Case report Successful implantation and immediate activation of Vagus Nerve Stimulation (VNS) during pregnancy in a patient with intractable epilepsy: A case illustration and review of the literature N. Jazebi a , N. Moghimi a , R. Lall b , E. Osadebey b , J. Ortega-Barnett b , T. Masel a,⇑ a Department of Neurology, University of Texas Medical Branch, Galveston, TX, United States b Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX, United States article info Article history: Received 5 February 2017 Accepted 13 March 2017 Available online xxxx Keywords: Epilepsy Pregnancy Vagus Nerve Stimulation (VNS) Refractory seizures abstract While Vagus Nerve Stimulation (VNS) is proven to be a safe and effective adjunctive therapy in the gen- eral population with medically intractable seizures, little is published about its implantation during preg- nancy. Here we illustrate the case of a 21 year old primigravid woman with medically refractory seizures who underwent safe and successful VNS implantation and immediate activation of the device in her 32nd week of pregnancy, resulting in dramatically improved seizure control and subsequent delivery of a healthy baby. Published by Elsevier Ltd. 1. Introduction Seizures during pregnancy can be a challenging clinical problem to manage and may be associated with devastating consequences. The prevalence of epilepsy in pregnant women is 0.7% according to population-based studies [1]. Literature reports that seizure fre- quency may alter during pregnancy and labor with some women with epilepsy experiencing increase seizure frequency [2,3]. Fur- thermore, seizures may cause obstetric complications such as pla- cental abruption, premature labor and delivery, and superficial abdominal hematomas secondary to fall [1]. Pregnant women with epilepsy are also at increased risk for spontaneous abortion, induc- tion of labor, caesarean section, and postpartum hemorrhage [1]. During 2006–2008, 14 women in the United Kingdom suffering from epilepsy died during pregnancy due to their seizure activity [2]. Abe et al. report that the incidence of major congenital malfor- mation in women without epilepsy is 1.6–2.2%, whereas that in WWE is higher, at 2.8–3.6%. Women with epilepsy who take AEDs during pregnancy have an incidence of 4.2–6.7% of major congen- ital malformation, and seizures may become refractory to previous AED regimens that were effective prior to pregnancy [1]. One potential adjunctive treatment for women with refractory seizures during pregnancy is vagal nerve stimulation (VNS). The exact mechanism of vagal nerve stimulation is not definitive however its use may play a role in the brainstem reticular forma- tion and nucleus solitarius tracts by modifying electrical stimuli [4]. This electrical stimuli modification may interfere with the stereotypical electrical activity distinctive of a seizure [5,6]. VNS placement during pregnancy may be effective for seizure control in patients with refractory seizures during pregnancy by allowing for superior seizure control at lower AED doses. This may result in improved perinatal outcomes and decreased risk of major congenital malformations. This technique, however, is poorly described in the existing literature and there is presently only a single case report of VNS implantation during pregnancy [7]. The device can be activated on demand when an external pro- grammer device is placed on the skin above the generator/battery allowing for at will activation and inactivation. Here we describe a case in which VNS implantation was safely and successfully performed in a patient with pharmacoresistant epilepsy during her 32nd week of pregnancy, resulting in a dra- matic reduction of seizures and an uncomplicated delivery of a healthy baby. 2. Case presentation A 21 year old female in her 3rd trimester of pregnancy pre- sented with refractory epileptic seizures since childhood. Imaging showed left frontotemporal focal cortical dysplasia. EEG showed focal interictal epileptiform discharges, and continuous EEG moni- toring showed subclinical focal electrographic seizures. At the time http://dx.doi.org/10.1016/j.jocn.2017.03.044 0967-5868/Published by Elsevier Ltd. ⇑ Corresponding author. E-mail address: nojazebi@utmb.edu (N. Jazebi). Journal of Clinical Neuroscience xxx (2017) xxx–xxx Contents lists available at ScienceDirect Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn Please cite this article in press as: Jazebi N et al. Successful implantation and immediate activation of Vagus Nerve Stimulation (VNS) during pregnancy in a patient with intractable epilepsy: A case illustration and review of the literature. J Clin Neurosci (2017), http://dx.doi.org/10.1016/j.jocn.2017.03.044