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Niazi F, Han A, Stamm L, Shlobin NA, Korman C, Hoang TS, Kielian A, Du Pont-Thibodeau G, Ducharme Crevier L, Major P, Nguyen DK, Bouthillier A, Ibrahim GM, Fallah A, Hadjinicolaou A, Weil AG. Outcome of emergency neurosurgery in patients with refractory and super-refractory status epilepticus: a systematic review and individual participant data meta-analysis. Front Neurol 2024; 15:1403266. [PMID: 38863514 PMCID: PMC11165020 DOI: 10.3389/fneur.2024.1403266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 04/23/2024] [Indexed: 06/13/2024] Open
Abstract
Background Refractory (RSE) and super-refractory status epilepticus (SRSE) are serious neurological conditions requiring aggressive management. Beyond anesthetic agents, there is a lack of evidence guiding management in these patients. This systematic review and individual participant data meta-analysis (IPDMA) seeks to evaluate and compare the currently available surgical techniques for the acute treatment of RSE and SRSE. Methods A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Individual Participant Data (PRISMA-IPD). Only patients who underwent surgery while in RSE and SRSE were included. Descriptive statistics were used to compare various subgroups. Multivariable logistic regression models were constructed to identify predictors of status epilepticus (SE) cessation, long-term overall seizure freedom, and favorable functional outcome (i.e., modified Rankin score of 0-2) at last follow-up. Results A total of 87 studies including 161 participants were included. Resective surgery tended to achieve better SE cessation rate (93.9%) compared to non-resective techniques (83.9%), but this did not reach significance (p = 0.071). Resective techniques were also more likely to achieve seizure freedom (69.1% vs. 34.4%, p = <0.0001). Older age at SE (OR = 1.384[1.046-1.832], p = 0.023) was associated with increased likelihood of SE cessation, while longer duration of SE (OR = 0.603[0.362-1.003], p = 0.051) and new-onset seizures (OR = 0.244[0.069-0.860], p = 0.028) were associated with lower likelihood of SE cessation, but this did not reach significance for SE duration. Only shorter duration of SE prior to surgery (OR = 1.675[1.168-2.404], p = 0.0060) and immediate termination of SE (OR = 3.736 [1.323-10.548], p = 0.014) were independently associated with long-term seizure status. Rates of favorable functional outcomes (mRS of 0-2) were comparable between resective (44.4%) and non-resective (44.1%) techniques, and no independent predictors of outcome were identified. Conclusion Our findings suggest that emergency neurosurgery may be a safe and effective alternative in patients with RSE/SRSE and may be considered earlier during the disease course. However, the current literature is limited exclusively to small case series and case reports with high risk of publication bias. Larger clinical trials assessing long-term seizure and functional outcomes are warranted to establish robust management guidelines.
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Affiliation(s)
- Farbod Niazi
- Department of Medicine, Université de Montréal, Montreal, QC, Canada
- Brain and Development Research Axis, CHU Sainte-Justine Research Centre, Montreal, QC, Canada
| | - Aline Han
- Department of Medicine, Université de Montréal, Montreal, QC, Canada
- Brain and Development Research Axis, CHU Sainte-Justine Research Centre, Montreal, QC, Canada
| | - Lauren Stamm
- Brain and Development Research Axis, CHU Sainte-Justine Research Centre, Montreal, QC, Canada
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Nathan A. Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Catherine Korman
- Brain and Development Research Axis, CHU Sainte-Justine Research Centre, Montreal, QC, Canada
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Thien S. Hoang
- Department of Health Sciences, Université de Montréal, Montreal, QC, Canada
| | - Agnieszka Kielian
- Department of Neurology, Boston Children’s Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Genevieve Du Pont-Thibodeau
- Division of Pediatric Intensive Care, Department of Pediatrics, Sainte-Justine University Hospital Centre, Montreal, QC, Canada
| | - Laurence Ducharme Crevier
- Division of Pediatric Intensive Care, Department of Pediatrics, Sainte-Justine University Hospital Centre, Montreal, QC, Canada
| | - Philippe Major
- Brain and Development Research Axis, CHU Sainte-Justine Research Centre, Montreal, QC, Canada
- Division of Neurology, Department of Pediatrics, Sainte-Justine University Hospital Centre, Montreal, QC, Canada
- Department of Neuroscience, Université de Montréal, Montreal, QC, Canada
| | - Dang K. Nguyen
- Department of Neuroscience, Université de Montréal, Montreal, QC, Canada
- Division of Neurology, University of Montreal Hospital Center (CHUM), Montreal, QC, Canada
| | - Alain Bouthillier
- Division of Neurosurgery, Department of Surgery, University of Montreal Hospital Center (CHUM), Montreal, QC, Canada
| | - George M. Ibrahim
- Division of Neurosurgery, Hospital for Sick Children, Toronto, ON, Canada
- Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, Canada
| | - Aria Fallah
- Department of Neurosurgery, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, United States
| | - Aristides Hadjinicolaou
- Brain and Development Research Axis, CHU Sainte-Justine Research Centre, Montreal, QC, Canada
- Division of Neurology, Department of Pediatrics, Sainte-Justine University Hospital Centre, Montreal, QC, Canada
- Department of Neuroscience, Université de Montréal, Montreal, QC, Canada
| | - Alexander G. Weil
- Brain and Development Research Axis, CHU Sainte-Justine Research Centre, Montreal, QC, Canada
- Department of Neuroscience, Université de Montréal, Montreal, QC, Canada
- Division of Neurosurgery, Department of Surgery, University of Montreal Hospital Center (CHUM), Montreal, QC, Canada
- Division of Neurosurgery, Department of Surgery, Sainte-Justine University Hospital Centre, Montreal, QC, Canada
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Mantoan Ritter L, Selway R. Perspective: Vagal nerve stimulation in the treatment of new-onset refractory status epilepticus. Front Neurol 2023; 14:1172898. [PMID: 37153661 PMCID: PMC10157031 DOI: 10.3389/fneur.2023.1172898] [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: 02/24/2023] [Accepted: 03/30/2023] [Indexed: 05/10/2023] Open
Abstract
Introduction Resistance to drug therapy is a major hurdle in new-onset refractory status epilepticus (NORSE) treatment and there is urgent need to develop new treatment approaches. Non-drug approaches such as neuromodulation offer significant benefits and should be investigated as new adjunct treatment modalities. An important unanswered question is whether desynchronizing networks by vagal nerve stimulation (VNS) may improve seizure control in NORSE patients. Main text We present a summary of published NORSE cases treated with VNS and our own data, discuss possible mechanisms of action, review VNS implantation timing, stimulation setting titration protocols and outcomes. Further, we propose avenues for future research. Discussion We advocate for consideration of VNS for NORSE both in early and late stages of the presentation and hypothesize a possible additional benefit from implantation in the acute phase of the disease. This should be pursued in the context of a clinical trial, harmonizing inclusion criteria, accuracy of documentation and treatment protocols. A study planned within our UK-wide NORSE-UK network will answer the question if VNS may confer benefits in aborting unremitting status epilepticus, modulate ictogenesis and reduce long-term chronic seizure burden.
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Affiliation(s)
- Laura Mantoan Ritter
- Epilepsy Centre, Clinical Neurosciences Department, King's College NHS Foundation Trust, London, United Kingdom
- Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
- *Correspondence: Laura Mantoan Ritter
| | - Richard Selway
- Epilepsy Centre, Clinical Neurosciences Department, King's College NHS Foundation Trust, London, United Kingdom
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Guo M, Xie P, Liu S, Luan G, Li T. Epilepsy and Autism Spectrum Disorder (ASD): The Underlying Mechanisms and Therapy Targets Related to Adenosine. Curr Neuropharmacol 2023; 21:54-66. [PMID: 35794774 PMCID: PMC10193761 DOI: 10.2174/1570159x20666220706100136] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 03/23/2022] [Accepted: 04/26/2022] [Indexed: 02/04/2023] Open
Abstract
Epilepsy and autism spectrum disorder (ASD) are highly mutually comorbid, suggesting potential overlaps in genetic etiology, pathophysiology, and neurodevelopmental abnormalities. Adenosine, an endogenous anticonvulsant and neuroprotective neuromodulator of the brain, has been proved to affect the process of epilepsy and ASD. On the one hand, adenosine plays a crucial role in preventing the progression and development of epilepsy through adenosine receptordependent and -independent ways. On the other hand, adenosine signaling can not only regulate core symptoms but also improve comorbid disorders in ASD. Given the important role of adenosine in epilepsy and ASD, therapeutic strategies related to adenosine, including the ketogenic diet, neuromodulation therapy, and adenosine augmentation therapy, have been suggested for the arrangement of epilepsy and ASD. There are several proposals in this review. Firstly, it is necessary to further discuss the relationship between both diseases based on the comorbid symptoms and mechanisms of epilepsy and ASD. Secondly, it is important to explore the role of adenosine involved in epilepsy and ASD. Lastly, potential therapeutic value and clinical approaches of adenosine-related therapies in treating epilepsy and ASD need to be emphasized.
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Affiliation(s)
- 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 100093, China
- Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing 100093, China
| | - Pandeng Xie
- 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 100093, China
- Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing 100093, China
| | - 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 100093, China
- Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing 100093, 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 100093, China
- Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing 100093, China
| | - Tianfu Li
- 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 100093, China
- Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing 100093, China
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Mamaril-Davis J, Vessell M, Ball T, Palade A, Shafer C, Aguilar-Salinas P, Fowler B, Mirro E, Neimat J, Sagi V, Bina RW. Combined Responsive Neurostimulation and Focal Resection for Super Refractory Status Epilepticus: A Systematic Review and Illustrative Case Report. World Neurosurg 2022; 167:195-204.e7. [PMID: 35948220 DOI: 10.1016/j.wneu.2022.07.141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Super-refractory status epilepticus (SRSE) is a neurologic emergency with high mortality and morbidity. Although medical algorithms typically are effective, when they do fail, options may be limited, and neurosurgical intervention should be considered. METHODS We report a case of SRSE treated acutely with responsive neurostimulation (RNS) and focal surgical resection after intracranial monitoring. We also conducted a systematic review of the literature for neurosurgical treatment of SRSE (e.g., neurostimulation). Only published manuscripts were considered. RESULTS Our patient's seizure semiology consisted of left facial twitching with frequent evolution to bilateral tonic-clonic convulsions. Stereoelectroencephalography and grid monitoring identified multiple seizure foci. The patient underwent right RNS placement with cortical strip leads over the lateral primary motor and premotor cortex as well as simultaneous right superior temporal and frontopolar resection. Status epilepticus resolved 21 days after surgical resection and placement of the RNS. The systematic review revealed 15 case reports describing 17 patients with SRSE who underwent acute neurosurgical intervention. There were 3 patients with SRSE with RNS placement as a single modality, all of whom experienced cessation of SE. Four patients with SRSE received vagus nerve stimulation (3 as a single modality and 1 with combined corpus callosotomy), of whom 1 had SE recurrence at 2weeks. Two patients with SRSE received deep brain stimulation, and the remaining 8 underwent surgical resection; none had recurrence of SE. CONCLUSIONS RNS System placement with or without resection can be a viable treatment option for select patients with SRSE. Early neurosurgical intervention may improve seizure outcomes and reduce complications.
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Affiliation(s)
- James Mamaril-Davis
- College of Medicine, The University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA
| | - Meena Vessell
- Department of Neurosurgery, University of Louisville Restorative Neuroscience, Louisville, Kentucky, USA
| | - Tyler Ball
- Department of Neurosurgery, University of Louisville Restorative Neuroscience, Louisville, Kentucky, USA
| | - Adriana Palade
- Department of Neurology, University of Louisville, Louisville, Kentucky, USA
| | - Christopher Shafer
- Department of Neurology, University of Louisville, Louisville, Kentucky, USA
| | - Pedro Aguilar-Salinas
- Department of Neurosurgery, Banner University Medical Center/The University of Arizona, Tucson, Arizona, USA
| | | | - Emily Mirro
- Neuropace, Inc., Mountain View, California, USA
| | - Joseph Neimat
- Department of Neurosurgery, University of Louisville Restorative Neuroscience, Louisville, Kentucky, USA
| | - Vishwanath Sagi
- Department of Neurology, University of Louisville, Louisville, Kentucky, USA
| | - Robert W Bina
- Department of Neurosurgery, Banner University Medical Center/The University of Arizona-Phoenix, Phoenix, Arizona, USA.
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Wickstrom R, Taraschenko O, Dilena R, Payne ET, Specchio N, Nabbout R, Koh S, Gaspard N, Hirsch LJ. International consensus recommendations for management of New Onset Refractory Status Epilepticus (NORSE) incl. Febrile Infection-Related Epilepsy Syndrome (FIRES): Statements and Supporting Evidence. Epilepsia 2022; 63:2840-2864. [PMID: 35997591 PMCID: PMC9828002 DOI: 10.1111/epi.17397] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/14/2022] [Accepted: 08/18/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To develop consensus-based recommendations for the management of adult and paediatric patients with NORSE/FIRES based on best evidence and experience. METHODS The Delphi methodology was followed. A facilitator group of 9 experts was established, who defined the scope, users and suggestions for recommendations. Following a review of the current literature, recommendation statements concerning diagnosis, treatment and research directions were generated which were then voted on a scale of 1 (strongly disagree) to 9 (strongly agree) by a panel of 48 experts in the field. Consensus that a statement was appropriate was reached if the median score was greater or equal to 7, and inappropriate if the median score was less than or equal to 3. The analysis of evidence was mapped to the results of each statement included in the Delphi survey. RESULTS Overall, 85 recommendation statements achieved consensus. The recommendations are divided into five sections: 1) disease characteristics, 2) diagnostic testing and sampling, 3) acute treatment, 4) treatment in the post-acute phase, and 5) research, registries and future directions in NORSE/FIRES. The detailed results and discussion of all 85 statements are outlined herein. A corresponding summary of findings and practical flowsheets are presented in a companion article. SIGNIFICANCE This detailed analysis offers insight into the supporting evidence and the current gaps in the literature that are associated with expert consensus statements related to NORSE/FIRES. The recommendations generated by this consensus can be used as a guide for the diagnosis, evaluation, and management of patients with NORSE/FIRES, and for planning of future research.
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Affiliation(s)
- Ronny Wickstrom
- Neuropaediatric UnitDepartment of Women's and Children's HealthKarolinska Institutet and Karolinska University HospitalStockholmSweden
| | - Olga Taraschenko
- Department of Neurological SciencesUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Robertino Dilena
- Neuropathophysiology UnitFoundation IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Eric T. Payne
- Department of Pediatrics, Section of NeurologyAlberta Children's HospitalCalgaryAlbertaCanada
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of NeurosciencesBambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network EpiCARERomeItaly
| | - Rima Nabbout
- Department of Pediatric Neurology, APHP, Member of EPICARE ERN, Centre de Reference Epilepsies RaresUniversite de Paris, Institut Imagine, INSERM 1163ParisFrance
| | - Sookyong Koh
- Department of Pediatrics, Children's Hospital and Medical CenterUniversity of NebraskaOmahaNebraskaUSA
| | | | - Lawrence J. Hirsch
- Department of Neurology, Comprehensive Epilepsy CenterYale UniversityNew HavenConnecticutUSA
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Luo T, Wang Y, Lu G, Zhou Y, Wang Y. Vagus nerve stimulation for super-refractory status epilepticus in febrile infection-related epilepsy syndrome: a pediatric case report and literature review. Childs Nerv Syst 2022; 38:1401-1404. [PMID: 34762158 DOI: 10.1007/s00381-021-05410-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 11/03/2021] [Indexed: 11/30/2022]
Abstract
Febrile infection-related epilepsy syndrome (FIRES) is a devastating epileptic encephalopathy with limited treatment options and unclear etiology. Vagus nerve stimulation (VNS) is an FDA-approved therapy for refractory epilepsy that has been shown to decrease the frequency and severity of seizures. There is a growing interest in alternate non-pharmaceutical therapies for managing super-refractory status epilepticus (SRSE). We present a 29-month-old case, diagnosed with FIRES, whose seizures were successfully controlled by utilization of VNS after ineffective response to intensive pharmacotherapy and ketogenic diet treatment. The VNS was planted after 14 days of refractory seizure activity with a following rapid parameter titration for 42 days without evident side effect, which finally controlled the seizure in the acute phase. VNS may be a potential candidate for the treatment of SRSE in FIRES.
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Affiliation(s)
- Tian Luo
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center, No. 399, Wanyuan Road, Minhang District, Shanghai, China
| | - Yixue Wang
- Department of Intensive Care Unit, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Guoping Lu
- Department of Intensive Care Unit, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Yuanfeng Zhou
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center, No. 399, Wanyuan Road, Minhang District, Shanghai, China.
| | - Yi Wang
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center, No. 399, Wanyuan Road, Minhang District, Shanghai, China.
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Migdady I, Rosenthal ES, Cock HR. Management of status epilepticus: a narrative review. Anaesthesia 2022; 77 Suppl 1:78-91. [PMID: 35001380 DOI: 10.1111/anae.15606] [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] [Accepted: 10/01/2021] [Indexed: 11/26/2022]
Abstract
Status epilepticus causes prolonged or repetitive seizures that, if left untreated, can lead to neuronal injury, severe disability, coma and death in paediatric and adult populations. While convulsive status epilepticus can be diagnosed using clinical features alone, non-convulsive status epilepticus requires confirmation by electroencephalogram. Early seizure control remains key in preventing the complications of status epilepticus. This is especially true for convulsive status epilepticus, which has stronger evidence supporting the benefit of treatment on outcomes. When status epilepticus becomes refractory, often due to gamma-aminobutyric acid and N-methyl-D-aspartate receptor modulation, anaesthetic drugs are needed to suppress seizure activity, of which there is limited evidence regarding the selection, dose or duration of their use. Seizure monitoring with electroencephalogram is often needed when patients do not return to baseline or during anaesthetic wean; however, it is resource-intensive, costly, only available in highly specialised centres and has not been shown to improve functional outcomes. Thus, the treatment goals and aggressiveness of therapy remain under debate, especially for non-convulsive status epilepticus, where prolonged therapeutic coma can lead to severe complications. This review presents an evidence-based, clinically-oriented and comprehensive review of status epilepticus and its definitions, aetiologies, treatments, outcomes and prognosis at different stages of the patient's journey.
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Affiliation(s)
- I Migdady
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - E S Rosenthal
- Department of Neurology, Divisions of Clinical Neurophysiology and Neurocritical Care Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - H R Cock
- Clinical Neurosciences Academic Group, Institute of Molecular and Clinical Sciences, St. George's University of London, London, UK
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Ochoa JG, Dougherty M, Papanastassiou A, Gidal B, Mohamed I, Vossler DG. Treatment of Super-Refractory Status Epilepticus: A Review. Epilepsy Curr 2021; 21:1535759721999670. [PMID: 33719651 PMCID: PMC8652329 DOI: 10.1177/1535759721999670] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Super-refractory status epilepticus (SRSE) presents management challenges due to the absence of randomized controlled trials and a plethora of potential medical therapies. The literature on treatment options for SRSE reports variable success and quality of evidence. This review is a sequel to the 2020 American Epilepsy Society (AES) comprehensive review of the treatment of convulsive refractory status epilepticus (RSE). METHODS We sought to determine the effectiveness of treatment options for SRSE. We performed a structured literature search (MEDLINE, Embase, CENTRAL, CINAHL) for studies on reported treatments of SRSE. We excluded antiseizure medications (ASMs) covered in the 2016 AES guideline on the treatment of established SE and the convulsive RSE comprehensive review of the 2020 AES. Literature was reviewed on the effectiveness of vagus nerve stimulation, ketogenic diet (KD), lidocaine, inhalation anesthetics, brain surgery, therapeutic hypothermia, perampanel, pregabalin (PGB), and topiramate in the treatment of SRSE. Two authors reviewed each therapeutic intervention. We graded the level of the evidence according to the 2017 classification scheme of the American Academy of Neurology. RESULTS For SRSE (level U; 39 class IV studies total), insufficient evidence exists to support that perampanel, PGB, lidocaine, or acute vagus nerve stimulation (VNS) is effective. For children and adults with SRSE, insufficient evidence exists to support that the KD is effective (level U; 5 class IV studies). For adults with SRSE, insufficient evidence exists that brain surgery is effective (level U, 7 class IV studies). For adults with SRSE insufficient, evidence exists that therapeutic hypothermia is effective (level C, 1 class II and 4 class IV studies). For neonates with hypoxic-ischemic encephalopathy, insufficient evidence exists that therapeutic hypothermia reduces seizure burden (level U; 1 class IV study). For adults with SRSE, insufficient evidence exists that inhalation anesthetics are effective (level U, 1 class IV study) and that there is a potential risk of neurotoxicity. CONCLUSION For patients with SRSE insufficient, evidence exists that any of the ASMs reviewed, inhalational anesthetics, ketogenic diet, acute VNS, brain surgery, and therapeutic hypothermia are effective treatments. Data supporting the use of these treatments for SRSE are scarce and limited mainly to small case series and case reports and are confounded by differences in patients' population, and comedications, among other factors.
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Affiliation(s)
| | | | | | | | - Ismail Mohamed
- Department of Pediatrics, University of Alabama, Birmingham, USA
| | - David G. Vossler
- University of Washington, Seattle, WA, USA
- Treatments Committee, American Epilepsy Society, Chicago, IL, USA
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MUCHAMAD GR, HANAYA R, MARUYAMA S, YONEE C, HOSOYAMA H, BABA Y, SATO M, SANO N, OTSUBO T, YOSHIMOTO K. Effects of Vagus Nerve Stimulation on Sustained Seizure Clusters: A Case Report. NMC Case Rep J 2021; 8:123-128. [PMID: 35079453 PMCID: PMC8769382 DOI: 10.2176/nmccrj.cr.2020-0137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 06/25/2020] [Indexed: 11/25/2022] Open
Abstract
Seizure clusters (SCs) are acute repetitive seizures with acute episodes of deterioration during seizure control. SCs can be defined as a series of grouped seizures with short interictal periods. Vagus nerve stimulation (VNS) is a treatment option for drug-resistant epilepsy. We present a case where VNS suppressed epileptic SCs, which had persisted for several months. A 13-year-old boy with congenital cerebral palsy and mental retardation had drug-resistant epilepsy with daily jerking movements and spasms in both sides of his body. The seizures were often clustered, and he experienced two sustained SC episodes that persisted for a few months even with prolonged use of continuous intravenous midazolam (IV-MDZ). The patient underwent VNS device placement at the second sustained SC and rapid induction of VNS. Because the tapering of IV-MDZ did not exacerbate the SC, midazolam was discontinued 4 weeks after VNS initiation. Non-refractory SCs also disappeared 10 months after VNS. The seizure severity was improved, and the frequency of seizures reduced from daily to once every few months. The epileptic activity on electroencephalography (EEG) significantly decreased. This case highlights VNS as an additional treatment option for SC. VNS may be a therapeutic option if SC resists the drugs and sustains. Additional studies are necessary to confirm our findings and to investigate how device implantation and stimulation parameters affect the efficacy of VNS.
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Affiliation(s)
- Galih Ricci MUCHAMAD
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Kagoshima, Japan
| | - Ryosuke HANAYA
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Kagoshima, Japan
- Epilepsy Center, Kagoshima University Hospital, Kagoshima, Kagoshima, Japan
| | - Shinsuke MARUYAMA
- Epilepsy Center, Kagoshima University Hospital, Kagoshima, Kagoshima, Japan
- Department of Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Kagoshima, Japan
| | - Chihiro YONEE
- Epilepsy Center, Kagoshima University Hospital, Kagoshima, Kagoshima, Japan
- Department of Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Kagoshima, Japan
| | - Hiroshi HOSOYAMA
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Kagoshima, Japan
- Epilepsy Center, Kagoshima University Hospital, Kagoshima, Kagoshima, Japan
| | - Yusei BABA
- Epilepsy Center, Kagoshima University Hospital, Kagoshima, Kagoshima, Japan
- Department of Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Kagoshima, Japan
| | - Masanori SATO
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Kagoshima, Japan
- Epilepsy Center, Kagoshima University Hospital, Kagoshima, Kagoshima, Japan
| | - Nozomi SANO
- Department of Pediatrics, Minami Kyushu National Hospital, Aira, Kagoshima, Japan
| | - Toshiaki OTSUBO
- Department of Neurosurgery, Fujimoto General Hospital, Miyakonojo, Miyazaki, Japan
| | - Koji YOSHIMOTO
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Kagoshima, Japan
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Abstract
For various reasons, status epilepticus in children is different than in adults. Pediatric specificities include status epilepticus epidemiology, underlying etiologies, pathophysiological mechanisms, and treatment options. Relevant data from the literature are presented for each of them, and questions remaining open for future studies on status epilepticus in childhood are listed.
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Specchio N, Pietrafusa N. New-onset refractory status epilepticus and febrile infection-related epilepsy syndrome. Dev Med Child Neurol 2020; 62:897-905. [PMID: 32372459 DOI: 10.1111/dmcn.14553] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2020] [Indexed: 12/11/2022]
Abstract
New-onset refractory status epilepticus (NORSE) and febrile infection-related epilepsy syndrome (FIRES) are relatively rare clinical presentations. They are characterized by de novo onset of refractory status epilepticus (RSE) without clearly identifiable acute or active cause (structural, toxic, or metabolic). We reviewed the literature using PubMed reports published between 2003 and 2019 and summarized the clinical, neurophysiological, imaging, and treatment findings. Focal motor seizures, which tend to evolve into status epilepticus, characterize the typical presentation. Disease course is biphasic: acute phase followed by chronic phase with refractory epilepsy and neurological impairment. Aetiology is unknown, but immune-inflammatory-mediated epileptic encephalopathy is suspected. Electroencephalograms show variety in discharges (sporadic or periodic, focal, generalized, or more frequently bilateral), sometimes with a multifocal pattern. About 70% of adult NORSE have abnormal magnetic resonance imaging (MRI); in paediatric series of FIRES, 61.2% of patients have a normal brain MRI at the beginning and only 18.5% during the chronic phase. No specific therapy for FIRES and NORSE currently exists; high doses of barbiturates and ketogenic diet can be used with some effectiveness. Recently, anakinra and tocilizumab, targeting interleukin pathways, have emerged as potential specific therapies. Mortality rate is around 12% in children and even higher in adults (16-27%).
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Affiliation(s)
- Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children Hospital, Rome, Italy.,European Reference Network EpiCARE, Rome, Italy
| | - Nicola Pietrafusa
- Rare and Complex Epilepsy Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children Hospital, Rome, Italy
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Specchio N, Ferretti A, Pietrafusa N, Trivisano M, Calabrese C, Carfì Pavia G, De Benedictis A, Marras CE, de Palma L, Vigevano F. Refractory Status Epilepticus in Genetic Epilepsy-Is Vagus Nerve Stimulation an Option? Front Neurol 2020; 11:443. [PMID: 32595584 PMCID: PMC7303322 DOI: 10.3389/fneur.2020.00443] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 04/27/2020] [Indexed: 11/13/2022] Open
Abstract
Refractory and super-refractory status epilepticus (RSE, SRSE) are severe conditions that can have long-term neurological consequences with high morbidity and mortality rates. The usefulness of vagus nerve-stimulation (VNS) implantation during RSE has been documented by anecdotal cases and in systematic reviews; however, the use of VNS in RSE has not been widely adopted. We successfully implanted VNS in two patients with genetic epilepsy admitted to hospital for SRSE; detailed descriptions of the clinical findings and VNS parameters are provided. Our patients were implanted 25 and 58 days after status epilepticus (SE) onset, and a stable remission of SE was observed from the seventh and tenth day after VNS implantation, respectively, without change in anti-seizure medication. We used a fast ramp-up of stimulation without evident side effects. Our results support the consideration of VNS implantation as a safe and effective adjunctive treatment for SRSE.
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Affiliation(s)
- Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Member of European Reference Network EpiCARE, Rome, Italy
| | - Alessandro Ferretti
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Member of European Reference Network EpiCARE, Rome, Italy
| | - Nicola Pietrafusa
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Member of European Reference Network EpiCARE, Rome, Italy
| | - Marina Trivisano
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Member of European Reference Network EpiCARE, Rome, Italy
| | - Costanza Calabrese
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Member of European Reference Network EpiCARE, Rome, Italy
| | - Giusy Carfì Pavia
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Member of European Reference Network EpiCARE, Rome, Italy
| | - Alessandro De Benedictis
- Neurosurgery Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Carlo Efisio Marras
- Neurosurgery Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Luca de Palma
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Member of European Reference Network EpiCARE, Rome, Italy
| | - Federico Vigevano
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Member of European Reference Network EpiCARE, Rome, Italy
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Increased ACh-Associated Immunoreactivity in Autonomic Centers in PTZ Kindling Model of Epilepsy. Biomedicines 2020; 8:biomedicines8050113. [PMID: 32397136 PMCID: PMC7277646 DOI: 10.3390/biomedicines8050113] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/03/2020] [Accepted: 05/05/2020] [Indexed: 12/11/2022] Open
Abstract
Experimental and clinical studies of cardiac pathology associated with epilepsy have demonstrated an impact on the autonomic nervous system (ANS). However, the underlying molecular mechanism has not been fully elucidated. Molecular investigation of the neurotransmitters related receptor and ion channel directing ANS might help in understanding the associated mechanism. In this paper, we investigated the role of acetylcholine (ACh), which demonstrates both sympathetic and parasympathetic roles in targeted expression in terms of the relevant receptor and ion channel. Inwardly rectifying potassium (Kir) channels play a significant role in maintaining the resting membrane potential and controlling cell excitability and are prominently expressed in both the excitable and non-excitable tissues. The immunoreactivity of ACh-activated Kir3.1 channel and muscarinic ACh receptors (M2) in autonomic centers such as the brainstem, vagus nerve (VN) and atria of heart was confirmed by both histological staining and pathological tissue analysis. Significant upregulations of Kir3.1 and M2 receptors were observed in pentylenetetrazol (PTZ)-kindled epileptic rats for all related tissues investigated, whereas no pathological difference was observed. These findings provide proof-of-concept that changes in ACh-associated immunoreactivity might be linked to the ANS dysfunctions associated with epilepsy.
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Benghanem S, Mazeraud A, Azabou E, Chhor V, Shinotsuka CR, Claassen J, Rohaut B, Sharshar T. Brainstem dysfunction in critically ill patients. Crit Care 2020; 24:5. [PMID: 31907011 PMCID: PMC6945639 DOI: 10.1186/s13054-019-2718-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 12/23/2019] [Indexed: 02/06/2023] Open
Abstract
The brainstem conveys sensory and motor inputs between the spinal cord and the brain, and contains nuclei of the cranial nerves. It controls the sleep-wake cycle and vital functions via the ascending reticular activating system and the autonomic nuclei, respectively. Brainstem dysfunction may lead to sensory and motor deficits, cranial nerve palsies, impairment of consciousness, dysautonomia, and respiratory failure. The brainstem is prone to various primary and secondary insults, resulting in acute or chronic dysfunction. Of particular importance for characterizing brainstem dysfunction and identifying the underlying etiology are a detailed clinical examination, MRI, neurophysiologic tests such as brainstem auditory evoked potentials, and an analysis of the cerebrospinal fluid. Detection of brainstem dysfunction is challenging but of utmost importance in comatose and deeply sedated patients both to guide therapy and to support outcome prediction. In the present review, we summarize the neuroanatomy, clinical syndromes, and diagnostic techniques of critical illness-associated brainstem dysfunction for the critical care setting.
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Affiliation(s)
- Sarah Benghanem
- Department of Neurology, Neuro-ICU, Sorbonne University, APHP Pitié-Salpêtrière Hospital, Paris, France
- Medical ICU, Cochin Hospital, AP-HP, Paris, France
| | - Aurélien Mazeraud
- Department of Neuro-ICU, GHU-Paris, Paris-Descartes University, Paris, France
- Laboratory of Experimental Neuropathology, Pastuer Institute, Paris, France
| | - Eric Azabou
- Department of Physiology, Clinical Neurophysiology Unit, APHP, Raymond Poincaré Hospital, University of Versailles Saint Quentin en Yvelines, Garches, France
| | - Vibol Chhor
- Department of Intensive Care Medicine, Saint-Joseph Hospital, Paris, France
| | - Cassia Righy Shinotsuka
- Intensive Care Unit and Postgraduate Program, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
- D'Or Institute for Research and Education, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jan Claassen
- Department of Neurology, Neuro-ICU, Columbia University, New York, NY, USA
| | - Benjamin Rohaut
- Department of Neurology, Neuro-ICU, Sorbonne University, APHP Pitié-Salpêtrière Hospital, Paris, France
- Department of Neurology, Neuro-ICU, Columbia University, New York, NY, USA
- Institut du Cerveau et de la Moelle épinière, ICM, INSERM UMRS 1127, CNRS UMR 7225, Pitié- Salpêtrière Hospital, Paris, F-75013, France
| | - Tarek Sharshar
- Department of Neuro-ICU, GHU-Paris, Paris-Descartes University, Paris, France.
- Laboratory of Experimental Neuropathology, Pastuer Institute, Paris, France.
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Dibué-Adjei M, Brigo F, Yamamoto T, Vonck K, Trinka E. Vagus nerve stimulation in refractory and super-refractory status epilepticus - A systematic review. Brain Stimul 2019; 12:1101-1110. [PMID: 31126871 DOI: 10.1016/j.brs.2019.05.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 05/06/2019] [Accepted: 05/08/2019] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Refractory status epilepticus (RSE) is the persistence of status epilepticus despite second-line treatment. Super-refractory SE (SRSE) is characterized by ongoing status despite 48 h of anaesthetic treatment. Due to the high case fatality in RSE of 16-39%, off label treatments without strong evidence of efficacy in RSE are often administered. In single case-reports and small case series totalling 28 patients, acute implantation of VNS in RSE was associated with 76% and 26% success rate in generalized and focal RSE respectively. We performed an updated systematic review of the literature on efficacy of VNS in RSE/SRSE by including all reported patients. METHODS We systematically searched EMBASE, CENTRAL, Opengre.eu, and ClinicalTrials.gov, and PubMed databases to identify studies reporting the use of VNS for RSE and/or SRSE. We also searched conference abstracts from AES and ILAE meetings. RESULTS 45 patients were identified in total of which 38 were acute implantations of VNS in RSE/SRSE. Five cases had VNS implantation for epilepsia partialis continua, one for refractory electrical status epilepticus in sleep and one for acute encephalitis with refractory repetitive focal seizures. Acute VNS implantation was associated with cessation of RSE/SRSE in 74% (28/38) of acute cases. Cessation did not occur in 18% (7/38) of cases and four deaths were reported (11%); all of them due to the underlying disease and unlikely related to VNS implantation. Median duration of the RSE/SRSE episode pre and post VNS implantation was 18 days (range: 3-1680 days) and 8 days (range: 3-84 days) respectively. Positive outcomes occurred in 82% (31/38) of cases. CONCLUSION VNS can interrupt RSE and SRSE in 74% of patients; data originate from reported studies classified as level IV and the risk for reporting bias is high. Further prospective studies are warranted to investigate acute VNS in RSE and SRSE.
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Affiliation(s)
- Maxine Dibué-Adjei
- LivaNova Deutschland GmbH, LivaNova PLC-owned Subsidiary, Lindberghstraße 25, 80939, Munich, Germany; Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstraße 5, D-40225, Düsseldorf, Germany.
| | - Francesco Brigo
- Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy; Department of Neurology, Franz Tappeiner Hospital, Merano, Italy
| | - Takamichi Yamamoto
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Kristl Vonck
- Brain Research Team, Department of Neurology, Ghent University, Ghent, Belgium
| | - Eugen Trinka
- Department of Neurology, Christian-Doppler University Hospital, Paracelsus Medical University, Centre for Cognitive Neuroscience, Salzburg, Austria; Institute of Public Health, Medical Decision Making and HTA, UMIT, Private University for Health Sciences, Medical Informatics and Technology, Hall in Tyrol, Austria
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16
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Arya R, Rotenberg A. Dietary, immunological, surgical, and other emerging treatments for pediatric refractory status epilepticus. Seizure 2019; 68:89-96. [DOI: 10.1016/j.seizure.2018.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 09/07/2018] [Accepted: 09/10/2018] [Indexed: 02/07/2023] Open
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San-Juan D, Dávila-Rodríguez DO, Jiménez CR, González MS, Carranza SM, Hernández Mendoza JR, Anschel DJ. Neuromodulation techniques for status epilepticus: A review. Brain Stimul 2019; 12:835-844. [PMID: 31053521 DOI: 10.1016/j.brs.2019.04.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 04/05/2019] [Accepted: 04/14/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Electroconvulsive therapy (ECT), Vagal Nerve Stimulation (VNS), Transcranial Magnetic Stimulation (TMS) and Deep Brain Stimulation (DBS) are neuromodulation therapies that have been used to treat Status Epilepticus (SE). OBJECTIVE Review the literature about the efficacy and safety of neuromodulation therapies in SE in humans. METHODS We searched studies in PubMed, Scopus, Google Scholar and Science Direct (inception to June 2018). Four review authors independently selected the studies, extracted data and assessed the methodological quality of the studies using the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions, PRISMA guidelines, Oxford and GRADE scales, and Murad et al., 2018 methodological quality and synthesis of case series and case reports. RESULTS We analyzed 27 articles (45 patients) with 4 different neuromodulation therapies. In ECT we found 80% rate of disruption of SE and 5% of adverse events was reported. Using iVNS 15/16 (93.7%) patients resolved the SE. All patients who underwent TMS and DBS aborted SE, however, 50% of patients with DBS had severe adverse events. CONCLUSIONS Case series and case reports suggest that neuromodulation therapies can abort SE in 80-100% of patients (Oxford scale and GRADE were level 4 and D) with a wide range of adverse effects, which claims for prospective studies on the relationship be-tween efficacy and safety.
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Affiliation(s)
- Daniel San-Juan
- Neurophysiology Department, National Institute of Neurology and Neurosurgery Manuel Velasco Suárez, Mexico City, Mexico.
| | | | - Christian Ramos Jiménez
- Faculty of Medicine, Autonomous University of State of Mexico, Toluca de Lerdo, State of Mexico, Mexico
| | | | | | - Jesús Ricardo Hernández Mendoza
- Faculty of Medicine Mexicali, Autonomous University of Baja California, Dr. Humberto Torres Sangines, Mexicali, Baja California, Mexico
| | - David J Anschel
- Comprehensive Epilepsy Center of Long Island, Port Jefferson, NY, USA
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18
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Gofton TE, Gaspard N, Hocker SE, Loddenkemper T, Hirsch LJ. New onset refractory status epilepticus research: What is on the horizon? Neurology 2019; 92:802-810. [PMID: 30894443 DOI: 10.1212/wnl.0000000000007322] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 01/17/2019] [Indexed: 12/14/2022] Open
Abstract
New-onset refractory status epilepticus (NORSE) is a clinical presentation, not a specific diagnosis, in a patient without active epilepsy or other preexisting relevant neurologic disorder, with new onset of refractory status epilepticus (RSE) that does not resolve after 2 or more rescue medications, without a clear acute or active structural, toxic, or metabolic cause. Febrile infection-related epilepsy syndrome is a subset of NORSE in which fever began at least 24 hours prior to the RSE. Both terms apply to all age groups. Until recently, NORSE was a poorly recognized entity without a consistent definition or approach to care. We review the current state of knowledge in NORSE and propose a roadmap for future collaborative research. Research investigating NORSE should prioritize the following 4 domains: (1) clinical features, etiology, and pathophysiology; (2) treatment; (3) adult and pediatric evaluation and management approaches; and (4) public advocacy, professional education, and family support. We consider international collaboration and multicenter research crucial in achieving these goals.
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Affiliation(s)
- Teneille E Gofton
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT.
| | - Nicolas Gaspard
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT
| | - Sara E Hocker
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT
| | - Tobias Loddenkemper
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT
| | - Lawrence J Hirsch
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT
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Vagus Nerve Stimulation (VNS) in Super Refractory New Onset Refractory Status Epilepticus (NORSE). Case Rep Neurol Med 2019; 2019:7852017. [PMID: 30805233 PMCID: PMC6360559 DOI: 10.1155/2019/7852017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 01/01/2019] [Accepted: 01/08/2019] [Indexed: 11/17/2022] Open
Abstract
The treatment protocol of status epilepticus has many associated toxicities so there is interest in alternate nonmedicinal therapies for managing New Onset Refractory Status Epilepticus (NORSE) patients. Vagus nerve stimulation (VNS) is an FDA-approved therapy for refractory epilepsy that has been shown to decrease the frequency and severity of seizures. We present the case of a patient with new-onset refractory status epilepticus (NORSE) whose seizures were successfully treated with vagus nerve stimulation. A 25-year-old male with no history of epilepsy or other neurological disorders presented with altered mental status and generalized tonic-clonic seizures following a two-week history of an upper respiratory tract infection. Lumbar puncture showed neutrophilic pleocytosis, and he was treated for bacterial and viral meningoencephalitis. In spite of treatment, his seizures began increasing in frequency. On day three, the patient entered status epilepticus (SE) refractory to intensive pharmacotherapy with maximal doses of valproate, levetiracetam, and propofol. On day four, SE remained refractory, so pentobarbital was introduced with targeted burst suppression pattern on electroencephalography (EEG). Patient continued to be refractory to these measures, so a vagus nerve stimulator (VNS) was implanted (day eight). Following VNS implantation, EEG demonstrated significant reduction of seizure activity and subsequent magnet swiping continued aborting electrographic seizures. No SE or electrographic seizures were reported for seventy-two hours, but few occasional discharges were reported. Seizures eventually recurred on day fourteen and the patient succumbed to his multiple comorbidities on day seventeen. Due to the efficacy of VNS in refractory epilepsy, there was interest in using it in refractory status epilepticus. Multiple case reports have described a benefit from implantation of VNS in the treatment of SE. The successful use of VNS to acutely terminate status epilepticus for seventy-two hours in this critically ill patient adds to current evidence that there is utility in using VNS for refractory status epilepticus.
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Serino D, Santarone ME, Caputo D, Fusco L. Febrile infection-related epilepsy syndrome (FIRES): prevalence, impact and management strategies. Neuropsychiatr Dis Treat 2019; 15:1897-1903. [PMID: 31371963 PMCID: PMC6635824 DOI: 10.2147/ndt.s177803] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 06/13/2019] [Indexed: 12/27/2022] Open
Abstract
Febrile infection-related epilepsy syndrome (FIRES) is a rare catastrophic epileptic encephalopathy with a yet undefined etiology, affecting healthy children. It is characterized by acute manifestation of recurrent seizures or refractory status epilepticus preceded by febrile illness, but without evidence of infectious encephalitis. To date, the absence of specific biomarkers poses a significant diagnostic challenge; nonetheless, early diagnosis is very important for optimal management. FIRES is mostly irreversible and its sequelae include drug-resistant epilepsy and neuropsychological impairments. The treatment of FIRES represents a significant challenge for clinicians and is associated with low success rates. Early introduction of ketogenic diet seems to represent the most effective and promising treatment. This review aims to highlight the most recent insights on clinical features, terminology, epidemiology, pathogenesis, diagnostic challenges and therapeutic options.
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Affiliation(s)
- Domenico Serino
- Department of Child Neurology, Royal Aberdeen Children's Hospital, Aberdeen, UK
| | | | - Davide Caputo
- Neurology Unit, Neuroscience Department, San Paolo Hospital, Milan, Italy
| | - Lucia Fusco
- Department of Neuroscience, Bambino Gesù Children's Hospital, Rome, Italy
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21
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Does emergent implantation of a vagal nerve stimulator stop refractory status epilepticus in children? Seizure 2018; 61:94-97. [DOI: 10.1016/j.seizure.2018.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 08/07/2018] [Accepted: 08/10/2018] [Indexed: 11/23/2022] Open
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Pizzi MA, Kamireddi P, Tatum WO, Shih JJ, Jackson DA, Freeman WD. Transition from intravenous to enteral ketamine for treatment of nonconvulsive status epilepticus. J Intensive Care 2017; 5:54. [PMID: 28808577 PMCID: PMC5549373 DOI: 10.1186/s40560-017-0248-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 08/03/2017] [Indexed: 11/25/2022] Open
Abstract
Background Nonconvulsive status epilepticus (NCSE) is a diagnosis that is often challenging and one that may progress to refractory NCSE. Ketamine is a noncompetitive N-methyl-d-aspartate antagonist that increasingly has been used to treat refractory status epilepticus. Current Neurocritical Care Society guidelines recommend intravenous (IV) ketamine infusion as an alternative treatment for refractory status epilepticus in adults. On the other hand, enteral ketamine use in NCSE has been reported in only 6 cases (1 adult and 5 pediatric) in the literature to date. Case presentation A 33-year-old woman with a history of poorly controlled epilepsy presented with generalized tonic-clonic seizures, followed by recurrent focal seizures that evolved into NCSE. This immediately recurred within 24 h of a prior episode of NCSE that was treated with IV ketamine. Considering her previous response, she was started again on an IV ketamine infusion, which successfully terminated NCSE. This time, enteral ketamine was gradually introduced while weaning off the IV formulation. Treatment with enteral ketamine was continued for 6 months and then tapered off. There was no recurrence of NCSE or seizures and no adverse events noted during the course of treatment. Conclusion This case supports the use of enteral ketamine as a potential adjunct to IV ketamine in the treatment of NCSE, especially in cases without coma. Introduction of enteral ketamine may reduce seizure recurrence, duration of stay in ICU, and morbidity associated with intubation.
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Affiliation(s)
- Michael A Pizzi
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - Prasuna Kamireddi
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - William O Tatum
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - Jerry J Shih
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224 USA.,Present Address: Department of Neurology, University of California, San Diego, CA USA
| | | | - William D Freeman
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224 USA
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23
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Khan FA, Poongkunran M, Buratto B. Desensitization of stimulation-induced weight loss: A secondary finding in a patient with vagal nerve stimulator for drug-resistant epilepsy. EPILEPSY & BEHAVIOR CASE REPORTS 2017; 8:51-54. [PMID: 28879091 PMCID: PMC5577401 DOI: 10.1016/j.ebcr.2017.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 07/01/2017] [Accepted: 07/13/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Fawad A Khan
- The International Center for Epilepsy at Ochsner, Ochsner Neuroscience Institute, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121, United States.,The University of Queensland School of Medicine, Ochsner Clinical School, 1514 Jefferson Highway, New Orleans, LA 70121, United States
| | - Mugilan Poongkunran
- The International Center for Epilepsy at Ochsner, Ochsner Neuroscience Institute, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121, United States
| | - Bonnie Buratto
- The International Center for Epilepsy at Ochsner, Ochsner Neuroscience Institute, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121, United States
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Poblete R, Sung G. Status Epilepticus and Beyond: A Clinical Review of Status Epilepticus and an Update on Current Management Strategies in Super-refractory Status Epilepticus. Korean J Crit Care Med 2017; 32:89-105. [PMID: 31723624 PMCID: PMC6786704 DOI: 10.4266/kjccm.2017.00252] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 05/05/2017] [Indexed: 12/03/2022] Open
Abstract
Status epilepticus and refractory status epilepticus represent some of the most complex conditions encountered in the neurological intensive care unit. Challenges in management are common as treatment options become limited and prolonged hospital courses are accompanied by complications and worsening patient outcomes. Antiepileptic drug treatments have become increasingly complex. Rational polytherapy should consider the pharmacodynamics and kinetics of medications. When seizures cannot be controlled with medical therapy, alternative treatments, including early surgical evaluation can be considered; however, evidence is limited. This review provides a brief overview of status epilepticus, and a recent update on the management of refractory status epilepticus based on evidence from the literature, evidence-based guidelines, and experiences at our institution.
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Affiliation(s)
- Roy Poblete
- Department of Neurology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Gene Sung
- Department of Neurology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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Abstract
Gastrointestinal (GI) motility disorders are common in clinical settings, including esophageal motility disorders, gastroesophageal reflux disease, functional dyspepsia, gastroparesis, chronic intestinal pseudo-obstruction, post-operative ileus, irritable bowel syndrome, diarrhea and constipation. While a number of drugs have been developed for treating GI motility disorders, few are currently available. Emerging electrical stimulation methods may provide new treatment options for these GI motility disorders. Areas covered: This review gives an overview of electrical therapies that have been, and are being developed for GI motility disorders, including gastroesophageal reflux, functional dyspepsia, gastroparesis, intestinal motility disorders and constipation. Various methods of gastrointestinal electrical stimulation are introduced. A few methods of nerve stimulation have also been described, including spinal cord stimulation and sacral nerve stimulation. Potentials of electrical therapies for obesity are also discussed. PubMed was searched using keywords and their combinations: electrical stimulation, spinal cord stimulation, sacral nerve stimulation, gastrointestinal motility and functional gastrointestinal diseases. Expert commentary: Electrical stimulation is an area of great interest and has potential for treating GI motility disorders. However, further development in technologies (devices suitable for GI stimulation) and extensive clinical research are needed to advance the field and bring electrical therapies to bedside.
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Affiliation(s)
- Jiande D Z Chen
- a Division of Gastroenterology and Hepatology, Department of Medicine , Johns Hopkins University , Baltimore , MD , USA.,b Department of Medicine , VA Medical Center , Oklahoma City , OK , USA
| | - Jieyun Yin
- a Division of Gastroenterology and Hepatology, Department of Medicine , Johns Hopkins University , Baltimore , MD , USA
| | - Wei Wei
- c Division of Gastroenterology , Wangjing Hospital of Chinese Medical Academy , Beijing , China
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Yamazoe T, Okanishi T, Yamamoto A, Yamada T, Nishimura M, Fujimoto A, Enoki H, Yokota T, Sato K, Yamamoto T. New-onset refractory status epilepticus treated with vagus nerve stimulation: A case report. Seizure 2017; 47:1-4. [DOI: 10.1016/j.seizure.2017.02.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 02/20/2017] [Accepted: 02/22/2017] [Indexed: 10/20/2022] Open
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Borsody MK, Garcia A, Bielawski DM, Yamada C, Sacristan E. Magnetic facial nerve stimulation in animal models of active seizure. Epilepsy Res 2017; 131:28-36. [PMID: 28236736 DOI: 10.1016/j.eplepsyres.2017.02.002] [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: 01/10/2016] [Revised: 01/04/2017] [Accepted: 02/07/2017] [Indexed: 11/16/2022]
Abstract
PURPOSE As part of our efforts to develop a non-invasive facial nerve stimulator as an emergency treatment for ischemic stroke, we considered possible safety consequences if the technology was misapplied to stroke mimics, e.g., seizure. We hypothesized that magnetic facial nerve stimulation would worsen epileptiform activity in two animal models of active seizures. The rat intraperitoneal kainate model and pig intracortical penicillin model were employed. Magnetic facial nerve stimulation was delivered unilaterally at a variety of stimulation parameters, and the effect on ictal epileptiform activity measured by electroencephalography was determined according to an established categorical scale. PRINCIPAL RESULTS In 6 rats and 3 pigs evaluated with 83 stimulation trials, only a single stimulation trial was associated with worsening epileptiform activity according to a standard categorization scheme. Surprisingly, a reduction in the severity of the epileptiform activity was observed in 20 of 50 stimulation trials using patterned stimulation (3 pulses at 30Hz repeated at 0.5-10Hz) versus 2 of 33 stimulation trials using simple monotonic patterns (P<0.005, chi-squared test). The reduction of epileptiform activity after stimulation lasted a few minutes and was reproducible. Major Conclusions Epileptiform activity measured by electroencephalography was not reliably worsened by repetitive facial nerve stimulation with pulsed magnetic energy, even when significant brain exposure to the magnetic field occurred as in the rat model. To the contrary, a temporary reduction in epileptiform activity was often, but not invariably, observed with certain stimulation parameters.
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Affiliation(s)
- Mark K Borsody
- NeuroSpring, 35756 Foothills, Sterling Heights, MI 48312, United States; Nervive, Inc., 526 S. Main St., Suite 801-A, Akron, OH 44311, United States.
| | - Andrea Garcia
- National Center for the Investigation of Imaging and Medical Instrumentation, Universidad Autónoma Metropolitana, Mexico City, Mexico
| | - Dawn M Bielawski
- NeuroSpring, 35756 Foothills, Sterling Heights, MI 48312, United States
| | - Chisa Yamada
- NeuroSpring, 35756 Foothills, Sterling Heights, MI 48312, United States
| | - Emilio Sacristan
- Nervive, Inc., 526 S. Main St., Suite 801-A, Akron, OH 44311, United States; National Center for the Investigation of Imaging and Medical Instrumentation, Universidad Autónoma Metropolitana, Mexico City, Mexico
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Bayrlee A, Ganeshalingam N, Kurczewski L, Brophy GM. Treatment of Super-Refractory Status Epilepticus. Curr Neurol Neurosci Rep 2016; 15:66. [PMID: 26299274 DOI: 10.1007/s11910-015-0589-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Super-refractory status epilepticus (SRSE) is a devastating neurological condition with limited treatment options. We conducted an extensive literature search to identify and summarize the therapeutic options for SRSE. The search mainly resulted in case reports of various pharmacologic and non-pharmacologic treatments. The success rate of each of the following agents, ketamine, inhaled anesthetics, intravenous immunoglobulin G (IVIG), IV steroids, ketogenic diet, hypothermia, electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), and vagal nerve stimulation (VNS), are discussed in greater detail. The choice of appropriate treatment options for a given patient is based on clinical presentation. This review focuses on evidence-based, pharmacotherapeutic strategies for patients in SRSE.
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Affiliation(s)
- Ahmad Bayrlee
- Department of Neurology, Virginia Commonwealth University, P.O. Box 980599, Richmond, VA, 23298, USA,
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Abstract
OPINION STATEMENT Convulsive status epilepticus (CSE) is a medical emergency with an associated high mortality and morbidity. It is defined as a convulsive seizure lasting more than 5 min or consecutive seizures without recovery of consciousness. Successful management of CSE depends on rapid administration of adequate doses of anti-epileptic drugs (AEDs). The exact choice of AED is less important than rapid treatment and early consideration of reversible etiologies. Current guidelines recommend the use of benzodiazepines (BNZ) as first-line treatment in CSE. Midazolam is effective and safe in the pre-hospital or home setting when administered intramuscularly (best evidence), buccally, or nasally (the latter two possibly faster acting than intramuscular (IM) but with lower levels of evidence). Regular use of home rescue medications such as nasal/buccal midazolam by patients and caregivers for prolonged seizures and seizure clusters may prevent SE, prevent emergency room visits, improve quality of life, and lower health care costs. Traditionally, phenytoin is the preferred second-line agent in treating CSE, but it is limited by hypotension, potential arrhythmias, allergies, drug interactions, and problems from extravasation. Intravenous valproate is an effective and safe alternative to phenytoin. Valproate is loaded intravenously rapidly and more safely than phenytoin, has broad-spectrum efficacy, and fewer acute side effects. Levetiracetam and lacosamide are well tolerated intravenous (IV) AEDs with fewer interactions, allergies, and contraindications, making them potentially attractive as second- or third-line agents in treating CSE. However, data are limited on their efficacy in CSE. Ketamine is probably effective in treating refractory CSE (RCSE), and may warrant earlier use; this requires further study. CSE should be treated aggressively and quickly, with confirmation of treatment success with epileptiform electroencephalographic (EEG), as a transition to non-convulsive status epilepticus is common. If the patient is not fully awake, EEG should be continued for at least 24 h. How aggressively to treat refractory non-convulsive SE (NCSE) or intermittent non-convulsive seizures is less clear and requires additional study. Refractory SE (RSE) usually requires anesthetic doses of anti-seizure medications. If an auto-immune or paraneoplastic etiology is suspected or no etiology can be identified (as with cryptogenic new onset refractory status epilepticus, known as NORSE), early treatment with immuno-modulatory agents is now recommended by many experts.
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Lionel KR, Hrishi AP. Seizures - just the tip of the iceberg: Critical care management of super-refractory status epilepticus. Indian J Crit Care Med 2016; 20:587-592. [PMID: 27829714 PMCID: PMC5073773 DOI: 10.4103/0972-5229.192047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Super-refractory status epilepticus (SRSE) is defined as status epilepticus (SE) that continues or recurs 24 h or more after the onset of anesthetic therapy, including those cases where SE recurs on the reduction or withdrawal of anesthesia. Although SRSE is a rare clinical problem, it is associated with high mortality and morbidity rates. This article reviews the treatment approaches and the systemic complications commonly encountered in patients with SRSE. As evident in our search of literature, therapy for SRSE and its complications have been based on clinical reports and expert opinions since there is a lack of controlled and randomized trials. Even though this complex condition starts as a neurological disorder, because of the associated systemic complications, it can be considered as a multisystem disorder requiring scrupulous attention and deliberate efforts to prevent, detect, and treat these systemic effects. We have critically reviewed the intensive care management for SRSE per se as well as its associated systemic complications. We believe that a good recovery can occur even after prolonged and severe SRSE as long as the systemic complications are detected early and managed appropriately.
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Affiliation(s)
- Karen Ruby Lionel
- Department of Neuroanesthesia and Neurocritical Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Ajay Prasad Hrishi
- Department of Neuroanesthesia and Neurocritical Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
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ZHOU XIAOYA, ZHOU LIPING, WANG SONGYUN, YU LILEI, WANG ZHUO, HUANG BING, CHEN MINGXIAN, WAN JUN, JIANG HONG. The Use of Noninvasive Vagal Nerve Stimulation to Inhibit Sympathetically Induced Sinus Node Acceleration: A Potential Therapeutic Approach for Inappropriate Sinus Tachycardia. J Cardiovasc Electrophysiol 2015; 27:217-23. [PMID: 26467778 DOI: 10.1111/jce.12859] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 09/27/2015] [Accepted: 10/08/2015] [Indexed: 11/27/2022]
Affiliation(s)
- XIAOYA ZHOU
- Department of Cardiology, Renmin Hospital of Wuhan University; Cardiovascular Research Institute of Wuhan University; Wuhan Hubei China
| | - LIPING ZHOU
- Department of Cardiology, Renmin Hospital of Wuhan University; Cardiovascular Research Institute of Wuhan University; Wuhan Hubei China
| | - SONGYUN WANG
- Department of Cardiology, Renmin Hospital of Wuhan University; Cardiovascular Research Institute of Wuhan University; Wuhan Hubei China
| | - LILEI YU
- Department of Cardiology, Renmin Hospital of Wuhan University; Cardiovascular Research Institute of Wuhan University; Wuhan Hubei China
| | - ZHUO WANG
- Department of Cardiology, Renmin Hospital of Wuhan University; Cardiovascular Research Institute of Wuhan University; Wuhan Hubei China
| | - BING HUANG
- Department of Cardiology, Renmin Hospital of Wuhan University; Cardiovascular Research Institute of Wuhan University; Wuhan Hubei China
| | - MINGXIAN CHEN
- Department of Cardiology; the Second Xiangya Hospital of Central South, University; Changsha Hunan China
| | - JUN WAN
- Department of Cardiology, Renmin Hospital of Wuhan University; Cardiovascular Research Institute of Wuhan University; Wuhan Hubei China
| | - HONG JIANG
- Department of Cardiology, Renmin Hospital of Wuhan University; Cardiovascular Research Institute of Wuhan University; Wuhan Hubei China
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