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Vagus Nerve Stimulation Therapy for the Treatment of Seizures in Refractory Postencephalitic Epilepsy: a Retrospective Study

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Vagus Nerve Stimulation Therapy for the Treatment of Seizures in Refractory Postencephalitic Epilepsy: a Retrospective Study fnins-15-685685 August 14, 2021 Time: 15:43 # 1 ORIGINAL RESEARCH published: 19 August 2021 doi: 10.3389/fnins.2021.685685 Vagus Nerve Stimulation Therapy for the Treatment of Seizures in Refractory Postencephalitic Epilepsy: A Retrospective Study Yulin Sun1,2†, Jian Chen1,2†, Tie Fang3†, Lin Wan1,2, Xiuyu Shi1,2,4, Jing Wang1,2, Zhichao Li1,2, Jiaxin Wang1,2, Zhiqiang Cui5, Xin Xu5, Zhipei Ling5, Liping Zou1,2 and Guang Yang1,2,4* 1 Department of Pediatrics, Chinese PLA General Hospital, Beijing, China, 2 Department of Pediatrics, The First Medical Center, Chinese PLA General Hospital, Beijing, China, 3 Department of Functional Neurosurgery, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing, China, 4 The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China, 5 Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China Edited by: Eric Meyers, Background: Vagus nerve stimulation (VNS) has been demonstrated to be safe and Battelle, United States effective for patients with refractory epilepsy, but there are few reports on the use of Reviewed by: VNS for postencephalitic epilepsy (PEE). This retrospective study aimed to evaluate the Sabato Santaniello, University of Connecticut, efficacy of VNS for refractory PEE. United States Ismail˙ Devecïoglu,˘ Methods: We retrospectively studied 20 patients with refractory PEE who underwent Namik Kemal University, Turkey VNS between August 2017 and October 2019 in Chinese PLA General Hospital *Correspondence: and Beijing Children’s Hospital. VNS efficacy was evaluated based on seizure Guang Yang reduction, effective rate (percentage of cases with seizure reduction ≥ 50%), McHugh [email protected] classification, modified Early Childhood Epilepsy Severity Scale (E-Chess) score, and †These authors have contributed equally to this work Grand Total EEG (GTE) score. The follow-up time points were 3, 6, and 12 months after VNS. Pre- and postoperative data were compared and analyzed. Specialty section: This article was submitted to Results: The median [interquartile range (IQR)] seizure reduction rates at 3, 6, and Neuroprosthetics, 12 months after VNS were 23.72% (0, 55%), 46.61% (0, 79.04%), and 67.99% (0, a section of the journal Frontiers in Neuroscience 93.78%), respectively. The effective rates were 30% at 3 months, 45% at 6 months, and Received: 25 March 2021 70% at 12 months. E-chess scores before the operation and at 3, 6, and 12 months Accepted: 31 July 2021 after the operation were 10 (10, 10.75), 9 (9, 10), 9 (9, 9.75), and 9 (8.25, 9) (P < 0.05), Published: 19 August 2021 respectively. GTE scores before surgery and at 12 months after the operation were Citation: Sun YL, Chen J, Fang T, Wan L, 11 (9, 13) and 9 (7, 11) (P < 0.05), respectively. The mean intensity of VNS current Shi XY, Wang J, Li ZC, Wang JX, was 1.76 ± 0.39 (range: 1.0–2.5) mA. No intraoperative complications or severe Cui ZQ, Xu X, Ling Z, Zou LP and post-operative adverse effects were reported. Yang G (2021) Vagus Nerve Stimulation Therapy for the Treatment Conclusions: Our study shows that VNS can reduce the frequency and severity of of Seizures in Refractory Postencephalitic Epilepsy: seizure in patients with refractory PEE. VNS has a good application prospect in patients A Retrospective Study. with refractory PEE. Front. Neurosci. 15:685685. doi: 10.3389/fnins.2021.685685 Keywords: vagus nerve stimulation, postencephalitic epilepsy, refractory epilepsy, encephalitis, children Frontiers in Neuroscience| www.frontiersin.org 1 August 2021| Volume 15| Article 685685 fnins-15-685685 August 14, 2021 Time: 15:43 # 2 Sun et al. VNS for Treatment of PEE INTRODUCTION before seizure onset or during the seizure. The stimulation amplitude associated with the magnet mode was 0.2 mA Encephalitis in early childhood may damage brain tissue higher than that associated with the normal mode, with other and it may cause neurological sequelae, including epilepsy. stimulation parameters kept constant. Epidemiological studies reported a 16.4–29% incidence of Follow-up was performed at 3, 6, and 12 months after epilepsy secondary to encephalitis, among which refractory implantation. We collected data including (1) demographics; (2) epilepsy accounts for 7–15% (Lee et al., 2007; Sellner and Trinka, age at onset; (3) encephalitis etiology; (4) seizure type; (5) seizure 2012; Singh et al., 2015; Pillai et al., 2016). Most cases of frequency; (6) number and dosage of ASMs; (7) VNS parameters; postencephalitic epilepsy (PEE) are intracatable and cannot be (8) improvement of cognitive, linguistic, and athletic ability; (9) treated by traditional epilepsy surgery because of the diffuse post-operative adverse effects; and (10) electroencephalogram epileptogenic foci, which are difficult to localize. The severity (EEG) findings. Informed consent was obtained from the and refractory nature of PEE necessitate the identification of children or their guardians for the purpose of this study. alternative treatment options. Since it was first proposed in 1988, Vagus nerve stimulation efficacy was evaluated based on the vagus nerve stimulation (VNS) has been recognized worldwide seizure reduction, effective rate, McHugh classification, modified as an approved and effective adjunctive therapy for medically Early Childhood Epilepsy Severity Scale (E-Chess), and Grand intractable epilepsy (Hajnsek et al., 2005; González et al., 2019). Total EEG (GTE) score. Seizure reduction was assessed as However, there are few reports on the treatment of refractory PEE follows: (baseline frequency − frequency with VNS)/(baseline by VNS, especially in children. To better evaluate the efficacy of frequency) × 100%. It was defined as NA (not available) if the VNS for PEE, we conducted an observational study of 20 patients value was negative, which meant the seizure frequency increases. under 18 years old, summarizing their clinical characteristics and The baseline frequency was recorded for 2 weeks before VNS long-term prognosis. operation (Riikonen, 2020). Effectiveness was defined as seizure reduction ≥ 50%, and the effective rate was defined as the percentage of responders with a seizure reduction rate was ≥50% MATERIALS AND METHODS (Colicchio et al., 2010). The McHugh classification was used to further evaluate the VNS efficacy (McHugh et al., 2007): Class All patients who were implanted with a stimulator (G111 IA (most obvious improvement) to Class V (no improvement). or G112, Pins Medical, Ltd., Beijing, China) with remote Seizure severity was assessed using a modified E-chess score programming function between August 2017 and October 2019 (Humphrey et al., 2008; Ho et al., 2018), which was calculated were included in our retrospective study, and they completed based on the following four severity indices: time period over at least 12 months of follow-up. Patients at the Chinese PLA which seizures occur, number of seizure types, number of ASMs General Hospital and Beijing Children’s Hospital were diagnosed used, and response to treatment. The score ranged from 3 (least according to the practical clinical definition of the International severe) to 12 (most severe). The McHugh classification and the Anti-Epilepsy Alliance (ILAE) (Fisher et al., 2017), which defines modified E-chess score were independently evaluated by two PEE as the occurrence of at least one unprovoked seizure after pediatric neurologists. If scores were inconsistent, they discussed the acute phase of encephalitis. All patients had been diagnosed and determined final scores. EEG abnormalities were evaluated as having drug-resistant epilepsy (DRE), which is defined by the using the GTE score (Limotai et al., 2018), which was calculated ILAE as the persistence of seizures at final follow-up despite the based on six items: frequency of rhythmic background activity, use of at least two appropriate anti-seizure medications (ASMs) diffuse slow-wave activity, reactivity of rhythmic background (Fisher et al., 2017; Kimizu et al., 2018). Classification of seizure activity, paroxysmal activity, focal abnormalities, and sharp- type was performed by at least two pediatric neurologists in wave activity. The score ranged from 1 (normal EEG) to 31 accordance with the 2017 ILAE classification proposal based on (most severe). The GTE scores were scored independently by clinical symptoms and EEG findings. The VNS stimulator was two EEG experts and were discussed and determined if they implanted by neurosurgeons according to standard procedures were inconsistent. We also recorded improvement in cognitive, (Révész et al., 2016). The stimulator was turned on within 2 weeks linguistic, and athletic abilities at 12 months after the operation, after implantation, and electrical stimulation was commenced at based on subjective feeling and descriptions given by the patients 0.2–0.5 mA depending on patient tolerance (signal frequency: or their guardians. The development level was also evaluated, 30 Hz, pulse width: 250 or 500 ms, duty cycle: 30 s on/3 or 5 min using the Gesell Developmental Schedules (GDS), but only in two off). The stimulation parameters were modified every 4 weeks patients (both aged < 6 years). in the first 3 months in accordance with observed therapeutic SPSS 22.0 statistical software (IBM Corp., Armonk, NY, effects and adverse reactions. Parameters were changed according United States) was used for data analysis. Categorical data to each patient’s situation. When the treatment effect was not are expressed as percentages, while the continuous data are
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