Safe and effective implantation and use of vagal nerve stimulation in new-onset refractory status epilepticus in early pregnancy: a case report
IntroductionThe management of new-onset refractory status epilepticus (NORSE) in pregnancy may be complicated by anti-seizure medication (ASM) polytherapy-associated teratogenicity. We aim to demonstrate the safety and efficacy of vagal nerve stimulation (VNS) in a pregnant patient presenting with N...
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| Format: | Article |
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Frontiers Media S.A.
2023-05-01
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| Series: | Frontiers in Neurology |
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| Online Access: | https://www.frontiersin.org/articles/10.3389/fneur.2023.1183080/full |
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| author | Malaika Jindal Laura Delaj Joel Winston Rishu Goel Sadia Bhatti Milena Angelova-Chee Richard Selway Laura Mantoan Ritter |
| author_facet | Malaika Jindal Laura Delaj Joel Winston Rishu Goel Sadia Bhatti Milena Angelova-Chee Richard Selway Laura Mantoan Ritter |
| author_sort | Malaika Jindal |
| collection | DOAJ |
| description | IntroductionThe management of new-onset refractory status epilepticus (NORSE) in pregnancy may be complicated by anti-seizure medication (ASM) polytherapy-associated teratogenicity. We aim to demonstrate the safety and efficacy of vagal nerve stimulation (VNS) in a pregnant patient presenting with NORSE.Case descriptionA 30-year old female, at 5-weeks' gestation presented with drug-refractory myoclonic status epilepticus, responsive only to high levels of anesthetic agents. The severity of seizures did not allow extubation, and the patient remained ventilated and sedated. VNS was implanted 26 days after seizure onset. The immediate post-operative output was 0.25 mA, which was rapidly titrated up to 0.5 mA the next morning, and to 0.75 mA that afternoon. This was further increased to 1.0 mA on 3rd day post-operation, and to 1.25 mA 7 days post-op. Myoclonic jerks diminished significantly 7 days post-op, allowing extubation. Twenty days after VNS implantation, no myoclonic jerks were observed. There was also a notable neurological improvement including increased alertness and mobility, and ability to obey commands. Drug overdose was subsequently found to be the most likely etiology of her NORSE. An early pregnancy assessment 17 days after VNS implantation showed a normally sited pregnancy, normal fetal heart activity and crown-rump length. The patient remained seizure free, gained functional independence and delivered a premature but otherwise healthy baby at 33 weeks' gestation.ConclusionNORSE is challenging to manage, further compounded in pregnancy due to the teratogenicity of ASMs and ASM polytherapy. This is the first case-study to report the safe implantation and use of VNS during the first trimester of pregnancy for the management of NORSE. |
| first_indexed | 2024-04-09T12:38:22Z |
| format | Article |
| id | doaj.art-2dbe1bff28f7456ca6b62aaedfc509b1 |
| institution | Directory Open Access Journal |
| issn | 1664-2295 |
| language | English |
| last_indexed | 2024-04-09T12:38:22Z |
| publishDate | 2023-05-01 |
| publisher | Frontiers Media S.A. |
| record_format | Article |
| series | Frontiers in Neurology |
| spelling | doaj.art-2dbe1bff28f7456ca6b62aaedfc509b12023-05-15T05:06:47ZengFrontiers Media S.A.Frontiers in Neurology1664-22952023-05-011410.3389/fneur.2023.11830801183080Safe and effective implantation and use of vagal nerve stimulation in new-onset refractory status epilepticus in early pregnancy: a case reportMalaika Jindal0Laura Delaj1Joel Winston2Rishu Goel3Sadia Bhatti4Milena Angelova-Chee5Richard Selway6Laura Mantoan Ritter7Faculty of Life Sciences and Medicine, King's College London, London, United KingdomDepartment of Neurology, East Kent Hospitals University National Health Service (NHS) Foundation Trust, Kent, United KingdomDepartment of Neurophsyiology, King's College Hospital, London, United KingdomDepartment of Obstetrics and Gynaecology, East Kent Hospitals University National Health Service (NHS) Foundation Trust, Kent, United KingdomDepartment of Obstetrics, King's College Hospital, London, United KingdomIntensive Care Unit, King's College Hospital, London, United KingdomDepartment of Neurosurgery, King's College Hospital, London, United KingdomDepartment of Neurology, King's College Hospital, London, United KingdomIntroductionThe management of new-onset refractory status epilepticus (NORSE) in pregnancy may be complicated by anti-seizure medication (ASM) polytherapy-associated teratogenicity. We aim to demonstrate the safety and efficacy of vagal nerve stimulation (VNS) in a pregnant patient presenting with NORSE.Case descriptionA 30-year old female, at 5-weeks' gestation presented with drug-refractory myoclonic status epilepticus, responsive only to high levels of anesthetic agents. The severity of seizures did not allow extubation, and the patient remained ventilated and sedated. VNS was implanted 26 days after seizure onset. The immediate post-operative output was 0.25 mA, which was rapidly titrated up to 0.5 mA the next morning, and to 0.75 mA that afternoon. This was further increased to 1.0 mA on 3rd day post-operation, and to 1.25 mA 7 days post-op. Myoclonic jerks diminished significantly 7 days post-op, allowing extubation. Twenty days after VNS implantation, no myoclonic jerks were observed. There was also a notable neurological improvement including increased alertness and mobility, and ability to obey commands. Drug overdose was subsequently found to be the most likely etiology of her NORSE. An early pregnancy assessment 17 days after VNS implantation showed a normally sited pregnancy, normal fetal heart activity and crown-rump length. The patient remained seizure free, gained functional independence and delivered a premature but otherwise healthy baby at 33 weeks' gestation.ConclusionNORSE is challenging to manage, further compounded in pregnancy due to the teratogenicity of ASMs and ASM polytherapy. This is the first case-study to report the safe implantation and use of VNS during the first trimester of pregnancy for the management of NORSE.https://www.frontiersin.org/articles/10.3389/fneur.2023.1183080/fullNORSEVNSpregnancyoutcomesstatus epilepticus |
| spellingShingle | Malaika Jindal Laura Delaj Joel Winston Rishu Goel Sadia Bhatti Milena Angelova-Chee Richard Selway Laura Mantoan Ritter Safe and effective implantation and use of vagal nerve stimulation in new-onset refractory status epilepticus in early pregnancy: a case report Frontiers in Neurology NORSE VNS pregnancy outcomes status epilepticus |
| title | Safe and effective implantation and use of vagal nerve stimulation in new-onset refractory status epilepticus in early pregnancy: a case report |
| title_full | Safe and effective implantation and use of vagal nerve stimulation in new-onset refractory status epilepticus in early pregnancy: a case report |
| title_fullStr | Safe and effective implantation and use of vagal nerve stimulation in new-onset refractory status epilepticus in early pregnancy: a case report |
| title_full_unstemmed | Safe and effective implantation and use of vagal nerve stimulation in new-onset refractory status epilepticus in early pregnancy: a case report |
| title_short | Safe and effective implantation and use of vagal nerve stimulation in new-onset refractory status epilepticus in early pregnancy: a case report |
| title_sort | safe and effective implantation and use of vagal nerve stimulation in new onset refractory status epilepticus in early pregnancy a case report |
| topic | NORSE VNS pregnancy outcomes status epilepticus |
| url | https://www.frontiersin.org/articles/10.3389/fneur.2023.1183080/full |
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