1408 - Modafinil and Memantine After Bilateral Pontine and Cerebellar Strokes in High-Risk Seizure Patient: a case report

Friday, February 20, 2026

5:00 PM - 6:30 PM AST

Presenting Author(s)

ZS

Zachary Satin, MD

Brain Injury Medicine Fellow
Icahn School of Medicine at Mount Sinai Hospital
New York, New York, United States

Co-Author(s)

SB

Sofia Barchuk, DO

Attending Physician
Mount Sinai Hospital
New York, New York, United States

Submitter(s)

ZS

Zachary Satin, MD

Icahn School of Medicine at Mount Sinai Hospital
New York, New York, United States

Case Diagnosis: Locked-in syndrome, disorder of consciousness

Case Description: 56-year-old male suffered dominant right vertebral and basilar artery occlusions, status-post tenecteplase and thrombectomy, resulting in bilateral cerebellar and pontine infarctions. His course was complicated by initial seizure, brain edema, minimal mental status requiring tracheostomy and percutaneous endoscopic gastrostomy placement, corneal abrasion, and obstructive hydrocephalus status-post extra-ventricular drain placement and removal and suboccipital craniotomy. Three months following his infarctions, he exhibited possible seizure activity, prompting discontinuation of amantadine and consult to physiatry for neuro-stimulant management. He was switched to modafinil, with significant recovery in wakefulness and attention. Memantine was added soon after, with further gains in participation, wakefulness, and communication. He progressed from minimally conscious state-minus to -plus and subsequently emerged following the addition of memantine. Both medications were well-tolerated without side effects. He was able to wean off assisted ventilation, increase therapy participation, and transfer to acute inpatient rehabilitation.

Discussions: This is a unique case in which a patient, demonstrating characteristics of both disorder of consciousness and locked-in syndrome due to questionable awareness with impaired arousal following his strokes, improved drastically with the addition of modafinil and memantine as measured by increased Coma Recovery Scale-Revised scores and clinical evaluation. Though amantadine is relatively well-tolerated and holds low seizure risk, especially at lower doses, caution should be taken in patients with seizure history. This case demonstrates the utility for the combination of modafinil and memantine, each of which appears to have lower seizure risk than amantadine, as viable neuro-stimulant agents for patients in disorders of consciousness or with locked-in syndrome to improve awareness, arousal, communication, and therapy participation.

Conclusions: This case highlights the challenging nature of diagnosing patients with disorder of consciousness versus locked-in syndrome, relevant concerns when starting neuro-stimulant medications, and potential benefits of modafinil and memantine in brain injury patients with higher seizure risk.