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Kong Y, Zhao K, Zeng D, Lu F, Li X, Wu Y, Jiang Z, Wen W. Effects of vagus nerve stimulation on cognitive function in patients with epilepsy: a systematic review and meta-analysis. Front Neurol 2024; 15:1332882. [PMID: 38405400 PMCID: PMC10884318 DOI: 10.3389/fneur.2024.1332882] [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: 11/06/2023] [Accepted: 01/19/2024] [Indexed: 02/27/2024] Open
Abstract
Background Previous studies showed that vagus nerve stimulation (VNS) can improve cognitive function in patients with epilepsy, but there is still great controversy about the effect of VNS on cognitive function in patients with epilepsy. Objective To investigate the effect of VNS on the cognitive function of epilepsy patients. Methods Clinical trials published in PubMed, The Cochrane Library, and Embase before September 20, 2022, were comprehensively searched. Primary outcomes were overall cognitive performance, executive function, attention, memory; Secondary outcomes were seizure frequency, mood, and quality of life (QOL). Random effects were used to calculate the pooled outcome. Results Twenty clinical trials were included. There was no significant improvement in overall cognitive performance in patients with epilepsy after VNS treatment (SMD = 0.07; 95% CI: -0.12 to 0.26; I2 = 0.00%) compared to pre-treatment. Compared to pre-treatment, there was no significant difference in executive function (SMD = -0.50; 95% CI: -1.50 to 0.50; p = 0.32), attention (SMD = -0.17; 95% CI: -0.43 to 0.09; p = 0.21) and memory (SMD = 0.64; 95% CI: -0.11 to 1.39; p = 0.09), but there were significant differences in seizure frequency, mood, and quality of life in patients with epilepsy after VNS. Conclusion This meta-analysis did not establish that VNS can significantly improve cognitive function in patients with epilepsy, but it shows that VNS can significantly improve the seizure frequency, mood and quality of life of patients with epilepsy. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier: CRD42023384059.
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Affiliation(s)
- Yurou Kong
- Center for Rehabilitation Medicine, Rehabilitation and Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Kun Zhao
- Center for Rehabilitation Medicine, Rehabilitation and Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Duchun Zeng
- Center for Rehabilitation Medicine, Rehabilitation and Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Feiao Lu
- Center for Rehabilitation Medicine, Rehabilitation and Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Xiang Li
- School of Medicine, Xiang'an Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Yulun Wu
- Center for Rehabilitation Medicine, Rehabilitation and Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Zengming Jiang
- Center for Rehabilitation Medicine, Rehabilitation and Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Wanshun Wen
- Center for Rehabilitation Medicine, Rehabilitation and Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
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Peña-Ceballos J, Moloney PB, Valentin A, O'Donnell C, Colleran N, Liggan B, Staunton-Grufferty B, Ennis P, Grogan R, Mullins G, Costello DJ, Doherty CP, Sweeney KJ, El Naggar H, Kilbride RD, Widdess-Walsh P, O'Brien D, Delanty N. Vagus nerve stimulation in refractory idiopathic generalised epilepsy: An Irish retrospective observational study. Seizure 2023; 112:98-105. [PMID: 37778300 DOI: 10.1016/j.seizure.2023.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 09/05/2023] [Accepted: 09/22/2023] [Indexed: 10/03/2023] Open
Abstract
OBJECTIVE Refractory idiopathic generalised epilepsy (IGE; also known as genetic generalised epilepsy) is a clinical challenge due to limited available therapeutic options. While vagus nerve stimulation (VNS) is approved as an adjunctive treatment for drug-resistant focal epilepsy, there is limited evidence supporting its efficacy for refractory IGE. METHODS We conducted a single-centre retrospective analysis of adult IGE patients treated with VNS between January 2003 and January 2022. We analysed the efficacy, safety, tolerability, stimulation parameters and potential clinical features of VNS response in this IGE cohort. RESULTS Twenty-three IGE patients were implanted with VNS between January 2003 and January 2022. Twenty-two patients (95.65%) were female. The median baseline seizure frequency was 30 per month (interquartile range [IQR]= 140), including generalised tonic-clonic seizures (GTCS), absences, myoclonus, and eyelid myoclonia with/without absences. The median number of baseline anti-seizure medications (ASM) was three (IQR= 2). Patients had previously failed a median of six ASM (IQR= 5). At the end of the study period, VNS therapy remained active in 17 patients (73.9%). amongst patients who continued VNS, thirteen (56.5% of the overall cohort) were considered responders (≥50% seizure frequency reduction). Amongst the clinical variables analysed, only psychiatric comorbidity correlated with poorer seizure outcomes, but was non-significant after applying the Bonferroni correction. Although 16 patients reported side-effects, none resulted in the discontinuation of VNS therapy. SIGNIFICANCE Over half of the patients with refractory IGE experienced a positive response to VNS therapy. VNS represents a viable treatment option for patients with refractory IGE, particularly for females, when other therapeutic options have been exhausted.
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Affiliation(s)
| | - Patrick B Moloney
- Department of Neurology, Beaumont Hospital, Dublin, Ireland; School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland; FutureNeuro, the Science Foundation Ireland Research Centre for Chronic and Rare Neurological Diseases, Dublin, Ireland
| | - Antonio Valentin
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Cara O'Donnell
- Department of Clinical Neurophysiology, Beaumont Hospital, Dublin, Ireland
| | - Niamh Colleran
- Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | - Brenda Liggan
- Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | | | - Patricia Ennis
- Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland
| | - Roger Grogan
- Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | - Gerard Mullins
- Department of Clinical Neurophysiology, Beaumont Hospital, Dublin, Ireland
| | - Daniel J Costello
- FutureNeuro, the Science Foundation Ireland Research Centre for Chronic and Rare Neurological Diseases, Dublin, Ireland; Department of Neurology, Cork University Hospital, Cork, Ireland
| | - Colin P Doherty
- FutureNeuro, the Science Foundation Ireland Research Centre for Chronic and Rare Neurological Diseases, Dublin, Ireland; Department of Neurology, St. James's Hospital, Dublin, Ireland; Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | | | - Hany El Naggar
- Department of Neurology, Beaumont Hospital, Dublin, Ireland; School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland; FutureNeuro, the Science Foundation Ireland Research Centre for Chronic and Rare Neurological Diseases, Dublin, Ireland
| | - Ronan D Kilbride
- Department of Neurology, Beaumont Hospital, Dublin, Ireland; Department of Clinical Neurophysiology, Beaumont Hospital, Dublin, Ireland
| | - Peter Widdess-Walsh
- Department of Neurology, Beaumont Hospital, Dublin, Ireland; Department of Clinical Neurophysiology, Beaumont Hospital, Dublin, Ireland
| | - Donncha O'Brien
- Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland
| | - Norman Delanty
- Department of Neurology, Beaumont Hospital, Dublin, Ireland; School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland; FutureNeuro, the Science Foundation Ireland Research Centre for Chronic and Rare Neurological Diseases, Dublin, Ireland.
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Fang YT, Lin YT, Tseng WL, Tseng P, Hua GL, Chao YJ, Wu YJ. Neuroimmunomodulation of vagus nerve stimulation and the therapeutic implications. Front Aging Neurosci 2023; 15:1173987. [PMID: 37484689 PMCID: PMC10358778 DOI: 10.3389/fnagi.2023.1173987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 06/12/2023] [Indexed: 07/25/2023] Open
Abstract
Vagus nerve stimulation (VNS) is a technology that provides electrical stimulation to the cervical vagus nerve and can be applied in the treatment of a wide variety of neuropsychiatric and systemic diseases. VNS exerts its effect by stimulating vagal afferent and efferent fibers, which project upward to the brainstem nuclei and the relayed circuits and downward to the internal organs to influence the autonomic, neuroendocrine, and neuroimmunology systems. The neuroimmunomodulation effect of VNS is mediated through the cholinergic anti-inflammatory pathway that regulates immune cells and decreases pro-inflammatory cytokines. Traditional and non-invasive VNS have Food and Drug Administration (FDA)-approved indications for patients with drug-refractory epilepsy, treatment-refractory major depressive disorders, and headaches. The number of clinical trials and translational studies that explore the therapeutic potentials and mechanisms of VNS is increasing. In this review, we first introduced the anatomical and physiological bases of the vagus nerve and the immunomodulating functions of VNS. We covered studies that investigated the mechanisms of VNS and its therapeutic implications for a spectrum of brain disorders and systemic diseases in the context of neuroimmunomodulation.
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Affiliation(s)
- Yi-Ting Fang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ye-Ting Lin
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wu-Lung Tseng
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Philip Tseng
- Cross College Elite Program, National Cheng Kung University, Tainan, Taiwan
- Research Center for Mind, Brain and Learning, National Chengchi University, Taipei, Taiwan
| | - Gia-Linh Hua
- School of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ying-Jui Chao
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Jen Wu
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Brandt C. Vagus nerve stimulation in people with epilepsy and intellectual disability—English version. ZEITSCHRIFT FÜR EPILEPTOLOGIE 2022. [DOI: 10.1007/s10309-022-00545-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Simpson HD, Schulze-Bonhage A, Cascino GD, Fisher RS, Jobst BC, Sperling MR, Lundstrom BN. Practical considerations in epilepsy neurostimulation. Epilepsia 2022; 63:2445-2460. [PMID: 35700144 PMCID: PMC9888395 DOI: 10.1111/epi.17329] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 02/02/2023]
Abstract
Neuromodulation is a key therapeutic tool for clinicians managing patients with drug-resistant epilepsy. Multiple devices are available with long-term follow-up and real-world experience. The aim of this review is to give a practical summary of available neuromodulation techniques to guide the selection of modalities, focusing on patient selection for devices, common approaches and techniques for initiation of programming, and outpatient management issues. Vagus nerve stimulation (VNS), deep brain stimulation of the anterior nucleus of the thalamus (DBS-ANT), and responsive neurostimulation (RNS) are all supported by randomized controlled trials that show safety and a significant impact on seizure reduction, as well as a suggestion of reduction in the risk of sudden unexplained death in epilepsy (SUDEP). Significant seizure reductions are observed after 3 months for DBS, RNS, and VNS in randomized controlled trials, and efficacy appears to improve with time out to 7 to 10 years of follow-up for all modalities, albeit in uncontrolled follow-up or retrospective studies. A significant number of patients experience seizure-free intervals of 6 months or more with all three modalities. Number and location of epileptogenic foci are important factors affecting efficacy, and together with comorbidities such as severe mood or sleep disorders, may influence the choice of modality. Programming has evolved-DBS is typically initiated at lower current/voltage than used in the pivotal trial, whereas target charge density is lower with RNS, however generalizable optimal parameters are yet to be defined. Noninvasive brain stimulation is an emerging stimulation modality, although it is currently not used widely. In summary, clinical practice has evolved from those established in pivotal trials. Guidance is now available for clinicians who wish to expand their approach, and choice of neuromodulation technique may be tailored to individual patients based on their epilepsy characteristics, risk tolerance, and preferences.
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Affiliation(s)
- Hugh D. Simpson
- Division of Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Gregory D. Cascino
- Division of Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Robert S. Fisher
- Department of Neurology, Stanford Neuroscience Health Center, Palo Alto, CA, USA
| | - Barbara C. Jobst
- Geisel School of Medicine at Dartmouth, Department of Neurology, Dartmouth-Hitchcock Medical Center, NH, USA
| | - Michael R. Sperling
- Division of Epilepsy, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Brian N. Lundstrom
- Division of Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN, USA
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Riestenberg RA, Sherman AE, Clark AJS, Shahlaie K, Zwienenberg M, Alden T, Bandt SK. Patient-Specific Characteristics Associated with Favorable Response to Vagus Nerve Stimulation. World Neurosurg 2022; 161:e608-e624. [PMID: 35202878 DOI: 10.1016/j.wneu.2022.02.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/12/2022] [Accepted: 02/14/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The expansion in treatments for medically refractory epilepsy heightens the importance of identifying patients who are likely to benefit from vagus nerve stimulation (VNS). Here, we identify predictors with a positive VNS response. METHODS We present a retrospective analysis of 158 patients with medically refractory epilepsy. Patients were categorized as VNS responders or nonresponders. Baseline characteristics and time to VNS response were recorded. Univariate and multivariate Cox regression were used to identify predictors of response. Recursive partitioning analysis was used to identify likely VNS responders. RESULTS Eighty-nine (56.3%) patients achieved ≥50% seizure frequency reduction. Left-hand dominance (hazard ratio [HR] 1.703, P = 0.038), age at epilepsy onset ≥15 years (HR 2.029, P = 0.005), duration of epilepsy ≥8 years (HR 1.968, P = 0.007) and age at implantation ≥35 years (HR 1.809, P = 0.020), and baseline seizure frequency <5/month (HR 1.569, P = 0.044) were significant univariate predictors of VNS response. Following multivariate Cox regression, left-hand dominance, age at epilepsy onset ≥15 years, and duration of epilepsy ≥8 years remained significant. With recursive partitioning analysis, patients with either age at epilepsy onset ≥15 years, left-hand dominance, or baseline seizure frequency <5/month were stratified into Group A and had a 73.9% responder rate; the remaining patients stratified into Group B had a 43.8% responder rate. CONCLUSIONS Patients with age at epilepsy onset ≥15 years, left-hand dominance, or baseline seizure frequency <5/month are ideal candidates for VNS.
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Affiliation(s)
- Robert A Riestenberg
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Department of Neurological Surgery, University of California, Davis, Sacramento, California, USA.
| | - Alain E Sherman
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Austin J S Clark
- Department of Neurological Surgery, University of California, Davis, Sacramento, California, USA
| | - Kiarash Shahlaie
- Department of Neurological Surgery, University of California, Davis, Sacramento, California, USA
| | - Marike Zwienenberg
- Department of Neurological Surgery, University of California, Davis, Sacramento, California, USA
| | - Tord Alden
- Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - S Kathleen Bandt
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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7
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Touma L, Dansereau B, Chan AY, Jetté N, Kwon CS, Braun KPJ, Friedman D, Jehi L, Rolston JD, Vadera S, Wong-Kisiel LC, Englot DJ, Keezer MR. Neurostimulation in People with Drug-Resistant Epilepsy: Systematic Review and Meta-Analysis from the ILAE Surgical Therapies Commission. Epilepsia 2022; 63:1314-1329. [PMID: 35352349 DOI: 10.1111/epi.17243] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/25/2022] [Accepted: 03/28/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Summarize the current evidence on efficacy and tolerability of vagus nerve stimulation (VNS), responsive neurostimulation (RNS), and deep brain stimulation (DBS) through a systematic review and meta-analysis. METHODS We followed the PRISMA reporting standards and searched Ovid Medline, Ovid Embase, and the Cochrane Central Register of Controlled Trials. We included published randomized controlled trials (RCT) and their corresponding open-label extension studies, as well as prospective case series, with ≥ 20 participants (excluding studies limited to children). Our primary outcome was the mean (or median when unavailable) percentage decrease in frequency, as compared to baseline, of all epileptic seizures at last follow-up. Secondary outcomes included proportion of treatment responders and proportion with seizure freedom. RESULTS We identified 30 eligible studies, six of which were RCTs. At long-term follow-up (mean 1.3 years), five observational studies for VNS reported a pooled mean percentage decrease in seizure frequency of 34.7% (95% CI: -5.1, 74.5). In the open-label extension studies for RNS, the median seizure reduction was 53%, 66%, and 75% at two, five, and nine years of follow-up, respectively. For DBS, the median reduction was 56%, 65%, and 75% at two, five, and seven years, respectively. The proportion of individuals with seizure freedom at last follow-up increased significantly over time for DBS and RNS while a positive trend was observed for VNS. Quality of life was improved in all modalities. The most common complications included hoarseness, cough and throat pain for VNS and implant site pain, headache, and dysesthesia for DBS and RNS. SIGNIFICANCE Neurostimulation modalities are an effective treatment option for drug resistant epilepsy, with improving outcomes over time and few major complications. Seizure reduction rates among the three therapies were similar during the initial blinded phase. Recent long-term follow-up studies are encouraging for RNS and DBS but are lacking for VNS.
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Affiliation(s)
- Lahoud Touma
- Research Centre of the Centre hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada.,Department of Neurosciences, Université de Montréal, Montréal, QC, Canada
| | - Bénédicte Dansereau
- Research Centre of the Centre hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada.,Department of Neurosciences, Université de Montréal, Montréal, QC, Canada
| | - Alvin Y Chan
- Department of Neurological Surgery, School of Medicine, University of California, Irvine, Orange, CA, USA
| | - Nathalie Jetté
- Department of Neurosurgery and Neurology, Icahn School of Medicine at Mount Sinai, NY, USA
| | - Churl-Su Kwon
- Department of Neurosurgery and Neurology, Icahn School of Medicine at Mount Sinai, NY, USA
| | - Kees P J Braun
- Department of Child Neurology, University Medical Center Utrecht, member of ERN EpiCARE, Utrecht, Netherlands
| | - Daniel Friedman
- Department of Neurology, New York University Langone Health, NY, USA
| | - Lara Jehi
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John D Rolston
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | - Sumeet Vadera
- Department of Neurological Surgery, School of Medicine, University of California, Irvine, Orange, CA, USA
| | | | - Dario J Englot
- Departments of Neurological Surgery, Neurology, Radiological, Electrical Engineering, and Biomedical Engineering, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mark R Keezer
- Research Centre of the Centre hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada.,Department of Neurosciences, Université de Montréal, Montréal, QC, Canada.,Honorary Researcher, Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands.,School of Public Health, Université de Montréal, Montréal, QC, Canada
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Liu S, Xiong Z, Wang J, Tang C, Deng J, Zhang J, Guo M, Guan Y, Zhou J, Zhai F, Luan G, Li T. Efficacy and potential predictors of vagus nerve stimulation therapy in refractory postencephalitic epilepsy. Ther Adv Chronic Dis 2022; 13:20406223211066738. [PMID: 35070253 PMCID: PMC8771757 DOI: 10.1177/20406223211066738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 11/24/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Vagus nerve stimulation (VNS) is a therapeutic approach for patients with refractory postencephalitic epilepsy (PEE), which is characterized by drug resistance and disappointing surgical outcomes. However, the efficacy of VNS has not yet been studied in patients with refractory PEE. The present study aimed to demonstrate the efficacy of VNS and evaluate potential clinical predictors in patients with refractory PEE. METHODS We retrospectively collected the outcomes of VNS with at least a 1-year follow-up in all patients with refractory PEE. Subgroups were classified as responders and non-responders according to the efficacy of VNS (⩾50% or < 50% reduction in seizure frequency). Preoperative data were analyzed to screen for potential predictors of VNS responsiveness. RESULTS A total of 42 refractory PEE patients who underwent VNS therapy were enrolled, with an average age of 21.13 ± 9.70 years. Seizure frequency was reduced by more than 50% in 64.25% of patients, and 7.14% of patients achieved seizure-free events after VNS therapy. In addition, the response rates increased over time, with 40.5%, 50.0% and 57.1%, respectively at 6 months, 12 months, and 24 months after VNS therapy. Preoperative duration of epilepsy, monthly seizure frequency, and spatial distribution of interictal epileptic discharges (IEDs) were correlated with responders (p < 0.05) in the univariate analysis. Further multivariate regression analysis demonstrated that refractory PEE patients with high monthly seizure frequency or Focal IEDs (focal or multifocal epileptiform discharges) achieved better efficacy on VNS (p = 0.010, p = 0.003, respectively). CONCLUSION VNS is an effective palliative therapy for patients with refractory PEE. Focal IEDs (focal or multifocal epileptiform discharges) and high seizure frequency were potential preoperative predictors of effectiveness after VNS therapy.
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Affiliation(s)
- Siqi Liu
- Department of Brain Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Zhonghua Xiong
- Department of Brain Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Jing Wang
- Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Chongyang Tang
- Department of Brain Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Jiahui Deng
- Department of Brain Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Jing Zhang
- Department of Brain Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Mengyi Guo
- Department of Brain Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Yuguang Guan
- Department of Brain Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Jian Zhou
- Department of Brain Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Feng Zhai
- Department of Brain Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Guoming Luan
- Department of Brain Institute, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Epilepsy Research, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Tianfu Li
- Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, XiangshanYikesong 50, Haidian District, Beijing 100093, China
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9
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Sainju RK, Dragon DN, Winnike HB, Ten Eyck P, Granner MA, Gehlbach BK, Richerson GB. Hypercapnic ventilatory response in epilepsy patients treated with VNS: A case-control study. Epilepsia 2021; 62:e140-e146. [PMID: 34265074 PMCID: PMC9113047 DOI: 10.1111/epi.16997] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 06/23/2021] [Accepted: 06/23/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Central CO2 chemoreception (CCR), a major chemical drive for breathing, can be quantified with a CO2 re-breathing test to measure the hypercapnic ventilatory response (HCVR). An attenuated HCVR correlates with the severity of respiratory dysfunction after generalized convulsive seizures and is a potential biomarker for sudden unexpected death in epilepsy (SUDEP) risk. Vagus nerve stimulation (VNS) may reduce SUDEP risk, but for unclear reasons the risk remains higher during the first 2 years after implantation. The vagus nerve has widespread connections in the brainstem, including key areas related to CCR. Here we examined whether chronic electrical stimulation of the vagus nerve induces changes in CCR. METHODS We compared the HCVR in epilepsy patients with or without an active VNS in a sex- and age-matched case-control study. Eligible subjects were selected from a cohort of patients who previously underwent HCVR testing. The HCVR slope, change in minute ventilation (VE) with respect to change in end tidal (ET) CO2 (∆ VE/ ∆ ETCO2) during the test was calculated for each subject. Key variables were compared between the two groups. Univariate and multivariate analyses were carried out for HCVR slope as dependent variable. RESULTS A total of 86 subjects were in the study. HCVR slope was significantly lower in the cases compared to the controls. Cases had longer duration of epilepsy and higher number of anti-epileptic drugs (AEDs) tried during lifetime. Having active VNS and ETCO2 were associated with a low HCVR slope while high BMI was associated with high HCVR slope in both univariate and multivariate analyses. DISCUSSION We found having an active VNS was associated with relatively attenuated HCVR slope. Although duration of epilepsy and number of AEDs tried during lifetime was significantly different between the groups, they were not predictors of HCVR slope in subsequent analysis. CONCLUSION Chronic electrical stimulation of the vagus nerve by VNS may be associated with an attenuated CCR [Correction added on 24 November 2021, after first online publication: The preceding sentence has been revised from “Chronic electrical stimulation of VNS nerve by VNS…”]. A larger prospective study may help to establish the time course of this effect in relation to the time of VNS implantation, whether there is a causal relationship, and determine how it affects SUDEP risk.
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Affiliation(s)
- Rup K Sainju
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Deidre N Dragon
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Harold B Winnike
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, IA, USA
| | - Patrick Ten Eyck
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, IA, USA
| | - Mark A Granner
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Brian K Gehlbach
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - George B Richerson
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
- Department of Molecular Physiology and Biophysics, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
- Iowa Neuroscience Institute, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
- Veterans Affairs Medical Center, Iowa City, IA, USA
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10
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Doddamani RS, Agrawal M, Samala R, Ramanujam B, Chandra PS, Tripathi M. Vagal Nerve Stimulation in the Management of Epilepsy - Recent Concepts. Neurol India 2021; 68:S259-S267. [PMID: 33318360 DOI: 10.4103/0028-3886.302475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Epilepsy surgery currently offers the best treatment for patients with drug-refractory epilepsy (DRE). Resective surgery, in the presence of a well-localized epileptogenic focus, remains the best modality towards achieving seizure freedom. However, localization of the focus may not be possible in all the cases of DRE, despite comprehensive epilepsy workup. Neuromodulation techniques such as vagal nerve stimulation (VNS), deep brain stimulation (DBS) and responsive neurostimulation (RNS) may be a good alternative in these cases. This article intends to provide an overview of VNS in the management of DRE, including indications, comprehensive preoperative workup, exemplified by case illustrations and outcomes by reviewing the evidence available in the literature.
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Affiliation(s)
| | - Mohit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Raghu Samala
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Bhargavi Ramanujam
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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11
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Comparison of efficiency between VNS and ANT-DBS therapy in drug-resistant epilepsy: A one year follow up study. J Clin Neurosci 2021; 90:112-117. [PMID: 34275533 DOI: 10.1016/j.jocn.2021.05.046] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/04/2021] [Accepted: 05/23/2021] [Indexed: 11/19/2022]
Abstract
Vagus nerve stimulation (VNS) and anterior thalamic deep brain stimulation (ANT-DBS) have both been used for treatments of drug-resistant epilepsy (DRE). However, there is no comparative study on the effectiveness of two methods from one single center. 17 patients with DRE who underwent VNS therapy and 18 patients who underwent DBS were enrolled. A retrospective study was performed starting from baseline before operation extending to 12 months after operation. The seizure types, duration of epilepsy, age at implantation, failed numbers of antiepileptic drugs (AEDs) before operation, history of craniotomy, stimulation parameters and response rate were described. The analysis of liner regression on the age of onset, duration of epilepsy, numbers of AEDs, and the seizure reduction at 12 months after operation was applied. The mean seizure reduction in patients with DBS at 3, 6, 9 and 12 months after the operation was 57.22%, 61.61%, 63.94% and 65.28%, and that in cases with VNS was 36.06%, 39.94%, 45.24% and 48.35%, respectively. At 1 year after the operation, the patients with older operation age, focal seizures and older age of onset responded better to VNS; and those older operation age, focal generalized seizures, history of craniotomy and longer duration of disease responded better to DBS. The efficiency of ANT-DBS was higher than that of VNS at each follow up time point. Patients can choose the appropriate treatment according to the individual clinical characteristics.
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12
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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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13
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Alqadi K, Aldhalaan H, Alghamdi A, Bamgadam F, Abu-Jabber A, Baeesa S, Althubaiti I, Baz S. Saudi Arabian Consensus Statement on Vagus Nerve Stimulation for Refractory Epilepsy. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2020; 9:75-81. [PMID: 33519349 PMCID: PMC7839567 DOI: 10.4103/sjmms.sjmms_578_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 08/09/2020] [Accepted: 11/23/2020] [Indexed: 11/04/2022]
Abstract
Vagus nerve stimulation (VNS) is an approved adjunctive therapy for refractory epilepsy and used in patients who are not candidates for resective epilepsy surgery. In Saudi Arabia, VNS device implantation is being performed since 2008 by several comprehensive epilepsy programs, but with variable protocols. Therefore, to standardize the use of VNS, a task force was established to create a national consensus. This group consisted of epileptologists, epilepsy surgeons and a VNS nurse coordinator working in comprehensive epilepsy centers and dealing with refractory epilepsy cases. The group intensively reviewed the literature using Medline, EMBASE, Web of Science and Cochrane Library, in addition to physician's manual. Evidence is reported as three stages: preimplantation and patient selection, a perioperative phase involving all stakeholders and post-operative care with specific programming pathways.
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Affiliation(s)
- Khalid Alqadi
- Department of Neurosciences, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hesham Aldhalaan
- Department of Neurosciences, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Abdulaziz Alghamdi
- Department of Neurosciences, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Fawzia Bamgadam
- Department of Neurosciences, King Fahad Medical Centre, Riyadh, Saudi Arabia
| | - Amal Abu-Jabber
- Department of Neurosciences, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Saleh Baeesa
- Department of Neurosciences, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.,Division of Neurosurgery, Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ibrahim Althubaiti
- Department of Neurosciences, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Salah Baz
- Department of Neurosciences, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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Li ST, Chiu NC, Hung KL, Ho CS, Kuo YT, Wu WH, Kuo YT, Wang HS, Lin KL, Hung PC, Chang YC, Hung PL, Fan PC, Lee WT, Yang RC, Ko FJ, Lin LC, Chou PC, Tsai JD, Hung KL, Chen HJ, Chang KP, Hsu TR, Ho CS, Chiu NC, Chen SJ, Fan HC, Lee HT, Shen EY, Kuo HT, Chang MY, Chang TM, Li ST, Yeh GC. Therapeutic effects of children with refractory epilepsy after vagus nerve stimulation in Taiwan. Pediatr Neonatol 2020; 61:606-612. [PMID: 32773364 DOI: 10.1016/j.pedneo.2020.07.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 05/07/2020] [Accepted: 07/10/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Vagus nerve stimulation (VNS) is used as an add-on treatment for epilepsy. This study aimed to use Taiwanese nationwide registry data to analyze the therapeutic effects of VNS in children with refractory epilepsy (RE) and try to explore predictive factors of VNS treatment effectiveness. METHODS This retrospective study collected data from December 2007 to December 2014. Patient variables included gender, age, VNS implantation date, epilepsy duration, seizure frequency, seizure type, etiology, and antiepileptic drug (AED) history. We divided patients into three groups: Group I as seizure frequency >80 times per month, Group II as seizure frequency 24-80 times per month, and Group III as seizure frequency <24 times per month. Multivariate regression analysis was performed to determine predictors of seizure frequency reduction after VNS treatment. RESULTS A total of 80 patients were included in this study. Three or more AED types were prescribed for 61 (77.1%) patients. Seizure frequency decreased significantly at 12 and 24 months after VNS treatment. The mean seizure reduction rates were 44.6% and 50.1% at 12 and 24 months after VNS treatment, with the difference between them reaching statistical significance (p = 0.001). In multivariate linear regression, high seizure frequency (Group I) was a positive predictor of seizure frequency reduction (p < 0.001). The most common complication was coughing (eight patients, 10%) and no patient had early withdrawal or premature termination of VNS use due to complications. CONCLUSION VNS is an effective palliative treatment for children with RE for different seizure types. Seizure reduction rate at 24 months after VNS was better than at 12 months after VNS. High seizure frequency can be regarded as a positive predictor for seizure frequency reduction in children with RE treated with VNS.
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Affiliation(s)
- Sung-Tse Li
- Department of Pediatrics, Hsinchu MacKay Memorial Hospital, Hsinchu, Taiwan; Department of Healthcare Management, Yuanpei University of Medical Technology, Hsinchu, Taiwan; Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
| | - Nan-Chang Chiu
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan; Department of Pediatrics, MacKay Children's Hospital, Taipei, Taiwan.
| | - Kun-Long Hung
- Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan; Department of Pediatrics, Fu-Jen Catholic University Hospital, New Taipei City, Taiwan; School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
| | - Che-Sheng Ho
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan; Department of Pediatrics, MacKay Children's Hospital, Taipei, Taiwan
| | - Yung-Ting Kuo
- Department of Pediatrics, Shuang Ho Hospital, Ministry of Health and Welfare, Taipei Medical University, New Taipei City, Taiwan; Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taiwan
| | - Wen-Hsiang Wu
- Department of Healthcare Management, Yuanpei University of Medical Technology, Hsinchu, Taiwan
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- Vagus Nerve Stimulation Study Group of Taiwan Child Neurology Society, Taiwan
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15
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Vagus nerve stimulation in patients with therapy-resistant generalized epilepsy. Epilepsy Behav 2020; 111:107253. [PMID: 32615417 DOI: 10.1016/j.yebeh.2020.107253] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/24/2020] [Accepted: 06/08/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND For patients with generalized epilepsy who do not respond to antiseizure medications, the therapeutic options are limited. Vagus nerve stimulation (VNS) is a treatment mainly approved for therapy-resistant focal epilepsy. There is limited information on the use of VNS on generalized epilepsies, including Lennox-Gastaut Syndrome (LGS) and genetic generalized epilepsy (GGE). METHODS We identified patients with a diagnosis of generalized epilepsy (including LGS and GGE), who underwent VNS implantation at the London Health Sciences Centre and Western University, London, Ontario, since this treatment became available in Canada in 1997 until July 2018. We assessed response to the treatment, including admissions to hospital and complications. RESULTS A total of 46 patients were included in this study with a history of therapy-resistant generalized epilepsy. The mean age at implantation was 24 years (interquartile range [IQR] = 17.8-31 years), significantly younger in the LGS group (p = 0.02) and 50% (n = 23) were female. The most common etiologies were GGE in 37% (n = 17) and LGS in 63% (n = 29). Median follow-up since VNS implantation was 63 months (IQR: 31-112.8 months). Of the LGS group 41.7% (n = 12) of patients had an overall seizure reduction of 50% or more, and 64.7% (n = 11) in the GGE group without statistical significance between the groups. The best response in seizure reduction was seen in generalized tonic-clonic seizures, with a significant reduction in the GGE group (p = 0.043). There was a reduction of seizure-related hospital admissions from 91.3% (N = 42) preimplantation, to 43.5% (N = 20) postimplantation (p < 0.05). The frequency of side effects due to the stimulation was almost equal in both groups (62.1% in LGS and 64.7% in GGE). CONCLUSIONS Vagus nerve stimulation should be considered as a treatment in patients with therapy-resistant generalized epilepsy, especially in cases with GGE.
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The Effect of Transcutaneous Auricular Vagal Nerve Stimulation (taVNS) on P3 Event-Related Potentials during a Bayesian Oddball Task. Brain Sci 2020; 10:brainsci10060404. [PMID: 32630571 PMCID: PMC7349824 DOI: 10.3390/brainsci10060404] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/20/2020] [Accepted: 06/23/2020] [Indexed: 02/05/2023] Open
Abstract
Transcutaneous auricular Vagal Nerve Stimulation (taVNS) is a non-invasive brain stimulation technique associated with possible modulation of norepinephrinergic (NE) activity. NE is suspected to contribute to generation of the P3 event-related potential. Recent evidence has produced equivocal evidence whether taVNS influences the P3 in healthy individuals during oddball tasks. We examined the effect of taVNS on P3 amplitudes using a novel visual Bayesian oddball task, which presented 200 sequences of three stimuli. The three consecutive stimuli in each sequence are labelled Draw 1, Draw 2 and Draw 3. In total, 47 Subjects completed this visual Bayesian oddball task under randomised sham and active taVNS stimulation in parallel with an electroencephalographic (EEG) recording. We conducted exploratory analyses of the effect of taVNS on P3 amplitudes separately for Draws. We found typical oddball effects on P3 amplitudes at Draws 1 and 2, but not Draw 3. At Draw 2, the oddball effect was enhanced during active compared to sham taVNS stimulation. These data provide evidence that taVNS influences parietal P3 amplitudes under specific circumstances. Only P3 amplitudes at Draw 2 were affected, which may relate to closure of Bayesian inference after Draw 2. Our findings seemingly support previously reported links between taVNS and the NE system.
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18
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González HFJ, Yengo-Kahn A, Englot DJ. Vagus Nerve Stimulation for the Treatment of Epilepsy. Neurosurg Clin N Am 2019; 30:219-230. [PMID: 30898273 DOI: 10.1016/j.nec.2018.12.005] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Vagus nerve stimulation (VNS) was the first neuromodulation device approved for treatment of epilepsy. In more than 20 years of study, VNS has consistently demonstrated efficacy in treating epilepsy. After 2 years, approximately 50% of patients experience at least 50% reduced seizure frequency. Adverse events with VNS treatment are rare and include surgical adverse events (including infection, vocal cord paresis, and so forth) and stimulation side effects (hoarseness, voice change, and cough). Future developments in VNS, including closed-loop and noninvasive stimulation, may reduce side effects or increase efficacy of VNS.
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Affiliation(s)
- Hernán F J González
- Department of Biomedical Engineering, Vanderbilt University Medical Center, 1500 21st Avenue South, 4340 Village at Vanderbilt, Nashville, TN 37232-8618, USA; Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, 1500 21st Avenue South, 4340 Village at Vanderbilt, Nashville, TN 37232-8618, USA.
| | - Aaron Yengo-Kahn
- Department of Neurological Surgery, Vanderbilt University Medical Center, 1121 21st Avenue South, Medical Center North, T4224, Nashville, TN 37232, USA
| | - Dario J Englot
- Department of Biomedical Engineering, Vanderbilt University Medical Center, 1500 21st Avenue South, 4340 Village at Vanderbilt, Nashville, TN 37232-8618, USA; Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, 1500 21st Avenue South, 4340 Village at Vanderbilt, Nashville, TN 37232-8618, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, 1500 21st Avenue South, 4340 Village at Vanderbilt, Nashville, TN 37232-8618, USA; Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, 1500 21st Avenue South, 4340 Village at Vanderbilt, Nashville, TN 37232-8618, USA
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19
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Wheless JW, Gienapp AJ, Ryvlin P. Vagus nerve stimulation (VNS) therapy update. Epilepsy Behav 2018; 88S:2-10. [PMID: 30017839 DOI: 10.1016/j.yebeh.2018.06.032] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 06/15/2018] [Indexed: 11/19/2022]
Abstract
Epilepsy affects millions of people worldwide. Approximately one-third have pharmacoresistant epilepsy, and of these, the majority are not candidates for epilepsy surgery. Vagus nerve stimulation (VNS) therapy has been an option to treat pharmacoresistant seizures for 30 years. In this update, we will review the clinical data that support the device's efficacy in children, adolescents, and adults. We will also review its side-effect profile, quality of life and cost benefits, and the impact the device has on sudden unexpected death in epilepsy (SUDEP). We will then discuss candidate selection and provide guidance on dosing and future models. Vagus nerve stimulation therapy is an effective treatment for many seizure types and epilepsy syndromes with a predictable and benign side-effect profile that supports its role as the most commonly prescribed device to treat pharmacoresistant epilepsy. "This article is part of the Supplement issue Neurostimulation for Epilepsy."
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Affiliation(s)
- James W Wheless
- Le Bonheur Comprehensive Epilepsy Program, Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, TN, United States; Department of Pediatrics, Pediatric Neurology Division, University of Tennessee Health Science Center, Memphis, TN, United States.
| | - Andrew J Gienapp
- Medical Education, Methodist University Hospital, Memphis, TN, United States; Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Phillippe Ryvlin
- Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
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Ryvlin P, Ciumas C, Wisniewski I, Beniczky S. Wearable devices for sudden unexpected death in epilepsy prevention. Epilepsia 2018; 59 Suppl 1:61-66. [DOI: 10.1111/epi.14054] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2017] [Indexed: 02/05/2023]
Affiliation(s)
- Philippe Ryvlin
- Department of Clinical Neurosciences; CHUV; Lausanne Switzerland
- Epilepsy Institute (IDEE); Lyon France
| | - Carolina Ciumas
- Department of Clinical Neurosciences; CHUV; Lausanne Switzerland
- Epilepsy Institute (IDEE); Lyon France
| | - Ilona Wisniewski
- Department of Clinical Neurosciences; CHUV; Lausanne Switzerland
| | - Sandor Beniczky
- Department of Clinical Neurophysiology; Danish Epilepsy Center; Dianalund Denmark
- Department of Clinical Neurophysiology; Aarhus University Hospital; Aarhus Denmark
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Ryvlin P, So EL, Gordon CM, Hesdorffer DC, Sperling MR, Devinsky O, Bunker MT, Olin B, Friedman D. Long-term surveillance of SUDEP in drug-resistant epilepsy patients treated with VNS therapy. Epilepsia 2018; 59:562-572. [DOI: 10.1111/epi.14002] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Philippe Ryvlin
- Department of Clinical Neurosciences; Vaud University Hospital; Lausanne Switzerland
- Epilepsy Institute (Institut Des ÉpilepsiEs; IDÉE); Lyon France
| | - Elson L. So
- Department of Neurology; Mayo Clinic; Rochester MN USA
| | | | | | - Michael R. Sperling
- Department of Neurology; Jefferson Comprehensive Epilepsy Center; Thomas Jefferson University; Philadelphia PA USA
| | - Orrin Devinsky
- Department of Neurology; Comprehensive Epilepsy Center; New York University Langone Medical Center; New York NY USA
| | | | - Bryan Olin
- Cyberonics, Inc. (LivaNova, PLC); Houston TX USA
| | - Daniel Friedman
- Department of Neurology; Comprehensive Epilepsy Center; New York University Langone Medical Center; New York NY USA
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Englot DJ, Rolston JD, Wright CW, Hassnain KH, Chang EF. Rates and Predictors of Seizure Freedom With Vagus Nerve Stimulation for Intractable Epilepsy. Neurosurgery 2017; 79:345-53. [PMID: 26645965 PMCID: PMC4884552 DOI: 10.1227/neu.0000000000001165] [Citation(s) in RCA: 163] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Supplemental Digital Content is Available in the Text. BACKGROUND: Neuromodulation-based treatments have become increasingly important in epilepsy treatment. Most patients with epilepsy treated with neuromodulation do not achieve complete seizure freedom, and, therefore, previous studies of vagus nerve stimulation (VNS) therapy have focused instead on reduction of seizure frequency as a measure of treatment response. OBJECTIVE: To elucidate rates and predictors of seizure freedom with VNS. METHODS: We examined 5554 patients from the VNS therapy Patient Outcome Registry, and also performed a systematic review of the literature including 2869 patients across 78 studies. RESULTS: Registry data revealed a progressive increase over time in seizure freedom after VNS therapy. Overall, 49% of patients responded to VNS therapy 0 to 4 months after implantation (≥50% reduction seizure frequency), with 5.1% of patients becoming seizure-free, while 63% of patients were responders at 24 to 48 months, with 8.2% achieving seizure freedom. On multivariate analysis, seizure freedom was predicted by age of epilepsy onset >12 years (odds ratio [OR], 1.89; 95% confidence interval [CI], 1.38-2.58), and predominantly generalized seizure type (OR, 1.36; 95% CI, 1.01-1.82), while overall response to VNS was predicted by nonlesional epilepsy (OR, 1.38; 95% CI, 1.06-1.81). Systematic literature review results were consistent with the registry analysis: At 0 to 4 months, 40.0% of patients had responded to VNS, with 2.6% becoming seizure-free, while at last follow-up, 60.1% of individuals were responders, with 8.0% achieving seizure freedom. CONCLUSION: Response and seizure freedom rates increase over time with VNS therapy, although complete seizure freedom is achieved in a small percentage of patients. ABBREVIATIONS: AED, antiepileptic drug VNS, vagus nerve stimulation
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Affiliation(s)
- Dario J Englot
- *UCSF Comprehensive Epilepsy Center, University of California, San Francisco, California; ‡Department of Neurological Surgery, University of California, San Francisco, California; §Cyberonics, Inc., Houston, Texas
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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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Puligheddu M, Melis M, Pillolla G, Milioli G, Parrino L, Terzano GM, Aroni S, Sagheddu C, Marrosu F, Pistis M, Muntoni AL. Rationale for an adjunctive therapy with fenofibrate in pharmacoresistant nocturnal frontal lobe epilepsy. Epilepsia 2017; 58:1762-1770. [DOI: 10.1111/epi.13863] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Monica Puligheddu
- Sleep Disorder Research Center; Department of Medical Sciences and Public Health; University of Cagliari; Cagliari Italy
| | - Miriam Melis
- Department of Biomedical Sciences; University of Cagliari; Monserrato Italy
| | - Giuliano Pillolla
- Department of Biomedical Sciences; University of Cagliari; Monserrato Italy
| | - Giulia Milioli
- Department of Neurosciences; Sleep Disorder Center; University of Parma; Parma Italy
| | - Liborio Parrino
- Department of Neurosciences; Sleep Disorder Center; University of Parma; Parma Italy
| | | | - Sonia Aroni
- Department of Biomedical Sciences; University of Cagliari; Monserrato Italy
| | - Claudia Sagheddu
- Department of Biomedical Sciences; University of Cagliari; Monserrato Italy
| | - Francesco Marrosu
- Sleep Disorder Research Center; Department of Medical Sciences and Public Health; University of Cagliari; Cagliari Italy
- Department of Medical Sciences and Public Health; University of Cagliari; Cagliari Italy
| | - Marco Pistis
- Department of Biomedical Sciences; University of Cagliari; Monserrato Italy
- Neuroscience Institute; National Research Council of Italy; Cagliari Italy
| | - Anna Lisa Muntoni
- Neuroscience Institute; National Research Council of Italy; Cagliari Italy
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Ravan M. Investigating the correlation between short-term effectiveness of VNS Therapy in reducing the severity of seizures and long-term responsiveness. Epilepsy Res 2017; 133:46-53. [DOI: 10.1016/j.eplepsyres.2017.04.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 03/08/2017] [Accepted: 04/08/2017] [Indexed: 12/18/2022]
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Sourbron J, Klinkenberg S, Kessels A, Schelhaas HJ, Lagae L, Majoie M. Vagus Nerve Stimulation in children: A focus on intellectual disability. Eur J Paediatr Neurol 2017; 21:427-440. [PMID: 28188025 DOI: 10.1016/j.ejpn.2017.01.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 10/26/2016] [Accepted: 01/23/2017] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Vagus Nerve Stimulation (VNS) can be an efficacious add-on treatment in patients with drug-resistant epilepsy, who are not eligible for surgery. Evidence of VNS efficacy in children with intellectual disability (ID) is scarce. OBJECTIVES The purpose of this study was to review all available VNS data in the pediatric population (≤18 years old) and focus on the subpopulation with ID since appropriate treatment of these children is often challenging and complex. METHODS Cochrane, EMBASE, PubMed and MEDLINE were used to collect all research associated to VNS and ID (or synonyms) leading to a total of 37 studies. Seven studies showed the results of patients with ID and those without separately; thereby only these studies were included in the VNS meta-analysis. RESULTS Our meta-analysis showed that VNS was less effective in pediatric epilepsy patients with ID compared to those without ID (Mantel-Haenszel meta-analysis; p = 0.028, OR 0.18 (CI 95% 0.039-0.84)). However, there were no prospective controlled studies. Numerous studies reported quality of life (QoL) improvements in this subpopulation. The most common adverse events were transient and well tolerated. Side effects on cognition and behavior were not reported. DISCUSSION These results might be a reason to consider VNS early on in the treatment of this subgroup. The significantly greater amount of retrospective studies, differences in follow-up (FU), lack of control data, heterogeneous series and limited number of patients could have biased the outcome measurements. Hence, current data do not exclude VNS for children with drug-resistant epilepsy and ID but should be interpreted with caution.
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Affiliation(s)
- Jo Sourbron
- Laboratory for Molecular Biodiscovery, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Sylvia Klinkenberg
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Alfons Kessels
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht, The Netherlands
| | | | - Lieven Lagae
- Department of Development and Regeneration, Section Pediatric Neurology, University Hospitals KU Leuven, Leuven, Belgium
| | - Marian Majoie
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands; Department of Neurology, Epilepsy Center Kempenhaeghe, The Netherlands.
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Crepeau AZ, Sirven JI. Management of Adult Onset Seizures. Mayo Clin Proc 2017; 92:306-318. [PMID: 28160877 DOI: 10.1016/j.mayocp.2016.11.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 11/11/2016] [Accepted: 11/28/2016] [Indexed: 12/12/2022]
Abstract
Epilepsy is a common yet heterogeneous disease. As a result, management often requires complex decision making. The ultimate goal of seizure management is for the patient to have no seizures and no considerable adverse effects from the treatment. Antiepileptic drugs are the mainstay of therapy, with more than 20 medications currently approved in the United States. Antiepileptic drug selection requires an understanding of the patient's epilepsy, along with consideration of comorbidities and potential for adverse events. After a patient has failed at least 2 appropriate antiepileptic drugs, they are determined to be medically refractory. At this time, additional therapy, including dietary, device, or surgical treatments, need to be considered, typically at a certified epilepsy center. All these treatments require consideration of the potential for seizure freedom, balanced against potential adverse effects, and can have a positive effect on seizure control and quality of life. This review article discussed the treatment options available for adults with epilepsy, including medical, surgical, dietary, and device therapies.
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Lam S, Lin Y, Curry DJ, Reddy GD, Warnke PC. Revision surgeries following vagus nerve stimulator implantation. J Clin Neurosci 2016; 30:83-87. [DOI: 10.1016/j.jocn.2016.01.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 01/26/2016] [Indexed: 10/22/2022]
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Serdaroglu A, Arhan E, Kurt G, Erdem A, Hirfanoglu T, Aydin K, Bilir E. Long term effect of vagus nerve stimulation in pediatric intractable epilepsy: an extended follow-up. Childs Nerv Syst 2016; 32:641-6. [PMID: 26767841 DOI: 10.1007/s00381-015-3004-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 12/23/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE Over the past two decades, vagus nerve stimulation (VNS) has become an accepted and viable treatment modality for intractable epilepsy both in children and adults. Earlier studies have demonstrated short-term seizure outcomes, usually for up to 5 years; so far, none have reported an extended outcome in children. We aimed to assess long term seizure outcome in children with intractable epilepsy for more than 5 years. METHODS We identified patients who had VNS implantation for treatment of intractable epilepsy from March 2000 to March 2015 at our Epilepsy Center and collected data including demographic, age at epilepsy onset and VNS implantation, duration of epilepsy, seizure type, number of antiepilepsy drugs (AEDs), and monthly seizure frequency before VNS implantation and at the last clinic visit. Phone surveys were conducted with patients without recent clinic follow-up. RESULTS Fifty-six patients (aged 4-17 at the time of implant) are the subjects of the study. Seizure reduction of >50 % was achieved in 9.8 % (6th month), 24 % (2nd year), 46.4 % (3rd year), and 54 %(5th year), and overall 35 (62.5 %) of the 56 subjects had a greater than 50 % reduction in seizure frequency at the last follow-up. Eleven patients became seizure free. The results, once obtained, were maintained steadily or even improved over time without any loss of efficacy during the follow-up. The only parameter, significantly related with clinical response, was age at seizure onset. The most frequent adverse events were hoarseness, cough, sore throat, and anorexia, experienced by 13 patients. Two patients had local wound infections and lead to the removal of the stimulator. An improvement in alertness, attention, and psychomotor activity, independent of the efficacy of vagal nerve stimulation, was observed in 8 patients. CONCLUSION To our knowledge, this is the first pediatric study evaluating seizure outcome over more than 5 years of follow-up, and demonstrates a favorable seizure outcome of >50 % seizure frequency in 62.5 % of patients and seizure freedom in 11 patients. It is well tolerated over an extended period of time.
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Affiliation(s)
- Ayse Serdaroglu
- Pediatric Neurology Department, Gazi University Faculty of Medicine, 10th Floor Besevler, Ankara, Turkey
| | - Ebru Arhan
- Pediatric Neurology Department, Gazi University Faculty of Medicine, 10th Floor Besevler, Ankara, Turkey.
| | - Gökhan Kurt
- Department of Neurosurgery, Gazi University Faculty of Medicine, 10th Floor Besevler, Ankara, Turkey
| | - Atilla Erdem
- Department of Neurosurgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Tugba Hirfanoglu
- Department of Neurosurgery, Gazi University Faculty of Medicine, 10th Floor Besevler, Ankara, Turkey
| | - Kursad Aydin
- Pediatric Neurology Department, Gazi University Faculty of Medicine, 10th Floor Besevler, Ankara, Turkey
| | - Erhan Bilir
- Department of Neurology, Gazi University Faculty of Medicine, 10th Floor Besevler, Ankara, Turkey
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Conway CR, Colijn MA, Schachter SC. Vagus Nerve Stimulation for Epilepsy and Depression. Brain Stimul 2015. [DOI: 10.1002/9781118568323.ch17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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Tratamiento con estimulación del nervio vago en pacientes con epilepsia resistente a los fármacos: experiencia en el Hospital Universitario Son Espases. Neurocirugia (Astur) 2013; 24:204-9. [DOI: 10.1016/j.neucir.2013.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 04/22/2013] [Accepted: 04/24/2013] [Indexed: 11/20/2022]
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Fauser S, Zentner J. Critical review of palliative surgical techniques for intractable epilepsy. Adv Tech Stand Neurosurg 2013; 39:165-94. [PMID: 23250841 DOI: 10.1007/978-3-7091-1360-8_7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
Approximately one third of epilepsy patients are not adequately treatable by antiepileptic medication. Curative resective epilepsy surgery can be performed in only a subgroup of these pharmacoresistent patients in whom the epileptogenic focus is localizable and does not overlap with eloquent brain areas. To the remaining patients (with bilateral or multiple epileptogenic foci, with epilepsy onset in eloquent areas, or with no identifiable epileptogenic focus) palliative epilepsy surgery can be offered if they suffer from disabling seizures. Standard palliative procedures currently comprise corpus callosotomy, multiple subpial transections, and vagus nerve stimulation. New approaches such as focus distant deep brain stimulation or direct stimulation of the hippocampus have gained the most interest. Feasibility studies, small pilot studies, and, recently, larger multicenter trials showed that direct brain stimulation shall be considered a potential helpful procedure in the field of palliative surgery. Moreover, with the increasing use of stereo-EEG in invasive video-EEG monitoring, stereo-EEG-guided thermocoagulation has the potential for a promising new treatment option in patients not amenable to resective epilepsy surgery. There is no general consensus on which palliative procedure is most effective in patients with difficult-to-treat epilepsy syndromes. The decision must be based on individual factors of a given patient. This review summarizes experience with palliative approaches collected in adult and pediatric patient series over the past decades and may help to thoroughly balance beneficial effects and risks of each procedure.
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Affiliation(s)
- Susanne Fauser
- Department of Neurosurgery, Epilepsy Center, University of Freiburg, Germany.
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Liang SF, Chen YC, Wang YL, Chen PT, Yang CH, Chiueh H. A hierarchical approach for online temporal lobe seizure detection in long-term intracranial EEG recordings. J Neural Eng 2013; 10:045004. [DOI: 10.1088/1741-2560/10/4/045004] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Arya R, Greiner HM, Lewis A, Mangano FT, Gonsalves C, Holland KD, Glauser TA. Vagus nerve stimulation for medically refractory absence epilepsy. Seizure 2013; 22:267-70. [DOI: 10.1016/j.seizure.2013.01.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 01/05/2013] [Accepted: 01/08/2013] [Indexed: 10/27/2022] Open
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Hoppe C, Wagner L, Hoffmann JM, von Lehe M, Elger CE. Comprehensive long-term outcome of best drug treatment with or without add-on vagus nerve stimulation for epilepsy: A retrospective matched pairs case–control study. Seizure 2013. [DOI: 10.1016/j.seizure.2012.11.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Kay BP, DiFrancesco MW, Privitera MD, Gotman J, Holland SK, Szaflarski JP. Reduced default mode network connectivity in treatment-resistant idiopathic generalized epilepsy. Epilepsia 2013; 54:461-70. [PMID: 23293853 DOI: 10.1111/epi.12057] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2012] [Indexed: 11/28/2022]
Abstract
PURPOSE Idiopathic generalized epilepsy (IGE) resistant to treatment is common, but its neuronal correlates are not entirely understood. Therefore, the aim of this study was to examine resting-state default mode network (DMN) functional connectivity in patients with treatment-resistant IGE. METHODS Treatment resistance was defined as continuing seizures despite an adequate dose of valproic acid (valproate, VPA). Data from 60 epilepsy patients and 38 healthy controls who underwent simultaneous electroencephalography (EEG) and resting-state functional magnetic resonance imaging (fMRI) were included (EEG/fMRI). Independent component analysis (ICA) and dual regression were used to quantify DMN connectivity. Confirmatory analysis using seed-based voxel correlation was performed. KEY FINDINGS There was a significant reduction of DMN connectivity in patients with treatment-resistant epilepsy when compared to patients who were treatment responsive and healthy controls. Connectivity was negatively correlated with duration of epilepsy. SIGNIFICANCE Our findings in this large sample of patients with IGE indicate the presence of reduced DMN connectivity in IGE and show that connectivity is further reduced in treatment-resistant epilepsy. DMN connectivity may be useful as a biomarker for treatment resistance.
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Affiliation(s)
- Benjamin P Kay
- Neuroscience Graduate Program, University of Cincinnati, Cincinnati, Ohio, USA.
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Seizure freedom in epilepsia partialis continua (EPC) through vagus nerve stimulation (VNS) therapy: A case report. EPILEPSY & BEHAVIOR CASE REPORTS 2013; 1:50-1. [PMID: 25667826 PMCID: PMC4150626 DOI: 10.1016/j.ebcr.2013.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 01/17/2013] [Accepted: 01/28/2013] [Indexed: 11/20/2022]
Abstract
Vagus nerve stimulation (VNS) is generally considered as a palliative treatment for patients with drug-resistant partial-onset epilepsy. We report a case in which a patient with drug-resistant epilepsia partialis continua (EPC), became seizure-free for 15 months with VNS combined with antiepileptic medication regimens. To our knowledge, similar cases have not been reported previously.
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Colicchio G, Montano N, Fuggetta F, Papacci F, Signorelli F, Meglio M. Vagus nerve stimulation in drug-resistant epilepsies. Analysis of potential prognostic factors in a cohort of patients with long-term follow-up. Acta Neurochir (Wien) 2012; 154:2237-40. [PMID: 23086106 DOI: 10.1007/s00701-012-1524-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 10/03/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND The results of vagus nerve stimulation (VNS) for the treatment of drug-resistant epilepsies are highly variable due to the lack of defined patient's selection criteria and a follow-up of published studies being generally too short. Here we report the outcome of VNS in a series with long-term follow-up and try to identify subgroups of patients who could be better candidates for this procedure. METHOD We studied 53 patients (33 male, 20 female) with a prospectively recorded follow-up (mean, 55.96 ± 43.53 months). The monthly average seizure frequency for each patient at baseline, 3, 6, 12 months, and each year until the latest follow-up after implant was measured and the percentage of "responders" and response time (RT) were calculated. We investigated the following potential prognostic role of these factors: age of onset of epilepsy, pre-implant epilepsy duration, etiology, and age at implant. RESULTS Globally, 40 % of patients responded to VNS (mean RT, 14.85 ± 16.85 months). Lesional etiology (p = 0.0179, logrank test), particularly ischemia (p = 0.011, Fisher exact test) and tuberous sclerosis (p = 0.0229, Fisher exact test), and age at implant <18 years (p = 0.0242, logrank test) were associated to better response to VNS. In the lesional subgroup the best results were observed in patients with a pre-implant epilepsy duration <15 years (p = 0.0204, logrank test) and an age at implant <18 years (p = 0.0187 logrank test). CONCLUSIONS The best candidate to VNS seems to be a patient with lesional etiology epilepsy (particularly post-ischemic and tuberous sclerosis) and a short duration of epilepsy who undergo VNS younger than 18 years.
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Chen CY, Lee HT, Chen CC, Kwan SY, Chen SJ, Hsieh LP, Tsai JD. Short-term results of vagus nerve stimulation in pediatric patients with refractory epilepsy. Pediatr Neonatol 2012; 53:184-7. [PMID: 22770107 DOI: 10.1016/j.pedneo.2012.04.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Revised: 06/14/2011] [Accepted: 06/27/2011] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Vagus nerve stimulation (VNS), an alternative method to manage patients with medically intractable epilepsy, has shown favorable results in reducing seizure relapse and improvements in quality of life. In 1997, the U.S. Food and Drug Administration approved the use of this device as an adjunctive therapy for intractable seizure in adults and adolescents older than 12 years of age. METHODS We present a preliminary study of pediatric patients, who suffered from medically intractable seizure and underwent VNS implantation after observation of the baseline seizure frequency. Classification of epileptic syndrome, seizure patterns, age of onset, seizure frequency reduction and adverse effects were recorded. RESULTS Patients who underwent VNS implantation included four adolescents and four children. The follow-up duration ranged from 9-33 months. All the patients were responders after the beginning of the stimulation. Five of the eight patients responded to VNS with a seizure frequency reduction rate > 50%, and four of the eight patients experienced a ≥ 90% seizure reduction. No significant adverse effects were noted in all patients during the observation period. CONCLUSION The effective management of medically intractable seizure remains challenging to most clinical physicians. In addition to ketogenic diet and epilepsy surgery, VNS provides an alternative way to manage this issue. Our results suggest that VNS is well tolerated in pediatric patients, and is a favorable and safe method of treating intractable seizure in common clinical practice.
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Affiliation(s)
- Chih-Yi Chen
- Department of Pediatrics, Chung Shan Medical University and Hospital, Taiwan
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Abstract
Therapeutic devices provide new options for treating drug-resistant epilepsy. These devices act by a variety of mechanisms to modulate neuronal activity. Only vagus nerve stimulation (VNS), which continues to develop new technology, is approved for use in the United States. Deep brain stimulation of anterior thalamus for partial epilepsy recently was approved in Europe and several other countries. Responsive neurostimulation, which delivers stimuli to 1 or 2 seizure foci in response to a detected seizure, recently completed a successful multicenter trial. Several other trials of brain stimulation are in planning or underway. Transcutaneous magnetic stimulation (TMS) may provide a noninvasive method to stimulate cortex. Controlled studies of TMS are split on efficacy, which may depend on whether a seizure focus is near a possible region for stimulation. Seizure detection devices in the form of shake detectors via portable accelerometers can provide notification of an ongoing tonic-clonic seizure, or peace of mind in the absence of notification. Prediction of seizures from various aspects of electroencephalography (EEG) is in early stages. Prediction appears to be possible in a subpopulation of people with refractory seizures, and a clinical trial of an implantable prediction device is underway. Cooling of neocortex or hippocampus reversibly can attenuate epileptiform EEG activity and seizures, but engineering problems remain in its implementation. Optogenetics is a new technique that can control excitability of specific populations of neurons with light. Inhibition of epileptiform activity has been demonstrated in hippocampal slices, but use in humans will require more work. In general, devices provide useful palliation for otherwise uncontrollable seizures, but with a different risk profile than with most drugs. Optimizing the place of devices in therapy for epilepsy will require further development and clinical experience.
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Affiliation(s)
- Robert S Fisher
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA, USA.
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Majkowska-Zwolińska B, Zwoliński P, Roszkowski M, Drabik K. Long-term results of vagus nerve stimulation in children and adolescents with drug-resistant epilepsy. Childs Nerv Syst 2012; 28:621-8. [PMID: 22222361 DOI: 10.1007/s00381-011-1670-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Accepted: 12/22/2011] [Indexed: 12/12/2022]
Abstract
PURPOSE The purpose of this study was to evaluate long-term seizure reduction and on-demand magnet use in children and adolescents with drug-resistant epilepsy who were treated with vagus nerve stimulation therapy. METHODS Fifty-seven children and adolescents under 18 years of age with drug-resistant epilepsy were implanted with a vagus nerve stimulation therapy device. Seizure reduction was evaluated at 6, 12, 24, 36, and 48 months after implantation. Magnet effect on seizure frequency was evaluated during the first week after implantation and after 6, 12, 24, 36, and 48 months of treatment. RESULTS The mean reduction in seizure frequency compared with baseline was significant at all time points up to 48 months post-implantation. At 12 months, the average reduction in seizure frequency was 52.4%, and at 48 months, it was 53.1% (observed case analysis). The use of a magnet to deliver extra "on-demand" stimulation between cycles resulted in cessation of seizures in 16.1% of patients, partial effect in 73.2%, and no effect in 10.7%, when evaluated within 1 week of implantation. The magnet effect decreased slightly with increasing time after implantation. A sub-analysis of children ≤12 years of age (N = 34) showed similar results after 36 months of follow-up. The therapy was well tolerated regardless of age. CONCLUSION Vagus nerve stimulation therapy is a safe and effective adjunctive treatment for children and adolescents of all ages with drug-resistant epilepsy.
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Englot DJ, Chang EF, Auguste KI. Vagus nerve stimulation for epilepsy: a meta-analysis of efficacy and predictors of response. J Neurosurg 2011; 115:1248-55. [PMID: 21838505 DOI: 10.3171/2011.7.jns11977] [Citation(s) in RCA: 294] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Vagus nerve stimulation (VNS) was approved by the US FDA in 1997 as an adjunctive treatment for medically refractory epilepsy. It is considered for use in patients who are poor candidates for resection or those in whom resection has failed. However, disagreement regarding the utility of VNS in epilepsy continues because of the variability in benefit reported across clinical studies. Moreover, although VNS was approved only for adults and adolescents with partial epilepsy, its efficacy in children and in patients with generalized epilepsy remains unclear. The authors performed the first meta-analysis of VNS efficacy in epilepsy, identifying 74 clinical studies with 3321 patients suffering from intractable epilepsy. These studies included 3 blinded, randomized controlled trials (Class I evidence); 2 nonblinded, randomized controlled trials (Class II evidence); 10 prospective studies (Class III evidence); and numerous retrospective studies. After VNS, seizure frequency was reduced by an average of 45%, with a 36% reduction in seizures at 3-12 months after surgery and a 51% reduction after > 1 year of therapy. At the last follow-up, seizures were reduced by 50% or more in approximately 50% of the patients, and VNS predicted a ≥ 50% reduction in seizures with a main effects OR of 1.83 (95% CI 1.80-1.86). Patients with generalized epilepsy and children benefited significantly from VNS despite their exclusion from initial approval of the device. Furthermore, posttraumatic epilepsy and tuberous sclerosis were positive predictors of a favorable outcome. In conclusion, VNS is an effective and relatively safe adjunctive therapy in patients with medically refractory epilepsy not amenable to resection. However, it is important to recognize that complete seizure freedom is rarely achieved using VNS and that a quarter of patients do not receive any benefit from therapy.
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Affiliation(s)
- Dario J Englot
- Department of Neurological Surgery, University of California, San Francisco, California 94143-0112, USA.
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Liang SF, Liao YC, Shaw FZ, Chang DW, Young CP, Chiueh H. Closed-loop seizure control on epileptic rat models. J Neural Eng 2011; 8:045001. [DOI: 10.1088/1741-2560/8/4/045001] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Rose S, Tao JX. Seizure freedom with VNS monotherapy: a case report. Seizure 2011; 20:735-7. [PMID: 21764334 DOI: 10.1016/j.seizure.2011.06.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2011] [Revised: 06/21/2011] [Accepted: 06/22/2011] [Indexed: 11/16/2022] Open
Abstract
Vagus nerve stimulation (VNS) is generally considered as a palliative treatment for patients with drug-resistant partial onset epilepsy. Although seizure freedom can be occasionally achieved in patients with VNS, anti-epileptic medications (AEDs) are commonly required to maintain seizure freedom. We report a case that a patient became seizure free for 5 years with VNS monotherapy. To our knowledge, a similar case has not been reported previously.
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Affiliation(s)
- Sandra Rose
- Adult Epilepsy Center, Departments of Neurology, The University of Chicago, Chicago, IL 60637, USA
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Abstract
Abstract
Neuromodulation strategies have been proposed to treat a variety of neurological disorders, including medication-resistant epilepsy. Electrical stimulation of both central and peripheral nervous systems has emerged as a possible alternative for patients who are not deemed to be good candidates for resective procedures. In addition to well-established treatments such as vagus nerve stimulation, epilepsy centers around the world are investigating the safety and efficacy of neurostimulation at different brain targets, including the hippocampus, thalamus, and subthalamic nucleus. Also promising are the preliminary results of responsive neuromodulation studies, which involve the delivery of stimulation to the brain in response to detected epileptiform or preepileptiform activity. In addition to electrical stimulation, novel therapeutic methods that may open new horizons in the management of epilepsy include transcranial magnetic stimulation, focal drug delivery, cellular transplantation, and gene therapy. We review the current strategies and future applications of neuromodulation in epilepsy.
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Affiliation(s)
- Faisal A Al-Otaibi
- King Faisal Specialist Hospital & Research Centre, Neurosciences Department, Riyadh, Saudi Arabia
| | - Clement Hamani
- Division of Neurosurgery, Toronto Western Hospital, Toronto Western Research Institute, Ontario, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Toronto Western Hospital, Toronto Western Research Institute, Ontario, Canada
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Ultra Low-Power Algorithm Design for Implantable Devices: Application to Epilepsy Prostheses. JOURNAL OF LOW POWER ELECTRONICS AND APPLICATIONS 2011. [DOI: 10.3390/jlpea1010175] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Elliott RE, Morsi A, Geller EB, Carlson CC, Devinsky O, Doyle WK. Impact of Failed Intracranial Epilepsy Surgery on the Effectiveness of Subsequent Vagus Nerve Stimulation. Neurosurgery 2011; 69:1210-7. [DOI: 10.1227/neu.0b013e3182230ae3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
Using the Cyberonics registry, Amar and colleagues reported poorer efficacy of vagus nerve stimulation (VNS) in patients who failed intracranial epilepsy surgery (IES).
OBJECTIVE
To study the impact of failed IES and other surrogate marker of severe epilepsy on VNS effectiveness in a large cohort with treatment-resistant epilepsy (TRE).
METHODS
We retrospectively reviewed 376 patients (188 female patients; 265 adults; mean age, 29.4 years at implantation) with TRE who underwent VNS implantation between 1997 and 2008 and had at least 1 year of follow-up. One hundred ten patients (29.3%) had failed ≥1 prior craniotomies for TRE, and 266 (70.7%) had no history of IES.
RESULTS
The mean duration of VNS therapy was 5.1 years. Patients with prior IES were more commonly male and adult, had a greater number of seizure types, and more commonly had focal or multifocal vs generalized seizures (P > .05). There was no significant difference in the mean percentage seizure reduction between patients with and without a history of IES (59.1% vs 56.5%; P = .42). There was no correlation between type of failed IES (callosotomy vs resection) and seizure reduction with VNS therapy.
CONCLUSION
Failed IES did not affect the response to VNS therapy. Unlike prior reports, patients with callosotomy did not respond better than those who had resective surgery. Nearly 50% of patients experienced at least 50% reduction in seizure frequency. For patients with TRE, including patients who failed cranial epilepsy surgeries, VNS should be considered a palliative treatment option.
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Affiliation(s)
- Robert E. Elliott
- Department of Neurosurgery, Neurosurgery and Psychiatry, New York University Langone Medical Center, New York, New York
| | - Amr Morsi
- Department of Neurosurgery, Neurosurgery and Psychiatry, New York University Langone Medical Center, New York, New York
| | - Eric B. Geller
- Department of Neurology, Saint Barnabas Medical Center, Livingston, New Jersey
| | - Chad C. Carlson
- Department of Neurology, Neurosurgery and Psychiatry, New York University Langone Medical Center, New York, New York
| | - Orrin Devinsky
- Department of Neurology, Neurosurgery and Psychiatry, New York University Langone Medical Center, New York, New York
| | - Werner K. Doyle
- Department of Neurosurgery, Neurosurgery and Psychiatry, New York University Langone Medical Center, New York, New York
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Cersósimo RO, Bartuluchi M, De Los Santos C, Bonvehi I, Pomata H, Caraballo RH. Vagus nerve stimulation: effectiveness and tolerability in patients with epileptic encephalopathies. Childs Nerv Syst 2011; 27:787-92. [PMID: 21038079 DOI: 10.1007/s00381-010-1314-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Accepted: 10/13/2010] [Indexed: 11/24/2022]
Abstract
PURPOSE We discuss the effectiveness, tolerability, and safety of vagus nerve stimulation (VNS) as adjunctive therapy in 26 patients with refractory epileptic encephalopathies (EEs). MATERIAL AND METHODS Twenty-six patients (17 male and 9 female) with electroclinical features compatible with Lennox-Gastaut syndrome (LGS) in 20 patients, Dravet syndrome (DS) in 3 patients, and epilepsy with myoclonic-astatic seizures (EMAS) in 3 patients implanted with the NCP system were analyzed. RESULTS In our series of patients with LGS, 17 cases showed a significant improvement in seizure control, with a reduction in seizure frequency of at least 50%. Seven of them previously had epileptic spasms. Three patients with EMAS and two patients with DS showed a significant improvement in seizure control, with a reduction in seizure frequency of at least 50%. A good clinical response was evident early and efficacy progressively improved with the duration of treatment up to 36 months. In patients who had a reduction in seizure frequency of at least 50%, quality of life (QOL) and neuropsychological performance improved. VNS was well-tolerated in all patients. CONCLUSION VNS is an effective and well-tolerated treatment for patients with epileptic encephalopathies EEs, improving QOL and neuropsychological performance.
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Affiliation(s)
- Ricardo O Cersósimo
- Neurology Department, Hospital de Niños Prof. Dr. Juan P Garrahan, Combate de los Pozos 1881, Buenos Aires, CP 1245, Argentina
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Vagus nerve stimulation in 436 consecutive patients with treatment-resistant epilepsy: long-term outcomes and predictors of response. Epilepsy Behav 2011; 20:57-63. [PMID: 21144802 DOI: 10.1016/j.yebeh.2010.10.017] [Citation(s) in RCA: 202] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Revised: 10/17/2010] [Accepted: 10/19/2010] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The goal of this study was to assess the efficacy and safety of vagus nerve stimulation in a consecutive series of adults and children with treatment-resistant epilepsy (TRE). METHODS In this retrospective review of a prospectively created database of 436 consecutive patients who underwent vagus nerve stimulator implantation for TRE between November 1997 and April 2008, there were 220 (50.5%) females and 216 (49.5%) males ranging in age from 1 to 76 years at the time of implantation (mean: 29.0 ± 16.5). Thirty-three patients (7.6%) in the primary implantation group had inadequate follow-up (<3 months from implantation) and three patients had early device removal because of infection and were excluded from seizure control outcome analyses. RESULTS Duration of vagus nerve stimulation treatment varied from 10 days to 11 years (mean: 4.94 years). Mean seizure frequency significantly improved following implantation (mean reduction: 55.8%, P<0.0001). Seizure control ≥ 90% was achieved in 90 patients (22.5%), ≥ 75% seizure control in 162 patients (40.5%), ≥ 50% improvement in 255 patients (63.75%), and <50% improvement in 145 patients (36.25%). Permanent injury to the vagus nerve occurred in 2.8% of patients. CONCLUSION Vagus nerve stimulation is a safe and effective palliative treatment option for focal and generalized TRE in adults and children. When used in conjunction with a multidisciplinary and multimodality treatment regimen including aggressive antiepileptic drug regimens and epilepsy surgery when appropriate, more than 60% of patients with TRE experienced at least a 50% reduction in seizure burden. Good results were seen in patients with non-U.S. Food and Drug Administration-approved indications. Prospective, randomized trials are needed for patients with generalized epilepsies and for younger children to potentially expand the number of patients who may benefit from this palliative treatment.
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Müller K, Fabó D, Entz L, Kelemen A, Halász P, Rásonyi G, Eross L. Outcome of vagus nerve stimulation for epilepsy in Budapest. Epilepsia 2010; 51 Suppl 3:98-101. [PMID: 20618411 DOI: 10.1111/j.1528-1167.2010.02620.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Vagus nerve stimulation (VNS) is a nonpharmacologic therapeutic option for patients with intractable epilepsy. Better clinical outcomes were recorded in nonfocal and Lennox-Gastaut syndrome (LGS). We conducted a 2-year, open label, prospective study to measure the seizure outcome of 26 VNS patients. The seizure numbers were assessed using clinician's global impression scale (CGI) and patient diaries. The average seizure reduction was 23% at the first year and 22% at the second year. Seizure reduction was more pronounced among patients with nonfocal than with focal epilepsy. The response rate was 50% at first year and 30% at the second year. The best CGI record for clinically significant improvement was 15% in the LGS group. The only statistically significant result was the reduction of the generalized tonic-clonic seizures (GTCS). The side-effect profile was good; however, the large number of mild and reversible effects influenced the stimulation parameters and thus probably the effectiveness of the therapy. We suggest that VNS is an optional treatment mostly in cases of therapy-resistant Lennox-Gastaut syndrome. Patients with GTCS may experience improvement such as reduction of seizure severity. We conclude that VNS is a safe neuromodulatory treatment, but future developments of neuromodulatory approaches are needed.
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Affiliation(s)
- Katalin Müller
- Department of Pediatrics, Semmelweis University, Budapest, Hungary
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