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Case Diagnosis Acquired brain injury (ABI) is a common cause of disability. It is defined as an insult to the brain that subsequently results in impairments of communication, cognition, sensorimotor function and behavior. Anoxic brain injuries can be particularly disabling. A common cause of a anoxic injury in children is cardiopulmonary arrest. The revised coma recovery scale (CRS-R) is a standardized assessment for level of arousal after brain injury. Case Description A 16 year old healthy boy was admitted after an unwitnessed pulseless cardiopulmonary arrest requiring 3 defibrillations and 2mg of epinephrine. His cardiac and genetic workup was negative. His brain imaging revealed diffuse ischemic injury to the temporal, parietal and occipital regions and the basal ganglia. His hospital course was complicated by dysautonomia requiring clonidine, propranolol, and lorazepam, hypertonicity and agitation requiring gabapentin and baclofen, botox injections, and serial casting, impaired sleep/wake cycles requiring melatonin and zolpidem, and decreased level of arousal. He was admitted to inpatient rehab from February 26 to April 5, 2016. He was trialed on multiple neuro-stimulants including zolpidem but did not emerge from a persistent vegetative state. Shortly after discharge, his parents reported a change in his level of alertness and command following after administration of zolpidem. During a follow up appointment, a trial of zolpidem confirmed improved CRS- R score from 6 to 14. Discussions Zolpidem is medication that stimulates the ω-1 site of a gamma aminobutyric acid (GABA)A receptor in the brain. The basal ganglia and striatum to the thalamus and motor cortices are abundant in these receptors. Moreover, it is hypothesized that the paradoxical effect of zolpidem in neurologic disorders is secondary to the agonism. There is a paucity of reports in children. Conclusions Zolpidem may have a paradoxical effect in the pediatric brain injury population after a prolonged period of medication.


Pediatrics | Rehabilitation and Therapy


Presented at the 2023 Annual Meeting- Association of Academic Physiatrists; Anaheim, CA; Feb 21-24, 2023.

Late Onset Paradoxical Effect of Zolpidem after Anoxic Brain Injury: A Pediatric Case Report