Methylphenidate treatment of attention-deficit/hyperactivity disorder secondary to traumatic brain injury: a critical appraisal of treatment studies

Methylphenidate Ameliorates Behavioural and Neurobiological Deficits in Executive Function for Patients with Chronic Traumatic Brain Injury

(1) Background: Traumatic brain injury (TBI) often results in cognitive impairments, including in visuospatial planning and executive function. Methylphenidate (MPh) demonstrates potential improvements in several cognitive domains in patients with TBI. The Tower of London (TOL) is a visuospatial planning task used to assess executive function. (2) Methods: Volunteers with a history of TBI (n = 16) participated in a randomised, double-blinded, placebo-controlled, fMRI study to investigate the neurobiological correlates of visuospatial planning and executive function, on and off MPh. (3) Results: Healthy controls (HCs) (n = 18) and patients on placebo (TBI-placebo) differed significantly in reaction time (p < 0.0005) and accuracy (p < 0.0001) when considering all task loads, but especially for high cognitive loads for reaction time (p < 0.001) and accuracy (p < 0.005). Across all task loads, TBI-MPh were more accurate than TBI-placebo (p < 0.05) but remained less accurate than HCs (p < 0.005). TBI-placebo substantially improved in accuracy with MPh administration (TBI-MPh) to a level statistically comparable to HCs at low (p = 0.443) and high (p = 0.175) cognitive loads. Further, individual patients that performed slower on placebo at low cognitive loads were faster with MPh (p < 0.05), while individual patients that performed less accurately on placebo were more accurate with MPh at both high and low cognitive loads (p < 0.005). TBI-placebo showed reduced activity in the bilateral inferior frontal gyri (IFG) and insulae versus HCs. MPh normalised these regional differences. MPh enhanced within-network connectivity (between parietal, striatal, insula, and cerebellar regions) and enhanced beyond-network connectivity (between parietal, thalamic, and cerebellar regions). Finally, individual changes in cerebellar-thalamic (p < 0.005) and cerebellar-parietal (p < 0.05) connectivity with MPh related to individual changes in accuracy with MPh. (4) Conclusions: This work highlights behavioural and neurofunctional differences between HCs and patients with chronic TBI, and that adverse differences may benefit from MPh treatment.

A Systematic Scoping Review of New Attention Problems Following Traumatic Brain Injury in Children

Objective: To summarize existing knowledge about the characteristics of attention problems secondary to traumatic brain injuries (TBI) of all severities in children. Methods: Computerized databases PubMed and PsychINFO and gray literature sources were used to identify relevant studies. Search terms were selected to identify original research examining new ADHD diagnosis or attention problems after TBI in children. Studies were included if they investigated any severity of TBI, assessed attention or ADHD after brain injury, investigated children as a primary or sub-analysis, and controlled for or excluded participants with preinjury ADHD or attention problems. Results: Thirty-nine studies were included in the review. Studies examined the prevalence of and risk factors for new attention problems and ADHD following TBI in children as well as behavioral and neuropsychological factors associated with these attention problems. Studies report a wide range of prevalence rates of new ADHD diagnosis or attention problems after TBI. Evidence indicates that more severe injury, injury in early childhood, or preinjury adaptive functioning problems, increases the risk for new ADHD and attention problems after TBI and both sexes appear to be equally vulnerable. Further, literature suggests that cases of new ADHD often co-occurs with neuropsychiatric impairment in other domains. Identified gaps in our understanding of new attention problems and ADHD include if mild TBI, the most common type of injury, increases risk and what brain abnormalities are associated with the emergence of these problems. Conclusion: This scoping review describes existing studies of new attention problems and ADHD following TBI in children and highlights important risk factors and comorbidities. Important future research directions are identified that will inform the extent of this outcome across TBI severities, its neural basis and points of intervention to minimize its impact.

Stimulant Therapy Utilization for Neurocognitive Deficits in Mild Traumatic Brain Injury

CONTEXT

There are 3.8 million mild traumatic brain injuries (mTBIs) that occur each year in the United States. Many are left with prolonged life-altering neurocognitive deficits, including difficulties in attention, concentration, mental fatigue, and distractibility. With extensive data on the safety and efficacy of stimulant medications in treating attention deficit, concentration difficulties and distractibility seen with attention deficit disorder, it is not surprising that interest continues regarding the application of stimulant medications for the persistent neurocognitive deficits in some mTBIs.

EVIDENCE ACQUISITION

Studies were extracted from PubMed based on the topics of neurocognitive impairment, mTBI, stimulant use in mTBI, stimulants, and the association between attention deficit/hyperactivity disorder and mTBI. The search criteria included a date range of 1999 to 2020 in the English language.

STUDY DESIGN

Literature review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Currently, there is very limited literature, and no guidelines for evaluating the use of stimulant medication for the treatment of prolonged neurocognitive impairments due to mTBI. However, a limited number of studies have demonstrated efficacy and safety of stimulants in the treatment of neurocognitive sequelae of mTBI in the adult, pediatric, military, and athletic populations.

CONCLUSION

There is limited evidence to suggest stimulant medication may be beneficial in patients with mTBI with persistent neurocognitive symtpoms. The decision to utilize stimulant medication for mTBI patients remains physician and patient preference dependent. Given the limited encouraging data currently available, physicians may consider stimulant medication in appropriate patients to facilitate the recovery of prolonged neurocognitive deficits, while remaining cognizant of potential adverse effects.

Neurotransmitter changes after traumatic brain injury: an update for new treatment strategies

Traumatic brain injury (TBI) is a pervasive problem in the United States and worldwide, as the number of diagnosed individuals is increasing yearly and there are no efficacious therapeutic interventions. A large number of patients suffer with cognitive disabilities and psychiatric conditions after TBI, especially anxiety and depression. The constellation of post-injury cognitive and behavioral symptoms suggest permanent effects of injury on neurotransmission. Guided in part by preclinical studies, clinical trials have focused on high-yield pathophysiologic mechanisms, including protein aggregation, inflammation, metabolic disruption, cell generation, physiology, and alterations in neurotransmitter signaling. Despite successful treatment of experimental TBI in animal models, clinical studies based on these findings have failed to translate to humans. The current international effort to reshape TBI research is focusing on redefining the taxonomy and characterization of TBI. In addition, as the next round of clinical trials is pending, there is a pressing need to consider what the field has learned over the past two decades of research, and how we can best capitalize on this knowledge to inform the hypotheses for future innovations. Thus, it is critically important to extend our understanding of the pathophysiology of TBI, particularly to mechanisms that are associated with recovery versus development of chronic symptoms. In this review, we focus on the pathology of neurotransmission after TBI, reflecting on what has been learned from both the preclinical and clinical studies, and we discuss new directions and opportunities for future work.

Polygenic Risk and Neural Substrates of Attention-Deficit/Hyperactivity Disorder Symptoms in Youths With a History of Mild Traumatic Brain Injury

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a major sequela of traumatic brain injury (TBI) in youths. The objective of this study was to examine whether ADHD symptoms are differentially associated with genetic risk and brain structure in youths with and without a history of TBI.

METHODS

Medical history, ADHD symptoms, genetic data, and neuroimaging data were obtained from a community sample of youths. ADHD symptom severity was compared between those with and without TBI (TBI n = 418, no TBI n = 3193). The relationship of TBI history, genetic vulnerability, brain structure, and ADHD symptoms was examined by assessing 1) ADHD polygenic score (discovery sample ADHD n = 19,099, control sample n = 34,194), 2) basal ganglia volumes, and 3) fractional anisotropy in the corpus callosum and corona radiata.

RESULTS

Youths with TBI reported greater ADHD symptom severity compared with those without TBI. Polygenic score was positively associated with ADHD symptoms in youths without TBI but not in youths with TBI. The negative association between the caudate volume and ADHD symptoms was not moderated by a history of TBI. However, the relationship between ADHD symptoms and structure of the genu of the corpus callosum was negative in youths with TBI and positive in youths without TBI.

CONCLUSIONS

The identification of distinct ADHD etiology in youths with TBI provides neurobiological insight into the clinical heterogeneity in the disorder. Results indicate that genetic predisposition to ADHD does not increase the risk for ADHD symptoms associated with TBI. ADHD symptoms associated with TBI may be a result of a mechanical insult rather than neurodevelopmental factors.

Short-term efficacy and tolerability of methylphenidate in children with traumatic brain injury and attention problems

PURPOSE

This study aims to investigate the short-term efficacy and tolerability of immediate-release methylphenidate (IR-MPH) in children with a history of traumatic brain injury (TBI).

METHODS

Twenty children with TBI (mean age: 12.7±3.1years) who had clinically significant attention deficit and/or hyperactivity-impulsivity symptoms and twenty children with primary Attention Deficit Hyperactivity Disorder (ADHD) (mean age: 12.3±3.05years) were included. Study measures, which included the Turgay DSM-IV based ADHD rating Scale (T-DSM-IV-S), Conners' Parent Rating Scale (CPRS), Conners' Teacher Rating Scale (CTRS-R) and Clinical Global Impression-Improvement Scale (CGI-I), were completed at the baseline for both of the groups. For the TBI group, study measures and an adverse effect scale developed by the authors were completed 8weeks after IR-MPH treatment (10mg dose t.i.d).

RESULTS

No significant difference was found regarding the baseline scale scores between the study groups. Among children with TBI, most of the scores on T-DSM-IV-S, CPRS and CTRS-R were found to improve significantly after MPH treatment, (p<0.05). 70% (N=14) of the sample were much improved at the endpoint. MPH was generally well-tolerated (95% had either no adverse effect or mild adverse effects).

CONCLUSION

In this preliminary open-label study, IR-MPH was found as a safe and effective treatment option for ADHD symptoms after TBI. However, future controlled studies are needed to confirm our findings.

Pharmacological treatment of disruptive behavior in children with fetal alcohol spectrum disorder

Fetal alcohol spectrum disorder (FASD) is considered to be the most common cause of developmental disability, affecting more than 1% of the general population in North America. Inattention, hyperactivity, and impulsivity afflict 50-90% of children with FASD and are 3-9 times more common than in the general population. Of importance, a large proportion of children with FASD are affected by oppositional defiant/conduct disorder (ODD/CD), including lack of social judgment and failure to learn from experience. These devastating numbers are contrasted by almost no pharmacological research into treatment of these pervasive conditions in FASD. This review focuses on analyzing the published evidence on the effectiveness and safety of therapy for disruptive behaviors in FASD. Often, the child afflicted by FASD will not be allowed to participate in class activities without such therapies, which makes such analysis critical.

Functional plasticity in childhood brain disorders: when, what, how, and whom to assess

At every point in the lifespan, the brain balances malleable processes representing neural plasticity that promote change with homeostatic processes that promote stability. Whether a child develops typically or with brain injury, his or her neural and behavioral outcome is constructed through transactions between plastic and homeostatic processes and the environment. In clinical research with children in whom the developing brain has been malformed or injured, behavioral outcomes provide an index of the result of plasticity, homeostasis, and environmental transactions. When should we assess outcome in relation to age at brain insult, time since brain insult, and age of the child at testing? What should we measure? Functions involving reacting to the past and predicting the future, as well as social-affective skills, are important. How should we assess outcome? Information from performance variability, direct measures and informants, overt and covert measures, and laboratory and ecological measures should be considered. In whom are we assessing outcome? Assessment should be cognizant of individual differences in gene, socio-economic status (SES), parenting, nutrition, and interpersonal supports, which are moderators that interact with other factors influencing functional outcome.

Traumatic brain injury-related attention deficits: treatment outcomes with lisdexamfetamine dimesylate (Vyvanse)

BACKGROUND AND OBJECTIVES

Attention deficits are often among the most persistent and debilitating impairments resulting from traumatic brain injury (TBI). This study examined the effects of lisdexamfetamine dimesylate (Vyvanse) in treating attention deficits due to moderate-to-severe TBI. It was the first study of lisdexamfetamine dimesylate with this population and, in fact, was the first controlled trial in this area examining a stimulant medication option other than methylphenidate.

METHODS

This was a 12-week, randomized, double-blind, placebo-controlled, cross-over trial. A total of 22 rigorously selected cases were enrolled, 13 of whom completed the trial. They were 16-42 years of age and had newly acquired attention deficits persisting for 6-34 months post-injury. They were assessed on a broad range of neuropsychological and behavioural measures at baseline, 6-weeks and at 12-weeks.

RESULTS AND CONCLUSIONS

Positive treatment effects were found involving selective measures of sustained attention, working memory, response speed stability and endurance and in aspects of executive functioning. No major problems with safety or tolerability were observed. Some moderating treatment effects were found from a broad range of pre-treatment subject characteristics and injury variables examined. Avenues for further research and treatment applications in this area are discussed.

Interventions for attention problems after pediatric traumatic brain injury: what is the evidence?

OBJECTIVE

To gain an understanding of the current state of the evidence for management of attention problems after traumatic brain injury (TBI) in children, determine gaps in the literature, and make recommendations for future research. TYPE: Focused systematic review.

LITERATURE SURVEY

PubMed/Medline and PsychINFO databases were searched for relevant articles published in English during the last 20 years. Keywords included "attention" "attention deficit and disruptive behavior disorders," and "brain injuries." Studies were limited to children.

METHODOLOGY

Titles were examined first and eliminated based on lack of relevancy to attention problems after brain injury in children. This was followed by an abstract and full text review. Article quality was determined based on the US Preventative Services Task Force recommendations for evidence grading.

SYNTHESIS

Four pharmacologic and 10 cognitive therapy intervention studies were identified. These studies varied in level of evidence quality but were primarily nonrandomized or cohort studies.

CONCLUSIONS

There are studies that demonstrate benefits of varying pharmacologic and cognitive therapies for the management of attention problems after TBI. However, there is a paucity of evidence available to definitively guide management of attention problems after pediatric TBI. Larger randomized, controlled trials and multicenter studies are needed to elucidate optimal treatment strategies in this population.

Neuropsychiatry of pediatric traumatic brain injury

Pediatric traumatic brain injury (TBI) is a major public health problem. Psychiatric disorders with onset before the injury are more common than population base rates. Novel (postinjury onset) psychiatric disorders (NPD) are also common and complicate child function after injury. Novel disorders include personality change due to TBI, secondary attention-deficit/hyperactivity disorder, other disruptive behavior disorders, and internalizing disorders. This article reviews preinjury psychiatric disorders as well as biopsychosocial risk factors and treatments for NPD.

Aggregated n-of-1 trials of central nervous system stimulants versus placebo for paediatric traumatic brain injury--a pilot study

Background

In 2006 there were 432,700 people in Australia who had acquired brain injury (ABI) with some limitation of activities; 90% of these were traumatic brain injuries (TBIs) and nearly a third sustained injury below age 15 years. One to four years post injury, 20% to 46% of children with traumatic brain injury (TBI) have clinically significant disorders of attention. There is controversy as to whether central nervous system (CNS) stimulants can be an effective method of treating these.

Objectives were to determine the efficacy of CNS stimulants for children with TBI, and to calculate the sample size for a larger trial using the Conners’ 3 Parent Rating Scales Score as the primary endpoint.

Methods

Pilot series of aggregated prospective randomised, double-blind, n-of-1 trials of stimulant versus placebo within individual patients. Setting: tertiary children’s public hospital. Participants: ten children aged 6 to 16 years more than 12 months post TBI with attention, concentration and behavioral difficulties on stimulants. Interventions: Three cycles of methylphenidate or dexamphetamine orally at doses titrated by physician compared to placebo. Main Outcome Measures: Conners 3 Parent (Conners 3-P) and Teacher (Conners 3-T) Rating Scales (Global Index), Behaviour Rating Inventory of Executive Function (BRIEF) and Eyberg Child Behaviour Inventory (ECBI).

Results

Five of ten patients completed the study. Data from 18 completed cycles from seven patients were analysed. The posterior mean difference between stimulant and placebo scores for the Conners 3-PS (Global Index) was 2.3 (SD 6.2; 95% credible region -1.0 to 6.1; posterior probability that this mean difference was greater than zero was 0.92), and for the Conners 3-T (Global Index) the posterior mean difference was 5.9 (SD 4.5; 95% credible region -3.1 to 14.9; posterior probability 0.93). Posterior mean differences suggest improvement in behaviour and executive function and a decrease in number and intensity of child behaviour problems when taking stimulants compared to placebo. Taken together these data are suggestive of a small benefit at group level.

Conclusions

In this pilot study, there was sufficient evidence that stimulants may be useful in management of behavioral and cognitive sequelae following TBI, to warrant a larger trial.

Trial registration

he trial was registered with the Australian and New Zealand Clinical Trials Registry: registration number ACTRN12609000873224.

The use of stimulant medication to treat neurocognitive deficits in patients with pediatric cancer, traumatic brain injury, and sickle cell disease: a review

Several chronic health conditions of childhood, including pediatric cancers, traumatic brain injury (TBI), and sickle cell disease (SCD) are associated with significant neurocognitive impairments that can compromise educational attainment and future vocational opportunities. The prominence of attentional deficits as part of the neurocognitive sequelae associated with each of these conditions has led some researchers to draw parallels with another chronic condition that manifests in childhood, specifically the inattentive subtype of attention-deficit/hyperactivity disorder (ADHD). Because ADHD shares similar neurocognitive and symptomatological features with pediatric cancer, TBI, and SCD, stimulant medications may be indicated to treat associated deficits in each condition. However, relatively few studies have investigated the safety and effectiveness of stimulant medications in treating neurocognitive sequelae in children with cancer, TBI, or SCD. Thus, clinicians have received little guidance regarding a potentially useful treatment modality for ameliorating the neurocognitive deficits that can profoundly impact the educational, psychosocial, and vocational development of youth with these chronic health conditions. We provide a review of the literature and synthesize current developments in research regarding treatment with stimulant medication for children with cancer, TBI, and SCD, as well as discuss special considerations for each condition.

ADHD: an integration with pediatric traumatic brain injury

This review examines the long-standing finding that ADHD is a common sequela of pediatric traumatic brain injury (PTBI) in light of the current conceptualization of ADHD as a dimensional, neuropsychologically heterogeneous disorder. The review contends that this conceptualization established the basis for concluding that frequently occurring symptoms caused by PTBI, such as slow processing speed, emotional dysregulation and disinhibition, are indicative of ADHD. Consequently, it concludes that ADHD following PTBI is even more common than the 30% rate the current literature suggests. It provides recommendations for the assessment and treatment of ADHD associated with PTBI.

Traumatic brain injury and secondary attention-deficit/hyperactivity disorder in children and adolescents: the effect of reward on inhibitory control

Poor inhibitory control and abnormalities in responding to rewards are characteristic of the developmental or primary form of attention-deficit/hyperactivity disorder (P-ADHD). A secondary form of ADHD (S-ADHD) may occur as a consequence of childhood traumatic brain injury (TBI), but the similarities and differences between these two forms of ADHD have not been well characterized. To address these issues, we studied two inhibitory control tasks under different reward conditions in four groups of children and adolescents: TBI who did not exhibit S-ADHD, TBI who did exhibit S-ADHD, P-ADHD, and healthy controls. Participants with TBI exhibited poor cancellation inhibition relative to controls. Although reward facilitated both cancellation and restraint inhibition similarly across groups, poor performance persisted in the P-ADHD group, and participants with S-ADHD exhibited a selective deficit in cancellation inhibition.

Executive skills and their functional implications: Approaches to rehabilitation after childhood TBI

BACKGROUND

It is widely acknowledged that children recover differently from adults following traumatic brain injury. The impact of neurological injury in the context of developing skills and changing expectations of behaviour requires a developmental approach to rehabilitation that considers children's abilities across home, school and community environments.

METHODS

This article aims to provide an overview of the impact of executive deficits on everyday functioning and to review information about intervention strategies that support long term development of skills.

RESULTS AND CONCLUSIONS

While individual disciplines are not directly referred to in this paper, input from a comprehensive and co-ordinated interdisciplinary team is crucial to understanding and reducing the impact of executive deficits on functional performance.

Memory and learning in pediatric traumatic brain injury: a review and examination of moderators of outcome

This article reviews empirically supported assessment methods to examine impairments in memory and learning following pediatric traumatic brain injury (TBI). Critical factors affecting outcome are explored with an emphasis on an examination of age at injury. The article closes with discussion of current evidence-based interventions for deficits in memory and learning following pediatric TBI.

Organisch bedingte psychische Störungen im Kindes- und Jugendalter - Vier Kasuistiken

Zusammenfassung: Die Aufgaben der Neuropsychologie im Rahmen der Diagnostik von psychischen Störungen im Kindes- und Jugendalter hat sich in den letzten Jahren sehr verändert. Während es früher häufig um die Frage ging, ob bei dem jungen Patienten eine Hirnschädigung vorliegt oder nicht, ist diese Aufgabe heute aufgrund der besseren Möglichkeiten der bildgebenden Verfahren eher in den Hintergrund gerückt. Anhand von vier Einzelfällen wird verdeutlicht, dass frühe Hirnschädigungen nicht nur unmittelbar, sondern auch mittelbar zu Beeinträchtigungen führen. Insbesondere die mittelbaren Folgen, wie z.B. Verhaltensauffälligkeiten und persistierende neuropsychologische Defizite im Entwicklungsverlauf, sind häufig der Grund für eine klinische Vorstellung. Die Besonderheiten von kinder- und jugendpsychiatrischen Patienten mit organisch bedingten psychischen Störungen hinsichtlich Diagnostik und Therapieverlauf werden anhand der ausgewählten Kasuistiken ausführlich diskutiert.

Puppets, robots, critics, and actors within a taxonomy of attention for developmental disorders

This review proposes a new taxonomy of automatic and controlled attention. The taxonomy distinguishes among the role of the attendee (puppet and robot, critic and actor), the attention process (stimulus orienting vs. response control), and the attention operation (activation vs. inhibition vs. adjustment), and identifies cognitive phenotypes by which attention is overtly expressed. We apply the taxonomy to four childhood attention disorders: attention deficit hyperactivity disorder, spina bifida meningomyelocele, traumatic brain injury, and acute lymphoblastic leukemia. Variations in attention are related to specific brain regions that support normal attention processes when intact, and produce disordered attention when impaired. The taxonomy explains group differences in behavioral inattention, hyperactivity, and impulsiveness, as well as medication response. We also discuss issues relevant to theories of the cognitive and neural architecture of attention: functional dissociations within and between automatic and controlled attention; the relative importance of type of brain damage and developmental timing to attention profile; cognitive-energetic models of attention and white matter damage; temporal processing deficits, attention deficits and cerebellar damage; and the issue of cognitive phenotypes as candidate endophenotypes.

Methylphenidate effect on hemispheric attentional imbalance in patients with traumatic brain injury: a psychophysical study

PRIMARY OBJECTIVE

We found spatially asymmetric allocation of attention in patients with traumatic brain injury (TBI) without overt asymmetry on neurological examination. The possible effect of Methylphenidate in reducing this asymmetry is evaluated in the current research.

RESEARCH DESIGN

Psychophysical study using a visual spatial attention task. Identification rates were measured after precuing attention to different visual field loci. TBI patients were tested before, during and after administration of Methylphenidate.

METHODS AND PROCEDURES

After precuing to a locus 5 degrees into the left or right hemifield, target patterns were presented briefly at the cued location (valid), or on the opposite side (invalid) - requiring an attentional shift. Patients were treated with a gradually increasing dosage of a psychostimulant over two weeks, followed by a similar two-week period of gradually diminishing dosage. Patients were tested before treatment, at its peak, and (twice) following its completion.

MAIN OUTCOME AND RESULTS

Patients demonstrated significantly worse performance with leftward than with rightward cross-hemifield shifts of attention. This difference was significantly reduced during and following treatment.

CONCLUSIONS

Asymmetric performance and improvement with treatment suggest that diffuse TBI damage leads to a lateralized attention-related deficit. These findings support the hypotheses that attention is a distributed and asymmetrically lateralized function. The findings are consistent with the conclusion that Methylphenidate may be an effective treatment for attentional deficits in TBI patients.

Controversies in the evaluation and management of minor blunt head trauma in children

PURPOSE OF REVIEW

We present data from recently conducted research regarding controversial aspects of the evaluation and management of children with minor blunt head trauma.

RECENT FINDINGS

Clinicians frequently but at times indiscriminately perform computed tomography scans for children with minor blunt head trauma resulting in potentially harmful radiation exposure. Recent guidelines recognize the limited but increasing data available to make strong recommendations regarding appropriate neuroimaging decisions. Investigators have derived and validated clinical prediction models to accurately identify patients with substantial traumatic brain injury, though no clear definitive rule exists. Children younger than 2 years appear to have a higher risk of intracranial injury following minor head trauma. These patients can be difficult to assess, with the evidence suggesting the need for a more conservative approach to diagnostic imaging. We present current and accepted definitions of concussion along with risk factors and treatment for postconcussion syndrome. Current return-to-play guidelines suggest that athletes who have sustained concussion should not resume play until symptoms have resolved because of the possibility, though rare, of second impact syndrome.

SUMMARY

Research in the management of children with minor head trauma is actively evolving. We present a review of recent developments that can influence current clinical practice.

Hemispheric visual atentional imbalance in patients with traumatic brain injury

We find a spatially asymmetric allocation of attention in patients with traumatic brain injury (TBI) despite the lack of obvious asymmetry in neurological indicators. Identification performance was measured for simple spatial patterns presented briefly to a locus 5 degrees into the left or right hemifield, after precuing attention to the same (ipsilateral) or opposite (cross-hemifield) side. Though the cue was non-predictive of target location overall, performance was significantly slower for cross than for ipsilateral trials in both patients and controls. We tested 21 TBI patients without overt focal brain damage and nine control subjects. Only patients demonstrated significantly worse performance for left side presentation in the ipsilateral condition. Furthermore, in the cross-hemifield condition, the left-right difference seen in TBI patients was significantly larger-reflecting a failure in producing a leftward attention shift. Again no significant difference was found in controls. These hemifield effects suggest an asymmetry in the ability of TBI patients in shifting attention to the left hemifield, whether from central fixation or from a cue in the contra-lateral hemifield. The results support basic hypotheses regarding visual attention: Attentional control may be asymmetric and attention may be a distributed, rather than localized cortical function.

Effect of methylphenidate on ICU and hospital length of stay in patients with severe and moderate traumatic brain injury

OBJECTIVE

Traumatic brain injury is one of the major causes of death and disability among young people. Methylphenidate, a neural stimulant and protective drug, which has been mainly used for childhood attention deficit/hyperactivity disorder, has shown some benefits in late psychosocial problems in patients with traumatic brain injury. Its effect on arousal and consciousness has been also revealed in the sub-acute phase of traumatic brain injury. We studied its effect on the acute phase of moderate and severe traumatic brain injury (TBI) in relation to the length of ICU and hospital admission.

PATIENTS AND METHODS

Severely and moderately TBI patients (according to inclusion and exclusion criteria) were randomized to treatment and control groups. The treatment group received methylphenidate 0.3mg/kg per dose PO BID by the second day of admission until the time of discharge, and the control group received a placebo. Admission information and daily Glasgow Coma Scale (GCS) were recorded. Medical, surgical, and discharge plans for patients were determined by the attending physician, blinded to the study.

RESULTS

Forty patients with severe TBI (GCS = 5-8) and 40 moderately TBI patients (GCS = 9-12) were randomly divided into treatment and control groups on the day of admission. In the severely TBI patients, both hospital and ICU length of stay, on average, were shorter in the treatment group compared with the control group. In the moderately TBI patients while ICU stay was shorter in the treatment group, there was no significant reduction of the period of hospitalization.

CONCLUSION

There were no significant differences between the treatment and control groups in terms of age, sex, post resuscitation GCS, or brain CT scan findings, in either severely or moderately TBI patients. Methylphenidate was associated with reductions in ICU and hospital length of stay by 23% in severely TBI patients (P = 0.06 for ICU and P = 0.029 for hospital stay time). However, in the moderately TBI patients who received methylphenidate, there was 26% fall (P = 0.05) only in ICU length of stay.