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Peña-Ceballos J, Moloney PB, Valentin A, O'Donnell C, Colleran N, Liggan B, Staunton-Grufferty B, Ennis P, Grogan R, Mullins G, Costello DJ, Doherty CP, Sweeney KJ, El Naggar H, Kilbride RD, Widdess-Walsh P, O'Brien D, Delanty N. Vagus nerve stimulation in refractory idiopathic generalised epilepsy: An Irish retrospective observational study. Seizure 2023; 112:98-105. [PMID: 37778300 DOI: 10.1016/j.seizure.2023.09.019] [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: 06/09/2023] [Revised: 09/05/2023] [Accepted: 09/22/2023] [Indexed: 10/03/2023] Open
Abstract
OBJECTIVE Refractory idiopathic generalised epilepsy (IGE; also known as genetic generalised epilepsy) is a clinical challenge due to limited available therapeutic options. While vagus nerve stimulation (VNS) is approved as an adjunctive treatment for drug-resistant focal epilepsy, there is limited evidence supporting its efficacy for refractory IGE. METHODS We conducted a single-centre retrospective analysis of adult IGE patients treated with VNS between January 2003 and January 2022. We analysed the efficacy, safety, tolerability, stimulation parameters and potential clinical features of VNS response in this IGE cohort. RESULTS Twenty-three IGE patients were implanted with VNS between January 2003 and January 2022. Twenty-two patients (95.65%) were female. The median baseline seizure frequency was 30 per month (interquartile range [IQR]= 140), including generalised tonic-clonic seizures (GTCS), absences, myoclonus, and eyelid myoclonia with/without absences. The median number of baseline anti-seizure medications (ASM) was three (IQR= 2). Patients had previously failed a median of six ASM (IQR= 5). At the end of the study period, VNS therapy remained active in 17 patients (73.9%). amongst patients who continued VNS, thirteen (56.5% of the overall cohort) were considered responders (≥50% seizure frequency reduction). Amongst the clinical variables analysed, only psychiatric comorbidity correlated with poorer seizure outcomes, but was non-significant after applying the Bonferroni correction. Although 16 patients reported side-effects, none resulted in the discontinuation of VNS therapy. SIGNIFICANCE Over half of the patients with refractory IGE experienced a positive response to VNS therapy. VNS represents a viable treatment option for patients with refractory IGE, particularly for females, when other therapeutic options have been exhausted.
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Affiliation(s)
| | - Patrick B Moloney
- Department of Neurology, Beaumont Hospital, Dublin, Ireland; School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland; FutureNeuro, the Science Foundation Ireland Research Centre for Chronic and Rare Neurological Diseases, Dublin, Ireland
| | - Antonio Valentin
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Cara O'Donnell
- Department of Clinical Neurophysiology, Beaumont Hospital, Dublin, Ireland
| | - Niamh Colleran
- Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | - Brenda Liggan
- Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | | | - Patricia Ennis
- Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland
| | - Roger Grogan
- Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | - Gerard Mullins
- Department of Clinical Neurophysiology, Beaumont Hospital, Dublin, Ireland
| | - Daniel J Costello
- FutureNeuro, the Science Foundation Ireland Research Centre for Chronic and Rare Neurological Diseases, Dublin, Ireland; Department of Neurology, Cork University Hospital, Cork, Ireland
| | - Colin P Doherty
- FutureNeuro, the Science Foundation Ireland Research Centre for Chronic and Rare Neurological Diseases, Dublin, Ireland; Department of Neurology, St. James's Hospital, Dublin, Ireland; Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | | | - Hany El Naggar
- Department of Neurology, Beaumont Hospital, Dublin, Ireland; School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland; FutureNeuro, the Science Foundation Ireland Research Centre for Chronic and Rare Neurological Diseases, Dublin, Ireland
| | - Ronan D Kilbride
- Department of Neurology, Beaumont Hospital, Dublin, Ireland; Department of Clinical Neurophysiology, Beaumont Hospital, Dublin, Ireland
| | - Peter Widdess-Walsh
- Department of Neurology, Beaumont Hospital, Dublin, Ireland; Department of Clinical Neurophysiology, Beaumont Hospital, Dublin, Ireland
| | - Donncha O'Brien
- Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland
| | - Norman Delanty
- Department of Neurology, Beaumont Hospital, Dublin, Ireland; School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland; FutureNeuro, the Science Foundation Ireland Research Centre for Chronic and Rare Neurological Diseases, Dublin, Ireland.
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Skrehot HC, Englot DJ, Haneef Z. Neuro-stimulation in focal epilepsy: A systematic review and meta-analysis. Epilepsy Behav 2023; 142:109182. [PMID: 36972642 DOI: 10.1016/j.yebeh.2023.109182] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/10/2023] [Accepted: 03/12/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVES Different neurostimulation modalities are available to treat drug-resistant focal epilepsy when surgery is not an option including vagus nerve stimulation (VNS), responsive neurostimulation (RNS), and deep brain stimulation (DBS). Head-to-head comparisons of efficacy do not exist between them nor are likely to be available in the future. We performed a meta-analysis on VNS, RNS, and DBS outcomes to compare seizure reduction efficacy for focal epilepsy. METHODS We systematically reviewed the literature for reported seizure outcomes following implantation with VNS, RNS, and DBS in focal-onset seizures and performed a meta-analysis. Prospective or retrospective clinical studies were included. RESULTS Sufficient data were available at years one (n = 642, two (n = 480), and three (n = 385) for comparing the three modalities with each other. Seizure reduction for the devices at years one, two, and three respectively were: RNS: 66.3%, 56.0%, 68.4%; DBS- 58.4%, 57.5%, 63.8%; VNS 32.9%, 44.4%, 53.5%. Seizure reduction at year one was greater for RNS (p < 0.01) and DBS (p < 0.01) compared to VNS. CONCLUSIONS Our findings indicate the seizure reduction efficacy of RNS is similar to DBS, and both had greater seizure reductions compared to VNS in the first-year post-implantation, with the differences diminishing with longer-term follow-up. SIGNIFICANCE The results help guide neuromodulation treatment in eligible patients with drug-resistant focal epilepsy.
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Affiliation(s)
- Henry C Skrehot
- Department of Neurology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Dario J Englot
- Departments of Neurological Surgery, Neurology, Radiology, Electrical Engineering, and Biomedical Engineering, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Zulfi Haneef
- Department of Neurology, Baylor College of Medicine, Houston, TX 77030, USA; Neurology Care Line, VA Medical Center, Houston, TX 77030, USA.
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Ferreira Soares D, Pires de Aguiar PH. Callosotomy vs Vagus Nerve Stimulation in the Treatment of Lennox-Gastaut Syndrome: A Systematic Review With Meta-Analysis. Neuromodulation 2022; 26:518-528. [PMID: 35989160 DOI: 10.1016/j.neurom.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/09/2022] [Accepted: 06/29/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Lennox-Gastaut syndrome (LGS) is a severe drug-resistant epileptic syndrome. Palliative treatments such as corpus callosotomy (CC) and vagus nerve stimulation (VNS) have emerged as treatments to reduce the number of seizures in patients. The aim of this study is to compare the effectiveness of CC and VNS in patients with LGS studied in the last 30 years. MATERIALS AND METHODS We conducted a systematic review with meta-analysis and collected papers from PubMed (MEDLINE), Ovidsp, Web of Science, and Cochrane Library data bases. The articles analyzed were published between January 1990 and December 2020. Keywords were chosen based on internal and external validation in the PubMed data base (the analysis is available in the Supplementary Data Supplementary Appendix). Prospective or retrospective case reports (n ≥ 2), case series, cohort studies, or case-control studies involving patients with LGS were included in the analysis. We selected studies that had no age or sex restriction and that provided data on seizures before and after treatments. Studies not written in English, published without peer review, or not indexed in the data bases were excluded. Other exclusion criteria were the absence of seizure data and the impossibility of extracting this information from the studies. To analyze the results, we used the random-effects model based on the assessment of heterogeneity (I2 statistics) in two scenarios. In scenario 1, we assessed the incidence of patients with a seizure reduction ≥ 50%; in scenario 2, we assessed the incidence of patients with a seizure reduction > 0%. RESULTS Of the 7418 articles found using the keywords, 32 were considered eligible. Of these, 18 articles were on VNS (175 patients) and 14 on CC (107 patients). For scenario 1 (seizure reduction ≥ 50%), CC had an incidence of 65% (95% CI, 37%-94%), with an I2 value of 82.7%; VNS had an incidence of 34% (95% CI, 11%-57%), with an I2 value of 80.7%. For scenario 2 (seizure reduction > 0%), CC had an incidence of 80% (95% CI, 58%-100%), with an I2 value of 84.7%; VNS had an incidence of 64% (95% CI, 38%-89%), with an I2 value of 90.8%. There was an overlap of confidence intervals, with no statistical difference between the treatments in both scenarios. DISCUSSION Our analysis of LGS showed that the CC and VNS treatments are significantly beneficial to reducing seizures, without superiority between them.
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Affiliation(s)
- Davi Ferreira Soares
- Department of Neurosurgery IAMSPE-State Government Employee Medical Assistance Institute, São Paulo, Brazil; Department of Neurosurgery, FMABC - ABC Medical School, Santo André, Brazil.
| | - Paulo Henrique Pires de Aguiar
- Department of Neurosurgery IAMSPE-State Government Employee Medical Assistance Institute, São Paulo, Brazil; Department of Neurosurgery, FMABC - ABC Medical School, Santo André, Brazil
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Benson A, Shahwan A. Monitoring the frequency and duration of epileptic seizures: "A journey through time". Eur J Paediatr Neurol 2021; 33:168-178. [PMID: 34120833 DOI: 10.1016/j.ejpn.2021.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 01/19/2021] [Accepted: 05/25/2021] [Indexed: 11/28/2022]
Abstract
Seizure monitoring plays an undeniably important role in diagnosing and managing epileptic seizures. Establishing the frequency and duration of seizures is crucial for assessing the burden of this chronic neurological disease, selecting treatment methods, determining how frequently these methods are applied, and informing short and long-term therapeutic decisions. Over the years, seizure monitoring tools and methods have evolved and become increasingly sophisticated; from home seizure diaries to EEG monitoring to cutting-edge responsive neurostimulation systems. In this article, the various methods of seizure monitoring are reviewed.
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Affiliation(s)
- Ailbhe Benson
- Department of Clinical Neurophysiology & Neurology, CHI at Temple Street, Dublin, Ireland.
| | - Amre Shahwan
- Department of Clinical Neurophysiology & Neurology, CHI at Temple Street, Dublin, Ireland.
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Thirunavu V, Du R, Wu JY, Berg AT, Lam SK. The role of surgery in the management of Lennox-Gastaut syndrome: A systematic review and meta-analysis of the clinical evidence. Epilepsia 2021; 62:888-907. [PMID: 33626200 DOI: 10.1111/epi.16851] [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: 10/06/2020] [Revised: 02/01/2021] [Accepted: 02/01/2021] [Indexed: 11/29/2022]
Abstract
Lennox-Gastaut syndrome (LGS) is a severe form of childhood onset epilepsy in which patients require multiple medications and may be candidates for palliative surgical intervention. In this meta-analysis, we sought to evaluate the impact of palliative vagus nerve stimulation (VNS), corpus callosotomy (CC), and resective surgery (RS) by analyzing their impact on seizure control, antiepileptic drug (AED) usage, quality of life (QOL), behavior, cognition, prognostic factors, and complications. A systematic search of PubMed MEDLINE, Scopus, and Cochrane Database of Systematic Reviews was performed to find articles that met the following criteria: (1) prospective/retrospective study with original data, (2) at least one LGS surgery patient aged less than 18 years, and (3) information on seizure frequency reduction (measured as percentage, Engel class, or qualitative comment). Seizures were analyzed quantitatively in a meta-analysis of proportions and a random-effects model, whereas other outcomes were analyzed qualitatively. Forty studies with 892 LGS patients met the selection criteria, with 19 reporting on CC, 17 on VNS, four on RS, two on RS + CC, one on CC + VNS, and one on deep brain stimulation. CC seizure reduction rate was 74.1% (95% confidence interval [CI] = 64.5%-83.7%), and VNS was 54.6% (95% CI = 42.9%-66.3%), which was significantly different (p < .001). RS seizure reduction was 88.9% (95% CI = 66.1%-99.7%). Many VNS patients reported alertness improvements, and most had no major complications. VNS was most effective for atonic/tonic seizures; higher stimulation settings correlated with better outcomes. CC patients reported moderate cognitive and QOL improvements; disconnection syndrome, transient weakness, and respiratory complications were noted. Greater callosotomy extent correlated with better outcomes. AED usage most often did not change after surgery. RS showed considerable QOL improvements for patients with localized seizure foci. In the reported literature, CC appeared to be more effective than VNS for seizure reduction. VNS may provide a similar or higher level of QOL improvement with lower aggregate risk of complications. Patient selection, anatomy, and seizure type will inform decision-making.
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Affiliation(s)
- Vineeth Thirunavu
- Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rebecca Du
- Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Joyce Y Wu
- Division of Pediatric Neurology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Anne T Berg
- Division of Pediatric Neurology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sandi K Lam
- Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Abdelmoity SA, Abdelmoity AA, Riordan SM, Kaufman C, Le Pichon JB, Abdelmoity A. The efficacy and tolerability of auto-stimulation-VNS in children with Lennox-Gastaut syndrome. Seizure 2021; 86:168-174. [PMID: 33626436 DOI: 10.1016/j.seizure.2021.02.015] [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] [Received: 05/03/2020] [Revised: 12/24/2020] [Accepted: 02/11/2021] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE Lennox-Gastaut syndrome (LGS) is a severe drug-resistant epilepsy (DRE) of childhood. The Vagus Nerve Stimulator (VNS) is established as a safe and effective treatment for DRE. This study assesses efficacy and tolerability of the auto-stimulation VNS models in pediatric patients with LGS. METHODS This is a retrospective chart review of a cohort of pediatric patients (Age 1-18 years old) with LGS implanted with an auto-stimulation VNS model at a single level four pediatric epilepsy center. Patient responder's rate was measured as seizure reduction over baseline and improvements in five quality-of-life measures as reported by the patients and families. Efficacy and tolerability were assessed at 1, 3, 6, 12, 18 and 24 months compared to baseline. RESULTS This cohort includes 71 consecutive children with Lennox-Gastaut syndrome who underwent implantation with one of two models of the auto-stimulation VNS. The average age of the children at implantation was 20.82 months. Of those patients, 55 % of patients achieved greater than 50 % seizure reduction at six months, 67.7 % at 12 months, and 65 % at 24 months. At 12 months 11 % of the patients were completely seizure free and at 24 months 17 % were seizure free. By 24 months post implantation most of the patient families reported at least a 50 % improvement rate in one or more of the quality-of-life measures. The most commonly reported adverse events were dysphonia, paresthesia, and shortness of breath, all of which were tolerated and subsided by 24 months. SIGNIFICANCE This study provides evidence that VNS models with the auto-stimulation paradigm based on detection of tachycardia are well tolerated and effective in a pediatric population with LGS. Furthermore, this study shows that for this population, the auto-stimulation models of the VNS may provide additional benefits over the earlier VNS versions.
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Affiliation(s)
| | - Ayman A Abdelmoity
- Division of Neurology, Department of Pediatrics, Children's Mercy Kansas City, United States
| | - Sean M Riordan
- Division of Neurology, Department of Pediatrics, Children's Mercy Kansas City, United States
| | - Christian Kaufman
- Section of Neurosurgery, Department of Surgery, Children's Mercy Kansas City, United States
| | - Jean-Baptiste Le Pichon
- Division of Neurology, Department of Pediatrics, Children's Mercy Kansas City, United States.
| | - Ahmed Abdelmoity
- Division of Neurology, Department of Pediatrics, Children's Mercy Kansas City, United States
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7
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De Ridder D, Langguth B, Vanneste S. Vagus nerve stimulation for tinnitus: A review and perspective. PROGRESS IN BRAIN RESEARCH 2020; 262:451-467. [PMID: 33931191 DOI: 10.1016/bs.pbr.2020.08.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Vagus nerve stimulation is a promising new tool in the treatment of chronic tinnitus. Current protocols involve pairing sounds, which exclude the tinnitus frequency, with simultaneous vagus nerve stimulation (VNS). This is based on extensive preclinical animal studies that demonstrate that pairing non-tinnitus sounds with VNS results in a tonotopic map plasticity. It is thought that by expanding the non-tinnitus sound representation, it is possible to overturn the expanded tonotopic map associated with the tinnitus frequency in these animal models. These findings have been translated into a clinical approach, where a clinically significant, but moderate improvement, in tinnitus distress and a modest benefit in tinnitus loudness perception has been shown. Yet, pairing tinnitus matched sound to VNS may produce tinnitus improvement by Pavlovian conditioning, in which the distressful tinnitus sound becomes associated with a relaxing "rest and digest" response from activation of the vagus nerve. If this hypothesis is correct, beneficial effects should be achieved with paired sounds that resemble the tinnitus sounds as much as possible. In conclusion, although the potential to use VNS to drive neural plasticity to reduce or eliminate the neural drivers of ongoing tinnitus is exciting, much work is needed to more completely understand the neural basis of tinnitus and to develop tailored therapies to address the suffering caused by this heterogeneous condition. Whether pairing of the vagus stimulation with non-tinnitus or tinnitus-matched sounds is essential is still to be determined.
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Affiliation(s)
- Dirk De Ridder
- Department of Surgical Sciences, Section of Neurosurgery, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
| | - Berthold Langguth
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Sven Vanneste
- Lab for Clinical and Integrative Neuroscience, School of Behavioral and Brain Sciences, University of Texas at Dallas, Richardson, TX, United States; Global Brain Health Institute & Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland
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Health Technology Assessment Report on Vagus Nerve Stimulation in Drug-Resistant Epilepsy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17176150. [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] [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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Florie MGMH, Pilz W, Dijkman RH, Kremer B, Wiersma A, Winkens B, Baijens LWJ. The Effect of Cranial Nerve Stimulation on Swallowing: A Systematic Review. Dysphagia 2020; 36:216-230. [PMID: 32410202 PMCID: PMC8004503 DOI: 10.1007/s00455-020-10126-x] [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] [Received: 01/05/2020] [Accepted: 05/02/2020] [Indexed: 01/09/2023]
Abstract
This systematic review summarizes published studies on the effect of cranial nerve stimulation (CNS) on swallowing and determines the level of evidence of the included studies to guide the development of future research on new treatment strategies for oropharyngeal dysphagia (OD) using CNS. Studies published between January 1990 and October 2019 were found via a systematic comprehensive electronic database search using PubMed, Embase, and the Cochrane Library. Two independent reviewers screened all articles based on the title and abstract using strict inclusion criteria. They independently screened the full text of this initial set of articles. The level of evidence of the included studies was assessed independently by the two reviewers using the A-B-C rating scale. In total, 3267 articles were found in the databases. In the majority of these studies, CNS was used for treatment-resistant depression or intractable epilepsy. Finally, twenty-eight studies were included; seven studies on treatment of depression, thirteen on epilepsy, and eight on heterogeneous indications. Of these, eight studies reported the effects of CNS on swallowing and in 20 studies the swallowing outcome was described as an adverse reaction. A meta-analysis could not be carried out due to the poor methodological quality and heterogeneity of study designs of the included studies. These preliminary data suggest that specific well-indicated CNS might be effective in reducing OD symptoms in selective patient groups. But it is much too early for conclusive statements on this topic. In conclusion, the results of these studies are encouraging for future research on CNS for OD. However, randomized, double-blind, sham-controlled clinical trials with sufficiently large sample sizes are necessary.
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Affiliation(s)
- Michelle G M H Florie
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, PO Box 5800, 6202 AZ, Maastricht, The Netherlands. .,GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - Walmari Pilz
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.,School for Mental Health and Neuroscience - MHeNs, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Remco H Dijkman
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Bernd Kremer
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.,GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Anke Wiersma
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, CAPHRI - Care and Public Health Research Institute, Maastricht University, PO Box 616, 6200 MD, Maastricht, The Netherlands
| | - Laura W J Baijens
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.,GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
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Ji T, Yang Z, Liu Q, Liao J, Yin F, Chen Y, Zou L, Li B, Gao Y, Shu X, Huang S, Gao F, Liang J, Lin SF, Peng J, Song S, Wang J, Che C, Sun W, Tian M, Yang L, Hua Y, Hao Y, Cai L, Li L, Jiang Y. Vagus nerve stimulation for pediatric patients with intractable epilepsy between 3 and 6 years of age: study protocol for a double-blind, randomized control trial. Trials 2019; 20:44. [PMID: 30642370 PMCID: PMC6332620 DOI: 10.1186/s13063-018-3087-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 11/30/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Recent clinical observations have reported the potential benefit of vagus nerve stimulation (VNS) as an adjunctive therapy for pediatric epilepsy. Preliminary evidence suggests that VNS treatment is effective for seizure reduction and mental development in young participants between 3 and 6 years of age who suffer from intractable epilepsy. However, robust clinical evidence for quantifying the difference of the efficacy and safety of VNS treatment in this specific patient population has yet to be reported. METHODS/DESIGN A two-armed, multicenter, randomized, double-blind, prospective trial will be carried out to evaluate whether VNS is beneficial and safe for pediatric epilepsy. Pediatric participants aged between 3 to 6 years old with intractable epilepsy will be recruited and randomly assigned to experimental and control groups with a 1:1 allocation using a computer-generating randomization schedule. Before enrollment, informed consent will be signed by the parents of the participants and the study researchers. Participants in the experimental group will receive electrical stimulation over 24 weeks under standard stimulation parameters. Participants in the control group will not receive any stimulation during the 12 weeks of the double-blind period. The guardians of the participants are required to keep a detailed diary to record seizure activity. Outcome assessments including seizure frequency, Gesell Mental Developmental Scale scores, use of antiepileptic drugs and dosages, and adverse events will be collected at baseline, 6, 12, 18 and/or 24 weeks after electrical stimulation is initiated. The effects of treatment will be analyzed with time and treatment group comparisons. DISCUSSION This trial will evaluate quantitative differences in efficacy and safety with/without VNS treatment for pediatric participants aged between 3 to 6 years with intractable epilepsy and will explore whether the current age range of VNS therapy can be expanded. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT03062514 , Registered on 23 February 2017.
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Affiliation(s)
- Taoyun Ji
- 0000 0004 1764 1621grid.411472.5Division of Pediatric Neurology, Pediatrics Department, Peking University First Hospital, No.1 Xi’an Men Street, West District, Beijing, 100034 China
- 0000 0004 1764 1621grid.411472.5Department of Pediatric Epilepsy Center, Peking University First Hospital, No.1 Xi’an Men Street, West District, Beijing, 100034 China
| | - Zhao Yang
- 0000 0001 0662 3178grid.12527.33National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China
| | - Qingzhu Liu
- 0000 0004 1764 1621grid.411472.5Department of Pediatric Epilepsy Center, Peking University First Hospital, No.1 Xi’an Men Street, West District, Beijing, 100034 China
| | - Jianxiang Liao
- 0000 0004 1806 5224grid.452787.bDepartment of Neurology, Shenzhen Children’s Hospital, Shenzhen, China
| | - Fei Yin
- 0000 0004 1757 7615grid.452223.0Department of Pediatrics, Xiangya Hospital of Central South University, Changsha, Hunan China
- Hunan Intellectual and Developmental Disabilities Research Center of Children, Changsha, Hunan China
| | - Yanhui Chen
- 0000 0004 1758 0478grid.411176.4Division of Pediatric Neurology, Pediatrics Department, Fujian Medical University Union Hospital, Fuzhou, China
- 0000 0004 1758 0478grid.411176.4Department of Epilepsy Center, Fujian Medical University Union Hospital, Fuzhou, China
| | - Liping Zou
- 0000 0004 1761 8894grid.414252.4Department of Pediatric, Chinese PLA General Hospital, Beijing, China
| | - Baomin Li
- grid.452402.5Pediatics Department, Qilu Hospital of Shandong University, Jinan, Shandong China
| | - Yuxing Gao
- 0000 0004 1769 9639grid.460018.bDivision of Pediatrics Neurology, Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Xiaomei Shu
- grid.413390.cDepartment of Pediatrics, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou China
| | - Shaoping Huang
- grid.452672.0Department of Pediatrics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Feng Gao
- grid.411360.1Department of Neurology, The Children’s Hospital, ZheJiang University School of Medicine, Hangzhou, China
| | - Jianmin Liang
- grid.452451.3Department of Pediatric Neurology, First Bethune Hospital, Jilin University, Changchun, China
- grid.452451.3Research Center of Neuroscience, First Bethune Hospital, Jilin University, Changchun, China
| | - Su Fang Lin
- 0000 0004 1806 5224grid.452787.bDepartment of Neurology, Shenzhen Children’s Hospital, Shenzhen, China
| | - Jing Peng
- 0000 0004 1757 7615grid.452223.0Department of Pediatrics, Xiangya Hospital of Central South University, Changsha, Hunan China
- Hunan Intellectual and Developmental Disabilities Research Center of Children, Changsha, Hunan China
| | - Shiwei Song
- 0000 0004 1758 0478grid.411176.4Department of Epilepsy Center, Fujian Medical University Union Hospital, Fuzhou, China
- 0000 0004 1758 0478grid.411176.4Department of Neurosurgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jing Wang
- 0000 0004 1761 8894grid.414252.4Department of Pediatric, Chinese PLA General Hospital, Beijing, China
| | - Chao Che
- grid.452402.5Pediatics Department, Qilu Hospital of Shandong University, Jinan, Shandong China
| | - Wenxiu Sun
- 0000 0004 1769 9639grid.460018.bDivision of Pediatrics Neurology, Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Maoqiang Tian
- grid.413390.cDepartment of Pediatrics, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou China
| | - Lin Yang
- grid.452672.0Department of Pediatrics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yi Hua
- grid.411360.1Department of Neurology, The Children’s Hospital, ZheJiang University School of Medicine, Hangzhou, China
| | - Yunpeng Hao
- grid.452451.3Department of Pediatric Neurology, First Bethune Hospital, Jilin University, Changchun, China
| | - Lixin Cai
- 0000 0004 1764 1621grid.411472.5Department of Pediatric Epilepsy Center, Peking University First Hospital, No.1 Xi’an Men Street, West District, Beijing, 100034 China
| | - Luming Li
- 0000 0001 0662 3178grid.12527.33National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China
- 0000 0001 0662 3178grid.12527.33Man-Machine-Environment Engineering Institute, School of Aerospace Engineering, Tsinghua University, Room_204, North Part, Mengminwei Technology Building, Beijing, 100084 China
- grid.499361.0Precision Medicine and Healthcare Research Center, Tsinghua-Berkeley Shenzhen Institute, Shenzhen, China
- 0000 0004 0369 153Xgrid.24696.3fCenter of Epilepsy, Beijing Institute for Brain Disorders, Beijing, 100069 China
| | - Yuwu Jiang
- 0000 0004 1764 1621grid.411472.5Division of Pediatric Neurology, Pediatrics Department, Peking University First Hospital, No.1 Xi’an Men Street, West District, Beijing, 100034 China
- 0000 0004 1764 1621grid.411472.5Department of Pediatric Epilepsy Center, Peking University First Hospital, No.1 Xi’an Men Street, West District, Beijing, 100034 China
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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: 102] [Impact Index Per Article: 17.0] [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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12
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Patel A, Wang L, Gedela S. Health Care Utilization Following Vagus Nerve Stimulation Therapy in Pediatric Epilepsy Patients From a Pediatric Accountable Care Organization. J Child Neurol 2018; 33:136-139. [PMID: 29172909 DOI: 10.1177/0883073817743639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Vagus nerve stimulation has been a therapy for epilepsy approved by the US Food and Drug Administration (FDA) for patients 4 and older and shown efficacy and safety in younger pediatric patients. METHODS The authors performed a retrospective analysis utilizing Medicaid claims from an accountable care organization to measure the intervention of vagus nerve stimulation therapy in regard to unplanned health care utilization. Thirteen unique patients were included who had vagus nerve stimulation therapy who had at least 6 months of continuous enrollment in a managed Medicaid health plan. Comparison with 12 months of data before and after vagus nerve stimulation implantation was performed. RESULTS Patients had statistically significant fewer unplanned inpatient visits per patient per enrollment month after vagus nerve stimulation implantation. CONCLUSION Utilizing claims data, vagus nerve stimulation implantation demonstrates a reduction in unplanned hospitalizations.
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Affiliation(s)
- Anup Patel
- 1 Department of Pediatrics and Neurology, Nationwide Children's Hospital, Columbus, OH, USA.,2 Ohio State University College of Medicine, Columbus, OH, USA
| | - Ling Wang
- 3 Data Resource Center, Nationwide Children's Hospital, Columbus, OH, USA
| | - Satyanarayana Gedela
- 1 Department of Pediatrics and Neurology, Nationwide Children's Hospital, Columbus, OH, USA.,2 Ohio State University College of Medicine, Columbus, OH, USA
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13
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Okanishi T, Fujimoto A, Nishimura M, Kanai S, Motoi H, Homma Y, Enoki H. Insufficient efficacy of vagus nerve stimulation for epileptic spasms and tonic spasms in children with refractory epilepsy. Epilepsy Res 2017; 140:66-71. [PMID: 29287185 DOI: 10.1016/j.eplepsyres.2017.12.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/27/2017] [Accepted: 12/11/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Vagus nerve stimulation (VNS) leads to palliation of refractory seizures. Epileptic spasms (ES) and tonic spasms (TS) appear in children with West syndrome and symptomatic generalized epilepsy. Both types of spasms are often characterized by truncal muscular contractions and ictal electroencephalography (EEG) findings comprising the contiguous phases: phase 1) 15-20 Hz, spindle-like fast activity (occur in 70%), 2) diffuse polyphasic δ/θ waves (100%), and 3) electrodecremental activity (70%). Here, we examined the effect of VNS on these spasms that are uniformly associated with the EEG and electromyogram changes. METHODS A consecutive series of 32 patients satisfied the inclusion criteria consisting of 1) medically refractory epilepsy, 2) VNS implantation between 2010 and 2015, 3) implantation of VNS before the age of 20 years, and 4) follow-up >2 years. From this cohort, 16 patients had spasms (ES/TS group), whereas the remaining 16 had partial seizures with or without secondary generalization (PS/SG group). We compared seizure outcomes between the two groups, and also determined the factors predicting these outcomes within the ES/TS group. RESULTS The outcomes after 2 years of implantation, defined using the McHugh classification, were as follows: II (for 2 patients), III (5), and V (9) in the ES/TS group; and I (3 patients), II (6), III (2), IV (1), and V (4) in the PS/SG group. The ES/TS group had significantly worse outcomes than the PS/SG group (p = 0.024, Mann-Whitney U test). Multivariate ordinal logistic regression analysis revealed that shorter mean durations of ictal events were associated with better seizure outcomes following VNS implantation (p = 0.007). SIGNIFICANCE Only 13% of the patients in the ES/TS group had seizure reductions of greater than 50%. VNS was less effective for the treatment of patients with ES/TS than for those with PS/SG and those described in previous studies.
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Affiliation(s)
- Tohru Okanishi
- Department of Child Neurology, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, 430-8558, Japan.
| | - Ayataka Fujimoto
- Epilepsy and Neurosurgery, Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, 430-8558, Japan
| | - Mitsuyo Nishimura
- Department of Clinical Neurophysiology, Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, 430-8558, Japan
| | - Sotaro Kanai
- Department of Child Neurology, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, 430-8558, Japan
| | - Hirotaka Motoi
- Department of Child Neurology, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, 430-8558, Japan
| | - Yoichiro Homma
- Department of General Internal Medicine, Seirei-Hamamatsu General Hospital, Hamamatsu, Shizuoka, 430-8558, Japan
| | - Hideo Enoki
- Department of Child Neurology, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, 430-8558, Japan
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14
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Englot DJ, Rolston JD, Wright CW, Hassnain KH, Chang EF. Rates and Predictors of Seizure Freedom With Vagus Nerve Stimulation for Intractable Epilepsy. Neurosurgery 2017; 79:345-53. [PMID: 26645965 PMCID: PMC4884552 DOI: 10.1227/neu.0000000000001165] [Citation(s) in RCA: 167] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Supplemental Digital Content is Available in the Text. BACKGROUND: Neuromodulation-based treatments have become increasingly important in epilepsy treatment. Most patients with epilepsy treated with neuromodulation do not achieve complete seizure freedom, and, therefore, previous studies of vagus nerve stimulation (VNS) therapy have focused instead on reduction of seizure frequency as a measure of treatment response. OBJECTIVE: To elucidate rates and predictors of seizure freedom with VNS. METHODS: We examined 5554 patients from the VNS therapy Patient Outcome Registry, and also performed a systematic review of the literature including 2869 patients across 78 studies. RESULTS: Registry data revealed a progressive increase over time in seizure freedom after VNS therapy. Overall, 49% of patients responded to VNS therapy 0 to 4 months after implantation (≥50% reduction seizure frequency), with 5.1% of patients becoming seizure-free, while 63% of patients were responders at 24 to 48 months, with 8.2% achieving seizure freedom. On multivariate analysis, seizure freedom was predicted by age of epilepsy onset >12 years (odds ratio [OR], 1.89; 95% confidence interval [CI], 1.38-2.58), and predominantly generalized seizure type (OR, 1.36; 95% CI, 1.01-1.82), while overall response to VNS was predicted by nonlesional epilepsy (OR, 1.38; 95% CI, 1.06-1.81). Systematic literature review results were consistent with the registry analysis: At 0 to 4 months, 40.0% of patients had responded to VNS, with 2.6% becoming seizure-free, while at last follow-up, 60.1% of individuals were responders, with 8.0% achieving seizure freedom. CONCLUSION: Response and seizure freedom rates increase over time with VNS therapy, although complete seizure freedom is achieved in a small percentage of patients. ABBREVIATIONS: AED, antiepileptic drug VNS, vagus nerve stimulation
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Affiliation(s)
- Dario J Englot
- *UCSF Comprehensive Epilepsy Center, University of California, San Francisco, California; ‡Department of Neurological Surgery, University of California, San Francisco, California; §Cyberonics, Inc., Houston, Texas
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15
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Beaumont E, Campbell RP, Andresen MC, Scofield S, Singh K, Libbus I, KenKnight BH, Snyder L, Cantrell N. Cervical vagus nerve stimulation augments spontaneous discharge in second- and higher-order sensory neurons in the rat nucleus of the solitary tract. Am J Physiol Heart Circ Physiol 2017; 313:H354-H367. [PMID: 28476920 DOI: 10.1152/ajpheart.00070.2017] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 05/01/2017] [Accepted: 05/01/2017] [Indexed: 02/07/2023]
Abstract
Vagus nerve stimulation (VNS) currently treats patients with drug-resistant epilepsy, depression, and heart failure. The mild intensities used in chronic VNS suggest that primary visceral afferents and central nervous system activation are involved. Here, we measured the activity of neurons in the nucleus of the solitary tract (NTS) in anesthetized rats using clinically styled VNS. Our chief findings indicate that VNS at threshold bradycardic intensity activated NTS neuron discharge in one-third of NTS neurons. This VNS directly activated only myelinated vagal afferents projecting to second-order NTS neurons. Most VNS-induced activity in NTS, however, was unsynchronized to vagal stimuli. Thus, VNS activated unsynchronized activity in NTS neurons that were second order to vagal afferent C-fibers as well as higher-order NTS neurons only polysynaptically activated by the vagus. Overall, cardiovascular-sensitive and -insensitive NTS neurons were similarly activated by VNS: 3/4 neurons with monosynaptic vagal A-fiber afferents, 6/42 neurons with monosynaptic vagal C-fiber afferents, and 16/21 polysynaptic NTS neurons. Provocatively, vagal A-fibers indirectly activated C-fiber neurons during VNS. Elevated spontaneous spiking was quantitatively much higher than synchronized activity and extended well into the periods of nonstimulation. Surprisingly, many polysynaptic NTS neurons responded to half the bradycardic intensity used in clinical studies, indicating that a subset of myelinated vagal afferents is sufficient to evoke VNS indirect activation. Our study uncovered a myelinated vagal afferent drive that indirectly activates NTS neurons and thus central pathways beyond NTS and support reconsideration of brain contributions of vagal afferents underpinning of therapeutic impacts.NEW & NOTEWORTHY Acute vagus nerve stimulation elevated activity in neurons located in the medial nucleus of the solitary tract. Such stimuli directly activated only myelinated vagal afferents but indirectly activated a subpopulation of second- and higher-order neurons, suggesting that afferent mechanisms and central neuron activation may be responsible for vagus nerve stimulation efficacy.
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Affiliation(s)
- Eric Beaumont
- Department of Biomedical Sciences, Quillen College of Medicine, East Tennessee State University, Johnson City, Tennessee;
| | - Regenia P Campbell
- Department of Biomedical Sciences, Quillen College of Medicine, East Tennessee State University, Johnson City, Tennessee
| | | | - Stephanie Scofield
- Department of Biomedical Sciences, Quillen College of Medicine, East Tennessee State University, Johnson City, Tennessee
| | - Krishna Singh
- Department of Biomedical Sciences, Quillen College of Medicine, East Tennessee State University, Johnson City, Tennessee.,James H. Quillen Veterans Affairs Medical Center, Johnson City, Tennessee; and
| | | | | | - Logan Snyder
- Department of Biomedical Sciences, Quillen College of Medicine, East Tennessee State University, Johnson City, Tennessee
| | - Nathan Cantrell
- Department of Biomedical Sciences, Quillen College of Medicine, East Tennessee State University, Johnson City, Tennessee
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16
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Sourbron J, Klinkenberg S, Kessels A, Schelhaas HJ, Lagae L, Majoie M. Vagus Nerve Stimulation in children: A focus on intellectual disability. Eur J Paediatr Neurol 2017; 21:427-440. [PMID: 28188025 DOI: 10.1016/j.ejpn.2017.01.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 10/26/2016] [Accepted: 01/23/2017] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Vagus Nerve Stimulation (VNS) can be an efficacious add-on treatment in patients with drug-resistant epilepsy, who are not eligible for surgery. Evidence of VNS efficacy in children with intellectual disability (ID) is scarce. OBJECTIVES The purpose of this study was to review all available VNS data in the pediatric population (≤18 years old) and focus on the subpopulation with ID since appropriate treatment of these children is often challenging and complex. METHODS Cochrane, EMBASE, PubMed and MEDLINE were used to collect all research associated to VNS and ID (or synonyms) leading to a total of 37 studies. Seven studies showed the results of patients with ID and those without separately; thereby only these studies were included in the VNS meta-analysis. RESULTS Our meta-analysis showed that VNS was less effective in pediatric epilepsy patients with ID compared to those without ID (Mantel-Haenszel meta-analysis; p = 0.028, OR 0.18 (CI 95% 0.039-0.84)). However, there were no prospective controlled studies. Numerous studies reported quality of life (QoL) improvements in this subpopulation. The most common adverse events were transient and well tolerated. Side effects on cognition and behavior were not reported. DISCUSSION These results might be a reason to consider VNS early on in the treatment of this subgroup. The significantly greater amount of retrospective studies, differences in follow-up (FU), lack of control data, heterogeneous series and limited number of patients could have biased the outcome measurements. Hence, current data do not exclude VNS for children with drug-resistant epilepsy and ID but should be interpreted with caution.
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Affiliation(s)
- Jo Sourbron
- Laboratory for Molecular Biodiscovery, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Sylvia Klinkenberg
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Alfons Kessels
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht, The Netherlands
| | | | - Lieven Lagae
- Department of Development and Regeneration, Section Pediatric Neurology, University Hospitals KU Leuven, Leuven, Belgium
| | - Marian Majoie
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands; Department of Neurology, Epilepsy Center Kempenhaeghe, The Netherlands.
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17
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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: 39] [Impact Index Per Article: 5.6] [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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18
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King HH, Cayce CT, Herrin J. Thermography Examination of Abdominal Area Skin Temperatures in Individuals With and Without Focal-Onset Epilepsy. Explore (NY) 2016; 13:46-52. [PMID: 27876238 DOI: 10.1016/j.explore.2016.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Indexed: 12/16/2022]
Abstract
Early osteopathic theory and practice, and the work of the medical intuitive Edgar Cayce suggested that the abdominal areas of individuals with epilepsy would manifest "cold spots." The etiology for this phenomenon was thought to be abdominal adhesions caused by inflammation and viscero-somatic reflexes caused by adhesions or injury to visceral or musculoskeletal system structures. Indeed, until that advent of electroencephalography in the 1930s, medical practice regarding epilepsy focused on abdominal neural and visceral structures. Following two hypotheses were formulated to evaluate any abdominal temperature phenomena: (1) an abdominal quadrant division analysis would find one or more quadrants "colder" in the focal-onset epilepsy group (ICD9-CM 345.4 and 345.5) compared to controls. (2) Total abdominal areas of individuals with focal-onset epilepsy wound be colder than a control group. METHODS Overall, 50 patients with the diagnosis of focal-onset epilepsy were recruited from the office of the Epilepsy Foundation of Florida and 50 control subjects with no history of epilepsy were recruited through advertising to the public. Under controlled room conditions all subjects had infrared thermographic images made and recorded by Med-Hot Model MH-731 FLIR equipment. RESULTS There were no significant demographic difference between experimental patients and control subjects, though the control group tended to be younger and more often male; however, these were controlled for in all analyses. In the quadrant analysis, there were significant differences in that more epileptic patients had colder left upper abdominal quadrant temperatures than the control group (66.8% versus 44.9%; P = .030). In the total abdominal analysis, however, there were no significant differences. DISCUSSION The results support the hypothesis that individuals with focal-onset epilepsy have colder abdominal areas. If substantiated in further research, present study results will require further examination of the mechanisms of action for epilepsy, and suggest the need for re-examination of older formulations of abdominal epilepsy, including the place of abdominal injury, inflammation, and adhesions in epileptic pathology. The concept of somato-visceral and viscero-somatic neurological interactions is one of the possible mechanisms underlying the "cold spot" findings and warrants further consideration.
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Affiliation(s)
- Hollis H King
- University of California San Diego School of Medicine, La Jolla, CA.
| | | | - Jeph Herrin
- Flying Buttress Associates, Charlottesville, VA
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19
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Katagiri M, Iida K, Kagawa K, Hashizume A, Ishikawa N, Hanaya R, Arita K, Kurisu K. Combined surgical intervention with vagus nerve stimulation following corpus callosotomy in patients with Lennox-Gastaut syndrome. Acta Neurochir (Wien) 2016; 158:1005-12. [PMID: 26979179 DOI: 10.1007/s00701-016-2765-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 02/29/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Lennox-Gastaut syndrome (LGS) is a drug-resistant pediatric epilepsy characterized by multiple seizure types, including drop attacks (DAs). Palliative procedures such as corpus callosotomy (CC) and vagus nerve stimulation (VNS) may be effective for adequate seizure control in LGS patients who are not candidates for resective surgery. We evaluated the efficacy of the combination of these two procedures for LGS-related seizures. METHOD Ten patients with LGS (age 3-30 years at VNS implantation) underwent CC and subsequent VNS. We evaluated surgical outcomes, particularly with respect to the efficacy of VNS on seizure reduction rates for different residual seizure types after CC. We compared clinical parameters, including sex, age, seizure duration, history, MRI findings, extent of CC, number of antiepileptic drugs, and neuropsychological states, between VNS responders and non-responders to predict satisfactory seizure outcomes with respect to residual seizures after CC. FINDINGS VNS was effective for residual seizures regardless of seizure type (except for DAs) after CC in patients with LGS. Six of ten (60%) patients had a satisfactory seizure outcome (≥50% seizure reduction) for all residual seizure types after VNS. Two of ten (20%) patients were seizure-free at 12 months post-VNS. Even those patients that were non-responders, with respect to all seizures including DAs, after prior CC showed favorable responses to subsequent VNS. Compared to VNS, excellent seizure outcomes for DAs were achieved after CC in seven of nine (77.8%) patients with DAs. Among the clinical parameters, only conversation ability before VNS was significantly different between responders and non-responders (p = 0.033). CONCLUSION Combined VNS and prior CC produced satisfactory seizure outcomes in LGS patients with different seizure types, including DAs. Even non-responders to prior CC responded to subsequent VNS for residual seizures, except for DAs. There is a greater likelihood that these procedures may be more feasible in patients who possess conversation ability prior to VNS.
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20
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Ghani S, Vilensky J, Turner B, Tubbs RS, Loukas M. Meta-analysis of vagus nerve stimulation treatment for epilepsy: correlation between device setting parameters and acute response. Childs Nerv Syst 2015; 31:2291-304. [PMID: 26493055 DOI: 10.1007/s00381-015-2921-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 09/23/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Vagus nerve stimulation (VNS) is an adjunctive neurophysiological treatment for those patients who have pharmacoresistant or surgically resistant partial onset epilepsy. OBJECTIVE The aim of this study is to determine the effects of high and low stimulation paradigms on a responder rate of ≥50 and ≥75% reduction in seizure frequency and associated adverse effects in adults and children. METHOD A literature search was performed using Medline, PubMed, EMBASE, and Cochrane library for studies using vagus nerve stimulation published from January 1980 until July 2014 for medically or surgically resistant partial onset seizures, in children and adults. No restrictions on languages were imposed. DATA COLLECTION AND ANALYSIS Four authors reviewed and selected studies for inclusion and exclusion. The search identified five randomized control trials that fit with our inclusion criteria. The following outcomes were evaluated: 50% or greater reduction in total seizure frequency, 75% or greater reduction in total seizure frequency, and adverse effects. RESULTS Four randomized controlled trials were analyzed in this meta-analysis. Results indicate high stimulation is more effective in adult patients who experienced ≥50 and ≥75% reduction in seizure frequency with a significant difference within both high and low stimulation groups. In children, there was no significant difference between the two groups and patients with ≥50 % reduction in seizures. Adverse effects such as hoarseness and dyspnea were more common in the high stimulation group where the remaining side effects were not statistically different among both groups. CONCLUSION High stimulation is more effective than low stimulation in producing a greater reduction in seizure frequency in patients with medically and surgically resistant epilepsy.
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Affiliation(s)
- S Ghani
- Department of Psychiatry, School of Medicine, University of Arizona, Tucson, AZ, USA.,Department of Anatomical Sciences, School of Medicine, St. George's University, Grenada, WI, USA
| | - J Vilensky
- Department of Anatomy and Cell Biology, School of Medicine, Indiana University, Fort Wayne, IN, USA
| | - B Turner
- Department of Anatomical Sciences, School of Medicine, St. George's University, Grenada, WI, USA
| | - R S Tubbs
- Department of Anatomical Sciences, School of Medicine, St. George's University, Grenada, WI, USA.,Pediatric Neurosurgery, Children's Hospital, Birmingham, AL, USA
| | - M Loukas
- Department of Anatomical Sciences, School of Medicine, St. George's University, Grenada, WI, USA.
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Chakravarthy K, Chaudhry H, Williams K, Christo PJ. Review of the Uses of Vagal Nerve Stimulation in Chronic Pain Management. Curr Pain Headache Rep 2015; 19:54. [DOI: 10.1007/s11916-015-0528-6] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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22
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He W, Wang XY, Zhou L, Li ZM, Jing XH, Lv ZL, Zhao YF, Shi H, Hu L, Su YS, Zhu B. Transcutaneous auricular vagus nerve stimulation for pediatric epilepsy: study protocol for a randomized controlled trial. Trials 2015; 16:371. [PMID: 26292720 PMCID: PMC4546033 DOI: 10.1186/s13063-015-0906-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 08/07/2015] [Indexed: 12/31/2022] Open
Abstract
Background Recently, clinical observations reported the potential benefit of vagus nerve stimulation (VNS) for pediatric epilepsy. Transcutaneous auricular vagus nerve stimulation (ta-VNS) is a newer non-invasive VNS, making it more accessible for treating pediatric epilepsy, yet there is limited clinical evidence for its effectiveness. Methods/Design A three-center, randomized, parallel, controlled trial will be carried out to evaluate whether ta-VNS improves pediatric epilepsy. Pediatric patients aged 2 to 14 years with epilepsy will be recruited and randomly assigned to transcutaneous auricular vagus nerve stimulation (ta-VNS) group, transcutaneous auricular non-vagus nerve stimulation (tan-VNS) group, and control group with a 1:1: sqrt(2) allocation, as per a computer generated randomization schedule stratified by study center using permuted blocks of random sizes. We will use Zelen’s design, in which randomization occurs before informed consent. Patients in the stimulation groups will receive tan-VNS or ta-VNS three times a day for 6 months. Patients in the control group will not be provided with any stimulation during the 6 months. The guardians of the patients are required to keep a detailed diary to record the data. Outcome assessment including seizure frequency, electroencephalogram (EEG), heart rate variability (HRV) analysis, quality of life (QOL) and adverse events will be made at baseline and 2, 4 and 6 months after ta-VNS initiation. The seizure frequency and adverse events will be followed up at 1 year and 1.5 years after ta-VNS initiation. Discussion Results of this trial will help clarify whether ta-VNS treatment is beneficial for pediatric patients, and will make clear whether the anticonvulsive effect of ta-VNS is correlated with the improvement of sympathovagal imbalance. Trial registration Clinical Trials Identifier: NCT02004340. Registration date: 13 November 2013. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0906-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Wei He
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, 100700, China. .,Hubei University of Chinese Medicine/Innovation Center of Preventive Treatment by Acupuncture and Moxibustion, Wuhan, 430061, China.
| | - Xiao-Yu Wang
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, 100700, China.
| | - Li Zhou
- Beijing Tian Tan Hospital, Capital Medical University, Beijing, 100050, China.
| | - Zhi-Mei Li
- Beijing Tian Tan Hospital, Capital Medical University, Beijing, 100050, China.
| | - Xiang-Hong Jing
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, 100700, China.
| | - Zhong-Li Lv
- Beijing Children Hospital, Capital Medical University, Beijing, 100045, China.
| | - Yu-Feng Zhao
- Clinical Evaluation Center, Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, 100700, China.
| | - Hong Shi
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, 100700, China.
| | - Ling Hu
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, 100700, China.
| | - Yang-Shuai Su
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, 100700, China.
| | - Bing Zhu
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, 100700, China. .,Hubei University of Chinese Medicine/Innovation Center of Preventive Treatment by Acupuncture and Moxibustion, Wuhan, 430061, China.
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23
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Conway CR, Colijn MA, Schachter SC. Vagus Nerve Stimulation for Epilepsy and Depression. Brain Stimul 2015. [DOI: 10.1002/9781118568323.ch17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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De Ridder D, Kilgard M, Engineer N, Vanneste S. Placebo-Controlled Vagus Nerve Stimulation Paired With Tones in a Patient With Refractory Tinnitus. Otol Neurotol 2015; 36:575-80. [DOI: 10.1097/mao.0000000000000704] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Restaino SM, Abliz E, Wachrathit K, Krauthamer V, Shah SB. Biomechanical and functional variation in rat sciatic nerve following cuff electrode implantation. J Neuroeng Rehabil 2014; 11:73. [PMID: 24758405 PMCID: PMC4022540 DOI: 10.1186/1743-0003-11-73] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 04/07/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nerve cuff electrodes are commonly and successfully used for stimulating peripheral nerves. On the other hand, they occasionally induce functional and morphological changes following chronic implantation, for reasons not always clear. We hypothesize that restriction of nerve mobility due to cuff implantation may alter nerve conduction. METHODS We quantified acute changes in nerve-muscle electrophysiology, using electromyography, and nerve kinematics in anesthetized Sprague Dawley rat sciatic nerves during controlled hindlimb joint movement. We compared electrophysiological and biomechanical response in uncuffed nerves and those secured within a cuff electrode using analysis of variance (ANOVA) and regression analysis. RESULTS Tethering resulting from cuff implantation resulted in altered nerve strain and a complex biomechanical environment during joint movement. Coincident with biomechanical changes, electromyography revealed significantly increased variability in the response of conduction latency and amplitude in cuffed, but not free, nerves following joint movement. CONCLUSION Our findings emphasize the importance of the mechanical interface between peripheral nerves and their devices on neurophysiological performance. This work has implications for nerve device design, implantation, and prediction of long-term efficacy.
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Affiliation(s)
| | | | | | | | - Sameer B Shah
- Fischell Department of Bioengineering, University of Maryland, College Park, MD, USA.
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26
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De Ridder D, Vanneste S, Engineer ND, Kilgard MP. Safety and Efficacy of Vagus Nerve Stimulation Paired With Tones for the Treatment of Tinnitus: A Case Series. Neuromodulation 2013; 17:170-9. [DOI: 10.1111/ner.12127] [Citation(s) in RCA: 118] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Revised: 08/15/2013] [Accepted: 09/06/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Dirk De Ridder
- Brai n, Tinnitus Research Initiative Clinic Antwerp & Department of Neurosurgery; University Hospital Antwerp; Belgium
- Department of Surgical Sciences, Dunedin School of Medicine; University of Otago; New Zealand
| | - Sven Vanneste
- Brai n, Tinnitus Research Initiative Clinic Antwerp & Department of Neurosurgery; University Hospital Antwerp; Belgium
- Department of Translational Neuroscience, Faculty of Medicine; University of Antwerp; Belgium
| | | | - Michael P. Kilgard
- School of Behavioral and Brain Sciences; University of Texas at Dallas; Richardson TX USA
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Fridley J, Reddy G, Curry D, Agadi S. Surgical treatment of pediatric epileptic encephalopathies. EPILEPSY RESEARCH AND TREATMENT 2013; 2013:720841. [PMID: 24288601 PMCID: PMC3833057 DOI: 10.1155/2013/720841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 08/31/2013] [Accepted: 09/04/2013] [Indexed: 11/17/2022]
Abstract
Pediatric epileptiform encephalopathies are a group of neurologically devastating disorders related to uncontrolled ictal and interictal epileptic activity, with a poor prognosis. Despite the number of pharmacological options for treatment of epilepsy, many of these patients are drug resistant. For these patients with uncontrolled epilepsy, motor and/or neuropsychological deterioration is common. To prevent these secondary consequences, surgery is often considered as either a curative or a palliative option. Magnetic resonance imaging to look for epileptic lesions that may be surgically treated is an essential part of the workup for these patients. Many surgical procedures for the treatment of epileptiform encephalopathies have been reported in the literature. In this paper the evidence for these procedures for the treatment of pediatric epileptiform encephalopathies is reviewed.
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Affiliation(s)
- J. Fridley
- Department of Neurosurgery, Baylor College of Medicine, 1709 Dryden, Houston, TX 77030, USA
| | - G. Reddy
- Department of Neurosurgery, Baylor College of Medicine, 1709 Dryden, Houston, TX 77030, USA
| | - D. Curry
- Department of Neurosurgery, Baylor College of Medicine, 1709 Dryden, Houston, TX 77030, USA
- Department of Surgery, Section of Pediatric Neurosurgery, Texas Children's Hospital, CCC Suite 1230, 6621 Fannin Street, Houston, TX 77030, USA
| | - S. Agadi
- Department of Neurology, Baylor College of Medicine, 6501 Fannin Street, NB302, Houston, TX 77030, USA
- Department of Pediatrics, Section of Neurology and Developmental Neuroscience, One Baylor Plaza, Houston, TX 77030, USA
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28
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Behavioural and cognitive effects during vagus nerve stimulation in children with intractable epilepsy - a randomized controlled trial. Eur J Paediatr Neurol 2013; 17:82-90. [PMID: 22878130 DOI: 10.1016/j.ejpn.2012.07.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 07/08/2012] [Accepted: 07/15/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND/AIMS In addition to effects on seizure frequency in intractable epilepsy, multiple studies report benefits of vagus nerve stimulation (VNS) on behavioural outcomes and quality of life. The present study aims to investigate the effects of VNS on cognition, mood in general, depression, epilepsy-related restrictions and psychosocial adjustment in children with intractable epilepsy, as well as the relation between these effects and seizure reduction. METHODS We conducted a randomized, active-controlled, double-blinded, add-on study in 41 children (age 4-18) with medically refractory epilepsy. We performed cognitive and behavioural testing at baseline (12 weeks), at the end of the blinded phase (20 weeks) in children receiving either high-output or low-output (active control) stimulation, and at the end of the open label phase (19 weeks) with all children receiving high-output stimulation. Seizure frequency was recorded using seizure diaries. RESULTS VNS did not have a negative effect on cognition nor on psychosocial adjustment. At the end of the follow-up phase we noted an improvement of mood in general and the depression subscale for the entire group, unrelated to a reduction of seizure frequency. At the end of the blinded phase a ≥50% reduction of seizure frequency occurred in 16% of the high-stimulation group and 21% of the low-stimulation group. At the end of the open-label follow-up phase, 26% of the children experienced a seizure frequency reduction of 50% or more (responders). CONCLUSIONS VNS has additional beneficial effects in children with intractable epilepsy. As opposed to anti-epileptic drugs, there are no negative effects on cognition. Moreover, we observed an improvement of mood in general and depressed feelings in particular, irrespective of a reduction in seizure frequency. These beneficial effects should be taken into account when deciding whether to initiate or continue VNS treatment in these children.
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Lancman G, Virk M, Shao H, Mazumdar M, Greenfield JP, Weinstein S, Schwartz TH. Vagus nerve stimulation vs. corpus callosotomy in the treatment of Lennox-Gastaut syndrome: a meta-analysis. Seizure 2012; 22:3-8. [PMID: 23068970 DOI: 10.1016/j.seizure.2012.09.014] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Revised: 09/18/2012] [Accepted: 09/22/2012] [Indexed: 10/27/2022] Open
Abstract
PURPOSE Lennox-Gastaut syndrome (LGS) is an epileptogenic disorder that arises in childhood and is typically characterized by multiple seizure types, slow spike-and-wave complexes on EEG and cognitive impairment. If medical treatment fails, patients can proceed to one of two palliative surgeries, vagus nerve stimulation (VNS) or corpus callosotomy (CC). Their relative seizure control rates in LGS have not been well studied. The purpose of this paper is to compare seizure reduction rates between VNS and CC in LGS using meta-analyses of published data. METHODS A systematic search of Pubmed, Ovidsp, and Cochrane was performed to find articles that met the following criteria: (1) prospective or retrospective study, (2) at least one patient diagnosed with Lennox-Gastaut syndrome, and (3) well-defined measure of seizure frequency reduction. Seizure reduction rates were divided into seizure subtypes, as well as total seizures, and categorized as 100%, >75%, and >50%. Patient groups were compared using chi-square tests for categorical variables and t-test for continuous measures. Pooled proportions with 95% confidence interval (95% CI) of seizure outcomes were estimated for total seizures and seizure subtypes using random effects methods. RESULTS 17 VNS and 9 CC studies met the criteria for inclusion. CC had a significantly better outcome than VNS for >50% atonic seizure reduction (80.0% [67.0-90.0%] vs. 54.1% [32.1-75.4%], p<0.05) and for >75% atonic seizure reduction (70.0% [48.05-87.0%] vs. 26.3% [5.8-54.7%], p<0.05). All other seizure types, as well as total number of seizures, showed no statistically significant difference between VNS and CC. CONCLUSIONS CC may be more beneficial for LGS patients whose predominant disabling seizure type is atonic. For all other seizure types, VNS offers comparable rates to CC.
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Affiliation(s)
- Guido Lancman
- Department of Neurological Surgery, Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA
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Thompson EM, Wozniak SE, Roberts CM, Kao A, Anderson VC, Selden NR. Vagus nerve stimulation for partial and generalized epilepsy from infancy to adolescence. J Neurosurg Pediatr 2012; 10:200-5. [PMID: 22768964 DOI: 10.3171/2012.5.peds11489] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Vagus nerve stimulation (VNS) is approved by the FDA for the treatment of partial epilepsy in patients older than 12 years. Authors of the current study performed a large retrospective analysis and comparison of VNS outcomes in children with an age ≥ and < 12 years, including those with partial and generalized epilepsy. METHODS A retrospective review of the records of pediatric patients (age < 18 years) who had undergone primary VNS system implantation between 2001 and 2010 by a single pediatric neurosurgeon was undertaken. Considered data included demographics, epilepsy type (partial vs generalized), seizure frequency, seizure duration, postictal period duration, and antiepileptic medication use. RESULTS One hundred forty-six patients (49% female) were followed up for a mean of 41 months after VNS implantation. Thirty-two percent of patients had partial epilepsy and 68% had generalized epilepsy. After VNS system implantation, seizure frequency was reduced in 91% of patients, seizure duration in 50%, postictal period in 49%, and antiepileptic medication use in 75%. There was no significant difference in age, sex, or duration of follow-up according to epilepsy type. Neither was there any significant difference in seizure frequency reduction, seizure duration, postictal period, medication use, overall clinical improvement, or improvement in quality of life based on an age ≥ or < 12 years or epilepsy type. CONCLUSIONS Vagus nerve stimulation reduced both seizure frequency and antiepileptic medication use in the majority of pediatric patients regardless of sex, age cohort, or epilepsy type. Vagus nerve stimulation also reduced seizure duration and postictal period in approximately half of the pediatric patients. Contrary to expectation, children with partial epilepsy do not benefit from VNS at higher rates than those with generalized epilepsy.
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Affiliation(s)
- Eric M Thompson
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR 97239, USA
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VanStraten AF, Ng YT. Update on the management of Lennox-Gastaut syndrome. Pediatr Neurol 2012; 47:153-61. [PMID: 22883278 DOI: 10.1016/j.pediatrneurol.2012.05.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 05/09/2012] [Indexed: 11/26/2022]
Abstract
Lennox-Gastaut syndrome is a severe childhood epilepsy disorder characterized by encephalopathy and multiple, often intractable, seizure types. The drop attack is the most frequently recognizable seizure type in this patient population, and is also the most dangerous physically, thus severely limiting quality of life. The diagnosis is confirmed by electroencephalography, for which the classic pattern is a slow 2.5 Hz generalized spike-and-wave. Newer pharmacologic treatments include rufinimide and clobazam. However, antiepileptic drugs are often exhausted in pursuit of seizure control requiring nonpharmacologic interventions. These include dietary therapies, vagus nerve stimulation, and epilepsy surgery, including corpus callosotomy and focal curative resection. Although large lobar resections are often required, very localized, discrete resections may be possible, as in symptomatic Lennox-Gastaut syndrome (specifically, hypothalamic hamartoma). We review the history of the disease and current management options.
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Affiliation(s)
- Amanda F VanStraten
- Department of Neurology, University of Oklahoma Health Sciences Center, 711 Stanton L. Young Boulevard, Oklahoma City, OK 73104, USA
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Klinkenberg S, Aalbers MW, Vles JSH, Cornips EMJ, Rijkers K, Leenen L, Kessels FGH, Aldenkamp AP, Majoie M. Vagus nerve stimulation in children with intractable epilepsy: a randomized controlled trial. Dev Med Child Neurol 2012; 54:855-61. [PMID: 22540141 DOI: 10.1111/j.1469-8749.2012.04305.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM The aim of this study was to evaluate the effects of vagus nerve stimulation (VNS) in children with intractable epilepsy on seizure frequency and severity and in terms of tolerability and safety. METHOD In this study, the first randomized active controlled trial of its kind in children, 41 children (23 males; 18 females; mean age at implantation 11y 2mo, SD 4y 2mo, range 3y 10mo-17y 8mo) were included. Thirty-five participants had localization-related epilepsy (25 symptomatic; 10 cryptogenic), while six participants had generalized epilepsy (four symptomatic; two idiopathic). During a baseline period of 12 weeks, seizure frequency and severity were recorded using seizure diaries and the adapted Chalfont Seizure Severity Scale (NHS3), after which the participants entered a blinded active controlled phase of 20 weeks. During this phase, half of the participants received high-output VNS (maximally 1.75mA) and the other half received low-output stimulation (0.25mA). Finally, all participants received high-output stimulation for 19 weeks. For both phases, seizure frequency and severity were assessed as during the baseline period. Overall satisfaction and adverse events were assessed by semi-structured interviews. RESULTS At the end of the randomized controlled blinded phase, seizure frequency reduction of 50% or more occurred in 16% of the high-output stimulation group and in 21% of the low-output stimulation group (p=1.00). There was no significant difference in the decrease in seizure severity between participants in the stimulation groups. Overall, VNS reduced seizure frequency by 50% or more in 26% of participants at the end of the add-on phase The overall seizure severity also improved (p<0.001). INTERPRETATION VNS is a safe and well-tolerated adjunctive treatment of epilepsy in children. Our results suggest that the effect of VNS on seizure frequency in children is limited. However, the possible reduction in seizure severity and improvement in well-being makes this treatment worth considering in individual children with intractable epilepsy.
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Affiliation(s)
- Sylvia Klinkenberg
- Department of Neurology, Maastricht University Medical Center, Maastricht, the Netherlands.
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Chen CY, Lee HT, Chen CC, Kwan SY, Chen SJ, Hsieh LP, Tsai JD. Short-term results of vagus nerve stimulation in pediatric patients with refractory epilepsy. Pediatr Neonatol 2012; 53:184-7. [PMID: 22770107 DOI: 10.1016/j.pedneo.2012.04.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Revised: 06/14/2011] [Accepted: 06/27/2011] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Vagus nerve stimulation (VNS), an alternative method to manage patients with medically intractable epilepsy, has shown favorable results in reducing seizure relapse and improvements in quality of life. In 1997, the U.S. Food and Drug Administration approved the use of this device as an adjunctive therapy for intractable seizure in adults and adolescents older than 12 years of age. METHODS We present a preliminary study of pediatric patients, who suffered from medically intractable seizure and underwent VNS implantation after observation of the baseline seizure frequency. Classification of epileptic syndrome, seizure patterns, age of onset, seizure frequency reduction and adverse effects were recorded. RESULTS Patients who underwent VNS implantation included four adolescents and four children. The follow-up duration ranged from 9-33 months. All the patients were responders after the beginning of the stimulation. Five of the eight patients responded to VNS with a seizure frequency reduction rate > 50%, and four of the eight patients experienced a ≥ 90% seizure reduction. No significant adverse effects were noted in all patients during the observation period. CONCLUSION The effective management of medically intractable seizure remains challenging to most clinical physicians. In addition to ketogenic diet and epilepsy surgery, VNS provides an alternative way to manage this issue. Our results suggest that VNS is well tolerated in pediatric patients, and is a favorable and safe method of treating intractable seizure in common clinical practice.
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Affiliation(s)
- Chih-Yi Chen
- Department of Pediatrics, Chung Shan Medical University and Hospital, Taiwan
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Vonck K, de Herdt V, Sprengers M, Ben-Menachem E. Neurostimulation for epilepsy. HANDBOOK OF CLINICAL NEUROLOGY 2012; 108:955-970. [PMID: 22939078 DOI: 10.1016/b978-0-444-52899-5.00040-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Kristl Vonck
- Department of Neurology, Ghent University Hospital, Ghent, Belgium.
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Englot DJ, Chang EF, Auguste KI. Vagus nerve stimulation for epilepsy: a meta-analysis of efficacy and predictors of response. J Neurosurg 2011; 115:1248-55. [PMID: 21838505 DOI: 10.3171/2011.7.jns11977] [Citation(s) in RCA: 299] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Vagus nerve stimulation (VNS) was approved by the US FDA in 1997 as an adjunctive treatment for medically refractory epilepsy. It is considered for use in patients who are poor candidates for resection or those in whom resection has failed. However, disagreement regarding the utility of VNS in epilepsy continues because of the variability in benefit reported across clinical studies. Moreover, although VNS was approved only for adults and adolescents with partial epilepsy, its efficacy in children and in patients with generalized epilepsy remains unclear. The authors performed the first meta-analysis of VNS efficacy in epilepsy, identifying 74 clinical studies with 3321 patients suffering from intractable epilepsy. These studies included 3 blinded, randomized controlled trials (Class I evidence); 2 nonblinded, randomized controlled trials (Class II evidence); 10 prospective studies (Class III evidence); and numerous retrospective studies. After VNS, seizure frequency was reduced by an average of 45%, with a 36% reduction in seizures at 3-12 months after surgery and a 51% reduction after > 1 year of therapy. At the last follow-up, seizures were reduced by 50% or more in approximately 50% of the patients, and VNS predicted a ≥ 50% reduction in seizures with a main effects OR of 1.83 (95% CI 1.80-1.86). Patients with generalized epilepsy and children benefited significantly from VNS despite their exclusion from initial approval of the device. Furthermore, posttraumatic epilepsy and tuberous sclerosis were positive predictors of a favorable outcome. In conclusion, VNS is an effective and relatively safe adjunctive therapy in patients with medically refractory epilepsy not amenable to resection. However, it is important to recognize that complete seizure freedom is rarely achieved using VNS and that a quarter of patients do not receive any benefit from therapy.
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Affiliation(s)
- Dario J Englot
- Department of Neurological Surgery, University of California, San Francisco, California 94143-0112, USA.
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Legarda SB, McMahon D, Othmer S, Othmer S. Clinical neurofeedback: case studies, proposed mechanism, and implications for pediatric neurology practice. J Child Neurol 2011; 26:1045-51. [PMID: 21576401 DOI: 10.1177/0883073811405052] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Trends in alternative medicine use by American health care consumers are rising substantially. Extensive literature exists reporting on the effectiveness of neurofeedback in the treatment of autism, closed head injury, insomnia, migraine, depression, attention deficit hyperactivity disorder, epilepsy, and posttraumatic stress disorder. We speculated that neurofeedback might serve as a therapeutic modality for patients with medically refractory neurological disorders and have begun referring patients to train with clinical neurofeedback practitioners. The modality is not always covered by insurance. Confident their child's medical and neurological needs would continue to be met, the parents of 3 children with epilepsy spectrum disorder decided to have their child train in the modality. The children's individual progress following neurofeedback are each presented here. A proposed mechanism and practice implications are discussed.
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Affiliation(s)
- Stella B Legarda
- Georgetown University Medical Center, Department of Pediatrics, Washington, DC 2000, USA.
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Abstract
Abstract
Neuromodulation strategies have been proposed to treat a variety of neurological disorders, including medication-resistant epilepsy. Electrical stimulation of both central and peripheral nervous systems has emerged as a possible alternative for patients who are not deemed to be good candidates for resective procedures. In addition to well-established treatments such as vagus nerve stimulation, epilepsy centers around the world are investigating the safety and efficacy of neurostimulation at different brain targets, including the hippocampus, thalamus, and subthalamic nucleus. Also promising are the preliminary results of responsive neuromodulation studies, which involve the delivery of stimulation to the brain in response to detected epileptiform or preepileptiform activity. In addition to electrical stimulation, novel therapeutic methods that may open new horizons in the management of epilepsy include transcranial magnetic stimulation, focal drug delivery, cellular transplantation, and gene therapy. We review the current strategies and future applications of neuromodulation in epilepsy.
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Affiliation(s)
- Faisal A Al-Otaibi
- King Faisal Specialist Hospital & Research Centre, Neurosciences Department, Riyadh, Saudi Arabia
| | - Clement Hamani
- Division of Neurosurgery, Toronto Western Hospital, Toronto Western Research Institute, Ontario, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Toronto Western Hospital, Toronto Western Research Institute, Ontario, Canada
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38
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Cersósimo RO, Bartuluchi M, De Los Santos C, Bonvehi I, Pomata H, Caraballo RH. Vagus nerve stimulation: effectiveness and tolerability in patients with epileptic encephalopathies. Childs Nerv Syst 2011; 27:787-92. [PMID: 21038079 DOI: 10.1007/s00381-010-1314-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Accepted: 10/13/2010] [Indexed: 11/24/2022]
Abstract
PURPOSE We discuss the effectiveness, tolerability, and safety of vagus nerve stimulation (VNS) as adjunctive therapy in 26 patients with refractory epileptic encephalopathies (EEs). MATERIAL AND METHODS Twenty-six patients (17 male and 9 female) with electroclinical features compatible with Lennox-Gastaut syndrome (LGS) in 20 patients, Dravet syndrome (DS) in 3 patients, and epilepsy with myoclonic-astatic seizures (EMAS) in 3 patients implanted with the NCP system were analyzed. RESULTS In our series of patients with LGS, 17 cases showed a significant improvement in seizure control, with a reduction in seizure frequency of at least 50%. Seven of them previously had epileptic spasms. Three patients with EMAS and two patients with DS showed a significant improvement in seizure control, with a reduction in seizure frequency of at least 50%. A good clinical response was evident early and efficacy progressively improved with the duration of treatment up to 36 months. In patients who had a reduction in seizure frequency of at least 50%, quality of life (QOL) and neuropsychological performance improved. VNS was well-tolerated in all patients. CONCLUSION VNS is an effective and well-tolerated treatment for patients with epileptic encephalopathies EEs, improving QOL and neuropsychological performance.
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Affiliation(s)
- Ricardo O Cersósimo
- Neurology Department, Hospital de Niños Prof. Dr. Juan P Garrahan, Combate de los Pozos 1881, Buenos Aires, CP 1245, Argentina
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Zamponi N, Passamonti C, Cappanera S, Petrelli C. Clinical course of young patients with Dravet syndrome after vagal nerve stimulation. Eur J Paediatr Neurol 2011; 15:8-14. [PMID: 20971664 DOI: 10.1016/j.ejpn.2010.09.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Revised: 09/21/2010] [Accepted: 09/27/2010] [Indexed: 10/18/2022]
Abstract
Medical treatment of Dravet syndrome is disappointing. Ketogenic Diet and neurostimulation procedures as Vagus Nerve Stimulation (VNS) and Deep Brain Stimulation are in ongoing evaluation. In the present study, the long-term effectiveness of VNS on seizures, cognition and behavior was retrospectively evaluated in eight young patients with DS and medically refractory epilepsy (mean age at VNS implant: 10.28 years, range: 5-25). The average duration of treatment was 54 months (range: 12-120). Compared to baseline (mean: 55; standard deviation: 83, range: 4-200), the mean number of monthly seizures after VNS implantation was 39 ± 67 at 3 months, 42 ± 67 at 6 months and 38 ± 69 at twelve months (not significant comparisons). In particular, VNS produced a mean seizure rate reduction of 12% at three months, 6% at six months, and 31% at twelve months. All patients but three experienced some reduction in seizure burden (range: 33-61%) at twelve months. Seizure outcome after one year of stimulation was rated as Mc Hugh class II (50-79% reduction in seizure frequency) in four patients, class III (<50% reduction) in one patient and class V (no improvement) in three patients. In this small case series of patients with DS, VNS therapy had a clinically significant effect in reducing seizures at twelve months in four of the eight patients. Even in patients in whom seizure reduction was not dramatic, a slight improvement in alertness and communicative skills was seen. The long-term clinical course of two selected cases is discussed.
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Affiliation(s)
- Nelia Zamponi
- Pediatric Neurology Department, Ospedali Riuniti, Ancona, Italy.
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Arhan E, Serdaroglu A, Kurt G, Bilir E, Durdağ E, Erdem A, Aksakal FN, Ozcelik A, Baykaner K. The efficacy of vagal nerve stimulation in children with pharmacoresistant epilepsy: practical experience at a Turkish tertiary referral center. Eur J Paediatr Neurol 2010; 14:334-9. [PMID: 19850501 DOI: 10.1016/j.ejpn.2009.09.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2008] [Revised: 06/18/2009] [Accepted: 09/27/2009] [Indexed: 11/16/2022]
Abstract
BACKGROUND Vagus nerve stimulation (VNS) is an effective therapy for pharmacoresistant epilepsy. Nevertheless, information regarding the long-term outcome of VNS in children is limited. AIM To describe the long-term outcome of VNS in patients with pharmacoresistant epilepsy treated at the Gazi University Medical Faculty Epilepsy Center, Turkey. PATIENTS AND METHODS The study included 24 patients - all younger than 18 years of age (mean age: 14.31 years). Median age at the time of VNS device implantation was 11 years. Median age at onset of epilepsy was 21 months and median duration of epilepsy was 126 months. All the patients' seizures were intractable with antiepileptic drug treatment and all had been treated with an average of 6+/-2 antiepileptic medications. In all, 12 patients had secondary generalized seizures and 12 had partial seizures. Because this was a retrospective open study, the number of seizures could not be enumerated in most of these cases. RESULTS The only factor that was associated with seizure reduction was duration of follow-up. Age at seizure onset and age at VNS device implantation were not associated with seizure reduction. The difference in seizure reduction between patients >12 years of age and patients <12 years of age was not significant. Mean percentage of seizure reduction after 6 months-7 years of treatment was, respectively, 22.5% (n=24) (6th month), 32% (n=20) (1st year), 42% (n=16) (2nd year), 50.45% (n=11) (3rd year), 52% (n=10) (4th year), 60% (n=8) (5th year), 61.25% (n=8) (6th year), and 61.6% (n=6) (7th year). The positive effect of VNS persisted throughout the follow-up period. CONCLUSIONS Although it is an expensive method, VNS is an effective treatment method. This series shows the necessity of long-term follow-up series for understanding the efficacy and advantages of VNS. Prospective, long-term double-blind studies with large samples are needed to confirm the present study's findings.
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Affiliation(s)
- Ebru Arhan
- Department of Pediatric Neurology, Faculty of Medicine, Gazi University, 10th floor, 06500 Beşevler/Ankara, Turkey.
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Fahy BG. Intraoperative and perioperative complications with a vagus nerve stimulation device. J Clin Anesth 2010; 22:213-22. [DOI: 10.1016/j.jclinane.2009.10.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Revised: 10/01/2009] [Accepted: 10/01/2009] [Indexed: 11/30/2022]
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Shahwan A, Bailey C, Maxiner W, Harvey AS. Vagus nerve stimulation for refractory epilepsy in children: More to VNS than seizure frequency reduction. Epilepsia 2009; 50:1220-8. [PMID: 19170732 DOI: 10.1111/j.1528-1167.2008.01940.x] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE Vagus nerve stimulation (VNS) is used increasingly as adjunctive therapy for refractory epilepsy. Studies of VNS in children report mainly seizure frequency reduction as a measure of efficacy and clinical details are often scanty. We report our experience with VNS in children with refractory epilepsy and emphasize the positive effects of VNS in terms of seizure severity. METHODS We reviewed 26 consecutive children who had VNS with a minimum follow-up period of 18 months. We examined their clinical characteristics, seizure types, seizure frequency, epilepsy syndrome diagnosis, and response to VNS in terms of seizure frequency and seizure severity. RESULTS Fifty-four percent of patients responded to VNS with >or=50% seizure frequency reduction. Patients with Lennox-Gastaut syndrome (LGS) and tonic seizures had a higher responder rate; 78% (seven of nine patients) (p < 0.01). Status epilepticus (SE) episodes were reduced or ceased in the four patients with recurrent SE. Seizure severity, duration, and recovery time decreased in all responders. Increased alertness was reported in all responders and three nonresponders. CONCLUSION Decreased seizure severity, recovery time, abolition of daytime drop attacks, and reduced hospitalization due to SE improved patients' lives over and above the benefit from seizure frequency reduction.
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Affiliation(s)
- Amre Shahwan
- Children's Neuroscience Centre, Royal Children's Hospital, Melbourne, Victoria, Australia
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Abstract
Vagus nerve stimulation (VNS) is a key tool in the treatment of patients with medically refractory epilepsy. Although the mechanism of action of VNS remains poorly understood, this modality is now the most widely used nonpharmacological treatment for drug-resistant epilepsy. The goal of this work is to review the history of VNS and provide information on recent advances and applications of this technology.
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Milby AH, Halpern CH, Baltuch GH. Vagus nerve stimulation in the treatment of refractory epilepsy. Neurotherapeutics 2009; 6:228-37. [PMID: 19332314 PMCID: PMC5084198 DOI: 10.1016/j.nurt.2009.01.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2008] [Revised: 01/16/2009] [Accepted: 01/17/2009] [Indexed: 10/21/2022] Open
Abstract
Many patients with epilepsy suffer from persistent seizures despite maximal anti-epileptic drug therapy. Chronic, intermittent vagus nerve stimulation has been proven to be an effective option for many patients suffering from refractory seizures who are not candidates for surgical resection. Although only a small minority of patients will be entirely seizure-free, vagus nerve stimulation, as an adjunct to medical therapy, may result in significant improvements in quality of life. Vagus nerve stimulation is generally well-tolerated, as device implantation is associated with a low rate of perioperative complications, and the majority of side effects are stimulation-dependent and thus reversible.
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Affiliation(s)
- Andrew H. Milby
- grid.412713.20000000404351019Department of Neurosurgery, Center for Functional and Restorative Neurosurgery, University of Pennsylvania Medical Center, 19104 Philadelphia, Pennsylvania
| | - Casey H. Halpern
- grid.412713.20000000404351019Department of Neurosurgery, Center for Functional and Restorative Neurosurgery, University of Pennsylvania Medical Center, 19104 Philadelphia, Pennsylvania
| | - Gordon H. Baltuch
- grid.412713.20000000404351019Department of Neurosurgery, Center for Functional and Restorative Neurosurgery, University of Pennsylvania Medical Center, 19104 Philadelphia, Pennsylvania
- grid.411115.10000000404350884Department of Neurosurgery, 3 Silverstein, Hospital of the University of Pennsylvania, 3400 Spruce Street, 19104 Philadelphia, PA
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Vonck K, De Herdt V, Boon P. Vagal nerve stimulation--a 15-year survey of an established treatment modality in epilepsy surgery. Adv Tech Stand Neurosurg 2009; 34:111-46. [PMID: 19368083 DOI: 10.1007/978-3-211-78741-0_5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Neurostimulation is an emerging treatment for neurological diseases. Electrical stimulation of the tenth cranial nerve or vagus nerve stimulation (VNS) has become a valuable option in the therapeutic armamentarium for patients with refractory epilepsy. It is indicated in patients with refractory epilepsy who are unsuitable candidates for epilepsy surgery or who have had insufficient benefit from such a treatment. Vagus nerve stimulation reduces seizure frequency with > 50% in 1/3 of patients and has a mild side effects profile. Research to elucidate the mechanism of action of vagus nerve stimulation has shown that effective stimulation in humans is primarily mediated by afferent vagal A- and B-fibers. Crucial brainstem and intracranial structures include the locus coeruleus, the nucleus of the solitary tract, the thalamus and limbic structures. Neurotransmitters playing a role may involve the major inhibitory neurotransmitter GABA but also serotoninergic and adrenergic systems. This manuscript reviews the clinical studies investigating efficacy and side effects in patients and the experimental studies aiming to elucidate the mechanims of action.
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Affiliation(s)
- K Vonck
- Department of Neurology, Ghent University Hospital, Gent, Belgium
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Abstract
Lennox-Gastaut syndrome (LGS) is a rare, age-related syndrome, characterized by multiple seizure types, a specific electro-encephalographic pattern, and mental regression. However, published data on the etiology, evolution, and therapeutic approach of LGS are contradictory, partly because the precise definition of LGS used in the literature varies. In the most recent classification, LGS belongs to the epileptic encephalopathies and is highly refractory to all antiepileptic drugs. Numerous treatments, medical and non-medical, have been proposed and results mostly from open studies or case series have been published. Sometimes, patients with LGS are included in a more global group of patients with refractory epilepsy. Only 6 randomized double-blind controlled trials of medical treatments, which included patients with LGS, have been published. Overall, treatment is rarely effective and the final prognosis remains poor in spite of new therapeutic strategies. Co-morbidities need specific treatment. This paper summarizes the definition, diagnosis and therapeutic approach to LGS, including not only recognized antiepileptic drugs, but also "off label" medications, immune therapy, diet, surgery and some perspectives for the future.
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Affiliation(s)
- Kenou van Rijckevorsel
- Reference Centre of Refractory Epilepsy, Cliniques Universitaires St Luc, Université Catholique de Louvain, Avenue Hippocrate, 10, B-1200 Brussels, Belgium.
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Jaseja H. Vagal nerve stimulation: exploring its efficacy and success for an improved prognosis and quality of life in cerebral palsy patients. Clin Neurol Neurosurg 2008; 110:755-62. [PMID: 18572305 DOI: 10.1016/j.clineuro.2008.05.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2007] [Revised: 04/29/2008] [Accepted: 05/09/2008] [Indexed: 02/08/2023]
Abstract
Cerebral palsy (CP) continues to pose a cause for major socioeconomic concern and medical challenge worldwide. It is associated with a multi-faceted symptomatology warranting a multi-dimensional management-approach. Recent recognition of neurocognitive impairment and its hopefully possible treatment has opened up a new dimension in its management to the neurologists. Vagal nerve stimulation (VNS) technique is presently emerging as an effective alternative anti-epileptic therapeutic measure in intractable epilepsy. VNS has recently been shown to possess a suppressive effect also on interictal epileptiform discharges (IEDs) that are now being widely accepted as established associates of neurocognitive impairment. In this paper, the author proposes VNS technique implantation in CP patients on account of its dual therapeutic effectiveness, i.e. anti-epileptic and IED-suppression. These two effects are likely to control seizures that are quite often drug-resistant and also improve neurocognition in CP patients, thus hoping for a better overall prognostic outcome and an improved quality of life of the CP patients by VNS.
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Affiliation(s)
- Harinder Jaseja
- Physiology Department, G.R. Medical College, Gwalior 474001, MP, India.
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Rossignol E, Lortie A, Thomas T, Bouthiller A, Scavarda D, Mercier C, Carmant L. Vagus nerve stimulation in pediatric epileptic syndromes. Seizure 2008; 18:34-7. [PMID: 18657451 DOI: 10.1016/j.seizure.2008.06.010] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2007] [Revised: 06/05/2008] [Accepted: 06/13/2008] [Indexed: 10/21/2022] Open
Abstract
Vagal nerve stimulation (VNS) has shown promising results in various cohorts of non-surgical refractory epilepsy in adults and children. However studies report a significant delay between implantation and clinical response. We describe a cohort of 28 children and adolescents prospectively followed, classified by epileptic syndromes and treated with VNS using a 6-week rapid ramping protocol between January 2000 and March 2005. Our cohort showed favorable outcome within 6 months which was sustained at 24 months: 68% (19/28) showing >or=50% reduction in seizure frequency, including 14% (4/28) who became seizure-free. VNS was particularly efficacious in children with cryptogenic generalized and partial epilepsies. Although adverse events occurred in 68% (19/28) of patients, most were transient. In conclusion, rapid ramping is associated with an early and lasting response in most children but with a slightly higher side-effect rate.
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Affiliation(s)
- E Rossignol
- Hôpital Sainte-Justine, Département de neurologie pédiatrique, Canada
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Danielsson S, Viggedal G, Gillberg C, Olsson I. Lack of effects of vagus nerve stimulation on drug-resistant epilepsy in eight pediatric patients with autism spectrum disorders: a prospective 2-year follow-up study. Epilepsy Behav 2008; 12:298-304. [PMID: 18053767 DOI: 10.1016/j.yebeh.2007.10.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2007] [Revised: 10/08/2007] [Accepted: 10/15/2007] [Indexed: 10/22/2022]
Abstract
Vagus nerve stimulation (VNS) therapy has been reported to reduce seizure frequency in some children with drug-resistant epilepsy who are not suitable candidates for epilepsy surgery. It has been suggested that there may be positive cognitive and/or behavioral effects independent of seizure control. We describe the effects of VNS with respect to seizure frequency, cognition, and autistic symptoms and behavior in eight children and adolescents with medically intractable epilepsy and autism. In comparison to baseline, seizure frequency had not decreased in anyone in our series at the 2-year follow-up. In three cases, minor improvements in general functioning were noted, but there were no positive cognitive effects. This open prospective pilot study highlights the need for more prospective studies to prevent false expectations of improvement in this severely disabled group.
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Affiliation(s)
- Susanna Danielsson
- Department of Pediatrics, Queen Silvia Children's Hospital, Göteborg, Sweden.
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Oh SM, Park EY, Choi IS, Cho YK, Kim YO, Kim CJ, Woo YJ, Kim JH. Therapeutic Effects of Vagus Nerve Stimulation in Intractable Childhood Epilepsy: Experience for 12 Months after VNS Implantation. Chonnam Med J 2008. [DOI: 10.4068/cmj.2008.44.1.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Soo Min Oh
- Department of Pediatrics, Chonnam National University Medical School, Gwangju, Korea
| | - Eun Young Park
- Department of Pediatrics, Chonnam National University Medical School, Gwangju, Korea
| | - Ik Sun Choi
- Department of Pediatrics, Chonnam National University Medical School, Gwangju, Korea
| | - Young Kuk Cho
- Department of Pediatrics, Chonnam National University Medical School, Gwangju, Korea
| | - Young Ok Kim
- Department of Pediatrics, Chonnam National University Medical School, Gwangju, Korea
| | - Chan Jong Kim
- Department of Pediatrics, Chonnam National University Medical School, Gwangju, Korea
| | - Young Jong Woo
- Department of Pediatrics, Chonnam National University Medical School, Gwangju, Korea
| | - Jae Hyoo Kim
- Department of Pediatrics, Chonnam National University Medical School, Gwangju, Korea
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