246 - Pros and Cons of Pharmacological Intervention in Disorders of Consciousness: A Case Report

Patient is a 30-year-old male with a past medical history of epilepsy who presented to the emergency department on 5/21/2024 for a fall from standing. His initial Glasgow coma score was 14, but deteriorated to 6 then 3, requiring intubation. Initial CT head demonstrated subdural hematomas and fractures of the skull. Repeat CT head showed a large intraparenchymal hemorrhage. He was admitted to the neuro ICU in unresponsive wakefulness. On 5/23, an emergent craniectomy was performed due to persistently elevated intracranial pressure. PM&R was consulted on 6/3 to evaluate for inpatient rehabilitation (IPR). At this time, he was visually tracking and inconsistently responded to verbal commands, behaviors consistent with a minimally conscious state (MCS). On 6/5, he did not meet criteria for emergence from MCS (EMCS), only demonstrating functional use of one object. On 6/7, post cranioplasty, he functionally utilized a pen and toothbrush, indicating EMCS.

Discussions:

A considerable literature has amassed around pharmacologic therapies in disorders of consciousness (DoC). Though randomized controlled trials have only demonstrated the efficacy of amantadine to date, several retrospective studies and case reports advocate for the use of agents such as zolpidem, baclofen, lorazepam, and others. For a patient with epilepsy in whom amantadine is contraindicated, these alternative drugs are attractive; however, we must pay attention to their notable side effect profiles which may affect their function. In some cases, non-intervention may prove more effective overall.

Conclusions:

Pharmacologic therapies have an important role in recovery from DoC after TBI; however, these drugs have considerable side effects which may detract from function leading to worse outcomes in the long run. Therefore, we must carefully weigh the pros and cons of these therapies.