Abstracts

Rationale: Status epilepticus is a neurologic emergency with high mortality. Vagal nerve stimulator (VNS) placement is a rarely utilized therapy for pharmacologically-resistant status epilepticus, and review of extant literature yields few published case reports. Further study is warranted to determine the efficacy of VNS in this setting. Methods: A 23 year old male on lamotrigine 200 mg BID, valproate 1000 mg BID, and leviteracetam 1500 mg BID for idiopathic primary generalized epilepsy presented to our hospital after non-compliance with his home medications for an unknown period of time. His baseline seizure activity was approximately one brief nocturnal myoclonic seizure per night. He suffered multiple generalized and myoclonic seizures in the Emergency Department and on the floor, and required intubation and transfer to the neurological intensive care unit for status epilepticus on the first evening of his admission despite aggressive treatment with benzodiazepines. He was treated with midazolam, propofol, ketamine, and pentobarbital intravenous infusions at varying intervals, in addition to leviteracetam, valproate, lamotrigine, topiramate, ethosuximide, clonazepam, and phenobarbital. The patient failed to improve, demonstrating repeated clinical and encephalographic seizure activity. Vagal nerve stimulator was placed on hospital day #25. Results: Original VNS settings included pulse width of 250 microseconds, output current of 1.0 milliamps, magnet current of 1.50 milliamps, on-time of 7 seconds, and off-time of 0.3 minutes. The patient showed no improvement over the first three days post-op prompting re-institution of pentobarbital intravenous infusion. Revision of VNS settings included an on-time of 30 seconds, and off-time of 1.1 minute. Sedative medications were weaned steadily and the patient was extubated eight days after VNS revision with ultimate goal of comfort measure care. Surprisingly, he awakened on hospital day #35. He continued to have multiple daily myoclonic seizures that were demonstrably halted utilizing VNS activation by magnet and intravenous benzodiazepines. He was ultimately discharged ten days after extubation to an inpatient rehabilitation facility on valproate, leviteracetam, phenobarbital, topiramate, and lamotrigine. He was followed up in clinic within one month, and had improved over his pre-hospital baseline - reporting only one nocturnal seizure per week. Conclusions: We present a case of a patient with refractory status epilepticus who spontaneously improved late in his hospital course after surgical placement of vagal nerve stimulator. Subsequent follow-up with this patient also demonstrated improvement over patient’s baseline seizure frequency.