical expertise and collaborated to provide consensus practical advice to improve the identification and management of comorbidities in PwE. This review provides a critical evaluation for the diagnosis and management of sleep-wake disorders, cardiovascular diseases, cognitive dysfunction, and depression in PwE. Whenever possible, clinical data have been provided. The PubMed database was the main search source for the literature review. The deleterious pathophysiological processes underlying neurological, cardiovascular, or psychiatric comorbidities in PwE interact with the processes responsible for generating seizures to increase cerebral and physiological dysfunction. This can increase the likelihood of developing drug-resistant epilepsy; therefore, early identification of comorbidities and intervention is imperative. The practical evidence-based advice presented in this article may help clinical neurologists and other specialist physicians responsible for the care and management of PwE.
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Affiliation(s)
- Jukka Peltola
- Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
- Department of NeurologyTampere University HospitalTampereFinland
| | - Rainer Surges
- Department of EpileptologyUniversity Hospital BonnBonnGermany
| | - Berthold Voges
- Department of Neurology, Epilepsy Center HamburgProtestant Hospital AlsterdorfHamburgGermany
| | - Tim J. von Oertzen
- Medical FacultyJohannes Kepler UniversityLinzAustria
- Department of Neurology 1, Neuromed CampusKepler University HospitalLinzAustria
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Alshehri KA, Abuhulayqah SH, Asiry MA, Alyamani SA. Vagus nerve stimulation in medically refractory epilepsy: Adverse effects and clinical correlates. NEUROSCIENCES (RIYADH, SAUDI ARABIA) 2024; 29:10-17. [PMID: 38195125 PMCID: PMC10827014 DOI: 10.17712/nsj.2024.1.20230006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 09/18/2023] [Indexed: 01/11/2024]
Abstract
OBJECTIVES To assess the frequency of adverse effects among pediatric and adult patients and the clinical variables associated with a higher probability of developing side effects. METHODS This retrospective study enrolled pediatric and adult patients who underwent Vagus nerve stimulation (VNS) implantation at our institution and had documented follow-up during clinic visits for at least 6 months after implantation. Data collected included demographic information, epilepsy diagnosis, and device data. RESULTS A total of 43 patients with drug-resistant epilepsy who received a VNS device at our institution were enrolled. The median follow-up period was 12 months. Fourteen patients (32.55%) reported no side effects from VNS therapy. Side effects ranged from mild to severe, with significant side effects observed in 8 patients. Data on therapy efficacy were collected, and 10 patients (23.26%) reported no change in seizure frequency following device implantation. CONCLUSION This study demonstrates that VNS is an important adjunct treatment option for epilepsy patients. Dysphagia and dyspnea can be significant adverse effects leading to treatment discontinuation, aspiration pneumonia, intensive care unit (ICU) admission, and prolonged hospital stay. These effects are more frequent in patients with symptomatic generalized epilepsy, global developmental delay at baseline, previous ICU admissions, abnormal brain magnetic resonance imaging findings, and seizures with multiple semiologies.
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Affiliation(s)
- Khaled A. Alshehri
- From the Neuroscience Center (Alshehri, Abuhulayqah, Asiry, Alyamani), King Faisal Specialist Hospital and Research Center, Riyadh, and from the Department of Medicine (Alshehri), Faculty of Medicine, Tabuk University, Tabuk, Kingdom of Saudi Arabia
| | - Shaima H. Abuhulayqah
- From the Neuroscience Center (Alshehri, Abuhulayqah, Asiry, Alyamani), King Faisal Specialist Hospital and Research Center, Riyadh, and from the Department of Medicine (Alshehri), Faculty of Medicine, Tabuk University, Tabuk, Kingdom of Saudi Arabia
| | - Mohammed A. Asiry
- From the Neuroscience Center (Alshehri, Abuhulayqah, Asiry, Alyamani), King Faisal Specialist Hospital and Research Center, Riyadh, and from the Department of Medicine (Alshehri), Faculty of Medicine, Tabuk University, Tabuk, Kingdom of Saudi Arabia
| | - Suad A. Alyamani
- From the Neuroscience Center (Alshehri, Abuhulayqah, Asiry, Alyamani), King Faisal Specialist Hospital and Research Center, Riyadh, and from the Department of Medicine (Alshehri), Faculty of Medicine, Tabuk University, Tabuk, Kingdom of Saudi Arabia
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Voges BR. Bi-level VNS therapy with different therapy modes at night and daytime improves seizures and quality of life in a patient with drug-resistant epilepsy. Epilepsy Behav Rep 2023; 24:100633. [PMID: 38045989 PMCID: PMC10692657 DOI: 10.1016/j.ebr.2023.100633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/13/2023] [Accepted: 11/05/2023] [Indexed: 12/05/2023] Open
Abstract
Induction or aggravation of sleep apnea is a known side effect of vagus nerve stimulation (VNS). We report the case of a 44 year old male with drug-resistant epilepsy and depression who did not experience any seizure reduction after 1 year of VNS but a worsening of depression and daytime sleepiness. After confirming VNS-associated sleep apnea we started the first bi-level VNS therapy with standard VNS settings during daytime and reduced settings during nighttime. Anti-seizure medication remained unchanged. Within 12 months his seizure frequency was reduced by 90 % and his depression improved, permitting a cessation of his antidepressant medication. The observations made in this case have contributed to the manufacturer of VNS developing new generator models that can automatically provide bi-level VNS.
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Affiliation(s)
- Berthold R. Voges
- Protestant Hospital Hamburg-Alsterdorf, Dpt. of Epileptology, Elisabeth-Flügge-Str.1, 22337 Hamburg, Germany
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Garrett AL, Burch J, Zhang Y, Li H, Sundar KM, Farney RJ. Depicting and defining sleep disturbed breathing associated with vagal nerve stimulation. Sleep Med 2023; 110:68-75. [PMID: 37542741 DOI: 10.1016/j.sleep.2023.07.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/13/2023] [Accepted: 07/27/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Vagal nerve stimulators (VNS), which have been approved for management of refractory epilepsy and depression, induce unique disturbances of breathing during sleep (SDBVNS) that are not captured well using standard criteria. The primary purpose of this retrospective study was to compare AASM definitions with alternative criteria to more accurately measure SDBVNS We also sought to assess outcome variables that may be clinically relevant and response to positive airway pressure therapy. METHODS We analyzed the electronic medical records and comprehensive polysomnography results of all adult subjects with active VNS for epilepsy who were referred to the sleep center for suspected sleep apnea (2015-2020). We compared standard AASM criteria for defining apneas/hypopnea index (AHIAASM) with three novel scoring criteria for hypopnea according to degree of oxygen desaturation associated with VNS events: AHIVNS0 (none required); AHIVNS2 (2% required); and AHIVNS3 (3% required). RESULTS Twenty-six subjects were included in the final analysis with 35 PSGs (14 females/12 males). The mean age was 33.6 years and mean body mass index (BMI) of 32.2 kg/m2. AHIAASM measured ≥ 15/hour in 7 (26.9%) subjects versus 21 (80.8%) by AHIVNS0; 15 (70.0%) by AHIVNS2; and 5 (19.2%) by AHIVNS3. Clinically significant hypoxemia was not present. The mean time SpO2<89% was 7 (20.8) minutes. Oximetry tracings often showed a desaturation pattern that resembled a sawfish rather than sawtooth. Arousals specifically linked to VNS activation were not elevated (2.9/hour). The baseline AHIVNS0 was 27.7/hour with a lowest AHIVNS0 on PAP of 27.9/hr. CONCLUSIONS AASM scoring criteria significantly underestimated the degree of VNS induced respiratory disturbances. VNS events were not associated with increased arousals or significant hypoxemia. PAP therapy was an ineffective treatment in this population. This study adds to the increasing body of evidence of sleep disordered breathing related to VNS and questions the clinical significance of this finding.
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Affiliation(s)
| | - Jason Burch
- Sleep Wake Center, University of Utah, Salt Lake City, UT, USA
| | - Yue Zhang
- Division of Statistics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Haojia Li
- Division of Statistics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | | | - Robert J Farney
- Pulmonary Division, University of Utah, Salt Lake City, UT, USA
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Statello R, Rossi S, Pisani F, Bonzini M, Andreoli R, Martini A, Puligheddu M, Cocco P, Miragoli M. Nocturnal Heart Rate Variability Might Help in Predicting Severe Obstructive Sleep-Disordered Breathing. BIOLOGY 2023; 12:biology12040533. [PMID: 37106734 PMCID: PMC10135696 DOI: 10.3390/biology12040533] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/22/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023]
Abstract
Obstructive sleep apnea (OSA) can have long-term cardiovascular and metabolic effects. The identification of OSA-related impairments would provide diagnostic and prognostic value. Heart rate variability (HRV) as a measure of cardiac autonomic regulation is a promising candidate marker of OSA and OSA-related conditions. We took advantage of the Physionet Apnea-ECG database for two purposes. First, we performed time- and frequency-domain analysis of nocturnal HRV on each recording of this database to evaluate the cardiac autonomic regulation in patients with nighttime sleep breathing disorders. Second, we conducted a logistic regression analysis (backward stepwise) to identify the HRV indices able to predict the apnea–hypopnea index (AHI) categories (i.e., “Severe OSA”, AHI ≥ 30; “Moderate-Mild OSA”, 5 ≥ AHI < 30; and “Normal”, AHI < 5). Compared to the “Normal”, the “Severe OSA” group showed lower high-frequency power in normalized units (HFnu) and higher low-frequency power in normalized units (LFnu). The standard deviation of normal R–R intervals (SDNN) and the root mean square of successive R–R interval differences (RMSSD) were independently associated with sleep-disordered breathing. Our findings suggest altered cardiac autonomic regulation with a reduced parasympathetic component in OSA patients and suggest a role of nighttime HRV in the characterization and identification of sleep breathing disorders.
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Zhidik AG, Kozhokaru AB. [Alternative methods of therapy for comorbid sleep disorders as a method of choice in adult patients with epilepsy]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:42-48. [PMID: 37655409 DOI: 10.17116/jnevro202312308142] [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: 09/02/2023]
Abstract
OBJECTIVE Systematization and generalization of data from domestic and foreign literature on alternative methods of treatment of sleep disorders in epilepsy. MATERIAL AND METHODS The search for data from domestic and foreign literary sources was carried out in the electronic databases Medline (PubMed), Scopus, Web of Science, eLibrary, CyberLeninka, Google Scholar. RESULTS The data of modern randomized trials, meta-analyzes on the effectiveness of various non-traditional methods as a method of choice for epilepsy with comorbid sleep disorders have been analyzed. CONCLUSIONS Complementary (alternative) treatments have many advantages over the classical pharmacotherapy of sleep disorders in epilepsy, in the form of non-invasiveness, low incidence of side-effects, ease of use, and lack of a dose-dependent effect. Of course, the targets of most of the above methods are not focused and not very specific, and the sample size is too small to obtain impartial and meaningful clinical conclusions, but this once again emphasizes the urgent need for large-scale clinical trials, which is necessary to develop evidence-based treatments for comorbid sleep disorders in epilepsy.
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Affiliation(s)
- A G Zhidik
- State Research Center - Burnasyan Federal Medical Biophysical Center, Moscow, Russia
| | - A B Kozhokaru
- State Research Center - Burnasyan Federal Medical Biophysical Center, Moscow, Russia
- Central State Medical Academy of Department of Presidential Affairs, Moscow, Russia
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Sethi NK. The Relationship Between Epilepsy, Obstructive Sleep Apnea, and Treatment Outcome. Sleep Med Clin 2022; 17:639-645. [DOI: 10.1016/j.jsmc.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Simpson HD, Schulze-Bonhage A, Cascino GD, Fisher RS, Jobst BC, Sperling MR, Lundstrom BN. Practical considerations in epilepsy neurostimulation. Epilepsia 2022; 63:2445-2460. [PMID: 35700144 PMCID: PMC9888395 DOI: 10.1111/epi.17329] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 02/02/2023]
Abstract
Neuromodulation is a key therapeutic tool for clinicians managing patients with drug-resistant epilepsy. Multiple devices are available with long-term follow-up and real-world experience. The aim of this review is to give a practical summary of available neuromodulation techniques to guide the selection of modalities, focusing on patient selection for devices, common approaches and techniques for initiation of programming, and outpatient management issues. Vagus nerve stimulation (VNS), deep brain stimulation of the anterior nucleus of the thalamus (DBS-ANT), and responsive neurostimulation (RNS) are all supported by randomized controlled trials that show safety and a significant impact on seizure reduction, as well as a suggestion of reduction in the risk of sudden unexplained death in epilepsy (SUDEP). Significant seizure reductions are observed after 3 months for DBS, RNS, and VNS in randomized controlled trials, and efficacy appears to improve with time out to 7 to 10 years of follow-up for all modalities, albeit in uncontrolled follow-up or retrospective studies. A significant number of patients experience seizure-free intervals of 6 months or more with all three modalities. Number and location of epileptogenic foci are important factors affecting efficacy, and together with comorbidities such as severe mood or sleep disorders, may influence the choice of modality. Programming has evolved-DBS is typically initiated at lower current/voltage than used in the pivotal trial, whereas target charge density is lower with RNS, however generalizable optimal parameters are yet to be defined. Noninvasive brain stimulation is an emerging stimulation modality, although it is currently not used widely. In summary, clinical practice has evolved from those established in pivotal trials. Guidance is now available for clinicians who wish to expand their approach, and choice of neuromodulation technique may be tailored to individual patients based on their epilepsy characteristics, risk tolerance, and preferences.
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Affiliation(s)
- Hugh D. Simpson
- Division of Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Gregory D. Cascino
- Division of Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Robert S. Fisher
- Department of Neurology, Stanford Neuroscience Health Center, Palo Alto, CA, USA
| | - Barbara C. Jobst
- Geisel School of Medicine at Dartmouth, Department of Neurology, Dartmouth-Hitchcock Medical Center, NH, USA
| | - Michael R. Sperling
- Division of Epilepsy, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Brian N. Lundstrom
- Division of Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN, USA
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Ye L, Xu J, Chen C, Zhang L, Wang S. Effects of anti-seizure therapies on sleep in patients with epilepsy: A literature review. Acta Neurol Scand 2022; 146:767-774. [PMID: 36071677 DOI: 10.1111/ane.13699] [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: 07/31/2022] [Accepted: 08/23/2022] [Indexed: 11/27/2022]
Abstract
Sleep disorder is common in epilepsy. With a recent rapid development in sleep medicine, it has been increasingly recognized that anti-seizure therapies, either anti-seizure medications (ASMs) or non-pharmaceutical approaches, can take direct or indirect influence on sleep in patients with epilepsy. Here, we systematically review the effect of anti-seizure treatments on sleep. ASMs targeting at different sites exerted various effects on both sleep structure and sleep quality. Non-pharmaceutical treatments including resective surgery, ketogenic diet, and transcranial magnetic stimulation appear to have a positive effect on sleep, while vagus nerve stimulation, deep brain stimulation, and brain-responsive neurostimulation are likely to interrupt sleep and exacerbate sleep-disordered breathing. The potential mechanisms underlying how non-pharmacological approaches affect sleep are also discussed. The limitation of most studies is that they were largely based on small cohorts by short-term observations. Further well-designed and large-scale investigations in this field are warranted. Understanding the effect of anti-seizure therapies on sleep can guide clinicians to optimize epilepsy treatment in the future.
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Affiliation(s)
- Lingqi Ye
- Epilepsy Center, Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jiahui Xu
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Cong Chen
- Epilepsy Center, Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Lisan Zhang
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shuang Wang
- Epilepsy Center, Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Sleep and Epilepsy. Neurol Clin 2022; 40:769-783. [DOI: 10.1016/j.ncl.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Chan JH, DelRosso LM, Ruth C, Wrede JE. A surface electrode adjacent to vagal nerve stimulator lead can aid in characterizing vagal nerve stimulator mediated pediatric sleep-disordered breathing: a case series of 7 patients. J Clin Sleep Med 2022; 18:1973-1981. [PMID: 35499280 PMCID: PMC9340602 DOI: 10.5664/jcsm.10050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES The vagal nerve stimulator (VNS) is a nonpharmacological treatment for refractory epilepsy. A side effect of the VNS is sleep-disordered breathing. The purpose of this study was to demonstrate how a surface electrode placed over the VNS lead can help distinguish whether sleep-disordered breathing is due to VNS discharge. METHODS Seven pediatric patients (aged 7.7 ± 2.2 years) with a VNS underwent a polysomnogram with an additional surface electrode on the left anterolateral neck to detect VNS discharge. The VNS-associated apnea-hypopnea index was calculated by determining the number of hypopneas and apneas occurring during VNS discharge. We evaluated the veracity of the VNS electrode by comparing signal duration and total number to those expected by programmed settings. We compared these findings to chin electromyogram signal change. RESULTS Three patients had an obstructive pattern with VNS discharge, and 3 had an increase in respiratory rate without gas exchange abnormalities, including 1 with both patterns; 1 patient experienced no respiratory abnormalities. The mean obstructive apnea-hypopnea index was 8.2 ± 8.3 events/h. The mean VNS-associated apnea-hypopnea index was 4.8 ± 6.2 events/h and accounted for 46.9 ± 30.2% of the total obstructive apnea-hypopnea index. The additional electrode captured a statistically high percentage of expected discharges (94.7 ± 6.5%) compared to chin electromyogram (36.1 ± 35.8%; P < .05). CONCLUSIONS We demonstrated that a surface electrode on the VNS lead can temporally coregister VNS discharges and enabled us to attribute sleep-disordered breathing to VNS stimulation in 4 patients. We propose that this sensor be standard procedure in patients with VNS undergoing polysomnogram. CITATION Chan JHM, DelRosso LM, Ruth C, Wrede JE. A surface electrode adjacent to vagal nerve stimulator lead can aid in characterizing vagal nerve stimulator-mediated pediatric sleep-disordered breathing: a case series of 7 patients. J Clin Sleep Med. 2022;18(8):1973-1981.
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Affiliation(s)
- Jeremy H.M. Chan
- Division of Pulmonary and Sleep Medicine, Seattle Children’s Hospital, Seattle, WA
| | - Lourdes M. DelRosso
- Division of Pulmonary and Sleep Medicine, Seattle Children’s Hospital, Seattle, WA
- Division of Neurology, Seattle Children’s Hospital, Seattle, WA
| | - Chris Ruth
- Seattle Children’s Sleep Center, Seattle Children’s Hospital, Seattle, WA
| | - Joanna E. Wrede
- Division of Pulmonary and Sleep Medicine, Seattle Children’s Hospital, Seattle, WA
- Division of Neurology, Seattle Children’s Hospital, Seattle, WA
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Interictal sleep recordings during presurgical evaluation: Bidirectional perspectives on sleep related network functioning. Rev Neurol (Paris) 2022; 178:703-713. [DOI: 10.1016/j.neurol.2022.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/08/2022] [Accepted: 03/08/2022] [Indexed: 11/23/2022]
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Sen A, Verner R, Valeriano JP, Lee R, Zafar M, Thomas R, Kotulska K, Jespers E, Dibué M, Kwan P. Vagus nerve stimulation therapy in people with drug-resistant epilepsy (CORE-VNS): rationale and design of a real-world post-market comprehensive outcomes registry. BMJ Neurol Open 2022; 3:e000218. [PMID: 35018342 PMCID: PMC8705076 DOI: 10.1136/bmjno-2021-000218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 11/21/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction The Vagus Nerve Stimulation Therapy System (VNS Therapy) is an adjunctive neuromodulatory therapy that can be efficacious in reducing the frequency and severity of seizures in people with drug-resistant epilepsy (DRE). CORE-VNS aims to examine the long-term safety and clinical outcomes of VNS in people with DRE. Methods and analysis The CORE-VNS study is an international, multicentre, prospective, observational, all-comers, post-market registry. People with DRE receiving VNS Therapy for the first time as well as people being reimplanted with VNS Therapy are eligible. Participants have a baseline visit (prior to device implant). They will be followed for a minimum of 36 months and a maximum of 60 months after implant. Analysis endpoints include seizure frequency (average number of events per month), seizure severity (individual-rated categorical outcome including very mild, mild, moderate, severe or very severe) as well as non-seizure outcomes such as adverse events, use of antiseizure medications, use of other non-pharmacological therapies, quality of life, validated measures of quality of sleep (Pittsburgh Sleep Quality Index or Children’s Sleep Habit Questionnaire) and healthcare resource utilisation. While the CORE-VNS registry was not expressly designed to test hypotheses, subgroup analyses and exploratory analysis that require hypothesis testing will be conducted across propensity score matched treatment groups, where possible based on sampling. Ethics and dissemination The CORE-VNS registry has already enrolled 823 participants from 61 centres across 15 countries. Once complete, CORE-VNS will represent one of the largest real-world clinical data sets to allow a more comprehensive understanding of the management of DRE with adjunctive VNS. Manuscripts derived from this database will shed important new light on the characteristics of people receiving VNS Therapy; the practical use of VNS across different countries, and factors influencing long-term response. Trail registration number NCT03529045.
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Affiliation(s)
- Arjune Sen
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, Oxfordshire, UK
| | - Ryan Verner
- Clinical and Medical Affairs, LivaNova Plc, London, UK
| | | | - Ricky Lee
- Department of Neurology, Ascension Medical Group, Wichita, Kansas, USA
| | - Muhammad Zafar
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rhys Thomas
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK.,Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Katarzyna Kotulska
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warszawa, Poland
| | - Ellen Jespers
- Clinical and Medical Affairs, LivaNova Plc, London, UK
| | - Maxine Dibué
- Clinical and Medical Affairs, LivaNova Plc, London, UK.,Department of Neurosurgery, Friedrich Schiller University Jena, Jena, Thüringen, Germany
| | - Patrick Kwan
- Department of Neuroscience, Central Clinical School, Monash University, Clayton, Victoria, Australia.,Epilepsy Unit, Brain Program, Alfred Hospital, Melbourne, Victoria, Australia.,Departments of Medicine and Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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An Unusual Pattern on Overnight Oximetry in a Child with Refractory Epilepsy. Ann Am Thorac Soc 2021; 18:714-716. [PMID: 33792517 DOI: 10.1513/annalsats.202009-1156cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Morkous SS. A Pediatric Patient With Seizures and Vagus Nerve Stimulation With Worsening Snoring and Apneas. Cureus 2021; 13:e14379. [PMID: 33987047 PMCID: PMC8110296 DOI: 10.7759/cureus.14379] [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] [Indexed: 11/16/2022] Open
Abstract
An 11-year-old female presents to the sleep clinic for evaluation for possible sleep-disordered breathing (SDB). She has a history of frequently intractable seizures for which she was tried on multiple antiepileptic medications. She had vagus nerve stimulation (VNS) implantation two years ago to treat her focal seizures. Nine months later, her seizures were controlled, but the family raised concerns about louder snoring and more frequently witnessed apneas. She had polysomnography (PSG) that showed severe obstructive sleep apnea (OSA) related to her VNS. The patient was diagnosed with SDB secondary to electrical activations of the implanted VNS. We describe an epilepsy patient whose case illustrates the possible respiratory complications (primarily OSA) associated with VNS. We will discuss the possible mechanisms of VNS related SDB and the importance of screening for SDB and advocate for a PSG both before and after VNS implantation.
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Affiliation(s)
- Sameh S Morkous
- Pediatric Neurology, Lehigh Valley Health Network (LVHN) Lehigh Valley Reilly Children's Hospital, Allentown, USA
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Clinical and Research Solutions to Manage Obstructive Sleep Apnea: A Review. SENSORS 2021; 21:s21051784. [PMID: 33806496 PMCID: PMC7961570 DOI: 10.3390/s21051784] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 12/13/2022]
Abstract
Obstructive sleep apnea (OSA), a common sleep disorder disease, affects millions of people. Without appropriate treatment, this disease can provoke several health-related risks including stroke and sudden death. A variety of treatments have been introduced to relieve OSA. The main present clinical treatments and undertaken research activities to improve the success rate of OSA were covered in this paper. Additionally, guidelines on choosing a suitable treatment based on scientific evidence and objective comparison were provided. This review paper specifically elaborated the clinically offered managements as well as the research activities to better treat OSA. We analyzed the methodology of each diagnostic and treatment method, the success rate, and the economic burden on the world. This review paper provided an evidence-based comparison of each treatment to guide patients and physicians, but there are some limitations that would affect the comparison result. Future research should consider the consistent follow-up period and a sufficient number of samples. With the development of implantable medical devices, hypoglossal nerve stimulation systems will be designed to be smart and miniature and one of the potential upcoming research topics. The transcutaneous electrical stimulation as a non-invasive potential treatment would be further investigated in a clinical setting. Meanwhile, no treatment can cure OSA due to the complicated etiology. To maximize the treatment success of OSA, a multidisciplinary and integrated management would be considered in the future.
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Peng W, Ding J, Wang X. The Management and Alternative Therapies for Comorbid Sleep Disorders in Epilepsy. Curr Neuropharmacol 2021; 19:1264-1272. [PMID: 33380304 PMCID: PMC8719297 DOI: 10.2174/1570159x19666201230142716] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 09/29/2020] [Accepted: 12/06/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND There is a complex and interactive relationship between sleep and epilepsy. Sleep disorders are common in patients with epilepsy, and methods for managing sleep disorders in patients with epilepsy are limited. OBJECTIVE This review addresses the relationship among sleep, sleep disorders, and epilepsy, focusing on the management of sleep disorders in epilepsy, including some complementary and alternative therapies. METHODS The terms related to "sleep" and "epilepsy" were searched in "Pubmed" and "Cochrane Library". RESULTS Sleep stages differently affect both seizures and interictal epileptiform discharges. Seizures disrupt sleep architecture greatly, especially when occurring during sleep in the night. Insomnia and obstructive sleep apnea (OSA) are the most frequent types of comorbid sleep disorders in patients with epilepsy. Pharmacological agents with both anti-convulsant and sedative effects are the priorities for comorbid sleep disorders in epilepsy. Continuous positive airway pressure (CPAP) therapy is the most effective non-pharmacological method to improve OSA and reduce seizures. Complementary and alternative therapies such as Chinese traditional medicine, cognitive behavioral therapy, meditation, yoga, neurofeedback, and acupuncture may have benefits in reducing seizures and improving sleep quality simultaneously by alleviating stress and seizure triggers; however, evidence- based therapies are still deficient. CONCLUSION Management of sleep disorders in patients with epilepsy is challenging. Large-scale randomized controlled clinical trials are in demand to guide the treatments in the future.
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Affiliation(s)
| | - Jing Ding
- Address correspondence to this author at the Department of Neurology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, 200032, Shanghai, China; Tel: 86-21-64041990-2926; Fax: 86-21-34160748; E-mail:
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Silva C, Iranzo A, Maya G, Serradell M, Muñoz-Lopetegi A, Marrero-González P, Gaig C, Santamaría J, Vilaseca I. Stridor during sleep: description of 81 consecutive cases diagnosed in a tertiary sleep disorders center. Sleep 2020; 44:5909297. [DOI: 10.1093/sleep/zsaa191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 09/02/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
Study Objectives
To describe the characteristics of stridor during sleep (SDS) in a series of adults identified by video-polysomnography (V-PSG).
Methods
Retrospective clinical, V-PSG, laryngoscopic, and therapeutic data of patients diagnosed with SDS in a tertiary referral sleep disorders center between 1997 and 2017.
Results
A total of 81 patients were identified (56.8% males, age 61.8 ± 11.2 years). Related etiologies were multiple system atrophy (MSA), amyotrophic lateral sclerosis, spinocerebellar ataxia type 1, anti-IgLON5 disease, fatal familial insomnia, brainstem structural lesions, vagus nerve stimulation, recurrent laryngeal nerve injury, the effect of radiotherapy on the vocal cords, cervical osteophytes, and others. Stridor during wakefulness coexisted in 13 (16%) patients and in MSA was only seen in the parkinsonian form. Laryngoscopy during wakefulness in 72 (88.9%) subjects documented vocal cord abductor impairment in 65 (90.3%) and extrinsic lesions narrowing the glottis in 2 (2.4%). The mean apnea–hypopnea index (AHI) was 21.4 ± 18.6 and CT90 was 11.5 ± 19.1. Obstructive AHI > 10 occurred in 52 (64.2%) patients and central apnea index >10 in 2 (2.4%). CPAP abolished SDS, obstructive apneic events and oxyhemoglobin desaturations in 58 of 60 (96.7%) titrated patients with optimal pressure of 9.0 ± 2.3 cm H20. Tracheostomy in 19 (23.4%) and cordotomy in 3 (3.7%) subjects also eliminated SDS.
Conclusions
SDS in adults is linked to conditions that damage the brainstem, recurrent laryngeal nerve, and vocal cords. V-PSG frequently detects obstructive sleep apnea and laryngoscopy usually shows vocal cord abductor dysfunction. CPAP, tracheostomy, and laryngeal surgery abolish SDS.
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Affiliation(s)
- Cristiana Silva
- Sleep Disorders Center, Neurology Service, Hospital Clínic de Barcelona, Universitat de Barcelona, IDIBAPS, Barcelona, Spain
| | - Alex Iranzo
- Sleep Disorders Center, Neurology Service, Hospital Clínic de Barcelona, Universitat de Barcelona, IDIBAPS, Barcelona, Spain
| | - Gerard Maya
- Sleep Disorders Center, Neurology Service, Hospital Clínic de Barcelona, Universitat de Barcelona, IDIBAPS, Barcelona, Spain
| | - Mónica Serradell
- Sleep Disorders Center, Neurology Service, Hospital Clínic de Barcelona, Universitat de Barcelona, IDIBAPS, Barcelona, Spain
| | - Amaia Muñoz-Lopetegi
- Sleep Disorders Center, Neurology Service, Hospital Clínic de Barcelona, Universitat de Barcelona, IDIBAPS, Barcelona, Spain
| | - Paula Marrero-González
- Sleep Disorders Center, Neurology Service, Hospital Clínic de Barcelona, Universitat de Barcelona, IDIBAPS, Barcelona, Spain
| | - Carles Gaig
- Sleep Disorders Center, Neurology Service, Hospital Clínic de Barcelona, Universitat de Barcelona, IDIBAPS, Barcelona, Spain
| | - Joan Santamaría
- Sleep Disorders Center, Neurology Service, Hospital Clínic de Barcelona, Universitat de Barcelona, IDIBAPS, Barcelona, Spain
| | - Isabel Vilaseca
- Otorhinolaryngology Service, Hospital Clínic de Barcelona, Universitat de Barcelona, CIBER Enfermedades Respiratorias, Bunyola, Spain
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