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Barra ME, Solt K, Yu X, Edlow BL. Restoring consciousness with pharmacologic therapy: Mechanisms, targets, and future directions. Neurotherapeutics 2024; 21:e00374. [PMID: 39019729 DOI: 10.1016/j.neurot.2024.e00374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 04/16/2024] [Accepted: 05/03/2024] [Indexed: 07/19/2024] Open
Abstract
Severe brain injury impairs consciousness by disrupting a broad spectrum of neurotransmitter systems. Emerging evidence suggests that pharmacologic modulation of specific neurotransmitter systems, such as dopamine, promotes recovery of consciousness. Clinical guidelines now endorse the use of amantadine in individuals with traumatic disorders of consciousness (DoC) based on level 1 evidence, and multiple neurostimulants are used off-label in clinical practice, including methylphenidate, modafinil, bromocriptine, levodopa, and zolpidem. However, the relative contributions of monoaminergic, glutamatergic, cholinergic, GABAergic, and orexinergic neurotransmitter systems to recovery of consciousness after severe brain injury are unknown, and personalized approaches to targeted therapy have yet to be developed. This review summarizes the state-of-the-science in the neurochemistry and neurobiology of neurotransmitter systems involved in conscious behaviors, followed by a discussion of how pharmacologic therapies may be used to modulate these neurotransmitter systems and promote recovery of consciousness. We consider pharmacologic modulation of consciousness at the synapse, circuit, and network levels, with a focus on the mesocircuit model that has been proposed to explain the consciousness-promoting effects of various monoaminergic, glutamatergic, and paradoxically, GABAergic therapies. Though fundamental questions remain about neurotransmitter mechanisms, target engagement and optimal therapy selection for individual patients, we propose that pharmacologic therapies hold great promise to promote recovery and improve quality of life for patients with severe brain injuries.
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Affiliation(s)
- Megan E Barra
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA; Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, MA, USA
| | - Ken Solt
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Xin Yu
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, MA, USA; Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, USA; Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
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2
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Zhou Y, Altonji KA, Kakkanatt A, Greenwald BD. Speech recovery after single-dose zolpidem in two minimally conscious patients with severe traumatic brain injuries: a case report. Brain Inj 2024; 38:337-340. [PMID: 38308526 DOI: 10.1080/02699052.2024.2311342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 01/24/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND In rare cases, zolpidem administration has been found to paradoxically improve cognition in patients with brain injury in disorders of consciousness. CASE PRESENTATION Two minimally conscious plus (MCS+) patients at baseline, a 24-year-old woman 8 weeks post-traumatic brain injury (TBI) and 23-year-old man 6 weeks post-TBI, demonstrated behavioral improvements after off-label, single-dose administration of 10 mg of zolpidem. DISCUSSION/CONCLUSION The patients demonstrated improved cognition on Coma Recovery Scale-Revised assessment after ingesting zolpidem. In particular, speech was substantially restored as one patient recovered functional communication and both demonstrated intelligible verbalizations for the first-time post-injuries following zolpidem. Overall, evidence is limited regarding the underlying mechanisms of various cognitive improvements in zolpidem response although studies incorporating neuroimaging are promising. The outcomes and similarities between these cases contribute to the current literature and highlight the need for rigorous studies in the future to guide zolpidem trials in patient care for those with DOC.
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Affiliation(s)
- Yi Zhou
- Department of Physical Medicine and Rehabilitation, JFK Johnson Rehabilitation Institute, Edison, New Jersey, USA
- Department of Physical Medicine and Rehabilitation, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Kathryn A Altonji
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Physical Medicine and Rehabilitation, Shirley Ryan AbilityLab, Chicago, Illinois, USA
| | - Ashley Kakkanatt
- Department of Physical Medicine and Rehabilitation, JFK Johnson Rehabilitation Institute, Edison, New Jersey, USA
- Department of Physical Medicine and Rehabilitation, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Brian D Greenwald
- Department of Physical Medicine and Rehabilitation, JFK Johnson Rehabilitation Institute, Edison, New Jersey, USA
- Department of Physical Medicine and Rehabilitation, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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3
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Arnts H, Tewarie P, van Erp W, Schuurman R, Boon LI, Pennartz CMA, Stam CJ, Hillebrand A, van den Munckhof P. Deep brain stimulation of the central thalamus restores arousal and motivation in a zolpidem-responsive patient with akinetic mutism after severe brain injury. Sci Rep 2024; 14:2950. [PMID: 38316863 PMCID: PMC10844373 DOI: 10.1038/s41598-024-52267-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 01/16/2024] [Indexed: 02/07/2024] Open
Abstract
After severe brain injury, zolpidem is known to cause spectacular, often short-lived, restorations of brain functions in a small subgroup of patients. Previously, we showed that these zolpidem-induced neurological recoveries can be paralleled by significant changes in functional connectivity throughout the brain. Deep brain stimulation (DBS) is a neurosurgical intervention known to modulate functional connectivity in a wide variety of neurological disorders. In this study, we used DBS to restore arousal and motivation in a zolpidem-responsive patient with severe brain injury and a concomitant disorder of diminished motivation, more than 10 years after surviving hypoxic ischemia. We found that DBS of the central thalamus, targeted at the centromedian-parafascicular complex, immediately restored arousal and was able to transition the patient from a state of deep sleep to full wakefulness. Moreover, DBS was associated with temporary restoration of communication and ability to walk and eat in an otherwise wheelchair-bound and mute patient. With the use of magnetoencephalography (MEG), we revealed that DBS was generally associated with a marked decrease in aberrantly high levels of functional connectivity throughout the brain, mimicking the effects of zolpidem. These results imply that 'pathological hyperconnectivity' after severe brain injury can be associated with reduced arousal and behavioral performance and that DBS is able to modulate connectivity towards a 'healthier baseline' with lower synchronization, and, can restore functional brain networks long after severe brain injury. The presence of hyperconnectivity after brain injury may be a possible future marker for a patient's responsiveness for restorative interventions, such as DBS, and suggests that lower degrees of overall brain synchronization may be conducive to cognition and behavioral responsiveness.
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Affiliation(s)
- Hisse Arnts
- Department of Neurosurgery, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Prejaas Tewarie
- Department of Clinical Neurophysiology and Magnetoencephalography Center, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Brain Imaging, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Systems and Network Neurosciences, Amsterdam, The Netherlands
| | - Willemijn van Erp
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands
- Accolade Zorg, Bosch en Duin, The Netherlands
- Libra Rehabilitation & Audiology, Tilburg, The Netherlands
| | - Rick Schuurman
- Department of Neurosurgery, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Lennard I Boon
- Department of Clinical Neurophysiology and Magnetoencephalography Center, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Brain Imaging, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Systems and Network Neurosciences, Amsterdam, The Netherlands
| | - Cyriel M A Pennartz
- Cognitive and Systems Neuroscience Group, Swammerdam Institute, Center for Neuroscience, University of Amsterdam, Amsterdam, The Netherlands
| | - Cornelis J Stam
- Department of Clinical Neurophysiology and Magnetoencephalography Center, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Brain Imaging, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Systems and Network Neurosciences, Amsterdam, The Netherlands
| | - Arjan Hillebrand
- Department of Clinical Neurophysiology and Magnetoencephalography Center, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Brain Imaging, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Systems and Network Neurosciences, Amsterdam, The Netherlands
| | - Pepijn van den Munckhof
- Department of Neurosurgery, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Zhong Z, Tao G, Hao S, Ben H, Qu W, Sun F, Huang Z, Qiu M. Alleviating sleep disturbances and modulating neuronal activity after ischemia: Evidence for the benefits of zolpidem in stroke recovery. CNS Neurosci Ther 2024; 30:e14637. [PMID: 38380702 PMCID: PMC10880125 DOI: 10.1111/cns.14637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 01/01/2024] [Accepted: 01/20/2024] [Indexed: 02/22/2024] Open
Abstract
AIMS Sleep disorders are prevalent among stroke survivors and impede stroke recovery, yet they are still insufficiently considered in the management of stroke patients, and the mechanisms by which they occur remain unclear. There is evidence that boosting phasic GABA signaling with zolpidem during the repair phase improves stroke recovery by enhancing neural plasticity; however, as a non-benzodiazepine hypnotic, the effects of zolpidem on post-stroke sleep disorders remain unclear. METHOD Transient ischemic stroke in male rats was induced with a 30-minute middle cerebral artery occlusion. Zolpidem or vehicle was intraperitoneally delivered once daily from 2 to 7 days after the stroke, and the electroencephalogram and electromyogram were recorded simultaneously. At 24 h after ischemia, c-Fos immunostaining was used to assess the effect of transient ischemic stroke and acute zolpidem treatment on neuronal activity. RESULTS In addition to the effects on reducing brain damage and mitigating behavioral deficits, repeated zolpidem treatment during the subacute phase of stroke quickly ameliorated circadian rhythm disruption, alleviated sleep fragmentation, and increased sleep depth in ischemic rats. Immunohistochemical staining showed that in contrast to robust activation in para-infarct and some remote areas by 24 h after the onset of focal ischemia, the activity of the ipsilateral suprachiasmatic nucleus, the biological rhythm center, was strongly suppressed. A single dose of zolpidem significantly upregulated c-Fos expression in the ipsilateral suprachiasmatic nucleus to levels comparable to the contralateral side. CONCLUSION Stroke leads to suprachiasmatic nucleus dysfunction. Zolpidem restores suprachiasmatic nucleus activity and effectively alleviates post-stroke sleep disturbances, indicating its potential to promote stroke recovery.
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Affiliation(s)
- Zhi‐Gang Zhong
- Department of Neurobiology, Institute for Basic Research on Aging and Medicine, School of Basic Medical SciencesFudan UniversityShanghaiChina
- Department of Pharmacology, School of Basic Medical Sciences, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain ScienceFudan UniversityShanghaiChina
| | - Gui‐Jin Tao
- Department of Neurobiology, Institute for Basic Research on Aging and Medicine, School of Basic Medical SciencesFudan UniversityShanghaiChina
- Department of Pharmacology, School of Basic Medical Sciences, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain ScienceFudan UniversityShanghaiChina
| | - Shu‐Mei Hao
- Department of Neurobiology, Institute for Basic Research on Aging and Medicine, School of Basic Medical SciencesFudan UniversityShanghaiChina
- Department of Pharmacology, School of Basic Medical Sciences, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain ScienceFudan UniversityShanghaiChina
| | - Hui Ben
- Department of Neurobiology, Institute for Basic Research on Aging and Medicine, School of Basic Medical SciencesFudan UniversityShanghaiChina
- Department of Pharmacology, School of Basic Medical Sciences, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain ScienceFudan UniversityShanghaiChina
| | - Wei‐Min Qu
- Department of Pharmacology, School of Basic Medical Sciences, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain ScienceFudan UniversityShanghaiChina
| | - Feng‐Yan Sun
- Department of Neurobiology, Institute for Basic Research on Aging and Medicine, School of Basic Medical SciencesFudan UniversityShanghaiChina
| | - Zhi‐Li Huang
- Department of Pharmacology, School of Basic Medical Sciences, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain ScienceFudan UniversityShanghaiChina
| | - Mei‐Hong Qiu
- Department of Neurobiology, Institute for Basic Research on Aging and Medicine, School of Basic Medical SciencesFudan UniversityShanghaiChina
- Department of Pharmacology, School of Basic Medical Sciences, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain ScienceFudan UniversityShanghaiChina
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Zandstra MG, Meijs H, Somers M, Stam CJ, de Wilde B, van Hecke J, Niemegeers P, Luykx JJ, van Dellen E. Associations between psychotropic drugs and rsEEG connectivity and network characteristics: a cross-sectional study in hospital-admitted psychiatric patients. Front Neurosci 2023; 17:1176825. [PMID: 37781262 PMCID: PMC10541222 DOI: 10.3389/fnins.2023.1176825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 08/22/2023] [Indexed: 10/03/2023] Open
Abstract
Introduction Resting-state EEG (rsEEG) characteristics, such as functional connectivity and network topology, are studied as potential biomarkers in psychiatric research. However, the presence of psychopharmacological treatment in study participants poses a potential confounding factor in biomarker research. To address this concern, our study aims to explore the impact of both single and multi-class psychotropic treatments on aforementioned rsEEG characteristics in a psychiatric population. Methods RsEEG was analyzed in a real-world cross-sectional sample of 900 hospital-admitted psychiatric patients. Patients were clustered into eight psychopharmacological groups: unmedicated, single-class treatment with antipsychotics (AP), antidepressants (AD) or benzodiazepines (BDZ), and multi-class combinations of these treatments. To assess the associations between psychotropic treatments and the macroscale rsEEG characteristics mentioned above, we employed a general linear model with post-hoc tests. Additionally, Spearman's rank correlation analyses were performed to explore potential dosage effects. Results Compared to unmedicated patients, single-class use of AD was associated with lower functional connectivity in the delta band, while AP was associated with lower functional connectivity in both the delta and alpha bands. Single-class use of BDZ was associated with widespread rsEEG differences, including lower functional connectivity across frequency bands and a different network topology within the beta band relative to unmedicated patients. All of the multi-class groups showed associations with functional connectivity or topology measures, but effects were most pronounced for concomitant use of all three classes of psychotropics. Differences were not only observed in comparison with unmedicated patients, but were also evident in comparisons between single-class, multi-class, and single/multi-class groups. Importantly, multi-class associations with rsEEG characteristics were found even in the absence of single-class associations, suggesting potential cumulative or interaction effects of different classes of psychotropics. Dosage correlations were only found for antipsychotics. Conclusion Our exploratory, cross-sectional study suggests small but significant associations between single and multi-class use of antidepressants, antipsychotics and benzodiazepines and macroscale rsEEG functional connectivity and network topology characteristics. These findings highlight the importance of considering the effects of specific psychotropics, as well as their interactions, when investigating rsEEG biomarkers in a medicated psychiatric population.
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Affiliation(s)
- Melissa G. Zandstra
- Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Hannah Meijs
- Research Institute Brainclinics, Brainclinics Foundation, Nijmegen, Netherlands
- Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands
| | - Metten Somers
- Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Cornelis J. Stam
- Department of Clinical Neurophysiology and MEG Center, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Bieke de Wilde
- Department of Psychiatry, Ziekenhuis Netwerk Antwerpen (ZNA), Antwerp, Belgium
| | - Jan van Hecke
- Department of Psychiatry, Ziekenhuis Netwerk Antwerpen (ZNA), Antwerp, Belgium
| | - Peter Niemegeers
- Department of Psychiatry, Ziekenhuis Netwerk Antwerpen (ZNA), Antwerp, Belgium
| | - Jurjen J. Luykx
- Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Research Institute Brainclinics, Brainclinics Foundation, Nijmegen, Netherlands
- Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands
| | - Edwin van Dellen
- Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Department of Neurology, Universitair Ziekenhuis (UZ), Brussels, Belgium
- Vrije Universiteit Brussel, Brussels, Belgium
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Gao Q, Hao J, Kang X, Yuan F, Liu Y, Chen R, Liu X, Li R, Jiang W. EEG dynamics induced by zolpidem forecast consciousness evolution in prolonged disorders of consciousness. Clin Neurophysiol 2023; 153:46-56. [PMID: 37454563 DOI: 10.1016/j.clinph.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 05/19/2023] [Accepted: 06/11/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE To explore whether the EEG dynamics induced by zolpidem can predict consciousness evolution in patients with prolonged disorders of consciousness (PDOC). METHODS We conducted a prospective explorative analysis on thirty-six patients with PDOC and eleven healthy controls. The EEG power spectrum was analyzed and categorized into 'ABCD' patterns at baseline and one hour after zolpidem administration at 10 mg. The clinical outcome was defined as consciousness improvement and no improvement six months after enrollment using the Coma Recovery Scale-Revised (CRS-R) score. RESULTS Zolpidem administration significantly increased the EEG power in the delta & theta bands and decreased EEG power in the beta bands in healthy controls. Further follow-up studies indicated that the increased EEG beta-band power induced by zolpidem can predict an improved consciousness six months after enrollment with an area under the receiver operating characteristic curve (AUC) of 0.829, the sensitivity of 94.38% and an accuracy of 81.48%. CONCLUSIONS Our work revealed that the specific EEG responses to zolpidem can predict consciousness recovery in PDOC patients. SIGNIFICANCE The zolpidem-induced specific EEG responses could potentially predict the recovery of PDOC patients, which may help clinicians and patients' families in their decision-making process.
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Affiliation(s)
- Qiong Gao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Jianmin Hao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Xiaogang Kang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Fang Yuan
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China; Department of Neurology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510000, China.
| | - Yu Liu
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Rong Chen
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Xiuyun Liu
- Department of Biomedical Engineering, College of Precision Instruments and Optoelectronics Engineering, Tianjin University, Tianjin 300072, China; Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin 300072, China.
| | - Rui Li
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
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Boisgontier J, Beccaria K, Saitovitch A, Blauwblomme T, Guida L, Fillon L, Dufour C, Grill J, Lemaitre H, Puget S, Vinçon-Leite A, Dangouloff-Ros V, Charpy S, Benichi S, Levy R, Roux CJ, Grévent D, Bourgeois M, Saidoun L, Gaillard R, Zilbovicius M, Boddaert N. Case Report: Zolpidem's paradoxical restorative action: A case report of functional brain imaging. Front Neurosci 2023; 17:1127542. [PMID: 37123350 PMCID: PMC10140395 DOI: 10.3389/fnins.2023.1127542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/09/2023] [Indexed: 05/02/2023] Open
Abstract
Zolpidem is a sedative drug that has been shown to induce a paradoxical effect, restoring brain function in wide range of neurological disorders. The underlying functional mechanism of the effect of zolpidem in the brain in clinical improvement is still poorly understood. Thus, we aimed to investigate rest brain function to study zolpidem-induced symptom improvement in a patient who developed postoperative pediatric cerebellar mutism syndrome, a postoperative complication characterized by delayed onset transient mutism/reduced speech that can occur after medulloblastoma resection. The patient experienced clinical recovery after a single dose of zolpidem. Brain function was investigated using arterial spin labeling MRI and resting-state functional MRI. Imaging was performed at three time-points: preoperative, postoperative during symptoms, and after zolpidem intake when the symptoms regressed. Whole brain rest cerebral blood flow (CBF) and resting state functional connectivity using Pearson coefficient correlations between pairs of regions of interest were investigated two-by-two at the different time points. A comparison between postoperative and preoperative images showed a significant decrease in rest CBF in the left supplementary motor area, Broca's area, and the left striatum and a decrease in functional connectivity within the dentato-thalamo-cortical and cortico-striato-pallido-thalamo-cortical loops. Post-zolpidem images showed increased CBF in the left striatum and increased functional connectivity within the disrupted loops relative to postoperative images. Thus, we observed functional changes within the broader speech network and thalamo-subcortical interactions associated with the paradoxical effect of zolpidem in promoting clinical recovery. This should encourage further functional investigations in the brain to better understand the mechanism of zolpidem in neurological recovery.
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Affiliation(s)
- Jennifer Boisgontier
- Department of Pediatric Radiology, Necker-Enfants Malades Hospital, AP-HP, Université Paris-Cité, Paris, France
- Imagine Institute, INSERM U1163, Université Paris Cité, Paris, France
- *Correspondence: Jennifer Boisgontier,
| | - Kévin Beccaria
- Department of Pediatric Neurosurgery, Necker-Enfants Malades Hospital, AP-HP, Université Paris-Cité, Paris, France
| | - Ana Saitovitch
- Department of Pediatric Radiology, Necker-Enfants Malades Hospital, AP-HP, Université Paris-Cité, Paris, France
- Imagine Institute, INSERM U1163, Université Paris Cité, Paris, France
| | - Thomas Blauwblomme
- Department of Pediatric Neurosurgery, Necker-Enfants Malades Hospital, AP-HP, Université Paris-Cité, Paris, France
| | - Lelio Guida
- Department of Pediatric Neurosurgery, Necker-Enfants Malades Hospital, AP-HP, Université Paris-Cité, Paris, France
| | - Ludovic Fillon
- Department of Pediatric Radiology, Necker-Enfants Malades Hospital, AP-HP, Université Paris-Cité, Paris, France
- Imagine Institute, INSERM U1163, Université Paris Cité, Paris, France
| | - Christelle Dufour
- Department of Pediatric and Adolescent Oncology, Gustave Roussy Institute, Villejuif, France
| | - Jacques Grill
- Department of Pediatric and Adolescent Oncology, Gustave Roussy Institute, Villejuif, France
| | - Hervé Lemaitre
- Neurodegenerative Diseases Institute, Neurofunctional Imaging Group (GIN), Univ. Bordeaux, CNRS, UMR 5293, Bordeaux, France
| | - Stéphanie Puget
- Department of Neurosurgery, Centre Hospitalier Universitaire de Fort de France, University of Antilles, Fort-de-France, Martinique
| | - Alice Vinçon-Leite
- Department of Pediatric Radiology, Necker-Enfants Malades Hospital, AP-HP, Université Paris-Cité, Paris, France
- Imagine Institute, INSERM U1163, Université Paris Cité, Paris, France
| | - Volodia Dangouloff-Ros
- Department of Pediatric Radiology, Necker-Enfants Malades Hospital, AP-HP, Université Paris-Cité, Paris, France
- Imagine Institute, INSERM U1163, Université Paris Cité, Paris, France
| | - Sarah Charpy
- Department of Pediatric Radiology, Necker-Enfants Malades Hospital, AP-HP, Université Paris-Cité, Paris, France
| | - Sandro Benichi
- Department of Pediatric Neurosurgery, Necker-Enfants Malades Hospital, AP-HP, Université Paris-Cité, Paris, France
| | - Raphaël Levy
- Department of Pediatric Radiology, Necker-Enfants Malades Hospital, AP-HP, Université Paris-Cité, Paris, France
- Imagine Institute, INSERM U1163, Université Paris Cité, Paris, France
| | - Charles-Joris Roux
- Department of Pediatric Radiology, Necker-Enfants Malades Hospital, AP-HP, Université Paris-Cité, Paris, France
- Imagine Institute, INSERM U1163, Université Paris Cité, Paris, France
| | - David Grévent
- Department of Pediatric Radiology, Necker-Enfants Malades Hospital, AP-HP, Université Paris-Cité, Paris, France
| | - Marie Bourgeois
- Department of Pediatric Neurosurgery, Necker-Enfants Malades Hospital, AP-HP, Université Paris-Cité, Paris, France
| | - Lila Saidoun
- Department of Pediatric and Adolescent Oncology, Gustave Roussy Institute, Villejuif, France
| | - Raphaël Gaillard
- Department of Psychiatry, Faculty of Medicine, Sainte-Anne Hospital, Université Paris Cité, Paris, France
| | - Monica Zilbovicius
- Ecole Normale Supérieure Paris-Saclay, INSERM U1299, ERL “Developmental Trajectories and Psychiatry”: Université Paris Saclay, Université de Paris, CNRS, Centre Borelli, France
| | - Nathalie Boddaert
- Department of Pediatric Radiology, Necker-Enfants Malades Hospital, AP-HP, Université Paris-Cité, Paris, France
- Imagine Institute, INSERM U1163, Université Paris Cité, Paris, France
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Identifying Patients with Epilepsy Having Depression/Anxiety Disorder Using Common Spatial Patterns of Functional EEG Networks. J Med Biol Eng 2022. [DOI: 10.1007/s40846-022-00726-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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9
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Hao Z, Xia X, Bai Y, Wang Y, Dou W. EEG Evidence Reveals Zolpidem-Related Alterations and Prognostic Value in Disorders of Consciousness. Front Neurosci 2022; 16:863016. [PMID: 35573300 PMCID: PMC9093050 DOI: 10.3389/fnins.2022.863016] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/15/2022] [Indexed: 02/02/2023] Open
Abstract
Effective treatment and accurate long-term prognostication of patients with disorders of consciousness (DOC) remain pivotal clinical issues and challenges in neuroscience. Previous studies have shown that zolpidem produces paradoxical recovery and induces similar change patterns in specific electrophysiological features in some DOC (∼6%). However, whether these specific features are neural markers of responders, and how neural features evolve over time remain unclear. Here, we capitalized on static and dynamic EEG analysis techniques to fully uncover zolpidem-induced alterations in eight patients with DOC and constructed machine-learning models to predict long-term outcomes at the single-subject level. We observed consistent patterns of change across all patients in several static features (e.g., decreased relative theta power and weakened alpha-band functional connectivity) after zolpidem administration, albeit none zolpidem responders. Based on the current evidence, previously published electrophysiological features are not neural markers for zolpidem responders. Moreover, we found that the temporal dynamics of the brain slowed down after zolpidem intake. Brain states before and after zolpidem administration could be completely characterized by the EEG features. Furthermore, long-term outcomes were accurately predicted using connectivity features. Our findings suggest that EEG neural signatures have huge potential to assess consciousness states and predict fine-grained outcomes. In summary, our results extend the understanding of the effects of zolpidem on the brain and open avenues for the application prospect of zolpidem and EEG in patients with DOC.
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Affiliation(s)
- Zexuan Hao
- Department of Electronic Engineering, Beijing National Research Center for Information Science and Technology (BNRist), Tsinghua University, Beijing, China
| | - Xiaoyu Xia
- Department of Neurosurgery, The First Medical Center of PLA General Hospital, Beijing, China
- Department of Neurosurgery, Hainan Hospital of PLA General Hospital, Sanya, China
| | - Yang Bai
- Center for Cognition and Brain Disorders, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Yong Wang
- Key Laboratory of Intelligent Rehabilitation and Neuromodulation of Hebei Province, Department of Electrical Engineering, Yanshan University, Qinhuangdao, China
| | - Weibei Dou
- Department of Electronic Engineering, Beijing National Research Center for Information Science and Technology (BNRist), Tsinghua University, Beijing, China
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10
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Therapies to Restore Consciousness in Patients with Severe Brain Injuries: A Gap Analysis and Future Directions. Neurocrit Care 2021; 35:68-85. [PMID: 34236624 PMCID: PMC8266715 DOI: 10.1007/s12028-021-01227-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023]
Abstract
Background/Objective For patients with disorders of consciousness (DoC) and their families, the search for new therapies has been a source of hope and frustration. Almost all clinical trials in patients with DoC have been limited by small sample sizes, lack of placebo groups, and use of heterogeneous outcome measures. As a result, few therapies have strong evidence to support their use; amantadine is the only therapy recommended by current clinical guidelines, specifically for patients with DoC caused by severe traumatic brain injury. To foster and advance development of consciousness-promoting therapies for patients with DoC, the Curing Coma Campaign convened a Coma Science Work Group to perform a gap analysis. Methods We consider five classes of therapies: (1) pharmacologic; (2) electromagnetic; (3) mechanical; (4) sensory; and (5) regenerative. For each class of therapy, we summarize the state of the science, identify gaps in knowledge, and suggest future directions for therapy development. Results Knowledge gaps in all five therapeutic classes can be attributed to the lack of: (1) a unifying conceptual framework for evaluating therapeutic mechanisms of action; (2) large-scale randomized controlled trials; and (3) pharmacodynamic biomarkers that measure subclinical therapeutic effects in early-phase trials. To address these gaps, we propose a precision medicine approach in which clinical trials selectively enroll patients based upon their physiological receptivity to targeted therapies, and therapeutic effects are measured by complementary behavioral, neuroimaging, and electrophysiologic endpoints. Conclusions This personalized approach can be realized through rigorous clinical trial design and international collaboration, both of which will be essential for advancing the development of new therapies and ultimately improving the lives of patients with DoC. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-021-01227-y.
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11
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Treatment and Prognosis After Hypoxic-Ischemic Injury. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00682-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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12
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Zhang B, O’Brien K, Won W, Li S. A Retrospective Analysis on Clinical Practice-Based Approaches Using Zolpidem and Lorazepam in Disorders of Consciousness. Brain Sci 2021; 11:brainsci11060726. [PMID: 34072336 PMCID: PMC8226545 DOI: 10.3390/brainsci11060726] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 05/24/2021] [Accepted: 05/27/2021] [Indexed: 12/03/2022] Open
Abstract
This is a retrospective study to investigate the results of using zolpidem and lorazepam in persons with disorders of consciousness (DoC) and to provide practical information for clinical application and further studies. The cohort included 146 patients (11 hemorrhagic stroke, 87 traumatic brain injury (TBI), 48 anoxic brain injury (ABI)) admitted to a specialized DoC rehabilitation program. A positive trial indicated a patient responded to either zolpidem or lorazepam with prominent functional improvements necessitating routine use of the medication. Non-responders had equivocal or negative (i.e., went to sleep) responses. Eleven patients with a stroke who had either medication were all non-responders. Of the remaining 135 patients, 95 received at least one medication trial. The overall positive rate was 11.6% (11/95), with 6.3% (5/79) for zolpidem and 14.0% (6/43) for lorazepam. Among TBI patients, the positive rate of the zolpidem trial (10.2%, 5/49) was slightly higher than that of the lorazepam trial (6.9%, 2/29; p > 0.05). Among ABI patients, the positive rate of the lorazepam trial (28.6%, 4/14) was significantly higher than that of the zolpidem trial (0%, 0/30; p = 0.007). Following a positive trial, most patients were continued on the medications on a regular basis before eventual discontinuation. Our results suggested the etiology of DoC, considering traumatic vs. anoxic injuries, may serve in guiding the clinical application of these medications in the treatment of DoC and in future prospective studies. We advocate for screening all patients with DoC using zolpidem and/or lorazepam.
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Affiliation(s)
- Bei Zhang
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (B.Z.); (W.W.)
- TIRR Disorders of Consciousness Program, TIRR Memorial Hermann Hospital, Houston, TX 77030, USA
| | - Katherine O’Brien
- TIRR Disorders of Consciousness Program, TIRR Memorial Hermann Hospital, Houston, TX 77030, USA
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX 77030, USA
| | - William Won
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (B.Z.); (W.W.)
| | - Sheng Li
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (B.Z.); (W.W.)
- TIRR Disorders of Consciousness Program, TIRR Memorial Hermann Hospital, Houston, TX 77030, USA
- Correspondence:
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