Intractable episodic bradycardia resulting from progressive lead traction in an epileptic child with a vagus nerve stimulator: a delayed complication

Vagus nerve stimulation (VNS) is used as palliation for adult and pediatric patients with intractable epilepsy who are not candidates for curative resection. Although the treatment is generally safe, complications can occur intraoperatively, perioperatively, and in a delayed time frame. In the literature, there are 2 reports of pediatric patients with implanted VNS units who had refractory bradycardia that resolved after the stimulation was turned off. The authors report the case of a 13-year-old boy with a history of vagus nerve stimulator placement at 2 years of age, who developed intractable episodic bradycardia that persisted despite the cessation of VNS and whose imaging results suggested vagus nerve tethering by the leads. He was subsequently taken to the operating room for exploration, where it was confirmed that the stimulator lead was exerting traction on the vagus nerve, which was displaced from the carotid sheath. After the vagus nerve was untethered and the leads were replaced, the bradycardia eventually resolved with continual effective VNS therapy. When placing a VNS unit in a very young child, accommodations must be made for years of expected growth. Delayed intractable bradycardia can result from a vagus nerve under traction by tethered stimulator leads.