Vagus nerve stimulation for epilepsy, clinical efficacy of programmed and magnet stimulation.
ABSTRACT Vagus nerve stimulation (VNS) by intermittent and programmed electrical stimulation of the left vagus nerve in the neck, has become widely available. It is an effective treatment for patients with refractory epilepsy. Patients can be provided with a magnet that allows to deliver additional stimulation trains. Since earlier studies have demonstrated the persistence of a stimulation effect after discontinuation of the stimulation train, we evaluated the clinical efficacy of VNS both in the programmed intermittent stimulation mode and magnet stimulation mode.
A group of 30 patients (16 F, 14 M) with medically refractory partial epilepsy, who were unsuitable candidates for resective surgery, were included in the study. The patients, their companions and caregivers were instructed on how to administer additional stimulation trains using a hand-held magnet when an aura or a seizure onset occurred. Patients or caregivers could recognize habitual seizures and were able to evaluate sudden interruption of these seizures. Using seizure diaries, detailed accounts of magnet use and regular clinic follow-up visits, data on seizure frequency and severity and number of magnet applications were collected. Patients who provided unreliable information were excluded from the analysis.
Forty-seven percent of all patients had an improvement in seizure control with a reduction in seizure frequency of more than 50% during a mean follow-up of 33 months (range: 4-67 months). More than half of the patients used the magnet and provided reliable information. In 63% of patients who were able to self-administer or receive additional magnet stimulation, seizures could be interrupted, be it consistently or occasionally. More than half of the patients who reported a positive effect of magnet stimulation became responders. In most cases the magnet was applied by a caregiver.
To our knowledge, this study is the first to explore the efficacy of magnet-induced vagus nerve stimulation. Results suggest that the magnet is a useful tool that provides patients and mainly caregivers with an additional means of controlling refractory seizures. Additional controlled studies comparing programmed stimulation and magnet-induced stimulation in monitoring conditions are warranted.
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ABSTRACT: In spite of the high success rate of many surgical procedures for pharmacoresistant epilepsy, a substantial number of patients do not become seizure-free. Different strategies for electrical modulation of the brain such as Deep Brain Stimulation, Vagal Nerve Stimulation and Transcraneal Magnetic Stimulation have gained considerable interest in the last decade as alternative therapies for patients with medically refractory epilepsy. Research into the mechanism of action of the strategies for electrical modulation of the brain suggests a crucial role of different molecules and channels such as glutamate, γ-aminobutyric acid, adenosine, brain-derived neurotrophic factor, calcium channels, sodium channels as well as extracellular potassium. Electrical modulation of the brain may reduce the overexpression of P-glycoprotein, a drug efflux transporter that reduces the absorption of antiepileptic drugs. Electrical modulation of the brain induces long-term effects associated with beneficial consequences on clinical symptoms observed during the postictal state. In addition, electrical modulation of the brain might also promote the neurogenesis in subjects with pharmacoresistant epilepsy in whom this process is decreased. Targeting the regulatory pathways in charge of the effects of electrical modulation of the brain is discussed as a means to improve its efficacy. Electrical modulation of the brain combined with pharmacotherapy may represent an innovative approach to avoid epileptogenesis, reduce seizure activity, induce beneficial effects during the postictal state, diminish the amount of antiepileptic drugs, and improve alertness, memory and mood in pharmacoresistant epilepsy.Pharmacology [?] Therapeutics 01/2013; · 7.75 Impact Factor
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ABSTRACT: Some patients receiving VNS Therapy report benefit from manually activating the generator with a handheld magnet at the time of a seizure. A review of 20 studies comprising 859 subjects identified patients who reported on-demand magnet mode stimulation to be beneficial. Benefit was reported in a weighted average of 45% of patients (range 0–89%) using the magnet, with seizure cessation claimed in a weighted average of 28% (range 15–67%). In addition to seizure termination, patients sometimes reported decreased intensity or duration of seizures or the post-ictal period. One study reported an isolated instance of worsening with magnet stimulation (Arch Pediatr Adolesc Med, 157, 2003 and 560). All of the reviewed studies assessed adjunctive magnet use. No studies were designed to provide Level I evidence of efficacy of magnet-induced stimulation. Retrospective analysis of one pivotal randomized trial of VNS therapy showed significantly more seizures terminated or improved in the active stimulation group vs the control group. Prospective, controlled studies would be required to isolate the effect and benefit of magnet mode stimulation and to document that the magnet-induced stimulation is the proximate cause of seizure reduction. Manual application of the magnet to initiate stimulation is not always practical because many patients are immobilized or unaware of their seizures, asleep or not in reach of the magnet. Algorithms based on changes in heart rate at or near the onset of the seizure provide a methodology for automated responsive stimulation. Because literature indicates additional benefits from on-demand magnet mode stimulation, a potential role exists for automatic activation of stimulation.Acta Neurologica Scandinavica 08/2014; · 2.44 Impact Factor
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ABSTRACT: Neurostimulation as a treatment for epilepsy has been around for almost 20 years in the form of vagus nerve stimulation. Newer types of neurostimulation are being developed and stand on the brink of approval for use. The two newest therapies, not yet approved in the United States, are deep brain stimulation and the Responsive Neurostimulator System . In fact, in Europe, approval has already been given for deep brain stimulation and newer forms of vagus nerve stimulation. Efficacy is similar between these therapies, and side effects are moderate, so what will be the future? The challenge will be to learn how to use these therapies correctly and offer the right treatment for the right patient.Epilepsy currents / American Epilepsy Society. 09/2012; 12(5):188-91.