Consciousness Recovery Induced by Intrathecal Baclofen Administration After Subarachnoid Hemorrhage -Two Case Reports-

Abstract

Two patients with subarachnoid hemorrhage recovered consciousness after intrathecal baclofen administration using an implanted intrathecal baclofen pump delivering 50 mg per day using a simple infusion mode. Intrathecal baclofen resulted in significant reduction of spasticity 3 months after the implantation. Case 1 was reduced to a completely bedridden state with spasticity and could slightly move her fingers following commands. However, the patient could eat food and wash her face with minimal assistance at 3 months after the implantation, and could stand up in the parallel bars with assistance and speak several words at 8 months. Case 2 was in a completely bedridden state at 10 months after onset and could neither drink water nor follow instructions. However, the patient became oriented and could eat by herself within 3 to 4 weeks of implantation. She could walk with a cane and use the stairs with minimal assistance at 2 and 3 months after implantation. The patient could speak fluently within 6 months of implantation. Flatulence and dysuria happened during the screening test, but these symptoms were not repeated after implantation of a pump-catheter-system and continuous intrathecal baclofen infusion. Continuous intrathecal baclofen infusion caused both improvement in muscle tone and spasms and consciousness recovery from the vegetative state. This therapy is a strong candidate treatment for patients with spasticity and consciousness disturbance.

Spasticity Management in Disorders of Consciousness

“…After receiving ITB therapy for a few months they both emerged from the MCS and showed a drastic reduction of spasticity (MAS score diminished from at least 2 points). The second one described two older patients (43 and 67 years) with subarachnoid hemorrhage who were candidates for ITB therapy as well [ 31 ]. The first patient showed a decrease of 1.5 points on average on the MAS scores after 8 months of treatment in addition to the clinical recovery (the patient was able to eat, brush his teeth, stand and speak).…”

“…Regarding therapeutic options for spasticity, several treatments were reviewed by Leong (physical, pharmacological and surgical) for spastic children [ 23 ]. None of the reviewed treatments seemed to present great benefits in the management of spasticity, with an exception for ITB therapy [ 21 , 22 , 29 , 30 , 31 , 32 , 33 ]. This could be partly explained by the paucity of randomized clinical trials assessing the effects of physical therapy.…”

Intrathecal baclofen therapy in severe head injury, first time in Nepal, a technique suitable for underdeveloped countries

“…[4] Our patient had both spasticity as well as very low consciousness and was in a vegetative state due to severe head injury. Both of these problems seemed to be markedly helped by ITB.…”

Pathophysiology of Acute Coma and Disorders of Consciousness: Considerations for Diagnosis and Management

“…184 Hypothermia results in attenuated stress response within particularly temperaturesensitive areas, including portions of the cortex, thalamus, and hippocampus-all structures involved in the generation and maintenance of arousal. 185 Global, but especially temperaturesensitive areas, including parts of the cortex, thalamus, and hippocampus [180][181][182][183][184][185] Medications Amantadine Inhibits NMDA receptors, dopamine agonist Nigrostriatal, mesolimbic, and frontostriatal pathways 197,198 Methylphenidate Cortical activation via dopamine and NE Prefrontal, frontal, posterior cingulate; retrosplenial, inferior parietal, temporal, and occipital cortices; precuneus 201,203 Modafinil/armodafinil Inhibits dopamine and NE transport; activates dopamine, glutamate, serotonin, and histamine release; GABA and orexin effects; thalamocortical coupling Hypothalamus, TMN, thalamocortical connections [197][198][199][200] Zolpidem Sedative hypnotic, GABA agonist Damaged neural tissue [201][202][203][204] IT Baclofen GABA agonist Spinal cord-cortical vs. thalamocortical circuitry [208][209][210][211] Electrical stimulation…”

“…Case reports of improvement in levels of consciousness after intrathecal baclofen in patients with persistent vegetative state reveal a range of improvement from return of spontaneous eye opening (improvement to minimally conscious state) to spontaneous motor movement, following commands, and spontaneous speech. [208][209][210][211] The authors of a five-patient case series postulated that intrathecal baclofen improves levels of arousal by one of two possible mechanisms: (1) the GABAergic action of baclofen modulates gating of signals from the spinal cord to the cortex, resulting in increased cortical awareness of self and stimuli perhaps by blocking sensory overload; or (2) beneficial effects within the brain, including improved stability and coherence of thalamocortical circuits, improving circadian rhythms and sleep-wakecycle regularity through GABAergic action on glutamate receptors, and increased alertness through serotoninergic actions. 208 No randomized placebo-controlled studies have been published at this time on the use of intrathecal baclofen in patients with disorders of consciousness.…”