The Rising Status of Phenobarbital: A Case for Use in Severe Refractory Hyperactive Poststroke Delirium

Up to 48% of patients who have had a stroke will experience poststroke delirium (PSD) that can be hyperactive, hypoactive, or mixed. Literature on treatment of the hyperactive subtype is specifically lacking. This case report describes the rapid resolution of severe refractory hyperactive PSD with phenobarbital.

A 58-year-old man with a left middle cerebral artery stroke presented with severe hyperactive PSD of 12 days duration, refractory to antipsychotics, alpha-2 agonists, gabapentin, therapeutic valproic acid, benzodiazepines, and ketamine infusion. An oral dose of phenobarbital 30.4 mg, followed by oral maintenance therapy was initiated on day 13 of admission with dramatic improvement. As his Richmond Agitation-Sedation score trended downwards to 0, he was able to cooperate with therapies. This allowed for discharge to a skilled nursing facility for rehabilitation and subsequently home 2 weeks later.

Hyperactive PSD is a common complication of stroke with little evidence to guide treatment strategies. This report suggests that phenobarbital, because of its varied mechanisms of action and unique neurochemistry, may be an unrecognized potential therapy.