TO THE EDITOR: We read with great interest the article by Maleknia et al.1(Maleknia P, McWilliams TD, Barkley A, et al. Postoperative seizure freedom after vagus nerve stimulator placement in children 6 years of age and younger.J Neurosurg Pediatr.2023;31[4]:329-332). The authors describe their institutional experience with vagus nerve stimulation (VNS) in patients ≤ 6 years old. Similar to our prior work,2their article details differences in demographics, complications, and seizure frequency outcomes between patients ages 0–3 versus 4–6 years at VNS implantation. This is the "first review of VNS placement in children 6 years and younger with a mean follow-up > 8 years."
Understanding the safety and effectiveness of VNS is timely, so we want to highlight interesting aspects of this article. First, a larger proportion of patients ages 4–6 (vs 0–3) years at VNS were White. Although formal statistical testing was not performed, this difference in racial distribution is stark enough to potentially be clinically significant. We believe that further investigation into access/availability of VNS for non-White patients at the authors’ institution and around the country is warranted. Late surgical referral can influence seizure frequency outcomes.3Understanding whether race influences epilepsy surgery referral would be worthwhile. Second, whereas the mean follow-up for patients in this cohort was 8 years, the range (0–21 years) indicates that the distribution may be right-skewed. The median follow-up duration may be a more informative measure of center. Furthermore, the authors focused on seizure frequency reduction outcomes at 5 years, not 8 years (Table 4). Third, given the importance of this paper, we have a question about data inclusion: how was the minimum follow-up duration 0 years when the inclusion criterion was > 1 year of follow-up (开云体育世界杯赔率, first paragraph)? Fourth, we think that in a cohort of 45 patients without statistical testing, some of the conclusion that "our study demonstrates ≥ 50% reduction in seizures" may require further investigation. Only 40% of the authors’ sample demonstrated ≥ 50% seizure frequency reduction by 5 years, so this claim may be misleading. The authors also claim that "our study demonstrates efficacy with generalized semiology"; however, it is unclear if generalized semiology was investigated in a subset analysis. Did the authors specifically investigate generalized seizures compared to, for example, focal seizures? How were generalized seizures defined/operationalized?
We respectfully draw the authors’ attention to our institution’s review of VNS in children ≤ 6 years,2and to other related manuscripts.4–7We previously statistically analyzed seizure frequency outcomes in our cohort of 99 pediatric patients who received VNS with follow-up of 4 years (n = 89 at the 4-year time point).2Our analysis assessed patients’ target semiologies, tracking them during VNS therapy. In other primary analyses of VNS before the age of 6 years (i.e., Zamponi et al.,7a retrospective analysis of 6 patients who underwent VNS implantation before the age of 3 years; mean follow-up of 42 months), improvements in seizure frequency control, quality of life, and/or caregiver/patient satisfaction have been observed.
In sum, Maleknia et al.’s results are consistent with prior evidence. Although the authors did not perform formal statistical testing, there appeared to be no differences in seizure frequency outcomes between cohorts, supporting the use of VNS in young children with drug-resistant epilepsy. We applaud the authors for their work and the implications of their findings.
Disclosures
亚伯博士报道个人费用Monteris读出cal and NeuroOne outside the submitted work.
References
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1 ↑
MalekniaP,McWilliamsTD,BarkleyA,Estevez-OrdonezD,RozzelleC,BlountJP.Postoperative seizure freedom after vagus nerve stimulator placement in children 6 years of age and younger.J Neurosurg Pediatr.2023;31(4)：329–332.
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2 ↑
MuthiahN,ZhangJ,RemickM,et al.Efficacy of vagus nerve stimulation for drug-resistant epilepsy in children age six and younger.Epilepsy Behav.2020;112:107373.
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3 ↑
JehiL,JetteN,KwonCS,et al.Timing of referral to evaluate for epilepsy surgery: Expert Consensus Recommendations from the Surgical Therapies Commission of the International League Against Epilepsy.Epilepsia.2022;63(10)：2491–2506.
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4 ↑
LimMJR,FongKY,ZhengY,et al.Vagus nerve stimulation for treatment of drug-resistant epilepsy: a systematic review and meta-analysis.Neurosurg Rev.2022;45(3)：2361–2373.
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5
TsaiJD,FanPC,LeeWT,et al.Vagus nerve stimulation in pediatric patients with failed epilepsy surgery.Acta Neurol Belg.2021;121(5)：1305–1309.
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6
XieH,MaJ,JiT,LiuQ,CaiL,WuY.Efficacy of vagus nerve stimulation in 95 children of drug-resistant epilepsy with structural etiology.Epilepsy Behav.2023;140:109107.
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7 ↑
ZamponiN,RychlickiF,CorpaciL,CesaroniE,TrignaniR.迷走神经刺激(VNS)是有效的in treating catastrophic 1 epilepsy in very young children.Neurosurg Rev.2008;31(3)：291–297.
