Disclosures: Brendan K. Skeehan, DO: No financial relationships or conflicts of interest

Case Description: 30-year-old female presented to IRF two months after a car accident and cardiac arrest (50minutes until ROSC). MRI revealed volume loss and symmetric bilateral basal ganglia hyperintensities consistent with global hypoxic ischemic injury. Patient transferred to IRF in vegetative state (VS) with a Revised JFK Coma Recovery Scale score of 5/23 (JFK CRS-R). Patient maintained initially on Amantidine and later Methylphenidate for neurostimulation, both with minimal neurocognitive improvement. Patient trialed on Zolpidem 5mg on Day14 and within 24 hours there was improvement in eye contact and intermittent command following. On Day17 Zolpidem increased to 10mg BID. Patient emerged to minimally conscious state (MCS) on Day30. Zolpidem weaned on Day59 and discontinued on Day62. Patient remained in MCS and was discharged to SAR on Day106. Patient seen at 1 month follow-up in stable neurocognitive condition.

Setting: IRF (Inpatient Rehabilitation Facility)

Patient: 30-year-old female Assessment/

Results: Patient’s neurocognitive status and JFK CRS-R scores remained largely unchanged through initial two weeks despite treatment with Amantidine and Methylphenidate. Initial scores were 6-7 (Days1-14) prior to Zolpidem and 9-10 within one day of therapeutic administration (Days17-30) and consistently 14-16 within 3 weeks of administration (Day31-45). Patient entered MCS on Day30.

Discussion: Zolpidem has off-label use for transient neurostimulation in patients with severe TBI and associated disorders of consciousness. Exact mechanism remains unknown but literature suggests it’s related to increased metabolism in anterior forebrain and subcortical structures as explained by the “mesocircuit hypothesis”. While it’s clear there is transient improvement, potential for persistent improvement and variability of response in patients warrants further investigation.

Conclusion: Transient improvement of neurocognitive function is evident after administration of Zolpidem in patients with Anoxic Brain Injury. Additional studies are necessary to explore mechanisms, potential sustainability, and patient response variability. Clinicians should consider off label Zolpidem if traditional pharmacology is ineffective.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/use-of-zolpidem-in-the-management-of-anoxic-brain-injury-and-associated-disorders-of-consciousness-a-case-report/