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12.11.2014
Vagus nerve stimulation (VNS), which attenuates seizure frequency, severity, and duration by chronic intermittent stimulation of the vagus nerve, is intended for use as an adjunctive treatment with antiepileptic drug (AED) therapies .
The VNS therapy system consists of the implantable pulse generator and bipolar VNS therapy lead, a programming wand with software, a tunneling tool, and a handheld magnet (Figure 4 . The magnet provided to patients as part of the VNS therapy system allows on-demand stimulation, which has the potential to abort seizures, either consistently or occasionally, among some patients or caregivers who are able to anticipate the onset of their seizures The additional stimulus train that results when the magnet is held over the generator is typically stronger than the programmed stimulus parameters This added ability of on-demand stimulation provides a greater sense of control for patients and their caregivers over their disorder, which can help improve how they perceive their quality of life The magnet also allows temporary interruption of stimulation if needed, particularly when singing or playing woodwind instruments or during speaking engagements . The implant surgery is most often performed as a day surgery under general anesthesia and typically lasts about 1 hour.7 The pacemaker-like generator device is generally implanted in the subcutaneous tissues of the upper left pectoral region, with a lead then run from the generator device to the left vagus nerve in the neck (Figure 4 . Once a generator reaches end of service, another surgery is required to replace the generator.
The routine lead test performed during surgery also has resulted in reports of bradycardia and asystole in a small number of patients (~0.
Response to VNS therapy has been shown to be age dependent, and therefore, VNS stimulus parameters may need to be adjusted differently for the pediatric patient. The mechanisms of action of VNS therapy are not fully understood, but they are believed to be manifold, owing to the diffuse distribution of vagal afferents throughout the central nervous system, and are distinct from those of traditional AED therapy.
Results from two randomized, placebo-controlled, double-blind trials (E03 and E05) were pivotal in demonstrating the antiseizure effect of VNS therapy. Although the controlled clinical trials did not focus specifically on the pediatric patient, the children and adolescents included in one of the five clinical studies (E04) responded at least as favorably as the adults Of the 60 pediatric patients included in the E04 open, prospective study, 16 were younger than age 12 (mean age, 13 .5 years) .
The largest study to date to evaluate the effectiveness, tolerability, and safety of VNS therapy among pediatric patients was a six-center, retrospective study of 125 patients aged 18 years or younger (41 patients aged less than 12 years) . Retrospective studies of the efficacy of VNS therapy among patients with Len-nox-Gastaut syndrome (LGS) have shown some success in reducing seizure frequency without adverse side effects 9 VNS therapy was performed on 50 patients from six centers (median age at implant was 13 years [range, 5 to 27 years]).
Tuberous sclerosis complex with complex partial or generalized tonic-clonic seizures Autism with symptomatic epilepsy addition, improvements in quality of life with minimal and tolerable side effects from both the surgery and therapy were reported for this patient population The most notable change in quality of life was an increase in alertness reported for more than half of the patients . A retrospective, multicenter, open-label study of 10 patients (mean age of 13 years) with tuberous sclerosis complex (TSC) receiving at least 6 months of VNS therapy (with a mean of 22 months) found a high response rate to VNS therapy, with 9 out of 10 patients experiencing at least a 50% reduction in seizure frequency. Preliminary data also suggest that VNS therapy may be effective among patients with epilepsy and either autism or Landau-Kleffner syndrome (LKS), childhood disorders in which epilepsy is a prominent comorbid condition 22 A small study of six pediatric patients (<16 years) with hypothalamic hamartomas and refractory epilepsy indicates that VNS therapy may have the ability to independently improve behavior and, to a lesser extent, decrease seizure frequency or severity in this patient population 20 Understanding And Treating AutismWhenever a doctor informs the parents that their child is suffering with Autism, the first & foremost question that is thrown over him is - How did it happen?
Kimberly Hedgspethwhat types of sezuires does the VNS Therapy is used for,and does medicard cover the cost of the VNS Therapy and does it hurt when it goes in.will I still be taking the same kind of medication if I recieve the surgery. Right-sided vagus nerve stimulation therapy in adult patients after failed left-sided placement. Introduction and Objectives: Vagus Nerve Stimulation (VNS) is a non-pharmacological alternative therapy for decreasing seizure frequency in patients with refractory epilepsy, usually placed on the left vagus nerve. Methods: We performed a retrospective review of two adult patients, who underwent a R-VNS procedure due to complicated or failed previous L-VNS implantation. Results: One of the patients was treated with L-VNS for 13 years but the device had to be removed because of mechanical malfunction. Conclusions: We conclude that R-VNS placement is an alternative therapy in those patients who cannot undergo L-VNS implantation.
UCSF is one of the only centers in the nation to offer a cutting-edge laser surgery treatment for adult and pediatric epilepsy. For certain patients, using laser ablation for treating seizures can be as or more effective than other therapeutic options, with less risk. MR-guided laser thermal ablation is an exciting new option for patients with epilepsy that increases both safety and efficacy.
Any patient with medically refractory epilepsy and MRI-visible lesions that have been confirmed as the source of the epilepsy are currently suitable candidates for laser thermal ablation therapy. Laser ablation is performed through a small ‘nick’ scalp incision and hole in the skull as opposed to an extensive scalp incisions and large cranial opening that is typical of standard epilepsy surgery. The majority of patients spend one night in the hospital and are discharged the following day. For more information or to find out if you are eligible for Visualase thermal ablation therapy, contact the Epilepsy Center at (415) 353-2437. As of January 2008, more than 45,000 patients with epilepsy have been implanted with the VNS therapy system worldwide, with approximately 30% of those patients being younger than age 18 at the time of their first implant Approximately one-third of patients receiving VNS therapy experience at least a 50% reduction in seizure frequency with no adverse cognitive or systemic effects 6 Moreover, clinical findings indicate that the effectiveness of VNS therapy continues to improve over time, independent of changes in AEDs or stimulation parameters 18 Tolerance does not appear to be a factor with VNS therapy, even after extended periods of time.


The median settings shown here are taken from the VNS therapy patient outcome registry (Cyberonics, Inc . Several studies indicate that pediatric patients may require higher output currents (Table 4 .
14 Studies suggest that altered vagal afferent activities resulting from VNS are responsible for mediating seizures 15 Rat studies indicate that VNS activation of the locus coeruleus may be a significant factor for the attenuation of seizures . 13 At 3 months, the median reduction in seizure frequency was 23% (n = 60); for the 46 patients with follow-up data available at 18 months, the median reduction was 42% . This study showed greater reductions in seizure frequency than those found in the pediatric subgroup of the E04 clinical trial, with a median reduction in seizure frequency at 3 months of 51 . Previous corpus callosotomy was not a contraindication for VNS therapy among this patient population, with the five patients who had undergone such surgery showing a 69% reduction in seizure frequency at 6 months .
Nonetheless, left side VNS (L-VNS) can be hindered because of the presence of intraoperative complications, postoperative fibrosis, or even mechanical malfunction of the device, forcing L-VNS explant. The second patient could not be implanted with L-VNS due to significant bleeding caused by the accidental tearing of an ectopic vein.
Close follow-up and frequent ECG monitoring is recommended following each increase in stimulation intensity, in order to detect the presence of cardiac side effects. A Lateral incision made along the anterior fold of the axilla; lead connector pin has been passed through a tunnel between the cervical and paraxillary incisions.
Seizure frequency was approximately three times per week (complex focal and generalized tonic-clonic episodes). Intraoperative Evoked Potential Monitoring (EPM) was used to analyze the stimulus waveform from the neck, for verification of an electrical discontinuity in patient number 2.
He reported daily atypical absence seizures with automatisms and occasional generalized tonic-clonic episodes. Plain thoracic x-rays displaying the vagus nerve stimulator (VNS) implanted on the right side in patient number one. With this new technique, a laser fiber is guided toward the source of a patient's seizures through a small hole in the skull. UCSF has the largest experience with laser ablation for epilepsy in the Bay Area and has done more procedures for pediatric epilepsy patients than any center in California. Treatment success is completely dependent on accurate placement of the laser fiber into the target lesion. Given that this technology is new, the long-term outcomes from laser ablation therapy are not completely known. Your medical records can be reviewed to determine whether you are a candidate or you may undergo further evaluation by an epileptologist specializing in medically refractory epilepsy. Two incisions are made during the procedure—one in the chest to create the generator pocket, and the other along a fold in the neck to expose the vagus nerve for placement of the electrode (Figure 4 .
The entire generator is replaced, rather than just the battery, so as to avoid opening the hermetically sealed titanium case of the generator, which could lead to a rejection reaction The generator-replacement surgery typically lasts approximately 10 to 15 minutes and is performed as a day surgery. 2 Neither of these cardiac events, however, has occurred after surgery during day-to-day treatment with VNS therapy, or in children; they are usually transient and self-limiting, and are rarely of clinical significance. Due to in animal models right side VNS (R-VNS) have shown to be as effective as left-sided stimulation in reducing the frequency of seizures, R-VNS could be considered in patients who may not tolerate L-VNS. Both patients were thought to be at high risk for left vagus nerve injury if L-VNS reimplantation was attempted, thus R-VNS was chosen. B A transverse incision is made along a right cervical crease and the helical electrodes are exposed. After a left temporal lobectomy and amygdalohippocampectomy, a 75% decrease in the total number of seizures was achieved (Engel III-A). The patient underwent L-VNS placement at another institution when he was 27 years-old, and complete control of seizure activity was achieved for 13 years.
Encircled upper arrow points to the VNS around the right vagus nerve trunk; VNS generator is positioned at the right paraxillary region (arrow). The laser heats and destroys the small, well-defined area of abnormal brain tissue, leaving the surrounding tissue unharmed.


In the event that the procedure incompletely treats a patient’s epilepsy, repeat treatments are equally straightforward and well-tolerated. Inaccurate placement of the laser is a potential risk and therefore injury to fragile or sensitive structures nearby is possible. Because the leads remain untouched during a generator replacement, only one incision is needed .
The objective is to examine our experience of R-VNS placement in two patients with intractable epilepsy. C Microscope view of the carotid sheath; the vagus nerve (arrow) is generally encountered deep and medial to the internal jugular vein (arrow heads), encased in firm areolar tissue lateral to the common carotid artery. However, two years after surgery the patient reported a seizure frequency similar to his preoperative seizure rate (Engel IV-B). At the time of subsequent battery replacement, the device became non-functional and the patient experienced a significant increase in seizure frequency.
The entire procedure is viewed in real time on MR images that show thermal maps displaying the distribution of heat to ensure safety and successful target treatment. For that reason, the majority of the treatment time is meant to ensure the accuracy of laser placement prior to initiating ablation. The device is often turned on in the operating room or in the office immediately after surgery, generally with a low initial setting of 0 . A new video-EEG study showed undifferentiated bioelectrical basal activity, so the patient was considered for implantation of a VNS. As with any brain procedure, there are risks of bleeding and infection, but these are always proportional to the size of the surgical exposure, treatment time and depth of treatment, all of which are lessened with laser therapy compared to open cranial surgery.
The processors are divided by the companies making the processors (Intel and AMD) then within those companies, a general ranking and purpose is offered for the kinds of processors each is offering. The negative (arrow) or the positive terminal (arrow head) can be applied first; the anchoring tether is generally applied last.
The first attempt to implant a L-VNS via left anterolateral cervicotomy failed due to significant bleeding of thyroid veins and the presence of a thin vagus nerve that was tightly adhered to carotid sheath. The most likely outcomes will depend largely on the type of epilepsy, the kind of lesion that is the source of their epilepsy and the details surrounding their particular laser treatment. Because the patient was at high risk of vascular injury and rebleeding, he was considered for placement of a R-VNS. Before L-VNS explant, intraoperative Evoked Potential Monitoring (EPM) was used to analyze the stimulus waveform from the neck, for verification of an electrical discontinuity. The L-VNS generator and distal lead were removed, but the proximal lead was hardly attached at left vagus nerve due to dense scarring; local scarred tissue and the short distance of available vagus nerve did not allow placement of a new L-VNS. The patient subsequently underwent R-VNS (Cyberonics® 302 model) implantation, via right anterolateral cervicotomy and right para-axillary generator (Cyberonics® 102 model) placement. Therefore, a R-VNS (Cyberonics® 302 model) and a right para-axillary generator (Cyberonics® 102 model) were implanted. A standard lead test and device diagnostics were performed in the operating room without problems and no arrhythmias were observed.
Following each increase in stimulation intensity, we performed a continuous 24-hour electrocardiogram in order to rule out the presence of arrthythmias or impairments in hearth rate; all of the Holter studies were normal. One year after right VNS implantation, the patient reported improved quality of life (Karnofsky 70), as well as a decrease in number (50%) and intensity of seizures.
At last follow-up, 7 months after surgery, a decrease in 95% of the total number of seizures was noted.



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