Incoherence of neuroimaging studies of attention deficit/hyperactivity disorder

Gray Matter Increase in Motor Cortex in Pediatric ADHD: A Voxel-Based Morphometry Study

OBJECTIVE

Several studies report that ADHD is associated with reduced gray matter (GM), whereas others report no differences in GM volume between ADHD patients and controls, and some even report more GM volume in individuals with ADHD. These conflicting findings suggest that reduced GM is not a universal finding in ADHD, and that more research is needed to delineate with greater accuracy the range of GM alterations.

METHOD

The present study aimed to identify GM alterations in ADHD using pediatric templates. 19 drug-naïve ADHD patients and 18 controls, all aged 7 to 14 years, were scanned using magnetic resonance imaging.

RESULTS

Relative to the controls, the ADHD patients had more GM, predominantly in the precentral and supplementary motor areas. Moreover, there were positive correlations between GM volume in these areas and ADHD scale scores.

CONCLUSION

The clinical and pathophysiological significance of increased GM in the motor areas remains to be elucidated by additional research.

Pediatric applications of functional magnetic resonance imaging

Pediatric functional MRI has been used for the last 2 decades but is now gaining wide acceptance in the preoperative workup of children with brain tumors and medically refractory epilepsy. This review covers pediatrics-specific difficulties such as sedation and task paradigm selection according to the child's age and cognitive level. We also illustrate the increasing uses of functional MRI in the depiction of cognitive function, neuropsychiatric disorders and response to pharmacological agents. Finally, we review the uses of resting-state fMRI in the evaluation of children and in the detection of epileptogenic regions.

A Review of the Pathophysiology, Etiology, and Treatment of Attention-Deficit Hyperactivity Disorder (ADHD)

Objective: To review the pathophysiology, etiology, and treatment of attention-deficit hyperactivity disorder (ADHD). Data Sources and Data Extraction: A literature search was conducted in PubMed and EMBASE using the terms attention deficit hyperactive disorder, ADHD, pathophysiology, etiology, and neurobiology. Limits applied were the following: published in the past 10 years (January 2003 to August 2013), humans, review, meta-analysis, and English language. These yielded 63 articles in PubMed and 74 in EMBASE. After removing duplicate/irrelevant articles, 86 articles and their relevant reference citations were reviewed. Data Synthesis: ADHD is a neurological disorder that affects children, but symptoms may persist into adulthood. Individuals suffering from this disorder exhibit hyperactivity, inattention, impulsivity, and problems in social interaction and academic performance. Medications used to treat ADHD such as methylphenidate, amphetamine, and atomoxetine indicate a dopamine/norepinephrine deficit as the neurochemical basis of ADHD, but the etiology is more complex. Moreover, these agents have poor adverse effect profiles and a multitude of drug interactions. Because these drugs are also dispensed to adults who may have concomitant conditions or medications, a pharmacist needs to be aware of these adverse events and drug interactions. This review, therefore, focuses on the pathophysiology, etiology, and treatment of ADHD and details the adverse effects and drug interaction profiles of the drugs used to treat it. Conclusions: Published research shows the benefit of drug therapy for ADHD in children, but given the poor adverse effect and drug interaction profiles, these must be dispensed with caution.

The early history of the neuroscience of attention-deficit/hyperactivity disorder

Research on the neurobiology and pharmacotherapy of attention-deficit/hyperactivity disorder (ADHD) has grown exponentially since 1980. A reasonable question is whether this research has improved our understanding and treatment of ADHD. This article describes relevant developments that took place roughly between 1900 and 1970. During this time, the efficacy of stimulant therapy for the disorder was established and the symptoms of ADHD were linked to many possible nervous system disorders including in the brain-stem, reticular formation, diencephalon, basal ganglia, frontal lobes, and cortex. In 1970, the catecholamine hypothesis of ADHD was proposed. It is concluded that early theories about the neurobiologic basis of ADHD anticipated core ideas of modern theory.

Advanced techniques in magnetic resonance imaging of the brain in children with ADHD

Attention deficit hyperactivity disorder (ADHD) affects about 5% of school-aged child. Previous published works using different techniques of magnetic resonance imaging (MRI) have demonstrated that there may be some differences between the brain of people with and without this condition. This review aims at providing neurologists, pediatricians and psychiatrists an update on the differences between the brain of children with and without ADHD using advanced techniques of magnetic resonance imaging such as diffusion tensor imaging, brain volumetry and cortical thickness, spectroscopy and functional MRI. Data was obtained by a comprehensive, non-systematic review of medical literature. The regions with a greater number of abnormalities are splenium of the corpus callosum, cingulate gyrus, caudate nucleus, cerebellum, striatum, frontal and temporal cortices. The brain regions where abnormalities are observed in studies of diffusion tensor, volumetry, spectroscopy and cortical thickness are the same involved in neurobiological theories of ADHD coming from studies with functional magnetic resonance imaging.

Neuronal correlates of ADHD in adults with evidence for compensation strategies--a functional MRI study with a Go/No-Go paradigm

Objective: Response inhibition impairment is one of the most characteristic symptoms of attention-deficit/hyperactivity disorder (ADHD). Thus functional magnetic resonance imaging (fMRI) during a Go/No-Go task seems to be an ideal tool for examining neuronal correlates of inhibitory control deficits in ADHD. Prior studies have shown frontostriatal abnormalities in children and adolescents. The aim of our study was to investigate whether adults with ADHD would still show abnormal brain activation in prefrontal brain regions during motor response inhibition tasks.

Methods: fMRI was used to compare brain activation in 15 untreated adult patients with ADHD and 15 healthy reference volunteers during performance of a Go/No-Go task.

Results: In contrast to various other studies with children and adolescents with ADHD, we found no significant difference in the activity of anterior cingulate cortex (ACC) or other frontostriatal structures between ADHD and healthy adults. Significantly enhanced activity was found in the parietal cortex, which is known to play an important role in building up attention.

Conclusion: We hypothesize that the enhanced activity is due to the ability of adult ADHD patients to compensate their deficits for a short time, which is demonstrated in our study by equal task performance in both groups.

Understanding decision-making deficits in neurological conditions: insights from models of natural action selection

Models of natural action selection implicate fronto-striatal circuits in both motor and cognitive 'actions'. Dysfunction of these circuits leads to decision-making deficits in various populations. We review how computational models provide insights into the mechanistic basis for these deficits in Parkinson's patients and those with ventromedial frontal damage. We then consider implications of the models for understanding behaviour and cognition in attention-deficit/hyperactivity disorder (ADHD). Incorporation of cortical noradrenaline function into the model improves action selection in noisy environments and accounts for response variability in ADHD. We close with more general clinical implications.

Asymmetry of prefrontal cortical convolution complexity in males with attention-deficit/hyperactivity disorder using fractal information dimension

BACKGROUND AND PURPOSE

Prefrontal cortex, known to be a crucial region for the function of attention, is generally thought to be largely associated with the pathogenesis of attention-deficit hyperactivity disorder (ADHD). Most previous structural imaging studies of ADHD reported abnormality of grey matter volume in prefrontal region. However, volume measure is affected by the size of the interrogated brain, which may cause the inconsistence of the volume based findings. The purpose of the current paper is to use a scale-free measure, fractal information dimension (FID), to assess the prefrontal cortical convolution complexity and asymmetry in ADHD patients.

METHODS

MRI scans from 12 boys with ADHD and 11 controls were carefully processed. Prefrontal cortex was outlined manually. FIDs of bilateral prefrontal cortical surface were examined in each case. Group differences of the bilateral prefrontal cortical convolution complexities and the asymmetry pattern were statistically tested.

RESULTS

We found a left-greater-than-right prefrontal cortical convolution complexity pattern in both groups. However, compared with healthy controls, the left prefrontal cortical convolution complexities of ADHD patients were significantly reduced, resulting in significant reduction of the normal left-greater-than-right cortical convolution complexity asymmetry pattern.

CONCLUSION

This study confirms and extends the existing anatomical knowledge about the brains of people with ADHD. The cortical convolution analysis method may also be applied to quantitatively assess changes in other neuropsychiatric syndromes as well.

No kinetic interaction between levetiracetam and cyclosporine: a case report

Levetiracetam is a new antiepileptic drug reported to be effective and well-tolerated in adults and children affected by epilepsy. Its lack of hepatic cytochrome metabolism is the theoretic basis for the absence of interactions with other drugs that follow this pathway. We present a 14-year-old girl who underwent orthotopic heart transplantation, followed by antirejection therapy including cyclosporine. Symptomatic occipital lobe epilepsy developed that was successfully treated with oxcarbazepine, but cyclosporine plasma levels decreased to below the antirejection threshold. Oxcarbazepine was replaced by levetiracetam. Levetiracetam did not affect the metabolism of cyclosporine, and cyclosporine plasma levels have remained in the therapeutic range up to now. The patient is still seizure-free and does not complain of any side effects after a 1-year follow-up. Further studies are necessary to confirm the lack of interactions between these drugs, which would make levetiracetam a useful therapeutic option in managing seizure control during antirejection therapy with cyclosporine.

Global and regional gray matter reductions in ADHD: A voxel-based morphometric study

Attention deficit hyperactivity disorder (ADHD) is a developmental disorder characterized by inattentiveness, motor hyperactivity and impulsivity. According to neuroimaging data, the neural substrate underlying ADHD seems to involve fronto-striatal circuits and the cerebellum. However, there are important discrepancies between various studies, probably due to the use of different techniques. The aim of this study is to examine cerebral gray (GM) and white (WM) matter abnormalities in a group of ADHD children using a voxel-based morphometry protocol. The sample consisted of 25 children/adolescents with DSM-IV TR diagnosis of ADHD (medicated, aged 6-16 years) who were compared with 25 healthy volunteer children/adolescents. ADHD brains on an average showed a global volume decrease of 5.4% as compared to controls. Additionally, there were regionally specific effects in the left fronto-parietal areas (left motor, premotor and somatosensory cortex), left cingulate cortex (anterior/middle/posterior cingulate), parietal lobe (precuneus bilaterally), temporal cortices (right middle temporal gyrus, left parahippocampal gyrus), and the cerebellum (bilateral posterior). There were no differences in WM volume between ADHD children and control subjects. The results are consistent with previous studies that used different techniques, and may represent a possible neural basis for some of the motor and attentional deficits commonly found in ADHD.

The ipsilateral silent period in boys with attention-deficit/hyperactivity disorder

OBJECTIVE

Characterize maturation of transcallosal inhibition (ipsilateral silent period [iSP]) in attention deficit/hyperactivity disorder (ADHD) using transcranial magnetic stimulation (TMS).

BACKGROUND

Maturation of the iSP is related to acquisition of fine motor skills in typically developing children suggesting that dexterous fine motor skills depend upon mature interhemispheric interactions. Since neuromotor maturation is abnormal in boys with ADHD we hypothesized that iSP maturation in these children would be abnormal. We studied iSP maturation in 12 boys with ADHD and 12 age-matched, typically developing boys, 7-13 years of age.

METHODS

Surface electromyographic activity was recorded from right first dorsal interosseus (FDI). During background activation, focal TMS was delivered at maximal stimulator output over the ipsilateral motor cortex.

RESULTS

Maturation of finger speed in boys with ADHD was significantly slower than that in the control group. The iSP latency decreased with age in the control group but not in the ADHD group.

CONCLUSIONS

These findings suggest the presence of a complex relationship between abnormalities of certain interhemispheric interactions (as represented by iSP latency) and delayed maturation of neuromotor skills in boys with ADHD.

SIGNIFICANCE

These data provide preliminary physiologic evidence supporting delayed or abnormal development of interhemispheric interactions in boys with ADHD.

Functional neuroimaging of attention-deficit/hyperactivity disorder: a review and suggested future directions

Over the past few decades, functional neuroimaging techniques have begun to provide unprecedented windows on the neurobiology of attention-deficit/hyperactivity disorder (ADHD) and the neural effects of medications used to treat the disorder. Convergent data from neuroimaging, neuropsychological, genetics, and neurochemical studies have implicated dysfunction of fronto-striatal structures (lateral prefrontal cortex, dorsal anterior cingulate cortex, caudate, and putamen) as likely contributing to the pathophysiology of ADHD. This review 1) provides an overview of the main imaging techniques being used to study ADHD; 2) discusses their relative strengths and weaknesses, highlighting how they can complement one another; 3) shows how the functional imaging literature, which has built on the structural imaging data, is now being used to test focused hypotheses regarding the neurobiological substrate of ADHD; and 4) suggests guidelines for improving future functional imaging studies. Although at present there are no accepted uses for functional imaging in diagnosing ADHD, this article mentions possible future clinical uses of imaging in ADHD.

Functional magnetic resonance imaging of phonologic processing in neurofibromatosis 1

Neurofibromatosis 1 is associated with reading disabilities, but few associations between neuroanatomic abnormalities and reading problems have been found. We examined the neuronal bases for phonologic processing, a core component of learning to read, in 15 individuals with neurofibromatosis 1 and 15 controls using functional magnetic resonance imaging (MRI). Our results revealed differential use of inferior and dorsolateral prefrontal cortical areas relative to posterior (temporal, parietal, and occipital) cortices for participants with neurofibromatosis 1 compared with controls during phonologic (rhyme) decisions. In addition, similar to previous brain imaging studies of reading deficits in the general population, poorer performance on one of the phonologic decision tasks was associated with increased signal change in the right superior temporal gyrus for the neurofibromatosis 1 group. Behavioral performance on the functional MRI tasks was related to academic reading measures for the neurofibromatosis 1 group. The differential patterns of functional connectivity observed here lend support to previous morphologic studies that suggested inferior frontal and superior temporal areas to be important mediators of reading and language development in neurofibromatosis 1.

The dopaminergic system in attention deficit/hyperactivity disorder

Numerous studies have shown the importance of the mesocorticolimbic dopamine system in the pathophysiology of attention deficit/hyperactivity disorder. However, there has been inconsistency in the findings of those studies. Varied and sometimes contradictory interpretation has been made on the basis of similar results. It is, therefore, still unclear whether the dopaminergic system is hypo- or hyperfunctioning in attention deficit/hyperactivity disorder. The majority of the functional brain imaging studies in both clinical and experimental settings support hypofunction of the basal ganglia which receive abundant dopaminergic afferent. The experimental studies, using dopamine-depleted animals, also support the hypodopaminergic hypothesis, whereas recent studies with the dopamine transporter knockout/knockdown mouse suggest hyperdopaminergic function as the underlying abnormality. In this review we attempt to clarify the issues raised by previous neuroimaging and functional neuroimaging studies. Research involving animal models with genetic traits, genetic manipulation or with brain lesions is analysed, concentrating on the significance of the dopaminergic system in the abnormal behavior of attention deficit/hyperactivity disorder. In addition, the functional state of the dopaminergic system is considered through the speculated mechanism of psychostimulant therapy of the disorder. No final conclusions have been reached regarding the pathological, biochemical and physiological mechanisms responsible for various symptoms. Inconsistency in the findings and their interpretations may indicate the heterogeneity of the pathogenesis of this syndrome.

Suprachiasmatic nucleus projection to the medial prefrontal cortex: a viral transneuronal tracing study

The viral transneuronal labeling method was used to examine whether the suprachiasmatic nucleus (SCN) is linked by multisynaptic connections to the medial prefrontal cortex of the rat. In separate experiments, pseudorabies virus (PRV) was injected into one of the three different cytoarchitectonic regions that comprise the medial prefrontal cortex: infralimbic (Brodmann area 25), prelimbic (Brodmann area 32), and cingulate (Brodmann area 24) cortical areas. After 4-days survival, extensive SCN transneuronal labeling was found following infralimbic cortex (ILC) injections, but almost none occurred when the PRV injections were centered in the prelimbic or cingulate areas. In the ILC cases, transneuronal labeling was localized mainly in the dorsomedial SCN, although a moderate number of labeled neurons were found in the ventrolateral SCN. About 13% of the infected neurons were vasopressin immunoreactive and 4% were vasoactive intestinal polypeptide-positive. Another set of experiments was performed in which the paraventricular thalamic nucleus (PVT) was destroyed 2 weeks prior to making PRV injections into the ILC. Almost no SCN transneuronal labeling occurred in these animals, suggesting that the SCN projection to the ILC is dependent on a relay in the PVT. We propose that the SCN sends timing signals, via its relay in the PVT, to the ILC. This pathway may modulate higher-level brain functions, such as attention, mood, or working memory. Assuming that a homologous circuit exists in humans, we speculate that neurochemical changes affecting this pathway may account for some of the symptoms associated with clinical depression and attention-deficit/hyperactivity disorder.