Disclosures: Saumya G. Aujla, MD: No financial relationships or conflicts of interest

Case Diagnosis: 7 year old boy with traumatic brain injury (TBI) in a minimally conscious state.

Case Description: The patient sustained a severe TBI with diffuse axonal injury, intraventricular hemorrhage, and subdural hemorrhage. Residual deficits included a minimally conscious state, spastic quadriplegia, complete dependence for all personal care, and autonomic instability. The patient did not tolerate several neurostimulation therapies, including amantadine due to myoclonic facial twitching, methylphenidate due to elevated blood pressure and heart rate, and higher dose bromocriptine due to drowsiness and nausea. His dextroamphetamine-amphetamine was titrated to 10 mg and low-dose bromocriptine was started at 1.25 mg, both administered at 8 AM and noon, with improved engagement and vocalization. Despite these efforts, he did not show significant progress in his overall consciousness. Eventually, zolpidem (non-benzodiazepine ᵞ-aminobutyric-acid-A agonist) was started for the chance of paradoxical neurostimulation.

Setting: Acute inpatient rehabilitation.Assessment/

Results: With administration of zolpidem 2.5 mg, he showed improvement in speech therapy, with improved efficiency of oropharyngeal swallow and pharyngeal tolerance of thin liquids. Patient showed no improvement in PT and OT, however he had no side effects of sedation. Zolpidem dose was increased to 5 mg at 8 AM the next day and patient demonstrated increased alertness, attentiveness, and was quicker to respond to stimuli with therapy. Interestingly, he remained consistently alert throughout the day, well after the expected effective duration of 4 hours.

Discussion: Chronic minimally conscious states are potential sequelae of TBI. The patient’s ongoing lack of responsiveness months into his acute inpatient rehabilitation warranted the novel use of zolpidem. Immediately after starting low dose zolpidem, patient displayed enhanced engagement and attentiveness.

Conclusion: Zolpidem may provide a benefit in chronic minimally conscious states in pediatric patients. A prospective, randomized clinical trial assessing the benefits of zolpidem at varying doses in those with disorders of consciousness and inadequate improvement to conventional treatments is warranted.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/paradoxical-effect-of-zolpidem-in-a-minimally-conscious-child-secondary-to-traumatic-brain-injury-a-case-report/