Vagus nerve stimulation in pediatric patients: is it really worthwhile?

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Vagus nerve stimulation in pediatric patients: Is it really worthwhile?

Authors: Vera C. Terra a, Luciano L. Furlanetti b, Altacílio Aparecido Nunes c, Ursula Thomé a,Meire Akico Nisyiama a, Américo C. Sakamoto a, Helio R. Machado a,
a Centro de Cirurgia de Epilepsia (CIREP), Departamento de Neurociências e Ciências do Comportamento, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, SP, Brazil
b Division of Stereotactic and Functional Neurosurgery, University Hospital Freiburg, Freiburg im Breisgau, Germany
c Departamento de Medicina Social, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, SP, Brazil

Source: Epilepsy and Behavior, November 5, 2013

Aim:

To determine efficacy of VNS in refractory epilepsy patients under the age of 18.

Methods:

A case–control prospective study of children with refractory epilepsy submitted to vagal nerve stimulator implantation and a control group with epilepsy treated with antiepileptic drugs. Patients under 18 years of age who underwent clinical or surgical treatment because of pharmacoresistant epilepsy from January 2009 to January 2012 were followed and compared with an age-matched control group at final evaluation.

Results:

Statistically significant differences were observed considering age at epilepsy onset (VNS group — 1.33 ± 1.45 years; controls — 3.23 ± 3.11; p = 0.0001), abnormal findings in neurological examination (p = 0.01), history of previous ineffective epilepsy surgery (p = 0.03), and baseline seizure frequency (p=0.0001). At long-term follow-up, 55.4% of the patients in the VNS group had at least 50% reduction of seizure frequency, with 11.1% of the patients presenting 95% reduction on seizure frequency. Also, a decrease in traumas and hospitalization due to seizures and a subjective improvement in mood and alertness were observed. The control group did not show a significant modification in seizure frequency during the study

Conclusion:

In this series, VNS patients evolved with a statistically significant reduction of the number of seizures, a decreased morbidity of the seizures, and the number of days in inpatient care. In accordance with the current literature, VNS has been proven to be an effective alternative in the treatment of paediatric patients with drug-resistant epilepsy.

http://www.ncbi.nlm.nih.gov/pubmed/24210463

Comments from reviewer, Prof Van Nieuwenhuizen:

The VNS group consisted of 36 patients; the control group of 72 patients: 26 waiting for epilepsy surgery, 24 patients with incomplete investigations that needed PET scan or subdural grids, 16 patients with vagal nerve stimulation indicated in which implantation could not be done because of insufficient local resources and 2 patients from families that refused implantation. Composition of the control group is obviously heterogeneous. Interesting differences between VNS group and control group are found: focal epilepsy was found in 52.8% of the VNS group and in 77.8% of the control group. Previous ineffective epilepsy surgery was more frequently found in the VNS group, indicative for the “back to the wall” image of VNS. Also a statistically significant difference was found regarding seizure frequency: 346 per month in the VNS group and 83 for the control group. This suggests that VNS implementation may be “forced” by number of seizures and not by seizure severity. As is stated in the abstract, VNS was effective in reducing number of seizures: 55.4% showed at least 50% reduction of seizure frequency; 11.1% had 95% reduction. This positive effect also regards traumas and hospitalizations. An important statement was made in the Conclusion section: “…however, at least in developing countries, the initial investment still represents a barrier for its implementation”. This reflects one part of the control group: “16 patients with vagal nerve stimulation indicated in which implantation could not be done because of insufficient local resources”.  A regrettable situation.

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