Paired vagus nerve stimulation therapy for posterior circulation ischemic strokes: illustrative cases

BACKGROUND: While the global disability burden due to stroke remains substantial, the emergence of novel neurorestorative therapies offers new opportunities for poststroke recovery. Vagus nerve stimulation (VNS) paired with upper extremity (UE) rehabilitation (paired VNS) is an FDA-approved therapy shown to improve UE impairment and reduce motor deficits in patients with chronic stroke. However, published evidence describing its use in posterior circulation strokes is limited. OBSERVATIONS: This case series presents 4 patients with persistent UE impairment following posterior fossa strokes who underwent implantation and treatment with paired VNS months to years after their cerebrovascular event. Functional improvements were observed in all cases, including gains in Fugl-Meyer Assessment for Upper Extremity or Wolf Motor Function Test scores. All patients also reported improved functional use of the affected limb during daily activities and improvements in their quality of life. LESSONS: These cases suggest that paired VNS therapy may support meaningful functional recovery following posterior fossa stroke, even years after the initial event. Improvements were observed in both objective motor outcomes and patient-reported function and quality of life. These observations expand the clinical experience with paired VNS in a stroke subpopulation associated with significant long-term disability, and contribute to addressing a gap in the literature. https://thejns.org/doi/10.3171/CASE26535.