Post-Operative Treatment with Intracranial Hypotension Venous Congestion Associated Brain Injury with Zolpidem.

A previously independent 75 year-old male developed post-operative intracranial hypotension associated venous congestion (PIHV) after an elective T10-Pelvis fusion which was complicated by durotomy. POD-0 MRI noted symmetric edema of the basal ganglia, thalami, and cerebellar cortex as well as smooth diffuse pachymeningeal enhancement and dural thickening, consistent with PIHV. On POD-0, patient developed tonic clonic seizures, and on POD-2 patient was unable to follow commands or blink to visual threat, able to track eyes to sound only, and spontaneously moved all extremities. Patient was started on Zolpidem 2.5mg on POD-2, and twelve hours later he had significantly improved motor function, arousal, verbalization, and followed simple commands. After three doses, patient was fully alert and oriented with improved mobility and comprehension. Six Zolpidem doses were administered in total, and repeat MRI on POD-16 showed markedly improved regional edema. Patient was admitted to a brain injury inpatient rehabilitation unit (IPR) and was discharged to home 9 days later with FIM gain of 17. Intracranial hypotension can adversely affect primary mesocircuit structures supporting arousal. Zolpidem, a selective α-1-subunit GABA-A agonist supports GABAergic tone in these regions. This patient’s clinical presentation and recovery paralleled selective basal ganglial-thalamic edema development and resolution.