Vagus nerve stimulation: Clinical experience in drug-resistant pediatric epileptic patients

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Vagal nerve stimulation in intractable epilepsy: clinical experience on 100 patients and review of the literature

Introduction: Vagus Nerve Stimulation (VNS) is an effective alternative treatment for patients with refractory epilepsy. Nevertheless, information regarding VNS is still limited. Materials and Methods: In the present non randomized, prospectic study we report our clinical safety and effectiveness of VNS in 100 patients (52 Males and 48 Females) with drug resistant epilepsy. Patient’s age at implant ranged from 0,64 to 51,04 years (mean age 15.3 years). The mean follow-up time was 54,8 months ( range 2 to 108,3 months). Seventeen patients suffered from Lennox-Gastaut Syndrome, 34 patients suffered from partial epilepsy with drop attacks and secondary bysinchronism on the EEG (Lennox Gastaut-like) and 49 patients had Partial Epilepsy without drop attacks. Data collection forms were designed for prospectively gathering data on each patient’s history, seizures, drug therapy, implant device settings and side effects. Patients were assessed prior the implant and 3, 12 and 24 months after surgery. Results: Seventy-eight patients completed the 24 months follow-up session. VNS produced a mean seizure rate reduction of 32% at 3 months, 41% at 12 months, and 45% at 24 months. At 24 months, only the Partial Epilepsy patients showed a seizures reduction of 50%, which is considered clinically significant. Moreover both the age at implant and epilepsy duration were inversely correlated with the percentage of seizure reduction at 24 months. Side effects were minor and transient; the most common were voice alteration and coughing during stimulation. In 7 patients electrode breakage occurred three years after the surgical procedure. Conclusion: In our study, clinical effectiveness is higher in younger children implanted before than 12 years with shorter epilepsy duration suggesting a precocious useful role of VNS. Patients with Lennox Gastaut Syndrome show a worse clinical response rather than other epileptic syndromes

Long-term seizure and behavioral outcomes after corpus callosotomy

Outcomes of corpus callosotomy (CC) have been mainly focused on seizures. The present study aimed to evaluate the long-term effects of CC on adaptive behaviors and caregivers' satisfaction in addition to seizures and to identify clinical predictors of postsurgical outcomes. Medical records of 26 patients (mean age at study time: 40 years, mean follow-up: 14 years) with childhood-onset epilepsy who underwent anterior or 2-stage complete CC were reviewed. A structured questionnaire was submitted to caregivers asking about relative changes in different seizure types, behavioral functions, and satisfaction with the postoperative outcomes. Formal neuropsychological assessment was carried out in a subgroup of patients. Selected clinical variables including age at surgery, extent of callosal section, length of follow-up, epilepsy syndrome, and presurgical cognitive level were submitted to multiple regression analysis. At the last follow-up visit, a reduction greater than 50% was observed mainly for drop attacks (65% of patients), followed by generalized tonic-clonic seizures (53%), and complex partial seizures (50%). No presurgical variables were significantly associated with seizure outcome. After surgery, more than half of patients showed attention enhancement, which was related to drop seizure improvement. Early age at surgery was associated with better behavioral regulation; complete CC slightly worsened language abilities. Satisfaction with surgery outcomes was expressed by 73% of caregivers and was dependent on drop seizure reduction and improvements in activities of daily living. A long-term positive psychosocial outcome is likely after CC also in severely disabled patients, especially if surgery is performed early

[11C]-Methionine Positron Emission Tomography in the Postoperative Imaging and Followup of Patients with Primary and Recurrent Gliomas

We investigated the sensitivity and specificity of [(11)C]-methionine positron emission tomography ([(11)C]-MET PET) in the management of glioma patients. We retrospectively analysed data from 53 patients with primary gliomas (16 low grade astrocytomas, 15 anaplastic astrocytomas and 22 glioblastomas) and Karnofsky Performance Status (KPS) > 70. Patients underwent [(11)C]-MET PET scans (N = 249) and parallel contrast-enhanced MRI (N = 193) and/or CT (N = 113) controls. In low grade glioma patients, MRI or CT findings associated with [(11)C]-MET PET additional data allowed discrimination residual disease from postsurgical changes in 96.22% of these cases. [(11)C]-MET PET early allowed detection of malignant progression from low grade to anaplastic astrocytoma with high sensitivity (91.56%) and specificity (95.18%). In anaplastic astrocytomas, we registered high sensitivity (93.97%) and specificity (95.18%) in the postoperative imaging and during the followup of these patients. In GBM patients, CT and/or MRI scans with additional [(11)C]-MET PET data registered a sensitivity of 96.92% in the postsurgical evaluation and in the tumour assessment during temozolomide therapy. A significant correlation was found between [(11)C]-MET mean uptake index and histologic grading (P < 0.001). These findings support the notion that complementary information derived from [(11)C]-MET PET may be helpful in postoperative and successive tumor assessment of glioma patient