Disclosures: Alexandra S. Jensen, DO: No financial relationships or conflicts of interest

Case Diagnosis: A 54-year-old African American female with akinetic mutism who presented after a hemorrhagic stroke.

Case Description: The patient was admitted twenty one days after a left thalamic hemorrhage due to hypertensive emergency. At time of admission for acute inpatient rehabilitation she did not attempt verbalization. Her lack of communication was initially thought to be behavioral, and she required maximal assistance for mobility and activities of daily living. Physical exam was notable for consistent command following on nonplegic side with no initiation of speech.

Setting: Inpatient Rehabilitation FacilityAssessment/

Results: While admitted she was trialed on neurostimulation for akinetic mutism. She failed amantadine, levodopa-carbidopa, modafinil, methylphenidate, donepezil, bromocriptine. Trial of zolpidem twice a day had a significant response. The dosing frequency was increased to every 6 hours and she continued to have improved initiation and verbalization. Dosing of zolpidem was held for one day to determine necessity of medication upon discharge. She continued to verbalize despite being off of zolpidem and was discharged to a skilled nursing facility at a set up to moderate assistance level.

Discussion: Akinetic mutism is characterized by intact consciousness and sensorimotor capacity with impaired goal directed behavior including speech. The pathophysiology is thought to be related to the dopaminergic pathways. It has well been documented in cases of stroke most commonly with bilateral anterior cingulate infarctions however is less common with thalamic strokes. Zolpidem is thought to reactivate the thalamocortical system through disinhibition of the globus pallidus in the basal ganglia.

Conclusion: We present an African American woman whose lack of speech was thought to be behavioral. Akinetic mutism should be considered in patients with thalamic strokes and impaired verbalization. It is important to think about the location of brain lesion but it is also important to leave implicit bias and stereotypes out of medicine because it can impact recovery.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/use-of-zolpidem-for-akinetic-mutism-in-left-thalamic-hemorrhagic-stroke-a-case-report/