Successful treatment of super-refractory focal status epilepticus: Surgery, vagus nerve stimulation, and botox for epilepsia partialis continua

Abstract

Super-refractory status epilepticus (SRSE) is a life-threatening condition characterized by persistent seizures lasting beyond seven days despite anesthetic therapy. Managing SRSE is challenging, particularly in cases resistant to conventional treatments. This case report presents a 41-year-old female with prolonged SRSE secondary to focal epilepsy, successfully treated with surgical resection, vagus nerve stimulation (VNS), and botulinum toxin (BoNT) therapy. The patient initially presented with left focal motor status epilepticus and a right frontal intracerebral hematoma. Despite an emergency craniotomy, her seizures persisted, leading to prolonged SRSE. After multiple failed sedation weaning attempts, a stepwise intervention approach was implemented consisting of an Electrocorticography (ECoG)-guided surgical resection of the residual epileptic focus, VNS implantation for long-term seizure modulation, BoNT therapy for residual epilepsia partialis continua (EPC). The combined approach of surgical resection and VNS implantation successfully terminated the status epilepticus. Residual Epilepsia Partialis Continua (EPC) was effectively managed with botulinum toxin therapy (BoNT). This case underscores the potential efficacy of combining surgical resection and VNS implantation in treating SRSE and highlights the beneficial effects of BoNT in managing residual EPC, offering a potential treatment pathway for similar refractory cases.

Keywords: Botulinum toxin therapy; Case report; Super-refractory status epilepticus; Surgical resection; Traumatic brain injury; Vagus nerve stimulation.

Fig. 1

(A) Pre-op Coronal T1 (B) Pre-op Axial T1 (C) Pre-op Axial T2 (D) Post-op Axial CTH (E) Post-op Coronal CTH.

Fig. 2

Pre-resection Electrocorticography (ECoG). Electrocorticography (ECoG), prior to resection at USC. Two Integra 4x5 grids with 10 mm inter-contact spacing were placed in the right frontoparietal parasagittal and right anterior-middle-posterior temporal regions within the resection cavity. Multifocal spikes are present, some are polyphasic and very broad affecting large parts of the recording grids. The most consistent foci with repetitive spiking were Grid 1 (inferior frontal resection cavity): channels 8, 9, 7, 13, and 14; and to a lesser extent, channels 4 and 5. Grid 2 (superior frontal resection cavity): channels 6, 7, 8, and 11.

Fig. 3

Scalp Electrocochleography (EEG) Recordings. Representative EEG Epochs shown. (A) EEG prior to transfer to USC, showing highly abnormal pattern prominent muscle artifact overlaying suspected epileptiform activity/severe background slowing. (B) EEG during weaning off sedation, demonstrating frequent generalized epileptiform discharges. (C) EEG after (BoNT) treatment, showing significant reduction in epileptiform discharges compared to (B). EEG Display Parameters (for A & B): Sensitivity 7 µV/mm, Low-Frequency Filter (LFF) 1.0 Hz, High-Frequency Filter (HFF) 70 Hz, Notch Filter 60 Hz ON, System: Cadwell Essentia (A) and Xltek EEG Machines (B). Original Sampling Rate: 200 Hz. Display Montage: Longitudinal Bipolar ('Double Banana’). For (C): Sensitivity 7 µV/mm, Low-Frequency Filter (LFF) 1.0 Hz, High-Frequency Filter (HFF) 70 Hz, Notch Filter 60 Hz ON, System: Nihon Kohden − Neurofax. Original Sampling Rate: 200 Hz. Display Montage: Longitudinal Bipolar ('Double Banana’).

Fig. 4

Video-EEG (vEEG) recordings demonstrating ictal correlate of myoclonic jerks and response to Botulinum toxin (BoNT) therapy. (A) vEEG epoch capturing a subtle left finger myoclonic jerk (video-confirmed) (B) vEEG epoch recorded after BoNT therapy, showing resolution of frequent epileptiform discharges. EEG Display Parameters (for A and B): Sensitivity 7 µV/mm, Low-Frequency Filter (LFF) 1.0 Hz, High-Frequency Filter (HFF) 70 Hz, Notch Filter 60 Hz ON, System: Nihon Kohden − Neurofax version QP-112AK Ver; Original Sampling Rate: 200 Hz. Display Montage: Longitudinal Bipolar ('Double Banana').