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McGrath H, Pennington Z, Cross MR, Hoffman EM, Gregg NM, Tasche KK, Bayan SL, Van Gompel JJ. Delayed vagal nerve compressive neuropathy following placement of vagal nerve stimulator: case report. Acta Neurochir (Wien) 2024; 166:193. [PMID: 38662025 DOI: 10.1007/s00701-024-06087-x] [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: 01/23/2024] [Accepted: 04/12/2024] [Indexed: 04/26/2024]
Abstract
Vagal neuropathy causing vocal fold palsy is an uncommon complication of vagal nerve stimulator (VNS) placement. It may be associated with intraoperative nerve injury or with device stimulation. Here we present the first case of delayed, compressive vagal neuropathy associated with VNS coil placement which presented with progressive hoarseness and vocal cord paralysis. Coil removal and vagal neurolysis was performed to relieve the compression. Larger 3 mm VNS coils were placed for continuation of therapy. Coils with a larger inner diameter should be employed where possible to prevent this complication. The frequency of VNS-associated vagal nerve compression may warrant further investigation.
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Affiliation(s)
- Hari McGrath
- Department of Neurosurgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | - Zach Pennington
- Department of Neurosurgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | | | | | | | - Kendall K Tasche
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Semirra L Bayan
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jamie J Van Gompel
- Department of Neurosurgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA.
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2
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Campbell CD, Ridge PC, McDonnell MJ, Ward C, Harrison MJ, Collins C, Rutherford RM. Recurrent Lung Injury Resulting From Unusual Cases of Aero-Digestive Disease. Dysphagia 2023; 38:1447-1448. [PMID: 36749391 DOI: 10.1007/s00455-023-10558-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 01/17/2023] [Indexed: 02/08/2023]
Affiliation(s)
- C D Campbell
- Department of Respiratory Medicine, University Hospital Galway, Galway, Ireland
| | - P C Ridge
- Department of Respiratory Medicine, University Hospital Galway, Galway, Ireland.
| | - M J McDonnell
- Department of Respiratory Medicine, University Hospital Galway, Galway, Ireland
| | - C Ward
- Department of Respiratory Medicine, Newcastle University, Newcastle, UK
| | - M J Harrison
- Department of Respiratory Medicine, University Hospital Galway, Galway, Ireland
| | - C Collins
- Department of Surgery, University Hospital Galway, Galway, Ireland
| | - R M Rutherford
- Department of Respiratory Medicine, University Hospital Galway, Galway, Ireland
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Broderick L, Tuohy G, Solymos O, Lakhani S, Staunton B, Ennis P, Clark N, Moppett IK, Chalissery A, Kilbride RD, Sweeney KJ, O'Brien D, O'Hare A, Harvey A, Larkin CM. Management of vagus nerve simulation therapy in the peri-operative period: Guidelines from the Association of Anaesthetists: Guidelines from the Association of Anaesthetists. Anaesthesia 2023; 78:747-757. [PMID: 37096456 DOI: 10.1111/anae.16012] [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: 03/06/2023] [Indexed: 04/26/2023]
Abstract
Vagus nerve stimulation is a well-established treatment option for patients with drug-resistant epilepsy and has an expanding range of other clinical indications. Side effects of vagus nerve stimulation therapy include: cough; voice changes; vocal cord adduction; rarely, obstructive sleep apnoea; and arrhythmia. Patients with implanted vagus nerve stimulation devices may present for unrelated surgery and critical care to clinicians who are unfamiliar with their function and safe management. These guidelines have been formulated by multidisciplinary consensus based on case reports, case series and expert opinion to support clinicians in the management of patients with these devices. The aim is to provide specific guidance on the management of vagus nerve stimulation devices in the following scenarios: the peri-operative period; peripartum period; during critical illness; and in the MRI suite. Patients should be aware of the importance of carrying their personal vagus nerve stimulation device magnet with them at all times to facilitate urgent device deactivation if necessary. We advise that it is generally safer to formally deactivate vagus nerve stimulation devices before general and spinal anaesthesia. During periods of critical illness associated with haemodynamic instability, we also advise cessation of vagus nerve stimulation and early consultation with neurology services.
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Affiliation(s)
| | - G Tuohy
- Rotunda Hospital, Dublin, Ireland
| | - O Solymos
- St Vincent's University Hospital, Dublin, Ireland
| | - S Lakhani
- The Walton Centre NHS Foundation Trust, Liverpool, UK
| | | | - P Ennis
- Beaumont Hospital, Dublin, Ireland
| | - N Clark
- Bristol Children's Hospital, Bristol, UK
| | | | | | | | | | | | - A O'Hare
- Beaumont Hospital, Dublin, Ireland
| | - A Harvey
- Royal Cornwall Hospital Trust, Cornwall, UK
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Comparing the accuracy of ultrasound-based measurements of the cervical vagus nerve. Sci Rep 2023; 13:884. [PMID: 36650212 PMCID: PMC9845339 DOI: 10.1038/s41598-023-27894-9] [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] [Received: 05/13/2022] [Accepted: 01/10/2023] [Indexed: 01/19/2023] Open
Abstract
Vagus nerve stimulation (VNS) has become a promising therapy especially for drug resistant epilepsy and other pathologies. Side effects or missing therapeutic success are observed due to cuff electrodes that are too narrow or too wide. Preoperative high-resolution ultrasound is used to evaluate the size of the cervical vagus nerve (CVN) to estimate the size of cuff electrodes for VNS. It remains unclear how precise ultrasound reflects the CVN dimensions, which has been the objective of this study. CVN cross-sections and diameters were investigated in 23 sides from 12 bodies, using ultrasound, histology, and CVN casting in situ as a reference. Morphometric data were obtained including fascicle count and nerve composition in histology. CVN yielded significant side-, age-, and BMI-related differences. CVN cross-sections were smaller in ultrasound when compared to casting and histology (1.5 ± 0.4 vs. 3.1 ± 0.9 vs. 2.3 ± 0.7 mm2). With the given setting in ultrasound, CVN cross-sections were consistently underestimated when compared to casting. Ultrasound-based cross-section measurements are related to a biased estimation of CVN size. A factor to correct for method related differences may help to adjust for accurate cuff electrode sizes for patient needs and to reduce undesired effects and potentially material consumption.
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Intra-operative monitoring as an adjuvant to standard vagus nerve stimulation implantation. Childs Nerv Syst 2021; 37:3809-3816. [PMID: 34302220 DOI: 10.1007/s00381-021-05295-5] [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: 05/27/2021] [Accepted: 07/14/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The treatment of refractory epilepsy by vagus nerve stimulation (VNS) is a well-established therapy. Complications following VNS insertion may be procedure-related or stimulation-related. Herein, we describe our technique of intra-operative neuro-monitoring (IONM) in an attempt to diminish these adverse events. METHODS This retrospective study describes 66 consecutive patients between the ages of 3 and 12 years who had undergone primary VNS implantation. The study population consisted of two cohorts, one in which the VNS device was implanted according to the standard described technique and a second group in which IONM was used as an adjuvant during the VNS device placement. Prior to VNS insertion, a Pediatric Voice Handicap Index (PVHI) was performed to assess voice-related quality of life, and this was repeated at 3 months following VNS insertion. RESULTS Sixty-six patients underwent the VNS implantation. Forty-three patients had a "standard" VNS insertion technique performed, whereas 23 had IONM performed during the VNS implantation. There were significant changes in the PVHI scores across both cohorts at 3-month follow-up. There were no statistically significant differences in PVHI scores between the monitored group and non-monitored group at 3-month follow up. CONCLUSIONS IONM can be used during VNS insertions to ensure correct placement of the leads on CNX. IONM may minimise vocal cord stimulation by placing the lead coils on the area of nerve eliciting the least amount of vocal cord EMG response. IONM however does not appear to improve voice outcomes at early follow up.
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Dawson J, Liu CY, Francisco GE, Cramer SC, Wolf SL, Dixit A, Alexander J, Ali R, Brown BL, Feng W, DeMark L, Hochberg LR, Kautz SA, Majid A, O'Dell MW, Pierce D, Prudente CN, Redgrave J, Turner DL, Engineer ND, Kimberley TJ. Vagus nerve stimulation paired with rehabilitation for upper limb motor function after ischaemic stroke (VNS-REHAB): a randomised, blinded, pivotal, device trial. Lancet 2021; 397:1545-1553. [PMID: 33894832 PMCID: PMC8862193 DOI: 10.1016/s0140-6736(21)00475-x] [Citation(s) in RCA: 182] [Impact Index Per Article: 60.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 02/16/2021] [Accepted: 02/19/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Long-term loss of arm function after ischaemic stroke is common and might be improved by vagus nerve stimulation paired with rehabilitation. We aimed to determine whether this strategy is a safe and effective treatment for improving arm function after stroke. METHODS In this pivotal, randomised, triple-blind, sham-controlled trial, done in 19 stroke rehabilitation services in the UK and the USA, participants with moderate-to-severe arm weakness, at least 9 months after ischaemic stroke, were randomly assigned (1:1) to either rehabilitation paired with active vagus nerve stimulation (VNS group) or rehabilitation paired with sham stimulation (control group). Randomisation was done by ResearchPoint Global (Austin, TX, USA) using SAS PROC PLAN (SAS Institute Software, Cary, NC, USA), with stratification by region (USA vs UK), age (≤30 years vs >30 years), and baseline Fugl-Meyer Assessment-Upper Extremity (FMA-UE) score (20-35 vs 36-50). Participants, outcomes assessors, and treating therapists were masked to group assignment. All participants were implanted with a vagus nerve stimulation device. The VNS group received 0·8 mA, 100 μs, 30 Hz stimulation pulses, lasting 0·5 s. The control group received 0 mA pulses. Participants received 6 weeks of in-clinic therapy (three times per week; total of 18 sessions) followed by a home exercise programme. The primary outcome was the change in impairment measured by the FMA-UE score on the first day after completion of in-clinic therapy. FMA-UE response rates were also assessed at 90 days after in-clinic therapy (secondary endpoint). All analyses were by intention to treat. This trial is registered at ClinicalTrials.gov, NCT03131960. FINDINGS Between Oct 2, 2017, and Sept 12, 2019, 108 participants were randomly assigned to treatment (53 to the VNS group and 55 to the control group). 106 completed the study (one patient for each group did not complete the study). On the first day after completion of in-clinic therapy, the mean FMA-UE score increased by 5·0 points (SD 4·4) in the VNS group and by 2·4 points (3·8) in the control group (between group difference 2·6, 95% CI 1·0-4·2, p=0·0014). 90 days after in-clinic therapy, a clinically meaningful response on the FMA-UE score was achieved in 23 (47%) of 53 patients in the VNS group versus 13 (24%) of 55 patients in the control group (between group difference 24%, 6-41; p=0·0098). There was one serious adverse event related to surgery (vocal cord paresis) in the control group. INTERPRETATION Vagus nerve stimulation paired with rehabilitation is a novel potential treatment option for people with long-term moderate-to-severe arm impairment after ischaemic stroke. FUNDING MicroTransponder.
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Affiliation(s)
- Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.
| | - Charles Y Liu
- USC Neurorestoration Center and Department of Neurological Surgery, USC Keck School of Medicine, Los Angeles, CA, USA; Rancho Los Amigos National Rehabilitation Center, Downey, CA, USA
| | - Gerard E Francisco
- Department of Physical Medicine and Rehabilitation, The University of Texas Health Science Center McGovern Medical School, Houston, TX, USA; The Institute for Rehabilitation and Research (TIRR) Memorial Hermann Hospital, Houston, Texas, USA
| | - Steven C Cramer
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; California Rehabilitation Institute, Los Angeles, CA, USA
| | - Steven L Wolf
- Department of Rehabilitation Medicine, Division of Physical Therapy, Emory University School of Medicine, Atlanta, GA, USA
| | - Anand Dixit
- Stroke Service, The Newcastle Upon Tyne Hospitals National Health Service Foundation Trust, Newcastle, UK
| | - Jen Alexander
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Rushna Ali
- Department of Neurosciences, Spectrum Health, Grand Rapids, MI, USA
| | - Benjamin L Brown
- Department of Neurosurgery, Ochsner Neuroscience Institute, Covington, LA, USA
| | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | | | - Leigh R Hochberg
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; School of Engineering and Carney Institute for Brain Science, Brown University, Providence, RI, USA; VA RR&D Center for Neurorestoration and Neurotechnology, VA Medical Center, Providence, RI, USA
| | - Steven A Kautz
- Ralph H Johnson VA Medical Center, Charleston, SC, USA; Department of Health Sciences and Research, Medical University of South Carolina, Charleston, SC, USA
| | - Arshad Majid
- Sheffield Institute for Neurological Sciences (SITraN), University of Sheffield, Sheffield, UK; Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, UK
| | - Michael W O'Dell
- Clinical Rehabilitation Medicine, Weill Cornell Medicine, New York City, NY, USA
| | | | | | - Jessica Redgrave
- Sheffield Institute for Neurological Sciences (SITraN), University of Sheffield, Sheffield, UK
| | - Duncan L Turner
- School of Health, Sport and Bioscience, University of East London, London, UK
| | | | - Teresa J Kimberley
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Physical Therapy, MGH Institute of Health Professions, Boston, MA, USA
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Wheless JW, Gienapp AJ, Ryvlin P. Vagus nerve stimulation (VNS) therapy update. Epilepsy Behav 2018; 88S:2-10. [PMID: 30017839 DOI: 10.1016/j.yebeh.2018.06.032] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 06/15/2018] [Indexed: 11/19/2022]
Abstract
Epilepsy affects millions of people worldwide. Approximately one-third have pharmacoresistant epilepsy, and of these, the majority are not candidates for epilepsy surgery. Vagus nerve stimulation (VNS) therapy has been an option to treat pharmacoresistant seizures for 30 years. In this update, we will review the clinical data that support the device's efficacy in children, adolescents, and adults. We will also review its side-effect profile, quality of life and cost benefits, and the impact the device has on sudden unexpected death in epilepsy (SUDEP). We will then discuss candidate selection and provide guidance on dosing and future models. Vagus nerve stimulation therapy is an effective treatment for many seizure types and epilepsy syndromes with a predictable and benign side-effect profile that supports its role as the most commonly prescribed device to treat pharmacoresistant epilepsy. "This article is part of the Supplement issue Neurostimulation for Epilepsy."
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Affiliation(s)
- James W Wheless
- Le Bonheur Comprehensive Epilepsy Program, Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, TN, United States; Department of Pediatrics, Pediatric Neurology Division, University of Tennessee Health Science Center, Memphis, TN, United States.
| | - Andrew J Gienapp
- Medical Education, Methodist University Hospital, Memphis, TN, United States; Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Phillippe Ryvlin
- Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
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Ouahchi Y, Duclos C, Marie JP, Verin E. Implication of the vagus nerve in breathing pattern during sequential swallowing in rats. Physiol Behav 2017; 179:434-441. [DOI: 10.1016/j.physbeh.2017.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 07/03/2017] [Accepted: 07/07/2017] [Indexed: 10/19/2022]
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Révész D, Rydenhag B, Ben-Menachem E. Complications and safety of vagus nerve stimulation: 25 years of experience at a single center. J Neurosurg Pediatr 2016; 18:97-104. [PMID: 27015521 DOI: 10.3171/2016.1.peds15534] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The goal of this paper was to investigate surgical and hardware complications in a longitudinal retrospective study. METHODS The authors of this registry study analyzed the surgical and hardware complications in 247 patients who underwent the implantation of a vagus nerve stimulation (VNS) device between 1990 and 2014. The mean follow-up time was 12 years. RESULTS In total, 497 procedures were performed for 247 primary VNS implantations. Complications related to surgery occurred in 8.6% of all implantation procedures that were performed. The respective rate for hardware complications was 3.7%. Surgical complications included postoperative hematoma in 1.9%, infection in 2.6%, vocal cord palsy in 1.4%, lower facial weakness in 0.2%, pain and sensory-related complications in 1.4%, aseptic reaction in 0.2%, cable discomfort in 0.2%, surgical cable break in 0.2%, oversized stimulator pocket in 0.2%, and battery displacement in 0.2% of patients. Hardware-related complications included lead fracture/malfunction in 3.0%, spontaneous VNS turn-on in 0.2%, and lead disconnection in 0.2% of patients. CONCLUSIONS VNS implantation is a relatively safe procedure, but it still involves certain risks. The most common complications are postoperative hematoma, infection, and vocal cord palsy. Although their occurrence rates are rather low at about 2%, these complications may cause major suffering and even be life threatening. To reduce complications, it is important to have a long-term perspective. The 25 years of follow-up of this study is of great strength considering that VNS can be a life-long treatment for many patients. Thus, it is important to include repeated surgeries such as battery and lead replacements, given that complications also may occur with these surgeries.
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Affiliation(s)
- David Révész
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience and Rehabilitation, The Sahlgrenska Academy at the University of Gothenburg; and.,Departments of 2 Neurosurgery and
| | - Bertil Rydenhag
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience and Rehabilitation, The Sahlgrenska Academy at the University of Gothenburg; and.,Departments of 2 Neurosurgery and
| | - Elinor Ben-Menachem
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience and Rehabilitation, The Sahlgrenska Academy at the University of Gothenburg; and.,Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Kumar R, Winston KR, Folzenlogen Z. Removal of Vagus Nerve Stimulator Leads and Reuse of Same Site for Reimplantation: Technique and Experience. World Neurosurg 2016; 91:190-4. [PMID: 27062916 DOI: 10.1016/j.wneu.2016.03.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 03/22/2016] [Accepted: 03/23/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE This report describes the authors' experience and technique in removing vagus nerve stimulator leads, including coils, and reuse of the same site on the vagus nerve for implantation of new coils. METHODS The charts of all patients who underwent complete removal by the authors of vagus nerve stimulator leads between 1 September 2001 and 1 July 2015 were retrospectively reviewed. RESULTS Thirty patients underwent 31 surgeries for removal of vagus nerve stimulator leads. Complete removal, including proximal coils around the vagus nerve, was achieved in all cases. Reimplantation was performed immediately at the same location in 24 patients, delayed in 1 patient, and never replaced in 6. Long-term vocal cord paralysis followed 2 of 9 surgeries performed with sharp dissection and followed one of 22 surgeries in which dissection was performed with monopolar microneedle electrocautery. CONCLUSIONS Vagus nerve stimulator coils can be removed from the vagus nerve, via monopolar microneedle electrocautery, and the same site reused for immediate reimplantation with relative safety.
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Affiliation(s)
- Ramesh Kumar
- Department of Neurosurgery of the University of Colorado School of Medicine, Aurora, Colorado, USA; Denver Health and Hospitals, Denver, Colorado, USA; University Hospital Colorado, Aurora, Colorado, USA; Children's Hospital Colorado, Aurora, Colorado, USA.
| | - Ken R Winston
- Department of Neurosurgery of the University of Colorado School of Medicine, Aurora, Colorado, USA; Denver Health and Hospitals, Denver, Colorado, USA; University Hospital Colorado, Aurora, Colorado, USA; Children's Hospital Colorado, Aurora, Colorado, USA
| | - Zach Folzenlogen
- Department of Neurosurgery of the University of Colorado School of Medicine, Aurora, Colorado, USA; University Hospital Colorado, Aurora, Colorado, USA; Children's Hospital Colorado, Aurora, Colorado, USA
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