Intractable pediatric epilepsy: Vagal nerve stimulation and the ketogenic diet

The control of seizures in the child who has medically intractable epilepsy and is not a surgical candidate is challenging. Two therapies have emerged as useful adjunctive therapies to be considered for such children. The Vagal nerve stimulator has been shown effective in adults and in a number of childhood refractory epilepsies, such as the Lennox-Gastaut syndrome. The ketogenic diet is a high-fat, low-carbohydrate, adequate-protein diet that has proven highly effective in suppressing seizures in children with medically refractory epilepsy, possibly through a metabolic switch from carbohydrates to fats as the primary cerebral energy source. Both methods avoid the cognitive side effects so commonly seen with antiepileptic drugs. Although the mechanism of action is not known precisely for either of these adjunctive therapies, they add an important and evolving dimension to the management of difficult-to-control epilepsy in children.