Abstract
We review the current state of knowledge of potentially useful drugs acting on the recovery of consciousness in severely brain-damaged patients. Exploratory and retrospective studies as well as case reports on the sporadic cases of recovery are discussed regarding pharmacological treatments such as amantadine, levodopa, bromocriptine, apomorphine, methylphenidate, zolpidem, baclofen, and lamotrigine. Potential underlying mechanisms explaining the effects of these drugs on the awakening and recovery of consciousness in this challenging population are also examined. Finally, we discuss the process of using single-subject methods to assess the off-label use of a specific medication.
This is a preview of subscription content, log in via an institution.
Buying options
Tax calculation will be finalised at checkout
Purchases are for personal use only
Learn about institutional subscriptionsReferences
Plum F, Posner JB. The diagnosis of stupor and coma. Philadelphia: F. A. Davis; 1983.
The Multi-Society Task Force on PVS. Medical aspects of the persistent vegetative state (1). N Engl J Med. 1994;330(21):1499–508.
Laureys S, Celesia GG, Cohadon F, Lavrijsen J, Leon-Carrion J, Sannita WG, Sazbon L, Schmutzhard E, von Wild KR, Zeman A, Dolce G. Unresponsive wakefulness syndrome: a new name for the vegetative state or apallic syndrome. BMC Med. 2010;8:68.
Giacino JT, Ashwal S, Childs N, Cranford R, Jennett B, Katz DI, Kelly JP, Rosenberg JH, Whyte J, Zafonte RD, Zasler ND. The minimally conscious state: definition and diagnostic criteria. Neurology. 2002;58(3):349–53.
Ciurleo R, Bramanti P, Calabro RS. Pharmacotherapy for disorders of consciousness: are ‘awakening’ drugs really a possibility? Drugs. 2013;73(17):1849–62.
Abbate C, Trimarchi PD, Basile I, Mazzucchi A, Devalle G. Sensory stimulation for patients with disorders of consciousness: from stimulation to rehabilitation. Front Hum Neurosci. 2014;8:616.
Klingshirn H, Grill E, Bender A, Strobl R, Mittrach R, Braitmayer K, Muller M. Quality of evidence of rehabilitation interventions in long-term care for people with severe disorders of consciousness after brain injury: a systematic review. J Rehabil Med. 2015;47(7):577–85.
Magrassi L, Maggioni G, Pistarini C, Di Perri C, Bastianello S, Zippo AG, Iotti GA, Biella GE, Imberti R. Results of a prospective study (CATS) on the effects of thalamic stimulation in minimally conscious and vegetative state patients. J Neurosurg. 2016;125(4):972–81.
Chew E, Zafonte R. Pharmacological management of neurobehavioral disorders following traumatic brain injury—a state-of-the-art review. J Rehabil Res Dev. 2009;46(6):851–79.
Robbins T. Arousal systems and attentional processes. Biol Psychol. 1997;45(1–3):57–71.
Harris CD. Neurophysiology of sleep and wakefulness. Respir Care Clin N Am. 2005;11(4):567–86.
Zafonte R, Lexell J, Cullen N. Possible applications for dopaminergic agents following traumatic brain injury: part 2. J Head Trauma Rehabil. 2001;16(1):112–6.
Saniova B, Drobny M, Kneslova L, Minarik M. The outcome of patients with severe head injuries treated with amantadine sulphate. J Neural Transm. 2004;111(4):511–4.
Whyte J, Katz D, Long D, DiPasquale MC, Polansky M, Kalmar K, Giacino J, Childs N, Mercer W, Novak P, Maurer P, Eifert B. Predictors of outcome in prolonged posttraumatic disorders of consciousness and assessment of medication effects: a multicenter study. Arch Phys Med Rehabil. 2005;86(3):453–62.
Sawyer E, Mauro L, Ohlinger M. Amantadine enhancement of arousal and cognition after traumatic brain injury. Ann Pharmacother. 2008;42(2):247–52.
Born JD. The Glasgow-Liège Scale. Prognostic value and evaluation of motor response and brain stem reflexes after severe head injury. Acta Neurochir. 1988;95:49–52.
Folstein M, Robins L, Helzer J. The mini-mental state examination. Arch Gen Psychiatry. 1983;40(7):812.
Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet. 1975;1(7905):480–4.
Rappaport M, Hall KM, Hopkins K, Belleza T, Cope DN. Disability rating scale for severe head trauma: coma to community. Arch Phys Med Rehabil. 1982;63(3):118–23.
Meythaler JM, Brunner RC, Johnson A, Novack TA. Amantadine to improve neurorecovery in traumatic brain injury-associated diffuse axonal injury: a pilot double-blind randomized trial. J Head Trauma Rehabil. 2002;17(4):300–13.
Rappaport M. The Coma/Near Coma Scale. 2000. http://www.tbims.org/combi/cnc
Zafonte R, Watanabe T, Mann N. Amantadine: a potential treatment for the minimally conscious state. Brain Inj. 1998;12(7):617–21.
Avecillas-Chasin JM, Barcia JA. Effect of amantadine in minimally conscious state of non-traumatic etiology. Acta Neurochir. 2014;156(7):1375–7.
Giacino JT, Whyte J, Bagiella E, Kalmar K, Childs N, Khademi A, Eifert B, Long D, Katz DI, Cho S, Yablon SA, Luther M, Hammond FM, Nordenbo A, Novak P, Mercer W, Maurer-Karattup P, Sherer M. Placebo-controlled trial of amantadine for severe traumatic brain injury. N Engl J Med. 2012;366(9):819–26.
Reynolds JC, Rittenberger JC, Callaway CW. Methylphenidate and amantadine to stimulate reawakening in comatose patients resuscitated from cardiac arrest. Resuscitation. 2013;84(6):818–24.
Horiguchi J, Inami Y, Shoda T. Effects of long-term amantadine treatment on clinical symptoms and EEG of a patient in a vegetative state. Clin Neuropharmacol. 1990;13(1):84–8.
Estraneo A, Pascarella A, Moretta P, Loreto V, Trojano L. Clinical and electroencephalographic on-off effect of amantadine in chronic non-traumatic minimally conscious state. J Neurol. 2015;262(6):1584–6.
Schnakers C, Hustinx R, Vandewalle G, Majerus S, Moonen G, Boly M, Vanhaudenhuyse A, Laureys S. Measuring the effect of amantadine in chronic anoxic minimally conscious state. J Neurol Neurosurg Psychiatry. 2008;79(2):225–7.
Giacino JT, Kalmar K, Whyte J. The JFK Coma Recovery Scale-Revised: measurement characteristics and diagnostic utility. Arch Phys Med Rehabil. 2004;85(12):2020–9.
Stelmaschuk S, Will MC, Meyers T. Amantadine to treat cognitive dysfunction in moderate to severe traumatic brain injury. J Trauma Nurs. 2015;22(4): 194–203; quiz E191–2.
Haig A, Ruess J. Recovery from vegetative state of six months’ duration associated with Sinemet (levodopa/carbidopa). Arch Phys Med Rehabil. 1990;71(13):1081–3.
Matsuda W, Matsumura A, Komatsu Y, Yanaka K, Nose T. Awakenings from persistent vegetative state: report of three cases with parkinsonism and brain stem lesions on MRI. J Neurol Neurosurg Psychiatry. 2003;74(11):1571–3.
Matsuda W, Komatsu Y, Yanaka K, Matsumura A. Levodopa treatment for patients in persistent vegetative or minimally conscious states. Neuropsychol Rehabil. 2005;15(3–4):414–27.
Krimchansky B, Keren O, Sazbon L, Groswasser Z. Differential time and related appearance of signs, indicating improvement in the state of consciousness in vegetative state traumatic brain injury (VS-TBI) patients after initiation of dopamine treatment. Brain Inj. 2004;18(11):1099–105.
Ugoya SO, Akinyemi RO. The place of L-dopa/carbidopa in persistent vegetative state. Clin Neuropharmacol. 2010;33(6):279–84.
Passler MA, Riggs RV. Positive outcomes in traumatic brain injury-vegetative state: patients treated with bromocriptine. Arch Phys Med Rehabil. 2001;82(3):311–5.
Whyte J, Vaccaro M, Grieb-Neff P, Hart T, Polansky M, Coslett HB. The effects of bromocriptine on attention deficits after traumatic brain injury: a placebo-controlled pilot study. Am J Phys Med Rehabil. 2008;87(2):85–99.
Millan M, Maiofiss L, Cussac D, Audinot V, Boutin J, Newman-Tancredi A. Differential actions of antiparkinson agents at multiple classes of monoaminergic receptor. I. A multivariate analysis of the binding profiles of 14 drugs at 21 native and cloned human receptor subtypes. J Pharmacol Exp Ther. 2002;303(2):791–804.
Fridman E, Calvar J, Bonetto M, Gamzu E, Krimchansky B, Meli F, Leiguarda R, Zafonte R. Fast awakening from minimally conscious state with apomorphine. Brain Inj. 2009;23(2):172–7.
Laureys S, Faymonville ME, Luxen A, Lamy M, Franck G, Maquet P. Restoration of thalamocortical connectivity after recovery from persistent vegetative state. Lancet. 2000;355(9217):1790–1.
Fridman E, Krimchansky B, Bonetto M, Galperin T, Gamzu E, Leiguarda R, Zafonte R. Continuous subcutaneous apomorphine for severe disorders of consciousness after traumatic brain injury. Brain Inj. 2010;24(4):636–41.
Moein H, Khalili H, Keramatian K. Effect of methylphenidate on ICU and hospital length of stay in patients with severe and moderate traumatic brain injury. Clin Neurol Neurosurg. 2006;108(6):539–42.
Kim YW, Shin JC, An YS. Effects of methylphenidate on cerebral glucose metabolism in patients with impaired consciousness after acquired brain injury. Clin Neuropharmacol. 2009;32(6):335–9.
Martin R, Whyte J. The effects of methylphenidate on command following and yes/no communication in persons with severe disorders of consciousness: a meta-analysis of n-of-1 studies. Am J Phys Med Rehabil. 2007;86(8):613–20.
Kaelin D, Cifu D, Mathies B. Methylphenidate effect on attention deficit in the acutely brain-injured adult. Arch Phys Med Rehabil. 1996;77(1):6–9.
Plenger P, Dixon C, Castillo R, Frankowski R, Yablon S, Levin H. Subacute methylphenidate treatment for moderate to moderately severe traumatic brain injury: a preliminary double-blind placebo-controlled study. Arch Phys Med Rehabil. 1996;77(6):536–40.
Whyte J, Hart T, Schuster K, Fleming M, Polansky M, Coslett H. Effects of methylphenidate on attentional function after traumatic brain injury. A randomized, placebo-controlled trial. Am J Phys Med Rehabil. 1997;76(6):440–50.
Whyte J, Hart T, Vaccaro M, Grieb-Neff P, Risser A, Polansky M, Coslett H. Effects of methylphenidate on attention deficits after traumatic brain injury: a multidimensional, randomized, controlled trial. Am J Phys Med Rehabil. 2004;83(6):401–20.
Kim J, Whyte J, Patel S, Europa E, Wang J, Coslett HB, Detre JA. Methylphenidate modulates sustained attention and cortical activation in survivors of traumatic brain injury: a perfusion fMRI study. Psychopharmacology (Berl). 2012;222(1):47–57.
Patrick P, Buck M, Conaway M, Blackman J. The use of dopamine enhancing medications with children in low response states following brain injury. Brain Inj. 2003;17(6):497–506.
Clauss RP, Guldenpfennig WM, Nel HW, Sathekge MM, Venkannagari RR. Extraordinary arousal from semi-comatose state on zolpidem. A case report. S Afr Med J. 2000;90(1):68–72.
Clauss RP, Nel W. Drug induced arousal from the permanent vegetative state. NeuroRehabilitation. 2006;21(1):23–8.
Hagen C, Malkmus D, Durham P. Levels of cognitive functioning. Downey: Rancho Los Amigos Hospital Inc.; 1987.
Brefel-Courbon C, Payoux P, Ory F, Sommet A, Slaoui T, Raboyeau G, Lemesle B, Puel M, Montastruc JL, Demonet JF, Cardebat D. Clinical and imaging evidence of zolpidem effect in hypoxic encephalopathy. Ann Neurol. 2007;62(1):102–5.
Cohen SI, Duong TT. Increased arousal in a patient with anoxic brain injury after administration of zolpidem. Am J Phys Med Rehabil. 2008;87(3):229–31.
Shames JL, Ring H. Transient reversal of anoxic brain injury-related minimally conscious state after zolpidem administration: a case report. Arch Phys Med Rehabil. 2008;89(2):386–8.
Appu M, Noetzel M. Clinically significant response to zolpidem in disorders of consciousness secondary to anti-N-methyl-D-aspartate receptor encephalitis in a teenager: a case report. Pediatr Neurol. 2014;50(3):262–4.
Lo Y, Tan E, Ratnagopal P, Chan L, Tan T. Zolpidem and its effects on hypoxic encephalopathy. Ann Neurol. 2008;64(4):477–8.
Singh R, McDonald C, Dawson K, Lewis S, Pringle A, Smith S, Pendland B. Zolpidem in a minimally conscious state. Brain Inj. 2008;22(1):103–6.
Whyte J, Myers R. Incidence of clinically significant responses to zolpidem among patients with disorders of consciousness: a preliminary placebo controlled trial. Am J Phys Med Rehabil. 2009;88(5):410–8.
Whyte J, Rajan R, Rosenbaum A, Katz D, Kalmar K, Seel R, Greenwald B, Zafonte R, Demarest D, Brunner R, Kaelin D. Zolpidem and restoration of consciousness. Am J Phys Med Rehabil. 2014;93(2):101–13.
Machado C, Estévez M, Pérez-Nellar J, Gutiérrez J, Rodríguez R, Carballo M, Chinchilla M, Machado A, Portela L, García-Roca MC, Beltrán C. Autonomic, EEG, and behavioral arousal signs in a PVS case after zolpidem intake. Can J Neurol Sci. 2011;38(2):341–4.
Machado C, Estevez M, Rodriguez R, Perez-Nellar J, Chinchilla M, DeFina P, Leisman G, Carrick FR, Melillo R, Schiavi A, Gutierrez J, Carballo M, Machado A, Olivares A, Perez-Cruz N. Zolpidem arousing effect in persistent vegetative state patients: autonomic, EEG and behavioral assessment. Curr Pharm Des. 2014;20(26):4185–202.
Thonnard M, Gosseries O, Demertzi A, Lugo Z, Vanhaudenhuyse A, Bruno M, Chatelle C, Thibaut T, Charland-Verville V, Habbal D, Schnakers C, Laureys S. Effect of zolpidem in chronic disorders of consciousness: a prospective open label study. Funct Neurol. 2013;28(4):259–64.
Du B, Shan A, Zhang Y, Zhong X, Chen D, Cai K. Zolpidem arouses patients in vegetative state after brain injury: quantitative evaluation and indications. Am J Med Sci. 2014;347(3):178–82.
Cohen L, Chaaban B, Habert MO. Transient improvement of aphasia with zolpidem. N Engl J Med. 2004;350(9):949–50.
Rodriguez-Rojas R, Machado C, Alvarez L, Carballo M, Estevez M, Perez-Nellar J, Pavon N, Chinchilla M, Carrick FR, DeFina P. Zolpidem induces paradoxical metabolic and vascular changes in a patient with PVS. Brain Inj. 2013;27(11):1320–9.
Chatelle C, Thibaut A, Gosseries O, Bruno MA, Demertzi A, Bernard C, Hustinx R, Tshibanda L, Bahri MA, Laureys S. Changes in cerebral metabolism in patients with a minimally conscious state responding to zolpidem. Front Hum Neurosci. 2014;8:917.
Williams ST, Conte MM, Goldfine AM, Noirhomme Q, Gosseries O, Thonnard M, Beattie B, Hersh J, Katz DI, Victor JD, Laureys S, Schiff ND. Common resting brain dynamics indicate a possible mechanism underlying zolpidem response in severe brain injury. Elife. 2013;2:e01157.
Calabro RS, Arico I, De Salvo S, Conti-Nibali V, Bramanti P. Transient awakening from vegetative state: is high-dose zolpidem more effective? Psychiatry Clin Neurosci. 2015;69(2):122–3.
Clauss RP, Nel WH. Effect of zolpidem on brain injury and diaschisis as detected by 99mTc HMPAO brain SPECT in humans. Arzneimittelforschung. 2004;54(10):641–6.
Hall S, Yamawaki N, Fisher A, Clauss R, Woodhall G, Stanford I. GABA(A) alpha-1 subunit mediated desynchronization of elevated low frequency oscillations alleviates specific dysfunction in stroke—a case report. Clin Neurophysiol. 2010;121(4):549–55.
Pistoia F, Sara M, Sacco S, Franceschini M, Carolei A. Silencing the brain may be better than stimulating it. The GABA effect. Curr Pharm Des. 2014;20(26):4154–66.
Schiff ND. Recovery of consciousness after brain injury: a mesocircuit hypothesis. Trends Neurosci. 2010;33(1):1–9.
Pistoia F, Sacco S, Sara M, Franceschini M, Carolei A. Intrathecal baclofen: effects on spasticity, pain, and consciousness in disorders of consciousness and locked-in syndrome. Curr Pain Headache Rep. 2015;19(1):466.
Turner M. Early use of intrathecal baclofen in brain injury in pediatric patients. Acta Neurochir. 2003;87:81–3.
Kawecki Z, Kwiatkowski S, Grzegorzewski P, Szlachta Jezioro I. Sudden improvement of all neurological functions after general anesthesia and two-day intrathecal infusion of baclofen in a child with primary brain-stem injury. Przegl Lek. 2007;64(2):13–4.
Sarà M, Sacco S, Cipolla F, Onorati P, Scoppetta C, Albertini G, Carolei A. An unexpected recovery from permanent vegetative state. Brain Inj. 2007;21(1):101–3.
Taira T, Hori T. Intrathecal baclofen in the treatment of post-stroke central pain, dystonia, and persistent vegetative state. Acta Neurochir Suppl. 2007;97(Pt 1):227–9.
Sarà M, Pistoia F, Mura E, Onorati P, Govoni S. Intrathecal baclofen in patients with persistent vegetative state: 2 hypotheses. Arch Phys Med Rehabil. 2009;90(7):1245–9.
Al-Khodairy AT, Wicky G, Nicolo D, Vuadens P. Influence of intrathecal baclofen on the level of consciousness and mental functions after extremely severe traumatic brain injury: brief report. Brain Inj. 2015;29(4):527–32.
Margetis K, Korfias SI, Gatzonis S, Boutos N, Stranjalis G, Boviatsis E, Sakas DE. Intrathecal baclofen associated with improvement of consciousness disorders in spasticity patients. Neuromodulation. 2014;17(7):699–704.
Hoarau X, Richer E, Dehail P, Cuny E. Comparison of long-term outcomes of patients with severe traumatic or hypoxic brain injuries treated with intrathecal baclofen therapy for dysautonomia. Brain Inj. 2012;26(12):1451–63.
Hoarau X, Richer E, Dehail P, Cuny E. A 10-year follow-up study of patients with severe traumatic brain injury and dysautonomia treated with intrathecal baclofen therapy. Brain Inj. 2012;26(7–8):927–40.
Taira T. Intrathecal administration of GABA agonists in the vegetative state. Prog Brain Res. 2009;177:317–28.
Coulter D. Antiepileptic drug cellular mechanisms of action: where does lamotrigine fit in? J Child Neurol. 1997;12(1):2–9.
Calabresi P, Centonze D, Cupini L, Costa C, Pisani F, Bernardi G. Ionotropic glutamate receptors: still a target for neuroprotection in brain ischemia? Insights from in vitro studies. Neurobiol Dis. 2003;12:82–8.
Showalter P, Kimmel D. Stimulating consciousness and cognition following severe brain injury: a new potential clinical use for lamotrigine. Brain Inj. 2000;14:997–1001.
Pistoia F, Mura E, Govoni S, Fini M, Sarà M. Awakenings and awareness recovery in disorders of consciousness: is there a role for drugs? CNS Drugs. 2010;24(8):625–38.
Clauss RP. Neurotransmitters in coma, vegetative and minimally conscious states, pharmacological interventions. Med Hypotheses. 2010;75(3):287–90.
Stahl S. Essential psychopharmacology: neuroscientific basis and practical applications. New York: Press CU; 2000.
Gosseries O, Charland-Verville V, Thonnard M, Bodart O, Laureys S, Demertzi A. Amantadine, apomorphine and zolpidem in the treatment of disorders of consciousness. Curr Pharm Des. 2014;20(26):4167–84.
Oliveira L, Fregni F. Pharmacological and electrical stimulation in chronic disorders of consciousness: new insights and future directions. Brain Inj. 2011;25(4):315–27.
Schiff ND. Central thalamic deep-brain stimulation in the severely injured brain: rationale and proposed mechanisms of action. Ann N Y Acad Sci. 2009;1157:101–16.
Schiff ND. Recovery of consciousness after severe brain injury: the role of arousal regulation mechanisms and some speculation on the heart-brain interface. Cleve Clin J Med. 2010;77(Suppl 3):S27–33.
Hammond FM, Barrett RS, Shea T, Seel RT, McAlister TW, Kaelin D, Ryser DK, Corrigan JD, Cullen N, Horn SD. Psychotropic medication use during inpatient rehabilitation for traumatic brain injury. Arch Phys Med Rehabil. 2015;96(8 Suppl):S256–3. e214
Larson EB. N-of-1 trials: a new future? J Gen Intern Med. 2010;25(9):891–2.
Lillie EO, Patay B, Diamant J, Issell B, Topol EJ, Schork NJ. The n-of-1 clinical trial: the ultimate strategy for individualizing medicine? Pers Med. 2011;8(2):161–73.
Backman CL, Harris SR, Chisholm JA, Monette AD. Single-subject research in rehabilitation: a review of studies using AB, withdrawal, multiple baseline, and alternating treatments designs. Arch Phys Med Rehabil. 1997;78(10):1145–53.
Ottenbacher KJ. Evaluating clinical change. Baltimore: Williams and Wilkins; 1986.
Whyte J. Design of brain injury rehabilitation treatment research. Handb Clin Neurol. 2015;128:779–94.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2018 Springer International Publishing AG
About this chapter
Cite this chapter
Gosseries, O., Whyte, J. (2018). Pharmacological Treatments. In: Schnakers, C., Laureys, S. (eds) Coma and Disorders of Consciousness. Springer, Cham. https://doi.org/10.1007/978-3-319-55964-3_11
Download citation
DOI: https://doi.org/10.1007/978-3-319-55964-3_11
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-55963-6
Online ISBN: 978-3-319-55964-3
eBook Packages: MedicineMedicine (R0)