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• W2169306312 abstract "See related article, p. 563 In this issue Murphy et al1Murphy JV the Pediatric VNS Study Group Left vagal nerve stimulation in children with medically refractory epilepsy.J Pediatr. 1999; 134: 563-566Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar outline the effectiveness of an implanted vagal nerve stimulator to reduce seizures in 60 children with intractable epilepsy. Over the 18 months after implantation, there was a reduction in seizure frequency of about 50%. The device was well tolerated, and only 5 children discontinued its use. The reader will note that most children in this study were teenagers, although the youngest was 3.6 years of age. We know little of the clinical profile of these children. In two thirds, the etiology of the epilepsy was unknown. In addition, it is not known whether the children were intellectually or neurologically normal, features often associated with intractable epilepsy in children. It seems improbable that stimulation of the vagus nerve would have an effect on epilepsy, and yet it does. The physiologic reason is unknown. The vagus nerve carries efferent parasympathetic instructions mainly to the gut but also to the heart, larynx, and other organs. Afferent messages are returned to the brain from a variety of viscera. When the vagus nerve is stimulated, the message is received in the medulla in the tractus solitarius and then projected widely through the nervous system.2Wilder BJ Vagal nerve stimulation.in: Epilepsy: a comprehensive textbook. : Lippincott-Raven Publishers, Philadelphia1997: 1353-1358Google Scholar The vagus nerve stimulator is implanted subcutaneously in the chest with the stimulating electrode on the left vagus nerve in the neck. The rate of stimulation is controlled transcutaneously, with higher rates of stimulation having greater anti-seizure effects. The patient can feel the “buzz” of the stimulator, but careful single-blind studies of several hundred adults have shown the device to be effective by comparing low, ineffective stimulation rates with higher rates.3Handforth A DeGiorgio CM Schachter SC Uthman BM Naritoku DK Tecoma ES et al.Vagus nerve stimulation therapy for partial-onset seizures: a randomized active-control trial.Neurology. 1998; 51: 48-55Crossref PubMed Scopus (863) Google Scholar Despite seizure reduction, very few adults or children have become free of seizures. Over time, the degree of seizure control with the stimulator seems to improve, which is quite different from new medications, which may gradually lose their “punch” after an initial response.2Wilder BJ Vagal nerve stimulation.in: Epilepsy: a comprehensive textbook. : Lippincott-Raven Publishers, Philadelphia1997: 1353-1358Google Scholar The vagal stimulator is expensive but seemingly well tolerated. Effects on the heart are minimal.4Frei MG Davidchack R Lawrence KS Osorio I Effects of vagal stimulation on human ECG [abstract].Epilepsia. 1998; 39: 200Google Scholar Who is a candidate for a vagal stimulator implant? First, it is important to note that Murphy et al1Murphy JV the Pediatric VNS Study Group Left vagal nerve stimulation in children with medically refractory epilepsy.J Pediatr. 1999; 134: 563-566Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar have reported only children with a few intractable epilepsy syndromes—those with localization-related epilepsy (usually with complex partial seizures) and those with generalized tonic-clonic seizures (presumably secondarily generalized in most cases). Unfortunately, there is little published information about the epilepsy types that are most frequently troublesome in childhood—epilepsies with mixtures of myoclonus, atypical absence, drop attacks, and tonic seizures (especially Lennox-Gastaut syndrome). Second, there is a need to define intractable epilepsy more clearly.5Camfield PR Camfield CS Antiepileptic drug therapy: When is epilepsy truly intractable?.Epilepsia. 1996; 37: S60-S65Crossref PubMed Scopus (98) Google Scholar Usually, intractable means that treatment with at least 3 appropriate anti-epileptic medications has failed. Third, physicians need to be reminded that over time many children with intractable epilepsy will gain seizure control. Huttenlocher and Hapke6Huttenlocher PR Hapke RJ A follow-up study of intractable seizures in childhood.Ann Neurol. 1990; 28: 699-705Crossref PubMed Scopus (184) Google Scholar noted that in 30% of 145 children with severe epilepsy control of seizures was achieved with conventional medical therapy during follow-up. After 10 years, 70% of those with normal intelligence were free of seizures. Fourth, other treatments for intractable epilepsy need consideration. Most trials of new anti-epileptic medications are “primary proof of efficacy trials”: patients with very frequent seizures are randomly assigned to receive the new drug or placebo for a few months. The number of patients with a ≥50% reduction in seizures is counted, and if this is greater than the number in the placebo group, the drug may be marketed.7Baker GA Camfield C Camfield P Cramer JA Elger CE Johnson AL et al.Commission on outcome measurement in epilepsy, 1994-1997: final report.Epilepsia. 1998; 39: 213-231Crossref PubMed Scopus (137) Google Scholar In these studies the number becoming free of seizures is usually minuscule, and the duration of the effect is often very short. There is little evidence that a never-ending series of new drug trials for a given patient holds much promise. The ketogenic diet is again in vogue. The success rate of children with intractable epilepsy treated with the diet is about 30%.8Freeman JM Vining EPG Pillas DJ Pyzik Pl Casey JC Kelly MT The efficacy of the ketogenic diet—1998: a prospective evaluation of intervention in 150 children.Pediatrics. 1998; 102: 11358-11363Crossref Scopus (466) Google Scholar The diet is more difficult but not impossible to manage in older children because of the taste of the food and the impact on life-style. Therefore if a school-aged child with epilepsy has not responded to treatment with 3 or 4 drugs, there really are only 3 major options—waiting, surgery, or the vagal nerve stimulator. If the child has a localized cortical lesion, surgical resection can be curative in 70%. Corpus callosotomy assists some children, but few become free of seizures. The vagal nerve stimulator must be viewed as palliative; there is a good chance that it will reduce the number of seizures but very little chance of a “cure.” The value of a 20% to 50% reduction in seizure frequency in children is of unknown long-term benefit. In adults, it would appear that major gains in quality of life require that the seizures stop,9Vickrery BG Hays RD Rausch R Sutherling WW Engel JP Brook RH Outcome assessment for epilepsy surgery: the impact of measuring health-related quality of life.Ann Neurol. 1995; 37: 158-166Crossref PubMed Scopus (182) Google Scholar although there is some suggestion that lesser responses are still of value.10Greathouse N Kay A Drake ME Goodman JM Improved quality of life after implantation of the vagus nerve stimulator [abstract].Epilepsia. 1998; 39: 195Google Scholar, 11Banez MJ Ritter FJ Frost MD Relationship between seizure control after vagus nerve stimulation and quality of life in pediatric patients [abstract].Epilepsia. 1998; 39: 224Google Scholar What type of data will investigators need to develop to help us to find the place for vagal nerve stimulation in children? First, how many children become completely free of seizures? Second, what is the impact on the child’s quality of life, especially if the response is only partial? Third, is there a recognizable profile for the best responders? Fourth, what is the response rate in mixed secondary generalized epilepsies? There is a clear need for additional research in this area. Currently, there should not be a stampede for the clinical use of this new technology." @default.
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• W2169306312 title "Vagal nerve stimulation for treatment of children with epilepsy" @default.
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