Vagus nerve stimulation in super-refractory status epilepticus following hypoxic brain injury: a case report and review of the literature

• Super-refractory status epilepticus occurred after hypoxic–ischemic brain injury from drug overdose. • Implanted left cervical vagus nerve stimulation was used as a rescue therapy after multiple anesthetic and antiseizure drug failures. • Gradual VNS titration was guided by continuous EEG and hemodynamic monitoring, with only transient, reversible bradycardia. • Seizure cessation was confirmed by continuous EEG and allowed stepwise withdrawal of anesthetic infusions and reduction of antiseizure medications. • The case integrates detailed titration, safety, and ethical considerations and is contextualized within the current SRSE VNS literature. Status epilepticus (SE) is a life-threatening neurological condition that can be resistant to pharmacological treatments, particularly when triggered by severe brain insults such as asphyxia. Refractory status epilepticus (RSE) is the persistence of SE despite second-line treatment. Super-refractory status epilepticus (SRSE) is an ongoing SE despite 48 h of anaesthetic treatment. While neonatal asphyxia is well-documented in the literature, adult cases can also result in significant neurological complications, including refractory seizures non-responsive to standard antiepileptic drugs. Brain CT scan demonstrated diffuse hypoxic-ischemic injury involving cortical and subcortical regions with loss of gray-white matter differentiation. Continuous EEG confirmed persistent electrographic status epilepticus despite sequential administration of midazolam and ketamine infusions. High case fatality in RSE ranges from 16 % to 39 %, necessitating alternative therapeutic approaches. Vagus nerve stimulation (VNS) has emerged as a promising adjunct therapy for SRSE, offering a non-pharmacological approach to seizure control. We present the case of a 32-year-old female who developed super-refractory status epilepticus (SRSE) following hypoxic injury caused by a ketamine and tramadol overdose. After failure of nine antiseizure and anesthetic agents over 20 days, left cervical vagus nerve stimulation (VNS) was implanted on day 21. EEG-confirmed seizure activity decreased progressively upon VNS initiation and titration; by week 3, both clinical seizures and electrographic discharges resolved. Antiseizure and anesthetic infusions were gradually tapered—midazolam and ketamine discontinued entirely by day 35—without recurrence. The Glasgow Coma Scale (GCS) score improved from 2T to 7T over these three weeks. Follow-up EEG demonstrated sustained suppression of epileptiform activity. This case highlights the effectiveness of VNS in controlling RSE and improving neurological function in patients with severe brain injury due to asphyxia when standard treatments failed. Its rapid benefits suggest early consideration in refractory cases, warranting further research.