Vagus nerve stimulation (VNS) is an alternative treatment for medically or surgically refractory epilepsy. The long-term efficacy and safety of VNS were evaluated in a large patient series at Ghent University Hospital and Dartmouth-Hitchcock Medical Center. Between March 1995 and February 2003, seizure frequency and type as well as prescribed antiepileptic drugs and side effects were prospectively assessed in 131 patients treated with VNS in either center. Patients with a minimum follow-up duration of 6 months were included in the efficacy and safety analysis. A total of 118 of 131 implanted patients had a minimum postimplantation follow-up period of 6 months (mean, 33 months). The mean age of these patients was 32 years and the mean duration of refractory epilepsy was 22 years. The mean reduction in monthly seizure frequency in all patients was 55% (range, 0-100; SD = 31.6). Seven percent of patients were free of seizures with impaired consciousness, 50% of patients had a seizure frequency reduction of more than 50%, and 21% of patients were nonresponders. Fifteen patients reported stimulation-related side effects such as hoarseness or gagging. In a large patient series from two geographically distinct epilepsy centers located in two different continents, VNS proved to be efficacious and safe during long-term follow-up.

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EOES or EOBL may be indicated by loss of seizure control, decreased or irregular perception of stimulation by the patient and loss of other VNS-induced effects. Postponing generator replacement may result into permanent loss of seizure control. In responders we suggest generator replacement before EOBL. Our results call for performance of prospective studies in larger patient groups that may eventually lead to general guidelines on the indication and timing of generator replacement.

Background: Although the causes of stroke recurrence are well known, no particular study deals with the specific issue of late-onset transient worsening of the neurological deficit (TWND) after an ischaemic stroke. Patients and Methods: In this retrospective study the aetiology of the TWNDs in 101 patients was compared to the causes of transient ischaemic attacks (TIAs) in 115 patients. All patients had a full cardiovascular and neuroimaging examination according to current guidelines. An electroencephalogram (EEG) was performed when necessary. The diagnosis of inhibitory seizures was retained when the EEG showed periodic lateralized epileptiform discharges or intermittent rhythmic delta activities, or when the patient developed typical seizures afterwards. Results: Arterial hypertension and diabetes were more prevalent vascular risk factors in TWND patients. Small-vessel disease and inhibitory seizures were a more frequent cause of TWNDs than of TIAs. Extracranial large-vessel disease predominates in TIA patients. The global prevalence of cardiac diseases as cause of TIAs and TWNDs was the same, although severe ulcerous plaques of the aortic arch and patent foramen ovale with atrial septum aneurysm occurred more frequently in TWND patients. Conclusions: The most frequent causes of late-onset TWNDs were different from those of TIAs. Apart from repeated neuroimaging of the brain, exhaustive cardiac investigations and EEG are mandatory in TWND patients.

Background: The cortical involvement of territorial infarcts is considered to be a significant risk factor for the development of early- as well as late-onset seizures. However, it is not known which cortical regions are more susceptible to the development of stroke-related seizures. Patients and Methods: In this retrospective study of 687 patients with territorial infarcts, 184 with stroke-related seizures were compared to 503 without seizures. The extent and the location of the infarcts were determined by computed tomography (CT) scans and/or magnetic resonance imaging (MRI) scans of the brain. The infarcts of the seizure and the non-seizure group were compared on digital cerebral vascular maps by superimposing the CT and/or MRI slices. Results: In patients with late-onset seizures, the infarcts were significantly more frequent in the temporal and parietal branches of the middle cerebral artery in comparison to the non-seizure group. In patients with early-onset seizures and in those with seizures due to a recurrent stroke, the territory of the temporal and occipital branches of the middle cerebral artery was the predilection side of the infarcts. Generalized tonic-clonic seizures occurred mainly in cases of infarction in the deep territory of the middle cerebral and of the anterior choroidal artery. Status epilepticus was significantly correlated with infarcts in the posterior temporal region. Conclusion: Some infarct regions are the sides of predilection for stroke-related seizures according to their type and their onset-time.