(Kiosk 4) Management of Severe Post-traumatic Brain Injury Agitation with Lithium: A Case Report

Case Diagnosis: Management of Severe Post-Traumatic Brain Injury Agitation with Lithium: A Case Report

Case Description or Program Description: A 50-year-old male with a history of alcohol abuse sustained a motorcycle accident with an initial Glasgow Coma Scale score of 7. CT head revealed bilateral subdural hematomas, subarachnoid hemorrhage, and bitemporal contusions. His case was complicated by severe post-traumatic agitation with Agitated Behavior Scale scores in the 40s. He was transferred to an acute inpatient rehabilitation facility on valproic acid, gabapentin, trazodone, clonidine, clonazepam, haloperidol, quetiapine, and propranolol for agitation management. Due to persistent agitation despite these many medications, lithium 150 mg twice daily was initiated on day 2 of inpatient rehabilitation. Lithium levels were obtained weekly and remained therapeutic.

Setting: Acute rehabilitation hospital

Assessment/Results: Agitation improved significantly and he tolerated weaning of many medications. By day 30 after the addition of lithium, multiple psychiatric medications including clonidine, haloperidol, and clonazepam had been discontinued. He was maintained on gabapentin, propranolol, quetiapine, trazodone, valproic acid, and lithium at the time of discharge. The patient was able to be discharged to subacute rehabilitation with improved agitation control.

Discussion (relevance): Agitation occurs in up to 41% of traumatic brain injury (TBI) patients yet there is no consensus on optimal pharmacologic management. Lithium offers neuroprotective properties including neurogenesis, angiogenesis, and anti-inflammatory effects. While few studies exist on lithium use for post-traumatic agitation, its use is supported by older literature in which lithium decreased aggressive behaviors and agitation in several patients.

Conclusions: Low-dose lithium may be beneficial to use for severe agitation in TBI patients unresponsive to other medications. Caution should be used in patients with a history of renal or thyroid disorders or those that may become pregnant. Additional research is needed to properly assess efficacy, long-term side effects, toxicity risk, dosage, and drug interactions.