Combined VNS-RNS Neuromodulation for Epilepsy.

The vagus nerve stimulator (VNS) and responsive nerve stimulator (RNS) are nonpharmacological devices approved for drug-resistant epilepsy. Vagus nerve stimulator was removed before placing an RNS in clinical trials. Two cases of bilateral mesial temporal epilepsy treated concurrently with VNS and bilateral mesial temporal RNS devices were reported. In each case, the VNS device was turned off temporarily, which allowed for a direct comparison of RNS recordings and efficacy with and without simultaneous VNS stimulation. Temporary VNS cessation lead to increased clinical and electrocorticographic seizures despite continued anti-seizure drugs and RNS stimulation. In one case, VNS eliminated seizures from one epileptogenic area, whereas VNS and RNS were required to treat seizures from the contralateral mesial temporal structure. In another case, VNS effectively decreased seizure spread to the symptomatogenic zone. These cases demonstrate synergistic neuromodulation with concurrent use of VNS and RNS in intractable bitemporal epilepsy.