Vagus Nerve Stimulator

Kesava Mandalaneni; Appaji Rayi

Vagus Nerve Stimulator

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Continuing Education Activity

This activity outlines the indications for the use of a vagal nerve stimulator. And also highlights the role of the interprofessional team in evaluating and treating the patients who meet the criteria for implantation of the device and further management.

Objectives:

Outline the neural pathways and structures associated with the vagus nerve.
Review the importance of vagus nerve stimulation in the treatment of chronic epilepsy and depression.
Describe the role of the vagus nerve in the anti-inflammatory pathways and the potential uses of a vagal nerve stimulator in curbing unwanted inflammatory conditions.
Explain interprofessional team strategies for coordination of care and communication to advance vagal nerve stimulation thereby improving overall outcomes.

Introduction

The Vagus nerve is the longest mixed cranial nerve associated structurally with the post olivary sulcus of the medulla oblongata. The literal translation of the vagus is 'wanderer,' which aptly represents its widespread interfacing of the cortex, brainstem, hypothalamus, and body. Its afferent and efferent pathways comprise about 80% and 20%, respectively. With a premise that venous hyperemia caused seizures, Dr. James Corning, a 19th-century neurologist from New York, devised instrumented carotid compression along with vagus nerve stimulation as a treatment intervention for seizures. His observations were not put to the test until the latter part of the 20th century. In the 1980s, various observational studies emerged in the cybernetic use of a vagus nerve stimulator (VNS) in refractory epilepsy.[1][2]

Currently, VNS is a Food and Drug Administration (FDA) approved treatment for various conditions like chronic epilepsy, refractory epilepsy, and depression. It is also being investigated in various other conditions like autoimmune and chronic inflammatory disorders.[3]

Anatomy and Physiology

The Vagus nerve connects many visceral organs with the brainstem and the cortex given its widespread course and distribution compared to the rest of the cranial nerves through the autonomic nervous system interface. It originates in the medulla oblongata as eight to ten rootlets from four nuclei, namely:[4][5]

Dorsal Motor Nucleus: This nucleus gives rise to the preganglionic parasympathetic visceromotor fibers.
Nucleus Tractus Solitarius (NTS): This nucleus receives the viscerosensory input from the gastrointestinal and respiratory system as well as the afferent taste input via the chorda tympani nerve of the 7th cranial nerve. These sensory afferents constitute over 80% of the vagus nerve. The projections from NTS are extensive, involving different regions of the brain, brainstem (including locus coeruleus and raphe nucleus), and the hypothalamus.[6]
Nucleus Ambiguous: This nucleus is associated with efferent outputs associated with the 9, 10, and 11 cranial nerves. It also contains the preganglionic parasympathetic neurons that innervate the postganglionic parasympathetic neurons to the heart.
Spinal Nucleus of Trigeminal Nerve: This nucleus receives general somatic sensory input from the back of the ear and the external auditory meatus.

The vagus nerve, after originating from the medulla oblongata, exits the cranium through the jugular foramen and travels down the neck within the carotid sheath along with the common carotid artery and the internal jugular vein.

Indications

The premise of the vagal nerve stimulation is to activate various neurochemical coordinates arising from the NTS to different parts of the brain. The FDA approved indications are:

Epilepsy

An implantable vagus nerve stimulator was used in 1988 in a patient with pharmaco-resistant epilepsy for the first time.[7] Initially, in 1997, the US FDA approved VNS to treat pharmaco-refractory partial-onset seizures in patients above 12 years of age. Later in 2017, extended for use in children above four years of age. Fewer side effects meant broader clinical applications beyond the approved guidelines to additional conditions like Lennox Gestaut syndrome, Rett syndrome, and epilepsy in pregnant women due to the lack of detrimental and teratogenic side effects.[8][9][10] Studies have also shown that the risk of sudden unexpected death in epilepsy (SUDEP) is reduced with the long-term use of VNS.[11]Mechanisms of action: A precise mechanism of action is still inconclusive, but the following are generally agreed upon based on human and animal studies. In animal epilepsy models, VNS has caused abruption of an ongoing seizure and a decrease in the frequency of chronic seizures.[12][13] Zabara postulated that high synchronization of the cortical and thalamocortical loops are the basis of the complex partial seizures in animal models, VNS intervention breaks these synchronized networks and thus mitigates seizure activity.[14] NTS projections to the raphe nuclei and the locus coeruleus play an important role in the VNS neuromodulation therapy, purportedly by increasing the serotonergic and noradrenergic transmission, evidenced by the increased levels of serotonin, noradrenaline (NA) and its metabolites in the cerebrospinal fluid (CSF) of the patients undergoing VNS stimulation. Serotonin and NA have known anti-seizure effects.[15][16][17]

Depression

The use of VNS for treatment-resistant depression was approved in 2005.[18] This approval was preceded by several controlled and uncontrolled studies that observed improved standardized mood scores following treatment with VNS in patients with treatment-resistant depression.[19][20] It was also observed that the patients with clinical refractory depression who claimed improvement due to VNS use relapsed into clinical depression after the removal of a VNS device or repairs arising due to battery issues of the device.[21][22] A meta-analysis revealed a substantial difference in response rates between those treated as usual versus those treated as usual with adjunctive VNS therapy.[23]Mechanisms of action: Again, the exact role of VNS in the treatment of clinically refractory depression is inconclusive; however various explanations as to why the VNS works include; better NA synaptic transmission through the locus coeruleus and other pathways and VNS mediated changes to the anti-convulsant system in the brain, which improves depression.[18][24]

Other Investigational Clinical Applications

The Vagus nerve plays an important role in conveying information about peripheral proinflammatory cytokines in the body to the brain (NTS) as the vagal afferents are sensitive to the presence of interleukins and prostaglandins.[25][26] In turn, NTS relays this information to various levels like the hypothalamus, limbic lobe, and the pituitary leading to activation of the hypothalamo-pituitary adrenal (HPA) axis leading to the release of cortisol from the adrenal cortex. The anti-inflammatory role of the vagal efferents is mediated through the vagovagal reflex, where vagal afferents activate the vagal efferents. The vagal cholinergic output from the dorsal motor nucleus inhibits the release of cytokines like TNFα from the macrophages, and this is commonly termed as the cholinergic anti-inflammatory pathway.[27][28] These anti-inflammatory abilities of the vagus nerve make it a target for modulation by VNS to affect the inflammatory conditions of the gut like the inflammatory bowel disease (IBD), and also other non-gut inflammations like rheumatoid arthritis (RA), diabetes mellitus (DM), sepsis, cardiovascular diseases, Alzheimer disease, intractable hiccups, and chronic pain.[27][29][27]

Transcutaneous Auricular Vagus Nerve Stimulation (taVNS)

This is a non-invasive method of delivering the transcutaneous stimulation directly to the auricular branch of the vagus nerve and has been widely discussed in recent days.

There are two subsets for taVNS that are closed-loop:

1. Respiratory-gated Auricular Vagal Afferent Nerve Stimulation (RAVANS)[30]: This works on the principle that inhalation induces transient inhibition of vagus nerve activity. This has shown some promise in treating pain disorders and migraines.

2. Motor Activated Auricular Vagus Nerve Stimulation (MAAVNS)[31]: This pairs taVNS with motor activity and has been found to be a promising neurorehabilitation tool and in facilitating motor learning in neonates. This technique is also being studied in adult post-stroke rehabilitation trials.

Contraindications

Vagotomy: Since the right vagus nerve supplies the sinoatrial node, the VNS is usually implanted in the left vagus nerve to prevent any cardiac dysrhythmias.[32] So, VNS cannot be used in patients who had a bilateral or left cervical vagotomy.

Diathermy: Since diathermy treatment (therapeutic ultrasound, microwave or shortwave) could cause heating of the VNS system, well above temperatures that could cause tissue damage to the nerves and blood vessels, it is contraindicated in people who have VNS implants.[33] There is no contraindication to diagnostic ultrasound.

Equipment

Commonly used vagus nerve stimulator devices consist of an implantable, non-rechargeable battery-powered VNS therapy pulse generator and the VNS therapy lead. There is also an external programming system that is used to change the stimulation setting according to the requirement. They require new batteries in about six years. The VNS therapy lead is placed surgically around the left vagus nerve in the carotid sheath and connected to a subcutaneous programmable pacemaker device that is placed over the left chest wall. The branches of the right vagus nerve predominantly innervate the sinoatrial (SA) node and those from the left vagus nerve predominantly innervate the atrioventricular (AV) node. Insertion on the right side can cause bradycardia and other arrhythmias due to this, but this fact has recently been challenged.[34]

Electrical signals generated from the pulse generator are transmitted to the vagus nerve via the VNS therapy lead. The patients can deactivate (turn OFF) or give an additional burst of stimulation on demand by placing or swiping the magnet provided to them over the pulse generator, respectively. The previously programmed stimulation resumes after the magnet is removed. The device has three modes, manual, automatic, and chronic.[35][36][37]

Personnel

Vagus nerve stimulator device ideally should be implanted by a neurosurgeon, general surgeon, vascular surgeon, or an ear-nose-throat surgeon trained in this procedure.[38] It involves an interprofessional team to determine the eligibility of the patient for the procedure (screening) and a close long-term follow-up and education after the procedure for good outcomes. The settings of the device would require periodic adjustments as necessary to result in an optimal response for the indicated clinical indication.

Preparation

The procedure is done under general anesthesia in a supine position with the neck extended by placing a shoulder pillow.

Technique or Treatment

The VNS is placed by placing two incisions - one 2-3 cm below the left clavicle and the other skin crease incision on the left side at the level of the thyroid cartilage.

The battery is placed deep into the subcutaneous fat in the chest wall through the former incision.

Via the latter incision, the subplatysmal plane is dissected and sternomastoid muscle is retracted posteriorly and the carotid sheath is identified. Within this sheath, the vagus nerve is usually found deep and medial to the internal jugular vein and lateral to the common carotid artery. The nerve is dissected off the surrounding tissues and the leads of the stimulator are coiled around the nerve. The leads are connected to the stimulator via a silicone sheath passed through a subcutaneous tunnel connecting them both. Both the wounds are closed in layers.

The working of the VNS is confirmed by comparing the heart rate measured from the vagus nerve with the heart rate from the anesthesia monitor.

Complications

Randomized controlled trials observed the following early complications (in descending order):

Voice alteration
Hoarseness
Cough
Tingling
Dyspnea

But generally, the patients show improved tolerance over a period of time. Intraoperative complications are rare and may include the following:

Vocal cord paralysis
Implant site infection
Left facial nerve paralysis
Horner syndrome

Chronic use of vagus nerve stimulation has not been evidenced to cause any significant or deleterious changes to cardio-respiratory functions.[39][40][41]

The VNS manufacturer's guidelines have to be strictly adhered to while performing magnetic resonance imaging scans of the cranium in patients having implanted VNS.[42]

The VNS battery usually has a lifetime of 3-5 years, after which it needs to be replaced.

Clinical Significance

The following uses for vagus nerve stimulation have been identified in the literature:

Refractory epilepsy[43]
Treatment-resistant depression[44]
Facilitating neuro-plasticity[45]
Cluster headaches and migraines[46]
Adult stroke rehabilitation[47]
Tinnitus[48]
Alzheimer disease[49]
Parkinson disease[50]
Autistic Spectrum Disorders[51]
Male infertility[52]
As prophylaxis for the systemic inflammatory response syndrome and postoperative ileus[53]
Inflammatory bowel diseases[54]
Psoriatic arthritis and ankylosing spondylitis[55]

Enhancing Healthcare Team Outcomes

Vagus nerve stimulation is an effective antiseizure treatment, albeit without significant treatment-related side effects. Based on the evidence from randomized controlled trials, VNS therapy is an adjunctive treatment aimed towards a maximal reduction in seizure frequency with reduced use of antiepileptic medications.[56] The general trend in patients, both children, and adults, with chronic epilepsy treated with VNS therapy, has been increased quality of life. At the same time, this effect is most significant in those with the highest seizure frequency reduction. Besides the antiseizure effect, VNS therapy leads to improved mood symptoms.

According to the American Psychiatric Association (APA) adjuvant long-term VNS therapy is specified by FDA in treatment-refractory depression, either unipolar or bipolar, with a history of failure to respond to at least four antidepressant medications. Better efficacy of electroconvulsive therapy (ECT) for treatment-resistant depression should be discussed with the patient and should be considered before the use of the VNS.

The extensive interface of the vagus nerve, between mind, body, gut, and brain, opens a plethora of therapeutic possibilities from seizures and depression to immune modulation. As Dacher Keltner puts it: "The vagus nerve is one of the great mind-body nexuses in the human nervous system."

Overall, an interprofessional team effort involving multiple specialists (neurologists, epileptologists, neurosurgeons, psychiatrists) and medical staff personnel are essential to provide and enhance patients care to achieve good outcomes. Patient education is crucial since these devices require active involvement when there is a need to intervene and provide on-demand stimulation.

Nursing, Allied Health, and Interprofessional Team Interventions

The following parameters are set by the VNS nurse, in conjunction with the neurologist, after the insertion of the VNS by the surgeon[57]:

Pulse width (microseconds) - length of time of a square pulse of current
Current intensity (milliampere) - amplitude, or strength, of the electrical pulse. VNS is most often delivered as current-controlled, rather than voltage-controlled.
Frequency (Hertz) - total number of cycles (the beginning of a pulse to the beginning of the next pulse) in a second.
On-Off Time - "On-time" is the time period in which the stimulation is delivered above an intensity of 0 mA (active stimulation) and the “off-time” is the time period when no stimulation is delivered (0 mA) (rest period).
Duration of stimulation - cumulative time of VNS treatment.

(Click Image to Enlarge)

Carotid Sinus Massage. Neck anatomy, including the carotid sinus, vagus nerve, sternocleidomastoid muscle, right common carotid artery, and cardiac plexus.

Contributed by B Palmer

(Click Image to Enlarge)

Vagus Nuclei

Contributed by O Chaigasame, MD

Details

References

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