Presentations

Abstract

Introduction:

The minimally conscious state (MCS) is a disorder of consciousness (DOC) in which a patient retains some level of awareness. Development of a standardized protocol for the treatment of MCS is ongoing with approaches including deep brain stimulation, spinal cord stimulation, and non- invasive neuromodulation therapies. Evidence supporting pharmacologic treatment has included amantadine, an N-methyl-D-aspartate (NMDA) antagonist and indirect dopamine agonist and zolpidem, a nonbenzodiazepine-benzodiazepine receptor agonist. We present a woman status-post severe cortical injury from cocaine usage who presented in the minimally conscious state (MCS-), who showed improvement with the use of zolpidem and amantadine augmentation.

Case Presentation:

Our patient, a 53-year-old woman with a past medical history of multiple sclerosis and psychiatric history of bipolar disorder and cocaine use disorder, presented to the emergency department (ED) for altered mental status. Physical examination, including vital signs, were unremarkable. An extensive ED workup was without conclusion, including a negative blood alcohol level and urine drug screen and MRI demonstrated symmetric white matter restricted diffusion, consistent with innate brain disease unlikely to improve with ECT per neurology. Her EEG was significant for non-specific, non-epileptic brain electrical abnormalities. We began zolpidem and on our next-day evaluation, our patient responded to simple commands although still visually fixated. After 4 days of treatment amantadine was added and after two weeks of this regimen, our patient improved such that staff was able to move her out of bed. By discharge, our patient demonstrated object manipulation, pursuit eye movements and reproducible movement to command. and was discharged to a skilled nursing facility on hospital day 64.

Discussion:

The response rate to zolpidem has been found to be approximately 6% for all DOC, which is low, however, the response is typically significant with patients rapidly emerging from MCS. Case Reports and studies are varied in their results, reporting everything from zero effect to full recovery after administration of zolpidem. This may differ based on the nature of the injury leading to MCS, however, one study found that zolpidem is less effective in improving MCS secondary to anoxic brain injury (ABI) while another report demonstrated recovery in their patients. In our patient, her MCS likely resulted from ABI secondary to her severe, chronic cocaine use disorder. On initial presentation to us, our patient demonstrated visual fixation and object manipulation by squeezing hands, both of which are indicative of MCS-. Our patient demonstrated an acute response to zolpidem, which improved with amantadine augmentation. While there is evidence supporting the use of amantadine and zolpidem in monotherapy for the treatment of MCS , to the best of these author's knowledge there are no studies revealing the effectiveness of combination therapy, although, it is possible that given increased time, either medication in mono therapy could have demonstrated efficacy.

Conclusion:

In conclusion, we believe this case emphasizes the importance for clinicians to recognize DOC, including MCS -/+, the paradoxical, albeit uncommon, effectiveness of zolpidem and combination therapies for treatment of DOC.