Guideline update VNS

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Evidence-based guideline update: Vagus nerve stimulation for the treatment of epilepsy: Report of the Guideline Development Subcomittee of the American Academy of Neurology.

Morris GL 3rd, Gloss D, Buchhalter J, Mack KJ, Nickels K, Harden C.

Neurology. 2013 Aug 28. [Epub ahead of print]

Source:

From the Aurora Epilepsy Center (G.L.M.), Sr. Luke’s Medical Center, Milwaukee, WI; Barrow Neurology Institute (D.G), Phoenix, AZ; University of Calgary (J.B), Canada; Mayo Clinic (K.L.M.; K.N.), Rochester, MN; and Hofstra University North Shore-Long Island Jewish Medical College (C.H.), Great Neck, NY.

Abstract

Objective:

To evaluate the evidence since the 1999 assessment regarding efficacy and safety of vagus nerve stimulation (VNS) for epilepsy, currently approved as adjunctive therapy for partial-onset seizures in patients > 12 years

Methods:

Review of the literature and identification of relevant published studies. Classification of these according to the American Academy of Neurology evidence-based methodology

Results:

VNS is associated with a > 50% seizure reduction in 55% (95% confidence interval(Ci) 50-59%) of 470 children with partial or generalized epilepsy (13 class III studies). VNS is associated with a > 50% seizure reduction in 55% (95% Ci 46-64%) OF 113 PATIENTS WITH Lennox-Gastaut syndrome (LGS) (4 class III studies). VNS is associated with an increase in ≥ 50% seizure reduction rates of ~7% from 1-5 years postimplantation (2 class III studies). VNS is associated with a significant improvement in standard mood scales in 31 adults with epilepsy (2 class III studies). Infection risk at the VNS implantation site in children is increased relative to that in adults (odds ratio 3.4, 95% Ci 1.0-11.2) VNS is possibly effective for seizures (both partial and generalized) in children, for LGS-associated seizures, and for mood problems in adults with epilepsy. VNS may have improved efficacy over time.

Conclusions:

VNS may be considered for seizures in children, for LGS-associated seizures and for improving mood in adults with epilepsy (Level C). VNS may be considered to have improved efficacy over time (Level C). Children should be carefully monitored for site infection after VNS implantation.

http://www.ncbi.nlm.nih.gov/pubmed/23986299

Comments reviewer, Prof Van Nieuwenhuizen:

This is an important paper: in particular for paediatric neurologists. In the 1999 AAN (American Academy of Neurology) technology assessment, indication for VNS was only given for children > 12 years with medically intractable partial seizures who are not candidates for potentially curative surgical resections (such as lesionectomies or mesial temporal lobectomies). At that time no recommendation could be given for VNS therapy in children < 12 years or children with Lennox-Gastaut Syndrome (LGS). That recommendation is now put forward: an important message for doctors treating these children. Important is also the finding that the responder rate (≥ 50% reduction of seizures) in children with LGS does not appear to differ from that of the general population of patients with refractory epilepsy. Another important statement of this update is that VNS may show improved efficacy over time as it is well known that both drug efficacy and efficacy of epilepsy surgery may decrease over time. No evidence could be found for better outcome of VNS therapy using rapid stimulation cycles (7 seconds “on” and 30 seconds “off” instead of 30 seconds “on” and 300 seconds “off”). As rapid cycle will hasten the time for battery (expensive) replacement, this is an important issue. Finally, special care is requested for handling the device in children, in particular developmentally delayed. Unpredictable behaviour (scratching of the implantation wound, wrestling) does increase the risk for infection.

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