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We aimed to determine the potentially modifiable risk factors that are predictive of post-traumatic brain injury seizures in relation to the severity of initial injury, neurosurgical interventions, neurostimulant use, and comorbidities. This retrospective study was conducted on traumatic brain injury (TBI) patients admitted to a single center from March 2008 to October 2017. We recruited 151 patients from a multiracial background with TBI, of which the data from 141 patients were analyzed, as 10 were excluded due to incomplete follow-up records or a past history of seizures. Of the remaining 141 patients, 33 (24.4%) patients developed seizures during long-term follow up post-TBI. Young age, presence of cerebral contusion, Indian race, low Glasgow Coma Scale (GCS) scores on admission, and use of neurostimulant medications were associated with increased risk of seizures. In conclusion, due to increased risk of seizures, younger TBI patients, as well as patients with low GCS on admission, cerebral contusions on brain imaging, and those who received neurostimulants or neurosurgical interventions should be monitored for post-TBI seizures. While it is possible that these findings may be explained by the differing mechanisms of injury in younger vs. older patients, the finding that patients on neurostimulants had an increased risk of seizures will need to be investigated in future studies.

Background/Objective Neurostimulants may improve or accelerate cognitive and functional recovery after intracerebral hemorrhage (ICH), ischemic stroke (IS), or subarachnoid hemorrhage (SAH), but few studies have described their safety and effectiveness in the intensive care unit (ICU). The objective of this study was to describe amantadine and modafinil administration practices during acute stroke care starting in the ICU and to evaluate safety and effectiveness. Methods Consecutive adult ICU patients treated with amantadine and/or modafinil following acute non-traumatic IS, ICH, or SAH were evaluated. Neurostimulant administration data were extracted from the electronic medication administration record, including medication (amantadine, modafinil, or both), starting dose, time from stroke to initiation, and whether the neurostimulant was continued at hospital discharge. Patients were considered responders if they met two of three criteria within 9 days of neurostimulant initiation: increase in Glasgow coma scale (GCS) score ≥ 3 points from pre-treatment baseline, improved wakefulness or participation documented in caregiver notes, or clinical improvement documented in physical or occupational therapy notes. Potential confounders of the effectiveness assessment and adverse drug effects were also recorded. Results A total of 87 patients were evaluable during the 3.7-year study period, including 41 (47%) with ICH, 29 (33%) with IS, and 17 (20%) with SAH. The initial neurostimulant administered was amantadine in 71 (82%) patients, modafinil in 13 (15%), or both in 3 (3%) patients. Neurostimulants were initiated a median of 7 (4.25, 12.75) days post-stroke (range 1–27 days) for somnolence (77%), not following commands (32%), lack of eye opening (28%), or low GCS (17%). The most common starting dose was 100 mg twice daily for both amantadine (86%) and modafinil (54%). Of the 79 patients included in the effectiveness evaluation, 42 (53%) were considered responders, including 34/62 (55%) receiving amantadine monotherapy and 8/24 (33%) receiving both amantadine and modafinil at the time they met the definition of a responder. No patient receiving modafinil monotherapy was considered a responder. The median time from initiation to response was 3 (2, 5) days. Responders were more frequently discharged home or to acute rehabilitation compared to non-responders (90% vs 62%, p = 0.006). Among survivors, 63/72 (88%) were prescribed a neurostimulant at hospital discharge. The most common potential adverse drug effect was sleep disruption (16%). Conclusions Neurostimulant administration during acute stroke care may improve wakefulness. Future controlled studies with a neurostimulant administration protocol, prospective evaluation, and discretely defined response and safety criteria are needed to confirm these encouraging findings. Electronic supplementary material The online version of this article (10.1007/s12028-020-00986-4) contains supplementary material, which is available to authorized users.