Abstract
Background and Purpose: Acute rehabilitation is known to enhance stroke recovery. However, poststroke lethargy
and fatigue can hinder participation in rehabilitation therapies. We hypothesized
that in patients with moderate to severe stroke complicated by poststroke fatigue
and lethargy early stimulant therapy with modafinil increases favorable discharge
disposition defined as transfer to acute inpatient rehabilitation or home. Methods: We retrospectively reviewed a cohort of patients with acute stroke admitted to the
stroke service over a 3-year period. All patients 18 years or older with confirmed
ischemic or hemorrhagic stroke, an NIHSS greater than or equal to 5 and documentation
of fatigue/lethargy in clinical documentation were included. We compared patients
that were treated with modafinil 50-200 mg to those managed with standard care. The
primary outcome measure was discharge disposition. Secondary outcome was 90 day modified
Rankin score (mRS). Statistical significance was determined using chi-square test
for association and logistic regression models. Logistic regression models were derived
in 2 ways with both raw data and an adjusted model that accounted for age, sex, and
NIHSS score to account for the lack of randomization. Results: This study included 199 stroke patients (145 ischemic, 54 hemorrhagic). Seventy-two
(36.2%) were treated with modafinil and 129 (64.8%) were discharged to acute inpatient
rehabilitation, while none were recommended for discharge home. Median NIHSS for modafinil
patients was 13.5 versus 11 for standard care patients (P = .059). In adjusted models, modafinil was associated with higher odds of favorable
discharge disposition (OR 2.00, 95% CI 1.01-3.95). Favorable outcome at 90 days defined
as mRS less than or equal to 2 occurred more frequently with modafinil (5.6% versus
3.3%) but this did not achieve statistical significance (P > .1). These results occurred despite the modafinil group requiring longer ICU stays
and having more in-hospital complications such as infections and need for percutaneous
gastrostomy tubes. The benefit of modafinil was seen across all subgroups except those
with severe stroke (NIHSS ≥ 15). There were no significant adverse events associated
with modafinil administration. Conclusions: Modafinil use in acute in-hospital stroke patients with moderate stroke complicated
by lethargy and fatigue was associated with improved discharge disposition. Randomized
controlled trials are needed to further study the safety, efficacy, and long-term
effects of modafinil in this patient population.
Key Words
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Article info
Publication history
Accepted:
December 29,
2019
Received in revised form:
November 8,
2019
Received:
September 11,
2019
Footnotes
Study Location: NYU Langone, Department of Neurology.
Funding: None.
Identification
DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.104645
Copyright
© 2020 Elsevier Inc. All rights reserved.
