An Institutional Experience with Cervical Vagus Nerve Trunk Stimulation for Medically Refractory Epilepsy: Rationale, Technique, and Outcome

An Institutional Experience with Cervical Vagus Nerve Trunk Stimulation for Medically Refractory... AbstractOBJECTIVE:Intermittent stimulation of the left cervical vagus nerve trunk is emerging as a novel adjunct in the treatment of medically refractory seizures. We sought to evaluate theoretical and practical issues attendant to this concept. We review the anatomic and physiological background arguing for clinical application of vagus nerve stimulation, discuss salient aspects of patient selection and the nuances of surgical technique, and present our observations of and results from application of the method.METHODS:Each of 18 patients with medically refractory epilepsy and at least six complex partial or secondarily generalized seizures per month underwent placement of a NeuroCybernetic Prosthesis pulse generator (Cyberonics, Webster, TX) in the chest, connected to helical platinum leads applied to the left cervical vagus nerve trunk. The patients were then randomized in a double-blinded fashion to receive either high (presumably therapeutic) or low (presumably less therapeutic) levels of vagus nerve stimulation. Reduction in seizure frequency, global assessments of quality of life, physiological measurements, and adverse events were recorded during a 3-month period. Patients in the low group were then crossed over to high-stimulation paradigms during a 15-month extension trial.RESULTS:All operations were successful, uneventful, and without adverse postoperative sequelae. One patient was excluded from analysis because of inadequate seizure calendars. Of the seven patients initially assigned to high stimulation, the mean reduction in seizure frequency was 71% at 3 months and 81% at 18 months. Five (72%) of these patients had a greater than 75% reduction in seizure frequency, and one (14%) remained seizure-free after more than 1.5 years of follow-up. The mean reduction in seizure frequency among the low-stimulation group was only 6% at 3 months. No serious complications, device failures, or physiological perturbations occurred.CONCLUSION:In our experience, vagus nerve stimulation has proven to be a safe, feasible, and potentially effective method of reducing seizures in select patient populations. However, the elements of strict definition for the application of the method require further study. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Neurosurgery Oxford University Press

An Institutional Experience with Cervical Vagus Nerve Trunk Stimulation for Medically Refractory Epilepsy: Rationale, Technique, and Outcome

An Institutional Experience with Cervical Vagus Nerve Trunk Stimulation for Medically Refractory Epilepsy: Rationale, Technique, and Outcome

SPEC IA L C L IN IC A L A R T IC LE An Institutional Experience with Cervical Vagus Nerve Trunk Stimulation for M edically Refractory Epilepsy: Rationale, Technique, and Outcome Arun Paul Amar, M.D., Christi N. Heck, M.D., Michael L. Levy, M.D., Thomas Smith, Christopher M. DeGiorgio, M.D., Sandra Oviedo, Michael L.J. Apuzzo, M.D. D epartm ents of N e u ro lo g ic a l Surgery (A P A , M LL, M LJA) and N e u ro lo g y ( C N H , T S , C M D , S O ), U n ive rsity of Southern C a lifo rn ia , Los A n geles, C a lifo rn ia OBJECTIVE: I n t e r m it t e n t s tim u la tio n o f th e le ft c e rv ic a l vagus nerve tr u n k is e m e rg in g as a n ovel a d ju n c t in the treatment o f m e d ic a lly r e fr a c to r y seizures. W e sought to evaluate th e o re tic a l and p ra c tic a l issues a tte n d a n t to this c o n ce p t. W e re v ie w th e a n a to m ic and p h y s io lo g ic a l b a ckg ro u n d a rg u in g fo r c lin ic a l a p p lic a tio n o f vagus nerve s tim u la tio n , discuss s a lie n t aspects o f p a tie n t se le ctio n and the nuances o f surgical te c h n iq u e , and present our observations o f and results fr o m a p p lic a tio n o f th e m e th o d . METHODS: Each o f 18 p a tie n ts w it h m e d ic a lly r e fra c to ry epilepsy and at least six c o m p le x p a rtia l o r s e c o n d a rily generalized seizures p e r m o n th u n d e rw e n t p la c e m e n t o f a N e u ro C y b e rn e tic Prosthesis pulse g e n e ra to r (C yb e ro n - ics, W ebster, TX) in th e chest, c o n n e c te d to h e lic a l p la tin u m leads a p p lie d to th e le ft c e rv ic a l vagus nerve tru n k . The patients w ere then randomized in a double-blinded fashion to receive either high (presumably therapeutic) o r low (presumably less therapeutic) levels o f vagus nerve stimulation. Reduction in seizure frequency, global assessments o f quality of life, physiological measurements, and adverse events were recorded during a 3-month period. Patients in the lo...
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Publisher
Oxford University Press
Copyright
© Published by Oxford University Press.
ISSN
0148-396X
eISSN
1524-4040
D.O.I.
10.1097/00006123-199812000-00001
Publisher site
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Abstract

AbstractOBJECTIVE:Intermittent stimulation of the left cervical vagus nerve trunk is emerging as a novel adjunct in the treatment of medically refractory seizures. We sought to evaluate theoretical and practical issues attendant to this concept. We review the anatomic and physiological background arguing for clinical application of vagus nerve stimulation, discuss salient aspects of patient selection and the nuances of surgical technique, and present our observations of and results from application of the method.METHODS:Each of 18 patients with medically refractory epilepsy and at least six complex partial or secondarily generalized seizures per month underwent placement of a NeuroCybernetic Prosthesis pulse generator (Cyberonics, Webster, TX) in the chest, connected to helical platinum leads applied to the left cervical vagus nerve trunk. The patients were then randomized in a double-blinded fashion to receive either high (presumably therapeutic) or low (presumably less therapeutic) levels of vagus nerve stimulation. Reduction in seizure frequency, global assessments of quality of life, physiological measurements, and adverse events were recorded during a 3-month period. Patients in the low group were then crossed over to high-stimulation paradigms during a 15-month extension trial.RESULTS:All operations were successful, uneventful, and without adverse postoperative sequelae. One patient was excluded from analysis because of inadequate seizure calendars. Of the seven patients initially assigned to high stimulation, the mean reduction in seizure frequency was 71% at 3 months and 81% at 18 months. Five (72%) of these patients had a greater than 75% reduction in seizure frequency, and one (14%) remained seizure-free after more than 1.5 years of follow-up. The mean reduction in seizure frequency among the low-stimulation group was only 6% at 3 months. No serious complications, device failures, or physiological perturbations occurred.CONCLUSION:In our experience, vagus nerve stimulation has proven to be a safe, feasible, and potentially effective method of reducing seizures in select patient populations. However, the elements of strict definition for the application of the method require further study.

Journal

NeurosurgeryOxford University Press

Published: Dec 1, 1998

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