Case Report: Vagus nerve stimulation in super-refractory status epilepticus: Delayed seizure control and focal cortical knife-blade atrophy

• Vagus nerve stimulation may contribute to seizure termination in super-refractory status epilepticus. • Clinical response to VNS in SRSE can be delayed. • Prolonged SRSE may lead to focal cortical atrophy beyond the mesial temporal lobe. Super-refractory status epilepticus (SRSE), defined as seizure activity persisting > 24 h despite anesthetic treatment, remains a therapeutic challenge with high morbidity and mortality. We report a 42-year-old man with Crohn’s disease who developed SRSE following a right posterior cerebral artery infarction. Despite treatment with multiple antiseizure medications, immunotherapy, intravenous anesthetics, and barbiturate coma, seizures persisted for 80 days. A vagus nerve stimulator (VNS) was implanted on day 57 after status epilepticus onset. Clinical improvement began within days, and complete cessation of clonic seizures occurred 23 days after implantation, allowing withdrawal of anesthetic agents. The patient was discharged with mild residual deficits and achieved good long-term functional recovery. Follow-up MRI revealed progressive focal atrophy of the right postcentral gyrus, correlating with cortical sensory deficits. This case highlights that VNS may contribute to seizure termination in SRSE even when implanted late, although clinical effects may be delayed. It also illustrates that prolonged SRSE can lead to focal cortical atrophy beyond the mesial temporal lobe.