1014 - Emergence from Disorders of Consciousness (DoC) in Traumatic Brain Injury Following Modifications to Anti-Epileptic Medications

A 38-year-old-female presented to an acute care hospital after falling down the stairs resulting in a TBI with loss of consciousness and GCS score of 3. Imaging showed right subdural hematoma with midline shift and cranial fractures. Complications included a decline in neurological status corroborated by worsening head imaging, which prompted decompressive hemicraniectomy. She developed seizures necessitating use of anti-epileptic drugs (AEDs); specifically, levetiracetam 3g daily. Upon admission to inpatient rehabilitation, she was in unresponsive wakefulness syndrome. Within a few days, she transitioned to a minimally conscious state, but progress was then limited for several weeks. Given her lack of progress and high dose of levetiracetam, her primary neurologist was contacted for dosing adjustment.  AEDs were changed from levetiracetam to brivaracetam 300mg daily. Within two days, the patient showed improvement with signs of emergence from DoC including speaking in short, complete sentences, ambulating with a walker, and improving memory/insight.

Discussions:

TBIs are a debilitating pathology that range widely in their outcomes. Many patients with TBIs experience seizures and require treatment with AEDs. While these medications improved over time, they still present with side-effects including sedation and agitation. Brivaracetam was approved as an alternative to levetiracetam, with reported higher efficacy and fewer side effects. In this patient, using an alternate AED allowed for significant improvement in consciousness. With these changes, she became more independent with ADLs and her cognition improved considerably.

Conclusions: Patients experiencing disorders of consciousness have fragile mental statuses that can be influenced by medications and their doses. Traditionally, neuro-stimulant medications are trialed to promote emergence. Here, we note that alteration in AEDs, even within the same class, resulted in significant cognitive improvements with subsequent increased independence. Review of AEDs is warranted given their significant side effect profile and ability to influence neurological recovery.