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Vagus Nerve Stimulation Therapy

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Vagus Nerve Stimulation
Electrical stimulation of the vagus nerve, the longest nerve in the body, is proving to be an effective treatment for epilepsy in many cases. Two vagus nerves run along each side of the neck, then down the esophagus to the gastrointestinal tract, they affect swallowing, speech, and many other bodily functions.

They also appear to connect to parts of the brain that are involved with seizures. In vagus nerve stimulation, a battery powered device similar to a pacemaker is implanted under the skin in the upper left of the chest and a lead is attached to the left vagus nerve in the lower part of the neck. The batteries wear out after three to five years and need to be removed and replaced.

Vagus nerve stimulation (VNS) is a newer type of treatment for hard to control seizures. VNS involves surgically placing a small battery inside the chest that is attached to wires that are programmed to deliver small burst of electrical energy into the brain.

It is used alongside anti–epileptic drugs especially for people whose epilepsy is difficult to control. It does not free people from seizures but it does reduce the number, length and severity of seizures. It may also reduce the length of the recovery time following seizures. Some patients feel it has improved the quality of their life.

Diagnosis of Epilepsy

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Epilepsy is essentially a clinical diagnosis i.e. from history and physical examination. Detailed account of the attack from patient and the eyewitness is more important than the results of all the investigations as regards confirmation of the diagnosis. It often gives clues to the basic cause as well. Thus every effort must be made to obtain this.

Investigations are done to confirm the diagnosis and determine the cause. Depending on the age of the onset of the first seizures and associated symptoms and signs, the doctor decides the number and priority of the investigations. They include:
  • Plain X–rays of skull and chest.
  • Blood count and haemoglobin concentration.
  • Electroencephalogram (EEG).
  • Cerebrospinal Fluid Examination obtained through lumbar puncture.
  • CT Scans and MRI Scans of the brain.
  • Angiography.
  • IQ test and personality tests.
Diagnosing a case of epilepsy
A patient’s detailed medical history is of utmost importance in diagnosing epilepsy. Many times family members who witness the seizure activity might be asked to keep a record of the time of the seizures, how long each seizure lasts, any aggravating factors like emotional stress, certain foods, smells or sounds etc.. This information can be crucial in the diagnosis of the type of epilepsy.

Usually, a neurologist would look into a case of epilepsy, although general physicians can also treat a person with seizures. The laboratory that would be required for epilepsy are:
  • Primary care investigations
    Chest X–ray to rule out malignancy. Blood tests (eg. full blood count, erythrocyte sedimentation rate, electrolytes, renal function, liver function, calcium, and glucose) could show an underlying disorder or metabolic disturbance.
  • Secondary care investigations
    Such as electroencephalography, neuroimaging, and metabolic screening in children, may aid seizure classification and help to determine the aetiology but they have limitations.
  • Magnetic resonance imaging (MRI)

    Can better define the structures of the brain in three dimensions and can look at discrete areas of brain activation.
  • Computed axial tomography (CAT)
    Has a role in the urgent assessment of seizures or when MRI is contraindicated, but it is less effective in detecting lesions.
  • Electroencephalography (EEG)
    The EEG is not foolproof. It can only measure abnormal electrical activity that occurs during the test period and should not be performed to ‘Exclude’ a diagnosis of epilepsy but should be used to support the classification of epileptic seizures and epilepsy syndromes when there is clinical doubt.
  • Positron emission tomography (PET)
    Scanning is a highly specialized, expensive and largely unavailable technique that detects cerebral blood flow and metabolism.
  • Single proton emission computerized tomography (SPECT)
    scanning is much cheaper and technically simpler than PET scanning it shows the areas where blood flows through your brain.

Treatment of Epilepsy

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Treatment of Epilepsy The neurology team will design a treatment plan according to medical condition, state of health and individual needs. They may also refer to additional doctors or other medical professionals. Most medical treatments can involve some risks or complications. The neurologist will explain any possible risks or complications involved. Don’t be afraid to ask the doctors, nurses or therapists about your treatment.

Drug Therapy
Medication
In many cases, seizures can be successfully prevented with medications. The type of medication you will receive depends on many factors. Your neurologist will explain how the medication should be taken and the side effects that may occur. Over a period of time medication regimen may be changed. It is very important that you take the medication exactly as directed. Call your neurologist if you have any questions about the medications or you experience some unexpected side effects. Some patients do not respond to medications and continue having seizures. In these cases, other treatments may be recommended.

The standard treatment for epilepsy is the regular use of one or more chemical substances called anti–epileptic or anti–convulsant drugs. The ideal situation is when a person takes as little medication as possible while maintaining seizure control.

Anti–epileptic drugs like phenytoin sodium, phenobarbitone, benzodiazepines are commonly used to control epilepsy. However the blood levels of these medicines need to be closely monitored so that adequate levels are constantly maintained. The most commonly used treatments are probably Dilantin, or Eptoin, Carbamazepine or Tegreto, and Phenobarbital, an older medication. The 1st two drugs are, in general well tolerated. Dilantin, is very effective as it is long acting and needs to be taken only once a day, the side effects are mostly cognitive and can cause problems with thought and memory, can lead people to tire easily and cause a kind of rash. Since it has been around for a long time it has been well researched and we are aware of its uses and limitations. The most common medication worldwide for seizures is Tegreto or carbamazepine. Chemically, it is very similarly to Dilantin but taken twice a day. But it is a different drug. The side effects are a bit different. If the dose is too high it can cause sedation and double vision.

Drug options
Over the past decade there have been a number of developments, with new more specific drugs becoming available. This is not to say that the older drugs have become obsolete. In fact, the newer preparations may not be at all suitable for some people. Each drug has two names, the generic, or chemical name (for example carbamazepine) and the trade name (for example Tegretol), given by the manufacturer. It is helpful for a person to know the generic names of his/her drugs, especially when travelling abroad.

Team work
Co–operation between you and your doctor is essential in establishing optimum control of your epilepsy. The more accurately you, or a family member, can describe your seizures and the effects of the medication, the more precise the doctor’s prescription can be. It is important that drugs are taken exactly as prescribed. Compliance is a major factor in the overall results that can be achieved. Your pharmacist is also able to assist with information and advice about your medication.

Side–effects
Like all drugs, anti–convulsants may have some side–effects. The appearance of these depends on each person’s individual response to the drug as well as how much of it he or she is taking. With only a few exceptions, side–effects associated with anti–convulsants drugs are mild and usually occur at the beginning of therapy, usually disappearing as the person becomes used to the drug. If side–effects do occur, they should be reported. Depending on the type of drug involved, the most frequent side–effects are drowsiness, irritability, nausea, rash, thickening of facial features, increase in body hair, physical clumsiness, overgrowth of gum tissue, and hyperactivity in children. Some drugs may produce emotional changes; occasionally a drug will actually increase rather than decrease the number of seizures a person experiences. However, many people are able to take the medication for years without experiencing any of these effects.

Ketogenic Diet
Special high–fat, low–protein, no–carbohydrate diet has been recommended for people with epilepsy who do not respond to medications. The diet mimics certain effects of starvation, which helps to prevent seizures. Dietician can help you to incorporate this diet into your family’s lifestyle. Strict adherence to the diet is essential for the treatment to be successful.

Surgery for Epilepsy
If seizures are confined to a part of the brain or if they are due to growths, surgical resection may cure the condition. Surgery helps lessen seizures after they’ve been on a couple of medications. Medications just suppress epilepsy, while surgery can be a cure. The best cases for surgery are patients with temporal lobe epilepsy. The temporal lobe lies next to the ear and can be removed without any effects that we are aware of. Conclusive testing is required before the person goes for surgery, as to define the exact area in the brain that is causing the seizures and that area is not important for other functions. Many of the patients don’t need to take anti–epileptic medications after surgery. What are the surgical treatments for Epilepsy?
Standard surgical procedures
If drug therapy fails to control seizures, particularly partial, over a two or three year period, surgery may be appropriate. Children and young adults are the preferred candidates, because older people have more difficulty with rehabilitation. Tests for Surgical Decision Making. Advances in imaging and monitoring, new surgical techniques, and a better understanding of the brain and epilepsy in infants as well as in older individuals have made surgery a more viable option than in previous decades. The general approach is first to locate the brain tissue that triggers the epileptic event using long term EEG monitoring, usually with added information from imaging techniques, such as MRI or PET scans.

If such tests detect a specific area in the brain as the location for the seizure, then surgery is possible. The physician then tries to determine if the offending nerve cells perform vital functions usually with the use of advanced MRI techniques. The surgeon’s goal is to remove just enough damaged tissue and no more in order to prevent seizures and limit brain injury. If the diagnostic tests indicate that more than one site is involved or they have conflicting results, then more invasive monitoring of the brain is required.

Surgical procedures may be considered to prevent seizures.
These procedures include:
Disconnection procedures – These procedured disrupt abnormal electrical activity that occurs in the brain and triggers epileptic seizures. Two types of disconnection operations are:
Corpus callostomy – Used to stop atonic and tonic seizures.
Multiple subpial transections – Used when seizures are caused by parts of the brain that can’t be removed.
Focal resections – Focal resections are the most common surgical approach for treating epilepsy and provide the best chance for patients to gain complete seizure control. These procedures involve the removal of a small area of the brain where seizures originate. New brain monitoring techniques allow doctors to better pinpoint brain tissue causing seizures.

Types of resections include
  • Temporal lobectomy – A portion of the temporal lobe is removed to control seizures.
  • Lobar resection – A portion of a seizure, producing lobe, frontal, parietal or occipital lobe – is removed, if it can be done without damaging vital functions.
  • Hemispherectomy – One sphere of the brain is removed or disabled. The remaining half of the brain takes over many of the functions of the half that was removed. This procedure is used to treat severe conditions that have not responded to other treatments.
  • Gamma Knife radiosurgery – The Gamma Knife delivers a finely focused, high dose of radiation to remove tissue without damaging surrounding tissue. Some types of seizures, such as gelastic seizures which are accompanied by brief, sudden bursts of emotion, can be treated with this technology.
  • Vagus nerve stimulation – This procedure involves minor surgery and is a relatively new treatment that helps prevent or lessen the severity of seizures. An electrical stimulator is implanted that sends regular electrical pulses through the vagus nerve to the brain to reduce the onset or frequency of seizes.
If a seizure occurs between doses of current, you or your child can pass a magnet over the device to trigger an additional dose. A child with a vagus nerve stimulator continues to take medication but sometimes can reduce the amount or number of medications. This procedure can treat a wide variety of seizure disorders when surgery isn’t an option.

Prevention and Follow–Up
To help cope with epilepsy and reduce your chance of injury from seizures, doctors recommend the following
  • Patient should carry identification, that indicates he or she has epilepsy. In an emergency, this information can ensure that you receive the right care.
  • Explain to your family, friends, teachers, relatives and sports coaches how to care for you if he or she has a seizure.
  • If you get regular or even occasional seizures, make sure he or she avoids dangerous situations and activities. Eg. Be careful when playing sports and should not swim unattended.
  • Should never stop taking seizure medication or change the amount taken without discussing it with a doctor first.
  • Always consult your doctor or pharmacist before taking other medications in addition to seizure drugs.

Signs and Symptoms of Epilepsy

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Epileptic seizures can take a very wide variety of forms but are broadly divided into generalized and focal or partial seizures. Partial or focal seizures affect part or a whole limb and may or may not become generalized. If there is no alteration in consciousness it is known as simple partial or Jacksonian seizures and if consciousness is altered or lost it is known as complex partial seizures, commonly known as psychomotor or temporal lobe epilepsy. Generalised seizures affect the whole body and consciousness is lost. However, by far the most common is Generalised seizures (involving the whole brain) commonly known as “Grand Mal” or “Tonic Clonic” seizures or major seizures.

People with epilepsy experience more than one type of seizure. The two categories of seizures are called generalized and partial.

A) Generalized Seizures
Generalized seizures result from electrical impulses arising from the entire brain. They typically occur without warning. There are six types of generalized seizures.
  • Absence seizure – You will lose awareness and stare blankly for a few seconds. Usually, there are no other symptoms. These seizures may occur several times a day.
  • Atonic seizure – During this kind of seizure, your muscles will relax, particularly in the arms and legs, which can cause you to suddenly fall and often injure themselves.
  • Clonic seizure – Both sides of your body jerk rhythmically at the same time.
  • Myoclonic seizure – Your body may jerk, as if being shocked by electricity. The jerks can range from a single muscle jerking to involvement of the entire body.
  • Tonic-clonic – You will lose consciousness and may also collapse. Your body becomes stiff and begins jerking. Finally, your child will fall into a deep sleep. Injuries such as tongue-biting can occur, as well as a loss of bladder control.
  • Tonic seizure – Your child’s muscles suddenly become very stiff.
B) Partial Seizures
Partial seizures originate from activity in a smaller part of the brain. They are divided into simple and complex.The difference between simple and complex seizures is that during simple partial seizures, your child will retain awareness. During complex partial seizures, your child will lose awareness.
  • Simple partial seizure – Your child may experience movements such as jerking or stiffening, various sensations. Full consciousness is retained.
  • Complex partial seizure This is the same as a simple partial seizure except that your child’s awareness is impaired. He or she may appear to be “Out of touch” or “Spaced out.” Your child also may involuntarily chew, walk, fidget or perform other repetitive movements or simple actions.

Although the symptoms listed below are not necessarily indicators of epilepsy, it is wise to consult a doctor if you or a member of your family experiences one or more of these symptoms:
  • “Blackouts” or periods of unclear memory.
  • Episodes of staring or unexplained periods of unresponsiveness.
  • Involuntary movement of arms and legs.
  • “Fainting spells” with involuntary urination or defecation followed by excessive fatigue. or
  • “Hearing of odd sounds”, distorted perceptions, feelings of fear or emotional distress that cannot be explained.
Seizures can be Generalized (‘Grand Mal’) or Partial (‘Petit Mal’ or ‘Absence’) or of a type that affects only a localized area of the brain (‘Partial seizures’). Generalized seizures manifest as episodes of involuntary twitching of the extremities, uncontrolled head movement, frothing at the mouth, rapid eye movement, usually followed by a period of unconsciousness. For a varying period of time after an epileptic seizure, the patient may be confused & unresponsive.

Seizures are partial when the abnormal electrical activity is limited to one part of the brain. Such partial seizures can cause periods of “Repetitive behavior” and altered consciousness. This is characterized by behavior, such as buttoning or unbuttoning a shirt. Such behavior, however, is unconscious, may be repetitive, and is usually not remembered.

Causes of Epilepsy

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It is estimated that 50 million people worldwide and 2.5 million Americans have epilepsy. About 75% of epileptic seizures start in childhood. About 5% of the population will have at least one seizure, not counting the 5% of children who have seizures caused by fevers. The cause can be determined for about 28% of partial epilepsy patients, but in nearly three quarters of all cases, the cause is unknown. The age of onset can sometimes offer a clue.

Possible Causes for Epilepsy including
Head injury: People who sustain a head injury as a result of an automobile accident, sports injury, fall, or act of violence may develop epilepsy. Epilepsy may begin immediately after an injury, or it may take many years to develop.
Birth trauma: Infants who suffer a lack of oxygen during birth may develop resulting damage to the brain’s electrical system.
Poisoning: Lead poisoning has been associated with the development of epilepsy. Likewise, more than 5,000 people each year are reported to develop seizures caused by alcoholism.
Infection: Infections that can affect the brain like meningitis, viral encephalitis, mumps, measles, and diphtheria can result in epilepsy. Brain tumors. In some instances, a seizure may be the first sign that a brain tumor exists. For others who have a brain tumor removed, seizures may result after treatment.

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