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Salama H, Salama A, Oscher L, Jallo GI, Shimony N. The role of neuromodulation in the management of drug-resistant epilepsy. Neurol Sci 2024; 45:4243-4268. [PMID: 38642321 DOI: 10.1007/s10072-024-07513-9] [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: 11/15/2023] [Accepted: 04/02/2024] [Indexed: 04/22/2024]
Abstract
Drug-resistant epilepsy (DRE) poses significant challenges in terms of effective management and seizure control. Neuromodulation techniques have emerged as promising solutions for individuals who are unresponsive to pharmacological treatments, especially for those who are not good surgical candidates for surgical resection or laser interstitial therapy (LiTT). Currently, there are three neuromodulation techniques that are FDA-approved for the management of DRE. These include vagus nerve stimulation (VNS), deep brain stimulation (DBS), and responsive neurostimulation (RNS). Device selection, optimal time, and DBS and RNS target selection can also be challenging. In general, the number and localizability of the epileptic foci, alongside the comorbidities manifested by the patients, substantially influence the selection process. In the past, the general axiom was that DBS and VNS can be used for generalized and localized focal seizures, while RNS is typically reserved for patients with one or two highly localized epileptic foci, especially if they are in eloquent areas of the brain. Nowadays, with the advance in our understanding of thalamic involvement in DRE, RNS is also very effective for general non-focal epilepsy. In this review, we will discuss the underlying mechanisms of action, patient selection criteria, and the evidence supporting the use of each technique. Additionally, we explore emerging technologies and novel approaches in neuromodulation, such as closed-loop systems. Moreover, we examine the challenges and limitations associated with neuromodulation therapies, including adverse effects, complications, and the need for further long-term studies. This comprehensive review aims to provide valuable insights on present and future use of neuromodulation.
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Affiliation(s)
- HusamEddin Salama
- Al-Quds University-School of Medicine, Abu Dis, Jerusalem, Palestine
| | - Ahmed Salama
- Al-Quds University-School of Medicine, Abu Dis, Jerusalem, Palestine
| | - Logan Oscher
- Department of Neurosurgery, Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, 600 5th Street South, St. Petersburg, FL, 33701, USA
| | - George I Jallo
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.
- Department of Neurosurgery, Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, 600 5th Street South, St. Petersburg, FL, 33701, USA.
| | - Nir Shimony
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, USA
- Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, TN, USA
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA
- Semmes-Murphey Clinic, Memphis, TN, USA
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2
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Alfihed S, Majrashi M, Ansary M, Alshamrani N, Albrahim SH, Alsolami A, Alamari HA, Zaman A, Almutairi D, Kurdi A, Alzaydi MM, Tabbakh T, Al-Otaibi F. Non-Invasive Brain Sensing Technologies for Modulation of Neurological Disorders. BIOSENSORS 2024; 14:335. [PMID: 39056611 PMCID: PMC11274405 DOI: 10.3390/bios14070335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 07/01/2024] [Accepted: 07/06/2024] [Indexed: 07/28/2024]
Abstract
The non-invasive brain sensing modulation technology field is experiencing rapid development, with new techniques constantly emerging. This study delves into the field of non-invasive brain neuromodulation, a safer and potentially effective approach for treating a spectrum of neurological and psychiatric disorders. Unlike traditional deep brain stimulation (DBS) surgery, non-invasive techniques employ ultrasound, electrical currents, and electromagnetic field stimulation to stimulate the brain from outside the skull, thereby eliminating surgery risks and enhancing patient comfort. This study explores the mechanisms of various modalities, including transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (TMS), highlighting their potential to address chronic pain, anxiety, Parkinson's disease, and depression. We also probe into the concept of closed-loop neuromodulation, which personalizes stimulation based on real-time brain activity. While we acknowledge the limitations of current technologies, our study concludes by proposing future research avenues to advance this rapidly evolving field with its immense potential to revolutionize neurological and psychiatric care and lay the foundation for the continuing advancement of innovative non-invasive brain sensing technologies.
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Affiliation(s)
- Salman Alfihed
- Microelectronics and Semiconductor Institute, King Abdulaziz City for Science and Technology (KACST), Riyadh 11442, Saudi Arabia; (S.A.)
| | - Majed Majrashi
- Bioengineering Institute, King Abdulaziz City for Science and Technology (KACST), Riyadh 11442, Saudi Arabia
| | - Muhammad Ansary
- Neuroscience Center Research Unit, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
| | - Naif Alshamrani
- Microelectronics and Semiconductor Institute, King Abdulaziz City for Science and Technology (KACST), Riyadh 11442, Saudi Arabia; (S.A.)
| | - Shahad H. Albrahim
- Bioengineering Institute, King Abdulaziz City for Science and Technology (KACST), Riyadh 11442, Saudi Arabia
| | - Abdulrahman Alsolami
- Microelectronics and Semiconductor Institute, King Abdulaziz City for Science and Technology (KACST), Riyadh 11442, Saudi Arabia; (S.A.)
| | - Hala A. Alamari
- Bioengineering Institute, King Abdulaziz City for Science and Technology (KACST), Riyadh 11442, Saudi Arabia
| | - Adnan Zaman
- Microelectronics and Semiconductor Institute, King Abdulaziz City for Science and Technology (KACST), Riyadh 11442, Saudi Arabia; (S.A.)
| | - Dhaifallah Almutairi
- Microelectronics and Semiconductor Institute, King Abdulaziz City for Science and Technology (KACST), Riyadh 11442, Saudi Arabia; (S.A.)
| | - Abdulaziz Kurdi
- Advanced Materials Institute, King Abdulaziz City for Science and Technology (KACST), Riyadh 11442, Saudi Arabia;
| | - Mai M. Alzaydi
- Bioengineering Institute, King Abdulaziz City for Science and Technology (KACST), Riyadh 11442, Saudi Arabia
| | - Thamer Tabbakh
- Microelectronics and Semiconductor Institute, King Abdulaziz City for Science and Technology (KACST), Riyadh 11442, Saudi Arabia; (S.A.)
| | - Faisal Al-Otaibi
- Neuroscience Center Research Unit, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
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Miron G, Halimeh M, Jeppesen J, Loddenkemper T, Meisel C. Autonomic biosignals, seizure detection, and forecasting. Epilepsia 2024. [PMID: 38837428 DOI: 10.1111/epi.18034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/17/2024] [Accepted: 05/22/2024] [Indexed: 06/07/2024]
Abstract
Wearable devices have attracted significant attention in epilepsy research in recent years for their potential to enhance patient care through improved seizure monitoring and forecasting. This narrative review presents a detailed overview of the current clinical state of the art while addressing how devices that assess autonomic nervous system (ANS) function reflect seizures and central nervous system (CNS) state changes. This includes a description of the interactions between the CNS and the ANS, including physiological and epilepsy-related changes affecting their dynamics. We first discuss technical aspects of measuring autonomic biosignals and considerations for using ANS sensors in clinical practice. We then review recent seizure detection and seizure forecasting studies, highlighting their performance and capability for seizure detection and forecasting using devices measuring ANS biomarkers. Finally, we address the field's challenges and provide an outlook for future developments.
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Affiliation(s)
- Gadi Miron
- Computational Neurology, Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Mustafa Halimeh
- Computational Neurology, Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Jesper Jeppesen
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Tobias Loddenkemper
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Christian Meisel
- Computational Neurology, Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- Bernstein Center for Computational Neuroscience, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
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4
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Neimat JS, Bina RW, Koenig SC, Demirors E, Guida R, Burke R, Melodia T, Jimenez J. A Novel Closed-Loop Electrical Brain Stimulation Device Featuring Wireless Low-Energy Ultrasound Power and Communication. Neuromodulation 2024:S1094-7159(24)00071-0. [PMID: 38819342 DOI: 10.1016/j.neurom.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 01/27/2024] [Accepted: 02/13/2024] [Indexed: 06/01/2024]
Abstract
OBJECTIVES This study aimed to indicate the feasibility of a prototype electrical neuromodulation system using a closed-loop energy-efficient ultrasound-based mechanism for communication, data transmission, and recharging. MATERIALS AND METHODS Closed-loop deep brain stimulation (DBS) prototypes were designed and fabricated with ultrasonic wideband (UsWB) communication technology and miniaturized custom electronics. Two devices were implanted short term in anesthetized Göttingen minipigs (N = 2). Targeting was performed using preoperative magnetic resonance imaging, and locations were confirmed postoperatively by computerized tomography. DBS systems were tested over a wide range of stimulation settings to mimic minimal, typical, and/or aggressive clinical settings, and evaluated for their ability to transmit data through scalp tissue and to recharge the DBS system using UsWB. RESULTS Stimulation, communication, reprogramming, and recharging protocols were successfully achieved in both subjects for amplitude (1V-6V), frequency (50-250 Hz), and pulse width (60-200 μs) settings and maintained for ≥six hours. The precision of pulse settings was verified with <5% error. Communication rates of 64 kbit/s with an error rate of 0.05% were shown, with no meaningful throughput degradation observed. Time to recharge to 80% capacity was <9 minutes. Two DBS systems also were implanted in the second test animal, and independent bilateral stimulation was successfully shown. CONCLUSIONS The system performed at clinically relevant implant depths and settings. Independent bilateral stimulation for the duration of the study with a 4F energy storage and full rapid recharge were achieved. Continuous function extrapolates to six days of continuous stimulation in future design iterations implementing application specific integrated circuit level efficiency and 15F storage capacitance. UsWB increases energy efficiency, reducing storage requirements and thereby enabling device miniaturization. The device can enable intelligent closed-loop stimulation, remote system monitoring, and optimization and can serve as a power/data gateway to interconnect the intrabody network with the Internet of Medical Things.
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Affiliation(s)
- Joseph S Neimat
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA.
| | - Robert W Bina
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA
| | - Steven C Koenig
- Department of Bioengineering, University of Louisville, Louisville, KY, USA; Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY, USA
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Diniz JBC, Alfonso Rodriguez Elvir F, Silva Santana L, Batista S, Glioche Gasparri L, Mota Telles JP, Dias Polverini A. Replacement of traditional vagus nerve stimulation with cardiac-based device and seizure reduction: A systematic review and meta-analysis. Seizure 2024; 118:65-70. [PMID: 38642446 DOI: 10.1016/j.seizure.2024.04.001] [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: 11/20/2023] [Revised: 03/22/2024] [Accepted: 04/02/2024] [Indexed: 04/22/2024] Open
Abstract
INTRODUCTION For patients with drug-resistant epilepsy (DRE) who are not suitable for surgical resection, neuromodulation with vagus nerve stimulation (VNS) is an established approach. However, there is limited evidence of seizure reduction when replacing traditional VNS (tVNS) device with a cardiac-based one (cbVNS). This meta-analysis compares the seizure reduction achieved by replacing tVNS with cbVNS in a population with DRE. METHODS We systematically searched PubMed, Embase, and Cochrane Central following PRISMA guidelines. The main outcomes were number of patients experiencing a ≥ 50 % and ≥80 % reduction in seizures, as defined by the McHugh scale. Additionally, we assessed the number of patients achieving freedom from seizures. RESULTS We included 178 patients with DRE from 7 studies who were initially treated with tVNS and subsequently had it replaced by cbVNS. The follow-up for cbVNS ranged from 6 to 37.5 months. There was a statistically significant reduction in seizure frequency with the replacement of tVNS by cbVNS, using a ≥ 50 % (OR 1.79; 95 % CI 1.07 to 2.97; I²=0 %; p = 0.03) and a ≥ 80 % (OR 2.06; 95 % CI 1.17 to 3.62; I²=0 %; p = 0.01) reduction threshold. Nineteen (13 %) participants achieved freedom from seizures after switching to cbVNS. There was no difference in the rate of freedom from seizures between groups (OR 1.85; 95 % CI 0.81 to 4.21; I²=0 %; p = 0.14). CONCLUSION In patients with DRE undergoing battery replacement, cbVNS might be associated with seizure reduction (≥50 % and ≥80 % threshold) after switching from tVNS. Randomised controlled trials are necessary to validate these findings.
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Affiliation(s)
| | | | | | - Sávio Batista
- Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - João Paulo Mota Telles
- Department of Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil.
| | - Allan Dias Polverini
- Neurosurgical Oncology Division, Hospital de Amor, Fundação Pio XII, Barretos, Brazil
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Daquin G, Bonini F. The landscape of drug resistant absence seizures in adolescents and adults: Pathophysiology, electroclinical spectrum and treatment options. Rev Neurol (Paris) 2024; 180:256-270. [PMID: 38413268 DOI: 10.1016/j.neurol.2023.11.010] [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: 10/02/2023] [Revised: 11/17/2023] [Accepted: 11/21/2023] [Indexed: 02/29/2024]
Abstract
The persistence of typical absence seizures (AS) in adolescence and adulthood may reduce the quality of life of patients with genetic generalized epilepsies (GGEs). The prevalence of drug resistant AS is probably underestimated in this patient population, and treatment options are relatively scarce. Similarly, atypical absence seizures in developmental and epileptic encephalopathies (DEEs) may be unrecognized, and often persist into adulthood despite improvement of more severe seizures. These two seemingly distant conditions, represented by typical AS in GGE and atypical AS in DEE, share at least partially overlapping pathophysiological and genetic mechanisms, which may be the target of drug and neurostimulation therapies. In addition, some patients with drug-resistant typical AS may present electroclinical features that lie in between the two extremes represented by these generalized forms of epilepsy.
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Affiliation(s)
- G Daquin
- Epileptology and Cerebral Rythmology, AP-HM, Timone hospital, Marseille, France
| | - F Bonini
- Epileptology and Cerebral Rythmology, AP-HM, Timone hospital, Marseille, France; Aix Marseille Univ, Inserm, INS, Inst Neurosci Syst, Marseille, France.
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7
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Drees C, Afra P, Verner R, Kaye L, Keith A, Jiang M, Szaflarski JP, Nichol K. Feasibility study of microburst VNS therapy in drug-resistant focal and generalized epilepsy. Brain Stimul 2024; 17:382-391. [PMID: 38499287 DOI: 10.1016/j.brs.2024.03.010] [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: 09/20/2023] [Revised: 01/31/2024] [Accepted: 03/12/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Vagus nerve stimulation (VNS) at low frequencies (≤30 Hz) has been an established treatment for drug-resistant epilepsy (DRE) for over 25 years. OBJECTIVE To examine the initial safety and efficacy performance of an investigational, high-frequency (≥250 Hz) VNS paradigm herein called "Microburst VNS" (μVNS). μVNS consists of short, high-frequency bursts of electrical pulses believed to preferentially modulate certain brain regions. METHODS Thirty-three (33) participants were enrolled into an exploratory feasibility study, 21 with focal-onset seizures and 12 with generalized-onset seizures. Participants were titrated to a personalized target dose of μVNS using an investigational fMRI protocol. Participants were then followed for up to 12 months, with visits every 3 months, and monitored for side-effects at all time points. This study was registered as NCT03446664 on February 27th, 2018. RESULTS The device was well-tolerated. Reported adverse events were consistent with typical low frequency VNS outcomes and tended to diminish in severity over time, including dysphonia, cough, dyspnea, and implant site pain. After 12 months of μVNS, the mean seizure frequency reduction for all seizures was 61.3% (median reduction: 70.4%; 90% CI of median: 48.9%-83.3%). The 12-month responder rate (≥50% reduction) was 63.3% (90% CI: 46.7%-77.9%) and the super-responder rate (≥80% reduction) was 40% (90% CI: 25.0%-56.6%). Participants with focal-onset seizures appeared to benefit similarly to participants with generalized-onset seizures (mean reduction in seizures at 12 months: 62.6% focal [n = 19], versus 59.0% generalized [n = 11]). CONCLUSION Overall, μVNS appears to be safe and potentially a promising therapeutic alternative to traditional VNS. It merits further investigation in randomized controlled trials which will help determine the impact of investigational variables and which patients are most suitable for this novel therapy.
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Affiliation(s)
- Cornelia Drees
- Mayo Clinic Arizona, Department of Neurology, Phoenix, AZ, USA; University of Colorado School of Medicine, Department of Neurology, Aurora, CO, USA
| | - Pegah Afra
- University of Utah School of Medicine, Department of Neurology, Salt Lake City, UT, USA; Weill-Cornell Medicine, Department of Neurology, New York, NY, USA; University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Ryan Verner
- LivaNova PLC (or a Subsidiary), Department of Clinical and Medical Affairs, London, UK
| | - Lesley Kaye
- University of Colorado School of Medicine, Department of Neurology, Aurora, CO, USA
| | - Amy Keith
- LivaNova PLC (or a Subsidiary), Department of Clinical and Medical Affairs, London, UK
| | - Mei Jiang
- LivaNova PLC (or a Subsidiary), Department Statistics and Data Science, London, UK
| | - Jerzy P Szaflarski
- University of Alabama at Birmingham School of Medicine, Department of Neurology, Birmingham, AL, USA
| | - Kathryn Nichol
- LivaNova PLC (or a Subsidiary), Department of Clinical and Medical Affairs, London, UK.
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Warnock J, Ashcroft C, Sabado RJ, Keithler A, Perdikis S. Complete Heart Block and Ventricular Asystole Caused by Vagus Nerve Stimulation Therapy. Cureus 2024; 16:e53314. [PMID: 38435952 PMCID: PMC10906750 DOI: 10.7759/cureus.53314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2024] [Indexed: 03/05/2024] Open
Abstract
Left vagus nerve stimulation (VNS) is an advanced therapeutic option for refractory, drug-resistant epilepsy. A 45-year-old woman with a history of refractory catamenial focal epilepsy since age 16, treated with a five-drug antiepileptic regimen and VNS (implanted eight and one-half years prior), presented with dyspnea, chest discomfort, and lightheadedness. During observation, symptoms recurred and were associated with bradycardia (<20 bpm) and a complete atrioventricular node (AVN) block. Following admission, she continued to experience recurrent symptomatic AVN block and transient ventricular asystole, temporally correlated with her baseline seizure activity and resultant activation of her VNS. Deactivation of VNS resolved her bradyarrhythmia, and she experienced no recurrence over 14 months of follow-up. This case highlights a therapeutic dilemma in cases of refractory epilepsy, with limited therapeutic options if seizure activity requires VNS to be controlled.
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Affiliation(s)
- Jarrod Warnock
- Internal Medicine, Brooke Army Medical Center, San Antonio, USA
| | - Cody Ashcroft
- Internal Medicine, Brooke Army Medical Center, San Antonio, USA
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Sellers KK, Cohen JL, Khambhati AN, Fan JM, Lee AM, Chang EF, Krystal AD. Closed-loop neurostimulation for the treatment of psychiatric disorders. Neuropsychopharmacology 2024; 49:163-178. [PMID: 37369777 PMCID: PMC10700557 DOI: 10.1038/s41386-023-01631-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/31/2023] [Accepted: 06/02/2023] [Indexed: 06/29/2023]
Abstract
Despite increasing prevalence and huge personal and societal burden, psychiatric diseases still lack treatments which can control symptoms for a large fraction of patients. Increasing insight into the neurobiology underlying these diseases has demonstrated wide-ranging aberrant activity and functioning in multiple brain circuits and networks. Together with varied presentation and symptoms, this makes one-size-fits-all treatment a challenge. There has been a resurgence of interest in the use of neurostimulation as a treatment for psychiatric diseases. Initial studies using continuous open-loop stimulation, in which clinicians adjusted stimulation parameters during patient visits, showed promise but also mixed results. Given the periodic nature and fluctuations of symptoms often observed in psychiatric illnesses, the use of device-driven closed-loop stimulation may provide more effective therapy. The use of a biomarker, which is correlated with specific symptoms, to deliver stimulation only during symptomatic periods allows for the personalized therapy needed for such heterogeneous disorders. Here, we provide the reader with background motivating the use of closed-loop neurostimulation for the treatment of psychiatric disorders. We review foundational studies of open- and closed-loop neurostimulation for neuropsychiatric indications, focusing on deep brain stimulation, and discuss key considerations when designing and implementing closed-loop neurostimulation.
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Affiliation(s)
- Kristin K Sellers
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Joshua L Cohen
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
| | - Ankit N Khambhati
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Joline M Fan
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, CA, USA
| | - A Moses Lee
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
| | - Edward F Chang
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Andrew D Krystal
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA.
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA.
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Su PYP, Arle J, Poree L. Closing the loop and raising the bar: Automated control systems in neuromodulation. Pain Pract 2024; 24:177-185. [PMID: 37638532 DOI: 10.1111/papr.13290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/04/2023] [Indexed: 08/29/2023]
Abstract
INTRODUCTION Neuromodulation has emerged as a promising therapy for the management of chronic pain, movement disorders, and other neurological conditions. Spinal cord stimulation (SCS) is a widely used form of neuromodulation that involves the delivery of electrical impulses to the spinal cord to modulate the transmission of pain signals to the brain. In recent years, there has been increasing interest in the use of automation systems to improve the efficacy and safety of SCS. This narrative review summarizes the status of Food and Drug Administration-approved autonomous neuromodulation devices including closed loop, feedforward, and feedback systems. The review discusses the advantages and disadvantages of each system and focuses specifically on the use of these systems for SCS. It is important for clinicians to understand the expanding role of automation in neuromodulation in order to select appropriate therapies founded on automation systems to the specific needs of the patient and the underlying condition. CONCLUSION The review also provides insights into the current state of the art in neuromodulation automation systems and discusses potential future directions for research in this field.
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Affiliation(s)
- Po-Yi Paul Su
- Department of Anesthesia, University of California San Francisco, San Francisco, California, USA
| | | | - Lawrence Poree
- Department of Anesthesia, University of California San Francisco, San Francisco, California, USA
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11
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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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12
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Pipatpratarnporn W, Muangthong W, Jirasakuldej S, Limotai C. Wrist-worn smartwatch and predictive models for seizures. Epilepsia 2023; 64:2701-2713. [PMID: 37505115 DOI: 10.1111/epi.17729] [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: 12/05/2022] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVE This study was undertaken to describe extracerebral biosignal characteristics of overall and various seizure types as compared with baseline physical activities using multimodal devices (Empatica E4); develop predictive models for overall and each seizure type; and assess diagnostic performance of each model. METHODS We prospectively recruited patients with focal epilepsy who were admitted to the epilepsy monitoring unit for presurgical evaluation during January to December 2020. All study participants were simultaneously applied gold standard long-term video-electroencephalographic (EEG) monitoring and an index test, E4. Two certified epileptologists independently determined whether captured events were seizures and then indicated ictal semiology and EEG information. Both were blind to multimodal biosignal findings detected by E4. Biosignals during 5-min epochs of both seizure events and baseline were collected and compared. Predictive models for occurrence overall and of each seizure type were developed using a generalized estimating equation. Diagnostic performance of each model was then assessed. RESULTS Thirty patients had events recorded and were recruited for analysis. One hundred eight seizure events and 120 baseline epochs were collected. Heart rate (HR), acceleration (ACC), and electrodermal activity (EDA) but not temperature were significantly elevated during seizures. Cluster analysis showed trends of greatest elevation of HR and ACC in bilateral tonic-clonic seizures (BTCs), as compared with non-BTCs and isolated auras. HR and ACC were independent predictors for overall seizure types, BTCs, and non-BTCs, whereas only HR was a predictor for isolated aura. Diagnostic performance including sensitivity, specificity, and area under the receiver operating characteristic (ROC) curve of the predictive model for overall seizures were 77.78%, 60%, and .696 (95% confidence interval = .628-.764), respectively. SIGNIFICANCE Multimodal extracerebral biosignals (HR, ACC, EDA) detected by a wrist-worn smartwatch can help differentiate between epileptic seizures and normal physical activities. It would be worthwhile to implement our predictive algorithms in commercial seizure detection devices. However, larger studies to externally validate our predictive models are required.
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Affiliation(s)
- Waroth Pipatpratarnporn
- Division of Neurology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Wichuta Muangthong
- Division of Neurology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Suda Jirasakuldej
- Chulalongkorn Comprehensive Epilepsy Center of Excellence, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Chusak Limotai
- Division of Neurology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Chulalongkorn Comprehensive Epilepsy Center of Excellence, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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13
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Yogev D, Goldberg T, Arami A, Tejman-Yarden S, Winkler TE, Maoz BM. Current state of the art and future directions for implantable sensors in medical technology: Clinical needs and engineering challenges. APL Bioeng 2023; 7:031506. [PMID: 37781727 PMCID: PMC10539032 DOI: 10.1063/5.0152290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 08/28/2023] [Indexed: 10/03/2023] Open
Abstract
Implantable sensors have revolutionized the way we monitor biophysical and biochemical parameters by enabling real-time closed-loop intervention or therapy. These technologies align with the new era of healthcare known as healthcare 5.0, which encompasses smart disease control and detection, virtual care, intelligent health management, smart monitoring, and decision-making. This review explores the diverse biomedical applications of implantable temperature, mechanical, electrophysiological, optical, and electrochemical sensors. We delve into the engineering principles that serve as the foundation for their development. We also address the challenges faced by researchers and designers in bridging the gap between implantable sensor research and their clinical adoption by emphasizing the importance of careful consideration of clinical requirements and engineering challenges. We highlight the need for future research to explore issues such as long-term performance, biocompatibility, and power sources, as well as the potential for implantable sensors to transform healthcare across multiple disciplines. It is evident that implantable sensors have immense potential in the field of medical technology. However, the gap between research and clinical adoption remains wide, and there are still major obstacles to overcome before they can become a widely adopted part of medical practice.
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Affiliation(s)
| | | | | | | | | | - Ben M. Maoz
- Authors to whom correspondence should be addressed: and
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14
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Fang YT, Lin YT, Tseng WL, Tseng P, Hua GL, Chao YJ, Wu YJ. Neuroimmunomodulation of vagus nerve stimulation and the therapeutic implications. Front Aging Neurosci 2023; 15:1173987. [PMID: 37484689 PMCID: PMC10358778 DOI: 10.3389/fnagi.2023.1173987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 06/12/2023] [Indexed: 07/25/2023] Open
Abstract
Vagus nerve stimulation (VNS) is a technology that provides electrical stimulation to the cervical vagus nerve and can be applied in the treatment of a wide variety of neuropsychiatric and systemic diseases. VNS exerts its effect by stimulating vagal afferent and efferent fibers, which project upward to the brainstem nuclei and the relayed circuits and downward to the internal organs to influence the autonomic, neuroendocrine, and neuroimmunology systems. The neuroimmunomodulation effect of VNS is mediated through the cholinergic anti-inflammatory pathway that regulates immune cells and decreases pro-inflammatory cytokines. Traditional and non-invasive VNS have Food and Drug Administration (FDA)-approved indications for patients with drug-refractory epilepsy, treatment-refractory major depressive disorders, and headaches. The number of clinical trials and translational studies that explore the therapeutic potentials and mechanisms of VNS is increasing. In this review, we first introduced the anatomical and physiological bases of the vagus nerve and the immunomodulating functions of VNS. We covered studies that investigated the mechanisms of VNS and its therapeutic implications for a spectrum of brain disorders and systemic diseases in the context of neuroimmunomodulation.
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Affiliation(s)
- Yi-Ting Fang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ye-Ting Lin
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wu-Lung Tseng
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Philip Tseng
- Cross College Elite Program, National Cheng Kung University, Tainan, Taiwan
- Research Center for Mind, Brain and Learning, National Chengchi University, Taipei, Taiwan
| | - Gia-Linh Hua
- School of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ying-Jui Chao
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Jen Wu
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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15
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Fisher RS. Deep brain stimulation of thalamus for epilepsy. Neurobiol Dis 2023; 179:106045. [PMID: 36809846 DOI: 10.1016/j.nbd.2023.106045] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 02/22/2023] Open
Abstract
Neuromodulation (neurostimulation) is a relatively new and rapidly growing treatment for refractory epilepsy. Three varieties are approved in the US: vagus nerve stimulation (VNS), deep brain stimulation (DBS) and responsive neurostimulation (RNS). This article reviews thalamic DBS for epilepsy. Among many thalamic sub-nuclei, DBS for epilepsy has been targeted to the anterior nucleus (ANT), centromedian nucleus (CM), dorsomedial nucleus (DM) and pulvinar (PULV). Only ANT is FDA-approved, based upon a controlled clinical trial. Bilateral stimulation of ANT reduced seizures by 40.5% at three months in the controlled phase (p = .038) and 75% by 5 years in the uncontrolled phase. Side effects related to paresthesias, acute hemorrhage, infection, occasional increased seizures, and usually transient effects on mood and memory. Efficacy was best documented for focal onset seizures in temporal or frontal lobe. CM stimulation may be useful for generalized or multifocal seizures and PULV for posterior limbic seizures. Mechanisms of DBS for epilepsy are largely unknown, but animal work points to changes in receptors, channels, neurotransmitters, synapses, network connectivity and neurogenesis. Personalization of therapies, in terms of connectivity of the seizure onset zone to the thalamic sub- nucleus and individual characteristics of the seizures, might lead to improved efficacy. Many questions remain about DBS, including the best candidates for different types of neuromodulation, the best targets, the best stimulation parameters, how to minimize side effects and how to deliver current noninvasively. Despite the questions, neuromodulation provides useful new opportunities to treat people with refractory seizures not responding to medicines and not amenable to resective surgery.
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Affiliation(s)
- Robert S Fisher
- Department of Neurology and Neurological Sciences and Neurosurgery by Courtesy, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, 213 Quarry Road, Room 4865, Palo Alto, CA 94304, USA.
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16
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Bakhtiarzadeh F, Zare M, Ghasemi Z, Dehghan S, Sadeghin A, Joghataei MT, Ahmadirad N. Neurostimulation as a Putative Method for the Treatment of Drug-resistant Epilepsy in Patient and Animal Models of Epilepsy. Basic Clin Neurosci 2023; 14:1-18. [PMID: 37346878 PMCID: PMC10279981 DOI: 10.32598/bcn.2022.2360.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 10/18/2022] [Accepted: 10/26/2022] [Indexed: 06/23/2023] Open
Abstract
A patient with epilepsy was shown to have neurobiological, psychological, cognitive, and social issues as a result of recurring seizures, which is regarded as a chronic brain disease. However, despite numerous drug treatments, approximately, 30%-40% of all patients are resistant to antiepileptic drugs. Therefore, newer therapeutic modalities are introduced into clinical practice which involve neurostimulation and direct stimulation of the brain. Hence, we review published literature on vagus nerve stimulation, trigeminal nerve stimulation, applying responsive stimulation systems, and deep brain stimulation (DBS) in animals and epileptic patient with an emphasis on drug-resistant epilepsy.
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Affiliation(s)
- Fatemeh Bakhtiarzadeh
- Department of Physiology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Meysam Zare
- Department of Physiology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Zahra Ghasemi
- Lunenfeld-Tanenbaum Research Institute, Toronto, Canada
| | - Samaneh Dehghan
- Stem cell and Regenerative Medicine Research Center, Iran University of Medical Sciences, Tehran, Iran
- Eye Research Center, The Five Senses Health Institute, Rasool Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Azam Sadeghin
- Department of Physiology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Mohammad Taghi Joghataei
- Department of Anatomy and Neuroscience, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
- Cellular and Molecular Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Nooshin Ahmadirad
- Cellular and Molecular Research Center, Iran University of Medical Sciences, Tehran, Iran
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17
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Brauer PR, Lamarre ED, Gau VL, Lorenz RR, Wu SS, Bryson PC. Laryngology Outcomes Following Implantable Vagus Nerve Stimulation. JAMA Otolaryngol Head Neck Surg 2023; 149:49-53. [PMID: 36416861 PMCID: PMC9685541 DOI: 10.1001/jamaoto.2022.3699] [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: 06/20/2022] [Accepted: 09/29/2022] [Indexed: 11/24/2022]
Abstract
Importance Vagus nerve stimulation (VNS) devices have gained widespread acceptance for treatment of resistant epilepsy and depression. The increasing number of procedures has resulted in an increasing number of iatrogenic injuries to the vagus nerve, which can have a significant effect on vocalization and quality of life. Objective To determine the relative frequency of laryngeal adverse effects reported to the US Food and Drug Administration (FDA) after VNS implantation and to analyze associated VNS device problems. Design, Setting, and Participants This retrospective cross-sectional analysis queried the FDA Manufacturer and User Facility Device Experience database of adverse events in the US between 1996 and 2020. Main Outcomes and Measures The primary outcome was the percent of adverse events reported to the FDA that included patients who received VNS with laryngeal adverse effects and the associated proportion of device problems after VNS surgery. Results A total of 12 725 iatrogenic vagus nerve issues were documented after VNS implantation, with apnea (n = 395; 3.1%) being the most common patient problem. Overall, 187 reports of laryngeal adverse effects associated with VNS devices were identified and represented the eighth most common iatrogenic vagus nerve problem reported to the FDA. Laryngeal adverse effects included 78 reports of voice alteration and 57 reports of paresis/paralysis. The VNS device problems frequently associated with laryngeal adverse effects were high impedance (n = 15, 8.02%), incorrect frequency delivery (n = 10, 5.35%), and battery problems (n = 11, 5.88%). The number of laryngeal adverse effect reports per year peaked in 2012 with 43 cases. Conclusions and Relevance This cross-sectional study found that although the literature demonstrates that vocal changes occur with nearly all VNS devices, the FDA receives adverse event reports of voice changes. Our results emphasize a potential need to improve patient counseling prior to VNS surgery to better set patient expectations regarding vocal changes and to prevent unnecessary patient concern. In addition, reports of vocal fold paresis/paralysis potentially suggest that patients may benefit from preoperative laryngeal assessment to differentiate preexisting vocal fold paralysis from that caused by VNS surgery.
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Affiliation(s)
- Philip R. Brauer
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- Head and Neck Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Eric D. Lamarre
- Head and Neck Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Victoria L. Gau
- Head and Neck Institute, The Cleveland Clinic, Cleveland, Ohio
| | | | - Shannon S. Wu
- Head and Neck Institute, The Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Paul C. Bryson
- Head and Neck Institute, The Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
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18
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Shamim D, Nwabueze O, Uysal U. Beyond Resection: Neuromodulation and Minimally Invasive Epilepsy Surgery. Noro Psikiyatr Ars 2022; 59:S81-S90. [PMID: 36578991 PMCID: PMC9767135 DOI: 10.29399/npa.28181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022] Open
Abstract
Epilepsy is a common neurological disease impacting both patients and healthcare systems. Approximately one third of patients have drug-resistant epilepsy (DRE) and are candidates for surgical options. However, only a small percentage undergo surgical treatment due to factors such as patient misconception/fear of surgery, healthcare disparities in epilepsy care, complex presurgical evaluation, primary care knowledge gap, and lack of systemic structures to allow effective coordination between referring physician and surgical epilepsy centers. Resective surgical treatments are superior to medication management for DRE patients in terms of seizure outcomes but may be less palatable to patients. There have been major advancements in minimally invasive surgeries (MIS) and neuromodulation techniques that may allay these concerns. Both epilepsy MIS and neuromodulation have shown promising seizure outcomes while minimizing complications. Minimally invasive methods include Laser Interstitial Thermal Therapy (LITT), RadioFrequency Ablation (RFA), Stereotactic RadioSurgery (SRS). Neuromodulation methods, which are more palliative, include Vagus Nerve Stimulation (VNS), Deep Brain Stimulation (DBS), and Responsive Neurostimulation System (RNS). This review will discuss the role of these techniques in varied epilepsy subtypes, their effectiveness in improving seizure control, and adverse outcomes.
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Affiliation(s)
- Daniah Shamim
- University of Kansas Medical Center, Department of Neurology, Kansas City, KS, USA
| | - Obiefuna Nwabueze
- University of Kansas Medical Center, Department of Neurology, Kansas City, KS, USA
| | - Utku Uysal
- University of Kansas Medical Center, Department of Neurology, Kansas City, KS, USA,Correspondence Address: Utku Uysal, MS University of Kansas School of Medicine 4000 Cambridge Street Mailstop 1065 Kansas City, KS 66160, USA • E-mail:
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19
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Simpson HD, Schulze-Bonhage A, Cascino GD, Fisher RS, Jobst BC, Sperling MR, Lundstrom BN. Practical considerations in epilepsy neurostimulation. Epilepsia 2022; 63:2445-2460. [PMID: 35700144 PMCID: PMC9888395 DOI: 10.1111/epi.17329] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 02/02/2023]
Abstract
Neuromodulation is a key therapeutic tool for clinicians managing patients with drug-resistant epilepsy. Multiple devices are available with long-term follow-up and real-world experience. The aim of this review is to give a practical summary of available neuromodulation techniques to guide the selection of modalities, focusing on patient selection for devices, common approaches and techniques for initiation of programming, and outpatient management issues. Vagus nerve stimulation (VNS), deep brain stimulation of the anterior nucleus of the thalamus (DBS-ANT), and responsive neurostimulation (RNS) are all supported by randomized controlled trials that show safety and a significant impact on seizure reduction, as well as a suggestion of reduction in the risk of sudden unexplained death in epilepsy (SUDEP). Significant seizure reductions are observed after 3 months for DBS, RNS, and VNS in randomized controlled trials, and efficacy appears to improve with time out to 7 to 10 years of follow-up for all modalities, albeit in uncontrolled follow-up or retrospective studies. A significant number of patients experience seizure-free intervals of 6 months or more with all three modalities. Number and location of epileptogenic foci are important factors affecting efficacy, and together with comorbidities such as severe mood or sleep disorders, may influence the choice of modality. Programming has evolved-DBS is typically initiated at lower current/voltage than used in the pivotal trial, whereas target charge density is lower with RNS, however generalizable optimal parameters are yet to be defined. Noninvasive brain stimulation is an emerging stimulation modality, although it is currently not used widely. In summary, clinical practice has evolved from those established in pivotal trials. Guidance is now available for clinicians who wish to expand their approach, and choice of neuromodulation technique may be tailored to individual patients based on their epilepsy characteristics, risk tolerance, and preferences.
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Affiliation(s)
- Hugh D. Simpson
- Division of Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Gregory D. Cascino
- Division of Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Robert S. Fisher
- Department of Neurology, Stanford Neuroscience Health Center, Palo Alto, CA, USA
| | - Barbara C. Jobst
- Geisel School of Medicine at Dartmouth, Department of Neurology, Dartmouth-Hitchcock Medical Center, NH, USA
| | - Michael R. Sperling
- Division of Epilepsy, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Brian N. Lundstrom
- Division of Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN, USA
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20
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Pollina L, Vallone F, Ottaviani MM, Strauss I, Carlucci L, Recchia FA, Micera S, Moccia S. A lightweight learning-based decoding algorithm for intraneural vagus nerve activity classification in pigs. J Neural Eng 2022; 19. [PMID: 35896098 DOI: 10.1088/1741-2552/ac84ab] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/27/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Bioelectronic medicine is an emerging field that aims at developing closed-loop neuromodulation protocols for the autonomic nervous system (ANS) to treat a wide range of disorders. When designing a closed-loop protocol for real time modulation of the ANS, the computational execution time and the memory and power demands of the decoding step are important factors to consider. In the context of cardiovascular and respiratory diseases, these requirements may partially explain why closed-loop clinical neuromodulation protocols that adapt stimulation parameters on patient's clinical characteristics are currently missing. APPROACH Here, we developed a lightweight learning-based decoder for the classification of cardiovascular and respiratory functional challenges from neural signals acquired through intraneural electrodes implanted in the cervical vagus nerve (VN) of 5 anaesthetized pigs. Our algorithm is based on signal temporal windowing, 9 handcrafted features, and Random Forest (RF) model for classification. Temporal windowing ranging from 50 ms to 1 sec, compatible in duration with cardio-respiratory dynamics, was applied to the data in order to mimic a pseudo real-time scenario. MAIN RESULTS We were able to achieve high balanced accuracy (BA) values over the whole range of temporal windowing duration. We identified 500 ms as the optimal temporal windowing duration for both BA values and computational execution time processing, achieving more than 86% for BA and a computational execution time of only ∼6.8 ms. Our algorithm outperformed in terms of balanced accuracy and computational execution time a state of the art decoding algorithm tested on the same dataset [1]. We found that RF outperformed other machine learning models such as Support Vector Machines, K-Nearest Neighbors, and Multi-Layer Perceptrons. SIGNIFICANCE Our approach could represent an important step towards the implementation of a closed-loop neuromodulation protocol relying on a single intraneural interface able to perform real-time decoding tasks and selective modulation of the VN.
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Affiliation(s)
- Leonardo Pollina
- Sant'Anna School of Advanced Studies, P.za Martiri della Liberta', 33, Pisa, 56127, ITALY
| | - Fabio Vallone
- Sant'Anna School of Advanced Studies, P.za Martiri della Liberta', 33, Pisa, 56127, ITALY
| | - Matteo M Ottaviani
- Scuola Superiore Sant'Anna, Istituto di Scienze Della Vita (ISV), P.za Martiri della Liberta', 33, Pisa, 56127, ITALY
| | - Ivo Strauss
- Scuola Superiore Sant'Anna, P.za Martiri della Libertà 33, Pisa, 56127, ITALY
| | - Lucia Carlucci
- Scuola Superiore Sant'Anna, Istituto di Scienze Della Vita (ISV), P.zza Martiri della Libertà 33, Pisa, 56127, ITALY
| | - Fabio A Recchia
- Scuola Superiore Sant'Anna, Istituto di Scienze Della Vita (ISV), P.za Martiri della Libertà 33, Pisa, 56127, ITALY
| | - Silvestro Micera
- Scuola Superiore Sant'Anna, P.za Martiri della Liberta', 33, Pisa, Toscana, 56127, ITALY
| | - Sara Moccia
- Scuola Superiore Sant'Anna, P.za Martiri della Liberta', 33, Pisa, 56127, ITALY
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21
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Abstract
BACKGROUND This is an updated version of the Cochrane Review published in 2015. Epilepsy is a chronic neurological disorder, characterised by recurring, unprovoked seizures. Vagus nerve stimulation (VNS) is a neuromodulatory treatment that is used as an adjunctive therapy for treating people with drug-resistant epilepsy. VNS consists of chronic, intermittent electrical stimulation of the vagus nerve, delivered by a programmable pulse generator. OBJECTIVES To evaluate the efficacy and tolerability of VNS when used as add-on treatment for people with drug-resistant focal epilepsy. SEARCH METHODS For this update, we searched the Cochrane Register of Studies (CRS), and MEDLINE Ovid on 3 March 2022. We imposed no language restrictions. CRS Web includes randomised or quasi-randomised controlled trials from the Specialised Registers of Cochrane Review Groups, including Epilepsy, CENTRAL, PubMed, Embase, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform. SELECTION CRITERIA We considered parallel or cross-over, randomised, double-blind, controlled trials of VNS as add-on treatment, which compared high- and low-level stimulation (including three different stimulation paradigms: rapid, mild, and slow duty-cycle), and VNS stimulation versus no stimulation, or a different intervention. We considered adults or children with drug-resistant focal seizures who were either not eligible for surgery, or who had failed surgery. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods, assessing the following outcomes: 1. 50% or greater reduction in seizure frequency 2. Treatment withdrawal (any reason) 3. Adverse effects 4. Quality of life (QoL) 5. Cognition 6. Mood MAIN RESULTS We did not identify any new studies for this update, therefore, the conclusions are unchanged. We included the five randomised controlled trials (RCT) from the last update, with a total of 439 participants. The baseline phase ranged from 4 to 12 weeks, and double-blind treatment phases from 12 to 20 weeks. We rated two studies at an overall low risk of bias, and three at an overall unclear risk of bias, due to lack of reported information about study design. Effective blinding of studies of VNS is difficult, due to the frequency of stimulation-related side effects, such as voice alteration. The risk ratio (RR) for 50% or greater reduction in seizure frequency was 1.73 (95% confidence interval (CI) 1.13 to 2.64; 4 RCTs, 373 participants; moderate-certainty evidence), showing that high frequency VNS was over one and a half times more effective than low frequency VNS. The RR for treatment withdrawal was 2.56 (95% CI 0.51 to 12.71; 4 RCTs, 375 participants; low-certainty evidence). Results for the top five reported adverse events were: hoarseness RR 2.17 (99% CI 1.49 to 3.17; 3 RCTs, 330 participants; moderate-certainty evidence); cough RR 1.09 (99% CI 0.74 to 1.62; 3 RCTs, 334 participants; moderate-certainty evidence); dyspnoea RR 2.45 (99% CI 1.07 to 5.60; 3 RCTs, 312 participants; low-certainty evidence); pain RR 1.01 (99% CI 0.60 to 1.68; 2 RCTs; 312 participants; moderate-certainty evidence); paraesthesia 0.78 (99% CI 0.39 to 1.53; 2 RCTs, 312 participants; moderate-certainty evidence). Results from two studies (312 participants) showed that a small number of favourable QOL effects were associated with VNS stimulation, but results were inconclusive between high- and low-level stimulation groups. One study (198 participants) found inconclusive results between high- and low-level stimulation for cognition on all measures used. One study (114 participants) found the majority of participants showed an improvement in mood on the Montgomery-Åsberg Depression Rating Scale compared to baseline, but results between high- and low-level stimulation were inconclusive. We found no important heterogeneity between studies for any of the outcomes. AUTHORS' CONCLUSIONS VNS for focal seizures appears to be an effective and well-tolerated treatment. Results of the overall efficacy analysis show that high-level stimulation reduced the frequency of seizures better than low-level stimulation. There were very few withdrawals, which suggests that VNS is well tolerated. Adverse effects associated with implantation and stimulation were primarily hoarseness, cough, dyspnoea, pain, paraesthesia, nausea, and headache, with hoarseness and dyspnoea more likely to occur with high-level stimulation than low-level stimulation. However, the evidence for these outcomes is limited, and of moderate to low certainty. Further high-quality research is needed to fully evaluate the efficacy and tolerability of VNS for drug-resistant focal seizures.
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Affiliation(s)
- Mariangela Panebianco
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Alexandra Rigby
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Anthony G Marson
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
- The Walton Centre NHS Foundation Trust, Liverpool, UK
- Liverpool Health Partners, Liverpool, UK
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22
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解 虎, 张 建. [Neuromodulation: Past, Present, and Future]. SICHUAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF SICHUAN UNIVERSITY. MEDICAL SCIENCE EDITION 2022; 53:559-563. [PMID: 35871723 PMCID: PMC10409452 DOI: 10.12182/20220760101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Indexed: 06/15/2023]
Abstract
Neuromodulation technology is one of the medical fields currently experiencing the most rapid development, witnessing a surge in the types of modulation techniques and a constant expansion of indications. Consequently, hundreds of thousands of patients with functional neurological disorders have benefited from the advancements in the field all over the world. Nevertheless, some challenges remain, for exmaple, the lack of a thorough understanding of the mechanism of neuromodulation, the long-standing controversy over the optimal targets of neuromodulation, the lack of reliable efficacy predictors, and the cumbersome and inefficient mode of postoperative programming. We anticipate that these issues will be resolved with the continued advancement in medical technology and the gradual revelation of the neural network mechanism of brain disorders. More individualized, precise, and intelligent neuromodulation technology will be the main direction of development in the future. Herein, we reviewed and commented on the evolution of neuromodulation technology, the current status of its applications, and its prospective development.
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Affiliation(s)
- 虎涛 解
- 首都医科大学附属北京天坛医院 神经外科 (北京 100070)Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - 建国 张
- 首都医科大学附属北京天坛医院 神经外科 (北京 100070)Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- 北京市神经外科研究所 (北京 100070)Beijing Institute of Neurosurgery, Beijing 100070, China
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23
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Sevcencu C. Single-interface bioelectronic medicines - concept, clinical applications and preclinical data. J Neural Eng 2022; 19. [PMID: 35533654 DOI: 10.1088/1741-2552/ac6e08] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 05/08/2022] [Indexed: 11/12/2022]
Abstract
Presently, large groups of patients with various diseases are either intolerant, or irresponsive to drug therapies and also intractable by surgery. For several diseases, one option which is available for such patients is the implantable neurostimulation therapy. However, lacking closed-loop control and selective stimulation capabilities, the present neurostimulation therapies are not optimal and are therefore used as only "third" therapeutic options when a disease cannot be treated by drugs or surgery. Addressing those limitations, a next generation class of closed-loop controlled and selective neurostimulators generically named bioelectronic medicines seems within reach. A sub-class of such devices is meant to monitor and treat impaired functions by intercepting, analyzing and modulating neural signals involved in the regulation of such functions using just one neural interface for those purposes. The primary objective of this review is to provide a first broad perspective on this type of single-interface devices for bioelectronic therapies. For this purpose, the concept, clinical applications and preclinical studies for further developments with such devices are here analyzed in a narrative manner.
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Affiliation(s)
- Cristian Sevcencu
- National Institute for Research and Development of Isotopic and Molecular Technologies, 67-103 Donat Street, Cluj-Napoca, 400293, ROMANIA
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24
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Intra- and Inter-Subject Perspectives on the Detection of Focal Onset Motor Seizures in Epilepsy Patients. SENSORS 2022; 22:s22093318. [PMID: 35591007 PMCID: PMC9105312 DOI: 10.3390/s22093318] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/19/2022] [Accepted: 04/22/2022] [Indexed: 01/15/2023]
Abstract
Focal onset epileptic seizures are highly heterogeneous in their clinical manifestations, and a robust seizure detection across patient cohorts has to date not been achieved. Here, we assess and discuss the potential of supervised machine learning models for the detection of focal onset motor seizures by means of a wrist-worn wearable device, both in a personalized context as well as across patients. Wearable data were recorded in-hospital from patients with epilepsy at two epilepsy centers. Accelerometry, electrodermal activity, and blood volume pulse data were processed and features for each of the biosignal modalities were calculated. Following a leave-one-out approach, a gradient tree boosting machine learning model was optimized and tested in an intra-subject and inter-subject evaluation. In total, 20 seizures from 9 patients were included and we report sensitivities of 67% to 100% and false alarm rates of down to 0.85 per 24 h in the individualized assessment. Conversely, for an inter-subject seizure detection methodology tested on an out-of-sample data set, an optimized model could only achieve a sensitivity of 75% at a false alarm rate of 13.4 per 24 h. We demonstrate that robustly detecting focal onset motor seizures with tonic or clonic movements from wearable data may be possible for individuals, depending on specific seizure manifestations.
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25
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Steinke KV, Möbius H, Christen HJ, Welkoborsky HJ. [Results of vagus nerve stimulator implantation in children and adolescents with treatment-refractory epilepsy]. HNO 2022; 70:389-395. [PMID: 35412064 DOI: 10.1007/s00106-022-01164-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2022] [Indexed: 11/04/2022]
Abstract
Vagus nerve stimulation (VNS) is a therapeutic procedure that can be applied in a palliative setting in patients with treatment-refractory epilepsy who are not suitable for epilepsy surgery. The mechanism of action of VNS is currently not completely understood but appears to depend on a modification of neurotransmitter metabolism. Data of 25 patients with treatment-refractory epilepsy who underwent implantation of a vagus nerve stimulator were retrospectively analyzed in a monocentric study. A reduction in epileptic seizure rate of 28% was observed 3 months after initial activation and of 32.9% after 6-12 months. The responder rate (reduction in seizure rate of more than 50% compared to before implantation) was 40% 6-12 months after initial activation. In one third of patients, a reduction in epileptic seizure rate of at least 75% occurred. Adverse effects of surgery or the stimulation were rare.
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Affiliation(s)
- Kim Vanessa Steinke
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf-Hals-Tumorzentrum, Klinikum Region Hannover GmbH, KRH Klinikum Nordstadt, Haltenhoffstraße 41, 30167, Hannover, Deutschland. .,Abteilung für HNO-Heilkunde, Kinder- und Jugendkrankenhaus Auf der Bult, Hannover, Deutschland.
| | - Hartmut Möbius
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf-Hals-Tumorzentrum, Klinikum Region Hannover GmbH, KRH Klinikum Nordstadt, Haltenhoffstraße 41, 30167, Hannover, Deutschland.,Abteilung für HNO-Heilkunde, Kinder- und Jugendkrankenhaus Auf der Bult, Hannover, Deutschland
| | - Hans-Jürgen Christen
- Abteilung für Neuropädiatrie, Kinder- und Jugendkrankenhaus Auf der Bult, Hannover, Deutschland
| | - Hans-Jürgen Welkoborsky
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf-Hals-Tumorzentrum, Klinikum Region Hannover GmbH, KRH Klinikum Nordstadt, Haltenhoffstraße 41, 30167, Hannover, Deutschland.,Abteilung für HNO-Heilkunde, Kinder- und Jugendkrankenhaus Auf der Bult, Hannover, Deutschland
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26
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Touma L, Dansereau B, Chan AY, Jetté N, Kwon CS, Braun KPJ, Friedman D, Jehi L, Rolston JD, Vadera S, Wong-Kisiel LC, Englot DJ, Keezer MR. Neurostimulation in People with Drug-Resistant Epilepsy: Systematic Review and Meta-Analysis from the ILAE Surgical Therapies Commission. Epilepsia 2022; 63:1314-1329. [PMID: 35352349 DOI: 10.1111/epi.17243] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/25/2022] [Accepted: 03/28/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Summarize the current evidence on efficacy and tolerability of vagus nerve stimulation (VNS), responsive neurostimulation (RNS), and deep brain stimulation (DBS) through a systematic review and meta-analysis. METHODS We followed the PRISMA reporting standards and searched Ovid Medline, Ovid Embase, and the Cochrane Central Register of Controlled Trials. We included published randomized controlled trials (RCT) and their corresponding open-label extension studies, as well as prospective case series, with ≥ 20 participants (excluding studies limited to children). Our primary outcome was the mean (or median when unavailable) percentage decrease in frequency, as compared to baseline, of all epileptic seizures at last follow-up. Secondary outcomes included proportion of treatment responders and proportion with seizure freedom. RESULTS We identified 30 eligible studies, six of which were RCTs. At long-term follow-up (mean 1.3 years), five observational studies for VNS reported a pooled mean percentage decrease in seizure frequency of 34.7% (95% CI: -5.1, 74.5). In the open-label extension studies for RNS, the median seizure reduction was 53%, 66%, and 75% at two, five, and nine years of follow-up, respectively. For DBS, the median reduction was 56%, 65%, and 75% at two, five, and seven years, respectively. The proportion of individuals with seizure freedom at last follow-up increased significantly over time for DBS and RNS while a positive trend was observed for VNS. Quality of life was improved in all modalities. The most common complications included hoarseness, cough and throat pain for VNS and implant site pain, headache, and dysesthesia for DBS and RNS. SIGNIFICANCE Neurostimulation modalities are an effective treatment option for drug resistant epilepsy, with improving outcomes over time and few major complications. Seizure reduction rates among the three therapies were similar during the initial blinded phase. Recent long-term follow-up studies are encouraging for RNS and DBS but are lacking for VNS.
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Affiliation(s)
- Lahoud Touma
- Research Centre of the Centre hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada.,Department of Neurosciences, Université de Montréal, Montréal, QC, Canada
| | - Bénédicte Dansereau
- Research Centre of the Centre hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada.,Department of Neurosciences, Université de Montréal, Montréal, QC, Canada
| | - Alvin Y Chan
- Department of Neurological Surgery, School of Medicine, University of California, Irvine, Orange, CA, USA
| | - Nathalie Jetté
- Department of Neurosurgery and Neurology, Icahn School of Medicine at Mount Sinai, NY, USA
| | - Churl-Su Kwon
- Department of Neurosurgery and Neurology, Icahn School of Medicine at Mount Sinai, NY, USA
| | - Kees P J Braun
- Department of Child Neurology, University Medical Center Utrecht, member of ERN EpiCARE, Utrecht, Netherlands
| | - Daniel Friedman
- Department of Neurology, New York University Langone Health, NY, USA
| | - Lara Jehi
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John D Rolston
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | - Sumeet Vadera
- Department of Neurological Surgery, School of Medicine, University of California, Irvine, Orange, CA, USA
| | | | - Dario J Englot
- Departments of Neurological Surgery, Neurology, Radiological, Electrical Engineering, and Biomedical Engineering, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mark R Keezer
- Research Centre of the Centre hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada.,Department of Neurosciences, Université de Montréal, Montréal, QC, Canada.,Honorary Researcher, Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands.,School of Public Health, Université de Montréal, Montréal, QC, Canada
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27
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Santhumayor B, Karkare S, Kothare S, Rodgers S. Evaluating vagus nerve stimulation treatment with heart rate monitoring in pediatric patients with intractable epilepsy. Childs Nerv Syst 2022; 38:547-556. [PMID: 34837500 DOI: 10.1007/s00381-021-05416-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 11/16/2021] [Indexed: 01/11/2023]
Abstract
PURPOSE Vagus nerve stimulators (VNS) have emerged as an effective treatment modality for pediatric patients suffering from intractable, drug-resistant epilepsy. Newer devices, AspireSR™ Model 106 and the SenTiva™ Model 1000 (VNS TherapyⓇ, LivaNova™), contain an "auto-stimulation" feature that detects ictal tachycardia and transmits pulsations to attenuate seizures. However, the exact benefits of auto-stimulation compared to its risks still merit further exploration. This study evaluates the utility of these specific devices in a heterogeneous population of pediatric and young adult patients with intractable epilepsy. METHODS This is a retrospective chart review of 55 patients who underwent either VNS insertion with or without an auto-stimulation-enabled VNS device at a single level four epilepsy center. Seizure frequency, seizure subtype, side effects, and change in anti-seizure medication load both before and after VNS implantations were collected from patient self-reporting at the time of VNS insertion and 12 months following implantation. Information regarding output current, auto-stimulation current, duty cycling, and auto-stimulation threshold of the device was obtained from documented VNS interrogation for patients with auto-stimulation-enabled VNS devices. RESULTS Patients with auto-stimulation-enabled VNS devices had a mean 56.0% (SD = 0.414) seizure frequency reduction 12 months post-VNS insertion, while patients without auto-stimulation-enabled VNS devices had a mean 41.6% (SD = 0.456) seizure frequency reduction during the same interval. The mean seizure frequency reduction 12 months post-VNS insertion for patients with a SenTiva™ 1000 model was 66.0% (SD = 0.426). For patients with auto-stimulation-enabled VNS devices, post-treatment seizure reduction was significantly correlated with daily auto-stimulation activation (R = 0.432, p = 0.025). CONCLUSION This study supports the clinical safety and utility of auto-stimulation-enabled VNS models, specifically the SenTiva™ 1000, in treating pediatric patients with intractable epilepsy of various subtypes and etiologies. Further research is needed to evaluate the sustained impact of auto-stimulation on long-term outcomes (≥ 2 years follow-up post-VNS).
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Affiliation(s)
- Brandon Santhumayor
- Division of Pediatric Neurosurgery, Cohen Children's Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New Hyde Park, NY, USA.
| | - Shefali Karkare
- Division of Pediatric Neurology, Cohen Children's Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New Hyde Park, NY, USA
| | - Sanjeev Kothare
- Division of Pediatric Neurology, Cohen Children's Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New Hyde Park, NY, USA
| | - Shaun Rodgers
- Division of Pediatric Neurosurgery, Cohen Children's Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New Hyde Park, NY, USA
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28
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Afra P, Adamolekun B, Aydemir S, Watson GDR. Evolution of the Vagus Nerve Stimulation (VNS) Therapy System Technology for Drug-Resistant Epilepsy. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 3:696543. [PMID: 35047938 PMCID: PMC8757869 DOI: 10.3389/fmedt.2021.696543] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/10/2021] [Indexed: 12/14/2022] Open
Abstract
The vagus nerve stimulation (VNS) Therapy® System is the first FDA-approved medical device therapy for the treatment of drug-resistant epilepsy. Over the past two decades, the technology has evolved through multiple iterations resulting in software-related updates and implantable lead and generator hardware improvements. Healthcare providers today commonly encounter a range of single- and dual-pin generators (models 100, 101, 102, 102R, 103, 104, 105, 106, 1000) and related programming systems (models 250, 3000), all of which have their own subtle, but practical differences. It can therefore be a daunting task to go through the manuals of these implant models for comparison, some of which are not readily available. In this review, we highlight the technological evolution of the VNS Therapy System with respect to device approval milestones and provide a comparison of conventional open-loop vs. the latest closed-loop generator models. Battery longevity projections and an in-depth examination of stimulation mode interactions are also presented to further differentiate amongst generator models.
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Affiliation(s)
- Pegah Afra
- Department of Neurology, Weill-Cornell Medicine, New York, NY, United States.,Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Bola Adamolekun
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Seyhmus Aydemir
- Department of Neurology, Weill-Cornell Medicine, New York, NY, United States
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29
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Sen A, Verner R, Valeriano JP, Lee R, Zafar M, Thomas R, Kotulska K, Jespers E, Dibué M, Kwan P. Vagus nerve stimulation therapy in people with drug-resistant epilepsy (CORE-VNS): rationale and design of a real-world post-market comprehensive outcomes registry. BMJ Neurol Open 2022; 3:e000218. [PMID: 35018342 PMCID: PMC8705076 DOI: 10.1136/bmjno-2021-000218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 11/21/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction The Vagus Nerve Stimulation Therapy System (VNS Therapy) is an adjunctive neuromodulatory therapy that can be efficacious in reducing the frequency and severity of seizures in people with drug-resistant epilepsy (DRE). CORE-VNS aims to examine the long-term safety and clinical outcomes of VNS in people with DRE. Methods and analysis The CORE-VNS study is an international, multicentre, prospective, observational, all-comers, post-market registry. People with DRE receiving VNS Therapy for the first time as well as people being reimplanted with VNS Therapy are eligible. Participants have a baseline visit (prior to device implant). They will be followed for a minimum of 36 months and a maximum of 60 months after implant. Analysis endpoints include seizure frequency (average number of events per month), seizure severity (individual-rated categorical outcome including very mild, mild, moderate, severe or very severe) as well as non-seizure outcomes such as adverse events, use of antiseizure medications, use of other non-pharmacological therapies, quality of life, validated measures of quality of sleep (Pittsburgh Sleep Quality Index or Children’s Sleep Habit Questionnaire) and healthcare resource utilisation. While the CORE-VNS registry was not expressly designed to test hypotheses, subgroup analyses and exploratory analysis that require hypothesis testing will be conducted across propensity score matched treatment groups, where possible based on sampling. Ethics and dissemination The CORE-VNS registry has already enrolled 823 participants from 61 centres across 15 countries. Once complete, CORE-VNS will represent one of the largest real-world clinical data sets to allow a more comprehensive understanding of the management of DRE with adjunctive VNS. Manuscripts derived from this database will shed important new light on the characteristics of people receiving VNS Therapy; the practical use of VNS across different countries, and factors influencing long-term response. Trail registration number NCT03529045.
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Affiliation(s)
- Arjune Sen
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, Oxfordshire, UK
| | - Ryan Verner
- Clinical and Medical Affairs, LivaNova Plc, London, UK
| | | | - Ricky Lee
- Department of Neurology, Ascension Medical Group, Wichita, Kansas, USA
| | - Muhammad Zafar
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rhys Thomas
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK.,Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Katarzyna Kotulska
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warszawa, Poland
| | - Ellen Jespers
- Clinical and Medical Affairs, LivaNova Plc, London, UK
| | - Maxine Dibué
- Clinical and Medical Affairs, LivaNova Plc, London, UK.,Department of Neurosurgery, Friedrich Schiller University Jena, Jena, Thüringen, Germany
| | - Patrick Kwan
- Department of Neuroscience, Central Clinical School, Monash University, Clayton, Victoria, Australia.,Epilepsy Unit, Brain Program, Alfred Hospital, Melbourne, Victoria, Australia.,Departments of Medicine and Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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30
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Wendt K, Denison T, Foster G, Krinke L, Thomson A, Wilson S, Widge AS. Physiologically informed neuromodulation. J Neurol Sci 2021; 434:120121. [PMID: 34998239 PMCID: PMC8976285 DOI: 10.1016/j.jns.2021.120121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 12/19/2021] [Accepted: 12/21/2021] [Indexed: 01/09/2023]
Abstract
The rapid evolution of neuromodulation techniques includes an increasing amount of research into stimulation paradigms that are guided by patients' neurophysiology, to increase efficacy and responder rates. Treatment personalisation and target engagement have shown to be effective in fields such as Parkinson's disease, and closed-loop paradigms have been successfully implemented in cardiac defibrillators. Promising avenues are being explored for physiologically informed neuromodulation in psychiatry. Matching the stimulation frequency to individual brain rhythms has shown some promise in transcranial magnetic stimulation (TMS). Matching the phase of those rhythms may further enhance neuroplasticity, for instance when combining TMS with electroencephalographic (EEG) recordings. Resting-state EEG and event-related potentials may be useful to demonstrate connectivity between stimulation sites and connected areas. These techniques are available today to the psychiatrist to diagnose underlying sleep disorders, epilepsy, or lesions as contributing factors to the cause of depression. These technologies may also be useful in assessing the patient's brain network status prior to deciding on treatment options. Ongoing research using invasive recordings may allow for future identification of mood biomarkers and network structure. A core limitation is that biomarker research may currently be limited by the internal heterogeneity of psychiatric disorders according to the current DSM-based classifications. New approaches are being developed and may soon be validated. Finally, care must be taken when incorporating closed-loop capabilities into neuromodulation systems, by ensuring the safe operation of the system and understanding the physiological dynamics. Neurophysiological tools are rapidly evolving and will likely define the next generation of neuromodulation therapies.
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Affiliation(s)
- Karen Wendt
- Department of Engineering Science and MRC Brain Network Dynamics Unit, University of Oxford, Oxford, UK.
| | - Timothy Denison
- Department of Engineering Science and MRC Brain Network Dynamics Unit, University of Oxford, Oxford, UK
| | - Gaynor Foster
- Welcony Inc., Plymouth, MN, United States of America
| | - Lothar Krinke
- Welcony Inc., Plymouth, MN, United States of America; Department of Neuroscience, School of Medicine, West Virginia University, Morgantown, WV, United States of America
| | - Alix Thomson
- Welcony Inc., Plymouth, MN, United States of America
| | - Saydra Wilson
- Department of Psychiatry and Behavioral Sciences, University of Minnesota-Twin Cities, Minneapolis, MN, United States of America
| | - Alik S Widge
- Department of Psychiatry and Behavioral Sciences, University of Minnesota-Twin Cities, Minneapolis, MN, United States of America; Medical Discovery Team on Additions, University of Minnesota, Minneapolis, MN, United States of America
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Abstract
Three neuromodulation therapies, all using implanted device and electrodes, have been
approved to treat adults with drug-resistant focal epilepsy, namely, the vagus nerve
stimulation in 1995, deep brain stimulation of the anterior nucleus of the thalamus
(ANT-DBS) in 2018 (2010 in Europe), and responsive neurostimulation (RNS) in 2014.
Indications for VNS have more recently extended to children down to age of 4. Limited or
anecdotal data are available in other epilepsy syndromes and refractory/super-refractory
status epilepticus. Overall, neuromodulation therapies are palliative, with only a
minority of patients achieving long-term seizure freedom, justifying favoring such
treatments in patients who are not good candidates for curative epilepsy surgery. About
half of patients implanted with VNS, ANT-DBS, and RNS have 50% or greater reduction in
seizures, with long-term data suggesting increased efficacy over time. Besides their
impact on seizure frequency, neuromodulation therapies are associated with various
benefits and drawbacks in comparison to antiseizure drugs. Yet, we lack high-level
evidence to best position each neuromodulation therapy in the treatment pathways of
persons with difficult-to-treat epilepsy.
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Affiliation(s)
- Philippe Ryvlin
- Department of Clinical Neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Lara E. Jehi
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
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32
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Villarreal J, Valaparla VL, Curtis K, Thottempudi N, Elrahi S, Gil Guevara A, Gogia B, Sun R, Masel T, Rai P. Neuromodulation in Intractable Epilepsy Through Responsive Vagal Nerve Stimulation: A Three-Year Retrospective Study at the University of Texas Medical Branch, Galveston. Cureus 2021; 13:e18698. [PMID: 34790456 PMCID: PMC8584105 DOI: 10.7759/cureus.18698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Vagus nerve stimulation (VNS) functions through neuromodulatory mechanisms to provide quality of life improvements to those with drug-resistant epilepsy. Responsive VNS (rVNS) generators are designed to further reduce seizure burden by detecting ictal tachycardia and aborting seizures soon after their onset. Methods: Electronic medical records were accessed from January 2015 to December 2018 to identify patients with epilepsy managed with rVNS generators. Data were collected on seizure burden before and after rVNS implantation. Seizure burden was compared using t-tests, and monthly seizure reductions were gauged with the McHugh scale. Twenty-seven individuals met inclusion criteria; 10 were eliminated due to prior VNS implantation or undocumented seizure frequencies. Results: The average seizure burden prior to rVNS implantation was 24.78 seizures/month. Following generator placement, the mean seizure frequencies at three months, six months, 12 months, and 18 months were 6.81, 16.57, 5.65, and 5.78 seizures/month, respectively. However, despite documented reductions in the average monthly seizure frequency, we found no statistically significant differences in seizure frequency relative to baseline. Conclusion: While many participants showed individual reductions in seizure burden, this study was unable to definitively conclude that rVNS therapy leads to statistically significant reduction in seizure burden.
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Affiliation(s)
- Joseph Villarreal
- Department of Neurology, University of Texas Medical Branch, Galveston, USA
| | | | - Kyra Curtis
- Department of Neurology, University of Texas Medical Branch, Galveston, USA
| | | | - Sama Elrahi
- Department of Neurology, University of Texas Medical Branch, Galveston, USA
| | - Andrea Gil Guevara
- Department of Neurology, University of Texas Medical Branch, Galveston, USA
| | - Bhanu Gogia
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Ruiqing Sun
- Department of Neurology, University of Texas Medical Branch, Galveston, USA
| | - Todd Masel
- Department of Neurology, University of Texas Medical Branch, Galveston, USA
| | - Prashant Rai
- Department of Neurology, University of Texas Medical Branch, Galveston, USA
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33
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Ryvlin P, Rheims S, Hirsch LJ, Sokolov A, Jehi L. Neuromodulation in epilepsy: state-of-the-art approved therapies. Lancet Neurol 2021; 20:1038-1047. [PMID: 34710360 DOI: 10.1016/s1474-4422(21)00300-8] [Citation(s) in RCA: 101] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 08/22/2021] [Accepted: 09/03/2021] [Indexed: 12/20/2022]
Abstract
Three neuromodulation therapies have been appropriately tested and approved in refractory focal epilepsies: vagus nerve stimulation (VNS), deep brain stimulation of the anterior nucleus of the thalamus (ANT-DBS), and closed-loop responsive neurostimulation of the epileptogenic zone or zones. These therapies are primarily palliative. Only a few individuals have achieved complete freedom from seizures for more than 12 months with these therapies, whereas more than half have benefited from long-term reduction in seizure frequency of more than 50%. Implantation-related adverse events primarily include infection and pain at the implant site. Intracranial haemorrhage is a frequent adverse event for ANT-DBS and responsive neurostimulation. Other stimulation-specific side-effects are observed with VNS and ANT-DBS. Biomarkers to predict response to neuromodulation therapies are not available, and high-level evidence to aid decision making about when and for whom these therapies should be preferred over other antiepileptic treatments is scant. Future studies are thus needed to address these shortfalls in knowledge, approve other forms of neuromodulation, and develop personalised closed-loop therapies with embedded machine learning. Until then, neuromodulation could be considered for individuals with intractable seizures, ideally after the possibility of curative surgical treatment has been carefully assessed and ruled out or judged less appropriate.
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Affiliation(s)
- Philippe Ryvlin
- Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Sylvain Rheims
- Department of Functional Neurology and Epileptology, Hospices Civils de Lyon, Lyon 1 University Lyon Neuroscience Research Center, Institut National de la Santé et de la Recherche Médicale U1028/CNRS UMR 5292 Epilepsy Institute, Lyon, France
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Arseny Sokolov
- Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Lara Jehi
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
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Hubbard I, Beniczky S, Ryvlin P. The Challenging Path to Developing a Mobile Health Device for Epilepsy: The Current Landscape and Where We Go From Here. Front Neurol 2021; 12:740743. [PMID: 34659099 PMCID: PMC8517120 DOI: 10.3389/fneur.2021.740743] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/03/2021] [Indexed: 11/13/2022] Open
Abstract
Seizure detection, and more recently seizure forecasting, represent important avenues of clinical development in epilepsy, promoted by progress in wearable devices and mobile health (mHealth), which might help optimizing seizure control and prevention of seizure-related mortality and morbidity in persons with epilepsy. Yet, very long-term continuous monitoring of seizure-sensitive biosignals in the ambulatory setting presents a number of challenges. We herein provide an overview of these challenges and current technological landscape of mHealth devices for seizure detection. Specifically, we display, which types of sensor modalities and analytical methods are available, and give insight into current clinical practice guidelines, main outcomes of clinical validation studies, and discuss how to evaluate device performance at point-of-care facilities. We then address pitfalls which may arise in patient compliance and the need to design solutions adapted to user experience.
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Affiliation(s)
- Ilona Hubbard
- Department of Clinical Neurosciences, Vaud University Hospital, Lausanne, Switzerland
| | - Sandor Beniczky
- Department of Clinical Neurophysiology, Danish Epilepsy Center, Dianalund, Denmark.,Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - Philippe Ryvlin
- Department of Clinical Neurosciences, Vaud University Hospital, Lausanne, Switzerland
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Atwood AC, Drees CN. Seizure Detection Devices: Five New Things. Neurol Clin Pract 2021; 11:367-371. [PMID: 34840863 PMCID: PMC8610510 DOI: 10.1212/cpj.0000000000001044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/15/2020] [Indexed: 11/15/2022]
Abstract
PURPOSE The purpose of this study was to review seizure detection devices (SDDs) and their mechanisms of action and efficacy and to reflect on potential improvements for future devices. RECENT FINDINGS There are 5 main categories of SDDs, these include EEG, heart rate detection (HR), electrodermal activity (EDA), motion detection, and EMG. These devices can be used in combination or in isolation to detect seizures. These devices are high in their sensitivity for convulsive seizures but are low in specificity because of a tendency to detect artifact. Overall, they perform poorly in identifying nonconvulsive seizures. SUMMARY SDDs are currently most useful in detecting convulsive seizures and thereby might help against sudden unexpected death in epilepsy, although they have a high false positive rate. These devices are much less adept at detecting more clinically subtle seizures.
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Mao H, Chen Y, Ge Q, Ye L, Cheng H. Short- and Long-Term Response of Vagus Nerve Stimulation Therapy in Drug-Resistant Epilepsy: A Systematic Review and Meta-Analysis. Neuromodulation 2021; 25:327-342. [PMID: 35396068 DOI: 10.1111/ner.13509] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 06/22/2021] [Accepted: 06/29/2021] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To compare the short- and long-term efficacies as well as tolerability of vagus nerve stimulation (VNS) for the patients with drug-resistant epilepsy (DRE) in comparison with status at baseline. MATERIALS AND METHODS We conducted a specific and systematic search in online data bases for relevant literature published prior to December 2020. The literature retrieved, including randomized clinical trials (RCTs) and observational studies, were then reviewed, and analyzed. A fixed-effect model was used to evaluate the pooled odds ratio (OR) of responder rates and complications associated with RCTs. A random-effect model was used to generate overall responder rates and overall incidences of complication. RESULTS A total of 61 studies, featuring 5223 patients, were included in our study. The pooled ORs of responder rates, hoarseness/voice change, throat pain, coughing, dyspnea, paresthesia, muscle pain, and headache during the short-term phase were 2.195 (p = 0.001), 5.527 (p = 0.0001), 0.935 (p = 0.883), 1.119 (p = 0.655), 2.901 (p = 0.005), 1.775 (p = 0.061), 3.606 (p = 0.123), and 0.928 (p = 0.806), respectively. The overall responder rates in 3, 6, 12, 24, 36, 48, and 60 months postoperatively were 0.421, 0.455, 0.401, 0.451, 0.482, 0.502, and 0.508, respectively. The overall incidences of complication were 0.274 for hoarseness/voice change, 0.099 for throat pain, 0.133 for coughing, 0.099 for dyspnea, 0.102 for paresthesia, 0.062 for muscle pain, 0.101 for headache, 0.015 for dysphagia, 0.013 for neck pain, 0.040 for infection, 0.030 for lead fracture, 0.019 for vocal cord palsy, and 0.020 for device malfunction, respectively. CONCLUSIONS The estimating of efficacy and tolerability, using data from the existing literature, indicated VNS therapy is a safe and effective treatment option for patients with DRE.
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Affiliation(s)
- Hongliang Mao
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China.,First Clinical Medical College, Anhui Medical University, Hefei, China
| | - Yonghao Chen
- First Clinical Medical College, Anhui Medical University, Hefei, China
| | - Qintao Ge
- First Clinical Medical College, Anhui Medical University, Hefei, China
| | - Lei Ye
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Hongwei Cheng
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
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Kulju T, Haapasalo J, Verner R, Dibué-Adjei M, Lehtimäki K, Rainesalo S, Peltola J. Frequency of Automatic Stimulations in Responsive Vagal Nerve Stimulation in Patients With Refractory Epilepsy. Neuromodulation 2021; 23:852-858. [PMID: 32840019 DOI: 10.1111/ner.13238] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/02/2020] [Accepted: 06/15/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND In vagal nerve stimulation (VNS) therapy, the release of VNS model 106 (AspireSR) allowed for responsive VNS (rVNS). rVNS utilizes a cardiac-based seizure detection algorithm to detect seizure-induced tachycardia to trigger additional stimulation. There are some studies suggesting clinical benefits of rVNS over traditional VNS, but the performance and significance of autostimulation mode in clinical practice are poorly understood. OBJECTIVES To assess the effect of initiation of rVNS therapy and altered stimulation settings on the number of daily stimulations and energy consumption in VNS therapy and to compare autostimulation performance in different epilepsy types. MATERIALS AND METHODS Retrospective follow-up of 30 patients with drug-resistant epilepsy treated with rVNS including 17 new implantations and 13 battery replaces at a single center in Finland. Our data consist of 208 different stimulation periods, that is, episodes with defined stimulation settings and both autostimulation and total stimulation performance-related data along with clinical follow-up. RESULTS The variation in autostimulation frequency was highly dependent on the duration of the OFF-time and autostimulation threshold (p < 0.05). There was a large additional effect of autostimulation mode on therapy time and energy consumption with longer OFF-times, but a minor effect with shorter OFF-times. Significantly more autostimulations were triggered in the temporal lobe and multifocal epilepsies than in extratemporal lobe epilepsies. CONCLUSIONS The initiation of autostimulation mode in VNS therapy increased the total number of stimulations. Shortening the OFF-time leads to a decreased number and share of automatic activations. Epilepsy type may affect autostimulation activity.
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Affiliation(s)
- Toni Kulju
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Joonas Haapasalo
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland.,The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Ryan Verner
- LivaNova USA, Neuromodulation Unit, Houston, TX, USA
| | - Maxine Dibué-Adjei
- Neuromodulation Medical Affairs, LivaNova PLC, London, UK.,Department of Neurosurgery, Heinrich Heine University Düsseldorf, Germany
| | - Kai Lehtimäki
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland
| | - Sirpa Rainesalo
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland
| | - Jukka Peltola
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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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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Doddamani RS, Agrawal M, Samala R, Ramanujam B, Chandra PS, Tripathi M. Vagal Nerve Stimulation in the Management of Epilepsy - Recent Concepts. Neurol India 2021; 68:S259-S267. [PMID: 33318360 DOI: 10.4103/0028-3886.302475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Epilepsy surgery currently offers the best treatment for patients with drug-refractory epilepsy (DRE). Resective surgery, in the presence of a well-localized epileptogenic focus, remains the best modality towards achieving seizure freedom. However, localization of the focus may not be possible in all the cases of DRE, despite comprehensive epilepsy workup. Neuromodulation techniques such as vagal nerve stimulation (VNS), deep brain stimulation (DBS) and responsive neurostimulation (RNS) may be a good alternative in these cases. This article intends to provide an overview of VNS in the management of DRE, including indications, comprehensive preoperative workup, exemplified by case illustrations and outcomes by reviewing the evidence available in the literature.
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Affiliation(s)
| | - Mohit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Raghu Samala
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Bhargavi Ramanujam
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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40
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Hamdi H, Spatola G, Lagarde S, McGonigal A, Paz-Paredes A, Bizeau A, Bartolomei F, Carron R. Use of Polyvinyl Alcohol Sponge Cubes for Vagal Nerve Stimulation: A Suggestion for the Wrapping Step. Technical Note and Step-by-Step Operative Technique. Oper Neurosurg (Hagerstown) 2021; 18:487-495. [PMID: 31386756 PMCID: PMC7594176 DOI: 10.1093/ons/opz227] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 05/29/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Vagal nerve stimulation (VNS) is an approved treatment for epilepsy and depression. Wrapping the helical electrodes around the nerve can prove technically challenging. However, a quick and efficient method to slightly elevate the nerve can highly facilitate this part of the procedure. OBJECTIVE To provide useful surgical tips to facilitate the procedure. METHODS Based on experience of more than 150 adult cases for mainly epilepsy (primary lead implant), the authors share their surgical technique to provide the experienced surgeons or newcomers to the field of VNS with some useful tips. All patients signed informed consent according to the local ethics committee guidelines. RESULTS The article consists of a detailed step-by-step description of the whole procedure illustrated through high-resolution colored photographs of the surgical field. Special reference is made to the usefulness of polyvinyl alcohol (PVA) sponge cubes to elevate the nerve instead of the commonly used silicon vessel loops. CONCLUSION The use of surgical microscope and PVA sponge cubes to elevate the nerve constitute key points to make VNS an easy surgery.
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Affiliation(s)
- Hussein Hamdi
- Department of Functional and Stereotactic Neurosurgery, Timone University Hospital, Marseille, France.,Aix Marseille Univ, APHM, INSERM, INS, Inst Neurosci Syst, Timone Hospital, Marseille, France.,Functional Neurosurgery and Stereotaxy Unit, Neurological Surgery Department, Tanta University, Egypt
| | - Giorgio Spatola
- Department of Functional and Stereotactic Neurosurgery, Timone University Hospital, Marseille, France.,Aix Marseille Univ, APHM, INSERM, INS, Inst Neurosci Syst, Timone Hospital, Marseille, France
| | - Stanislas Lagarde
- Epileptology Department, Aix Marseille Univ, APHM, INSERM, INS, Inst Neurosci Syst, Timone Hospital, Marseille, France
| | - Aileen McGonigal
- Epileptology Department, Aix Marseille Univ, APHM, INSERM, INS, Inst Neurosci Syst, Timone Hospital, Marseille, France
| | - Armando Paz-Paredes
- Department of Functional and Stereotactic Neurosurgery, Timone University Hospital, Marseille, France
| | - Alain Bizeau
- Department of Cervico-Facial Surgery, Sainte Musse Hospital, Toulon, France
| | - Fabrice Bartolomei
- Epileptology Department, Aix Marseille Univ, APHM, INSERM, INS, Inst Neurosci Syst, Timone Hospital, Marseille, France
| | - Romain Carron
- Department of Functional and Stereotactic Neurosurgery, Timone University Hospital, Marseille, France.,Aix Marseille Univ, APHM, INSERM, INS, Inst Neurosci Syst, Timone Hospital, Marseille, France
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41
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Natesan A, Behar S. Technology-Dependent Children. Emerg Med Clin North Am 2021; 39:641-660. [PMID: 34215407 DOI: 10.1016/j.emc.2021.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
There are a growing number of medically complex children with implanted devices. Emergency physicians with a basic knowledge of these devices can troubleshoot and fix many of the issues that may arise. Recognition of malfunction of these devices can reduce morbidity and mortality among this special population. In this article, we review common issues that may arise in children with gastrostomy tubes, central nervous system shunts, cochlear implants, and vagal nerve stimulators.
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Affiliation(s)
- Alamelu Natesan
- Pediatrics, UCLA David Geffen School of Medicine, Los Angeles, CA, USA. https://twitter.com/amlun
| | - Solomon Behar
- Pediatric Emergency Medicine, Long Beach Memorial/Miller Children's Hospital, 2801 Atlantic Avenue, Long Beach, CA 90806, USA; Voluntary Faculty, Department of Pediatrics, UC Irvine School of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.
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Opie NL, O'Brien TJ. The potential of closed-loop endovascular neurostimulation as a viable therapeutic approach for drug-resistant epilepsy: A critical review. Artif Organs 2021; 46:337-348. [PMID: 34101849 DOI: 10.1111/aor.14007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/23/2021] [Accepted: 05/27/2021] [Indexed: 11/30/2022]
Abstract
Over the last few decades, biomedical implants have successfully delivered therapeutic electrical stimulation to reduce the frequency and severity of seizures in people with drug-resistant epilepsy. However, neurostimulation approaches require invasive surgery to implant stimulating electrodes, and surgical, medical, and hardware complications are not uncommon. An endovascular approach provides a potentially safer and less invasive surgical alternative. This article critically evaluates the feasibility of endovascular closed-loop neuromodulation for the treatment of epilepsy. By reviewing literature that reported the impact of direct electrical stimulation to reduce the frequency of epileptic seizures, we identified clinically validated extracranial, cortical, and deep cortical neural targets. We identified veins in close proximity to these targets and evaluated the potential of delivering an endovascular implant to these veins based on their diameter. We then compared the risks and benefits of existing technology to describe a benchmark of clinical safety and efficacy that would need to be achieved for endovascular neuromodulation to provide therapeutic benefit. For the majority of brain regions that have been clinically demonstrated to reduce seizure occurrence in response to delivered electrical stimulation, vessels of appropriate diameter for delivery of an endovascular electrode to these regions could be achieved. This includes delivery to the vagus nerve via the 13.2 ± 0.9 mm diameter internal jugular vein, the motor cortex via the 6.5 ± 1.7 mm diameter superior sagittal sinus, and the cerebellum via the 7.7 ± 1.4 mm diameter sigmoid sinus or 6.2 ± 1.4 mm diameter transverse sinus. Deep cerebral targets can also be accessed with an endovascular approach, with the 1.9 ± 0.5 mm diameter internal cerebral vein and 1.2-mm-diameter thalamostriate vein lying in close proximity to the anterior and centromedian nuclei of the thalamus, respectively. This work identified numerous veins that are in close proximity to conventional stimulation targets that are of a diameter large enough for delivery and deployment of an endovascular electrode array, supporting future work to assess clinical efficacy and chronic safety of an endovascular approach to deliver therapeutic neurostimulation.
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Affiliation(s)
- Nicholas L Opie
- Vascular Bionics Laboratory, Department of Medicine, The University of Melbourne, Parkville, VIC, Australia.,Synchron Inc., San Francisco, CA, USA
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia.,Department of Neurology, Alfred Health, Melbourne, VIC, Australia
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Stumpp L, Smets H, Vespa S, Cury J, Doguet P, Delbeke J, Nonclercq A, El Tahry R. Vagus Nerve Electroneurogram-Based Detection of Acute Pentylenetetrazol Induced Seizures in Rats. Int J Neural Syst 2021; 31:2150024. [PMID: 34030610 DOI: 10.1142/s0129065721500246] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
On-demand stimulation improves the efficacy of vagus nerve stimulation (VNS) in refractory epilepsy. The vagus nerve is the main peripheral parasympathetic connection and seizures are known to exhibit autonomic symptoms. Therefore, we hypothesized that seizure detection is possible through vagus nerve electroneurogram (VENG) recording. We developed a metric able to measure abrupt changes in amplitude and frequency of spontaneous vagus nerve action potentials. A classifier was trained using a "leave-one-out" method on a set of 6 seizures and 3 control recordings to utilize the VENG spike feature-based metric for seizure detection. We were able to detect pentylenetetrazol (PTZ) induced acute seizures in 6/6 animals during different stages of the seizure with no false detection. The classifier detected the seizure during an early stage in 3/6 animals and at the onset of tonic clonic stage of the seizure in 3/6 animals. EMG and motion artefacts often accompany epileptic activity. We showed the "epileptic" neural signal to be independent from EMG and motion artefacts. We confirmed the existence of seizure related signals in the VENG recording and proved their applicability for seizure detection. This detection might be a promising tool to improve efficacy of VNS treatment by developing new responsive stimulation systems.
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Affiliation(s)
- Lars Stumpp
- Institute of Neuroscience, Université Catholique de Louvain, Brussels, Belgium
| | - Hugo Smets
- BEAMS Department, Université libre de Bruxelles, Brussels, Belgium
| | - Simone Vespa
- Institute of Neuroscience, Université Catholique de Louvain, Brussels, Belgium
| | - Joaquin Cury
- BEAMS Department, Université libre de Bruxelles, Brussels, Belgium
| | | | - Jean Delbeke
- Institute of Neuroscience, Université Catholique de Louvain, Brussels, Belgium
| | | | - Riem El Tahry
- Institute of Neuroscience, Université Catholique de Louvain, Brussels, Belgium.,Cliniques Universitaires Saint Luc, Center for Refractory Epilepsy, Brussels, Belgium
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Wang Y, Zhan G, Cai Z, Jiao B, Zhao Y, Li S, Luo A. Vagus nerve stimulation in brain diseases: Therapeutic applications and biological mechanisms. Neurosci Biobehav Rev 2021; 127:37-53. [PMID: 33894241 DOI: 10.1016/j.neubiorev.2021.04.018] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 04/12/2021] [Accepted: 04/18/2021] [Indexed: 12/21/2022]
Abstract
Brain diseases, including neurodegenerative, cerebrovascular and neuropsychiatric diseases, have posed a deleterious threat to human health and brought a great burden to society and the healthcare system. With the development of medical technology, vagus nerve stimulation (VNS) has been approved by the Food and Drug Administration (FDA) as an alternative treatment for refractory epilepsy, refractory depression, cluster headaches, and migraines. Furthermore, current evidence showed promising results towards the treatment of more brain diseases, such as Parkinson's disease (PD), autistic spectrum disorder (ASD), traumatic brain injury (TBI), and stroke. Nonetheless, the biological mechanisms underlying the beneficial effects of VNS in brain diseases remain only partially elucidated. This review aims to delve into the relevant preclinical and clinical studies and update the progress of VNS applications and its potential mechanisms underlying the biological effects in brain diseases.
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Affiliation(s)
- Yue Wang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Gaofeng Zhan
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Ziwen Cai
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Bo Jiao
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Yilin Zhao
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Shiyong Li
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Ailin Luo
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Lo WB, Chevill B, Philip S, Agrawal S, Walsh AR. Seizure improvement following vagus nerve stimulator (VNS) battery change with cardiac-based seizure detection automatic stimulation (AutoStim): early experience in a regional paediatric unit. Childs Nerv Syst 2021; 37:1237-1241. [PMID: 33174154 DOI: 10.1007/s00381-020-04962-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 11/03/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE The recent VNS models (AspireSR® Model 106, SenTiva™ Model 1000 (VNS Therapy®, LivaNova)) include a new function of cardiac-based seizure detection (CBSD) automatic stimulation, known as 'AutoStim'. This algorithm uses tachycardia as a proxy to a seizure, and the battery delivers a closed-loop electrical current in addition to its programmed stimulation. This function leads to further seizure reduction in adults, but this advantage has not been reported in the paediatric population. This study aims to investigate whether battery change with AutoStim leads to further seizure reduction in children. METHODS This observational study included the first 10 cases of VNS battery change from non-AutoStim to AutoStim function. During the battery change operation, the new VNS was switched on, with the same normal and magnet mode settings as the previous VNS. The AutoStim mode was activated at the same time. Data on seizure burden were collected at 3 time points: (1) before the first VNS insertion, (2) before battery replacement (post-1st VNS) and (3) 12 months post-battery change (post-AutoStim). The net effect of AutoStim, the only changed parameter, was evaluated by comparing the seizure burden prior to and 12 months following battery change in each child. RESULTS The seizure reduction improved significantly from 60 to 83% following battery change with AutoStim. Categorising the outcome according the McHugh classification, children achieving class I and II outcome (≥ 50% seizure reduction) improved from 70 to 90%. CONCLUSION This is the first study to demonstrate the additional efficacy of AutoStim in children treated with VNS.
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Affiliation(s)
- William B Lo
- Department of Neurosurgery, Birmingham Children's Hospital, Birmingham, B4 6NH, UK.
| | - Bethany Chevill
- Department of Neurology, Birmingham Children's Hospital, Birmingham, B4 6NH, UK
| | - Sunny Philip
- Department of Neurology, Birmingham Children's Hospital, Birmingham, B4 6NH, UK
| | - Shakti Agrawal
- Department of Neurology, Birmingham Children's Hospital, Birmingham, B4 6NH, UK
| | - A Richard Walsh
- Department of Neurosurgery, Birmingham Children's Hospital, Birmingham, B4 6NH, UK
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Closed-loop vagal nerve stimulation for intractable epilepsy: A single-center experience. Seizure 2021; 88:95-101. [PMID: 33839564 DOI: 10.1016/j.seizure.2021.03.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/26/2021] [Accepted: 03/29/2021] [Indexed: 11/22/2022] Open
Abstract
PURPOSE A new class of heart-rate sensing, closed-loop vagal nerve stimulator (VNS) devices for refractory epilepsy may improve seizure control by using pre-ictal autonomic changes as an indicator for stimulation. We compared our experience with closed- versus open-loop stimulator implantation at a single institution. METHODS We conducted a retrospective chart review of consecutive VNS implantations performed from 2004 to 2018. Bivariate and multivariable analyses were performed to compare changes in seizure frequency and clinical outcomes (Engel score) with closed- versus open-loop devices. Covariates included age, duration of seizure history, prior epilepsy surgery, depression, Lennox Gastaut Syndrome (LGS), tonic seizures, multiple seizure types, genetic etiology, and VNS settings. We examined early (9-month) and late (24-month) outcomes. RESULTS Seventy subjects received open-loop devices, and thirty-one received closed-loop devices. At a median of 8.5 months, there was a greater reduction of seizure frequency after use of closed-loop devices (median 75% [IQR 10-89%]) versus open-loop (50% [0-78%], p < 0.05), confirmed in multivariable analysis (odds ratio 2.72 [95% CI 1.02 - 7.4]). Similarly, Engel outcomes were better after closed-loop compared to open-loop confirmed in the multivariable analysis at the early timepoint (OR 0.26 [95% CI 0.09 - 0.69]). These differences did not persist at a median of 24.5 months. CONCLUSIONS This retrospective single-center study suggests the use of closed-loop VNS devices is associated with greater seizure reduction and more favorable clinical outcomes than open-loop devices at 9-months though not at 24-months. Expansion of this study to other centers is warranted to increase the generalizability of our study.
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Beniczky S, Wiebe S, Jeppesen J, Tatum WO, Brazdil M, Wang Y, Herman ST, Ryvlin P. Automated seizure detection using wearable devices: A clinical practice guideline of the International League Against Epilepsy and the International Federation of Clinical Neurophysiology. Epilepsia 2021; 62:632-646. [PMID: 33666944 DOI: 10.1111/epi.16818] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/23/2020] [Accepted: 12/23/2020] [Indexed: 12/15/2022]
Abstract
The objective of this clinical practice guideline (CPG) is to provide recommendations for healthcare personnel working with patients with epilepsy on the use of wearable devices for automated seizure detection in patients with epilepsy, in outpatient, ambulatory settings. The Working Group of the International League Against Epilepsy (ILAE) and the International Federation of Clinical Neurophysiology (IFCN) developed the CPG according to the methodology proposed by the ILAE Epilepsy Guidelines Working Group. We reviewed the published evidence using The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement and evaluated the evidence and formulated the recommendations following the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. We found high level of evidence for the accuracy of automated detection of generalized tonic-clonic seizures (GTCS) and focal-to-bilateral tonic-clonic seizures (FBTCS) and recommend the use of wearable automated seizure detection devices for selected patients when accurate detection of GTCS and FBTCS is recommended as a clinical adjunct. We also found a moderate level of evidence for seizure types without GTCS or FBTCS. However, it was uncertain whether the detected alarms resulted in meaningful clinical outcomes for the patients. We recommend using clinically validated devices for automated detection of GTCS and FBTCS, especially in unsupervised patients, where alarms can result in rapid intervention (weak/conditional recommendation). At present, we do not recommend clinical use of the currently available devices for other seizure types (weak/conditional recommendation). Further research and development are needed to improve the performance of automated seizure detection and to document their accuracy and clinical utility.
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Affiliation(s)
- Sándor Beniczky
- Department of Clinical Neurophysiology, Danish Epilepsy Centre and Aarhus University Hospital, Dianalund, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus C, Denmark
| | - Samuel Wiebe
- Department of Clinical Neurosciences and Clinical Research Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Jesper Jeppesen
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus C, Denmark
| | - William O Tatum
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
| | - Milan Brazdil
- Brno Epilepsy Center, Department of Neurology, St. Anne's University Hospital and Medical Faculty of Masaryk University, Brno, Czech Republic.,Behavioral and Social Neuroscience Research Group, Central European Institute of Technology, Masaryk University, Brno, Czech Republic
| | - Yuping Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Susan T Herman
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Philippe Ryvlin
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Université de Lausanne, Lausanne, Switzerland
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Automated seizure detection using wearable devices: A clinical practice guideline of the International League Against Epilepsy and the International Federation of Clinical Neurophysiology. Clin Neurophysiol 2021; 132:1173-1184. [PMID: 33678577 DOI: 10.1016/j.clinph.2020.12.009] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The objective of this clinical practice guideline (CPG) is to provide recommendations for healthcare personnel working with patients with epilepsy, on the use of wearable devices for automated seizure detection in patients with epilepsy, in outpatient, ambulatory settings. The Working Group of the International League Against Epilepsy and the International Federation of Clinical Neurophysiology developed the CPG according to the methodology proposed by the ILAE Epilepsy Guidelines Working Group. We reviewed the published evidence using The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement and evaluated the evidence and formulated the recommendations following the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. We found high level of evidence for the accuracy of automated detection of generalized tonic-clonic seizures (GTCS) and focal-to-bilateral tonic-clonic seizures (FBTCS) and recommend use of wearable automated seizure detection devices for selected patients when accurate detection of GTCS and FBTCS is recommended as a clinical adjunct. We also found moderate level of evidence for seizure types without GTCs or FBTCs. However, it was uncertain whether the detected alarms resulted in meaningful clinical outcomes for the patients. We recommend using clinically validated devices for automated detection of GTCS and FBTCS, especially in unsupervised patients, where alarms can result in rapid intervention (weak/conditional recommendation). At present, we do not recommend clinical use of the currently available devices for other seizure types (weak/conditional recommendation). Further research and development are needed to improve the performance of automated seizure detection and to document their accuracy and clinical utility.
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Guzner A, Macken M. The relationship between duty cycle, tachycardia threshold and autostimulation delivery in cardio-responsive vagus nerve stimulation. Epilepsy Behav 2021; 116:107728. [PMID: 33486238 DOI: 10.1016/j.yebeh.2020.107728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/16/2020] [Accepted: 12/18/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Many patients with epilepsy are unable to completely control seizures with medication alone. Vagus nerve stimulation is an effective nonpharmacologic option for treatment-resistant epilepsy. AutoStim technology is a relatively new VNS feature that provides extra stimulations in response to tachycardia, which often precedes seizures. This feature adds a currently unknown number of extra stimulations per day. This study aims to evaluate that actual stimulations' patients receive per day as a function of varying VNS settings. METHODS This project was a retrospective chart review. All patients with implanted VNS devices with AutoStim technology managed at Northwestern's epilepsy clinic were included in the study. Data were collected on duty cycle, tachycardia threshold, expected number of stimulations per day, normal mode stimulations per day, and AutoStims per day. Associations between all variables were evaluated. RESULTS Sixty-seven patients with VNS stimulators met inclusion criteria leading to 305 unique VNS interrogation results. This study demonstrated the smallest number of extra stimulations between tachycardia thresholds of 40 and 60 with absolute minimums at 35 and 45. Our results also demonstrate a trend of decreasing extra stimulations per day with increased duty cycle at each tachycardia threshold evaluated. CONCLUSIONS These data demonstrate the effect of duty cycle and tachycardia threshold on extra stimulations per day and demonstrated the optimal settings for reducing extra stimulations. This research provides reassurance and information to patients and providers about the actual number of stimulations patients receive with AutoStim technology.
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Affiliation(s)
- Alex Guzner
- Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
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Spindler P, Vajkoczy P, Schneider UC. Closed-loop vagus nerve stimulation. Patient-tailored therapy or undirected treatment? INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.101003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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