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Case Reports
. 2026 Jan 14;18(1):e101572.
doi: 10.7759/cureus.101572. eCollection 2026 Jan.

Anesthetic Management of a Patient With a Vagal Nerve Stimulator and Poorly Controlled Seizures

Lakshmi N Kurnutala  1 , Nickhil Rugnath  1 , Rhea Arora  1 , Ryan Nazari  2
Affiliations
Case Reports

Anesthetic Management of a Patient With a Vagal Nerve Stimulator and Poorly Controlled Seizures

Lakshmi N Kurnutala et al. Cureus. .

Abstract

Vagal nerve stimulation (VNS) is an emerging adjunctive therapy for patients with drug-resistant epilepsy. While it can reduce seizure frequency, it rarely results in complete seizure control. It introduces unique challenges in the perioperative setting, including risks of intraoperative seizures, VNS-induced bradyarrhythmias, and respiratory complications. We present a complex case of a 63-year-old woman with treatment-resistant epilepsy managed with VNS, who underwent open reduction and internal fixation (ORIF) for bilateral femur fractures. On the night before surgery, the patient experienced a tonic-clonic seizure with status epilepticus on the surgical floor, managed with intravenous levetiracetam and midazolam. Despite neurology clearance, intraoperative seizure activity was suspected under general anesthesia, identified by a sudden rise in Bispectral Index (BIS) values. The episode was treated with intravenous levetiracetam, resulting in BIS stabilization and presumed seizure resolution. This case underscores the heightened perioperative seizure risk in patients with VNS, the importance of continuing antiepileptic therapy, maintaining vigilant intraoperative monitoring, including BIS or continuous electroencephalography (cEEG) monitoring, and selecting anesthetic agents that minimize pro-convulsant potential. The anesthesia team, in collaboration with neurologists, should be well-versed in VNS function, associated complications, and emergency deactivation procedures. This multidisciplinary approach is crucial to optimizing surgical outcomes in patients with refractory epilepsy, providing a comprehensive and reassuring treatment process.

Keywords: bis; epilepsy; general anesthesia; status epilepticus; vns.

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Conflict of interest statement

Human subjects: Informed consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. Patient chest X-ray showing the vagal nerve stimulator on the left side of the chest.
Figure 2
Figure 2. Intraoperative BIS monitoring.
Spikes in BIS (yellow arrows) and electromyography (EMG) (orange arrows) indicate the use of electrocautery during surgery. A sudden increase in BIS (red arrow) without a change in EMG indicates increased electrical activity in the brain and the possibility of a seizure. BIS: Bispectral Index
See this image and copyright information in PMC

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