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Jia J, Guo J, Yao L, Zhang D. Editorial: Novel technologies targeting the rehabilitation of neurological disorders. Front Neurosci 2024; 18:1367286. [PMID: 38595971 PMCID: PMC11002261 DOI: 10.3389/fnins.2024.1367286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 03/13/2024] [Indexed: 04/11/2024] Open
Affiliation(s)
- Jie Jia
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Jingchun Guo
- State Key Laboratory of Medical Neurobiology, MOE Frontier Center for Brain Science, Department of Translational Neuroscience of Shanghai Jing'an District Centre Hospital, Institutes of Brain Science, Fudan University, Shanghai, China
| | - Lin Yao
- College of Computer Science, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Dingguo Zhang
- Department of Electronic and Electrical Engineering, University of Bath, Bath, United Kingdom
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2
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Mensah-Brown KG, Naylor RM, Graepel S, Brinjikji W. Neuromodulation: What the neurointerventionalist needs to know. Interv Neuroradiol 2024:15910199231224554. [PMID: 38454831 DOI: 10.1177/15910199231224554] [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: 03/09/2024] Open
Abstract
Neuromodulation is the alteration of neural activity in the central, peripheral, or autonomic nervous systems. Consequently, this term lends itself to a variety of organ systems including but not limited to the cardiac, nervous, and even gastrointestinal systems. In this review, we provide a primer on neuromodulation, examining the various technological systems employed and neurological disorders targeted with this technology. Ultimately, we undergo a historical analysis of the field's development, pivotal discoveries and inventions gearing this review to neuro-adjacent subspecialties with a specific focus on neurointerventionalists.
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Affiliation(s)
| | - Ryan M Naylor
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
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Marqueyssat GS, Valton L, Civade E, Laborde C. [Evaluation of the relevance of the pharmaceutical educational interview on the knowledge and satisfaction of patients who received a vagus nerve neurostimulator implantation]. ANNALES PHARMACEUTIQUES FRANÇAISES 2024; 82:163-173. [PMID: 37625530 DOI: 10.1016/j.pharma.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 07/11/2023] [Accepted: 08/21/2023] [Indexed: 08/27/2023]
Abstract
INTRODUCTION Vagal neurostimulation (VNS) medical devices (MDs) are used to treat drug-resistant epilepsy. Using a magnet, the patient can activate on the stimulations in order to stop a seizure or interrupt the adverse effects (AEs) of the device. The objective is to evaluate the improvement of the patients' knowledge about the VNS following a pharmaceutical educational interview (PEI) as well as their satisfaction. MATERIALS AND METHODS The pharmaceutical educational interview regarding drugs and DMs was performed by the clinical pharmacist at the patient's bed after VNS implantation. A questionnaire about VNS devices (operation, adverse effects, recommendations) and assessing knowledge was submitted to patients before and after the PEI. Satisfaction was assessed by the Likert scale. RESULTS From March 2020 to August 2021, 18 implanted patients were included in the study. In 78% of cases (14/18), the total number of good responses after PEI increased. The mean good response was significantly increased from 16.11/25 (64%) before PEI to 22.33/25 (89%) after PEI (P-value<0.01). The maximum satisfaction score (4/4) was given in 71% of the items. DISCUSSION-CONCLUSION The results support the relevance of PEI. Patients feel a need for information and consider the interview useful. An improvement in knowledge was observed, which allows us to hope for an optimization of the effectiveness of the device, in particular, a reduction in seizures and AE. This study shows the feasibility and the interest of the development of clinical pharmacy applied to medical devices in complementarity with the expertise on drugs.
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Affiliation(s)
- Gaël-Sean Marqueyssat
- Pôle pharmacie, équipe de pôle neurosciences et céphalique, CHU de Toulouse, Toulouse, France.
| | - Luc Valton
- Explorations neurophysiologiques, CHU de Purpan, Toulouse, France; Centre de recherche cerveau et cognition (CerCo), University of Toulouse, 31300 Toulouse, France
| | - Elodie Civade
- Pôle pharmacie, équipe de pôle neurosciences et céphalique, CHU de Toulouse, Toulouse, France
| | - Charlotte Laborde
- Pôle pharmacie, équipe de pôle neurosciences et céphalique, I2MC équipe Ceramic, UFR Santé service de Pharmacie clinique, CHU de Toulouse, Toulouse, France
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Raspin C, Faught E, Armand J, Barion F, Pollit V, Murphy J, Danielson V. An economic evaluation of vagus nerve stimulation as an adjunctive treatment to anti-seizure medications for the treatment of drug resistant epilepsy in the United States. J Med Econ 2023; 26:189-199. [PMID: 36691763 DOI: 10.1080/13696998.2023.2171230] [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] [Indexed: 01/25/2023]
Abstract
INTRODUCTION People with recurrent epileptic seizures are typically treated with anti-seizure medications (ASMs). Around a third of epilepsy patients fail to achieve an adequate response to ASMs and may be eligible to receive vagus nerve stimulation (VNS) therapy for their drug-resistant epilepsy (DRE) if they are unsuited to surgery. VNS received approval from the United States (US) Food and Drug Administration agency. However, there has to date been no comprehensive cost effectiveness evaluation of VNS within the US setting. This study was designed, using a US Medicare perspective, to estimate costs and quality-adjusted life years (QALYs) associated with VNS as an adjunct to ongoing ASM therapy, compared to ASMs alone. METHODS We developed a cohort state transition model in Microsoft Excel, with four health states defined by different percentage reductions in seizure frequency, with a 3-month cycle and transition probabilities derived from published clinical trials and registry data. Sensitivity analyses were conducted to understand the impact of parameter uncertainty. Costs included the VNS device, placement, programming, battery changes, and removal; ASM therapy; adverse events associated with VNS (dyspnea, hoarseness, and cough); and costs associated with seizure burden (i.e. hospitalizations, emergency department visits, neurologist visits). RESULTS Under base case assumptions, treatment with VNS was associated with a 0.385 QALY gain and a $109,678 saving per patient, when compared with ASM therapy alone. The incremental net monetary benefit (iNMB) was $128,903 at a threshold of $50,000 per QALY, with the positive iNMB indicating that VNS is a highly cost effective treatment. This result is explained by the modeled reduction in relative seizure frequency and associated reduction in healthcare resource use that the VNS group experienced. Sensitivity analyses supported this conclusion. CONCLUSIONS VNS was evaluated as a cost effective addition to the current standard of care in the treatment of DRE in the US Medicare context.
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Affiliation(s)
| | - Edward Faught
- Department of Neurology, Emory University, Atlanta, GA, USA
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Blond BN, Hirsch LJ. Updated review of rescue treatments for seizure clusters and prolonged seizures. Expert Rev Neurother 2022; 22:567-577. [PMID: 35862983 DOI: 10.1080/14737175.2022.2105207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Although the treatment of epilepsy primarily focuses on prevention, recurrent seizures are unfortunately an ongoing reality, particularly in people with epilepsy who live with chronic refractory seizures. Rescue medications are agents which can be administered in urgent/emergent seizure episodes such as seizure clusters or prolonged seizures with the goal of terminating seizure activity, preventing morbidity, and decreasing the risk of further seizures. AREAS COVERED This review first discusses clinical opportunities for rescue medications, with particular attention focused on seizure clusters and prolonged seizures, including their epidemiology, risk factors, and associated morbidity. Current rescue medications, their indications, efficacy, and adverse effects are discussed. We then discuss rescue medications and formulations which are currently under development, concentrating on practical aspects relevant for clinical care. EXPERT OPINION Rescue medications should be considered for all people with epilepsy with ongoing seizures. Recent rescue medications including intranasal formulations provide considerable advantages. New rescue medications are being developed which may expand opportunities for effective treatment. In the future, combining rescue medications with seizure detection and seizure prediction technologies should further expand opportunities for use and should reduce the morbidity of seizures and provide increased comfort, control, and quality of life for people living with epilepsy.
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Affiliation(s)
- Benjamin N Blond
- Department of Neurology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY
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6
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Möbius H, Welkoborsky HJ. Vagus nerve stimulation for conservative therapy-refractive epilepsy and depression. Laryngorhinootologie 2022; 101:S114-S143. [PMID: 35605616 DOI: 10.1055/a-1660-5591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Numerous studies confirm that the vagus nerve stimulation (VNS) is an efficient, indirect neuromodulatory therapy with electrically induced current for epilepsy that cannot be treated by epilepsy surgery and is therapy-refractory and for drug therapy-refractory depression. VNS is an established, evidence-based and in the long-term cost-effective therapy in an interdisciplinary overall concept.Long-term data on the safety and tolerance of the method are available despite the heterogeneity of the patient populations. Stimulation-related side effects like hoarseness, paresthesia, cough or dyspnea depend on the stimulation strength and often decrease with continuing therapy duration in the following years. Stimulation-related side effects of VNS can be well influenced by modifying the stimulation parameters. Overall, the invasive vagus nerve stimulation may be considered as a safe and well-tolerated therapy option.For invasive and transcutaneous vagus nerve stimulation, antiepileptic and antidepressant as well as positive cognitive effects could be proven. In contrast to drugs, VNS has no negative effect on cognition. In many cases, an improvement of the quality of life is possible.iVNS therapy has a low probability of complete seizure-freedom in cases of focal and genetically generalized epilepsy. It must be considered as palliative therapy, which means that it does not lead to healing and requires the continuation of specific medication. The functional principle is a general reduction of the neuronal excitability. This effect is achieved by a slow increase of the effectiveness sometimes over several years. Responders are those patients who experience a 50% reduction of the seizure incidence. Some studies even reveal seizure-freedom in 20% of the cases. Currently, it is not possible to differentiate between potential responders and non-responders before therapy/implantation.The current technical developments of the iVNS generators of the new generation like closed-loop system (cardiac-based seizure detection, CBSD) reduce also the risk for SUDEP (sudden unexpected death in epilepsy patients), a very rare, lethal complication of epilepsies, beside the seizure severity.iVNS may deteriorate an existing sleep apnea syndrome and therefore requires possible therapy interruption during nighttime (day-night programming or magnet use) beside the close cooperation with sleep physicians.The evaluation of the numerous iVNS trials of the past two decades showed multiple positive effects on other immunological, cardiological, and gastroenterological diseases so that additional therapy indications may be expected depending on future study results. Currently, the vagus nerve stimulation is in the focus of research in the disciplines of psychology, immunology, cardiology as well as pain and plasticity research with the desired potential of future medical application.Beside invasive vagus nerve stimulation with implantation of an IPG and an electrode, also devices for transdermal and thus non-invasive vagus nerve stimulation have been developed during the last years. According to the data that are currently available, they are less effective with regard to the reduction of the seizure severity and duration in cases of therapy-refractory epilepsy and slightly less effective regarding the improvement of depression symptoms. In this context, studies are missing that confirm high evidence of effectiveness. The same is true for the other indications that have been mentioned like tinnitus, cephalgia, gastrointestinal complaints etc. Another disadvantage of transcutaneous vagus nerve stimulation is that the stimulators have to be applied actively by the patients and are not permanently active, in contrast to implanted iVNS therapy systems. So they are only intermittently active; furthermore, the therapy adherence is uncertain.
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Affiliation(s)
- H Möbius
- Klinik für HNO-Heilkunde, Kopf- und Halschirurgie, KRH Klinikum Nordstadt, Hannover.,Abt. für HNO-Heilkunde, Kinderkrankenhaus auf der Bult, Hannover
| | - H J Welkoborsky
- Klinik für HNO-Heilkunde, Kopf- und Halschirurgie, KRH Klinikum Nordstadt, Hannover.,Abt. für HNO-Heilkunde, Kinderkrankenhaus auf der Bult, Hannover
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Ryvlin P, Rheims S, Hirsch LJ, Sokolov A, Jehi L. Neuromodulation in epilepsy: state-of-the-art approved therapies. Lancet Neurol 2021; 20:1038-1047. [PMID: 34710360 DOI: 10.1016/s1474-4422(21)00300-8] [Citation(s) in RCA: 101] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 08/22/2021] [Accepted: 09/03/2021] [Indexed: 12/20/2022]
Abstract
Three neuromodulation therapies have been appropriately tested and approved in refractory focal epilepsies: vagus nerve stimulation (VNS), deep brain stimulation of the anterior nucleus of the thalamus (ANT-DBS), and closed-loop responsive neurostimulation of the epileptogenic zone or zones. These therapies are primarily palliative. Only a few individuals have achieved complete freedom from seizures for more than 12 months with these therapies, whereas more than half have benefited from long-term reduction in seizure frequency of more than 50%. Implantation-related adverse events primarily include infection and pain at the implant site. Intracranial haemorrhage is a frequent adverse event for ANT-DBS and responsive neurostimulation. Other stimulation-specific side-effects are observed with VNS and ANT-DBS. Biomarkers to predict response to neuromodulation therapies are not available, and high-level evidence to aid decision making about when and for whom these therapies should be preferred over other antiepileptic treatments is scant. Future studies are thus needed to address these shortfalls in knowledge, approve other forms of neuromodulation, and develop personalised closed-loop therapies with embedded machine learning. Until then, neuromodulation could be considered for individuals with intractable seizures, ideally after the possibility of curative surgical treatment has been carefully assessed and ruled out or judged less appropriate.
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Affiliation(s)
- Philippe Ryvlin
- Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Sylvain Rheims
- Department of Functional Neurology and Epileptology, Hospices Civils de Lyon, Lyon 1 University Lyon Neuroscience Research Center, Institut National de la Santé et de la Recherche Médicale U1028/CNRS UMR 5292 Epilepsy Institute, Lyon, France
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Arseny Sokolov
- Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Lara Jehi
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
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Stumpp L, Smets H, Vespa S, Cury J, Doguet P, Delbeke J, Nonclercq A, El Tahry R. Vagus Nerve Electroneurogram-Based Detection of Acute Pentylenetetrazol Induced Seizures in Rats. Int J Neural Syst 2021; 31:2150024. [PMID: 34030610 DOI: 10.1142/s0129065721500246] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
On-demand stimulation improves the efficacy of vagus nerve stimulation (VNS) in refractory epilepsy. The vagus nerve is the main peripheral parasympathetic connection and seizures are known to exhibit autonomic symptoms. Therefore, we hypothesized that seizure detection is possible through vagus nerve electroneurogram (VENG) recording. We developed a metric able to measure abrupt changes in amplitude and frequency of spontaneous vagus nerve action potentials. A classifier was trained using a "leave-one-out" method on a set of 6 seizures and 3 control recordings to utilize the VENG spike feature-based metric for seizure detection. We were able to detect pentylenetetrazol (PTZ) induced acute seizures in 6/6 animals during different stages of the seizure with no false detection. The classifier detected the seizure during an early stage in 3/6 animals and at the onset of tonic clonic stage of the seizure in 3/6 animals. EMG and motion artefacts often accompany epileptic activity. We showed the "epileptic" neural signal to be independent from EMG and motion artefacts. We confirmed the existence of seizure related signals in the VENG recording and proved their applicability for seizure detection. This detection might be a promising tool to improve efficacy of VNS treatment by developing new responsive stimulation systems.
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Affiliation(s)
- Lars Stumpp
- Institute of Neuroscience, Université Catholique de Louvain, Brussels, Belgium
| | - Hugo Smets
- BEAMS Department, Université libre de Bruxelles, Brussels, Belgium
| | - Simone Vespa
- Institute of Neuroscience, Université Catholique de Louvain, Brussels, Belgium
| | - Joaquin Cury
- BEAMS Department, Université libre de Bruxelles, Brussels, Belgium
| | | | - Jean Delbeke
- Institute of Neuroscience, Université Catholique de Louvain, Brussels, Belgium
| | | | - Riem El Tahry
- Institute of Neuroscience, Université Catholique de Louvain, Brussels, Belgium.,Cliniques Universitaires Saint Luc, Center for Refractory Epilepsy, Brussels, Belgium
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Fisher B, DesMarteau JA, Koontz EH, Wilks SJ, Melamed SE. Responsive Vagus Nerve Stimulation for Drug Resistant Epilepsy: A Review of New Features and Practical Guidance for Advanced Practice Providers. Front Neurol 2021; 11:610379. [PMID: 33584511 PMCID: PMC7874068 DOI: 10.3389/fneur.2020.610379] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/14/2020] [Indexed: 01/17/2023] Open
Abstract
Vagus nerve stimulation (VNS) is a safe and effective therapy that has been available for over 20 years for adults and children with drug resistant epilepsy (DRE). Since U.S. Food and Drug Administration approval in 1997, VNS has been implanted in over 100,000 patients including over 30,000 children as an adjunctive therapy in reducing the frequency of seizures in patients 4 years of age and older with focal seizures that are refractory to antiseizure medications. VNS Therapy® has evolved over time and currently offers closed-loop, responsive stimulation as well as advanced features that streamline dosing and patient management. Advanced Practice Providers (APPs) such as nurse practitioners, physician assistants and clinical nurse specialists are integral in a comprehensive healthcare team, and dedicated VNS clinics have formed at comprehensive epilepsy centers across the world that are often managed by APPs. This approach improves access, education, and continuity of care for those with VNS or those considering VNS. Here we provide a review for APPs on the VNS Therapy® system focused on new features, dosing, and troubleshooting strategies with the goal to provide guidance to those managing VNS patients.
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Affiliation(s)
- Breanne Fisher
- Division of Neurology, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Julie A DesMarteau
- Department of Neurosciences, Medical University of South Carolina, Charleston, SC, United States
| | - Elizabeth H Koontz
- Department of Neurosciences, Medical University of South Carolina, Charleston, SC, United States
| | - Seth J Wilks
- Neuromodulation Division, LivaNova, Houston, TX, United States
| | - Susan E Melamed
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
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Toffa DH, Touma L, El Meskine T, Bouthillier A, Nguyen DK. Learnings from 30 years of reported efficacy and safety of vagus nerve stimulation (VNS) for epilepsy treatment: A critical review. Seizure 2020; 83:104-123. [PMID: 33120323 DOI: 10.1016/j.seizure.2020.09.027] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 09/23/2020] [Accepted: 09/25/2020] [Indexed: 12/11/2022] Open
Abstract
Three decades after its introduction as an adjuvant therapeutic option in the management of selective drug-resistant epilepsy cases (DRE), vagus nerve stimulation (VNS) retains growing interest. An implantable device was first approved for epilepsy in Europe in 1994 and in the United States (US) in 1997. Subsequent modifications improved the safety and the efficacy of the system. The most recent application of vagal neurostimulation is represented by transcutaneous devices that are claimed to have strong therapeutic potential. In this review, we sought to analyze the most meaningful available data describing the indications, safety and efficacy of the different approaches of VNS in clinical practice. Therefore, we identified studies reporting VNS efficacy and/or safety in epilepsy and its comorbidities from January 1990 to February 2020 from various databases including PubMed, Scopus, Cochrane, US government databases and VNS manufacturer published resources. In general, VNS efficacy becomes optimal around the sixth month of treatment and a 50-100 % seizure frequency reduction is achieved in approximately 45-65 % of the patients. However, some clinically relevant differences have been reported with specific factors such as epilepsy etiology or type, patient age as well as the delay of VNS therapy onset. VNS efficacy on seizure frequency has been demonstrated in both children and adults, in lesional and non-lesional cases, in focal and generalized epilepsies, on both seizures and epilepsy comorbidities. Regarding the latter, VNS can lead to an improvement of about 25-35 % in depression scores, 35 % in anxiety scores and 25 % in mood assessment scores. If non-invasive devices are undeniably safer, their efficacy is limited due to the scarcity of large cohort studies and the disparity of methodological approaches (study design and stimulation parameters). Overall, we believe that there is a progress margin for improving the safety of implantable devices and, above all, the effectiveness of the various VNS approaches.
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Affiliation(s)
- Dènahin Hinnoutondji Toffa
- Department of Neurology, CHUM, University of Montreal, Montreal, Canada; CHUM Research Center, University of Montreal, Montreal, Canada.
| | - Lahoud Touma
- Department of Neurology, CHUM, University of Montreal, Montreal, Canada
| | | | - Alain Bouthillier
- Department of Neurosurgery, CHUM, University of Montreal, Montreal, Canada
| | - Dang Khoa Nguyen
- Department of Neurology, CHUM, University of Montreal, Montreal, Canada; CHUM Research Center, University of Montreal, Montreal, Canada
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Mohrsen SA. Vagus nerve stimulation: a pre-hospital case report. Br Paramed J 2020; 5:34-37. [PMID: 33456389 PMCID: PMC7783950 DOI: 10.29045/14784726.2020.09.5.2.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introduction: Vagus nerve stimulation (VNS) is an adjunct therapy to anti-epileptics in patients where combination drug therapy alone has failed. The VNS device resembles an implantable defibrillator, and can be found underneath the clavicle on either side of the chest. By using a strong ring magnet, the device can be manipulated to seize function or operate on higher intensities, depending on how it is applied. The use of vagal stimulation is increasingly common and VNS is being explored for a range of other medical complaints. Case: This case study discusses the encounter between a paramedic and a woman presenting with a choking sensation, isolated uvular deviation and stable cardiorespiratory functions. Following a short period of observation without adverse events, she was discharged on scene and advised to see her specialist epilepsy nurse. Conclusion: Side effects of VNS increase with intensity of stimulation and can manifest throughout any branch of the vagus nerve. Its therapeutic mechanism of action is yet to be fully understood. The symptoms of over-stimulation are often frightening but benign, and although life-threatening events are rare, they require rapid recognition and immediate intervention.
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Yokoyama R, Akiyama Y, Enatsu R, Suzuki H, Suzuki Y, Kanno A, Ochi S, Mikuni N. The Immediate Effects of Vagus Nerve Stimulation in Intractable Epilepsy: An Intra-operative Electrocorticographic Analysis. Neurol Med Chir (Tokyo) 2020; 60:244-251. [PMID: 32295979 PMCID: PMC7246227 DOI: 10.2176/nmc.oa.2019-0221] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
The purpose of this study was to investigate whether and how vagus nerve stimulation (VNS) reduces the epileptogenic activity in the bilateral cerebral cortex in patients with intractable epilepsy. We analyzed the electrocorticograms (ECoGs) of five patients who underwent callosotomy due to intractable epilepsy even after VNS implantation. We recorded ECoGs and analyzed power spectrum in both VNS OFF and ON phases. We counted the number of spikes and electrodes with epileptic spikes, distinguishing unilaterally and bilaterally hemispherically spread spikes as synchronousness of the epileptic spikes in both VNS OFF and ON phases. There were 24.80 ± 35.55 and 7.20 ± 9.93 unilaterally spread spikes in the VNS OFF and ON phases, respectively (P = 0.157), and 35.8 ± 29.21 and 10.6 ± 13.50 bilaterally spread spikes in the VNS OFF and ON phases, respectively (P = 0.027). The number of electrodes with unilaterally and bilaterally spread spikes in the VNS OFF and ON phases was 3.84 ± 2.13 and 3.59 ± 1.82 (P = 0.415), and 8.20 ± 3.56 and 6.89 ± 2.89 (P = 0.026), respectively. The ECoG background power spectra recordings in the VNS OFF and ON phases were also analyzed. The spectral power tended to be greater in the high-frequency band at VNS ON phase than OFF phase. This study showed the reduction of epileptogenic spikes and spread areas of the spikes by VNS as immediate effects, electrophysiologically.
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Affiliation(s)
| | | | - Rei Enatsu
- Department of Neurosurgery, Sapporo Medical University
| | - Hime Suzuki
- Department of Neurosurgery, Sapporo Medical University
| | - Yuto Suzuki
- Department of Neurosurgery, Sapporo Medical University
| | - Aya Kanno
- Department of Neurosurgery, Sapporo Medical University
| | - Satoko Ochi
- Department of Neurosurgery, Sapporo Medical University
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Kawaji H, Yamamoto T, Fujimoto A, Uchida D, Ichikawa N, Yamazoe T, Okanishi T, Sato K, Nishimura M, Tanaka T, Namba H. Additional seizure reduction by replacement with Vagus Nerve Stimulation Model 106 (AspireSR). Neurosci Lett 2019; 716:134636. [PMID: 31751671 DOI: 10.1016/j.neulet.2019.134636] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 10/25/2019] [Accepted: 11/17/2019] [Indexed: 11/19/2022]
Abstract
AspireSR is a novel vagus nerve stimulation (VNS) device which detects ictal heart rate changes and automatically apply additional stimulus. We investigated the difference of the efficacy between AspireSR and preceding VNS models in patients with device replacement. We retrospectively reviewed the clinical data of 17 patients whose VNS devices were changed because of battery discharge. The rates of seizure reduction, the number of antiepileptic drugs (AEDs) used and device parameters between the two devices were evaluated. AspireSR improved significantly the rates of seizure reduction of the patients. Four patients out of 11 patients with low response to the preceding VNS models (no change or <50 % reduction) achieved>50 % seizure reduction. The AEDs used were not different in the observed periods. The device parameters were low setting in AspireSR compared to preceding VNS models. AspireSR decrease significantly seizure frequencies compared to the preceding VNS models. Change of the devices to AspireSR at the time of battery empty could be recommendable.
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Affiliation(s)
- Hiroshi Kawaji
- Departments of Neurosurgery, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Naka-ku, Hamamatsu, 430-8558, Japan; Departments of Neurosurgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Takamichi Yamamoto
- Departments of Neurosurgery, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Naka-ku, Hamamatsu, 430-8558, Japan; Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Naka-ku, Hamamatsu, 430-8558, Japan; Departments of Neurosurgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Ayataka Fujimoto
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Naka-ku, Hamamatsu, 430-8558, Japan
| | - Daiki Uchida
- Departments of Neurosurgery, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Naka-ku, Hamamatsu, 430-8558, Japan
| | - Naoki Ichikawa
- Departments of Neurosurgery, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Naka-ku, Hamamatsu, 430-8558, Japan; Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Naka-ku, Hamamatsu, 430-8558, Japan
| | - Tomohiro Yamazoe
- Departments of Neurosurgery, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Naka-ku, Hamamatsu, 430-8558, Japan
| | - Tohru Okanishi
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Naka-ku, Hamamatsu, 430-8558, Japan
| | - Keishiro Sato
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Naka-ku, Hamamatsu, 430-8558, Japan
| | - Mitsuyo Nishimura
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Naka-ku, Hamamatsu, 430-8558, Japan
| | - Tokutaro Tanaka
- Departments of Neurosurgery, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Naka-ku, Hamamatsu, 430-8558, Japan; Departments of Neurosurgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Hiroki Namba
- Departments of Neurosurgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan.
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14
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Mattsson MO, Simkó M. Emerging medical applications based on non-ionizing electromagnetic fields from 0 Hz to 10 THz. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2019; 12:347-368. [PMID: 31565000 PMCID: PMC6746309 DOI: 10.2147/mder.s214152] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 08/23/2019] [Indexed: 12/13/2022] Open
Abstract
The potential for using non-ionizing electromagnetic fields (EMF; at frequencies from 0 Hz up to the THz range) for medical purposes has been of interest since many decades. A number of established and familiar methods are in use all over the world. This review, however, provides an overview of applications that already play some clinical role or are in earlier stages of development. The covered methods include modalities used for bone healing, cancer treatment, neurological conditions, and diathermy. In addition, certain other potential clinical areas are touched upon. Most of the reviewed technologies deal with therapy, whereas just a few diagnostic approaches are mentioned. None of the discussed methods are having such a strong impact in their field of use that they would be expected to replace conventional methods. Partly this is due to a knowledge base that lacks mechanistic explanations for EMF effects at low-intensity levels, which often are used in the applications. Thus, the possible optimal use of EMF approaches is restricted. Other reasons for the limited impact include a scarcity of well-performed randomized clinical trials that convincingly show the efficacy of the methods and that standardized user protocols are mostly lacking. Presently, it seems that some EMF-based methods can have a niche role in treatment and diagnostics of certain conditions, mostly as a complement to or in combination with other, more established, methods. Further development and a stronger impact of these technologies need a better understanding of the interaction mechanisms between EMF and biological systems at lower intensity levels. The importance of the different physical parameters of the EMF exposure needs also further investigations.
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Affiliation(s)
- Mats-Olof Mattsson
- SciProof International AB, Östersund, Sweden.,Strömstad Akademi, Institute for Advanced Studies, Strömstad, Sweden
| | - Myrtill Simkó
- SciProof International AB, Östersund, Sweden.,Strömstad Akademi, Institute for Advanced Studies, Strömstad, Sweden
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15
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Musselman ED, Pelot NA, Grill WM. Empirically Based Guidelines for Selecting Vagus Nerve Stimulation Parameters in Epilepsy and Heart Failure. Cold Spring Harb Perspect Med 2019; 9:cshperspect.a034264. [PMID: 30181356 DOI: 10.1101/cshperspect.a034264] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Vagus nerve stimulation (VNS) is a promising therapy to treat patients with epilepsy and heart failure. Outcomes of preclinical studies and clinical trials indicate that the selection of stimulation parameters has a direct impact on therapeutic efficacy and patient tolerability, suggesting that both the efficacy and tolerability of VNS could potentially be improved with a change in stimulation parameters. In this review, the success of translating stimulation parameters for epilepsy and heart failure from preclinical studies in animal models to human use in the clinic is evaluated on the basis of patient outcomes and stimulation-induced side effects. Data suggest that patients receiving VNS for epilepsy may experience improved seizure reduction by increasing the frequency and/or duty cycle of stimulation as well as incorporating closed-loop systems to deliver stimulation closer to seizure onset. Further, data suggest that VNS for heart failure is limited by the inability to activate the nerve fibers mediating therapeutic benefit without co-activation of side effect-inducing fibers. This may explain why pivotal trials of VNS for heart failure failed to meet primary efficacy outcomes despite promising preclinical outcomes in animal models. Improved characterization of the relationship between the stimulation parameter space and recruitment of the underlying fiber populations will likely expand the use of VNS to treat a variety of diseases and also improve upon current understanding of the mechanisms of action underlying VNS.
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Affiliation(s)
- Eric D Musselman
- Department of Biomedical Engineering, Duke University, Durham, North Carolina 27708
| | - Nicole A Pelot
- Department of Biomedical Engineering, Duke University, Durham, North Carolina 27708
| | - Warren M Grill
- Department of Biomedical Engineering, Duke University, Durham, North Carolina 27708.,Department of Electrical and Computer Engineering, Duke University, Durham, North Carolina 27708.,Department of Neurobiology, Duke University, Durham, North Carolina 27708.,Department of Neurosurgery, Duke University, Durham, North Carolina 27708
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16
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Yield of conventional and automated seizure detection methods in the epilepsy monitoring unit. Seizure 2019; 69:290-295. [DOI: 10.1016/j.seizure.2019.05.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/07/2019] [Accepted: 05/20/2019] [Indexed: 11/20/2022] Open
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17
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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: 93] [Impact Index Per Article: 18.6] [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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18
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Safe Parameters for Utilizing Magnetic Growth Rods in Patient With a Vagal Nerve Stimulator and Case Report. J Pediatr Orthop 2019; 39:e289-e292. [PMID: 30839480 DOI: 10.1097/bpo.0000000000001294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Magnetic growing rods are being utilized more frequently in children with early-onset scoliosis. Many of these children have multiple medical problems and additional medical devices implanted that utilize similar magnetic technology, including vagal nerve stimulator (VNS) devices. There is some concern that the external remote controller (ERC) used to control the magnetic growth rod will interact with these devices during lengthening procedures. We believe there are safe parameters which allow the magnetic growth rod ERC to be utilized in patients with an implanted VNS. METHODS A VNS device was tested in a simulation with the magnetic growth rods ERC to determine if it would activate/inactivate the device during a lengthening procedure. This study consists of 2 simulations. Simulation 1 evaluates placing the VNS adjacent to the ERC in the same coronal plane. Simulation 2 elevates the ERC placement above the device to simulate the thickness of a torso while increasing the distance of the VNS from the ERC in the coronal plane. RESULTS The time of exposure of the VNS device to the magnetic field had no correlation with activation. Distance had an effect on device activation. In the coronal plane of the device, activation occurred 43% of the time at 0 cm, 71% at 4 cm, and 5% activation at 8 cm. Greater than 10 cm had no activation. In the sagittal plane with the ERC 8 cm above the device, activation occurred 71% at 0 cm distance, 38% at 2 cm, and no activation occurred at a distance of >4 cm. CONCLUSIONS Utilization of the magnetic growth rod ERC can be carried out safely in patients with a VNS. Simulations show that an actuator implanted 4 cm from the VNS device in the coronal plane in a child with >8 cm chest wall thickness will not activate the VNS device. When choosing a rod configuration for implantation, the child's chest wall thickness and the ERC placement should be considered.
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Wong S, Mani R, Danish S. Comparison and Selection of Current Implantable Anti-Epileptic Devices. Neurotherapeutics 2019; 16:369-380. [PMID: 31062294 PMCID: PMC6554379 DOI: 10.1007/s13311-019-00727-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Implantable neural stimulators represent an advanced treatment adjunct to medication for pharmacoresistant epilepsy and alternative for patients that are not good candidates for resective surgery. Three treatment modalities are currently FDA-approved: vagus nerve stimulation, responsive neurostimulation, and deep brain stimulation. These devices were originally trialed in very similar patient populations with focal epilepsy, but head-to-head comparison trials have not been performed. As such, device selection may be challenging due to large overlaps in clinical indications and efficacy. Here we will review the data reported in the original pivotal clinical trials as well as long-term experience with these technologies. We will highlight differences in their features and mechanisms of action which may help optimize device selection on a case-by-case basis.
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Affiliation(s)
- Stephen Wong
- Department of Neurology, Rutgers - Robert Wood Johnson Medical School, 125 Paterson St., Ste 6200, New Brunswick, NJ, 08901, USA.
| | - Ram Mani
- Department of Neurology, Rutgers - Robert Wood Johnson Medical School, 125 Paterson St., Ste 6200, New Brunswick, NJ, 08901, USA
| | - Shabbar Danish
- Department of Neurosurgery, Rutgers - Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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20
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Wheless JW, Gienapp AJ, Ryvlin P. Vagus nerve stimulation (VNS) therapy update. Epilepsy Behav 2018; 88S:2-10. [PMID: 30017839 DOI: 10.1016/j.yebeh.2018.06.032] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 06/15/2018] [Indexed: 11/19/2022]
Abstract
Epilepsy affects millions of people worldwide. Approximately one-third have pharmacoresistant epilepsy, and of these, the majority are not candidates for epilepsy surgery. Vagus nerve stimulation (VNS) therapy has been an option to treat pharmacoresistant seizures for 30 years. In this update, we will review the clinical data that support the device's efficacy in children, adolescents, and adults. We will also review its side-effect profile, quality of life and cost benefits, and the impact the device has on sudden unexpected death in epilepsy (SUDEP). We will then discuss candidate selection and provide guidance on dosing and future models. Vagus nerve stimulation therapy is an effective treatment for many seizure types and epilepsy syndromes with a predictable and benign side-effect profile that supports its role as the most commonly prescribed device to treat pharmacoresistant epilepsy. "This article is part of the Supplement issue Neurostimulation for Epilepsy."
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Affiliation(s)
- James W Wheless
- Le Bonheur Comprehensive Epilepsy Program, Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, TN, United States; Department of Pediatrics, Pediatric Neurology Division, University of Tennessee Health Science Center, Memphis, TN, United States.
| | - Andrew J Gienapp
- Medical Education, Methodist University Hospital, Memphis, TN, United States; Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Phillippe Ryvlin
- Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
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21
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Ryvlin P, Ciumas C, Wisniewski I, Beniczky S. Wearable devices for sudden unexpected death in epilepsy prevention. Epilepsia 2018; 59 Suppl 1:61-66. [DOI: 10.1111/epi.14054] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2017] [Indexed: 02/05/2023]
Affiliation(s)
- Philippe Ryvlin
- Department of Clinical Neurosciences; CHUV; Lausanne Switzerland
- Epilepsy Institute (IDEE); Lyon France
| | - Carolina Ciumas
- Department of Clinical Neurosciences; CHUV; Lausanne Switzerland
- Epilepsy Institute (IDEE); Lyon France
| | - Ilona Wisniewski
- Department of Clinical Neurosciences; CHUV; Lausanne Switzerland
| | - Sandor Beniczky
- Department of Clinical Neurophysiology; Danish Epilepsy Center; Dianalund Denmark
- Department of Clinical Neurophysiology; Aarhus University Hospital; Aarhus Denmark
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22
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Nirwan N, Vyas P, Vohora D. Animal models of status epilepticus and temporal lobe epilepsy: a narrative review. Rev Neurosci 2018; 29:757-770. [DOI: 10.1515/revneuro-2017-0086] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 01/26/2018] [Indexed: 11/15/2022]
Abstract
Abstract
Temporal lobe epilepsy (TLE) is the chronic and pharmacoresistant form of epilepsy observed in humans. The current literature is insufficient in explicating the comprehensive mechanisms underlying its pathogenesis and advancement. Consequently, the development of a suitable animal model mimicking the clinical characteristics is required. Further, the relevance of status epilepticus (SE) to animal models is dubious. SE occurs rarely in people; most epilepsy patients never experience it. The present review summarizes the established animal models of SE and TLE, along with a brief discussion of the animal models that have the distinctiveness and carries the possibility to be developed as effective models for TLE. The review not only covers the basic requirements, mechanisms, and methods of induction of each model but also focuses upon their major limitations and possible modifications for their future use. A detailed discussion on chemical, electrical, and hypoxic/ischemic models as well as a brief explanation on the genetic models, most of which are characterized by development of SE followed by neurodegeneration, is presented.
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Affiliation(s)
- Nikita Nirwan
- Neurobehavioral Pharmacology Laboratory , Department of Pharmacology , School of Pharmaceutical Education and Research, Jamia Hamdard , New Delhi 110062 , India
| | - Preeti Vyas
- Neurobehavioral Pharmacology Laboratory , Department of Pharmacology , School of Pharmaceutical Education and Research, Jamia Hamdard , New Delhi 110062 , India
| | - Divya Vohora
- Neurobehavioral Pharmacology Laboratory , Department of Pharmacology , School of Pharmaceutical Education and Research, Jamia Hamdard , New Delhi 110062 , India
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23
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Ryvlin P, So EL, Gordon CM, Hesdorffer DC, Sperling MR, Devinsky O, Bunker MT, Olin B, Friedman D. Long-term surveillance of SUDEP in drug-resistant epilepsy patients treated with VNS therapy. Epilepsia 2018; 59:562-572. [DOI: 10.1111/epi.14002] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Philippe Ryvlin
- Department of Clinical Neurosciences; Vaud University Hospital; Lausanne Switzerland
- Epilepsy Institute (Institut Des ÉpilepsiEs; IDÉE); Lyon France
| | - Elson L. So
- Department of Neurology; Mayo Clinic; Rochester MN USA
| | | | | | - Michael R. Sperling
- Department of Neurology; Jefferson Comprehensive Epilepsy Center; Thomas Jefferson University; Philadelphia PA USA
| | - Orrin Devinsky
- Department of Neurology; Comprehensive Epilepsy Center; New York University Langone Medical Center; New York NY USA
| | | | - Bryan Olin
- Cyberonics, Inc. (LivaNova, PLC); Houston TX USA
| | - Daniel Friedman
- Department of Neurology; Comprehensive Epilepsy Center; New York University Langone Medical Center; New York NY USA
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24
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Pulliam CL, Peterson EJ, Herron JA, Denison T. Designing Neuromodulation Devices for Feedback Control. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00023-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Robbins JW, Lacy J, Puccioni M. Novel implantation of vagus nerve stimulator AspireSR pulse generator: Technical note. INTERDISCIPLINARY NEUROSURGERY 2017. [DOI: 10.1016/j.inat.2017.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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26
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Seizure detection and neuromodulation: A summary of data presented at the XIII conference on new antiepileptic drug and devices (EILAT XIII). Epilepsy Res 2017; 130:27-36. [DOI: 10.1016/j.eplepsyres.2017.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 01/08/2017] [Indexed: 01/22/2023]
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Jennum P, Sabers A, Christensen J, Ibsen R, Kjellberg J. Socioeconomic evaluation of vagus stimulation: A controlled national study. Seizure 2016; 42:15-19. [DOI: 10.1016/j.seizure.2016.08.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 08/28/2016] [Accepted: 08/30/2016] [Indexed: 11/25/2022] Open
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Abstract
There are more than 12 new antiepileptic drugs approved in the last 2 decades. Even with these newer agents, seizure remission is still unachievable in around 30% of patients with partial-onset seizures (POS). Brivaracetam (BRV) is chemically related to levetiracetam (LEV) and possesses a strong binding affinity for the synaptic vesicle protein 2A tenfold above that of LEV, and other possible modes of antiepileptic actions. BRV is now under Phase III development for POS, but data from one Phase III trial also suggested its potential efficacy for primary generalized seizures. The purpose of this review is to provide updated information on the mechanisms of action of the available antiepileptic drugs, with a focus on BRV to assess its pharmacology, pharmacokinetics, clinical efficacy, safety, and tolerability in patients with uncontrolled POS. To date, six Phase IIb and III clinical trials have been performed to investigate the efficacy, safety, and tolerability of BRV as an adjunctive treatment for patients with POS. Generally, BRV was well tolerated and did not show significant difference in safety profile, compared to placebo. The efficacy outcomes of BRV, although not consistent across trials, did indicate that BRV was a promising add-on therapy for patients with POS. In conclusion, the many favorable attributes of BRV, like its high oral efficacy, good tolerability, dosing regimen, and minimal drug interaction, make it a promising antiepileptic therapy for patients with uncontrolled partial-onset epilepsy.
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Affiliation(s)
- Lan Gao
- Deakin Population Health SRC, Faculty of Health, Deakin University, Burwood, Victoria, Australia
| | - Shuchuen Li
- School of Biomedical Sciences and Pharmacy, The University of Newcastle, Callaghan, NSW, Australia
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George E, Elman I, Becerra L, Berg S, Borsook D. Pain in an era of armed conflicts: Prevention and treatment for warfighters and civilian casualties. Prog Neurobiol 2016; 141:25-44. [PMID: 27084355 DOI: 10.1016/j.pneurobio.2016.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 03/23/2016] [Accepted: 04/08/2016] [Indexed: 12/13/2022]
Abstract
Chronic pain is a common squealae of military- and terror-related injuries. While its pathophysiology has not yet been fully elucidated, it may be potentially related to premorbid neuropsychobiological status, as well as to the type of injury and to the neural alterations that it may evoke. Accordingly, optimized approaches for wounded individuals should integrate primary, secondary and tertiary prevention in the form of thorough evaluation of risk factors along with specific interventions to contravene and mitigate the ensuing chronicity. Thus, Premorbid Events phase may encompass assessments of psychological and neurobiological vulnerability factors in conjunction with fostering preparedness and resilience in both military and civilian populations at risk. Injuries per se phase calls for immediate treatment of acute pain in the field by pharmacological agents that spare and even enhance coping and adaptive capabilities. The key objective of the Post Injury Events is to prevent and/or reverse maladaptive peripheral- and central neural system's processes that mediate transformation of acute to chronic pain and to incorporate timely interventions for concomitant mental health problems including post-traumatic stress disorder and addiction We suggest that the proposed continuum of care may avert more disability and suffering than the currently employed less integrated strategies. While the requirements of the armed forces present a pressing need for this integrated continuum and a framework in which it can be most readily implemented, this approach may be also instrumental for the care of civilian casualties.
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Affiliation(s)
- E George
- Center for Pain and the Brain, Harvard Medical School (HMS), United States; Department of Anesthesia, Critical Care and Pain Medicine, MGH, HMS, Boston, MA, United States; Commander, MC, USN (Ret), United States
| | - I Elman
- Center for Pain and the Brain, Harvard Medical School (HMS), United States; Department of Psychiatry, Boonshoft School of Medicine and Dayton VA Medical Center, United States; Veterans Administration Medical Center, Dayton, OH, United States
| | - L Becerra
- Center for Pain and the Brain, Harvard Medical School (HMS), United States; Department of Anesthesia, Critical Care and Pain Medicine, BCH, HMS, Boston, MA, United States; Departments of Psychiatry and Radiology, MGH, Boston, MA, United States
| | - Sheri Berg
- Center for Pain and the Brain, Harvard Medical School (HMS), United States; Department of Anesthesia, Critical Care and Pain Medicine, MGH, HMS, Boston, MA, United States
| | - D Borsook
- Center for Pain and the Brain, Harvard Medical School (HMS), United States; Department of Anesthesia, Critical Care and Pain Medicine, BCH, HMS, Boston, MA, United States; Departments of Psychiatry and Radiology, MGH, Boston, MA, United States.
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30
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Fisher RS, Afra P, Macken M, Minecan DN, Bagić A, Benbadis SR, Helmers SL, Sinha SR, Slater J, Treiman D, Begnaud J, Raman P, Najimipour B. Automatic Vagus Nerve Stimulation Triggered by Ictal Tachycardia: Clinical Outcomes and Device Performance--The U.S. E-37 Trial. Neuromodulation 2015; 19:188-95. [PMID: 26663671 PMCID: PMC5064739 DOI: 10.1111/ner.12376] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 09/25/2015] [Accepted: 10/11/2015] [Indexed: 12/22/2022]
Abstract
Objectives The Automatic Stimulation Mode (AutoStim) feature of the Model 106 Vagus Nerve Stimulation (VNS) Therapy System stimulates the left vagus nerve on detecting tachycardia. This study evaluates performance, safety of the AutoStim feature during a 3‐5‐day Epilepsy Monitoring Unit (EMU) stay and long‐ term clinical outcomes of the device stimulating in all modes. Materials and Methods The E‐37 protocol (NCT01846741) was a prospective, unblinded, U.S. multisite study of the AspireSR® in subjects with drug‐resistant partial onset seizures and history of ictal tachycardia. VNS Normal and Magnet Modes stimulation were present at all times except during the EMU stay. Outpatient visits at 3, 6, and 12 months tracked seizure frequency, severity, quality of life, and adverse events. Results Twenty implanted subjects (ages 21–69) experienced 89 seizures in the EMU. 28/38 (73.7%) of complex partial and secondarily generalized seizures exhibited ≥20% increase in heart rate change. 31/89 (34.8%) of seizures were treated by Automatic Stimulation on detection; 19/31 (61.3%) seizures ended during the stimulation with a median time from stimulation onset to seizure end of 35 sec. Mean duty cycle at six‐months increased from 11% to 16%. At 12 months, quality of life and seizure severity scores improved, and responder rate was 50%. Common adverse events were dysphonia (n = 7), convulsion (n = 6), and oropharyngeal pain (n = 3). Conclusions The Model 106 performed as intended in the study population, was well tolerated and associated with clinical improvement from baseline. The study design did not allow determination of which factors were responsible for improvements.
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Affiliation(s)
- Robert S Fisher
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Pegah Afra
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Micheal Macken
- Department of Neurology, Northwestern University, Chicago, IL, USA
| | | | - Anto Bagić
- University of Pittsburgh Comprehensive Epilepsy Center (UPCEC), Pittsburgh, PA, USA
| | - Selim R Benbadis
- Department of Neurology, University of South Florida & Tampa General Hospital, Tampa, FL, USA
| | | | - Saurabh R Sinha
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Jeremy Slater
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - David Treiman
- Epilepsy Center, Barrow Neurological Institute, Phoenix, AZ, USA
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31
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Outcome-centered antiepileptic therapy: Rate, rhythm and relief.: Implementing AAN Epilepsy Quality Measures in clinical practice. Epilepsy Behav 2015; 53:108-11. [PMID: 26539703 DOI: 10.1016/j.yebeh.2015.09.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 09/17/2015] [Accepted: 09/19/2015] [Indexed: 11/22/2022]
Abstract
Clinicians who manage patients with epilepsy are expected to assess the relevance of clinical trial results to their practice, integrate new treatments into the care algorithm, and implement epilepsy quality measures, with the overall goal of improving patient outcomes. A disease-based clinical framework that helps with choice and combinations of interventions facilitates provision of efficient, cost-effective, and high-quality care. This article addresses the current conceptual framework that informs clinical evaluation of epilepsy, explores gaps between development of treatment options, quality measures and clinical goals, and proposes an outcome-centered approach that bridges these gaps with the aim of improving patient and population-level clinical outcomes in epilepsy.
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Abstract
Various neurostimulation modalities have emerged in the field of epilepsy. Despite the fact that delivery of an electrical current to the hyperexcitable epileptic brain might, at first, seem contradictory, neurostimulation has become an established therapeutic option with a promising efficacy and adverse effects profile. In "responsive" neurostimulation the strategy is to interfere as early as possible with the accumulation of seizure activity to prematurely abort or even prevent an upcoming seizure. The design of technology required for responsive stimulation is more challenging compared with devices for open-loop neurostimulation. The achievement of therapeutic success is dependent on adequate sensing and stimulation algorithms and a fast coupling between both. The benefits of delivering current only at the time of an approaching seizure merit further investigation. Current experience with responsive neurostimulation in epilepsy is still limited, but seems promising.
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Affiliation(s)
- Sofie Carrette
- a Laboratory for Clinical and Experimental Neurophysiology, Neurobiology and Neuropsychology (LCEN3), Ghent University, Department of Neurology , Ghent University Hospital, Institute for Neuroscience , Ghent , Belgium
| | - Paul Boon
- a Laboratory for Clinical and Experimental Neurophysiology, Neurobiology and Neuropsychology (LCEN3), Ghent University, Department of Neurology , Ghent University Hospital, Institute for Neuroscience , Ghent , Belgium
| | - Mathieu Sprengers
- a Laboratory for Clinical and Experimental Neurophysiology, Neurobiology and Neuropsychology (LCEN3), Ghent University, Department of Neurology , Ghent University Hospital, Institute for Neuroscience , Ghent , Belgium
| | - Robrecht Raedt
- a Laboratory for Clinical and Experimental Neurophysiology, Neurobiology and Neuropsychology (LCEN3), Ghent University, Department of Neurology , Ghent University Hospital, Institute for Neuroscience , Ghent , Belgium
| | - Kristl Vonck
- a Laboratory for Clinical and Experimental Neurophysiology, Neurobiology and Neuropsychology (LCEN3), Ghent University, Department of Neurology , Ghent University Hospital, Institute for Neuroscience , Ghent , Belgium
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ATPergic signalling during seizures and epilepsy. Neuropharmacology 2015; 104:140-53. [PMID: 26549853 DOI: 10.1016/j.neuropharm.2015.11.001] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 11/01/2015] [Accepted: 11/02/2015] [Indexed: 10/22/2022]
Abstract
Much progress has been made over the last few decades in the identification of new anti-epileptic drugs (AEDs). However, 30% of epilepsy patients suffer poor seizure control. This underscores the need to identify alternative druggable neurotransmitter systems and drugs with novel mechanisms of action. An emerging concept is that seizure generation involves a complex interplay between neurons and glial cells at the tripartite synapse and neuroinflammation has been proposed as one of the main drivers of epileptogenesis. The ATP-gated purinergic receptor family is expressed throughout the brain and is functional on neurons and glial cells. ATP is released in high amounts into the extracellular space after increased neuronal activity and during chronic inflammation and cell death to act as a neuro- and gliotransmitter. Emerging work shows pharmacological targeting of ATP-gated purinergic P2 receptors can potently modulate seizure generation, inflammatory processes and seizure-induced brain damage. To date, work showing the functional contribution of P2 receptors has been mainly performed in animal models of acute seizures, in particular, by targeting the ionotropic P2X7 receptor subtype. Other ionotropic P2X and metabotropic P2Y receptor family members have also been implicated in pathological processes following seizures such as the P2X4 receptor and the P2Y12 receptor. However, during epilepsy, the characterization of P2 receptors was mostly restricted to the study of expressional changes of the different receptor subtypes. This review summarizes the work to date on ATP-mediated signalling during seizures and the functional impact of targeting the ATP-gated purinergic receptors on seizures and seizure-induced pathology. This article is part of the Special Issue entitled 'Purines in Neurodegeneration and Neuroregeneration'.
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Impact of vagus nerve stimulation on secondary care burden in children and adults with epilepsy: Review of routinely collected hospital data in England. Epilepsy Behav 2015; 52:68-73. [PMID: 26409132 DOI: 10.1016/j.yebeh.2015.08.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 08/18/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE We evaluated the long-term medical and economic benefits of vagus nerve stimulation (VNS) therapy for 704 adults and children with epilepsy. A pre-post analysis was conducted using Hospital Episode Statistics (HES) data (April 2008-July 2014). Seven hundred and four patients with epilepsy diagnoses (ICD-10 G40.x or G41.x), one or more procedures for vagus nerve stimulator implantation, and six or more months of available HES data pre- and post-VNS were selected. The pre-VNS period averaged 39.1 months. The post-VNS period extended from implantation to device removal, death, or study end (up to six years), with a mean duration of 36.4 months. Incidence rate ratios (IRRs) and cost differences (£2014) were estimated. Mean age was 28.3 years. RESULTS Inpatient admissions decreased post-VNS compared with pre-VNS (adjusted IRR=0.81, P<0.001). Overall, outpatient consultations increased post-VNS compared with pre-VNS (adjusted IRR=1.34, P<0.001). However, outpatient consultations exhibited a decreasing trend in the post-VNS period (adjusted IRR=0.96, P<0.001), suggesting that much of the increased outpatient activity in the post-VNS period relates to follow-up management of the VNS device in the immediate period following implantation, with comparable outpatient resource burden at 36 months post-VNS. No significant changes in clinical events were observed; however, average epilepsy-related medical costs were lower post-VNS than pre-VNS (adjusted cost difference -£110 quarterly, P=0.001). CONCLUSIONS Vagus nerve stimulation is associated with increased outpatient resource utilization and decreased inpatient admissions, with a reduction in long-term epilepsy-related medical costs post-implantation.
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Yuan H, Silberstein SD. Vagus Nerve and Vagus Nerve Stimulation, a Comprehensive Review: Part II. Headache 2015; 56:259-66. [DOI: 10.1111/head.12650] [Citation(s) in RCA: 126] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2015] [Indexed: 12/30/2022]
Affiliation(s)
- Hsiangkuo Yuan
- Jefferson Headache Center, Thomas Jefferson University; Philadelphia PA USA
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Schneider UC, Bohlmann K, Vajkoczy P, Straub HB. Implantation of a new Vagus Nerve Stimulation (VNS) Therapy® generator, AspireSR®: considerations and recommendations during implantation and replacement surgery--comparison to a traditional system. Acta Neurochir (Wien) 2015; 157:721-8. [PMID: 25673257 DOI: 10.1007/s00701-015-2362-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 01/22/2015] [Indexed: 12/22/2022]
Abstract
INTRODUCTION The most widely used neuro-stimulation treatment for drug-resistant epilepsy is Vagus Nerve Stimulation (VNS) Therapy®. Ictal tachycardia can be an indicator of a seizure and, if monitored, can be used to trigger an additional on-demand stimulation, which may positively influence seizure severity or duration. A new VNS Therapy generator model, AspireSR®, was introduced and approved for CE Mark in February 2014. In enhancement of former models, the AspireSR has incorporated a cardiac-based seizure-detection (CBSD) algorithm that can detect ictal tachycardia and automatically trigger a defined auto-stimulation. To evaluate differences in preoperative, intraoperative and postoperative handling, we compared the AspireSR to a conventional generator model (Demipulse®). METHOD Between February and September 2014, seven patients with drug-resistant epilepsy and ictal tachycardia were implanted with an AspireSR. Between November 2013 and September 2014, seven patients were implanted with a Demipulse and served as control group. Operation time, skin incision length and position, and complications were recorded. Handling of the new device was critically evaluated. RESULTS The intraoperative handling was comparable and did not lead to a significant increase in operation time. In our 14 operations, we had no significant short-term complications. Due to its larger size, patients with the AspireSR had significantly larger skin incisions. For optimal heart rate detection, the AspireSR had to be placed significantly more medial in the décolleté area than the Demipulse. The preoperative testing is a unique addition to the implantation procedure of the AspireSR, which may provide minor difficulties, and for which we provide several recommendations and tips. The price of the device is higher than for all other models. CONCLUSIONS The new AspireSR generator offers a unique technical improvement over the previous Demipulse. Whether the highly interesting CBSD feature will provide an additional benefit for the patients, and will rectify the additional costs, respectively, cannot be answered in the short-term. The preoperative handling is straightforward, provided that certain recommendations are taken into consideration. The intraoperative handling is equivalent to former models-except for the placement of the generator, which might cause cosmetic issues and has to be discussed with the patient carefully. We recommend the consideration of the AspireSR in patients with documented ictal tachycardia to provide a substantial number of patients for later seizure outcome analysis.
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