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Abdullahi A, Etoom M, Badaru UM, Elibol N, Abuelsamen AA, Alawneh A, Zakari UU, Saeys W, Truijen S. Vagus nerve stimulation for the treatment of epilepsy: things to note on the protocols, the effects and the mechanisms of action. Int J Neurosci 2024; 134:560-569. [PMID: 36120993 DOI: 10.1080/00207454.2022.2126776] [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: 06/27/2022] [Revised: 08/19/2022] [Accepted: 08/26/2022] [Indexed: 10/14/2022]
Abstract
Epilepsy is a chronic brain disorder that is characterized by repetitive un-triggered seizures that occur severally within 24 h or more. Non-pharmacological methods for the management of epilepsy were discussed. The non-pharmacological methods include the vagus nerve stimulation (VNS) which is subdivided into invasive and non-invasive techniques. For the non-invasive techniques, the auricular VNS, stimulation of the cervical branch of vagus nerve in the neck, manual massage of the neck, and respiratory vagal nerve stimulation were discussed. Similarly, the stimulation parameters used and the mechanisms of actions through which VNS improves seizures were also discussed. Use of VNS to reduce seizure frequency has come a long way. However, considering the cost and side effects of the invasive method, non-invasive techniques should be given a renewed attention. In particular, respiratory vagal nerve stimulation should be considered. In doing this, the patients should for instance carry out slow-deep breathing exercise 6 to 8 times every 3 h during the waking hours. Slow-deep breathing can be carried out by the patients on their own; therefore this can serve as a form of self-management.HIGHLIGHTSEpilepsy can interfere with the patients' ability to carry out their daily activities and ultimately affect their quality of life.Medications are used to manage epilepsy; but they often have their serious side effects.Vagus nerve stimulation (VNS) is gaining ground especially in the management of refractory epilepsy.The VNS is administered through either the invasive or the non-invasive methodsThe invasive method of VNS like the medication has potential side effects, and can be costly.The non-invasive method includes auricular VNS, stimulation of the neck muscles and skin and respiratory vagal nerve stimulation via slow-deep breathing exercises.The respiratory vagal nerve stimulation via slow-deep breathing exercises seems easy to administer even by the patients themselves.Consequently, it is our opinion that patients with epilepsy be made to carry out slow-deep breathing exercise 6-8 times every 3 h during the waking hours.
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Affiliation(s)
- Auwal Abdullahi
- Department of Physiotherapy, Bayero University Kano, Nigeria
- Department of Rehabilitation Sciences and Physiotherapy, University of Antwerp, Antwerp, Belgium
| | - Mohammad Etoom
- Department of Physiotherapy, Aqaba University of Technology, Aqaba, Jordan
| | | | - Nuray Elibol
- Department of Physiotherapy and Rehabilitation Sciences, Ege University, Izmir, Turkey
| | | | - Anoud Alawneh
- Department of Physiotherapy, Aqaba University of Technology, Aqaba, Jordan
| | - Usman Usman Zakari
- Department of Physiotherapy, Federal Medical Center, Birnin Kudu, Jigawa State, Nigeria
| | - Wim Saeys
- Department of Rehabilitation Sciences and Physiotherapy, University of Antwerp, Antwerp, Belgium
| | - Steven Truijen
- Department of Rehabilitation Sciences and Physiotherapy, University of Antwerp, Antwerp, Belgium
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Wernisch L, Edwards T, Berthon A, Tessier-Lariviere O, Sarkans E, Stoukidi M, Fortier-Poisson P, Pinkney M, Thornton M, Hanley C, Lee S, Jennings J, Appleton B, Garsed P, Patterson B, Buttinger W, Gonshaw S, Jakopec M, Shunmugam S, Mamen J, Tukiainen A, Lajoie G, Armitage O, Hewage E. Online Bayesian optimization of vagus nerve stimulation. J Neural Eng 2024; 21:026019. [PMID: 38479016 DOI: 10.1088/1741-2552/ad33ae] [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: 03/13/2023] [Accepted: 03/13/2024] [Indexed: 04/04/2024]
Abstract
Objective.In bioelectronic medicine, neuromodulation therapies induce neural signals to the brain or organs, modifying their function. Stimulation devices capable of triggering exogenous neural signals using electrical waveforms require a complex and multi-dimensional parameter space to control such waveforms. Determining the best combination of parameters (waveform optimization or dosing) for treating a particular patient's illness is therefore challenging. Comprehensive parameter searching for an optimal stimulation effect is often infeasible in a clinical setting due to the size of the parameter space. Restricting this space, however, may lead to suboptimal therapeutic results, reduced responder rates, and adverse effects.Approach. As an alternative to a full parameter search, we present a flexible machine learning, data acquisition, and processing framework for optimizing neural stimulation parameters, requiring as few steps as possible using Bayesian optimization. This optimization builds a model of the neural and physiological responses to stimulations, enabling it to optimize stimulation parameters and provide estimates of the accuracy of the response model. The vagus nerve (VN) innervates, among other thoracic and visceral organs, the heart, thus controlling heart rate (HR), making it an ideal candidate for demonstrating the effectiveness of our approach.Main results.The efficacy of our optimization approach was first evaluated on simulated neural responses, then applied to VN stimulation intraoperatively in porcine subjects. Optimization converged quickly on parameters achieving target HRs and optimizing neural B-fiber activations despite high intersubject variability.Significance.An optimized stimulation waveform was achieved in real time with far fewer stimulations than required by alternative optimization strategies, thus minimizing exposure to side effects. Uncertainty estimates helped avoiding stimulations outside a safe range. Our approach shows that a complex set of neural stimulation parameters can be optimized in real-time for a patient to achieve a personalized precision dosing.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Guillaume Lajoie
- Université de Montréal and Mila-Quebec AI Institute, Montréal, Canada
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Furlanis GM, Fascetti Leon F, Bresolin N, Favaro J, Baro V, D'Amico A, Denaro L, Sartori S, Landi A. Aesthetic transaxillary subpectoral placement of vagus nerve stimulator in children and young adults: A technical note. Epilepsy Behav 2023; 147:109419. [PMID: 37677901 DOI: 10.1016/j.yebeh.2023.109419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/20/2023] [Accepted: 08/25/2023] [Indexed: 09/09/2023]
Abstract
INTRODUCTION Vagus nerve stimulation (VNS) is a neuromodulation therapy for drug-resistant epilepsy (DRE), refractory status epilepticus, and treatment-resistant depression. The lead is tunneled into the subcutaneous space and connected to the generator, which is usually implanted in a subcutaneous pocket below the clavicle. Surgical complications in the chest region include skin breakdown or infection. An alternative approach is to perform a subclavear subpectoral implantation. In our surgical series, we report a new aesthetic implantation method for VNS generators in children and young patients: the transaxillary subpectoral placement. MATERIALS AND METHODS From May 2021 to May 2023, 10 vagus nerve stimulation generators were placed subpectorally with a transaxillary approach by the authors. We considered operative time, surgical complications such as blood loss, infections, device migration, pain, and adverse events at follow-up. RESULTS In this surgical series, we reviewed all cases of subpectoral implantation of VNS generators in children and young adults at our institution in the last 2 years. All patients were treated with subpectoral Sentiva 1000 (Livanova PLC) insertion with axillary access by a neurosurgeon and a pediatric surgeon. The operative time was slightly longer compared to the traditional subcutaneous implant. All generators reported impedances within the optimal range. Blood loss was not significant and no other perioperative complications were reported. Patients and families were highly satisfied with the outcomes in terms of comfort and aesthetic results after surgery and at the last follow-up. No cases of infection occurred, and no malfunctions or displacements of the generator were registered at clinical follow-up. CONCLUSION The transaxillary subpectoral placement of theVNS generator is an aesthetic and anatomic approach, which provides several benefits to children and young adults.
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Affiliation(s)
- Giulia Melinda Furlanis
- Pediatric and Functional Neurosurgery Unit, Department of Neuroscience, Padua University Hospital, Italy.
| | - Francesco Fascetti Leon
- Pediatric Surgery Unit, Department of Women's and Children's Health, Padua University Hospital, Italy
| | - Nicola Bresolin
- Pediatric and Functional Neurosurgery Unit, Department of Neuroscience, Padua University Hospital, Italy
| | - Jacopo Favaro
- Pediatric Neurology and Neurophysiology, Department of Women's and Children's Health, Padua University Hospital, Italy
| | - Valentina Baro
- Pediatric and Functional Neurosurgery Unit, Department of Neuroscience, Padua University Hospital, Italy
| | - Alberto D'Amico
- Pediatric and Functional Neurosurgery Unit, Department of Neuroscience, Padua University Hospital, Italy
| | - Luca Denaro
- Pediatric and Functional Neurosurgery Unit, Department of Neuroscience, Padua University Hospital, Italy
| | - Stefano Sartori
- Pediatric Neurology and Neurophysiology, Department of Women's and Children's Health, Padua University Hospital, Italy
| | - Andrea Landi
- Pediatric and Functional Neurosurgery Unit, Department of Neuroscience, Padua University Hospital, Italy
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LoPresti MA, Huang J, Shlobin NA, Curry DJ, Weiner HL, Lam SK. Vagus nerve stimulator revision in pediatric epilepsy patients: a technical note and case series. Childs Nerv Syst 2023; 39:435-441. [PMID: 36434283 DOI: 10.1007/s00381-022-05769-0] [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: 07/20/2022] [Accepted: 11/16/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Vagus nerve stimulation (VNS) is an adjunctive treatment in children with intractable epilepsy. When lead replacement becomes necessary, the old leads are often truncated and retained and new leads are implanted at a newly exposed segment of the nerve. Direct lead removal and replacement are infrequently described, with outcomes poorly characterized. We aimed to describe our experience with feasibility of VNS lead removal and replacement in pediatric patients. METHODS Retrospective review examined 14 patients, at a single, tertiary-care, children's hospital, who underwent surgery to replace VNS leads, with complete removal of the existing lead from the vagus nerve and placement of a new lead on the same segment of the vagus nerve, via blunt and sharp dissection without use of electrocautery. Preoperative characteristics, stimulation parameters, and outcomes were collected. RESULTS Mean age at initial VNS placement was 7.6 years (SD 3.5, range 4.5-13.4). Most common etiologies of epilepsy were genetic (5, 36%) and cryptogenic (4, 29%). Lead replacement was performed at a mean of 6.0 years (SD 3.8, range 2.1-11.7) following initial VNS placement. Reasons for revision included VNS lead breakage or malfunction. There were no perioperative complications, including surgical site infection, voice changes, dysphagia, or new deficits postoperatively. Stimulation parameters after replacement surgery at last follow-up were similar compared to preoperatively, with final stimulation parameters ranging from 0.25 mA higher to 1.5 mA lower to maintain baseline seizure control. The mean length of follow-up was 7.9 years (SD 3.5, range 3.1-13.7). CONCLUSION Removal and replacement of VNS leads are feasible and can be safely performed in children. Further characterization of surgical technique, associated risk, impact on stimulation parameters, and long-term outcomes are needed to inform best practices in VNS revision.
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Affiliation(s)
- Melissa A LoPresti
- Division of Pediatric Neurosurgery, Texas Children's Hospital; Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA.,Division of Pediatric Neurosurgery, Lurie Children's Hospital; Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jonathan Huang
- Division of Pediatric Neurosurgery, Lurie Children's Hospital; Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nathan A Shlobin
- Division of Pediatric Neurosurgery, Lurie Children's Hospital; Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Daniel J Curry
- Division of Pediatric Neurosurgery, Texas Children's Hospital; Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Howard L Weiner
- Division of Pediatric Neurosurgery, Texas Children's Hospital; Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Sandi K Lam
- Division of Pediatric Neurosurgery, Lurie Children's Hospital; Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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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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Transcutaneous vagus nerve stimulation - A brief introduction and overview. Auton Neurosci 2022; 243:103038. [DOI: 10.1016/j.autneu.2022.103038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 09/25/2022] [Accepted: 09/25/2022] [Indexed: 12/28/2022]
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Liu CY, Russin J, Adelson DP, Jenkins A, Hilmi O, Brown B, Lega B, Whitworth T, Bhattacharyya D, Schwartz TH, Krishna V, Williams Z, Uff C, Willie J, Hoffman C, Vandergrift WA, Achrol AS, Ali R, Konrad P, Edmonds J, Kim D, Bhatt P, Tarver BW, Pierce D, Jain R, Burress C, Casavant R, Prudente CN, Engineer ND. Vagus nerve stimulation paired with rehabilitation for stroke: Implantation experience from the VNS-REHAB trial. J Clin Neurosci 2022; 105:122-128. [PMID: 36182812 DOI: 10.1016/j.jocn.2022.09.013] [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: 07/29/2022] [Revised: 09/16/2022] [Accepted: 09/20/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Vagus Nerve Stimulation (VNS) paired with rehabilitation delivered by the Vivistim® Paired VNS™ System was approved by the FDA in 2021 to improve motor deficits in chronic ischemic stroke survivors with moderate to severe arm and hand impairment. Vagus nerve stimulators have previously been implanted in over 125,000 patients for treatment-resistant epilepsy and the surgical procedure is generally well-tolerated and safe. In this report, we describe the Vivistim implantation procedure, perioperative management, and complications for chronic stroke survivors enrolled in the pivotal trial. METHODS The pivotal, multisite, randomized, triple-blind, sham-controlled trial (VNS-REHAB) enrolled 108 participants. All participants were implanted with the VNS device in an outpatient procedure. Thrombolytic agents were temporarily discontinued during the perioperative period. Participants were discharged within 48 hrs and started rehabilitation therapy approximately 10 days after the Procedure. RESULTS The rate of surgery-related adverse events was lower than previously reported for VNS implantation for epilepsy and depression. One participant had vocal cord paresis that eventually resolved. There were no serious adverse events related to device stimulation. Over 90% of participants were taking antiplatelet drugs (APD) or anticoagulants and no adverse events or serious adverse events were reported as a result of withholding these medications during the perioperative period. CONCLUSIONS This study is the largest, randomized, controlled trial in which a VNS device was implanted in chronic stroke survivors. Results support the use of the Vivistim System in chronic stroke survivors, with a safety profile similar to VNS implantations for epilepsy and depression.
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Affiliation(s)
- 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.
| | - Jonathan Russin
- 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
| | - David P Adelson
- Barrow Neurological Institute, Phoenix Children's Hospital, University of Arizona, Phoenix, USA
| | - Alistair Jenkins
- Royal Victoria Infirmary Newcastle, Newcastle upon Tyne, England, UK
| | - Omar Hilmi
- NHS Greater Glasgow and Clyde, Glasgow, UK
| | | | | | | | | | | | | | | | - Christopher Uff
- Royal London Hospital and Major Trauma Centre. Whitechapel, London, E1 1FR, UK
| | | | | | | | | | - Rushna Ali
- Department of Neurosciences, Spectrum Health, Grands Rapids, MI, USA
| | | | | | | | | | | | | | - Ravi Jain
- MicroTransponder Inc, Austin, TX, USA
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Arafat T, Miron G, Strauss I, Fahoum F. Electrodiagnostic artifacts due to neurostimulation devices for drug resistant epilepsy. Epilepsy Behav Rep 2022; 20:100566. [PMID: 36276845 PMCID: PMC9583742 DOI: 10.1016/j.ebr.2022.100566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/11/2022] [Accepted: 09/25/2022] [Indexed: 11/24/2022] Open
Abstract
Neurostimulation devices for epilepsy commonly induce EEG and/or ECG artifacts. Neurostimulation-related artifacts are intermittent and could mimic ictal EEG changes or cardiac rhythm abnormalities. Clinicians should be aware of different EEG and ECG artifact patterns to accurately interpret test findings and avoid unnecessary diagnostics and treatment.
Background Methods Results Conclusions
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Miron G, Strauss I, Fried I, Fahoum F. Anterior thalamic deep brain stimulation in epilepsy patients refractory to vagus nerve stimulation: A single center observational study. Epilepsy Behav Rep 2022; 20:100563. [PMID: 36119948 PMCID: PMC9471437 DOI: 10.1016/j.ebr.2022.100563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 08/10/2022] [Accepted: 08/26/2022] [Indexed: 10/31/2022] Open
Abstract
Patients with drug resistant epilepsy refractory to treatment with vagal nerve stimulation benefited from anterior thalamic deep brain stimulation. We report a combined neuromodulation approach of simultaneous vagal nerve and deep brain stimulation. Additional studies are needed to assess safety and efficacy of simultaneous VNS and DBS treatment.
Anterior thalamic deep brain stimulation (DBS) is a palliative treatment that may be considered in patients with drug resistant epilepsy (DRE) that fail treatment with vagus nerve stimulation (VNS). Combining VNS and DBS treatment is a therapeutic approach rarely reported. This single center observational study aims to describe response to DBS treatment in 11 epilepsy patients resistant to medications and VNS. Patients either had inactivated VNS (DBS only) or were treated with simultaneous DBS and VNS (DBS-VNS). Focal impaired awareness (FIA) and most disabling seizure rates were examined pre-DBS implantation, 3 months following implantation, and last follow up. Overall, a decrease in FIA (47.0 ± 30.7 %, p = 0.02) and most disabling seizure rate (54.8 ± 34.2 %, p = 0.03) was seen at last follow-up (average follow-up 28.5 ± 13.5 months). Eight of 11 patients were DBS responders (most disabling seizure rate reduction above 50%). No difference in seizure control was found between seven DBS only and four DBS-VNS patients. Our results argue that patients who have failed antiseizure medication and VNS therapies, could benefit from better seizure control if treated with adjunctive DBS. Larger prospective studies are needed to assess the efficacy and safety of combined neurostimulation treatments in DRE.
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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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Settell ML, Skubal AC, Chen RCH, Kasole M, Knudsen BE, Nicolai EN, Huang C, Zhou C, Trevathan JK, Upadhye A, Kolluru C, Shoffstall AJ, Williams JC, Suminski AJ, Grill WM, Pelot NA, Chen S, Ludwig KA. In vivo Visualization of Pig Vagus Nerve "Vagotopy" Using Ultrasound. Front Neurosci 2021; 15:676680. [PMID: 34899151 PMCID: PMC8660563 DOI: 10.3389/fnins.2021.676680] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 11/01/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Placement of the clinical vagus nerve stimulating cuff is a standard surgical procedure based on anatomical landmarks, with limited patient specificity in terms of fascicular organization or vagal anatomy. As such, the therapeutic effects are generally limited by unwanted side effects of neck muscle contractions, demonstrated by previous studies to result from stimulation of (1) motor fibers near the cuff in the superior laryngeal and (2) motor fibers within the cuff projecting to the recurrent laryngeal. Objective: Conventional non-invasive ultrasound, where the transducer is placed on the surface of the skin, has been previously used to visualize the vagus with respect to other landmarks such as the carotid and internal jugular vein. However, it lacks sufficient resolution to provide details about the vagus fascicular organization, or detail about smaller neural structures such as the recurrent and superior laryngeal branch responsible for therapy limiting side effects. Here, we characterize the use of ultrasound with the transducer placed in the surgical pocket to improve resolution without adding significant additional risk to the surgical procedure in the pig model. Methods: Ultrasound images were obtained from a point of known functional organization at the nodose ganglia to the point of placement of stimulating electrodes within the surgical window. Naïve volunteers with minimal training were then asked to use these ultrasound videos to trace afferent groupings of fascicles from the nodose to their location within the surgical window where a stimulating cuff would normally be placed. Volunteers were asked to select a location for epineural electrode placement away from the fascicles containing efferent motor nerves responsible for therapy limiting side effects. 2-D and 3-D reconstructions of the ultrasound were directly compared to post-mortem histology in the same animals. Results: High-resolution ultrasound from the surgical pocket enabled 2-D and 3-D reconstruction of the cervical vagus and surrounding structures that accurately depicted the functional vagotopy of the pig vagus nerve as confirmed via histology. Although resolution was not sufficient to match specific fascicles between ultrasound and histology 1 to 1, it was sufficient to trace fascicle groupings from a point of known functional organization at the nodose ganglia to their locations within the surgical window at stimulating electrode placement. Naïve volunteers were able place an electrode proximal to the sensory afferent grouping of fascicles and away from the motor nerve efferent grouping of fascicles in each subject (n = 3). Conclusion: The surgical pocket itself provides a unique opportunity to obtain higher resolution ultrasound images of neural targets responsible for intended therapeutic effect and limiting off-target effects. We demonstrate the increase in resolution is sufficient to aid patient-specific electrode placement to optimize outcomes. This simple technique could be easily adopted for multiple neuromodulation targets to better understand how patient specific anatomy impacts functional outcomes.
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Affiliation(s)
- Megan L. Settell
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States
- Wisconsin Institute of Neuroengineering (WITNe), University of Wisconsin-Madison, Madison, WI, United States
| | - Aaron C. Skubal
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States
- Wisconsin Institute of Neuroengineering (WITNe), University of Wisconsin-Madison, Madison, WI, United States
| | - Rex C. H. Chen
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States
- Wisconsin Institute of Neuroengineering (WITNe), University of Wisconsin-Madison, Madison, WI, United States
| | - Maïsha Kasole
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States
- Wisconsin Institute of Neuroengineering (WITNe), University of Wisconsin-Madison, Madison, WI, United States
| | - Bruce E. Knudsen
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States
- Wisconsin Institute of Neuroengineering (WITNe), University of Wisconsin-Madison, Madison, WI, United States
| | - Evan N. Nicolai
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States
- Wisconsin Institute of Neuroengineering (WITNe), University of Wisconsin-Madison, Madison, WI, United States
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN, United States
| | - Chengwu Huang
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Chenyun Zhou
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
- Department of Ultrasound, West China Hospital of Sichuan University, Chengdu, China
| | - James K. Trevathan
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States
- Wisconsin Institute of Neuroengineering (WITNe), University of Wisconsin-Madison, Madison, WI, United States
| | - Aniruddha Upadhye
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, United States
- Louis Stokes Cleveland VA Medical Center, Cleveland, OH, United States
| | - Chaitanya Kolluru
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, United States
- Louis Stokes Cleveland VA Medical Center, Cleveland, OH, United States
| | - Andrew J. Shoffstall
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, United States
- Louis Stokes Cleveland VA Medical Center, Cleveland, OH, United States
| | - Justin C. Williams
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States
- Wisconsin Institute of Neuroengineering (WITNe), University of Wisconsin-Madison, Madison, WI, United States
- Department of Neurosurgery, University of Wisconsin-Madison, Madison, WI, United States
| | - Aaron J. Suminski
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States
- Wisconsin Institute of Neuroengineering (WITNe), University of Wisconsin-Madison, Madison, WI, United States
- Department of Neurosurgery, University of Wisconsin-Madison, Madison, WI, United States
| | - Warren M. Grill
- Department of Biomedical Engineering, Duke University, Durham, NC, United States
- Department of Electrical and Computer Engineering, Duke University, Durham, NC, United States
- Department of Neurobiology, Duke University, Durham, NC, United States
- Department of Neurosurgery, Duke University, Durham, NC, United States
| | - Nicole A. Pelot
- Department of Biomedical Engineering, Duke University, Durham, NC, United States
| | - Shigao Chen
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Kip A. Ludwig
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States
- Wisconsin Institute of Neuroengineering (WITNe), University of Wisconsin-Madison, Madison, WI, United States
- Department of Neurosurgery, University of Wisconsin-Madison, Madison, WI, United States
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Management and outcome of vagus nerve stimulator implantation: experience of an otolaryngeal/neuropediatric cooperation. Eur Arch Otorhinolaryngol 2021; 278:3891-3899. [PMID: 34196736 PMCID: PMC8382619 DOI: 10.1007/s00405-021-06943-x] [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: 02/16/2021] [Accepted: 06/12/2021] [Indexed: 11/02/2022]
Abstract
OBJECTIVE Vagus nerve stimulator (VNS) implantation is an established therapy for pharmacoresistant epilepsy that is not amenable to curative epilepsy surgery. Historically, VNS implantation has been performed by neurosurgeons, but otolaryngologist involvement is increasingly common. In this retrospective study, we aimed to evaluate the efficacy and safety of VNS implantation in children and adolescents from the otolaryngologists' perspective. METHODS This study included children and adolescents who had undergone VNS implantation at the study center between 2014 and 2018. Patient files were analyzed with regards to the durations of device implantation and hospitalization, postoperative complications, and clinical outcome, including seizure frequency, clinical global impression of improvement (CGI-I) score, and quality of life (QoL). RESULTS A total of 73 children underwent VNS surgery. The median age at implantation was 9.3 ± 4.6 years, and median epilepsy duration before VNS surgery was 6 ± 4 years. Lennox-Gastaut syndrome was the most common syndrome diagnosis (62.3%), and structural abnormalities (49.3%) the most frequent etiology. Operation times ranged from 30 to 200 min, and median postoperative hospitalization length was 2 ± 0.9 days. No complications occurred, except for four revisions and two explantations due to local infections (2.7%). Among our patients, 76.7% were responders (≥ 50% reduction in seizure frequency), 72.1% showed improved CGI-I scores, and 18.6-60.5% exhibited considerable improvements in the QoL categories energy, emotional health, and cognitive functions. CONCLUSION Our results indicate that VNS implantation is a highly effective and safe treatment option for children and adolescents with AED-refractory epilepsies who are not candidates for curative epilepsy surgery.
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Katagiri M, Otsubo H, Kagawa K, Seyama G, Hashizume A, Okamura A, Ishikawa N, Hanaya R, Arita K, Kurisu K, Iida K. Interpersonal communication skills related to seizure outcomes in pediatric patients with vagus nerve stimulation. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.101080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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14
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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: 66] [Impact Index Per Article: 22.0] [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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15
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Okamura A, Otsubo H, Hashizume A, Kagawa K, Katagiri M, Seyama G, Kurisu K, Iida K. Secondary epileptogenesis on gradient magnetic-field topography correlates with seizure outcomes after vagus nerve stimulation. Epilepsy Res 2020; 167:106463. [PMID: 32987243 DOI: 10.1016/j.eplepsyres.2020.106463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 08/07/2020] [Accepted: 09/07/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the correlation between secondary unilateral or bilateral spreading on gradient magnetic-field topography (GMFT) before and after vagus nerve stimulation (VNS), and postoperative seizure outcomes. METHODS We analyzed pre- and post-VNS magnetoencephalography (MEG) in 15 patients with VNS implants. We applied McHugh classification to evaluate seizure outcomes. GMFT visualized the spatiotemporal spread of the gradient magnetic field from MEG (>300 fT/cm) before and after the spike peak. We compared the proportion of bilaterally spreading (PBS) MEG spikes and seizure outcomes. We also compared the interhemispheric time difference (ITD) between patients with and without corpus callosotomy. RESULTS We allocated patients with favorable seizure outcomes of class I and II to group A (9 patients) and poor outcomes of class III-V to group B (6 patients). The number of post-VNS MEG spikes was significantly reduced compared to pre-VNS MEG spikes in group A, but not in group B. Group A showed significantly higher preoperative PBS than group B. Postoperative ITD significantly decreased in 5 patients who underwent corpus callosotomy compared to 10 patients without. CONCLUSION GMFT can detect the inter- and intrahemispheric spreading of spikes with high spatiotemporal resolution on the brain surface. Frequent interictal MEG spikes propagating bilaterally on GMFT may reflect a favorable seizure outcome after VNS. GMFT can identify dependent secondary epileptogenic spikes responding to VNS, which may be used to control generalized seizures in a subset of patients with pharmaco-resistant epilepsy.
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Affiliation(s)
- Akitake Okamura
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan; Epilepsy Center, Hiroshima University Hospital, Hiroshima, Japan
| | - Hiroshi Otsubo
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Akira Hashizume
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan; Epilepsy Center, Hiroshima University Hospital, Hiroshima, Japan
| | - Kota Kagawa
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan; Epilepsy Center, Hiroshima University Hospital, Hiroshima, Japan
| | - Masaya Katagiri
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan; Epilepsy Center, Hiroshima University Hospital, Hiroshima, Japan
| | - Go Seyama
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan; Epilepsy Center, Hiroshima University Hospital, Hiroshima, Japan
| | - Kaoru Kurisu
- Department of Neurosurgery, Chugoku Rosai Hospital, Hiroshima, Japan
| | - Koji Iida
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan; Epilepsy Center, Hiroshima University Hospital, Hiroshima, Japan.
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Ahmed U, Chang YC, Cracchiolo M, Lopez MF, Tomaio JN, Datta-Chaudhuri T, Zanos TP, Rieth L, Al-Abed Y, Zanos S. Anodal block permits directional vagus nerve stimulation. Sci Rep 2020; 10:9221. [PMID: 32513973 PMCID: PMC7280203 DOI: 10.1038/s41598-020-66332-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 05/14/2020] [Indexed: 11/10/2022] Open
Abstract
Vagus nerve stimulation (VNS) is a bioelectronic therapy for disorders of the brain and peripheral organs, and a tool to study the physiology of autonomic circuits. Selective activation of afferent or efferent vagal fibers can maximize efficacy and minimize off-target effects of VNS. Anodal block (ABL) has been used to achieve directional fiber activation in nerve stimulation. However, evidence for directional VNS with ABL has been scarce and inconsistent, and it is unknown whether ABL permits directional fiber activation with respect to functional effects of VNS. Through a series of vagotomies, we established physiological markers for afferent and efferent fiber activation by VNS: stimulus-elicited change in breathing rate (ΔBR) and heart rate (ΔHR), respectively. Bipolar VNS trains of both polarities elicited mixed ΔHR and ΔBR responses. Cathode cephalad polarity caused an afferent pattern of responses (relatively stronger ΔBR) whereas cathode caudad caused an efferent pattern (stronger ΔHR). Additionally, left VNS elicited a greater afferent and right VNS a greater efferent response. By analyzing stimulus-evoked compound nerve potentials, we confirmed that such polarity differences in functional responses to VNS can be explained by ABL of A- and B-fiber activation. We conclude that ABL is a mechanism that can be leveraged for directional VNS.
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Affiliation(s)
- Umair Ahmed
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, 11030, USA
| | - Yao-Chuan Chang
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, 11030, USA
| | - Marina Cracchiolo
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, 11030, USA
- Biorobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Maria F Lopez
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, 11030, USA
| | - Jacquelyn N Tomaio
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, 11030, USA
| | - Timir Datta-Chaudhuri
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, 11030, USA
| | - Theodoros P Zanos
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, 11030, USA
| | - Loren Rieth
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, 11030, USA
| | - Yousef Al-Abed
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, 11030, USA
| | - Stavros Zanos
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, 11030, USA.
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17
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Adair D, Truong D, Esmaeilpour Z, Gebodh N, Borges H, Ho L, Bremner JD, Badran BW, Napadow V, Clark VP, Bikson M. Electrical stimulation of cranial nerves in cognition and disease. Brain Stimul 2020; 13:717-750. [PMID: 32289703 PMCID: PMC7196013 DOI: 10.1016/j.brs.2020.02.019] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 02/13/2020] [Accepted: 02/17/2020] [Indexed: 02/06/2023] Open
Abstract
The cranial nerves are the pathways through which environmental information (sensation) is directly communicated to the brain, leading to perception, and giving rise to higher cognition. Because cranial nerves determine and modulate brain function, invasive and non-invasive cranial nerve electrical stimulation methods have applications in the clinical, behavioral, and cognitive domains. Among other neuromodulation approaches such as peripheral, transcranial and deep brain stimulation, cranial nerve stimulation is unique in allowing axon pathway-specific engagement of brain circuits, including thalamo-cortical networks. In this review we amalgamate relevant knowledge of 1) cranial nerve anatomy and biophysics; 2) evidence of the modulatory effects of cranial nerves on cognition; 3) clinical and behavioral outcomes of cranial nerve stimulation; and 4) biomarkers of nerve target engagement including physiology, electroencephalography, neuroimaging, and behavioral metrics. Existing non-invasive stimulation methods cannot feasibly activate the axons of only individual cranial nerves. Even with invasive stimulation methods, selective targeting of one nerve fiber type requires nuance since each nerve is composed of functionally distinct axon-types that differentially branch and can anastomose onto other nerves. None-the-less, precisely controlling stimulation parameters can aid in affecting distinct sets of axons, thus supporting specific actions on cognition and behavior. To this end, a rubric for reproducible dose-response stimulation parameters is defined here. Given that afferent cranial nerve axons project directly to the brain, targeting structures (e.g. thalamus, cortex) that are critical nodes in higher order brain networks, potent effects on cognition are plausible. We propose an intervention design framework based on driving cranial nerve pathways in targeted brain circuits, which are in turn linked to specific higher cognitive processes. State-of-the-art current flow models that are used to explain and design cranial-nerve-activating stimulation technology require multi-scale detail that includes: gross anatomy; skull foramina and superficial tissue layers; and precise nerve morphology. Detailed simulations also predict that some non-invasive electrical or magnetic stimulation approaches that do not intend to modulate cranial nerves per se, such as transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (TMS), may also modulate activity of specific cranial nerves. Much prior cranial nerve stimulation work was conceptually limited to the production of sensory perception, with individual titration of intensity based on the level of perception and tolerability. However, disregarding sensory emulation allows consideration of temporal stimulation patterns (axon recruitment) that modulate the tone of cortical networks independent of sensory cortices, without necessarily titrating perception. For example, leveraging the role of the thalamus as a gatekeeper for information to the cerebral cortex, preventing or enhancing the passage of specific information depending on the behavioral state. We show that properly parameterized computational models at multiple scales are needed to rationally optimize neuromodulation that target sets of cranial nerves, determining which and how specific brain circuitries are modulated, which can in turn influence cognition in a designed manner.
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Affiliation(s)
- Devin Adair
- Department of Biomedical Engineering, City College of New York, New York, NY, USA
| | - Dennis Truong
- Department of Biomedical Engineering, City College of New York, New York, NY, USA
| | - Zeinab Esmaeilpour
- Department of Biomedical Engineering, City College of New York, New York, NY, USA.
| | - Nigel Gebodh
- Department of Biomedical Engineering, City College of New York, New York, NY, USA
| | - Helen Borges
- Department of Biomedical Engineering, City College of New York, New York, NY, USA
| | - Libby Ho
- Department of Biomedical Engineering, City College of New York, New York, NY, USA
| | - J Douglas Bremner
- Department of Psychiatry & Behavioral Sciences and Radiology, Emory University School of Medicine, Atlanta, GA, USA; Atlanta VA Medical Center, Decatur, GA, USA
| | - Bashar W Badran
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Vitaly Napadow
- Martinos Center for Biomedical Imaging, Department of Radiology, MGH, Harvard medical school, Boston, MA, USA
| | - Vincent P Clark
- Psychology Clinical Neuroscience Center, Dept. Psychology, MSC03-2220, University of New Mexico, Albuquerque, NM, 87131, USA; Department of Psychology, University of New Mexico, Albuquerque, NM, 87131, USA; The Mind Research Network of the Lovelace Biomedical Research Institute, 1101 Yale Blvd. NE, Albuquerque, NM, 87106, USA
| | - Marom Bikson
- Department of Biomedical Engineering, City College of New York, New York, NY, USA.
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18
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Kochilas HL, Cacace AT, Arnold A, Seidman MD, Tarver WB. Vagus nerve stimulation paired with tones for tinnitus suppression: Effects on voice and hearing. Laryngoscope Investig Otolaryngol 2020; 5:286-296. [PMID: 32337360 PMCID: PMC7178458 DOI: 10.1002/lio2.364] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 01/23/2020] [Accepted: 02/08/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE In individuals with chronic tinnitus, our interest was to determine whether daily low-level electrical stimulation of the vagus nerve paired with tones (paired-VNSt) for tinnitus suppression had any adverse effects on motor-speech production and physiological acoustics of sustained vowels. Similarly, we were also interested in evaluating for changes in pure-tone thresholds, word-recognition performance, and minimum-masking levels. Both voice and hearing functions were measured repeatedly over a period of 1 year. STUDY DESIGN Longitudinal with repeated-measures. METHODS Digitized samples of sustained frontal, midline, and back vowels (/e/, /o/, /ah/) were analyzed with computer software to quantify the degree of jitter, shimmer, and harmonic-to-noise ratio contained in these waveforms. Pure-tone thresholds, monosyllabic word-recognition performance, and MMLs were also evaluated for VNS alterations. Linear-regression analysis was the benchmark statistic used to document change over time in voice and hearing status from a baseline condition. RESULTS Most of the regression functions for the vocal samples and audiometric variables had slope values that were not significantly different from zero. Four of the nine vocal functions showed a significant improvement over time, whereas three of the pure tone regression functions at 2-4 kHz showed some degree of decline; all changes observed were for the left ear, all were at adjacent frequencies, and all were ipsilateral to the side of VNS. However, mean pure-tone threshold changes did not exceed 4.29 dB from baseline and therefore, would not be considered clinically significant. In some individuals, larger threshold shifts were observed. No significant regression/slope effects were observed for word-recognition or MMLs. CONCLUSION Quantitative voice analysis and assessment of audiometric variables showed minimal if any evidence of adverse effects using paired-VNSt over a treatment period of 1 year. Therefore, we conclude that paired-VNSt is a safe tool for tinnitus abatement in humans without significant side effects. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Helen L. Kochilas
- North Atlanta Ears, Nose, Throat & Allergy, AlpharettaGeorgia
- Present address:
North Atlanta Ears, Nose, Throat & AllergyAlpharettaGeorgia
| | - Anthony T. Cacace
- Department of Communication Sciences & Disorders, Wayne State University, DetroitMichigan
| | - Amy Arnold
- The Hearing Clinic, BrightonMichigan
- Present address:
The Hearing ClinicBrightonMichigan
| | - Michael D. Seidman
- Florida ENT Surgical Specialists, Florida Hospital Medical Group, Head & Neck Surgery Center of Florida, CelebrationFlorida
- Present address:
Florida Hospital Medical GroupHead & Neck Surgery Center of FloridaCelebrationFlorida
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19
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Cozzens JW. The Surgical Technique of Vagus Nerve Stimulator Implantation. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00042-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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20
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Bonaz B, Sinniger V, Pellissier S. The Vagus Nerve in the Neuro-Immune Axis: Implications in the Pathology of the Gastrointestinal Tract. Front Immunol 2017; 8:1452. [PMID: 29163522 PMCID: PMC5673632 DOI: 10.3389/fimmu.2017.01452] [Citation(s) in RCA: 184] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 10/17/2017] [Indexed: 12/12/2022] Open
Abstract
The vagus nerve (VN) is the longest nerve of the organism and a major component of the parasympathetic nervous system which constitutes the autonomic nervous system (ANS), with the sympathetic nervous system. There is classically an equilibrium between the sympathetic and parasympathetic nervous systems which is responsible for the maintenance of homeostasis. An imbalance of the ANS is observed in various pathologic conditions. The VN, a mixed nerve with 4/5 afferent and 1/5 efferent fibers, is a key component of the neuro-immune and brain-gut axes through a bidirectional communication between the brain and the gastrointestinal (GI) tract. A dual anti-inflammatory role of the VN is observed using either vagal afferents, targeting the hypothalamic–pituitary–adrenal axis, or vagal efferents, targeting the cholinergic anti-inflammatory pathway. The sympathetic nervous system and the VN act in synergy, through the splenic nerve, to inhibit the release of tumor necrosis factor-alpha (TNFα) by macrophages of the peripheral tissues and the spleen. Because of its anti-inflammatory effect, the VN is a therapeutic target in the treatment of chronic inflammatory disorders where TNFα is a key component. In this review, we will focus on the anti-inflammatory role of the VN in inflammatory bowel diseases (IBD). The anti-inflammatory properties of the VN could be targeted pharmacologically, with enteral nutrition, by VN stimulation (VNS), with complementary medicines or by physical exercise. VNS is one of the alternative treatments for drug resistant epilepsy and depression and one might think that VNS could be used as a non-drug therapy to treat inflammatory disorders of the GI tract, such as IBD, irritable bowel syndrome, and postoperative ileus, which are all characterized by a blunted autonomic balance with a decreased vagal tone.
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Affiliation(s)
- Bruno Bonaz
- Division of Hepato-Gastroenterology, Grenoble University Hospital, Grenoble, Alpes, France.,U1216, INSERM, GIN, Grenoble Institute of Neurosciences, University Grenoble Alpes, Grenoble, France
| | - Valérie Sinniger
- Division of Hepato-Gastroenterology, Grenoble University Hospital, Grenoble, Alpes, France.,U1216, INSERM, GIN, Grenoble Institute of Neurosciences, University Grenoble Alpes, Grenoble, France
| | - Sonia Pellissier
- Laboratoire Inter-Universitaire de Psychologie, Personnalité, Cognition et Changement Social LIP/PC2S-EA4145, University Savoie Mont Blanc, Chambéry, France
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21
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Oliveira TVHFD, Francisco AN, Demartini Junior Z, Stebel SL. The role of vagus nerve stimulation in refractory epilepsy. ARQUIVOS DE NEURO-PSIQUIATRIA 2017; 75:657-666. [DOI: 10.1590/0004-282x20170113] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 06/07/2017] [Indexed: 11/22/2022]
Abstract
ABSTRACT Vagus nerve stimulation is an adjunctive therapy used to treat patients with refractory epilepsy who are not candidates for resective surgery or had poor results after surgical procedures. Its mechanism of action is not yet fully comprehended but it possibly involves modulation of the locus coeruleus, thalamus and limbic circuit through noradrenergic and serotonergic projections. There is sufficient evidence to support its use in patients with focal epilepsy and other seizure types. However, it should be recognized that improvement is not immediate and increases over time. The majority of adverse events is stimulation-related, temporary and decreases after adjustment of settings. Future perspectives to improve efficacy and reduce side effects, such as different approaches to increase battery life, transcutaneous stimulation and identification of prognostic factors, should be further investigated.
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22
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Bonaz B, Sinniger V, Pellissier S. Vagus nerve stimulation: a new promising therapeutic tool in inflammatory bowel disease. J Intern Med 2017; 282:46-63. [PMID: 28421634 DOI: 10.1111/joim.12611] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Inflammatory bowel disease (IBD), that is Crohn's disease (CD) and ulcerative colitis, affects about 1.5 million persons in the USA and 2.2 million in Europe. The pathophysiology of IBD involves immunological, genetic and environmental factors. The treatment is medico-surgical but suspensive. Anti-TNFα agents have revolutionized the treatment of IBD but have side effects. In addition, a non-negligible percentage of patients with IBD stop or take episodically their treatment. Consequently, a nondrug therapy targeting TNFα through a physiological pathway, devoid of major side effects and with a good cost-effectiveness ratio, would be of interest. The vagus nerve has dual anti-inflammatory properties through its afferent (i.e. hypothalamic-pituitary-adrenal axis) and efferent (i.e. the anti-TNFα effect of the cholinergic anti-inflammatory pathway) fibres. We have shown that there is an inverse relationship between vagal tone and plasma TNFα level in patients with CD, and have reported, for the first time, that chronic vagus nerve stimulation has anti-inflammatory properties in a rat model of colitis and in a pilot study performed in seven patients with moderate CD. Two of these patients failed to improve after 3 months of vagus nerve stimulation but five were in deep remission (clinical, biological and endoscopic) at 6 months of follow-up and vagal tone was restored. No major side effects were observed. Thus, vagus nerve stimulation provides a new therapeutic option in the treatment of CD.
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Affiliation(s)
- B Bonaz
- University Clinic of Hepato-Gastroenterology, University Hospital, Grenoble, France.,University Grenoble Alpes, Grenoble Institute of Neurosciences (GIN), Inserm (U1216), Grenoble, France
| | - V Sinniger
- University Clinic of Hepato-Gastroenterology, University Hospital, Grenoble, France.,University Grenoble Alpes, Grenoble Institute of Neurosciences (GIN), Inserm (U1216), Grenoble, France
| | - S Pellissier
- University Clinic of Hepato-Gastroenterology, University Hospital, Grenoble, France.,Laboratoire Inter-Universitaire de Psychologie, Personnalité, Cognition et Changement Social (LIP/PC2S), University Savoie Mont-Blanc, Chambéry, France
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23
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Giordano F, Zicca A, Barba C, Guerrini R, Genitori L. Vagus nerve stimulation: Surgical technique of implantation and revision and related morbidity. Epilepsia 2017; 58 Suppl 1:85-90. [DOI: 10.1111/epi.13678] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Flavio Giordano
- Department of Neurosurgery; Anna Meyer Hospital; University of Firenze; Firenze Italy
| | - Anna Zicca
- Department of Neuroanaesthesiology; Anna Meyer Hospital; University of Firenze; Firenze Italy
| | - Carmen Barba
- Pediatric Neurology Unit; Anna Meyer Hospital; University of Firenze; Firenze Italy
| | - Renzo Guerrini
- Pediatric Neurology Unit; Anna Meyer Hospital; University of Firenze; Firenze Italy
| | - Lorenzo Genitori
- Department of Neurosurgery; Anna Meyer Hospital; University of Firenze; Firenze Italy
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24
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Martlé V, Van Ham LML, Boon P, Caemaert J, Tshamala M, Vonck K, Raedt R, Polis I, Bhatti S. Vagus Nerve Stimulator Placement in Dogs: Surgical Implantation Technique, Complications, Long-Term Follow-Up, and Practical Considerations. Vet Surg 2016; 45:71-8. [PMID: 26731597 DOI: 10.1111/vsu.12427] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe a modified implantation procedure of a vagus nerve stimulation (VNS) device in dogs and to report short- and long-term complications. STUDY DESIGN Descriptive, experimental study. ANIMALS Healthy, adult Beagle dogs (n = 10). METHODS A VNS Therapy(®) System was implanted in the left cervical region of anesthetized dogs. During and within 48 hours after surgery, electrocardiography (ECG) and impedance testing of the system were performed. Dogs were monitored daily and the impedance of the system was determined regularly until VNS devices were surgically removed 3 years after implantation. RESULTS The implantation procedure was successful in all dogs without intraoperative complications. ECG monitoring and impedance tests were within normal limits during and within 48 hours after surgery. Postoperative seroma formation was common (70%). One dog developed an irreversible Horner's syndrome leading to removal of the device 5 months after implantation. Another dog developed trauma-induced damage of the lead requiring surgical revision. The device could be safely removed in all dogs; however, electrodes were left in place to avoid nerve damage. At removal, the anchor tether was dislodged in 40% of dogs and the lead was twisted in 50% of dogs. CONCLUSION Implantation of a VNS Therapy(®) System is safe and feasible in dogs; however, seroma formation, twisting of the lead, and dislodgement of the anchor tether were common. Practical improvements in the technique include stable device placement, use of a compression bandage, and exercise restriction. Regular evaluation of lead impedance is important, as altered values can indicate serious complications.
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Affiliation(s)
- Valentine Martlé
- Faculty of Veterinary Medicine, Department of Small Animal Medicine and Clinical Biology, Ghent University, Merelbeke, Belgium
| | - Luc M L Van Ham
- Faculty of Veterinary Medicine, Department of Small Animal Medicine and Clinical Biology, Ghent University, Merelbeke, Belgium
| | - Paul Boon
- Faculty of Medicine and Health Sciences, Department of Neurology
| | - Jacques Caemaert
- Faculty of Medicine and Health Sciences, Department of Neurosurgery, Ghent University Hospital, Ghent, Belgium
| | - Mulenda Tshamala
- Faculty of Veterinary Medicine, Department of Small Animal Medicine and Clinical Biology, Ghent University, Merelbeke, Belgium
| | - Kristl Vonck
- Faculty of Medicine and Health Sciences, Department of Neurology
| | - Robrecht Raedt
- Faculty of Medicine and Health Sciences, Department of Neurology
| | - Ingeborgh Polis
- Faculty of Veterinary Medicine, Department of Small Animal Medicine and Clinical Biology, Ghent University, Merelbeke, Belgium
| | - Sofie Bhatti
- Faculty of Veterinary Medicine, Department of Small Animal Medicine and Clinical Biology, Ghent University, Merelbeke, Belgium
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Verlinden TJM, Rijkers K, Hoogland G, Herrler A. Morphology of the human cervical vagus nerve: implications for vagus nerve stimulation treatment. Acta Neurol Scand 2016; 133:173-82. [PMID: 26190515 DOI: 10.1111/ane.12462] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The vagus nerve has gained a role in the treatment of certain diseases by the use of vagus nerve stimulation (VNS). This study provides detailed morphological information regarding the human cervical vagus nerve at the level of electrode implant. RESULTS Eleven pairs of cervical vagus nerves and four pairs of intracranial vagus nerves were analysed by the use of computer software. It was found that the right cervical vagus nerve has an 1.5 times larger effective surface area on average than the left nerve [1,089,492 ± 98,337 vs 753,915 ± 102,490 μm(2), respectively, (P < 0.05)] and that there is broad spreading within the individual nerves. At the right side, the mean effective surface area at the cervical level (1,089,492 ± 98,337 μm(2)) is larger than at the level inside the skull base (630,921 ± 105,422) (P < 0.05). This could imply that the vagus nerve receives anastomosing and 'hitchhiking' branches from areas other than the brainstem. Furthermore, abundant tyrosine hydroxylase (TH)- and dopamine ß-hydroxylase (DBH)-positive staining nerve fibres could be identified, indicating catecholaminergic neurotransmission. In two of the 22 cervical nerves, ganglion cells were found that also stained positive for TH and DBH. Stimulating the vagus nerve may therefore induce the release of dopamine and noradrenaline. A sympathetic activation could therefore be part of mechanism of action of VNS. Furthermore, it was shown that the right cervical vagus nerve contains on average two times more TH-positive nerve fibres than the left nerve (P < 0.05), a fact that could be of interest upon choosing stimulation side. We also suggest that the amount of epineurial tissue could be an important variable for determining individual effectiveness of VNS, because the absolute amount of epineurial tissue is widely spread between the individual nerves (ranging from 2,090,000 to 11,683,000 μm(2)). CONCLUSIONS We conclude by stating that one has to look at the vagus nerve as a morphological entity of the peripheral autonomic nervous system, a composite of different fibres and (anastomosing and hitchhiking) branches of different origin with different neurotransmitters, which can act both parasympathetic and sympathetic. Electrically stimulating the vagus nerve therefore is not the same as elevating the 'physiological parasympathetic tone', but may also implement catecholaminergic (sympathetic) effects.
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Affiliation(s)
- T. J. M. Verlinden
- Department of Anatomy & Embryology; Faculty of Health, Medicine and Life Sciences; Maastricht University; Maastricht the Netherlands
| | - K. Rijkers
- Department of Neurosurgery; School for Mental Health and Neuroscience; Maastricht University Medical Center; Maastricht the Netherlands
- Department of Neurosurgery; Zuyderland Hospital; Heerlen the Netherlands
| | - G. Hoogland
- Department of Neurosurgery; School for Mental Health and Neuroscience; Maastricht University Medical Center; Maastricht the Netherlands
| | - A. Herrler
- Department of Anatomy & Embryology; Faculty of Health, Medicine and Life Sciences; Maastricht University; Maastricht the Netherlands
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Townsley R, Hilmi O. The use of nerve monitoring in the placement of vagal nerve stimulators. Clin Otolaryngol 2016; 42:959-961. [DOI: 10.1111/coa.12519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2015] [Indexed: 11/28/2022]
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Ghani S, Vilensky J, Turner B, Tubbs RS, Loukas M. Meta-analysis of vagus nerve stimulation treatment for epilepsy: correlation between device setting parameters and acute response. Childs Nerv Syst 2015; 31:2291-304. [PMID: 26493055 DOI: 10.1007/s00381-015-2921-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 09/23/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Vagus nerve stimulation (VNS) is an adjunctive neurophysiological treatment for those patients who have pharmacoresistant or surgically resistant partial onset epilepsy. OBJECTIVE The aim of this study is to determine the effects of high and low stimulation paradigms on a responder rate of ≥50 and ≥75% reduction in seizure frequency and associated adverse effects in adults and children. METHOD A literature search was performed using Medline, PubMed, EMBASE, and Cochrane library for studies using vagus nerve stimulation published from January 1980 until July 2014 for medically or surgically resistant partial onset seizures, in children and adults. No restrictions on languages were imposed. DATA COLLECTION AND ANALYSIS Four authors reviewed and selected studies for inclusion and exclusion. The search identified five randomized control trials that fit with our inclusion criteria. The following outcomes were evaluated: 50% or greater reduction in total seizure frequency, 75% or greater reduction in total seizure frequency, and adverse effects. RESULTS Four randomized controlled trials were analyzed in this meta-analysis. Results indicate high stimulation is more effective in adult patients who experienced ≥50 and ≥75% reduction in seizure frequency with a significant difference within both high and low stimulation groups. In children, there was no significant difference between the two groups and patients with ≥50 % reduction in seizures. Adverse effects such as hoarseness and dyspnea were more common in the high stimulation group where the remaining side effects were not statistically different among both groups. CONCLUSION High stimulation is more effective than low stimulation in producing a greater reduction in seizure frequency in patients with medically and surgically resistant epilepsy.
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Affiliation(s)
- S Ghani
- Department of Psychiatry, School of Medicine, University of Arizona, Tucson, AZ, USA.,Department of Anatomical Sciences, School of Medicine, St. George's University, Grenada, WI, USA
| | - J Vilensky
- Department of Anatomy and Cell Biology, School of Medicine, Indiana University, Fort Wayne, IN, USA
| | - B Turner
- Department of Anatomical Sciences, School of Medicine, St. George's University, Grenada, WI, USA
| | - R S Tubbs
- Department of Anatomical Sciences, School of Medicine, St. George's University, Grenada, WI, USA.,Pediatric Neurosurgery, Children's Hospital, Birmingham, AL, USA
| | - M Loukas
- Department of Anatomical Sciences, School of Medicine, St. George's University, Grenada, WI, USA.
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De Ridder D, Kilgard M, Engineer N, Vanneste S. Placebo-Controlled Vagus Nerve Stimulation Paired With Tones in a Patient With Refractory Tinnitus. Otol Neurotol 2015; 36:575-80. [DOI: 10.1097/mao.0000000000000704] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Orosz I, McCormick D, Zamponi N, Varadkar S, Feucht M, Parain D, Griens R, Vallée L, Boon P, Rittey C, Jayewardene AK, Bunker M, Arzimanoglou A, Lagae L. Vagus nerve stimulation for drug-resistant epilepsy: a European long-term study up to 24 months in 347 children. Epilepsia 2014; 55:1576-84. [PMID: 25231724 DOI: 10.1111/epi.12762] [Citation(s) in RCA: 150] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2014] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To gain insight into the long-term impact of vagus nerve stimulation (with VNS Therapy) in children with drug-resistant epilepsy, we conducted the largest retrospective multicenter study to date over an extended follow-up period of up to 24 months. METHODS The primary objective was to assess change in seizure frequency of the predominant seizure type (defined as the most disabling seizure) following VNS device implantation. Treating physicians collected data from patient records from baseline to 6, 12, and 24 months of follow-up. RESULTS The analysis population included 347 children (aged 6 months to 17.9 years at the time of implant). At 6, 12, and 24 months after implantation, 32.5%, 37.6%, and 43.8%, respectively, of patients had ≥ 50% reduction in baseline seizure frequency of the predominant seizure type. The responder rate was higher in a subgroup of patients who had no change in antiepileptic drugs (AEDs) during the study. Favorable results were also evident for all secondary outcome measures including changes in seizure duration, ictal severity, postictal severity, quality of life, clinical global impression of improvement, and safety. Post hoc analyses demonstrated a statistically significant correlation between VNS total charge delivered per day and an increase in response rate. VNS Therapy is indicated as adjunctive therapy in children with focal, structural epilepsies, who for any reason are not good candidates for surgical treatment following the trial of two or more AEDs. Children with predominantly generalized seizures from genetic, structural epilepsies, like Dravet syndrome or Lennox-Gastaut syndrome, could also benefit from VNS Therapy. SIGNIFICANCE The results demonstrate that adjunctive VNS Therapy in children with drug-resistant epilepsy reduces seizure frequency and is well tolerated over a 2-year follow-up period. No new safety issues were identified. A post hoc analysis revealed a dose-response correlation for VNS in patients with epilepsy.
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Affiliation(s)
- Iren Orosz
- Department of Neuropediatrics, Children's Hospital, University of Leubeck, Leubeck, Germany
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Buschman HP, Storm CJ, Duncker DJ, Verdouw PD, van der Aa HE, van der Kemp P. Heart rate control via vagus nerve stimulation. Neuromodulation 2013; 9:214-20. [PMID: 22151709 DOI: 10.1111/j.1525-1403.2006.00062.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objectives. There is ample and well-established evidence that direct electrical stimulation of the vagus nerve can change heart rate in animals and humans. Since tachyarrhythmias cannot always be controlled through medication, we sought, in this pilot study, to elucidate whether a clinical implantable lead system that is used in cervical vagus nerve stimulation therapy (VNS therapy) also can be used for control of heart rate, and tachycardia in particular. Materials and Methods. Experiments were carried out in three pigs (weight 21-26 kg) under general anesthesia. The right and left vagus nerves in the neck region were exposed by dissection, and bipolar, multiturn, helical, silicone leads were wrapped around the vagus nerves. Stimulation was applied by an external device with multivariable settings: frequency 10-100 Hz, pulse duration 100-700 µsec; delay 0-0.5 msec; current 0.5-14 mA. Measurements were performed under normal sinus rhythm (RR-interval 501 ± 30 msec) and during isoprenaline-induced tachycardia (RR-interval 284 ± 11 msec). Results. VNS, under optimal pacing conditions (100 Hz; 5 mA; 0.2 msec; 70 msec delay), in an electrocardiogram-triggered (ECG-triggered) pacing mode, increased RR-intervals by approximately 40%, irrespective of the duration of the RR-interval preceding VNS. The maximum effect on heart rate was established within approximately 5 sec after the onset of stimulation and was reversible and reproducible. No differences were found between stimulation of the right or left vagus nerve. Conclusion. VNS can be used effectively and rapidly to decrease heart rate, in acute settings, when connected to an external pacing system. Future devices that are fully implantable may be used for nonpharmacological treatment of illnesses in which tachycardia results in deterioration of cardiac function.
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Affiliation(s)
- Hendrik P Buschman
- Twente Institute for Neuromodulation (TWIN), Medisch Spectrum Twente, Enschede; Biomedical Signals and Systems group, University of Twente, Enschede; Department of Cardiology, Medisch Centrum Rijnmond-Zuid, Rotterdam; Experimental Cardiology, Thoraxcenter, Cardiovascular Research Institute COEUR, Erasmus Medical Center Rotterdam, Rotterdam; Department of Neurosurgery, Medisch Spectrum Twente, Enschede; Foundation for Aviation Medicine Research, Oegstgeest, The Netherlands
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Patel KS, Moussazadeh N, Doyle WK, Labar DR, Schwartz TH. Efficacy of vagus nerve stimulation in brain tumor-associated intractable epilepsy and the importance of tumor stability. J Neurosurg 2013; 119:520-5. [PMID: 23600931 DOI: 10.3171/2013.3.jns121890] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Vagus nerve stimulation (VNS) is a viable option for patients with medically intractable epilepsy. However, there are no studies examining its effect on individuals with brain tumor-associated intractable epilepsy. This study aims to evaluate the efficacy of VNS in patients with brain tumor-associated medically intractable epilepsy. METHODS Epilepsy surgery databases at 2 separate epilepsy centers were reviewed to identify patients in whom a VNS device was placed for tumor-related intractable epilepsy between January 1999 and December 2011. Preoperative and postoperative seizure frequency and type as well as antiepileptic drug (AED) regimens and degree of tumor progression were evaluated. Statistical analysis was performed using odds ratios and t-tests to examine efficacy. RESULTS Sixteen patients were included in the study. Eight patients (50%) had an improved outcome (Engel Class I, II, or III) with an average follow-up of 39.6 months. The mean reduction in seizure frequency was 41.7% (p = 0.002). There was no significant change in AED regimens. Seizure frequency decreased by 10.9% in patients with progressing tumors and by 65.6% in patients with stable tumors (p = 0.008). CONCLUSIONS Vagus nerve stimulation therapy in individuals with brain tumor-associated medically intractable epilepsy was shown to be comparably effective in regard to seizure reduction and response rates to the general population of VNS therapy patients. Outcomes were better in patients with stable as opposed to progressing tumors. The authors' findings support the recommendation of VNS therapy in patients with brain tumor-associated intractable epilepsy, especially in cases in which imminent tumor progression is not expected. Vagus nerve stimulation may not be indicated in more malignant tumors.
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Affiliation(s)
- Kunal S Patel
- Departments of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY 10065, USA
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Shi C, Flanagan SR, Samadani U. Vagus nerve stimulation to augment recovery from severe traumatic brain injury impeding consciousness: a prospective pilot clinical trial. Neurol Res 2013; 35:263-76. [PMID: 23485054 PMCID: PMC4568744 DOI: 10.1179/1743132813y.0000000167] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES Traumatic brain injury (TBI) has high morbidity and mortality in both civilian and military populations. Blast and other mechanisms of TBI damage the brain by causing neurons to disconnect and atrophy. Such traumatic axonal injury can lead to persistent vegetative and minimally conscious states (VS and MCS), for which limited treatment options exist, including physical, occupational, speech, and cognitive therapies. More than 60 000 patients have received vagus nerve stimulation (VNS) for epilepsy and depression. In addition to decreased seizure frequency and severity, patients report enhanced mood, reduced daytime sleepiness independent of seizure control, increased slow wave sleep, and improved cognition, memory, and quality of life. Early stimulation of the vagus nerve accelerates the rate and extent of behavioral and cognitive recovery after fluid percussion brain injury in rats. METHODS We recently obtained Food and Drug Administration (FDA) approval for a pilot prospective randomized crossover trial to demonstrate objective improvement in clinical outcome by placement of a vagus nerve stimulator in patients who are recovering from severe TBI. Our hypothesis is that stimulation of the vagus nerve results in increased cerebral blood flow and metabolism in the forebrain, thalamus, and reticular formation, which promotes arousal and improved consciousness, thereby improving outcome after TBI resulting in MCS or VS. DISCUSSION If this study demonstrates that VNS can safely and positively impact outcome, then a larger randomized prospective crossover trial will be proposed.
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Affiliation(s)
- Chen Shi
- Department of Neurosurgery, New York University School of Medicine and NYU Langone Medical Center, 550 First Ave. New York, NY 10016
| | - Steven R. Flanagan
- Department of Rehabilitation Medicine, New York University School of Medicine and NYU Langone Medical Center, 240 E. 38 St. New York, NY 10016
| | - Uzma Samadani
- Department of Neurosurgery, New York University School of Medicine and NYU Langone Medical Center, 550 First Ave. New York, NY 10016
- Division of Neurosurgery, New York Harbor Healthcare System Manhattan Veterans Hospital, 423 E. 23 St. New York, NY 10010
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Bonaz B, Picq C, Sinniger V, Mayol JF, Clarençon D. Vagus nerve stimulation: from epilepsy to the cholinergic anti-inflammatory pathway. Neurogastroenterol Motil 2013; 25:208-21. [PMID: 23360102 DOI: 10.1111/nmo.12076] [Citation(s) in RCA: 197] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The brain and the gut communicate bidirectionally through the autonomic nervous system (ANS). The vagus nerve (VN), a major component of the ANS, plays a key role in the neuro-endocrine-immune axis to maintain homeostasia through its afferents (through the activation of the hypothalamic pituitary adrenal axis and the central ANS) and through its efferents (i.e. the cholinergic anti-inflammatory pathway; CAP). The CAP has an anti-TNF effect both through the release of acetylcholine at the distal VN acting on macrophages and through the connection of the VN with the spleen through the splenic sympathetic nerve. Vagus nerve stimulation (VNS) of vagal afferents at high frequency (20-30 Hz) is used for the treatment of drug-resistant epilepsy and depression. Low-frequency (5 Hz) VNS of vagal efferents activates the CAP for an anti-inflammatory effect that is as an anti-TNF therapy in inflammatory diseases were TNF is a key cytokine as represented by experimental sepsis, postoperative ileus, burn-induced intestinal barrier injury, colitis. However, both vagal afferents and efferents are activated by VNS. PURPOSE The objective of this review was to explore the following: (i) the supporting evidence for the importance of VNS in epilepsy (and depression) and its mechanisms of action, (ii) the anti-inflammatory characteristics of the VN, (iii) the experimental evidence that VNS impact on inflammatory disorders focusing on the digestive tract, and (iv) how VNS could potentially be harnessed therapeutically in human inflammatory disorders such as inflammatory bowel diseases, irritable bowel syndrome, postoperative ileus, rheumatoid arthritis as an anti-inflammatory therapy.
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Affiliation(s)
- B Bonaz
- Clinique Universitaire d'Hépato-Gastroentérologie, CHU de Grenoble, Grenoble Cedex, France.
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Vonck K, de Herdt V, Sprengers M, Ben-Menachem E. Neurostimulation for epilepsy. HANDBOOK OF CLINICAL NEUROLOGY 2012; 108:955-970. [PMID: 22939078 DOI: 10.1016/b978-0-444-52899-5.00040-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Kristl Vonck
- Department of Neurology, Ghent University Hospital, Ghent, Belgium.
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Iturri Clavero F, González Uriarte A, Tamayo Medel G, Pomposo Gaztelu IC, Cano Dorronsoro M, Martínez Ruiz A. [Perioperative considerations in vagal nerve stimulator implantation]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2010; 57:431-438. [PMID: 20857639 DOI: 10.1016/s0034-9356(10)70270-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Vagal nerve stimulation has become an a important tool in the treatment of refractory epilepsy, which continues to be the main indication for this technique. Other therapeutic indications are emerging, however, and vagal nerve stimulation has now been approved for major depression. Additional possible uses under study include morbid obesity, Alzheimer disease, chronic pain syndromes, and certain neuropsychologic disorders. This review considers perioperative aspects relevant to using this therapeutic procedure with a view to facilitating better and more integrated management of its application.
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Affiliation(s)
- F Iturri Clavero
- Servicio de Anestesiología y Reanimación, Hospital de Cruces, Baracaldo,. Bizkaia.
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Zamponi N, Petrelli C, Passamonti C, Moavero R, Curatolo P. Vagus nerve stimulation for refractory epilepsy in tuberous sclerosis. Pediatr Neurol 2010; 43:29-34. [PMID: 20682200 DOI: 10.1016/j.pediatrneurol.2010.03.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2009] [Revised: 01/27/2010] [Accepted: 03/01/2010] [Indexed: 10/19/2022]
Abstract
The goal of the study was to assess the long-term seizure and neuropsychologic outcomes of patients with tuberous sclerosis and refractory epilepsy who received vagus nerve stimulator implantation. Eleven patients with a follow-up period of at least 12 months were studied retrospectively. The mean age at the time of implantation was 14 years (range, 2-35). Seizure outcome was rated as class I (>80% seizure frequency reduction) in 1 (9%), class II (50-79% reduction) in 7 (63%), and class III (<50% reduction) in 3 (27%). No patient experienced permanent adverse effects after the procedure. A significant increase of adaptive behaviors and quality of life was observed. Patients who had implantation during childhood exhibited a greater improvement in cognitive and neuropsychologic functioning. Vagus nerve stimulation can be considered an effective and safe therapeutic option in patients with tuberous sclerosis and refractory epilepsy who are not candidates for epilepsy surgery.
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Affiliation(s)
- Nelia Zamponi
- Pediatric Neurology Department, Ospedali Riuniti, Ancona, Italy.
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Coykendall DS, Gauderer MWL, Blouin RR, Morales A. Vagus nerve stimulation for the management of seizures in children: an 8-year experience. J Pediatr Surg 2010; 45:1479-83. [PMID: 20638528 DOI: 10.1016/j.jpedsurg.2010.02.066] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2009] [Revised: 02/17/2010] [Accepted: 02/19/2010] [Indexed: 11/29/2022]
Abstract
BACKGROUND Medication-resistant seizure disorder is a challenging, debilitating, and expensive condition. Although multiple interventions are now available, none is universally effective. In 1997, vagus nerve stimulation (VNS) was approved for treatment of refractory seizures in patients older than 12 years. Vagus nerve stimulation has shown some benefit for these individuals, but less is known about its use in patients younger than 12 years. This review analyzes the safety and efficacy of VNS in young children. METHODS From March 2000 to February 2008, patients with medication-resistant seizures were implanted with a neurocybernetic prosthesis. Two weeks later, the device was activated. The children were followed for at least 3 months, and adjustments were made. Retrospective chart review was performed to collect data. RESULTS Of 28 patients, the mean age at implantation was 8 years and 5 months. Twenty-one (75%) children were younger than 12 years. There were no surgical complications. Two children were reimplanted for lead malfunction, and 4 generators were replaced. Two children had transitory adverse effects (hoarseness and stridor). Mean follow-up was 3 years and 5 months. At 1 year, 52% of children had greater than 50% reduction in seizures. CONCLUSIONS Although the effectiveness of VNS is variable and unpredictable, safety is high even in young children. Because of the potential benefit for these complex patients, the implantation of this nerve stimulation device should be included in the armamentarium of pediatric surgeons.
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Affiliation(s)
- David S Coykendall
- Division of Pediatric Surgery, Children's Hospital, Greenville Hospital System, University Medical Center, Greenville, SC 29605, USA
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Colicchio G, Policicchio D, Barbati G, Cesaroni E, Fuggetta F, Meglio M, Papacci F, Rychlicki F, Scerrati M, Zamponi N. Vagal nerve stimulation for drug-resistant epilepsies in different age, aetiology and duration. Childs Nerv Syst 2010; 26:811-9. [PMID: 20091042 DOI: 10.1007/s00381-009-1069-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Accepted: 12/02/2009] [Indexed: 10/19/2022]
Abstract
PURPOSE The aim of the study was to compare the outcome with respect to age of implant, aetiology and duration of epilepsy. METHODS One hundred thirty-five drug-resistant epileptic patients, excluded from ablative surgery, were submitted to vagal nerve stimulation (1995-2007). Aetiology was cryptogenic in 57 and symptomatic in 78 patients. Ages of implant were 0.5-6 years (18 patients), 7-12 years (32 patients), 13-18 years (31 patients) and more than 18 years (54 patients). Epilepsy types were Lennox-Gastaut (18 patients), severe multifocal epilepsy (33 patients) and partial (84 patients). Duration of epilepsy is 3 months to 57 years. Clinical outcome was determined by comparing the seizure frequency after stimulation at 3-6-12-18-24-36 months with the previous 3 months. 'Responders' were the patients experiencing a seizure frequency reduction of 50% or more during follow-up. In statistical analysis, Wilcoxon and McNemar tests, general linear model for repeated measures, logistic regression and survival analysis were used. RESULTS The seizure frequency reduction was significant in the group as a whole between baseline and the first follow-up (Wilcoxon test). The percentage of responder increases with time (McNemar test p = 0.04). Univariate analysis showed a significant effect of the age of implant on seizure frequency reduction: Adult patient had worst clinical outcome than children (p < 0.001) and adolescents (p = 0.08). Patients with severe multifocal epilepsy had better percentage seizure reduction compared with Lennox-Gastaut and partial (p = 0.03). Lesser duration of epilepsy had positive influence on outcome. Multivariate analysis confirmed age of implant to be the strongest factor influencing prognosis. Furthermore, positive is the association between lesional aetiology and young age. CONCLUSIONS The best responder could be a young lesional epileptic patient; after 3 years of follow-up, the percentage of responders is still in progress.
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Affiliation(s)
- Gabriella Colicchio
- Neurosurgery, Catholic University, Largo Agostino Gemelli 1, 00168, Rome, Italy.
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Ortler M, Unterhofer C, Dobesberger J, Haberlandt E, Trinka E. Complete removal of vagus nerve stimulator generator and electrodes. J Neurosurg Pediatr 2010; 5:191-4. [PMID: 20121370 DOI: 10.3171/2009.9.peds0810] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Vagus nerve stimulation has become widely used in the palliative treatment of refractory epilepsy. Removal of a vagus nerve stimulator may be desirable or even necessary due to lack of efficacy, intolerable side effects, signs of infection, or failure of the device. Unless the lead or the helical electrodes are defective, only the generator is explanted and the electrodes are usually left behind for fear of damaging nerve or surrounding structures. The authors review their experience with complete removal of the stimulating electrodes and pacemaker-like generator device in 9 consecutive patients, 3 of whom were children. Using microsurgical techniques, the authors were able to completely remove the stimulator, including electrodes in all patients. All nerves remained morphologically intact. One case of temporary and one of permanent clinically silent ipsilateral vocal cord paresis were observed.
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Affiliation(s)
- Martin Ortler
- Clinical Department of Neurosurgery, Innsbruck Medical University, Innsbruck, Austria.
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Boon P, Raedt R, de Herdt V, Wyckhuys T, Vonck K. Electrical stimulation for the treatment of epilepsy. Neurotherapeutics 2009; 6:218-27. [PMID: 19332313 PMCID: PMC5084197 DOI: 10.1016/j.nurt.2008.12.003] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2008] [Accepted: 12/31/2008] [Indexed: 01/24/2023] Open
Abstract
Despite the advent of new pharmacological treatments and the high success rate of many surgical treatments for epilepsy, a substantial number of patients either do not become seizure-free or they experience major adverse events (or both). Neurostimulation-based treatments have gained considerable interest in the last decade. Vagus nerve stimulation (VNS) is an alternative treatment for patients with medically refractory epilepsy, who are unsuitable candidates for conventional epilepsy surgery, or who have had such surgery without optimal outcome. Although responder identification studies are lacking, long-term VNS studies show response rates between 40% and 50% and long-term seizure freedom in 5% to 10% of patients. Surgical complications and perioperative morbidity are low. Research into the mechanism of action of VNS has revealed a crucial role for the thalamus and cortical areas that are important in the epileptogenic process. Acute deep brain stimulation (DBS) in various thalamic nuclei and medial temporal lobe structures has recently been shown to be efficacious in small pilot studies. There is little evidence-based information on rational targets and stimulation parameters. Amygdalohippocampal DBS has yielded a significant decrease of seizure counts and interictal EEG abnormalities during long-term follow-up. Data from pilot studies suggest that chronic DBS for epilepsy may be a feasible, effective, and safe procedure. Further trials with larger patient populations and with controlled, randomized, and closed-loop designs should now be initiated. Further progress in understanding the mechanism of action of DBS for epilepsy is a necessary step to making this therapy more efficacious and established.
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Affiliation(s)
- Paul Boon
- Reference Center for Refractory Epilepsy and Laboratory for Clinical and Experimental Neurophysiology (LCEN), Department of Neurology, Ghent University Hospital, Ghent, Belgium.
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Milby AH, Halpern CH, Baltuch GH. Vagus nerve stimulation in the treatment of refractory epilepsy. Neurotherapeutics 2009; 6:228-37. [PMID: 19332314 PMCID: PMC5084198 DOI: 10.1016/j.nurt.2009.01.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2008] [Revised: 01/16/2009] [Accepted: 01/17/2009] [Indexed: 10/21/2022] Open
Abstract
Many patients with epilepsy suffer from persistent seizures despite maximal anti-epileptic drug therapy. Chronic, intermittent vagus nerve stimulation has been proven to be an effective option for many patients suffering from refractory seizures who are not candidates for surgical resection. Although only a small minority of patients will be entirely seizure-free, vagus nerve stimulation, as an adjunct to medical therapy, may result in significant improvements in quality of life. Vagus nerve stimulation is generally well-tolerated, as device implantation is associated with a low rate of perioperative complications, and the majority of side effects are stimulation-dependent and thus reversible.
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Affiliation(s)
- Andrew H. Milby
- grid.412713.20000000404351019Department of Neurosurgery, Center for Functional and Restorative Neurosurgery, University of Pennsylvania Medical Center, 19104 Philadelphia, Pennsylvania
| | - Casey H. Halpern
- grid.412713.20000000404351019Department of Neurosurgery, Center for Functional and Restorative Neurosurgery, University of Pennsylvania Medical Center, 19104 Philadelphia, Pennsylvania
| | - Gordon H. Baltuch
- grid.412713.20000000404351019Department of Neurosurgery, Center for Functional and Restorative Neurosurgery, University of Pennsylvania Medical Center, 19104 Philadelphia, Pennsylvania
- grid.411115.10000000404350884Department of Neurosurgery, 3 Silverstein, Hospital of the University of Pennsylvania, 3400 Spruce Street, 19104 Philadelphia, PA
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Vonck K, De Herdt V, Boon P. Vagal nerve stimulation--a 15-year survey of an established treatment modality in epilepsy surgery. Adv Tech Stand Neurosurg 2009; 34:111-46. [PMID: 19368083 DOI: 10.1007/978-3-211-78741-0_5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Neurostimulation is an emerging treatment for neurological diseases. Electrical stimulation of the tenth cranial nerve or vagus nerve stimulation (VNS) has become a valuable option in the therapeutic armamentarium for patients with refractory epilepsy. It is indicated in patients with refractory epilepsy who are unsuitable candidates for epilepsy surgery or who have had insufficient benefit from such a treatment. Vagus nerve stimulation reduces seizure frequency with > 50% in 1/3 of patients and has a mild side effects profile. Research to elucidate the mechanism of action of vagus nerve stimulation has shown that effective stimulation in humans is primarily mediated by afferent vagal A- and B-fibers. Crucial brainstem and intracranial structures include the locus coeruleus, the nucleus of the solitary tract, the thalamus and limbic structures. Neurotransmitters playing a role may involve the major inhibitory neurotransmitter GABA but also serotoninergic and adrenergic systems. This manuscript reviews the clinical studies investigating efficacy and side effects in patients and the experimental studies aiming to elucidate the mechanims of action.
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Affiliation(s)
- K Vonck
- Department of Neurology, Ghent University Hospital, Gent, Belgium
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Abstract
Many patients with epilepsy suffer from persistent seizures despite maximal antiepileptic drug (AED) therapy. Chronic, intermittent vagus nerve stimulation (VNS) has proven to be a safe, effective option for patients suffering from refractory seizures who are not candidates for surgical resection. Although only a small minority of patients will be entirely seizure-free, VNS as an adjunct to medical therapy does appear to provide a significant amount of improvement in quality of life. Reports of antidepressant effects independent of seizure control, along with the use of multiple AEDs in the treatment of depression, has led to the investigation of VNS as a potential adjunctive treatment for major depressive disorder. Both the number of severely depressed patients refractory to available pharmacologic options and the need for repeated treatments and significant side effects associated with electroconvulsive therapy have heightened the interest in VNS for this patient population. Pilot studies of VNS for depression have shown impressive response rates; however, the effect appears to be gradual in onset, as demonstrated by the lack of a favorable response in a short-term, randomized controlled study. Investigation is thus needed to establish the potential role of VNS as an adjunctive treatment for severe depression.
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Affiliation(s)
- Andrew H. Milby
- grid.412713.20000000404351019Department of Neurosurgery, Center for Functional and Restorative Neurosurgery, University of Pennsylvania Medical Center, 19104 Philadelphia, Pennsylvania
| | - Casey H. Halpern
- grid.412713.20000000404351019Department of Neurosurgery, Center for Functional and Restorative Neurosurgery, University of Pennsylvania Medical Center, 19104 Philadelphia, Pennsylvania
| | - Gordon H. Baltuch
- grid.412713.20000000404351019Department of Neurosurgery, Center for Functional and Restorative Neurosurgery, University of Pennsylvania Medical Center, 19104 Philadelphia, Pennsylvania
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García-March G, Sánchez-Ledesma M, Broseta J. Estimulación eléctrica vagal en el tratamiento de la epilepsia rebelde. Situación actual. Neurocirugia (Astur) 2008. [DOI: 10.1016/s1130-1473(08)70208-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Casazza M, Avanzini G, Ferroli P, Villani F, Broggi G. Vagal nerve stimulation: Relationship between outcome and electroclinical seizure pattern. Seizure 2006; 15:198-207. [PMID: 16531077 DOI: 10.1016/j.seizure.2006.02.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2005] [Revised: 01/18/2006] [Accepted: 02/08/2006] [Indexed: 11/22/2022] Open
Abstract
In recent years, vagal nerve stimulation (VNS) has been proposed as a possible way to improve the control of refractory (partial and generalized) seizures. To date, however, there is no complete understanding of the underlying mechanism for this action nor are there any available guidelines or criteria for the selection of those candidates that might be most suitable for this kind of neuromodulating surgery. This report presents evidence that should be helpful in defining the clinical criteria for using VNS for the treatment of refractory seizures. We report on 17 patients with severe partial refractory epilepsy and polymorphous seizures, who have been operated on previously or who were excluded from epilepsy surgery and for whom, at least, one seizure type has been electrographically recorded. Sixteen of these patients also had falling seizures. Our objective was to identify responders and to correlate the outcome of their seizures with the EEGraphic onset of their seizure. Follow-up ranged from 4 to 9 years. The results of this study indicate a significant reduction of seizures in only four patients and better outcome in patients where the onset of seizure activity occurred in the temporal area. Patients with frontal or frontocentral seizures resulted in the poorest outcomes. In four patients with Lennox-Gastaut syndrome VNS produced no significant reduction of seizures, while falling seizures decreased significantly in three patients with retropulsive falls. These results of this small series of patients suggest that VNS might be more suitable in patients with temporal rather than frontal or central seizure onset. Further studies are required to support this hypothesis.
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Affiliation(s)
- Marina Casazza
- Division of Neurophysiopathology, Istituto Nazionale Neurologico C.Besta, via Celoria 11, 20133 Milano, Italy.
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Ronkainen E, Korpelainen JT, Heikkinen E, Myllylä VV, Huikuri HV, Isojärvi JIT. Cardiac Autonomic Control in Patients with Refractory Epilepsy before and during Vagus Nerve Stimulation Treatment: A One-Year Follow-up Study. Epilepsia 2006; 47:556-62. [PMID: 16529621 DOI: 10.1111/j.1528-1167.2006.00467.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE To elucidate possible effect of vagus nerve stimulation (VNS) therapy on interictal heart rate (HR) variability in patients with refractory epilepsy before and after 1-year VNS treatment. METHODS A 24-hour electrocardiogram (ECG) was recorded at the baseline and after 12 months of VNS treatment in 14 patients with refractory epilepsy, and once in 28 healthy age- and sex-matched control subjects. Time and frequency domain measures, along with fractal and complexity measures of HR variability, were analyzed from the ECG recordings. RESULTS The mean value of the RR interval (p=0.008), standard deviation of N-N intervals (SDNN) (p<0.001), very-low frequency (VLF) (p<0.001), low-frequency (LF) (p=0.001), and high-frequency (HF) (p=0.002) spectral components of HR variability, and the Poincaré components SD(1) (p=0.005) and SD(2) (p<0.001) of the patients with refractory epilepsy were significantly lower than those of the control subjects before VNS implantation. The nocturnal increase in HR variability usually seen in the normal population was absent in patients with refractory epilepsy. VNS had no significant effects on any of the HR-variability indexes despite a significant reduction in the frequency of seizures. CONCLUSIONS HR variability was reduced, and the nocturnal increase in HR variability was not present in patients with refractory epilepsy. One-year treatment with VNS did not have a marked effect on HR variability, suggesting that impaired cardiovascular autonomic regulation is associated with the epileptic process itself rather than with recurrent seizures.
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Affiliation(s)
- Eija Ronkainen
- Department of Neurology, University of Oulu, Oulu, Finland
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Murphy JV, Patil AA. Improving the lives of patients with medically refractory epilepsy by electrical stimulation of the nervous system. Expert Rev Med Devices 2006; 2:175-89. [PMID: 16293054 DOI: 10.1586/17434440.2.2.175] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Vagal nerve stimulation proved effective in animal models of epilepsy, and in open and double-blinded trials, in over 450 patients. Seizure reduction improved for at least 2 years. Almost 50% of treated patients achieve at least a 50% reduction in seizure frequency. Other advantages include termination of a seizure and improved alertness. Benefits were demonstrated in children, partial and generalized epilepsies, and in specific neurologic syndromes.
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Affiliation(s)
- Jerome V Murphy
- Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
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Abstract
Vagus nerve stimulation (VNS) is an established anticonvulsant therapy in treatment-resistant patients with epilepsy. The known anatomical projections of the vagus nerve to many brain regions that have been implicated in mood disorders suggest that VNS may also have useful antidepressant effects. There has been growing interest in the potential application of VNS in the nonpharmacological management of treatment-resistant depression. Results from an open-label study, in which 59 subjects with treatment-resistant depression were treated for 10 weeks with VNS therapy, reported a 31% response rate. In a recent controlled double-blind trial of VNS and depression, short-term treatment for 10 weeks failed to demonstrate statistical improvement over sham treatment. Results from the long-term phase of this trial may be more significant, however published data are awaited.
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Affiliation(s)
- Sally P Walsh
- Department of Neurology, Georgetown University Medical Center, Washington, DC 20057, USA.
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Huf RL, Mamelak A, Kneedy-Cayem K. Vagus nerve stimulation therapy: 2-year prospective open-label study of 40 subjects with refractory epilepsy and low IQ who are living in long-term care facilities. Epilepsy Behav 2005; 6:417-23. [PMID: 15820352 DOI: 10.1016/j.yebeh.2005.01.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2004] [Revised: 01/18/2005] [Accepted: 01/28/2005] [Indexed: 10/25/2022]
Abstract
Treating seizures among patients with mental retardation/developmental disabilities (MR/DD) is difficult owing in large part to the presence of additional comorbidities and the resulting need for polytherapy. Therefore, a nonpharmacological treatment option is needed for this population. This prospective, open-label study documented the long-term outcome of 40 low-IQ (<70) patients living in long-term care facilities who received vagus nerve stimulation (VNS) therapy for pharmacoresistant epilepsy. Subjects were seen every 1 to 3 months by their neurologist (R.H.). Seizure frequency, antiepileptic medication, and quality-of-life information were documented preimplantation and quarterly thereafter through 2 years. The surgery and therapy were well tolerated. Seizures were reduced by at least 50% for 11 subjects. Antiepileptic medications were reduced from 3.3 per subject at baseline to an average of 2.3 per subject after 2 years. According to caregiver reports, overall quality of life improved for the majority of subjects; also, using the Client Development Evaluation Report (CDER), statistically significant improvements were reported at both 1 and 2 years in attention span, word usage, clarity of speech, standing balance, washing dishes, and household chores. VNS is a viable treatment option for low-IQ patients with pharmacoresistant epilepsy who are living in long-term care facilities.
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Affiliation(s)
- Roger L Huf
- Epilepsy and Brain Mapping Program, Huntington Memorial Hospital, Pasadena, CA, USA.
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