Session Title: Neurological Rehabilitation Case and Research Report
Session Time: 12:30pm-2:00pm
Location: Research Hub - Kiosk 5
Disclosures: Lauren M. Desmarais, DO: Nothing to disclose
Case Description: Patient admitted for staged T10-Pelvic fusion, complicated by durotomy and repaired intra-operatively. On post-op day (POD)-0, patient developed multiple tonic clonic seizures. POD-0 MRI showed symmetric edema of the basal ganglia, thalami, and cerebellar cortex, and smooth diffuse pachyminengeal enhancement and dural thickening consistent with venous congestion and intracranial hypotension. POD-2 exam revealed inability to follow commands or blink to visual threat, ability to track eyes to sound but not objects, and spontaneous movement of all extremities. Patient started Zolpidem 2.5 mg at bedtime on POD-2, and 12 hours after dose patient was able to visually track, verbalize yes/no responses to questions, and follow simple commands. After three doses, patient was verbal and oriented to self, place, and year with insight to his hospital admission. In addition to command following and orientation, he could recite the months of the year backwards. Six zolpidem doses given in total.
Setting: Tertiary Hospital
Patient: Previously independent 75-year-old male who developed intracranial hypotension after elective lumbar fusion.
Assessment/Results: Patient was admitted to a brain injury inpatient rehabilitation unit (IPR) with Functional Independent Measure (FIM) change from 71-89 over a 9-day period. He discharged to home with homecare, ambulating with Minimum Assistance and a wheeled walker. Repeat MRI on POD16 showed marked improvement in basal ganglia, thalami, and cerebellum edema.
Discussion: Intracranial hypotension has a propensity to adversely affect deep structures including thalamus, globus pallidus, and striatum, primary structures supporting arousal. Zolpidem, a selective alpha-1-subunit GABA-A agonist, may support GABAergic tone in these regions, and subsequently, normalize neurotransmission, and paradoxically, level of arousal. Patient clinical presentation and recovery paralleled selective mesocircuit development and resolution of cerebral edema.
Conclusion: This is the first reported case, to our knowledge, of medication management for sequelae of intracranial hypotension. Zolpidem in conjunction with IPR may improve functional outcomes for patients who developed intracranial hypotension.
Level of Evidence: Level V
To cite this abstract in AMA style:Desmarais LM, Milleville K, Wagner A, Galang GF. Post-operative Zolpidem for Treating CNS Hypotension Induced Brain Injury [abstract]. PM R. 2019; 11(S2)(suppl 2). https://pmrjabstracts.org/abstract/post-operative-zolpidem-for-treating-cns-hypotension-induced-brain-injury/. Accessed December 3, 2023.
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