Transforming pediatric epilepsy care: Real‐world insights from a leading single‐center study on vagus nerve treatment outcomes
Lalit Bansal, Fatima Jaafar, Anmol Kapoor, Leena Abdelmoity, Ahmed Madkoor, Christian B. Kaufman, Ahmed Abdelmoity
Abstract
OBJECTIVE: Vagus nerve stimulation (VNS) is utilized increasingly in the management of drug-resistant epilepsy (DRE), yet its long-term efficacy and prognostic indicators remain incompletely understood. This study evaluated both short- and long-term seizure outcomes in pediatric patients with DRE following VNS therapy, with a focus on the influence of stimulation parameters and the potential predictors of a favorable response. METHODS: A retrospective review was conducted of pediatric patients who underwent implantation of a vagus nerve stimulator between 2003 and 2023 at a Level 4 epilepsy center. Seizure burden and non-seizure outcomes were assessed at multiple follow-up intervals. Outcomes were further analyzed by seizure type and variations in VNS stimulation parameters. RESULTS: A total of 400 pediatric patients received VNS therapy, with a mean follow-up duration of 4.92 years (median 3.5 years; interquartile range [IQR] = 2 to 6.97 years). Seizure frequency improved progressively, with a responder rate (RR, defined as ≥50% reduction in seizure frequency) reaching 90.5% at last follow-up, and 20.5% of patients achieving seizure freedom. Subgroup analysis revealed RRs of 88.6% for generalized epilepsy, 93.1% for focal epilepsy, and 90% for combined epilepsy, with the highest rate of seizure freedom observed for focal epilepsy (31.6%, p = .006; Bonferroni-adjusted p* = .048). Early vagus nerve stimulator implantation (≤2 years from seizure onset) was associated with improved outcomes (p = .034; p* = .272). Higher stimulation parameters, particularly ultra-rapid duty cycle, correlated with greater seizure reduction (p = .018; p* = .144). Subjective quality of life improvement was reported in 90% of patients, including enhancement in attention, development, and academic performance. VNS therapy was well tolerated, with mostly mild adverse events; the most common was obstructive sleep apnea, which was managed through parameter adjustments. SIGNIFICANCE: This study underscores the long-term efficacy and safety of VNS therapy in pediatric DRE, particularly in patients receiving higher duty cycle and output current. Early implantation, focal epilepsy, and optimized stimulation parameters were associated with better seizure control and substantial subjective improvements in quality of life.