1632 - Paradoxical Sedation Associated with Methylphenidate Use in a Patient with a Disorder of Consciousness from Traumatic Brain Injury: A Case Report

A 42-year-old woman with a past medical history of anxiety, hypertension, and a self-reported history of attention-deficit/hyperactivity disorder (ADHD) was admitted to acute inpatient rehabilitation in a disorder of consciousness (DoC) after sustaining a traumatic brain injury (TBI) following a motor vehicle crash. Her rehabilitation course was significant for multiple soft tissue infections, sunken flap syndrome requiring cranioplasty, and hydrocephalus requiring ventriculoperitoneal shunt placement. After acute care hospitalization for shunt setting adjustment, the patient was readmitted to acute inpatient rehabilitation for neuro-stimulant medication trials to optimize her cognitive status. She was treated with methylphenidate; however, she developed significant fatigue and drowsiness, which resolved upon discontinuation of this medication.

Discussions:

Cognitive impairment is common after TBI, especially in DoC patients. While there is limited data on the use of neurostimulant medications, methylphenidate is commonly used to address this impairment. Methylphenidate is a central nervous system stimulant that increases the synaptic and extracellular concentration of dopamine and norepinephrine by blocking their reuptake.

Meta-analysis studies have shown that methylphenidate use in patients with TBI is associated with improved processing speed, vigilance-associated attention (i.e., selective, sustained, and divided attention), executive memory, baseline speed, inhibitory control, and variability in responding. Commonly known side effects include increased heart rate and blood pressure, gastrointestinal upset, insomnia, and irritability. There have also been rare reports of paradoxical sedation associated with its use, specifically in children with ADHD.

Conclusions:

While studies have shown that methylphenidate treatment improved cognition in TBI patients, there are cases when this medication can result in increased drowsiness and fatigue in certain patient populations. As such, this case highlights the importance of obtaining a thorough premorbid history and the need for constant vigilance when monitoring the effects of neuro-stimulant medications in patients in a DoC, as they may potentially have unintended and deleterious effects.