Vagus nerve stimulation for medically refractory epilepsy: efficacy and cost-benefit analysis

Introduction. Vagus nerve stimulation is a novel treatment for patients with medically refractory epilepsy, who are not candidates for conventional epilepsy surgery, or who have had such surgery without optimal outcome. To date only studies with relatively short follow-up are available. In these studies efficacy increased with time and reached a maximum after a period of 6 to 12 months. Implantation of a vagus nerve stimulator requires an important financial investment but a cost-benefit analysis has not been published. Patients and Methods. Our own experience with VNS in Gent comprises 15 patients with mean age of 29 years (range: 17-44 years) and mean duration of epilepsy of 18 years (range: 4-32 years). All patients underwent a comprehensive presurgical evaluation and were found not to be suitable candidates for resective epilepsy surgery. Mean post-implantation follow-up is 24 months (range: 7-43 months). In patients with follow-up of at least one year, efficacy of treatment in terms of seizure control and seizure severity was assessed one year before and after the implantation of a vagus nerve stimulator. Epilepsy-related direct medical costs (ERDMC) before and after the implantation were also compared. Results. A mean reduction of seizure frequency from 14 seizures/month (range: 2-40/month) to 8 seizures/month (range: 0-30/month) was achieved (Wilcoxon signed rank test n = 14; p = 0.0016). Five patients showed a marked seizure reduction of greater than or equal to 50%; 6 became free of complex partial seizures, 3 of whom became entirely seizure free for more than 12 months; 2 patients had a worthwhile reduction of seizure frequency between 30-50%; in 2 patients seizure frequency reduction has remained practically unchanged. Seizure freedom or greater than or equal to 50% seizure reduction was achieved within the first 4 months after implantation in 6/11 patients. Before the implantation, the mean yearly epilepsy-related direct medical costs per patient were estimated to be 8830 US$(n = 13; range: 1879-31129 US$; sd = 7667); the average number of hospital admission days per year was 21 (range: 4-100; sd = 25.7). In the 12 months after implantation, ERDMC had decreased to 4215 US$(range: 615-11794 US$; sd = 3558) (Wilcoxon signed rank test n = 13; p = 0.018) and the average number of admission days to 8 (range: 0-35) (Wilcoxon signed rank test n = 13; p = 0.023). Conclusion. VNS is an effective treatment of refractory epilepsy and remains effective during long-term follow-up. Cost-benefit analysis suggests that the cost of VNS is saved within two years following implantation

Are spontaneous epidural haematoma in sickle cell disease a rare complication?: a report of two new cases

Background. Sickle cell anaemia, an autosomal recessive disease relatively common among the black races, gives rise sometimes to neurological complications. Among these, spontaneous epidural haematoma constitutes a rare event that is not always easy to treat in the Third world conditions. Methods. Two new cases are described and their pathology is compared with the five already described cases in the literature. A vaso-occlusive pathological process as in the orbital compression syndrome is thought to be implicated in the generation of the spontaneous epidural haematoma. Results. When facing an epidural haematoma as a complication of sickle cell disease in a hospital of the Third world conditions, a cautious attitude towards surgery should be observed because of the high complication rate. If the relation between the haematoma and the anaemia is not immediately apparent, we are in favour of starting treatment with antibiotics

Spinal-cord stimulation in chronic pain: evaluation of results, complications and technical considerations in 69 patients

Sixty-nine patients undergoing spinal cord stimulation (SCS) were studied for a period of up to 8 years. Indications, implantation techniques, and stimulation systems are presented in this article. Pain-suppressor effects of SCS are reviewed, assessing the clinical efficacy over time as well as complications with the stimulation device. Immediately following implantation, inadequate pain relief was noted in 20% of the patients. Decrease of the efficacy of pain alleveation occurs during the first 3 years after implantation. Most failures are noted in patients presenting with failed back surgery. This study also demonstrates that SCS systems should offer the capability of both monopolar and bipolar stimulation modes by the use of multipolar electrodes