Drugs for behavior disorders after traumatic brain injury: Systematic review and expert consensus leading to French recommendations for good practice

Dysregulation of the dopaminergic system secondary to traumatic brain injury: implications for mood and anxiety disorders

Traumatic brain injury (TBI) represents a public health issue with a high mortality rate and severe neurological and psychiatric consequences. Mood and anxiety disorders are some of the most frequently reported. Primary and secondary damage can cause a loss of neurons and glial cells, leading to dysfunction of neuronal circuits, which can induce imbalances in many neurotransmitter systems. Monoaminergic systems, especially the dopaminergic system, are some of the most involved in the pathogenesis of neuropsychiatric and cognitive symptoms after TBI. In this work, we summarize the studies carried out in patients who have suffered TBI and describe alterations in the dopaminergic system, highlighting (1) dysfunction of the dopaminergic neuronal circuits caused by TBI, where modifications are shown in the dopamine transporter (DAT) and alterations in the expression of dopamine receptor 2 (D2R) in brain areas with dopaminergic innervation, thus establishing a hypodopaminergic state and (2) variations in the concentration of dopamine and its metabolites in biological fluids of post-TBI patients, such as elevated dopamine (DA) and alterations in homovanillic acid (HVA). On the other hand, we show a large number of reports of alterations in the dopaminergic system after a TBI in animal models, in which modifications in the levels of DA, DAT, and HVA have been reported, as well as alterations in the expression of tyrosine hydroxylase (TH). We also describe the biological pathways, neuronal circuits, and molecular mechanisms potentially involved in mood and anxiety disorders that occur after TBI and are associated with alterations of the dopaminergic system in clinical studies and animal models. We describe the changes that occur in the clinical picture of post-TBI patients, such as alterations in mood and anxiety associated with DAT activity in the striatum, the relationship between post-TBI major depressive disorders (MDD) with lower availability of the DA receptors D2R and D3R in the caudate and thalamus, as well as a decrease in the volume of the substantia nigra (SN) associated with anxiety symptoms. With these findings, we discuss the possible relationship between the disorders caused by alterations in the dopaminergic system in patients with TBI.

Neuropharmacology in Traumatic Brain Injury

One of the primary goals in traumatic brain injury (TBI) treatment is to minimize secondary brain damage and promote neuroprotection. In TBI rehabilitation, we seek to facilitate neurologic recovery and restore what independence is possible given a patient's physical and cognitive impairments. These goals must be balanced with treatment of the various symptoms that may occur following TBI. This is challenging given the fact that many of the typical treatments for certain symptoms also come with side effects which could be problematic in the TBI population.

Amantadine for Traumatic Brain Injury-Supporting Evidence and Mode of Action

Traumatic brain injury (TBI) is an important global clinical issue, requiring not only prevention but also effective treatment. Following TBI, diverse parallel and intertwined pathological mechanisms affecting biochemical, neurochemical, and inflammatory pathways can have a severe impact on the patient's quality of life. The current review summarizes the evidence for the utility of amantadine in TBI in connection to its mechanism of action. Amantadine, the drug combining multiple mechanisms of action, may offer both neuroprotective and neuroactivating effects in TBI patients. Indeed, the use of amantadine in TBI has been encouraged by several clinical practice guidelines/recommendations. Amantadine is also available as an infusion, which may be of particular benefit in unconscious patients with TBI due to immediate delivery to the central nervous system and the possibility of precise dosing. In other situations, orally administered amantadine may be used. There are several questions that remain to be addressed: can amantadine be effective in disorders of consciousness requiring long-term treatment and in combination with drugs approved for the treatment of TBI? Do the observed beneficial effects of amantadine extend to disorders of consciousness due to factors other than TBI? Well-controlled clinical studies are warranted to ultimately confirm its utility in the TBI and provide answers to these questions.

Prognosis and enhancement of recovery in disorders of consciousness

Disorders of consciousness after severe brain injury encompass conditions of coma, vegetative state/unresponsive wakefulness syndrome, and minimally conscious state. DoC clinical presentation pose perplexing challenges to medical professionals, researchers, and families alike. The outcome is uncertain in the first weeks to months after a brain injury, with families and medical providers often making important decisions that require certainty. Prognostication for individuals with these conditions has been the subject of intense scientific investigation that continues to strive for valid prognostic indicators and algorithms for predicting recovery of consciousness. This manuscript aims to provide an overview of the current clinical landscape surrounding prognosis and optimizing recovery in DoC and the current and future research that could improve prognostic accuracy after severe brain injury. Improved understanding of these factors will aid healthcare professionals in providing optimal care, fostering hope, and advocating for ethical practices in the management of individuals with DoC.

Antipsychotic Drugs: The Antithesis to Neurorehabilitation in Models of Pre-Clinical Traumatic Brain Injury

Sixty-nine million traumatic brain injuries (TBIs) are reported worldwide each year, and, of those, close to 3 million occur in the United States. In addition to neurobehavioral and cognitive deficits, TBI induces other maladaptive behaviors, such as agitation and aggression, which must be managed for safe, accurate assessment and effective treatment of the patient. The use of antipsychotic drugs (APDs) in TBI is supported by some expert guidelines, which suggests that they are an important part of the pharmacological armamentarium to be used in the management of agitation. Despite the advantages of APDs after TBI, there are significant disadvantages that may not be fully appreciated clinically during decision making because of the lack of a readily available updated compendium. Hence, the aim of this review is to integrate the existing findings and present the current state of APD use in pre-clinical models of TBI. The studies discussed were identified through PubMed and the University of Pittsburgh Library System search strategies and reveal that APDs, particularly those with dopamine2 (D2) receptor antagonism, generally impair the recovery process in rodents of both sexes and, in some instances, attenuate the potential benefits of neurorehabilitation. We believe that the compilation of findings represented by this exhaustive review of pre-clinical TBI + APD models can serve as a convenient source for guiding informed decisions by critical care clinicians and physiatrists contemplating APD use for patients exhibiting agitation.

Agitation after traumatic brain injury: a review of current and future concepts in diagnosis and management

OBJECTIVES

Agitation and aggression are common following traumatic brain injury. The challenges related to these disorders affect all stages of recovery, from the acute hospital to the community setting. The aim of this literature review is to provide an updated overview of the current state of post-traumatic agitation research.

METHODS

We performed a PubMed literature review which included recent confirmatory and novel research as well as classic and historical studies to integrate past and future concepts.

RESULTS

Areas explored include the personal and societal effects of post-traumatic agitation, methods for defining and diagnosing several neurobehavioral disorders, and pathophysiology and management of agitation and aggression. Target areas for future study are identified and discussed.

DISCUSSION

While much progress has been made in understanding post-traumatic agitation, there remain several key areas that require further elucidation to support the care and treatment for people with traumatic brain injury.

Evaluation, Treatment, and Outcomes of Viral and Autoimmune Encephalitis in Children

Viral encephalitis and autoimmune encephalitis are currently the most common causes of encephalitis. Determining the causative agent is helpful in initiating medical treatment that may help reduce long-term sequelae. Cerebrospinal fluid, neuroimaging, serologic, and electroencephalogram in combination with clinical manifestations play a role in determining the cause of the encephalitis. Although motor dysfunction tends to improve, there is a significant risk of long-term neurologic and cognitive sequelae. These persistent deficits that occur in childhood indicate the importance for ongoing rehabilitative services to maximize functional skills, improve cognitive deficits, and assist with community integration.

Mania Following Traumatic Brain Injury: A Systematic Review

OBJECTIVE

Traumatic brain injury (TBI) is a leading cause of mortality and morbidity worldwide. Mania is an uncommon, but debilitating, psychiatric occurrence following TBI. The literature on mania following TBI is largely limited to case reports and case series. In the present review, the investigators describe the clinical, diagnostic, and treatment characteristics of mania following TBI.

METHODS

A systematic search of MEDLINE, EMBASE, and PsycINFO was conducted for English-language studies published from 1980 to July 15, 2021. The included studies provided the required individual primary data and sufficient information on clinical presentation or treatment of manic symptoms. Studies with patients who reported a history of mania or bipolar disorder prior to TBI and studies with patients who sustained TBI before adulthood were excluded.

RESULTS

Forty-one studies were included, which reported information for 50 patients (the mean±SD age at mania onset was 39.1±14.3 years). Patients were more frequently male, aged <50 years, and without a personal or family history of psychiatric disorders. Although 74% of patients reported mania developing within 1 year following TBI, latencies of up to 31 years were observed. Illness trajectory varied from a single manic episode to recurrent mood episodes. Rapid cycling was reported in six patients. Mood stabilizers and antipsychotics were most frequently used to improve symptoms.

CONCLUSIONS

Heterogeneity of lesion locations and coexisting vulnerabilities make causality difficult to establish. Valproate or a second-generation antipsychotic, such as olanzapine or quetiapine, may be considered first-line therapy in the absence of high-level evidence for a more preferred treatment. Early escalation to combined therapy (mood stabilizer and second-generation antipsychotic) is recommended to control symptoms and prevent recurrence. Larger prospective studies and randomized controlled trials are needed to refine diagnostic criteria and provide definitive treatment recommendations.

Pharmacological management of neuropsychiatric symptoms in geriatric traumatic brain injury: a scoping review

OBJECTIVE

This scoping review aimed to summarize the existing knowledge base on the pharmacological management of neuropsychiatric symptoms in geriatric TBI and identify gaps in the literature to guide future research.

METHODS

Seven electronic databases and nine gray literature databases were systematically searched for articles that examined pharmacological management of neuropsychiatric symptoms in adults aged 65 years and over with TBI. The search was guided by four main concepts and selected based on inclusion criteria. Unpublished studies and abstract-only articles were excluded.

RESULTS

Eight studies met full inclusion criteria. Patterns of psychotropic medication prescription and prescribing principles for geriatric TBI were elucidated. There were no clear or consistent prescribing guidance. Therefore, prescribing recommendations could not be addressed. Current management is inferred from research primarily done in younger adults, or extrapolated from the literature and practice of treating other psychiatric and neurological disorders.

CONCLUSION

There are significant gaps in knowledge and no evidence-based guidelines for the treatment of neuropsychiatric symptoms in geriatric TBI. TBI among older adults is distinct from those of younger adults and thereby demands a unique approach to treatment and research. The authors' proposed guideline is an important first step in facilitating guideline development and future research.

Pharmacological Treatment of Disinhibition in Acquired Brain Injury

PURPOSE/BACKGROUND

Traumatic brain injury is a major universal public health concern and results in chronic neurobehavioral sequelae including disinhibition. Objectives of this study were to review the literature on pharmacological treatment of disinhibition post-acquired brain injury (ABI), describe a snapshot of pharmacotherapy used in ABI at a tertiary neuropsychiatric unit in British Columbia, Canada, and share expert opinion.

METHODS/PROCEDURES

A retrospective chart review of 11 patients from October to December 2021 was conducted based on exclusion criteria: age greater than 18 years, primary neurodegenerative conditions, or aphasia. Patient demographics, behavioral and cognitive test results, and disinhibition treatment were recorded. A brief review of the literature was conducted to find the best available evidence of pharmacological interventions to treat disinhibition post-ABI.

FINDINGS/RESULTS

In ABI, there was a high utilization of antipsychotics and benzodiazepines, at 91% and 64% respectively, in patients with severe cognitive deficit and disinhibition. Mood stabilizers and nonselective β-blockers were less prescribed in this population at 73% and 18%. At the point of data collection, all the patients had responded well to treatment and were in the maintenance phase of their pharmacological treatment.

IMPLICATIONS/CONCLUSIONS

A limited number of studies with weak methodology suggest that mood stabilizers and β-blockers should be first line for disinhibition treatment. Our findings are complementary to the literature describing treatment of severe disinhibition. The choice of treatment for disinhibition depends on factors including nature and severity of target symptoms, level of drug evidence, patient-tailored objectives, concurrent psychiatric diagnoses, clinical experience of clinicians, adverse drug reactions, and treatment acuity.

Associations between β-blockers and psychiatric and behavioural outcomes: A population-based cohort study of 1.4 million individuals in Sweden

BACKGROUND

β-blockers are widely used for treating cardiac conditions and are suggested for the treatment of anxiety and aggression, although research is conflicting and limited by methodological problems. In addition, β-blockers have been associated with precipitating other psychiatric disorders and suicidal behaviour, but findings are mixed. We aimed to examine associations between β-blockers and psychiatric and behavioural outcomes in a large population-based cohort in Sweden.

METHODS AND FINDINGS

We conducted a population-based longitudinal cohort study using Swedish nationwide high-quality healthcare, mortality, and crime registers. We included 1,400,766 individuals aged 15 years or older who had collected β-blocker prescriptions and followed them for 8 years between 2006 and 2013. We linked register data on dispensed β-blocker prescriptions with main outcomes, hospitalisations for psychiatric disorders (not including self-injurious behaviour or suicide attempts), suicidal behaviour (including deaths from suicide), and charges of violent crime. We applied within-individual Cox proportional hazards regression to compare periods on treatment with periods off treatment within each individual in order to reduce possible confounding by indication, as this model inherently adjusts for all stable confounders (e.g., genetics and health history). We also adjusted for age as a time-varying covariate. In further analyses, we adjusted by stated indications, prevalent users, cardiac severity, psychiatric and crime history, individual β-blockers, β-blocker selectivity and solubility, and use of other medications. In the cohort, 86.8% (n = 1,215,247) were 50 years and over, and 52.2% (n = 731,322) were women. During the study period, 6.9% (n = 96,801) of the β-blocker users were hospitalised for a psychiatric disorder, 0.7% (n = 9,960) presented with suicidal behaviour, and 0.7% (n = 9,405) were charged with a violent crime. There was heterogeneity in the direction of results; within-individual analyses showed that periods of β-blocker treatment were associated with reduced hazards of psychiatric hospitalisations (hazard ratio [HR]: 0.92, 95% confidence interval [CI]: 0.91 to 0.93, p < 0.001), charges of violent crime (HR: 0.87, 95% CI: 0.81 to 0.93, p < 0.001), and increased hazards of suicidal behaviour (HR: 1.08, 95% CI: 1.02 to 1.15, p = 0.012). After stratifying by diagnosis, reduced associations with psychiatric hospitalisations during β-blocker treatment were mainly driven by lower hospitalisation rates due to depressive (HR: 0.92, 95% CI: 0.89 to 0.96, p < 0.001) and psychotic disorders (HR: 0.89, 95% CI: 0.85 to 0.93, p < 0.001). Reduced associations with violent charges remained in most sensitivity analyses, while associations with psychiatric hospitalisations and suicidal behaviour were inconsistent. Limitations include that the within-individual model does not account for confounders that could change during treatment, unless measured and adjusted for in the model.

CONCLUSIONS

In this population-wide study, we found no consistent links between β-blockers and psychiatric outcomes. However, β-blockers were associated with reductions in violence, which remained in sensitivity analyses. The use of β-blockers to manage aggression and violence could be investigated further.

Rehabilitation Outcomes of Cortical Blindness and Characteristics Secondary to Cardiac Arrest: A Review

We reviewed the published literature on rehabilitation outcomes in patients with cortical blindness (CB) and highlighted the characteristic features and prognosis of CB due to cardiac arrest. The studies excluded were those involving the pediatric population (<age 16), written in a language other than English, and studies with no mention of outcomes. The literature search was done by PubMed and EBSCOhost databases from the oldest available literature through November 2019. Due to the scarcity of published literature and a qualitative description of outcomes, a narrative review of the literature was deemed appropriate. Seven case reports and one retrospective cohort study met the inclusion criteria. Cognitive and visual impairments were significant barriers to rehabilitation in CB. Improvement of visual deficits occurred within one to two months. Those with complete blindness, cognitive impairments, and a delay in resuscitation were more likely to have poorer functional outcomes in the performance of activities of daily living and were less likely to be discharged home. This is the most comprehensive review of published literature to focus on the function of patients with cortical blindness. The limitations include the small number of published literature and the qualitative approach utilized. Despite the limitations, the findings of this review can inform future studies that would investigate the most efficient and comprehensive methods of CB rehabilitation.

An Uncontrollable, Aggressive Patient at a Free-Standing Emergency Department

We present the case of an aggressive male patient who was unable to be successfully sedated with conventional medications in the ED and ultimately required intubation to ensure the safety of the patient himself and the staff. After admission to the ICU, he was found to have atrophy of the frontal and bilateral lobes secondary to a traumatic brain injury (TBI) 19 years prior. Managing the patient required collaboration with the intensivist, hospitalist, and psychiatry and neurology teams for 10 months, and he was refused admission to multiple psychiatric facilities due to safety concerns because of his high level of aggression and unpredictability. An out-of-state, high-security facility eventually accepted the patient. The second challenge was finding a highly trained medical team willing to transport the patient. This case illustrates the difficulty and safety concerns with regard to managing an aggressive patient with previous TBI when the commonly used medications do not produce the desired effect. A literature search did not reveal a standard protocol or consensus on managing these types of patients in emergent situations.

Risk factors for suicidal behavior/ideation and hostility/aggression in patients with bipolar disorders: An analysis using the Japanese Adverse Drug Event Report database

The present study attempted to identify risk factors for suicidality and hostility/aggression in patients with bipolar disorders. Data on 3521 patients were extracted from the Japanese Adverse Drug Event Report (JADER) database. There were 134 reports regarding suicidal behavior/ideation, and 129 patients were judged to have it. Standardized Medical Dictionary for Regulatory Activities queries indicated that 248 adverse drug events pertained to hostility/aggression, and 218 patients were considered to show hostility/aggression. A multiple logistic regression analysis revealed the association of the risk for suicidal behavior/ideation with bipolar II disorder [adjusted odds ratio (aOR): 4.55, 95% confidence interval (CI): 1.90-10.9], male sex (aOR: 1.23, 95% CI: 1.02-1.48), age <50 years (aOR: 1.75, 95% CI: 1.43-2.15), the administration of aripiprazole (aOR: 1.27, 95% CI: 1.00-1.60), and akathisia (aOR: 3.05, 95% CI: 1.80-5.18), while lithium carbonate decreased its odds (aOR: 0.664, 95% CI: 0.537-0.821). The risk of hostility/aggression was associated with male sex (aOR: 1.22, 95% CI: 1.06-1.40), lithium carbonate (aOR: 0.823, 95% CI: 0.710-0.953), and carbamazepine (aOR: 0.693, 95% CI: 0.500-0.961). No association between suicidal behavior/ideation and hostility/aggression was recognized. The present study proposes factors related with suicidal behavior/ideation and hostility/aggression in patients with bipolar disorders using the JADER database. Lithium carbonate appeared to decrease the risks of suicidal behavior/ideation and hostility/aggression in patients with bipolar disorders, and akathisia may be associated with the former risk. Further studies are required to evaluate the identified signals.

Implementing a behavior management approach in the hospital setting for individuals with challenging behaviors during acute traumatic brain injury

PRIMARY OBJECTIVE

This study aimed to determine if implementing a clinically pragmatic behavior management approach for challenging behaviors during acute TBI reduces use of restraints, security incidences, acute length of stay admission and cost, thereby improving progress to rehabilitation.

RESEARCH DESIGN

This pilot study involved a behavior management group (n = 27), compared with a historical control group (n = 74).

METHOD AND PROCEDURES

The behavior management group received care following the implementation of a behavior management approach for challenging behaviors during acute TBI at two hospitals in South Australia.

MAIN OUTCOMES AND RESULTS

Fidelity results demonstrated high level of adherence to the implemented behavior management approach. The behavior management group had significant lower use of mechanical restraints (p = 0.03), and significantly lower acute admission costs (p = 0.034). Trends in lower pharmacological restraint usage, lower acute hospital length of stay and time from admission to rehabilitation acceptance were recorded.

CONCLUSIONS

These pilot results contribute to improving quality of health care but methodological limitations make outcomes difficult to interpret as a direct result of the intervention. Future studies are required to investigate evidence-based behavior management interventions for acute TBI patients using more rigorous knowledge translation implementation designs.

Risk factors and consequences of traumatic brain injury in a Swiss male population cohort

OBJECTIVE

To investigate the risk factors for and the consequences (ie, substance use disorders (SUD), depression, personality traits) of traumatic brain injury (TBI) in young Swiss men.

DESIGN

This is a three-wave cohort study. Risk factors were measured at baseline (2010-2012) and at follow-up 1 (FU1; 2012-2014), while the consequences and TBI were measured at follow-up 2 (FU2; 2016-2018).

SETTING

Switzerland.

PARTICIPANTS

All participants at FU2 (Mage=25.43, SD=1.25) of the Cohort Study on Substance Use Risk Factors (N=4881 young Swiss men after listwise deletion).

MEASURES

The outcomes measured were TBI, SUD (ie, alcohol, nicotine, cannabis, other illicit drugs), depression and personality traits (ie, sensation seeking, anxiety-neuroticism, sociability, aggression-hostility) at FU2. The predictors were previous TBI (lifetime TBI but not in the past 12 months at FU2), SUD, personality traits and sociodemographics (highest level of achieved education, age, linguistic region) measured at FU1.

RESULTS

At FU2, 3919 (80.3%) participants reported to never have had TBI, 102 (2.1%) have had TBI in the last 12 months (TBI new cases), and 860 (17.6%) have had TBI during their lifetime but not in the 12 months preceding FU2 (previous TBI). Low educational attainment (OR=3.93, 95% CI 2.10 to 7.36), depression (OR=2.87, 95% CI 1.35 to 6.11), nicotine dependence (OR=1.72, 95% CI 1.09 to 2.71), high sociability (OR=1.18, 95% CI 1.07 to 1.30), high aggression-hostility (OR=1.15, 95% CI 1.06 to 1.26) and high sensation seeking (OR=1.33, 95% CI 1.04 to 1.68) at FU1 were significantly associated with TBI new cases at FU2. Previous TBI was significantly associated with nicotine dependence (OR=1.46, 95% CI 1.16 to 1.83), depression (OR=2.16, 95% CI 1.56 to 2.99) and aggression-hostility (B=0.14, 95% CI >0.00 to 0.28) at FU2.

CONCLUSION

Low educational attainment and depression are the most significant risk factors associated with increased odds of future TBI, while depression, nicotine dependence and high aggression-hostility are the main consequences of previous TBI. TBI should be considered an underlying factor in the treatment of depression, SUD or unfavourable personality profiles.

Brain anomalies in early psychosis: From secondary to primary psychosis

Brain anomalies are frequently found in early psychoses. Although they may remain undetected for many years, their interpretation is critical for differential diagnosis. In secondary psychoses, their identification may allow specific management. They may also shed light on various pathophysiological aspects of primary psychoses. Here we reviewed cases of secondary psychoses associated with brain anomalies, reported over a 20-year period in adolescents and young adults aged 13-30 years old. We considered age at first psychotic symptoms, relevant medical history, the nature of psychiatric symptoms, clinical red flags, the nature of the brain anomaly reported, and the underlying disease. We discuss the relevance of each brain area in light of normal brain function, recent case-control studies, and postulated pathophysiology. We show that anomalies in all regions, whether diffuse, multifocal, or highly localized, may lead to psychosis, without necessarily being associated with non-psychiatric symptoms. This underlines the interest of neuroimaging in the initial workup, and supports the hypothesis of psychosis as a global network dysfunction that involves many different regions.

Effectiveness of Pharmacotherapy for Depression after Adult Traumatic Brain Injury: an Umbrella Review

Symptoms of depression are common following traumatic brain injury (TBI), impacting survivors' ability to return to work, participate in leisure activities, and placing strain on relationships. Depression symptoms post TBI are often managed with pharmacotherapy, however, there is little research evidence to guide clinical practice. There have been a number of recent systematic reviews examining pharmacotherapy for post TBI depression. The aim of this umbrella review was to synthesize systematic reviews and meta-analyses of the effectiveness of pharmacotherapy for the management of post TBI depression in adults. Eligible reviews examined any pharmacotherapy against any comparators, for the treatment of depression in adults who had sustained TBI. Seven databases were searched, with additional searching of online journals, Research Gate, Google Scholar and the TRIP Medical Database to identify published and unpublished systematic reviews and meta-analyses in English up to May 2020. A systematic review of primary studies available between March 2018 and May 2020 was also conducted. Evidence quality was assessed using Joanna Briggs Institute Critical Appraisal Instruments. The results are presented as a narrative synthesis. Twenty-two systematic reviews were identified, of which ten reviews contained a meta-analysis. No new primary studies were identified in the systematic review. There was insufficient high quality and methodologically rigorous evidence to recommend prescribing any specific drug or drug class for post TBI depression. The findings do show, however, that depression post TBI is responsive to pharmacotherapy in at least some individuals. Recommendations for primary studies, systematic reviews and advice for prescribers is provided. Review Registration PROSPERO (CRD42020184915).

The effect of clopidogrel and aspirin on the severity of traumatic brain injury in a rat model

Traumatic Brain Injury (TBI) is one of the leading causes of death and disability worldwide. Aspirin (ASA) and clopidogrel (CLOP) are antiplatelet agents that inhibit platelet aggregation. They are implicated in worsening the intracerebral haemorrhage (ICH) risk post-TBI. However, antiplatelet drugs may also exert a neuroprotective effect post-injury. We determined the impact of aspirin and clopidogrel treatment, alone or in combination, on ICH and brain damage in an experimental rat TBI model. We assessed changes in platelet aggregation and measured serum thromboxane by enzyme immune assay. We also explored a panel of brain damage and apoptosis biomarkers by immunoblotting. Rats were treated with aspirin and/or clopidogrel for 48 h prior to TBI and sacrificed 48 h post-injury. In rats treated with antiplatelet agents prior to TBI, platelet aggregation was completely inhibited, and serum thromboxane was significantly decreased, compared to the TBI group without treatment. TBI increases UCHL-1 and GFAP, but decreases hexokinase expression compared to the non-injured controls. All groups treated with antiplatelet drugs prior to TBI had decreased UCH-L1 and GFAP serum levels compared to the TBI untreated group. Furthermore, the ASA and CLOP single treatments increased the hexokinase serum levels. We confirmed that αII-spectrin cleavage increased post-TBI, with the highest cleavage detected in CLOP-treated rats. Aspirin and/or clopidogrel treatment prior to TBI is a double-edged sword that exerts a dual effect post-injury. On one hand, ASA and CLOP single treatments increase the post-TBI ICH risk, with a further detrimental effect from the ASA + CLOP treatment. On the other hand, ASA and/or CLOP treatments are neuroprotective and result in a favourable profile of TBI injury markers. The ICH risk and the neuroprotection benefits from antiplatelet therapy should be weighed against each other to ameliorate the management of TBI patients.

Treatment Patterns of Anxiety and Posttraumatic Stress Disorder Following Traumatic Brain Injury

OBJECTIVE

Symptoms of mental disorders are common, are underrecognized, and contribute to worse outcomes after traumatic brain injury (TBI). Post-TBI, prevalence of anxiety disorders and prevalence of posttraumatic stress disorder (PTSD) are comparable with that of depression, but evidence-based treatment guidelines are lacking. The investigators examined psychotropic medication use and psychotherapy patterns among individuals diagnosed with anxiety disorders and PTSD post-TBI.

METHODS

Administrative claims data were used to compare the prevalence and patterns of pharmacotherapy and psychotherapy utilization among individuals diagnosed with an anxiety disorder or PTSD post-TBI.

RESULTS

Among 207,354 adults with TBI, prevalence of anxiety disorders was 20.5%, and prevalence of PTSD was 0.6% post-TBI. Receipt of pharmacotherapy pre- and post-TBI (anxiety: pre-TBI=58.4%, post-TBI=76.2%; PTSD: pre-TBI=53.7%, post-TBI=75.2%) was considerably more common than receipt of psychotherapy (anxiety: pre-TBI=5.8%, post-TBI=19.1%; PTSD: pre-TBI=11.2%, post-TBI=36.0%). Individuals diagnosed with anxiety were 66% less likely to receive psychotherapy compared with individuals diagnosed with PTSD, although engagement in psychotherapy decreased faster over time among those with PTSD. Overall, psychotropic medication use and rates of antidepressant prescription use in the anxiety group were higher compared with those in the PTSD group. Benzodiazepines were the second most commonly prescribed medication class in the anxiety group, even though judicious use is warranted post-TBI.

CONCLUSIONS

Further exploration of differences and risks associated with pharmacotherapy for anxiety and PTSD post-TBI is warranted to refine treatment guidelines. The low level of psychotherapy engagement suggests that barriers and facilitators to psychotherapy utilization post-TBI should be examined in future studies.

The Use of Atypical Antipsychotics for Managing Agitation After Traumatic Brain Injury

OBJECTIVE

This study examined the use of antipsychotics for managing agitation during posttraumatic amnesia (PTA) after traumatic brain injury (TBI) and its relationship with agitated behavior.

DESIGN

Observational prospective study with correlational design.

SETTING

Inpatient rehabilitation hospital for TBI.

PARTICIPANTS

A total of 125 consecutive admissions who were in PTA and had moderate-severe TBI.

MEASURES

Antipsychotic use was compared with agitation levels as measured by the total scores on the Agitated Behavior Scale (ABS).

RESULTS

Atypical antipsychotics were used in one-third of participants to manage agitation. Antipsychotic use was more common in participants with high levels of global agitation; however, there were many on antipsychotics who had mild or even no agitation according to the ABS. Uncontrolled observational data found no reduction in agitation after antipsychotic commencement or dose increase.

CONCLUSIONS

Antipsychotics are commonly used to manage agitation after TBI despite limited evidence of efficacy. Agitation should be formally monitored in PTA to ensure antipsychotics are used to manage more severe agitation and for evaluating treatment response. Research is needed to understand why prescribers are using antipsychotics when agitation is mild or below clinical thresholds.

Oxcarbazepine for Behavioral Disorders after Brain Injury: Factors Influencing Efficacy

Carbamazepine and oxcarbazepine are used for behavioral disorders following organic diseases. After severe acquired brain injury, patients may develop frontal symptoms. In our neurological rehabilitation routine, oxcarbazepine is used for better safety over carbamazepine, although its efficacy is not clarified. We aimed to improve knowledge on this use of oxcarbazepine, by probing clinical factors associated with response. We retrospectively examined the clinical records of our patients, collecting clinical variables and outcomes of efficacy, both clinician-rated and caregiver/self-rated. We described the distribution of clinical variables and examined their associations via logistic regressions. Patients in our cohort were predominantly pediatric, with frontal lobe damage and irritable/reactive. With an oxcarbazepine median dose of 975 mg, almost half of patients improved. We found several clinical factors associated with clinician-rated efficacy: absence of frontal damage and absence of irritability/reactivity symptoms; clinical factors associated with caregivers/patients-rated efficacy were: higher DRS score at baseline and higher patient age. In this retrospective study, we observed that oxcarbazepine was differentially efficacious in patients with specific characteristics. Our study could not examine drug therapy separately from neuropsychological therapy, nor the influence of dose. Our associative results should be verified experimentally, also assessing causality and establishing dose-related efficacy and safety.

Pharmacological Treatment of Agitation and/or Aggression in Patients With Traumatic Brain Injury: A Systematic Review of Reviews

OBJECTIVE

To systematically review the available literature on the pharmacological management of agitation and/or aggression in patients with traumatic brain injury (TBI), synthesize the available data, and provide guidelines.

DESIGN

Systematic review of systematic reviews.

MAIN MEASURES

A literature review of the following websites was performed looking for systematic reviews on the treatment of agitation and/or aggression among patients with TBI: PubMed, CINAHL, DynaMed, Health Business Elite, and EBSCO (Psychology and behavioral sciences collection). Two researchers independently assessed articles for meeting inclusion/exclusion criteria. Data were extracted on year of publication, reviewed databases, dates of coverage, search limitations, pharmacological agents of interest, and a list of all controlled studies included. The included controlled studies were then examined to determine potential reasons for any difference in recommendations.

RESULTS

The literature review led to 187 citations and 67 unique publications after removing the duplicates. Following review of the title/abstracts and full texts, a total of 11 systematic reviews were included. The systematic reviews evaluated the evidence for safety and efficacy of the following medications: amantadine, amphetamines, methylphenidate, antiepileptics, atypical and typical antipsychotics, benzodiazepines, β-blockers, and sertraline.

CONCLUSIONS

On the basis of the results of this literature review, the authors recommend avoiding benzodiazepines and haloperidol for treating agitation and/or aggression in the context of TBI. Atypical antipsychotics (olanzapine in particular) can be considered as practical alternatives for the as-needed management of agitation and/or aggression in lieu of benzodiazepines and haloperidol. Amantadine, β-blockers (propranolol and pindolol), antiepileptics, and methylphenidate can be considered for scheduled treatment of agitation and/or aggression in patients with TBI.

Effectiveness of pharmacotherapy for depression after traumatic brain injury in adults: an umbrella review protocol

OBJECTIVE

The objective of this review is to synthesize systematic reviews of the effectiveness of pharmacotherapy vs any other comparator for the management of post-traumatic brain injury depression in adults.

INTRODUCTION

Depression following a traumatic brain injury can have a considerable impact on the life of the individual, their family members, and the health care system. There have been several recent systematic reviews and meta-analyses on pharmacologic treatment for depression caused by post-traumatic brain injury. These reviews differ in conduct, quality, and reporting, and have discordant results and conclusions. Therefore, an umbrella review can provide prescribers with a summary of the evidence.

INCLUSION CRITERIA

This review will consider systematic reviews of studies of adults 16 years or older who have sustained a traumatic brain injury of any severity at any time in the past, who are receiving pharmacotherapy for depression of any severity in any health care setting. Studies that include the following outcomes will be considered: change in symptoms of depression and occurrence of harms.

METHODS

MEDLINE, Embase, CINAHL, PsycINFO, Cochrane Database of Systematic Reviews, Epistemonikos, and PROSPERO will be searched, as well as Google Scholar, ResearchGate, TRIP Medical Database, and hand searching journals. There will be no restriction on publication date. Only systematic reviews published in English will be considered. Screening of articles, assessment of methodological quality, and data extraction will be performed independently by two reviewers. A Grading of Recommendations, Assessment, Development and Evaluation Summary of Findings will be presented. Data will be summarized in narrative form with supporting tables.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020184915.

Psychotropic and pain medication use in individuals with traumatic brain injury-a Swedish total population cohort study of 240 000 persons

OBJECTIVE

To examine psychotropic and pain medication use in a population-based cohort of individuals with traumatic brain injury (TBI), and compare them with controls from similar backgrounds.

METHODS

We assessed Swedish nationwide registers to include all individuals diagnosed with incident TBI between 2006 and 2012 in hospitals or specialist outpatient care. Full siblings never diagnosed with TBI acted as controls. We examined dispensed prescriptions for psychotropic and pain medications for the 12 months before and after the TBI.

RESULTS

We identified 239 425 individuals with incident TBI, and 199 658 unaffected sibling controls. In the TBI cohort, 36.6% had collected at least one prescription for a psychotropic or pain medication in the 12 months before the TBI. In the 12 months after, medication use increased to 45.0%, an absolute rate increase of 8.4% (p<0.001). The largest post-TBI increases were found for opioids (from 16.3% to 21.6%, p<0.001), and non-opioid pain medications (from 20.3% to 26.6%, p<0.001). The majority of prescriptions were short-term; 20.6% of those prescribed opioids and 37.3% of those with benzodiazepines collected prescriptions for more than 6 months. Increased odds of any psychotropic or pain medication were associated with individuals before (OR: 1.62, 95% CI: 1.59 to 1.65), and after the TBI (OR: 2.30, 95% CI: 2.26 to 2.34) as compared with sibling controls, and ORs were consistently increased for all medication classes.

CONCLUSION

High rates of psychotropic and pain medications after a TBI suggest that medical follow-up should be routine and review medication use.

[Mental disorders after acquired CNS damage]

Mental disorders are a frequent consequence of acquired central nervous damage. If not recognized and treated early, they have a negative impact on the course of neurological rehabilitation. This article deals with the diagnosis and treatment of mental disorders after acquired damage to the central nervous system.

A Role for the Amygdala in Impairments of Affective Behaviors Following Mild Traumatic Brain Injury

Mild traumatic brain injury (TBI) results in chronic affective disorders such as depression, anxiety, and fear that persist up to years following injury and significantly impair the quality of life for patients. Although a great deal of research has contributed to defining symptoms of mild TBI, there are no adequate drug therapies for brain-injured individuals. Preclinical studies have modeled these deficits in affective behaviors post-injury to understand the underlying mechanisms with a view to developing appropriate treatment strategies. These studies have also unveiled sex differences that contribute to the varying phenotypes associated with each behavior. Although clinical and preclinical studies have viewed these behavioral deficits as separate entities with unique neurobiological mechanisms, mechanistic similarities suggest that a novel approach is needed to advance research on drug therapy. This review will discuss the circuitry involved in the expression of deficits in affective behaviors following mild TBI in humans and animals and provide evidence that the manifestation of impairment in these behaviors stems from an amygdala-dependent emotional processing deficit. It will highlight mechanistic similarities between these different types of affective behaviors that can potentially advance mild TBI drug therapy by investigating treatments for the deficits in affective behaviors as one entity, requiring the same treatment.

When Mind Meets the Brain: Essentials of Well-Coordinated Management of Psychiatric Disorders in Neurological Diseases

BACKGROUND

The management of psychiatric disorders in neurological diseases (PDND) creates special challenges that cannot be adequately addressed by either psychiatry or neurology alone. However, the literature on clinician-friendly recommendations on how to coordinate neurological and psychiatric care is limited.

OBJECTIVE

This narrative review will provide practical instructions on how to efficiently integrate psychiatric and neurological care in inpatient management of PDND.

METHODS

We reviewed articles published as recently as January, 2021 in five electronic databases. We included articles that assessed human care, focused on adults, and examined how to better coordinate care between different medical specialties, particularly, between psychiatry and neurology.

RESULTS

Eighty-four manuscripts were included in this review, of which 23 (27%) discussed general principles of well-coordinated care of PDND in inpatient settings (first part of this review), and 61 (73%) were used to provide recommendations in specific neurological diseases (second part of this review).

CONCLUSIONS

General principles of well-coordinated care of PDND include recommendations for both the primary team (usually neurology) and the consulting team (psychiatry). Primary teams should delineate a specific question, establish roles, and follow up on the recommendations of the consulting team. Consultants should do their independent assessment, be organized and specific in their recommendations, and anticipate potential problems. One of the most important aspect to develop well-coordinated care is the establishment of clear, frank and, preferably oral, communication between the teams. Practical difficulties in the management of PDND include pharmacodynamic and pharmacokinetic interactions as well as mutual dependency between psychiatry and neurology.

Amantadine: reappraisal of the timeless diamond-target updates and novel therapeutic potentials

The aim of the current review was to provide a new, in-depth insight into possible pharmacological targets of amantadine to pave the way to extending its therapeutic use to further indications beyond Parkinson's disease symptoms and viral infections. Considering amantadine's affinities in vitro and the expected concentration at targets at therapeutic doses in humans, the following primary targets seem to be most plausible: aromatic amino acids decarboxylase, glial-cell derived neurotrophic factor, sigma-1 receptors, phosphodiesterases, and nicotinic receptors. Further three targets could play a role to a lesser extent: NMDA receptors, 5-HT3 receptors, and potassium channels. Based on published clinical studies, traumatic brain injury, fatigue [e.g., in multiple sclerosis (MS)], and chorea in Huntington's disease should be regarded potential, encouraging indications. Preclinical investigations suggest amantadine's therapeutic potential in several further indications such as: depression, recovery after spinal cord injury, neuroprotection in MS, and cutaneous pain. Query in the database http://www.clinicaltrials.gov reveals research interest in several further indications: cancer, autism, cocaine abuse, MS, diabetes, attention deficit-hyperactivity disorder, obesity, and schizophrenia.

A narrative review of pharmacologic approaches to symptom management of pediatric patients diagnosed with anti-NMDA receptor encephalitis

Anti-N-Methyl-D-Aspartate Receptor Encephalitis (ANMDARE) is one of the most common autoimmune encephalitis in the pediatric population. Patients with ANMDARE initially present with a prodrome of neuropsychiatric symptoms followed by progressively worsening seizures, agitation, and movement disorders. Complications can include problems such as aggression, insomnia, catatonia, and autonomic instability. Due to the complexity of this disease process, symptom management can be complex and may lead to significant polypharmacy. The goal of this review is to educate clinicians about the challenges of managing this disorder and providing guidance in symptom management.

Drug Use in Pediatric Patients Admitted to Rehabilitation For Severe Acquired Brain Injury: Analysis of the Associations With Rehabilitation Outcomes

INTRODUCTION

Patients with severe acquired brain injuries require drug therapies in intensive care for life support and injury treatment. Patients who then access rehabilitation usually maintain their drug treatments long term, with a potential influence on the rehabilitation course. Whereas drug effects have been reported for specific drugs and clinical issues in adults, comprehensive data on pediatric patients with traumatic and non-traumatic injuries are scant.

OBJECTIVES

The aims of this study were to describe the therapeutic classes and groups of drugs prescribed to pediatric inpatients recovering from severe acquired brain injury when they enter rehabilitation; to assess whether clinical variables may determine the use of drug classes; and to assess whether the use of drug classes may be associated with differences in rehabilitation outcomes.

METHODS

We carried out a retrospective chart review, following a previous study on the clinical-epidemiological characteristics of our patients. We collected information on drug therapies present at admittance to rehabilitation and analyzed their distribution according to therapeutic classes and groups. We verified the associations of drug groups with clinical variables (putatively antecedents to drug use) and with rehabilitation outcomes (putatively resultant of drug use and of clinical variables) in regression models. The clinical variables considered were injury etiology, Glasgow Outcome Score (GOS) at admittance to rehabilitation, sex, age at injury, plus two aggregate factors resulting from the previous work, 'neurological dysfunction' regarding the use of devices and 'injury severity' regarding the neurological status. The rehabilitation outcomes used were death after rehabilitation, persistence of a vegetative/minimally conscious state, coma duration, duration of the rehabilitation stay, rehabilitation efficiency (GOS at discharge minus GOS at admittance, divided by the length of rehabilitation stay).

RESULTS

We described the distribution of drug classes and groups among pediatric patients with severe acquired brain injuries. Regarding the associations between drug classes and clinical variables, we found greater use of cardiovascular agents with higher patient age, 'neurological dysfunction' score, and with an etiology of hypoxic brain injury. The use of antithrombotic agents was greater with higher patient age and 'neurological dysfunction' score. Glucocorticoid use was greater with higher GOS at admittance and with several etiologies: brain tumor, infective encephalitis, and autoimmune encephalitis. Regarding drug classes and rehabilitation outcomes, we found that the use of cardiovascular drugs was associated with increased occurrence of death after rehabilitation. The use of antispastic drugs was associated with a more frequent permanence in vegetative/minimally conscious states. The use of antispastic drugs and melatonin was associated with longer coma duration. The use of glucocorticoid drugs was associated with decreased rehabilitation efficiency.

CONCLUSIONS

We provided a description of drug use in pediatric rehabilitation after severe acquired brain injuries, which was lacking in the literature. Prospective studies should verify our associative observations regarding clinical variables, drugs use, and outcomes, to assess causality.

Challenges of Delirium Management in Patients with Traumatic Brain Injury: From Pathophysiology to Clinical Practice

Traumatic brain injury (TBI) can initiate a very complex disease of the central nervous system (CNS), starting with the primary pathology of the inciting trauma and subsequent inflammatory and CNS tissue response. Delirium has long been regarded as an almost inevitable consequence of moderate to severe TBI, but more recently has been recognized as an organ dysfunction syndrome with potentially mitigating interventions. The diagnosis of delirium is independently associated with prolonged hospitalization, increased mortality and worse cognitive outcome across critically ill populations. Investigation of the unique problems and management challenges of TBI patients is needed to reduce the burden of delirium in this population. In this narrative review, possible etiologic mechanisms behind post-traumatic delirium are discussed, including primary injury to structures mediating arousal and attention and secondary injury due to progressive inflammatory destruction of the brain parenchyma. Other potential etiologic contributors include dysregulation of neurotransmission due to intravenous sedatives, seizures, organ failure, sleep cycle disruption or other delirium risk factors. Delirium screening can be accomplished in TBI patients and the presence of delirium portends worse outcomes. There is evidence that multi-component care bundles including an analgesia-prioritized sedation algorithm, regular spontaneous awakening and breathing trials, protocolized delirium assessment, early mobility and family engagement can reduce the burden of ICU delirium. The aim of this review is to summarize the approach to delirium in TBI patients with an emphasis on pathogenesis and management. Emerging CNS-active drug therapies that show promise in preclinical studies are highlighted.

Traumatic brain injury and mood disorders

Traumatic brain injury is an increasing cause of morbidity worldwide. Neuropsychiatric impairments, such as behavioral dysregulation and depression, have significant impacts on recovery, functional outcomes, and quality of life of patients with traumatic brain injuries. Three patient cases, existing literature, and expert opinion are used to select pharmacotherapy for the treatment of target symptoms while balancing safety and tolerability.

Efficacy and Harms of Pharmacological Interventions for Anxiety after Traumatic Brain Injury: Systematic Review

After a traumatic brain injury (TBI), many persons experience significant and debilitating problems with anxiety. The aim of this systematic review was to critically evaluate the evidence regarding efficacy of pharmacological interventions for anxiety after TBI. We reviewed studies published in English before July 2020 and included original research on pharmacological interventions for anxiety after TBI in adults ≥16 years of age. MEDLINE, PubMed, CINAHL, EMBASE, PsycINFO, and CENTRAL databases were searched, with additional searching of key journals, clinical trials registries, and international drug regulators. The primary outcomes of interest were reduction in symptoms of anxiety and occurrence of harms. The secondary outcomes of interest were changes in depression, cognition, quality of life, and participation. Data were summarized in a narrative synthesis, and evidence quality was assessed using the Cochrane Risk of Bias tool. Only a single non-peer-reviewed, randomized controlled trial of 19 male military service members with mild TBI met inclusion criteria. This study found no significant effect of citalopram on anxiety symptoms over a 12-week intervention. The trial was stopped early because of poor recruitment, and much of the study detail was not included in the report. The methodological quality of the study was difficult to assess because of the lack of detail. No recommendations could be drawn from this review. There is a critical need for adequately powered and controlled studies of pharmacological interventions for anxiety after TBI across all severities that examine side-effect profiles and consider issues of comorbidity and effects of long-term pharmacotherapy.

Nutritional interventions to improve neurophysiological impairments following traumatic brain injury: A systematic review

Traumatic brain injury (TBI) accounts for significant global health burden. Effects of TBI can become chronic even following mild injury. There is a need to develop effective therapies to attenuate the damaging effects of TBI and improve recovery outcomes. This literature review using a priori criteria (PROSPERO; CRD42018100623) summarized 43 studies between January 1998 and July 2019 that investigated nutritional interventions (NUT) delivered with the objective of altering neurophysiological (NP) outcomes following TBI. Risk of bias was assessed for included studies, and NP outcomes recorded. The systematic search resulted in 43 of 3,748 identified studies met inclusion criteria. No studies evaluated the effect of a NUT on NP outcomes of TBI in humans. Biomarkers of morphological changes and apoptosis, oxidative stress, and plasticity, neurogenesis, and neurotransmission were the most evaluated NP outcomes across the 43 studies that used 2,897 animals. The risk of bias was unclear in all reviewed studies due to poorly detailed methodology sections. Taking these limitations into account, anti-oxidants, branched chain amino acids, and ω-3 polyunsaturated fatty acids have shown the most promising pre-clinical results for altering NP outcomes following TBI. Refinement of pre-clinical methodologies used to evaluate effects of interventions on secondary damage of TBI would improve the likelihood of translation to clinical populations.

A Cross-Sectional Study of Treatments for Behavioral Disorders Following Traumatic Brain Injury: Comparison With French Recommendations

OBJECTIVE

To give a cross-sectional overview of ongoing management of behavioral disorders following traumatic brain injury (TBI) in a region of France, to compare this with recent recommendations from the French Society of Physical Medicine and Rehabilitation (SOFMER), and to evaluate associations between treatments and participant characteristics.

SETTING

Outpatients referred to medical or community-based facilities in a region of France.

PARTICIPANTS

One hundred twenty-nine adults with moderate to severe TBI, in the postacute period (over 3 months postinjury).

DESIGN

Cross-sectional cohort study.

MAIN MEASURES

Sociodemographic data, ongoing interventions including psychotherapy and medication, behavioral disorders assessed by the Behavioral Dysexecutive Syndrome Inventory (BDSI).

RESULTS

Thirty-three percent of participants received ongoing psychotherapy and 43% were on medication. The most prescribed medications were antidepressants (21%), neuroleptics (18%), anxiolytics (16%), and mood stabilizers (14%). Eighty-five participants (71%) presented a current Behavioral Dysexecutive Syndrome (BDS) according to the BDSI. These participants more frequently received treatment (P = .004), psychotherapy (P = .048), medications (often 2 or more) (P = .007), and particularly antiepileptic mood stabilizers (P = .037) compared with those without BDS.

CONCLUSION

Although recommended as first-line treatment, few participants with BDS received psychotherapy. Medications were overused, especially neuroleptics in view of their potential adverse effects. In contrast, recommended medications, such as mood stabilizers and β-blockers, did not appear to be highly prescribed whatever the evolution. Compliance with recommendations seemed insufficient.

Clinical Approach to Personality Change Due to Another Medical Condition

BACKGROUND

Medical personality change (MPC) is a codable diagnosis (i.e., F07.0) that deserves consideration when a patient is inexplicably no longer "acting like him/herself." Its presentation ranges from subtle to severe and is often characterized by bafflingly poor judgment and impairment in several aspects of a person's life. Despite the global impact that MPC can have on a patient's functioning, occupation, and relationships, this condition receives far less clinical consideration than better known syndromes such as depression or anxiety and is often likely incorrectly formulated as such.

OBJECTIVE/METHODS

This article provides a clinically focused review of MPC. We review its clinical assessment followed by a review of its subtypes, which we have categorized to reflect the behavioral correlates of known frontotemporal-subcortical circuits. These include the apathetic type (ventromedial prefrontal cortex), the labile and disinhibited types (orbitofrontal cortex), and the aggressive and paranoid types (medial temporal lobes).

RESULTS

For each of these 3 categories, we describe the clinical presentation and review management strategies. For each category, we focus on 3 common causes for MPC-traumatic brain injury, Huntington disease, and brain tumors-which we have selected because clinical features of MPC due to these conditions generalize to many other etiologies of MPC.

CONCLUSIONS

MPC warrants clinical attention for the range of dysfunction and distress it can cause. It also deserves further scientific study to better characterize its phenotypes, to tailor instruments for its clinical assessment, and to identify effective treatments.

Use of CGRP receptor blocker erenumab in the management of post-traumatic headache: a case series of 5 women

CONTEXT

Post-traumatic headache (PTH) is a disabling headache disorder and the most common sequela of mild traumatic brain injury. The pathophysiology of PTH is poorly understood and there is limited available evidence to guide prophylactic medication selection. Emerging understanding of the pathophysiology of migraine headaches has led to the development of monoclonal antibodies, including erenumab. Erenumab has shown promise for the prevention of primary migraine headache; however, it has not yet been studied in PTH.

CASE SERIES

five women (average age 43.0 ± 17.9y) received treatment with erenumab for PTH secondary to mTBI. The average duration of PTH prior to starting erenumab was 32.0 ± 18.2 months. All patients were taking at least one daily headache prophylactic therapy prior to erenumab. The average pre-erenumab headache intensity was 86/100. On erenumab, the average reported reduction in headache intensity was 51.1%. After starting erenumab, all five patients were able to discontinue one or more medication(s). The most common side effect was constipation (three patients). There were no serious adverse events after an average follow-up of 3.4 ± 1.5 months. One patient discontinued erenumab during this period of follow-up after the resolution of her headaches.

CONCLUSION

Erenumab appears to be safe and effective for the management of PTH.

Irritability Disorders in Adults: Diagnostic Categories Missing in Plain Sight?

Research into irritability has focused largely on its developmental and child-adolescent manifestations. Although irritability appears to be as elemental an experience as anxiety or depression, diagnoses highlighting irritability as the focal ingredient have yet to be delineated for adults. Instead, irritability-related diagnoses in adults have largely emphasized externalizing behaviors, depressed mood, and personality. Consequently, patients complaining of irritability are sometimes shoehorned into diagnostic categories that they do not experience as authentic representations of their lived experiences. This article proposes that the symptom of irritability might be productively reenvisioned as a focal point, analogous to anxiety and depression, around which irritability-related syndromes and disorders in adults might coalesce. If anxiety, depressive, insomnia, and pain disorders, why not irritability disorders? Both state and trait characteristics of irritability can lend themselves to DSM diagnostic frames. Based on clinical observations, specific irritability disorders in adults can be envisioned, modeled as Irritability Disorder of Adulthood, Irritability Disorder Secondary to Another Medical Condition, Substance-Induced Irritability Disorder, Adjustment Disorder With Irritable Mood, and the like. Further delineation of irritability phenomena, syndromes, and possible disorders in adults is warranted to advance investigation, guide assessment, and improve treatment.

Evidence for the management of challenging behaviours in patients with acute traumatic brain injury or post-traumatic amnesia: An Umbrella Review

Objective:

To synthesise the current best evidence on both pharmacological and non-pharmacological behaviour management interventions for adult patients in the acute hospital setting with traumatic brain injury (TBI) or post-traumatic amnesia (PTA).

Data Sources:

A comprehensive search of 10 electronic databases was completed.

Study Selection:

Systematic reviews (SRs) published in English before September 2018 were included. Initial search resulted in 4604 citations, 2916 for title and abstract screening with duplicates removed, and 2909 articles failed to meet the inclusion criteria leaving seven reviews for inclusion. Five reporting pharmacological management approaches, two reporting non-pharmacological management approaches, and one reporting both pharmacological and non-pharmacological management approaches.

Data Extraction:

Methodological quality was assessed independently by two reviewers using the Critical Appraisal Skills Programme Tool for SRs. Data were extracted from the studies based on the recommendations of the Joanna Briggs Institute (JBI) Methodology for JBI Umbrella Reviews.

Data Synthesis:

The SRs were of low-to-moderate quality overall. High-quality SRs were characterised by low numbers of studies and significant biases. The evidence relating to pharmacological interventions demonstrates low level and variable quality. The evidence relating to non-pharmacological interventions was limited and of low quality.

Conclusions:

The current evidence for the management of challenging behaviours in patients with acute TBI/PTA is generally equivocal, potentially reflecting the heterogeneity of patients with TBI and their clinical behaviours. More studies with rigorous methodologies are required to investigate the most suitable pharmacological and non-pharmacological behavioural interventions for the acute phase of TBI or PTA.

An Update on the Complexity and Importance of Accurately Diagnosing Post-Traumatic Stress Disorder and Comorbid Traumatic Brain Injury

As awareness for diagnosing and screening patients for trauma has grown, more effective evidence-based treatments are available to treat post-traumatic stress disorder (PTSD). Despite these gains, several patients are non-responsive to care and research has shifted to determining barriers for cure or improvement. With the advent of modern warfare, the combination of intermittent explosive devices and more robust armor has resulted in service members surviving blasts that historically would have been lethal, resulting in a rise in traumatic brain injuries (TBIs). Post-traumatic stress disorder and TBI are often comorbid and can serve as the aforementioned barriers for cure or improvement for each other if one goes unrecognized. This mini-review will discuss the importance of diagnosing both entities, especially when they are comorbid, by examining how misdiagnosis may interfere with treatment outcomes. Several recent advances in methods to successfully distinguish between the two disorders will be reviewed.

Associations and Outcomes Between Chronic Traumatic Encephalopathy and Vasculitis in Adult Patients

Chronic traumatic encephalopathy (CTE) results from brain injuries and traumas due to accelerated impacts on the head. In severe cases, the diseases cause brain damage, given the head trauma. On the other hand, vasculitis occurs through antibodies that mistake protein vessels as foreign, hence fighting them and resulting in their damage. Examination is usually conducted through blood tests, with antibodies being identified in the antineutrophil cytoplasm. It is unfortunate that its devastating effects also affect the brain of a human, hence leading to dis-functioning. When vasculitis is left untreated, it results in multiple adverse effects on the human body and health both in the short term and in the long term. This study aims to bring to the awareness of neurosurgeons the associations between CTE and vasculitis. This study has proved that there is a close correlation between the progression of CTE and vasculitis. The inflammatory of the blood vessels, as witnessed in vasculitis, increases the risk factors for CTE. The scaling of the vessels and manifestation of different vasculitis conditions in active central nervous system cells results in the worsening of neurodegeneration of the CTE disease.

Pharmacotherapy for the Pseudobulbar Affect in Individuals Who Have Sustained a Traumatic Brain Injury: a Systematic Review

Pseudobulbar affect is a debilitating condition that significantly reduces quality of life for many individuals following traumatic brain injury (TBI). It is characterized by embarrassing and often uncontrollable episodes of crying or laughter. The aim of this systematic review was to evaluate the effectiveness of pharmacotherapy as compared to all other comparators for the management of pseudobulbar affect in adults who have sustained TBI. Six databases were searched, with additional hand searching of journals, clinical trials registries and international drug regulators to identify published and unpublished studies in English up to June 2018. Studies were eligible for this review if they included adults who had sustained a medically confirmed TBI and presented with pseudobulbar affect. All pharmacotherapy and comparator interventions were considered for inclusion, and study design was not limited to randomised controlled trials. Evidence quality was assessed using Joanna Briggs Institute Critical Appraisal Instruments. Two quasi-experimental studies examining the effectiveness of dextrometamorphan/quinidine (DM/Q) were identified. These studies reported that DM/Q was effective in reducing symptoms of pseudobulbar affect and had a positive safety profile, over follow-up periods of 3 months (n = 87) and 12 months (n = 23). However, both studies were limited by lack of a control group and a high dropout rate. The findings of twelve case reports examining the effectiveness of DM/Q (n = 6) and anti-depressants (n = 6) are also discussed. Further research is required to determine which pharmacological interventions provide the best outcomes for individuals with pseudobulbar affect following TBI, with consideration given to side effect profiles and financial costs.

The Efficacy and Harms of Pharmacological Interventions for Aggression After Traumatic Brain Injury-Systematic Review

Background: Aggression is a commonly reported problem following traumatic brain injury (TBI). It may present as verbal insults or outbursts, physical assaults, and/or property destruction. Aggressive behavior can fracture relationships and impede participation in treatment as well as a broad range of vocational and social activities, thereby reducing the individual's quality of life. Pharmacological intervention is frequently used to control aggression following TBI. The aim of this systematic review was to critically evaluate the evidence regarding efficacy of pharmacological interventions for aggression following TBI in adults.

Methods: We reviewed studies in English, available before December 2018. MEDLINE, PubMed, CINAHL, EMBASE, PsycINFO, and CENTRAL databases were searched, with additional searching of key journals, clinical trials registries, and international drug regulators. The primary outcomes of interest were reduction in the severity of aggression and occurrence of harms. The secondary outcomes of interest were changes in quality of life, participation, psychological health (e.g., depression, anxiety), and cognitive function. Evidence quality was assessed using the Cochrane Risk of Bias tool and the Joanna Briggs Institute Critical Appraisal Instruments.

Results: Ten studies were identified, including five randomized controlled trials (RCTs) and five case series. There were positive, albeit mixed, findings for the RCTs examining the use of amantadine in reducing irritability (n = 2) and aggression (n = 2). There were some positive findings favoring methylphenidate in reducing anger (n = 1). The evidence for propranolol was weak (n = 1). Individual analysis revealed differential drug response across individuals for both methylphenidate and propranolol. The less rigorous studies administered carbamazepine (n = 2), valproic acid (n = 1), quetiapine (n = 1), and sertraline (n = 1), and all reported reductions in aggression. However, given the lack of a control group, it is difficult to discern treatment effects from natural change over time.

Conclusions: This review concludes that a recommendation for use of amantadine to treat aggression and irritability in adults following TBI is appropriate. However, there is a need for further well-designed, adequately powered and controlled studies of pharmacological interventions for aggression following TBI.

The Impact of Introducing a Physical Medicine and Rehabilitation Trauma Consultation Service to an Academic Level 1 Trauma Center

OBJECTIVE

Previous retrospective studies suggest that early physical medicine and rehabilitation (PM&R) consultation for trauma patients improves outcome and reduces acute care length of stay (LOS). There have not been controlled studies to evaluate this impact. This study assesses the impact of PM&R consultations on acute trauma patients.

DESIGN

This study compared measured outcomes before and after the introduction of a PM&R consultation service to the trauma program at a large academic hospital. The primary outcome measure was acute care LOS.

RESULTS

The 274 historical controls and 76 patients who received a PM&R consultation were not different in injury severity score, age, or sex. Length of stay was not different between the two groups. However, when early (≤8 days after injury) versus late (>8 days) consults were compared, the early group had a markedly lower LOS (12 vs. 30 days, P < 0.001). When adjusted for injury severity score, an early consult was associated with an 11.8-day lower LOS (P < 0.001). The early consult group also had fewer complications and less usage of benzodiazepines and antipsychotics.

CONCLUSIONS

An acute care PM&R consultation of 8 days or less after admission is associated with a shorter acute care LOS, fewer complications, and less use of benzodiazepines and antipsychotics.

Traumatic Brain Injury Temporal Proteome Guides KCC2-Targeted Therapy

Advancing therapeutics for traumatic brain injury (TBI) remains a challenge, necessitating testable targets with interventions appropriately timed to intercede on evolving secondary insults. Neuroproteomics provides a global molecular approach to deduce the complex post-translational processes that underlie secondary events after TBI. Yet method advancement has outpaced approaches to interrogate neuroproteomic complexity, in particular when addressing the well-recognized temporal evolution of TBI pathobiology. Presented is a detailed account of the temporal neuroproteomic response to mild-moderate rat controlled cortical impact within perilesioned somatosensory neocortex across the first two weeks after injury. Further, this investigation assessed use of artificial neural network and functional enrichment analyses to discretize the temporal response across some 2047 significantly impacted proteins. Results were efficiently narrowed onto ion transporters with phenotypic relevance to abnormal GABAergic transmission and a delayed decline amenable to intervention under managed care conditions. The prototypical target potassium/chloride co-transporter 2 (KCC2 or SLC12A5) was investigated further with the KCC2-selective modulator CLP290. Guided by post-translational processing revealed one-day after insult to precede KCC2 protein loss a day after, CLP290 was highly effective at restoring up to 70% of lost KCC2 localization, which was significantly correlated with recovery of sham-level function in assessed somatosensory behavioral tasks. The timing of administration was important, with no significant improvement observed if given earlier, one-hour after insult, or later when KCC2 protein decline begins. Results portend importance for a detailed post-translational characterization when devising TBI treatments, and support the therapeutic promise of KCC2-targeted CLP290 intervention for positive functional recovery after brain injury.

The Influence of the Val66Met Polymorphism of Brain-Derived Neurotrophic Factor on Neurological Function after Traumatic Brain Injury

Functional outcomes after traumatic brain injury (TBI) vary widely across patients with apparently similar injuries. This variability hinders prognosis, therapy, and clinical innovation. Recently, single nucleotide polymorphism (SNPs) that influence outcome after TBI have been identified. These discoveries create opportunities to personalize therapy and stratify clinical trials. Both of these changes would propel clinical innovation in the field. This review focuses on one of most well-characterized of these SNPs, the Val66Met SNP in the brain-derived neurotrophic factor (BDNF) gene. This SNP influences neurological function in healthy subjects as well as TBI patients and patients with similar acute insults to the central nervous system. A host of other patient-specific factors including ethnicity, age, gender, injury severity, and post-injury time point modulate this influence. These interactions confound efforts to define a simple relationship between this SNP and TBI outcomes. The opportunities and challenges associated with personalizing TBI therapy around this SNP and other similar SNPs are discussed in light of these results.

Pharmacological interventions for agitated behaviours in patients with traumatic brain injury: a systematic review

OBJECTIVE

The aim of this systematic review was to assess the efficacy and safety of pharmacological agents in the management of agitated behaviours following traumatic brain injury (TBI).

METHODS

We performed a search strategy in PubMed, OvidMEDLINE, Embase, CINAHL, PsycINFO, Cochrane Library, Google Scholar, Directory of Open Access Journals, LILACS, Web of Science and Prospero (up to 10 December 2018) for published and unpublished evidence on the risks and benefits of 9 prespecified medications classes used to control agitated behaviours following TBI. We included all randomised controlled trials, quasi-experimental and observational studies examining the effects of medications administered to control agitated behaviours in TBI patients. Included studies were classified into three mutually exclusive categories: (1) agitated behaviour was the presenting symptom; (2) agitated behaviour was not the presenting symptom, but was measured as an outcome variable; and (3) safety of pharmacological interventions administered to control agitated behaviours was measured.

RESULTS

Among the 181 articles assessed for eligibility, 21 studies were included. Of the studies suggesting possible benefits, propranolol reduced maximum intensities of agitation per week and physical restraint use, methylphenidate improved anger measures following 6 weeks of treatment, valproic acid reduced weekly agitated behaviour scale ratings and olanzapine reduced irritability, aggressiveness and insomnia between weeks 1 and 3 of treatment. Amantadine showed variable effects and may increase the risk of agitation in the critically ill. In three studies evaluating safety outcomes, antipsychotics were associated with an increased duration of post-traumatic amnesia (PTA) in unadjusted analyses. Small sample sizes, heterogeneity and an unclear risk of bias were limits.

CONCLUSIONS

Propranolol, methylphenidate, valproic acid and olanzapine may offer some benefit; however, they need to be further studied. Antipsychotics may increase the length of PTA. More studies on tailored interventions and continuous evaluation of safety and efficacy throughout acute, rehabilitation and outpatient settings are needed.

PROSPERO REGISTRATION NUMBER

CRD42016033140.