- Research article
- Open Access
The auriculo-vagal afferent pathway and its role in seizure suppression in rats
© He et al.; licensee BioMed Central Ltd. 2013
- Received: 20 November 2012
- Accepted: 30 July 2013
- Published: 9 August 2013
The afferent projections from the auricular branch of the vagus nerve (ABVN) to the nucleus tractus solitaries (NTS) have been proposed as the anatomical basis for the increased parasympathetic tone seen in auriculo-vagal reflexes. As the afferent center of the vagus nerve, the NTS has been considered to play roles in the anticonvulsant effect of cervical vagus nerve stimulation (VNS). Here we proposed an “auriculo-vagal afferent pathway” (AVAP), by which transcutaneous auricular vagus nerve stimulation (ta-VNS) suppresses pentylenetetrazol (PTZ)-induced epileptic seizures by activating the NTS neurons in rats.
The afferent projections from the ABVN to the NTS were firstly observed in rats. ta-VNS increased the first grand mal latency of the epileptic seizure and decreased the seizure scores in awake rats. Furthermore, when the firing rates of the NTS neurons decreased, epileptiform activity manifested as electroencephalogram (EEG) synchronization increased with 0.37±0.12 s delay in anaesthetized rats. The change of instantaneous frequency, mean frequency of the NTS neurons was negative correlated with the amplitude of the epileptic activity in EEG traces. ta-VNS significantly suppressed epileptiform activity in EEG traces via increasing the firing rates of the neurons of the NTS. In comparison with tan-VNS, the anticonvulsant durations of VNS and ta-VNS were significantly longer (P<0.01). There was no significant difference between the anticonvulsant durations of VNS and ta-VNS (P>0.05). The anticonvulsant effect of ta-VNS was weakened by reversible cold block of the NTS.
There existed an anatomical relationship between the ABVN and the NTS, which strongly supports the concept that ta-VNS has the potential for suppressing epileptiform activity via the AVAP in rats. ta-VNS will provide alternative treatments for neurological disorders, which can avoid the disadvantage of VNS.
- Firing Rate
- Vagus Nerve Stimulation
- Nucleus Tractus Solitarius
- Epileptiform Activity
- Anticonvulsant Effect
The innervations of the external ear have contributions from cranial nerves and cervical nerves . Among these innervations, the auricular branch of the vagus nerve (ABVN), which is often termed the Alderman's nerve or the Arnold's nerve, mainly innervates the external auditory canal and the auricular concha. Arnold's reflexes manifested as hyperactive vagal responses have been clinically observed [2, 3]. Previous studies preliminarily proposed that the Arnold's reflexes might be mediated via the afferent connections from the ABVN to the nucleus tractus solitarius (NTS) [4–7].
The NTS not only plays important roles in autonomic regulations, but also receives extensive projections from other brain structures. Both the autonomic system and the central nervous system could be modified by auricular vagal stimulation via projections from the ABVN to the NTS, herein referred to as the “auriculo-vagal afferent pathway” (AVAP).
Epilepsy is a disorder of the brain characterized by an enduring predisposition to generate epileptic seizures and by the neurobiologic, cognitive, psychological, and social consequences of this condition. Left cervical vagus nerve stimulation (VNS) has been approved by the U.S. Food and Drug Administration (FDA) as an adjunctive treatment for refractory partial-onset seizures in adults and adolescents . VNS attenuates seizure frequency, seizure severity, and is associated with positive changes in mood, memory and quality of life . The anti-seizure effect of VNS is considered to be mediated via vagal afferent projections to the NTS, then via pathways from the NTS to other brain structures which correlate with the pathogenesis of epilepsy, with a result to electroencephalogram (EEG) desynchronization .
Together, these studies suggest the hypothesis that transcutaneous auricular vagus nerve stimulation (ta-VNS) suppresses epileptic seizures via the AVAP. In the present study, afferent projections of the ABVN in rats have been studied by using morphological techniques. Then behavioural and electrophysiological experiments in rats were performed to explore the roles of the AVAP in the anticonvulsant effect of ta-VNS.
Five different animal experiments were performed in the present study, including (1) afferent projections of the ABVN in rats by using cholera toxin subunit B (CTB) tracing technique, (2) ta-VNS on t seizures in awake rats, (3) ta-VNS on electroencephalography (EEG) and the firing of the NTS neurons in anaesthetized rats, (4) ta-VNS on the field potentials (FPs) of the primary somatosensory in anaesthetized rats, and (5) the effect of reversible cooling the NTS neurons on epileptiform activity in EEG traces in anaesthetized rats. ta-VNS, transcutaneous auricular non-vagus nerve stimulation (tan-VNS), or vagus nerve stimulation (VNS) were performed in experiment (2) – (5) as needed to observe the anticonvulsant efficacy of the ta-VNS. The detailed experimental procedures are as follows.
Totally ninety four adult male healthy rats, Sprague Dawley, weighing 250–320 g, were used. Rats feeding with normal diet were housed in a room maintained at 24±1°C and illuminated for 12 hours (07:00 to 19:00) every day. Food and water were freely available. Rats were allowed to adapt to the environment for 7 days prior to the experiment. Epileptiform activity was evoked by intraperitoneal injection of pentylenetetrazol (PTZ, 60 mg/kg; Sigma-Aldrich, St. Louis, MO, U.S.A.). For anaesthesia, 10% urethane (1.2 g/kg, via intraperitoneal route) was initiated. Additional sodium pentobarbital was administered to prolong the anaesthetic state. Animals were euthanized by urethane over-dose at the end of the study. All studies were approved by the Institutional Animal Care and Use Committee of China Academy of Chinese Medical Sciences and were in accordance with National Institutes of Health guidelines.
Tracing study on central projections of primary afferent fibers of the ABVN
Microinjection was carried out on 9 rats. Under anaesthesia, microsyringe contained 1% CTB (List Biological Labs, Campbell, CA, USA) solution was inserted subcutaneously into the junction of cavity of the auricular concha and postero-inferior wall of the external acoustic meatus for a depth of 2–3 mm along the auricular surface, and a total of 3 μl 1% CTB was injected slowly. After injection, the needle was retained about one min and then withdrawn carefully. On the third surviving day, the rats were deeply anaesthetized with ether (Beijing Chemical Plant, Beijing, China) and transcardially perfused with 100 ml of 0.9% saline and immediately followed by 300 ml of 4% paraformaldehyde in 0.1M phosphate buffered solution (PB, pH 7.4).
The brain stem, cervical spinal cord and cervical ganglia were dissected out and stored in 30% sucrose PB at 4°C and allowed to sink. Serial sections of brain stem, cervical spinal cord and cervical ganglia were cut at a thickness of 40 μm on a freezing microtome (MICROM, HM 400 R, Walldorf, Germany) and collected in 0.1M PB. The sections were processed for immunofluorescence staining. In brief, sections were incubated in a blocking solution containing 3% normal rabbit serum and 0.3% Triton X-100 in 0.1M PB for 1 hr, then transferred to goat anti-CTB (List Biological Labs) at a dilution of 1:1000 in 0.1M PB containing 1% rabbit serum and 0.3% Triton X-100 for overnight at 4°C. On the following day, after washing three times with 0.1M PB, sections were exposed to rabbit anti-goat Alexa 488 secondary antibody (1:500; Molecular Probes, Eugene, OR, USA) for 2 hr and then washed with 0.1M PB. Slides were coverslipped using Immu-mount (Thermo Shandon, Pittsburgh, USA) to improve visualization of labeling. The anatomical structure of tissue sections was determined cytoarchitecturally based on The Rat Brain in Stereotaxic Coordinates (Paxinos and Watson, 1998). The tissue samples were observed and recorded with a fluorescent microscope (Y-IDP; Nikon Co., Tokyo, Japan) equipped with a digital camera (DMX1200C; Nikon, Japan). Digital images were finally processed with Adobe Photoshop CS2 (Adobe Systems, San Jose, CA, USA).
Observation on epileptic behaviour
Thirty awake rats were divided into three groups: control group (n=10), tan-VNS group (n=10), ta-VNS group (n=10). Rats in the control group were treated with intraperitoneal injection of PTZ. Rats in the tan-VNS group were firstly treated with tan-VNS for 30 min, then treated with intraperitoneal injection of PTZ. Rats in the ta-VNS group were firstly treated with ta-VNS for 30 min, then treated with intraperitoneal injection of PTZ. After intraperitoneal injection of PTZ, the latency of the first grand mal and the scores of epileptic seizures in the rats were observed within 30 min. Epileptic behaviours were scored according to the standard of Racine′s scale . The observers of behavioral seizures were blinded to the treatment.
Simultaneous recording of EEG and the extracellular discharges of the NTS neurons in anaesthetized rats
Thirty one anesthetized rats were fixed on the stereotaxic apparatus with the incisor bar placed 3.3 mm below the interaural line. After craniotomies, bipolar silver globe electrodes (diameter of 1 mm) were placed over the dura in two holes (distance to the bregma, AP: ±1.0 mm, ML: 2.0 mm) respectively for the recording of epidural EEG. EEG signals were amplified by Amplifier WPI (World Precision Instrument, Sarasota, USA) with low frequency filter at 1 Hz and high frequency filter at 100 Hz. The extracellular discharge signals of the NTS neurons (distance to the bregma, AP: -11.3 ~ −14.3 mm; ML: 0 ~ 1.3 mm, DV: 4 ~ 7 mm) were recorded by glass microelectrodes (10-20MΩ, pulled by Narishige PE-2 vertical puller from a filamented glass) which were backfilled with 2% pontamine sky blue. Firings of the NTS neurons recorded from the glass electrodes were fed through an Xcel-3 microelectrode amplifier (FHC, Bowdoin, USA) with low frequency filter at 1 Hz and high frequency filter at 15 KHz. Both signals were captured online and analyzed offline using the CED 1401-plus data acquisition system and the Spike 2 package (Cambridge Electronic Devices, Cambridge, UK). After recording, the site was histological fixed for locating recording site. Data out of the site of the NTS were deleted.
In each rat, signals at baseline were recorded for five min firstly. Then the rat was treated with intraperitoneal injection of PTZ. Signals after PTZ were recorded for five min. After PTZ, tan-VNS, ta-VNS and VNS were randomized to stimulate in the rats for 30 s respectively. There was an interval of 30 min before beginning the next stimulation.
Microelectrode array recording of FPs in primary somatosensory in anaesthetized rats
The array with sixteen microelectrodes were implanted into the somatosensory cortices for use in recording FPs after craniotomy in 12 rats after anaesthesia. After being inserted in the correct position, the microelectrodes were cemented to skull screws by use of dental cement. FPs were collected by using Cerebus™ 5.0 Data Acquisition System at a sampling rate of 1000 Hz and a bandpass at 1–100 Hz, and were analyzed by Spike 2 package.
Firstly the rats were treated with intraperitoneal injection of PTZ. After PTZ, tan-VNS, ta-VNS were randomized to stimulate in the rats for 30 s respectively. There was an interval of 30 min before beginning the next stimulation.
Reversible cooling the NTS neurons on the EEG changes in anaesthetized rats
Twelve anaesthetized rats were fixed on the stereotaxic apparatus. An occipital craniotomy was performed in order to gain access to the dorsal surface of the medulla oblongata. A portion of the cerebellum was aspirated so that the dorsal surface of the medulla could be clearly visualized 3 mm caudal and 3 mm rostral to the obex. The bottom of a V-shaped glass tube was gently placed on the region equivalent to the area of the NTS around the obex. In order to keep the function of the NTS neurons reversible, –4°C ethylene glycol (≥98% radiochemical purity basis, PLC, aqueous solution, Sigma) was injected through the V-shaped glass tube to cool the NTS neurons physically.
There were steps for this experiment. The rats were treated with following steps including (a) intraperitoneal injection of PTZ, (b) ta-VNS for 30 s, (c) cooling of the NTS, (d) ta-VNS for 30 s during cooling of the NTS, (e) removing cooling of the NTS, (f) ta-VNS for 30 s. In the whole experiment, the EEG signals of the rats were recorded continuously.
In EEG tracings or FPs tracings, an epileptiform activity was shown as a highly synchronous and large-amplitude activity at least 3 times the amplitude of baseline. The firing rate of the NTS neurons was calculated in 30 s. Data were analysed with SPSS 10.0 program (SPSS Inc. Chicago, IL). Values are presented as mean ± SEM. Kolmogorov-Smirnof test was used to evaluate if groups fit normal distributions. Normally distributed groups were analysed by parametric tests. Comparison between two groups was analysed by Independent-Samples T test. Comparison between three groups was analysed by One-Way ANOVA followed by LSD or Dunnett's T3 post-hoc test. Nonnormally distributed groups were analysed by Mann–Whitney test. P < 0.05 was considered significant.
Afferent projections from the auricular concha to the NTS were demonstrated in the rats
ta-VNS pre-treatment suppressed epileptic behaviour in awake rats
ta-VNS suppressed epileptiform activity in EEG tracings by increasing the firing rates of the NTS neurons
ta-VNS suppressed epileptiform activity in FPs of cortices
The anticonvulsant effect of ta-VNS was weakened by reversible cold block of the NTS
In the present study, we first observed the afferent nerve terminals in NTS projected from the ABVN. Further, it was also observed that ta-VNS suppressed epileptiform activity via activating firing of the NTS neurons. The anticonvulsant effect of ta-VNS was weakened by reversible cold block of the NTS.
As the only peripheral branch, the ABVN is the last phylogenetic remnant of the nerve which innervates the lateral line organs in fish and amphibia. It is a mixed nerve composed of the vagus nerve, the glossopharyngeal nerve and the facial nerve . Anatomical studies showed that the ABVN was distributed to the posterior wall of the external auditory canal . Recently, the relationship between the ABVN with the NTS was investigated. Brain stem potentials elicited by ta-VNS are considered to be conducted via the ABVN to the NTS [14–16]. Functional MRI studies also demonstrated that ta-VNS on the left tragus was associated with higher order relay nuclei of vagal afferent pathways . We firstly observed the afferent projections from the ABVN to the NTS in the rats, which provides the anatomical evidence to support the AVAP.
VNS has been utilized in suppressing epilepsy for decades. The common parameters of VNS were 30 s on, and 5 min off. The pulse width of stimulation was 0.25-0.5 ms. The output currents were 0.25-4 mA in 0.25-mA steps . As the primary vagal afferent nucleus, the NTS has been considered to play an important role in the mechanism of VNS for the treatment of epilepsy . The NTS electrical stimulation interferes with epileptogenesis [18, 19]. An increase in gamma aminobutyric acid transmission or a decrease in glutamate transmission in the medial subnulceus of the NTS reduces susceptibility to limbic motor seizures in the rats . But the technique for VNS has some disadvantages such as surgery risks, high costs and unknown long-term effects of the electrical stimulation of the vagus on the central nervous such as sleep apnea, headache . ta-VNS is performed on the peripheral branch of the vagus nerve and is easy to be removed, which may provide a less-invasive treatment for epilepsy by decreasing or eliminating these disadvantages.
In the present study, it was observed that ta-VNS pretreatment had anticonvulsant effect in awake animals, which was in accordance with previous VNS pretreatment study . In our electrophysiological study, it was the first to reveal in vivo the relationship between the firing rates of the NTS neurons and the epileptiform activity in rats. The consecutive changes of the two signals suggested that the firing of NTS neurons was negatively correlated with epileptiform activity. We also found that ta-VNS substantially increase the firing rates of the NTS neurons, and suppresses epileptiform activity in in awake and anaesthetized rats, which supports the hypothesis that ta-VNS suppresses epileptiform activity via the AVAP.
Furthermore, prolonged anticonvulsant durations by VNS, ta-VNS and tan-VNS were observed in our study. tan-VNS was stimulated at the exterior margin of the auricle, which is mainly innervated by the great auricular nerve (GAN). Except for cervical vagus nerve, the ABVN, the central projections of the GAN in the solitary tract (SN) has also been shown . Therefore, the prolonged suppression of epileptiform activity by these three stimulations may be correlated with prolonged increasing of firing rates of the NTS neurons.
There were limitations in the present study. Sodium pentobarbital was administered to prolong the anaesthetic state. It is of possibility that use of this agent altered the dynamics of PTZ-induced seizures . In our experiment, after each administration of sodium pentobarbital, we began the stimulation only if the epileptiform discharges were stable, to avoid the effect of sodium pentobarbital on the anticonvulsant effect of ta-VNS. Though there was no statistical difference between the anticonvulsant duration of VNS and ta-VNS, we cannot make a conclusion that the anticonvulsant effect of ta-VNS is the same as that of VNS. Recently, it was found in a pilot study that an overall reduction of seizure frequency in five patients after 9 months of ta-VNS . We have also reported the anticonvulsant effect of ta-VNS in pediatric epilepsy patients . Further studies should be made on the long-term effect of ta-VNS, and to find optimized parameters of ta-VNS for seizure suppression.
The relation between the auricular branch of the vagus nerve and the autonomic and central nervous system is herein referred to as the “auriculo-vagal afferent pathway” (AVAP). The present study firstly observed the afferent projections from the ABVN to the NTS in the rat, with provided the anatomical evidence to support the AVAP. ta-VNS can suppress epileptiform activity via the AVAP. Further studies should be performed on the long-term effect of ta-VNS, and find optimized parameters of ta-VNS for seizure suppression in clinic.
This work was supported by National Basic Reaearch Program (973 Program, No. 2011CB505201), National Natural Science Foundation of China Research Grants (No. 81273829, 30901931), and Beijing Natural Science Foundation (No. 7102120). We are grateful to Prof. Jun-Ling Liu and Gary Lu for their reading of the manuscript.
- Ueno N, Sudo H, Hattori Y, Yuge K, Miyaki T, Ito H: [Innervation of the external ear in humans and the musk shrew]. Nihon Jibiinkoka Gakkai Kaiho. 1993, 96 (2): 212-218. 10.3950/jibiinkoka.96.212.View ArticlePubMedGoogle Scholar
- Bloustine S, Langston L, Miller T: Ear-cough (Arnold's) reflex. Ann Otol Rhinol Laryngol. 1976, 85 (3 pt 1): 406-407.View ArticlePubMedGoogle Scholar
- Engel D: The gastroauricular phenomenon and related vagus reflexes. Arch Psychiatr Nervenkr. 1979, 227 (3): 271-277. 10.1007/BF00367396.View ArticlePubMedGoogle Scholar
- Chien CH, Shieh JY, Ling EA, Tan CK, Wen CY: The composition and central projections of the internal auricular nerves of the dog. J Anat. 1996, 189 (Pt 2): 349-362.PubMed CentralPubMedGoogle Scholar
- Gupta D, Verma S, Vishwakarma SK: Anatomic basis of Arnold's ear-cough reflex. Surg Radiol Anat. 1986, 8 (4): 217-220. 10.1007/BF02425070.View ArticlePubMedGoogle Scholar
- Nomura S, Mizuno N: Central distribution of primary afferent fibers in the Arnold's nerve (the auricular branch of the vagus nerve): a transganglionic HRP study in the cat. Brain Res. 1984, 292 (2): 199-205. 10.1016/0006-8993(84)90756-X.View ArticlePubMedGoogle Scholar
- Tekdemir I, Aslan A, Elhan A: A clinico-anatomic study of the auricular branch of the vagus nerve and Arnold's ear-cough reflex. Surg Radiol Anat. 1998, 20 (4): 253-257.PubMedGoogle Scholar
- Schachter SC, Saper CB: Vagus nerve stimulation. Epilepsia. 1998, 39 (7): 677-686. 10.1111/j.1528-1157.1998.tb01151.x.View ArticlePubMedGoogle Scholar
- Ben-Menachem E: Vagus-nerve stimulation for the treatment of epilepsy. Lancet Neurol. 2002, 1 (8): 477-482. 10.1016/S1474-4422(02)00220-X.View ArticlePubMedGoogle Scholar
- Henry TR: Therapeutic mechanisms of vagus nerve stimulation. Neurology. 2002, 59 (6 Suppl 4): S3-14.View ArticlePubMedGoogle Scholar
- Dorr AE, Debonnel G: Effect of vagus nerve stimulation on serotonergic and noradrenergic transmission. J Pharmacol Exp Ther. 2006, 318 (2): 890-898. 10.1124/jpet.106.104166.View ArticlePubMedGoogle Scholar
- Racine RJ: Modification of seizure activity by electrical stimulation. II. Motor seizure. Electroencephalogr Clin Neurophysiol. 1972, 32 (3): 281-294. 10.1016/0013-4694(72)90177-0.View ArticlePubMedGoogle Scholar
- Fanselow EE, Reid AP, Nicolelis MA: Reduction of pentylenetetrazole-induced seizure activity in awake rats by seizure-triggered trigeminal nerve stimulation. J Neurosci. 2000, 20 (21): 8160-8168.PubMedGoogle Scholar
- Fallgatter AJ, Neuhauser B, Herrmann MJ, Ehlis AC, Wagener A, Scheuerpflug P, Reiners K, Riederer P: Far field potentials from the brain stem after transcutaneous vagus nerve stimulation. J Neural Transm. 2003, 110 (12): 1437-1443. 10.1007/s00702-003-0087-6.View ArticlePubMedGoogle Scholar
- Polak T, Ehlis AC, Langer JB, Plichta MM, Metzger F, Ringel TM, Fallgatter AJ: Non-invasive measurement of vagus activity in the brainstem - a methodological progress towards earlier diagnosis of dementias?. J Neural Transm. 2007, 114 (5): 613-619. 10.1007/s00702-007-0625-8.View ArticlePubMedGoogle Scholar
- Polak T, Markulin F, Ehlis AC, Langer JB, Ringel TM, Fallgatter AJ: Far field potentials from brain stem after transcutaneous vagus nerve stimulation: optimization of stimulation and recording parameters. J Neural Transm. 2009, 116 (10): 1237-1242. 10.1007/s00702-009-0282-1.View ArticlePubMedGoogle Scholar
- Dietrich S, Smith J, Scherzinger C, Hofmann-Preiss K, Freitag T, Eisenkolb A, Ringler R: [A novel transcutaneous vagus nerve stimulation leads to brainstem and cerebral activations measured by functional MRI]. Biomed Tech (Berl). 2008, 53 (3): 104-111.View ArticleGoogle Scholar
- Magdaleno-Madrigal VM, Martinez-Vargas D, Valdes-Cruz A, Almazan-Alvarado S, Fernandez-Mas R: Preemptive effect of nucleus of the solitary tract stimulation on amygdaloid kindling in freely moving cats. Epilepsia. 2010, 51 (3): 438-444. 10.1111/j.1528-1167.2009.02337.x.View ArticlePubMedGoogle Scholar
- Magdaleno-Madrigal VM, Valdes-Cruz A, Martinez-Vargas D, Martinez A, Almazan S, Fernandez-Mas R, Fernandez-Guardiola A: Effect of electrical stimulation of the nucleus of the solitary tract on the development of electrical amygdaloid kindling in the cat. Epilepsia. 2002, 43 (9): 964-969. 10.1046/j.1528-1157.2002.05702.x.View ArticlePubMedGoogle Scholar
- Walker BR, Easton A, Gale K: Regulation of limbic motor seizures by GABA and glutamate transmission in nucleus tractus solitarius. Epilepsia. 1999, 40 (8): 1051-1057. 10.1111/j.1528-1157.1999.tb00818.x.View ArticlePubMedGoogle Scholar
- Labar D: Vagus nerve stimulation for epilepsy. Clin Neurosci Res. 2004, 4: 81-88. 10.1016/j.cnr.2004.06.007.View ArticleGoogle Scholar
- Takaya M, Terry WJ, Naritoku DK: Vagus nerve stimulation induces a sustained anticonvulsant effect. Epilepsia. 1996, 37 (11): 1111-1116. 10.1111/j.1528-1157.1996.tb01033.x.View ArticlePubMedGoogle Scholar
- Liu D, Hu Y: The central projections of the great auricular nerve primary afferent fibers–an HRP transganglionic tracing method. Brain Res. 1988, 445 (2): 205-210.23. 10.1016/0006-8993(88)91179-1.View ArticlePubMedGoogle Scholar
- Barberio M, Reiter PD, Kaufman J, Knupp K, Dobyns EL: Continuous infusion pentobarbital for refractory status epilepticus in children. J Child Neurol. 2012, 27 (6): 721-726. 10.1177/0883073811424941.View ArticlePubMedGoogle Scholar
- Stefan H, Kreiselmeyer G, Kerling F, Kurzbuch K, Rauch C, Heers M, Kasper BS, Hammen T, Rzonsa M, Pauli E, et al: Transcutaneous vagus nerve stimulation (t-VNS) in pharmacoresistant epilepsies: a proof of concept trial. Epilepsia. 2012, 53 (7): e115-118. 10.1111/j.1528-1167.2012.03492.x.View ArticlePubMedGoogle Scholar
- He W, Jing XH, Wang XY, Rong PJ, Li L, Shi H, Shang HY, Wang YP, Zhang JG, Zhu B: Transcutaneous auricular vagus nerve stimulation as a complementary therapy for pediatric epilepsy: a pilot trial. Epilepsy Behav. in pressGoogle Scholar
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