Vagus nerve stimulation is an effective and safe adjunctive treatment for patients with refractory partial-onset seizures. It represents the advent of a new, nonpharmacologic treatment for epilepsy.

Summary:Purpose: To determine the long-term efficacy of vagus nerve stimulation (VNS) for refractory seizures. VNS is a new treatment for refractory epilepsy. Two short-term double-blind trials have demonstrated its safety and efficacy, and one long-term study in 114 patients has demonstrated a cumulative improvement in efficacy at 1 year. We report the largest prospective long-term study of VNS to date.Methods: Patients with six or more complex partial or generalized tonic-clonic seizures enrolled in the pivotal E05 study were prospectively evaluated for 12 months. The primary outcome variable was the percentage reduction in total seizure frequency at 3 and 12 months after completion of the acute E05 trial, compared with the preimplantation baseline. Subjects originally randomized to low stimulation (active-control group) were crossed over to therapeutic stimulation settings for the first time. Subjects initially randomized to high settings were maintained on high settings throughout the 12-month study.Results: The median reduction at 12 months after completion of the initial double-blind study was 45%. At 12 months, 35% of 195 subjects had a >50% reduction in seizures, and 20% of 195 had a >75% reduction in seizures.Conclusions: The efficacy of VNS improves during 12 months, and many subjects sustain >75% reductions in seizures. Key Words: Vagus nerve stimulation-Intractable epilepsy.Vagus nerve stimulation (VNS) has emerged as an effective treatment for medically intractable epilepsy ( 1-3). VNS uses an implantable, programmable pulse generator powered by a lithium battery, which is connected to a helical bipolar lead. The lead is attached to the midcervical portion of the left vagus nerve and delivers

Objective To determine if specific measures of heart rate variability (HRV) are associated with the total score on a seven-item inventory for Sudden Unexplained Death in Epilepsy (SUDEP). Methods Nineteen subjects with intractable partial seizures, at least three per month, were enrolled in a randomized clinical trial of omega-3 fatty acids in epilepsy. At study entry, subjects underwent a 1-hour ECG recording for the determination of HRV. To estimate the risk of SUDEP, we assembled a seven-item inventory (The SUDEP-7 Inventory) from risk factors prospectively validated by Walczak al. [6] The SUDEP-7 score was then correlated with measures of HRV using the Pearson Correlation and other parametric and non-parametric methods. Results Subjects were highly refractory, with a mean seizure frequency of 22.8 seizures per month. Scores on the SUDEP-7 inventory ranged from 1 – 7 of a maximum possible score of 12. RMSSD, a measure of high frequency HRV was inversely correlated with the SUDEP-7 score, r = −0.64, p =0.004. Subjects with higher SUDEP-7 scores had reduced levels of HRV (RMSSD). Other time-dependent measures of HRV (SDNN, SDANN) were not significantly correlated with SUDEP risk scores. Conclusions RMSSD, a measure of HRV, which reflects the integrity of vagus nerve-mediated autonomic control of the heart, is highly associated with the total score on a new 7-item SUDEP risk inventory. Lower RMSSD values were associated with higher risk scores on a new SUDEP risk inventory. This provides new evidence that HRV (specifically RMSSD) is a marker of SUDEP risk.

Here we put forward a roadmap that summarizes important questions that need to be answered to determine more effective and safer treatments. A key concept in management of neurocysticercosis is the understanding that infection and disease due to neurocysticercosis are variable and thus different clinical approaches and treatments are required. Despite recent advances, treatments remain either suboptimal or based on poorly controlled or anecdotal experience. A better understanding of basic pathophysiologic mechanisms including parasite survival and evolution, nature of the inflammatory response, and the genesis of seizures, epilepsy, and mechanisms of anthelmintic action should lead to improved therapies.