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Guidelines for the pharmacologic treatment of neurobehavioral sequelae of traumatic brain injury [Guideline]
Warden, Deborah L; Gordon, Barry; McAllister, Thomas W; Silver, Jonathan M; Barth, Jeffery T; Bruns, John; Drake, Angela; Gentry, Tony; Jagoda, Andy; Katz, Douglas I; Kraus, Jess; Labbate, Lawrence A; Ryan, Laurie M; Sparling, Molly B; Walters, Beverly; Whyte, John; Zapata, Ashley; Zitnay, George
There is currently a lack of evidence-based guidelines to guide the pharmacological treatment of neurobehavioral problems that commonly occur after traumatic brain injury (TBI). It was our objective to review the current literature on the pharmacological treatment of neurobehavioral problems after traumatic brain injury in three key areas: aggression, cognitive disorders, and affective disorders/anxiety/ psychosis. Three panels of leading researchers in the field of brain injury were formed to review the current literature on pharmacological treatment for TBI sequelae in the topic areas of affective/anxiety/ psychotic disorders, cognitive disorders, and aggression. A comprehensive Medline literature search was performed by each group to establish the groups of pertinent articles. Additional articles were obtained from bibliography searches of the primary articles. Group members then independently reviewed the articles and established a consensus rating. Despite reviewing a significant number of studies on drug treatment of neurobehavioral sequelae after TBI, the quality of evidence did not support any treatment standards and few guidelines due to a number of recurrent methodological problems. Guidelines were established for the use of methylphenidate in the treatment of deficits in attention and speed of information processing, as well as for the use of beta-blockers for the treatment of aggression following TBI. Options were recommended in the treatment of depression, bipolar disorder/mania, psychosis, aggression, general cognitive functions, and deficits in attention, speed of processing, and memory after TBI. The evidence-based guidelines and options established by this working group may help to guide the pharmacological treatment of the person experiencing neurobehavioral sequelae following TBI. There is a clear need for well-designed randomized controlled trials in the treatment of these common problems after TBI in order to establish definitive treatment standards for this patient population.
PMID: 17020483
ISSN: 0897-7151
CID: 426322
Effects of rivastigmine on cognitive function in patients with traumatic brain injury
Silver, J M; Koumaras, B; Chen, M; Mirski, D; Potkin, S G; Reyes, P; Warden, D; Harvey, P D; Arciniegas, D; Katz, D I; Gunay, I
OBJECTIVE: To compare the efficacy and safety of rivastigmine (3 to 6 mg/day) vs placebo over 12 weeks in patients with traumatic brain injury and persistent cognitive impairment. METHODS: This prospective, randomized, double-blind, placebo-controlled study was conducted in 157 patients at least 12 months after injury. The primary efficacy measures were the Cambridge Neuropsychological Test Automated Battery (CANTAB) Rapid Visual Information Processing (RVIP) A' subtest and the Hopkins Verbal Learning Test (HVLT). The primary efficacy outcome was the proportion of patients who demonstrated 1.0 SD or greater improvement from baseline at week 12 on CANTAB RVIP A' or HVLT. RESULTS: The percentage of responders at week 12 on either the CANTAB RVIP A' or HVLT was 48.7% for rivastigmine and 49.3% for placebo (p = 0.940). Furthermore, for the overall study population, there were no significant differences for any of the secondary efficacy variables. In a subgroup of patients with moderate to severe memory impairment (n = 81), defined as 25% impairment or greater on HVLT at baseline, rivastigmine was significantly better than placebo for a number of measures, including the proportion of HVLT responders and CANTAB RVIP mean latency. CONCLUSIONS: Rivastigmine was safe and well tolerated in patients with traumatic brain injury with cognitive deficits. Rivastigmine shows promising results in the subgroup of patients with traumatic brain injury with moderate to severe memory deficits
PMID: 16966534
ISSN: 1526-632x
CID: 68753
Long term effects of rivastigmine in patients with traumatic brain injury with cognitive deficits: Results of a 26-week open-label extension to a 12-week double-blind study [Meeting Abstract]
Gunay, Ibrahim; Koumaras, Barbara; Silver, Jonathan
ISI:000241038300236
ISSN: 0364-5134
CID: 426572
Clinical significance of dilated Virchow-Robin spaces in mild traumatic brain injury
Inglese, Matilde; Grossman, Robert I; Diller, Leonard; Babb, James S; Gonen, Oded; Silver, Jonathan M A; Rusinek, Henry
PRIMARY OBJECTIVE: To investigate the relationship between the number of dilated Virchow-Robin spaces (VRS) and neurocognitive findings in patients with traumatic brain injury (TBI). RESEARCH DESIGN: Thirty-eight patients with TBI and 21 controls were studied. METHODS AND PROCEDURES: Fifteen patients underwent MRI within a mean interval of 5.4 (range 1-12) days from the brain injury and 23 after an average period of 5.5 (range 0.2-31) years. All subjects were examined with a battery of 13 neuropsychological tests (NP). MAIN OUTCOMES AND RESULTS: The average number of VRS was significantly higher in patients than in controls. There were no significant differences between patients and controls in terms of NP tests. The number of VRS showed a significant inverse correlation with processing speed and a positive correlation with visual perceptual of attention only in patients studied within a short delay of trauma. CONCLUSIONS: VRS are not directly associated to neurocognitive findings, suggesting that they may represent a result of the shear-strain injury
PMID: 16403696
ISSN: 0269-9052
CID: 66693
Pharmacotherapy of posttraumatic cognitive impairments
Arciniegas, David B; Silver, Jonathan M
Pharmacotherapy may contribute to the rehabilitation of persons with posttraumatic cognitive impairments. This article reviews first the neurobiological consequences of traumatic brain injury with a particular emphasis on acute and long-term posttraumatic neurochemical disturbances. Studies of pharmacotherapies for posttraumatic cognitive impairments are reviewed next, and are organized according to medication class and the neurotransmitter system they affect most. Based on the evidence provided by that review, augmentation of posttraumatic cerebral catecholaminergic and cholinergic function are suggested as potentially useful neurochemical targets for pharmacologic intervention in this population. More specifically, it is suggested that persons with posttraumatic impairments in arousal, speed of processing, and possibly attention may benefit most from treatment with an agent that augments cerebral catecholaminergic function, and that persons whose predominant posttraumatic impairment is in the domain of memory may benefit most from treatment with cholinesterase inhibitors. Practical considerations regarding the use of pharmacotherapies for posttraumatic cognitive impairments are offered, and the need for additional research in this area is highlighted
PMCID:5471537
PMID: 16720958
ISSN: 0953-4180
CID: 140334
Behavioral neurology and neuropsychiatry is a subspecialty [Comment]
Silver, Jonathan M
PMID: 16720790
ISSN: 0895-0172
CID: 426332
Treatment of depression following traumatic brain injury
Alderfer, Benjamin S; Arciniegas, David B; Silver, Jonathan M
Depression is a common consequence of traumatic brain injury (TBI), and is a source of substantial distress and disability for persons with TBI and their families. This article offers a practical approach to the evaluation and treatment of this condition. Diagnostic and etiologic considerations relevant to this issue are reviewed first. Next, somatic therapies for posttraumatic depression, including antidepressant medications and electroconvulsive therapy, are discussed. Use of these therapies is also considered in the context of the common medical and neurological comorbidities among persons with TBI. Finally, psychosocial interventions relevant to the care of persons with posttraumatic depression are presented
PMID: 16304490
ISSN: 0885-9701
CID: 140332
The differential diagnosis of pseudobulbar affect (PBA). Distinguishing PBA among disorders of mood and affect. Proceedings of a roundtable meeting
Arciniegas, David B; Lauterbach, Edward C; Anderson, Karen E; Chow, Tiffany W; Flashman, Laura A; Hurley, Robin A; Kaufer, Daniel I; McAllister, Thomas W; Reeve, Alison; Schiffer, Randolph B; Silver, Jonathan M
This monograph summarizes the proceedings of a roundtable meeting convened to discuss pseudobulbar affect (PBA). Two didactic lectures were presented followed by a moderated discussion among 11 participants. Post-meeting manuscript development synthesized didactic- and discussion-based content ad incorporated additional material from the neuroscience literature. A conceptual framework with which to distinguish between disorders of mood and affect is presented first, and disorders of affect regulation are then reviewed briefly. A detailed description of the most common of these disorders, PBA, is the focus of the remainder of the monograph. The prevalence, putative neuranatomic and neurochemical bases of PBA are reviewed, and current and emerging methods of evaluation and treatment of persons with PBA are discussed. The material presented in this monograph will help clinicians better recognize, diagnose, and treat PBA, and will form a foundation for understanding and interpreting future studies of this condition.
PMID: 15962457
ISSN: 1092-8529
CID: 426292
Effects of rivastigmine in patients with traumatic brain injury with cognitive deficits: Results of a 12 week double-blind study [Meeting Abstract]
Mirski, DF; Rabinowicz, A; Koumaras, B; Chen, M; Hanover, E; Potkin, SG; Arciniegas, D; Reyes, P; Warden, D; Harvey, PD; Silver, JM
ISI:000227841502390
ISSN: 0028-3878
CID: 426562
Effects of rivastigmine in patients with traumatic brain injury with cognitive deficits: Results of a 12-week double-blind study [Meeting Abstract]
Mirski, D; Koumaras, B; Chen, M; Potkin, S; Silver, J
ISI:000233197600143
ISSN: 0364-5134
CID: 426592