1006 - Emergence from Post-Traumatic Amnesia Despite Post-Traumatic Vasospasm after Severe TBI: A Case Report

A 19-year-old male endured a skateboarding accident, resulting in severe TBI (GCS 4), found to have subdural hemorrhage with 1.3 cm midline shift, uncal herniation, and ventriculomegaly, requiring emergent right hemicraniectomy decompression. CT Head on day four noted hypodensities of bilateral ACA, right MCA, and right PCA, consistent with ischemic stroke, likely from initial compression and herniation. There was concern for right MCA vasospasm after elevated velocities noted on serial transcranial doppler, confirmed on angiogram, requiring vasospasm treatment for nearly one month. The patient underwent cranioplasty and was transferred to a disorder of conscious-specific acute IPR program. His IPR course was significant for multiple neurostimulant trials and identification of post-traumatic hydrocephalus requiring ventriculoatrial shunt placement. Ultimately, the patient emerged from both a disorder of consciousness (DoC) and from post-traumatic amnesia (although remaining non-verbal due to severe motor speech apraxia). By discharge, his primary neurostimulant medications were bromocriptine, Sinemet, and methylphenidate.


Discussions:

Post-traumatic vasospasm (PTV) is a known sequelae of TBI, often occurring in the first twenty days after injury. PTV typically has shorter duration and lacks significant long-term neurologic deficits when compared to vasospasm after SAH. Although PTV did significantly impede this patient’s recovery, with the addition and titration of neurostimulants, he not only emerged from a minimally conscious state but also—particularly with the use of methylphenidate—emerged from post-traumatic amnesia. 


Conclusions:

Despite its vasoconstrictive properties, with careful monitoring, methylphenidate can be used in TBI after PTV to improve arousal and executive functioning. Severe TBI patients can gain substantial benefit from specialized DoC programs given the programs’ ability to optimize pharmacologic management with controlled medication trials and to provide DoC-specific intensive therapies.