Epilepsy is a neurological disorder characterized by recurrent, unprovoked seizures that can significantly impact an individual’s quality of life. While antiepileptic drugs (AEDs) remain the first line of treatment, some patients, about 1/3, do not achieve satisfactory seizure control despite multiple and or maximal dosages. For these individuals, alternative treatment options like vagus nerve stimulation (VNS) are gaining attention.

This blog explores VNS as a therapeutic option for epilepsy in both adults and children, discussing who might benefit, the surgical technique involved, potential side effects, and expected outcomes.

Who might benefit from vagus nerve stimulation?

VNS is typically considered for patients with drug-resistant epilepsy, meaning they do not respond adequately to at least two different AEDs. This treatment is suitable for both adults and children, especially those aged 12 and up. Here are specific groups that may benefit from VNS:

• Drug-resistant epilepsy patients: Individuals who have not found relief through traditional medications may find VNS offers an alternative approach.
• Patients with high surgical risk: For those who are not candidates for resective surgery due to the location of the seizures or other medical conditions, VNS can be a safer option.
• Children and adolescents: Younger patients often experience different seizure types, and VNS can help manage seizures without the cognitive side effects of many medications.
• Individuals seeking a multi-faceted approach: VNS can complement other treatments, including medication and behavioral therapy, providing a comprehensive management plan.

Overview of the surgical technique

Vagus nerve stimulation is a minimally invasive procedure that involves implanting a pulse generator, pacemaker like device under the skin of the chest to stimulate the vagus nerve, which runs from the brainstem to the abdomen. Here’s a breakdown of the surgical technique:

• Preoperative assessment: Patients undergo evaluations to determine their eligibility and to understand their specific type of epilepsy.
• Procedure: The procedure is typically performed under general anesthesia and usually lasts about an hour. A small incision is made on the neck to expose the vagus nerve, which is located just above the clavicle. A lead wire is wrapped around the vagus nerve, and a pulse generator is implanted under the skin in the chest area.
• Activation: After surgery, the device is activated and a schedule increase in dosage is built in every two weeks, and patients usually undergo regular follow-up visits to adjust the stimulation settings once reaching therapeutic doses, which can be fine-tuned to achieve optimal seizure control.
• Maintenance: The battery life of the pulse generator is typically 5 to 10 years, after which surgical replacement is necessary. Regular appointments will ensure the device functions optimally, and the stimulation is appropriately adjusted.

Additionally, the device can be activated if there is concern of seizure coming on by swiping a magnet (supplied with the device) over the pulse generator. This will set off an extra stimulation to try and interfere with the spread of the seizure. As well, the device can often detect when a seizure has come on and will also provide an extra stimulus.

Potential side effects

While VNS can be an effective alternative for treating epilepsy, it’s essential to be aware of potential side effects, which may include:

• Hoarseness: Patients may experience temporary or persistent changes in voice, particularly during stimulation. This side effect commonly occurs but generally resolves over time.
• Sore throat: Some patients report discomfort or pain in the throat area. This can also be a temporary issue, especially during the initial weeks post-implantation.
• Coughing: VNS may trigger coughing, particularly during stimulation, but this side effect usually subsides as the body adjusts.
• Shortness of breath: Some users may experience mild respiratory distress. This is usually transient but should be monitored.
• Potential psychological effects: There may be an association between VNS and mood changes, including anxiety or depression in some patients, though further research is needed to ascertain this relationship.

While these side effects are typically manageable, it’s crucial for patients and their healthcare teams to maintain open communication to navigate any adverse experiences effectively.

Potential outcomes

The outcomes of VNS for epilepsy can vary widely among patients and depend on several factors, including the individual’s age, type of epilepsy, and how well they respond to the stimulation. Here are some potential outcomes to consider:

• Seizure reduction: Studies have shown that many patients experience a significant reduction in seizure frequency, with some individuals achieving more than a 50% decrease in seizures after a few months to a year of treatment.
• Quality of life improvement: Beyond reducing the frequency of seizures, many patients report an enhanced quality of life, with improved mood and cognitive function, largely due to diminished stress related to seizure management. VNS has preliminarily been shown to improve brain function and connectivity leading to improved cognitive function.
• Potential for medication reduction: Successfully integrating VNS into a treatment plan may allow some patients to reduce their reliance on antiepileptic drugs, potentially lessening medication-related side effects.
• Long-term management: VNS offers a long-term solution for managing epilepsy, with ongoing adjustments made to stimulation settings to refine the therapy’s effectiveness over time.
• Complementary treatment: For individuals already benefiting from medication, VNS can serve as an adjunctive therapy. This means that while patients continue their existing antiepileptic drugs, VNS can help further stabilize their condition and provide an additional layer of control over seizures. The synergy between VNS and medications may enhance overall treatment efficacy, enabling patients to better manage their epilepsy.
• Long-term effectiveness: VNS is designed to provide consistent long-term stimulation to the vagus nerve, which can help maintain a reduction in seizure frequency over time. Unlike some other interventional therapies that may require repeated procedures or adjustments, VNS is typically a sustained treatment, with ongoing benefits reported by many patients’ years after the initial implantation.
• Emergency response: VNS devices specific for epilepsy come equipped with a magnet that patients can use to activate the device manually during a seizure. This feature allows individuals to potentially shorten the duration or severity of a seizure episode, providing a sense of autonomy and control during a critical time.
• Research and future directions: Current research is ongoing to assess the full range of benefits and to optimize VNS therapy. Studies are examining the effects of varying stimulation parameters, the potential for newer, more efficient devices, and the long-term impact of VNS on cognitive function and behavior. Emerging research indicates that VNS may even hold potential benefits for other conditions, such as depression and anxiety, paving the way for broader applications in mental health management.
• Patient and family education: One of the key components of successful VNS treatment is education and support for both patients and their families. Empowering patients with knowledge regarding their condition, the role of VNS, and how to manage their health proactively can significantly enhance treatment outcomes. Support groups and educational programs can also foster a sense of community and normalcy for those living with epilepsy. We recommend contacting our local Epilepsy Foundation West Virginia (https://www.epilepsy.com/local/west-virginia) for more information.
• Individual variability: It’s important to recognize that outcomes are individualized. Factors such as age, seizure type, and the presence of comorbid conditions can influence how one responds to VNS treatment. Some patients may experience remarkable results, while others may find their seizure control only moderately improved. Tailoring treatment plans to align with personal health goals and feedback from the patient is essential for optimal success.

Vagus nerve stimulation presents a promising avenue for epilepsy management in both adults and children, especially for those who have not achieved satisfactory control with conventional medications. By understanding who might benefit from this treatment, the surgical procedure involved, possible side effects, and likely outcomes, patients and their families can make more informed decisions about their epilepsy management strategies.

As always, it’s crucial for patients to engage in thorough discussions with their healthcare providers to evaluate whether VNS is a suitable option based on their specific circumstances. The evolving landscape of epilepsy treatments, including VNS, offers hope for enhanced seizure control and improved quality of life for countless individuals grappling with this challenging condition.

Ultimately, VNS is not a cure for epilepsy, but it represents a significant step forward in the journey toward better management of the disorder, providing patients with a chance to reclaim their lives from the grip of seizures. As research continues to explore the full potential of this therapy, it’s likely VNS will endure as a valuable tool in the quest for effective epilepsy treatment.

If you believe you might have drug resistant epilepsy and may benefit from VNS, contact us at 1-855-WVU-CARE(2273), or visit us online at the WVU Medicine Children’s Neuroscience Center Epilepsy Program or the Epilepsy Center at the Rockefeller Neuroscience Institute. You’ve come to the right place.