Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via Google Scholar Articles by Johnson, B. Articles by Bhalerao, S. Search for Related Content PubMed Citation Articles by Johnson, B. Articles by Bhalerao, S. Alzheimer's Disease Traumatic Brain Injury Other Somatic Therapy

Results of Galantamine Treatment in Acute Traumatic Brain Injury

TO THE EDITOR: Traumatic brain injury (TBI) is a major problem affecting approximately 1.4 million Americans every year.¹ Those who survive the initial injury are often left with long-term physical and cognitive impairment. Numerous theories exist regarding the pathophysiology that causes the cognitive and behavioral sequelae of TBI, but recent evidence suggest a role for decreased cholinergic activity.² Also, there is preliminary evidence to suggest the efficacy of cholinergic agents in improving attention and memory.³

Recently, a nonrandomized, retrospective, open-label study found that galantamine, donepezil, and rivastigmine were associated with subjective improvement in vigilance, concentration, initiation, and general functioning that was often evident after the first dose.⁴ Furthermore, a recent case report found that galantamine used as an adjuvant for risperidone was effective in treating both negative and positive symptoms of schizophrenia-like psychosis after TBI, including affective flattening, alogia, and aggressiveness.⁵ Consequently, there has been growing interest in the use of central acetylcholinesterase inhibitors (CAI) after TBI.

Here, we present a case of a patient with an acute TBI in whom galantamine was ineffective in treating both the cognitive and behavioral sequelae of injury.

Case Report

A 35-year-old man with a history of alcohol abuse, Cluster B traits, and two previous head injuries presented after a motor vehicle accident-associated TBI. He sustained multiple injuries, including a C5–C7 fracture and subdural hemorrhages; he was admitted to neurosurgery with a Glascow Coma Score of 7. CT scan revealed bifrontal contusions with a small volume of subdural and subarachnoid blood and a right temporal lobe encephalomalacia, possibly related to a previous trauma.

Three weeks after admission, he was referred to the Psychiatry Dept. because of cognitive impairment, wandering, and cued aggressive behaviors. On examination, he had severe impairment of short-term memory, increased distractibility, perseveration, decreased insight, tangential thought process, and illogical thought content. After delirium had been ruled out, he was diagnosed with a cognitive disorder, not otherwise specified, with behavioral disturbances, and he was treated with 0.25 mg of risperidone prn up to 4 times daily and galantamine 4 mg bid as an adjunct for control of aggression and to improve cognitive deficits.

After 1 week of therapy, there was no significant improvement in behavioral or cognitive functioning as demonstrated through staff evaluations and established tests of cognition (Mini-Mental State Exam, Luria Hand test, clock-drawing, and copying diagram of alternating shapes).

Discussion

On the basis of the evidence to date, we expected galantamine to be of value in our patient. Many outcome measures examined in previous studies (memory, attention, aggression) were areas that had been affected in our patient. However, in our case, galantamine did not bring about significant improvement. We acknowledge that the study by Tenovuo⁴ evaluated the use of CAI in patients with established TBI (i.e., stable symptoms for at least 1 year after trauma); however, we wanted to determine whether this treatment would be effective in the acute scenario.

There are a number of potential reasons why galantamine was not effective in our patient, including inadequate dosage and length of follow-up, exposure to multiple previous TBIs, and inaccurate assessment measures. It is also possible that some of the aggressive behaviors exhibited were part of his normal baseline functioning and not a result of the brain injury.

However, we should remain skeptical regarding the use of CAI in treating acute TBI-associated deficits, despite the recent reports in the literature. It is difficult to make any solid decisions on the efficacy and safety of this therapy without evidence from well-designed randomized, controlled studies. Few therapies currently exist for the treatment of TBI, so even modest gains seen with a particular therapeutic modality may prove to be useful.

REFERENCES

1. Langlois JA, Rutland-Brown W, Thomas KE: Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths. Atlanta, GA, U.S. Dept. of Health and Human Services, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2004
2. Murdoch I, Perry EK, Court JA, et al: Cortical cholinergic dysfunction after human head injury. J Neurotrauma 1998; 15:295–305[Medline]
3. Griffin SL, van Reekum R, Masanic C: A review of cholinergic agents in the treatment of neurobehavioral deficits following traumatic brain injury. J Neuropsychiatry Clin Neurosci 2003; 15:17–26[Abstract/Free Full Text]
4. Tenovuo O: Central acetylcholinesterase inhibitors in the treatment of chronic traumatic brain injury: clinical experience in 111 patients. Prog Neuropsychopharmacol Biol Psychiatry 2005; 29:61–67[CrossRef][Medline]
5. Bennouna M, Greene VB, Defranoux L: Adjuvant galantamine to risperidone improves negative and cognitive symptoms in a patient presenting with schizophrenia-like psychosis after traumatic brain injury. J Clin Psychopharmacol 2005; 25:505–507[CrossRef][Medline]

Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via Google Scholar Articles by Johnson, B. Articles by Bhalerao, S. Search for Related Content PubMed Citation Articles by Johnson, B. Articles by Bhalerao, S. Alzheimer's Disease Traumatic Brain Injury Other Somatic Therapy

Get information about faster international access.

Privacy Policy

Copyright © 2007 Academy of Psychosomatic Medicine. All rights reserved.

Home | Search | Current Issue | Past Issues | Subscribe | All APPI Journals | Help | Contact Us