Vagus nerve stimulation explained

Vagus nerve stimulation
Synonym:Vagal nerve stimulation

Vagus nerve stimulation (VNS) is a medical treatment that involves delivering electrical impulses to the vagus nerve. It is used as an add-on treatment for certain types of intractable epilepsy, cluster headaches, treatment-resistant depression and stroke rehabilitation.

Medical use

Epilepsy

VNS is used to treat drug-resistant epilepsy.[1]

In the United States, VNS is approved as adjunctive therapy for those 4 years of age or older with refractory focal onset seizures. In the European Union, VNS is approved as an adjunctive therapy for patients with either generalized or focal onset seizures without any age restrictions.[2] It is recommended that VNS is only pursued following an adequate trial of at least 2 appropriately chosen anti-seizure medications and that the patient is ineligible for epilepsy surgery.[3] This is because epilepsy surgery is associated with a higher probability of resulting in seizure freedom.[4] Patients who have poor adherence or tolerance of anti-seizure medications may be good candidates for VNS.[5]

VNS may provide benefit for particular epilepsy syndromes and seizure types such as Lennox-Gastaut syndrome, tuberous sclerosis complex related epilepsy, refractory absence seizures and atonic seizures.[6] [7] [8] [9] There are also reports of VNS being successfully utilized in patients with refractory and super-refractory status epilepticus.[10]

Cluster headaches

The UK National Institute for Health and Care Excellence (NICE) in the UK recommends VNS for cluster headaches.[11] device was used in these studies:

Treatment-resistant depression

VNS is used to treat treatment-resistant major depressive disorder (TR-MDD).[12] The UK NICE guidance (from 2020) stated that "Evidence on its efficacy is limited in quality." and encouraged further research studies "in the form of randomised controlled trials with a placebo or sham stimulation arm."[13]

Stroke rehabilitation

In 2021 the U.S. Food and Drug Administration approved the MicroTransponder Vivistim Paired VNS System (Vivistim System) to treat moderate to severe upper extremity motor deficits associated with chronic ischemic stroke.[14] [15]

Beyond its use in epilepsy and depression, VNS has shown potential benefits in treating other conditions such as inflammatory diseases. Ongoing research is exploring the broader applications of VNS in various medical fields.[16]

Efficacy

Epilepsy

A meta-analysis of 74 clinical studies with 3321 patients found that VNS produced an average 51% reduction in seizures after 1 year of therapy.[17] Approximately 50% of patients had an equal to or greater than 50% reduction in seizures at the time of last follow-up. Long-term studies have shown that response to VNS increases over time. For instance, a study that followed 74 patients for 10–17 years found a seizure frequency reduction of 50-90% in 38.4%, 51.4%, 63.6% and 77.8% of patients at 1-, 2-, 10- and 17-years following implantation, respectively.[18] Approximately, 8% have total resolution of seizures.[19] VNS has also been shown to reduce rates of sudden unexpected death in epilepsy (SUDEP) and to improve quality of life metrics.[20] [21] A number of predictors of a favorable clinical response have been identified including epilepsy onset > 12 years of age, generalized epilepsy type, non-lesional epilepsy, posttraumatic epilepsy and those who have less than a 10-year history of seizures.[22]

Long-term cognitive outcomes are at least stable following VNS.[23]

One study of children with epilepsy found that a post hoc analysis revealed a dose–response correlation for VNS.[24]

Depression

A 2022 narrative review concluded that "The use of VNS is an approved, effective and well-tolerated long-term therapy for chronic and treatment-resistant depression. Further sham-controlled studies over a longer observational period are desirable".[25] [26]

The review also found that, "Many studies and case series demonstrated the efficacy of VNS as an adjuvant procedure for TRD (treatment resistant depression). The effect occurs with a latency period of 3–12 months and possibly increases with the duration of VNS."[25] One study of only 10 weeks found no effect.[27]

A 2020 review concluded "Reviewed studies strongly suggest that VNS ameliorates depressive symptoms in drug-resistant epileptic patients and that the VNS effect on depression is uncorrelated to seizure response.[28]

In one study higher electrical dose parameters were associated with response durability.[29]

Wellbeing

VNS may have positive wellbeing, mood and quality of life effects.[30] [31]

Studies have found improvements in standard patient-reported mood assessment scales in adult patients with epilepsy after using VNS,[3] and some have found no association between mood change and reduction in seizure frequency.[32] [33] Another study of epilepsy patients measured a general mood improvement, and suggested that VNS may improve unspecific states of indisposition and dysphoria.[34] Patients with comorbid depression have been found to have mood improvements with VNS therapy.[35]

Quality of life (QOL) improvement was also associated with VNS use.[36] One study of children with epilepsy found that better quality of life outcomes after VNS implantation were strongly associated with shorter duration of preoperative seizures and implantation at a young age.[37]

Anxiety reduction has been associated with VNS use.[38] [39] [40] Another study showed improvement in anxiety, depression and QOL scores that were not correlated with a reduction in seizure frequency.[41]

However these studies were small, and recommendations have been made that larger studies with randomised control groups be undertaken.[42]

Heart diseases

In cardiac arrest VNS used in conjunction with cardiopulmonary resuscitation (CPR) has been shown to increase recovery time

Notes and References

  1. Panebianco . Mariangela . Rigby . Alexandra . Marson . Anthony G . Vagus nerve stimulation for focal seizures . Cochrane Database of Systematic Reviews . 14 July 2022 . 2022 . 7 . CD002896 . 10.1002/14651858.CD002896.pub3 . 9281624 . 35833911 .
  2. Wheless . James W. . Gienapp . Andrew J. . Ryvlin . Phillippe . Vagus nerve stimulation (VNS) therapy update . Epilepsy & Behavior . November 2018 . 88 . 2–10 . 10.1016/j.yebeh.2018.06.032 . 30017839 . 51679627 .
  3. Morris . George L. . Gloss . David . Buchhalter . Jeffrey . Mack . Kenneth J. . Nickels . Katherine . Harden . Cynthia . Evidence-based guideline update: Vagus nerve stimulation for the treatment of epilepsy: Report of the Guideline Development Subcommittee of the American Academy of Neurology . Neurology . 15 October 2013 . 81 . 16 . 1453–1459 . 10.1212/wnl.0b013e3182a393d1 . 23986299 . 3806910 .
  4. Fisher . Robert S. . Handforth . Adrian . Reassessment: Vagus nerve stimulation for epilepsy [RETIRED]: A Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology . Neurology . September 1999 . 53 . 4 . 666–669 . 10.1212/wnl.53.4.666 . 10489023. 20845641 . free .
  5. Helmers . Sandra L. . Duh . Mei Sheng . Guérin . Annie . Sarda . Sujata P. . Samuelson . Thomas M. . Bunker . Mark T. . Olin . Bryan D. . Jackson . Stanley D. . Faught . Edward . Clinical and economic impact of vagus nerve stimulation therapy in patients with drug-resistant epilepsy . Epilepsy & Behavior . October 2011 . 22 . 2 . 370–375 . 10.1016/j.yebeh.2011.07.020 . 21872534 . 7869407 .
  6. Grioni . Daniele . Landi . Andrea . Does Vagal Nerve Stimulation Treat Drug-Resistant Epilepsy in Patients with Tuberous Sclerosis Complex? . World Neurosurgery . January 2019 . 121 . 251–253 . 10.1016/j.wneu.2018.10.077 . 30347295 . 53034756 .
  7. Braakman . Hilde M. . Creemers . Joke . Hilkman . Danny M. . Klinkenberg . Sylvia . Koudijs . Suzanne M. . Debeij-van Hall . Mariette . Cornips . Erwin M. . 2018 . Improved seizure control and regaining cognitive milestones after vagus nerve stimulation revision surgery in Lennox–Gastaut syndrome . Epilepsy & Behavior Case Reports . 10 . 111–113 . 10.1016/j.ebcr.2018.08.002 . 30364578 . 6197149 .
  8. Arya . Ravindra . Greiner . Hansel M. . Lewis . Amanda . Mangano . Francesco T. . Gonsalves . Cornelia . Holland . Katherine D. . Glauser . Tracy A. . Vagus nerve stimulation for medically refractory absence epilepsy . Seizure . May 2013 . 22 . 4 . 267–270 . 10.1016/j.seizure.2013.01.008 . 23391567 . 14917920 . free .
  9. Rolston . John D. . Englot . Dario J. . Wang . Doris D. . Garcia . Paul A. . Chang . Edward F. . Corpus callosotomy versus vagus nerve stimulation for atonic seizures and drop attacks: A systematic review . Epilepsy & Behavior . October 2015 . 51 . 13–17 . 10.1016/j.yebeh.2015.06.001 . 26247311 . 5261864 .
  10. Dibué-Adjei . Maxine . Brigo . Francesco . Yamamoto . Takamichi . Vonck . Kristl . Trinka . Eugen . Vagus nerve stimulation in refractory and super-refractory status epilepticus – A systematic review . Brain Stimulation . September 2019 . 12 . 5 . 1101–1110 . 10.1016/j.brs.2019.05.011 . 31126871 . 153310356 . free .
  11. Web site: The Nurosym/Parasym . www.nice.org.uk.
  12. Carreno FR, Frazer A . July 2017 . Vagal Nerve Stimulation for Treatment-Resistant Depression . Neurotherapeutics . 14 . 3 . 716–727 . 10.1007/s13311-017-0537-8 . 5509631 . 28585221.
  13. Web site: 1 Recommendations | Implanted vagus nerve stimulation for treatment-resistant depression | Guidance | NICE . 12 August 2020 .
  14. Web site: FDA Approves First-of-Its-Kind Stroke Rehabilitation System . . 31 August 2021 .
  15. Liu . Charles Y. . Russin . Jonathan . Adelson . David P. . Jenkins . Alistair . Hilmi . Omar . Brown . Benjamin . Lega . Bradley . Whitworth . Tony . Bhattacharyya . Dev . Schwartz . Theodore H. . Krishna . Vibhor . Williams . Ziv . Uff . Christopher . Willie . Jon . Hoffman . Caitlin . Vandergrift . William A. . Achrol . Achal Singh . Ali . Rushna . Konrad . Peter . Edmonds . Joseph . Kim . Daniel . Bhatt . Pragnesh . Tarver . Brent W. . Pierce . David . Jain . Ravi . Burress . Chester . Casavant . Reema . Prudente . Cecília N. . Engineer . Navzer D. . Vagus nerve stimulation paired with rehabilitation for stroke: Implantation experience from the VNS-REHAB trial . Journal of Clinical Neuroscience . November 2022 . 105 . 122–128 . 10.1016/j.jocn.2022.09.013 . 36182812 .
  16. Web site: June 2024 . What Is Vagus Nerve Stimulation? . live . https://web.archive.org/web/20240727090627/https://prolifehc.com/post/What-Is-Vagus-Nerve-Stimulation . July 27, 2024 . July 26, 2024 . www.prolifehc.com.
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  19. Englot . Dario J. . Rolston . John D. . Wright . Clinton W. . Hassnain . Kevin H. . Chang . Edward F. . Rates and Predictors of Seizure Freedom With Vagus Nerve Stimulation for Intractable Epilepsy . Neurosurgery . September 2016 . 79 . 3 . 345–353 . 10.1227/NEU.0000000000001165 . 4884552 . 26645965 .
  20. Englot . Dario J. . Hassnain . Kevin H. . Rolston . John D. . Harward . Stephen C. . Sinha . Saurabh R. . Haglund . Michael M. . Quality-of-life metrics with vagus nerve stimulation for epilepsy from provider survey data . Epilepsy & Behavior . January 2017 . 66 . 4–9 . 10.1016/j.yebeh.2016.10.005 . 27974275 . 5258831 .
  21. Ryvlin . Philippe . So . Elson L. . Gordon . Charles M. . Hesdorffer . Dale C. . Sperling . Michael R. . Devinsky . Orrin . Bunker . Mark T. . Olin . Bryan . Friedman . Daniel . Long-term surveillance of SUDEP in drug-resistant epilepsy patients treated with VNS therapy . Epilepsia . March 2018 . 59 . 3 . 562–572 . 10.1111/epi.14002 . 29336017 . 3782079 . free .
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