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Gill S, Devlin KN, Yuan H, Mintzer S, Skidmore C, Wu C, Sperling MR, Nei M. Long-Term Seizure Outcome With or Without Vagal Nerve Stimulation Therapy. Neurol Clin Pract 2024; 14:e200358. [PMID: 39185099 PMCID: PMC11341084 DOI: 10.1212/cpj.0000000000200358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 06/04/2024] [Indexed: 08/27/2024]
Abstract
Background and Objectives To compare long-term seizure control in patients with long-term VNS (vagal nerve stimulator) stimulation (VNS-on) with those who discontinued VNS after >3 years (VNS-off). Methods Patients with refractory epilepsy with VNS therapy for >3 years (and follow-up for >2 years after VNS discontinuation for VNS-off patients) were included. Patients with brain surgery <3 years after VNS were excluded. We compared the percentage of patients with ≥50% seizure reduction (50% responder rate) and change in seizure frequency within and between groups in follow-up. Results Thirty-three VNS-on and 16 VNS-off patients were evaluated. VNS-on patients underwent stimulation for 9.7 years (mean). VNS-off patients had VNS treatment for 6.5 years (mean), discontinued treatment, then had additional 8.0 years (mean) follow-up. 50% responder rates were similar between groups (VNS-on: 54.5% vs VNS-off at last-on: 37.5%, p = 0.26; vs VNS-off at the last follow-up: 62.5%, p = 0.60). VNS-on patients had a significant reduction in seizure frequency at the last follow-up compared with baseline (median [Mdn] = -4.5 seizures/month, interquartile range [IQR] = 14.0, 56% reduction, p = 0.013). VNS-off patients also showed significant seizure reduction while still continuing VNS therapy (Mdn = -1.0 seizures/month, IQR = 13.0, 35% reduction, p = 0.020) and, after discontinuing therapy, at the last follow-up compared with baseline (Mdn = -3.2, IQR = 11.0, 52% reduction, p = 0.020). The 2 groups were comparable in seizure frequency change both at the last-on visit (absolute change, p = 0.62; relative change, p = 0.50) at the last follow-up (absolute change, p = 0.67; relative change, p = 0.76). Discussion Patients who discontinued VNS therapy and those who continued therapy had similar response during active treatment and similar long-term outcomes, suggesting that factors such as the natural disease course and/or medication treatment strongly affect long-term outcomes.
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Affiliation(s)
- Sonia Gill
- Jefferson Comprehensive Epilepsy Center (SG, SM, CS, MRS, MN), Department of Neurology, Thomas Jefferson University Hospital; Department of Psychological and Brain Sciences (KND), Drexel University; Jefferson Headache Center (HY), Department of Neurology, Thomas Jefferson University Hospital; Department of Neurosurgery (CW), Thomas Jefferson University Hospital, Philadelphia, PA; and Inova Medical Group - Neurology (SG), Fairfax, VA
| | - Kathryn N Devlin
- Jefferson Comprehensive Epilepsy Center (SG, SM, CS, MRS, MN), Department of Neurology, Thomas Jefferson University Hospital; Department of Psychological and Brain Sciences (KND), Drexel University; Jefferson Headache Center (HY), Department of Neurology, Thomas Jefferson University Hospital; Department of Neurosurgery (CW), Thomas Jefferson University Hospital, Philadelphia, PA; and Inova Medical Group - Neurology (SG), Fairfax, VA
| | - Hsiangkuo Yuan
- Jefferson Comprehensive Epilepsy Center (SG, SM, CS, MRS, MN), Department of Neurology, Thomas Jefferson University Hospital; Department of Psychological and Brain Sciences (KND), Drexel University; Jefferson Headache Center (HY), Department of Neurology, Thomas Jefferson University Hospital; Department of Neurosurgery (CW), Thomas Jefferson University Hospital, Philadelphia, PA; and Inova Medical Group - Neurology (SG), Fairfax, VA
| | - Scott Mintzer
- Jefferson Comprehensive Epilepsy Center (SG, SM, CS, MRS, MN), Department of Neurology, Thomas Jefferson University Hospital; Department of Psychological and Brain Sciences (KND), Drexel University; Jefferson Headache Center (HY), Department of Neurology, Thomas Jefferson University Hospital; Department of Neurosurgery (CW), Thomas Jefferson University Hospital, Philadelphia, PA; and Inova Medical Group - Neurology (SG), Fairfax, VA
| | - Christopher Skidmore
- Jefferson Comprehensive Epilepsy Center (SG, SM, CS, MRS, MN), Department of Neurology, Thomas Jefferson University Hospital; Department of Psychological and Brain Sciences (KND), Drexel University; Jefferson Headache Center (HY), Department of Neurology, Thomas Jefferson University Hospital; Department of Neurosurgery (CW), Thomas Jefferson University Hospital, Philadelphia, PA; and Inova Medical Group - Neurology (SG), Fairfax, VA
| | - Chengyuan Wu
- Jefferson Comprehensive Epilepsy Center (SG, SM, CS, MRS, MN), Department of Neurology, Thomas Jefferson University Hospital; Department of Psychological and Brain Sciences (KND), Drexel University; Jefferson Headache Center (HY), Department of Neurology, Thomas Jefferson University Hospital; Department of Neurosurgery (CW), Thomas Jefferson University Hospital, Philadelphia, PA; and Inova Medical Group - Neurology (SG), Fairfax, VA
| | - Michael R Sperling
- Jefferson Comprehensive Epilepsy Center (SG, SM, CS, MRS, MN), Department of Neurology, Thomas Jefferson University Hospital; Department of Psychological and Brain Sciences (KND), Drexel University; Jefferson Headache Center (HY), Department of Neurology, Thomas Jefferson University Hospital; Department of Neurosurgery (CW), Thomas Jefferson University Hospital, Philadelphia, PA; and Inova Medical Group - Neurology (SG), Fairfax, VA
| | - Maromi Nei
- Jefferson Comprehensive Epilepsy Center (SG, SM, CS, MRS, MN), Department of Neurology, Thomas Jefferson University Hospital; Department of Psychological and Brain Sciences (KND), Drexel University; Jefferson Headache Center (HY), Department of Neurology, Thomas Jefferson University Hospital; Department of Neurosurgery (CW), Thomas Jefferson University Hospital, Philadelphia, PA; and Inova Medical Group - Neurology (SG), Fairfax, VA
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Durez A, Theys T, van Loon J, Van Paesschen W. Retention rate of vagus nerve stimulation for the treatment of drug-resistant epilepsy: A single-centre, retrospective study. Epilepsy Res 2024; 203:107383. [PMID: 38795656 DOI: 10.1016/j.eplepsyres.2024.107383] [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: 03/11/2024] [Revised: 05/07/2024] [Accepted: 05/19/2024] [Indexed: 05/28/2024]
Abstract
The aim of this single-centre, retrospective, observational study was to evaluate long-term effectiveness of vagus nerve stimulation (VNS) in drug-resistant epilepsy (DRE) by using retention rate as a surrogate measure for seizure reduction. We included all patients with DRE, treated at the adult neurology department of the University Hospitals Leuven and who started VNS therapy from January 1, 1994, until May 1, 2021, with follow-up data cutoff on January 1, 2023. Retention rate of VNS was defined as the percentage of patients who maintain VNS at established time points. We estimated cumulative retention rate and battery replacement rate and correlated these with seizure reduction, using Kaplan-Meier analysis. Statistical analysis of potential predictors of VNS outcome (age, sex and epilepsy duration at implantation) was performed using mono- and multivariate analyses. VNS was started in 110 patients with DRE, with a mean follow-up of 8.7 years (SD 6.5). VNS was discontinued in 55 patients (50%), with ineffectiveness as the main reason for discontinuation (98%). The battery was replaced at least once in 42 patients (38%). Estimated retention rates were 70%, 52%, 45% and 33% after 5, 10, 15 and 20 years, respectively. Estimated first battery replacement rates were 16%, 42% and 47% after 5, 10 and 15 years, respectively. Both estimates showed a statistically significant correlation with seizure reduction. No independent predictors of long-term outcome of VNS were found. This is the first long-term study using retention rate of VNS to assess effectiveness. VNS is a well-tolerated therapy, but retention rates decline with long follow-up.
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Affiliation(s)
- Astrid Durez
- Department of Neurology, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium
| | - Tom Theys
- Department of Neurosurgery, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium
| | - Johannes van Loon
- Department of Neurosurgery, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium
| | - Wim Van Paesschen
- Department of Neurology, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium; Laboratory for Epilepsy Research, KU Leuven, Leuven, Belgium.
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Cramer SW, McGovern RA, Chen CC, Park MC. Clinical Benefit of Vagus Nerve Stimulation for Epilepsy: Assessment of Randomized Controlled Trials and Prospective Non-Randomized Studies. J Cent Nerv Syst Dis 2023; 15:11795735231151830. [PMID: 36654850 PMCID: PMC9841854 DOI: 10.1177/11795735231151830] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 12/27/2022] [Indexed: 01/13/2023] Open
Abstract
We examined the efficacy of vagal nerve stimulation (VNS) for patients suffering from medically intractable epilepsy. Four randomized controlled trials (RCTs - 3 adult RCTs and 1 pediatric RCT) were identified in our comprehensive literature search. Across the 4 studies, high frequency VNS stimulation (frequency >20 Hz) consistently achieved a greater seizure frequency reduction (23.4-33.1%) relative to low frequency VNS stimulation (1 Hz, .6-15.2%). We identified 2 RCTs examining whether the parameters of stimulation influenced seizure control. These studies reported that VNS achieved seizure control comparable to those reported by the first 4 RCTs (22-43% seizure frequency reduction), irrespective of the parameters utilized for VNS stimulation. In terms of VNS associated morbidity, these morbidities were consistently higher in adults who underwent high frequency VNS stimulation (eg dysphonia 37-66%, dyspnea 6-25.3%). However, no such differences were observed in the pediatric population. Moreover, <2% of patients withdrew from the RCTs/prospective studies due to intolerable symptoms. To provide an assessment of how the risks and benefits of VNS impact the patient experience, 1 study assessed the well-being of enrolled patients (as a secondary end point) and found VNS was associated with an overall improvement in well-being. Consistent with this observation, we identified a prospective, non-randomized study that demonstrated improved quality of life for epilepsy patients managed with VNS and best medical practice relative to best medical practice alone. In aggregate, these RCT studies support the efficacy and benefit of VNS as a neuro-modulatory platform in the management of a subset of medically refractory epilepsy patients.
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Affiliation(s)
- Samuel W Cramer
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA,Delaware St SE, D-429 Mayo Memorial Building, MMC 96, Minneapolis, MN 55455, USA.
| | - Robert A McGovern
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA,Department of Neurology, University of Minnesota, Minneapolis, MN, USA
| | - Clark C Chen
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Michael C Park
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA,Department of Neurology, University of Minnesota, Minneapolis, MN, USA
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Xue T, Chen S, Bai Y, Han C, Yang A, Zhang J. Neuromodulation in drug-resistant epilepsy: A review of current knowledge. Acta Neurol Scand 2022; 146:786-797. [PMID: 36063433 DOI: 10.1111/ane.13696] [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: 08/05/2022] [Accepted: 08/16/2022] [Indexed: 11/30/2022]
Abstract
Nearly 1% of the global population suffers from epilepsy. Drug-resistant epilepsy (DRE) affects one-third of epileptic patients who are unable to treat their condition with existing drugs. For the treatment of DRE, neuromodulation offers a lot of potential. The background, mechanism, indication, application, efficacy, and safety of each technique are briefly described in this narrative review, with an emphasis on three approved neuromodulation therapies: vagus nerve stimulation (VNS), deep brain stimulation of the anterior nucleus of the thalamus (ANT-DBS), and closed-loop responsive neurostimulation (RNS). Neuromodulatory approaches involving direct or induced electrical currents have been developed to lessen seizure frequency and duration in patients with DRE since the notion of electrical stimulation as a therapy for neurologic diseases originated in the early nineteenth century. Although few people have attained total seizure independence for more than 12 months using these treatments, more than half have benefitted from a 50% drop in seizure frequency over time. Although promising outcomes in adults and children with DRE have been achieved, challenges such as heterogeneity among epilepsy types and etiologies, optimization of stimulation parameters, a lack of biomarkers to predict response to neuromodulation therapies, high-level evidence to aid decision-making, and direct comparisons between neuromodulatory approaches remain. To solve these existing gaps, authorize new kinds of neuromodulation, and develop personalized closed-loop treatments, further research is needed. Finally, both invasive and non-invasive neuromodulation seems to be safe. Implantation-related adverse events for invasive stimulation primarily include infection and pain at the implant site. Intracranial hemorrhage is a frequent adverse event for DBS and RNS. Other stimulation-specific side-effects are mild with non-invasive stimulation.
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Affiliation(s)
- Tao Xue
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shujun Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yutong Bai
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chunlei Han
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anchao Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jianguo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Muthiah N, Sharma N, Vodovotz L, White GE, Abel TJ. Predictors of vagus nerve stimulation complications among pediatric patients with drug-resistant epilepsy. J Neurosurg Pediatr 2022; 30:284-291. [PMID: 35901694 DOI: 10.3171/2022.6.peds2289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/02/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Complications from vagus nerve stimulator (VNS) procedures are common and can have important implications for morbidity and seizure control, yet predictors of complications are poorly understood. The objective of this study was to assess clinical factors associated with minor and major complications from VNS procedures among pediatric patients with drug-resistant epilepsy. METHODS The authors performed an 11-year retrospective review of patients who underwent VNS procedures for drug-resistant epilepsy at age < 21 years. The primary outcome was complications (minor or major) following VNS surgery. Preoperative and surgery characteristics were compared between patients who developed versus those who did not develop complications. Multivariable Poisson regression was performed to determine the association between preoperative characteristics and infection. RESULTS Of 686 surgeries, 48 complications (7.0%) developed; there were 7 minor complications (1.0%) and 41 major complications (6.0%). Surgeries with minor complications were an average of 68 minutes longer than those without minor complications (p < 0.001). The incidence rate of infection was 1 per 100 person-years, with 3% of procedures complicated by infection. Poisson regression revealed that after adjusting for age at surgery, duration of surgery, and primarily motor seizure semiology, the incident rate of infection for revision surgeries preceded by ≥ 2 procedures was 19 times that of first-time revisions. CONCLUSIONS The overall minor complication rate was 1% and the overall major complication rate was 6% for VNS procedures. Longer surgery duration was associated with the development of minor complications but not major complications. Repeat incisions to the VNS pocket may be associated with higher incident rate of infection, highlighting a need for longer-lasting VNS pulse generator models.
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Affiliation(s)
| | - Nikhil Sharma
- 1Department of Neurological Surgery, University of Pittsburgh
| | - Lena Vodovotz
- 1Department of Neurological Surgery, University of Pittsburgh
| | - Gretchen E White
- 2Institute for Clinical Research Education, University of Pittsburgh; and
| | - Taylor J Abel
- 1Department of Neurological Surgery, University of Pittsburgh
- 3Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania
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Guo M, Wang J, Tang C, Deng J, Zhang J, Xiong Z, Liu S, Guan Y, Zhou J, Zhai F, Luan G, Li T. Vagus nerve stimulation for refractory posttraumatic epilepsy: Efficacy and predictors of seizure outcome. Front Neurol 2022; 13:954509. [PMID: 35968289 PMCID: PMC9366668 DOI: 10.3389/fneur.2022.954509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 07/01/2022] [Indexed: 11/16/2022] Open
Abstract
Background Traumatic brain injury (TBI) has been recognized as an important and common cause of epilepsy since antiquity. Posttraumatic epilepsy (PTE) is usually associated with drug resistance and poor surgical outcomes, thereby increasing the burden of the illness on patients and their families. Vagus nerve stimulation (VNS) is an adjunctive treatment for medically refractory epilepsy. This study aimed to determine the efficacy of VNS for refractory PTE and to initially evaluate the potential predictors of efficacy. Methods We retrospectively collected the outcomes of VNS with at least a 1-year follow-up in all patients with refractory PTE. Subgroups were classified as responders and non-responders according to the efficacy of VNS (≥50% or <50% reduction in seizure frequency). Preoperative data were analyzed to screen for potential predictors of VNS efficacy. Results In total, forty-five patients with refractory PTE who underwent VNS therapy were enrolled. Responders were found in 64.4% of patients, and 15.6% of patients achieved seizure freedom at the last follow-up. In addition, the responder rate increased over time, with 37.8, 44.4, 60, and 67.6% at the 3-, 6-, 12-, and 24-month follow-ups, respectively. After multivariate analysis, generalized interictal epileptic discharges (IEDs) were found to be a negative predictor (OR: 4.861, 95% CI: 1.145–20.632) of VNS efficacy. Conclusion The results indicated that VNS therapy was effective in refractory PTE patients and was well tolerated over a 1-year follow-up period. Patients with focal or multifocal IEDs were recognized to have better efficacy after VNS therapy.
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Affiliation(s)
- Mengyi Guo
- Beijing Key Laboratory of Epilepsy Research, Department of Brian Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Jing Wang
- Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Chongyang Tang
- Beijing Key Laboratory of Epilepsy Research, Department of Brian Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Epilepsy Research, Department of Neurosurgery, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Jiahui Deng
- Beijing Key Laboratory of Epilepsy Research, Department of Brian Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Jing Zhang
- Beijing Key Laboratory of Epilepsy Research, Department of Brian Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Zhonghua Xiong
- Beijing Key Laboratory of Epilepsy Research, Department of Brian Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Siqi Liu
- Beijing Key Laboratory of Epilepsy Research, Department of Brian Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Yuguang Guan
- Beijing Key Laboratory of Epilepsy Research, Department of Brian Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Epilepsy Research, Department of Neurosurgery, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Jian Zhou
- Beijing Key Laboratory of Epilepsy Research, Department of Brian Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Epilepsy Research, Department of Neurosurgery, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Feng Zhai
- Beijing Key Laboratory of Epilepsy Research, Department of Brian Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Epilepsy Research, Department of Neurosurgery, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Guoming Luan
- Beijing Key Laboratory of Epilepsy Research, Department of Brian Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Epilepsy Research, Department of Neurosurgery, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
- *Correspondence: Guoming Luan
| | - Tianfu Li
- Beijing Key Laboratory of Epilepsy Research, Department of Brian Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
- Tianfu Li
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Goggins E, Mitani S, Tanaka S. Clinical perspectives on vagus nerve stimulation: present and future. Clin Sci (Lond) 2022; 136:695-709. [PMID: 35536161 PMCID: PMC9093220 DOI: 10.1042/cs20210507] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 04/15/2022] [Accepted: 04/22/2022] [Indexed: 12/30/2022]
Abstract
The vagus nerve, the great wanderer, is involved in numerous processes throughout the body and vagus nerve stimulation (VNS) has the potential to modulate many of these functions. This wide-reaching capability has generated much interest across a range of disciplines resulting in several clinical trials and studies into the mechanistic basis of VNS. This review discusses current preclinical and clinical evidence supporting the efficacy of VNS in different diseases and highlights recent advancements. Studies that provide insights into the mechanism of VNS are considered.
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Affiliation(s)
- Eibhlin Goggins
- Division of Nephrology and Center for Immunity, Inflammation, and Regenerative Medicine, University of Virginia, Charlottesville, VA, U.S.A
| | - Shuhei Mitani
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Shinji Tanaka
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
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Magisetty R, Park SM. New Era of Electroceuticals: Clinically Driven Smart Implantable Electronic Devices Moving towards Precision Therapy. MICROMACHINES 2022; 13:161. [PMID: 35208286 PMCID: PMC8876842 DOI: 10.3390/mi13020161] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/14/2022] [Accepted: 01/18/2022] [Indexed: 12/15/2022]
Abstract
In the name of electroceuticals, bioelectronic devices have transformed and become essential for dealing with all physiological responses. This significant advancement is attributable to its interdisciplinary nature from engineering and sciences and also the progress in micro and nanotechnologies. Undoubtedly, in the future, bioelectronics would lead in such a way that diagnosing and treating patients' diseases is more efficient. In this context, we have reviewed the current advancement of implantable medical electronics (electroceuticals) with their immense potential advantages. Specifically, the article discusses pacemakers, neural stimulation, artificial retinae, and vagus nerve stimulation, their micro/nanoscale features, and material aspects as value addition. Over the past years, most researchers have only focused on the electroceuticals metamorphically transforming from a concept to a device stage to positively impact the therapeutic outcomes. Herein, the article discusses the smart implants' development challenges and opportunities, electromagnetic field effects, and their potential consequences, which will be useful for developing a reliable and qualified smart electroceutical implant for targeted clinical use. Finally, this review article highlights the importance of wirelessly supplying the necessary power and wirelessly triggering functional electronic circuits with ultra-low power consumption and multi-functional advantages such as monitoring and treating the disease in real-time.
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Affiliation(s)
- RaviPrakash Magisetty
- Department of Convergence IT Engineering, Pohang University of Science and Technology (POSTECH), Pohang 37673, Korea;
| | - Sung-Min Park
- Department of Convergence IT Engineering, Pohang University of Science and Technology (POSTECH), Pohang 37673, Korea;
- Department of Electrical Engineering, Pohang University of Science and Technology (POSTECH), Pohang 37673, Korea
- Department of Mechanical Engineering, Pohang University of Science and Technology (POSTECH), Pohang 37673, Korea
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Muthiah N, Akwayena E, Vodovotz L, Sharma N, Jeong JH, White GE, Abel TJ. Comparison of traditional and closed loop vagus nerve stimulation for treatment of pediatric drug-resistant epilepsy: A propensity-matched retrospective cohort study. Seizure 2022; 94:74-81. [PMID: 34872020 PMCID: PMC11423706 DOI: 10.1016/j.seizure.2021.11.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/08/2021] [Accepted: 11/23/2021] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE For epilepsy patients with drug-resistant, unresectable epilepsy, vagus nerve stimulation (VNS) is an option for seizure control. Approximately 40-70% of patients will achieve ≥50% seizure reduction with VNS. New closed loop VNS models detect ictal tachycardia and responsively stimulate the vagus nerve. The effectiveness of closed loop VNS compared to traditional VNS for pediatric epilepsy is unknown. METHODS An 11-year retrospective electronic medical record review at Children's Hospital of Pittsburgh was performed. Patients with drug-resistant epilepsy who underwent VNS implantation were included. Patients were divided into groups based on VNS model: traditional versus closed loop. Those who transitioned from traditional to closed loop VNS were excluded. Given potential for selection bias, propensity scores matching was utilized to compare traditional to closed loop VNS patients. Patients with focal versus generalized epilepsy were also separately analyzed. The primary outcome was "VNS response", defined as at least 50% seizure frequency reduction from baseline. RESULTS A total of 320 patients were included in this sample. The percentage of matched patients (total n = 220: n = 179 traditional VNS, n = 41 closed loop VNS) who responded to VNS after one year of therapy was 43% for traditional VNS and 39% for closed loop VNS (p = 0.64). After two years of therapy, a higher proportion of closed loop VNS patients than traditional VNS patients responded to VNS among all subgroups, though no differences were statistically significant (p>0.05). Notably, for those with generalized epilepsy, 73% of closed loop patients responded to VNS compared to only 46% of traditional patients (p = 0.10). After two years of VNS therapy, patients were taking approximately the same quantity of antiseizure medications as baseline (change of +0.074 +/- 0.90 ) with no difference between VNS models (p = 0.87). SIGNIFICANCE Among pediatric patients with drug-resistant epilepsy, closed loop VNS trends towards a higher rate of VNS response after two years of treatment, especially among generalized epilepsy patients. Neither model of VNS allows patients to reduce antiseizure medication quantity after two years.
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Affiliation(s)
- Nallammai Muthiah
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Emefa Akwayena
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lena Vodovotz
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nikhil Sharma
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jong-Hyeon Jeong
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA; Clinical and Translational Science Institute (CTSI), University of Pittsburgh, Pittsburgh, PA, USA
| | - Gretchen E White
- Clinical and Translational Science Institute (CTSI), University of Pittsburgh, Pittsburgh, PA, USA; Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA.
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Kostov KH, Kostov H, Larsson PG, Henning O, Eckmann CAC, Lossius MI, Peltola J. Norwegian population-based study of long-term effects, safety, and predictors of response of vagus nerve stimulation treatment in drug-resistant epilepsy: The NORPulse study. Epilepsia 2021; 63:414-425. [PMID: 34935136 DOI: 10.1111/epi.17152] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/06/2021] [Accepted: 12/08/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study was undertaken to evaluate the efficacy of vagus nerve stimulation (VNS) over time, and to determine which patient groups derive the most benefit. METHODS Long-term outcomes are reported in 436 epilepsy patients from a VNS quality registry (52.8% adults, 47.2% children), with a median follow-up of 75 months. Patients were stratified according to evolution of response into constant responders, fluctuating responders, and nonresponders. The effect was evaluated at 6, 12, 24, 36, and 60 months. Multivariate regression analysis was used to identify predictors of response. RESULTS The cumulative probability of ≥50% seizure reduction was 60%; however, 15% of patients showed a fluctuating course. Of those becoming responders, 89.5% (230/257) did so within 2 years. A steady increase in effect was observed among constant responders, with 48.7% (19/39) of those becoming seizure-free and 29.3% (39/133) with ≥75% seizure reduction achieving these effects within 2-5 years. Some effect (25%-<50%) at 6 months was a positive predictor of becoming a responder (odds ratio [OR] = 10.18, p < .0001) and having ≥75% reduction at 2 years (OR = 3.34, p = .03). Patients without intellectual disability had ORs of 3.34 and 3.11 of having ≥75% reduction at 2 and 5 years, respectively, and an OR of 6.22 of being seizure-free at last observation. Patients with unchanged antiseizure medication over the observation period showed better responder rates at 2 (63.0% vs. 43.1%, p = .002) and 5 years (63.4% vs. 46.3%, p = .031) than patients whose antiseizure medication was modified. Responder rates were higher for posttraumatic (70.6%, p = .048) and poststroke epilepsies (75.0%, p = .05) than other etiologies (46.5%). SIGNIFICANCE Our data indicate that the effect of VNS increases over time and that there are important clinical decision points at 6 and 24 months for evaluating and adjusting the treatment. There should be better selection of candidates, as certain patient groups and epilepsy etiologies respond more favorably.
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Affiliation(s)
| | - Hrisimir Kostov
- National Center for Epilepsy, Oslo University Hospital, Oslo, Norway
| | | | - Oliver Henning
- National Center for Epilepsy, Oslo University Hospital, Oslo, Norway
| | | | - Morten Ingvar Lossius
- National Center for Epilepsy, Oslo University Hospital, Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jukka Peltola
- Department of Neurology, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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11
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Abstract
Three neuromodulation therapies, all using implanted device and electrodes, have been
approved to treat adults with drug-resistant focal epilepsy, namely, the vagus nerve
stimulation in 1995, deep brain stimulation of the anterior nucleus of the thalamus
(ANT-DBS) in 2018 (2010 in Europe), and responsive neurostimulation (RNS) in 2014.
Indications for VNS have more recently extended to children down to age of 4. Limited or
anecdotal data are available in other epilepsy syndromes and refractory/super-refractory
status epilepticus. Overall, neuromodulation therapies are palliative, with only a
minority of patients achieving long-term seizure freedom, justifying favoring such
treatments in patients who are not good candidates for curative epilepsy surgery. About
half of patients implanted with VNS, ANT-DBS, and RNS have 50% or greater reduction in
seizures, with long-term data suggesting increased efficacy over time. Besides their
impact on seizure frequency, neuromodulation therapies are associated with various
benefits and drawbacks in comparison to antiseizure drugs. Yet, we lack high-level
evidence to best position each neuromodulation therapy in the treatment pathways of
persons with difficult-to-treat epilepsy.
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Affiliation(s)
- Philippe Ryvlin
- Department of Clinical Neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Lara E. Jehi
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
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12
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Shlomovitz O, Ben-Zeev B, Pleniceanu O, Greenberger S, Lahav E, Mini S, Tzadok M. An Israeli tuberous sclerosis cohort: the efficacy of different anti-epileptic strategies. Childs Nerv Syst 2021; 37:3827-3833. [PMID: 34491422 DOI: 10.1007/s00381-021-05348-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 08/27/2021] [Indexed: 11/25/2022]
Abstract
AIM We aimed to describe the experience of a large single-center cohort for the clinical, radiological, and genetic characteristics, as well as to determine the efficacy of different anti-epileptic strategies in children and adults with tuberous sclerosis complex (TSC). METHODS We carried out a historical cohort study on 91 TSC patients treated in a single center between 2008 and 2018. RESULTS Our cohort comprised 46 males and 45 females, with a median age of 15.6 years at the last follow-up. Mean follow-up time was 2.5 ± 0.75-5.5 years (range 0-9.5 years). Of those tested, a disease-causing mutation was identified in 90% of patients, 53% in TSC2, and 37% in TSC1. Epilepsy prevalence was similar among TSC1 and TSC2 mutated patients. The most common radiological finding were cortical tubers in 95% of patients, while subependymal giant cell astrocytoma (SEGA) were detected in 36% of patients. Notably, infantile spasms (IS) were diagnosed in 29%, with SEGA representing the only finding significantly different in prevalence between those with and without IS (62% vs. 28%, respectively, p = 0.009). Lastly, we did not find any difference in efficacy between three anti-epileptic treatments: Vagus nerve stimulation (VNS), CBD-based products, and the ketogenic diet, all showing approximately 30%-40% response rates. SIGNIFICANCE Altogether, we provide a comprehensive description of our experience in treating TSC, which could serve to expand current knowledge of the disease and its treatments.
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Affiliation(s)
- Omer Shlomovitz
- Department of Pediatrics B, Sheba Medical Center, Tel-Hashomer and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Bruria Ben-Zeev
- Pediatric Neurology Units, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Ramat Gan, Israel
| | - Oren Pleniceanu
- Division of Pediatric Nephrology, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shoshana Greenberger
- Dermatology Department, Pediatric Dermatology Service, Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Einat Lahav
- Division of Pediatric Nephrology, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Ramat Gan, Israel
| | - Sharon Mini
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Institute of Nephrology and Hypertension, Sheba medical center, Ramat Gan, Israel
| | - Michal Tzadok
- Pediatric Neurology Units, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Ramat Gan, Israel
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Ryvlin P, Rheims S, Hirsch LJ, Sokolov A, Jehi L. Neuromodulation in epilepsy: state-of-the-art approved therapies. Lancet Neurol 2021; 20:1038-1047. [PMID: 34710360 DOI: 10.1016/s1474-4422(21)00300-8] [Citation(s) in RCA: 108] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 08/22/2021] [Accepted: 09/03/2021] [Indexed: 12/20/2022]
Abstract
Three neuromodulation therapies have been appropriately tested and approved in refractory focal epilepsies: vagus nerve stimulation (VNS), deep brain stimulation of the anterior nucleus of the thalamus (ANT-DBS), and closed-loop responsive neurostimulation of the epileptogenic zone or zones. These therapies are primarily palliative. Only a few individuals have achieved complete freedom from seizures for more than 12 months with these therapies, whereas more than half have benefited from long-term reduction in seizure frequency of more than 50%. Implantation-related adverse events primarily include infection and pain at the implant site. Intracranial haemorrhage is a frequent adverse event for ANT-DBS and responsive neurostimulation. Other stimulation-specific side-effects are observed with VNS and ANT-DBS. Biomarkers to predict response to neuromodulation therapies are not available, and high-level evidence to aid decision making about when and for whom these therapies should be preferred over other antiepileptic treatments is scant. Future studies are thus needed to address these shortfalls in knowledge, approve other forms of neuromodulation, and develop personalised closed-loop therapies with embedded machine learning. Until then, neuromodulation could be considered for individuals with intractable seizures, ideally after the possibility of curative surgical treatment has been carefully assessed and ruled out or judged less appropriate.
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Affiliation(s)
- Philippe Ryvlin
- Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Sylvain Rheims
- Department of Functional Neurology and Epileptology, Hospices Civils de Lyon, Lyon 1 University Lyon Neuroscience Research Center, Institut National de la Santé et de la Recherche Médicale U1028/CNRS UMR 5292 Epilepsy Institute, Lyon, France
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Arseny Sokolov
- Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Lara Jehi
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
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14
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Guglielmi G, Eschbach KL, Alexander AL. Smaller Knife, Fewer Seizures? Recent Advances in Minimally Invasive Techniques in Pediatric Epilepsy Surgery. Semin Pediatr Neurol 2021; 39:100913. [PMID: 34620456 DOI: 10.1016/j.spen.2021.100913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 02/02/2023]
Abstract
Children with drug-resistant epilepsy are at high risk for developmental delay, increased mortality, psychiatric comorbidities, and requiring assistance with activities of daily living. Despite the advent of new and effective pharmacologic therapies, about one in 5 children will develop drug-resistant epilepsy, and most of these children continue to have seizures despite trials of other medication. Epilepsy surgery is often a safe and effective option which may offer seizure freedom or at least a significant reduction in seizure burden in many children. However, despite published evidence of safety and efficacy, epilepsy surgery remains underutilized in the pediatric population. Patient and family fears about the risks of surgery may contribute to this gap. Less invasive surgical techniques may be more palatable to children with epilepsy and their caregivers. In this review, we present recent advances in minimally invasive techniques for the surgical treatment of epilepsy as well as intriguing possibilities for the future. We describe the indications for, benefits of, and limits to minimally-invasive techniques including Stereo-encephalography, laser interstitial thermal ablation, deep brain stimulation, focused ultrasound, stereo-encephalography-guided radiofrequency ablation, endoscopic disconnections, and responsive neurostimulation.
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Affiliation(s)
- Gina Guglielmi
- Graduate Medical Education, Neurological Surgery Residency, Carle BroMenn Medical Center, Normal IL; Section of Pediatric Neurology, Children's Hospital Colorado, Aurora CO; Department of Pediatrics, University of Colorado Anschutz School of Medicine, Aurora CO; Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora CO; Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora CO
| | - Krista L Eschbach
- Graduate Medical Education, Neurological Surgery Residency, Carle BroMenn Medical Center, Normal IL; Section of Pediatric Neurology, Children's Hospital Colorado, Aurora CO; Department of Pediatrics, University of Colorado Anschutz School of Medicine, Aurora CO; Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora CO; Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora CO
| | - Allyson L Alexander
- Graduate Medical Education, Neurological Surgery Residency, Carle BroMenn Medical Center, Normal IL; Section of Pediatric Neurology, Children's Hospital Colorado, Aurora CO; Department of Pediatrics, University of Colorado Anschutz School of Medicine, Aurora CO; Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora CO; Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora CO.
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15
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Factors Affecting Vagus Nerve Stimulation Outcomes in Epilepsy. Neurol Res Int 2021; 2021:9927311. [PMID: 34394987 PMCID: PMC8357517 DOI: 10.1155/2021/9927311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/06/2021] [Accepted: 07/30/2021] [Indexed: 11/18/2022] Open
Abstract
Epilepsy as a common neurological disease is mostly managed effectively with antiepileptic medications. One-third of patients do not respond to medical treatments requiring alternative therapies. Vagus nerve stimulation (VNS) has been used in the last decades for the treatment of medically resistant epilepsy. Despite the extensive use of VNS in these patients, factors associated with clinical outcomes of VNS remain to be elucidated. In this study, we evaluated factors affecting VNS outcomes in epileptic patients to have a better understanding of patients who are better candidates for VNS therapy. Several databases including PubMed, Scopus, and Google Scholar were searched through June 2020 for relevant articles. The following factors were assessed in this review: previous surgical history, age at implantation and gender, types of epilepsy, duration of epilepsy, age at epilepsy onset, frequency of attacks, antiepileptic drugs, VNS parameters, EEG findings, MRI findings, and biomarkers. Literature data show that nonresponder rates range between 25% and 65%. Given the complexity and diversity of factors associated with response to VNS, more clinical studies are needed to establish better paradigm for selection of patients for VNS therapy.
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16
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Al Omari AI, Nuseir A, Kanaan Y, Al-Ashqar R, Alzoubi F. The feasibility of vagal nerve stimulation revision surgery and surgical techniques: a retrospective review. Acta Otolaryngol 2021; 141:719-723. [PMID: 34003719 DOI: 10.1080/00016489.2021.1916588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND With the large number of VNS implants performed worldwide, the need for removal or replacement of the device in selected cases is emerging, this removal or replacement of VNS can be challenging. AIMS/OBJECTIVE To describe the feasibility and safety of revising vagal nerve stimulation surgery in terms of the indications, surgical techniques, and outcomes. MATERIALS AND METHODS A retrospective study, a series of eight cases with VNS implants that needed revision surgery have been reviewed, four devices were completely removed and four were only revised. The revision surgery was performed after a range of 7 months to 6 years, due to different reasons. Initial surgeries and revisions were performed at the otolaryngology department in a major tertiary center. CONCLUSIONS AND SIGNIFICANCE We concluded that the previously implanted vagal nerve stimulation electrodes can be completely removed without any significant sequelae on the nerve. It may also be re-implanted safely at the previously used segment of the vagus nerve with a similar outcome in seizure control as the initial implantation.
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Affiliation(s)
- Ahmad I. Al Omari
- Otolaryngology Department, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Amjad Nuseir
- Otolaryngology Department, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Yazan Kanaan
- Otolaryngology Department, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Ra’ed Al-Ashqar
- Otolaryngology Department, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Firas Alzoubi
- Otolaryngology Department, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
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17
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Shan W, Mao X, Wang X, Hogan RE, Wang Q. Potential surgical therapies for drug-resistant focal epilepsy. CNS Neurosci Ther 2021; 27:994-1011. [PMID: 34101365 PMCID: PMC8339538 DOI: 10.1111/cns.13690] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/07/2021] [Accepted: 05/18/2021] [Indexed: 12/19/2022] Open
Abstract
Drug-resistant focal epilepsy (DRFE), defined by failure of two antiepileptic drugs, affects 30% of epileptic patients. Epilepsy surgeries are alternative options for this population. Preoperative evaluation is critical to include potential candidates, and to choose the most appropriate procedure to maximize efficacy and simultaneously minimize side effects. Traditional procedures involve open skull surgeries and epileptic focus resection. Alternatively, neuromodulation surgeries use peripheral nerve or deep brain stimulation to reduce the activities of epileptogenic focus. With the advanced improvement of laser-induced thermal therapy (LITT) technique and its utilization in neurosurgery, magnetic resonance-guided LITT (MRgLITT) emerges as a minimal invasive approach for drug-resistant focal epilepsy. In the present review, we first introduce drug-resistant focal epilepsy and summarize the indications, pros and cons of traditional surgical procedures and neuromodulation procedures. And then, focusing on MRgLITT, we thoroughly discuss its history, its technical details, its safety issues, and current evidence on its clinical applications. A case report on MRgLITT is also included to illustrate the preoperational evaluation. We believe that MRgLITT is a promising approach in selected patients with drug-resistant focal epilepsy, although large prospective studies are required to evaluate its efficacy and side effects, as well as to implement a standardized protocol for its application.
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Affiliation(s)
- Wei Shan
- Department of NeurologyBeijing Tiantan HospitalCapital Medical UniversityBeijingChina
- National Center for Clinical Medicine of Neurological DiseasesBeijingChina
- Beijing Institute for Brain DisordersBeijingChina
- Beijing Key Laboratory of Neuro‐modulationBeijingChina
| | - Xuewei Mao
- Shandong Key Laboratory of Industrial Control TechnologySchool of AutomationQingdao UniversityQingdaoChina
| | - Xiu Wang
- National Center for Clinical Medicine of Neurological DiseasesBeijingChina
| | - Robert E. Hogan
- Departments of Neurology and NeurosurgerySchool of MedicineWashington University in St. LouisSt. LouisMOUSA
| | - Qun Wang
- Department of NeurologyBeijing Tiantan HospitalCapital Medical UniversityBeijingChina
- National Center for Clinical Medicine of Neurological DiseasesBeijingChina
- Beijing Institute for Brain DisordersBeijingChina
- Beijing Key Laboratory of Neuro‐modulationBeijingChina
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18
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Jain P, Arya R. Vagus Nerve Stimulation and Seizure Outcomes in Pediatric Refractory Epilepsy: Systematic Review and Meta-analysis. Neurology 2021; 96:1041-1051. [PMID: 33849993 DOI: 10.1212/wnl.0000000000012030] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 02/18/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We synthesized evidence for effectiveness of vagus nerve stimulation (VNS) as adjuvant therapy in pediatric drug-resistant epilepsy (DRE) by obtaining pooled estimates for seizure outcomes and analyzing their determinants. METHODS MEDLINE, EMBASE, and Cochrane databases were searched up to July 2019 for original research on VNS in pediatric (≤18 years of age) epilepsy. The primary outcome was 50% responder rate (50% RR), the proportion of patients with ≥50% seizure reduction, at the last reported follow-up. Other outcomes included a 50% RR and proportion of seizure-free patients at additional reported time points. A random-effects meta-analysis with restricted maximum likelihood estimation was performed to obtain pooled effect estimates. Meta-regression using multiple linear models was performed to obtain determinants of seizure outcomes and sources of heterogeneity. RESULTS A total of 101 studies were included. The pooled prevalence estimates for a 50% RR and seizure freedom at last follow-up (mean 2.54 years) were 56.4% (95% confidence intervals [CIs] 52.4, 60.4) and 11.6% (95% CI 9.6, 13.9), respectively. Fewer antiseizure medications (ASMs) tried before VNS and later age at onset of seizures were associated with better seizure outcomes following VNS implantation. An effect of sex distribution of studies on long-term outcomes and a potential publication bias for short-term outcomes were also observed. CONCLUSION Pooled evidence supports possible effectiveness of VNS in pediatric DRE, although complete seizure freedom is less common. Early referral (fewer trials of ASMs) may be a modifiable factor for desirable seizure outcomes with VNS from a clinical perspective.
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Affiliation(s)
- Puneet Jain
- From the Epilepsy Program (P.J.), Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Division of Pediatric Neurology (P.J.), Department of Pediatrics, Danat Al Emarat Hospital for Women and Children, Abu Dhabi, United Arab Emirates; Comprehensive Epilepsy Center (R.A.), Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; and Department of Pediatrics (R.A.), University of Cincinnati College of Medicine, Cincinnati, OH
| | - Ravindra Arya
- From the Epilepsy Program (P.J.), Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Division of Pediatric Neurology (P.J.), Department of Pediatrics, Danat Al Emarat Hospital for Women and Children, Abu Dhabi, United Arab Emirates; Comprehensive Epilepsy Center (R.A.), Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; and Department of Pediatrics (R.A.), University of Cincinnati College of Medicine, Cincinnati, OH.
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Imai J, Katagiri H. Regulation of systemic metabolism by the autonomic nervous system consisting of afferent and efferent innervation. Int Immunol 2021; 34:67-79. [PMID: 33982088 DOI: 10.1093/intimm/dxab023] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 05/10/2021] [Indexed: 12/18/2022] Open
Abstract
Autonomic nerves, sympathetic and parasympathetic, innervate organs and modulate their functions. It has become evident that afferent and efferent signals of the autonomic nervous system play important roles in regulating systemic metabolism, thereby maintaining homeostasis at the whole-body level. Vagal afferent nerves receive signals, such as nutrients and hormones, from the peripheral organs/tissues including the gastrointestinal tract and adipose tissue then transmit these signals to the hypothalamus, thereby regulating feeding behavior. In addition to roles in controlling appetite, areas in the hypothalamus serves as regulatory centers of both sympathetic and parasympathetic efferent fibers. These efferent innervations regulate the functions of peripheral organs/tissues, such as pancreatic islets, adipose tissues and the liver, which play roles in metabolic regulation. Furthermore, recent evidence has unraveled the metabolic regulatory systems governed by autonomic nerve circuits. In these systems, afferent nerves transmit metabolic information from peripheral organs to the central nervous system (CNS) and the CNS thereby regulates the organ functions through the efferent fibers of autonomic nerves. Thus, the autonomic nervous system regulates the homeostasis of systemic metabolism, and both afferent and efferent fibers play critical roles in its regulation. In addition, several lines of evidence demonstrate the roles of the autonomic nervous system in regulating and dysregulating the immune system. This review introduces variety of neuron-mediated inter-organ cross-talk systems and organizes the current knowledge of autonomic control/coordination of systemic metabolism, focusing especially on a liver-brain-pancreatic β-cell autonomic nerve circuit, as well as highlighting the potential importance of connections with the neuronal and immune systems.
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Affiliation(s)
- Junta Imai
- Department of Metabolism and Diabetes, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Hideki Katagiri
- Department of Metabolism and Diabetes, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
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20
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Collins L, Boddington L, Steffan PJ, McCormick D. Vagus nerve stimulation induces widespread cortical and behavioral activation. Curr Biol 2021; 31:2088-2098.e3. [DOI: 10.1016/j.cub.2021.02.049] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 02/01/2021] [Accepted: 02/17/2021] [Indexed: 01/02/2023]
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21
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Mercante B, Nuvoli S, Sotgiu MA, Manca A, Todesco S, Melis F, Spanu A, Deriu F. SPECT imaging of cerebral blood flow changes induced by acute trigeminal nerve stimulation in drug-resistant epilepsy. A pilot study. Clin Neurophysiol 2021; 132:1274-1282. [PMID: 33867259 DOI: 10.1016/j.clinph.2021.01.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 12/17/2020] [Accepted: 01/19/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To explore the cortical areas targeted by acute transcutaneous trigeminal nerve stimulation (TNS) in patients with drug-resistant epilepsy (DRE) using single photon emission computed tomography (SPECT). METHODS Ten patients with DRE underwent brain SPECT at baseline and immediately after a 20-minute TNS (0.25 ms; 120 Hz; 30 s ON and 30 s OFF) applied bilaterally to the infraorbital nerve. The French Color Standard International Scale was used for qualitative analyses and z-scores were used to calculate the Odds Ratio (OR). RESULTS At baseline global hypoperfusion (mainly in temporo-mesial, temporo-parietal and fronto-temporal and temporo-occipital areas) was detected in all patients. Following TNS, a global increase in cortical tracer uptake and a significant decrease in median hypoperfusion score were observed. A significant effect favoring a general TNS-induced increase in cortical perfusion (OR = 4.96; p = 0.0005) was detected in 70% of cases, with significant effects in the limbic (p = 0.003) and temporal (p = 0.003) lobes. Quantitative analyses of z-scores confirmed significant TNS-induced increases in perfusion in the temporal (+0.59 SDs; p = 0.001), and limbic (+0.43 SDs; p = 0.03) lobes. CONCLUSION Short-term TNS is followed a global increase in cortical perfusion, namely in the temporal and limbic lobes. SIGNIFICANCE The TNS-induced perfusion increase may reflect neurons' activity changes in cortical areas implicated in the epilepsy network.
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Affiliation(s)
- Beniamina Mercante
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Susanna Nuvoli
- Unit of Nuclear Medicine, Department of Medical, Surgical and Experimental Science, University of Sassari, Sassari, Italy
| | - Maria A Sotgiu
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Andrea Manca
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Sara Todesco
- Neurology Unit, «A. Segni» Hospital, ASL n. 1, Sassari, Italy
| | - Francesco Melis
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Angela Spanu
- Unit of Nuclear Medicine, Department of Medical, Surgical and Experimental Science, University of Sassari, Sassari, Italy
| | - Franca Deriu
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy.
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22
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Lo WB, Chevill B, Philip S, Agrawal S, Walsh AR. Seizure improvement following vagus nerve stimulator (VNS) battery change with cardiac-based seizure detection automatic stimulation (AutoStim): early experience in a regional paediatric unit. Childs Nerv Syst 2021; 37:1237-1241. [PMID: 33174154 DOI: 10.1007/s00381-020-04962-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 11/03/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE The recent VNS models (AspireSR® Model 106, SenTiva™ Model 1000 (VNS Therapy®, LivaNova)) include a new function of cardiac-based seizure detection (CBSD) automatic stimulation, known as 'AutoStim'. This algorithm uses tachycardia as a proxy to a seizure, and the battery delivers a closed-loop electrical current in addition to its programmed stimulation. This function leads to further seizure reduction in adults, but this advantage has not been reported in the paediatric population. This study aims to investigate whether battery change with AutoStim leads to further seizure reduction in children. METHODS This observational study included the first 10 cases of VNS battery change from non-AutoStim to AutoStim function. During the battery change operation, the new VNS was switched on, with the same normal and magnet mode settings as the previous VNS. The AutoStim mode was activated at the same time. Data on seizure burden were collected at 3 time points: (1) before the first VNS insertion, (2) before battery replacement (post-1st VNS) and (3) 12 months post-battery change (post-AutoStim). The net effect of AutoStim, the only changed parameter, was evaluated by comparing the seizure burden prior to and 12 months following battery change in each child. RESULTS The seizure reduction improved significantly from 60 to 83% following battery change with AutoStim. Categorising the outcome according the McHugh classification, children achieving class I and II outcome (≥ 50% seizure reduction) improved from 70 to 90%. CONCLUSION This is the first study to demonstrate the additional efficacy of AutoStim in children treated with VNS.
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Affiliation(s)
- William B Lo
- Department of Neurosurgery, Birmingham Children's Hospital, Birmingham, B4 6NH, UK.
| | - Bethany Chevill
- Department of Neurology, Birmingham Children's Hospital, Birmingham, B4 6NH, UK
| | - Sunny Philip
- Department of Neurology, Birmingham Children's Hospital, Birmingham, B4 6NH, UK
| | - Shakti Agrawal
- Department of Neurology, Birmingham Children's Hospital, Birmingham, B4 6NH, UK
| | - A Richard Walsh
- Department of Neurosurgery, Birmingham Children's Hospital, Birmingham, B4 6NH, UK
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Direct measurement of vagal tone in rats does not show correlation to HRV. Sci Rep 2021; 11:1210. [PMID: 33441733 PMCID: PMC7807082 DOI: 10.1038/s41598-020-79808-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/07/2020] [Indexed: 02/07/2023] Open
Abstract
The vagus nerve is the largest autonomic nerve, innervating nearly every organ in the body. “Vagal tone” is a clinical measure believed to indicate overall levels of vagal activity, but is measured indirectly through the heart rate variability (HRV). Abnormal HRV has been associated with many severe conditions such as diabetes, heart failure, and hypertension. However, vagal tone has never been directly measured, leading to disagreements in its interpretation and influencing the effectiveness of vagal therapies. Using custom carbon nanotube yarn electrodes, we were able to chronically record neural activity from the left cervical vagus in both anesthetized and non-anesthetized rats. Here we show that tonic vagal activity does not correlate with common HRV metrics with or without anesthesia. Although we found that average vagal activity is increased during inspiration compared to expiration, this respiratory-linked signal was not correlated with HRV either. These results represent a clear advance in neural recording technology but also point to the need for a re-interpretation of the link between HRV and “vagal tone”.
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Zhu J, Xu C, Zhang X, Qiao L, Wang X, Zhang X, Yan X, Ni D, Yu T, Zhang G, Li Y. Epilepsy duration as an independent predictor of response to vagus nerve stimulation. Epilepsy Res 2020; 167:106432. [DOI: 10.1016/j.eplepsyres.2020.106432] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/19/2020] [Accepted: 07/17/2020] [Indexed: 12/16/2022]
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Marras CE, Colicchio G, De Palma L, De Benedictis A, Di Gennaro G, Cavaliere M, Cesaroni E, Consales A, Asioli S, Caulo M, Villani F, Zamponi N. Health Technology Assessment Report on Vagus Nerve Stimulation in Drug-Resistant Epilepsy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E6150. [PMID: 32847092 PMCID: PMC7504285 DOI: 10.3390/ijerph17176150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 07/31/2020] [Accepted: 08/13/2020] [Indexed: 01/12/2023]
Abstract
Background: Vagus nerve stimulation (VNS) is a palliative treatment for medical intractable epileptic syndromes not eligible for resective surgery. Health technology assessment (HTA) represents a modern approach to the analysis of technologies used for healthcare. The purpose of this study is to assess the clinical, organizational, financial, and economic impact of VNS therapy in drug-resistant epilepsies and to establish the congruity between costs incurred and health service reimbursement. Methods: The present study used an HTA approach. It is based on an extensive detailed bibliographic search on databases (Medline, Pubmed, Embase and Cochrane, sites of scientific societies and institutional sites). The HTA study includes the following issues: (a) social impact and costs of the disease; (b) VNS eligibility and clinical results; (c) quality of life (QoL) after VNS therapy; (d) economic impact and productivity regained after VNS; and (e) costs of VNS. Results: Literature data indicate VNS as an effective treatment with a potential positive impact on social aspects and on quality of life. The diagnosis-related group (DRG) financing, both on national and regional levels, does not cover the cost of the medical device. There was an evident insufficient coverage of the DRG compared to the full cost of implanting the device. Conclusions: VNS is a palliative treatment for reducing seizure frequency and intensity. Despite its economic cost, VNS should improve patients' quality of life and reduce care needs.
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Affiliation(s)
- Carlo Efisio Marras
- Neurosurgery Unit, Department of Neuroscience, IRCCS Bambino Gesù Children Hospital, 00165 Rome, Italy; (A.D.B.); (M.C.)
| | - Gabriella Colicchio
- Department of Neurosurgery, UCSC Gemelli University Hospital, 00167 Rome, Italy;
| | - Luca De Palma
- Pediatric Neurology Unit, Department of Neuroscience, IRCCS Bambino Gesù Children Hospital, 00165 Rome, Italy;
| | - Alessandro De Benedictis
- Neurosurgery Unit, Department of Neuroscience, IRCCS Bambino Gesù Children Hospital, 00165 Rome, Italy; (A.D.B.); (M.C.)
| | | | - Marilou Cavaliere
- Neurosurgery Unit, Department of Neuroscience, IRCCS Bambino Gesù Children Hospital, 00165 Rome, Italy; (A.D.B.); (M.C.)
- Institute of Neurosurgery, University of Milan Bicocca, 20900 Milan, Italy
| | - Elisabetta Cesaroni
- Pediatric Neurology Unit, Salesi Children Hospital, 60123 Ancona, Italy; (E.C.); (N.Z.)
| | | | - Sofia Asioli
- Department of Biomedical and Neuromotor Sciences, Section of Anatomic Pathology, Bellaria Hospital, University of Bologna, 40139 Bologna, Italy;
| | - Massimo Caulo
- Department of Neuroscience, Imaging and Clinical Sciences, University of Chieti, 66100 Chieti, Italy;
| | - Flavio Villani
- Division of Clinical Neurophysiology and Epilepsy Center, IRCCS, San Martino Hospital, 16132 Genoa, Italy;
| | - Nelia Zamponi
- Pediatric Neurology Unit, Salesi Children Hospital, 60123 Ancona, Italy; (E.C.); (N.Z.)
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Wang AJ, Bick SK, Williams ZM. Vagus Nerve Stimulation versus Responsive Neurostimulator System in Patients with Temporal Lobe Epilepsy. Stereotact Funct Neurosurg 2020; 98:21-29. [PMID: 32074618 DOI: 10.1159/000504859] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 11/18/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Patients with medically refractory temporal lobe epilepsy (TLE) are candidates for neuromodulation procedures. While vagus nerve stimulation (VNS) was historically the procedure of choice for this condition, the responsive neurostimulation system (RNS) has come into favor for its more targeted approach. While both VNS and RNS have been reported as efficacious treatments for TLE, the outcomes of these 2 procedures have not been directly compared. This study aims to compare outcomes following VNS versus RNS for TLE. METHODS We retrospectively reviewed the records of all patients with TLE who underwent VNS or RNS placement at our institution from 2003 to 2018. The primary outcome was change in seizure frequency. Other outcomes included Engel score, change in anti-epileptic medications, and complications. RESULTS Twenty-three patients met inclusion criteria; 11 underwent VNS and 12 underwent RNS. At baseline, the 2 groups were statistically similar regarding age at surgery, epilepsy duration, and preoperative seizure frequency. At last follow-up, both groups displayed reduced seizure frequency (mean reduction of 46.3% for the VNS group and 58.1% for the RNS group, p = 0.49). Responder rate, Engel score, and change in medications were statistically similar between groups. Compared to 0.0% of the VNS group, 13.3% of the RNS group experienced infection requiring re-operation. CONCLUSION Despite their different mechanisms, VNS and RNS resulted in similar response rates for patients with TLE. We suggest that VNS should not be excluded as a treatment for patients with medically refractory TLE who are not candidates for resective or ablative procedures.
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Affiliation(s)
- Amy J Wang
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah K Bick
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ziv M Williams
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA,
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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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29
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Epilepsy: Neuromodulation. Stereotact Funct Neurosurg 2020. [DOI: 10.1007/978-3-030-34906-6_27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Fan J, Shan W, Wu J, Wang Q. Research progress of vagus nerve stimulation in the treatment of epilepsy. CNS Neurosci Ther 2019; 25:1222-1228. [PMID: 31429206 PMCID: PMC6834923 DOI: 10.1111/cns.13209] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 07/28/2019] [Accepted: 07/30/2019] [Indexed: 12/18/2022] Open
Abstract
The International League Against Epilepsy (ILAE) defined drug-resistant epilepsy (DRE) that epilepsy seizure symptoms cannot be controlled with two well-tolerated and appropriately chosen antiepileptic drugs, whether they are given as monotherapy or in combination. According to the WHO reports, there is about 30%-40% of epilepsy patients belong to DRE. These patients need some treatments other than drugs, such as epilepsy surgery, and neuromodulation treatment. Traditional surgical approaches may be limited by the patient's clinical status, pathological tissue location, or overall prognosis. Thus, neuromodulation is an alternative choice to control their symptoms. Vagus nerve stimulation (VNS) is one of the neuromodulation methods clinically, which have been approved by the Food and Drug Administration (FDA). In this review, we systematically describe the clinical application, clinical effects, possible antiepileptic mechanisms, and future research directions of VNS for epilepsy.
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Affiliation(s)
- Jing‐Jing Fan
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- National Clinical Research Center for Medicine of Neurological DiseasesBeijingChina
- Beijing Institute for Brain DisordersBeijingChina
- Advanced Innovation Center for Human Brain ProtectionCapital Medical UniversityBeijingChina
| | - Wei Shan
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- National Clinical Research Center for Medicine of Neurological DiseasesBeijingChina
- Beijing Institute for Brain DisordersBeijingChina
- Advanced Innovation Center for Human Brain ProtectionCapital Medical UniversityBeijingChina
| | - Jian‐Ping Wu
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- National Clinical Research Center for Medicine of Neurological DiseasesBeijingChina
- Advanced Innovation Center for Human Brain ProtectionCapital Medical UniversityBeijingChina
| | - Qun Wang
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- National Clinical Research Center for Medicine of Neurological DiseasesBeijingChina
- Beijing Institute for Brain DisordersBeijingChina
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31
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Kavčič A, Kajdič N, Rener-Primec Z, Krajnc N, Žgur T. Efficacy and tolerability of vagus nerve stimulation therapy (VNS) in Slovenian epilepsy patients: younger age and shorter duration of epilepsy might result in better outcome. Acta Clin Croat 2019; 58:255-264. [PMID: 31819321 PMCID: PMC6884381 DOI: 10.20471/acc.2019.58.02.08] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
To review the outcome of vagus nerve stimulation (VNS) therapy in all implanted Slovenian patients with drug-resistant epilepsy, data on 48 patients implanted between 2001 and 2015 were obtained retrospectively from medical records. The outcome was assessed in 2016. Out of 48 patients, 39 responded at follow up. The seizure frequency was reduced in 18 (46.2%) patients; 13 (33.3%) of them reported ≥50% reduction after 12 months of therapy. The responder rate was higher among patients implanted before the age of six years. Ictal severity decreased in 22 (56.4%), seizure duration in 19 (48.7%) and post-ictal recovery time in 22 (56.4%) patients. Favorable effects on the quality of life (QOL) were improved alertness in 33.3%, concentration in 41.0%, energy and mood in 38.5%, and memory in 17.9% of patients. Reduced seizure burden and improved QOL were more often observed in patients implanted at a younger age. Shorter duration of epilepsy was significantly associated with QOL improvement. Adverse effects were transient. Overall positive effects showed VNS to be a safe, well-tolerated and effective adjunctive treatment in most severe drug-resistant epilepsy patients. Implantation at a younger age and shorter duration of epilepsy before implantation could be important predictors of better outcome.
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Affiliation(s)
| | - Nina Kajdič
- 1Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; 2Department of Child, Adolescent and Developmental Neurology, Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia; 3Department of Pediatrics, Slovenj Gradec General Hospital, Slovenj Gradec, Slovenia; 4Department of Clinical Neurophysiology, Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Zvonka Rener-Primec
- 1Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; 2Department of Child, Adolescent and Developmental Neurology, Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia; 3Department of Pediatrics, Slovenj Gradec General Hospital, Slovenj Gradec, Slovenia; 4Department of Clinical Neurophysiology, Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Natalija Krajnc
- 1Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; 2Department of Child, Adolescent and Developmental Neurology, Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia; 3Department of Pediatrics, Slovenj Gradec General Hospital, Slovenj Gradec, Slovenia; 4Department of Clinical Neurophysiology, Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Tomaž Žgur
- 1Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; 2Department of Child, Adolescent and Developmental Neurology, Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia; 3Department of Pediatrics, Slovenj Gradec General Hospital, Slovenj Gradec, Slovenia; 4Department of Clinical Neurophysiology, Medical Centre Ljubljana, Ljubljana, Slovenia
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González HFJ, Yengo-Kahn A, Englot DJ. Vagus Nerve Stimulation for the Treatment of Epilepsy. Neurosurg Clin N Am 2019; 30:219-230. [PMID: 30898273 DOI: 10.1016/j.nec.2018.12.005] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Vagus nerve stimulation (VNS) was the first neuromodulation device approved for treatment of epilepsy. In more than 20 years of study, VNS has consistently demonstrated efficacy in treating epilepsy. After 2 years, approximately 50% of patients experience at least 50% reduced seizure frequency. Adverse events with VNS treatment are rare and include surgical adverse events (including infection, vocal cord paresis, and so forth) and stimulation side effects (hoarseness, voice change, and cough). Future developments in VNS, including closed-loop and noninvasive stimulation, may reduce side effects or increase efficacy of VNS.
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Affiliation(s)
- Hernán F J González
- Department of Biomedical Engineering, Vanderbilt University Medical Center, 1500 21st Avenue South, 4340 Village at Vanderbilt, Nashville, TN 37232-8618, USA; Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, 1500 21st Avenue South, 4340 Village at Vanderbilt, Nashville, TN 37232-8618, USA.
| | - Aaron Yengo-Kahn
- Department of Neurological Surgery, Vanderbilt University Medical Center, 1121 21st Avenue South, Medical Center North, T4224, Nashville, TN 37232, USA
| | - Dario J Englot
- Department of Biomedical Engineering, Vanderbilt University Medical Center, 1500 21st Avenue South, 4340 Village at Vanderbilt, Nashville, TN 37232-8618, USA; Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, 1500 21st Avenue South, 4340 Village at Vanderbilt, Nashville, TN 37232-8618, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, 1500 21st Avenue South, 4340 Village at Vanderbilt, Nashville, TN 37232-8618, USA; Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, 1500 21st Avenue South, 4340 Village at Vanderbilt, Nashville, TN 37232-8618, USA
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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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Markert MS, Fisher RS. Neuromodulation - Science and Practice in Epilepsy: Vagus Nerve Stimulation, Thalamic Deep Brain Stimulation, and Responsive NeuroStimulation. Expert Rev Neurother 2018; 19:17-29. [DOI: 10.1080/14737175.2019.1554433] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Matthew S. Markert
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Robert S. Fisher
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
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35
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Bautista RED, Persaud AS. Epilepsy wellness: The standard of care for the 21st century. Epilepsy Behav 2018; 87:241-242. [PMID: 30170896 DOI: 10.1016/j.yebeh.2018.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 07/30/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Ramon Edmundo D Bautista
- Comprehensive Epilepsy Program, Department of Neurology, University of Florida Health Sciences Center/Jacksonville, United States of America.
| | - Amanda S Persaud
- Comprehensive Epilepsy Program, Department of Neurology, University of Florida Health Sciences Center/Jacksonville, United States of America
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36
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Hartshorn A, Jobst B. Responsive brain stimulation in epilepsy. Ther Adv Chronic Dis 2018; 9:135-142. [PMID: 29963302 PMCID: PMC6009082 DOI: 10.1177/2040622318774173] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 04/10/2018] [Indexed: 12/29/2022] Open
Abstract
Stimulation devices are considered in patients with drug-resistant epilepsy and who are not surgical candidates. Responsive neurostimulation (RNS) is a cortically based stimulator activated by electrocorticography (ECoG) patterns. Stimulation is applied directly to the seizure focus. The vagal nerve stimulator AspireSR 106 is also a responsive device which, in addition to basal stimulation, is activated by tachycardia. Deep brain stimulation of the anterior nucleus of the thalamus is used in Europe for intractable epilepsy and yields similar response rates to RNS using duty cycle stimulation. Chronic subthreshold cortical stimulation is an experimental form of constant, low-level stimulation applied to a seizure focus. These modalities are discussed and compared in this review.
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Affiliation(s)
- Alendia Hartshorn
- Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756-1000, USA
| | - Barbara Jobst
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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Neurostimulation for drug-resistant epilepsy: a systematic review of clinical evidence for efficacy, safety, contraindications and predictors for response. Curr Opin Neurol 2018; 31:198-210. [DOI: 10.1097/wco.0000000000000534] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Preoperative Heart Rate Variability as Predictors of Vagus Nerve Stimulation Outcome in Patients with Drug-resistant Epilepsy. Sci Rep 2018; 8:3856. [PMID: 29497072 PMCID: PMC5832772 DOI: 10.1038/s41598-018-21669-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 02/08/2018] [Indexed: 12/14/2022] Open
Abstract
Vagus nerve stimulation (VNS) is an adjunctive treatment for drug-resistant epilepsy (DRE). However, it is still difficult to predict which patients will respond to VNS treatment and to what extent. We aim to explore the relationship between preoperative heart rate variability (HRV) and VNS outcome. 50 healthy control subjects and 63 DRE patients who had received VNS implants and had at least one year of follow up were included. The preoperative HRV were analyzed by traditional linear methods and heart rhythm complexity analyses with multiscale entropy (MSE). DRE patients had significantly lower complexity indices (CI) as well as traditional linear HRV measurements than healthy controls. We also found that non-responders0 had significantly lower preoperative CI including Area 1-5, Area 6-15 and Area 6-20 than those in the responders0 while those of the non-responders50 had significantly lower RMSSD, pNN50, VLF, LF, HF, TP and LF/HF than the responders50. In receiver operating characteristic (ROC) curve analysis, Area 6-20 and RMSSD had the greatest discriminatory power for the responders0 and non-responders0, responders50 and non-responders50, respectively. Our results suggest that preoperative assessment of HRV by linear and MSE analysis can help in predicting VNS outcomes in patients with DRE.
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A modern epilepsy surgery treatment algorithm: Incorporating traditional and emerging technologies. Epilepsy Behav 2018; 80:68-74. [PMID: 29414561 PMCID: PMC5845806 DOI: 10.1016/j.yebeh.2017.12.041] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 12/30/2017] [Accepted: 12/31/2017] [Indexed: 12/13/2022]
Abstract
Epilepsy surgery has seen numerous technological advances in both diagnostic and therapeutic procedures in recent years. This has increased the number of patients who may be candidates for intervention and potential improvement in quality of life. However, the expansion of the field also necessitates a broader understanding of how to incorporate both traditional and emerging technologies into the care provided at comprehensive epilepsy centers. This review summarizes both old and new surgical procedures in epilepsy using an example algorithm. While treatment algorithms are inherently oversimplified, incomplete, and reflect personal bias, they provide a general framework that can be customized to each center and each patient, incorporating differences in provider opinion, patient preference, and the institutional availability of technologies. For instance, the use of minimally invasive stereotactic electroencephalography (SEEG) has increased dramatically over the past decade, but many cases still benefit from invasive recordings using subdural grids. Furthermore, although surgical resection remains the gold-standard treatment for focal mesial temporal or neocortical epilepsy, ablative procedures such as laser interstitial thermal therapy (LITT) or stereotactic radiosurgery (SRS) may be appropriate and avoid craniotomy in many cases. Furthermore, while palliative surgical procedures were once limited to disconnection surgeries, several neurostimulation treatments are now available to treat eloquent cortical, bitemporal, and even multifocal or generalized epilepsy syndromes. An updated perspective in epilepsy surgery will help guide surgical decision making and lay the groundwork for data collection needed in future studies and trials.
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Oliveira TVHFD, Francisco AN, Demartini Junior Z, Stebel SL. The role of vagus nerve stimulation in refractory epilepsy. ARQUIVOS DE NEURO-PSIQUIATRIA 2017; 75:657-666. [DOI: 10.1590/0004-282x20170113] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 06/07/2017] [Indexed: 11/22/2022]
Abstract
ABSTRACT Vagus nerve stimulation is an adjunctive therapy used to treat patients with refractory epilepsy who are not candidates for resective surgery or had poor results after surgical procedures. Its mechanism of action is not yet fully comprehended but it possibly involves modulation of the locus coeruleus, thalamus and limbic circuit through noradrenergic and serotonergic projections. There is sufficient evidence to support its use in patients with focal epilepsy and other seizure types. However, it should be recognized that improvement is not immediate and increases over time. The majority of adverse events is stimulation-related, temporary and decreases after adjustment of settings. Future perspectives to improve efficacy and reduce side effects, such as different approaches to increase battery life, transcutaneous stimulation and identification of prognostic factors, should be further investigated.
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Al Omari AI, Alzoubi FQ, Alsalem MM, Aburahma SK, Mardini DT, Castellanos PF. The vagal nerve stimulation outcome, and laryngeal effect: Otolaryngologists roles and perspective. Am J Otolaryngol 2017; 38:408-413. [PMID: 28390806 DOI: 10.1016/j.amjoto.2017.03.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 03/05/2017] [Accepted: 03/31/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Epilepsy is one of the most common neurologic disorders. Vagus nerve stimulation (VNS), first investigated in 1938 and subsequently studied as a potential therapy for epilepsy. The FDA approved the use of VNS in 1997 as an adjunctive non-pharmacologic symptomatic treatment option for refractory epilepsy for adults and adolescents over 12years. VNS can cause laryngeal and voice side effects that can be managed by otolaryngologists safely and effectively. OBJECTIVES This study is to review the outcomes of vagal nerve stimulator (VNS) implantation in terms of the surgical procedures, complications, seizure frequency, and the clinical effect on larynx and vocal folds motion. METHODS Series of thirty consecutive patients who had VNS implantation between 2007 and 2014 were recruited. Seizure-frequency outcome, surgical complications and device adverse effects of VNS were retrospectively reviewed. Additional evaluation included use of the Voice Handicap Index and Maximum Phonation Time (MPT) were conducted before and after the implantation. Videolaryngoscopy was used to evaluate the vocal fold mobility before and after the VNS implantation. RESULTS Seizure frequency reduction over a minimum of 2years of follow up demonstrated: 100% in seizure frequency reduction in 1 patient, drastic reduction in seizure frequency (70-90%) in 9 patients, a good reduction in terms of seizure frequency (50%) in 8 patients, a 30% reduction in 5 patients, no response in 6 patients, and 1 patient had increased frequency. The most commonly reported adverse effects after VNS activation were coughing and voice changes with pitch breaks, as well as mild intermittent shortness of breath in 33% of patients. For those patients secondary supraglottic muscle tension and hyper function with reduced left vocal fold mobility were noticed on videolaryngoscopy, though none had aspiration problems. Surgical complications included a wound dehiscence in one patient (3%) which was surgically managed, minor intra-operative bleeding 3%; a superficial wound infection in one patient (3%) which was treated conservatively, none of the complications necessitated VNS removal. CONCLUSIONS VNS appears to be an effective non-pharmacologic adjuvant therapy in patients with medically refractory seizures. With the favorable adverse-effect profile previously described, VNS is generally well tolerated and of a great benefit to such patients. Laryngeal side effects, of which hoarseness being of the greatest repetition, are the most common after the VNS implantation. VNS can affect the voice and reduced vocal cord motion on the implantation side with secondary supraglottic muscle tension. Otolaryngologists are not only capable of performing VNS implantation, but can also manage surgical complications, assess laryngeal side effects and treat them as needed.
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Liu H, Yang Z, Huang L, Qu W, Hao H, Li L. Heart-rate variability indices as predictors of the response to vagus nerve stimulation in patients with drug-resistant epilepsy. Epilepsia 2017; 58:1015-1022. [PMID: 28440954 DOI: 10.1111/epi.13738] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess heart-rate variability (HRV) measures of interictal electrocardiography (ECG) for drug-resistant epilepsy and to relate the findings to the outcome of vagus nerve stimulation (VNS) treatment. METHODS Time-domain, frequency-domain, and nonlinear analyses were used to analyze preoperative HRV measures in 32 patients with drug-resistant epilepsy who had received VNS implants at the same hospital and 32 healthy age- and sex-matched control subjects. HRV measurements based on ambulatory 24 h ECG recordings were analyzed to identify seizure reduction 1 year after VNS treatment. Responders were defined as having at least 50% seizure reduction 1 year after treatment. RESULTS Patients with drug-resistant epilepsy had significantly lower time domain (SDNN, RMSSD, pNN50), frequency domain (VLF, LF, HF, TP), and nonlinear (SD1, SD2) HRV measurements than matched healthy controls. None of the analyzed HRV measures of the responders differed significantly from their controls, whereas those of the nonresponders had significantly lower RMSSD, pNN50, HF, and SD1 than the responders. SIGNIFICANCE The preoperative HRV indices demonstrate that nonresponders have more pronounced impairment of their cardiac autonomic function than the responders. Presurgical HRV measurements representing parasympathetic cardiac control or vagal tone were significantly associated with the responsiveness to VNS. Thus the measurements show promise for predicting the reduction of seizure frequency after VNS treatment.
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Affiliation(s)
- Hongyun Liu
- National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China.,Department of Biomedical Engineering, Chinese PLA General Hospital, Beijing, China
| | - Zhao Yang
- National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China
| | - Lei Huang
- National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China
| | - Wei Qu
- National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China
| | - Hongwei Hao
- National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China
| | - Luming Li
- National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China.,Man-Machine-Environment Engineering Institute, School of Aerospace Engineering, Tsinghua University, Beijing, China.,Precision Medicine & Healthcare Research Center, Tsinghua-Berkeley Shenzhen Institute, Shenzhen, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
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Ali R, Elsayed M, Kaur M, Air E, Mahmood N, Constantinou J, Schwalb J. Use of social media to assess the effectiveness of vagal nerve stimulation in Dravet syndrome: A caregiver's perspective. J Neurol Sci 2017; 375:146-149. [DOI: 10.1016/j.jns.2017.01.057] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 01/13/2017] [Accepted: 01/19/2017] [Indexed: 10/20/2022]
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Schulze-Bonhage A. Brain stimulation as a neuromodulatory epilepsy therapy. Seizure 2017; 44:169-175. [DOI: 10.1016/j.seizure.2016.10.026] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/27/2016] [Accepted: 10/27/2016] [Indexed: 12/27/2022] Open
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Englot DJ, Hassnain KH, Rolston JD, Harward SC, Sinha SR, Haglund MM. Quality-of-life metrics with vagus nerve stimulation for epilepsy from provider survey data. Epilepsy Behav 2017; 66:4-9. [PMID: 27974275 PMCID: PMC5258831 DOI: 10.1016/j.yebeh.2016.10.005] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 10/06/2016] [Accepted: 10/08/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Drug-resistant epilepsy is a devastating disorder associated with diminished quality of life (QOL). Surgical resection leads to seizure freedom and improved QOL in many epilepsy patients, but not all individuals are candidates for resection. In these cases, neuromodulation-based therapies such as vagus nerve stimulation (VNS) are often used, but most VNS studies focus exclusively on reduction of seizure frequency. QOL changes and predictors with VNS remain poorly understood. METHOD Using the VNS Therapy Patient Outcome Registry, we examined 7 metrics related to QOL after VNS for epilepsy in over 5000 patients (including over 3000 with ≥12months follow-up), as subjectively assessed by treating physicians. Trends and predictors of QOL changes were examined and related to post-operative seizure outcome and likelihood of VNS generator replacement. RESULTS After VNS therapy, physicians reported patient improvement in alertness (58-63%, range over follow-up period), post-ictal state (55-62%), cluster seizures (48-56%), mood change (43-49%), verbal communication (38-45%), school/professional achievements (29-39%), and memory (29-38%). Predictors of net QOL improvement included shorter time to implant (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.1-1.6), generalized seizure type (OR, 1.2; 95% CI, 1.0-1.4), female gender (OR, 1.2; 95% CI, 1.0-1.4), and Caucasian ethnicity (OR, 1.3; 95% CI, 1.0-1.5). No significant trends were observed over time. Patients with net QOL improvement were more likely to have favorable seizure outcomes (chi square [χ2]=148.1, p<0.001) and more likely to undergo VNS generator replacement (χ2=68.9, p<0.001) than those with worsened/unchanged QOL. SIGNIFICANCE VNS for drug-resistant epilepsy is associated with improvement on various QOL metrics subjectively rated by physicians. QOL improvement is associated with favorable seizure outcome and a higher likelihood of generator replacement, suggesting satisfaction with therapy. It is important to consider QOL metrics in neuromodulation for epilepsy, given the deleterious effects of seizures on patient QOL.
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Affiliation(s)
- Dario J. Englot
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - John D. Rolston
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Stephen C. Harward
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Saurabh R. Sinha
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michael M. Haglund
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
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Seizure outcomes in nonresective epilepsy surgery: an update. Neurosurg Rev 2016; 40:181-194. [PMID: 27206422 DOI: 10.1007/s10143-016-0725-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 01/31/2016] [Accepted: 03/06/2016] [Indexed: 12/18/2022]
Abstract
In approximately 30 % of patients with epilepsy, seizures are refractory to medical therapy, leading to significant morbidity and increased mortality. Substantial evidence has demonstrated the benefit of surgical resection in patients with drug-resistant focal epilepsy, and in the present journal, we recently reviewed seizure outcomes in resective epilepsy surgery. However, not all patients are candidates for or amenable to open surgical resection for epilepsy. Fortunately, several nonresective surgical options are now available at various epilepsy centers, including novel therapies which have been pioneered in recent years. Ablative procedures such as stereotactic laser ablation and stereotactic radiosurgery offer minimally invasive alternatives to open surgery with relatively favorable seizure outcomes, particularly in patients with mesial temporal lobe epilepsy. For certain individuals who are not candidates for ablation or resection, palliative neuromodulation procedures such as vagus nerve stimulation, deep brain stimulation, or responsive neurostimulation may result in a significant decrease in seizure frequency and improved quality of life. Finally, disconnection procedures such as multiple subpial transections and corpus callosotomy continue to play a role in select patients with an eloquent epileptogenic zone or intractable atonic seizures, respectively. Overall, open surgical resection remains the gold standard treatment for drug-resistant epilepsy, although it is significantly underutilized. While nonresective epilepsy procedures have not replaced the need for resection, there is hope that these additional surgical options will increase the number of patients who receive treatment for this devastating disorder-particularly individuals who are not candidates for or who have failed resection.
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Bonaz B, Sinniger V, Pellissier S. Anti-inflammatory properties of the vagus nerve: potential therapeutic implications of vagus nerve stimulation. J Physiol 2016; 594:5781-5790. [PMID: 27059884 DOI: 10.1113/jp271539] [Citation(s) in RCA: 324] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 03/24/2016] [Indexed: 12/30/2022] Open
Abstract
Brain and viscera interplay within the autonomic nervous system where the vagus nerve (VN), containing approximately 80% afferent and 20% efferent fibres, plays multiple key roles in the homeostatic regulations of visceral functions. Recent data have suggested the anti-inflammatory role of the VN. This vagal function is mediated through several pathways, some of them still debated. The first one is the anti-inflammatory hypothalamic-pituitary-adrenal axis which is stimulated by vagal afferent fibres and leads to the release of cortisol by the adrenal glands. The second one, called the cholinergic anti-inflammatory pathway, is mediated through vagal efferent fibres that synapse onto enteric neurons which release acetylcholine (ACh) at the synaptic junction with macrophages. ACh binds to α-7-nicotinic ACh receptors of those macrophages to inhibit the release of tumour necrosis (TNF)α, a pro-inflammatory cytokine. The last pathway is the splenic sympathetic anti-inflammatory pathway, where the VN stimulates the splenic sympathetic nerve. Norepinephrine (noradrenaline) released at the distal end of the splenic nerve links to the β2 adrenergic receptor of splenic lymphocytes that release ACh. Finally, ACh inhibits the release of TNFα by spleen macrophages through α-7-nicotinic ACh receptors. Understanding of these pathways is interesting from a therapeutic point of view, since they could be targeted in various ways to stimulate anti-inflammatory regulation in TNFα-related diseases such as inflammatory bowel disease and rheumatoid arthritis. Among others, VN stimulation, either as an invasive or non-invasive procedure, is becoming increasingly frequent and several clinical trials are ongoing to evaluate the potential effectiveness of this therapy to alleviate chronic inflammation.
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Affiliation(s)
- Bruno Bonaz
- University Clinic of Hepato-Gastroenterology, University Hospital, F-38000, Grenoble, France. .,Université Grenoble Alpes, Grenoble Institut des Neurosciences, GIN, Inserm, U1216, F-38000, Grenoble, France.
| | - Valérie Sinniger
- University Clinic of Hepato-Gastroenterology, University Hospital, F-38000, Grenoble, France.,Université Grenoble Alpes, Grenoble Institut des Neurosciences, GIN, Inserm, U1216, F-38000, Grenoble, France
| | - Sonia Pellissier
- University Clinic of Hepato-Gastroenterology, University Hospital, F-38000, Grenoble, France.,Department of Psychology, Université Savoie Mont-Blanc, F-73011, Chambéry, France
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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: 16] [Impact Index Per Article: 2.0] [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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Wasade VS, Schultz L, Mohanarangan K, Gaddam A, Schwalb JM, Spanaki-Varelas M. Long-term seizure and psychosocial outcomes of vagus nerve stimulation for intractable epilepsy. Epilepsy Behav 2015; 53:31-6. [PMID: 26515157 DOI: 10.1016/j.yebeh.2015.09.031] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 09/19/2015] [Accepted: 09/21/2015] [Indexed: 11/25/2022]
Abstract
Vagus nerve stimulation (VNS) is a widely used adjunctive treatment option for intractable epilepsy. Most studies have demonstrated short-term seizure outcomes, usually for up to 5 years, and thus far, none have reported psychosocial outcomes in adults. We aimed to assess long-term seizure and psychosocial outcomes in patients with intractable epilepsy on VNS therapy for more than 15 years. We identified patients who had VNS implantation for treatment of intractable epilepsy from 1997 to 2013 at our Comprehensive Epilepsy Program and gathered demographics including age at epilepsy onset and VNS implantation, epilepsy type, number of antiepilepsy drugs (AEDs) and seizure frequency before VNS implantation and at the last clinic visit, and the most recent stimulation parameters from electronic medical records (EMR). Phone surveys were conducted by research assistants from May to November 2014 to determine patients' current seizure frequency and psychosocial metrics, including driving, employment status, and use of antidepressants. Seizure outcomes were based on modified Engel classification (I: seizure-free/rare simple partial seizures; II: >90% seizure reduction (SR), III: 50-90% SR, IV: <50% SR; classes I to III (>50% SR)=favorable outcome). A total of 207 patients underwent VNS implantation, 15 of whom were deceased at the time of the phone survey, and 40 had incomplete data for medical abstraction. Of the remaining 152, 90 (59%) were contacted and completed the survey. Of these, 51% were male, with the mean age at epilepsy onset of 9.4 years (range: birth to 60 years). There were 35 (39%) patients with extratemporal epilepsy, 19 (21%) with temporal, 18 (20%) with symptomatic generalized, 5 (6%) with idiopathic generalized, and 13 (14%) with multiple types. Final VNS settings showed 16 (18%) patients with an output current >2 mA and 14 (16%) with rapid cycling. Of the 80 patients with seizure frequency information, 16 (20%) had a modified Engel class I outcome, 14 (18%) had class II, 24 (30%) had class III, and 26 (33%) had class IV. Eighty percent said having VNS was worthwhile. Among the 90 patients, 43 patients were ≥ 18 years old without developmental delay in whom psychosocial outcomes were further analyzed. There was a decrease in the number of patients driving (31% vs 14%, p=0.052) and working (44% vs 35%, p=0.285) and an increase in the number of patients using antidepressant medication (14% vs 28%, p=0.057) at the time of survey compared to before VNS. In this subset, patients with >50% SR (60%) were taking significantly fewer AEDs at the time of survey compared to patients with unfavorable outcomes (median: 3 vs 4, p=0.045). The associations of >50% SR with the psychosocial outcomes of driving, employment, and antidepressant use were not significant, although 77% of this subset said VNS was worthwhile. This is the first study that assesses both seizure and psychosocial outcomes, and demonstrates favorable seizure outcomes of >50% SR in 68% of patients and seizure freedom in 20% of patients. A large majority of patients (80%) considered VNS therapy worthwhile regardless of epilepsy type and psychosocial outcomes.
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Affiliation(s)
- Vibhangini S Wasade
- Department of Neurology, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA; Department of Public Health Sciences, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA; Department of Neurosurgery, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA.
| | - Lonni Schultz
- Department of Neurology, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA; Department of Public Health Sciences, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA; Department of Neurosurgery, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA
| | - Karthik Mohanarangan
- Department of Neurology, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA; Department of Public Health Sciences, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA; Department of Neurosurgery, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA
| | - Aryamaan Gaddam
- Department of Neurology, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA; Department of Public Health Sciences, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA; Department of Neurosurgery, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA
| | - Jason M Schwalb
- Department of Neurology, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA; Department of Public Health Sciences, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA; Department of Neurosurgery, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA
| | - Marianna Spanaki-Varelas
- Department of Neurology, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA; Department of Public Health Sciences, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA; Department of Neurosurgery, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA
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Abstract
Abstract
BACKGROUND:
Vagus nerve stimulation (VNS) is an established surgical treatment for medically intractable epilepsy with more than 75 000 devices implanted worldwide. While there are many reports documenting efficacy, complications, and clinical use, there are very few reports concerning VNS battery replacement and revision surgeries.
OBJECTIVE:
To review our experience with VNS battery replacement and revision surgery.
METHODS:
We retrospectively reviewed 1144 consecutive VNS procedures performed by a single surgeon between 1998 and 2012. Six hundred forty-four of those procedures were the initial placement of the VNS device. These patients were then followed to determine when a battery change occurred and what type of revision or removal was necessary.
RESULTS:
In the study, 46% of patients required at least 1 or more type of battery replacement or revision surgery. The most common types of surgery were for generator battery depletion (27%), poor efficacy (9%), and lead malfunction (8%). Only 2% of patients were noted to have an infection.
CONCLUSION:
VNS battery replacement, revisions, and removals account for almost one-half of all VNS procedures. Our findings suggest important long-term expectations for VNS including expected complications, battery life, and other surgical issues. Review of the literature suggests that this is the first large review of VNS revisions by a single center. Our findings are important to better characterize long-term surgical expectations of VNS therapy. A significant portion of patients undergoing VNS therapy will eventually require revision.
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Affiliation(s)
- Jonathan D. Couch
- Saint Barnabas Medical Center, Livingston, New Jersey
- Hackensack University Medical Center, Hackensack, New Jersey
| | | | - Werner K. Doyle
- Saint Barnabas Medical Center, Livingston, New Jersey
- New York University Langone Medical Center, New York, New York
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