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Roth J, Bergman L, Weil AG, Brunette-Clement T, Weiner HL, Treiber JM, Shofty B, Cukiert A, Cukiert CM, Tripathi M, Sarat Chandra P, Bollo RJ, Machado HR, Santos MV, Gaillard WD, Oluigbo CO, Ibrahim GM, Jallo GI, Shimony N, O'Neill BR, Budke M, Pérez-Jiménez MÁ, Mangano FT, Iwasaki M, Iijima K, Gonzalez-Martinez J, Kawai K, Ishishita Y, Elbabaa SK, Bello-Espinosa L, Fallah A, Maniquis CAB, Ben-Zvi I, Tisdall M, Panigrahi M, Jayalakshmi S, Blount JP, Dorfmüller G, Bulteau C, Stone SS, Bolton J, Singhal A, Connolly M, Alsowat D, Alotaibi F, Ragheb J, Uliel-Sibony S. Added value of corpus callosotomy following vagus nerve stimulation in children with Lennox-Gastaut syndrome: A multicenter, multinational study. Epilepsia 2023; 64:3205-3212. [PMID: 37823366 DOI: 10.1111/epi.17796] [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: 08/04/2023] [Revised: 10/01/2023] [Accepted: 10/09/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVE Lennox-Gastaut syndrome (LGS) is a severe form of epileptic encephalopathy, presenting during the first years of life, and is very resistant to treatment. Once medical therapy has failed, palliative surgeries such as vagus nerve stimulation (VNS) or corpus callosotomy (CC) are considered. Although CC is more effective than VNS as the primary neurosurgical treatment for LGS-associated drop attacks, there are limited data regarding the added value of CC following VNS. This study aimed to assess the effectiveness of CC preceded by VNS. METHODS This multinational, multicenter retrospective study focuses on LGS children who underwent CC before the age of 18 years, following prior VNS, which failed to achieve satisfactory seizure control. Collected data included epilepsy characteristics, surgical details, epilepsy outcomes, and complications. The primary outcome of this study was a 50% reduction in drop attacks. RESULTS A total of 127 cases were reviewed (80 males). The median age at epilepsy onset was 6 months (interquartile range [IQR] = 3.12-22.75). The median age at VNS surgery was 7 years (IQR = 4-10), and CC was performed at a median age of 11 years (IQR = 8.76-15). The dominant seizure type was drop attacks (tonic or atonic) in 102 patients. Eighty-six patients underwent a single-stage complete CC, and 41 an anterior callosotomy. Ten patients who did not initially have a complete CC underwent a second surgery for completion of CC due to seizure persistence. Overall, there was at least a 50% reduction in drop attacks and other seizures in 83% and 60%, respectively. Permanent morbidity occurred in 1.5%, with no mortality. SIGNIFICANCE CC is vital in seizure control in children with LGS in whom VNS has failed. Surgical risks are low. A complete CC has a tendency toward better effectiveness than anterior CC for some seizure types.
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Affiliation(s)
- Jonathan Roth
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Lottem Bergman
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Alexander G Weil
- Division of Neurosurgery, Department of Surgery, Sainte-Justine University Hospital Centre and University of Montreal Hospital Centre, Montreal, Quebec, Canada
| | - Tristan Brunette-Clement
- Division of Neurosurgery, Department of Surgery, Sainte-Justine University Hospital Centre and University of Montreal Hospital Centre, Montreal, Quebec, Canada
| | - Howard L Weiner
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Jeffrey M Treiber
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Ben Shofty
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Arthur Cukiert
- Department of Neurosurgery, Epilepsy Surgery Program, Clinica Cukiert, Sao Paulo, Brazil
| | - Cristine Mella Cukiert
- Department of Neurology and Neurophysiology, Epilepsy Surgery Program, Clinica Cukiert, Sao Paulo, Brazil
| | - Manjari Tripathi
- Center of Excellence for Epilepsy and MEG, AIIMS, New Delhi, India
| | | | - Robert J Bollo
- Division of Pediatric Neurosurgery, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Hélio Rubens Machado
- Division of Pediatric Neurosurgery, Center for Epilepsy Surgery in Children, Ribeirão Preto Medical School, University of São Paulo, Sao Paulo, Brazil
| | - Marcelo Volpon Santos
- Division of Pediatric Neurosurgery, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Sao Paulo, Brazil
| | - William D Gaillard
- Department of Neurology, Children's National Medical Center, Washington, District of Columbia, USA
| | - Chima O Oluigbo
- Department of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA
| | - George M Ibrahim
- Department of Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - George I Jallo
- Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Nir Shimony
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, Tennessee, USA
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brent R O'Neill
- Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Marcelo Budke
- Department of Neurosurgery, Niño Jesus University Children's Hospital, Madrid, Spain
| | | | - Francesco T Mangano
- Division of Pediatric Neurosurgery, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Masaki Iwasaki
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Keiya Iijima
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Jorge Gonzalez-Martinez
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kensuke Kawai
- Department of Neurosurgery, Jichi Medical University, Tochigi, Japan
| | - Yohei Ishishita
- Department of Neurosurgery, Jichi Medical University, Tochigi, Japan
| | - Samer K Elbabaa
- Pediatric Neurosurgery, Leon Pediatric Neuroscience Center of Excellence, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Luis Bello-Espinosa
- Pediatric Neurology and Epilepsy, Leon Pediatric Neuroscience Center of Excellence, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Aria Fallah
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Cassia A B Maniquis
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Ido Ben-Zvi
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK
- Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Martin Tisdall
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK
- Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Manas Panigrahi
- Department of Neurosurgery, Krishna Institute of Medical Sciences, Hyderabad, India
| | - Sita Jayalakshmi
- Department of Neurology, Krishna Institute of Medical Sciences, Hyderabad, India
| | - Jeffrey P Blount
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Children's Hospital of Alabama, Birmingham, Alabama, USA
| | - Georg Dorfmüller
- Pediatric Neurosurgery Department, Rothschild Foundation Hospital, Paris, France
| | | | - Scellig S Stone
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffrey Bolton
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ashutosh Singhal
- Division of Pediatric Neurosurgery, Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mary Connolly
- Comprehensive Epilepsy Program, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Daad Alsowat
- Neuroscience Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Faisal Alotaibi
- Neuroscience Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - John Ragheb
- Department of Surgery, Nicklaus Children's Hospital, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Shimrit Uliel-Sibony
- Pediatric Neurology Unit, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
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Hamdi H, Boissonneau S, Valton L, McGonigal A, Bartolomei F, Regis J. Radiosurgical Corpus Callosotomy for Intractable Epilepsy: Retrospective Long-Term Safety and Efficacy Assessment in 19 Patients an Review of the Literature. Neurosurgery 2023; 93:156-167. [PMID: 36861968 DOI: 10.1227/neu.0000000000002394] [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: 06/17/2022] [Accepted: 12/06/2022] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Some patients suffering from intractable epileptic seizures, particularly drop attacks (DAs), are nonremediable by curative techniques. Palliative procedure carries a significant rate of surgical and neurological complications. OBJECTIVE To propose evaluation of safety and efficacy of Gamma Knife corpus callosotomy (GK-CC) as an alternative to microsurgical corpus callosotomy. METHODS This study included retrospective analysis of 19 patients who underwent GK-CC between 2005 and 2017. RESULTS Of the 19 patients, 13 (68%) had improvement in seizure control and 6 had no significant improvement. Of the 13/19 (68%) with improvement in seizures, 3 (16%) became completely seizure-free, 2 (11%) became free of DA and generalized tonic-clonic but with residual other seizures, 3 (16%) became free of DA only, and 5 (26%) had >50% reduction in frequency of all seizure types. In the 6 (31%) patients with no appreciable improvement, there were residual untreated commissural fibers and incomplete callosotomy rather than failure of Gamma Knife to disconnect. Seven patients showed a transient mild complication (37% of patients, 33% of the procedures). No permanent complication or neurological consequence was observed during the clinical and radiological workup with a mean of 89 (42-181) months, except 1 patient who had no improvement of epilepsy and then aggravation of the pre-existing cognitive and walking difficulties (Lennox-Gastaut). The median time of improvement after GK-CC was 3 (1-6) months. CONCLUSION Gamma Knife callosotomy is safe and accurate with comparable efficacy to open callosotomy in this cohort of patients with intractable epilepsy suffering from severe drop attacks.
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Affiliation(s)
- Hussein Hamdi
- Department of Functional Neurosurgery and Gamma Knife Radiosurgery, Timone University Hospital, Aix-Marseille University, APHM, CHU Timone, Marseille, France
- Aix Marseille Univ, INSERM, INS, Inst Neurosci Syst, Marseille, France
- Functional and Stereotactic Unit, Neurological Surgery Department, Tanta University, Egypt
| | - Sébastien Boissonneau
- Department of Neurosurgery Aix-Marseille University, APHM, CHU Timone, Marseille, France
- Aix Marseille Univ, INSERM, INS, Inst Neurosci Syst, Marseille, France
| | - Luc Valton
- Department of Neurology, Hôpital PP Riquet-Purpan, Toulouse University Hospital, University of Toulouse, Toulouse, France
- Centre de Recherche Cerveau et Cognition (CerCo), UMR 5549, CNRS, Toulouse Mind and Brain Institute (TMBI), University of Toulouse, University Paul Sabatier, Toulouse, France
| | - Aileen McGonigal
- Department of Clinical Neurophysiology, APHM, APHM, CHU Timone, Marseille, France
- Aix Marseille Univ, INSERM, INS, Inst Neurosci Syst, Marseille, France
- Department of Neurosciences, Mater Hospital, Brisbane and Faculty of Medicine, University of Queensland, Australia
| | - Fabrice Bartolomei
- Department of Clinical Neurophysiology, APHM, APHM, CHU Timone, Marseille, France
- Aix Marseille Univ, INSERM, INS, Inst Neurosci Syst, Marseille, France
| | - Jean Regis
- Department of Functional Neurosurgery and Gamma Knife Radiosurgery, Timone University Hospital, Aix-Marseille University, APHM, CHU Timone, Marseille, France
- Aix Marseille Univ, INSERM, INS, Inst Neurosci Syst, Marseille, France
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Kuo CY, Tsai MH, Lin HH, Wang YC, Singh AK, Chang CC, Lin JJ, Hung PC, Lin KL. Identification and clinical characteristics of a novel missense ADGRG1 variant in bilateral Frontoparietal Polymicrogyria: The electroclinical change from infancy to adulthood after Callosotomy in three siblings. Epilepsia Open 2023; 8:154-164. [PMID: 36524291 PMCID: PMC9977754 DOI: 10.1002/epi4.12685] [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: 10/06/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE Bilateral frontoparietal polymicrogyria (BFPP) is a rare genetic-related migration disorder. It has been attributed to loss-of-function of the ADGRG1 gene, which encodes an adhesion G protein-coupled receptor, ADGRG1/GPR56. We report the EEG findings of BFPP in three Asian patients, and confirmed that change in protein function was caused by the novel missense variant (p.Leu290Pro). METHODS We reviewed the medical records of three siblings with BFPP including one elder girl and two identical twin boys from birth to adulthood. The clinical symptoms, electroencephalography (EEG), brain MRI, whole-exome sequencing, treatment including medications, neuromodulation, and epilepsy surgery, and clinical outcomes were reviewed. The protein structure of a novel missense variant (p.Leu290Pro) was predicted by in silico studies, and molecular analysis was performed via typical flow cytometry and Western blotting. RESULTS The elder girl (Patient 1) was 22 years old and the twin boys (Patients 2 and 3) were 20 years old at the time of publication. All of them presented with typical clinical symptoms/signs and MRI findings of BFPP. Whole-exome sequencing followed by Sanger confirmation showed that all three patients had compound heterozygous variants in the ADGRG1 gene. The missense variant (p.Leu290Pro) was confirmed to be related to a reduction in cell surface GPR56 expression. High-amplitude rhythmic activity was noted in sleep EEG during infancy, which may have been due to excessive sleep spindle, and the rhythm disappeared when they were of pre-school age. Partial callosotomy provided short-term benefits in seizure control in Patients 1 and 2, and combined vagus nerve stimulation and partial callosotomy provided longer benefits in Patient 3. SIGNIFICANCE Sleep EEG findings of high-amplitude rhythmic activity in our BFPP cases were only noted during infancy and childhood. We also confirmed that the missense variant (p.Leu290Pro) led to loss of function due to a reduction in cell surface GPR56 expression.
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Affiliation(s)
- Cheng-Yen Kuo
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Meng-Han Tsai
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Hsi-Hsien Lin
- Department of Microbiology and Immunology, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Chi Wang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Abhishek Kumar Singh
- Department of Biological Sciences, Indian Institute of Science Education and Research, Mohali, India
| | - Chin-Chen Chang
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Taoyuan, Taiwan.,School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Po-Cheng Hung
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Taoyuan, Taiwan.,School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kuang-Lin Lin
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Taoyuan, Taiwan.,School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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4
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Hale AT, Barkley AS, Blount JP. Corpus Callosotomy Is a Safe and Effective Procedure for Medically Resistant Epilepsy. Adv Tech Stand Neurosurg 2023; 48:355-369. [PMID: 37770691 DOI: 10.1007/978-3-031-36785-4_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
Corpus callosotomy (CC) is an effective surgical treatment for medically resistant generalized or multifocal epilepsy (MRE). The premise of CC extrapolates from the observation that the corpus callosum is the predominant commissural pathway that allows spread and synchroneity of epileptogenic activity between the hemispheres. Candidacy for CC is typically reserved for patients seeking palliative epilepsy treatment with the goal of reducing the frequency of drop attacks, although reduction of other seizure semiologies (absence, complex partial seizures, and tonic-clonic) has been observed. A reduction in morbidity affiliated with evolution of surgical techniques to perform CC has improved the safety profile of the procedure without necessarily sacrificing efficacy.
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Affiliation(s)
- Andrew T Hale
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Ariana S Barkley
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Jeffrey P Blount
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA.
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Belal A, Allmen GV, Kommuru I, Lankford J, Mosher JC, Shah M, Funke M, Watkins M, Patel R. Complete corpus callosotomy using a frameless navigation probe through a minicraniotomy in children with medically refractory epilepsy: A case series and technical note. Surg Neurol Int 2022; 13:585. [PMID: 36600777 PMCID: PMC9805650 DOI: 10.25259/sni_1188_2021] [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: 11/28/2021] [Accepted: 09/13/2022] [Indexed: 12/24/2022] Open
Abstract
Background Medically refractory epilepsy constitutes up to one-third of the epilepsy pediatric patients. Corpus callosotomy (CC) has been used for the treatment of medically refractory epilepsy in children with atonic seizures and generalized tonic-clonic (GTC) seizures. In this case series study, we are describing a novel technique for CC using the frameless navigation probe through a minicraniotomy. Methods Thirteen pediatric patients with the diagnosis of medically refractory epilepsy predominantly GTC with drop attack who underwent extensive Phase I. An L-shape was done, then through a 4 × 3 cm craniotomy, we were able to open the interhemispheric fissure until the corpus callosum is visualized. The Stealth probe is then used to go down to the midline raphe which is followed anteriorly then traced posteriorly to the anterior border of the vein of Galen. Finally, the Stealth probe is used to confirm the completeness of the callosotomy. Results The procedure was accomplished successfully with no intraoperative complications; mean surgical time is 3 h:07 m. The mean follow-up was 31.5 months. All patients achieved significant seizure control. No patients experienced worsening of their atonic seizures after surgery compared with their preoperative state; however, six patients achieved Engel Class I, four patients achieved Engel Class II, and three patients achieved Engel Class III. Conclusion Complete CC using a frameless navigation probe is a novel and effective technique for the treatment of medically refractory epilepsy with a very good surgical and seizure outcomes, minimal neurological morbidity, minimal blood loss, and short OR time.
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Affiliation(s)
- Ahmed Belal
- Department of Pediatric Neurosurgery, McGovern Medical School, University of Texas, Houston and Children’s Memorial Hermann Hospital, Texas, United States.,Department of Neurosurgery, Indiana University, Texas, United States.,Corresponding author: Ahmed Belal, Department of Pediatric Neurosurgery, McGovern Medical School, University of Texas, Houston and Children’s Memorial Hermann Hospital, Houston, Texas, United States.
| | - Gretchen Von Allmen
- Department of Pediatric Neurology, McGovern Medical School at UTHouston and Children’s Memorial Hermann Hospital, Texas, United States
| | - Indira Kommuru
- Department of Pediatric Neurology, McGovern Medical School at UTHouston and Children’s Memorial Hermann Hospital, Texas, United States
| | - Jeremy Lankford
- Department of Pediatric Neurology, McGovern Medical School at UTHouston and Children’s Memorial Hermann Hospital, Texas, United States
| | - John C. Mosher
- Department of Neurology, University of Texas Health Science Center at Houston, Texas, United States
| | - Manish Shah
- Department of Pediatric Neurosurgery, McGovern Medical School, University of Texas, Houston and Children’s Memorial Hermann Hospital, Texas, United States
| | - Michael Funke
- Department of Pediatric Neurology, McGovern Medical School at UTHouston and Children’s Memorial Hermann Hospital, Texas, United States
| | - Michael Watkins
- Department of Pediatric Neurology, McGovern Medical School at UTHouston and Children’s Memorial Hermann Hospital, Texas, United States
| | - Rajan Patel
- Department of Radiology, McGovern Medical School at UTHouston and Children’s Memorial Hermann Hospital, Houston, Texas, United States
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Lim MJR, Fong KY, Zheng Y, Chua CYK, Miny S, Lin JB, Nga VDW, Ong HT, Rathakrishnan R, Yeo TT. Vagus nerve stimulation for treatment of drug-resistant epilepsy: a systematic review and meta-analysis. Neurosurg Rev 2022; 45:2361-2373. [PMID: 35217961 DOI: 10.1007/s10143-022-01757-9] [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: 12/04/2021] [Revised: 02/04/2022] [Accepted: 02/12/2022] [Indexed: 11/28/2022]
Abstract
To analyze the efficacy and safety of high-frequency VNS versus control (low-frequency VNS or no VNS) in patients with DRE using data from randomized controlled trials (RCTs). An electronic literature search was conducted on PubMed, EMBASE, and Cochrane Controlled Register of Trials (CENTRAL); 12 RCTs reporting seizure frequency or treatment response in studies containing a high-frequency VNS treatment arm (conventional VNS or transcutaneous VNS [tVNS]) compared to control (low-frequency VNS or no VNS) were included. Seizure frequency, treatment response (number of patients with ≥ 50% reduction in seizure frequency), quality of life (QOL), and adverse effects were analyzed. Seizure frequency was reported in 9 studies (718 patients). Meta-analysis with random-effects models favored high-frequency VNS over control (standardized mean difference = 0.82, 95%-CI = 0.39-1.24, p < .001). This remained significant for subgroup analyses of low-frequency VNS as the control, VNS modality, and after removing studies with moderate-to-high risk of bias. Treatment response was reported in 8 studies (758 patients). Random-effects models favored high-frequency VNS over control (risk ratio = 1.57, 95%-CI = 1.19-2.07, p < .001). QOL outcomes were reported descriptively in 4 studies (363 patients), and adverse events were reported in 11 studies (875 patients). Major side effects and death were not observed to be more common in high-frequency VNS compared to control. High-frequency VNS results in reduced seizure frequency and improved treatment response compared to control (low-frequency VNS or no VNS) in patients with drug-resistant epilepsy. Greater consideration for VNS in patients with DRE may be warranted to decrease seizure frequency in the management of these patients.
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Affiliation(s)
- Mervyn Jun Rui Lim
- Division of Neurosurgery, University Surgical Centre, National University Hospital, Singapore, Singapore.
| | - Khi Yung Fong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yilong Zheng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Christopher Yuan Kit Chua
- Division of Neurology, University Medical Centre, National University Hospital, Singapore, Singapore
| | - Samuel Miny
- Systematic Review Unit, National University Hospital, Singapore, Singapore
| | - Jeremy Bingyuan Lin
- Division of Pediatric Neurology, Department of Pediatrics, Khoo Teck Puat - National University Children's Medical Institute, National University Hospital, Singapore, Singapore
| | - Vincent Diong Weng Nga
- Division of Neurosurgery, University Surgical Centre, National University Hospital, Singapore, Singapore
| | - Hian Tat Ong
- Division of Pediatric Neurology, Department of Pediatrics, Khoo Teck Puat - National University Children's Medical Institute, National University Hospital, Singapore, Singapore
| | - Rahul Rathakrishnan
- Division of Neurology, University Medical Centre, National University Hospital, Singapore, Singapore
| | - Tseng Tsai Yeo
- Division of Neurosurgery, University Surgical Centre, National University Hospital, Singapore, Singapore
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Sharawat IK, Panda PK, Sihag RK, Panda P, Dawman L. Efficacy and safety of corpus callosotomy and ketogenic diet in children with Lennox Gastaut syndrome: a systematic review and meta-analysis. Childs Nerv Syst 2021; 37:2557-2566. [PMID: 33871716 DOI: 10.1007/s00381-021-05174-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 04/15/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Both corpus callosotomy (CC) and the ketogenic diet (KD) are commonly used in patients with Lennox Gastaut syndrome (LGS), as a significant proportion of these patients develop pharmacoresistant epilepsy. But no systematic review has yet compared the efficacy and safety of these two measures. METHODS We conducted a systematic search on various databases to collating all available literature until 30th November 2020 with a primary objective to compare the efficacy of KD and CC in terms of the proportion of patients with complete seizure freedom, at least 75% and 50% reduction in seizure frequency at various time points after the institution of these modalities. We also attempted to compare the proportion and nature of adverse effects, impact on EEG, cognition, and behavior with these modalities. We only included original articles enrolling at least 10 patients with CC or KD for quantitative synthesis to determine a pooled estimate. We used a fixed or random effects model, depending on the degree of heterogeneity. RESULTS We selected 23 and 7 articles describing the efficacy of CC and KD in 436 and 185 LGS patients out of 217 search items, but none of the studies compared directly these two entities. The indirect comparison between the pooled estimate of all patients with individual modalities revealed more patients with CC had seizure freedom, at least 75% and 50% reduction in seizure frequency (p=0.0001, 0.01, and 0.04 respectively). The proportion of patients with adverse effects was also higher for CC patients (p=0.01), although the proportion with serious adverse effects was not significantly different between the two modalities. Patients selected for CC were older, had higher seizure burden, more lag time after the onset of seizures, and received more number of antiseizure medications previously. Due to the availability of limited data, a firm conclusion could not be determined regarding the effect on EEG, cognition, and behavior with CC and KD. CONCLUSION CC is more efficacious than KD in reducing seizure frequency in patients with LGS, although it has relatively more adverse effects during the immediate perioperative period.
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Affiliation(s)
- Indar Kumar Sharawat
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Prateek Kumar Panda
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India.
| | - Rakesh Kumar Sihag
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Pragnya Panda
- Department of Neurology, King George Medical University, Lucknow, 226003, India
| | - Lesa Dawman
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
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Shimogawa T, Mukae N, Morioka T, Tanaka S, Sakata A, Uehara T, Mizoguchi M. Possible relationship between vagus nerve stimulation and ictal discharges revealed by long-term electroencephalographic and electrocorticographic monitoring in a non-responsive patient. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.101066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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A systematic review of magnetic resonance imaging in patients with an implanted vagus nerve stimulation system. Neuroradiology 2021; 63:1407-1417. [PMID: 33846830 PMCID: PMC8376717 DOI: 10.1007/s00234-021-02705-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 03/29/2021] [Indexed: 12/20/2022]
Abstract
Purpose Vagus nerve stimulation (VNS) is an effective adjunctive treatment for drug-resistant epilepsy (DRE) and difficult-to-treat depression (DTD). More than 125.000 patients have been implanted with VNS Therapy® System (LivaNova PLC) since initial approval. Patients with DRE often require magnetic resonance imaging (MRI) of the brain during the course of their disease. VNS Therapy System devices are labeled to allow MRI under certain conditions; however, there are no published comprehensive articles about the real-world experience using MRI in patients with implanted VNS devices. Methods A systematic review in accordance with PRISMA statement was performed using PubMed database. Full-length articles reporting MRI (1.5 T or 3 T scanner) of patients with implanted VNS for DRE or DTD and published since 2000 were included. The primary endpoint was a positive outcome that was defined as a technically uneventful MRI scan performed in accordance with the VNS Therapy System manufacturer guidelines and completed according to the researchers’ planned scanning protocol without harm to the patient. Results Twenty-six articles were eligible with 25 articles referring to the VNS Therapy System, and 216 patients were included in the analysis. No serious adverse events or serious device-related adverse events were reported. MRI scan was prematurely terminated in one patient due to a panic attack. Conclusion This systematic review indicates that cranial MRI of patients with an implanted VNS Therapy System can be completed satisfactorily and is tolerable and safe using 1.5 T and 3 T MRI scanners when performed in adherence to the VNS manufacturer’s guidelines. Supplementary Information The online version contains supplementary material available at 10.1007/s00234-021-02705-y.
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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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Ye VC, Mansouri A, Warsi NM, Ibrahim GM. Atonic seizures in children: a meta-analysis comparing corpus callosotomy to vagus nerve stimulation. Childs Nerv Syst 2021; 37:259-267. [PMID: 32529546 DOI: 10.1007/s00381-020-04698-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/21/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Atonic seizures are associated with a particularly poor response to medical treatment. We performed a systematic review and meta-analysis to compare the efficacy of corpus callosotomy (CC) and vagus nerve stimulation (VNS) in the management of atonic seizures in the pediatric population. METHODS A literature search was performed in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and recommendations, focusing on atonic seizures, CC, and VNS in pediatric populations. Pertinent clinical data were extracted and analyzed. Pooled effects between groups were calculated as standardized error (SE) with 95% confidence intervals (CIs). To assess for statistical significance, the Z-test was performed, using the pooled effect size (ES) and 95% CI for each intervention. RESULTS A total of 31 studies met the inclusion criteria, with 24 studies encompassing 425 children treated with CC and 7 studies encompassing 108 children treated with VNS. Twenty-four studies were included in a meta-analysis. There was a statistically significant difference in the primary outcome of atonic seizure control in favor of CC (overall effect size (ES) 0.73, 95% CI 0.69-0.77 for CC, ES 0.4, 95% CI 0.28-0.51 for VNS, p = 0.003). There was a higher rate of complications requiring reoperation in the CC cohort (6.6% vs. 3.8%) and a 14% rate of symptomatic disconnection syndrome. CONCLUSIONS While both techniques are safe, CC provides a much higher chance of effectively managing this morbid seizure type albeit with a higher risk of re-operation and disconnection syndrome.
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Affiliation(s)
- Vincent C Ye
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Canada
| | - Alireza Mansouri
- Department of Neurosurgery, Pennsylvania State University, Hershey, PA, USA
| | - Nebras M Warsi
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Canada
| | - George M Ibrahim
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Canada.
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
- Program in Neurosciences and Mental Health Research Institute, Department of Surgery, Institute of Biomaterials and Biomedical Engineering, The University of Toronto, Toronto, Canada.
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Liu A, Rong P, Gong L, Song L, Wang X, Li L, Wang Y. Efficacy and Safety of Treatment with Transcutaneous Vagus Nerve Stimulation in 17 Patients with Refractory Epilepsy Evaluated by Electroencephalogram, Seizure Frequency, and Quality of Life. Med Sci Monit 2018; 24:8439-8448. [PMID: 30467307 PMCID: PMC6266629 DOI: 10.12659/msm.910689] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background This study aimed to investigate the efficacy and safety of treatment with transcutaneous vagus nerve stimulation (tVNS) for patients with refractory epilepsy by evaluation of the frequency of seizures, electroencephalogram (EEG) changes, and quality of life on follow-up at three months and six months. Material/Methods EEG evaluation followed baseline evaluation with EEG at three months and six months following tVNS treatment. The frequency of seizures was recorded during the six-month study period. Before and after tVNS treatment, patients completed the Self-Rating Anxiety Scale (SAS), the Self-Rating Depression Scale (SDS), the Liverpool Seizure Severity Scale (LSSS), the Quality of Life in Epilepsy Inventory (QOLIE-31), and the Pittsburg Sleep Quality Index (PSQI). Results Seventeen patients completed six months of tVNS treatment. Following three months of tVNS therapy, the frequency of epileptic seizures decreased in 13/17 subjects, with an average reduced seizure rate of 31.3%. Following six months of tVNS treatment, the frequency of epileptic seizures decreased in 16/17 subjects, with an average reduced seizure rate of 64.4%. There were 14/17 cases with abnormal EEG at baseline; 2/17 patients had improved EEGs by three months, and 10/17 patients had improved EEGs by six months. During the study period, there were no adverse events associated with tVNS treatment, but the effects on sleep were inconclusive. Conclusions This preliminary study showed that tVNS was an effective and safe adjuvant treatment for refractory epilepsy that reduced seizure frequency and reduced abnormal EEG changes following clinical improvement.
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Affiliation(s)
- Aihua Liu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China (mainland)
| | - Peijing Rong
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China (mainland)
| | - Li Gong
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China (mainland)
| | - Lu Song
- Department of Neurology, Xuanwu Hospital, Capital Medical University,, Beijing, China (mainland)
| | - Xian Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China (mainland)
| | - Liping Li
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China (mainland)
| | - Yuping Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China (mainland)
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Chan AY, Rolston JD, Lee B, Vadera S, Englot DJ. Rates and predictors of seizure outcome after corpus callosotomy for drug-resistant epilepsy: a meta-analysis. J Neurosurg 2018:1-10. [PMID: 29999448 DOI: 10.3171/2017.12.jns172331] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 12/23/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVECorpus callosotomy is a palliative surgery for drug-resistant epilepsy that reduces the severity and frequency of generalized seizures by disconnecting the two cerebral hemispheres. Unlike with resection, seizure outcomes remain poorly understood. The authors systematically reviewed the literature and performed a meta-analysis to investigate rates and predictors of complete seizure freedom and freedom from drop attacks after corpus callosotomy.METHODSPubMed, Web of Science, and Scopus were queried for primary studies examining seizure outcomes after corpus callosotomy published over 30 years. Rates of complete seizure freedom or drop attack freedom were recorded. Variables showing a potential relationship to seizure outcome on preliminary analysis were subjected to formal meta-analysis.RESULTSThe authors identified 1742 eligible patients from 58 included studies. Overall, the rates of complete seizure freedom and drop attack freedom after corpus callosotomy were 18.8% and 55.3%, respectively. Complete seizure freedom was significantly predicted by the presence of infantile spasms (OR 3.86, 95% CI 1.13-13.23), normal MRI findings (OR 4.63, 95% CI 1.75-12.25), and shorter epilepsy duration (OR 2.57, 95% CI 1.23-5.38). Freedom from drop attacks was predicted by complete over partial callosotomy (OR 2.90, 95% CI 1.07-7.83) and idiopathic over known epilepsy etiology (OR 2.84, 95% CI 1.35-5.99).CONCLUSIONSThe authors report the first systematic review and meta-analysis of seizure outcomes in both adults and children after corpus callosotomy for epilepsy. Approximately one-half of patients become free from drop attacks, and one-fifth achieve complete seizure freedom after surgery. Some predictors of favorable outcome differ from those in resective epilepsy surgery.
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Affiliation(s)
- Alvin Y Chan
- 1Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - John D Rolston
- 2Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Brian Lee
- 3Department of Neurological Surgery, University of Southern California, Los Angeles
| | - Sumeet Vadera
- 4Department of Neurological Surgery, University of California, Irvine, California; and
| | - Dario J Englot
- 5Department of Neurological Surgery, Vanderbilt University, Nashville, Tennessee
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Abstract
Lennox-Gastaut syndrome (LGS) is considered an epileptic encephalopathy and is defined by a triad of multiple drug-resistant seizure types, a specific EEG pattern showing bursts of slow spike-wave complexes or generalized paroxysmal fast activity, and intellectual disability. The prevalence of LGS is estimated between 1 and 2% of all patients with epilepsy. The etiology of LGS is often divided into two groups: identifiable (genetic-structural-metabolic) in 65 to 75% of the patients and LGS of unknown cause in others. Lennox-Gastaut syndrome may be considered as secondary network epilepsy. The seizures in LGS are usually drug-resistant, and complete seizure control with resolution of intellectual and psychosocial dysfunction is often not achievable. Reduction in frequency of the most incapacitating seizures (e.g., drop attacks and tonic-clonic seizures) should be the major objective. Valproate, lamotrigine, and topiramate are considered to be the first-line drugs by many experts. Other effective antiepileptic drugs include levetiracetam, clobazam, rufinamide, and zonisamide. The ketogenic diet is an effective and well-tolerated treatment option. For patients with drug resistance, a further therapeutic option is surgical intervention. Corpus callosotomy is a palliative surgical procedure that aims at controlling the most injurious seizures. Finally, vagus nerve stimulation offers reasonable seizure improvement. The long-term outcome for patients with LGS is generally poor. This syndrome is often associated with long-term adverse effects on intellectual development, social functioning, and independent living.
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