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Yeap TB, Koo TH, Ang SY, Ab Mukmin L. Perianaesthetic management on a child with Lennox-Gastaut Syndrome for vagus nerve stimulation (VNS) placement. BMJ Case Rep 2023; 16:e255897. [PMID: 38011949 PMCID: PMC10685940 DOI: 10.1136/bcr-2023-255897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Abstract
Vagus nerve stimulation (VNS) is a neurostimulatory modality in treating patients with medically resistant epilepsy (MRE). It was introduced in 1997 and has been proven to reduce patients' dependency on antiepileptic drugs and seizure frequency. However, the usage of VNS in children with MRE has been limited, especially those with Lennox Gastaut Syndrome (LGS). Our teenage boy with this syndrome developed MRE and successfully underwent VNS placement. We discuss the perianaesthetic challenges, a brief description of VNS and the reported successes in patients with LGS.
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Affiliation(s)
- Tat Boon Yeap
- Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia
| | - Thai Hau Koo
- Department of Internal Medicine, Hospital Universiti Sains Malaysia, Kota Bahru, Kelantan, Malaysia
| | - Song Yee Ang
- Department of Neurosciences, School of Medical Sciences, Hospital Universiti Sains Malaysia, Kota Bahru, Kelantan, Malaysia
| | - Laila Ab Mukmin
- Department of Anaesthesia and Intensive Care Unit, Hospital Universiti Sains Malaysia, Kota Bahru, Kelantan, Malaysia
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Mao H, Chen Y, Ge Q, Ye L, Cheng H. Short- and Long-Term Response of Vagus Nerve Stimulation Therapy in Drug-Resistant Epilepsy: A Systematic Review and Meta-Analysis. Neuromodulation 2021; 25:327-342. [PMID: 35396068 DOI: 10.1111/ner.13509] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 06/22/2021] [Accepted: 06/29/2021] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To compare the short- and long-term efficacies as well as tolerability of vagus nerve stimulation (VNS) for the patients with drug-resistant epilepsy (DRE) in comparison with status at baseline. MATERIALS AND METHODS We conducted a specific and systematic search in online data bases for relevant literature published prior to December 2020. The literature retrieved, including randomized clinical trials (RCTs) and observational studies, were then reviewed, and analyzed. A fixed-effect model was used to evaluate the pooled odds ratio (OR) of responder rates and complications associated with RCTs. A random-effect model was used to generate overall responder rates and overall incidences of complication. RESULTS A total of 61 studies, featuring 5223 patients, were included in our study. The pooled ORs of responder rates, hoarseness/voice change, throat pain, coughing, dyspnea, paresthesia, muscle pain, and headache during the short-term phase were 2.195 (p = 0.001), 5.527 (p = 0.0001), 0.935 (p = 0.883), 1.119 (p = 0.655), 2.901 (p = 0.005), 1.775 (p = 0.061), 3.606 (p = 0.123), and 0.928 (p = 0.806), respectively. The overall responder rates in 3, 6, 12, 24, 36, 48, and 60 months postoperatively were 0.421, 0.455, 0.401, 0.451, 0.482, 0.502, and 0.508, respectively. The overall incidences of complication were 0.274 for hoarseness/voice change, 0.099 for throat pain, 0.133 for coughing, 0.099 for dyspnea, 0.102 for paresthesia, 0.062 for muscle pain, 0.101 for headache, 0.015 for dysphagia, 0.013 for neck pain, 0.040 for infection, 0.030 for lead fracture, 0.019 for vocal cord palsy, and 0.020 for device malfunction, respectively. CONCLUSIONS The estimating of efficacy and tolerability, using data from the existing literature, indicated VNS therapy is a safe and effective treatment option for patients with DRE.
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Affiliation(s)
- Hongliang Mao
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China.,First Clinical Medical College, Anhui Medical University, Hefei, China
| | - Yonghao Chen
- First Clinical Medical College, Anhui Medical University, Hefei, China
| | - Qintao Ge
- First Clinical Medical College, Anhui Medical University, Hefei, China
| | - Lei Ye
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Hongwei Cheng
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
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Subgroup analysis of seizure and cognitive outcome after vagal nerve stimulator implantation in children. Childs Nerv Syst 2021; 37:243-252. [PMID: 32361930 DOI: 10.1007/s00381-020-04628-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 04/16/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Vagal nerve stimulator (VNS) implantation at an early age seems to lead to improved quality of life and cognitive outcome. The aim of this analysis is to evaluate whether specific patient or seizure characteristics might lead to better seizure control, cognitive outcome, and higher quality of life in children undergoing VNS implantation. METHODS Primary outcome measure was reduction in seizure frequency. Secondary outcome measures were epilepsy outcome assessed by McHugh and Engel classifications, reduction in antiepileptic drugs (AED), developmental and cognitive outcome, as well as quality of life assessed through the pediatric quality of life (PEDSQL™) questionnaire and care giver impression (CGI) scale. Forty-five consecutive children undergoing VNS implantation were analyzed for the following subgroups: age (categorized to 1-2 years old, 3-5 years old, 6-12 years old, and 13-18 years old), sex, underlying cause (categorized to idiopathic, encephalitis, stroke, syndromic), duration of preoperative seizures (dichotomized to under or above 89 months, corresponding to the median of the whole cohort), and preoperative seizure frequency (dichotomized to under and above 360 seizures per month). RESULTS Encephalitis as the underlying cause for seizures was the only variable significantly associated with higher reduction rate of seizure frequency. Patients with VNS implantation at the age of ≤ 2 years showed a strong association with better developmental and cognitive outcome, as well as quality of life. Shorter duration of preoperative seizures and higher preoperative seizure frequency showed a strong association with better developmental outcome, as well as quality of life. Engel outcome scores were significantly better in patients with epilepsy due to encephalitis (100% Engel I-III). However, patients with epilepsy due to encephalitis showed significantly higher complication rates (71.4%, p = 0.045). CONCLUSIONS Children suffering from epilepsy due to encephalitis show higher seizure reduction rates after VNS implantation when compared with children suffering from epilepsy due to other causes. Developmental and cognitive outcomes as well as quality of life of children undergoing VNS implantation is strongly associated with shorter duration of preoperative seizures and implantation at a young age.
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Parisi C, Candela-Cantó S, Serrano M, Catala A, Aparicio J, Hinojosa J. Life-threatening secondary hemophagocytic lymphohistiocytosis following vagal nerve stimulator infection in a child with CHD2 myoclonic encephalopathy: a case report. Childs Nerv Syst 2020; 36:2851-2856. [PMID: 32170405 DOI: 10.1007/s00381-020-04558-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 02/27/2020] [Indexed: 01/28/2023]
Abstract
Vagus nerve stimulation (VNS) is a surgical treatment available for patients affected by generalized refractory epilepsy. The authors report the case of a 15-year-old girl affected by CHD2-related myoclonic encephalopathy and BLM haploinsufficiency due to a deletion of 15q25.3q26.2 region, who suffered from secondary hemophagocytic lymphohistiocytosis (SHLH) after a VNS wound infection. SHLH has sporadically been described in epileptic patients. Based on indirect evidence that shows immune dysregulation in patients with CHD2 mutations and BLM mutations, we hypothesize that the genetic background of this patient may have played a critical role in the development of the syndrome.
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Affiliation(s)
- Cristiano Parisi
- Neurosurgery Unit, Neuroscience Department, Azienda Ospedaliera Universitaria Integrata, Verona, Italy.
| | - Santiago Candela-Cantó
- Pediatric Neurosurgery Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain.,Pediatric Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain
| | - Mercedes Serrano
- Neurology Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain.,U-703 Centre for Biomedical Research on Rare Diseases (CIBER-ER), Instituto de Salud Carlos III, Barcelona, Spain
| | - Albert Catala
- Department of Hematology, Institut de Recerca Hospital Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain
| | - Javier Aparicio
- Pediatric Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain.,Neurology Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain.,U-703 Centre for Biomedical Research on Rare Diseases (CIBER-ER), Instituto de Salud Carlos III, Barcelona, Spain
| | - José Hinojosa
- Pediatric Neurosurgery Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain.,Pediatric Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain
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5
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Vagus nerve stimulation in patients with therapy-resistant generalized epilepsy. Epilepsy Behav 2020; 111:107253. [PMID: 32615417 DOI: 10.1016/j.yebeh.2020.107253] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/24/2020] [Accepted: 06/08/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND For patients with generalized epilepsy who do not respond to antiseizure medications, the therapeutic options are limited. Vagus nerve stimulation (VNS) is a treatment mainly approved for therapy-resistant focal epilepsy. There is limited information on the use of VNS on generalized epilepsies, including Lennox-Gastaut Syndrome (LGS) and genetic generalized epilepsy (GGE). METHODS We identified patients with a diagnosis of generalized epilepsy (including LGS and GGE), who underwent VNS implantation at the London Health Sciences Centre and Western University, London, Ontario, since this treatment became available in Canada in 1997 until July 2018. We assessed response to the treatment, including admissions to hospital and complications. RESULTS A total of 46 patients were included in this study with a history of therapy-resistant generalized epilepsy. The mean age at implantation was 24 years (interquartile range [IQR] = 17.8-31 years), significantly younger in the LGS group (p = 0.02) and 50% (n = 23) were female. The most common etiologies were GGE in 37% (n = 17) and LGS in 63% (n = 29). Median follow-up since VNS implantation was 63 months (IQR: 31-112.8 months). Of the LGS group 41.7% (n = 12) of patients had an overall seizure reduction of 50% or more, and 64.7% (n = 11) in the GGE group without statistical significance between the groups. The best response in seizure reduction was seen in generalized tonic-clonic seizures, with a significant reduction in the GGE group (p = 0.043). There was a reduction of seizure-related hospital admissions from 91.3% (N = 42) preimplantation, to 43.5% (N = 20) postimplantation (p < 0.05). The frequency of side effects due to the stimulation was almost equal in both groups (62.1% in LGS and 64.7% in GGE). CONCLUSIONS Vagus nerve stimulation should be considered as a treatment in patients with therapy-resistant generalized epilepsy, especially in cases with GGE.
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Xiong J, Cao Y, Yang W, Chen Z, Yu Q. Can we predict response to vagus nerve stimulation in intractable epilepsy. Int J Neurosci 2020; 130:1063-1070. [PMID: 31914344 DOI: 10.1080/00207454.2020.1713777] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Since vagus nerve stimulation (VNS) was approved by the Food and Drug Administration (FDA). A number of studies show that VNS was effective to reduce seizure frequency. However, there was still some patients treated with VNS having poor or even no clinical effect. OBJECTIVES The purpose of the present review was to identify factors predicting the effect of VNS therapy and to select patients suitable for VNS treatment. METHOD PubMed and Medline was searched with this terms "epilepsy," "vagus nerve stimulation," "vagal nerve stimulation," "VNS," "intractable," and "refractory".We selected studies by predefining inclusion and exclusion criteria. RESULTS the effectiveness of VNA was confirmed by a number of studies. We find many studies exploring the predictive factors to VNS. However there was no any study finding factors correlating clearly with the outcome of VNS. Although, we find these factors, such as post-traumatic epilepsy, temporal lobe epilepsy and focal interictal epileptiform discharges (IEDs), were favorable for the treatment of VNS, while comprehensive IEDs and neuronal migration disorders were indicative of the poor effect. Also, temporal lobe epilepsy was generally effectively controlled by this therapy and yougers seemed to get more benefit from VNS. Additionally, other indexes, such as cytokine profile, slow cortical potential (SCP) shift, preoperative heart rate variability (HRV), EEG reactivity and connectomic profiling, maybe predict the results of VNS. CONCLUSION In summary, these conventional and other new factors should be analyzed further by more science and rigorous experimental design to identify the clear correlation with the outcome of VNS therapy.
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Affiliation(s)
- Jinbiao Xiong
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Yiyao Cao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Weidong Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Zhijuan Chen
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Qing Yu
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
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Schulze-Bonhage A. Long-term outcome in neurostimulation of epilepsy. Epilepsy Behav 2019; 91:25-29. [PMID: 30929666 DOI: 10.1016/j.yebeh.2018.06.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 06/06/2018] [Accepted: 06/06/2018] [Indexed: 02/07/2023]
Abstract
For patients with pharmacoresistant focal epilepsy, neurostimulation offers nonpharmacological strategies to improve seizure control. Vagus nerve stimulation (VNS), deep brain stimulation of the anterior thalamic nuclei, and responsive neurostimulation (RNS) are approved therapies which have shown efficacy in randomized short-term trials. Controlled data from prospective studies are needed to confirm reports on stable or even increasing evidence from studies with longer follow-up and to confirm that neurostimulation may offer advantages also regarding cognitive tolerability and sudden unexpected death in epilepsy (SUDEP)-risk. Here, a review of long-term outcomes is given, highlighting both achievements in terms of efficacy and tolerability and limitations of conclusions thereon related to an uncontrolled data basis and decreasing cohort sizes. This article is part of the Special Issue? "Individualized Epilepsy Management: Medicines, Surgery and Beyond".
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Affiliation(s)
- Andreas Schulze-Bonhage
- Epilepsy Center, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Germany.
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Soleman J, Stein M, Knorr C, Datta AN, Constantini S, Fried I, Guzman R, Kramer U. Improved quality of life and cognition after early vagal nerve stimulator implantation in children. Epilepsy Behav 2018; 88:139-145. [PMID: 30269032 DOI: 10.1016/j.yebeh.2018.09.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Revised: 09/08/2018] [Accepted: 09/12/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVE In patients with drug-resistant epilepsy, reduction of seizure duration and frequency at an early age is beneficial. Vagal nerve stimulator (VNS) was shown to reduce seizure frequency and duration in children; however, data in children under the age of 12 years are sparse. The aim of this study was to compare seizure outcome and quality of life after early (≤5 years of age) and late (>5 years of age) implantation of VNS in children. METHODS This study reviewed 45 consecutive children undergoing VNS implantation. Primary outcome measure was the reduction of seizure frequency. Secondary outcome measures were epilepsy outcome assessed by the McHugh and Engel classifications, reduction of antiepileptic drugs (AEDs), psychomotor development, and quality of life measured by the Pediatric Quality of Life (PEDSQL™) questionnaire and caregiver impression (CGI) scale. The mean follow-up time was 72.3 months (±39.8 months). RESULTS Out of 45 patients included, in 14 (31.1%), VNS was implanted early and in 31, (68.9%) late. Reduction of seizure frequency, McHugh and Engel classifications, and reduction of AED were comparable in both groups. Quality of life measured by the CGI scale (2.1 ± 1.7 in the early group vs. 3.6 ± 1.6 in the late group; p = 0.004), as well as the difference of total PEDSQL™ Core scores (12.0 ± 24.0 in the early group vs. -5.2 ± 14.9 in the late group; p = 0.01) and cognitive PEDSQL™ Core (30.6 ± 32.0 in the early group vs. 2.4 ± 24.3 in the late group; p = 0.03) between preoperative and follow-up was significantly higher in the early implantation group. CONCLUSION Early VNS implantation in children leads to a significantly better quality of life and cognitive outcome compared with late implantation while reduction of seizure frequency and epilepsy outcome seems comparable. Therefore, in children with drug-resistant epilepsy, VNS implantation should be considered as early as possible.
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Affiliation(s)
- Jehuda Soleman
- Departments of Neurosurgery and Pediatric Neurosurgery, Tel-Aviv Medical Center and Dana Children's Hospital, Tel Aviv University, Tel Aviv, Israel; Department of Neurosurgery and Division of Pediatric Neurosurgery, Children's University Hospital of Basel (UKBB), Basel, Switzerland.
| | - Maya Stein
- Departments of Neurosurgery and Pediatric Neurosurgery, Tel-Aviv Medical Center and Dana Children's Hospital, Tel Aviv University, Tel Aviv, Israel
| | - Corine Knorr
- Department of Neurosurgery and Division of Pediatric Neurosurgery, Children's University Hospital of Basel (UKBB), Basel, Switzerland
| | - Alexandre N Datta
- Department of Pediatric Neurology, Children's University Hospital of Basel (UKBB), Basel, Switzerland
| | - Shlomi Constantini
- Departments of Neurosurgery and Pediatric Neurosurgery, Tel-Aviv Medical Center and Dana Children's Hospital, Tel Aviv University, Tel Aviv, Israel
| | - Itzhak Fried
- Departments of Neurosurgery and Pediatric Neurosurgery, Tel-Aviv Medical Center and Dana Children's Hospital, Tel Aviv University, Tel Aviv, Israel
| | - Raphael Guzman
- Department of Neurosurgery and Division of Pediatric Neurosurgery, Children's University Hospital of Basel (UKBB), Basel, Switzerland
| | - Uri Kramer
- Pediatric Neurology Unit, Dana Children's Hospital, Tel Aviv University, Tel Aviv, Israel
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Soleman J, Knorr C, Datta AN, Strozzi S, Ramelli GP, Mariani L, Guzman R. Early vagal nerve stimulator implantation in children: personal experience and review of the literature. Childs Nerv Syst 2018; 34:893-900. [PMID: 29255920 DOI: 10.1007/s00381-017-3694-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 12/10/2017] [Indexed: 01/14/2023]
Abstract
AIM Data concerning the benefit of vagal nerve stimulation (VNS) in children under the age of 12 years is sparse. It was shown that reduction of seizure frequency and duration at an early age could lead to better psychomotor development. We therefore compare the outcome between early (≤ 5 years of age) and late (> 5 years of age) implantation of VNS in children. METHODS This study is a prospective review of patients analyzing primarily the reduction of seizure frequency and secondarily epilepsy outcome assessed by the McHugh and Engel classification, reduction of antiepileptic drugs (AED), psychomotor development measured by the Vineland Adaptive Behavior Scale (VABS), and quality of life using the caregiver impression (CGI) scale. Mean follow-up time was 36 and 31 months in the early and late group, respectively. RESULTS Out of 12 consecutive VNS implantations for therapy refractory epilepsy, 5 were early implantations and 7 late implantations. Reduction of seizure frequency, McHugh and Engel classification, quality of life, psychomotor development and reduction of AED were comparable in both groups. One patient in the late group suffered from a postoperative infection resulting in explanation of the VNS device and re-implantation on the opposite side, while mortality rate was 0%. CONCLUSIONS VNS seems to be a safe and feasible therapy in children even under the age of 5 years. Responder rate, quality of life, and psychomotor development do not seem to be influenced by the child's age at implantation; however, larger studies analyzing the outcome of early VNS implantation are warranted.
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Affiliation(s)
- Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
- Division of Pediatric Neurosurgery, Children's University Hospital of Basel (UKBB), Basel, Switzerland.
| | - Corine Knorr
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Division of Pediatric Neurosurgery, Children's University Hospital of Basel (UKBB), Basel, Switzerland
| | - Alexandre N Datta
- Department of Pediatric Neurology, Children's University Hospital of Basel (UKBB), Basel, Switzerland
| | - Susi Strozzi
- Department of Pediatric Neurology, University Hospital of Bern, Bern, Switzerland
| | - Gian Paolo Ramelli
- Department of Pediatric Neurology, Children's Hospital of Bellinzona, Bellinzona, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Division of Pediatric Neurosurgery, Children's University Hospital of Basel (UKBB), Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Division of Pediatric Neurosurgery, Children's University Hospital of Basel (UKBB), Basel, Switzerland
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Trezza A, Landi A, Grioni D, Pirillo D, Fiori L, Giussani C, Sganzerla EP. Adverse Effects and Surgical Complications in Pediatric Patients Undergoing Vagal Nerve Stimulation for Drug-Resistant Epilepsy. ACTA NEUROCHIRURGICA. SUPPLEMENT 2017; 124:43-47. [PMID: 28120051 DOI: 10.1007/978-3-319-39546-3_7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Vagal nerve stimulation (VNS) is an effective treatment for drug-resistant epilepsy that is not suitable for resective surgery, both in adults and in children. Few reports describe the adverse effects and complications of VNS. The aim of our study was to present a series of 33 pediatric patients who underwent VNS for drug-resistant epilepsy and to discuss the adverse effects and complications through a review of the literature.The adverse effects of VNS are usually transient and are dependent on stimulation of the vagus and its efferent fibers; surgical complications of the procedure may be challenging and patients sometimes require further surgery; generally these complications affect VNS efficacy; in addition, hardware complications also have to be taken into account.In our experience and according to the literature, adverse effects and surgical and hardware complications are uncommon and can usually be managed definitely. Careful selection of patients, particularly from a respiratory and cardiac point of view, has to be done before surgery to limit the incidence of some adverse effects.
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Affiliation(s)
- A Trezza
- Neurosurgery, Department of Surgery and Translational Medicine, Milan Center for Neuroscience, San Gerardo Hospital, University of Milano Bicocca, via Pergolesi 33, 20900, Monza, Italy.
| | - A Landi
- Neurosurgery, Department of Surgery and Translational Medicine, Milan Center for Neuroscience, San Gerardo Hospital, University of Milano Bicocca, via Pergolesi 33, 20900, Monza, Italy
| | - D Grioni
- Unit of Pediatric Neurophysiology, Child Neuropsychiatric Clinic, San Gerardo Hospital, University of Milano Bicocca, via Pergolesi 33, 20900, Monza, Italy
| | - D Pirillo
- Neurosurgery, Department of Surgery and Translational Medicine, Milan Center for Neuroscience, San Gerardo Hospital, University of Milano Bicocca, via Pergolesi 33, 20900, Monza, Italy
| | - L Fiori
- Neurosurgery, Department of Surgery and Translational Medicine, Milan Center for Neuroscience, San Gerardo Hospital, University of Milano Bicocca, via Pergolesi 33, 20900, Monza, Italy
| | - C Giussani
- Neurosurgery, Department of Surgery and Translational Medicine, Milan Center for Neuroscience, San Gerardo Hospital, University of Milano Bicocca, via Pergolesi 33, 20900, Monza, Italy
| | - E P Sganzerla
- Neurosurgery, Department of Surgery and Translational Medicine, Milan Center for Neuroscience, San Gerardo Hospital, University of Milano Bicocca, via Pergolesi 33, 20900, Monza, Italy
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11
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Kim MJ, Yum MS, Kim EH, Lee YJ, Lee J, Hong S, You SJ, Hwang YS, Ko TS. An interictal EEG can predict the outcome of vagus nerve stimulation therapy for children with intractable epilepsy. Childs Nerv Syst 2017; 33:145-151. [PMID: 27714458 DOI: 10.1007/s00381-016-3261-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 09/25/2016] [Indexed: 12/18/2022]
Abstract
PURPOSE This study aimed to evaluate the long-term efficacy of vagus nerve stimulation (VNS) in children and adolescents with intractable epilepsy and identify predictive factors for responsiveness to VNS. METHODS Medical records of pediatric patients who underwent VNS implantation at two Korean tertiary centers were reviewed. At 0.5, 1, 3, and 5 years post-VNS implantation, the frequency of the most disabling seizures in each patient was assessed. Responders were defined as showing an overall 50 % reduction from baseline seizure frequency during follow-up. The clinical characteristics of responders and non-responders were compared. RESULTS Among 58 patients, approximately half (29/58) were responders. The mean age at implantation was 10.9 years (range, 2.7-20.9) and the mean follow-up duration after VNS implantation was 8.4 years (range, 1-15.5). At 0.5, 1, 3, and 5 years after implantation, 43.1, 50.0, 56.9, and 58.1 % of patients exhibited ≥50 % seizure frequency reduction disabling seizures. The patients with focal or multifocal epileptiform discharges were more likely to be responders than those with generalized epileptiform activities by video or conventional EEG at the time of VNS implantation (Pearson's and χ 2 test, p = 0.001). No other clinical variables were found to be associated with seizure outcomes. Wound infections caused VNS removal in two cases. All other adverse events, including cough and hoarseness, were tolerable. CONCLUSION VNS is a well-tolerated and effective adjuvant therapy in pediatric patients with intractable epilepsy. Notably, patients with focal epileptiform discharges alone rather than those with generalized epileptiform discharges maybe better candidates for VNS.
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Affiliation(s)
- Min-Jee Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine, 43 Olympic-ro, Songpa-gu, Seoul, 138-736, South Korea
| | - Mi-Sun Yum
- Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine, 43 Olympic-ro, Songpa-gu, Seoul, 138-736, South Korea
| | - Eun-Hee Kim
- Department of Pediatrics, CHA Gangnam Medical Center, CHA University, Pocheon-si, South Korea
| | - Yun-Jeong Lee
- Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine, 43 Olympic-ro, Songpa-gu, Seoul, 138-736, South Korea
| | - Junkyo Lee
- Department of Neurosurgery, Asan Medical Center Children's Hospital, Ulsan University College of Medicine, Seoul, South Korea
| | - Seokho Hong
- Department of Neurosurgery, Asan Medical Center Children's Hospital, Ulsan University College of Medicine, Seoul, South Korea
| | - Su Jeong You
- Department of Pediatrics, Sanggye Paik Hospital, Inje University College of Medicine, 1342 Dongil-ro, Nowon-gu, Seoul, 139-707, South Korea.
| | - Yong Soon Hwang
- Department of Neurosurgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, South Korea
| | - Tae-Sung Ko
- Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine, 43 Olympic-ro, Songpa-gu, Seoul, 138-736, South Korea.
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Lam S, Lin Y, Curry DJ, Reddy GD, Warnke PC. Revision surgeries following vagus nerve stimulator implantation. J Clin Neurosci 2016; 30:83-87. [DOI: 10.1016/j.jocn.2016.01.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 01/26/2016] [Indexed: 10/22/2022]
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Révész D, Rydenhag B, Ben-Menachem E. Complications and safety of vagus nerve stimulation: 25 years of experience at a single center. J Neurosurg Pediatr 2016; 18:97-104. [PMID: 27015521 DOI: 10.3171/2016.1.peds15534] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The goal of this paper was to investigate surgical and hardware complications in a longitudinal retrospective study. METHODS The authors of this registry study analyzed the surgical and hardware complications in 247 patients who underwent the implantation of a vagus nerve stimulation (VNS) device between 1990 and 2014. The mean follow-up time was 12 years. RESULTS In total, 497 procedures were performed for 247 primary VNS implantations. Complications related to surgery occurred in 8.6% of all implantation procedures that were performed. The respective rate for hardware complications was 3.7%. Surgical complications included postoperative hematoma in 1.9%, infection in 2.6%, vocal cord palsy in 1.4%, lower facial weakness in 0.2%, pain and sensory-related complications in 1.4%, aseptic reaction in 0.2%, cable discomfort in 0.2%, surgical cable break in 0.2%, oversized stimulator pocket in 0.2%, and battery displacement in 0.2% of patients. Hardware-related complications included lead fracture/malfunction in 3.0%, spontaneous VNS turn-on in 0.2%, and lead disconnection in 0.2% of patients. CONCLUSIONS VNS implantation is a relatively safe procedure, but it still involves certain risks. The most common complications are postoperative hematoma, infection, and vocal cord palsy. Although their occurrence rates are rather low at about 2%, these complications may cause major suffering and even be life threatening. To reduce complications, it is important to have a long-term perspective. The 25 years of follow-up of this study is of great strength considering that VNS can be a life-long treatment for many patients. Thus, it is important to include repeated surgeries such as battery and lead replacements, given that complications also may occur with these surgeries.
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Affiliation(s)
- David Révész
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience and Rehabilitation, The Sahlgrenska Academy at the University of Gothenburg; and.,Departments of 2 Neurosurgery and
| | - Bertil Rydenhag
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience and Rehabilitation, The Sahlgrenska Academy at the University of Gothenburg; and.,Departments of 2 Neurosurgery and
| | - Elinor Ben-Menachem
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience and Rehabilitation, The Sahlgrenska Academy at the University of Gothenburg; and.,Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Meng FG, Jia FM, Ren XH, Ge Y, Wang KL, Ma YS, Ge M, Zhang K, Hu WH, Zhang X, Hu W, Zhang JG. Vagus Nerve Stimulation for Pediatric and Adult Patients with Pharmaco-resistant Epilepsy. Chin Med J (Engl) 2016; 128:2599-604. [PMID: 26415797 PMCID: PMC4736866 DOI: 10.4103/0366-6999.166023] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background: Over past two decades, vagus nerve stimulation (VNS) has been widely used and reported to alleviate seizure frequency worldwide, however, so far, only hundreds of patients with pharmaco-resistant epilepsy (PRE) have been treated with VNS in mainland China. The study aimed to evaluate the effectiveness of VNS for Chinese patients with PRE and compare its relationship with age cohort and gender. Methods: We retrospectively assessed the clinical outcome of 94 patients with PRE, who were treated with VNS at Beijing Fengtai Hospital and Beijing Tiantan Hospital between November 2008 and April 2014 from our database of 106 consecutive patients. The clinical data analysis was retrospectively examined. Results: Seizure frequency significantly decreased with VNS therapy after intermittent stimulation of the vagus nerve. At last follow-up, we found McHugh classifications of Class I in 33 patients (35.1%), Class II in 27 patients (28.7%), Class III in 20 patients (21.3%), Class IV in 3 patients (3.2%), and Class V in 11 patients (11.7%). Notably, 8 (8.5%) patients were seizure-free while ≥50% seizure frequency reduction occurred in as many as 60 patients (63.8%). Furthermore, with regard to the modified Engel classification, 12 patients (12.8%) were classified as Class I, 11 patients (11.7%) were classified as Class II, 37 patients (39.4%) were classified as Class III, 34 patients (36.2%) were classified as Class IV. We also found that the factors of gender or age are not associated with clinical outcome. Conclusions: This comparative study confirmed that VNS is a safe, well-tolerated, and effective treatment for Chinese PRE patients. VNS reduced the seizure frequency regardless of age or gender of studied patients.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Jian-Guo Zhang
- Beijing Key Laboratory of Neuromodulation, Beijing Municipal Science and Technology Commission; Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
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Mathon B, Bédos-Ulvin L, Baulac M, Dupont S, Navarro V, Carpentier A, Cornu P, Clemenceau S. Évolution des idées et des techniques, et perspectives d’avenir en chirurgie de l’épilepsie. Rev Neurol (Paris) 2015; 171:141-56. [DOI: 10.1016/j.neurol.2014.09.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 08/10/2014] [Accepted: 09/30/2014] [Indexed: 10/24/2022]
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Terra VC, Furlanetti LL, Nunes AA, Thomé U, Nisyiama MA, Sakamoto AC, Machado HR. Vagus nerve stimulation in pediatric patients: Is it really worthwhile? Epilepsy Behav 2014; 31:329-33. [PMID: 24210463 DOI: 10.1016/j.yebeh.2013.10.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 10/06/2013] [Accepted: 10/10/2013] [Indexed: 11/27/2022]
Abstract
Vagus nerve stimulation (VNS) seems to be effective in the management of selected cases of pharmacoresistant epilepsy in children. This was a case-control prospective study of children with refractory epilepsy submitted to vagal nerve stimulator implantation and a control group with epilepsy treated with antiepileptic drugs. Patients under 18years of age who underwent clinical or surgical treatment because of pharmacoresistant epilepsy from January 2009 to January 2012 were followed and compared with an age-matched control group at final evaluation. Statistically significant differences were observed considering age at epilepsy onset (VNS group - 1.33±1.45years; controls - 3.23±3.11; p=0.0001), abnormal findings in neurological examination (p=0.01), history of previous ineffective epilepsy surgery (p=0.03), and baseline seizure frequency (p=0.0001). At long-term follow-up, 55.4% of the patients in the VNS group had at least 50% reduction of seizure frequency, with 11.1% of the patients presenting 95% reduction on seizure frequency. Also, a decrease in traumas and hospitalization due to seizures and a subjective improvement in mood and alertness were observed. The control group did not show a significant modification in seizure frequency during the study. In this series, VNS patients evolved with a statistically significant reduction of the number of seizures, a decreased morbidity of the seizures, and the number of days in inpatient care. In accordance with the current literature, VNS has been proven to be an effective alternative in the treatment of pediatric patients with drug-resistant epilepsy.
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Affiliation(s)
- Vera C Terra
- Centro de Cirurgia de Epilepsia (CIREP), Departamento de Neurociências e Ciências do Comportamento, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, SP, Brazil.
| | - Luciano L Furlanetti
- Division of Stereotactic and Functional Neurosurgery, University Hospital Freiburg, Freiburg im Breisgau, Germany
| | - Altacílio Aparecido Nunes
- Departamento de Medicina Social, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, SP, Brazil
| | - Ursula Thomé
- Centro de Cirurgia de Epilepsia (CIREP), Departamento de Neurociências e Ciências do Comportamento, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, SP, Brazil
| | - Meire Akico Nisyiama
- Centro de Cirurgia de Epilepsia (CIREP), Departamento de Neurociências e Ciências do Comportamento, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, SP, Brazil
| | - Américo C Sakamoto
- Centro de Cirurgia de Epilepsia (CIREP), Departamento de Neurociências e Ciências do Comportamento, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, SP, Brazil
| | - Helio R Machado
- Centro de Cirurgia de Epilepsia (CIREP), Departamento de Neurociências e Ciências do Comportamento, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, SP, Brazil
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Yu C, Ramgopal S, Libenson M, Abdelmoumen I, Powell C, Remy K, Madsen JR, Rotenberg A, Loddenkemper T. Outcomes of vagal nerve stimulation in a pediatric population: A single center experience. Seizure 2014; 23:105-11. [DOI: 10.1016/j.seizure.2013.10.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 10/04/2013] [Accepted: 10/07/2013] [Indexed: 11/16/2022] Open
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Van Wagoner ZD, Evans DC, Askegard-Giesmann JR, Kenney BD. Perforated Peptic Ulcer in a Child With a Vagus Nerve Stimulator for Seizure Control. Brain Stimul 2013; 6:972-3. [DOI: 10.1016/j.brs.2013.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 04/27/2013] [Indexed: 11/26/2022] Open
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Healy S, Lang J, Te Water Naude J, Gibbon F, Leach P. Vagal nerve stimulation in children under 12 years old with medically intractable epilepsy. Childs Nerv Syst 2013; 29:2095-9. [PMID: 23681311 DOI: 10.1007/s00381-013-2143-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 04/30/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aims to assess the efficacy and safety of vagal nerve stimulation (VNS) in children less than 12 years old operated on at the University Hospital Wales. METHOD Retrospective review of patients undergoing VNS insertion, over a 3-year period, was undertaken. All children had a minimum follow-up period of 2 years. Sixteen patients were identified via the paediatric epilepsy surgery database. A case note review and telephone evaluation was conducted. Seizure frequency using the McHugh classification was the primary outcome measure, with anti-epileptic drug (AED) use as a secondary outcome measure. RESULTS There were 10 males and 6 females. The mean time with epilepsy prior to surgery was 5.7 years and the mean age at the time of surgery was 7.6 years. Overall, nine (56 %) children experienced a reduction in their seizure frequency of 50 % or more. Of these, four (25 %) had a reduction of more than 80 %. Seven children (44 %) had no reduction in their seizure frequency, although two of these patients reported benefit regarding seizure control and post-ictal recovery. The VNS system was removed in two patients due to infection and no benefit, respectively. Half of the cohort (50 %) reduced the number of anti-epileptic drugs post-surgery, and there was an overall mean reduction of AED of 0.5. CONCLUSION This study suggests that VNS is a safe and effective adjuvant therapy in children under 12 years old, with over half reporting significant benefit. Further studies are needed to enable preoperative selection of patients in order to maximise the potential benefit.
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Affiliation(s)
- S Healy
- College of Medicine, University Hospital of Wales, Cardiff, UK
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He W, Jing X, Wang X, Rong P, Li L, Shi H, Shang H, Wang Y, Zhang J, Zhu B. Transcutaneous auricular vagus nerve stimulation as a complementary therapy for pediatric epilepsy: a pilot trial. Epilepsy Behav 2013; 28:343-6. [PMID: 23820114 DOI: 10.1016/j.yebeh.2013.02.001] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Revised: 02/01/2013] [Accepted: 02/02/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We investigated the safety and efficacy of transcutaneous auricular vagus nerve stimulation (ta-VNS) for the treatment of pediatric epilepsy. METHODS Fourteen pediatric patients with intractable epilepsy were treated by ta-VNS of the bilateral auricular concha using an ear vagus nerve stimulator. The baseline seizure frequency was compared with that after 8weeks, from week 9 to 16 and from week 17 to the end of week 24, according to the seizure diaries of the patients. RESULTS One patient dropped out after 8weeks of treatment due to lack of efficacy, while the remaining 13 patients completed the 24-week study without any change in medication regimen. The mean reduction in seizure frequency relative to baseline was 31.83% after week 8, 54.13% from week 9 to 16 and 54.21% from week 17 to the end of week 24. The responder rate was 28.57% after 8weeks, 53.85% from week 9 to 16 and 53.85% from week 17 to the end of week 24. No severe adverse events were reported during treatment. CONCLUSION Transcutaneous auricular VNS may be a complementary treatment option for reducing seizure frequency in pediatric patients with intractable epilepsy and should be further studied.
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Affiliation(s)
- Wei He
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, China
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21
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Complications of vagal nerve stimulation for drug-resistant epilepsy: a single center longitudinal study of 143 patients. Seizure 2013; 22:827-33. [PMID: 23867218 DOI: 10.1016/j.seizure.2013.06.011] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 06/19/2013] [Accepted: 06/25/2013] [Indexed: 01/07/2023] Open
Abstract
PURPOSE To longitudinally study surgical and hardware complications to vagal nerve stimulation (VNS) treatment in patients with drug-resistant epilepsy. METHODS In a longitudinal retrospective study, we analyzed surgical and hardware complications in 143 patients (81 men and 62 women) who between 1994 and 2010 underwent implantation of a VNS-device for drug-resistant epilepsy. The mean follow-up time was 62 ± 46 months and the total number of patient years 738. RESULTS 251 procedures were performed on 143 patients. 16.8% of the patients were afflicted by complications related to surgery and 16.8% suffered from hardware malfunctions. Surgical complications were: superficial infection in 3.5%, deep infection needing explantation in 3.5%, vocal cord palsy in 5.6%, which persisted in at least 0.7% for over one year, and other complications in 5.6%. Hardware-related complications were: lead fracture in 11.9% of patients, disconnection in 2.8%, spontaneous turn-off in 1.4% and stimulator malfunction in 1.4%. We noted a tendency to different survival times between the two most commonly used lead models as well as a tendency to increased infection rate with increasing number of stimulator replacements. CONCLUSION In this series we report on surgical and hardware complications from our 16 years of experience with VNS treatment. Infection following insertion of the VNS device and vocal cord palsy due to damage to the vagus nerve are the most serious complications related to the surgery. Avoiding unnecessary reoperations in order to reduce the appearances of these complications are of great importance. It is therefore essential to minimize technical malfunctions that will lead to additional surgery. Further studies are needed to evaluate the possible superiority of the modified leads.
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Cukiert A, Cukiert CM, Burattini JA, Lima AM, Forster CR, Baise C, Argentoni-Baldochi M. A Prospective Long-Term Study on the Outcome After Vagus Nerve Stimulation at Maximally Tolerated Current Intensity in a Cohort of Children With Refractory Secondary Generalized Epilepsy. Neuromodulation 2013; 16:551-6; discussion 556. [DOI: 10.1111/j.1525-1403.2012.00522.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Revised: 08/13/2012] [Accepted: 09/13/2012] [Indexed: 11/30/2022]
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Kalanithi PSA, Arrigo RT, Tran P, Gephart MH, Shuer L, Fisher R, Boakye M. Rehospitalization and Emergency Department Use Rates Before and After Vagus Nerve Stimulation for Epilepsy: Use of State Databases to Provide Longitudinal Data Across Multiple Clinical Settings. Neuromodulation 2013; 17:60-4; discussion 64-5. [DOI: 10.1111/ner.12051] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 01/21/2013] [Accepted: 02/01/2013] [Indexed: 12/01/2022]
Affiliation(s)
- Paul S. A. Kalanithi
- Department of Neurosurgery; Stanford University Hospitals and Clinics; Stanford CA USA
| | - Robert T. Arrigo
- Stanford School of Medicine; Stanford University; Stanford CA USA
| | - Pelu Tran
- Stanford School of Medicine; Stanford University; Stanford CA USA
| | | | - Lawrence Shuer
- Department of Neurosurgery; Stanford University Hospitals and Clinics; Stanford CA USA
| | - Robert Fisher
- Department of Neurology; Stanford University Hospitals and Clinics; Stanford CA USA
| | - Maxwell Boakye
- Center for Advanced Neurosurgery; University of Louisville; Louisville KY USA
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Behavioural and cognitive effects during vagus nerve stimulation in children with intractable epilepsy - a randomized controlled trial. Eur J Paediatr Neurol 2013; 17:82-90. [PMID: 22878130 DOI: 10.1016/j.ejpn.2012.07.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 07/08/2012] [Accepted: 07/15/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND/AIMS In addition to effects on seizure frequency in intractable epilepsy, multiple studies report benefits of vagus nerve stimulation (VNS) on behavioural outcomes and quality of life. The present study aims to investigate the effects of VNS on cognition, mood in general, depression, epilepsy-related restrictions and psychosocial adjustment in children with intractable epilepsy, as well as the relation between these effects and seizure reduction. METHODS We conducted a randomized, active-controlled, double-blinded, add-on study in 41 children (age 4-18) with medically refractory epilepsy. We performed cognitive and behavioural testing at baseline (12 weeks), at the end of the blinded phase (20 weeks) in children receiving either high-output or low-output (active control) stimulation, and at the end of the open label phase (19 weeks) with all children receiving high-output stimulation. Seizure frequency was recorded using seizure diaries. RESULTS VNS did not have a negative effect on cognition nor on psychosocial adjustment. At the end of the follow-up phase we noted an improvement of mood in general and the depression subscale for the entire group, unrelated to a reduction of seizure frequency. At the end of the blinded phase a ≥50% reduction of seizure frequency occurred in 16% of the high-stimulation group and 21% of the low-stimulation group. At the end of the open-label follow-up phase, 26% of the children experienced a seizure frequency reduction of 50% or more (responders). CONCLUSIONS VNS has additional beneficial effects in children with intractable epilepsy. As opposed to anti-epileptic drugs, there are no negative effects on cognition. Moreover, we observed an improvement of mood in general and depressed feelings in particular, irrespective of a reduction in seizure frequency. These beneficial effects should be taken into account when deciding whether to initiate or continue VNS treatment in these children.
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Jadhav T, Cross JH. Surgical Approaches to Treating Epilepsy in Children. Curr Treat Options Neurol 2012; 14:620-9. [DOI: 10.1007/s11940-012-0203-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Thompson EM, Wozniak SE, Roberts CM, Kao A, Anderson VC, Selden NR. Vagus nerve stimulation for partial and generalized epilepsy from infancy to adolescence. J Neurosurg Pediatr 2012; 10:200-5. [PMID: 22768964 DOI: 10.3171/2012.5.peds11489] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Vagus nerve stimulation (VNS) is approved by the FDA for the treatment of partial epilepsy in patients older than 12 years. Authors of the current study performed a large retrospective analysis and comparison of VNS outcomes in children with an age ≥ and < 12 years, including those with partial and generalized epilepsy. METHODS A retrospective review of the records of pediatric patients (age < 18 years) who had undergone primary VNS system implantation between 2001 and 2010 by a single pediatric neurosurgeon was undertaken. Considered data included demographics, epilepsy type (partial vs generalized), seizure frequency, seizure duration, postictal period duration, and antiepileptic medication use. RESULTS One hundred forty-six patients (49% female) were followed up for a mean of 41 months after VNS implantation. Thirty-two percent of patients had partial epilepsy and 68% had generalized epilepsy. After VNS system implantation, seizure frequency was reduced in 91% of patients, seizure duration in 50%, postictal period in 49%, and antiepileptic medication use in 75%. There was no significant difference in age, sex, or duration of follow-up according to epilepsy type. Neither was there any significant difference in seizure frequency reduction, seizure duration, postictal period, medication use, overall clinical improvement, or improvement in quality of life based on an age ≥ or < 12 years or epilepsy type. CONCLUSIONS Vagus nerve stimulation reduced both seizure frequency and antiepileptic medication use in the majority of pediatric patients regardless of sex, age cohort, or epilepsy type. Vagus nerve stimulation also reduced seizure duration and postictal period in approximately half of the pediatric patients. Contrary to expectation, children with partial epilepsy do not benefit from VNS at higher rates than those with generalized epilepsy.
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Affiliation(s)
- Eric M Thompson
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR 97239, USA
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Helmers SL, Duh MS, Guérin A, Sarda SP, Samuelson TM, Bunker MT, Olin BD, Jackson SD, Faught E. Clinical outcomes, quality of life, and costs associated with implantation of vagus nerve stimulation therapy in pediatric patients with drug-resistant epilepsy. Eur J Paediatr Neurol 2012; 16:449-58. [PMID: 22261080 DOI: 10.1016/j.ejpn.2012.01.001] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Revised: 12/30/2011] [Accepted: 01/01/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND VNS (Vagus Nerve Stimulation Therapy) is approved in the USA to treat refractory epilepsy as adjunctive to antiepileptic drugs (AEDs) in patients ≥12 years with complex partial seizures. AIMS To evaluate clinical outcomes, quality-adjusted life years (QALY), and costs associated with VNS in pediatric patients with drug-resistant epilepsy in a real-world setting. METHODS A retrospective analysis was conducted using Medicaid data (USA). Patients had ≥1 neurologist visits with epilepsy diagnosis (ICD-9 345.xx, 780.3x), ≥1 procedure claims for VNS implantation, ≥1 AEDs, ≥6-months of Pre- and Post-VNS continuous enrollment. Pre-VNS period was 6-months and Post-VNS period extended from implantation until device removal, death, Medicaid disenrollment, or study end (up to 3 years). Incidence rate ratios (IRR) and costs ($2010) were estimated. QALYs were estimated using number of seizure-related events. RESULTS For patients 1-11 years old (N = 238), hospitalizations and emergency room visits were reduced Post-VNS vs. Pre-VNS (adjusted IRR = 0.73 [95% CI: 0.61-0.88] and 0.74 [95% CI: 0.65-0.83], respectively). Average total healthcare costs were lower Post-VNS vs. Pre-VNS ($18,437 vs. $18,839 quarterly [adjusted p = 0.052]). For patients 12-17 years old (N = 207), hospitalizations and status epilepticus events were reduced Post-VNS vs. Pre-VNS (adjusted IRR = 0.43 [95% CI: 0.34-0.54] and 0.25 [95% CI: 0.16-0.39], respectively). Average total healthcare costs were lower Post-VNS vs. Pre-VNS period ($14,546 vs. $19,695 quarterly [adjusted p = 0.002]). Lifetime QALY gain after VNS was 5.96 (patients 1-11 years) and 4.82 years (patients 12-17 years). CONCLUSIONS VNS in pediatric patients is associated with decreased resource use and epilepsy-related events, cost savings, and QALY gain.
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Affiliation(s)
- Sandra L Helmers
- Emory University School of Medicine, Atlanta, GA 30322, United States.
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Horowitz G, Amit M, Fried I, Neufeld MY, Sharf L, Kramer U, Fliss DM. Vagal nerve stimulation for refractory epilepsy: the surgical procedure and complications in 100 implantations by a single medical center. Eur Arch Otorhinolaryngol 2012; 270:355-8. [DOI: 10.1007/s00405-012-2118-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 07/10/2012] [Indexed: 12/01/2022]
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Majkowska-Zwolińska B, Zwoliński P, Roszkowski M, Drabik K. Long-term results of vagus nerve stimulation in children and adolescents with drug-resistant epilepsy. Childs Nerv Syst 2012; 28:621-8. [PMID: 22222361 DOI: 10.1007/s00381-011-1670-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Accepted: 12/22/2011] [Indexed: 12/12/2022]
Abstract
PURPOSE The purpose of this study was to evaluate long-term seizure reduction and on-demand magnet use in children and adolescents with drug-resistant epilepsy who were treated with vagus nerve stimulation therapy. METHODS Fifty-seven children and adolescents under 18 years of age with drug-resistant epilepsy were implanted with a vagus nerve stimulation therapy device. Seizure reduction was evaluated at 6, 12, 24, 36, and 48 months after implantation. Magnet effect on seizure frequency was evaluated during the first week after implantation and after 6, 12, 24, 36, and 48 months of treatment. RESULTS The mean reduction in seizure frequency compared with baseline was significant at all time points up to 48 months post-implantation. At 12 months, the average reduction in seizure frequency was 52.4%, and at 48 months, it was 53.1% (observed case analysis). The use of a magnet to deliver extra "on-demand" stimulation between cycles resulted in cessation of seizures in 16.1% of patients, partial effect in 73.2%, and no effect in 10.7%, when evaluated within 1 week of implantation. The magnet effect decreased slightly with increasing time after implantation. A sub-analysis of children ≤12 years of age (N = 34) showed similar results after 36 months of follow-up. The therapy was well tolerated regardless of age. CONCLUSION Vagus nerve stimulation therapy is a safe and effective adjunctive treatment for children and adolescents of all ages with drug-resistant epilepsy.
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Clark AJ, Kuperman RA, Auguste KI, Sun PP. Intractable episodic bradycardia resulting from progressive lead traction in an epileptic child with a vagus nerve stimulator: a delayed complication. J Neurosurg Pediatr 2012; 9:389-93. [PMID: 22462703 DOI: 10.3171/2011.12.peds11124] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Vagus nerve stimulation (VNS) is used as palliation for adult and pediatric patients with intractable epilepsy who are not candidates for curative resection. Although the treatment is generally safe, complications can occur intraoperatively, perioperatively, and in a delayed time frame. In the literature, there are 2 reports of pediatric patients with implanted VNS units who had refractory bradycardia that resolved after the stimulation was turned off. The authors report the case of a 13-year-old boy with a history of vagus nerve stimulator placement at 2 years of age, who developed intractable episodic bradycardia that persisted despite the cessation of VNS and whose imaging results suggested vagus nerve tethering by the leads. He was subsequently taken to the operating room for exploration, where it was confirmed that the stimulator lead was exerting traction on the vagus nerve, which was displaced from the carotid sheath. After the vagus nerve was untethered and the leads were replaced, the bradycardia eventually resolved with continual effective VNS therapy. When placing a VNS unit in a very young child, accommodations must be made for years of expected growth. Delayed intractable bradycardia can result from a vagus nerve under traction by tethered stimulator leads.
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Affiliation(s)
- Aaron J Clark
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
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Englot DJ, Chang EF, Auguste KI. Vagus nerve stimulation for epilepsy: a meta-analysis of efficacy and predictors of response. J Neurosurg 2011; 115:1248-55. [PMID: 21838505 DOI: 10.3171/2011.7.jns11977] [Citation(s) in RCA: 299] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Vagus nerve stimulation (VNS) was approved by the US FDA in 1997 as an adjunctive treatment for medically refractory epilepsy. It is considered for use in patients who are poor candidates for resection or those in whom resection has failed. However, disagreement regarding the utility of VNS in epilepsy continues because of the variability in benefit reported across clinical studies. Moreover, although VNS was approved only for adults and adolescents with partial epilepsy, its efficacy in children and in patients with generalized epilepsy remains unclear. The authors performed the first meta-analysis of VNS efficacy in epilepsy, identifying 74 clinical studies with 3321 patients suffering from intractable epilepsy. These studies included 3 blinded, randomized controlled trials (Class I evidence); 2 nonblinded, randomized controlled trials (Class II evidence); 10 prospective studies (Class III evidence); and numerous retrospective studies. After VNS, seizure frequency was reduced by an average of 45%, with a 36% reduction in seizures at 3-12 months after surgery and a 51% reduction after > 1 year of therapy. At the last follow-up, seizures were reduced by 50% or more in approximately 50% of the patients, and VNS predicted a ≥ 50% reduction in seizures with a main effects OR of 1.83 (95% CI 1.80-1.86). Patients with generalized epilepsy and children benefited significantly from VNS despite their exclusion from initial approval of the device. Furthermore, posttraumatic epilepsy and tuberous sclerosis were positive predictors of a favorable outcome. In conclusion, VNS is an effective and relatively safe adjunctive therapy in patients with medically refractory epilepsy not amenable to resection. However, it is important to recognize that complete seizure freedom is rarely achieved using VNS and that a quarter of patients do not receive any benefit from therapy.
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Affiliation(s)
- Dario J Englot
- Department of Neurological Surgery, University of California, San Francisco, California 94143-0112, USA.
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Abstract
OBJECT Vagal nerve stimulator (VNS) hardware infections are fraught with difficult management decisions. As with most implanted medical device-related infections, standard practice traditionally involves complete hardware removal, systemic antibiotic therapy, and subsequent reimplantation of the device. To avoid the potential morbidity of 2 repeat left carotid sheath surgical dissections, the authors have implemented a clinical protocol for managing VNS infections that involves generator removal and antibiotic therapy without lead removal. METHODS A prospective, single-surgeon database was compared with hospital billing records to identify patients who underwent primary implantation or reimplantation of a VNS lead, generator, or both, from January 2001 to May 2010, at Oregon Health & Science University. From these records, the authors identified patients with VNS hardware infections and characterized their management, using a lead salvage protocol. RESULTS In their review, the authors found a matching cohort of 206 children (age 3 months-17 years) who met the inclusion criteria. These children underwent 258 operations (including, in some children, multiple operations for generator end of life and/or lead malfunction). Six children experienced a single postimplantation infection (2.3% of the 258 operative cases), and no child experienced repeated infection. A lead-salvage protocol was used in 4 of 6 infected patients and was successful in 3 (75%), with clinical follow-up ranging from 10 months to 7.5 years. The fourth patient subsequently underwent lead removal and later reimplantation in standard fashion, with no adverse sequelae. CONCLUSIONS Vagal nerve stimulator lead salvage is a safe and potentially advantageous strategy in the management of VNS-related infection. Further study is necessary to validate appropriate patient selection, success rates, and risks of this approach.
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Affiliation(s)
- Susan E Wozniak
- Department of Neurological Surgery, Oregon Health & Science University, 3303 SW Bond Avenue, Portland, OR 97239, USA
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Yang AC, Zhang JG, Rong PJ, Liu HG, Chen N, Zhu B. A new choice for the treatment of epilepsy: electrical auricula-vagus-stimulation. Med Hypotheses 2011; 77:244-5. [PMID: 21601370 DOI: 10.1016/j.mehy.2011.04.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Accepted: 04/11/2011] [Indexed: 11/26/2022]
Abstract
Preliminary reports have suggested that chronic, intermittent electrical stimulation of the cervical vagus nerve (VNS) is an effective treatment for patients who suffered from medically refractory epilepsy. But the traditional VNS is an invasive and implantable procedure that will bring some injury to the patient. Anatomic studies have confirmed the existence of auricular branch of the vagus nerve-Arnold nerve. The Arnold nerve mainly consists of afferent fibers and the superficial sites of the Arnold nerve are optimal for electrical stimulation. We hypothesized that electrical auricula-vagus-stimulation could be a new choice for the treatment of epilepsy.
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Affiliation(s)
- An-chao Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Current World Literature. Curr Opin Neurol 2011; 24:183-90. [DOI: 10.1097/wco.0b013e32834585ec] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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